BBO Discussion Forums: Luke Warm was right, I was wrong - BBO Discussion Forums

luke warm, on 2012-June-29, 15:25, said:

The insurance premiums we pay subsidize the treatment of the uninsured. So does everyone else's. I'm surprised that you did not know that. Where did you think the money comes from to treat the uninsured?

PassedOut, on 2012-June-29, 15:57, said:

no offense, but i'm pretty sure i know more about this than you do...

you said:

Quote

you made it sound as if your company, individually, pays higher premiums to cover your employees... you worded things in a way that suggested you were speaking personally about your own company... btw, what company(s) insures your employees and how large a group is covered?

do all your employees choose coverage, or do you simply pay the premiums for everyone? insurance companies, among others, use actuaries to determine premiums year to year... premiums vary, even within the same group, depending on level of coverage, which dependents are covered, type of plan, type of employee (active vs. retired), etc... i've dealt with actuaries for years, so i know what they use when computing premiums

now it's true that providers change their rates year to year also, based on actual dollars and cents... they will not lose money, unless forced to do so by the gov't... and these increases in prices have to be and are accounted for by the actuaries, within legal limits... i think that's what you mean when you say we all pay for the uninsured, and in that sense it's true... but most businesses don't provide insurance to all employees, especially since to do so they'd have to pay too high a percentage of the premium, if not the whole premium... they do offer it to all employees, within limits (full time, active duty, etc), but offering and providing are two different words

luke warm, on 2012-June-30, 06:44, said:

Yes, I was speaking about the companies that my family owns.

It could be useful to have a substantial and realistic look at health policy as we move into the election. Mostly, it is a mess. Obama did not create the mess, it was a pre-existing condition.

The llocal county paper (Carroll County Times) notes that somewhat upwards of 5% of our residents lack insurance. This includes 524 who are under the age of 18. I confess I know little or nothing of what happens when they need medical help. It is reasonable to ask what conservatives believe should happen.

When I was six or so I contracted pneumonia. My mother called Dr. Setzer, he treated me, I survived, my mother paid him. This simple model is long since gone. Now I have Medicare. As part of my retirement I have supplemental coverage from Aetna. I have some sort of thing that pays something for eyeglasses. Something else for dental. And something for prescriptions. I need a consultant to keep it straight. Actually my wife is pretty patient with sorting through it, but she also gets confused.

A family in our circle is going through a rough time. He lost his job, and his health coverage. They have kids and were elgible for some help, including really good health insurance. Then he got another job, so they lost that help. Fortunately (?) he lost that job so now they have the good insurance again.

What is the conservative plan for health care? What should be the plan? Going back again to my childhood, I got hurt in a fall and my parents took me to the hospital. They would not admit me until my father went home and brought in proof he could pay. Is that what conservatives want? It would be a plan.

My own selfish interests are in two areas. I would like enough clarity so that I do not have to attend three seminars to have some idea of what my coverage is. And I would like better doctors. I have had two friends with serious problems treated at Johns Hopkins. The care was excellent. But the local care for more modest issues is really pretty bad. I have had good health but I am 73 so I encounter doctors more often than I did thirty years ago. And my wife has had some issues, some of a serious nature. Once you get away from the major centers, the care sucks. Very large egos, very modest ability. Improving care is high on my list of desired features.


Anyway, I would like to here what conservatives believe should happen to the uninsured when they need medical care. Let them die? This applies to children as well? Or should we say that those who can afford insurance must get it, and those who cannot afford it will be given some help? In short, the medical situation is a mess, Obama did not create the mess, what is the conservative plan for dealing with this mess? It could make for a very interesting discussion in an election year.

kenberg, on 2012-June-30, 07:26, said:

Are we talking about doctors, or bridge players?

I agree with you, it's a mess. I don't count myself as a conservative, but I think if somebody needs treatment, he should get it. How we as a society pay for it, well, I don't have any killer ideas, but I will say I'm not sure the insurance model is the right way to go about it.

My father was a cardiologist. One of his patients was a local farmer. Apparently the farmer didn't have the money to pay Dad, so every year he'd bring over half a dozen or so bushels of peaches and apples. They were good peaches and apples. I guess you pay what you can, and doctors of my Dad's generation, at least, accepted that. Dad did complain about the bean counters taking over, especially in hospitals. But I don't think he had any better idea than I do how to deal with the problem.

It occurred to me that the bit about egos might flow both ways.

Anyway, we agree it's a mess, and I am in your corner in not being clear about the solution.

Politically, I am not at all sure the Republicans have a clear field if they want to run against Obama on health care. There will always be a group that will cuss out Obama if they stub a toe in the driveway, but we just have to hope this is only a modest portion of the electorate.


