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  #151  
Old 08-18-2019, 11:17 PM
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I don't know how the typical insurance company is organized. Just seemed to me that most of their workaday activity was enrolling new members and processing claims, both of which would still need to be done under single-payer.
The paperwork of health insurance and healthcare in general would be far more streamlined if it weren't for the current hodgepodge system of multiple insurers, profit-maximizing plan design and marketing, and aggressive claims denial:
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Analysis: A Health Care Overhaul Could Kill 2 Million Jobs, And That’s OK

[...] The first casualties of a Medicare for All plan, said Dr. Kevin Schulman, a physician-economist at Stanford, would be the “intermediaries that add to cost, not quality.” For example, the armies of administrators, coders, billers and claims negotiators who make good middle-class salaries and have often spent years in school learning these skills. There would be far less need for drug and device sales representatives who ply their trade office to office and hospital to hospital in a single-payer system, or one in which prices are set at a national level. [...]

Robert Pollin, an economist at the Political Economy Research Institute of the University of Massachusetts-Amherst, is frustrated not just by the doomsday predictions but also by how proponents of Medicare for All tend to gloss over the jobs issue.

“Every proponent of Medicare for All — including myself — has to recognize that the biggest source of cost-saving is layoffs,” he said. He has calculated that Medicare for All would result in job losses (mostly among administrators) “somewhere in the range of 2 million” — about half on the insurers’ side and half employed in hospitals and doctors’ offices to argue with the former.
Given that the healthcare industry currently employs somewhere between 15 and 20 million people, a loss of 2 million jobs in the sector is not trivial. If half of those jobs are on the insurers' side, that suggests that over 10% of the total work currently done by health insurance industry employees is just the bureaucratic red tape associated with a for-profit multi-player system, and would become unnecessary in a more efficient single-payer setup.
  #152  
Old 08-19-2019, 12:09 AM
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I'll have to take your word for it. I don't know how the typical insurance company is organized. Just seemed to me that most of their workaday activity was enrolling new members and processing claims, both of which would still need to be done under single-payer.
In the Canadian single-payer system, I've been enrolled exactly once: by my parents when Medicare was brought in by the Douglas government. Now, most Canadians are enrolled at birth. You only have to change your enrolment if you move to another province. That doesn't take a lot of employees in the provincial Medicare offices.

As for processing claims, other consists of the doctor or hospital sending in a bill. Our system doesn't have the yin and yang of insurance adjusters challenging a claim, and the doctor's office arguing why it should be paid.
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  #153  
Old 08-19-2019, 12:26 AM
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I apologize for not reading this whole thread (the sniping gets tiresome) so maybe this has already been discussed, but how does the promise to eliminate private insurance square with fact that over a third (and rapidly growing) of Medicare coverage is now Medicare Advantage, run by private insurance companies?
It depends on the proposal, and there's no reason to think it would be enacted as-is, but the Sanders bill (the most commonly-discussed version of Medicare For All) doesn't put anyone on the current Medicare system, which is actually abolished in the plan, and replaced by a whole new and entirely public system also called Medicare.

Last edited by Lord Feldon; 08-19-2019 at 12:27 AM.
  #154  
Old 08-19-2019, 04:47 AM
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So as stands the pitch is to take away what you now have, be it private or Medicare, and replace it with a something different unknown exactly what except that it is single payer?
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  #155  
Old 08-20-2019, 08:23 PM
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So as stands the pitch is to take away what you now have, be it private or Medicare, and replace it with a something different unknown exactly what except that it is single payer?
To be fair, the Sanders plan is not exactly "unknown" -- it's been fairly well fleshed out. Nor is single payer really much of mystery -- one has only to look north to Canada, read the terms and principles of the Canada Health Act, and say "it will look a lot like this in its broad outlines".

Rather more definitive, I'd say, than Trump's election promise to replace Obamacare with "something terrific", which turned out to be good enough to get him elected. And which turned out to mean "replace Obamacare with nothing" and he couldn't even do that. I believe that option will be offered again in 2020 for those who prefer that sort of thing.
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Old 08-20-2019, 11:23 PM
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Except that it what his website states the is blatantly misleading, aimed at promulgating a false narrative that it is an expansion of Medicare. To quote
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This is how Medicare is delivered today for all Americans over age 65 ...
As detailed above a third of Medicare right now is administered by private companies and utilizes panels that operate under value-based care (VBC) payment models. Canada and many other nations are moving more towards these approaches as well.

No that doesn’t flesh anything out and it is not honest in that it does not at all make clear that Medicare as is will be removed as an option.

He states that patients can see whoever they want but that is not how the Canadian system works. You need a referral from the GP to see a specialist.

Sanders belief is that paying providers less per service by being able to dictate pricing is the key to getting greater value. How the ACA has delivered is by encouraging the systems that work smarter thereby avoiding preventable admissions and stays that too long because there is not the incentive to organize the processes efficiently. The evolution in progress is a move away from being paid more by doing more and to population wide outcome measurements. I can’t find that in his bill.

Better than Trump’s empty words is a low bar.
  #157  
Old 08-21-2019, 01:09 AM
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Except that it what his website states the is blatantly misleading, aimed at promulgating a false narrative that it is an expansion of Medicare. To quote As detailed above a third of Medicare right now is administered by private companies and utilizes panels that operate under value-based care (VBC) payment models. Canada and many other nations are moving more towards these approaches as well.
All I can say is that our opinions on this differ. Medicare will have to be substantially rejigged in order to function as a viable UHC system, and whether this is an "expansion of Medicare" or something entirely different is a matter of opinion. Presenting it as an expansion of something people are already familiar with is a useful way of communicating the intent.

