Gas Bandit's Political Thread V: The Vampire Likes Bats

[GasBandit]

If you could explain the step between current fucked up system and competitive market place I might consider it. But so far you've only insisted that market forces are the only way to do it while ignoring all the complications that would entail.

Oh, everything is complicated, I don't disagree there - if there was a simple way to fix such things, it'd have been done already.

The last few dozen times it's been brought up, I've given some examples of how to get the ball rolling in the right direction. First of all, we have to decouple insurance from health care providers. Make it stop being a medical payment plan, but instead return to being actual insurance, a vouchsafe against catastrophic circumstances, not something that is expected to be the purse for all medical expenses. Get them away from being provided by employers, because most people don't get a choice of who their insurance company is, it's whoever their employer contracts with, so that's another place competition and individual choice is cut out. A possible mid-step solution may be switching employer plans away from insurance into an HSA, and let the employee obtain their own insurance. The insurance company also must not be the "customer" of the health care provider, it needs to all be through the patient, so as to remove opportunities for collusion and to make "in network" be an obsolete concept. As Krisken says, prices need to be publicized up front so that consumers can compare.

The immediate problem most people bring up at this point is that when you're bleeding out on the pavement, you don't have time to compare prices. I'll refer to a previous post at this point -

Let me just throw this idea out there, off the top of my head.
The primary problem, as you point out in an extremely emotional way, is that when a loved one is turning blue or bleeding out, you don't have time to comparison shop. But when you call 911, you aren't calling a specific ambulance or hospital or emergicare company, you're calling a government switchboard. They are the ones who decide which ambulance comes to pick you up. What if they started using a technology that has been around for at least 20 years - the electronic auction? The healthcare providers (or rather their administrators) can submit "bids" as often as they like for the all-inclusive cost of an ambulance trip to the emergency room, and when a call comes in, the dispatcher has an easy interface showing the least expensive bids and their locations. There's no time delay involved because the ambulances were bidding on responding to your emergency, days, even weeks, before your emergency even took place. As companies fail to win bids realize that slightly less money is better than no money, they'll lower their bids for the next emergencies, which will cause the other companies to do the same when they see they're not winning bids, and over a relatively short amount of time, there's a very palpable shrinking effect on the cost of an ambulance ride. This is the kicker - for capitalism to work, there has to be competition. Most of the problems with the price of our medical care has come about as a result of collusion aimed to undermine competition.

Is this idea perfect? No. Is it better than what we have? I think so. Are there even more options, that were not thought of by a layman over the course of a weeknight's sleep? Wouldn't be surprised at all.

But those aren't the debates we're having, either here, or on a national scale. It's locked into "status quo vs single payer," because the people at the top level of this debate have their own axes to grind, and that trickles down through the tribalism. Big Medicine has deep pockets, so they buy one side, and their street-level minions follow along because the OTHER side are headed up by the Ruinous Powers - the socialists, and their every-man-on-the-street followers are just as rabid because not accepting socialism means you want families to die horribly in squalid and abject poverty, you privileged scum.

But the truth is there's more than one way to skin a cat, and it doesn't take much looking at the underlying causes of the problem to find those other ways.

Do you really not know the term invisible hand of the market? I thought you at least had to know who Adam Smith is to call yourself a Libertarian.

Oh, I know it, I just don't use it, because it sounds too quasireligious/mystic, which feeds into the exact kind of "invisible magical nonsense" argument that detractors are so fond of making. So, when you mock the "invisible hand of the market" as rhetoric against me, you are in fact committing a straw man fallacy - you're arguing against someone else's metaphor to try to disprove me.

Have literally never heard anybody but you use that phrase. Especially since insurance never covers all of the costs.

I'm surprised, because it's the prevailing sentiment on how laypeople think medical insurance is supposed to work. "I pay my $250 a month, pound my infant with amoxicillin until it stops sniffling forever because it's paid for."

That doesn't stop airfare, automobiles, internet, hotels, banks, ticket vendors, real estate, etc. etc. etc. from having hidden fees. I'm really not seeing how competition forces businesses to be up front about costs.

"Hidden" is a relative thing. When I buy an airline ticket, the final price is always given to me up front. I don't care how they break up that cost into "hidden fees" at the time, I pay them once and know how much it is I'm paying. Same goes for every car I've ever bought. And in each case, those prices are already as low as they are because I have the option to always, at any moment, say "nope, I'm not paying that, I'm going somewhere else." You'll seldom see a price come down faster than when a car salesman is watching someone put their checkbook back in their pocket.

 

[Frank]

Hey y'all, abolish ICE.

https://www.thedailybeast.com/trans...fore-death-pathologist-finds?via=twitter_page

 

[Eriol]

You'll seldom see a price come down faster than when a car salesman is watching someone put their checkbook back in their pocket.

Or a Jewelry Salesman. You should have seen how much of a "Deal" I could have gotten on my girlfriend's (now wife) engagement ring when we were ring shopping before we were "really" engaged (though when you go ring shopping together, haven't you "kind of" asked at that point?). This guy dropped the price of something from something like $6k to less than $3k. In the end, I surprised her with something else, but it was tempting on-the-spot, and (probably) wasn't crap either.

 

[AshburnerX]

Or a Jewelry Salesman. You should have seen how much of a "Deal" I could have gotten on my girlfriend's (now wife) engagement ring when we were ring shopping before we were "really" engaged (though when you go ring shopping together, haven't you "kind of" asked at that point?). This guy dropped the price of something from something like $6k to less than $3k. In the end, I surprised her with something else, but it was tempting on-the-spot, and (probably) wasn't crap either.

This is happening a lot now because Jewelry sellers are desperate to unload inventory. Diamonds, especially diamond engagement rings, are something else we millennials are killing (by not making enough money to waste money on one). Most of the millennial couples I know went with plain gold/silver rings.

