There must be a pony in here somewhere.

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Jennifer
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Re: There must be a pony in here somewhere.

Post by Jennifer » 28 Feb 2018, 12:54

Based on my perusal of social media (obviously not synonymous with scientifically rigorous polling), there are many who feel that even if single-payer taxes DO prove more than their current "taxes plus health insurance premiums plus out of pocket med costs," it would be worth it in exchange for both the security of knowing "At least my family and I won't lose coverage if I lose my job, plus my fellow Americans will also be helped under such circumstances."
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Dangerman
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Re: There must be a pony in here somewhere.

Post by Dangerman » 28 Feb 2018, 13:01

I looked and apropos of nothing, the reduced payroll FICA deduction after the tax cut puts $90/month in my pocket, assuming that the payroll people are doing the math correctly.

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JasonL
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Re: There must be a pony in here somewhere.

Post by JasonL » 28 Feb 2018, 13:47

Nothin means nothin until there’s a real proposal with a real price tag broken out by real taxpayer categories.

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fyodor
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Re: There must be a pony in here somewhere.

Post by fyodor » 28 Feb 2018, 15:02

JasonL wrote:
28 Feb 2018, 13:47
Nothin means nothin until there’s a real proposal with a real price tag broken out by real taxpayer categories.
And even that would change with time via trial and error, I would think anyway. I don't know how other countries handled it, but I can't imagine they'd come anywhere close to nailing it on the first try.
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JasonL
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Re: There must be a pony in here somewhere.

Post by JasonL » 28 Feb 2018, 15:20

That's totally true. It's not that single payer is impossible or doomed to failure, it's just that there's a large expectations gap when all you ever talk about is the benefits and in particular without noting that other countries have long since gotten used to certain things we are not used to. The costs make it real. There is a common misconception that it won't cost that much or you can just tax Warren Buffet and be done. Nope. There is a common belief that cost savings here will be comparable to cost savings else where when there are reasons to believe that will be very difficult to deliver. You want to snap your fingers and cut GP income by a third and specialist income by half? There will be some supply side issues if you try to do that. There is a common belief that care would look basically like it does now - go as many times as junior has sniffles, get access to every new thing, etc. The party saying "no" to all that is private now but would be the government at some point with limited ways around it. And, of course, my bailiwick - we are used to new stuff showing up that is funded in large part by private investment. You eliminate that and you either get limited new stuff or you raise the cost to all public systems to replace that investment - in which case the cost/benefit doesn't look quite as dramatic as it does now with investment not being a line item in cost.

Over some period of time doc expectations for income would come down and patient expectations for total cost would come up and people would get used to things.

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Re: There must be a pony in here somewhere.

Post by Aresen » 28 Feb 2018, 15:22

fyodor wrote:
28 Feb 2018, 15:02
JasonL wrote:
28 Feb 2018, 13:47
Nothin means nothin until there’s a real proposal with a real price tag broken out by real taxpayer categories.
And even that would change with time via trial and error, I would think anyway. I don't know how other countries handled it, but I can't imagine they'd come anywhere close to nailing it on the first try.
Medicare in Canada was imposed nationally by the Liberal Party with much screaming and hollering. (There had previously been much screaming and hollering in Saskatchewan, including a Doctor's strike, when the NDP government there imposed it a few years before.)

Within a few years, it was untouchable politically and the only argument was about how each party could 'improve' it. The costs have risen continuously, with predictable results.

(Plus what JasonL said above.)
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JasonL
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Re: There must be a pony in here somewhere.

Post by JasonL » 28 Feb 2018, 15:28

I wonder what the mean income difference for Canadian docs was in the before time and the decade after implementation. That's honestly one of the hardest things to grapple with in the US. A huge percent of our costs are specialists getting 2X international averages and GPs getting 33% more. Loss aversion is going to make cuts of that magnitude feel like even more and ugh. You'd probably have to have public assistance to pay off doc debt.

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Re: There must be a pony in here somewhere.

