Trumpling the Truth

Turdacious · Post by **Turdacious** » Mon Jun 26, 2017 1:02 am

nafod wrote: ↑Sun Jun 25, 2017 11:35 pm A lot of hand waving. I read the rest of it, which mostly lists a bunch of outcomes as opposed to actions. I get it, it is fodder for low information voters, but...details?

Is this what the Senate was given by the House?

Yes and no.
Allowing small businesses to band together to self insure (part of the Ryan plan) is something that, I believe, isn't in the House plan but in the Senate one. This part is interesting because it has potential to lower small business insurance costs significantly, but will also affect state revenues (because states can't tax these types of plans). It might have a big impact on how many businesses offer health insurance. Implementing this effectively is up to the Dept of Labor-- they'll need to develop the expertise to do this in a pretty short period of time. This is good for small businesses, but could create a lot of problems for states and for the individual markets (because it may raise the risk profile of this section of the market).
If I remember right, the House bill mandates that interstate health insurance sales be allowed, but I don't think the Senate bill does. I hope not-- mandated interstate health insurance sales is a terrible idea.
Neither the House or Senate version do much to eliminate defensive medicine or limit liability.
A lot of the stuff about drug development is in the hands of the FDA, and Commissioner Gottlieb is saying all the right things.

Does either plan do anything that really bends the cost curve down while focusing on quality? Not really.

A lot of the success of either plan is going to come from how well executive agencies perform, and there is a lot of room for improvement.

dead man walking · Post by **dead man walking** » Mon Jun 26, 2017 1:32 am

Turdacious wrote: ↑Mon Jun 26, 2017 1:02 am Does either plan do anything that really bends the cost curve down while focusing on quality? Not really.

the numbers out there say 1% of population is responsible for 20% of health care costs.

20% responsible for 50% of costs.

fda just rushed through a new drug for rare genetic condition that is fatal. $1MM/yr. it's not proven.

gotta send old people out in a blizzard, if you want cost containment. trusting in the market is no different from trusting in god.

Turdacious · Post by **Turdacious** » Mon Jun 26, 2017 1:53 am

dead man walking wrote: ↑Mon Jun 26, 2017 1:32 am
Turdacious wrote: ↑Mon Jun 26, 2017 1:02 am Does either plan do anything that really bends the cost curve down while focusing on quality? Not really.
the numbers out there say 1% of population is responsible for 20% of health care costs.

20% responsible for 50% of costs.

fda just rushed through a new drug for rare genetic condition that is fatal. $1MM/yr. it's not proven.

gotta send old people out in a blizzard, if you want cost containment. trusting in the market is no different from trusting in god.

Health care on a budget always involves hard choices, but we're not good at even making the easier ones.

Just to give you an idea, if you work out (even walking regularly) and watch what you eat your chance of being a 1%er decline dramatically.

nafod · Post by **nafod** » Mon Jun 26, 2017 2:47 pm

Turdacious wrote: ↑Mon Jun 26, 2017 1:02 amDoes either plan do anything that really bends the cost curve down while focusing on quality? Not really.

That's really the nugget of it for me. Most of the stuff being discussed right now is rearranging the deck chairs on the Titanic.

So many other countries have better outcomes for less cost.

Turdacious · Post by **Turdacious** » Mon Jun 26, 2017 6:41 pm

nafod wrote: ↑Mon Jun 26, 2017 2:47 pm
Turdacious wrote: ↑Mon Jun 26, 2017 1:02 amDoes either plan do anything that really bends the cost curve down while focusing on quality? Not really.
That's really the nugget of it for me. Most of the stuff being discussed right now is rearranging the deck chairs on the Titanic.

So many other countries have better outcomes for less cost.

Pretty much. IMHO the biggest change of the last few years is that the responsibility for controlling our costs is increasingly on us individually, and controlling those costs takes prior planning. If you haven't read it yet, check out Elizabeth Rosenthal's American Sickness. The second part of the book has a lot of tips to help families control their medical costs.

JimZipCode · Post by **JimZipCode** » Mon Jun 26, 2017 10:10 pm

Turdacious wrote: ↑Mon Jun 26, 2017 6:41 pmIf you haven't read it yet, check out Elizabeth Rosenthal's American Sickness. The second part of the book has a lot of tips to help families control their medical costs.

