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Author Topic: Universal Health Insurance is Coming to the US
Lavalamp
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quote:
Originally posted by pH:
You know, no one ever answered Pix's question about controversial procedures (beyond this Canada vs. US abortion thing). And beyond that, what about simply unconventional procedures or methods of therapy? Who decides what off-label uses of what drugs are acceptable?

-pH

Why would making sure everyone has health insurance change any of those things. I didn't answer Pixiest's earlier post about this stuff because it just didn't strike me as particularly relevant to the solution that's being proposed, as far as I understand it.


If all we're doing is making the insurance cheaper by putting EVERYONE into the same pool, I'm not exactly sure how this changes anything except for small insurance carriers who may be suddenly exposed to increased competition in niche markets they formerly served.

If, as I suspect, the US system merely makes it so that every insurer offers a low rate for basic (minimum) coverage, I don't really anticipate the social upheaval that would come from government-control.

The big change here is that the insurance pool is larger for everyone, and most people (if not all) should see a lower premium as a result. IF what the insurers have been telling my SMALL company all these years is true, at any rate.

If there was a way for my company to join a larger pool and save money on policies, we'd do it. I don't see that happening without government intervention because there's no incentive for the insurers to pool our risks with anyone else's when they can just hit both smaller units at a higher rate. Insurance sales persons are cheap, so the cost of having a bunch more salespersons around to go bit by bit is just not enough of a cost to make it worth their while to save on that.

Look, the BIG lie in the current Health INSURANCE system is that the insurers tell us that employees in bigger companies aren't subsidized by the higher rates charged to the employees in smaller companies. They get better rates SOLELY because they have a bigger pool, of mostly younger employees all paying premiums but not necessarily using the services. What that is true, it is also true that the insurers lower their rates (relatively speaking) in order to get the business of the larger companies and so they don't make nearly as much profit from those folks as they do from an equivalent person (young/healthy) who happens to work for a small company.

They don't like to admit this, though, because the solution is patently obvious -- form larger pools and bludgeon the insurers into providing better rates to employees currently covered in the smaller pools.

What has forced their hand...I don't know. But something changed recently either in Congress or in the competitive arena of insurance to make people realize that things can't go on like they have for much longer. The insurance costs at small companies are crippling. Not just in terms of dollars spent on the policies either, but in terms of competitiveness and in terms of the amount of time the annual renewal of policies takes up. I won't go into specifics for my company, but I know that there's a lot of low-ball initial pricing going on, with 11th hour "underwriter bumps" when they think you'll be so tired of the whole thing that you'll sign just to have it over with.

On top of that, you can NEVER count on having the same coverage from one year to the next. The insurer from year A just seems not interested in keeping customers in year B. They raise rates, refuse to negotiate, and little companies have no leverage.


Now, contrast that with a system wherein everyone is in the same pool. Suddenly, there's no worries about who you work for. If you work for a giant mega-corp or a mom-and-pop, you'll still get the same rate. And why shouldn't you? What has the size of your company got to do with your personal health? (Okay, it does have a little to do with, but only in specific situations -- larger companies have better Safety programs generally, but we're talking lots of jobs that don't require that kind of thing).

So...
What I'm not really groking to is resistance forming the largest possible pools and thus getting the lowest possible rates.

If that's the basics of this solution, I'm happy.


If, on top of that, the government decides it can afford to subsidize the insurance of more people than it could before, and thus make sure that more people have health insurance coverage, I'm not just okay with it, I think we've done a good day's work.


I don't really see how this ends up creating a huge bureaucracy, gets us out of funding research, meddles with private industry, or personal choice. It's not like the government is the one offering the insurance. No checks will be written to the government.


It just seems like over 1/2 of the arguments against this proposal are about things that aren't being proposed.

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fugu13
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The largest pools do not lead to the lowest possible rates. An insurance company needs to calculate their expected payout for a given pool, (which will incidentally be higher than the average expected medical cost of pool members, since people who know they will have higher costs are more likely to enroll), then determine rates based off it.

Trying to 'bludgeon' insurers into charging any amount significantly less than that will only result in undersupply of insurance, particularly if the large fixed cost of supplying anyone in the nation is forced. Its all very well to have insurance plans that are cheap enough for everybody when there aren't enough companies willing to employ enough people to make it happen efficiently. You want to know what causes those long waits? The assumption that mandating a price makes that the cost. No, the cost is still the real cost, but part of it is transformed (frequently into waits, such as when there were gasoline controls).

Insurance salesmen may be cheap, but the real suppliers of insurance (the reinsurers) are calculating and efficient. The very fact that insurance costs are so closely attuned to health care costs should indicate how much health care costs determine them.

People previously members of higher average risk pools will see lower rates. People previously members of lower average risk pools might well see higher rates. Combining everyone together does not magically lower the expected payout of the group so that everyone has lower rates.

Furthermore, even if one has large pools it can be more efficient to have multiple ones. For instance, re: dividing up by state, if some rates are higher risk than others, it makes sense to have different insurance rates in those states.

Besides the obvious economic efficiency argument (and the externalities criticism doesn't apply if its reasonably feasible for everyone to be covered), it creates an incentive for people to move to states with lower rates . . . which are also the ones with less risk, which will mean exposing the people who move to less risk (assuming, which is reasonable, that a substantial part of typical risk is environmental), will mean lowering overall healthcare costs and improving overall health.

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ClaudiaTherese
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quote:
Originally posted by Dagonee:
That's 1/3 of the cost for administration, right?

Right.
quote:
Do you know where the rest is coming from? (And if I'm being too presumptuous asking so many questions, let me know. I find this terribly fascinating but never have the energy to really research it.)

The rest of what? (The rest of the cost difference in toto?)

No worries about asking questions. I've just been busy at work and in the rest of my life, and also -- though it shames me to say -- I think I've gone over this so many times that I get irritable more easily than ever before. For so many years I would write these long, involved, step-by-step posts that laid out the whole situation as I saw it. And nobody but Rakeesh seemed to read them. *grin

It may be that my best role is to just point the way to resources. I'm really not sure. But, as noted above, it's worth avoiding ticking people off right from the get-go.

