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Old 08-14-2009, 12:36 PM   #41
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Why not take one issue, say portability and solve that. Nothing else just that. Structure a bill that allows portability. It should not have to be 1000 pages, should not have any other type of reform, just solve portability. Vote on it sign it and then ask what is the next thing that needs to be solved. Lets say it is cut cost through streamlining of medical records. Once more one bill on only one issue.

While this may take longer, if the bills were short and clear, without all the hidden agendas, I think most Americans would go along with it. Sooner or later you are going to get down to an issue that just does not have public support.
Amen.

I also believe that we could make real progress this way. Build up trust a step at a time. Start with issues with a clear benefit and that have good public support. It looks like that would actually go faster, because it sure looks like the current proposals are going nowhere.

I would not even label it as "compromise", it's just an alternate path.

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Old 08-14-2009, 12:41 PM   #42
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Why not take one issue, say portability and solve that. Nothing else just that.
That would be a good start. In my opinion, one of the worst things about our health care system is the link between health insurance and employment. (And one of the worst things about the current proposal is that if anything, it strengthens the link between employer and health insurance.)

How many people still work for health insurance when they could otherwise retire, which eliminates potential job openings for people who still NEED the paycheck? How many people have great ideas and an entrepreneurial spirit but don't unleash them because leaving their j*b to pursue it means losing their health insurance?

Health insurance tied to employment puts shackles on many of us when our talents and energies might be put to better use elsewhere, and it prevents people from being able to leave their j*bs for someone who still badly needs one.
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Old 08-14-2009, 12:53 PM   #43
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That would be a good start. In my opinion, one of the worst things about our health care system is the link between health insurance and employment. (And one of the worst things about the current proposal is that if anything, it strengthens the link between employer and health insurance.)

How many people still work for health insurance when they could otherwise retire, which eliminates potential job openings for people who still NEED the paycheck? How many people have great ideas and an entrepreneurial spirit but don't unleash them because leaving their j*b to pursue it means losing their health insurance?

Health insurance tied to employment puts shackles on many of us when our talents and energies might be put to better use elsewhere, and it prevents people from being able to leave their j*bs for someone who still badly needs one.
OK, I'll play.

By portability, you mean that you take your insurance coverage with you? That means you get to pay the same premium even if you are no longer provide services to your old employer? And if they change coverage, you get what you get? Even if they chose to drop coverage?

How about NO employer provided insurance coverage at all? People have to buy their own, they can buy through their employer or directly from a carrier, or through a club or association (the 'group' plan). If they buy from their employer, they don't get to exempt the premium cost from income tax on their salary.

Those who itemize may be able to deduct the cost of premiums.

Oh, did I mention that without the upfront income tax exemption the cost would be a lot higher, because employers can't deduct the cost of insurance when they file their taxes. You wouldn't always get the employers contribution to the premium you get today. Today, most carriers require an employer to contribute 50% or more of the monthly premium before they will issue a group plan. For comparison: try COBRA.

Yikes!

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Old 08-14-2009, 01:18 PM   #44
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Why not take one issue, say portability and solve that. Nothing else just that. Structure a bill that allows portability. It should not have to be 1000 pages, should not have any other type of reform, just solve portability. Vote on it sign it and then ask what is the next thing that needs to be solved. Lets say it is cut cost through streamlining of medical records. Once more one bill on only one issue.
I have thought that this should be the dems strategy. Not necessarily the portability issue, but attacking it bit by bit as agreement is reached.
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Old 08-14-2009, 01:20 PM   #45
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I do not believe that this is the only thing stopping getting to healthier behavior.

On so many issues, there is a lot of distance between what is supposed to be healthy, and what various groups are pushing, and actual scientific proof that these are accurate. The recent debate on this board about heart healthy diets, fats, and carbohydrates, and Rich's input which I believe has strongly changed over the last year or so might be enough to convince us that public health consensus on some important topics would not necessarily align with science.

Did a typical 60 year old man 80 years ago suffer from not having the government tell him how to live? Let's not forget that study funding, the media and government health panels are not really medical science, they are highly political operations.

Ha
I didn't mean to imply that it was. I agree that there are complicated evidence issues. But then again, just about everyone knows that exercise is good for you and reducing calories is the way to lose weight. The rest is fine tuning.
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Old 08-14-2009, 01:21 PM   #46
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I have thought that this should be the dems strategy.
Probably so. The simple truth is that most people are satisfied with their current health coverage, but the big fear is in losing it and then getting sick. Or getting sick to the point where you'd be screwed if you lost your current insurance, making job loss a double-whammy (there's that ornery link to employment again).

If we did nothing this year but create a way to guarantee portability without creating higher costs through adverse selection, that would be a huge first step. And real portability would also go a long way to weaken the link to employer, because someone could leave their job and keep their current plan (or transfer to another plan with no underwriting).
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Old 08-14-2009, 01:48 PM   #47
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OK, I'll play.

By portability, you mean that you take your insurance coverage with you? That means you get to pay the same premium even if you are no longer provide services to your old employer? And if they change coverage, you get what you get? Even if they chose to drop coverage?

