Why people are afraid of universal health care

[Emily Lake]

collect quality-of-results statistics from all the single-payer and mixed public/private systems in other countries, identify who has the top-rated system, and hire that country's experts to rebuild the American system in its image.

Sounds reasonable to me. If you put some faces and names to it, it might even be compelling.
I don’t think you need to be a HC professional to understand that our system is not cost effective compared to most UHC Countries’. The first step toward implementation of positive change IMO is to figure out the resistance points. That usually leads to people whose ox would be gored. Such people have thus far had ample oxen (resources) to keep the lobby up. Otherwise we probably would long since invested in collecting quality-of-results statistics from all the single-payer and mixed public/private systems in other countries, identifying who has the top-rated system, and hiring that country's experts to rebuild the American system in its image.

(Vote Blue)

Whose ox gets gored?

AMA - and pretty much any other medical association you can think of that has a vested interest in increasing or maintaining their ability to bill whatever the hell they want and get any service covered by either insurers or the government
USPSTF - and various other quasi-government bodies that define what is required to be covered by insurers, even if it doesn't make a huge amount of sense
NAIC - and various other insurance commission related bodies that maintain state-level insurance controls
Various Health Insurers - although they rarely work together some of them are quite large

But mostly... the political parties themselves get gored, because health care has been a divisive topic that has been weaponized by both Dems and Reps.

 

[Emily Lake]

Why would anyone assume that a YHC would not have some form of outside rsgulation?

Who? It's the government setting the standard of care. It's the government providing the care. That's a fox guarding the henhouse.

Yeah, and it's kinda fucked up. I have been billed for stuff that had a subtle coding difference that it is ridiculous for a surgeon to need to know. Now they have to ask not only what is this person's condition and what can I do for it, but also stuff like what are the conditions under which x,y,z screenings I might order fall under which subset of codes that depend on things like differences between diagnostic or preventative (the ins co's definitions), and what will or will not leave the patient liable for the bill.
Anyhow I got billed and told them to go back to the surgeon and get themselves an new code.
"We can't do that, you have to do it".
"Will I need to pay a co-pay for a visit so I can explain it to him?"
"I don't know..."

I was pissed but I booked an appointment with the cardiologist.
They asked what it was about, and when I told them, they said they'd check with The Doctor and call me back.
They called back the next morning and said no need to come in, they understood and would get the bill re-coded and re-sent.
And that was that. But it took a lot of digging just to figure out why they were billing me in the first place, what would have kept that from happening - the whole system seems to just suck the life out of you, even as it heals.

Most reputable insurers will handle that sort of a dispute for you, if you call them. You might have to be transferred away from a general customer service number, but most of the time you can ask for claims or for appeals and grievances.

Note I said *reputable*. Not all insurance companies are created equal, and some are more cut-throat than others. So no guarantees. But if you run into this sort of a situation in the future, it might be worth at least trying your insurance company first, it could potentially save you a bit of hassle.

 

[Emily Lake]

In my area, more and more health care systems are declining patients with Medicare Advantage plans.

Could you post a link or two on that? Isn't happening around me. I've never encountered it or heard of anyone else encountering it.

Okay, I did a bit of googling. It seems 1% of non-pediatricians do not participate in Medicare.

Try Alaska

It varies a LOT by location

 

[Toni]

The drawbacks I observe are that a lot of providers limit the number of their Medicaid ( low income) patients and increasingly, Medicare patients because Medicare and Medicaid pay so poorly, often not covering the actual cost of treatment.

Medicaid is often very low, but it can be done. Most successful Medicaid plans have very tight controls on what procedures a patient is allowed to get, when they can get them, what they have to try first, etc. They almost always require an assigned primary care doctor who you have to see prior to any treatments by any other provider (except emergency), and they require referrals from that PCP for all other services. They're very tightly managed, which places very strict limits on how much excess a provider can bill for. It's not actually the cost per service that's limiting for providers, it's not being able to send everyone for every possible sort of exam. It's being required to do an xray when the initial diagnosis is a broken bone, and not being allowed to send that patient for a CT scan or an MRI instead.

It's entirely possible for a reasonable provider to make a reasonable margin on Medicare rates. Lots of providers aren't reasonable.

