patrick.net

tatupu70 says

The disconnect between behavior and cost is interesting. I’m laughing thinking of peoples’ reaction to a sliding scale of premiums based on body mass index or # of donuts eaten/month. I think it’s an interesting idea, but it might be a problem politically.

You've unfortunately done this several times ... swap a word in someone's description of a position in order to change the meaning of that position to something other than what was intended.... I never said the word "behavior." That is your word, which, while is broadly accurate, you have narrowly applied... My actual statemement was: "Second, it seems to me that the consumer is way too disconnected from the cost of health care service for it to be considered as operating properly as a “free market.”

People with medical insurance are generally insulated from either the true or the inflated costs of medical services because all they generally see are premium payments and relatively small co-payments. This may result in many more trips to doctors for minor things that do not require it, or numerous "second" opinions for the same thing, or simple unquestioning of the treatments, medications, etc., required. I know of no person, liberal or conservative, who thinks before going to the doctor: "What is going to be my burden on the whole system? If I incur more medical cost to the system than my premiums cover, for routine/non-emergency treatments, how will that affect the costs of everyone?" The general rule seems to be, if there is any question, go to the doctor: you are already paying the insurance and it costs very little to just get the consulation and peace of mind.

I think that's an example of the free market at work actually. As others (Nomo?) have pointed out, there are policies out there with high deductibles/copays, but nobody wants them. For whatever reason, people seem to prefer higher premium policies...

That's a slippery slope as well Not sure we want to discourage people from visiting the Dr. if they might be sick. Most diseases are much less costly when caught early.

tatupu70 says

Again–you didn’t answer my question. How would it lower costs?

tatupu70 says

lived in several states and have enjoyed health care benefits from the same companies. Cigna, United Healthcare, etc. support plans in all states, don’t they? What exactly would this “increased competition” do? How would it lower costs? Further, most companies with sites in multiple states have the same exact plan for everyone. Again–don’t see how it would increase competition.

Those are some pretty big gorilla companies you gave as examples, which often have offices/registrations in every state. If you saw a plan by a company based in only TX with no footprint or office in any other state, or plan catered specifically to any other state, and you lived in VA, could you buy into that plan from that company? If not, then your options and opportunities to select a plan to your liking based on price, coverage, or whatever other factors, are limited. If this were addressed, the outcome based on the increased customer choice, expanded company markets (with lower overhead), and associated increased competition could help lower costs. It should be self-evident that increased competition among companies would help lower costs, except to those who deny that competition or market forces ever does this and only government intervention results in cost decreases.

Here is an older article I found regarding an initiative in Colorado (I do not know the outcome)....

http://facethestate.com/articles/lawmaker-proposes-revolutionary-shift-health-care-purchasing

DENVER – Colorado would become the first state in the country to allow its citizens to purchase out-of-state health insurance under a bill proposed by Rep. Cory Gardner, R-Yuma.
....
Currently, state law permits health insurers to sell only policies in Colorado that comply with state regulations and mandates on care, even if the same company does business in other states. Consequently, there is no national market for health insurance, unlike life insurance or banking services, which are regulated by states but may be purchased across state lines.

tatupu70 says

I think that’s an example of the free market at work actually. As others (Nomo?) have pointed out, there are policies out there with high deductibles/copays, but nobody wants them. For whatever reason, people seem to prefer higher premium policies…
That’s a slippery slope as well Not sure we want to discourage people from visiting the Dr. if they might be sick. Most diseases are much less costly when caught early.

It might be the free market at work, and if so then it is a good example of where the free market is not working well in that aspect. It might also be the result of government intervention and policy, or a collission/collusion between the two. I do not have enough background or information on how this came to be so I can't conclude one way or the other. My impression is that neither do you, nor nearly anyone else posting here. The slippery slope argument works both ways: My point is essentially that we are on the opposite slope right now. The issue is how do we get the slope to be flatter or less slippery.

Paralithodes says

Those are some pretty big gorilla companies you gave as examples, which often have offices/registrations in every state. If you saw a plan by a company based in only TX with no footprint or office in any other state, or plan catered specifically to any other state, and you lived in VA, could you buy into that plan from that company? If not, then your options and opportunities to select a plan to your liking based on price, coverage, or whatever other factors, are limited. If this were addressed, the outcome based on the increased customer choice, expanded company markets (with lower overhead), and associated increased competition could help lower costs. It should be self-evident that increased competition among companies would help lower costs, except to those who deny that competition or market forces ever does this and only government intervention results in cost decreases.

