« Your Unemployment Is Your Fault | destor23's Blog | Don't Let States Opt Out Of The Public Option »
If We Can't Fight The Trigger, Join It.
Looks like if there is going to be a public option it's going to have a trigger attached to it. The public option, even a weak one, won't actually become available unless the private insurance industry fails to deliver cost savings or to cover everyone, though we all know that these simple metrics will be written so broadly and with so much wiggle room that the trigger will likely never be pulled. A trigger on the public option means no public option.
Fine.
So let's add a second trigger -- on the individual mandate. The mandate exists because insurance companies say that if they have to cover everyone regardless of pre-existing conditions that people will refuse to buy insurance until they get sick. It's called the "Free rider" problem and it's very compelling.
But it's also hypothetical. We don't have any evidence that people will actually behave that way. For example, a lot of insurance policies won't let you make a claim in the first 3-6 months -- that alone creates a risk to not buying insurance until you think you're sick. What if you break your leg, you going to wait 6 months to get it set?
There's an excellent chance that the free rider problem isn't actually real. But, who am I to judge? Let the insurance companies prove that it's a problem and if it is, by all means we can have a mandate to solve it. But, make them prove it. And lets make the trigger rules at least as vague as the public option trigger rules will be.
Fine.
So let's add a second trigger -- on the individual mandate. The mandate exists because insurance companies say that if they have to cover everyone regardless of pre-existing conditions that people will refuse to buy insurance until they get sick. It's called the "Free rider" problem and it's very compelling.
But it's also hypothetical. We don't have any evidence that people will actually behave that way. For example, a lot of insurance policies won't let you make a claim in the first 3-6 months -- that alone creates a risk to not buying insurance until you think you're sick. What if you break your leg, you going to wait 6 months to get it set?
There's an excellent chance that the free rider problem isn't actually real. But, who am I to judge? Let the insurance companies prove that it's a problem and if it is, by all means we can have a mandate to solve it. But, make them prove it. And lets make the trigger rules at least as vague as the public option trigger rules will be.
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we all know that these simple metrics will be written so broadly and with so much wiggle room that the trigger will likely never be pulled.
Actually I am assuming that they will be met simply by firing the people that insurance currently employees to screw us. Since Rescission, and Preexisting conditions, and other discrimination will be outlawed. They won't need them anymore. Presto! an initial 20% savings in the first 2 years. Amazing!!! And everyone covered too!
September 30, 2009 4:40 PM | Reply | Permalink
Of course they will need to staff a whole new department that provides both the government and covered a yearly report showing who's been insurance naughty and who's been insurance nice.
Seriously though - medical claims will still be referred to adjusters regardless the standards that they use, they'll just be approving stuff they used to reject. The idea that suddenly the insurance system will be able to eliminate adjusters because rescission is no longer a part of the process doesn't really compute.
September 30, 2009 9:55 PM | Reply | Permalink
Well, actually, the adjusters will be given more claims and fewer will be empoyed. Without having to research medical histories, that time is saved and can be filled with more claims.
October 1, 2009 12:10 PM | Reply | Permalink
Researching medical histories has not been my experience of what an adjuster actually does (adjusters made up the bulk of my former company's client base). Med history is generally already in the claimant's file. I can seen an overhead reduction in the process of writing policies, but don't understand exactly were the huge time savings in administering them is coming from. It is difficult to see how they they will add 40 million new customers making claims and not hire more adjusters.
The system is geared to knock out those with $20K+ health issues. That's when the "medical research" part comes in, it's actually a very small percentage of the cases. There's a computer system specifically designed to handle the bulk of that research - which is why it's so fucked up that they wait for a big claim instead of checking the policy application for issues on the front-end before they take people's money. Mostly today's adjusters are riding herd on mundane process stuff and fraud. I don't see anything in the bill that changes that.
October 1, 2009 4:29 PM | Reply | Permalink
Yes, if they are going to use a 'trigger' instead of giving us an actual, real, effective public option then they certainly can forget the mandate altogether but a 'trigger' that goes into effect only if the public option trigger gets pulled would be okay with me.
I prefer to stick with the simple message... no mandate... without a real, public option available to all.
September 30, 2009 5:02 PM | Reply | Permalink
Okay, TPM keeps eating my comments, which is one of the reasons that I'm so scarce around here these days, so hopefully this one goddamn goes through:
An interesting proposition. It would seem that one good trigger deserves another. However, one important dimension to the free-rider problem is emergency room healthcare. If, as in your scenario, you broke your leg right today there is no way you could wait for insurance. Insurance doesn't factor in, at least not yet.
First, you would likely go to an emergency room. Assuming you could actually pay the subsequent bills, then everything would work out fine. However, we've stipulated that you're uninsured in this scenario. Since you couldn't afford hundreds in monthly premiums, are we to assume that you can suddenly afford thousands in hospital bills? Not likely. This is evidenced by the majority share of bankruptcies catalyzed by medical bills.
So, you don't pay and maybe you do or don't end up in bankruptcy, but the end result is that the hospital eats the cost of treating you, which in turn gets factored into their bottom line, which raises their operating costs in the future, which ultimately amounts to increased premiums from insurance companies.