 

[Dubyamn]

Oh, I know it, I just don't use it, because it sounds too quasireligious/mystic, which feeds into the exact kind of "invisible magical nonsense" argument that detractors are so fond of making. So, when you mock the "invisible hand of the market" as rhetoric against me, you are in fact committing a straw man fallacy - you're arguing against someone else's metaphor to try to disprove me.

Awww I'm sorry I'm using a term correctly but you are none the less offended by it.

I'm surprised, because it's the prevailing sentiment on how laypeople think medical insurance is supposed to work. "I pay my $250 a month, pound my infant with amoxicillin until it stops sniffling forever because it's paid for."

So your understanding is that it's the cost of amoxicillin that is bankrupting the helathcare system. Also that apparently that medical insurance pays for the entire cost of the amoxicillin.

 

[Krisken]

I mean, it’s a diamond ring, which has its price artificially inflated to begin with.

 

[Dei]

I have a really small diamond engagement ring because at the time my husband and I got married/engaged we were poor as fuck. My mother keeps acting like I should upgrade my ring because we have more money now, even though I hate big jewellery and prefer the sentimental value of the ring I have. It's very irritating to me.

 

[GasBandit]

Awww I'm sorry I'm using a term correctly but you are none the less offended by it.

No, you aren't using it correctly, because you're trying to use it as a wedge to ridicule terminology I am not using. I'm sorry you're so bad at argument.

So your understanding is that it's the cost of amoxicillin that is bankrupting the helathcare system. Also that apparently that medical insurance pays for the entire cost of the amoxicillin.

Of course not, what, did @lien steal your login info? Because you're pulling the same bullshit he does. I'm using hyperbole to illustrate the common, flawed expectations of the layperson, along with a side reference to similar idiocy bringing about antibiotic resistance problem.

I mean, it’s a diamond ring, which has its price artificially inflated to begin with.

Indeed. Health care does as well.

 

[Dubyamn]

No, you aren't using it correctly, because you're trying to use it as a wedge to ridicule terminology I am not using. I'm sorry you're so bad at argument.

It would be you're so bad at arguing not your so bad at argument.

Of course not, what, did @lien steal your login info? Because you're pulling the same bullshit he does. I'm using hyperbole to illustrate the common, flawed expectations of the layperson, along with a side reference to similar idiocy bringing about antibiotic resistance problem.

Like I said I've never heard anybody say anything like that. Every person I've ever known has known that a illness is going to cost them with insurance less than without insurance. But you can see why it's confusing when you say that one of the big problems in healthcare is that people don't know what anything costs and don't care and the example you provide is giving amoxicillin to a child. You can see that right?

I have however heard doctors shocked at what the treatments they have given me cost.

 

[figmentPez]

"Hidden" is a relative thing. When I buy an airline ticket, the final price is always given to me up front. I don't care how they break up that cost into "hidden fees" at the time, I pay them once and know how much it is I'm paying. Same goes for every car I've ever bought. And in each case, those prices are already as low as they are because I have the option to always, at any moment, say "nope, I'm not paying that, I'm going somewhere else." You'll seldom see a price come down faster than when a car salesman is watching someone put their checkbook back in their pocket.

No, the final price is not given to you up front. The airline looks for chances to upsell you all the time. Baggage fees, charges for drinks. If you get to the airport with bags that are too heavy, it's to late to avoid that fee; unless you want to leave your bag behind. Want to have something to drink on the plane? Hope you brought your wallet. You really think hospitals won't do exactly the same thing? They'll charge for every extra thing they can, and anyone who doesn't know enough to prepare beforehand will have to pay. Let me tell you, there is no way to account for every possible thing before checking into the hospital, and not everyone will have the option to change hospitals once they've started treatment. It's not hard for a traveler to weigh their bag before heading to the airport, if they've read the fine print. Hospitals are much more complex. You really think that even after an expert reads all the fine print that they'll be adequately prepared to provide an alternative to every upcharge a hospital can throw at them? Even when some of those extra charges will be emergency situations that are life or death?

When you're talking banking, it's easy to say "to avoid overdraft fees, just carefully balance your checking account". It's a lot harder to say "to avoid a defibrillation fee, just avoid flatlining on the operation table." What about going to the emergency room for treatment? Yeah, really great time to shop around and decide if you're willing to pay the fee. Good luck getting a flat fee up front before diagnostics even start. Oh, and are you really going to say "no, that's too expensive, take me to another hospital" when you're in danger of dying without immediate treatment?

Medical care isn't like buying a car. It isn't even like going on a trip. It's a lot more complicated. I can't even imagine the spreadsheet it would take to compare prices for hospital stays where each has a base fee, then additional charges for additional diagnostic tests, food charges, bed charges, extra care charges, etc. etc. Even "simple" procedures would get extremely complicated when you account for possible emergency services.

 

[Fun Size]

When my kids were born, going through the bill and calling bullshit on everything we didn't get but they charged us for was exhausting.

 

[Krisken]

No, you aren't using it correctly, because you're trying to use it as a wedge to ridicule terminology I am not using. I'm sorry you're so bad at argument.


Of course not, what, did @lien steal your login info? Because you're pulling the same bullshit he does. I'm using hyperbole to illustrate the common, flawed expectations of the layperson, along with a side reference to similar idiocy bringing about antibiotic resistance problem.


Indeed. Health care does as well.

Lol, one is superficial, one is literally life or death. C’mon, you can’t possibly equate the two.

 

[GasBandit]

It would be you're so bad at arguing not your so bad at argument.

That's really splitting a hair there. Ahem - Webster's first definition of Argument as a verb does not use the -ing suffix (really that would be the present participle form of argue - and there's a difference between arguing and argument). Besides, is grammar really all you have left to fall back on at this point? Wouldn't you like to address any of the other things I said in post 16,486 OTHER than a single, nitpicked line of hyperbole? Especially since you specifically requested me to post them?

Like I said I've never heard anybody say anything like that.

Well, alright then.

Every person I've ever known has known that a illness is going to cost them with insurance less than without insurance.

