A common thread in conservative plans is the idea that an HSA and a high amount of patient payment before insurance really kicks in will reduce healthcare costs because those people getting MRIs because it is fun will stop.
I haven’t seen the issues brought up in the New Yorker article addressed, which seems to indicate that the doctors are more responsible for patients for excessive procedures.
Remove the tax subsidy for employer-provided healthcare. This will let people buy insurance independent of their jobs. No more staying in crappy dead-end jobs for fear of losing your coverage. Plus, increased competition since you get to pick more than the handful of plans your employer offers.
You might not have noticed, Der Trihs, but you don’t live in a Captain Planet cartoon.
This is, essentially, the much loathed “public option” that’s been proposed, except for the combination of existing programs into one thing.
Also, on the issue of tort reform it’s not likely as meaningful a step as it’s portrayed to be.
No, in a cartoon the good guys win.
And here we go again…
:rolleyes:
I am sure the poor would jump at the chance for a tax-deferred health savings account, as they can already see the tax benefits they are reaping from their 401K’s.
Why isn’t anyone responding to mazinger_z’s points? He’s actually describing the type of system most market-oriented economists are talking about.
(on Preview: I see Fear Itself responded, but only to take a cheap shot at a single point while completely ignoring the other part of the post about providing entitlements for the poor)
I posted almost the exact same solution in another thread, and killed the thread. It seems that it’s a lot easier to attack the weakest ideas for reform than the strongest…
So let’s try again.
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End the tax incentives for employer based healthcare. This is not something that should be encouraged.
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Create Health Savings Accounts, which are fully tax deductible. So those with employer-based programs, the employers can give you employer contributions to your HSA, and you still get the same tax deduction. But now your HSA is portable, and people without employer based health care can contribute to their own HSAs and get the same tax deduction. No more distortions favoring those who get health care through employers.
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Create a universal insurance program, for catastrophic costs only. The idea is that no one should go bankrupt or lose their house or be permanently impoverished because of expensive chronic medical problems or because of accidents or sudden serious illness. The way you implement this is to cover all medical bills over a certain amount - in other words, univeral insurance, but with annual deductibles.
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Set up a progressive scale for the deductible based on household income or wealth. What you’re trying to achieve is common utility across all income levels (i.e. the cost of health care should hurt about the same for someone who earns $20,000 per year as someone who earns $2 million per year). This might mean the deductible before catastrophic care kicks in might be $1000 for low income people, and $500,000 for people who earn millions per year.
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Some form of tax credit for health care costs for the truly needy.
So let’s talk about the problems in health care, and how this solves them.
The first problem is adverse selection. When individuals buy health insurance, the insurance company is at a disadvantage, because of an information asymmetry. You know a lot more about your health than the insurance company does. So if the insurance company prices insurance at the level for people of average health, people who are above average in health will not buy it. This means the insurance companies are going to get a skewed clientele - people who are more likely than others to need health care. So… They price their insurance higher to compensate. This drives out the next-healthiest people. You wind up with a ‘lemon market’. The current solution to this problem is employer-based healthcare - by insuring a large block of people together, the insurance company gets closer to the statistical average health, and can price its insurance more efficiently.
The plan above solves this problem by having insurance company’s risk capped. The big worry for them is that they’ll take on a patient with some condition that winds up costing them millions of dollars. If the downside risk is capped by the government plan, insurance companies don’t need to charge a risk premium, and the adverse selection problem is greatly mitigated.
The next problem in health care is the third-party payer problem. Simply put, the price system is broken. People with universal coverage have no incentive to limit their use of the health care system. Doctors who are paid by a third party and not by the customer have no incentive to control prices or refrain from needless tests. Insurance companies know this, so their solution is an ever-increasing amount of red tape forcing doctors and hospitals to documents every treatment, every little expense. So the system’s management costs go through the roof.
This plan helps solve this problem by making people responsible for the first level of their own health care costs. Once you connect payments back with customers, they have an incentive to seek out the best value in health care. And once the first level of transactions are done without the involvement of the insurance company, the paperwork requirements diminish greatly.