Personally, I don't think that we should accept the trigger scheme at all. The triggers won't get pulled, either for the public option or for the mandate, and reforms will be impotent in the face of rapidly inflating costs.
September 30, 2009 5:37 PM | Reply | Permalink
Glad your comment went through and I miss you around here (and I know I'm not the only one).
I agree with you -- the uninsured are a problem that we all pay for. I'm really not against a mandate. I'm against a mandate when the only option people have is to contract with a private company. I think it's inherently wrong for the federal government to require people to buy a product form a for profit company.]
I feel like my position is the compromise position: a mandate, all private insurers can stay in business and a national public plan is offered immediately so that people can choose between a private provider or Medicare style coverage. In that instance, I bet I'd pick Medicare for my basics and a supplemental plan from the privates and we'd all be happy and better off for it.
What I don't accept is the government requiring me to write checks to Aetna.
September 30, 2009 6:34 PM | Reply | Permalink
Yeah, I'm with you. It's hard to understand how it is that the public option, which is a compromise at its very heart, is now one polar end of our apparent choices. It's certainly doesn't give me a lot of confidence in the ability of the Dems to deliver.
September 30, 2009 7:26 PM | Reply | Permalink
I wouldn't be as much against mandates if the penalty was used as pre-payment for a policy covering the American being penalized.
The way it's implemented, once a person takes the hit, they get nothing and have even less money to buy insurance. It seems very likely those at the edges (who aren't able to make a budget the government has estimated should be reasonable for X income level) will end up in a spiral where they simply end up paying tons of tax that is then used to offset subsidized policies - but the person penalized still won't have shit. It seems like it's going to make another class of uninsured that is just getting brutally taxed but stuck on the "emergency room" plan for life.
September 30, 2009 10:06 PM | Reply | Permalink
Yeah, that's just smart kgb.
The great thing about single payer is that you just sign people up. They pay taxes and you give them health care! No need for a sign up, you've already paid.
If we're going to fine people for not buying health insurance we should, when we take the fine, also give them health insurance!
September 30, 2009 10:11 PM | Reply | Permalink
I started out a pretty big skeptic of the single-payer solution. But the more I've learned the more it just makes sense. I'd far rather have an honest tax and a baseline of coverage than this bullshit.
And another thing, kind of OT but needs to be said somewhere. Dental should be a part of basic care. We just had a lady in town with 7 kids and a full time job (WalMart of course) die as a result of abscessed teeth because her plan didn't cover dental. This article doesn't get into it much, but the CDA Press (can't find a link) went in-depth about the physical stress fighting that much infection causes.
How the hell can we set out to fix health care and then put together a plan that really doesn't fix it?
September 30, 2009 11:07 PM | Reply | Permalink
Yeah, agree with you there too. Dental is part of health care. So is vision. So is mental. I know that will strike some as overly genereous but it's just true.
It's 2009 and as you linked, somebody died of tooth decay. They died of tooth decay. That we allow that to happen is pure pathology.
September 30, 2009 11:19 PM | Reply | Permalink
I'm sure I will be labeled something awful for saying this: but people of lesser incomes shouldn't have 7 kids. That's a tremendous financial burden.
Cause and effect.
One thing I would make available for free to anyone is contraception (and abortion). Having too many children prevents people from rising out of poverty.
That's my own pipe dream to be sure.
October 1, 2009 5:27 AM | Reply | Permalink
What if they're farmers. Surely a guy like yourself isn't against child labor?
October 1, 2009 1:10 PM | Reply | Permalink
I've heard you say it before. Some people wouldn't exchange the love of a family for increased financial status ... go figure. I don't think that means she deserves to be dead from a situation which with dental insurance likely wouldn't have gotten to the point where it was expensive to repair or a major health issue.
I do agree full reproductive health services should be included in benefits packages.
October 1, 2009 4:44 PM | Reply | Permalink
WE MISS THE HAT! WE MISS THE HAT!
But not "The Shirt." ;-)
September 30, 2009 7:06 PM | Reply | Permalink
Destor - The free rider concept is not hypothetical. Currently, tens of millions of Americans are voluntarily uninsured and are mainly the young and healthy - e.g., those who would drive down the average cost of insurance premiums if they were insured. To compensate, insurers exclude the high risk or unhealthy individuals, or charge them unaffordable rates.
If insurers were required by insurance reform to accept all comers, the high risk group would now be included, at non-discriminatory rates, which would drive up average costs. This would further discourage those who are already the voluntary uninsured, and would guarantee a system further tilted toward unaffordability.
The insurance actuaries have already made this calculation, which is why they exclude so many individuals from insurance purchases. There's not much guesswork involved in calculating the costs of those they now exclude, and essentially no guesswork involved in predicting that those voluntarily uninsured today would almost certainly remain voluntarily uninsured if premium costs are driven up further.
September 30, 2009 5:50 PM | Reply | Permalink
Good points, Fred, as always. I'm more cynical than you, I think. I don't believe that the insurance companies jack up the rates for high risk people in order to make up for losses among the voluntarily uninsured, I think that they jack up rates on the high risk people because they know the high risk people will pay because those people know they are high risk and don't want to die.
