Don’t Discriminate Against Mutants Like Me
nytimes.com
nytimes.com
Also, because it's Hacker News and a lot of folks here are engaged in start-ups, I wonder why I hear relatively more from tech about basic income than single-payer health. While basic income goes further, single-payer health removes a major burden / friction for creating a start up.
Also, from a labor standpoint, decoupling health benefits from work allows start-ups to play with less-than-full-time employment arrangements. Having more people fractionally employed might be just the safety valve we need until automation job loss is more comprehensively addressed. But I digress.
Private insurance companies and employers (the two places most Americans get their health insurance from) may not want to pay for the higher costs associated with higher risk people like this. Employers would be especially susceptible to this sort of discrimination if proposed legislation allowing employers to demand genetic tests of their employees passes.
https://www.washingtonpost.com/news/to-your-health/wp/2017/0...
Because a single-payer health system (like the NHS) largely prevents this discrimination.
Seriously though, I quoted the reference exactly in my question, since I knew people would be touchy about the subject. Based upon other people's reaction to my question, some people are very touchy about the subject even when addressed elliptically and without pre-formed notions.
Thank you for your answer.
Wage controls during WW2: http://www.npr.org/templates/story/story.php?storyId=1140451...
Without either the individual mandate (which is itself a half-assed approximation to single payer healthcare) or group health insurance (through employers or some other non-health-related cooperative), people put off getting health insurance until they get sick, the risk pool stops being a pool and the whole concept of "insurance" falls apart.
You will find that the jurisprudence surrounding those clauses bears no resemblance whatever to what the clauses actually say. For example, look up Wickard v. Filburn and see if you think that Supreme Court decision used a reasonable interpretation of what Congress can regulate under the guise of "interstate commerce".
Interestingly, though, the clause under which the individual mandate was found constitutional was actually the Taxing Clause--the Supreme Court said it was not constitutional under either the Commerce Clause or the Necessary and Proper Clause, which was how the government had argued the case. In other words, the Supreme Court said that, while it was not constitutional to require everyone to purchase health insurance, it was constitutional to tax people who didn't. Go figure.
The full opinion is here:
Imagine if all roads were turnpikes with tolls. Single payer has the government pay those tolls. But for local roads, we would rather remove the toll booths and allow free and easy access. The same could be true of preventative care, basic access to an NP or similar, well child care, and such.
I never thought of the issue that way but now that I hear it I absolutely agree. I do not plan on having a child... ever so this may sound a little trollish but please bear with me here.
Anyone who is against gender discrimination (or thinks there is no discrimination against women based on gender) should be FOR free of cost and generally available quality child care for all. I think a lot of bias against women in the work force will go away if we don't have a mindset that women will quit the workforce once they have children.
I'm not sure I follow?
If families have access to free of cost quality child care, they are now making a choice based on their preference as opposed to a decision bring made for them by environmental circumstances. This might help decrease perception of hostility.
(this assumes, perhaps incorrectly, that you live in the US)
On our behalf, collectively, with our money. Some people still haven't processed just what "single payer" means.
In food, grocers are (roughly speaking, here) analogous to insurers and food is analogous to care utilization. Grocers want to maximize sales of food at the best price possible: they make more money by moving their product. Insurers want to minimize utilization: they make less money by "moving" their product.
In the case of food, the grocers' and buyers' incentives are aligned: people need food, and grocers want to provide it. In the case of medicine, this isn't the case: people need care, and the access providers don't want to provide it.
It makes sense to me that an insurer would never be a good analogy for a grocery store, but that problem seems specific to the insurance model, rather than to medicine itself. That's more what I meant to ask about. If we imagine that hospitals and patients work like grocery stores and their customers, a few obvious problems come up:
- Healthcare is too complicated for patients to make informed choices. - Emergency medicine is too urgent for patients to have much choice anyway. - Demand for care is unevenly and unfairly distributed, because of conditions people are born with.
So I guess my question is, how much of medicine (in terms of dollars) hits those problems? Cancer treatment seems to hit at least two out of three. But on the other hand, a lot of dentistry seems not to.
Of course you have incentives. Hospital administrators want to cut costs, doctors want to redirect patients to their private offices, suppliers want to increase profits (and will offer kickbacks to doctors and administrators), etc.
If you have humans, you have incentives. Regulation can change some, but not eliminate them.
