[kenberg]

Art, I am not sure if you had me in mind with "those who believe in personal choice". Certainly I understand that there is often an emergency to be handled. We do the best we can in such situations. But there are other times, including life threatening situations, when choices can be made.

As we go through a re-design of the delivery of healthcare, preservation of choice will be important to me. I think it will be important to many. Which means that those who want public support for the re-design should take this into account.

[kenberg]

HighLow21, on 2013-November-18, 12:19, said:

Definitely not rich, at least by the standards of where a higher income tax rate would start applying if I were drawing the tax map (or if Obama were). But yes I own a cell phone and an adorable little 2013 MINI Convertible and I recognize how wealthy that makes me.

I've always said that if you have cable you're rich. You can afford to junk $100+ per month on home entertainment.

We have cable. I can not really explain why. We keep asking ourselves that. Lazy, I guess.

[Cyberyeti]

HighLow21, on 2013-November-18, 12:19, said:

Definitely not rich, at least by the standards of where a higher income tax rate would start applying if I were drawing the tax map (or if Obama were). But yes I own a cell phone and an adorable little 2013 MINI Convertible and I recognize how wealthy that makes me.

I've always said that if you have cable you're rich. You can afford to junk $100+ per month on home entertainment.

It depends what you would be spending otherwise, I have friends who "can't justify cable" then go down the pub every Saturday to have a few beers and watch the football. They probably spend nearly as much as the cable sub just doing that when you figure they'd need phone and broadband anyway which is packaged in with the cable.

[kenberg]

I have been thinking more about medical insurance. I think I favor pregnancy coverage for men. Maybe not exactly that, but consider Angelina Jolie.

The point is this. With many things we have become very good at finding out a great deal. Ms. Jolie had her genes checked and found that she was a high risk for cancer. She acted on this in a way to protect her life, an insurance company might act on the same information to protect their profits. Taken to extremes, an unregulated insurance industry could, and in time would, tailor every policy to every person's genes. Briefly, but not too inaccurately, life is a pre-existing condition and we should insure people even if they have this condition.

When I first bought a car in 1954 I paid exactly the same amount for my auto insurance as my father paid for his. Later insurance companies sorted on age and gender. And then, I think, they sorted on academic grades. At any rate, insurance companies want to sort us all out. At some point, and we may well have reached it, this sorting goes against the very concept of pooled risk.

My thinking on many issues has started to run along lines of us having become to good at things. Electronic surveillance has become too good. Genetic testing has become too good. Now electronic surveillance uncovers terrorist plots and genetic testing can save lives so we are not going to stop doing it. But there are side effects to all of this technological talent and we have to deal with them. I think we need to prevent insurance companies from slicing and dicing too much. If this means guys have to insure against pregnancy, so be it.

[awm]

kenberg, on 2013-November-18, 16:45, said:

We have cable. I can not really explain why. We keep asking ourselves that. Lazy, I guess.

In a fit of extreme frustration with Comcast, I canceled our cable service after moving to our new condo. We got Apple TV instead, and subscribed to Hulu and Netflix. This combination saves us about $80/month. Of course it is occasionally annoying that we cannot watch the news or the latest cable shows, but the cost savings are significant and the aggravation savings are priceless.

[hrothgar]

awm, on 2013-November-18, 20:02, said:

In a fit of extreme frustration with Comcast, I canceled our cable service after moving to our new condo. We got Apple TV instead, and subscribed to Hulu and Netflix. This combination saves us about $80/month. Of course it is occasionally annoying that we cannot watch the news or the latest cable shows, but the cost savings are significant and the aggravation savings are priceless.

Same here. No regrets about cord cutting.

(Though I also purchased a digital antenna which comes in handy now and then)

[helene_t]

kenberg, on 2013-November-18, 17:33, said:

At some point, and we may well have reached it, this sorting goes against the very concept of pooled risk.

As long as you don't know your genetics, you have a certain risk of having the disease gene, and it makes sense to take insurance to hedge that.

As soon as you know your genes, it doesn't make sense any more. There is a still a certain risk, given your genetic profile, which you can hedge against. But you can't hedge against the disease gene itself.