The next problem in a public health care system is that you lose ‘early adopters’ - the very rich willing pay large amounts for experimental drugs and new devices. This stuff is insanely expensive. But under this plan, the rich are paying huge amounts of their own money for their own health care, with no involvement by government or insurance companies. So they can still choose to pay for the incredibly expensive treatments. This is critical, because it’s the early adopters that prove out new technologies and drugs and pay for the R&D costs, which then lowers the price of those treatments so the rest of us can afford them.
There are plenty of models for this kind of health care system, and they work very well. For example, dentistry in Canada works much like this. Dentistry is completely private, and people pay for it with their own money. But very expensive dentistry due to catastrophic problems is covered by the government. If I need reconstructive dental surgery after an accident, the government pays. If I just need a filling or a cleaning, I pay.
The result is that dentistry is a competitive profession. Dentists set up offices all over the place. There are no waiting lists for dentists. There is tremendous innovation. Dentists offer varying levels of service (some offer nitrous oxide at an added cost, others don’t. Some set up TV’s over the chair to keep the patient distracted, some don’t). You can pick and choose how much you want to pay.
And because the government pays for catastrophic dentistry, many companies in Canada offer additional dental insurance for their employees at a very reasonable cost. I’ve got very good dental coverage through my employer, and it doesn’t cost much at all.
Canada is moving more and more to HSAs and to delisting medical services from our single-payer plan.
I’m not so sure why the left is so opposed to this. It maintains personal freedom, it avoids the moral hazards that come from removing personal responsibility from health care, it requires much less structural change in the current system, and it would wind up costing far less.
Here’s a good overview of current research on Consumer Driven Health Care Plans. There is actual data on cost savings and it’s very good. In addition, research has shown no decline in the level of care under such programs, and in fact show a significant increase in the amount of preventative care people get, and consequently better health outcomes for people under such plans.
What’s not to like?
is this a refundable tax credit?
If so, are providers likely to wait until April to get paid?
If not, of what use is a tax credit to someone who pays no taxes? (37% of households).
Conservative, here, responding to the OP.
IMHO, you haven’t labelled all of the problems. You missed a few:
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People seem to believe that they are entitled to the best care, no matter the cost and no matter who must pay it.
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People believe that employers must provide insurance, and will actively seek out a different company if one does not.
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Virtually all people have a type of insurance prone to abuses.
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It costs a heck of a lot to be a doctor.
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Torts. (described by others)
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The first, above, is my biggest peeve. If a new procedure comes out that guarantees that you will live and all symptoms will go away no matter what symptoms you have and no matter what cause, but said treatment costs $57 billion purely in expenses for the docs (ie. at no profit), people will still demand that they are entitled to it. The fact of the matter is that some things are expensive (to develop, to attempt, to buy eqipment for, etc), and some things are TOO expensive for us to provide, no matter how good they are. The line must be drawn somewhere, and while no line will be “fair” (there will be “haves” and “have-nots” no matter what we do), ability to pay seems like the best line to me. The right to “life, liberty, and the pursuit of happiness” does not, IMNSHO, mean the right to “all possible medical methods to save one’s life”.
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If employers did NOT provide insurance, but, instead, gave more money (enough to cover the costs thereof) and told you to get your own, there would be far more competition. As it is, if I have Kaiser, and my cousin dies from a routine procedure because of negligence (actually happened), I can’t change to another provider. Kaiser has little reason to even change what doctors they use. Kaiser’s sole point of competition is in making themselves look cheap to the employers that pay for my insurance.
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Since virtually everyone has insurance (I saw 88% quoted in another thread, but 70% would be plenty for this argument), doctors are not payed by the people they provide service to. They are payed instead by someone else (either the insurer or the hospital they work at). As such, if they are greedy (or just having trouble making ends meet after the huge costs of medical school), they are incentivized into running more tests and prescribing more medications than truly necessary, and the patient has no reason to object. So the costs for treatment increase, causing the insurance companies to pay more, causing insurance rates to increase, causing people to ask the doctor for MORE tests “since they’re paying for it anyway” (I’ve heard this argument myself many times).
