Comment by cwyers | Hacker News Reader

Comment by cwyers | Hacker News Reader

On one hand, having an ombudsman (whatever you want to call it) is a good thing for an institution like the Times.

On the other hand... having Liz Spayd in that role is pointless, so this isn't a loss. The past year has shown us how the New York Times has let false equivalence and the need to sell newspapers to both sides of the aisle has severely damaged the quality of the paper's coverage, and Spayd has continually carried water for this rather than hold the paper to account. I for one am tired of watching the Times sell itself with ads about how the truth is more important than ever and then follow it up with coverage like this:

https://www.nytimes.com/2017/05/03/us/politics/health-care-f...

Where Pelosi saying "Up to 17 million children" is supposed to be misleading because it chooses the high side estimate, when that is exactly what 'up to' means.

Getting rid of the public editor won't make this better, but not having to read a public editor who won't confront this sort of coverage head-on will at least make me a bit less cranky about it.

I'd feel more able to agree with you if the NYT didn't carry water for some whoppers ("you can keep you doctor", "insurers will compete for your business", etc.) back when the ACA was passed in the first place.

Insurer's response to ACA reminds me of a Frank & Ernest comic, which I can't find right now, sorry:

Two USPS workers. Package label says "Do not bend, fold, mutilate." One says to the other "Doesn't say anything about crumple!"

Har har har.

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I had high hopes for ACA. I believed the 15% medical loss ratio was the poison pill that would eventually drive insurers out of business, and therefore lead to Medicare for All. For comparison, Medicare's is under 5%, meaning 95 cents for every dollar spent goes to patient care, vs coke and prostitutes for the execs.

Silly me. There's no set of rules that can't be broken, gamed.

So now I'm for dozing it all down and rebuilding with universal coverage, single payer, using the capitation model (reward wellness vs fee for service). No more incrementalism. Just do it.

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Aside: Mid 2000s, my team created, implemented, supported 5 regional health information exchanges (eg BHIX). It was clear then, to everyone in healthcare IT, that we were pushing cooked noodles across hot pavement. Since then, it's only gotten worse. Overhead continues to grow geometrically, due to things like ICD-10 and meaningful care, without nudging the patient care (outcomes) needle one bit.

I can't explain it.

I just read about cost disease. It seems to explain rising costs, but I don't understand the mechanism, or what to do about it.

https://en.wikipedia.org/wiki/Baumol%27s_cost_disease

And this book blew my mind:

"The Utopia of Rules: On Technology, Stupidity, and the Secret Joys of Bureaucracy"

by David Graeber

http://amzn.to/2mi169U

Putting any kind of cap on efficiency of a middle man is asinine. The only outcome is the realization that the only way to make more profits is increase the top line number (i.e. Premiums).

Our government has capped APRs for credit cards. Then, banks added fees, reduced services. Then govt capped fees.

Whackamole.

Is this a legit analogy? If so, is either side wrong? How would you handle it, if you were King?

My only notion for healthcare is to change the incentives. Reward wellness vs treat disease.

> My only notion for healthcare is to change the incentives.

That's only a recipe for lobbying over what bureaucrats designate "wellness" and "disease".

The best way to fix healthcare is to cut out more middlemen. The person whose health is being cared for (or their loved ones) needs to decide when another $10k scan or $65k pill regimen is worth it compared to using the cash to pay off their (grand)kids' student loans.

If all of this is filtered through insurers, lawyers, and government officials, there is incentives to meet budgets and increase revenue, but there's no win for the actual people and families all this is supposed to be taking care of.

Wellness is easily measured. Life expectancy, sick days, patient surveys. The fight happens during rationing (bureaucratic triage).

So you'd eliminate pharmacy benefit management companies?

https://en.wikipedia.org/wiki/Pharmacy_benefit_management#Li...

Or are you saying eliminate insurers (insurance) altogether?

The government can't be rational about what a balanced meal looks like or how tomatoes (fruit? veg?) fit in the picture.

There's a reason food lobbying groups exist.

> Or are you saying eliminate insurers (insurance) altogether?

I'm not saying there's an easy answer, but as long as all health transactions are paying for one party's health with another party's money, we'll have bad outcomes.

If the problem is that it's expensive to live, then let's talk about that problem (negative income tax credit, minimum income, optimize for cost of living, etc.) instead of trying to bureaucracy (private or public) our way into utopia.

According to the government a slice of pizza counts as a serving of vegetables because of the tomato sauce.

This may not be what you mean, but this comment triggered a thought. If it were possible to really measure wellness and reward or punish providers accordingly, the new "health insurance" would be a sort of reinsurance that such providers purchased to control risks related to their patients' health. No, it wouldn't be cheap, and yes, the costs would be passed on to someone.