Post by Highway » 28 Feb 2018, 15:31

JasonL wrote:
28 Feb 2018, 15:28
I wonder what the mean income difference for Canadian docs was in the before time and the decade after implementation. That's honestly one of the hardest things to grapple with in the US. A huge percent of our costs are specialists getting 2X international averages and GPs getting 33% more. Loss aversion is going to make cuts of that magnitude feel like even more and ugh. You'd probably have to have public assistance to pay off doc debt.
Plus the doctor shortage in the US that's perpetrated by the lack of residence slots and collusion between the government and the industry (i.e. if they really wanted more doctors, they'd actually get them).
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Re: There must be a pony in here somewhere.

Post by lunchstealer » 28 Feb 2018, 16:46

Eric the .5b wrote:
28 Feb 2018, 08:36
lunchstealer wrote:
28 Feb 2018, 03:21
Yeah, I think we need to get out in front of it and find the least bad option.
Libertarians can totally do that.

Nobody else will actually care what we support or pay any attention, though. The effect well be exactly the same as if we advocated "two men enter; one man leaves" for cost control.

ETA: Let's be real. This is the libertarian anti-moment. Both sides of the aisle in this country are loudly, vigorously rejecting almost all the stances we ever agreed with them on. In my lifetime, I've never seen the right so nakedly bigoted with so little interest in markets or individual rights. I've never seen the left so hostile to civil liberties. The things we care about and stand for mean nothing to them, right now.
Dammit Eric, you're supposed to tell me what I want to hear! Everyone loves libertarians and are secretly jealous they're not us and hates to implement our plans but they have to because they know we're right!
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Eric the .5b
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Re: There must be a pony in here somewhere.

Post by Eric the .5b » 28 Feb 2018, 18:52

Aresen wrote:
28 Feb 2018, 10:36
Eric the .5b wrote:
28 Feb 2018, 08:36
The effect well be exactly the same as if we advocated "two men enter; one man leaves" for cost control.
Hey! We could halve the cost of health care right there! :twisted:
I didn't say the idea was entirely without merit. :D
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Eric the .5b
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Re: There must be a pony in here somewhere.

Post by Eric the .5b » 28 Feb 2018, 18:54

lunchstealer wrote:
28 Feb 2018, 16:46
Dammit Eric, you're supposed to tell me what I want to hear! Everyone loves libertarians and are secretly jealous they're not us and hates to implement our plans but they have to because they know we're right!
Not until someone from reason ponies the fuck up for me to write that. :D
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Re: There must be a pony in here somewhere.

Post by Mo » 28 Feb 2018, 20:06

Singapore is Morbamacare too, with a public option on top.
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fyodor
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Re: There must be a pony in here somewhere.

Post by fyodor » 06 Apr 2018, 20:55

Good idea?

Partial disclosure: it's about price disclosure.
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JasonL
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Re: There must be a pony in here somewhere.

Post by JasonL » 07 Apr 2018, 06:51

Done right, yes. I would standardize a pricing disclosure using principles from the HUD-1/ Pricing Disclosure.

The nonsense in medical billing begins with an arbitrary top line, that back in the day was never intended to be paid by a private consumer. The discounted insurance rate is the first “real” number. From there insurance does disclose co pays and deductibles pretty well but standardized language / template would be helpful.

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Re: There must be a pony in here somewhere.

Post by Warren » 07 Apr 2018, 09:55

I like it. Definitely a step in the right direction. As long as you got third-party payer though, I'm not sure how much force you can put into market forces.
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Jennifer
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Re: There must be a pony in here somewhere.

Post by Jennifer » 12 Apr 2018, 10:04

The Economist learns, unsurprisingly, that the firms which profit the most from America's healthcare system are not pharmaceutical companies or actual care providers, but "an army of corporate health care middlemen."

https://www.economist.com/news/business ... are-system
EVERY year America spends about $5,000 more per person on health care than other rich countries do. Yet its people are not any healthier. Where does all the money go? One explanation is waste, with patients wolfing down too many pills and administrators churning out red tape. There is also the cost of services that may be popular and legitimate but do nothing to improve medical outcomes. Manhattan’s hospitals, with their swish reception desks and menus, can seem like hotels compared with London’s bleached Victorian structures.

