What a got damn shitshow. [warning politics]

[PonoBill]

I think you are correct quickbeam, as far as it goes. The difference is not just individual vs collective, it's also the quality vs availability issue that your nurse friend encountered. Baseline care has an affordability aspect, I'm sure you see that in Canada regarding the length of time you might have to wait for specialized care, and how many people need to approve something drastic and expensive.

When people say "I don't want to pay for someone else's care" they may be expressing part of that difference. There is no consistent mechanism for determining how far medical intervention will go, or what kind of expensive, specialized care you qualify for. That's what all the "death panel" nonsense is about. Even in countries with more of a collective culture there would probably be objection to a person who had never paid medical insurance, never contributed to social security, getting hundreds of thousands of dollars worth of medical care to extend their life. Especially if their condition resulted from a host of poor life choices.

In reality, medicare is a collective backstop of baseline care that can be supplemented with other care levels. It generally applies only to those over 65, and working Americans have been paying into it since 1966. It's a controlled cost system and could be extended to cover baseline care for all Americans. The current medical insurance paid into companies transitioned to medicare would easily cover the costs. But it would also clearly be socialized medicine and would be an existential threat to VERY big businesses. Might be a challenge.

People hate Obamacare because it's a pile of crap. An unworkable plan that was forced through by executive order and legislative chicanery, and it was based on straightforward deception. I caused enormous switching costs and has drastically and negatively impacted healthcare cost and quality for most Americans. So yeah, not popular.

Any president could reform the American healthcare system, he'd just have to buck the vested interest of many of the world's largest companies.

Trump probably has the best chance of doing something constructive of any president we've had in recent history, primarily because he's a narcissistic twit. People with similar power don't really influence him directly, he could tell those hospital/pharma/insurance CEOs to get stuffed--and might. But it's totally random whether or not he would. It's clear to me that any president being elected by a more normal process will be owned to a large part by those large corporations, unions, and rentiers. Election reform first, healthcare later, unless Trump accidentally does something worthwhile.

Nice post, Surfshaver, I learned some worthwhile stuff reading it--thanks.

[surfshaver]

Pono nails it on the head. Medicare, ie -- the government, is the only payer who has the negotiating power to extract a reasonable price from the providers.  This is why single payer systems work.  Pono is also right in saying this would threaten the inflated economic profit of very big businesses. 

[Subber]

Pono nails it on the head. Medicare, ie -- the government, is the only payer who has the negotiating power to extract a reasonable price from the providers.  This is why single payer systems work.  Pono is also right in saying this would threaten the inflated economic profit of very big businesses.

Medicare could already do that right now - we don't need a single payer system for Medicare to negotiate reasonable prices.
Of course, doctors, hospitals, drug companies and their lobbies would not like it a bit.

With the huge increases in technology, software, imaging, telecommunications, materials, etc.
the costs of health care should have plummeted but it hasn't - the government being hijacked by those listed above is the signature.
(the other area where you see this is education - where costs should have plummeted but we are held hostage
by collusion.)

[Tom]

A10, you're catching on fast. Now here's one thing more about how our health insurance system tries to operate. Half of the people insured get their health insurance from their employer, or the company that employs one of their family members. Don't ask why, it's just the way it is.

Now let's say you are an accountant or a janitor, if you work for company A you get a very complete and excellent health insurance program for you and your family and it may cost you very little to participate. If you work for company B, you get a substandard health insurance program that costs you quite a bit.  If you work for a very small firm, or maybe work for yourself, you have to go on the open market and buy insurance from whom every you can. Prior to ACA, with the employee provided insurance, you were automatically insured without a physical, it you bought it on your own, the insurance company could decline to sell it to you for whatever reason they felt like.

I think that one of the biggest reasons so many people are against ACA is because they have employee covered insurance, which they looked at as being no cost to them. When I'd ask friends about what they think of Obamacare, they say, I don't need it, I don't want to pay for it, I get my insurance for free. Obamacare is only for those that aren't willing to work.

