Potus
Potus2036
Jr. Member
Posts: 1,841
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« on: January 11, 2017, 10:13:29 PM » |
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Allow me to come to the table with a coherent, opposing view of things.
These policy "innovations" like insurance cooperatives and the public option are treated as though they're a shift in the paradigm of healthcare. That's not the case, however. In reality, we've been moving toward control of healthcare decisionmaking, investment, and costs by a vast bureaucracy for a few generations now. The directly state-controlled components of healthcare have been complemented with various maybe-maybe-not-state-controlled components, like the cooperatives in question. But, the cooperatives aren't the major shift presented in this legislation. The public option is a more significant step down our current path.
Public healthcare has a pretty troubled history outside of outright patient satisfaction surveys. Medicaid, in particular, has been linked to no changes in health outcomes relative to being uninsured. That's a pretty significant black mark on the program. Medicare has a slightly, but not much, better track record on health outcomes. Both programs suffer from narrowing networks, limited choice, and an outdated Soviet-style payment negotiation system.
The narrow network/choice limitation issues are also linked to the problem of expensive private insurance. It has to do with reimbursement rates in the Medicaid and, to a lesser extent, Medicare programs. Allow me to get a bit into the weeds here. A procedure costs $100,. An uninsured patient is billed the full $100 by the healthcare provider, but will likely only pay $20 of it. Healthcare providers are limited in their ability to collect debts, something I'm not opposing, so the uninsured patient will end up paying only their initial $20 payment. The healthcare provider bills a Medicaid patient the same $100. The state/regional Medicaid bureaucrats respond saying, "We will pay you $60." The purchasing power of Medicare/Medicaid that the healthcare providers are forced to accept that.
In caring for these two patients, the healthcare provider has provided $200 worth of care and received $80 in payment. This leaves $120 as uncompensated care. In this cost, there is a lot of market information that won't be fixed by government fiat, such as the scarcity and quality of talented doctors, PAs, nurses, etc. This is why we are willing to pay so much for our healthcare, and why medical jobs pay so well.
Now, a commercially insured patient goes in for that same $100 procedure. The insurance companies reimburse healthcare providers "at-cost w/a haircut" for the sake of the example, let's say a 5% haircut. The healthcare provider has provided an additional $100 in care with $120 in uncompensated care. They are for-profit institutions, so they add an additional $30 to the bill to attempt to turn a profit. The commercial insurer is billed $250 for a $100 procedure. The healthcare provider has made $12.50 in profit under this scenario.
The commercial insurer will, in response to higher payouts, increase health insurance premiums. This makes health-improving, quality private insurance further out of reach for working class people, who begrudgingly accept Medicaid as a poor substitute.
Many healthcare providers dodge the issues inherent in public healthcare by refusing to accept, leading to limited choices for the poor and elderly.
The Affordable Care partially recognized the opportunity to "bend the cost curve" by shifting uninsured patients from their very low reimbursement rates to Medicaid's better-but-still-bad reimbursement rate of 60%. In our scenario above, this reduces the uncompensated care passed off to private insurers by $40.
For some reason, the law's authors didn't take the extra step to shifting people to quality private coverage that can travel with them through life, the workforce, and health status. They instead chose to expand what is commonly agreed upon as the worst health insurance in the Western World. This is my case against expanding public insurance to larger swathes of the population. The end result will be reductions in access and quality while increasing the cost of insurance that guarantees access and quality. I suggest a different approach be taken.
The first step should be to strengthen the ability of the patient to govern their own healthcare and insurance. A standardized, formula-based annual contribution to a health savings account, designed to suit the Senate's liking, would be a monumental shift in direction for our healthcare industry. I would like to see health savings accounts be able to cover the cost of insurance offered on a liberalized, competitive exchange.
There should also be a broad liberalization of the healthcare marketplace. Lower barriers to entry, lift rules against capital investment, allow more universities to build medical schools, reduce the effect of broken courts on the marketplace, streamline the ability of new drugs and treatments to reach patients, and so much more. We've never really tried this in modern healthcare, but other successful opening of markets suggests it will be very successful.
I could talk further about an alternative bill, but chances are that this chamber will want to continue with this version of the bill because work has already been put into it. Happy to be on hand for something different, should you desire.
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