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Old 10-13-2009, 04:13 PM   #21
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I'd rather fund Medicare for all than line up the pockets of some CEO with government subsidies provided by my tax dollars. I see much less waste in Medicare. But that's my opinion.
Medicare reimbursement rates are very low compared to other patients. Many doctors won't even take new Medicare patients. If everyone paid Medicare's rates, I suspect we'd see a lot of doctors FIREing.
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Old 10-13-2009, 04:28 PM   #22
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When you add it up, I'm just not convinced that a government agency with government employees, government benefits and government's general disdain for cost-cutting would be cheaper than private industry, even after allowing for a reasonable profit.
Although I'm not a government employee, I work at a government organization. Last year, my cost was 3.82 times more than my actual salary. In other words, for every one of me who is supposed to be doing real work, there are 3.82 others on overhead accounts doing who knows what. Worse, my efficiency is fairly low due to the regulations that must be followed. At best, I'm probably "50% efficient." I have no reason to believe it will be any different with health care. So no, I don't trust the government's ability to control costs in health care or anything else.
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Old 10-13-2009, 04:30 PM   #23
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Wow -- I'm playing with this calculator and putting in various income amounts, and these are looking like serious incentives to get off the hamster wheel and relax on a lower income.

For a family of 4 in a medium-cost area, the Baucus plan (as one example) gives a subsidy of $6,499 on a $50,000 income at my age (44). At $80,000 the subsidy is $1,068.

So by gaining $30,000 of added income, you lose $5,431 in subsidy. That's essentially equivalent to an extra 18% tax on every dollar you earn above $50,000 -- above and beyond all existing taxes!

Get me off this hamster wheel!
I have considered the same thing. This adds an extra layer of progressive taxation. Marginal rates shoot up quickly. If the loss of health insurance credits is an effective 18% marginal tax rate, and I am hit by 15% fed income tax and 7% state income tax, plus 8% SS/Medicare tax, as a worker I'm facing a 48% marginal tax rate, as a FIREe, I am facing a 40% marginal tax rate. Those are some pretty strong disincentives to earning income, especially at relatively low income levels.

Roth IRA's, municipal bonds, paying off the mortgage, and learning to live on a lower income may be good strategies under this new effective taxation scheme. High marginal taxation rates would also make part time earned income more attractive since it could be sheltered (ie you would consume your after tax savings and add to tax favored savings without necessarily realizing any income).

Ultimately it is all guesswork as to what the ultimate plan will look like and the specifics of the plan. All I know is that I'll be sharpenin the ole "cheat da gobmint outta der money" pencil once whatever plan comes to fruition.
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Old 10-13-2009, 04:35 PM   #24
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Medicare reimbursement rates are very low compared to other patients. Many doctors won't even take new Medicare patients. If everyone paid Medicare's rates, I suspect we'd see a lot of doctors FIREing.
As I said in my first post, those Medicare reimbursement rates would have to go higher. With medicare for all, doctors wouldn't be able to refuse Medicare patients because they'd go out of business. But I agree, Medicare for all would take a chunk out of doctor's income... and mine... which ironically would delay FIRE. Everyone seems to be looking for a solution which won't require any sacrifice on their part. It's ludicrous.
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Old 10-13-2009, 04:43 PM   #25
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Although I'm not a government employee, I work at a government organization. Last year, my cost was 3.82 times more than my actual salary. In other words, for every one of me who is supposed to be doing real work, there are 3.82 others on overhead accounts doing who knows what. Worse, my efficiency is fairly low due to the regulations that must be followed. At best, I'm probably "50% efficient." I have no reason to believe it will be any different with health care. So no, I don't trust the government's ability to control costs in health care or anything else.
Wow, now I am really ticked off. My taxes go to pay for some lazy people's salary, pensions and benefits. Now I am depressed. Perhaps the US can't pull it off after all.
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Old 10-13-2009, 05:10 PM   #26
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Again, if the profit motive directly led to higher costs, why on earth would so many services cost more with the USPS than FedEx or UPS? Could it be that FedEx and UPS manage costs more effectively because of competitive pressures AND the need to show shareholders a profit?
Apples and oranges. USPS is required to try to pay for their own operation, yet they are required to subsidize the cost of some things (like mailing a letter - try to tell my elderly little old lady friend in Portland that she must pay close to $20 to mail me a letter vs under 50 cents via USPS).
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Old 10-14-2009, 09:13 AM   #27
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Everyone seems to be looking for a solution which won't require any sacrifice on their part. It's ludicrous.
It's called "political reality." Every special interest is going to be fighting tooth and nail to protect their fiefdom. And our fearless leaders don't have the courage to tell their favorite and most powerful ones to shut up and share the sacrifice.
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Old 10-14-2009, 10:09 AM   #28
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IMO, the fallacy with this is the assumption is that elimination of the profit motive will guarantee that government can do it cheaper. Maybe they can, maybe they can't, but if experience in other areas is any indication (look at parcel delivery, USPS versus UPS or FedEx), if government-provided services have a higher cost structure than the private "for profit" sector (wages, benefits, waste), some or all of the "non-profit discount" could vanish -- and possibly even be more expensive than for-profit businesses that have to keep overhead costs down to be more competitive and responsive to shareholders.
The one piece of information we have is that Medicare does have a substantially lower percentage of its expenses go to administration rather than care than insurance companies do, even discounting money paid out in profits.
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Old 10-14-2009, 10:42 AM   #29
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The one piece of information we have is that Medicare does have a substantially lower percentage of its expenses go to administration rather than care than insurance companies do, even discounting money paid out in profits.
I've heard this often, but some people claim it is a very misleading metric. Their argument:
Medicare's admin costs may be lower than private insurance when expressed as a % of claims paid, but Medicare costs are higher on a per-patient basis. The lower Medicare admin costs as a % of claims don't reflect any great efficiency on Medicare's part, but just the fact that their average patients are so much sicker that the average cost per patient is higher. Billing costs tend to be fairly fixed per procedure: it doesn't cost any more to process a claim for a $40K procedure than it does for a ten dollar procedure. Medicare patients are old and sick, they have expensive procedures so Medicare can spread their admin costs over a very large expenditure baseline.