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rivka
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quote:
And nobody but Rakeesh seemed to read them. *grin
Hey! [No No]
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katharina
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I read them, CT. You convinced me. [Smile]
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Dagonee
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quote:
The rest of what? (The rest of the cost difference in toto?)
Yes. Using Canada and UK as examples, we need to cut 40-60% from our costs (rough math) to match them. We get 5% from admin savings, so we need to come up with 35-55% additional savings. I assume we get some from reduced acute illness through more universal preventative care, which should be quantifiable. I'm trying to figure where the rest of the savings come from.

quote:
But, as noted above, it's worth avoiding ticking people off right from the get-go.
For the life of me, I can't remember the last time you ticked me off. [Smile]
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Mucus
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Dag:
quote:

How utterly patronizing of you. You haven't led Pixiest anywhere, and she certainly doesn't need you to do so.

I'm not entirely sure if you mean being compared to a student is patronizing or just the correction itself.

If its the correction, well, I've seen posters commenting on people's spelling or grammar on this forum, and quite bluntly I might add.
I simply made a suggestion based on my appreciation of the fact that many previous posters had points based in hospital wait times, or WHO statistics, or any number of pieces of evidence. Posts of that sort seemed to be more constructive and I looked forward to more of the same. *shrug*

If its simply being compared to a student, well, I can't do much about the connotations that you apply onto that. Different people have different experiences and appreciation of academic experience.

quote:
She's not better served by going and doing the research to support someone else's position.
Someone else's position? I haven't even taken sides in this debate. You can read each of my posts in this thread to confirm it. In a very real sense, I don't care about the outcome, I'm not American and simply have been reading out of curiosity.
My "position" if any was simply that one can learn from other experiences, which does not seem to be inherently a controversial position.

AvidReader:
quote:

This thread has made me realize that I'm a scary patriot. When I saw Mucus asking why didn't we just see how Canada had dealt with UHC issues, my first thought was, "Why do I give a crap about Canada? I don't want to do it their way."

Eh. Its just Not Invented Here. Its not your fault, everyone suffers from it, as the link will aptly demonstrate. This quote is a bit ironic though.
quote:
While the etymology is perhaps apocryphal, the American National Institutes of Health (NIH) is said to either to be the direct inspiration for the term, as a play on its acronym or as an organization subject to this attitude.
pH:
quote:

It's great to say that the US should just do what Country X should do when it comes to gun control, except that Country X did it's gun control thing years ago. We're not frozen in time here.

Good thing in my very first post, I said
quote:
"How was the abortion debate handled in Canada... How is our experience different?" "
*shrug*
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Dagonee
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quote:
If its simply being compared to a student, well, I can't do much about the connotations that you apply onto that. Different people have different experiences and appreciation of academic experience.
No, it's the connotation that you need to treat her like you're her parent. Lest we forget the analogy at issue:

quote:
"Mom, how do I solve this math question?"

"I don't know, not my area of expertise. But maybe you should find a textbook on calculus and find out instead of working out from first principles what formula to use for integrals."

"What? You should have just given me the answer! How dare you ask me to do research instead of giving me a simple answer!"

quote:
Someone else's position? I haven't even taken sides in this debate. You can read each of my posts in this thread to confirm it. In a very real sense, I don't care about the outcome, I'm not American and simply have been reading out of curiosity.
Good. I didn't say you had taken a position. But the position you're asking her to research is not her own.

quote:
My "position" if any was simply that one can learn from other experiences, which does not seem to be inherently a controversial position.
That's not controversial. What's controversial is taking someone to task for not doing it when you can't be bothered to do it either. And, in the course of doing so, suggesting that you're doing her a favor by both chiding her and refusing to give information that it seems you possess.
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pH
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quote:
Originally posted by Lavalamp:
quote:
Originally posted by pH:
You know, no one ever answered Pix's question about controversial procedures (beyond this Canada vs. US abortion thing). And beyond that, what about simply unconventional procedures or methods of therapy? Who decides what off-label uses of what drugs are acceptable?

-pH

Why would making sure everyone has health insurance change any of those things. I didn't answer Pixiest's earlier post about this stuff because it just didn't strike me as particularly relevant to the solution that's being proposed, as far as I understand it.


If all we're doing is making the insurance cheaper by putting EVERYONE into the same pool, I'm not exactly sure how this changes anything except for small insurance carriers who may be suddenly exposed to increased competition in niche markets they formerly served.

If, as I suspect, the US system merely makes it so that every insurer offers a low rate for basic (minimum) coverage, I don't really anticipate the social upheaval that would come from government-control.

The big change here is that the insurance pool is larger for everyone, and most people (if not all) should see a lower premium as a result. IF what the insurers have been telling my SMALL company all these years is true, at any rate.

If there was a way for my company to join a larger pool and save money on policies, we'd do it. I don't see that happening without government intervention because there's no incentive for the insurers to pool our risks with anyone else's when they can just hit both smaller units at a higher rate. Insurance sales persons are cheap, so the cost of having a bunch more salespersons around to go bit by bit is just not enough of a cost to make it worth their while to save on that.

Look, the BIG lie in the current Health INSURANCE system is that the insurers tell us that employees in bigger companies aren't subsidized by the higher rates charged to the employees in smaller companies. They get better rates SOLELY because they have a bigger pool, of mostly younger employees all paying premiums but not necessarily using the services. What that is true, it is also true that the insurers lower their rates (relatively speaking) in order to get the business of the larger companies and so they don't make nearly as much profit from those folks as they do from an equivalent person (young/healthy) who happens to work for a small company.

They don't like to admit this, though, because the solution is patently obvious -- form larger pools and bludgeon the insurers into providing better rates to employees currently covered in the smaller pools.

What has forced their hand...I don't know. But something changed recently either in Congress or in the competitive arena of insurance to make people realize that things can't go on like they have for much longer. The insurance costs at small companies are crippling. Not just in terms of dollars spent on the policies either, but in terms of competitiveness and in terms of the amount of time the annual renewal of policies takes up. I won't go into specifics for my company, but I know that there's a lot of low-ball initial pricing going on, with 11th hour "underwriter bumps" when they think you'll be so tired of the whole thing that you'll sign just to have it over with.

On top of that, you can NEVER count on having the same coverage from one year to the next. The insurer from year A just seems not interested in keeping customers in year B. They raise rates, refuse to negotiate, and little companies have no leverage.


