# Is there anything in the ACHA that will actually improve quality of health care or reduce costs? **URL:** \ **Category:** Miscellaneous and Personal Stuff I Must Share\ **Created:** [May 6, 2017, 2:43pm UTC](https://boards.straightdope.com/t/is-there-anything-in-the-acha-that-will-actually-improve-quality-of-health-care-or-reduce-costs/786005 "2017-05-06T14:43:36Z")\ **Posts on this page:** 12\ **Page:** 2
**Author:** ![Orwell](https://avatars.discourse-cdn.com/v4/letter/o/dfb087/32.png) [@Orwell](https://boards.straightdope.com/u/Orwell)\ **Post date:** [May 8, 2017, 3:21pm UTC](https://boards.straightdope.com/t/is-there-anything-in-the-acha-that-will-actually-improve-quality-of-health-care-or-reduce-costs/786005/21 "2017-05-08T15:21:34Z")
> [@Johnny\_L.A](#): > > You missed the point. But not everyone understands satire. Indeed. Including those who attempt it. ---
**Author:** ![Grim\_Render](https://avatars.discourse-cdn.com/v4/letter/g/a87d85/32.png) [@Grim\_Render](https://boards.straightdope.com/u/Grim_Render)\ **Post date:** [May 8, 2017, 3:42pm UTC](https://boards.straightdope.com/t/is-there-anything-in-the-acha-that-will-actually-improve-quality-of-health-care-or-reduce-costs/786005/22 "2017-05-08T15:42:21Z")
> [@Orwell](#): > > Only on SDMB would “free market distortion and inefficiency” have heads nodding and go unchallenged. One of the problems with the health care system is that it is far removed from the free market, and also very inefficient because of that. There is a huge disconnect between who pays and who benefits, and also between how prices are set and negotiated/agreed to by patients and insurance companies. Another problem is that healthcare is fundamentally unsuited for market delivery. Yes, third-party payer is one of the problems with the current setup. However, so is extreme lack of price elasticity, large information asymmetries, and a number of other externalities that pervert market functioning. By now, we have quite a large body of data on nations running various healthcare setups, as well as a lot of theory. All of it indicates that any healthcare market needs to be heavily regulated to avoid market failure. ---
**Author:** ![Czarcasm](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/czarcasm/32/4050_2.png) [@Czarcasm](https://boards.straightdope.com/u/Czarcasm)\ **Post date:** [May 8, 2017, 4:21pm UTC](https://boards.straightdope.com/t/is-there-anything-in-the-acha-that-will-actually-improve-quality-of-health-care-or-reduce-costs/786005/23 "2017-05-08T16:21:02Z")
Negotiate with doctors? How does that work? ---
**Author:** ![John\_Mace](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/john_mace/32/185_2.png) [@John\_Mace](https://boards.straightdope.com/u/John_Mace)\ **Post date:** [May 8, 2017, 6:50pm UTC](https://boards.straightdope.com/t/is-there-anything-in-the-acha-that-will-actually-improve-quality-of-health-care-or-reduce-costs/786005/24 "2017-05-08T18:50:22Z")
> [@Czarcasm](#): > > Negotiate with doctors? How does that work? You start with a chicken, and then go from there. ---
**Author:** ![Wesley\_Clark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wesley_clark/32/20581_2.png) [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)\ **Post date:** [May 8, 2017, 11:27pm UTC](https://boards.straightdope.com/t/is-there-anything-in-the-acha-that-will-actually-improve-quality-of-health-care-or-reduce-costs/786005/25 "2017-05-08T23:27:06Z")
> [@Orwell](#): > > Only on SDMB would “free market distortion and inefficiency” have heads nodding and go unchallenged. One of the problems with the health care system is that it is far removed from the free market, and also very inefficient because of that. There is a huge disconnect between who pays and who benefits, and also between how prices are set and negotiated/agreed to by patients and insurance companies. > > It seems to me the system needs to go one of two directions: a) much further toward free market dynamics where consumers can compare and negotiate providers and prices, or b) much farther toward single-payer nationalized medicine where costs can be constrained by fiat. What we have now is the worst of both worlds. > > And to answer the OP, I don’t see how the ACHA does much of anything to improve quality or lower costs, overall. There would be winners and losers, much as what happened with ACA. But I don’t buy for a minute