As for the voluntarily uninsured -- these aren't people out to game the system. I think they're more likely people who are: 1) In low paying jobs and can't afford to let their employers take money from their checks; 2) Small business employees and the employer either doesn't offer insurance or the premiums are sky high or 3) Self employed and can't afford insurance both because prices are high for individuals and because the tax code penalizes the self employed in this regard.
One thing I'd like you to answer, because I'm really curious as to what you think is: isn't a mandate a subsidy for the private insurance industry?
September 30, 2009 6:29 PM | Reply | Permalink
To answer your last question first, yes, mandates would transfer federal subsidy dollars to insurers via low income subscribers. To me, this reality illustrates a psychological element to the debate that I find troubling - i.e., the notion that if something benefits the insurance industry, it should be resisted, even if it's good for someone else. In this case, tens of millions of currently uninsured individuals will become new insurance industry customers, and that will surely benefit the insurers. It will also benefit the tens of millions who are uninsured, and particularly the many millions who have trouble affording insurance today, but will be helped by the subsidies. We have to decide whether we're more interested in punishing insurers or helping ordinary Americans, because we can't do both in the current political atmosphere.
Regarding the breakdown, many uninsured conclude it would cost them too much, but many others - particularly the young - can afford the premiums but consider themselves "the young and invulnerable" and decline to purchase insurance they could afford. I do agree with you about the tax code inequity, because the self-employed pay premiums out of after-tax income, while those with employer-provided benefits receive those benefits tax free in lieu of income; that should be fixed.
Finally, most opposition to reform, including opposition to mandates, comes from the elderly - particularly those concerned about changes in Medicare. The younger generation is not monolithic, but the polling data I've seen suggest that a majority supports the current reform proposals. They support both mandates and a public option, but I don't believe they want to hold the former hostage to the latter, and most seem willing to make sacrifices they can afford if it will redound to the benefit of those who most need help.
September 30, 2009 7:15 PM | Reply | Permalink
Not only are they young and healthy, they are YOUNG! One could argue that the generational transfer of wealth from young to old is immoral. Between enormous budget deficits and unfunded liabilities (social security, medicare), there is a real risk of lowering our children's standard of living relative to their parents. It won't surprise me at all if health care passes with mandates but no real plan to reduce costs, the young may never vote again. It is a recipe for having them believe the worst about government (and their elders).
How about means-testing for benefit programs like medicare and social security? How about raising the age for both programs? When social security was enacted in 1935, life expectancy was 63 years old; now it is 78. Meanwhile, the age for collecting benefits hasn't changed at all (in fact, you can collect a reduced benefit at 62). BUT...no politician will propose these types of changes, as they will be voted out by the ME generation (everyone over 40, myself included). No hard choices, no sacrifice, no facing the reality of growing liabilities beyond our assets.
September 30, 2009 6:30 PM | Reply | Permalink
Great point, John. I'm 34. Not young but I'm at the point where I'm really just starting to spend on health care -- starting a family, making sure I get my annual physical and occasionally doing some things that my body used to be fine with but winding up injured for it.
The way I see health reform now... NOTHING changes for me after the bill becomes law. I still overpay my premiums, I still have a high deductible that means I'm basically paying both insurance premiums AND medical bills and I get nothing.
And getting nothing will make me mad at the party I supported, in part, because: "do you really want the Republicans running health care?"
Sigh, that's what I have!
If the what Obama signs into law doesn't reduce costs and increase services for people like me (and there are a lot of us) then there's going to be a big problem.
And you're right -- winning over people 10 years my junior is going to be really hard.
September 30, 2009 6:57 PM | Reply | Permalink
Destor,
Whether for you, your insurance company or your employer (whoever is paying the bills), the things you describe -- physicals, starting a family, injuries -- are definitely not the health care cost problems. Chronic illnesses drive a disproportionate amount of the costs in the healthcare system -- diabetes, hypertension, heart disease, cancer -- and these affect us older folks much more. Especially those who smoke, don't exercise and are overweight. I'd love to see those risk factors play into the entire health care debate some more...but I'm even more cynical than you :)
September 30, 2009 8:55 PM | Reply | Permalink
That might be true if we didn't all get old and oh so much quicker than you young ones want to believe!!!
Plus, you young folks vastly underestimate the likelihood of becoming ill or injured and the long term cost.
You think it costs a lot to cover someone who has a debilitating illness or injury when they are 85 - what do you think it costs when they are 25?!
I'm 58 and I can't tell you how many women I know who have had breast cancer. Some died. Some live and fight it off time and again.
I know several families whose teen-age kids suffered life-changing car accidents.
I know families with children in their 20's who have SPMI.
I know a fit and active guy who had a heart attack and a triple bypass at 40.
The best thing about being young and healthy, is that you can't imagine ever being anything but young and healthy. Enjoy it while it lasts. It might not last as long as you think.
