Saturday, August 20, 2016

The Morality of Healthcare Financing

MP US Exceptionalism continues to drive excellent discussion.
"Maybe, Just Maybe: The power of the presidency has been so downsized by an ineffective congress that realistically, change just might suggest a tyrant could soon be in control? 
Let's say if all candidates or at least the major two, pass by the concept of a free society, then all credibility; hope for a functioning democracy is a dream ending...who knows?
Sleeping at the gate: The 'people' are left out...and rather than ever being the recipients of positive change like universal health care etc..and if major parties are content with or zeroing into those false gods like money and power and greed, downsizing the people who seem at times to be in a catatonic state of denial? Better wake up Joe B and Joanna too eh?" Beryl 
"Left Out? "The 'people' are left out...and rather than ever being the recipients of positive change"  Now you do realize that a large portion of US citizens consider that changing to Single Payer would be a negative change...   Gallup Healthcare Poll Results
My point is that people's voices are being heard, but their voice opposes your view of "positive". Maybe because they will be paying more and getting less. 
I work with people from many countries, there are definitely pros and cons to single payer plans. That is why most countries have Private Options on top of the public system. Personally I am against single payer for several reasons:
  • Patient does not bear the costs. Little incentive to live healthy.
  • Rationing and long waits for some services.
  • Price controls do not work well, something is going to slip.
  • other
So I am happy that my voice is being heard." G2A

"Rationing of health care under single-payer systems isn't caused by the fact that they are single-payer. They're caused by other policy decisions -- specifically, the desire to limit health care spending. Need proof? There's a single payer system very near to us that doesn't ration care in the way that, say Canada or Britain do -- it's called Medicare and it serves every American over the age of 65. 
We should also acknowledge that our current multiple-payer system also rations care -- by the ability to pay. Every system will ration care to some extent, what we need to decide is on what basis we choose to ration." Sean

"People in America who go to school, learn, work hard, make good choices, work hard, etc get the best medical care in the world when they need it. The disabled and old get the best medical care in the world when they need it. 
Those who do not fit into either category struggle and are handled on a case by case basis. Makes sense to me." G2A

"Really? Ask a doctor if she decides who gets the best care based on their moral worthiness. 
If a disabled or old person did not go to school, learn, work hard, make good choices, work hard, etc does he or she still get the best medical care in the world when they need it?" RB

"Moral Worthiness: I am not sure this is a moral issue, I think this is more of a capitalism and person financial management issue. Thankfully the USA's systems reward the smartest hardest working saving /investing people very well. This is one reason why we are such an exceptional country. 
And yes the best hospitals / Doctors would like to get paid. Thankfully we do live in a society that believes in charity and caring for the old, disabled, so they get good care." G2A

"Pay to play health care is inherently immoral: The idea that people who fail to meet someone or another's moral standard (such as a work ethic) are rightly doomed to suffer injury illness and death is morally bankrupt. 
The idea that financial incentives are (or should be) the primary driver of individual health care, safety, or lifestyle decisions is simply daft. People don't exercise or eat healthy diet because it saves them money, on the contrary many people pay an incredible amount of money to exercise and eat healthy food. 
Nor do people seek to avoid injury for financial reasons... pain avoidance and fear of death are basic biological mechanisms. 
Furthermore we've seen time and time again now financial priorities distort health care and safety decisions frequently producing increased injury and illness. We never had millions of uninsured Americans because they were all lazy an "unproductive" members of society. 
I hate to say but the idea that people who fail to meet some standard of work ethic deserve their fate of death and suffering looks a lot like "final solution" logic." Paul

"Immoral: No system is perfect, however I think ours is best. Pretty much everyone gets some care, but the most responsible citizens get the best care.

The Liberal view that citizens have a right to food, housing and healthcare just because they are standing on American soil is also flawed and doomed to cause disaster. And I would say that it is also immoral because it allows "free loaders" to live as parasites on the efforts of others. (ie drain on society) And if you doubt that there are a significant number of freeloaders within our society, just take part in a group activity, look at our crime statistics, look at the academic failure within our schools, our large welfare roles, etc.