From 2005:
- Medicare's average admin cost per enrollee: $509
- Private Insurance's admin costs per enrollee (includes profit): $453.

Here's a groovy chart:


Again, consider the source (Heritage Foundation). Like every thinktank, they frame things to fit their world view, but I've found them to be factually accurate. A "per person" expression of admin costs is likely just as valid as a "percent of benefits paid" metric. If so, there's good reason to doubt that a Medicare-like government program would be a money saver if the program includes younger, less ill, populations.

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Old 10-14-2009, 08:55 PM   #30
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IMO, the fallacy with this is the assumption is that elimination of the profit motive will guarantee that government can do it cheaper.
I don't know about cheaper, but you do get rid of this phenomenon as reported in the WSJ today . . .

Quote:
At least two home insurers in Florida have begun dropping policyholders who filed claims for property damage linked to drywall imported from China. Disputes with insurance companies are increase as a growing number of homeowners file claims for property damage they say is caused by defective drywall. Insurers are fighting the claims and in some instances using the information in them to drop the policies
Or this classic . . .

Lott Sues Over Katrina Damage - ABC News

Profit motive is fine. But for insurance companies, honoring claims is considered a "loss". In other words, the profit motive is in direct conflict with what an insurance company is paid to do.
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Old 10-14-2009, 09:00 PM   #31
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I've heard this often, but some people claim it is a very misleading metric. Their argument:
Medicare's admin costs may be lower than private insurance when expressed as a % of claims paid, but Medicare costs are higher on a per-patient basis. The lower Medicare admin costs as a % of claims don't reflect any great efficiency on Medicare's part, but just the fact that their average patients are so much sicker that the average cost per patient is higher. Billing costs tend to be fairly fixed per procedure: it doesn't cost any more to process a claim for a $40K procedure than it does for a ten dollar procedure. Medicare patients are old and sick, they have expensive procedures so Medicare can spread their admin costs over a very large expenditure baseline.

From 2005:
- Medicare's average admin cost per enrollee: $509
- Private Insurance's admin costs per enrollee (includes profit): $453.

Here's a groovy chart:


Again, consider the source (Heritage Foundation). Like every thinktank, they frame things to fit their world view, but I've found them to be factually accurate. A "per person" expression of admin costs is likely just as valid as a "percent of benefits paid" metric. If so, there's good reason to doubt that a Medicare-like government program would be a money saver if the program includes younger, less ill, populations.

"There are three kinds of lies: lies, damned lies, and statistics."
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I read an economist debunking the Heritage Foundation information and conclusions, but don't have it at hand right now. I'll see if I can dig it up later.