September 30, 2009 7:15 PM | Reply | Permalink
Bluebell,
My point isn't that young people should have no insurance...but that the equation for them is negative. In the aggregate, forcing ALL young people (say, under 40) to have insurance creates a huge profit for the insurance companies -- costs for the young are much lower than the premiums will be. Fred Moolten is absolutely right that this mandate creates the money that offsets the higher costs for the insurance companies from having to accept all people, regardless of physical condition. The plans being crafted usually include restrictions on insurance companies to charge more for older people, hence they can't charge less for younger ones.
Meanwhile, these young adults are in their early careers and are earning less than they will when they are in their 30's, 40's or 50's. (again, in the aggregate...there will be those that don't fit the averages). It is hard to argue to them that this health care reform is something other than (another) transfer of money from them to the generation of 40-70 year olds. You know them...they (we) created the deficits, had the bubbles (internet and housing), ran up the debts and are setting up the rules so we never have to reduce our benefits.
September 30, 2009 8:25 PM | Reply | Permalink
I understand that it's hard to convince them but as someone who has been paying into the system for 40 years and who has not yet collected a dime, I don't have much sympathy. I'm too busy caring for my 88 year old mother and am I ever glad she is covered by Medicare and Social Security though she buys supplemental coverage as well.
If you are fortunate you live to be old. The alternative is not great. You do collect in the end. Paying in now ties you to the next generation. It's not just a generational transfer. It's an inter-generational commitment. It's a social commitment.
The young may not want to hear it or don't want to worry about it -- but if their legacy is to undercut the security of the aging, I guarantee you no one younger than they are is going to care for them in the future. They think they've got it tough now? Let them spend some time with folks over 80 and let them learn how to be tough.
Time flies.
September 30, 2009 9:05 PM | Reply | Permalink
Good luck to you (and your mother).
My first post tied the mandates to a REAL program to reduce costs. Absent a real program to reduce costs, the mandates only delay the day of insolvency of the system, they don't change the outcome...in which case, I do think it amounts to a generational transfer of money. If we (the over 40 crowd) leave a self-sustaining system, then I'm all for the mandates. I am still desperate for our elected officials to treat us like adults (whether we deserve it or not). Tell the truth, say there are some things we can afford, there are some things we cannot and they'll continue to try to close the gap between our aspirations and abilities.
September 30, 2009 9:15 PM | Reply | Permalink
Well, let's end our unfunded wars and see how we do. I still can't figure out why only healthcare costs real money.
September 30, 2009 10:31 PM | Reply | Permalink
Ain't that the truth.
October 1, 2009 1:14 PM | Reply | Permalink
Hallo. Back up, reread, and 'splain yerself, lucy.
I object to your premise, utterly. Insurance companies will never charge "less" even if they can. It would be contrary to what their function actually is.
The fact is they charge the highest rate, period, (their lame justifications notwithstanding). Even if they could charge "less" they would not. Dude! I've been self-employed for over a dozen years. The game is that they continually raise the rates, hefty hikes-- 5 or 6 times a year--regardless of whether one put in claims or not, thus forcing one to seek out new insurance every couple of years. Those who get ill are SOL, to put it politely, as they won't reinsure anyone who is actually ill. It's a scam, it's legalized graft, and one thing that won't change is that eventually you or a family member will get older, will get ill, and get caught up in it. You will be paying higher rates for your situation while everyone else is paying higher rates because that is the corporate fargin' business model. It's been such a great profit generaotor that now they are applying it to even previously "safe" group plans.
I have no doubt that this plausible deniability rationale was crafted by insurance company execs. Why would they want to charge less? That would require a sense of decency and a willingness to act responsibly and honor agreements. None are qualities I would ascribe to Medical Insurance Corporations.
It may seem "logical" to you, but these corporations do not operate on logic, they operate on a market mentality which has no interest in long term benefits, or social good. They are soulless, inhuman markets, and it's high time we recognized the nature of that beast. Our forefathers had the presence of mind to give them a human lifespan, an effective equalizer whose time has come again.
What you refer to are qualities that taxes, regulation, and governance are supposed to address in order to moderate these built-in inequities, but as corporations own government now, we're on our own, and they do indeed own us. This is why the SCotUS is arguing corporate 'personhood' now. Now there is a total illogical abomination, a corporation is a person that should be allowed to buy elections. Grrrrrrrrrrreat. How's that logic working now?
Lets hope that our Court is not a soulless, bought and paid for tool. I have my doubts.
Please don't buy the naive line that corporations are made up of humans. They are headed by computers and greedy elitists like Avishai who consider you to be something less than human, and act accordingly.
The grand irony is that they themselves are anything but human.
September 30, 2009 10:07 PM | Reply | Permalink
All I'm saying is that a person who is 25, fit, active and a non-smoker will cost less to insure than someone who is 50, obese and smokes. The proposals in congress have them pay the same premium...and that is silly. Even a public option should be able (actually, be required) to either incentivize good behavior or penalize bad behavior (two sides of same coin).
I may not share your view of insurance companies, but I haven't had your experiences...so I won't comment one way or the other.