Note - for the most part, actual real life primary care doctors are reasonable, and the rates for Medicaid, Medicare, and Commercial visits aren't hugely different. It's facilities and other kinds of providers that are a problem imnsho.

Medicare reimbursement pricees are closely followed by private insurance companies—why should they pay out $100/office visit when Medicare gets to pay $85????

 

[Emily Lake]

The drawbacks I observe are that a lot of providers limit the number of their Medicaid ( low income) patients and increasingly, Medicare patients because Medicare and Medicaid pay so poorly, often not covering the actual cost of treatment.

Medicaid is often very low, but it can be done. Most successful Medicaid plans have very tight controls on what procedures a patient is allowed to get, when they can get them, what they have to try first, etc. They almost always require an assigned primary care doctor who you have to see prior to any treatments by any other provider (except emergency), and they require referrals from that PCP for all other services. They're very tightly managed, which places very strict limits on how much excess a provider can bill for. It's not actually the cost per service that's limiting for providers, it's not being able to send everyone for every possible sort of exam. It's being required to do an xray when the initial diagnosis is a broken bone, and not being allowed to send that patient for a CT scan or an MRI instead.

It's entirely possible for a reasonable provider to make a reasonable margin on Medicare rates. Lots of providers aren't reasonable.

Note - for the most part, actual real life primary care doctors are reasonable, and the rates for Medicaid, Medicare, and Commercial visits aren't hugely different. It's facilities and other kinds of providers that are a problem imnsho.

Medicare reimbursement pricees are closely followed by private insurance companies—why should they pay out $100/office visit when Medicare gets to pay $85????

I can't tell if this is serious or sarcasm, Toni.

 

[Toni]

The drawbacks I observe are that a lot of providers limit the number of their Medicaid ( low income) patients and increasingly, Medicare patients because Medicare and Medicaid pay so poorly, often not covering the actual cost of treatment.

Medicaid is often very low, but it can be done. Most successful Medicaid plans have very tight controls on what procedures a patient is allowed to get, when they can get them, what they have to try first, etc. They almost always require an assigned primary care doctor who you have to see prior to any treatments by any other provider (except emergency), and they require referrals from that PCP for all other services. They're very tightly managed, which places very strict limits on how much excess a provider can bill for. It's not actually the cost per service that's limiting for providers, it's not being able to send everyone for every possible sort of exam. It's being required to do an xray when the initial diagnosis is a broken bone, and not being allowed to send that patient for a CT scan or an MRI instead.

It's entirely possible for a reasonable provider to make a reasonable margin on Medicare rates. Lots of providers aren't reasonable.

Note - for the most part, actual real life primary care doctors are reasonable, and the rates for Medicaid, Medicare, and Commercial visits aren't hugely different. It's facilities and other kinds of providers that are a problem imnsho.

Medicare reimbursement pricees are closely followed by private insurance companies—why should they pay out $100/office visit when Medicare gets to pay $85????

I can't tell if this is serious or sarcasm, Toni.

I myself never worked in billing but it was a small medical office and the women in billing and insurance talked about the processes, etc. so, this would be second hand ‘knowledge’ I suppose. The same sorts of things were discussed at another medical provider I worked for in a different capacity.

I’ve read articles talking about billing, etc.

Here is this article:

In the Shadow of a Giant: Medicare’s Influence on Private Physician Payments - PMC

We analyze Medicare’s influence on private insurers’ payments for physicians’ services. Using a large administrative change in reimbursements for surgical versus medical care, we find that private prices follow Medicare’s lead. A $1.00 increase in ...

pmc.ncbi.nlm.nih.gov

Insurers negotiate prices with providers all the time. Provider networks are an example of just how medical practices and insurers work together to determine what the payment an insurer is willing to pay for what. Service/procedure/test. Medical providers often accept a reduction in payment because they believe they can make their profit in volume as the insurer guarantees them more patients driven to their practice.

Medicare is an insurer—an extremely large one. Typically it pays less than other insurers will pay. Other private insurers set their own reimbursement rates according to the Medicare schedule of payments.

 

[Bomb#20]

It's still a bargain between private parties for mutual benefit: a paid transfer of a risk from someone it's too much for to someone else who's more risk tolerant, not an externalization of cost onto society as a whole.