Who has 65k cash to toss around like that? :)

If the doctor can't effectively predict what benefit said scan or pill regimen will provide (50% chance of 10 year life extension,90% chance of 2 years...? not even getting into quality of life), how does the consumer make informed choices? This approach devolves to if you have money you get care, if not, you don't, regardless of need or efficacy. Similar to any other market.

There or some easy decisions to make in medical care (set the broken bone, stop the bleeding), but less so when it comes to areas driving price increases.

Adding layers is potentially problematic, as is removing them. Single payer and no-payer are attractive solutions due to ideological simplicity.

I wonder if a tax funded provision of care rationed similarly to the organ transplant system would be workable...

> Who has 65k cash to toss around like that? :)

Most people who are paying that much for pills are retired middle class people trying to stay healthy into old age. Or alive for a few more years. But people should be able to pay for typical levels of healthcare. The fact that this isn't true is a question of economics and employment opportunities, not entirely problem with the "healthcare system" itself.

> There or some easy decisions to make in medical care (set the broken bone, stop the bleeding), but less so when it comes to areas driving price increases.

> Single payer and no-payer are attractive solutions due to ideological simplicity.

I agree with this first sentence more than the second. These decisions are never all that simple. And they are made even more complicated or perverse when you ignore that the best alternative for a bureaucrat (private or public) approving treatments is saying "no" and going home for a Scotch. The best alternative for the patient is saying "yes" and spending $300k and live another year in diapers.

If people were spending their own money, they would also think about:

- grandkids that want to go to college

- underfunded soup kitchens in their neighborhoods

- not reverse mortgaging the family home they wanted to pass down to their loved ones

- going on a "farewell" cruise

And that's just one category of health care decisions. There are more mundane ones like "Should I try the generic treatment for a week to see if it helps? Or should I put $3k into the boutique one and save the hassle?" I wouldn't know how a (even highly qualified, well meaning) bureaucrat in Atlanta would make a better decision than the person getting treated.

> Most people who are paying that much for pills are retired middle class people trying to stay healthy into old age

What of all the people whose lifespan is cut early by disease? Getting cancer or some other serious disease at a young age just due to sheer dumb luck is less common, but still quite prevalent. Or let's just think about traffic accidents? It's just preposterous to me that people should ever have to worry about sudden illness or injury. If you're looking for bloat and overspending, why not slash the defense budget instead?

> The best alternative for the patient is saying "yes" and spending $300k and live another year in diapers.

Wait, wasn't this exactly what republicans criticized obamacare for? The accusation was that there were "death panels" that would decide whether it's "worth it" to put all that money into that one dying patient, or whether it's better spent elsewhere. So we don't like it when obamacare appears to be doing it, but now that obamacare is gone we want it?

> What of all the people whose lifespan is cut early by disease?

Actual insurance and government welfare programs are for things you can't otherwise save for. Let's not burn straw men, here.

> If you're looking for bloat and overspending, why not slash the defense budget instead?

That's fine, too. But paying for the healthcare of an entire country is far more expensive than even U.S. defense spending. And cutting defense spending doesn't address the structural problems of having party A pay party B to pay party C to produce good health in party D.

> The accusation was that there were "death panels" that would decide whether it's "worth it" to put all that money into that one dying patient, or whether it's better spent elsewhere.

I want the patient to be able to decide (for instance) that another year on the lam from the reaper isn't worth the high price tag. That only really works if the savings goes to what they want: family, charity, community, etc. and not back into the general fund of a government or corporation.

One issue here is that health care can get really complicated really fast. Which makes it quite a bit more difficult for many consumers to make an informed decision.

Because health care is complicated, in an idea world, there would be a layer to distill all of the complicated scientific information into simpler, scientifically sound recommendations. In theory, this is what your doctor should do. In practice, this system is currently broken in the United States. It is easy to demonstrate cases of over-treatment in the current medical system. (http://www.newyorker.com/magazine/2015/05/11/overkill-atul-g...).

If the consumer was paying for everything with full price visibility, would this change? I'm not sure. The problem here is a large amount of people would have no idea whether the prescription / test the doctor is requesting is worthwhile or bunk.

In fact, I think some of the over-treatment today is by "by patient request". One reason given for why doctors write antibiotic prescriptions for viral infections (which as we should know is scientifically useless and may in fact be harmful due to the potential of allergic reactions) is to make patients feel better by making it seem like something is being done. (http://ideas.time.com/2012/04/16/why-doctors-uselessly-presc...). The same probably goes for even more expensive cases (MRIs for most back pain cases, for instance).

Think of what we see in the "alternative medicine" market. There may be a few hidden undiscovered gems in that field, but in the majority of cases people pay sometimes a ton of money for what ends up being a rather expensive placebo effect at best (or harmful snake oil at worst). All of this both because medical science is difficult to understand (where glossy marketing is easy to understand), and also because in many cases medical science has unsatisfactory answers for people desperate to be healed.