I am actually living proof that money can be a good incentive to living healthier. My company implemented a two tier premium system and I will be paying an extra $180/month for family coverage if I do not lower my sugars and triglycerides. Therefore I am changing my diet somewhat. Now I wish more programs would do this, I mean why should my co-workers need to pay more for my bad choices?

Why should our society have to pay the huge healthcare costs in part created because of sky rocketing obesity, etc?
G2A Healthcare Cost Drivers 

54 comments:

Anonymous said...

It's a dilemma. On the one hand, people complain health care is too expensive. On the other hand, people complain about rationing. It is simply logically impossible to avoid both criticisms, and I personally gave up trying several months ago.

--Hiram

John said...

As we have discussed before, there are many inconsistencies between what we want from the system and what we want to pay...


- Unhealthy Americans abound
- Americans want to save everyone
- Saving everyone weakens Americans
- Americans insist everyone MUST stay alive
Link2
- Americans love lawsuits
- Americans and Doctors love expensive tests
- American Government bureaucracy
- Private insurance bureaucracy, profits & wages
- Pharmaceutical personnel, profits & wages
- Medical device personnel, profits & wages
- Healthcare bureaucracy, profits & wages
- Excessive medical licensing requirements

John said...

The Religious Conservatives want to force people to stay alive no matter the cost and/or if it is against their wishes.

The Liberals want everyone to get excellent care whether they are a hard working people adding to the value of our society or deadbeats/criminals who detract from the value of our society.

And most everyone wants the system to cover them fully no matter what irresponsible life style choices they make. Be it obesity, smoking, having babies after 35 yrs old, etc, etc, etc...

There are a lot of issues involved.

Anonymous said...

There are all sorts of ways we can ration health care. But it's all rationing.

==Hiram

John said...

Rationing Defined: The process of a governing body controlling the issuance of goods and services to the public. This is typically necessary if demand for the item outweighs the available supply. Governments are known to take part of rationing during hard economic times or war. During extended periods of rationing, black markets are often created to supply consumers with the controlled good.

Read more: BD Rationing

John said...

Hiram,
After studying the various definitions of rationing, I disagree.

The healthcare system in America is not a scarce resource. There are no significant waiting lines and the government does not determine who can have how much for the vast majority of Americans. It is only those who are on Medicaid and Medicare who are limited by governmental allocations.

If you want a new hip and have money / insurance that hip can be installed fairly soon. One of my co-workers just had one implanted.

Anonymous said...

The healthcare system in America is not a scarce resource.

In that case, rationing isn't necessary. And the fact of excess supply should keep prices down.

Problem solved.

--Hiram

Anonymous said...

One of the things I don't see is bidding for health care in eBay, which I view as a free market. I don't see surgeons competing in what they sell hip replacements for, something that would have the potential to drive prices down. Assuming excess supply, I wonder why they don't. Why don't medical professionals avail themselves of these free market opportunities?

--Hiram

John said...

I am not sure being the low cost provider would be too successful of a marketing campaign for hospitals / doctors. Though it does seem to work for Lasik.

I assume if customers/ patients were being billed directly, there would be a lot more price competition. But with government and insurance companies in between us and the cost... "Who cares what it costs, I want the best for my family"...

PBS Hospital Marketing
Kaiser Doctor Patient Speed Dating

Anonymous said...

I am not sure being the low cost provider would be too successful of a marketing campaign for hospitals / doctors.


I assume if customers/ patients were being billed directly, there would be a lot more price competition.

Well which is it? Is competition good or bad? But this is what nearly always happen when we discuss healthcare. We get whipsawed between competing goals. Whenever we get closer to the rock, we hear complaints that we are getting too far from the hard place. In this case, measures which would tend to lower price, are criticized for the perception at least, of lowering quality. So the result has been we have neither low prices nor high quality.

--Hiram

jerrye92002 said...