September 30, 2009 10:31 PM | Reply | Permalink
Right, which is why we all pay the same in Social Security? According to your logic, young people should pay a buck per pay period and old retired people should just go off and die.
Of COURSE it is cheaper to insure younger healthy people, but as I pointed out, (being Chicken Obvious) younger, healthy people become older and/or unhealthy people regardless of lifestyle.
Tell me, what is the point of insurance? You pay into it when you are young and healthy precisely due to the uncertainty of possibly getting ill and certainly getting old.
It is one pool that we all dive into, not a bunch of increasingly lush and pristine lagoons depending on your age. Here's a shallow argument for ya: is it fair that I, who have hardly ever, personally, used medical services, have to pay a higher rate for than some youngster down the street who has had the misfortune to get leukemia? I don't have it, I've been paying for YEARS, why should I subsidize your farking knee surgery because you were dumb enough to jog on asphalt? Or your food poisoning for eating home grown veggies you let your dog piss on? I'll take the overweight fifty something smoker any day, thanks. At least they have the decency to die quickly of a massive heart attack, unlike you who will linger for years and years and use up far more than your share of healthcare dollars by your selfish belief in "fitness." How many times have you been to a doctor for trifles due to strained muscles and hemorrhoids and tummy upsets? Nevermind, I don't want to know, but I do know that people that engage in sports and microbiology are out a lot more than slobs whose constitutions can survive a few germs.
See how that doesn't work too well? Your ideal is not a model that could ever work. Insurance is insurance, not healthcare.
You may want to rethink based on the reality of what insurance is for. It is not to protect healthy people, it is to help sick people.
'Kay?
September 30, 2009 10:52 PM | Reply | Permalink
Really don't want to argue...i'll pass.
September 30, 2009 11:01 PM | Reply | Permalink
I'd say can't but...wotevah.
September 30, 2009 11:12 PM | Reply | Permalink
You have others here that understand what you say. Many others.
October 1, 2009 5:28 AM | Reply | Permalink
That makes one of you.
October 1, 2009 1:16 PM | Reply | Permalink
But kudos, as I see below that you are flexible of mind.
October 1, 2009 1:25 PM | Reply | Permalink
Talk about flawed logic:
You don't pay for it because you will need it when you get old. Were that the case then no one would buy it until they are old.
It's really all quite simple: you make a decision to purchase insurance because "accidents will happen."
October 1, 2009 4:38 AM | Reply | Permalink
So I should be penalized because I am sick but want to remain alive? I am being told I have to pay a kings ransom for my life? Maybe the congressman for Florida is right. The plan they have in store for me is to 'die fast'.
The morals of this country are rotten to the core. Even a life itself must have a price tag on it. This country deserves whatever it gets...and what that is going to be is a royal f@*king. We're all f@*ked, just some of you don't know it yet. The rest of the industrialized world provide health care for all their people. But no, we can't dare have something that un-American here in The United States of Greedy Heartless Bastards...
September 30, 2009 11:00 PM | Reply | Permalink
My example was a bad one. My apologies. Let me try again. Two people, both healthy, both 25. One fit, non-smoker; the other obese and smokes. Should their premiums in the public option be equal? Nothing about genetics or pre-existing conditions or other risk factors. Just two behavior items that are indicators for future health costs. My question is...in an ideal health care plan, which would include a public option, no denied coverage for pre-existing conditions, and a mandate for insurance, how can we also have a place for personal responsibility in addition to the societal responsibility?
September 30, 2009 11:08 PM | Reply | Permalink
OK, fine, but it should be offset by premiums for genetics, family history, and youthful indiscretions. Oh hey, sexual behavior, too. good looking people that fuck a lot should pay higher premiums. Oh, and I think we should all have insurance company monitors because self-reporting is for suckers.
Have we leveled that field yet? Or would you like to continue down your slippery slope?
September 30, 2009 11:15 PM | Reply | Permalink
I suspect we are coming at this from different places and with different views. I doubt we have much left to say of substance on the matter that might influence the other. Whatever we were going to learn from the discussion has been learned. God Bless.
September 30, 2009 11:21 PM | Reply | Permalink
Sure, personal responsibility. If we leave out genetics, how about risky sexual behavior? A passion for spelunking?
It seems difficult to know where this process would end.
September 30, 2009 11:28 PM | Reply | Permalink
you might be right...it might be too hard to have any place for personal responsibility in the health care system.
September 30, 2009 11:31 PM | Reply | Permalink
No, I concede. People who live near waste dumps and coal mines should have to pay for their proclivity to develop illnesses. Inner cities, too, are are not responsible places to raise a child. Every kid has asthma.
September 30, 2009 11:54 PM | Reply | Permalink
I wasn't being flippant. I've changed my mind as a result of the discussion. I agree...too complex, too many variables to try to have the health care system modify behavior. It is the wrong way.
October 1, 2009 12:02 AM | Reply | Permalink
sorry I misread you.
In NYC, a staggering number of children have asthma. I know people who have died of asthma.
I have a feeling that the life expectancy of this country is going to start sinking, if it hasn't already,due to causes having nothing to do with reckless personal choices.