[Subber]

...
Let me give you an example from my own life.  I have suffered my whole life from sinus disorders.  My sinus doctors are a part of USC's hospital and have their offices there.  I have been seeing them for 15 years.

I had a recent visit where my doctor performed a "debridement" where he used the endoscope to wash out my sinuses.  I did not ask for this procedure, the doctor decided to do it on the spot.

When the bill came, the procedure cost was $1500.  For something that took 3 minutes.

But more importantly, in addition they charged a "facility fee."  The facility fee was $4500.

That's right.  A doctor visit that cost $6000.

I have very expensive private insurance, and my out of pocket cost for this doctor visit was close to $2000.

I had never seen this "facility fee" before and was flabbergasted.  I spoke to the hospital, who said they instituted this fee in the last year to "defray the costs of operating the hospital."  I pointed out that I hadn't used the hospital, but simply went to my doctor's office.   They replied that since the doctor's office was physically housed within a building that was considered to be a part of the hospital complex, that it was in fact part of the hospital.

I researched facility fees and found this to be something done by hospitals around the country and has been a subject of protest.

This is the classic definition of economic rent.  A vigorish or tax excised by a property owner for no other reason than they can get away with it.

What made it even more egregious is that this fee was 3 times the cost of the actual treatment itself.

How can hospitals get away with this?  Because there is no one stopping them.

This outrageous overcharging brings to light one thing that could easily result in lower prices charged to the medical consumer --
-- Prices/Fees should be supplied ahead of time.
It baffles me why this is not required, except, well, you know, certain parties don't want it.

I would bet if the doctor had told you in advance of these charges, you would have said no,
or would have at least slept on it (even the procedure was sprung on you) and possibly
looked elsewhere.

A major problem is that you get to know the extent of the charges After the procedure.
Very often it is even months afterwards that the bills keep rolling in.

How can anyone make an fair economic allocation of their resources
when they do not know how much something is going to cost until months later?

It is not "green!"

[Area 10]

This is fascinating and I'm learning a lot. Some great posts here.

So would Bernie Sanders have moved your healthcare system to a more socialised baseline basis - because it seems like that although the word "socialism" is to US citizens to be on a par with "paedophile" in terms of the attractiveness of the label, the options for healthcare change you are exploring here are ones that come closer to those in e.g. Europe. The standard of healthcare in the U.K. is very variable, but if you get sick in France or Germany (especially France) you get a very high standard of treatment indeed, and it's all pretty much free. So you can break your leg skiing in Chamonix and get the best orthopaedic treatment in the world free of charge.

But we do pay a lot more taxes. And yes, in Europe we accept culturally that some people will essentially be leeches on the system. But we generally accept that as the price you pay to keep big business out of the doctor' consulting room. It's a matter of who you trust more. We generally trust our governments to look after our interests more than we do big business. But the level of mistrust of government in the US seems to be much much higher, to the point that a few of you almost feel like the government is fundamentally detrimental to your happiness. But maybe I'm wrong -?

I generally pay about a third of my total income in direct taxation each year - and on top of that about 0.01% in healthcare costs. How much would you guys be spending in direct tax if the healthcare coverage you currently receive (either privately or through your employer) was paid for through taxation?

[PonoBill]

Pono nails it on the head. Medicare, ie -- the government, is the only payer who has the negotiating power to extract a reasonable price from the providers.  This is why single payer systems work.  Pono is also right in saying this would threaten the inflated economic profit of very big businesses.

Medicare could already do that right now - we don't need a single payer system for Medicare to negotiate reasonable prices.
Of course, doctors, hospitals, drug companies and their lobbies would not like it a bit.

With the huge increases in technology, software, imaging, telecommunications, materials, etc.
the costs of health care should have plummeted but it hasn't - the government being hijacked by those listed above is the signature.
(the other area where you see this is education - where costs should have plummeted but we are held hostage
by collusion.)

Medicare IS a single payer system.