Well, yes (assuming the illness takes them above their deductible), but that's a separate matter from what I'm saying - they may know they'll be charged differently, but they also don't know what the charge will be, and they assume that (beyond a certain point) it'll mostly be the insurance company's problem, anyway.

But you can see why it's confusing when you say that one of the big problems in healthcare is that people don't know what anything costs and don't care and the example you provide is giving amoxicillin to a child. You can see that right?

Alright, I will concede that I shouldn't mix one gripe into another. What I should have said was something like "I pay my premiums and here's the amount of my deductible, so bring on everything you've got for treatment, I'm not even going to ask how much it costs."

I have however heard doctors shocked at what the treatments they have given me cost.

Yeah. I always have to be careful when I have this discussion not to say that doctors are overcharging because most of the time the doctors have no idea what is being charged for their services, and it would be futile for them to even attempt to learn because it varies from situation to situation. Rather, I try to use the term "health care providers" to generalize, and shift the blame for the collusion to the administrative health care staff who keep the chargemaster locked away and are a huge part of the problem.

No, the final price is not given to you up front. The airline looks for chances to upsell you all the time. Baggage fees, charges for drinks. If you get to the airport with bags that are too heavy, it's to late to avoid that fee; unless you want to leave your bag behind. Want to have something to drink on the plane? Hope you brought your wallet.

I really hate to be put in the position to defend airlines here, because they do do a lot of bogus shit, but at this point the baggage thing is well known and no longer a surprise to anyone, and I don't really think you can call the cost of a drink a "hidden fee."

You really think hospitals won't do exactly the same thing?

Not to be a broken record, but I was in the hospital this year. And yeah, they did try to tack on an x-ray I'd already paid for. But you know what they didn't do? Stop everything until I got out my wallet. They sent a bill for it later, which I disputed.

Medical care isn't like buying a car. It isn't even like going on a trip. It's a lot more complicated. I can't even imagine the spreadsheet it would take to compare prices for hospital stays where each has a base fee, then additional charges for additional diagnostic tests, food charges, bed charges, extra care charges, etc. etc. Even "simple" procedures would get extremely complicated when you account for possible emergency services.

It's gotten this way because the current environment has cultivated such processes - IE, they're going to send as bloated an invoice as possible to your insurance company, who's going to then dicker and kibitz and send it back, and the dance keeps going. We've got to burn down this private little garden that's been growing between hospitals and insurers, and make it in the hospital's interest to simplify charges instead of complicate them. Because when they're in competition, as soon as one starts doing it, the others are going to have to outdo that to stay in the running. Granted, we also do need to be watching for collusion like a hawk.

When my kids were born, going through the bill and calling bullshit on everything we didn't get but they charged us for was exhausting.

I can only imagine. Maybe there ought to be some sort of penalty for falsified charges, allowing a small grace margin for honest mistakes.

Lol, one is superficial, one is literally life or death. C’mon, you can’t possibly equate the two.

That they are different products of varying degrees of demand doesn't mean the prices of both aren't artificially inflated.

 

[figmentPez]

Not to be a broken record, but I was in the hospital this year. And yeah, they did try to tack on an x-ray I'd already paid for. But you know what they didn't do? Stop everything until I got out my wallet. They sent a bill for it later, which I disputed.

And what would you have done if it weren't a bogus charge? What if it were a legitimately necessary, but incidental, procedure that they were just wildly overcharging for? Something that was not part of the plan for the procedure, but became necessary because of complications.

and I don't really think you can call the cost of a drink a "hidden fee."

Well, you can't bring your own water on the plane, and yes some airlines do charge for non-alcoholic drinks. Going the length of a flight without water is possible for some, not possible for others. This directly relates to how medical charges stack up. Some people who check into a hospital will incur extra expenses that others won't, and it's not as easy to predict as who will need water. Want to make a spreadsheet comparing all the possible extra costs? Because that's what's going to be necessary to know the true cost of any hospital stay in advance.

You're basically asking people to gamble on if they're one of the lucky few who will get their medical fees subsidized by those who run into, sometimes unavoidable, additional charges.

 

[GasBandit]

And what would you have done if it weren't a bogus charge? What if it were a legitimately necessary, but incidental, procedure that they were just wildly overcharging for? Something that was not part of the plan for the procedure, but became necessary because of complications.

There's a concept already established in such areas, including medicine, of Fair Market Value for services. For example, they come up in regards to something called Stark Laws, which aren't all that relevant to what we're talking about here - they mostly deal with preventing doctors from making referrals to entities with which they have a financial arrangement - but this does establish that "fair market value" of medical services is a legal concept that exists in health care.

Thus, a hospital in our hypothetical situation could not invent an absurd amount for a service you need while admitted to their care, and if they tried to do so, under the "costs published up front" model we're talking about, you could point to their own published prices and those of their competitors to demonstrate fair market value. So, if it was something you did need, and they did provide it, they still shouldn't be able to "gotcha" you with a ridiculously overinflated cost for that service.

 

[figmentPez]

There's a concept already established in such areas, including medicine, of Fair Market Value for services. For example, they come up in regards to something called Stark Laws, which aren't all that relevant to what we're talking about here - they mostly deal with preventing referrals to entities with which you have a financial arrangement - but this does establish that "fair market value" of medical services is a legal concept that exists in health care.

Thus, a hospital in our hypothetical situation could not invent an absurd amount for a service you need while admitted to their care, and if they tried to do so, under the "costs published up front" model we're talking about, you could point to their own published prices and those of their competitors to demonstrate fair market value. So, if it was something you did need, and they did provide it, they still shouldn't be able to "gotcha" you with a ridiculously overinflated cost for that service.

So, what you're saying is that you'd be relying on government regulation to keep the costs in check, and not competition between businesses? We're right back to the fact that the system you're promoting is not "capitalism" but something that uses capitalistic principles that are combined with the government protections of other systems.