Saved it to my Amazon cart a couple weeks ago.

dead man walking wrote: ↑Mon Jun 26, 2017 1:32 amthe numbers out there say 1% of population is responsible for 20% of health care costs.

Atul Gawande did a piece about a community medical program, that focused on the 1%. I think this is the piece:

The Hot Spotters
Can we lower medical costs by giving the neediest patients better care?
http://www.newyorker.com/magazine/2011/ ... t-spotters

The Camden Coalition has been able to measure its long-term effect on its first thirty-six super-utilizers. They averaged sixty-two hospital and E.R. visits per month before joining the program and thirty-seven visits after—a forty-per-cent reduction. Their hospital bills averaged $1.2 million per month before and just over half a million after—a fifty-six-per-cent reduction.
These results don’t take into account Brenner’s personnel costs, or the costs of the medications the patients are now taking as prescribed, or the fact that some of the patients might have improved on their own (or died, reducing their costs permanently). The net savings are undoubtedly lower, but they remain, almost certainly, revolutionary. Brenner and his team are out there on the boulevards of Camden demonstrating the possibilities of a strange new approach to health care: to look for the most expensive patients in the system and then direct resources and brainpower toward helping them.
...
The critical flaw in our health-care system that people like Gunn and Brenner are finding is that it was never designed for the kind of patients who incur the highest costs. Medicine’s primary mechanism of service is the doctor visit and the E.R. visit. (Americans make more than a billion such visits each year, according to the Centers for Disease Control.) For a thirty-year-old with a fever, a twenty-minute visit to the doctor’s office may be just the thing. For a pedestrian hit by a minivan, there’s nowhere better than an emergency room. But these institutions are vastly inadequate for people with complex problems: the forty-year-old with drug and alcohol addiction; the eighty-four-year-old with advanced Alzheimer’s disease and a pneumonia; the sixty-year-old with heart failure, obesity, gout, a bad memory for his eleven medications, and half a dozen specialists recommending different tests and procedures.

I think I read a different, re-worked version of this essay. But this is the kind of thing he was talking about.

TerryB · Post by **TerryB** » Tue Jun 27, 2017 3:39 am

Is there a good reason not to allow the sale of insurance across state lines, and what are those reasons? Why is Congress unwilling to allow it? It seems it would increase competition and thereby reduce costs.

johno · Post by **johno** » Tue Jun 27, 2017 4:15 am

JimZipCode wrote: ↑Mon Jun 26, 2017 10:10 pm The Hot Spotters
The critical flaw in our health-care system that people like Gunn and Brenner are finding is that it was never designed for the kind of patients who incur the highest costs. Medicine’s primary mechanism of service is the doctor visit and the E.R. visit. (Americans make more than a billion such visits each year, according to the Centers for Disease Control.)

You could throw some street EMT's, Paramedics, ER nurses, and ER doctors in a room for 60 minutes, and find a way to save billions in ER costs. Hint: not every sprained ankle requires an ambulance ride to the ER. Nor every cold.

Step One - Empower the Gatekeepers to say, "No." And protect them from liability when their decisions are made in good faith after a decent workup.

Turdacious · Post by **Turdacious** » Tue Jun 27, 2017 4:24 am

TerryB wrote: ↑Tue Jun 27, 2017 3:39 am Is there a good reason not to allow the sale of insurance across state lines, and what are those reasons? Why is Congress unwilling to allow it? It seems it would increase competition and thereby reduce costs.

First off, it is allowed, if a state allows it. Georgia (I think) legalized it several years ago and it didn't catch on, primarily because out of state providers couldn't get a network of in-providers. There's a strong local element to health care. It does occur within small regions: BCBS-Kansas City, for example, covers parts of both Missouri and Kansas in the KC metro area.