[Subber]

Pono nails it on the head. Medicare, ie -- the government, is the only payer who has the negotiating power to extract a reasonable price from the providers.  This is why single payer systems work.  Pono is also right in saying this would threaten the inflated economic profit of very big businesses.

Medicare could already do that right now - we don't need a single payer system for Medicare to negotiate reasonable prices.
Of course, doctors, hospitals, drug companies and their lobbies would not like it a bit.

With the huge increases in technology, software, imaging, telecommunications, materials, etc.
the costs of health care should have plummeted but it hasn't - the government being hijacked by those listed above is the signature.
(the other area where you see this is education - where costs should have plummeted but we are held hostage
by collusion.)

Medicare IS a single payer system.

Almost. And they do a crap job of negotiating for us.
Negotiating here is one area where Trump could add a lot of value.
Don't hold your breath.
As I think you indicated, the vested interest are very strong.
Sooner or later, we will see what the deal with Trump is.

[PonoBill]

Bernie would probably have not. As much as I like the guy, he showed some true colors when he lost against Hillary. He's controlled by the party. He might be outspoken about a number of things, but the leash was obviously still there. Obamacare wasn't single payer because the party wouldn't permit it. End of story.

Middle-class Americans pay about one-third of their income in direct taxes and THEN pay 20K in insurance costs--either directly or in concert with their employer. Health insurance for middle-class workers used to be free--an affordable benefit employers offered. Now it isn't--employees pay about 5K of the 20K and the plans are not nearly as generous and have numerous restrictions about who they can receive care from. Once more reason working Americans generally hate Obamacare--unless they have a relative or friend being propped up by the ACA, in which case the hatred is mitigated a bit.

Subber--I read my Medicare statements. There's a good reason Doctors don't like us geezers. Some of the payout for services is astonishingly small. Hospital facility charges seem to be rejected totally--which must piss the hospitals off enormously.

[surfshaver]

Subber makes an interesting point.  Unlike during the industrial era, when most advances in technology were inflationary -- increasing returns on labor AND capital -- the info tech era has been highly deflationary -- Moore's law, the impact of the internet, lower switching costs, etc  The benefits of information/digital tech in healthcare should lead to efficiency and lower costs, but it doesn't because of regulatory capture.

The other clear but extremely important point he makes is that unlike any other industry, the consumers of health care don't know what the prices of goods and services are before they purchase them.  Even worse the price of those services is different depending on who the customer is (ie a hospital charges less for a routine procedure like blood work to someone on medicare than someone with private insurance).

When pricing isn't transparent, when a service provider can charge two prices for the same good or service, you don't have a market.  You have a monopoly.

[SUP Leave]

...
Let me give you an example from my own life.  I have suffered my whole life from sinus disorders.  My sinus doctors are a part of USC's hospital and have their offices there.  I have been seeing them for 15 years.

I had a recent visit where my doctor performed a "debridement" where he used the endoscope to wash out my sinuses.  I did not ask for this procedure, the doctor decided to do it on the spot.

When the bill came, the procedure cost was $1500.  For something that took 3 minutes.

But more importantly, in addition they charged a "facility fee."  The facility fee was $4500.

That's right.  A doctor visit that cost $6000.

I have very expensive private insurance, and my out of pocket cost for this doctor visit was close to $2000.

I had never seen this "facility fee" before and was flabbergasted.  I spoke to the hospital, who said they instituted this fee in the last year to "defray the costs of operating the hospital."  I pointed out that I hadn't used the hospital, but simply went to my doctor's office.   They replied that since the doctor's office was physically housed within a building that was considered to be a part of the hospital complex, that it was in fact part of the hospital.

I researched facility fees and found this to be something done by hospitals around the country and has been a subject of protest.

This is the classic definition of economic rent.  A vigorish or tax excised by a property owner for no other reason than they can get away with it.

What made it even more egregious is that this fee was 3 times the cost of the actual treatment itself.