Also, you don't seem to be accounting for the fact that the hospital you're at could just be charging a ridiculous amount on a regular basis for the procedure you underwent in an emergency circumstance. That could very well be their normal price for the procedure, knowing full well that most people won't choose to get that specific procedure from them, while they'll still be able to make a nice profit from all the people who need it as an in conjunction with some other procedure. Once again, medicine is not like buying a car. You don't go into a car dealership, and unexpectedly find yourself needing to get a bike rack added on in a life or death situation. (But the car dealer might very well carry bike racks, sold at 10x the cost of getting one at a bike shop, and 20x the cost of one from Amazon.) You might, however, go into a hospital that specializes in heart treatment, and suddenly find yourself in need of an epinephrine shot because you had an unknown allergy. "Oh, what's that? Other hospitals only charge $500 for that? Well, we charge $3,000, it's on our books, if you came to us asking for it, that's how much we'd charge you."

We're back to "Fire vs Cave". The inevitable result of fire is burning everything to the ground. It's only when fire is controlled that it's useful. You have to build up systems to keep fire in check in order to use it. Seems to me that's a damn good comparison to capitalism. The inevitable result of unconstrained capitalism is businesses using their capital to exploit others. It's only through systems built up to keep that in check that the competition provided by capitalism can be used safely. There must be checks and balances put on the system by government in order for it to work. Which means it's ridiculously unfair for you to compare your specific type of "capitalism" to any and all forms of "socialism", lumping it all together and declaring one failure the responsibility of all other vaguely associated concepts.

I don't see why a universal health care system couldn't do the exact same thing as an individual shopping for prices. How is the government determining "fair market value" in your "capitalist" system differ from determining "fair market value" in a "single payer" system? Because it can't be based solely on how it's decided if the procedure happens, because we were just talking about emergency procedures, which you said were still made cheap by "fair market value" and the competition of your system. Most health care isn't optional, and quite a bit of it is time sensitive.

I'm done arguing with you, because you keep rigging the system to compare your hypothetical ideal against cherry picked examples of existing systems that failed. You deny that any failure of a capitalist system has anything to do with your own proposals, often claiming that government regulations are to blame for the failure, while your proposed system explicitly relies on government regulations to make it work.

 

[PatrThom]

they're going to send as bloated an invoice as possible to your insurance company, who's going to then dicker and kibitz and send it back, and the dance keeps going.

Even just this would make me so much happier. I hate FINALLY getting a bill for some service from eleven months ago, because by then I don’t even remember what was done, whether it is accurate, or even if the physician listed is even still with that particular hospital.

—Patrick

 

[Dubyamn]

That's really splitting a hair there. Ahem - Webster's first definition of Argument as a verb does not use the -ing suffix (really that would be the present participle form of argue - and there's a difference between arguing and argument). Besides, is grammar really all you have left to fall back on at this point? Wouldn't you like to address any of the other things I said in post 16,486 OTHER than a single, nitpicked line of hyperbole? Especially since you specifically requested me to post them?

Oh I'm sorry are only you allowed to ignore an entire argument to make fun of one little thing?

As for your points I actually agree in separating insurance from employment. However HSAs are in no way a solution even in the midterm due to the way that years worth of savings can be wiped out by small hospital stays. Then of course you have people going out into the single payer market which has really only become civilized after the ACA which if it was implemented fully would do more good for more people than your idea.

As for the Emergency bidding idea I think the biggest problem would be how it would swamp certain ERs and leave others empty. It also would result in a concentration of Ambulances around the ERs with the lowest bids while other areas have no Ambulances nearby. It also doesn't address people who take themselves to the ER or are driven by family members which is the way I've always gotten to the ER. I assume that there can be various fixes to that but after all of that you will still have people getting ER bills that they just aren't able to pay. I mean the majority of Americans would be wiped out by a $600 emergency. I think I've had a bill lower than that once and that was because I walked out AMA when they wouldn't provide me the kind of treatment that I needed. Right now those free riders are covered by the increased costs on the rest of us because the hospitals aren't going to lose money so they'll make up the difference in other ways.

It also doesn't really solve the big problems of the Healthcare system. Those being super users who are the 5% of the population that are responsible for 50% of the healthcare costs and end of life care which are by far the biggest healthcare costs. In a system that you advocate those 5% of people are effectively dead since they would never be able to pay of those bills even if those bills were cut in half.

Honestly I think that getting the super users into the VA and setting up a government hospice care system would do more to solve the problem than all of your ideas put together. And it would be far more humane than sucking the kids with cancer dry and then sending them home to die in pain.

Alright, I will concede that I shouldn't mix one gripe into another. What I should have said was something like "I pay my premiums and here's the amount of my deductible, so bring on everything you've got for treatment, I'm not even going to ask how much it costs."

Ah yes the person who can be terribly casual about dropping $10,000 because the rest of their bill will be paid by insurance.

 

[Dei]

HSAs are a terrible solution because for the most part, people who can afford to pay into them could afford service anyways, and those who really can't probably aren't getting taxed on that money anyways.

 

[GasBandit]

So, what you're saying is that you'd be relying on government regulation to keep the costs in check, and not competition between businesses?

I'm not sure how this follows. I'm not, nor have I advocated, complete anarchy or freedom from laws and regulations. Part of the definition of fair market value is a that it is set in a situation where neither party is under duress to pay it. The competition is what lowers the fair market value to affordable levels. After all, as things stand right now, if you go off the hidden chargemasters, fair market value might still be ruinously high for some things - the aim of competition is to force those numbers out in the open (which naturally will shrink them), and once there, the law says that you can't say you'll charge one price and then charge another.

Also, you don't seem to be accounting for the fact that the hospital you're at could just be charging a ridiculous amount on a regular basis for the procedure you underwent in an emergency circumstance. That could very well be their normal price for the procedure, knowing full well that most people won't choose to get that specific procedure from them, while they'll still be able to make a nice profit from all the people who need it as an in conjunction with some other procedure... "Oh, what's that? Other hospitals only charge $500 for that? Well, we charge $3,000, it's on our books, if you came to us asking for it, that's how much we'd charge you."

I did account for that. That's what FMV is. And what you describe is known as bad faith, and already can get them into trouble.