VBC (or VBHC) is related to the capitation model I described previously. It's not the same thing but rather is a feature that can work with capitation models. And, again, it has little or nothing to do with private insurance except coincidentally. In Canada it works under the government single-payer model, and in the US, under Medicare Advantage, the administering "sponsors" (which may also be non-insurance organizations) operate as contractors to the federal Centers for Medicare and Medicaid Services, and must conform to their rules and standards.
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No that doesn’t flesh anything out and it is not honest in that it does not at all make clear that Medicare as is will be removed as an option.
Well, it's many pages of detailed information, and it should be obvious that Medicare and Medicaid as we know it today would become totally redundant. I don't understand why you keep going on about this. Is there any other way you could possibly imagine MfA could work?
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He states that patients can see whoever they want but that is not how the Canadian system works. You need a referral from the GP to see a specialist.
It absolutely **is** how the Canadian system works. I can see any doctor I want, or go to any hospital or clinic I want. It's true that you need a referral the first time you see a specialist, but it would be hugely misleading to see this as some kind of obstacle rather than what it is, a matter of medical protocol to direct patients to the appropriate resources, collaboratively with the patient's wishes. In many cases the patient might have no idea what specialist she needs, or who the most qualified ones are for a particular condition. Just recently I told my doctor that I wasn't happy with the cardiologist that the hospital had set me up with for followups after my surgery and I wished I could see the wonderful cardiologist who had looked after me in the hospital, and that's exactly what was done.
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Sanders belief is that paying providers less per service by being able to dictate pricing is the key to getting greater value. How the ACA has delivered is by encouraging the systems that work smarter thereby avoiding preventable admissions and stays that too long because there is not the incentive to organize the processes efficiently. The evolution in progress is a move away from being paid more by doing more and to population wide outcome measurements. I can’t find that in his bill.
Efficiencies and negotiated, transparent, uniform provider fees are both essential to a viable and sustainable health care system. Let me make a general comment about an important aspect of this using length of hospital stays as an example. All health care systems strive for efficiencies, and perhaps more accurately, all strive to minimize costs. The problem is that private insurance -- and unfortunately Medicare, too, because it operates as a parallel system in the same costly environment -- often do it in ways that are counterproductive to the patient's interests. Thus both private insurance (often) and Medicare have arbitrary limits on length of hospital stays irrespective of what the patient actually needs. You can literally have sick patients dumped out into the street because their time is up. This has never occurred in the single-payer system in Canada, ever, to the best of my knowledge, and indeed would be contrary to its fundamental patient-centric principles. But to an insurance company focused on costs and profits, it's just business.
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Old 08-21-2019, 08:40 AM
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Presenting it as an expansion of something that people know and are comfortable with instead of the taking that system away and replacing it is untruthful IMHO. It may or may not be that the new system would be better but it not expanding Medicare to all.

Agreed that it is unfair to portray requiring referrals to specialists as obstacles rather than medical protocols that direct patients to the appropriate resources. But that process has long been demonized as such and claiming that a plan eliminates that when it does not is being untruthful.

Your understanding of how the shift to Value Based Care has been playing out in the United States is very incorrect. No there are not arbitrary lengths of stay. There are benchmarks that organizations have for populations, normed by scores for the population that account for levels of comorbid conditions and with incentives for achieving various quality metrics. Improve your complete system, invest more in keeping the population from having the complications or diseases that lead to admissions and readmissions and in better more seamless outpatient support seamlessly provided and you achieve better outcomes with fewer admissions and shorter lengths of stay across the population as a whole. Kicking someone out while still sick because of and arbitrary guideline is NOT how it is done and would be counterproductive to those goals, and the bonuses for hitting those goals are the only way to not lose money in the process.

Single payer has many advantages. But selling it by misrepresenting both what it actually is and what the system in America is transitioning into with the ACA as the catalyst is wrong.
  #159  
Old 08-21-2019, 09:06 AM
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https://www.statnews.com/2019/03/22/...ontrols-costs/

The ACA has, despite continuous major kneecapping by the GOP, been hugely successful. It has improved the access, improved quality, and decreased costs. No question that it is as is far from a finished product. Expanding Medicare as an option to all, expanding Medicaid, and yes working on pricing and pharmacy benefits reform, are all part of it.
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Old 08-21-2019, 10:44 AM
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Your understanding of how the shift to Value Based Care has been playing out in the United States is very incorrect. No there are not arbitrary lengths of stay. There are benchmarks that organizations have for populations, normed by scores for the population that account for levels of comorbid conditions and with incentives for achieving various quality metrics. Improve your complete system, invest more in keeping the population from having the complications or diseases that lead to admissions and readmissions and in better more seamless outpatient support seamlessly provided and you achieve better outcomes with fewer admissions and shorter lengths of stay across the population as a whole. Kicking someone out while still sick because of and arbitrary guideline is NOT how it is done and would be counterproductive to those goals, and the bonuses for hitting those goals are the only way to not lose money in the process.
Just to be clear on this point, I wasn't talking here about the Value Based Care model. I was saying that in traditional insurance models, there are pressures from insurers, hospital administrators, and -- due to out-of-pocket costs -- sometimes from the patients themselves, for early discharge to a point that is sometimes unsafe.
  #161  
Old 08-21-2019, 12:57 PM
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https://www.telegraph.co.uk/news/hea...ures-show.html

Early discharges are a problem in Canada.
  #162  
Old 08-21-2019, 03:33 PM
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https://www.telegraph.co.uk/news/hea...ures-show.html

Early discharges are a problem in Canada.
This is the first time I've ever seen the UK confused with Canada! Granted, we share the same Queen, but still ... different sides of the ocean and all that!

The elderly are a special problem as there can be non-medical lifestyle considerations post-discharge. Even so, here in actual Canada, when my mother was hospitalized and decided it was time to move to a nursing home, she was put on a waiting list and in the meantime moved to the geriatric ward. We eventually convinced her she'd be better off coming to live with us, but otherwise she would have remained in hospital as long as necessary until a suitable nursing home could have taken her, thus assuring continuous care. When she did come live with us, the health system provided free medical equipment, nursing services, and regular visits by a home care worker and a dietician.

That said, the problem of early hospital discharges is more general and greatly exacerbated in the US, in part because of the highly mercenary nature of the whole health care system, because of specifically enumerated limitations, and because of the often exorbitant out-of-pocket costs involved.
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Old 08-21-2019, 04:01 PM
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My bad. Came up with Canada search term. Point stands though: single payer as much as it has to commend it is not a miracle cure. And contracting for lower fees is not where the big curve inflection comes from.

I do not mean to piss on the Canadian (or UK ��) systems. But advertising a system in their image as Medicare for All is incorrect and selling them with implications of no referrals see who you want and never any problems of the systems squeezing to save money is also wrong. IMHO.
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Old 08-21-2019, 06:26 PM
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And contracting for lower fees is not where the big curve inflection comes from.
I beg to differ. Why do you think the per-capita cost of health care in Canada is half of what it is in the US? These countries are right next to each other, have almost identical socioeconomic systems and living costs, and the costs of medical equipment and facilities are essentially the same. The major factors are negotiated uniform provider fees and the fact that these fees can be as low as they are because administrative costs are so much lower -- in fact most of the administrative complexities encountered in US health care simply do not exist at all in single-payer.