Now, contrast that with a system wherein everyone is in the same pool. Suddenly, there's no worries about who you work for. If you work for a giant mega-corp or a mom-and-pop, you'll still get the same rate. And why shouldn't you? What has the size of your company got to do with your personal health? (Okay, it does have a little to do with, but only in specific situations -- larger companies have better Safety programs generally, but we're talking lots of jobs that don't require that kind of thing).

So...
What I'm not really groking to is resistance forming the largest possible pools and thus getting the lowest possible rates.

If that's the basics of this solution, I'm happy.


If, on top of that, the government decides it can afford to subsidize the insurance of more people than it could before, and thus make sure that more people have health insurance coverage, I'm not just okay with it, I think we've done a good day's work.


I don't really see how this ends up creating a huge bureaucracy, gets us out of funding research, meddles with private industry, or personal choice. It's not like the government is the one offering the insurance. No checks will be written to the government.


It just seems like over 1/2 of the arguments against this proposal are about things that aren't being proposed.

As far as I can tell, absolutely NONE of this even comes close to addressing the actual question, which is quite relevant when you consider that there are a good deal of unconventional procedures and off-label drug uses on which many people already rely.

-pH

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Mucus
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quote:
Originally posted by Dagonee:
No, it's the connotation that you need to treat her like you're her parent. Lest we forget the analogy at issue:

Actually, if you might have noticed. That analogy was specifically applied as a response to *you*, not her. Her response, I specifically noted before, was a proper objection to whether the evidence was useful enough, not whether one should look at it at all.

quote:
Good. I didn't say you had taken a position. But the position you're asking her to research is not her own.

I'm still not sure what "position" you're referring to. To go back to the textbook analogy (if you don't find it too patronising). When one is referred to a math textbook, there may be an answer, or more likely there will be similar examples and case studies that will point the way to an answer. In this case, I just said "for example" the Alberta scenario, but I have no stake in it.
As I have said before, the evidence may lead to support her position, it may not. To go back to the textbook, I just know it may be useful if she's interested in it.

quote:
That's not controversial. What's controversial is taking someone to task for not doing it when you can't be bothered to do it either.
I cannot agree. Its not my point, its her point. It seems clear to me that if one brings up a point, one should have evidence to back it up.

It seems strange that I can only criticize her for not doing research if I have done the research in question. This would be a strange view if applied to say, reviewing academic papers. Imagine if a review committee had to have previously done all the research behind a paper in order to determine whether the paper had sufficient backing. It would somehow eliminate the point of doing the paper in the first place! Instead, its much more reasonable to assume that they only have enough knowledge to judge whether the paper had logically and sufficiently presented its evidence.

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twinky
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quote:
Originally posted by pH:
And, as Dag said, if you really think we should consider how it worked in other countries, why not say something about it instead of expecting us to automatically jump to it?

Plenty has been said about it in the last three pages. I don't understand your complaint.

quote:
Originally posted by pH:
It's great to say that the US should just do what Country X should do when it comes to gun control...

Saying that Country X doesn't have Problem Y, while the U.S. does, isn't the same as saying the U.S. should do exactly what Country X does.

quote:
Originally posted by pH:
...except that Country X did it's gun control thing years ago. We're not frozen in time here.

I don't see anyone in this thread suggesting that you shouldn't attempt to learn from both the successes and mistakes of other countries.
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Dagonee
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quote:
Actually, if you might have noticed. That analogy was specifically applied as a response to *you*, not her.
More speciousness. Your response to me was a response to a statement about why your original response to Pixiest was not "useful" (the standard you seem to be applying here). In making that response, you specifically and explicitly stated that my comment was the equivalent of saying a student should be told the answers rather than pointed to a place to learn how to do a problem. To say that analogy did not equate Pixiest to the student is disingenuous in the extreme.

Further, the analogy was still a dishonest representation of what I said. You still haven't corrected that dishonesty. You still can decide you want to be honest here.

quote:
I'm still not sure what "position" you're referring to. To go back to the textbook analogy (if you don't find it too patronising). When one is referred to a math textbook, there may be an answer, or more likely there will be similar examples and case studies that will point the way to an answer. In this case, I just said "for example" the Alberta scenario, but I have no stake in it.
As I have said before, the evidence may lead to support her position, it may not. To go back to the textbook, I just know it may be useful if she's interested in it.

You didn't just say "You might want to check out what happened in Alberta." You also gave a little lecture about how useless her questions were. They weren't useless. The raised a very specific point, one that has yet to be addressed at all.

quote:
Its not my point, its her point. It seems clear to me that if one brings up a point, one should have evidence to back it up.
She asked - presumably the proponents - how this would be handled. She doesn't need to provide evidence that someone else handled it in a particular way.

quote:
It seems strange that I can only criticize her for not doing research if I have done the research in question. This would be a strange view if applied to say, reviewing academic papers. Imagine if a review committee had to have previously done all the research behind a paper in order to determine whether the paper had sufficient backing. It would somehow eliminate the point of doing the paper in the first place! Instead, its much more reasonable to assume that they only have enough knowledge to judge whether the paper had logically and sufficiently presented its evidence.
You're analogy is, once again, sadly misplaced. Pixiest isn't the author of the paper; she's the peer reviewer. The author is the proponent of the change to the health care system. As you said, "Imagine if a review committee had to have previously done all the research behind a paper in order to determine whether the paper had sufficient backing."

Why on earth are you trying to hold the review committee to that standard when you've admitted it's ridiculous to do so.

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rjzeller
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Comparing healthcare in the US with systems in other nations, such as the UK and Canada is fruitless and gets us nowhere. There are differences that go far beyond the healthcare system itself that impact the statistical outcomes one may witness.

One of the biggest problems in the US with healthcare is we're trying to maintain a private system, but strip all the motivators that make private systems work. Why? Becuase we have an entitlement mindset that ALL of us should have access to the SAME quantity and quality of care. Maybe we should, maybe we shouldn't, but we cannot apply one set of solutions to an environment that wasn't designed for them without a major overhaul in both structure and attitude.

The pool of medical talent in the US is highly limited, and some could argue this is an artificial limitation. The result, nevertheless, is higher than average incomes and costs. To become a doctor in the US takes great investments in time and money, and we limit how many people get accepted into the programs that would turn them into doctors.