We're back to "Fire vs Cave". The inevitable result of fire is burning everything to the ground. It's only when fire is controlled that it's useful. You have to build up systems to keep fire in check in order to use it. Seems to me that's a damn good comparison to capitalism. The inevitable result of unconstrained capitalism is businesses using their capital to exploit others. It's only through systems built up to keep that in check that the competition provided by capitalism can be used safely. There must be checks and balances put on the system by government in order for it to work. Which means it's ridiculously unfair for you to compare your specific type of "capitalism" to any and all forms of "socialism", lumping it all together and declaring one failure the responsibility of all other vaguely associated concepts.

You've built some caricature of my position that doesn't actually apply to my arguments, here. I've not advocated for unrestrained capitalism, I've only advocated against socialism, and pointed out that the system as it stands does not represent properly functioning capitalism (and socialists are erroneously saying it DOES represent it, or even moreso, is its natural endgame). I've advocated increasing competition, not abolishing oversight, and certainly not eliminating competition by going from a 4-payer system to a single-payer system.

I don't see why a universal health care system couldn't do the exact same thing as an individual shopping for prices.How is the government determining "fair market value" in your "capitalist" system differ from determining "fair market value" in a "single payer" system?

Because in the former example, the government simply picks prices (and approves procedures), whereas in the latter example, market competition sets prices and the individual approves procedures.

Because it can't be based solely on how it's decided if the procedure happens, because we were just talking about emergency procedures, which you said were still made cheap by "fair market value" and the competition of your system. Most health care isn't optional, and quite a bit of it is time sensitive.

Yeah, a lot of it will necessitate advance publication of rates, and a little bit of consumer watchdog activity. The prices cannot be hidden, and ideally also be called out in advance by kibitzers who can say things like "Mercy Hospital is trying to charge 5x what it should for the XYZ drug, which is often but not always needed in the wake of Lumbego surgery, whereas MediPhysicians Centre actually charges a little under the rate," etc. That sort of thing already happens as it stands, and it exerts downward pressure on prices. It isn't instant, I grant you, but it does lower prices within a reasonable amount of time.

I'm done arguing with you, because you keep rigging the system to compare your hypothetical ideal against cherry picked examples of existing systems that failed. You deny that any failure of a capitalist system has anything to do with your own proposals, often claiming that government regulations are to blame for the failure, while your proposed system explicitly relies on government regulations to make it work.

I never claimed it didn't! I have explicitly, multiple times, said that government has a role in this process - but that that role is not to BE the process. Government's role in these matters is to enforce good faith and competition, not to be the store. You can decide you're "done" if you want, but don't kid yourself that I'm being ludicrous and you're not.

As for your points I actually agree in separating insurance from employment. However HSAs are in no way a solution even in the midterm due to the way that years worth of savings can be wiped out by small hospital stays. Then of course you have people going out into the single payer market which has really only become civilized after the ACA which if it was implemented fully would do more good for more people than your idea.

The ACA cooked the books to pay for 10 years of subsidies with 7 years of taxes, and double dipped on projected medicare savings. It's insolvent, and coming apart at the seams. I think you'd find HSAs to be much more of a viable option if the money that employers were putting towards insurance premiums went into the HSA instead, it'd help build it up a lot faster. But yes, there'd probably be a little bit of roughness during the transition period. Roughness is preferable to collapse, however.

As for the Emergency bidding idea I think the biggest problem would be how it would swamp certain ERs and leave others empty. It also would result in a concentration of Ambulances around the ERs with the lowest bids while other areas have no Ambulances nearby.

The "bids" would not be infinite, but rather a number of bids would be entered in the system from each provider according to the number of cases they think they could handle at that time. As their bids are used up in the system, other bids would become prominent.

It also doesn't address people who take themselves to the ER or are driven by family members which is the way I've always gotten to the ER.

Well, that's a valid point too, but as you say there are probably ways to deal with that as well.

I assume that there can be various fixes to that but after all of that you will still have people getting ER bills that they just aren't able to pay. I mean the majority of Americans would be wiped out by a $600 emergency. I think I've had a bill lower than that once and that was because I walked out AMA when they wouldn't provide me the kind of treatment that I needed. Right now those free riders are covered by the increased costs on the rest of us because the hospitals aren't going to lose money so they'll make up the difference in other ways.

There's a middle ground, surely a great deal lower than where prices are right now. Forcing competition in the various manners I've described, plus more that are no doubt out there, will help to find the balance between affordability and indigence. After all, how things are NOW, hospitals are CERTAINLY not having any problems whatsoever covering the indigent - the makeup of the staff parking lots are testament to that. The money's there to be found in their own budgets.

It also doesn't really solve the big problems of the Healthcare system. Those being super users who are the 5% of the population that are responsible for 50% of the healthcare costs and end of life care which are by far the biggest healthcare costs. In a system that you advocate those 5% of people are effectively dead since they would never be able to pay of those bills even if those bills were cut in half.

Those superusers are the same reason that government single-payer would sink as well, though. And really, it's a different animal than the 20 year old with cancer or the 30 year old about to have a baby. Are you comforable with a panel of Trump appointees deciding who gets what end-of-life care vs palliative care vs being sent home with some aspirin? I myself am not...

Honestly I think that getting the super users into the VA and setting up a government hospice care system would do more to solve the problem than all of your ideas put together. And it would be far more humane than sucking the kids with cancer dry and then sending them home to die in pain.

Eesh, with how badly the VA has been mismanaged, you really think so? I wouldn't trust any of my relatives to the VA if I could help it.

Ah yes the person who can be terribly casual about dropping $10,000 because the rest of their bill will be paid by insurance.

Hrm, I dunno about your plan, but the only time I ever had a 10k deductible was when it was part of a bundle with an HSA. Before and after that, the deductibles were much lower.

HSAs are a terrible solution because for the most part, people who can afford to pay into them could afford service anyways, and those who really can't probably aren't getting taxed on that money anyways.

What if, once employers were no longer buying your insurance for you, they instead put that money into your HSA?

