Miscellaneous And Off Topic Subjects

[Dr. Strangelove]

House Intel Committee wants Trump to turn over any evidence that Trump Tower was wiretapped by tomorrow

http://thehill.com/homenews/house/323554-house-intel-committee-calls-for-wiretap-evidence-by-monday-report

[Da Geezer]

Jeff, I don't disagree but, DaGeezer is not looking for reasoned well thought out discussion. He spouts talking points and refuses to engage in critical thinking about these issues. Anyone who wants to discuss issues and exchange ideas, I'm in.

Well....my thoughts on the matter arise from actual experience with a pre-existing condition. In 1958, my bill read simply "Geezer.....Surgery.....$5,000". There was no insurance for what was then considered experimental surgery. In 1967 I had insurance.

I'm simply saying that the trade-off of buying health insurance when a person comes of age, with the "threat", if you will, of no coverage for pre-existing conditions, in my experience, is sufficient to induce reasonably mature persons to acquire at least some form of health insurance. Of course, a 26-year-old may choose not to get insurance, but he might get it at age 30, 35 or 40. But at those ages, there would be some sort of time period, like 2 years or so from the inception of the policy, during which the person would not be covered for pre-existing conditions (the way it was before the ACA).

The problem with the individual mandate is obvious. If the government can require you to buy something that sounds reasonable today, they can require you to buy (or not buy) something that may be unreasonable tomorrow. Everything we do has some connection to our health and therefore everything we do can be regulated through control of health care. That is the reason that those who seek control over others seek control over health care delivery and over education as the twin pillars of communism/socialism/statism.

[Dr. Strangelove]

Paul Ryan was asked directly today whether more people would have coverage under the new plan. He said: "That's up to the people to decide". This, to me, is a tacit admission that fewer people will soon have health insurance because they will be asked to pay a lot more for it or choose their IPhones, to put it in the binary that Jason Chaffetz chose.

[SeattleLionsFan]

Talent,
I know you were talking politics and not policy, but you are dead right. Everyone gets sick at some point. Even if you've lived a virtuous life, at some point you'll get sick. This is exactly why insurance is a terrible model to pay for that health care, at least as it is now. There's not really a risk that you'll get sick. You'll get sick. Insurance just adds unnecessary inefficiency in the system.

So the questions really should be, IMO, 1) as a society how much are we willing to let people not receive healthcare services, and 2) what is the best mechanism to ensure that those services are paid for?

I think as a society we should try to treat everyone, but only for the most serious conditions. Heart disease, cancer, aids, catastrophic injuries, etc. Convenience problems (colds, ED, contraception, dry eye) not so much. Of course there is much debate about what conditions go in what bucket.

To pay for this, I would suggest universal healthcare, but with caveats. 1) limited treatment options (a 10 dollar pill instead of a 100 pill that does the same thing in half the time) and 2) a high ($15,000??) deductible This should help insure people get care and docs get paid. Plus it has the benefit of incentivizing people to skip the doc for trivial matters.

The last thing would be to encourage an insurance industry to cover the deductible or uncovered treatments that people could buy, or HSA's.

The last thin is encouraging society to have real conversations about healthcare and it's necessity. Do you need to see a doctor for the sniffles? How much extraordinary care is really necessary in a end of life situation? We need to reduce demand, and those are two big drivers that I think can be changed quickly.

[Dr. Strangelove]

On another note, Sec. Price claimed this morning that no one will be worse off financially due to this healthcare bill. Which seems laughable, until you consider that he's banking on millions of people choosing to go without insurance, and therefore be 'better off financially than before".

[Dr. Strangelove]

Welp...

[ame]https://twitter.com/SteveKingIA/status/840980755236999169[/ame]

[hack]

King and Wilders probably getting their order from the same person.

[Dr. Strangelove]

There's a great deal being implied and left unsaid here...

[ame]https://twitter.com/PreetBharara/status/841000145630175232[/ame]

[iam416]

I think as a society we should try to treat everyone, but only for the most serious conditions. Heart disease, cancer, aids, catastrophic injuries, etc. Convenience problems (colds, ED, contraception, dry eye) not so much. Of course there is much debate about what conditions go in what bucket.

Yeah, it's the car insurance model, right. You pay for your oil changes, new filters, new spark plugs and other general maintenance. You get in a wreck then you don't have to pay the thousands.

If your model could work, then I'd be on board. As a side note, I think the more routine services -- physicals, flu shots, hey, I'm sick! and other stuff borders on a commodity good. If it's a commodity good, paying out of your own pocket + competition should drive prices as low as they can be. Cancer and surgery and other shit -- that's not a commodity good.

The one thing nearly everyone seems to agree on is that you ought not go bankrupt or lose your house or whatever because you fell victim to some sort of malady. Addressing that as the core principle -- which is what you do -- makes a lot of sense to me. The more you move away from the principle, the less I think government ought to be involved in any way.

[Jeff Buchanan]

With respect to health care there are two fundamental starting points that have to be identified before there can be meaningful discussion.

First, one has to decide who or what entity they think has responsibility for paying the cost of maintaining an individual’s good health or mitigate failing health. Is it the individual, the employer, government or some combination of the three? One can make a good case for any or all of these being responsible. But you have to pick one before you can explore the second starting point: delivery of the care.