Doctors make significantly higher salaries in the US than in canada (since every salary survey differs in the real dollar amounts, I'll leave it up to the generalized statment, but they all seem to confirm that US doctors make much higher salaries). And that doesn't even account for differences in taxation.

There are also controls affecting clinician behavior, such as tort/malpractice concerns, insurance limitations, differences in coding practices, availability of specialized care, patient demands, and so forth.

Pharmaceuticals are forced to sell for lower than they otherwise would in some countries due to regulations, so they charge higher where they can.

We have an insurance industry that is actually a maintenance plan, NOT an insurance plan. Our demands on health insurance are NOT the same as they are for auto, home, or life insurance.

We continually focus on quick, no-pain solutions to the healthcare dilemma in the US. And the reason is that we do NOT have a system, we have a mixture of the following:

Financing of health coverage
Different types of coverages
Provider reimbursment schemes
Different delivery systems
multiple ownerships and governance of care
Multiple regulatory environments

And why such a hodge-podge of coverage and costs?

Most consumers do not face any financial consequences for their healthcare choices, providers have wide economic and clinical autonomy, there is almost NO information about provider quality, healthcare information technology lags behind other industries, and the focus is on acute care--not management and prevention.

The result is a series of one-off solutions that simply do not work: certificate of need, Pay-or-play plans, purchasing coalitions, pay-for-performance, consumer-directed healthcare, and so on. While some of these showed short term drops in costs, there was always a rebound with higher-than-before costs.

Sharing of health information is arduous and costly, and privacy regulations make administration costs staggering (how often do you have to completely re-register when you move or start attending a new medical facility?).

We have a system that is overloaded with regulations, artificial restrictions on talent and avialability, lack of accountability and data on providers, extreemly high salaries, and exceptionally high administrative costs; yet at the same time, we expect everything for a $10 copay and access to the best of everything even if we don't need it. And thus we continually demadn the best when often second-best will do.

How do you tell one patient that they only need the $5000 pacemaker when their insurance will cover them for the $50,000 model just as well? Which do you think they're going to choose?

Which are YOU going to push on them, all things being equal, if your pay is influenced by the amount of services you bill?

Too many things have to change in order for the system to right itself IF we insist on making the costs to the consumer transparent. So long as the consumer is NOT the one paying the bill, the system remains broken unless you cut salaries and profit from the entire picture.

This is why a universalized plan will not work in the US, not unless you make some major changes across the entire spectrum of healthcare in this country. And if you do, be prepared for significant decreases in the development and funding for new drugs, practices, and treatments.

The less we pay directly, regardless of whether it's uncle Same or some newfangled HMO, the higher our costs will be, and the worse, not better, the problem will get.

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ClaudiaTherese
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Well, rivka and katharina, it's great to know that you were reading. [Smile]
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Mucus
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Dagonee:
quote:

Your response to me was a response to a statement about why your original response to Pixiest was not "useful" (the standard you seem to be applying here). In making that response, you specifically and explicitly stated that my comment was the equivalent of saying a student should be told the answers rather than pointed to a place to learn how to do a problem. To say that analogy did not equate Pixiest to the student is disingenuous in the extreme.

I did not say that I did not equate her to a student. I said that the analogy was specifically directed at you. In the analogy, I specifically equated *you* to a student that lashes out at a parent for suggesting an alternative source of evidence. A curious student that examines the evidence is admirable, the latter is not.

In any case, this side-thread is getting long and we can both agree that neither of us will be convinced, let alone have this debate contribute to the issue of UHI.

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Christine
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quote:
This is why a universalized plan will not work in the US, not unless you make some major changes across the entire spectrum of healthcare in this country. And if you do, be prepared for significant decreases in the development and funding for new drugs, practices, and treatments.
I agree.
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ClaudiaTherese
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quote:
Originally posted by [rjzeller]:
And if you do, be prepared for significant decreases in the development and funding for new drugs, practices, and treatments.

I think we'd be amazed at the outcomes if we successfully used the ones we already have.

----

Edited to add: Of note, much promising research is being done outside of the US, such as the development of the Edmonton Protocol for pancreas islet cell transplantation (removes the need for insulin therapy for diabetics). There is certainly promising research on tap in the US, but I'm not sure it is outcomes-driven as much as profit-driven. I'm wary of sinking money into doing new things just for the sake of them being new -- I want to see it justified in substantial expected outcomes.

[ February 13, 2007, 03:41 PM: Message edited by: ClaudiaTherese ]

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ClaudiaTherese
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quote:
Originally posted by Dagonee:
I assume we get some from reduced acute illness through more universal preventative care, which should be quantifiable. I'm trying to figure where the rest of the savings come from.

I bet a good bit of it is through reduced chronic illness through more universal preventative care. Diabetes and hypertension are huge drains on morbidity and mortality, and they are pretty much asymptomatic for most of the course. [So if you aren't being screened and managed early, the endgame is exponentially worse. And when such a huge number of people are only being seen acutely through EDs, then you are going to have people showing up with the serious complications of late-stage disease: heart attacks, gangrene needing leg amputation, strokes, blindness, kidney failure, etc.]

This is quantifiable, though, and I should find the numbers. I have them somewhere. Work calls first, though.
quote:
For the life of me, I can't remember the last time you ticked me off. [Smile]
Whew! [Smile] I respect you, so that's an important marker for me.
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fugu13
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I think a lot of research done in the US is profit driven. I think that's why we have so much more research (including per capita) than other countries. I rather like that we have a system that allows it to be profitable for people to develop new medical techniques and technologies.
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Dagonee
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I misused acute - and I knew that when I typed it, and meant to change it. I should stick with my own jargon. [Smile]
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Christine
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CT -- just a nit: that quote you attributed to me was by rjzeller...I just agreed. [Smile]

Of course, speaking as someone with a (non life-threatening) condition that is currently untreatable, I have a vested interest in those new procedures, drugs, and treatments.

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ClaudiaTherese
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quote:
Originally posted by fugu13:
I think a lot of research done in the US is profit driven. I think that's why we have so much more research (including per capita) than other countries. I rather like that we have a system that allows it to be profitable for people to develop new medical techniques and technologies.

I like new technologies, too -- I'm just wary of publically funding them unless they deliver significant M&M outcomes.*** To the extent that we avoid universal coverage in trade-off for more research, that's what we are doing.