As a physician would you rather bill $100 for a procedure and risk not getting paid at all while having to employ backroom clerks to chase patients and insurance companies, all while dealing with mountains of paperwork and wasting time fighting with insurance bureaucrats yourself, or would you rather bill $50 and be guaranteed full payment with no hassle, no overhead, and no time-wasting frustrations?
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I do not mean to piss on the Canadian (or UK ��) systems. But advertising a system in their image as Medicare for All is incorrect and selling them with implications of no referrals see who you want and never any problems of the systems squeezing to save money is also wrong. IMHO.
Sanders has visited Canada to familiarize himself with the system here and ISTM that it's fair to say he's largely modeling his proposal on the basic principles here. I don't think he's ever claimed that there are "no referrals" for specialists but we've already agreed that this is a red herring that has nothing to do with choice. It's fundamental to the Canadian system that there are no restrictive "networks" that limit who you can see according to what plan you have. There is only one plan and it covers everyone, for everything that is medically necessary, for all providers, all of whom have the same fees. It's a win all around in terms of patient flexibility and administrative simplicity. The big problem with it from a private insurer standpoint is it's hard for an insurer to make money in it. Some of us consider that a feature, not a bug!
  #165  
Old 08-21-2019, 07:15 PM
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...The big problem with it from a private insurer standpoint is it's hard for an insurer to make money in it. Some of us consider that a feature, not a bug!
Possibly there are areas of human life in which paying a middleman makes sense.

But I'm pretty sure that health care is not one of them.
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Old 08-21-2019, 09:15 PM
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DSeid forgive me, but I'm not followeing you on this referral thing? Are you saying people on UHC system don't get to choose their refferal? Or that people who oppose UHC are putting that up as an objection? Or what?
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Old 08-22-2019, 07:33 AM
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They, like Americans in many plans, need to have their primary physician send them and cannot just go to whatever sort of specialist they want. When describing that circumstance in America words like “gatekeeper” and “obstacles to care” get used and is often demonized and bemoaned. When the Canadian system is discussed it is directing a patient to appropriate resources ...

I read Sanders’s site as implying that the plan would eliminate those sorts of “obstacles.”

The Canadian system is a fine model. But attaching the branding of Medicare to that model is very inaccurate and implying that it does what it does not (and really should not) as its marketing is the sort of misdirection that would bite you in the end.
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Old 08-22-2019, 08:28 PM
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They, like Americans in many plans, need to have their primary physician send them and cannot just go to whatever sort of specialist they want. When describing that circumstance in America words like “gatekeeper” and “obstacles to care” get used and is often demonized and bemoaned. When the Canadian system is discussed it is directing a patient to appropriate resources ...

I read Sanders’s site as implying that the plan would eliminate those sorts of “obstacles.”
It's still unclear whether you agree with these critics or not. And this is a highly distorted description of the reality. The first part of the first sentence -- "need to have their primary physician send them" is true but the second part -- "cannot just go to whatever sort of specialist they want" is false. No, you cannot demand a referral to a brain surgeon because your toe hurts and your palm reader told you that you might have a brain tumor, but if a specialist is medically indicated you have the right to see any one you want and the single-payer system will fully cover it.

There is nothing evil about the concept of a "gatekeeper" to assure the most appropriate and properly prioritized access to health care services, and every health care system in the world has them. I've used that term myself in describing the medical profession in the context of single-payer health coverage. The problem with the private insurance system in the US is that the gatekeeper is an insurance bureaucrat who isn't interested in the best interests of the patient, but in the best financial interests of the insurance company. A gatekeeper has to be a qualified medical professional completely centered on the interests of the patient and nothing else. That's what primary care physicians are qualified to do, while insurance bureaucrats have pretty much the opposite interests.

A good example of a gatekeeper in a medical context is the triage nurse in ER, who determines what kind of specialist the patient needs to see, at least as a first evaluation, and what the urgency is. This is very much analogous to what a primary care physician does when it comes to referrals, and I'm frankly astonished that the idea of specialist referrals has to be debated at all. I'm reminded of when a very good friend of mind took her young child to the doctor with some symptoms she was becoming concerned about, and the doctor deemed that she needed to see a specialist -- not in the mythical distant future that forms the basis of naysayers' tales about wait times in the Canadian health care system -- she needed to see a specialist right now. And that's just what was done, the same day. It turned out to be a false alarm and nothing serious but the symptoms very easily could have been extremely serious, and this is how the proper role of "gatekeeper" works, and one of many reasons that the PCP is involved in referrals.

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The Canadian system is a fine model. But attaching the branding of Medicare to that model is very inaccurate and implying that it does what it does not (and really should not) as its marketing is the sort of misdirection that would bite you in the end.
I've read the most comprehensive description of Bernie's plan I could find, and I see nothing misleading in it. With reference to the above comments, it makes statements like these:
Increase Access & Choice: Patients can see the doctors they want, since the “out of network” limitations of a private system will vanish with single payer.

Allows doctors to make decisions in the best interest of patients, rather than based on complex private plans engineered to deliver profits.

No premiums, deductibles or copays for any medical services.

Separates health coverage from employment, so everyone will have more flexibility to change employers, or even consider starting their own business, without the risk and fear of losing their health benefits.

Bernie is proposing a healthcare system like what is found in Canada, Europe, and other developed nations.
... all of which is exactly correct. The only aspect in which branding the plan as "Medicare" might be misleading is that Medicare is a pretty crappy health insurance system compared to most systems in the rest of the world. To my mind Bernie calling his plan "Medicare for All" already gives it a black eye, but it's still a useful way to convey to the American mindset what it seeks to achieve. What he really should be saying is "It's like Medicare, only for everyone, and without any of the stupid limitations imposed on it by the insurance lobby".
  #169  
Old 08-22-2019, 11:59 PM
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https://www.washingtonpost.com/polit...7ce_story.html
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The idea of Medicare-for-all — a unified government health program that would take over the basic function of private insurance — became a liberal litmus test at the outset of the presidential campaign, distinguishing Democratic contenders who cast themselves as bold visionaries from more moderate pragmatists.[...]

But in recent months, amid polling that shows concern among voters about ending private insurance, several of the Democratic hopefuls have shifted their positions or their tone, moderating full-throated endorsement of Medicare-for-all and adopting ideas for allowing private insurance in some form.[...]

This unmistakable, if sometimes subtle, shift in tone stems in part from Democrats’ fear of giving away a newfound advantage over Republicans on health care.
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  #170  
Old 08-23-2019, 01:05 AM
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I agree with DSeid about the dishonesty of calling thiis single payer bill “Medicare for All”. Why don’t they call it “Medicaid for All”? That would be more accurate. But of course they don’t want to be accurate. They want to dishonestly sell it as something it’s not, and that means we are going to pay the political price sooner or later when people discover what it really is.

From Kimstu’s cite describing how the plan Warren and Sanders (two of the top three in the polls) are pushing could kill 2 million jobs:


Quote:
For example, the armies of administrators, coders, billers and claims negotiators who make good middle-class salaries and have often spent years in school learning these skills.