I'm not saying that knowledgeable bureaucrats are completely correct (ideally the doctor and patient are making the informed decisions together, not the bureaucrats) but I can't see not having some layer that aims to eliminate the current perverse incentives in the system.

HHS doesn't actually pay medical costs with that 95%. They take a 5% cut for their own overhead and then turn around and pay a group of private insurance companies to provide coverage with the rest.

I think the 5% includes the administrative cost of the third-party administrators as well as HHS itself. The 95% is payments to hospitals, doctors, pharmacies, etc.

I believe the ACA itself was a poison pill that would make the system so inefficient to drive it to collapse and bring about single payer.

The failure of Republicans to implement an alternative has pretty much guaranteed it.

I think this is right. If not a deliberate poison pill, implementation of the ACA was a strong "foot in the door" technique for those who want single payer. Though, even before the ACA, the government is deeply involved in the system (employer based tax incentives, Medicare, etc)

I don't find that surprising though. I think Obama himself said that ACA was just a start and would have to be revisited. (Citation needed, I know.) What's amazing is just how bad conservatives have been at articulating the free market case for health care and insurance.

I'm hoping Donald Trump is the poison pill that will bring about the Progressive movement.

He's a poison pill alright, but I'm not sure who's going to feel the poison.

He's either the end of the Democrat establishment (the election and post-election hysterics are unheard of in my lifetime), or the end of the Republican establishment (if he crashes and burns as bad as certain circles think he will).

Healthcare costs grew under the ACA, but the rate of growth slowed. I don't think it was more inefficient than continuing with the old system would have been. Right now though they're working to defund as many parts of the ACA as they can, so even if it doesn't get repealed, it's going to be in bad shape from now on.

It's important to recognize that capitation provides a powerful economic incentive to provide as little care as possible. Every pill, X-ray, MRI, or surgery comes straight out of the insurer's bottom line. You'd like to see an allergist/rheumatologist/orthopedic surgeon? How about the thirty-third of Nevember? Instead you can talk to a high-schooler in another country with a wellness script.

I don't see how reporting a politican's comments were "carrying water". At the time Obama said that you could keep your doctor I don't think there was any way to disprove his statement, because the ACA hadn't been enacted yet.

I'm not carrying water for the ACA, which I think is not-very-good law, and I remember back when even congressional Democrats thought it was "the stupid compromise we can get Max Baucus and Joe Lieberman to allow to pass the Senate" and not a hill worth dying on.

What's the alternative?

I remember similar things said of their prior ombudsmans (ombudsmen? ombudespersons? ha). I stopped reading NYT when they helped sell Bush's Folly in Iraq, so I don't have a dog in this fight.

I ask because I've been eagerly awaiting the next iteration of journalism. Though I can't guess what that'd look like.

Frederic Filloux (mondaynote.com) has some notions. Mostly how to make it viable.

And I really wanted the Nerd TV 2.0 format experiment to happen (publish all source material as-is, much like we're asking for academics).

And lastly I really wanted the wikipedia model, as envisioned by Clay Shirky in Cognitive Surplus, to become more mainstream, but I don't know why that format isn't replicated more widely.

> false equivalence and the need to sell newspapers to both sides of the aisle

What does that mean? Are you saying you would prefer the paper take a more hardline stance in favor of one side because you perceive that side to be objectively superior in some manner?

Case in point: in the Washington Post story regarding Jared Kushners attempts to bypass government oversight of diplomatic negotiations with Russia, both WaPo and NYT both received comments from Kushner confidants alleging these contacts were intended to facilitate cooperation of military actions in Syria. WaPo refused to publish these comments unless they could specify that they were Kushner confidants speaking in his defense. NYT had no such qualms, instead allowing these partisans to be presented as anonymous neutral parties, in exchange for their continued access.

Allowing Kushner to present his spin as neutral is a de facto false equivalence and shifting the 'objective' reality, which other organizations (WaPo) who practice investigative journalism, as opposed to access journalism, refused to allow themselves to be used for.

Everybody is a political hack. There is no such thing as objective reporting. You are expressing a sentiment which reflects a suspicious and conspiratorial perspective on the Russia dealings. Rush Limbaugh would express a sentiment reflecting a dismissive attitude towards that topic. Both you and Rush believe that you are reporting the objective truth, but you would point out the false equivalence of comparing your enlightened and objective opinion with Rush's obvious partisan hackery. And so it goes.

TIL that reporting on the potential conflicts of interest in a sources comments are signs of political hackery.

You do yourself a disservice by misrepresenting my point. A lot of folks throw around the phrase "false equivalence" to mean that the current president is abnormally and objectively bad, and that those opposed to the administration posses some sort of moral and intellectual superiority. This is the broader hypocrisy to which I am referring.

I said it's a false equivalence to present trumps detractors as detractors, and trumps supporters as a neutral party.

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