Which is great, if the risk that's too much for people is a fairly rare thing - something that affects only merchants shipping valuable cargoes, or only middle class men who can afford a nice house, but can't afford for it to be replaced if it burns to the ground.

As any actuary will tell you, insurance works best if the pool is as wide as possible. If lots of people buy insurance, then even large claims can be paid without huge premiums being needed.

But just how much better does insurance work if the pool is as wide as possible? As any actuary can also tell you, the Law of Diminishing Returns applies here. The improvement you get from going from 1 covered person to 9 million is huge. The improvement you get from going from 9 million covered people to 27 million is negligible.

And of course, all insurance is externalization of the cost of a future disaster onto a wider society of insured persons.

"of course", the man says. You're pretty much torpedoing the whole concept of "externalization" here -- that's like saying when I pay the grocer for food I'm "externalizing" onto her the cost of paying a truck driver to carry the food from the farmer. In private insurance everybody pays his own expected cost, and the unexpected cost of the future disaster is borne by people who, like the grocer, volunteered to pay that cost in return for good and sufficient consideration. That's not the sort of thing "externalization" refers to.

When the disaster that might befall an individual can affect third parties, it is even commonplace to make the purchase of insurance mandatory - car insurance is mandatory in many jurisdictions to provide this protection for third parties.

So, mandatory insurance being a useful and necessary thing,

I don't see how that's a useful analogy. Mandatory insurance being a useful and necessary thing to deal with risks people impose on others doesn't imply it's a useful and necessary thing to deal with people's risks to themselves. We don't make drivers buy collision insurance, just liability insurance.

and a wide pool being highly desirable for effective insurance, it makes perfect sense for health insurance to be mandatory, and to have a single insurer.

But monopolies need controls in addition to the monetary controls that (supposedly) keep non-monoply corporations honest.

Bingo. Just how much monetary control does it take to keep non-monopoly corporations honest? See above about diminishing returns. The improvement you get from going from 1 seller to 3 is huge. The improvement you get from going from 3 sellers to 9 million is negligible. So when we sum the benefits of pool widening and the benefits of competition, it makes perfect sense for health insurance to have not too many insurers, but more than one.

And the obvious way to provide such controls, is to give the general public a vote, when deciding who is to be in charge of the monopoly.

Hmm, yes, that works so well at keeping elected representatives honest.

If there's only one seller, the buying public will have very little idea whether the person in charge of the monopoly is running it efficiently, because they have nothing to compare its costs to.

Such elected "monopolies managers" are these days typically known as "governments".

And my government allows its subjects a bandwidth of half a bit per year for us to tell it how we want to be governed. Your government allows about a third of a bit per year. Do you have reason think the public will choose to devote that fraction of a bit to explaining what's wrong with the single-payer health service?

 

[Bomb#20]

the private model delivers better care to those it serves than the public models.

That's lovely. How do those it doesn't serve feel about the standard of care they don't get?

Someone said it isn't a moral issue. But of course it's a moral issue.

In case you're talking about me, I didn't say whether to deliver care to those the private model doesn't serve isn't a moral issue; I said moral philosophy is a lousy way to figure out what's the best way to do it.

Whether to keep the private model around for those it serves and add on an additional mechanism to care for the poor, or to kill off the private model and make all its users switch to the new mechanism, is a question for economists who know something about the unique challenges of health care, not a question for moral philosophers preaching abstract formulas that would apply equally to feeding or curing people. There is no sane reason we should take for granted that "Should we make all doctors government employees?" and "Should we make all farmers government employees?" have to have the same answer. Moral philosophy is all too often just a lame excuse for not doing a cost/benefit analysis.

 

[ZiprHead]

Whether to keep the private model around for those it serves and add on an additional mechanism to care for the poor, or to kill off the private model and make all its users switch to the new mechanism, is a question for economists who know something about the unique challenges of health care, not a question for moral philosophers preaching abstract formulas that would apply equally to feeding or curing people.

Morality should be included in all economic discussions. By pure economic standards, we would just kill all prisoners who get a life sentence. Incurable disease? Kill the patient. Disabled child requiring lifetime care? Kill the child. Slavery? Sure!

Moral philosophy is all too often just a lame excuse for not doing a cost/benefit analysis.

How do you determine benefit without morality?