October 1, 2009 12:14 AM | Reply | Permalink
This has nothing to do with healthcare. This has to do with enforcing environmental laws that are already on the books -- and aren't being enforced because of lack of money.
Again, we are back to what resources are available.
October 1, 2009 5:32 AM | Reply | Permalink
Yes the premiums should be the same...nothing. Single payer.
Just for the record I am a 47 year-old (on Friday) male, smoker, 5' 10", 177 lbs, with type 2 Diabetes and mild hypertension. I work hard to keep my conditions under control with regular doctor visits, generic drugs, eating properly and as much exercise as I can get. But there are many tests I should have done but which I can't afford due to not having insurance. I had insurance up to last year when because of my conditions the insurance company jacked my rates a full 50%, and that was the 3rd time I had a 30%+ increase in my premiums in three renewal cycles. There is NO way in hell that any insurance company will take me. So what you're saying is because of the demographic I belong to I should have to pay whatever is asked of me, right? I am deserving of what I am getting? There is something very cold and inhumane at the core of the soul of this country.
September 30, 2009 11:32 PM | Reply | Permalink
no, that isn't what i'm saying. for the record, i'm 6'1", 235 lbs (obese, in the bmi calculation) and also smoke. the fact that I smoke and weight too much means i am taking more risks as a result of my choices and i think it is reasonable that i pay more for coverage. others disagree.
However, it might be too hard and too complex. Maybe just increase the tax on tobacco and fast food or sugar rather than tying it to the health care side of the equation. probably more effective anyway.
September 30, 2009 11:41 PM | Reply | Permalink
Those are user taxes and very punitive on, and targeted at, the lower and middle classes John. Meanwhile the wealthy, who run health insurers, are doctors, work in big Pharma, etc, are allowed to reap a windfall. OK tax tobacco and junk food only if the rich pay their fair share. It shouldn't be put on the backs of only 95% of Americans. And by saying we can't go after the wealthy because it is so difficult is defeatist. I say repeal the Bush tax cuts and use that money as part of their share. They were doing just fine in the 1990's before those cuts in their taxes were made...
October 1, 2009 1:09 AM | Reply | Permalink
Why? Wait I get it, because we are less important in terms of our humanity since we will 'cost' more money to keep alive, right? I guess elitists who sit in judgement of the worth of others are in rare form this week here at the cafe...
September 30, 2009 11:12 PM | Reply | Permalink
Che-yeah.
September 30, 2009 11:16 PM | Reply | Permalink
No, you aren't less important as a human.
But there is no obligation for society to pour resources into you either beyond some mean value... because just as you aren't less important as a human, you aren't particularly special either.
That's the key point that many on the left miss: sound insurance is based on averages not exceptions.
October 1, 2009 5:00 AM | Reply | Permalink
Bullshit CT...in your world I am. Just like certain people in Avishai's world are unemployable and just don't matter because they are a drag, that being a burden, on our society. And many people have come down with conditions, many/most unlike me in their cases, that is due to no fault of their own.
You are no different than him despite your condemnations of him.
October 1, 2009 9:39 AM | Reply | Permalink
Since you have no idea of my medical conditions, your statement is not only sanctimonious but illogical as well.
October 1, 2009 2:40 PM | Reply | Permalink
Amen
October 1, 2009 2:53 PM | Reply | Permalink
John - Although I don't agree necessarily that the young will be alienated by the type of reform that eventually passes, I fully agree that it would be very unfortunate if it did not lower costs. Semi-fortunately, the proposals do contain modest cost-reduction endeavors, mainly in the form of programs for comparative effectiveness research, incentives to replace specialty care with primary care, to substitute various bundled or accountable care payment mechanisms for standard fee for service, and to change Medicare payments to hospitals so as to reward efficiency increases and penalize excessive readmission rates. These don't go far enough, but are a decent start.
Means testing is a topic that has been analyzed in extraordinary detail by historians, philosophers, and social scientists, and the conclusions are generally fairly similar. Programs that are means tested almost inevitably end up providing inadequate benefits to those most in need, and the inadequacy worsens in hard times. It's simply a reflection of the natural human tendency to be more generous supporting programs that involve some self interest than those that benefit only others. On the other hand, something short of outright discrimination between eligible and ineligible recipients, but more along the lines of scaled back benefits for those least in need is sometimes a reasonable compromise between cheating the unfortunate on one hand and wasting money on the other.
September 30, 2009 7:29 PM | Reply | Permalink
Fred,
Your post is reasonable, and well reasoned, as usual. It is so frustrating that neither the Democrats nor the Republicans will say the truth -- "we can't afford all we want, and we may have promised more than we can deliver. So, folks, Social Security and Medicare are now going to be indexed to life expectancy...and eligibility will gradually go up from 65 years old to 73 years old over the next 10 years."
In reality, only the Democrats could do this -- the Republicans don't have the moral authority to do so (since they are widely viewed -- with good reason -- as the greedy party of the rich).
September 30, 2009 8:40 PM | Reply | Permalink
How about we index the empire while we're at it and close a military base every time we add a month to the eligibility age. And if you could figure out a clever way to stop corporate America from age discrimination and get them back on the track of contributing to pensions it might help your plan as well.