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Doctors themselves are only sometimes and only partially to blame. But even if they’re charging a huge hourly amount for what they do, or ordering more tests than they should, there’s a reason for it – they had to give up a huge portion of their life, working very long hours and paying huge tuition bills. And in my opinion, it’s not entirely necessary. Yes, if you’re seeing a dermatologist, you want him to have significant background so that he doesn’t prescribe something that will, say, stop your heart. But modern docs have to take WAY more “background” classes than makes any sense. I believe that if more specialization was allowed, you could have docs of differing levels of knowledge, with differing school costs, offering services at differing prices, and all giving more than adequate levels of care (in their specialization) as long as they work together. This would have the side benefit of making medical school more accessible, meaning more doctors (which has also been pointed out as a lacking resource).
I don’t believe that any kind of UHS is going to solve the above problems. If anything, I’m afraid it will make these problems worse. Honestly, everyone agrees that the insurance providers are part of the problem, right? So how is forcing MORE insurance going to help?
So what’s my proposed alternative? Well, you’re not going to like it, but I don’t like yours, so we’re even. 
I propose that we tackle the above issues, rather than what I believe are the symptoms that most ppl talk about. I believe that these cause those, not the other way around. I’m honestly not sure what the BEST way to do this is, but here’s an “off the top of my head” proposal (I’m sure someone else could come up with better):
A) Disallow companies from providing health insurance. Force them to redirect all premiums back to the employees they were providing the benefit for. I realize that this takes away freedom from the companies offering insurance. I see this as a necessary evil, and perhaps a temporary one.
B) Force a doctor-patient relationship based on money. Something as simple as “your insurance premiums are tied to the number of doctor visits you have had in the previous x yrs” may suffice, but I’d bet we could do better. Maybe even a lagging heuristic of real costs.
C) Allow a form of health-care worker that is allowed to perform simpler tasks, but not harder ones, and can open their own clinic. Essentially this may well be nurses setting up their own shops. Honestly, I’ve known a lot of nurses that were better doctors than the doctors were. Lack of a piece of paper doesn’t mean a lack of knowledge or skill. At the same time, encourage more specialization by reducing medical GE reqs. “MD” is too well defined and too often “required”.
D) Give ER and other docs a limit on the expense of procedures they may perform on someone whose insurance or other ability to pay has not been verified. If they are “sure” they could save someone with something “just a touch over the limit” and it turns out the person can’t pay it, make the doctor himself liable for the costs above said limit. Obviously, charities may be formed (and should be allowed to be) to handle overages as well. I realize that this may cause problems (“Well, nurse, he died because we couldn’t do procedure x” “But doctor, his ID and accounts just came through! That was Bill Gates, and he had plenty enough to cover x!”), but I believe it’s a lesser evil than is currently in place (or alternatives that I’ve seen).
E) Set up tax-free medical expense accounts and encourage people to use them. This allows people to save for trouble, and is also another way to induce the insurance companies to provide a good service for a good price (since otherwise ppl will go elsewhere… ie. their own savings).
F) If you must have the government spend more money, have them spend it on the education of patients. The “ask your doctor” commercials I’ve seen recently are REALLY STUPID. But they’re right, and I can hope that they will work.
If we can do the above things, I don’t believe that we’ll need any further reform. Though, granted, this will stir up the nest quite enough. 
Yep. Both.
That little said, I’ve been convinced for years that health insurance should be more along the lines of car insurance. Spend your own money and none of the insurance company’s on the little shit - a doctor’s check-up or a ding in the fender; spend some of your own money and some of the insurance company’s on the medium shit - physical therapy for a rotator cuff or a windshield replacement; spend very little of your own money and very much of the insurance company’s on the major shit - colon cancer surgery or a car totalled by the bus driver missing a red light.
I feel that something is wrong with insurance that covers a $100 doctor visit, but doesn’t cover the $10,000 treatment that results from that.
That would upend the system. Think about the chicken littles right now who fear losing their current coverage.
HSA’s are stupid. You have a thousand dollar deductible you’re going to have people putting off preventative care. It’s exactly the wrong solution for the problems we have.
SOCIALIST!!!1111ONE
Poor people will still avoid the deductible and shy away from going to the doctor.
Is this to be a refundable tax credit?
So government high deductible plans are just for sick people, right? :dubious:
What will happen is poor people will go to the cheapest doctors. And cheap doctors will be like shitty schools, underfunded and grimy.