 

[bigfield]

I don't get it; Many here seem to love the insurance companies more than their countrymen (and -women)?

I don't see anyone who feels that way.

It's just we don't trust the conflict of interest inherent to UHC. Keep the regulators separate from what they regulate!

"I don't trust the government to operate anything that they also regulate".

 

[T.G.G. Moogly]

In case you're talking about me, I didn't say whether to deliver care to those the private model doesn't serve isn't a moral issue; I said moral philosophy is a lousy way to figure out what's the best way to do it.

Are you saying there is a difference between moral philosophy and determining moral issues? And no, I wasn't referring to anyone in particular, just remembering the point being made.

Certainly UHC can be delivered by different means. I am all for persons who desire some higher level of care to use the free market to do so. I do not like the present arrangement where I cannot buy catastrophic insurance and instead have to buy a plan that includes coverage for a stubbed toe or getting a cold and all manor of minor things that insurance was never intended to cover. I think that's wrong and likely just a sellout to special interests. That's what makes it so expensive. If our home and auto "insurance" worked similarly it would make them unaffordable as well, even if every John and Jane Doe were contributing.

U.S. Health "insurance" is purposely made to be extremely complicated. The amount of money that goes into things other than providing coverage is criminal, even with the ACA 80% rule. That should be 99.99%.

 

[laughing dog]

the private model delivers better care to those it serves than the public models.

That's lovely. How do those it doesn't serve feel about the standard of care they don't get?

Someone said it isn't a moral issue. But of course it's a moral issue.

In case you're talking about me, I didn't say whether to deliver care to those the private model doesn't serve isn't a moral issue; I said moral philosophy is a lousy way to figure out what's the best way to do it.

Whether to keep the private model around for those it serves and add on an additional mechanism to care for the poor, or to kill off the private model and make all its users switch to the new mechanism, is a question for economists who know something about the unique challenges of health care, not a question for moral philosophers preaching abstract formulas that would apply equally to feeding or curing people. There is no sane reason we should take for granted that "Should we make all doctors government employees?" and "Should we make all farmers government employees?" have to have the same answer. Moral philosophy is all too often just a lame excuse for not doing a cost/benefit analysis.

Cost/benefit analysis helps to illustrate the tradeoffs inherent in any decision, along with quantifying the costs and benefits. But it cannot ultimately answer a question about social policy unless it is combined with moral judgments.

For example, suppose some CBA on switching to a UHC saves 1000 lives per year at a cost of net cost ( excluding an explicit value on a life) of $ 6 billion per year. Depending on the value of a life, the CBA could be positive or negative. That’s where values and morals come to play.

 

[Bomb#20]

Whether to keep the private model around for those it serves and add on an additional mechanism to care for the poor, or to kill off the private model and make all its users switch to the new mechanism, is a question for economists who know something about the unique challenges of health care, not a question for moral philosophers preaching abstract formulas that would apply equally to feeding or curing people.

Morality should be included in all economic discussions. By pure economic standards, we would just kill all prisoners who get a life sentence. Incurable disease? Kill the patient. Disabled child requiring lifetime care? Kill the child. Slavery? Sure!

Show your work. You appear to have made those inferences by neglecting the interests of the prisoners, patient, disabled child, and slaves. Calculating the benefit to your ingroup and disregarding the cost to your outgroup does not qualify as "pure economic standards".

I watched it. It was heavy on the asserting and light on the debunking.

Moral philosophy is all too often just a lame excuse for not doing a cost/benefit analysis.

How do you determine benefit without morality?

It's not clear any moral judgment is involved in calculating that the harm to the slave exceeds the benefit to the master. One need only observe that slaves frequently risked their lives trying to escape, while masters rarely risked their lives trying to retrieve them.

 

[Bomb#20]

In case you're talking about me, I didn't say whether to deliver care to those the private model doesn't serve isn't a moral issue; I said moral philosophy is a lousy way to figure out what's the best way to do it.

Are you saying there is a difference between moral philosophy and determining moral issues?

Yes -- it's much like the difference between science and philosophy of science. Copernicus didn't need to know or care about parsimony and falsifiability to figure out the earth going around the sun was a better explanation for the planets backing up in the sky than Ptolemy's epicycles. We monkeys have been doing moral judgment for about thirty million years, moral philosophy for maybe thirty thousand.