She seems to think that’s fine and dandy, and so does wolfpup. And in an abstract sense of economic efficiency, it is good.

But this is not the Wonky Policy forum, it’s the Elections forum. How on Earth could this be good politics? The benefits of eliminating that inefficiency will be diffuse and barely noticeable to average folks, while the pain for those 2 million people, in a demographic that is highly likely to vote, from being out of a job they spent years learning how to do will be intense and focused but reverberate throughout entire families and friendship groups.


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remember that when compared to Americans, Canadians live longer, live healthier for longer

Is this still true if we correct for demographic differences between the countries? What if we just compare the educated middle-class folks who are happy with their private employer provided health insurance? Are they living shorter and sicker lives than their counterparts in Canada?


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Rather more definitive, I'd say, than Trump's election promise to replace Obamacare with "something terrific", which turned out to be good enough to get him elected.

Because that’s much better politics, and Democrats need to learn this more generally, not just about healthcare. They should not be releasing specific white papers every week on this, that, or the other thing. They should be talking vaguely but passionately about vistas of blue skies, amber waves of grain, the greatness of America (“whose greatness comes from the hard-working people who get up every day and do what needs to be done to take care of their families”, yadda yadda), strong leadership for the 21st century, and stirring rhetoric like that. No specifics that give your opponent something to latch on to and attack you for. This is Politics 101!
  #171  
Old 08-23-2019, 01:32 AM
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But this is not the Wonky Policy forum, it’s the Elections forum. How on Earth could this be good politics? The benefits of eliminating that inefficiency will be diffuse and barely noticeable to average folks, while the pain for those 2 million people, in a demographic that is highly likely to vote, from being out of a job they spent years learning how to do will be intense and focused but reverberate throughout entire families and friendship groups.
!
You know how nobody cares about any job losses when they talk about government programs being cut? Same thing for insurance employees. They have basically the exact same image in the American mind as the Government beaurocrat.
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Old 08-23-2019, 01:54 AM
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I don’t think many people care in the abstract about coal miners’ jobs getting cut either, but the coal miners do and the people who love them do. Same thing here.
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Old 08-23-2019, 02:32 AM
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I agree with DSeid about the dishonesty of calling thiis single payer bill “Medicare for All”. Why don’t they call it “Medicaid for All”? That would be more accurate. But of course they don’t want to be accurate. They want to dishonestly sell it as something it’s not, and that means we are going to pay the political price sooner or later when people discover what it really is.
And what do you think they'll discover? I think they'll discover that Bernie's plan -- if it could possibly be implemented in the ideal form described -- will be exactly the single-payer system they were led to expect. Those who are simply swayed by what something is called instead of what it actually is are the sorts who probably never read the policy proposal and don't understand the difference between Medicare and Medicaid anyway.
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From Kimstu’s cite describing how the plan Warren and Sanders (two of the top three in the polls) are pushing could kill 2 million jobs:


She seems to think that’s fine and dandy, and so does wolfpup. And in an abstract sense of economic efficiency, it is good.

But this is not the Wonky Policy forum, it’s the Elections forum. How on Earth could this be good politics? The benefits of eliminating that inefficiency will be diffuse and barely noticeable to average folks, while the pain for those 2 million people, in a demographic that is highly likely to vote, from being out of a job they spent years learning how to do will be intense and focused but reverberate throughout entire families and friendship groups.
Is it also your contention that the government should have banned automatic telephone switching systems from being introduced into telephone system exchanges because millions of switchboard operators would lose their jobs -- fine deserving young women who did nothing wrong? Or that the first automobiles should have been banned to protect horse breeders and buggy manufacturers?

You seem to be ignoring the fact that Canada transitioned from private health insurance to single-payer and somehow we survived. It happened over the course of many years in a series of transitional stages which provided ample time to adjust -- the general population greatly welcoming the reforms, and those in the predatory health insurance industry eventually finding honest jobs.
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Is this still true if we correct for demographic differences between the countries? What if we just compare the educated middle-class folks who are happy with their private employer provided health insurance? Are they living shorter and sicker lives than their counterparts in Canada?
From my recollection of such statistics, probably not. Which is a very good reason why everyone should have the same health care plan as in Canada, or, to put it a different way, everyone should have the same health care plan as "educated middle-class folks who are happy with their private employer provided health insurance" in the US. The latter of which, incidentally, cease being quite so happy with it the first time a major claim is denied and they have to sell their house or declare bankruptcy, or if they lose their jobs.
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Because that’s much better politics, and Democrats need to learn this more generally, not just about healthcare. They should not be releasing specific white papers every week on this, that, or the other thing. They should be talking vaguely but passionately about vistas of blue skies, amber waves of grain, the greatness of America ...
No, because the demographic that Democrats are targeting are not the kind of morons and indiscriminating ideologues that voted for Trump.
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Old 08-23-2019, 02:53 AM
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I don’t think many people care in the abstract about coal miners’ jobs getting cut either, but the coal miners do and the people who love them do. Same thing here.
Except for rare pockets, insurance companies don't make up the soul of a town like the mine in coal country. Really not comparable.
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Old 08-23-2019, 03:16 AM
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No, because the demographic that Democrats are targeting are not the kind of morons and indiscriminating ideologues that voted for Trump.

Democrats are not targeting Rust Belt swing voters who chose Trump in 2016? That’s news to me, and would be a big mistake.

You’re still trying to make a wonky, utilitarian policy argument. That’s not how politics works, especially here. More’s the pity, because if it did, we could dispense with all the campaign theatrics and just have everyone take their time making a sober, diligent study of each candidate’s record and the white papers of their policy proposals. Maybe in Denmark or somewhere, that’s how it actually works. But we are nowhere remotely near having such a body politic.
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Old 08-23-2019, 08:02 AM
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wolfpup we’ll need to leave ourselves disagreeing about how accurate the portrayal is in general but this
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in the US is that the gatekeeper is an insurance bureaucrat who isn't interested in the best interests of the patient,
warrants specific comment.

We agree on the need for primary care provider (PCP) referrals tp specialists. Many do not. PCPs following appropriate guidelines is seen by some as an “obstacle”.

To the comment the PCP following appropriate guidelines applied as appropriate to the specific circumstances is how the gatekeeper function is accomplished in both systems. In both systems the PCP is the gatekeeper and is looking out for the patient’s best interests.

No question that in the US inappropriate referrals are placed as it makes the patient happy. They may get denied and should be. And sometimes the reason for something expensive to be needed outside of the guideline is not immediately clear and requires explanation. How many times in over30 years have I not been able to get my patients the referrals approved that they’ve needed? ZERO. A few time it’s required explanations.