Here is one thing driving costs up: Obama administration has commanded that ALL Obamacare policies insure for sex reassignment surgery that, according to the latest science, is NOT a medically necessary or medically desirable procedure. Not only that, John, but science has finally "discovered" that sexual orientation is NOT inborn, and that sexual identity is not fluid.
http://dailysignal.com/2016/08/22/almost-everything-the-media-tells-you-about-sexual-orientation-and-gender-identity-is-wrong/?utm_source=TDS_Email&utm_medium=email&utm_campaign=MorningBell&mkt_tok=eyJpIjoiT1dRNE5qa3hZV1V3TmpWbCIsInQiOiJONXNPVkFzRUM2V0VwanJJYUhCNHB1WXpxb3M3bmNDd21SM1d6K1wvVGZ5RFlxQnpiMjBCellnaWl2M3FUS1g3aWRUejlGWXJjcUdcL0RwUTgxbFltNkVUYnpPcGlPTlpWejJRaTk3VXlzbWpNPSJ9

QED.

PS: give me a simple "formula" for posting a link

John said...

DS Sexual Orientation

Link Language

John said...

Jerry, You are apparently incorrect.

ACA Facts

"See our take on the anti-discrimination ruling here, to be clear, it stops short of requiring health plans to pay for gender transition, but makes a lot of headway (explained in the article)."

John said...

Hiram,
Competition is good, but competition is imperfect when the person paying for the product or service is not the one receiving or using the product or service. And when government mandates a huge number of rules on the system.

Personally I think we have high quality and high prices due to the above mentioned causal factors.

Anonymous said...

"Competition is good, but competition is imperfect when the person paying for the product or service is not the one receiving or using the product or service."

That's why doctors should be forced to offer their services on eBay. Patients have an interest in quality of care that can be the source of competition. But then insurers have an interest in keeping fees low which also can be a source of competition.

As always, and no matter how you look at it, it's a question of priority. Do we health care to be high quality or low cost? Our historic refusal to make this choice only ensures that it is neither.

--Hiram

John said...

Actually the three legs of the stool in this case are:
- Quality
- Availability
- Cost

This is typical. And we in America prioritize availability and quality because of the way our system works.

Personally I think the quality of our healthcare for those who pay their premiums is great. Do you disagree? Rationale?

Anonymous said...

I was kind of assuming availability was off the table, partly because we don't deny health care even to those who can't afford, and partly because availability is wrapped up in quality. If needed health care isn't available to you, the quality of your health care is poor.

Everyone is in favor of good affordable health care. You can read that in the platforms. The reason we didn't have it was not because we didn't agree on the goals, it was because our system of government made it impossible to pass one. Obamacare became possible only because of a confluence of political events that has never occurred before and is unlikely to ever occur again.

--Hiram

John said...

Please remember that we reward members of our society who learn in school, work hard, make good choices, save, invest, stay married, get along with others, etc. Therefore I was very specific in saying "quality of our healthcare for those who pay their premiums".

And no: Quality and Availability are very different.

If you are in Canada and want to see an allergist, you may need to wait 6+ months. (true story) In the USA if you are insured you can see an allergist in 2 weeks. That is a huge difference in availability.

Now both of the Allergist may be equally capable and provide the same quality of care.

John said...

"Everyone is in favor of good affordable health care."

I would say yes and no.

- Yes they want good affordable healthcare for themselves and their family.

- No they are not all willing to live healthier lifestyles and make better decisions to help lower the costs. (high obesity levels, Moms having babies after age 35 yrs, few exercise regularly, etc)

- No they do not want to pay higher healthcare costs because of the choices other people make.

Sean said...

So you don't want women having children when they're young and not able to take care of them, and then you're going to shame them based on the largely outdated notion that you shouldn't have kids after the age of 35?

Sean said...

"If you are in Canada and want to see an allergist, you may need to wait 6+ months. (true story) In the USA if you are insured you can see an allergist in 2 weeks. That is a huge difference in availability."

That's true, and it's based on how Canada choose to ration healthcare versus how we do it. Canada rations health care to control spending and it strongly prioritizes acute problems. We ration health care on ability to pay. If you're uninsured, chances are you aren't seeing that allergist at any point in time.

Anonymous said...

Please remember that we reward members of our society who learn in school, work hard, make good choices, save, invest, stay married, get along with others, etc.

And we reward members who don't do those things too. Not so long ago, Mitt Romney was paid millions of dollars for a job where he never even showed up once for work.

--Hiram

John said...

Sean,
Out dated... Really?

Really?

