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Old 05-06-2010, 10:20 AM   #21
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Get rid of co-payments, make coverage guaranteed-issue with a 24-month waiting period for pre-existing conditions. This will avoid people jumping on and off plans. No first-dollar benefits except preventative care. Require minimum deductible levels be tied to income. Get rid of the tax-exempt status of employer health benefits. Offer a 150% tax deduction up to a given limit for contributions to a health savings account (current law is a 100% deduction). Limit non-economic damages on malpractice lawsuits.

I'm not on any political side, I'm on the common sense side. So there's a start.
Three cheers for dgoldenz! A serious response to Gone4Goods's challenge.

A few (off the cuff and not completely thought out) responses
1. Waiting periods would help, but not eliminate one of the biggest problems with our existing system: the fact that emergency rooms are required to treat all comers combined with the large number of uninsured poor. A waiting period would be an incentive for middle class folks to not jump in and out, but the poor would probably still not be insured.
2. Limiting malpractice awards is OK only if you replace it with other deterents. Presently, civil courts are the only deterrent to lots of things. Folks don't like it (for good reason) but eliminating the only deterrent to socially damaging actions is not the solution. I would also like to see some numbers on the cost of malpractice claims.
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Old 05-06-2010, 10:25 AM   #22
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Originally Posted by IndependentlyPoor View Post
Three cheers for dgoldenz! A serious response to Gone4Goos's challenge.

A few (off the cuff and not completely thought out) responses
1. Waiting periods would help, but not eliminate one of the biggest problems with our existing system: the fact that emergency rooms are required to treat all comers combined with the large number of uninsured poor. A waiting period would be an incentive for middle class folks to not jump in and out, but the poor would probably still not be insured.
2. Limiting malpractice awards is OK only if you replace it with other deterents. Presently, civil courts are the only deterrent to lots of things. Folks don't like it (for good reason) but eliminating the only deterrent to socially damaging actions is not the solution. I would also like to see some numbers on the cost of malpractice claims.
Thanks. I don't think we'll ever be able to solve the ER problem unless the government goes the non-politically-correct route and tells hospitals to turn people away. People who don't buy insurance will always abuse this law.

The malpractice problem stems from the massive cost of malpractice insurance to doctors and the eggshells they have to walk on to make sure they aren't sued. Ask an OBGYN what they pay for malpractice insurance and your eyes will probably pop out of your head. I'm sure the defensive medicine thing has probably been beaten to death here before, so I'll leave it at that.
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Old 05-06-2010, 10:36 AM   #23
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Defense budget 664B
Defense.gov News Release: DoD Releases Fiscal 2010 Budget Proposal

2010 Budget Deficit 1.56T
Obama's 2010 budget: deficit soars amid job spending | Reuters

--- Eliminate all Defense spending - still 900B annual deficit.----
Not so fast:

For the 2010 fiscal year, the president's base budget of the Department of Defense rose to $533.8 billion. Adding spending on "overseas contingency operations" brings the sum to $663.8 billion.[1][2]
When the budget was signed into law on October 28, 2009, the final size of the Department of Defense's budget was $680 billion, $16 billion more than President Obama had requested.[3][4] Adm. Mike Mullen, the chairman of the Joint Chiefs of Staff expected an additional supplemental spending bill, possibly in the range of $40–50 billion, by the Spring of 2010 in order to support the wars in Iraq and Afghanistan.[5] Defense-related expenditures outside of the Department of Defense constitute between $216 billion and $361 billion in additional spending, bringing the total for defense spending to between $880 billion and $1.03 trillion in fiscal year 2010.[6]

Military budget of the United States - Wikipedia, the free encyclopedia
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Old 05-06-2010, 10:41 AM   #24
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Not so fast:

For the 2010 fiscal year, the president's base budget of the Department of Defense rose to $533.8 billion. Adding spending on "overseas contingency operations" brings the sum to $663.8 billion.[1][2]
When the budget was signed into law on October 28, 2009, the final size of the Department of Defense's budget was $680 billion, $16 billion more than President Obama had requested.[3][4] Adm. Mike Mullen, the chairman of the Joint Chiefs of Staff expected an additional supplemental spending bill, possibly in the range of $40–50 billion, by the Spring of 2010 in order to support the wars in Iraq and Afghanistan.[5] Defense-related expenditures outside of the Department of Defense constitute between $216 billion and $361 billion in additional spending, bringing the total for defense spending to between $880 billion and $1.03 trillion in fiscal year 2010.[6]

Military budget of the United States - Wikipedia, the free encyclopedia
Wait a sec......I thought we were "getting out" of Iraq soon............that should save some dough............
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Old 05-06-2010, 10:50 AM   #25
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Wait a sec......I thought we were "getting out" of Iraq soon............that should save some dough............
Pull the other one, it has bells on.
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Old 05-06-2010, 10:52 AM   #26
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There would be no price discrimination,
What about subsidies for low income people?
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Old 05-06-2010, 10:58 AM   #27
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Three cheers for dgoldenz! A serious response to Gone4Goods's challenge.

