Monday, January 31, 2011

Open Health Care Thread

This post is to transport a conversation that was happening over on facebook. I'll post the immediate comment and then my response to it, and then we'll go from there. This post is really about asking questions of those who oppose the recent health care law and/or government health care in general.

The basic question: what do you propose instead to solve the problems of health care and provide coverage for the 15% of Americans who don't have it?

Here's the previous comment:

Where do you get your 15% of uninsured number? I would like to verify that stat as there are many numbers flying around out there. You want ideas, here are few that pop to mind. I may adjust them as I think about and research them a bit more.

Secondly, I agree with Durham that opening state lines would increase competition. Just look what Geico has done to the auto insurance. Right now there are 3-4 insurance groups in MN that we can choose from. Next, I would make insurance portable. Meaning that I should be able to purchase a plan and move it with my family, no matter who my employer is. We could also group "like" families together in coops to purchase group plans, Those that want GOlD plans with small deducts could be in a group, those that can only afford high deduct/hsa would be grouped together. Those that are in poverty, could be grouped in another group to buy discounted basic coverage insurance.

I am not a huge fan of the way MN has it MN Care, but it is an option for those out there who cannot get/afford other insurance.

I would also like to see a menu at the Dr. office. When I have to decide on care, I would like to know what it is going to cost me/insurance. Under either system, the patient rarely knows the cost of procedures until the bill arrives.

TORT reform could go a long way to curb expenses. Dr. would be able to buy insurance for less, therefore charge less for services and still make money. The medical field is not a cure all, it is a practice that does the best it can to help people stay/get healthy.

You stated that there are only 2 options: Either we provide MORE care to the uninsured, so that they can get cheaper preventative care and treat things before they become emergencies. You're on the record as being opposed to this. Are you still? Or we deny people care. And that means, quite literally, letting them die. This is not true. This is where charity, churches, and non-profits come into play.

Again, it boils down to choices. The choices we make have an impact on our lives. I like the choices I have under the current system. I do not think the "change" coming is going to benefit the majority of the people."
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Here's my response:

The 15% number comes from all over. For example, http://www.gallup.com/poll/121820/one-six-adults-without-health-insurance.aspx. It's actually higher than 15%.

How would opening state lines lead to competition? In reality. I understand it in theory. But in reality there are some issues. I asked Durham a bunch of questions in response to this claim about eliminating state lines. Here they are: I'm curious about this assertion. What do you have to back it up? What is preventing a company from selling insurance now that would be different if it were sold across state lines? What would a "low cost" plan look like? Are there some out there now? Aren't there essentially national companies now that operate in most states just under slightly different corporate forms, in order to comply with the different laws of each state? Wouldn't eliminating state lines just allow them to merge and then we'd only have a few super huge insurance companies that could prevent all competition?

Plus, health care insurance is so expensive to finance that it is almost impossible to start up a health insurance company. You need hundreds of million of dollars in reserves. And if you're going to operate on a national level you'd need significantly more. Even if you had national competition you'd be looking at nearly 0 new entries into the market. That means what we've got now is what we'd have then, right? So how does that make it better? Except that it gives the insurance companies that already exist more power and ability to control doctors and keep out competitors.


I would make insurance portable. Meaning that I should be able to purchase a plan and move it with my family, no matter who my employer is.

I completely agree with separating insurance from employers. But how do you propose to do this? The reason it isn't happening now has more to do with cost (no one can afford insurance on their own, they need their employer's help) and with insurance companies not wanting to insure people who are individually purchasing, except at high rates and low coverage. In fact, right now there's a federal law that allows you to keep your coverage if you pay for it, but that law only runs for a short time after you lose employment. So I'm curious about how you would suggest we bring about this change?

We could also group "like" families together in coops to purchase group plans.

Um, have you read about how individuals can join coops to purchase insurance under the new health care law? You know why that doesn't exist now? Because insurance companies won't allow it, since it gives consumers more power. Insurance companies like selling to individuals because then they can offer bare bones coverage at high prices, since the consumer has little buying power. Employer plans are much better than individual plans for just this reason; employers come with a nice little pre-set risk pool and more money, making it worth it for the insurance company to offer better deals. You need some way to organize a coop and direct that money, and that's one of the big things this new plan does. How would you do it differently?

Those that are in poverty, could be grouped in another group to buy discounted basic coverage insurance.