"A woman's risk of having a baby with chromosomal abnormalities increases with her age. Down syndrome is the most common chromosomal birth defect, and a woman's risk of having a baby with Down syndrome is:[5]
At age 20, 1 in 1,441
At age 25, 1 in 1,383
At age 30, 1 in 959
At age 35, 1 in 338
At age 40, 1 in 84
At age 45, 1 in 32
At age 50, 1 in 44"

John said...

Sean,
"ration health care on ability to pay"

A. As noted above, by definition it is not "rationing". The service is not scarce and no one is controlling forced allocation. Just like food and housing is not rationed in America.

B. Now I realize you are happy to remove all negative natural consequences from those who make bad choices, and place those burdens on the backs of those who make good choices. I just disagree with the morality and long term consequences of doing that.

By the way, the order is pretty simple, logical, proven and aligned with our modern world:
0 - ~22: Learn, Have Fun, Work
~22 - ~35: Get married, Make family, Have fun, Learn, Work
35+: Raise family, Have fun, Learn, Work

John said...

Hiram,
Are you still after Romney... And yes there are exceptions to every rule...

However as long as he was adding value to the organization in someway, it does not matter if he shows up for work. That is between him and the group paying him.

By the way, please remember that Romney did the following well. "learn in school, work hard, make good choices, save, invest, stay married, get along with others, etc"

Anonymous said...

Are you still after Romney

He is such a great example. But lots of people work hard and don't make much money, and lots of people don't work hard and make lots of money. Lots of people make good moral choices like become teachers, and make ok incomes, and lots of people make bad moral choices and become investment bankers and become vastly wealthy. The notion that morality plays a role in the distribution of wealth seems questionable at best.
And I don't think it can or even should.

--Hiram


Sean said...

Advanced maternal age is one of many risk factors involved in pregnancy, and one that doctors have gotten plenty good at dealing with. Are you going to do pre-conception genetic screening on everyone so that we can prevent people with risk of passing along certain conditions from having children? Are you going to monitor everyone's behavior to see if they rack up a certain number of "Appelen Points" against their record? Where does it end?

Anonymous said...

I would have pointed to Donald Trump, but sadly Trump went bankrupt in the immoral businesses he entered into. The Donald is a guy who couldn't even make sin profitable.

--Hiram

Sean said...

"Now I realize you are happy to remove all negative natural consequences from those who make bad choices"

Yet again, please stop putting words in my mouth. I hope this is one condition you haven't passed n to your children.

And, again, there's nothing "natural" about the way our system works.

John said...

I can not think of anything more natural than a system where the recipient pays for a service or product.

Imagine the earliest barters between humans.

Did Bob tell Dan???

"You give that service to me and Bill must pay for it!!!"

No !!!

Bob and Dan agreed what Bob must give Dan and what Dan would provide. Then Bob would either need to pay the price, go elsewhere or not get the service.

John said...

Sean,
To ensure I do not put words in your mouth, what is your preferred healthcare solution?

I believe you are a supporter of Medicare and Medicaid, both of which take money from Bill to pay Dan for Bob's service.

Am I incorrect?

John said...

By the way, even ACA takes money from Bill to pay Dan for Bob's service."

Sean said...

If one were drawing up a system from scratch, some form of single payer would make sense.

Since we're not doing that, we need to build on the ACA and make it better. Given cost projections have come in under budget thus far, we could afford, for instance, to address some of the problems in the individual markets whether it is subsidizing providers to increase competition in some areas (premium increases are lower in competitive areas) or increasing subsidies to citizens, which would increase the number of folks with coverage and improve the coverage they do have.

States, like Minnesota, which use a "clearinghouse" model for their exchanges, could switch to an "active purchaser" model in which the state takes an active role in approving only plans that meet its goals, not just any plan that meets the base requirements. For instance, MNSure plans tend to be low premium/high deductible. The problem with this is that the tax credits available under the ACA are primarily based on the premium. This means that in actuality, people pay more out of pocket here than they do in many other states which have higher premiums and lower deductibles.

We could allow younger people to buy into Medicare if they wanted, too.

We can also do some systemic things to reduce costs. Allowing Medicare to negotiate drug prices would be a major win for that program, for starters. Similarly, Medicare has been in the process of doing more competitive bidding for some supplies and tests -- that should be expanded.

Now, what would *you* do?