The most controversial source of excess spending, though, is rent-seeking by health-care firms. This is when companies extract outsize profits relative to the capital they deploy and risks they take. Schumpeter has estimated the scale of gouging across the health-care system. Although it does not explain the vast bulk of America’s overspending, the sums are big by any other standard, with health-care firms making excess profits of $65bn a year. Surprisingly, the worst offenders are not pharmaceutical firms but an army of corporate health-care middlemen.

In crude terms, the health-care labyrinth comprises six layers, each involving the state, mutual organisations and private firms. People and employers pay insurance companies, which pay opaque aggregators known as pharmacy-benefit managers and preferred provider organisers. They in turn pay doctors, hospitals and pharmacies, which in turn pay wholesalers, who pay the manufacturers of equipment and drugs. Some conglomerates span several layers. For example on March 8th Cigna, an insurance firm, bid $67bn for Express Scripts, a benefit manager. A system of rebates means money flows in both directions so that the real price of products and services (net of rebates) is obscured.

To work out who is stiffing whom, Schumpeter has examined the top 200 American listed health-care firms. Excess profits are calculated as those earned above a 10% return on capital (excluding goodwill), a yardstick of the maximum that should be possible in any perfectly competitive industry. For drugmakers the figures treat research and development (R&D) as an asset that is depreciated over 15 years, roughly the period they have to exploit patents on discoveries. The data are from Bloomberg.

Total excess profits amount to only about 4% of America’s health-care overspending. But this still makes health care the second biggest of the giant rent-seeking industries that have come to dominate parts of the economy. The excess profits of the health-care firms are equivalent to $200 per American per year, compared with $69 for the telecoms and cable TV industry and $25 captured by the airline oligopoly. Only the five big tech “platform” firms, with a figure of $250, are more brazen gougers.

Everyone hates pharmaceutical firms, but their share of health-care rent-seeking is relatively trivial, especially once you include the many midsized and small firms that are investing heavily. Across the economy, average prices received by drug manufacturers have risen by about 5% per year, net of the rebates. But their costs have risen, too. As a result, even for the 15 biggest global drugs firms, returns on capital have halved since the glory days of the late 1990s, and are now barely above the cost of capital. As employer schemes get stingier, employees are being forced to pay more of their drug costs; they are price-conscious.

Meanwhile the effectiveness of R&D seems to have fallen. Richard Evans of SSR, a research firm, tracks the number of high-quality patents (defined as those cited in other patent applications) that drug firms generate per dollar of R&D. This metric has dropped sharply over the past decade. Shareholders may groan, but for the economy overall the system seems to be working. Big pharma is still splurging on R&D but not making out like a bandit.

As the drug industry has come back down to earth, the returns of the 46 middlemen on the list have soared. Fifteen years ago they accounted for a fifth of industry profits; now their share is 41%. Health-insurance companies generate abnormally high returns, but so do the wholesalers, the benefit managers and the pharmacies. In total middlemen capture $126 of excess profits a year per American, or about two-thirds of the whole industry’s excess profits. Express Scripts earns billions while having less than $1bn of physical plants and no disclosed investment in R&D. This year the combined profits of three wholesalers that few outsiders have heard of are expected to exceed those of Starbucks.

The dark view is that pockets of rent-seeking have become endemic in America’s economy. Wherever products are too complex for customers to understand, and where subsidies and complex regulation add to the muddle, huge profits can opaquely be made. Remember mortgage-backed securities?