September 30, 2009 10:39 PM | Reply | Permalink
Don't understand what 'index the empire' means, but i'd be all for closing military bases. No need to hijack this thread (i'm worried i've already posted too much), but look at the behavior of congress back during the BRAC closure recommendations.
September 30, 2009 10:47 PM | Reply | Permalink
We could learn from the swiss...
http://www.nytimes.com/2009/10/01/health/policy/01swiss.html?ref=business
September 30, 2009 10:10 PM | Reply | Permalink
Yes, by all means let's learn from the nation with the second most expensive health care costs in the world ... and most expensive in all of Europe!
If they can't have THE most expensive system ... the industry will push for the second most expensive model and then riddle it with loopholes.
(Cool compare-em page: http://www.npr.org/templates/story/story.php?storyId=110997469 )
September 30, 2009 10:31 PM | Reply | Permalink
I only meant that they seem to have reconciled the goals of cost and coverage without rationing. Seems like an interesting idea...and much less expensive than what we have now. If 'good' could pass, I don't want to see us wait for 'perfect'.
September 30, 2009 10:41 PM | Reply | Permalink
The biggest problem with pointing at the Swiss (or Dutch or whatever) is that nobody is actually proposing something that looks like their system. Here we are at the butt-end of the process with bills on the table that tried to balance things in an American way in which a public option plays a key component in maintaining upwards-cost controls. Shy of scrapping everything and adopting one of these other nation's solutions wholecloth, it's all just an attempt to try and derail the solution on the table - or a dishonest attempt to make what the insurance industry is trying to sell look like something it is not.
FireDogLake did a pretty good look at the NYT article and how it totally fails to explain *WHY* the Swiss model is able to control costs.
October 1, 2009 4:58 PM | Reply | Permalink
That's not exactly true. In the 1980s, Reagan and O'Neil worked out a modification to Social Security which, among other things, raised the age for full retirement benefits, depending on the year of your birth. For me, full retirement won't come until age 67. (I think the "early retirement" option at age 62 came about as part of this deal, too.)
-- ARG
October 1, 2009 2:27 PM | Reply | Permalink
Interesting, that's not the way Wendel Potter described the formula that insurance companies use to determine rates and exclusions ... and he was one of the top executives at Cigna.
Why should we believe your version instead of his?
September 30, 2009 10:11 PM | Reply | Permalink
So people like me, who are already sick (type 2 Diabetes)*, and got priced out of the market get what out of this? I didn't see it addressed in Destor's post. Insurance companies are going to be forced to give me insurance at the rates that healthy twenty-something year olds get? I doubt it...or maybe when monkeys fly. They should at least open up medicare to people with preexisting conditions and who are priced out of the market, but then again I don't expect that to happen.
Looks like I, and probably hundreds of thousands people like me, will remain shit out of luck. The chances are we (me and my peeps) could possibly be dead by the time any trigger is pulled, if it ever is. I ain't gonna pay the extortion like rates they want me to, because I can't. I would have to file for bankruptcy. So in the meantime we (me and my peeps again) are going to try to destroy this system and make all of your rates go up until nobody can afford it...have a nice day!!!
:)
* risks include: heart attack, stroke, amputations, kidney failure, and blindness
September 30, 2009 10:45 PM | Reply | Permalink
Good on ya! You go! I'll help!
=D
I tell you, sometimes I just don't understand people. The whole "I got mine, fark you" attitude is so self-defeating, and stoopid, it's a wonder it is one that seems to get so much traction.
Good grief, even when I was "young" and "healthy" and had a gold-plated health policy, i understood that that could change in an instant, and voted for Clinton precisely because he was going to help people less fortunate.
I figured that was normal. I guess I was wrong.
September 30, 2009 11:09 PM | Reply | Permalink
Wot? help me get sick, destroy the system and die? :-P :)
Ya know I am just kidding Bwak. I know you are fully supportive of me and like people. But I don't want to have to go there. A disease like type 2 Diabetes is very managable if treated. But they won't let us get treated so what choice do we have. In this game we've lost to the protectors of the corporate profits.
=(
September 30, 2009 11:17 PM | Reply | Permalink
I know, my kid is SoL herself, a manageable condition, but a total surprise. Didn't run in either family, who knows why it happened. When she was little she asked me why. How does one answer that? I suppose some would say I should have told her that she should have snuck less junk food and played harder at recess--right?
What makes me angry is that no one is immune from health issues. Chances are they, or a family member, will have one, so what is this BS about "tiers of service?"
Tomorrow that 'perfect' persons life may change due to illness or an accident. That is what insurance is for.
Healthcare? That's something else, and should be paid for and managed on a different business model. Period.
I am losing hope, Libertine. I just don't understand what is wrong with Americans, that they can't see the difference.
September 30, 2009 11:24 PM | Reply | Permalink
Here's what you miss:
You got dealt an unfair hand in life. That's unfortunate and I'm sorry. Diabetes will shorten your life expectancy simply because you have it.