Anonymous said...

"I believe you are a supporter of Medicare and Medicaid, both of which take money from Bill to pay Dan for Bob's service."

Does private insurance somehow do this differently? I have to assume you're not a fan of having your premium be used to help other people.

Joel

John said...

With insurance, only those who pay their full premium can take from the pool.

With Medicare, Medicaid and ACA, one can draw from the pool whether they paid full, partial or no premium.

That is a HUGE difference. One is citizens combining their money to spread out the risk. The other is simply wealth transfer in many cases.

Anonymous said...

"One is citizens combining their money to spread out the risk. The other is simply wealth transfer in many cases."

Tomato. tomato.

Joel

John said...

More like Tomato and Grapefruit...

Should you have to pay more for cable so others can get it at steep discount or free?

Should you pay more for your property insurance so others can get it at steep discount or free?

Should you have to pay more for a new car so others can get it at steep discount or free?

John said...

Sean,
Not sure about genetic testing, however here are the criteria used by the Interactive Health Program that I am enrolled in.
- Blood Pressure
- Triglycerides
- Glucose
- LDL Cholesterol
- Smoking

They have deemed these to "lifestyle driven". And if you do have a true medical condition and are working with a Doctor, the Doctor can send in a Waiver.

John said...

The big question is what are we willing to do as a society to promote healthy living?

These trends are definitely headed the wrong way.

Do we really think it makes sense to charge people who live a healthy lifestyle higher insurance premiums to keep the premiums lower for people who live an unhealthy lifestyle and take high risk actions?

Doesn't that seem totally backwards?

Anonymous said...

Do we really think it makes sense to charge people who live a healthy lifestyle higher insurance premiums to keep the premiums lower for people who live an unhealthy lifestyle and take high risk actions?

Sure, it makes sense, but it's not the sort of thing everyone has to agree with. We went without a health care policy for a long time, not because we didn't need one, but because people couldn't agree on what made sense.

--Hiram

John said...

So you are saying it makes to you to:

- Charge people more for making healthy lifestyle choices

- So others can make unhealthy choices and pay less.

Really? Please help me understand your rationale.

Maybe this is why America is so unhealthy... And our costs are so high...

Sean said...

"To ensure I do not put words in your mouth, what is your preferred healthcare solution?"

I had a long response to this yesterday that seems to have vanished into the ether, so let me summarize.

If we were starting from scratch, I would say some form of single payer would be ideal.

Since we're not doing so, then I would build incrementally on the ACA. There are reforms within the ACA structure that would help significantly. I won't bore you with the details, since you're already light on your knowledge of how the ACA actually works in the first place.

There are also a number of things we can do to make Medicare work better: drug price negotiation, expanded use of competitive bidding for equipment and tests, continuing to crack down on Medicare Advantage programs that are more expensive than the base program itself for starters.

Sean said...

What it really comes down to is the fact that we've decided as a society that health care isn't like grapefruit or a car. It was Ronald Reagan who signed the provision into law that an emergency room can't turn you away if you've suffered a serious injury or illness. So one way or another, we already have a "mandate" at some level that you're going to be able to get some level of care.

So the question becomes, then, how do we best organize our system to provide care to everyone?

Our current system isn't working. We spend far more and get far less than other first world countries. Conservatives would rectify this problem by doing more of what makes us different from these countries, while others would say that maybe our exceptionalism isn't working to our advantage here and we could adopt some pieces of what work other places. (For instance, European hospitals have dramatically lower rates of infections than American hospitals because they use different practices. Not only would it save us money, but it would spare us the human costs as well.)

Anonymous said...


- Charge people more for making healthy lifestyle choices

- So others can make unhealthy choices and pay less.

Sure, given that we don't deny care to those who need it, no matter what kind of choices they make. For one thing, all of us make choices that are in varying degrees healthy or unhealthy. Generally, the Republican solution is to put the unhealthy in an insurance pool of their own and make the taxpayers pay for it. It always comes down to an allocation of the burden.

--Hiram

John said...

I think these should stay the exception and not the systemic norm.

jerrye92002 said...

"Jerry, You are apparently incorrect. ACA Facts"

Or am I? Obamacare covers!