In a socialised system (Sweden) the distinction is irrelevant. The government takes all risks upon itself, it doesn't matter whether they are the same for everybody (because we don't screen for disease genes) or whether some people have higher risks than others.

But in a system with for-profit insurance companies, the people with known disease genes just have bad luck. Unless they took insurance before they got screened.

In particular, you would have to take out pregnancy insurance before your gender becomes known. And you would have to take out insurance against inheritable diseases before your parents (and grand-grand-grand parents) becomes known to carry the disease gene.

[kenberg]

helene_t, on 2013-November-19, 05:20, said:

In a socialised system (Sweden) the distinction is irrelevant. The government takes all risks upon itself, it doesn't matter whether they are the same for everybody (because we don't screen for disease genes) or whether some people have higher risks than others.

But in a system with for-profit insurance companies, the people with known disease genes just have bad luck. Unless they took insurance before they got screened.

So: can we, and should we, prevent insurance companies from sorting on the basis of genetic information. It has been observed, no doubt correctly, that the U.S. will not be adopting the Swedish approach. Good news or bad news, we won't be doing it. But it's at least my opinion that we are not all a bunch of Ayn Rand enthusiasts either. So it seems that there should be support for simply forbidding insurance companies to sort on genetic information. How broadly this should be drawn is open to debate. Suppose we said "Can't sort on race, can't sort on gender, can't sort on indications of proclivity to diseases such as cancer or Alzheimer's". It seems possible to insist on such behavior. In fact, I gather that this is part of the ACA, and I was saying that to the extent that it is, this seems right.

I really do see this as part of a much larger problem of effectively coping with our vastly developed technology. When I was a child my mother often had only the vaguest idea of where I was. My grandchildren have cellphones, quite possibly equipped with gps. There are pluses, but there are also minuses. Most of us value a little isolation, at least I do. Anyway, we can now locate people, we can call them day or night wherever they are, we can (or at least the NSA can) eavesdrop on their conversations, we can track down all sorts of stuff. Maybe it's too much. We are not prepared to give up the pluses, but we might want to deal with the minuses.

[Winstonm]

There was a time not all that long ago when insurance was indemnity - we could pick any doctor we wanted, who then made the decision regarding our treatment plan, and the insurance company picked up the bill. This was changed by Richard Nixon, who introduced us all to managed care via HMOs - in an effort to retain the "for profit" aspects of American healthcare. As resistance grew to this type of plan, PPOs were advanced as a solution, but the expanded plans were more costly and hurt the bottom line of the businesses who offered them to employees as well as of the insurance companies who had to pay the claims, so those companies began to reduce risk by raising co-payments, and when that wasn't enough they began eliminating certain plans and offering plans with higher and then higher and then higher still deductibles.

In many respects, the plans became more of a self-insure/disaster-only type where the insurance company took the massive risk of catastrophe while day-to-day healthcare was left to individuals.

There is nothing particularly wrong with that idea if you are in the upper middle class - perhaps 20% of all citizens. But it is a crushing burden for the 80% who cannot afford to self-insure even the smaller stuff.

The ACA is an attempt to address some of those problems. I am hopeful that the implementation will succeed and the law is given a chance to work. To continue to leave the nation's healthcare in the hands of a few profit-driven insurance executives who only feign free choice should be unacceptable to a great nation, or even a so-so nation.

[Trinidad]

kenberg, on 2013-November-19, 09:07, said:

So: can we, and should we, prevent insurance companies from sorting on the basis of genetic information. It has been observed, no doubt correctly, that the U.S. will not be adopting the Swedish approach. Good news or bad news, we won't be doing it. But it's at least my opinion that we are not all a bunch of Ayn Rand enthusiasts either. So it seems that there should be support for simply forbidding insurance companies to sort on genetic information. How broadly this should be drawn is open to debate. Suppose we said "Can't sort on race, can't sort on gender, can't sort on indications of proclivity to diseases such as cancer or Alzheimer's". It seems possible to insist on such behavior. In fact, I gather that this is part of the ACA, and I was saying that to the extent that it is, this seems right.

There are two fundamental reasons for insurance. The idea behind an insurance is that we all together carry the risks that we can't afford to carry as individuals, making them affordable again.

That means:

• If I fall victim to the risk, I will be taken care off (security).
  