How can hospitals get away with this?  Because there is no one stopping them.

This outrageous overcharging brings to light one thing that could easily result in lower prices charged to the medical consumer --
-- Prices/Fees should be supplied ahead of time.
It baffles me why this is not required, except, well, you know, certain parties don't want it.

I would bet if the doctor had told you in advance of these charges, you would have said no,
or would have at least slept on it (even the procedure was sprung on you) and possibly
looked elsewhere.

A major problem is that you get to know the extent of the charges After the procedure.
Very often it is even months afterwards that the bills keep rolling in.

How can anyone make an fair economic allocation of their resources
when they do not know how much something is going to cost until months later?

Great stuff in this thread.

It is often amazing getting a medical bill, you see what insurance covered and what you have to pay and think how many layers of bullshit is there between me and my doctor? I have asked the cost of a procedure plenty of times before it starts and have asked what about if I pay cash or check today? If you are in a less-incorporated office I have found prices to drop as much as 50%. I recommend you find a primary care doctor who will operate this way if at all possible. There is still a bit of a free market out there if you hunt it down. My small town doctors have told me that there are not many young guys who want to go out and own a small practice anymore, they are all going corporate/conglomerate - which is a shame.

To sharpen some of the points above. The reason people hate Obamacare is that the bill itself is 1000 pages of garbage and the only option it had was to make healthcare costs rise above what they were.The administration of the changes (reading the thing) for the insurance companies alone, raised cost to the consumer, before they had to start covering pre-existing conditions. The intent was "healthcare for everybody", but the truth was it was "healthcare for everybody at gun-point". The intent was good, but the mechanics were deeply flawed (it was an impossible dream).

What we have now is a forced transaction between the consumer and the insurance company and healthcare provider. Tell me that I have to provide engineering for everyone who comes in the door, and that some of them will pay through a highly convoluted bureaucratic system - from which you should expect payment within a year. I am going to raise my price - with no compunction for the actual cost - because the actual cost is almost unknown anyway. I will have to raise the fees for the cash-payers as well, just to pay rent while I wait for my payments from the government.


To Paul Ryan's credit Trumpcare is only 70 pages, but it still cements many of Obamacare's anti market policies.

A10 asked for the solution and my solution will be highly unpopular, but here goes:

- We had/have a crappy system for the poor and old - Medicare - It can stay, but we need to make it possible for poorer people to access (buy) some additional insurance (i.e. make it cheaper), so that health care facilities change their willingness to work with medicare patients.

- Repeal O-care, let insurance cross state lines, put the choice back in the hands of the consumer. Tom is right that Employers provide most of the insurance. I provide it for my people and the cost of it is a joke (we have basically 3 choices, all expensive). If I could go back to where it was 4 years ago, I could employ 1 or 2 more people with ease.

- Stop forcing the market on health care, let the transactions be more personal.

Basically, get the government out of health care. I am fine with paying for someone else's care, but not through the government where the ROI is cents on the dollar. If you told me I could pull out my tax money that goes to entitlements and give it directly to a charity, I would choose the charity every time. A charity has a mission statement, a burueacrats mission statement is "me first".

[surfshaver]

Pono's last point is true as well -- part of the reason why health care providers charge private insurance holders so much is that they don't make much profit from medicare.

Underlying all of this is the economic concept of a "social good" -- something that benefits the society as a whole.

Consider utilities.  Water and Power are considered necessities, and the providers enjoy monopoly power.  As a result, they are highly regulated so they can't abuse that monopoly power to charge egregious amounts for water and power.  As a result their profit margins are low but stable.  A dividend stock, as they say for widows and orphans.

Smart people have argued that the banking system is basically a utility and should be regulated as such.  I'm talking about the commercial banks which have government-insured deposits.  This is why the repeal of Glass-Steagal was so destructive.  The world's biggest banks could gamble with house money.  Except it wasn't theirs, it was ours.