Either way, thank you for the rest of that article, because it points out how really, really stupid the Obamacare rules are. Insurers may not "discriminate" between men and women in health care coverage or cost. I guess those old bachelor farmers use a lot of prenatal care.

Insurance makes sense when the premiums you pay cover the expected cost of your care (plus overhead). If you smoke or do drugs or are female, your premiums should be a bit higher to cover that. If you don't your premiums should be lower. The trouble with government is the one-size-fits-all nature of those "solutions." High-risk people should pay more in premiums, not less, and people should be allowed to buy the coverage they want, need and can afford rather than what some beanie-baby bureaucrat thinks would be "good for them" because somebody else is picking up the tab. Simple solution to uninsured people and high insurance costs? Get government out of the health care market!

John said...

"High-risk people should pay more in premiums, not less"

I think you just made a huge step towards Sean's concern that I am supporting premiums based on genetic testing...

And you certainly made a case for not offering affordable insurance to a person who has a pre-existing condition or is older.

The program my company works with has tried to identify characteristics are that caused by behavior, not sex, race, age, family history, genetics, etc. And that is why they have the waiver, just in case a Doctor thinks it is.

John said...

So what would you do if a man developed breast cancer, have the insurance company not cover it?

John said...

By the way, it looks like Medicare covers it now but ACA policies still do not.

"Now, federal law prohibits health insurance companies from discriminating against transgender people, and it bars insurers from denying coverage based on pre-existing conditions. That makes it possible for more transgender people to purchase private plans. And in states that expanded their Medicaid programs, those with low incomes may get free coverage.

The federal anti-discrimination regulations have yet to be written, but California insurance regulators have said that companies must treat transgender patients the same as other patients. For example, if plans cover hormones for post-menopausal women, they must also cover them for transgender women. Medicare, the program for the elderly and disabled, lifted its ban on covering sex reassignment surgery earlier this year."

jerrye92002 said...

"So what would you do if a man developed breast cancer, have the insurance company not cover it?"

What do I have to do with it? Why should I or any government bureaucrat have anything to say about a private contract between insurer and insured? If the man payed the premiums and his policy covered cancer, end of discussion. And I would go further and say the doctor and patient should determine the course of treatment, not the insurance company's detailed rules or what they "offer" to pay for it.

We started out talking about the "morality" of health care financing. The only acceptable moral basis for receiving health care is a fair exchange between patient and provider. Having a third party involved as insurer (or charitable donor) can be tricky but OK, again, so long as the contract is mutually agreed among all three parties. Anything else, especially government involvement on any of the three sides, is immoral.

John said...

"If the man paid the premiums and his policy covered cancer, end of discussion."

And if his policy did not cover breast cancer... He dies in the street? And or goes bankrupt?

John said...

Are you okay with genetic testing to determine insurance premium cost and availability then?

jerrye92002 said...

Again, why is it my affair? He dies in the street, taps into his savings, asks for charity, or whatever he needs to do to make up for the fact that he shortsightedly did not contract for that coverage. The big problem here is that from Obama on down there is this notion that having health INSURANCE is equivalent to having health CARE and the two are basically unrelated. Right now you have some practitioners who simply refuse to see Medicaid or Medicare (or Obamacare) patients because the "insurance" payments are inadequate. "But I have insurance!" It doesn't matter.

No, I don't like the idea of genetic testing for setting insurance premiums; I think that would belie the notion of a "pool." Besides, these are monthly or annual premiums, and genetics manifest randomly over a lifetime. But I do like the notion of charging for dangerous behaviors, like being female or a smoker (assuming the added premium is a reasonable actuarial cost).

jerrye92002 said...

You mentioned pre-existing conditions. Again, it is not a matter for government to be stepping into private contracts to "solve." That situation would be well-handled if we did away with the government incentives (and requirements) for employer coverage by making health insurance portable and personally tax-deductible and available across state lines. It would greatly reduce the size of the PEC problem. Beyond that, we already have (had) state high-risk pools that charged a higher premium, maybe subsidized. Better than that, really, were insurance policies that had either an 'exclusion' for your condition altogether, or an exclusionary period during which that condition wasn't covered but afterwards it was. They may have been slightly more expensive than regular insurance, but rightly so, the point being you could GET insurance.