• If someone else falls victim to the risk, he will be taken care off (solidarity).

To me, these are inseparable in an insurance. In the USA, these are separated. The American society knows very little organized large scale solidarity and the emphasis is on the security part: An insurance is basically "a gamble that something bad will happen to you". And to gamble properly, you need to know the odds. What is the probability that something bad will happen to me? And what will it cost me? Obviously, odds vary from individual to individual. The "slicing and dicing" is there to accommodate "gamblers" with different probabilities and costs.

I think that solidarity is important. At a minimum everything that people cannot influence themselves (e.g. their genes) should not be "sliced or diced". On top of that, I am fairly convinced that we tend to think that there is much more free will than there really is. That -to me- means that even those things that many think we can influence (education, lifestyle) should not be sliced and diced.

But, of course, this is a moral question. The above is my opinion but if someone says that insurances should ignore the solidarity aspect and go for infinitesimal slicing and dicing then I can't prove him wrong based on facts.

So, a political decision needs to be made to answer the moral question: Do we only want health insurance for individual security or do we also want it for the solidarity?

You can't answer this question if you are not aware of these two aspects of insurance.

Rik

[kenberg]

There is an upcoming mathematics talk for the general public. I have enough sense not to bother people with this ordinarily, but I thought that some of you might find the abstract , especially the last lines, amusing:

Quote

Public opinion polls routinely show that large majorities of Americans support cutting spending and oppose raising taxes. But when lists of government programs are presented one by one, cuts in each program face majority opposition. What's going on here? A typical account is that Americans are irrational thinkers who want a free lunch, with low taxes and big government programs for all. The truth is more complicated. In fact, trying to put together the opinions of a heterogeneous population can lead to paradoxical results, even when the individuals involved are perfectly rational. The math that explains the puzzling polling on the budget--first discovered by Condorcet in the midst of the French Revolution, and culminating in the Nobel-winning work of Kenneth Arrow--also explains the vexingness of the Bush-Gore-Nader clash in Florida in 2000, and the apparently irrational decisions made by slime molds, primitive brainless creatures who biologists believe to be similar in certain respects to electorates.

More info at http://www.maa.org/m...-public-opinion

[blackshoe]

ArtK78, on 2013-November-18, 15:22, said:

When you need them, YOU NEED THEM, and there is no time to exercise personal choice in the choice of physicians or hospitals.

And this is why we expect that physicians and hospitals will charge reasonably for their services. Six million bucks for about six weeks in the hospital? A million bucks a week. No. Something is wrong with this picture. Obama proposes to "fix it" by socializing medicine. Is that the best answer? I don't know. I doubt it, but I don't know. Why don't I know? Because I don't know how we got where we are. More to the point, I'm not entirely sure where we are. I don't think we can talk about solutions until we've clearly identified the problem. It seems that hospitals (and HMOs?) grossly overcharge for their services, and the man in the street must hope that his insurance company can keep his actual costs to a reasonable level. It seems also that, so far at least, insurance companies have mostly been able to do this. But some people don't have or can't afford insurance. For them, it's a case of "if the stay in the hospital doesn't kill you, the sticker shock will". Something Must Be Done. Fair enough. But we got where we are somehow, and I doubt it "just happened". Somewhere in the past, we went down the wrong path. Where was that, what exactly did we do wrong? That is what we need to fix. The fact that some people can't afford insurance is not the problem, it's just a symptom.

[Cthulhu D]

blackshoe, on 2013-November-19, 16:51, said:

And this is why we expect that physicians and hospitals will charge reasonably for their services. Six million bucks for about six weeks in the hospital? A million bucks a week. No. Something is wrong with this picture. Obama proposes to "fix it" by socializing medicine. Is that the best answer? I don't know. I doubt it, but I don't know. Why don't I know? Because I don't know how we got where we are. More to the point, I'm not entirely sure where we are. I don't think we can talk about solutions until we've clearly identified the problem. It seems that hospitals (and HMOs?) grossly overcharge for their services, and the man in the street must hope that his insurance company can keep his actual costs to a reasonable level. It seems also that, so far at least, insurance companies have mostly been able to do this. But some people don't have or can't afford insurance. For them, it's a case of "if the stay in the hospital doesn't kill you, the sticker shock will". Something Must Be Done. Fair enough. But we got where we are somehow, and I doubt it "just happened". Somewhere in the past, we went down the wrong path. Where was that, what exactly did we do wrong? That is what we need to fix. The fact that some people can't afford insurance is not the problem, it's just a symptom.