that the ACA lowered costs overall. How would the free market be used to lower costs and drive up quality? Even the market based solutions I"ve heard require the public sector to structure the system. Examples [ul] [li]Making all medical prices transparent[/li][li]Letting Americans buy medication from overseas[/li][li]Letting the public sector negotiate prices with medical providers[/li][li]Making it easier for Americans to travel overseas for care (surgery, long term care, rehabilitation, etc)[/li][/ul] Things like that would lower costs w/o reducing services or quality. But none has arisen organically and would require the public sector to force providers to do each of them. Also, because medical costs can be so high, how much of a role is there really for market forces? 1% of Americans use about 20-25% of medical spending. 5% of Americans use 50-60% of medical spending. 20% use up 80% of all medical spending 50% use up about 96% of medical spending. So basically 1 in 100 people is using up to 1/4 of all medical spending, which means many of the rest aren’t using much. Most people use very little medicine, some people use a bit, and some people use a ton. How will market forces work in that situation? It isn’t like buying a car, where you have 100 people and 100 cars, and all 100 people buy 1 car each. What if the market was you had 100 people and 100 cars, but 1 person bought 25 cars, or 5 people bought 60 cars? How would they negotiate prices on a 50k a year salary for 25 cars? What if they were unconscious? What if they had a high school education and didn’t understand the first thing about what medical care they actually needed? ---
**Author:** ![CandidGamera](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/candidgamera/32/2878_2.png) [@CandidGamera](https://boards.straightdope.com/u/CandidGamera)\ **Post date:** [May 9, 2017, 2:15pm UTC](https://boards.straightdope.com/t/is-there-anything-in-the-acha-that-will-actually-improve-quality-of-health-care-or-reduce-costs/786005/26 "2017-05-09T14:15:06Z")
> [@Orwell](#): > > Only on SDMB would “free market distortion and inefficiency” have heads nodding and go unchallenged. One of the problems with the health care system is that it is far removed from the free market, and also very inefficient because of that. There is a huge disconnect between who pays and who benefits, and also between how prices are set and negotiated/agreed to by patients and insurance companies. > > It seems to me the system needs to go one of two directions: a) much further toward free market dynamics where consumers can compare and negotiate providers and prices, or b) much farther toward single-payer nationalized medicine where costs can be constrained by fiat. What we have now is the worst of both worlds. > > And to answer the OP, I don’t see how the ACHA does much of anything to improve quality or lower costs, overall. There would be winners and losers, much as what happened with ACA. But I don’t buy for a minute that the ACA lowered costs overall. So we pass legislation that forces hospitals to publicize their prices, so you can shop around and make an informed decision about where to shop. Seems reasonable enough. Okay, you’ve just had a heart attack. You can pay $20,000 nearby, or let the ambulance drive you two hours to pay $10,000. (Plus two grand for the ambulance.) Please, sir, I know it’s very hard to hold a pen with your arm going numb, but we want you to save money! If finances are tight, you can even opt out entirely - pay nothing, and just ride it out, hope for the best. Which will it be, sir? In other words… You can’t have a free market where consumption is mandatory on pain of death. ---
**Author:** ![Orwell](https://avatars.discourse-cdn.com/v4/letter/o/dfb087/32.png) [@Orwell](https://boards.straightdope.com/u/Orwell)\ **Post date:** [May 9, 2017, 2:22pm UTC](https://boards.straightdope.com/t/is-there-anything-in-the-acha-that-will-actually-improve-quality-of-health-care-or-reduce-costs/786005/27 "2017-05-09T14:22:30Z")
> [@Wesley\_Clark](#): > > How would the free market be used to lower costs and drive up quality? > > Even the market based solutions I"ve heard require the public sector to structure the system. > > Examples > [ul] > [li]Making all medical prices transparent[/li][li]Letting Americans buy medication from overseas[/li][li]Letting the public sector negotiate