OK--I think I understand the issue. But it's really not a lack of competition--any company can offer health care in any state as long as they meet that state's requirements. You're implying that there are barriers to entry that are artificially restricting competition and therefore choice. I don't see that at all.

Could that little company in TX offer health care to someone in Maine? They don't know the Drs or hospitals there. And, if so, why isn't it operating in Maine? If they could offer better coverage for cheaper, why aren't they doing it??

tatupu70 says

OK–I think I understand the issue. But it’s really not a lack of competition–any company can offer health care in any state as long as they meet that state’s requirements. You’re implying that there are barriers to entry that are artificially restricting competition and therefore choice. I don’t see that at all.

You deny that the states' requirements are a barrier to entry? On what grounds?
http://en.wikipedia.org/wiki/Barriers_to_entry

You disagree with the article and assert that there is a national market for health insurance, and you can purchase health care across state lines even if the plan you may specifically want to chose for yourself does not comply with your resident state mandates?

Paralithodes says

You deny that the states’ requirements are a barrier to entry? On what grounds?
http://en.wikipedia.org/wiki/Barriers_to_entry
You disagree with the article and assert that there is a national market for health insurance, and you can purchase health care across state lines even if the plan you may specifically want to chose for yourself does not comply with your resident state mandates?

No that's not what I said. I said "You’re implying that there are barriers to entry that are artificially restricting competition and therefore choice". Cherry picking phrases is just the sort of practice that you constantly accuse me and others of doing. To get to the crux of the issue--how much do the different state mandates limit competition? And would creating a national mandate reduce or increase costs? In my mind, it's just as likely your costs would go up--it depends on whether the state you currently live in has business friendly or consumer friendly mandates....

tatupu70 says

No that’s not what I said. I said “You’re implying that there are barriers to entry that are artificially restricting competition and therefore choice”. Cherry picking phrases is just the sort of practice that you constantly accuse me and others of doing.

That's exactly right, I am implying that the state requirements are in fact barriers to entry that artificially restrict competition and therefore choice. You said that you "don't see that at all." So do you deny that state requirements are a barrier to entry, or do you not deny it? If you do not deny it, then I accept that I misunderstood you and apologize for taking your phrase out of context. If you do deny it, then how exactly did I cherry pick anything?

How exactly would an increase in competition make costs go up? If a state has a business friendly or consumer friendly mandate, as you put it (though the two are NOT mutually exclusive), then the degree to which it is business unfriendly will simply be a remaining barrier to entry.

I deny that the differing state mandates restrict competition and therefore choice. They are such a low barrier as to be almost non-existent. Remember--we're not talking about the mandates themselves as a barrier-only the difference between one state and another state. You're always going to have mandates regardless.

If you got rid of the individual state mandates, you would almost certainly have to develop a Federal mandate to replace them. This Federal Mandate would likely be more restrictive than some of the individual state mandates. I would argue that costs will increase in those states under that scenario.

So apparenty I cherry-picked nothing!

OK--I'm tiring of your semantics. You misrepresented what I said, but whatever. Do you have a comment on the substance of my post?

tatupu70 says

OK–I think I understand the issue. But it’s really not a lack of competition–any company can offer health care in any state as long as they meet that state’s requirements. You’re implying that there are barriers to entry that are artificially restricting competition and therefore choice. I don’t see that at all.
Could that little company in TX offer health care to someone in Maine? They don’t know the Drs or hospitals there. And, if so, why isn’t it operating in Maine? If they could offer better coverage for cheaper, why aren’t they doing it??

Establishing a provider list (which means negotiating a rate schedule with doctors and hospitals) is a lot of work and introduces a lot of administrative overhead. I don't see any way that could change without MAJOR regulatory intervention like in Switzerland or the Netherlands. Even the very big insurers can't just dictate rates to doctors (although they do try) and have to invest major resources in negotiating reimbursement rates. This is why your insurer will tell you to double check even with doctors they list to make sure they are still working together.
As to the extra overhead for an insurer who wants to operate in more than one state and deal with that states regulation, I don't know really but I suspect it is pretty minor for the big players. A friend of mine who did tech consulting for a large national insurer in Florida tells me that almost none of the business rules were for Florida-specific issues or regulations. For a hypothetical small Texas company it probably would be harder.
I don't really have a problem with replacing insurance regulation at the state level with national regulation, but I think it would be VERY difficult politically.