Here is one report: http://institute.ourfuture.org/files...lan_Choice.pdf

When you compare apples to apples, medicare to private medicare advantage plans, medicare has far lower admin costs.
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Old 10-14-2009, 09:12 PM   #32
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I read an economist debunking the Heritage Foundation information and conclusions, but don't have it at hand right now. I'll see if I can dig it up later.
Don't spend a lot of time on it, but I'll be interested if you find it. The rationale made sense to me.

And another thing-- If I think private insurance companies are making a big profit, I can get part of that by just buying their stock. There's no "money return route" I can use for the government plan.
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Old 10-14-2009, 10:22 PM   #33
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Here is one report: http://institute.ourfuture.org/files...lan_Choice.pdf

When you compare apples to apples, medicare to private medicare advantage plans, medicare has far lower admin costs.
Thanks for the this analysis. As you can imagine, it (the Hacker Report") has drawn a lot of attention and rebuttal. The main two counterarguments are:
-- The comparison populations are not apples-to-apples as the Medicare Advantage population is much healthier (leading to the 'small denominator' reason for the Medicare Advantage having a higher admin % of claims).
For example, the The Medicare Payment Advisory Commission (MedPAC) report from Jun 08 (from Chart 6-2 on pg 62)
Self reported health status of those in the programs:
Regular Medicare:"Excellent/very good" = 24%, "Good/fair"=29%, "poor" = 47%
MedicareAdvantage*: Excellent/very good"= 41%, "good/fair"=38%, "poor"= 21%
(* AKA "Medicare Managed Care")

So, maybe not "apples-to-apples"--the Medicare folks reported they were less healthy by quite a bit

A second point made by Heritage is one I'm not qualified to comment on. As I understand it, the types of things counted as "costs" were very different in the two cases. Hacker's Medicare costs apparently included only the costs to process the claim and cut the check to the provider. It counted none of the costs for admin done in the doctors' offices and by other medical providers (I imagine this includes all the laborious coding and everything else that they do to send the bills, track the paperwork, etc). The Medicare Advantage plans were largely HMOs, and Hacker counted all their back-office costs in his "admin costs" numerator. If I've got this right, it certainly would explain why the Medicare number is so much lower--it's not measuring the same thing. If the costs for the same functions are included, Medicare ends up having higher admin costs even on a "per dollar of services provided" measure and includng hte profits earned by the health insurers. Here's Heritage Foundation's explanation of why they think Hacker misused the GAO numbers:
Quote:
Since the bulk of Medicare Advantage plans are HMO plans, the 16.7% figure includes both functions of operating a health plan and functions that occur in doctors’ offices and health plans. In traditional Medicare, the fees paid to physicians and hospitals include an amount attributable to their internal administrative costs. For physicians, that amount averages 17.3% of their fees — this is administrative costs in addition to costs incurred at the Medicare program level. Hacker says this comes up to 2%, but is actually 3% or 6%, depending on whether you count just the cost of the Medicare bureaucracy, or include with that cost the costs other government agencies incur in support of Medicare.
Sorry for the wonk-a-thon. I'm fighting well out of my weight class here, so I'll not be surprised if I've misinterpreted a major element.
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Old 10-16-2009, 05:52 PM   #34
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I also just don't know enough to judge the criticisms on both sides, I'll see what else I can find out if I get a chance. It sure shows you though how hard it is to get your arms around this. I can't trust the Foundation's arguments and Krugman doesn't give a response, he just attacks.
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Old 10-16-2009, 06:48 PM   #35
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I've heard this often, but some people claim it is a very misleading metric.

Medicare's admin costs may be lower than private insurance ...
Color me skeptical also. The words "govt run" and "efficient" in the same sentence just seem hard for me to take. True comparisons are difficult. But if anyone wants to claim that the govt can do this better than a freer market (freer than we have today), I'm reminded of that phrase:

Extraordinary claims require extraordinary evidence. (Carl Sagan)

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Old 10-16-2009, 08:18 PM   #36
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Well, I can't find the original article I read. Here is a discussion on a blog that reinforces the lack of consensus on the issue: Does Medicare actually have higher administrative costs than private insurers? - Statistical Modeling, Causal Inference, and Social Science

It would be interesting to have a non-partisan look at the data, which clearly is complex, to see if this could be pinned down with more accuracy.



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I think that we aren't talking about alien abduction or life after death.
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Old 10-16-2009, 08:36 PM   #37
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It would be interesting to have a non-partisan look at the data, which clearly is complex, to see if this could be pinned down with more accuracy.
It would be useful, but at this point I think we've run out of "non-partisans" to do that analysis. The last one in the building, the CBO, figuratively hopped over the fence with their, well, "extremely charitable" analysis of Chairman Baucus's markup.