Health care is similar.  IF viewed as a social good, then it should be available to all and those in the business who are motivated by getting wealthy would do other things.  This is how it works in other countries.

I have had many arguments with doctors (usually ex-jock orthopedic surgeons, btw) who argue that without profit motive, doctors would not strive to provide the best care, and that the best doctors are in our system because they can make more money.

While this may be true for some, it is patently untrue in general.  The US does not have a monopoly on doctors who do cutting edge research and who are at the top of their profession.  Indeed many doctors at the best teaching hospitals and universities would make more money in private practice. 

[SUP Leave]

Health care is similar.  IF viewed as a social good, then it should be available to all and those in the business who are motivated by getting wealthy would do other things.  This is how it works in other countries.

I have had many arguments with doctors (usually ex-jock orthopedic surgeons, btw) who argue that without profit motive, doctors would not strive to provide the best care, and that the best doctors are in our system because they can make more money.

While this may be true for some, it is patently untrue in general.  The US does not have a monopoly on doctors who do cutting edge research and who are at the top of their profession.  Indeed many doctors at the best teaching hospitals and universities would make more money in private practice.

Pretty good point here. I also agree that what happens (especially in metro-areas) is that the healthcare providers can collude or monopolize the market. This is where I would say government intervention is justified, like you said above in the way they regulate utility providers. We all should have access to healthcare, but not be forced to use it.

And for the last 40 years, everyone has had access to healthcare. Now, the quality of care and general experience at the free clinic vs that of a primary care physician in a private office is much different. It has to be, but at least the option is there. To my point above, if we could fund charitable organizations who provide healthcare or research more directly. We would get a better bang for the buck and better healthcare for all.

[Subber]

Pretty good point here. I also agree that what happens (especially in metro-areas) is that the healthcare providers can collude or monopolize the market. This is where I would say government intervention is justified, like you said above in the way they regulate utility providers. We all should have access to healthcare, but not be forced to use it.

And for the last 40 years, everyone has had access to healthcare. Now, the quality of care and general experience at the free clinic vs that of a primary care physician in a private office is much different. It has to be, but at least the option is there. To my point above, if we could fund charitable organizations who provide healthcare or research more directly. We would get a better bang for the buck and better healthcare for all.

Actually it is big business, big labor (AMA, doctors and nurses unions, which are big business), pharma, insurance.
in collusion or controlling/manipulating Government.
Government is already heavily involved. 
More direct involvement by government would probably be even worse - please let me opt out!

An excellent example IS utilities - same sort of collusion.
They just raised utility rates around here - both gas (last fall), and electricity, a month ago.
After raising them both a few years ago.

Bbbbbuuuuttt, of course, the general public is clueless (and not at all helped by the media)
that
The CRB (Commodity Research Board) index of commodity prices is DOWN 39% from 2014!
-- And it is down 51% from its higher high of 2008.
How far back you can go to get today's CRB level? it is all the way back to 2003
- even worse, it was the same level in 2001 and even back in 1997!
but our rates are dramatically higher, geeze.

Also, natural gas futures are DOWN 53%! from their 2013 spike high; and they are down 81%! from their 2008 higher spike high.
How far back in time you can go to have natural gas prices equal to today's - at least 1995!!

So, actually, natural gas prices and electricity prices should be a lot lower, heading downwards,
rather than up and up and up (just like institutionalized "medical care") as they are under government "oversight."

This type of situation in institutionalized "health care" and in "education" and utilities is where Government
is heavily involved.  Hmmmm, I wonder which direction we should actually be heading?

Not that I expect the right things to be done - I doubt it, unfortunately.

[pdxmike]

It's never made sense to me that health insurance has been tied with employment.  I know it's a huge hassle for companies.  It also limits employee choice.  It also hides the costs from employees.  The whole system also is tough on people who don't get insurance through employers, and thus have no clout. 


The only saving grace is that insurance has become so complicated that millions of employed people would be without it if they had to handle it themselves.  It's hard enough for the people at companies whose job is to handle health insurance.