And no amount of money will change that fact.
Insurance will never be a mechanism to allow everyone the same life span -- even if we had infinite resources, which we don't.
Life is inherently unfair. We all have our own individual burdens to bare. Perhaps we should be using insurance money to give a person plastic surgery and increase their facial attractiveness to level the playing field of their success in life?
A national health care plan must be run in a fiscally sound way unlike Social Security (which wasn't even originally set up with the types of benefits that are now available from it) if you expect it to survive as a national policy.
And if you want to really claim that things should be more fair, then it still stacks against you: how fair is it to burden an unborn generation with additional debt, because you, personally, "greedily" want a few more years of life?
As I said, the world is unfair and not equitable. And no amount of social engineering will change that. It's possible to smooth out the bumps, but the mistake is thinking you will eliminate them.
October 1, 2009 5:15 AM | Reply | Permalink
Ummmmm...I missed 'this'? No CT, I am very well aware of it and have been since day 1
when I heard the nurse say to the doctor, after I pissed in the cup, glucose. So no need to address the rest of your post if it is predicated on something that isn't true.
But the bottom line is even though I will be living a life that is going to be shorter than most I will not stop trying to stay alive and just lay down and die. I, and millions like me with high maintenence conditions, will not buy insurance at extortionary rates, I will seek treatment to try to extend my life as long as possible and the rest of you will have to pay.
October 1, 2009 9:22 AM | Reply | Permalink
You wrote:
Again, this isn't accurate. You will only be living a life shorter than that would have been without diabetes.
And as I said above, since you have no idea as to my own personal medical conditions, your statements and counterarguments really come down to sanctimonious posturing. (And I'm factoring in all the your sarcasm -- I do get that.)
October 1, 2009 2:44 PM | Reply | Permalink
I'm with you on the trigger.
Only make it this: If in five years America's health system is still ranked #20 or worse, we implement single payer immediately.
(That's called "The Trigger that is DAMN SURE TO FIRE")
September 30, 2009 11:22 PM | Reply | Permalink
The tigger's trigger makes sense, go figger.
October 1, 2009 3:01 PM | Reply | Permalink
One more thought...if I am 'mandated' to buy insurance on the private market or face a tax penalty I won't buy the insurance nor pay the fine. And if the want to send me to jail that is fine. At least there I will get free health care...
October 1, 2009 12:06 AM | Reply | Permalink
Comparisons to car and life insurance are valuable here.
You don't force someone with a $50K salary and $10K assets to buy $1M of car insurance protection. It makes no sense.
Similarly, not everyone should be forced to buy health insurance.
However: if someone chooses not to, they will have to pay all out of pocket costs... going into bankruptcy/liens/garnishes/etc. if it exceeds their ability to pay.
NO EXCEPTIONS.
If the thought of screwing up your life scares you because everyone should know "accidents will happen", the government comes to the rescue and offers you a form of life insurance you buy.
Problem solved. Buy it if you want it, or pay the terrible price for being stupid.
As far as buying insurance, it should be like life insurance. If you wait to buy the health care you pre-existing conditions will affect your rates. Just as with life insurance, you can lock in lower rates for a longer period of time because the odds of a payout by the insurance company have diminished. Similarly, healthcare rates should be pro-rated for age and a few other things like smoking, BMI, and a few other items of their control. It should not be pro-rated for "lifestyle" nor "family genetics" nor "place of residence."
Again, you incentivize people by letting them know that they will be covered cheaper if any conditions strikes them. If they choose to gamble and not buy, well, tough luck.
The point is the following: these types of choices today don't exist because there is no cost-effective option. But once one does exist, there is no excuse. If a person chooses not to participate, it's that person's problem... not society's.
Were the government to force everyone to have some level of healthcare, that's tantamount to what would be a regressive tax on the citizens -- and I think we all agree that regressive taxes are something to avoid.
If one is progressive, they really should be looking at carrots and incentives, not sticks and mandates. Government dictates should be left to the realm of those who are right of center.
October 1, 2009 4:56 AM | Reply | Permalink
Heh, I kind of like this.
I actually wouldn't mind simply packaging the mandate and the public option into a single trigger provision. This would be an easy case to make, Democratic leadership would simply have to start explicitly making the case that the two are reasonably linked: with the mandate the government creates an obligation to buy insurance, and with the public option the government makes a promise that an adequate insurance option will be available to purchase. It is simply cruel to do the one without doing the other. Under this reasoning the public option would simply be a precondition for the mandate, and so the mandate would "trigger" on the public option launching.
And if it didn't trigger? Well, the HCR bills under consideration without the public option are at least still better than nothing, so long as you remove the mandate. Although under this scheme the insurance companies would be rather than trying to fight the case where the trigger ever happens, would be desperately trying to ensure it does trigger...
Unfortunately it does not seem very plausible a plan such as this would get taken up at this late date. The left, both the grassroots and Congressional leaders, seem to have closed off such paths by granting the mandate from the beginning and not beginning to act like it was an intrinsically harmful thing until the public option looked to be in doubt.
October 1, 2009 1:16 PM | Reply | Permalink