It makes far more sense than single payer, because it cannot be traded away easily by the recipients during bad decisions, so it is a stronger safety net.
But it is also far cheaper and more efficient than basic income, because buyers don't compete so prices don't go up across the board "patio style".
In an individual-pays system, those with expensive conditions or those who are poorer lose out. In a government-pays system those without political leverage lose out - often still those who are poorer.
The British NHS, for example, has been the target of much ire due to different (and arbitrary-seeming) spending priorities in different parts of the country, often called the "postcode lottery".
However, as your reduce the cost of providing healthcare with single payer systems you increase society's ability to provide high quality healthcare. Remember, if a doctor sees 1000 people a month then you can detect fraud by randomly sampling 20 cases. However, if 10 companies each need to check for fraud they may investigate 10 cases each, but with 10 X 10 that's still more effort. Further, they are each going to try and cost shift to the others, which is an expensive zero sum game.
Or they'll coordinate to avoid the duplication, usually by having some kind of industry society/non-profit that does the checking.
If we care about equal protection of all American citizens -- and I believe that we should -- the solution is not to legally prohibit employers from performing genetic screenings, it's simply to cover healthcare for high-risk individuals, or ideally everyone, at the national level with single-payer care. That way there's no incentive to cheat anti-genetic-discrimination laws, business don't have to worry about getting hit with an unexpected multi-million dollar expense, and the cost of coverage to everyone shows up on the national ledger, where it honestly belongs.
I would find that to be a ridiculous risk for those not actually in the business. The whole idea behind insurance is to spread the risk among lots of people. If a medium-sized business is underwriting their own policy, I would think they would quickly go bankrupt more often than not.
These are far more potent threats to traditional pastoral and agricultural traditions than tax policy. If it was just a bunch of family farms competing against each other (or more likely forming co-ops given history) then it might be a bit more of a fair playing field.
OK, but then why would employers even bother to query the genetics of their employees? So they could STILL discriminate on the basis of genetics (regardless of whether it cost them in medical insurance)?
Classifying those with certain genetic mutations as disabled, could be another solution to this problem. Although it should, in theory render them immune from. discrimination, it's a highly imperfect solution that could lead to a very ugly society.
Id rather just keep that information completely private. Companies have been able to operate just fine without the data provided by genetic tests since time immemorial. Employers are not allowed to ask about whether or not you are. married, have kids, your religion, your ethnicity etc. It might not be fair, but it is a trade-off/tax that I would happily pay to ensure that people, through no fault of their own, experience a new class of systemic, institutional discrimination.
Obviously there are approaches that make sense to be common to running both business and government (that probably apply to most everything else as well because they'd seem like "common sense") but, at a high level, to say "run government like a business" is one of those things that only sounds reasonable (possibly) until you think about it.
One is whether we should accurately assess risk and probable healthcare costs. To which: yes, obviously.
But the other is whether our existing system can do that without ruining people's lives for reasons they can't control. To which: no, probably not.
The article points out that for insurers (or employers who underwrite their own insurance), mandates to cover people mean that dropping/firing someone in a high risk pool makes more sense than pricing accordingly. We already have regular problems with people getting dropped as they claim, we should expect to see people dropped because they will claim too.
Sure, risk pooling makes sense. But in practice we have a strikingly inefficient market that will probably respond to this information in a way that ruins a lot of lives unnecessarily.
This is the price. There will be other prices.
So-called "red state morons" who "vote against their own economic interests" often tout a hazy, poorly thought out rationale of "freedom" as the driving force behind their choices.
There is, however, a decent heuristic at work here. They know that there's no such thing as a free lunch.
Just because they have no idea how they'll be made to pay for it doesn't mean they're wrong.
I'm already paying for health insurance. Its not, nor has it ever been, a free lunch. Diving into my genetics is completely uncalled for. Stop calling health care buyers moochers, thanks.
Also somehow almost all other wealthy western nations do better than us by almost all metrics in healthcare and they don't need to do this either. What's wrong with Americans?
Regular wellness checks, etc., while wonderful, are a free lunch. They are not insurable. You can't insure for regular, scheduled services. Because math.[1]
If you see things like this - things that are either exorbitantly expensive or defy the bounds of underwriting or both you should expect to pay other prices, elsewhere.