But think about what he's saying . . .

1) Guaranteed issue
2) No discrimination for pre-existing conditions
3) No / restricted price discrimination
4) Subsidies for low income people?

This is basically the plan we have that people have equated with all kinds of atrocities.

The differences are actually kind of small. Instead of an individual mandate he has a 24 month exception for PEC, which doesn't apply to most people. I don't think that will be strong enough, but it's worth a try and could be amended later if needs be. The addition of mandatory deductibles is a good addition to the current legislation and one of the positive changes we could have seen introduced in a real bi-partisan bill.

But the nuts and bolts of what dgoldenz is proposing is Obamacare.

So the "serious alternative" to "Obamacare" is to adopt 90+% of Obamacare and tweak it around the edges? That's not the debate I was hearing last year. I'm all for it. But call a spade a spade and stop pretending that there is some radically different proposal out there that is far superior to the legislation we have.
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Old 05-06-2010, 11:08 AM   #28
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Easy. We can eliminate underwriting by ensuring that ALL folks, including the young and healthy, are in the pool. Even insurers have gone on the record as accepting this, but *everyone* into the pool is needed or else it blows up with adverse selection.

How do we do that? For one thing, the penalties need to be stronger.
Agreed.

But, again, what you describe is basically the legislation we have. Your suggested change is to make Obamacare even more intrusive and stronger than it already is. I think you are right. But this isn't an argument to reverse course. It is an argument to hit the accelerator in the direction that the current legislation already takes us.
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Old 05-06-2010, 11:19 AM   #29
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So the "serious alternative" to "Obamacare" is to adopt 90+% of Obamacare and tweak it around the edges? That's not the debate I was hearing last year. I'm all for it. But call a spade a spade and stop pretending that there is some radically different proposal out there that is far superior to the legislation we have.
Many people have had fairly widespread agreement on the "goals" of health care reform (i.e. eliminate underwriting, get everyone into the pool, put a lid on double-digit cost increases, for example).

The bulk of the disagreement is in how we get there. We may both agree that we want to get from Los Angeles to Boston, but we may disagree strongly on the best route to use to arrive at the destination.

But the 800 pound gorilla that Obamacare does not really address is cost control. This is why I think we're solving this backwards. First work on cost control, *then* maybe we can create sustainable health care reform. Until we can get control of costs (ideally without rationing), any reform is possibly doomed to fail because of unsustainable cost increases.

And I think the way they phase out individual health insurance subsidies (and the income range where it phases out) effectively amounts to an utterly massive middle class tax increase that I find strongly objectionable. The funding mechanism is part of the "how we get there" which many people can disagree on.
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Old 05-06-2010, 11:22 AM   #30
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But the 800 pound gorilla that Obamacare does not really address is cost control.
So what is the policy that keeps all of the things you like and also controls costs? (be careful because many of them are likely to be in the bill)

And how do you avoid phasing out subsidies. There are only two ways I can see. 1) Subsidize everyone. 2) Subsidize no one. Which do you prefer?
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Old 05-06-2010, 11:23 AM   #31
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Not so fast:
"Fast" or "Not so fast." are our only choices for the future.
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Old 05-06-2010, 11:25 AM   #32
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So what is the policy that keeps all of the things you like and also controls costs? (be careful because many of them are likely to be in the bill)
No first-dollar coverage except for preventive care (and perhaps those below the poverty level).

Stronger penalties for being uninsured so there can be no financial advantage for not buying at least the cheapest available (highest deductible) coverage.

Breaking the link between employment and health insurance so people can buy the coverage most suited for them. (If anything I think Obamacare *strengthens* the link by writing employer responsibilities/penalties into law.)

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And how do you avoid phasing out subsidies. There are only two ways I can see. 1) Subsidize everyone. 2) Subsidize no one. Which do you prefer?
Obviously I don't want to subsidize Warren Buffett. But the way the subsidy is phased out means that from about $40-80K, those who buy individual insurance lose more than 15 cents in subsidy for every dollar earned in that income range. It may not be a 15% tax technically, but it has the same financial effect.

This puts the "effective" marginal loss of income to taxes and subsidies higher for someone earning $60K than someone earning $60M. I would think you of all people here would find that strongly objectionable.
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Old 05-06-2010, 11:32 AM   #33
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Thanks. I don't think we'll ever be able to solve the ER problem unless the government goes the non-politically-correct route and tells hospitals to turn people away. People who don't buy insurance will always abuse this law.
It is a lot worse than just politically-incorrect. If health care providers were allowed to refuse emergency service to the uninsured, it would effectively kill-off ambulance service (or drive it into being a purely government service). No EMS provider could risk dispatching a unit to an accident only to find that the injured were poor and uninsured.