Second, it's because of how we handle health insurer failure in the US. If an insurer fails, state guarantee association agree to pay the outstanding bills to providers. These are funded by assessing a fee to all health insurers in the state to cover the cost. Essentially this ensures that state regulators (because in the short term this costs the state money), health care providers, and other insurers have a vested interest in insurers not failing. It's the primary reason that state insurance commissions shut down the Obamacare insurance co-ops before they went broke on their own-- that way their constituency (state taxpayers) didn't feel the pain, just a different constituency (federal taxpayers). It's also why, when insurers were setting rates the last couple years, and HHS was sitting around with their thumbs up their asses, that state regulators were insisting that health insurers pay higher rates. State regulators, warts and all, are the adults in the room. HHS doesn't have the capacity for national insurance regulation, and doesn't seem poised to develop it.

Third, it's because state regulators, especially on the East Coast, are still smarting from the Penn Treaty failure. Penn Treaty was a long-term care insurer (a type of health insurance) which went tits up, and ratepayers in several states are having to pay higher long term care rates because of it-- outstanding liabilities are over $4b.

I have no problem with interstate insurance competition, I have a problem with unfunded mandates from good idea fairies that destabilize local markets.

nafod · Post by **nafod** » Tue Jun 27, 2017 11:55 am

TerryB wrote: ↑Tue Jun 27, 2017 3:39 am Is there a good reason not to allow the sale of insurance across state lines, and what are those reasons? Why is Congress unwilling to allow it? It seems it would increase competition and thereby reduce costs.

Turd knows more than I do on this (ouch) but on a separate reason, the opening of interstate banking resulted in too big to fail banking behemoths that are essentially insured by the government and so can take huge risks, while before the system was "antifragle" to quote Tassab, with a bank failure just nudging the system and making everyone smarter as a result. Might be the same with insurance.

Turdacious · Post by **Turdacious** » Tue Jun 27, 2017 12:15 pm

nafod wrote: ↑Tue Jun 27, 2017 11:55 am
TerryB wrote: ↑Tue Jun 27, 2017 3:39 am Is there a good reason not to allow the sale of insurance across state lines, and what are those reasons? Why is Congress unwilling to allow it? It seems it would increase competition and thereby reduce costs.
Turd knows more than I do on this (ouch) but on a separate reason, the opening of interstate banking resulted in too big to fail banking behemoths that are essentially insured by the government and so can take huge risks, while before the system was "antifragle" to quote Tassab, with a bank failure just nudging the system and making everyone smarter as a result. Might be the same with insurance.

Exactly. Another big factor in this is that a lot of hospitals run on very thin margins; even a significant delay in payments can cause havoc.

Let's say an irresponsible insurer with a history of corruption (we'll call them the State of Illinois) makes decades of promises they don't pay for and then can't pay its medical bills. That could cause a lot of havoc. Hypothetically of coarse (see here and here).

dead man walking · Post by **dead man walking** » Tue Jun 27, 2017 2:13 pm

to pay for the tax cut legislation (dba "health care"), r's are willing to let approx 28,000 people a year die early.

odds of dying are increased by 3%-29% for those without insurance

buzzfeed quotes experts, citing annals of internal medicine.

http://annals.org/aim/article/2635326/r ... nce-deadly

"pro-life" is a misnomer when used to describe conservative xtians.

Turdacious · Post by **Turdacious** » Tue Jun 27, 2017 2:38 pm

CBO and JCT have endeavored to develop budgetary estimates that are in the middle of the distribution of potential outcomes. Such estimates are inherently inexact because the ways in which federal agencies, states, insurers, employers, individuals, doctors, hospitals, and other affected parties would respond to the changes made by this legislation are all difficult to predict. In particular, predicting the overall effects of the myriad ways that states could implement waivers is especially difficult.

https://www.cbo.gov/publication/52849
The key wildcards here states and federal agencies. This bill puts the ball firmly in the courts of the states- how they react determines what benefits people get and how many people lose insurance.

The article from the Annals mentions the Oregon Health Experiment. That well designed experiment showed that expanding Medicaid coverage using existing Medicaid rules resulted in no real health improvement for the beneficiaries (it did help beneficiaries financially). This bill gives states the freedom to improve their health care systems or really screw them up, assuming the feebs stay out of their way.