When you say "discounted basic insurance" what do you mean? Who would give them a discount? Especially considering the poor generally have worse health and cost a health insurance company more money in payouts. Who would pay for these plans? I'm curious about what you envision here.

I would also like to see a menu at the Dr. office. When I have to decide on care, I would like to know what it is going to cost me/insurance. Under either system, the patient rarely knows the cost of procedures until the bill arrives.
Again, not a bad idea. But if you have a menu at the doctor's office that shows the standard charge, how will you know what discount your insurance company is getting? How will you know your copay? Will a menu really help you know ahead of time what your bill will be? And maybe more important, will it change what services you get? "Well, I need a bypass, but that's too much, so instead I'll just get some stitches..." ? A menu makes some sense, but since we aren't operating in a cash-for-services environment, it might be a little pointless, right?
TORT reform could go a long way to curb expenses. Dr. would be able to buy insurance for less, therefore charge less for services and still make money.

I really like some tort reform ideas. I think the best one is the idea of expert courts, where a judge trained in medical issues handles the trial, instead of an uneducated lay jury who can frequently just feel sympathetic for a victim of doctor mistakes, even if the doctor did everything they should have. I also think error reduction should be focused in other areas, besides using lawsuits to keep doctors in check. So yeah, tort reform has some merit. But we're talking about something that costs about 3.6 billion a year in a 2.3 trillion dollar industry. That's like 1.5%. If we got rid of all medical malpractice suits we'd still save only 1.5%. If you're paying $15,000 a year for insurance that'll save you just $225. Now that's nothing to sneeze at, sure. And I'm all for it. But it's not a solution (and remember, my example is if we make doctors 100% immune to all malpractice suits). Especially since malpractice payouts aren't increasing like health care costs are.
This is where charity, churches, and non-profits come into play.
Well, I've talked about this before. But I'm curious. Where do you think this money will come from? Total U.S. charitable giving reached a record high in 2007 at $314 billion. Total health care expenses per person in the U.S. were $7,290 in 2007. (That was the most reliable data I could find. It was at $6700 in 2006 according to the WHO. They've gone up since.) We'll round total U.S. population down to 300 million. If just 15% of the population is uninsured, then that's 45,000,000. If those 45 million each spend the 2007 per capita amount on health care (and mind you the poor are generally less healthy and spend more on health care) then that would mean they cost 328,050,000,000.
Or about 15 billion more per year than all charities combined raised in their best year ever.

That's just the reality. That's what the uninsured cost. So I reassert: you have two options. You can either give them better coverage through the government so that they can get cheaper preventative treatments or you can tell them tough luck and let them die. Which do you prefer?

Thursday, January 27, 2011

Government As Other

A bit of a rant here... Over the past few years there seems to be a pervasive and growing concept of government as "the other". I've had people describe government as a bunch of fat-cats sitting in back rooms smoking cigars.

Where does this image come from? It's clearly not accurate. If it were, Representative Giffords would never have been in the line of fire. Instead she was out meeting voters and getting ideas from them.

So what causes this concept of government-as-other? I mean, we're a government "of the people." My representative is a former high school teacher. There are a ton of similar representatives. I'm curious what possible facts this idea can even be founded on. I know a large number of people who are government employees. They work as teachers, as EPA staffers creating nation-wide initiatives to recycle electronics, as attorneys taking on abusive and dangerous employers, as welfare workers who help the neediest members of society and are constantly trying to fight waste (the other day I almost wasn't able to get a copy of a file because it cost the government $.30. Please don't tell me about run-away spending in welfare.). These are all people who are devoted public servants. None of them are perfect, I'm sure. But they're all doing very good and important work.

More important, they're all people. Just like everyone else. There is no "government-as-other." The government is us. What it does is what we tell it to do. We don't need rhetoric railing against government. That's the same as railing against people. That is what the tea party and small government advocates are doing. They're presenting an image of the world that says "government is this big bad entity that's wasting all of our money," never paying attention to the fact that they, their family members, roughly 20 million Americans employed in government and 300 million of their neighbors are "the government."

The rhetoric upsets me. It doesn't upset me because it's loud and filled with vitriol. It upsets me because it's founded on an absurdist reality. We can discuss government waste and excess spending. We can discuss whether entitlements have gone too far or what tax policy will lead to more jobs. We can discuss military expenditures and congressional budgets and anything else under the sun. But we can only discuss it when we're operating in reality.

And in reality, we are the government.

Where do we go
Where do we go now?