The insurance company that gets the best rates for hospital care is Medicare. Not for drugs though because you ban Medicare from negotiating with the drug companies. A simple fix would be to give everyone access to Medicare's negotiated prices for all services, and let them negotiate with drug companies. Also legalise parallel imports from Canada and the like. Also, change your patent and copyright protection laws.

As for what happened, well it's obvious. Everyone else went down various degrees of a national insurance / single pay scheme, and you didn't. The specific issue is that you have misaligned incentives. The insurance companies are rewarded for denying your coverage. This is literally the most profitable move for them to make at any point in time. It is also the opposite of what you want as the customer. The only way to fix this is by having the insurance companies incentives aligned to yours. There is a similar incentives misalignment in the US about primary care and acute care. In the US the hospitals are finacially rewarded if you come to hospital and need expensive treatment for something easily preventable in primary care. (There are probably similar incentives to overtreat in primary care, but getting people to show up to primary care is hard enough). But for you the customer, going to hospital is a bad outcome. Incentives are misaligned again.

You could do this in lots of ways, and I invite you to think of some. The reason public sector insurance works better is there is no profit motive for the government to screw you out of coverage, and they can capture more of the positive externalities created by keeping you alive. Incentives are better aligned. Similar where the government is responsible for both primary and acute care, they want to get you out of acute care and into primary care - which is also your desired outcome.

[WellSpyder]

Cthulhu D, on 2013-November-20, 06:39, said:

The specific issue is that you have misaligned incentives. The insurance companies are rewarded for denying your coverage. This is literally the most profitable move for them to make at any point in time. It is also the opposite of what you want as the customer. The only way to fix this is by having the insurance companies incentives aligned to yours.

Doesn't the same issue apply to any insurance in any country? But we have relatively free markets for house insurance, for instance. Or for car insurance, subject to a requirement (in the UK at least) that all drivers buy insurance meeting certain minimum levels.

[Winstonm]

blackshoe, on 2013-November-19, 16:51, said:

And this is why we expect that physicians and hospitals will charge reasonably for their services. Six million bucks for about six weeks in the hospital? A million bucks a week. No. Something is wrong with this picture. Obama proposes to "fix it" by socializing medicine. Is that the best answer? I don't know. I doubt it, but I don't know. Why don't I know? Because I don't know how we got where we are. More to the point, I'm not entirely sure where we are. I don't think we can talk about solutions until we've clearly identified the problem. It seems that hospitals (and HMOs?) grossly overcharge for their services, and the man in the street must hope that his insurance company can keep his actual costs to a reasonable level. It seems also that, so far at least, insurance companies have mostly been able to do this. But some people don't have or can't afford insurance. For them, it's a case of "if the stay in the hospital doesn't kill you, the sticker shock will". Something Must Be Done. Fair enough. But we got where we are somehow, and I doubt it "just happened". Somewhere in the past, we went down the wrong path. Where was that, what exactly did we do wrong? That is what we need to fix. The fact that some people can't afford insurance is not the problem, it's just a symptom.

I can't believe you think Obama suggested socialized medicine. Still, I think you hit on some important points. One thing I can assure you of is the administrative costs of medicine in the US is outrageous compared to other industrialized nations that provide some form of national healthcare. Of every dollar spent in the U.S. on healthcare, about 30% goes to "cost of doing business", which has nothing directly to do with promoting health care for anyone.

[Winstonm]

Here are some facts to back my previous claim.

Quote

After exclusions, health administration accounted for 31.0 percent of U.S. health expenditures vs. 16.7 percent of Canadian.

Quote

But we got where we are somehow, and I doubt it "just happened". Somewhere in the past, we went down the wrong path. Where was that, what exactly did we do wrong? That is what we need to fix.