 

[Dei]

What if, once employers were no longer buying your insurance for you, they instead put that money into your HSA?

But not everyone has a job that gives them insurance. So my point still stands.

 

[GasBandit]

But not everyone has a job that gives them insurance. So my point still stands.

Enough people do, however, that it can get the process started, and get the prices on the downward slope such that care becomes affordable instead of ruinous.

 

[Dei]

Enough people do, however, that it can get the process started, and get the prices on the downward slope such that care becomes affordable instead of ruinous.

Part of the reason the ACA markets exist is because people don't have insurance through work and get it through the marketplace. How many people had insurance for the first time once the marketplace became a thing? It's a pretty big number.

 

[figmentPez]

I did account for that. That's what FMV is. And what you describe is known as bad faith, and already can get them into trouble.

How is that bad faith if it's what every cardiologist charges for the procedure? An allergist might be cheaper, a GP might be cheaper, but if you're in the cardiology wing, that's the price. I'm pretty sure it's already done that way.

 

[AshburnerX]

Enough people do, however, that it can get the process started, and get the prices on the downward slope such that care becomes affordable instead of ruinous.

Many jobs that advertise having insurance don't deliver it in practice because the business will simply schedule you just under the federally mandated minimum that requires them to provide it for you or classify you as a contractor so they don't even have to jump through that loophole. Why would we trust companies to act in good faith in regards to HSAs when they already aren't doing it in regards to insurance? Why do we EVER trust companies to act in good faith with their workers?

And I'll echo the "only reason I have insurance is because of the ACA" thing from @Dei. They are STILL fighting to get back the old pre-existing medical conditions exemption.

 

[PatrThom]

HSAs are a terrible solution because for the most part, people who can afford to pay into them could afford service anyways, and those who really can't probably aren't getting taxed on that money anyways.

I don’t remember if I already posted this, but one of my wife’s Internet friends keeps horses, and that friend posted some gingerbread-covered meme about how people who keep horses live longer, to which my wife replied that people who can afford to keep horses are also people more likely to be able to afford healthcare.

—Patrick

 

[GasBandit]

Part of the reason the ACA markets exist is because people don't have insurance through work and get it through the marketplace. How many people had insurance for the first time once the marketplace became a thing? It's a pretty big number.

I was counting the pre-ACA number, which (albeit inflated for reasons I brought up in 2010) was commonly bandied about to be something akin to 47 million people, or about 18% of the population. The number of people estimated to have newly gotten insurance via ACA was about 5.4 million, putting proof to my assertions about the "47 million" figure. Even if I drop my points about how that number was wrong and we use it anyway, moving 82% of the population to this system would definitely have an effect on costs, which would then directly benefit those 18%.

How is that bad faith if it's what every cardiologist charges for the procedure? An allergist might be cheaper, a GP might be cheaper, but if you're in the cardiology wing, that's the price. I'm pretty sure it's already done that way.

That's different from what you said, you said "I know the others charge $500 but here we charge $3000" in a situation where the patient is not in a position to refuse, which is the very essence of bad-faith negotiation and definitely does not figure into fair market value (which is actually legally defined as what price would be set when both parties had the option to walk away).

Many jobs that advertise having insurance don't deliver it in practice because the business will simply schedule you just under the federally mandated minimum that requires them to provide it for you or classify you as a contractor so they don't even have to jump through that loophole.

That's not how the figures are calculated, though, and furthermore, not how hiring works. When they make you your offer, they can't tell you you're getting health insurance and then not give it to you any more than they could pay you less than agreed - all this has to be settled up front, and you have the option to walk away. And yes, every business definitely has part time staff that are part time explicitly for the purpose of not having to provide health insurance, but that isn't a "gotcha" or bad faith - it was clearly outlined as part of the offer.

Why do we EVER trust companies to act in good faith with their workers?

That's getting a little more philosophical than I think would merit this discussion.

 

[figmentPez]

That's different from what you said, you said "I know the others charge $500 but here we charge $3000" in a situation where the patient is not in a position to refuse, which is the very essence of bad-faith negotiation and definitely does not figure into fair market value (which is actually legally defined as what price would be set when both parties had the option to walk away).

How is it different than what I said? Everyone who goes into a cardiologist has the option to walk away and not get heart surgery, but if they do go through with the surgery they run the risk of having an allergic reaction and getting charged out the nose for it because they had to get treatment while they were undergoing a cardiological procedure.

What incentive, under your system, is there for a cardiologist to offer higher up front costs to offset the lost money for not having such a "hidden" fee? (which isn't hidden, it's available, it's just a roll of the dice if you'll have to pay it.)

Also, you mentioned duress earlier. How is any decision about cancer, ALS, Alzheimer's, etc. ever a decision not made under duress? Oh yeah, the option to walk away and not have treatment, such fairly made decision, solely determined by financial considerations. And there are never any medical conditions where the treatment of which has a regional monopoly. There's no comparison between the cost of infastructure for medical diagnostics and the infastructure cost for cable companies. Fucking bullshit.

 

[AshburnerX]

And yes, every business definitely has part time staff that are part time explicitly for the purpose of not having to provide health insurance, but that isn't a "gotcha" or bad faith - it was clearly outlined as part of the offer.

Booking someone 1 hour under the federally mandated minimum, consistently, isn't "part time staff", it's 39 hours a week with expected "off the clocks" overtime. It is explicitly exploitation and vastly different than hiring a handful of workers for 15-25 hours a week. It's also the only work a lot of people can get when they are too experienced to be treated as disposable but no one actually wants to promote them to the position they are actually fulfilling.

It's the Lance Corporal of the retail world; you're not getting that promotion and the benefits with it unless someone dies or fucks up severely, but leaving might not be an option ether.

 

[Dei]

I was counting the pre-ACA number, which (albeit inflated for reasons I brought up in 2010) was commonly bandied about to be something akin to 47 million people, or about 18% of the population. The number of people estimated to have newly gotten insurance via ACA was about 5.4 million, putting proof to my assertions about the "47 million" figure. Even if I drop my points about how that number was wrong and we use it anyway, moving 82% of the population to this system would definitely have an effect on costs, which would then directly benefit those 18%.