How about NO employer provided insurance coverage at all? People have to buy their own, they can buy through their employer or directly from a carrier, or through a club or association (the 'group' plan). If they buy from their employer, they don't get to exempt the premium cost from income tax on their salary.

Those who itemize may be able to deduct the cost of premiums.

Oh, did I mention that without the upfront income tax exemption the cost would be a lot higher, because employers can't deduct the cost of insurance when they file their taxes. You wouldn't always get the employers contribution to the premium you get today. Today, most carriers require an employer to contribute 50% or more of the monthly premium before they will issue a group plan. For comparison: try COBRA.

Yikes!

Rita
Yeah, there is the cost problem, with many not being able to afford COBRA. Big companies and government get a better insurance deal because of bargaining power so their policies can at a reasonable cost. But smaller business policies are much more expensive. Frankly, I saved money going from COBRA to a risk pool, which is a higher cost plan than average.

Some employers self insure with stop loss policies. That doesn't port well

****, it is complicated. Again, it is because we don't have a health care system.

Some ideas on piece by piece fixes:

If you made underwriting illegal, the problem is adverse selection unless you require all to have insurance. So cost goes up. Requiring all to have insurance leads to all sorts of other issues, like cost barriers, that congress is having a hard time sorting through. In the long run I think everyone needs to be required to be insured to make the health care sector work. As they work on that I suggest immediately provide that:

(1)If you are insured and have been for at least a certain period of time (maybe a year), whether or not it is a group plan, you should be able to get into another plan without a preexisting condition waiting period and no underwriting. This may help address the adverse selection issue as people cannot just wait until they are sick to buy insurance. This would be an expansion of current HIPAA rules. THis is a twist on the portability suggestion that doesn't quite work.

(2) Create a subsidized federal risk pool for those who are uninsured currently and cannot be insured due to underwriting. After a year or two or three, move them to category number one. There may have to be a preexisting condition waiting period to avoid adverse selection.

(3) Regulate insurance company profits and admin costs that can be passed on to customers. Treat them like a utility. This would be harder. The alternative, price regulation, may be even more difficult.

(4) It gets harder when talking about what to do with people who can't afford insurance. Maybe while we work on reform we have a temporary recession increase in medicaid funding (states are being killed on this) and broaden who are eligible for medicaid. Right now states are narrowing who are eligible because of shortage of funds. Maybe, like earned income credit, also have a cash money credit for lower income people who can only buy insurance with a bit of extra money.

This is just thinking off the top of my head while watching HGTV, so don't bite my head off for the weaknesses.
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Old 08-14-2009, 02:28 PM   #48
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I didn't mean to imply that it was. I agree that there are complicated evidence issues. But then again, just about everyone knows that exercise is good for you and reducing calories is the way to lose weight. The rest is fine tuning.
With respect to exercise, likely yes. Best way to lose weight? IMO, the "experts" are still driving well beyond their headlights. Read Taubes.

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Old 08-14-2009, 03:36 PM   #49
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(1)If you are insured and have been for at least a certain period of time (maybe a year), whether or not it is a group plan, you should be able to get into another plan without a preexisting condition waiting period and no underwriting. This may help address the adverse selection issue as people cannot just wait until they are sick to buy insurance. This would be an expansion of current HIPAA rules. THis is a twist on the portability suggestion that doesn't quite work.
This is a good idea, and to work properly it needs to be coupled with very large (and stable) risk pools, the fewer the better. One of the problems, especially in the individual insurance market, is that the insurance companies actually create adverse selection by constantly coming out with new (and usually cheaper) policies which require underwriting. Those who can pass underwriting switch to the new policies, which have a new risk pool, thereby leaving their old (and now sicker) risk pool behind. Those who can't switch face higher than average premium increases due to the fact that they are now in a more unhealthy risk pool. This game repeats itself, and leaves a bunch of unhealthy risk pools in its wake. In the extreme, this can result in the insurance company eventually deciding to cancel all the policies that were originally issued for a given risk pool, leaving those folks without insurance, thereby forcing them into a state risk pool (or its equivalent).
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Old 08-14-2009, 04:26 PM   #50
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Martha,
I just picked portability as first. The point is just pick one and only one. Then write as simple a bill as possible. Something everyone can understand. However, I will confess I have little faith that politicians of either party are capable of doing this, and I have even less faith that the voters will do anything to correct this.
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Old 08-14-2009, 05:31 PM   #51
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Yeah, I understand.
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Old 08-14-2009, 07:19 PM   #52
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The "one problem at a time" approach sounds like a good way to incrementally lick all the problems, but I wonder what it would produce. If it is a building-block approach, the first problem you pick (and the solution we decide upon for it) would, deliberately or not, set us on a course that could make the other problems even more difficult to solve, or introduce entirely new ones.

Big change all at once is very scary and politically very hard. I think this President has lost his chance--squandered his capital and goodwill on other projects-of-the-week. It's too bad we can't set up 50 experiments in the 50 states--let's see what works for the US. That would let us gain confidence gradually when we see the results of a particular approach. Unfortunately, state-by-state programs don't work, as the sick people would move to the states that provide them the most advantages, and businesses vote with their feet.

