We Need to Design Health Care Reform That Puts Patients Before Profits • Hacker News Board

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#181

Post by tptacek » Fri, Oct 18, 2019, 9:06 PM UTC

CharlesColeman wrote: post #178

tptacek wrote: post #174

Earlier quoted context omitted.

This is a very popular argument in favor of single-payer. But Medicare already has authority over the most expensive and intensive segment of the health care market and has not effectively "bullied" providers down. It's not my argument that a single payer system can't do this, but rather that it doesn't appear to matter whether you have single payer or not; either way, radical change will be required from providers,…

Those are two separate questions: whether the payer has enough power to bully the providers into reforming, and whether it actually chooses to use that power to do so. Medicare may have the power, but may not have the will to use it (for instance, IIRC, it's forbidden by law to use its market power to secure better drug prices). A payer reform like single-payer will get us a lot closer to solving provider cost proble…

That's a dodge. How does it get us any closer to solver provider costs, when the evidence available suggests it has never done so before despite having enormous authority to do so in the existing system?

Remember that the argument isn't that single-payer is bad. It's that it's not actually relevant to the current problem. There may be a variety of reasons why single-payer is better than private; "will automatically solve provider-side costs" can't, from what I see, be one of them. If there's some reform that occurs after M4A that gets provider costs in line, let's just do that reform first.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#182

Post by kerkeslager » Fri, Oct 18, 2019, 9:11 PM UTC

tptacek wrote: post #173

kerkeslager wrote: post #172

Earlier quoted context omitted.

I'm saying that a doctor's contribution to society is a lot more than a health insurance CEO's and yet that is not reflected in their salary. It wouldn't surprise me if doctor pay was a larger factor in healthcare costs. But doctor pay is an inherent cost of healthcare, and while we can certainly lower their pay, it's not entirely clear to me what a fair pay would be. Health insurance CEOs, and indeed most of what a…

These are arguments about making people feel better about the system, but not about making the system meaningfully better.

Well, I think removing private health insurance from the equation is the first step. Doctor pay indeed might be too high, but what can we do about it? Health insurance companies are a bit part of what determines doctor pay.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#183

Post by tptacek » Fri, Oct 18, 2019, 9:14 PM UTC

kerkeslager wrote: post #182

tptacek wrote: post #173

Earlier quoted context omitted.

These are arguments about making people feel better about the system, but not about making the system meaningfully better.

Well, I think removing private health insurance from the equation is the first step. Doctor pay indeed might be too high, but what can we do about it? Health insurance companies are a bit part of what determines doctor pay.

Why is removing private health insurance the best next step? Medicare also overpays for care, both historically and compared to other countries.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#184

Post by rayiner » Fri, Oct 18, 2019, 9:18 PM UTC

dragonwriter wrote: post #126

rayiner wrote: post #121

Earlier quoted context omitted.

The Sanders bill plans to pay for Medicare for All with taxes that are much lower than the social insurance taxes in France or Germany. That is pure fantasy. That gives me little comfort that its accurately accounting for costs.

> The Sanders bill plans to pay for Medicare for All with taxes that are much lower than the social insurance taxes in France or Germany. The US has much weaker non-healthcare social insurance than France or Germany, and a much larger per-capita economic activity to tax, so lower social insurance taxes for equivalent healthcare seems to be expected rather than suspicious.

France’s healthcare tax is 20%. Sanders’ proposal is about 14.4%.

As to per capita economic activity—the assumption is that we’ll be as cost efficient as France in absolute dollar terms, not even just percentage of GDP terms? When we spend 30% more on primary education per student than France?

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#185

Post by rayiner » Fri, Oct 18, 2019, 9:29 PM UTC

tptacek wrote: post #176

pcwalton wrote: post #171

Earlier quoted context omitted.

Doesn't your argument suggest that a functional national health care policy should focus on both controlling payer-side costs and provider-side costs? Like the Swiss system does—payer-side costs are capped as a fraction of household income, and provider-side costs are tightly managed so that the total economic burden remains reasonable. To me it seems that both sides are presenting a false dichotomy where none need e…

I'm receptive to all reforms! Reforming health care administration is worth doing; even if it doesn't make health care "affordable", these are big numbers we're talking about, and percentage-point changes in administration costs still generate money we can use on other things. Where we get into trouble is when we start contemplating radical reorganizations of the existing system without a clear goal or path to achiev…

> So I could be receptive to single-payer if there was some clear idea of how it would get our costs in line with European systems.

This here.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#186

Post by shantly » Fri, Oct 18, 2019, 10:34 PM UTC

creaghpatr wrote: post #35

aaavl2821 wrote: post #33

Earlier quoted context omitted.

Large hospitals systems have been forming regional monopolies for the last few decades. First they would buy other hospitals to increase negotiating leverage with insurers, then they started buying outpatient clinics to control patient flow. They can also increase the amount they charge at outpatient clinics once the larger hospital system buys them. Hospital spend represents 30% of US healthcare spend, and physician…

Healthcare stocks comprise a not insignificant part of many Americans' 401k portfolios, the downstream economic effects of dismantling healthcare would extend way beyond the hospital/pharma industry.

Hospitals & hospice are the ones who're gonna suck up all that sweet 401k money eventually anyway, in most cases. Inheritance is dead for the middle class—the elderly are, in the best case, sustained by their retirement accounts until they get sick in the last 5-10 years of their life and the healthcare industry siphons off all their money.