Just a short story about egos:
My wife took a spill and broke her tibia, her fibula, and three metatarsals. Ouch! There was a first cast and then, after three weeks or so, a second cast. A nurse's aide cut off the first cast and began putting on a new one. She was obviously both nervous and inexperienced. An older aide came in to assist a bit, and then the doc came in. He took over briefly, did a few wraps, announced "This isn't rocket science" and left. That night Becky became very aware that the cast was not right. Mostly it was too loose and was rubbing her ankle uncomfortably and right near the break. She called the next morning. Of course she could not speak directly to the doctor, but the receptionist took a message and called back with the doc's response "It can't be too loose because I did it". It's difficult to say so many wrong things in a single short sentence. First, he didn't do it. Second, if he did do it, it is still possible for it to be done wrong. Third, if the patient calls and says it is too loose, there is a fine chance it is too loose. It is inconvenient to get into his office with a broken ankle, probably the complaint is for real. Anyway, Becky insisted, the receptionist said she would call back later. She didn't. The next day Becky called again and an appointment was made with a different doctor in the same office. Becky went in, they announced the cast was too loose, it was replaced with a good cast.


I would love to say that the sort of arrogance experienced here is rare. Most unfortunately it is not. Becky was seeing this guy because of knee problems and he has a strong reputation as being one of the best in the county (a rather low bar in my view). She will need her knees replaced eventually. We are looking around, I don't want him touching her.

luke warm, on 2012-June-29, 15:25, said:

There is a correlation between i.q. and petulance? Probably so.

mgoetze, on 2012-June-29, 05:15, said:

I suspect he wants the freedom to decide.

One can believe that wearing seatbelts and motorcycle helmets is a good idea, but still reasonably be against laws requiring everyone to wear them.

luke warm, on 2012-June-30, 06:44, said:

He's speaking about his own company, but I don't think he's suggesting that his company is unique. What he's saying is that ALL insurance premiums are higher than they would be if there weren't so many uninsured people. Insurance companies subsidize them, and then pass this cost along to all their policyholders in the form of higher premiums.

Since he's a business owner, and his company pays the bulk of the insurance premiums for his employees, it's coming out of his bottom line.

barmar, on 2012-June-30, 13:58, said:

Indeed

JLOGIC, on 2012-July-01, 01:40, said:

On the other side, I am not sure any insurance company would give you the freedom to decide without Obama's healthcare reform...

cherdano, on 2012-July-01, 03:55, said:

Indeed.

http://www.nytimes.c...20Dubinsky.html

PassedOut, on 2012-June-30, 07:08, said:

you still didn't tell me, do your employees *all* have coverage? do you pay the full premium? what type plan is it, hsa/msa/hra or other?

one thing's for sure... if the reps control the gov't next year and repeal ACA, they need to have something with which to replace it... people won't stand for just saying no, imo... what to replace it with - yep, that's the rub... some things do stand out, though

with all due respect to passedout, the present tax structure favors him (as far as providing health care goes)... well, not him so much, but employer-based care... it needs to change from that to a more market driven system, because if someone loses the employment upon which his coverage is based, it's hard or impossible to retain coverage (portability) except with cobra... and cobra is usually too expensive for all but the very ill (for whom a 3rd party will often pay the premiums)... so exactly what is a market based system, and how would that make care more available and affordable?

there are many "plans" out there, some of which are actually quite good... well, "good" as in "better than now"... but one thing above all has to be done - allow competition across state lines... this immediately drove down rates in the auto industry... also, the premiums for individual (as opposed to group) plans should be tax-exempt...

hsa type plans (high deductible/low premium) also lower costs... such plans do two things: 1) because they have a high deductible they let patients (consumers, actually) understand that shopping for health care is just as important as shopping for anything else... and 2) they cover the catastrophic illnesses at an acceptable level... so you end up paying for your own doc visits but the bigger illnesses are more or less paid for... it's kinda like you buying your own batteries and tires, but having geico pay when you get rear-ended

the interstate competition thing also has the effect of increasing the size of groups, a driver of premiums... i need to stop because the list of things needing done is just too long, but one more is (or should be) obvious... at the risk of being stoned, not everyone needs everything - a major weakness of plans now... health plans should be offered that are geared to groups of individuals, not to everyone... if i want to buy an individual plan, for example, i do not need a substance abuse rider... nor do i much care for pregnancy related treatments/drugs (what we'll call the sandra fluke rider)... when such things are mandated, prices *must* reflect this mandate

you'll notice i didn't mention tort reform... well, i guess i did, just now... that would be in the first "whereas" statement

The problem with individual insurance is that the insurer will price it (or make it available) based completely on the person's medical history. This means anyone with a history of even minor issues (asthma, acne, etc) can easily find themselves priced completely out of the market. Of course, it doesn't help that a lot of people figure they can save money by not bothering to have insurance until a medical problem comes up, then try to acquire it! In fact this is what typically happens now on the individual market. Modifying the tax credit to give benefit to individuals instead of (or in addition to) employers will cause employers to stop offering health care, throwing more people to the mercies of the individual market which is a total disaster. What's necessary is to form larger groups and to make sure that everyone has health insurance (i.e. you pay a low premium either in the form of a tax or a payment to an insurer over the long haul, and then the insurance is there if/when you need it).