***So, for example, there is likely to be a lot of money in yet another anti-seasonal-allergy medication, even if it is of minimal benefit. But do we really need another Claritin, especially when there are around 80,000 leg amputations from diabetes per year?

Sure, if it's all private enterprise, that's great. But given that "more research" is being cited as a reason to hold onto the system we have, I think that research is acknowledged as being indirectly subsidized. And it shouldn't be subsidized to line private pockets, especially without really good cause.

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ClaudiaTherese
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quote:
Originally posted by Christine:
CT -- just a nit: that quote you attributed to me was by rjzeller...I just agreed. [Smile]

My apologies! A very large nit, and well worth squashing.
quote:
Of course, speaking as someone with a (non life-threatening) condition that is currently untreatable, I have a vested interest in those new procedures, drugs, and treatments.

And I'm all for getting you that new research, but I wouldn't trade off public subsidy for it at the expense of more serious or life-threatening conditions. On the other hand, for all I know, your condition may well be one I would consider should be on that list. I don't know, as I don't know your details (and you shouldn't have to disclose them!).

But I do think there should be a list of some sort, you know? If there is public subsidy, even indirectly.

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kmbboots
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quote:
Originally posted by ClaudiaTherese:
Well, rivka and katharina, it's great to know that you were reading. [Smile]

I'm reading, too. Mostly just to combat my withdrawal symptoms, though, (i miss you!) because I was already convinced.
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Dagonee
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CT, the idea that the lack of public health care amounts to a subsidy (even an indirect one) because a public system would alter research priorities speaks to a very deep theoretical problem I have with most government enterprise. It hints at the idea that the government establishes the baseline for human endeavor. This is chilling to me.

(And I know there are other, more direct subsidies for such research, including tax deductibility for employer-sponsored health plans. I'm not speaking to actual payments here.)

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fugu13
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I think its entirely possible to preserve the incentives for research and move to a system that makes it reasonable for everyone to obtain good health insurance and good healthcare.

Actually, I think it can be done with remarkably little public funding of any kind (billions, certainly, but relatively few billions).

Provided insurance groups are made large enough and adequate funding is provided for people at low income ranges (in a way that does not disincentivize earning more money), and health insurance companies are allowed to competitively bid to provide insurance to the various groups, we'll continue to have strong health care research incentives. The only public money heading that way will be that providing health insurance to the needy, and that will only happen indirectly and mostly non-directably.

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fugu13
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I should point out that the effective government subsidy of health care now is much higher than most calculations, because it includes the tax breaks to employers for paying (large) parts of employee insurance, disproportionately incentivizing healthcare compensation.
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ClaudiaTherese
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quote:
Originally posted by Dagonee:
CT, the idea that the lack of public health care amounts to a subsidy (even an indirect one) because a public system would alter research priorities speaks to a very deep theoretical problem I have with most government enterprise. It hints at the idea that the government establishes the baseline for human endeavor. This is chilling to me.

(And I know there are other, more direct subsidies for such research, including tax deductibility for employer-sponsored health plans. I'm not speaking to actual payments here.)

I don't understand what you are saying, and I'm not sure we aren't talking past each other. Can you reword it?

(I'll be offline until tonight -- lunch break is over. Will chack back later when I am less distracted, though.)

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Dagonee
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quote:
Can you reword it?
Maybe. [Smile] Rather, I know I can reword it, but I don't know if I can make it more understandable.

A subsidy is generally considered to be monetary assistance given by the government to a private enterprise. Subsidies absolutely do not have to be actual payments. For example, government-granted monopoly is a subsidy if it results in the ability to charge higher prices. The essence of these kinds of subsidies is that the government somehow alters what would have happened absent government intervention and that this alteration leads to someone acquiring profit they otherwise would not have.

You describe the current system - which allows companies to profit from self-directed research in a way they would not under public health care - as a "subsidy." If I understand what you meant by reference to a list, the specific mechanism providing that subsidy is the lack of government input into which drugs are covered.

What particularly bothers me about this is that government inaction is seen as a subsidy. Now, I'm not saying that government inaction doesn't benefit someone financially - it almost always does. Nor am I saying that government inaction is always good or better.

I don't find anything problematic about acknowledging that our current policy choices regarding medical care have resulted in some people making out like bandits. But the idea that not being interfered with amounts to a subsidy - in effect a gift from the government - is what I find to be chilling.

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Christine
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CT: I'm not shy about disclosing my condition -- you would probably notice if we met in person, anyway. I am legally blind. That is to say that with best correction, the vision in my better eye is 20/200...what this means in practice is that I am currently inches away from a screen that has text blown up several times normal.

I would never presume to rank this on a list of conditions. I suppose it falls somewhere between heart disease and wart removal, but that's as specific as you'll get from me. [Smile]

I'm not thrilled with the idea of having the government rank it, either. I'll default to Dagonee on this point, though, since I'm really not sure how to put this -- it's more of a knee-jerk reaction at the moment. [Smile]

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Counter Bean
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I hope that it never happens in my lifetime, the cure for the health care system is universal insurance for doctors with caps on malpractice pay for lawyers. Half the cost of medicine would vanish overnight.
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Lavalamp
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pH:

I should've put a break in my post -- only the first few sentences were addressing the quotation from your earlier post.


As for off-label uses of medicines -- if you can get an insurance company to pay for it now, you'll probably be able to get an insurance company to pay for it later. Even if such things won't be covered under the kinds of basic coverage that everyone is likely to have, there are going to be LOTS of supplemental coverages out there -- often employer paid as a perk or a way to attract employees in hard-to-fill positions.


fugu--
What I don't really get is the logic behind saying that people who save now because they're in a big pool wouldn't continue to pay low rates (or even see an even lower rate) when they're part of an even bigger pool. Are you assuming that the larger pool will necessarily include a greater proportion of people of higher risk or proven ill-health? Or is this based on assuming that since the insurance system is going to pick up the acute care treatment tab for a bunch of folks who currently don't have insurance, that the overall outflow of money alone is going to drive up the "base" or lowest-possible rates.


As for regional or state-level efficiencies, the only thing I can see this being better for is regulation. State insurance regulators are often quite adept at forcing concessions from major insurers (if you want to sell auto insurance to our citizens, you darned well better offer home-owner's insurance -- that sort of thing). They are also fairly well experienced in going after carriers that pull various scams and or fail to meet regulatory requirements.