It is ironic that we, as a polity, see no problem with mandating that health care providers must care for those who cannot pay, but recoil at the idea of mandated universal coverage.
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Old 05-06-2010, 11:51 AM   #34
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I don’t see how costs can be controlled. Insurance companies have become intermediaries and have an unlimited profit motive. This conflicts with providers and patients alike. Providers are spending immense amounts in demand generation. The health care industry promises a degree of diagnostic and treatment certainty that cannot be met by any individual provider but leads to endless testing.

Cost containment demands guaranteed payment as a prerequisite. This is now mostly, but not entirely, covered. Not yet resolved, but at least the main cause of cost shifting has been dealt with. This will limit some of the exploitation and arbitrage going on now and allow for a more systematic approach to cost management.
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Old 05-06-2010, 11:54 AM   #35
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But call a spade a spade and stop pretending that there is some radically different proposal out there that is far superior to the legislation we have.
OK. I am feeling mischievous today.
I posted a version of this somewhat radical idea last fall, and as I recall, it was met with stony silence.

Four simple rules to fix the healthcare system.
1. Prohibit exclusions for preexisting conditions.
2. Mandate universal minimum coverage (with subsidies for the truly poor).
3. Insurers may offer any policy features they wish above a required minimum set, and may set any price they wish for this optional coverage, but the prices charged must be the same for everybody.
4. Policies may be canceled only for non-payment or other breach of contract, not because the client was seriously injured or contracted an expensive disease.
Essentially, such regulations would just create one giant group comprising everybody in the country. Insurers would compete to sell policies to the members of this group just like it sells policies to employee groups. Want to raise the rates? Fine, but you have to raise them equally for everybody. Want to change the rules on say, deductibles? No problem, but the changes apply to everybody. There would still be plenty of room to compete. Insurance companies are competing just fine with their employer based group policies now and they have similar restrictions on raising rates. Why not just extend the existing model? Indeed, the precedent for required minimum insurance already exists in our auto liability policies.

So here is another straw man. Commence firing.
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Old 05-06-2010, 02:40 PM   #36
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You pay, up to your deductible. I think you are confusing co-payments with co-insurance.

Co-payment = fixed cost for service, like a doctor's office visit being $20 or ER visit being $100
Co-insurance = percent you pay after the chosen deductible


OK, this might have been answered already, but I have only gotten to your response...

I do not think co-pays are that big a deal when it comes to utiliztion of services. Almost every time we have gone to the doctor in the last few years the actual costs after the insurance discount is only a few dollars more than my co-pay... (mine are $30 for normal doc and $50 for specialist)...

Most of the time the various tests are not covered by the co-pay.. so I pay there..


The one thing that I think needs to happen more is preventive care... that would probably save more money than anything else (well, except if we stopped being a fat nation etc. etc.... ) ...

I can go either way with this though....
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Old 05-06-2010, 02:46 PM   #37
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Surprise. There will be some unintended consequences and higher costs to employers and employees.

We need some more help from our gvmt. Just like they helped us with credit cards.

- Stay tuned for energy policy and imiigration reform.
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Old 05-06-2010, 02:48 PM   #38
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I don’t see how costs can be controlled. Insurance companies have become intermediaries and have an unlimited profit motive. This conflicts with providers and patients alike. Providers are spending immense amounts in demand generation. The health care industry promises a degree of diagnostic and treatment certainty that cannot be met by any individual provider but leads to endless testing.

Cost containment demands guaranteed payment as a prerequisite. This is now mostly, but not entirely, covered. Not yet resolved, but at least the main cause of cost shifting has been dealt with. This will limit some of the exploitation and arbitrage going on now and allow for a more systematic approach to cost management.
+1
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Old 05-06-2010, 02:49 PM   #39
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I do not think co-pays are that big a deal when it comes to utiliztion of services. Almost every time we have gone to the doctor in the last few years the actual costs after the insurance discount is only a few dollars more than my co-pay... (mine are $30 for normal doc and $50 for specialist)..
When cost-cutting backfires | Harvard Gazette Online
Though the copayment increases were counterproductive for elderly patients with a chronic disease like diabetes or hypertension, the study showed that copayments worked as desired for those not chronically ill. Those patients reduced office visits and prescription drug utilization with no negative effects on their health.
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Old 05-06-2010, 03:02 PM   #40
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When cost-cutting backfires | Harvard Gazette Online
Though the copayment increases were counterproductive for elderly patients with a chronic disease like diabetes or hypertension, the study showed that copayments worked as desired for those not chronically ill. Those patients reduced office visits and prescription drug utilization with no negative effects on their health.
I agree that copays are an absolute requirement. Research I've seen in other areas show less overall usage and higher levels of satisfaction when people pay something rather than nothing per activity.
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