I have an idea on what has happened. With cost of administration of the various insurances, hospitals and other health providers have raised prices to defray those costs - which led to higher charges for insurance, which meant insurance companies altered the plans they offered, which meant more cost to the hospitals and healthcare providers to keep up with the changes, requiring additional staff or retraining staff and those costs were included in higher costs for care, etc., etc.

All the while there has been no transparency in charges so it was impossible for consumers to compare prices and, for most, nearly impossible to use a less costly provider - even if one were known - due to restrictions of their insurance policy or distance from a lower-cost facility/doctor.

I think Lincoln said it best: "A house divided cannot stand." So, too, a healthcare house.

[helene_t]

Quote

After exclusions, health administration accounted for 31.0 percent of U.S. health expenditures vs. 16.7 percent of Canadian.

Eurostat claims administrative costs vary between 1.1% and 7% in EU member countries, and that it is 7% in the USA. But the Danish counties claim a much higher figure for Denmark, namely 4.3%. Presumably there are many different ways to calculate those numbers.

[HighLow21]

WellSpyder, on 2013-November-20, 08:44, said:

Doesn't the same issue apply to any insurance in any country? But we have relatively free markets for house insurance, for instance. Or for car insurance, subject to a requirement (in the UK at least) that all drivers buy insurance meeting certain minimum levels.

(1) Housing insurance is different -- your decision to opt out of housing insurance doesn't affect the rates for MY insurance. It's different for car insurance or health insurance.

(2) That's exactly what Obamacare is designed to do -- all citizens must have insurance that meets certain minimum requirements, and Obamacare creates a market for doing so.

What's the problem?

[mike777]

HighLow21, on 2013-November-20, 12:35, said:

(1) Housing insurance is different -- your decision to opt out of housing insurance doesn't affect the rates for MY insurance. It's different for car insurance or health insurance.

(2) That's exactly what Obamacare is designed to do -- all citizens must have insurance that meets certain minimum requirements, and Obamacare creates a market for doing so.

What's the problem?

I agree, creating a market is good news, having some minimum regulations are fine.

I think the argument is it goes further more than that to the point of paying insurance companies if they don't profit but still an excellent point.


Also as many posters point we are told over and over again Canada does health care at half the cost. The main point of free markets over the long run is better health care at lower prices from competition seeking profits. The argument is millions of decisions in the free markets are better at allocating scarce resources than the government. Now of course Winston and many others argue the govt is more efficient and one reason is they don't have a profit motive to worry about if they own the entire industry. But Canada does not own the entire industry and Canada does worry about the profit motive, they deal with for profit companies.


So either the USA does not have free markets or free markets don't work or health care sucks in Canada and no one know it or Canada has free markets that work better than the USA. Let us keep in mind Canada does have some form of free capital markets in health care.

I am having my inlaws flying in this afternnon. They are lawyers who work in the insurance industry over decades and decades. They work on both sides, the corp side and the patient side of the law. I will ask them.

[Winstonm]

mike777, on 2013-November-20, 12:59, said:

I agree, creating a market is good news, having some minimum regulations are fine.

I think the argument is it goes further more than that to the point of paying insurance companies if they don't profit but still an excellent point.


Also as many posters point we are told over and over again Canada does health care at half the cost. The main point of free markets over the long run is better health care at lower prices from competition seeking profits. The argument is millions of decisions in the free markets are better at allocating scarce resources than the government. Now of course Winston and many others argue the govt is more efficient and one reason is they don't have a profit motive to worry about if they own the entire industry. But Canada does not own the entire industry and Canada does worry about the profit motive, they deal with for profit companies.


So either the USA does not have free markets or free markets don't work or health care sucks in Canada and no one know it or Canada has free markets that work better than the USA. Let us keep in mind Canada does have some form of free capital markets in health care.

I am having my inlaws flying in this afternnon. They are lawyers who work in the insurance industry over decades and decades. They work on both sides, the corp side and the patient side of the law. I will ask them.

Mike,

One argument I make is that in the U.S. it is fallacious to suggest that millions of decisions in a free market comes anywhere close to describing the American system of healthcare delivery. Private healthcare insurance policies in the US are primarily chosen by companies and corporations from a small list of providers, and after the choice is made those companies offer to their employees a handful of options from within the chosen provider's services.


This system has nothing to do with the free market ideas of Adam Smith. This is Reaganomics in action.