I don't actually see that a national pool would necessarily change that. Plenty of people work for multi-state companies. Their insurance is regulated in every state where employees take policies. The pool is based on the employees of the company, not where they are domiciled.

If anything, you might see some terrible inequalities in the system if you forced it to be state-wide pools. States with low populations, or those that have chosen to attract retirees and thus have a skewed age distribution, states that are tending to lose population (usually disproportionately losing working-age people), are going to be hit hard for no good reason, IMO. Why not let people live where they want and if you need to adjust for local factors, then when the policies come due, you adjust. State regulators can keep an eye on that sort of thing without requiring that the pool of all possible insureds be in their state. As long as one person in their state has insurance with company X, the existing state regulatory authority could have some control.

Anyway, I'm interested in trying to puzzle through this logic if you have a chance to answer.

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Dagonee
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quote:
the cure for the health care system is universal insurance for doctors with caps on malpractice pay for lawyers. Half the cost of medicine would vanish overnight.
That costs us $950 billion a year? Got a cite for that?
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Will B
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An alternative method would be to change the way we discourage malpractice.

There was a doctor in my hometown who ordered a penicillin shot for a patient at the ER, without seeing him first, without checking for allergies. The patient was allergic, and died. The doctor lost the malpractice suit, of course. Which meant that everyone's premiums went up, and he kept practicing.

In effect, when malpractice happens, it's other patients that pay -- both with money, and by being stuck with the same dangerous doctors.

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Mrs.M
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A couple of things:

Infant mortality statistics are extremely misleading. The US has very low infant mortality, comparable (if not lower) than other industrialized nations. The disparity in the statistics comes from what each country counts as a stillbirth and what they count as a miscarriage. Some European countries count every infant death before 40 weeks gestation as a miscarriage. Many (if not all) of those are counted as stillbirths in the US. Then you get into issues of when or if the the baby took its first breath and it goes from there. I was the one who linked to a Canadian study that confirmed the above (sorry, I didn't bookmark it and I don't have it in me to look it up right now). Additionally, there is the issue of fertility treatments - these create far more high-risk pregnancies, which can cause infant mortality rates to rise. This certainly is not due to poor health care.

I also want to point out that there are many US organizations dedicated to helping uninsured families. I know things are far from perfect, but I feel it's unfair not to acknowledge the work that is done to help out a large number of families. For example, here in Virginia we have FAMIS, which makes health care available to children whose families qualify. Aerin and I went to the VA State Legislature with the March of Dimes last week to lobby to get FAMIS eligibility raised from 175% to 200% (they're still in session, but we're fairly confident it'll be raised). This will put FAMIS on a funding level with WIC (another great organization that helps mothers and children).

Again, I realize that the US healthcare system needs improvement. Both my mother and my daughter have had severe health problems that cost huge amounts of money and needlessly complex navigation through insurance claims. We pay for our own coverage and you would not believe the cost. However, we're not just a bunch of monsters who are content to let people suffer and die.

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Lyrhawn
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quote:
Originally posted by Will B:
An alternative method would be to change the way we discourage malpractice.

There was a doctor in my hometown who ordered a penicillin shot for a patient at the ER, without seeing him first, without checking for allergies. The patient was allergic, and died. The doctor lost the malpractice suit, of course. Which meant that everyone's premiums went up, and he kept practicing.

In effect, when malpractice happens, it's other patients that pay -- both with money, and by being stuck with the same dangerous doctors.

I'm allergic to penicillin, and all the other illins, and I have to say that exact kind of thing spooks me severely.
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pH
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quote:
Originally posted by Lavalamp:
pH:

I should've put a break in my post -- only the first few sentences were addressing the quotation from your earlier post.


As for off-label uses of medicines -- if you can get an insurance company to pay for it now, you'll probably be able to get an insurance company to pay for it later. Even if such things won't be covered under the kinds of basic coverage that everyone is likely to have, there are going to be LOTS of supplemental coverages out there -- often employer paid as a perk or a way to attract employees in hard-to-fill positions.

So, if I'm reading you correctly, you're saying, "Don't worry about it if it's not covered by basic...you can always pay extra for it to be covered!" Yes or no? If yes, this is better than the current system why?

-pH

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Lavalamp
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pH, the cost of your basic coverage should be reduced. That saves you some money. If you choose to use that money to pay for supplementary coverage, then if you later need one of those off-label uses, you have a chance of being covered even though under today's system you wouldn't.

This proposal is remarkably simple and not all that far reaching in terms of reform. You'd still deal with the same insurers, the same health-care providers and the whole thing is run by private enterprise. Same as today.

It's just that it should be cheaper to get coverage for the basic stuff.

By basic, I'm thinking they mean a bare-bones health insurance that has moderate co-pays and covers most acute diseases and injuries, and a fair number of chronic conditions.

The only thing this proposal does differently is make it so the pool of people you're included in when they fix your rates is a lot larger than is currently done. Insurers for decades have explained the high prices by saying that costs rise in inverse proportion to the size of the insurance pool.

That's not the only cost component, of course (there are the actual costs of treatments paid for by the companies), but it is the one that makes things most inequitable and has no relationship to the health of the individual insured. For example, a healthy 25-year-old working for a 12 person company is going to pay much more for his insurance than if he worked for a large company. The reason given for THAT unfair differential is that by taking a job with a small company, he is stuck in a pool that (statistically) has higher health care cost per person than places with more employees...on average.

By putting everyone in the same pool, that 25-year-old should end up with the best possible rate (although fugu seems to believe this may not necessarily be true -- I'm hoping for more details there). In fact, everyone should end up with the best possible rate that their age/gender bracket could obtain.

The other thing that this simple proposal does is make it more affordable for unemployed, underemployed, and people who work for companies that don't offer a health insurance benefit to get insurance at affordable rates. Currently, if you try to get insurance as a "self-employed" individual, the rates are ruinous. You essentially form a pool of one from the insurer's perspective, although there are some companies that do offer this type of coverage among consultants and such who will build a pool from among all members in a certain category. The risk is spread across such a small pool that the costs are at the highest end of the scale.