This isn’t a problem. The rich wouldn’t be using the public option in any case.
Probably because dental doesn’t cost very much at all in general.
Because HSA’s for poor people and the sick sounds like a pretty stupid solution.
Everything?
Refundable tax credit, health bursary, debt forgiveness, emergency funding application, whatever. If we can agree on the principle, we can hash out the details.
What the poor can NOT have is unlimited, absolutely free health care. There are huge moral hazards involved there. And I believe that adults need to be responsible for themselves. This notion that people should be totally divorced from major costs in life infantilizes the population and treats them as wards of the state.
What we can agree on is that your medical expenses should not cause you to lose your home, or drop out of school, or go into debt for the rest of your life. But there’s no reason that people cannot pay for at least as much of their health care as they currently pay for cigarettes, booze, cable TV, or any number of other luxuries. It’s critical that individuals not be completely divorced from the costs they incur on society wherever possible, and that health care providers have some incentive to provide the most cost-effective care they can for their customers. That’s one of the key aspects of cost control.
We can debate exactly how much cost the poor should incur, and how they should pay for it. But remember, if the poor don’t want to be at risk for maybe a $1000/yr deductible, they’re free to apply for gap insurance. If it works like auto insurance, it might be available extremely inexpensively for those who are in good health, but if you keep making claims you become higher risk and the cost goes up.
So it might work like this: A young couple just starting out buys gap insurance to cover their $1000/yr deductible, and they pay $250/yr for it, with a new deductible of $100. If they don’t make a claim against it for a couple of years, the price drops to $150. So they have an incentive to pay for small medical bills and checkups out of their own pocket to keep their insurance costs low. But if they get really sick and incur a $10,000 medical bill, the insurance company ponies up $900, they pay $100, and the government pays for the rest. Next year, perhaps their gap insurance goes up to $300. But that’s still only $25/mo.
Insurance systems like that work. That’s how auto insurance works. You pay for your own routine maintenance, and if you ding your car for $200 in damages you’re likely to pay it yourself rather than file a claim and drive up your insurance costs. But if you get in a major accident, it doesn’t ruin you. You pay a few hundred bucks, the insurance company picks up the rest.
Now, if we REALLY want to reform the system, we put the elderly under the same program and scrap Medicare. There’s no reason today why the government should pay the health care bills of Warren Buffet. The elderly poor can perhaps have their deductible completely waived, so they are still covered. But Medicare is a huge cost sink, and part of the reason is that you’ve completely divorced the cost of health care from the people who use the system most heavily. Then the rich ones die while having a lot of their money intact, and you tax it from them as an estate tax. What an inefficient way to do things. Make those with the ability to pay cover their own health costs.
You can do the same with Medicaid. This system can be made to work for the poor as well, so now you can scrap Medicare, Medicaid, and unify the entire health care system under market-driven principles while still protecting the poor.
I wouldn’t advocate the removal of Medicare right now, for the simple reason that it’s politically impossible. But as the system is shown to work and be cost-effective, it could be the next phase of reform if the people are happy with the new one.
And here’s one last big feature: If you don’t like it, you can still go to a government plan five or ten or twenty years from now. But if you go to a government plan, it will be very, very difficult to get away from it because the change in fundamental incentives will cause the system to completely restructure. And you know that once the people are given an entitlement, it’s nearly impossible to eliminate it. So try the market-based reforms first before completely overhauling the system.
People who have health insurance through their employer can get the same benefit through employer-contributed HSAs. They lose nothing.
You didn’t even bother to read my cite, did you? It turns out that’s NOT the case. In fact, it’s the opposite. When people know they are going to be on the hook for some of their medical costs, they have more incentive to look after themselves and do preventative care.
If it’s truly catastrophic coverage only, it will sell. As I’ve already said, systems like this have been proposed by market-oriented economists and conservatives like them. No one yells socialism because the goverment provides insurance against natural disasters like floods.
Again, that turns out to be not the case. Read the cite.
See my response to Fear Itself.
I have no idea what you’re talking about. Could you clarify?
Uh-huh. All those doctors, just waiting to stop cleaning their ORs once they can latch onto those poor people.
Say, how about that $4 prescription plan at Wal-Mart? Maybe you’d see more innovation like that. This is a bad thing?