The other big wildcard is the Dept of Labor-- how they implement the expansion of association health plans will have a big impact on the health landscape.

climber511 · Post by **climber511** » Tue Jun 27, 2017 4:57 pm

Big issue with no real easy answers. Who knew health care could be so complicated? :)
It seems that at some level we are deciding if "everyone" or at least most people "deserve" or will be able to be insured? Saying that people will now have "choice" makes no sense to me when talking about people who can barely pay their bills. Buying insurance or paying for rent or food is not much of a choice and many of the people I know fall into the Poverty income level and that's what would happen to them. A senior making $50000 might have to pay $20000 WTH - we all know that can't work. Even considering the CBO numbers are off - there are some gaping holes with the math here - not even considering the tax cut aspect for a minute. For openers - most poorer people don't owe taxes already so no help there. I'm no fan of the ACA but this doesn't sound even as good as that mess on the surface. I was just watching FOX News and even they were having trouble getting the math to work out so I think there's a problem here. In my personal case as a 69 year old senior I now pay 20% of my gross income out for Medicare and health insurance - not an easy thing to balance that. And it might possibly double? I am going to be screwed big time if that figure holds true or even close to that.
Welcome to America - a third world country where "not dying" is going to be a "luxury" reserved for the rich.

Herv100 · Post by **Herv100** » Tue Jun 27, 2017 5:18 pm

Make sure you all don't blame the people who just charged me $800 to give my son some Tylenol after a bike wreck. It's all the insurance companies' fault and the gubment's for not paying it for me.

Turdacious · Post by **Turdacious** » Tue Jun 27, 2017 5:37 pm

climber511 wrote: ↑Tue Jun 27, 2017 4:57 pm For openers - most poorer people don't owe taxes already so no help there.

IMHO this is another area where it gets interesting. I don't see any way where states don't have to raise taxes because of this-- partially because the bill strips revenue sources from them and because they will have to contribute more to Medicaid.

Forget property taxes (which many seniors get a break on) for a moment, I would expect almost every state to raise sales taxes (food, gas, electricity, phone, etc...), which will really affect retirees on fixed incomes. I'd also expect states to get much tougher on asset recovery in their Medicaid programs.

tonkadtx · Post by **tonkadtx** » Tue Jun 27, 2017 7:41 pm

Make sure you all don't blame the people who just charged me $800 to give my son some Tylenol after a bike wreck. It's all the insurance companies' fault and the gubment's for not paying it for me.

I'm just starting my clinicals now...there are people here who have waaaaay more experience than me but a few reasons:

- You are supplementing everyone who didn't pay their bill.
- Medicare/Medicaid sets a reimbursement schedule then doesn't follow it, and it often takes months to collect and providers often only see a percentage.
- Patient Satisfaction/Liability has become such a huge part of medicine (see the opiate, antibiotic, and ambulance taxi issues)
-It is nearly impossible to self insure unless you're rich. Ask the question, "what's the price if I pay you in cash?" People look at you like you have nine heads.

There's a reason medical billing and coding has become a legitimate WELL PAYING profession.

nafod · Post by **nafod** » Tue Jun 27, 2017 7:56 pm

Herv100 wrote: ↑Tue Jun 27, 2017 5:18 pm Make sure you all don't blame the people who just charged me $800 to give my son some Tylenol after a bike wreck. It's all the insurance companies' fault and the gubment's for not paying it for me.

It was probably that Trump University sweatshirt you were wearing.

Herv100 · Post by **Herv100** » Tue Jun 27, 2017 8:55 pm

tonkadtx wrote: ↑Tue Jun 27, 2017 7:41 pm
Make sure you all don't blame the people who just charged me $800 to give my son some Tylenol after a bike wreck. It's all the insurance companies' fault and the gubment's for not paying it for me.
I'm just starting my clinicals now...there are people here who have waaaaay more experience than me but a few reasons:

- You are supplementing everyone who didn't pay their bill.

No, I'm paying the "government contract" price, even though I have private insurance. Like any industry, when the govt pays, you charge double, triple, hell, 5 times the cost.

tonkadtx · Post by **tonkadtx** » Tue Jun 27, 2017 10:10 pm

No, I'm paying the "government contract" price, even though I have private insurance. Like any industry, when the govt pays, you charge double, triple, hell, 5 times the cost.