I think, with respect to the question of who or what entity has the responsibility for paying for the cost of care, or in this case, a part of it, I'll go the hybrid approach. For the government's role in providing HC, the Medicare/Medicaid model works and there is a good deal of research that demonstrates it does. I was in favor of the ACA’s Medicaid expansion. I no longer am – too costly and it was a step towards a single-payor system that I am now opposed to. Drop back and re-think this one.

Fundamentally, these two programs (Medicare and Medicaid pre ACA), paid for by the Federal government, are your safety nets.

What isn’t working in my view, and I’m tending to agree with Geezer, is the current situation and expectation by the employed where employers pay for health insurance for their employees. The reason it isn’t working has a lot to do with how health care is delivered and the inherent lack of any mechanism to track outcomes and find efficient processes to deliver the best outcomes at the lowest cost. So, I’ll move on to discuss that second starting point.

A fundamental change is needed in the way care is delivered. Currently, care is delivered in a disorganized way with the patient entering the care process by seeing any number of providers, generalists or specialists, despite attempts to limit that - none of that working at all. Then the care seeker moves randomly, without coordination, between any number of providers of care. At the endpoint, some ill-defined outcome is achieved. Or not.

Individual HC entities from independent practitioners to large HMOs (e.g., Kaiser - and the trend is in this direction with big hospital corporations offering birth to death HC plans) compete for the largest piece of the HC reimbursement pie they can grab and this is regardless of outcomes. Keeping the lights on and remaining profitable is dependent on the number of encounters generated and procedures completed. Each encounter and or procedure is separate from the others, and no one coordinates the care.

One example - robotic surgery came to the surgical specialties and hospitals about 5-10y ago. The equipment and OR suites required to perform robotic surgeries are massively expensive. Do they produce better outcomes? Do they lower costs? Despite tons of research and studies to show they do both, they don't conclusively lower costs or produce better outcomes. They are fancy Cadillac care for big hospitals to market and market them they do passing both the capital investment costs and the high cost of these procedures on to the HC consumer.

In the current delivery model, duplication of effort, delays, inefficiency and high costs are inevitable. No one is measuring patient outcomes, how long the process takes, or how much the care costs. Because of this the value of care never improves; it just gets more costly in an environment where providers of care, large and small, are profit and margin driven in its delivery (see above example). In the current model, the one outside of Medicare/Medicaid, employers just pay more to get medical care for their employees or, more likely and this is the trend, they shift the uncontrolled rising costs of that care to the employee.

This says nothing about the under 65 unemployed who do not qualify for Medicaid or those choosing to not get HC insurance. This group is simply priced out of the market by the upward pressure and spiraling costs of HC paid for by deep pocketed employers who either feel compelled to provide these benefits to employees or are locked into union contracts to provide benefits to current workers and retirees.

There are examples of health care delivery entities, even now in the US and abroad, that have shifted from being profit and margin driven in the delivery of care to being value driven. The best of them embracing this fundamental shift, have organized into Integrated Practice Units (IPUs). In this delivery model one medical condition, for example diabetes or low back pain, is evaluated and treated within a designated IPU for that condition with mechanisms in place to track the best processes to achieve the best outcome for that condition at the lowest cost. These are just two examples of a wide range, literally thousands, of conditions that can be grouped together into IPUs.

This approach can be exquisitely shaped by free market factors. Organizations that are cost effective and deliver the best product (outcomes) within an IPU at the lowest cost will thrive through their own efficiency and those that don’t will wither. There is a ton of nitty gritty, business stuff to this and I've linked to one of many articles on the subject of health care delivery using this model. It is a classic example of the effect of competition that in an appropriately regulated free market environment can succeed.

I’m not exactly sure what kinds of government involvement are required to regulate the HC market place, if any. Those talking about the concept of IPUs generally see that HC entities organizing like this will do well by simply being the cheapest way to offer HC across a wide array of IPUs providing specific types of care.

Insurance companies would purchase services from the cheapest HC entities doing this and sell individual insurance policies to consumers. Policy pricing, like life insurance, would be based on risk. Federally subsidized high risk pools, e.g, end of life and neonatal intensive care - two of the most expensive elements of the HC product, could be implemented.

In conclusion, repeal the entirety of the ACA – it was implemented without much thought given to the requirement to identify the two fundamental starting points for decision making and program implementation - who provides HC and how is it provided. Keep Medicare/Medicaid (pre ACA) and phase out employer provided health insurance.

https://hbr.org/2013/10/the-strategy-that-will-fix-health-care

[SeattleLionsFan]

I don't know that I agree that the question of who pays for health insurance is really Herman to the situation. At least in Washington, the group health market is the only one that works outside of the ACA mandate.

[Dr. Strangelove]

It's official...Scotland seeking to hold another independence referendum next year or early 2019

[iam416]

Yeah, if they really want to trade London rule for Brussels rule and go down in flames with the EU, then, well, that would be a quintessentially Scottish decision.

[hack]

I haven't see anything specific on this, but I presume that North Sea oil would go with them. That revenue could go from supporting 65m people to 5m.

[froot loops]

The UK is in a pickle, the Brexit talks are not going well. Having a second Scottish referendum was assured after the Brexit vote.