Certainly UHC can be delivered by different means. I am all for persons who desire some higher level of care to use the free market to do so. I do not like the present arrangement where I cannot buy catastrophic insurance and instead have to buy a plan that includes coverage for a stubbed toe or getting a cold and all manor of minor things that insurance was never intended to cover. I think that's wrong and likely just a sellout to special interests. That's what makes it so expensive. If our home and auto "insurance" worked similarly it would make them unaffordable as well, even if every John and Jane Doe were contributing.

U.S. Health "insurance" is purposely made to be extremely complicated. The amount of money that goes into things other than providing coverage is criminal, even with the ACA 80% rule. That should be 99.99%.

I don't think the way our system has evolved was nefarious; it's just been repeatedly pushed and tweaked and duct-taped in an endless effort to fix something that was wrong with it, by too many chefs, most of whom didn't know what the consequences of their messing with it would be. Good intentions, meet road to hell.

 

[Bomb#20]

... Whether to keep the private model around for those it serves and add on an additional mechanism to care for the poor, or to kill off the private model and make all its users switch to the new mechanism, is a question for economists who know something about the unique challenges of health care, not a question for moral philosophers preaching abstract formulas that would apply equally to feeding or curing people. ... Moral philosophy is all too often just a lame excuse for not doing a cost/benefit analysis.

Cost/benefit analysis helps to illustrate the tradeoffs inherent in any decision, along with quantifying the costs and benefits. But it cannot ultimately answer a question about social policy unless it is combined with moral judgments.

For example, suppose some CBA on switching to a UHC saves 1000 lives per year at a cost of net cost ( excluding an explicit value on a life) of $ 6 billion per year. Depending on the value of a life, the CBA could be positive or negative. That’s where values and morals come to play.

I don't disagree. IIRC some economist did a calculation, based on observed tradeoffs, that the U.S. government valued a citizen's life at $6,000,000, the Japanese government valued a citizen's life at $60,000, and the Vietnamese government valued a citizen's life at $600. Which way we want our governments to go on that is a moral judgment, not one an economist has special expertise on. But the moral judgment we need is a raw one, a consultation with our intuitive moral senses, not any sort of reasoning from abstract moral premises. Arguments like "Illness is neither an indulgence for which people have to pay nor an offence for which they should be penalized, but a misfortune the cost of which should be shared by the community." tell us jack squat about whether saving a thousand lives is worth six billion dollars.

 

[Elixir]

Well… we have the raw numbers from COVID.
While enduring an estimated one million “excess deaths” we (Trump) ran up a 7 trillion $ debt. So with inflation, the number has to be around $7m/citizen.
If I knew I was worth that much I’d have sold out long ago!

 

[ZiprHead]

Whether to keep the private model around for those it serves and add on an additional mechanism to care for the poor, or to kill off the private model and make all its users switch to the new mechanism, is a question for economists who know something about the unique challenges of health care, not a question for moral philosophers preaching abstract formulas that would apply equally to feeding or curing people.

Morality should be included in all economic discussions. By pure economic standards, we would just kill all prisoners who get a life sentence. Incurable disease? Kill the patient. Disabled child requiring lifetime care? Kill the child. Slavery? Sure!

Show your work. You appear to have made those inferences by neglecting the interests of the prisoners, patient, disabled child, and slaves. Calculating the benefit to your ingroup and disregarding the cost to your outgroup does not qualify as "pure economic standards".

Why not

I watched it. It was heavy on the asserting and light on the debunking.

Moral philosophy is all too often just a lame excuse for not doing a cost/benefit analysis.

How do you determine benefit without morality?

It's not clear any moral judgment is involved in calculating that the harm to the slave exceeds the benefit to the master. One need only observe that slaves frequently risked their lives trying to escape, while masters rarely risked their lives trying to retrieve them.

Morality involves asking why the slave tries to escape and why the master deserves to keep the slave.

 

[Bomb#20]

Whether to keep the private model around for those it serves and add on an additional mechanism to care for the poor, or to kill off the private model and make all its users switch to the new mechanism, is a question for economists who know something about the unique challenges of health care, not a question for moral philosophers preaching abstract formulas that would apply equally to feeding or curing people.