Anyway, I learned something about the methodology behind the claims/counterclaims regarding these admin costs, so I'm better for having explored it a little. Thanks for the information.
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Old 10-16-2009, 10:30 PM   #38
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I think that we aren't talking about alien abduction or life after death.
Yeah, but unlike government efficiency, alien abductions and life after death have at least a tiny chance of being real...
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Old 10-17-2009, 07:19 AM   #39
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But what good do you do by cutting costs if you don't pass those cost cuts to the consumer? Yes, it makes the corporation more profitable, but it doesn't lower cost for us. Profits for health insurers have exploded in the past 10 years, yet premiums keep outpacing inflation. The insurers might have cut costs during the time to boost their bottom line, but have you personally benefited from those cut cutting measures? I know I didn't (well except as a share holder that is).
The bill in the House addresses this exact thing. I don't know about the Bacus bill, but I'm sure if both are passed it would find it's way into the final bill, because nobody has complained about it. In the main bill in the House insurance companies must refund any income over a certain percentage of medical expenses. What exactly the language means is undetermined, because they haven't come up with the definitions of the terms yet. My take and what seems to be to point of the clause is: An insurance company takes in 100 million in premiums. The must refund anything over let's say 20% of medical spending. Using the 100 million figure, if an insurance company spends 50 million on medical expenses they can only keep 10 million in excess of the medical spending. The other 40 million would have to refunded back to the consumer. Nobody knows what exactly is included in medical spending, because the term has not been defined and won't be until after the bill passes. This has some interesting facets also. If the insurance company's admin costs are not included in medical spending then the "director of huge government health control department" can easily force insurance companies to go out of business, or can keep them as profitable as they are now. With this provision in place why do we need a government option to "keep the insurers honest"? Doesn't this clause do that? It seems to me the only reason to have a government option would be so they can put unrealistic earnings caps on health insurers and have the government policy there for everyone to fall into. The government can easily claim that the private health insurers refused to become more efficient and as a result went out of business. Few will believe the health insurers side of the story because health insurance companies are bad. In the end it would be a government take over of how much an insurance company can make. Also nobody knows what the percentages are because they also haven't been defined and won't be until after the bill is signed into law.
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Old 10-17-2009, 09:26 AM   #40
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So we are discussing two approaches to driving down the cost of private insurance:
1) Government controlled pricing for services, overhead, and profit.
2) A "government option" medical care provider to compete with private insurers. But this "competitor" gets the use of free (or very much reduced price) capital, has affiliates that regulate and can fine its private competitors , etc. Not quite a level playing field.

What about a third option?
3) Make changes so the private insurers compete aggressively to provide products that meet the requirements of individual consumers while also meeting the greater requirements of society.

"Requirements of society" might include
1) All policies must provide "free" (i.e. no co-pay) preventive medical services (this is a "societal requirement" becasue these services are very efficient in driving down system-wide costs that frequently get shouldered by taxpayers)
2) All applicants must be accepted at the standard rate (This is a "societal requirement" because the American public now believes everyone should have medical care--even if someone else has to pay for it. ) Inclusion of this "societal requirement" will also necessitate a mandate that everyone buy insurance--I don't think there's any other way to do it.
3) Provide coverage without regard for employment status (this is a "societal requirement" because delinkng medical care from employment makes the labor market more efficient and makes our industries more competitive worldwide)

We know how to facilitate competition: Allow cross-state sales of insurance products, standardize policy types, give consumers access to information about customer satisfaction with the insurers and provide consumers with easy access to information on health care outcomes from various procedures at various providers, etc. We don't have either a free or an efficient market today, which is why prices are high and why profits for health insurers are where they are. Efficient markets always drive down margins, and this is a much more effective method of doing it than government committees. Lots of things make our present market inefficient (opacity of pricing information, layer upon layer of interconnected pricing interdependencies, the existence of a fourth player (the employer) in the already complex three-player market "game" of consumer, health care provider, insurance company).

Let the free market do its magic, but within a confine that serves the needs of society (as presently understood) as well as the needs of individual consumers.

(Editorial: I am not comfortable with this "greater needs of society" requirement, but purists must face the fact that this is where America is headed--it is what people want. Apparently the Constitution, as presently interpreted, does not protect us from building a nanny state. So, let's go there with as little damage to individual liberty as possible)
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