The "purchasing insurance across state lines" thing is not so beneficial as it's made out to be. The problem is that most regulation of insurance (in terms of what benefits must be provided, what information should be provided to enable people to make as informed a decision as possible, under what conditions pricing can be determined or recision can happen, etc) is at the state level. Simply allowing purchase of insurance across state lines will cause all insurers to be based in the state with the most lax regulation, thus short-circuiting any level of regulation whatsoever. This is what happens with credit cards for example, and caused a great deal of problems for many people until the recent financial reform bill created a federal agency (the consumer protection bureau, which Republicans are determined to short-circuit or dismantle by the way) that could put in place some common-sense reforms like adding language to the bill letting people know how long it will take to pay off the card by making minimum payments. Further, one of the big problems in health insurance is the prevalence of very large insurers (economies of scale are a big deal with insurance) which can then gauge their customers who have little recourse (starting a "small independent insurance company" is basically infeasible because of the need to negotiate lower-than-market rates with a wide range of hospitals and doctors). Insurance across state lines can make this worse as well.

Tort reform is a fine idea in principle, but every analysis I've seen indicates that it won't do a whole lot to control costs.

A single-payer system is by far the best solution to these problems, but it seems politically infeasible in the US and would also cause a great deal of upheaval in the US economy (health insurance companies are big business after all). What the ACA does is to enforce some standards at the federal level (insurance companies must spend a large fraction of revenue on actual health care, their pricing policy has to be fair, they can't kick people off insurance as soon as they get sick, etc) while also establishing exchanges which should allow people to better compare different options and allow individuals and small businesses (which are basically on the individual market) to aggregate and protect themselves somewhat. It also institutes the individual mandate, which (while unpopular), is a defense against free loaders who depend on legally mandated hospital-provided emergency care and/or take advantage of the new law to buy insurance only when they get sick. The idea is to create a national pool for health care (much like a single payer system) but run by private business (with some government regulation to prevent abuses) rather than managed directly by the federal government. Given the political and economic realities this is a reasonable solution... although I think a gradual path to single payer (i.e. by lowering the age for medicare eligibility at a slow rate) might be an improvement.

luke warm, on 2012-July-01, 09:36, said:

Of course all of the expenses of doing business are tax-deductible, but they are still expenses. The problem with the drastic increase in healthcare premiums is that those increases neither improve revenue nor provide employees with additional coverage. And, unlike most other expenses, we have no direct control over increases in healthcare premiums.

Of course the details vary a bit by business, but between 2000 and 2010 one of our businesses experienced rate increases of around 20% per year per employee, resulting in premiums five times higher for the same coverage. Many, many other businesses experienced like increases. And it's infuriating to be paying so much for services as rife with waste and inefficiency as the US healthcare system, when we who pay the premiums work so hard to root out waste and inefficiency in our own businesses.

By the way, I agree with you that people should not have to depend upon their employers for insurance, but we have to deal with the world as it is until "what should be" happens.

luke warm, on 2012-July-01, 09:36, said:

Yes, to me, one of the most disturbing things about the healthcare reform that we got was that we could have gotten tort reform at the same time. But instead the republicans in congress decided that their number one goal was to defeat Obama, not to fix the broken healthcare system.

luke warm, on 2012-July-01, 09:36, said:

That analogy is clearly nonsense. If I have to buy my own batteries and tires, and I neglect them and they suffer serious damage that was avoidable, I have to pay to solve the problem. If I have to pay for my own doctors visits, and I neglect them and I suffer serious illness that was avoidable, everyone else has to pay to solve the problem.

awm, on 2012-July-01, 10:26, said:

It should reduce the number of unnecessary diagnostic tests performed. But we'll still have the problem that expensive devices must be used in order to pay for themselves, so the effects will be very gradual.

luke warm, on 2012-July-01, 09:36, said:

Pity so many studies show that individuals are unable to make well informed decisions regarding health care spending.

My parents are now at the age where health care plans are critical to their well being. Regretfully, I'm not sure whether either my mother or my father is in good enough condition to make major investment decisions. In our case, my sister and I are available to lend a hand and help sort things out, but I shudder to think what would happen if they were on their own.

awm, on 2012-July-01, 10:26, said:

yes, it's obvious that the larger the group, the better cost controls one has... your opinion of interstate health care aside, it would still lower costs... yes, insurance companies do have political pull, but only because our politicians are more interested in two things: making money and staying in power

lalldonn, on 2012-July-01, 10:43, said:

many industry people, on both sides of the political spectrum, disagree with your cavalier dismissal

hrothgar, on 2012-July-01, 10:53, said:

darwinism at work... regrettable, perhaps, but there it is... lucky for us we have big brother to make decisions for us

luke warm, on 2012-July-01, 16:48, said:

It's only cavalier when you omit the reasoning in your quotation rather than doing the normal thing and pointing out why you disagree with it. Allow me to reiterate, that analogy, as you used it anyway, was CLEARLY nonsense.