In the case of health care, consolidation has probably made things worse by muting competition. There are now five big insurance companies, three big wholesalers, three large pharmacy chains and three big benefit managers. The current vogue is for “vertical mergers” in which firms expand into different layers. As well as Cigna and Express Scripts, Aetna, another insurer, and CVS, a pharmacy and benefits manager, are merging. All these firms insist competition will be boosted. But they are also projecting the deals will boost their combined profits by $1.4bn.

Amazon and the health-care jungle

Yet perhaps capitalism is not broken and new contenders will eventually be tempted in. Amazon has acquired wholesale pharmacy licences in multiple states. It is also teaming up with JPMorgan Chase and Berkshire Hathaway to create a new health system for their staff. These initiatives are at an early stage, but investors are sufficiently worried that they value the intermediaries on abnormally low multiples of profits, suggesting earnings may fall. People often get upset when conventional industries are hit by digital competition. Few would lament it in the case of health-care middlemen.
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JasonL
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Re: There must be a pony in here somewhere.

Post by JasonL » 12 Apr 2018, 14:08

The people profiting most is not how to describe that piece though. The article stipulates that the rents in the middle men space “do not account for the vast majority of American overspending”.

These guys are getting more than you’d think, but providers like hospital groups are raking it in - more than pharma by a lot.

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Re: There must be a pony in here somewhere.

Post by Painboy » 12 Apr 2018, 15:00

I will also point out one of the architects of Obamacare stated that one of it's goals was to increase consolidation of those organizations as they believed they could reduce bureaucratic costs. He's since admitted that idea didn't actually work to reduce costs.

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Re: There must be a pony in here somewhere.

Post by JD » 13 Apr 2018, 10:58

Painboy wrote:
12 Apr 2018, 15:00
I will also point out one of the architects of Obamacare stated that one of it's goals was to increase consolidation of those organizations as they believed they could reduce bureaucratic costs. He's since admitted that idea didn't actually work to reduce costs.
I wonder if that was shades of the old thinking "Competition is wasteful and destructive." You don't usually see it expressed that baldly these days, but it does continue to influence some people's thinking.
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Aresen
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Re: There must be a pony in here somewhere.

Post by Aresen » 13 Apr 2018, 11:05

JD wrote:
13 Apr 2018, 10:58
Painboy wrote:
12 Apr 2018, 15:00
I will also point out one of the architects of Obamacare stated that one of it's goals was to increase consolidation of those organizations as they believed they could reduce bureaucratic costs. He's since admitted that idea didn't actually work to reduce costs.
I wonder if that was shades of the old thinking "Competition is wasteful and destructive." You don't usually see it expressed that baldly these days, but it does continue to influence some people's thinking.
I still hear it. Usually from people who say things like "Why do we need so many different brands of cereal / makes of car?"

The same people will usually turn around minutes later and call the oil and gas industry a 'monopoly'.
If Trump supporters wanted a tough guy, why did they elect such a whiny bitch? - Mo

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Re: There must be a pony in here somewhere.

Post by Painboy » 13 Apr 2018, 13:59

Aresen wrote:
13 Apr 2018, 11:05
JD wrote:
13 Apr 2018, 10:58
Painboy wrote:
12 Apr 2018, 15:00
I will also point out one of the architects of Obamacare stated that one of it's goals was to increase consolidation of those organizations as they believed they could reduce bureaucratic costs. He's since admitted that idea didn't actually work to reduce costs.
I wonder if that was shades of the old thinking "Competition is wasteful and destructive." You don't usually see it expressed that baldly these days, but it does continue to influence some people's thinking.
I still hear it. Usually from people who say things like "Why do we need so many different brands of cereal / makes of car?"

The same people will usually turn around minutes later and call the oil and gas industry a 'monopoly'.
It's that technocratic mode of thinking that bureaucracy can be scaled up in the same way as mass production. But not only do you get to a point where each additional layer has diminishing returns, you also reach a point where it actual becomes negative. What's worse is that it becomes inflexible and stifles any possibility of innovation.

It's that mentality that thinks all the world's problems can be solved with a long enough checklist.

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