That's actually a fair and correct point as well. But my point stands, loss is budgeted into pricing.

dead man walking · Post by **dead man walking** » Tue Jun 27, 2017 11:44 pm

tonkadtx wrote: ↑Tue Jun 27, 2017 7:41 pm
- You are supplementing everyone who didn't pay their bill.
an important but often overlooked point.

my and your insurance helps pay for people who don't have insurance and don't pay their medical bills. those people are free riders. they actually do have insurance--me and you and everyone else who has a policy. the obamacare mandate requiring everyone to pay for a policy addresses this flaw in the system.

is there any other way to address free riders? hospitals aren't going to start kicking out the uninsured, are they?

Turdacious · Post by **Turdacious** » Wed Jun 28, 2017 12:02 am

dead man walking wrote: ↑Tue Jun 27, 2017 11:44 pm
tonkadtx wrote: ↑Tue Jun 27, 2017 7:41 pm
- You are supplementing everyone who didn't pay their bill.
an important but often overlooked point.

my and your insurance helps pay for people who don't have insurance and don't pay their medical bills. those people are free riders. they actually do have insurance--me and you and everyone else who has a policy. the obamacare mandate requiring everyone to pay for a policy addresses this flaw in the system.

is there any other way to address free riders? hospitals aren't going to start kicking out the uninsured, are they?
Thanks to a Reagan era law called EMTALA they have an obligation to stabilize or treat depending on the medical condition. Having to provide this un reimbursed care is a big reason a lot of hospitals, especially in poor and rural areas, are becoming urgent care clinics. Both Obamacare and the Senate Republican proposal have mechanisms that try to prevent this from happening. It's hard to say which one will work better because the Senate proposal gives states more discretion in how to give additional money to hospitals serving poorer populations.

powerlifter54 · Post by **powerlifter54** » Wed Jun 28, 2017 2:01 pm

Let is be very clear, the price curve was moved by Barrack Hussein Obama when he got his Gruber buddies to formulate a concept based on deception. By their own admission. Furthermore, when you claim to pass it to see what is in it, and you promise free Healthcare to 30 million people, who just happen to be your voters, and claim the cost will go down for the people actually paying the bills, you made a problem much much worse. And gave away the Presidency.

No the cost didn't go down $2500 a family. Yes over 88% of Obamacare recipients were subsidized . Yes the people who actually had insurance have to pay more premiums and deductibles for those who don't pay.

I don't like either of the Bills right now. But the hashing out and real debate of costs and unsustained growth and the choice to be insured or not, but not to be able to come to the table when you need care with your "pre-existing condition", is great public policy debate, and out in the open.

Thanks Obama.

syaigh · Post by **syaigh** » Wed Jun 28, 2017 3:35 pm

Turdacious wrote: ↑Wed Jun 28, 2017 12:02 am
dead man walking wrote: ↑Tue Jun 27, 2017 11:44 pm
tonkadtx wrote: ↑Tue Jun 27, 2017 7:41 pm
- You are supplementing everyone who didn't pay their bill.
an important but often overlooked point.

my and your insurance helps pay for people who don't have insurance and don't pay their medical bills. those people are free riders. they actually do have insurance--me and you and everyone else who has a policy. the obamacare mandate requiring everyone to pay for a policy addresses this flaw in the system.

is there any other way to address free riders? hospitals aren't going to start kicking out the uninsured, are they?
Thanks to a Reagan era law called EMTALA they have an obligation to stabilize or treat depending on the medical condition. Having to provide this un reimbursed care is a big reason a lot of hospitals, especially in poor and rural areas, are becoming urgent care clinics. Both Obamacare and the Senate Republican proposal have mechanisms that try to prevent this from happening. It's hard to say which one will work better because the Senate proposal gives states more discretion in how to give additional money to hospitals serving poorer populations.

As an ER doc, and obligated to treat anyone who comes through the door, my husband typically collects 30% of what he bills. Not the sme for specialists who are not obligated to provide what may be care necessary to sustain life. Lots of problems to fix. Lots of debates to be had.

nafod · Post by **nafod** » Wed Jun 28, 2017 3:56 pm

Trump should ban sugar. That'd piss a couple of folks off, but save billions in health care costs eventually.

IGX

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