This is the sort of shit that bothers me. The Canadian system is wonderful. Cutting all those administrative jobs saves money and getting to one less complicated system would be great. What is and is not covered on each plan confused even experts.

Creating fictions like that bugaboo to sell it though is wrong.

Meanwhile the practical. Telling Americans that they all have to give up their own eggs that they may like, be it Medicare or private, for the promise of a better omelet for all to come, telling those millions who work for the industry who worry that it might be their job that is cut that it is worth it for the greater good, when the current ACA approach has already been delivering well and could do so much more without GOP kneecapping and some expansions with public options and more... wont sell.
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Old 08-25-2019, 07:32 AM
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Single payer has many advantages. But selling it by misrepresenting both what it actually is and what the system in America is transitioning into with the ACA as the catalyst is wrong.
And one of the things about Sanders is that he's not yet come clean on the cost of his plan. I think people should be more critical of that aspect of his M4A. He's made the statement that middle class families would save $3,000 under his plan. But studies don't back him up. And various fact-checkers don't agree.

https://www.politifact.com/truth-o-m...-would-save-3/

"....Sanders said that multiple studies show that under Medicare for All "average middle-class families will save $3,000 every year." The studies don’t back him up.

One is based on 2016 numbers that are outdated, especially when it comes to current tax rates. Another deals only with New York state, excluded the high cost of long-term care, and offered a range of possible outcomes.

A lot depends on the actual taxes to raise money, and we don’t have a specific proposal from Sanders.

We rate Sanders’ claim Mostly False."
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Old 08-25-2019, 07:52 AM
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I agree with DSeid about the dishonesty of calling thiis single payer bill “Medicare for All”. Why don’t they call it “Medicaid for All”? That would be more accurate. But of course they don’t want to be accurate. They want to dishonestly sell it as something it’s not, and that means we are going to pay the political price sooner or later when people discover what it really is.
If Sanders and Warren were supporting the actual Medicare for All, based on the real Medicare, they would be supporting a basic health program that about 1/3 of people get through a private contractor, via Medicare Advantage plan (like my parents), or where millions purchase a supplement plan on top of it.

I agree with you. Sanders' label of his plan is just pure politics.

Medicaid for All is more accurate, since the people who have it generally have no co-pays (mostly). But Medicaid isn't as popular, because it's a hassle to get enrolled, since it's means-tested. And a lot of doctors don't take Medicaid patients, because the reimbursement rates are so low. Some people have it, but can't see a decent doctor. So, his political side says let's call it "Medicare"....

That's one aspect of Sanders' plan that should be scrutinized. If we throw out our entire system, and replace it with what he inaccurately labels as "Medicare For All", what would happen to our medical providers?

https://www.nytimes.com/2019/04/21/h...hospitals.html

quoting the link:

Hospitals could lose as much as $151 billion in annual revenues, a 16 percent decline, under Medicare for all, according to Dr. Kevin Schulman, a professor of medicine at Stanford University and one of the authors of a recent article in JAMA looking at the possible effects on hospitals.

“There’s a hospital in every congressional district,” he said. Passing a Medicare for all proposal in which hospitals are paid Medicare rates “is going to be a really hard proposition.”

Richard Anderson, the chief executive of St. Luke’s University Health Network, called the proposals “naďve.” Hospitals depend on insurers’ higher payments to deliver top-quality care because government programs pay so little, he said.

“I have no time for all the politicians who use the health care system as a crash-test dummy for their election goals,” Mr. Anderson said.
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Old 08-25-2019, 07:55 AM
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Except for rare pockets, insurance companies don't make up the soul of a town like the mine in coal country. Really not comparable.
OK, but it's still millions of jobs, often that pay a good living wage. If we're going to get rid of an industry, we need better talking points than they "don't make up the soul of a town"....that's extremely weak.
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Old 08-25-2019, 08:07 AM
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OK, but it's still millions of jobs, often that pay a good living wage. If we're going to get rid of an industry, we need better talking points than they "don't make up the soul of a town"....that's extremely weak.
It's not a talking point, it's a reason you don't need a lot of talking points on the issue. Insurance jobs are spread out so they aren't as much of a concern as a voting block.
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Old 08-25-2019, 08:20 AM
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It's not a talking point, it's a reason you don't need a lot of talking points on the issue. Insurance jobs are spread out so they aren't as much of a concern as a voting block.
OK, so they're spread out and therefore we aren't concerned about them as a voting block. Let's try that in an election, and see how far it goes.

https://www.kff.org/other/state-indi...2:%22asc%22%7D

According to Kaiser, even in WV, healthcare is 15% of employment. I don't know what % of those people would lose their job under a Sanders "M4A" plan, but I'm sure they'll be comforted to know that they're spread out and aren't a concern. What your talking point - or lack thereof, to borrow your representation of what you're saying - implies is that these people don't matter because they're not an organized enough voting block. I have my doubts about how well that comes across in an election to these types of voters, and their families.

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Old 08-25-2019, 08:37 AM
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OK, so they're spread out and therefore we aren't concerned about them as a voting block. Let's try that in an election, and see how far it goes.

https://www.kff.org/other/state-indi...2:%22asc%22%7D

According to Kaiser, even in WV, healthcare is 15% of employment. I don't know what % of those people would lose their job under a Sanders "M4A" plan, [...]
Well, get back to me when you do. People actually providing care are unlikely to lose their jobs so that number means nothing without knowing the breakdown.
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Old 08-25-2019, 11:36 AM
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Well, get back to me when you do. People actually providing care are unlikely to lose their jobs so that number means nothing without knowing the breakdown.
Linked earlier by Kimstu. And some more detail here.

As of 2012 at least the ratio of doctors to non-doctors had grown to 1:16 and 10 of those 16 were "purely administrative and management staff, receptionists and information clerks, and office clerks". That comes to about 59% of those who work within the industry would be at risk of being the ones who lose their jobs, which is a good thing for overall efficiency and cost, but a hard sell to the ones who worry that the job lost will be theirs. And of the clinical workers? Many won't be afraid of losing their job but will be aware that as the hospital and practices get paid less the pain will be shared, both by salary and more importantly by short-staffing and higher loads per provider. Some will look beyond their own self-interest and be sold on a greater good promise ... but many not. How many coal miners have been sold on the idea that their industry's job losses are worth it for the greater good?

One more thing to point out from Kimstu's link. No the pain is NOT evenly spread out. It would hurt some areas, some particularly important from an electoral college perspective, more than others.
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Some geographic areas would be hit particularly hard. A single hospital system is by far the biggest employer in many post-manufacturing cities like Pittsburgh and Cleveland. Hospitals and hospital corporations make up the top six employers in Boston and two of the top three in Nashville. Hartford is known as the insurance capital of the world. Where would New Jersey be if drugmakers took a big hit, or Minnesota if device makers vastly shrank their workforce? (That may be why some Democratic representatives and senators from these left-leaning states have been quiet or inconsistent on Medicare expansion.)