The OTHER other thing this proposal would do is disentangle basic health care insurance coverage from employment. You could keep the same coverage when you change jobs. You can keep it if you decide to take a year off from work and travel the country. You could keep it if you are laid off and decide to free-lance. Having affordable insurance isn't contingent on finding an employer desperate enough for employees to offer this as a benefit.

This is not a panacea, though. Coverage will still cost money. People who suddenly find themselves without income are still going to have to figure out whether and how to pay their premium. If coverage lapses, you'll still have problems trying to pay any medical bills for services during that uncovered period.

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fugu13
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Bob, the benefit isn't from being in a large group, its from being in a large group with a low expected payout (and to a lesser extent, a lower variance).

Additionally, given the vast numbers of baby boomers who would, if the current situation continues, be covered under Medicare as they aged, I am prepared to say the people at most large firms will become part of a pool with noticable higher average expected payouts if the entire nation is made one pool.

As for being hit hard for no good reason, my personal opinion is that, provided the system is structured so that health insurance is still affordable in order to avoid externalities, it only makes sense for people who are going to require more medical care to pay more. In fact, I think it is vitally important we preserve that characteristic as much as possible, because a large part of what makes markets have such better outcomes than other attempted solutions is the incentive to better one's self and one's situation.

Back to this best possible rate stuff. Lets imagine two groups of 25 year olds (males, even, just to simplify the situation), both groups statistically large (say, over 10k people). One group are coal miners, and one group are accountants. When you merge these groups, the cost of insurance for the coal miners will go down, and the cost of insurance for the accountants will go up. This is because the coal miners will have a far higher expected health cost than the accountants.

In fact, no matter how many people you add to the group, the insurance for people previously members of the group above a midpoint (approximately the average expected health cost) will be lowered, and the insurance for people below the midpoint will be increased, so long as the groups the people would otherwise be part of are statistically large.

Any group you present to me, if I can find a way to slice it up such that all slices are sufficiently large and the slices do not have the same average expected healthcare costs as the whole, then the insurance for the slices with lower average expected healthcare cost would be lower.

There's no way an insurance company can afford to charge people less than the average expected healthcare cost for a group (well, excepting if they overcharged for a while or had some really low health cost years which allowed them to invest significant sums, and they'd also have to do well in the investments -- usually the variance in health cost would prevent the accumulation of sufficient capital in this way to have lower costs); if they did, they'd lose money, and that isn't even counting the costs of administration.

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Counter Bean
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The direct cost is over 100 billion, plus the fact that the cost remains a barrier to entry for medical practitioners, an incentive to leave the business of medicine early and an incentive to leave certain areas of medicine that then go up in cost because only a handful of doctors are practicing (OBGYN for example) The cost of lost practitioners in the field is difficult to calculate, but a comparison to cost of care before the escallation of TORT cost is a place to start. The debt load on young surgeons and doctors, the cost in interest, it goes on and on. It is clear that the Lawyers have been engaged in a direct attack on our quality of life in order to shift wealth from the pool meant to sustain our health and well being to gild their personal nests.

If we as a Country believe that practicing medicine is a virtue we want to encourage, we should bear the premium cost with universal malpractice insurance and throttle frivolous lawsuits by not allowing lawyers to collect any of the damages. Take the insurance away from the insurance companies with profit motive and take the profit motive away from the lawyers, doctors are directly contributing to the public welfare, lets pull the leaches off them.

Report on Cost of Malpractice Insurance

[ February 14, 2007, 02:42 PM: Message edited by: Counter Bean ]

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Dagonee
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Where do you get the 100 billion from? According to the chart on page 15 of your link, medical malpractice tort cost only $20.9 in 2000.

Even if I accept your 100 billion number, you're still only about 13% of the way toward proving you can get rid of half the costs. And that would require that all medical tort costs are bad - which clearly they aren't. I haven't seen any evidence from you concerning what percentage of tort damages should not have been awarded.

I'm all for doing something about irrational tort awards, to the extent they exist. However, too many of the caps are limiting actual damages. If a medical error results in a need for lifelong care, then the award should cover that lifelong care. At least some of the caps that have been put in place do not.

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aspectre
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Just something to think about: Americans no longer the tallest peoples
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Lavalamp
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fugu,

I guess I'd want to look at how many people are already in insurance pools that include 10,000 healthy people in low-risk occupations before I concede this point.

I just don't think this is going to be nearly the problem you seem to think it is.

I'm insured in a group that includes about 10 people.

Most of the people I know are insured in groups that include a few hundred people.

I know there must be some people in pools of several thousand employees. And sure, I can at least imagine some pools that include only office workers who never travel or something along those lines. But I'm trying to think of a single company that has an insurance pool in the thousands where practically everyone is young, healthy and works in an office.


I buy your statistical reasoning. I just don't see where there are real world examples to match your hypothethical. And even if there are, what percentage of US workers with health insurance are in those situations?

If this new plan "harms" 1% of all US workers, heck, let's give them a subsidy too to take away their pain.

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Counter Bean
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Double the number of OBGYNs and you half the cost, you must look deeper then mere money and see the economic impact that results, it is the shortsightedness inherent in the profit incentive for the TORT system that gives rise to the second and third tier consequences.

Law itself needs to be simplified, all law should be in language that a sixth grade student can follow, those that make the law should not have ties to those that profit from its enforcement any more then insiders should be allowed to trade on their knowledge. Overlooking this has given rise to the most profitable swindle since women convinced men they do not like sex and are owed something for it.

The impact of this profession, so demanding that it creates a group who, unless exceptional are competent in their field and ignorant in every other, men and women with a level of functional competence so far below that of a typical savage it makes them unfit for survival in any world but the specialized one of their creation, yet they find themselves in leadership roles in a society that really needs leaders who are expert pragmatists, not experts in the silly game they create to employ each other.

Even if I accept your belief that some TORT is of benefit to society you cannot seriously suggest that some class of people should have aristocratic status and wealth for the occasional justice they manage to achieve. Justice is the duty and responsibility of every man, not to be delegated to a too specialized few.

The systematic persecution of doctors for the sin of being wealthy from their extraordinary contribution to society is one of the greatest injustices of all.

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ElJay
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I'm in a pool of several thousand people. I work for a company that employees around 50,000, but since we're spread across many states, I believe we are actually in several pools. But there's at least 6,000 in my state.