prices with medical providers[/li][li]Making it easier for Americans to travel overseas for care (surgery, long term care, rehabilitation, etc)[/li][/ul] > > Things like that would lower costs w/o reducing services or quality. But none has arisen organically and would require the public sector to force providers to do each of them. The public sector (government) is the reason we can’t buy drugs from other countries. The government is the barrier. Medical prices aren’t transparent largely due to the complex system of insurance we have. The insurance industry is also largely responsible for the inability to negotiate prices, as the contracts they require providers to sign prohibit negotiating lower prices for anyone with insurance, even when the patient is the one paying most of the cost. And trips for medical care are becoming more and more popular, due to various things driving up costs here. ---
**Author:** ![Orwell](https://avatars.discourse-cdn.com/v4/letter/o/dfb087/32.png) [@Orwell](https://boards.straightdope.com/u/Orwell)\ **Post date:** [May 9, 2017, 2:39pm UTC](https://boards.straightdope.com/t/is-there-anything-in-the-acha-that-will-actually-improve-quality-of-health-care-or-reduce-costs/786005/28 "2017-05-09T14:39:26Z")
> [@CandidGamera](#): > > So we pass legislation that forces hospitals to publicize their prices, so you can shop around and make an informed decision about where to shop. Seems reasonable enough. > > Okay, you’ve just had a heart attack. You can pay $20,000 nearby, or let the ambulance drive you two hours to pay $10,000. (Plus two grand for the ambulance.) Please, sir, I know it’s very hard to hold a pen with your arm going numb, but we want you to save money! If finances are tight, you can even opt out entirely - pay nothing, and just ride it out, hope for the best. Which will it be, sir? > > In other words… > > You can’t have a free market where consumption is mandatory on pain of death. You’re looking at one type of event requiring medical care. But what about routine visits, tests, elective surgeries, etc. It is virtually impossible to call around and get pricing, and any provided figures are estimates that may or may not be accurate. As mentioned above, it’s largely due to the insanely complex insurance system in place. When I say one option is to go free market, I mean that there would be no insurance at all for routine care. It would be like it was 50 years ago. Families had major medical insurance (at a reasonable rate) for extraordinary medical events, but paid out of their pocket for routine care. Similar to homeowners insurance, where you don’t expect your insurance company to pay for landscaping or fixing a porch. You only file a claim when it’s a sizeable loss. A typical physician’s office had one or two secretaries handling all of the billing and admin. Now a small doctor’s office needs a small army to handle all of the insurance and government requirements. But, in reality, I don’t see that happening, so from a practical standpoint we have to go the other way. I’m in favor of completely separating health insurance from employment. If this wasn’t the system that developed over the years, there would be no logical reason to tie a job with health insurance, with all of the inequities and inefficiencies involved. For many companies, providing health insurance represents $15-20k of payroll on top of a salary or wage. And it handcuffs people to jobs that provide such a benefit. It’s a ridiculous system. And the ACA and ACHA are doing nothing to improve it. ---
**Author:** ![Johnny\_L.A](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/johnny_l.a/32/1084_2.png) [@Johnny\_L.A](https://boards.straightdope.com/u/Johnny_L.A)\ **Post date:** [May 9, 2017, 5:45pm UTC](https://boards.straightdope.com/t/is-there-anything-in-the-acha-that-will-actually-improve-quality-of-health-care-or-reduce-costs/786005/29 "2017-05-09T17:45:21Z")
I read [this article](http://investmentwatchblog.com/did-you-know-that-before-1973-it-was-illegal-in-the-us-to-profit-off-of-health-care-the-health-maintenance-organization-act-of-1973-passed-by-nixon-changed-everything/) this morning that claims ‘\*\*efore 1973 it was illegal in the US to profit off of health care. The Health Maintenance Organization Act of 1973 passed by Nixon changed everything.’ The style of writing suggests an agenda, so I’d like to know the facts. ISTR that at some point Nixon thought single-payer might be a good idea, but the unions thought it was ‘communist’. Or maybe it was the other way around. I’d root around for myself, but my program just ended and I need to get back to the data… ---
