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