Most of us work in offices, although some climb telephone pools. But injuries sustained doing that are covered by workman's comp, not their health plan.

There are just as many old/overweight/smoking people here as there are in the rest of the population. There's no earthly reason I should get to pay less for insurance than people who work for Bob's company except for the fact that the insurance companies want my company's business more. Because they're taking the same risk by insuring 60 companies of 100 people as one company of 6000, so except for a slightly higher administrative cost, I don't get what the argument is. I don't buy that Bob's company pays more because it has significantly higher risk, I think it pays more because it has significantly less bargining power.

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ElJay
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And just to be clear what we're talking about here -- my monthly contribution is $120.43 for individual coverage for medical, dental, vision, short and long term disability, and basic life at one and a half times my annual salary. Medical alone would be $94, I pay about $13 each for the dental and short term, and the company covers the vision, long term, and life entirely. I have a $25 co-pay on office visits, $35 for specialists, up to an annual max that I don't really know because I don't go to the doctor all that often. I've never worried about or encountered something not being covered, and while I don't have a lot of comparative data, I believe I have what you would call very good coverage.

If someone who works for a small company or is self-insured wouldn't mind posting what you pay, I'd appreciate it.

Oh, also, I'm management. If I was a union employee at my company my monthly contribution for the medical would be $0, it's paid in full by the company. I'm not sure about the dental and short-term, but I wouldn't be surprised either way.

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Dagonee
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Is there any particular reason you're typing TORT over and over again, instead of tort?
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fugu13
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ElJay: most of the differences in what insurance costs employees nowadays emerges from the bargaining process between employers and insurance companies. This both distorts the market, allowing insurance companies to charge more than they might otherwise, and means that parts of insurance payments are made by the private companies, making employee costs not directly comparable. The cost paid by the employer is still a benefit to the employee, though, and did the employer not pay it the employee's salary would be higher.

Furthermore, note how I keep specifying sufficiently large insurance pools. In smaller pools, the variance in costs from year to year is very high, meaning that to ensure those contracts are profitable the insurance company needs to charge more. This also means they make more profit off of those, because across all the different small companies the average is still the same as it would be for that group of people, but since each contract needs to make money and a much higher percentage of the contracts have higher costs than for groups with similar averages, insurance companies charge more. Its more a matter of statistics than leverage.

Once you're talking about a sufficiently large pool, though, the variance effect becomes sufficiently small the group can be compared directly to other large tools, even if there's a significant difference in actual sizes.

Btw, I'm curious how you know you have as many old/overweight/smoking people as there are in the rest of the population. For instance, I'd be surprised if nearly 8.5% of your employees were over 70 (the percentage in the population from the 2000 census is about 8.4%). It doesn't take a difference of very many people, particularly for the higher risk groups, to make a huge difference in the expected cost of health care -- five percent of the population accounts for about half of total health care expenditures ( http://www.ahrq.gov/research/ria19/expendria.htm ).

Bob: notice the statistic above. Five percent of the US population incurs nearly 50% of the health care costs. Obviously not all of those would be insured, but still. This means that nearly half the population is below the average health care expenditure in the US. Everyone currently a member of a large group which has a distribution on the left side of that incredibly lopsided distribution will likely have an increase in insurance costs, and I know you know enough statistics to know that's going to likely include a large number of people. As far as real world examples, that would require significant proprietary healthcare and insurance data, so its unsurprising I don't have any. However, given that insurance groups are currently frequently segregated by profession and location, and that profession and location can both have significant impact on expected health care costs, its very likely there are groups all over the distribution.

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fugu13
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Oh, as far as pools where people are young, healthy, and work in an office, look into the big four accounting firms (and associated wannabes). Tens of thousands of employees, mostly shortly out of college and from middle class families with good family health insurance. About as low risk as you can get, minus the stress of being a big four accountant.

But it doesn't matter, much, the group only has to have a slightly higher percentage of healthy people have a significantly lower expected health cost.

For instance, imagine there's a company with 10k employees, 8000 of whom have an average expected health care cost of $1k, and 2000 of whom have an average expected health care cost of $4000. The average expected health care cost for a group covering that entire company would be $1600, so health insurance for that group would have to be more than that.

Now imagine a firm where 8000 of the employees have $1k average expected health cost, and 2000 employees have a $3k average expected health cost instead. Suddenly the average expected health care cost for the company becomes $1400, a savings of $200 a year. Obviously these are entirely concocted numbers, but they should help illustrate how a relatively small change in average expected health costs for even a small-ish subset of an overall group can result in meaningful differences in overall cost.

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ElJay
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fugu, I know that the employer pays a significant chunk of the insurance cost. . . and I believe they prefer it that way, instead of paying a higher salary, because they get a tax break for it. As I understand it, they still would under the proposed plan Bob listed, except the difference is that every company would be taxed the same percentage and that money would be used to subsidize insurance costs for everyone. Thus leveling the playing field between different sized companies and companies that currently do or don't provide benefits.

My listing of my costs should be disconnected from my first post, and was more because I'm interested in what the disparities actually are between someone like myself, who (I think) has a pretty good deal, and someone who isn't part of as large a barginning pool. I know that can't be a direct comparison without knowledge of exactly what percent the companies pay, but it can give an idea.

For demographics, I should have said as many old people as the rest of the working population. I'd also be surprised if 8.5% of our employees were over 70, but I'd also be surprised if a very high percentage of people over 70 are working at all. We do have several people over 60 that I'm aware of, and all of my employees are old enough to be my mother. For smokers and overweight, I know more smokers at work (by far) than I know in the rest of my life combined. Driving/walking by my building at any one time you'll see more people outside smoking than in front of any other building downtown of any size. (Indoor smoking in the workplace is illegal in my city, so I don't think it's just that other buildings have snoking lounges.) I'll count at lunch tomorrow, if you like. And 6 people in my office of 200 have undergone gastric bypass surgery in the last 2 years. So that's at least 3% morbidly obese. For just "overweight," I'm eyeballing it. [Razz]

Added: Forgot to mention, we also have a planning group working on the fact that a high percentage of our middle management staff is approaching retirement age and we don't have enough younger managers in the pipeline to replace them. That's another reason I think we have at least as many "older" employees as most other companies out there.

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