Stop being so anti-semantic! To comment on your post... I strongly disagree with your opinion on the state mandates and the degree to which they are or aren't barriers to entry. I am not sure whether I agree or not about the Federal mandate: I could see the argument for some type of minimums in plans that cross state lines, but the depth or scope is something to think on further: I'm sure we would disagree on the details. I am, however, very surprised that you would oppose this because costs may increase under some states (which we have to assume from your statement might be below those minimum standards in the first place).

Paralithodes says

Stop being so anti-semantic! To comment on your post… I strongly disagree with your opinion on the state mandates and the degree to which they are or aren’t barriers to entry. I am not sure whether I agree or not about the Federal mandate: I could see the argument for some type of minimums in plans that cross state lines, but the depth or scope is something to think on further: I’m sure we would disagree on the details. I am, however, very surprised that you would oppose this because costs may increase under some states (which we have to assume from your statement might be below those minimum standards in the first place).

Actually, I'm a rabid anti-dentite. You really think the DIFFERENCE between state mandates limits competition?? I just don't see how that is possible. Do you have any examples of specific differences that would be a large barrier to entry?

Like bdrasin said--I would imagine that it costs a heck of a lot more to set up a provider list in a new state than it does meeting any differences in mandates. That is a much larger barrier to entry...

I never said I oppose it--just that I don't think it will make a hill of beans difference in cost.

tatupu70 says

Actually, I’m a rabid anti-dentite.

LOL! Great comeback!!!!!!!!!

Yes, I think the difference in state mandates limits competition. The article re. Colorado can serve as the example that there is no national market for health insurance due to state regulations making it difficult to put into effect. You may be correct about the provider list, but there is no way to test that theory without opening these state constraints in the first place. If you are correct, if it makes no difference, then what is there to lose with trying this approach? Nothing. A barrier falls and no one does anything. No cost, no new real regulation, etc.

Paralithodes says

Yes, I think the difference in state mandates limits competition. The article re. Colorado can serve as the example that there is no national market for health insurance due to state regulations making it difficult to put into effect. You may be correct about the provider list, but there is no way to test that theory without opening these state constraints in the first place. If you are correct, if it makes no difference, then what is there to lose with trying this approach? Nothing. A barrier falls and no one does anything. No cost, no new real regulation, etc.

The problem is you can't just "open" the state constraints. Do you mean get rid of all state constraints? Or provide a Federal mandate that overrides all state contraints? Seems like opening up a whole new can of worms to me. For very little gain.

Nomograph says

theoakman says

Ask anyone that received laser eye surgery. It’s probably the only area of health care that the market is allowed to function.

Lasik, breast augmentation, and tummy tucks market aren’t really the best examples now, are they?
What AdHominem and a couple others here are really demonstrating is that they place more value on their free market ideology than they do on their fellow human beings. If people must die on the alter of unregulated free markets, so be it because free markets are what is most important in life for these people (or so they think).
Most people place more value on their fellow human beings than they do on free market ideologies.

What's wrong with Lasik? It's a procedure that corrects eyesight. If you care to take notice, it works a hell of a lot cheaper and more effectively than the eyeglass industry despite its reliance on equipment that costs 10 times as much than the stuff your traditional eye doctor uses. Hell, they even advertise their prices in every newspaper.
Most people grossly exaggerate the necessities of health care. They want the government to pay for their antibiotic ointment. They want the government to pay for their pain meds after they get a tooth pulled. They want the government to pay for their flu shot.
If most people who advocate health care for everyone truly cared about the sick and needy, they would draw a distinction between essential medical care like heart surgery and everyday simple care. We could easily create a safety net for essential health care at relatively little cost.
I'm pretty sure no one in their right mind wants the government paying for people's aspirin and tylenol. Yet somehow, people think that anything that gets written on a blue piece of paper shouldn't be paid for out of pocket. There is no reason why we couldn't cover expensive medical procedures through the government yet leave your yearly checkup to be paid out of pocket. Am I still sounding like a free market ideologue?

theoakman says

We could easily create a safety net for essential health care at relatively little cost.

Really? How do you figure? Essential health is the most expensive... Do you think the flu shots are what is breaking the bank?

tatupu70 says

The problem is you can’t just “open” the state constraints. Do you mean get rid of all state constraints? Or provide a Federal mandate that overrides all state contraints? Seems like opening up a whole new can of worms to me. For very little gain.