That's different from what you said, you said "I know the others charge $500 but here we charge $3000" in a situation where the patient is not in a position to refuse, which is the very essence of bad-faith negotiation and definitely does not figure into fair market value (which is actually legally defined as what price would be set when both parties had the option to walk away).


That's not how the figures are calculated, though, and furthermore, not how hiring works. When they make you your offer, they can't tell you you're getting health insurance and then not give it to you any more than they could pay you less than agreed - all this has to be settled up front, and you have the option to walk away. And yes, every business definitely has part time staff that are part time explicitly for the purpose of not having to provide health insurance, but that isn't a "gotcha" or bad faith - it was clearly outlined as part of the offer.


That's getting a little more philosophical than I think would merit this discussion.

18% of the population is a pretty small number overall. Does that include their dependants?

 

[Dubyamn]

The ACA cooked the books to pay for 10 years of subsidies with 7 years of taxes, and double dipped on projected medicare savings. It's insolvent, and coming apart at the seams. I think you'd find HSAs to be much more of a viable option if the money that employers were putting towards insurance premiums went into the HSA instead, it'd help build it up a lot faster. But yes, there'd probably be a little bit of roughness during the transition period. Roughness is preferable to collapse, however.

Coming apart at the seams is what happens when a president takes a bat to the whole thing out of spite. Course all of that's really beside the point. You would have hated it even after it stabilized even though it's the only feasible way I've seen to separate employment from insurance. But if the companies don't save money I don't see them buying in and if they don't keep up with the price of healthcare I don't see how the employees don't get screwed.

There's a middle ground, surely a great deal lower than where prices are right now. Forcing competition in the various manners I've described, plus more that are no doubt out there, will help to find the balance between affordability and indigence. After all, how things are NOW, hospitals are CERTAINLY not having any problems whatsoever covering the indigent - the makeup of the staff parking lots are testament to that. The money's there to be found in their own budgets.

Like I said we're already paying for the free riders. It's built into the system and will remain in the system.

Those superusers are the same reason that government single-payer would sink as well, though. And really, it's a different animal than the 20 year old with cancer or the 30 year old about to have a baby. Are you comforable with a panel of Trump appointees deciding who gets what end-of-life care vs palliative care vs being sent home with some aspirin? I myself am not...

I know it's a different animal and that's why I brought it up.

Eesh, with how badly the VA has been mismanaged, you really think so? I wouldn't trust any of my relatives to the VA if I could help it.

Pays for my uncle's medical bills and my grandfather's hip replacement. From what I've seen they're getting better treatment than I am.

Sure the plural of anecdote isn't data but we're talking about plans that will put hundreds of thousands of people out of work. We're fucking huge pie in the sky thinking right now. Why is your fantasy any more legitimate than mine?

Hrm, I dunno about your plan, but the only time I ever had a 10k deductible was when it was part of a bundle with an HSA. Before and after that, the deductibles were much lower.

They're called catastrophic plans and they are popular due to the fact that they are the cheapest plans you can buy due to the useful fact that in most cases the company doesn't have to pay out dick.

 

[figmentPez]

Oh, and Gas, regarding how you've been talking up the fact that you got a discount for paying for your surgery out of pocket. Yeah, I couldn't even find a doctor willing to see me for my broken hand without insurance. I couldn't find a doctor willing to even take an appointment to see me, even though I was willing to pay out of pocket, unless I had insurance that they would take. The only care I ever got for my hand was one emergency room visit, because I only have catastrophic coverage. I'm lucky it healed without any major problems, because I don't know what I'd do when I couldn't even get a doctor to talk to me, let alone treat me.

 

[GasBandit]

How is it different than what I said?

What you said first was:

Oh, what's that? Other hospitals only charge $500 for that? Well, we charge $3,000, it's on our books

And what you moved the goalpost to was:

How is that bad faith if it's what every cardiologist charges for the procedure?

Every cardiologist charging the same vs a cardiologist doing gotcha-pricing higher than other ones.

Everyone who goes into a cardiologist has the option to walk away and not get heart surgery, but if they do go through with the surgery they run the risk of having an allergic reaction and getting charged out the nose for it because they had to get treatment while they were undergoing a cardiological procedure.

Yes, and generally that sort of thing is listed under the consent form they make you sign before you go under the knife. Seems like, in the spirit of our drive for transparent pricing for the sake of comparison shopping, the cost should probably be put on there too, I'd assert.

What incentive, under your system, is there for a cardiologist to offer higher up front costs to offset the lost money for not having such a "hidden" fee? (which isn't hidden, it's available, it's just a roll of the dice if you'll have to pay it.)

They wouldn't have to, since they'd have to be up front about the potential costs, as I said, and be subject to public consumer advocacy scrutiny and ridicule. And once the first doc buckles to the temptation to lower his rates, the others have to follow suit to not lose out.

Also, you mentioned duress earlier. How is any decision about cancer, ALS, Alzheimer's, etc. ever a decision not made under duress?

The definition of Fair Market Value requires assumption of no duress for the purposes of pricing, not implying that medical purchases are always made without duress. As in, the prices have to be set in advance in a manner as if there is no duress, and then those are the prices that get charged even in a situation where there IS duress.

Booking someone 1 hour under the federally mandated minimum, consistently, isn't "part time staff", it's 39 hours a week with expected "off the clocks" overtime. It is explicitly exploitation and vastly different than hiring a handful of workers for 15-25 hours a week.

It's also very illegal in all 50 states (at least the off the clock/book overtime part).

It's also the only work a lot of people can get when they are too experienced to be treated as disposable but no one actually wants to promote them to the position they are actually fulfilling.

I'm going to need some figures on what constitutes "a lot," preferably with some sourcing, here.

18% of the population is a pretty small number overall. Does that include their dependants?