Morality should be included in all economic discussions. By pure economic standards, we would just kill all prisoners who get a life sentence. Incurable disease? Kill the patient. Disabled child requiring lifetime care? Kill the child. Slavery? Sure!

Show your work. You appear to have made those inferences by neglecting the interests of the prisoners, patient, disabled child, and slaves. Calculating the benefit to your ingroup and disregarding the cost to your outgroup does not qualify as "pure economic standards".

Why not

I can't even.

What principle of economics do you know of that says "These people matter; those people don't."?

How do you determine benefit without morality?

It's not clear any moral judgment is involved in calculating that the harm to the slave exceeds the benefit to the master. One need only observe that slaves frequently risked their lives trying to escape, while masters rarely risked their lives trying to retrieve them.

Morality involves asking why the slave tries to escape and why the master deserves to keep the slave.

Certainly. I wasn't raising any objection to using morality, just answering your question about how it's possible not to.

 

[Spacetime Inhabitant]

... Whether to keep the private model around for those it serves and add on an additional mechanism to care for the poor, or to kill off the private model and make all its users switch to the new mechanism, is a question for economists who know something about the unique challenges of health care, not a question for moral philosophers preaching abstract formulas that would apply equally to feeding or curing people. ... Moral philosophy is all too often just a lame excuse for not doing a cost/benefit analysis.

Cost/benefit analysis helps to illustrate the tradeoffs inherent in any decision, along with quantifying the costs and benefits. But it cannot ultimately answer a question about social policy unless it is combined with moral judgments.

For example, suppose some CBA on switching to a UHC saves 1000 lives per year at a cost of net cost ( excluding an explicit value on a life) of $ 6 billion per year. Depending on the value of a life, the CBA could be positive or negative. That’s where values and morals come to play.

I don't disagree. IIRC some economist did a calculation, based on observed tradeoffs, that the U.S. government valued a citizen's life at $6,000,000, the Japanese government valued a citizen's life at $60,000, and the Vietnamese government valued a citizen's life at $600. Which way we want our governments to go on that is a moral judgment, not one an economist has special expertise on. But the moral judgment we need is a raw one, a consultation with our intuitive moral senses, not any sort of reasoning from abstract moral premises. Arguments like "Illness is neither an indulgence for which people have to pay nor an offence for which they should be penalized, but a misfortune the cost of which should be shared by the community." tell us jack squat about whether saving a thousand lives is worth six billion dollars.

Yet in practice the US government (the Republican controlled House of Representatives, and many US states) treats American lives like they are worth 60 cents. Also, what is with all the 6s in these evaluations? If some other economists (say Asian ones) did a similar evaluation I suggest that the results would be quite different. For one thing the Asians would take into account how society has a responsibility to its citizens, so give people a high social worth, whereas American "individualism" and exceptionalism (which is ingrained in many American mentalities, and reflected in their world view) would only see how its citizens are of value to the corporate state, as economic units.

 

[ZiprHead]

Whether to keep the private model around for those it serves and add on an additional mechanism to care for the poor, or to kill off the private model and make all its users switch to the new mechanism, is a question for economists who know something about the unique challenges of health care, not a question for moral philosophers preaching abstract formulas that would apply equally to feeding or curing people.

Morality should be included in all economic discussions. By pure economic standards, we would just kill all prisoners who get a life sentence. Incurable disease? Kill the patient. Disabled child requiring lifetime care? Kill the child. Slavery? Sure!

Show your work. You appear to have made those inferences by neglecting the interests of the prisoners, patient, disabled child, and slaves. Calculating the benefit to your ingroup and disregarding the cost to your outgroup does not qualify as "pure economic standards".

Why not

I can't even.

What principle of economics do you know of that says "These people matter; those people don't."?

That's easy. The one that doesn't include morality.

How do you determine benefit without morality?

It's not clear any moral judgment is involved in calculating that the harm to the slave exceeds the benefit to the master. One need only observe that slaves frequently risked their lives trying to escape, while masters rarely risked their lives trying to retrieve them.

Morality involves asking why the slave tries to escape and why the master deserves to keep the slave.

Certainly. I wasn't raising any objection to using morality, just answering your question about how it's possible not to.

Your original point was that morality should not be included in the cost/benefit analysis. Are you backing away from that now? Because it sure looks like you are.