So yeah, go ahead and hit my retirement account for 20% in exchange for fixing healthcare—properly, like a real friggin' modern country I mean. Seems like a bargain.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#187

Post by dsfyu404ed » Fri, Oct 18, 2019, 11:34 PM UTC

Balgair wrote: post #160

4ntonius8lock wrote: post #148

Earlier quoted context omitted.

> The politicians, the newspaper editors, the online trolls, etc. are all people too and probably want to see everyone get good healthcare at good prices So then it's a good idea to remind people of the absurd, as in the post you answered. Dismissing the absurd as merely being a consequence of not 'thinking about winning' is an oversimplification. To me such a dismissive, one liner post is designed for ego-gratificat…

The poster you are replying to is a troll, likely. I'd disengage with the poster and not continue the conversation, as they do not tend to comment 'in good faith'. Their HN profile bio as of 8pm GMT states: "When you read a HN article about some despot in a foreign land having the intellectuals lined up and shot it seems irrational. When you read the comments and you realize the despot might be on to something." 'Iro…

I understand you're going to use the least charitable reading because you disagree with me but it was supposed to be a comment about the quality of discourse in internet comments.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#188

Post by CharlesColeman » Sat, Oct 19, 2019, 12:06 AM UTC

tptacek wrote: post #181

CharlesColeman wrote: post #178

Earlier quoted context omitted.

Those are two separate questions: whether the payer has enough power to bully the providers into reforming, and whether it actually chooses to use that power to do so. Medicare may have the power, but may not have the will to use it (for instance, IIRC, it's forbidden by law to use its market power to secure better drug prices). A payer reform like single-payer will get us a lot closer to solving provider cost proble…

That's a dodge. How does it get us any closer to solver provider costs, when the evidence available suggests it has never done so before despite having enormous authority to do so in the existing system? Remember that the argument isn't that single-payer is bad. It's that it's not actually relevant to the current problem. There may be a variety of reasons why single-payer is better than private; "will automatically s…

It isn't a dodge, and I'm not claiming a single-payer system "will automatically solve provider-side costs" (which is an odd thing for you to put in quotes, since I said no such thing). What I am saying is that such a system opens up avenues to pressure providers that aren't available in other systems (or are more easy for providers to escape [1]), and that potential gets us closer to solving those problems. After that, it's a question of political will to use those powers.

[1] e.g. by refusing to accept Medicare patients or by charging non-Medicare patients more to compensate. The alternatives to the single-payer for providers (e.g. concierge medicine) are likely to be far more limited.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#189

Post by claudeganon » Sat, Oct 19, 2019, 12:18 AM UTC

tptacek wrote: post #156

claudeganon wrote: post #155

Earlier quoted context omitted.

Hasn’t done what? Apologies, you’ll have to elaborate. Medicare fee schedules do put downward pressure on costs, which is why they’re under attack, but lack sufficient power to push down prices because they are not universal and exclude drug costs. Japan has universal price controls (and cheaper healthcare) for precisely these reasons. As to your second question, fee for service is too perverse of an incentive. What…

What does universality have to do with it? They already cover virtually everyone in the most expensive segments of the market. They're not controlling costs for those patients; Medicare overpays, hugely, both compared to other countries and in historical terms (costs have skyrocketed over the last 20 years). I think the burden of proof is on you for this argument. "Excluding drug costs" can't be the problem, because…

What does being the sole payer for services give you, besides a monopoly on payments and all the leverage that comes with it? It should be self-evident, but the ability to negotiate far better prices from healthcare suppliers. Medicare for All’s (not Medicare’s) “unique ability” is this ability to say do these things or you won’t get paid or paid as much. It’s a big part of what single payer systems do around the world to drive down costs and what allows for consistent care to prevent the development of more expensive conditions.

Medicare doesn’t have this advantage because it is not “universal” in any regard and doesn’t have this leverage. The cost pressure from the ever escalating supplier-insurance war further down the chain bleeds into it, as thaumaturgy outlined. Not the very least in the form of lingering injuries and chronic illnesses in its beneficiaries that could’ve been better managed through a universal system before they came onboard.

Which is related to your point about drug costs - the inability of Medicare to collectively negotiate drug prices allows them to be as ridiculous as they are in the US, which of course leads to horrible outcomes for managing care. When people can’t afford medicine, ration it, etc, their conditions worsen and become more expensive to treat. Even if the medicines themselves are not a large, direct source of upward pressure on costs, their inaccessibility creates the circumstances (and need) for more expensive care. And this happens throughout the system as people self-ration various, necessary forms of care.

TLDR; Because Medicare isn’t universal coverage and it and it’s beneficiaries don’t exist in a vacuum.

Re: We Need to Design Health Care Reform That Puts Patients Before Profits

#190

Post by claudeganon » Sat, Oct 19, 2019, 12:31 AM UTC

rayiner wrote: post #179

claudeganon wrote: post #136

Earlier quoted context omitted.

As I mentioned to Raiyner, you should really read Tim Faust’s book to understand how single-payer can drive down costs, but I’ll highlight this from one of his articles: “ As the sole purchaser, the federal government is immediately able to set just prices for health care services (for example, by negotiating the cost of drugs). With the weight of the full cost of health care falling squarely on its shoulders, it has…

These are just general concepts. It’s on the same level as “the market will drive down prices because hospitals and insurers will compete.” What I’m talking about is actual data about what is entailed, for example in “bilk[ing] payers.”

Then see thaumaturgy’s comment above about how suppliers and insurances do this in the current system.