As the Colorado article states, this already occurs for some other types of insurance, other services, etc. So there is certainly precedent. Whether this means getting rid of all constraints or some, what type of federal mandate, and even whether there would be very little gain is all conjecture at this point. You see very little gain, I see very little lost.... tomatoes tomahtoes, neither of us can definitively prove anything. However, this approach means less Federal government control over the solutions compared to current approaches (though it would actually take Federal government action to initiate), so I can see why one side would more or less dismiss it out of hand - doesn't fit the ideology.

tatupu70 says

theoakman says

We could easily create a safety net for essential health care at relatively little cost.

Really? How do you figure? Essential health is the most expensive… Do you think the flu shots are what is breaking the bank?

I might be mistaken but I'm pretty sure his examples went beyond the flu shot, and his examples were only a few of the possibile examples that could be given.

As a common peasant I don't see the [Ll]ibertarians ever protesting openly over the failings of capitalism. If there's ever a failing, it's always because we weren't PURIST enough. I never see any of them decrying billion-dollar paydays & insurance cartel behavior. Crony capitalism rigs the game, and that is the endpoint of it all. Alan Greenspan would tell us that fraud is not a valid reason to lock people up, because the "free market" self-regulates and fraudulent behavior results in exile for the bad people.

Paralithodes says

As the Colorado article states, this already occurs for some other types of insurance, other services, etc. So there is certainly precedent. Whether this means getting rid of all constraints or some, what type of federal mandate, and even whether there would be very little gain is all conjecture at this point. You see very little gain, I see very little lost…. tomatoes tomahtoes, neither of us can definitively prove anything. However, this approach means less Federal government control over the solutions compared to current approaches (though it would actually take Federal government action to initiate), so I can see why one side would more or less dismiss it out of hand - doesn’t fit the ideology.

I guess the devil is in teh details as far as I'm concerned. You ask a bunch of good questions but then dismiss them as if they are inconsequential. They are not, IMO.

And it seems to me that it would be more Federal control--you're basically taking states' power to regulate health insurance and giving it to the Feds. How does that reduce Federal government control??

It makes me wonder if you realize what you are asking for?

tatupu70 says

I guess the devil is in teh details as far as I’m concerned. You ask a bunch of good questions but then dismiss them as if they are inconsequential. They are not, IMO.

I don't dismiss them. I just happen to agree that the devil is in the details and I doubt either of us are really educated enough on them to come to any solid conclusions either way.

tatupu70 says

And it seems to me that it would be more Federal control–you’re basically taking states’ power to regulate health insurance and giving it to the Feds. How does that reduce Federal government control??
It makes me wonder if you realize what you are asking for?

If the state line solution is to have the Federal government force states to remove restrictions that interfere with interstate commerce, without significant Federal regulations of its own, then this Federal "control" is in line with the Constitution. As you say, the devil is in the details.... Do I realize what I am asking for? Maybe, maybe not... It depends upon the details... Certainly there are people who would propose varying government control for the same solution, from practically none to strict oversight.

I think Libertarianism is not about just having small government. In reality government can become a form of oppression and be out of the control by those it governs.

So I think the goal of libertarianism is to have a government that is too weak to oppress any individual yet have the power to stop those who break social contract or commit crimes if society desires such an action.

Of course a lot of people miss that point and with tunnel vision for some reason ask for unilateral deregulation instead.

Exactly Chris,

The problem is people like Greenspan. People who believe that "fraud doesn't exist" and that we need no policing and regulations. Ultimately they believe in fire departments at most, but perhaps not police and certainly not SEC. Glass-Steagall Act? Ptooey, don't need such nonsense, megabanks will always do what's right.

That ultimately was my problem with Libertarian Party and why I first left. There are moderate Libertarians with whom I can agree but far too many for whom "government is always the problem and we don't need any". Those people are unfortunately the ones who give the public face, and are the only ones with any real power.

thunderlips11 says

You can also remind them that the top rate was 90% back in the 1950s, when evil socialist Eisenhower kept the US economy in the doledrums after WW2, LOL.

To be fair, would you please also remind us what income bracket had that 90% top rate applied to, what would that be today in inflation-adjusted terms, and how many people in the whole country had been in that bracket? Somehow those who love to talk about that 90% rate NEVER mention those things.