Stanford researchers estimate that 5,000 community hospitals would lose more than $151 billion under a Medicare for All plan; that would translate into the loss of 860,000 to 1.5 million jobs. ...
What state is Pittsburgh in? Achh who cares about PA voters? Cleveland ... Ohio? No need to even think about a win there. Minnesota? Meh. Suburban to much more so rural districts whose hospitals have been closing up shop as it is? Who needs 'em.

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Old 08-25-2019, 04:30 PM
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The argument that ill people there should not be single payor health care because it would terminate many private insurance jobs directly tied to billing sick people is opprobrious because it burns money for no good cause while people remain untreated and often die for lack of money.
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Old 08-25-2019, 05:28 PM
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Linked earlier by Kimstu. And some more detail here.

As of 2012 at least the ratio of doctors to non-doctors had grown to 1:16 and 10 of those 16 were "purely administrative and management staff, receptionists and information clerks, and office clerks". That comes to about 59% of those who work within the industry would be at risk of being the ones who lose their jobs, which is a good thing for overall efficiency and cost, but a hard sell to the ones who worry that the job lost will be theirs. And of the clinical workers? Many won't be afraid of losing their job but will be aware that as the hospital and practices get paid less the pain will be shared, both by salary and more importantly by short-staffing and higher loads per provider. Some will look beyond their own self-interest and be sold on a greater good promise ... but many not. How many coal miners have been sold on the idea that their industry's job losses are worth it for the greater good?

One more thing to point out from Kimstu's link. No the pain is NOT evenly spread out. It would hurt some areas, some particularly important from an electoral college perspective, more than others. What state is Pittsburgh in? Achh who cares about PA voters? Cleveland ... Ohio? No need to even think about a win there. Minnesota? Meh. Suburban to much more so rural districts whose hospitals have been closing up shop as it is? Who needs 'em.
You're mixing different issues, much of which I didn't address at all but you sound like you're rebutting me. Yes, you'll need some talking points about lower salaries and maybe less of certain procedures. I don't know how much of that admin/management staff is directly tied to the private insurance industry but it's certainly not all of them as you assert. Hospitals will still need receptionists and an HR department.

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Old 08-25-2019, 05:44 PM
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The argument that ill people there should not be single payor health care because it would terminate many private insurance jobs directly tied to billing sick people is opprobrious because it burns money for no good cause while people remain untreated and often die for lack of money.
They aren't making that argument. They're saying that those job losses are a political pitfall that must be addressed.
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Old 08-25-2019, 05:53 PM
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The argument that ill people there should not be single payor health care because it would terminate many private insurance jobs directly tied to billing sick people is opprobrious because it burns money for no good cause while people remain untreated and often die for lack of money.
People with private health insurance have better outcomes in the US than people who are uninsured or people with Medicaid. Studies have shown this ad nauseum. So, we're supposed to get rid of an industry that's associated with better outcomes for the population it serves?

Private Health insured people have better mortality than uninsured.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775760/

Women with private insurance have better outcomes with breast cancer than uninsured or those with medicaid (not that I have a problem with medicaid, but it's better to have private insurance):

https://www.nejm.org/doi/full/10.105...99307293290507

Also, children in Southern California have better access to care if they have private insurance vs government-funded insurance:

https://www.ncbi.nlm.nih.gov/pubmed/15520090

I can post these kinds of studies day and night....
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Old 08-25-2019, 06:00 PM
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People with insurance have better outcomes than people without insurance. I stand amazed.
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Old 08-25-2019, 06:39 PM
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You're mixing different issues, much of which I didn't address at all but you sound like you're rebutting me. Yes, you'll need some talking points about lower salaries and maybe less of certain procedures. I don't know how much of that admin/management staff is directly tied to the private insurance industry but it's certainly not all of them as you assert. Hospitals will still need receptionists and an HR department.
Not rebutting, attempting to answer: what percent of people in healthcare are at risk of losing their jobs under MfA?

The estimates given in those links are overall as a result. Working for a hospital's HR department or as a receptionist does not save your job if the hospital folds, which many community hospitals have been doing already and which predictions are many more will as payments get squeezed. Direct ties are not the issue, fear for job and income security is.

Let's do one more to actually put it as that percent. In 2016 there were "there were 21.8 million people working in health care settings or in health occupations ... 14 percent of all jobs in the United States." 2 million of them, almost 10%, will be lost, and many many more will be worried that it will be their job that is lost, or salary cut, or work demands increased.

Those voters (and their families) will consider their own self-interest at least as much as they will consider the possibility that it will result in a greater good. Be scornful of that fact Muffin if you want, but it is a real political consideration, even if you have only disdain for such considerations.

And let's be real here. MfA will not get passed even with a highly unlikely narrow D majority in the Senate (you won't get every D to vote for it and no Rs will cross the aisle on it). The question is what advocating for it accomplishes, for good or ill, politically, vs building on the huge successes of the ACA with Medicare for all who want it and other improvements.

Medicaid as is is not a fair comparison to privater insurance btw. Many providers do not take it (limited access) and if they did there would still be a huge selection bias with those on Medicaid much more likely to be experiencing other challenges associated with lower income ... "the social determinants of health" and structural factors.
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Old 08-25-2019, 06:43 PM
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People with insurance have better outcomes than people without insurance. I stand amazed.

Also better than those on Medicaid. There was a randomized study in Oregon that found putting uninsured people on Medicaid had very disappointing and meager results.


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The argument that ill people there should not be single payor health care because it would terminate many private insurance jobs directly tied to billing sick people is opprobrious because it burns money for no good cause while people remain untreated and often die for lack of money.

Again, this is politics. It’s wildly and inarguably inefficient to have military bases spread around the country, but have you seen the political firestorms that break out any time anyone tries to close some of them? NIMBY!

ETA: Also, you are either strawmanning us on the other side, or are guilty of the fallacy of a falsely excluded middle. We are talking about getting everyone who is currently uninsured coverage, but without single payer. Much less efficient, but it doesn’t jeopardize anyone’s jobs, and it still covers everyone. Patching holes rather than tearing off the roof and starting over.

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Old 08-25-2019, 07:38 PM
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In 2016 there were "there were 21.8 million people working in health care settings or in health occupations ... 14 percent of all jobs in the United States." 2 million of them, almost 10%, will be lost, and many many more will be worried that it will be their job that is lost, or salary cut, or work demands increased.

Those voters (and their families) will consider their own self-interest at least as much as they will consider the possibility that it will result in a greater good. Be scornful of that fact Muffin if you want, but it is a real political consideration, even if you have only disdain for such considerations.