[1] This is insurance 101. You cannot insure against regular, universally consumed services. There is no underwriting pool there. You cannot buy an auto policy that includes regular tire replacement - and if you could, the premiums would include 100% of the tires cost (plus admin).
It's not a free lunch. They paid the admission fee with their health.
Regular wellness checkups are also not a free lunch. They're priced into the policies. You absolutely can insure against regularly consumed services, as long as the premium is enough to cover it and to do the underwriting for the unexpected expenses. Look at dental or vision insurance. The vast majority of what they cover are regular wellness visits.
Putting that aside, free wellness visits are also in the interest of the insurer. It's far cheaper to prevent disease or to treat it early than it is to deal with it later. Those savings from this so-called "free lunch" ends up right back in their pockets.
That is called fee for service. Maybe it gets bundled with actual insurance, but it's not insurance. Regular, universal expenses are not underwritable.
Insurance is a technical term that has a strict meaning. You are absolutely correct that regular wellness checkups, etc., can positively affect the outcomes of that insurance pool, but they are not, themselves, insurable. They have to be paid for somewhere.
Therefore, it fits the definition of insurance, even though the likelihood of a claim is relatively high.
You're using the word "paid" in a sense that isn't relevant in context.
"Health insurance" doesn't really work like most insurance anyway, because people. It is of course sensible to construct a system to understand true costs, but sometimes you're just going to pay them, even if the math doesn't work (although honestly, it probably works fine if your model is good enough. An insurance company won't think about the externalities that a federal government has to, for example)
Combined with the USA no longer being a "wealthy western nation" for a variety of reasons revolving around extreme income inequality, massive demographic changes, etc. Europe is no longer a peer. America is demographically no longer a euro nation and the long term trends indicate something vaguely "South African" in our future. A peer to the USA in 2017 or in the future, would be found in South America or Africa. Compared to those real peers, we're doing a great job in medical and educational fields. Yes we suck compared to Germans but "we americans" are not Germans, not anymore, so whats the point of that observation exactly? If our Africans are the best educated and healthiest Africans on the planet, if our South Americans are the best educated and healthiest South Americans on the planet, whats the problem exactly? Even legacy races like whites, USA has some of the best educated white people on the planet. Our averages might be dismal for various human biological differences reasons, but broken out into hyphenated-american groups, all our groups kick butt individually.
With respect to people not understanding the politics, according to the BLS there's only 100M full time employees over 25 years of age of which most but not all have bennies such as health insurance. Google claims the USA population is 319M. Pondering why the winners of a democratic election would screw over employees with bennies is like being surprised at the result of two wolves and a sheep voting on dinner.
Combining this, some of the numbers are insane. Every working person has to pay in their insurance and taxes enough money for roughly three likely incredibly expensive deaths. Very theoretically in some kind of pre-historic Egyptian sense a culture can afford a middle class lifetime income level cost of death/medical care on a 1:1 basis without creating too much of a pyramid inflation scheme. However if a nation intentionally wipes out its middle class like the USA replacing with struggling working class you can't expect each working class lifetime income to fund three middle class financial scale deaths.
The medical system has to match the economic system. Either the medical system has to be collapsed to South American or African levels, or the economic system has to be improved to Euro levels. "F you I've got mine" utterly eliminates any possibility of economic improvement, income inequality will increase permanently no matter what. That means medical care must collapse to, on average, African or South American levels. To insist otherwise is to risk sounding like one of those old people in the 70s who assumed we would never destroy our own industrial base intentionally, so surely the factories will reopen soon. I am curious what the hospital/health care equivalent is of the "rust belt" meme, because health care today is like a labor intensive assembly line factory in the USA in 1970, you may as well start counting the months until the jobs are gone and the buildings are abandoned to urban explorers, there literally is no alternative.
I'm not sure this is necessarily bad. Most lifespan improvement and quality of life improvement over the last centuries in western and formerly western countries came from civil engineers who had their glory stolen by the medical complex. Don't get me wrong, I'm sure it'll be bad, but unless we go "pol pot" on the civil engineers, we're not going back to 1800s era death rates. If we do that, then we're really doomed.
What is an 'existing condition'? In my experience, it is a condition discovered while under a previous, different insurance policy. The policies for most large employers are happy to cover preexisting conditions, in my experience, while individual and small group policies are not.
Which should concern the entrepreneurs out there.