I actually thought it was a pretty large number... and as I said, it's larger than the what actually proved to be the case. I don't know for a fact if the figure included dependents or not, but I believe it did, as the repeated narrative of 2010 was the constant harping of "47 million americans without medical care!" despite almost every word of the sentence being untrue.

Coming apart at the seams is what happens when a president takes a bat to the whole thing out of spite. Course all of that's really beside the point. You would have hated it even after it stabilized even though it's the only feasible way I've seen to separate employment from insurance.

How would it have stabilized when the funding was a shell-game from the start?

I know it's a different animal and that's why I brought it up.

Ok, so, to repeat the question, Are you comforable with a panel of Trump appointees deciding who gets what end-of-life care vs palliative care vs being sent home with some aspirin?

Pays for my uncle's medical bills and my grandfather's hip replacement. From what I've seen they're getting better treatment than I am.

Sure the plural of anecdote isn't data but we're talking about plans that will put hundreds of thousands of people out of work. We're fucking huge pie in the sky thinking right now. Why is your fantasy any more legitimate than mine?

Well, I'm genuinely glad it worked out for your uncle and grandfather. There's been a lot of people who haven't been as fortunate. The mismanagement of the VA has been a rather prominent scandal over the past 4 years or so, with "rampant fraud, corruption, cover-ups, excessive and contradictory spending, inadequate care, a massive backlog of benefits claims, and a secretary position nobody can seem to hold down." It spurred full on criminal investigations by the FBI and congress. Hundreds of veterans died waiting for care. But naturally government bureaucrats covered for their own, and those who were deemed culpable were shuffled around to other positions or allowed to resign quietly instead of face criminal charges - and even that last part ended up only happening to 3 VA administrators.

Oh, and Gas, regarding how you've been talking up the fact that you got a discount for paying for your surgery out of pocket. Yeah, I couldn't even find a doctor willing to see me for my broken hand without insurance. I couldn't find a doctor willing to even take an appointment to see me, even though I was willing to pay out of pocket, unless I had insurance that they would take. The only care I ever got for my hand was one emergency room visit, because I only have catastrophic coverage. I'm lucky it healed without any major problems, because I don't know what I'd do when I couldn't even get a doctor to talk to me, let alone treat me.

Well, I can't speak to your experience and any suggestions I would have made are obviously well past the point of usefulness now. Part and parcel of the system I'm outlining, however, would make that exact thing (refusing to see a patient who wants to pay up front instead of use insurance) go away.

 

[figmentPez]

Every cardiologist charging the same vs a cardiologist doing gotcha-pricing higher than other ones.

Ah, I see where I confused you. I meant, from the very beginning, to imply that they were charging more because it was something they were offering "off-menu", so to speak. I thought that was clearly implied by my comparison to a car dealer selling a bike rack for an exorbitant price. As in "we specialize in cardiology, but we can do other things for a higher price". It would make sense that an emergency non-cardiac procedure would cost more from a cardiologist than from a practice that specializes in that other procedure/medication, would it not? The charge for medication in in ambulance might be higher than the same medication in a hospital, and different still in a remote location, etc.

Let me ask you, when you went in for your surgery, did you look over the potential costs for every single possible emergency treatment you might require, should something have gone wrong during the procedure? NO? Why not? Was that not something you factored into the cost of what you were paying? OH, so it makes perfect sense that medical companies would use such a circumstance to pad their profits. After all, if no one is actively comparing those prices when shopping for a provide, and there's no standard by which to measure if their higher prices are too high, other than what the market will bear, then there's no incentive for them to bring those prices down. The "Fair Market Value" would be what's normally charged for emergency additional care, and that would be a very high price because almost no one looks at all those possible, but rare, cases, until they're already stuck for the bill for it.

 

[GasBandit]

Ah, I see where I confused you. I meant, from the very beginning, to imply that they were charging more because it was something they were offering "off-menu", so to speak. I thought that was clearly implied by my comparison to a car dealer selling a bike rack for an exorbitant price. As in "we specialize in cardiology, but we can do other things for a higher price". It would make sense that an emergency non-cardiac procedure would cost more from a cardiologist than from a practice that specializes in that other procedure/medication, would it not? The charge for medication in in ambulance might be higher than the same medication in a hospital, and different still in a remote location, etc.

Well, if we're still talking about heart transplant surgery here (which is, after all, what kicked off this whole latest tempest), it stands to reason that the surgery is taking place in a full blown hospital, yes? So, I'm not sure we'd really be dealing with a separate cardiologist-specific menu of prices here. For example, though I went in for stomach surgery, I did have a few issues after the surgery but I was not charged gastroenterologist-specific pricing for those X-rays, the morphine, etc. I got a separate bill afterwards from the various other hospital departments involved. Which segues nicely into your next question...

Let me ask you, when you went in for your surgery, did you look over the potential costs for every single possible emergency treatment you might require, should something have gone wrong during the procedure? NO? Why not? Was that not something you factored into the cost of what you were paying? OH, so it makes perfect sense that medical companies would use such a circumstance to pad their profits. After all, if no one is actively comparing those prices when shopping for a provide, and there's no standard by which to measure if their higher prices are too high, other than what the market will bear, then there's no incentive for them to bring those prices down. The "Fair Market Value" would be what's normally charged for emergency additional care, and that would be a very high price because almost no one looks at all those possible, but rare, cases, until they're already stuck for the bill for it.

I didn't look too deeply beforehand, no, though I was advised of common complications that might arise from surgery (up to and including death), it was all pretty boldly put on the consent form. I honestly wasn't too concerned about it because if I thought there was anything untoward going on, I could dispute it when I got the bill - which is something I did actually end up doing because they tried to charge me for more x-rays then they took. I wish I could have known that I wouldn't have had much pain during my recovery at home, I could have maybe saved myself a couple hundred bucks for the two bottles of vicodin they gave me that I never ended up using.

But this is how things are now, as opposed to how I'm trying to communicate they should actually be in a market that doesn't rely on obfuscation-via-insurance.