I think, unfortunately, it's going to take a crisis to get a solution to this problem. We don't have a crisis now--we have a long-term chronic problem that affects (primarily) those with the least societal influence. A problem among that population could fester for decades (more) without resolution. Here's my Malthusian prognostication: I think we'll have a crisis when our dysfunctional system (which disconnects the cost of services from the recipients, etc) finally causes sufficient price escalation in medical care that it impacts our economy in general. When these costs (and other factors already in place--including a huge US national debt) make the US noncompetitive and we have a surplus of workers looking for jobs, employers will finally decide that they can dump the by now way-too-expensive medical insurance plans and still keep their employees (and even stay in business). Then we'll have a marketplace for individual policies, and a huge number of people falling through the cracks and into an impossibly stressed government safety net. With the economy in a slump ("no new taxes!") and faced with renewed public pressure and an exhausted credit line, Uncle Sam does what he often does in these situations--passes an unfunded mandate. In this case, it is a mandate for everyone to be covered by some minimal, standard individual health insurance plan available from numerous private sources. Underwriting is prohibited in these approved health insurance policies/plans (making them available and affordable to those with previously existing conditions, but increasing the cost for all others somewhat). The needy get vouchers. Voila! This is how we get to where we ought to be anyway (portability, universal coverage, a choice of insurers and delivery means, all the advantages a free market brings to almost every other area of our economy--reduced costs, innovation, etc) but in the most painful way possible.
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Old 08-14-2009, 08:47 PM   #53
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Solving the first problem, could cause problems for the solution to the others, however, it also seems that the same problem exist if you try to solve everything at once. It seems infinitely more difficult to solve all problems at once.
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Old 08-14-2009, 08:49 PM   #54
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SamClem, I agree. bit when you got such a mess it might be the only way to deal with it politically, even if it isn't sensible. I want the whole sector fixed but I am worried that it won't occur. My incremental changes aren't that different from where you think we will end up.

I don't know that I agree that the President squandered his political capital. Many of the projects of the week bailouts occurred before he was in office, which tarnished the legislative bodies. Our public is impatient. No matter who was president if you have a deep recession you can't expect government to turn it around in six months or a year. Plus, we can never run a counter experiment to see how things would be without bailouts.

I am not impressed with our country right now. I dislike the lack of empathy. I dislike that health care for the poor is being cut by just about every state, including Minnesota. I dislike the rhetoric coming out of the legislature. I dislike the press coverage, which just seems to thrive on excitement. I dislike that people think having a 1000 page plan is bad just because it is a 1000 pages. I used to have clients who wanted to have short agreements as if somehow that made life simpler. Well, I easily could convince them otherwise but the series of "what ifs" that an agreement should address.

Well, it still might happen. But given people don't seem to be expressing much empathy for those without, eventually may be further out than I hoped. The issue may be how close to a crisis we are.
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Old 08-14-2009, 09:03 PM   #55
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At least this time I am thankful we have a 2 party system. Its nice to see some give and take. Trying to railroad an absurd system would not be good for us in the long haul
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Old 08-14-2009, 09:06 PM   #56
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I don't know that I agree that the President squandered his political capital. Many of the projects of the week bailouts occurred before he was in office, which tarnished the legislative bodies. Our public is impatient. No matter who was president if you have a deep recession you can't expect government to turn it around in six months or a year. Plus, we can never run a counter experiment to see how things would be without bailouts.
Yes, the responsibility for the rapidly-increasing public resistance to big government programs rests with the previous and current legislature as well as President Obama (and Bush). It's just that the toll is so much more evident on President Obama. We're used to being disgusted with Congress, but there were such high hopes among those who voted for Obama. And his popularity has definitely suffered more as the public wariness grows and he adopts a more defensive, less inclusive and optimistic, approach to his communications with the public. It all happened so quickly.
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Old 08-14-2009, 09:48 PM   #57
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....I stll think they'll eventually determine that eating chocolate and cooking with lard will be major positive health factors.
Only Dark Chocolate!!! Not the run-of-the-mill plain-jane milk chocolate!
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Old 08-14-2009, 09:59 PM   #58
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Only Dark Chocolate!!! Not the run-of-the-mill plain-jane milk chocolate!
Dark chocolate is better anyway! mmmmm!!
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Old 08-14-2009, 10:16 PM   #59
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Dark chocolate is better anyway! mmmmm!!
That's what my Doc told me....he knows that I like chocolate from time to time....So he told me that that was fine, just be sure that it's dark chocolate, because it's better for me!

I REALLY like my Doc!!!
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Old 08-15-2009, 11:26 AM   #60
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That's what my Doc told me....he knows that I like chocolate from time to time....So he told me that that was fine, just be sure that it's dark chocolate, because it's better for me!

I REALLY like my Doc!!!
Two birds with one stone. Have some port with some nice dark chocolate. Both are good for the heart
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