**Author:** ![jasg](https://avatars.discourse-cdn.com/v4/letter/j/f0a364/32.png) [@jasg](https://boards.straightdope.com/u/jasg)\ **Post date:** [May 9, 2017, 6:40pm UTC](https://boards.straightdope.com/t/is-there-anything-in-the-acha-that-will-actually-improve-quality-of-health-care-or-reduce-costs/786005/30 "2017-05-09T18:40:24Z")
> [@Johnny\_L.A](#): > > I read [this article](http://investmentwatchblog.com/did-you-know-that-before-1973-it-was-illegal-in-the-us-to-profit-off-of-health-care-the-health-maintenance-organization-act-of-1973-passed-by-nixon-changed-everything/) this morning that claims ‘\*\*efore 1973 it was illegal in the US to profit off of health care. The Health Maintenance Organization Act of 1973 passed by Nixon changed everything.’ > > The style of writing suggests an agenda, so I’d like to know the facts. ISTR that at some point Nixon thought single-payer might be a good idea, but the unions thought it was ‘communist’. Or maybe it was the other way around. > > I’d root around for myself, but my program just ended and I need to get back to the data… I think that author’s ‘for-profit’ position is a bit over the top. The original HMO, [Kaiser](https://share.kaiserpermanente.org/article/fast-facts-about-kaiser-permanente/) was (and still is) a non-profit and was held up as a model HMO. If the bill was a favor for Kaiser, why is it still non-profit? Also, the 1973 Bill was proposed by Ted Kennedy and was signed by Nixon as a favor to the left. I don’t doubt that had unintended consequences but it appears to have been originally intended to manage the boom in healthcare that followed Medicare/Medicaid in 1965. This [paper](https://web.stanford.edu/class/e297c/poverty_prejudice/soc_sec/fighting.htm) from Stanford points out that the Reagan administration reformed the 1973 bill in a manner that appears that appears to have had a greater effect. > [@](#): > > The corporate world had kept a close eye on the transformation of the health care system since the passage of Medicare and Medicaid, which attracted doctors to elderly and poor patients. This form of public financing was very lucrative to investors, who already owned hospital chains and nursing homes that exploited Medicare and Medicaid for handsome revenues. Ironically, the effort’s for cost containment also created opportunities for corporate development. The corporate world decided to jump in and shape the HMO reform rather than be shaped by it. Government, starved for a solution, welcomed this intervention by the for-profit sector and in 1980 President Reagan reformed the original HMC) Act of 1973 to include a fund to subsidize the establishment of for-profit HMOs (Kuttner, 1996). Now it was pressure of creating efficient, business-like management of the health care system that was undermining the traditional professional sovereignty of health care providers. Thus the HMOs, in addition to the for-profit hospitals, came under control of corporate organizations ---
**Author:** ![brujaja](https://avatars.discourse-cdn.com/v4/letter/b/4af34b/32.png) [@brujaja](https://boards.straightdope.com/u/brujaja)\ **Post date:** [May 16, 2017, 5:09am UTC](https://boards.straightdope.com/t/is-there-anything-in-the-acha-that-will-actually-improve-quality-of-health-care-or-reduce-costs/786005/31 "2017-05-16T05:09:19Z")
This has all been very enlightening. FWIW, I doubt the unions would ever have characterized single-payer as “communist.” It was probably Nixon. ---
**Author:** ![Hari\_Seldon](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/hari_seldon/32/5173_2.png) [@Hari\_Seldon](https://boards.straightdope.com/u/Hari_Seldon)\ **Post date:** [May 17, 2017, 12:58am UTC](https://boards.straightdope.com/t/is-there-anything-in-the-acha-that-will-actually-improve-quality-of-health-care-or-reduce-costs/786005/32 "2017-05-17T00:58:16Z")
A substantial number of the sickest would die and that would certainly reduce costs. And you don’t need ice floes for that to happen. [Previous page](https://boards.straightdope.com/t/is-there-anything-in-the-acha-that-will-actually-improve-quality-of-health-care-or-reduce-costs/786005.md?page=1)