They would if it becomes single-payer. They have to in Canada. The head of the Canadian Chamber of Commerce went to the US for treatment because he was on a long waiting list in Canada. So did the Premier of Ontario.
Really? Reconstructive surgery is just a drop in the bucket? Surgery and treatment for oral cancer? You’re just making stuff up now.
Only to people with their minds closed. Cas Sunnstein, one of Obama’s advisors, wrote a book about how the behavior of the poor can be changed with ‘nudges’. Rather than government mandating health care, the government can ‘nudge’ people into responsible behavior by changing defaults. For example, the government can require that employers must contribute some amount of the employee’s income directly into a savings account, and that the employee must take positive steps to cancel that and get the money. The employee is still free to do anything at all with the money, but the default case is that it goes into a savings account. There is strong evidence that such small ‘nudges’ can make dramatic differences.
And we’re not talking about a significant amount of a poor person’s income here. If the poor have a $1000 deductible on their catastrophic insurance, an HSA contribution of $30/mo would probably be enough to pay for gap insurance, or after three years the HSA would have enough in it to completely cover a year in which someone had to seek medical care. Even the poorest of the working poor can afford $30/mo for their own health care.
You didn’t even bother to think about it, did you? You just looked for some quick ways to dismiss it out of hand. You didn’t bother to read the cite, you didn’t offer any substantial rebuttals. Just curt dismissals. The only reason I even bothered to respond was because there may be other people reading this who deserve reasonable debate. Your mind is apparently closed.
Except they want their plans. It has become a talking point of the right that the plans they love must never be taken away from them. That’s why the bill is written the way it is.
When I was growing up I was poor, and I promise you, people will not go to the doctor if it means they can’t gas up their car.
You overestimate the right in this country. They would, at this point, yell socialism at anything, so long as they can hurt the administration in the process.
Forcing people to pay a thousand dollars when they break their arm is pretty far from nudging people to be healthy. It would only make worse the existing problems in this country. Maybe you should hop down to America and hang out at an ER for awhile. This plan would do nothing to stem the tide of bankruptcies that healthcare costs contribute to, it would probably increase them because the deductibles would be larger and more widespread.
Well that at least I’d agree with.
I was assuming that your plan had a separate private system. I didn’t realize that you intended it to be a single payer system. Which, by the way, America simply isn’t ready for. The sniveling hysterics of the last week show that the angry, uninformed and stupid aren’t willing to learn just yet. A couple years with a good working public plan will snap them out of it, but to go cold into a system like you describe would face far more opposition than the current plan.
No, there will be very cheap doctors and very expensive ones. The cheap ones will be in run down parts of town and the expensive ones will be in posh neighborhoods.
No, I’m all for it. If wall mart can come up with a way to have a cheap, skilled doctor working there, cool beans.
As I said, I was thinking you wanted this system layered on top of the current one.
Weren’t you saying they’d cover catastrophic dental stuff?
Nudge, nudge… I’m all for nudging.
I’m not saying it can’t work, I’m saying the current plan is better. The deductible insurance would still have them having to come up with a hundred dollars for a doctor’s visit though and that will still push people living paycheck to paycheck into putting off their healthcare.
I thought about it, then closed my mind.
Actually, it won’t. Individual coverage is much more expensive than group for a variety of reasons other than greed. It has to do with the size of the “risk pool”. You have to make it so that everyone is in the same pool somehow, or people who are not covered at work will pay through the nose.
Dude, you are starting to sound like the Ann Coulter of the Left.
We’re talking about pap smears and catheters, not Tom Cruise face transplants.
Nonsense, Guin. Somebody who claims to have been hurt by the liberals at a town hall meeting here in St. Louis (Ken Gladney) is asking for contributions because he just got laid off and has no heath insurance.
Regardless of whether or not the comment was true about any 1 person, to say that it’s true of all conservatives is pretty silly. I could say the same thing about liberals and citing a liberal and then I’d be no better than Ann Coulter, don’t you agree?
Personally, I think she’s a nut job and I’d rather she didn’t argue on my side. In fact, I’d argue that she’s NOT on my side, regardless of whether or not we both disagree with liberals.
Similarly, I don’t think that acting like her does your side any favors.