And let's be real here. MfA will not get passed even with a highly unlikely narrow D majority in the Senate (you won't get every D to vote for it and no Rs will cross the aisle on it). The question is what advocating for it accomplishes, for good or ill, politically, vs building on the huge successes of the ACA with Medicare for all who want it and other improvements.

QFT. Great, great post. In summary, it won’t get passed; or if it does, it will provoke a huge political backlash.

So insisting on the Democratic nominee championing it is either pure virtue signaling or a completely unrealistic idea of what can actually be accomplished in the next Congress. It’s one thing to take a greater downside risk if there’s a bigger potential upside. But there is very unlikely to be a bigger upside here and the downside is that we end up with the same as, or less than, we have now.
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Old 08-25-2019, 08:10 PM
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Not rebutting, attempting to answer: what percent of people in healthcare are at risk of losing their jobs under MfA?
As I said, I was only talking about job losses in the insurance business. A switch to M4A will cause a massive shakeup and lots of things will have to be done to calm fears. That will depend on exactly what M4A is because no one's plan seems to literally be Medicare for all. The only point I was making was that losing medical insurance jobs isn't very politically worrisome because the jobs are diffused and it's a profession with very little public sympathy.
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Old 08-25-2019, 08:29 PM
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WEIRD. Because I could swear that in response to a claim
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According to Kaiser, even in WV, healthcare is 15% of employment. I don't know what % of those people would lose their job under a Sanders "M4A" plan
you had stated
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Well, get back to me when you do.
I gave you the percent and the estimates of how many would be concerned that they or theirs would be of that percent of those employed in healthcare. I noted that the job losses would be of more impact in some states than others and specifically in a few more electorally important states.

It was the actual question.

Not sure why in that context anyone would give a flying fuck about job losses specific to the insurance business and only that but you do you man.

Meanwhile - How would you go about calming those fears during an election in which it was noted, accurately, that these voters in these key states would be at significant risk of losing their jobs or if kept making less and/or working harder, in a disruptive fashion, for the greater good?
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Old 08-25-2019, 09:29 PM
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People with private health insurance have better outcomes in the US than people who are uninsured or people with Medicaid. Studies have shown this ad nauseum. So, we're supposed to get rid of an industry that's associated with better outcomes for the population it serves?

Private Health insured people have better mortality than uninsured.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775760/

Women with private insurance have better outcomes with breast cancer than uninsured or those with medicaid (not that I have a problem with medicaid, but it's better to have private insurance):

https://www.nejm.org/doi/full/10.105...99307293290507

Also, children in Southern California have better access to care if they have private insurance vs government-funded insurance:

https://www.ncbi.nlm.nih.gov/pubmed/15520090

I can post these kinds of studies day and night....
1. Re: insured vs uninsured outcomes: so you're surprised that having access to health care results in better outcomes than not having access to health care. Duly noted, but most of us aren't surprised by the bleeding obvious.

2. Re: insurance vs Medicaid: so you're surprised that funding top-tier ongoing health care including preventative services results in better outcomes than the care from an artificially limited substandard tier, the patients of which have typically had spotty to non-existent health care for much of their lives due to poverty. Duly noted, but again, most of us aren't surprised at all.

3. Re: all of the above, including the claim that "children in Southern California have better access to care if they have private insurance vs government-funded insurance": be prepared to be surprised again, because residents of Canada on average live longer healthier lives than Americans despite living under the yoke of evil "government-funded insurance"! In point of serious fact, better health outcomes in Canada are largely because of a lifetime of guaranteed access to health care with no monetary obstacles to such access. The same results generally hold for most European countries, too.

I have no doubt that you "can post these kinds of studies day and night" but without the proper comparative context your implied conclusions are worthless.
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Old 08-25-2019, 09:49 PM
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2. Re: insurance vs Medicaid: so you're surprised that funding top-tier ongoing health care including preventative services results in better outcomes than the care from an artificially limited substandard tier, the patients of which have typically had spotty to non-existent health care for much of their lives due to poverty. Duly noted, but again, most of us aren't surprised at all.

Wait, so now the majority of Americans on private health insurance are correct to like it and to want to keep it? Because they are getting such top-tier care, including preventative services? You can’t have it both ways.


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3. Re: all of the above, including the claim that “children in Southern California have better access to care if they have private insurance vs government-funded insurance": be prepared to be surprised again, because residents of Canada on average live longer healthier lives than Americans despite living under the yoke of evil "government-funded insurance"! In point of serious fact, better health outcomes in Canada are largely because of a lifetime of guaranteed access to health care with no monetary obstacles to such access.

And again, I want to see the health comparisons of well educated middle class Canadians with well educated middle class Americans. If the Canadians still come out significantly ahead, that is impressive. If not, you are making a collectivist utilitarian argument that will not only not fly in American politics but will be political poison. If you want to lament that American voters are so selfish, go right ahead. But that is the political playing field we are dealing with.

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  #196  
Old 08-25-2019, 10:19 PM
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Wait, so now the majority of Americans on private health insurance are correct to like it and to want to keep it? Because they are getting such top-tier care, including preventative services? You can’t have it both ways.
There's no "both ways" here. You are once again mischaracterizing what I said. Properly administered single-payer, as in Canada, is generally equivalent to top-tier insured care in the US and in many ways vastly superior, particularly in the absence of any co-pays or deductibles and the unconditional nature of coverage. In the US, "government-funded" coverages like Medicare and Medicaid are the poor cousins of insured care, and this is by design, at the behest of the insurance lobby and Republican "free-market" ideologues.

And if this causes people to believe, as an ingrained part of US health care culture, that government-funded health care coverage is always limited and substandard, well, that's a bonus side effect that health insurers are going to exploit to the max!
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And again, I want to see the health comparisons of well educated middle class Canadians with well educated middle class Americans. If the Canadians still come out significantly ahead, that is impressive. If not, you are making a collectivist utilitarian argument that will not only not fly in American politics but will be political poison. If you want to lament that American voters are so selfish, go right ahead. But that is the political playing field we are dealing with.
I'm not lamenting the fact that they're selfish, I'm lamenting the fact that they're stupid, because they seem happy to pay twice as much as necessary for health care while being stuck with often enormous out-of-pocket costs for the dubious privilege of having insurance bureaucrats stand between them and their health care providers. I'm quite familiar with insurance companies as I have to deal with them on house insurance and car insurance, and I'm horrified that anyone would have to deal with their critical medically necessary health care that way.
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Old 08-26-2019, 02:30 AM
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Selfish, stupid, whatever you want to say: their vote counts just as much regardless. And if you follow American politics at all, you should not be surprised that it is not the most rationally presented, wonky argument that wins out.
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Old 08-26-2019, 06:36 AM
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WEIRD. Because I could swear that in response to a claim you had statedI gave you the percent and the estimates of how many would be concerned that they or theirs would be of that percent of those employed in healthcare. I noted that the job losses would be of more impact in some states than others and specifically in a few more electorally important states.

It was the actual question.

Not sure why in that context anyone would give a flying fuck about job losses specific to the insurance business and only that but you do you man.

Meanwhile - How would you go about calming those fears during an election in which it was noted, accurately, that these voters in these key states would be at significant risk of losing their jobs or if kept making less and/or working harder, in a disruptive fashion, for the greater good?
I was talking about insurance industry jobs the whole time. The context is all my posts leading up to the one you just quoted.
  #199  
Old 08-26-2019, 08:19 AM
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... I'm lamenting the fact that they're stupid ...
SlackerInc is exactly right and you do keep trying to have a different conversation than what this op is about, trying to convince other posters how wonderful the Canadian system is compared to the American one, while whether it is, or is not, is not the question at hand. The question of the op, the one the rest of us are having, is the Elections forum question about its elections impact.

In this context, for example, the issue of whether or not so many American voters would not vote for a gay candidate that one could not win, is not a discussion about how that should be an immaterial bit of information and those who think that way are ignorant and prejudiced ... the discussion and debate is whether or not the statement is true.

So you think American voters are stupid. Well, looking at who our president is that is a hard thesis to argue against.

But whether or not a ... lack of enthusiasm ... for a disruptive revolutionary approach to improving our healthcare system by forcing everyone to give up what they currently have (be it private or Medicare or whatever) for an attempt to get to a system similar to the one in Canada, causing rapid significant job losses pay cuts and job stresses across the healthcare industry, is or is not stupid, the reality is it would be politically idiotic to have that be the flag to wave.

Politically the GOP has weakness on healthcare with the unforced error of continuing to try to repeal the ACA. The ACA in fact has delivered quite a lot. Politically a Democratic candidate should be leveraging that GOP weakness, not arguing that they agree the ACA is so horrible that it should be scrapped and replaced. Politically you leverage their weakness by pointing out how many of the current issues with the ACA are a result of intentional GOP kneecapping trying to sabotage it with voters' healthcare problems as cynical political civilian casualties. Politically you remind voters that the ACA was a compromise that could pass at the time and that it should be improved upon with specific ideas of how ... ideas that are less disruptive and ones that allow them to have choices about it.

CarnalK the discussion was regarding the 2 million jobs estimated to be lost across healthcare, how that was where much of the cost savings would occur, which is good, but how the threat of job loss could be of political consequence nevertheless. You were responding to Slacker's comment
Quote:
... those 2 million people, in a demographic that is highly likely to vote, from being out of a job they spent years learning how to do will be intense and focused but reverberate throughout entire families and friendship groups.
Your responding that "Insurance jobs are spread out so they aren't as much of a concern" is most generously understood to mean the impact of these job losses across healthcare that would occur because of the removal of the insurance industry are so spread out as to not matter so much politically. An incorrect statement but one that actually has relevance to the discussion. Because how many jobs are lost literally ONLY by those directly working for an insurance company is not what was being discussed or the item that matters. That would have been a stupid non-response to Slacker's comment about the 2 million voters who would lose their jobs that they had spent years developing skills for. You really meant that? Okay.
  #200  
Old 08-26-2019, 11:52 AM
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SlackerInc is exactly right and you do keep trying to have a different conversation than what this op is about, trying to convince other posters how wonderful the Canadian system is compared to the American one, while whether it is, or is not, is not the question at hand. The question of the op, the one the rest of us are having, is the Elections forum question about its elections impact.

In this context, for example, the issue of whether or not so many American voters would not vote for a gay candidate that one could not win, is not a discussion about how that should be an immaterial bit of information and those who think that way are ignorant and prejudiced ... the discussion and debate is whether or not the statement is true.

So you think American voters are stupid. Well, looking at who our president is that is a hard thesis to argue against.

But whether or not a ... lack of enthusiasm ... for a disruptive revolutionary approach to improving our healthcare system by forcing everyone to give up what they currently have (be it private or Medicare or whatever) for an attempt to get to a system similar to the one in Canada, causing rapid significant job losses pay cuts and job stresses across the healthcare industry, is or is not stupid, the reality is it would be politically idiotic to have that be the flag to wave.

Politically the GOP has weakness on healthcare with the unforced error of continuing to try to repeal the ACA. The ACA in fact has delivered quite a lot. Politically a Democratic candidate should be leveraging that GOP weakness, not arguing that they agree the ACA is so horrible that it should be scrapped and replaced. Politically you leverage their weakness by pointing out how many of the current issues with the ACA are a result of intentional GOP kneecapping trying to sabotage it with voters' healthcare problems as cynical political civilian casualties. Politically you remind voters that the ACA was a compromise that could pass at the time and that it should be improved upon with specific ideas of how ... ideas that are less disruptive and ones that allow them to have choices about it.
DSeid, I don't really disagree with this, and contrary to how it might appear to you, I do believe that Democrats should put forward a cautious transitionary approach mainly built around introducing a public option to the ACA. I understand that people are fearful of revolutionary changes, and I think Sanders' all-or-nothing proposal that would ban private insurance is a serious mistake.

But, having said all that, Democrats should also pursue fact-based policies and fight back against some of the falsehoods and fearmongering that the insurance industry has been promulgating about UHC for decades, like the stuff that I refuted in post #194. What's next, accusations of death panels, or people dying in Canada due to wait times, or -- per Republican mouthpiece Betsy Mccaughey and the AHIP lobby -- people in the UK allegedly having to go blind in one eye before they get treatment for the other? This is the kind of scaremongering disinformation that has been going on for years and that Democrats need to strongly oppose. In fact you yourself seemed to be buying in to some of this by citing how well Medicare Advantage works with the aid of private insurers, when the fact is that MA works just because capitation and outcome-based management are good ideas, and the insurers are strictly held in line by their contractual obligations to CMS.

Ultimately the government could almost certainly do it better themselves, but that's neither here not there as we might as well acknowledge that in the US -- the world's foremost hotbed of free-market ideals -- private health insurance will always be around and the best we can hope for is a public/private two-tier hybrid where hopefully you guys have governments with enough integrity to protect the public tier from being reduced to a lowly second-rate system thrown like a bone solely to the poor and indigent. This is precisely why Canada strictly prohibits private insurance for medically necessary services, even though countries in Europe, with a much stronger sense of social solidarity, manage just fine with limited participation in a private insurance tier.
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