Healthcare

[phgreek]

They're fair questions, and it's one of the main arguments used in favor of nationalizing -- there are efficiencies to going that way.

The reasons we don't do it within the current structure are varied, and not all of them are good reasons:
1) Status as "insurance" -- regulation of all forms of insurance has historically fallen within state police power;
2) Some of the insurance variations reflect actual differences among the states -- the cost of insuring a resident varies wildly by state which means that an insurer needs a different level of capitalization to support the same population in different states;
3) This feeds into the one above, but providers vary wildly among the states -- a state like Florida or Louisiana is going to have more rural providers and a better per-capita capacity to handle tropical diseases than a state like Minnesota. There's also a significant difference in both surge capacity and the need for such capacity in a coastal state than in an inland state. There are also wide variations in provider sophistication and capacity to operate as insurers or ACOs, which is typically regulated by insurance commissioners. These variations have a dramatic impact on the state insurance code (legal, not regulatory) governing the insurer-provider relationship;
4) The insurer-pharmacy relationship is highly variable and depends on the level of fragmentation of that market within a state -- where the state has high levels of independents it tends to be more heavy-handed with PBM regulation than in a state where chains predominate;
5) Incentivizing national provider networks will require busting state oligopolies. In Louisiana, for example, the Blues and Medicaid are nearly the entire market. Same for a state like Alabama (I think Alabama may actually be the most monopolistic, but that's purely from memory). They will actively work to prohibit providers from contracting with foreign insurers. Nationalizing will also create intense pressure on state legislatures to pass price controls -- this happens in the pharmacy market already, where health insurers' use of national wholesale price lists as the basis for reimbursement creates pressure to implement state-level price adjustments.
6) The provider network structure scales very poorly. It would really be better to do away with it entirely if you're going to nationalize. It's not a good or a bad option (okay, gun to my head, it's probably a good thing on balance to do away with it), just a reality

I'm sure I can come up with more thinking through it further

Thanks for the response...gonna take me more than 30 seconds to digest. Headed out the door. But will spend time with it over the weekend.

 

[IrishinSyria]

Tulsi Gabbard (D-HI) just said the AHCA will literally pull the rug out from people. LITERALLY. In written, prepared remarks. We elect 535 members of Congress in a nation of 300 million citizens and we can't find Representatives with a fundamental understanding of the English language.

Also, C-SPAN is my new favorite channel.

Also, I'm trying to figure out which of our elected leaders are stupid, which are liars, and which are both. I'm guessing most are both. "The AHCA will end maternity care." Um, what? As if maternity care never existed before the Affordable Care Act.

The trouble with literally.

Literally every time someone complains about the misuse of the word literally I link to this post.

 

[Goldedommer44]

Do you believe in ANY personal responsibility whatsoever? Why do you believe adults shouldn't have to live with the consequences of their actions? I'm not talking about the poor and handicapped, I'm talking about able bodied people who CHOOSE not to insure themselves.

Also, it's not $50 extra per year. It's hundreds of dollars per month.

I do believe in personal responsibility but the other option is what we had 10 years ago where people without insurance just go to the ER and we have to pay for that anyway, but just at a MUCH higher cost. Or someone can't afford to buy insurance and then get in a car accident. Those costs are never going to get paid and have to be written off by the hospital and will end up bankrupting them.

Just the Maturnity care portion of insurance is not hundreds of dollars a month. It is a smaller portion of a much large pool. We say we care about life, but only until they are born then it is up for them to fend for themselves?

 

[Legacy]

Per Capita Caps in Medicaid — Lessons from the Past (New England Journal of Medicine)

 

[Valpodoc85]

I do believe in personal responsibility but the other option is what we had 10 years ago where people without insurance just go to the ER and we have to pay for that anyway, but just at a MUCH higher cost. Or someone can't afford to buy insurance and then get in a car accident. Those costs are never going to get paid and have to be written off by the hospital and will end up bankrupting them.

Just the Maturnity care portion of insurance is not hundreds of dollars a month. It is a smaller portion of a much large pool. We say we care about life, but only until they are born then it is up for them to fend for themselves?

I can tell you as a physician, there is still plenty of "no pays" in the ER. Two ways: guy buys insurance pays $4600 a year has $500 in the bank. Needs ER visit (because he can't find an internist to see him). Has $5000 dollar deductible. Or would rather pay $2300 tax penalty than $4600 insurance plan with $5000 deductible. Either way they are "functionally" without what we historically call insurance.

 

[Goldedommer44]

I can tell you as a physician, there is still plenty of "no pays" in the ER. Two ways: guy buys insurance pays $4600 a year has $500 in the bank. Needs ER visit (because he can't find an internist to see him). Has $5000 dollar deductible. Or would rather pay $2300 tax penalty than $4600 insurance plan with $5000 deductible. Either way they are "functionally" without what we historically call insurance.

I would agree that there are still no pays in the ER and still people without insurance but that person you talk about will now not go bankrupt because he has SOMETHING to cover him and his family. It may not be the best insurance but the hospital has some way to recoup some money out of the situation and the person can recover from it.

It's not a perfect system by any means but it is far better then what he had 10 years ago IMP

 

[Goldedommer44]

The other part is that those people who where paying NOTHING and going to the ER for medical care are not AT LEAST paying something for insurance. It may be small but they are at least Contributing unlike before

 

[Valpodoc85]

I would agree that there are still no pays in the ER and still people without insurance but that person you talk about will now not go bankrupt because he has SOMETHING to cover him and his family. It may not be the best insurance but the hospital has some way to recoup some money out of the situation and the person can recover from it.

It's not a perfect system by any means but it is far better then what he had 10 years ago IMP

True, this functions as major medical, however, these folks don't tend to seek early medical care because of the out of pocket cost. The people with no insurance and paying a tax penalty... I think they would be happy to go back a few years.

The affordable healthcare act works at some level, no doubt. But it would seem we could do better. Also I do not think AHCA is sustainable. Market cost is heading up. Good luck with rates, especially the "market place" plans down the road.

 

[irishroo]

I worked in the pharma business for about 25 years and I never saw any data on this. But personally I would prefer that rather then re-importing drugs from Canada, the Congress pass a law and set prices just like Canada and Europe. When I first started my career in the mid 80's it was a different business. It really was about developing drugs for the good of society and making a reasonable profit. This started to change in the early to mid 90's and prices for drugs still under patent are ridiculous as are profit margins. Sorry to say but the US really needs institute price controls.

Putting aside my previous issue with the impact to R&D, is that economically feasible in the US? I have no experience with pharma so I'm not speaking from a position of knowledge but how big is the revenue stream from American drug prices and how much would it decrease if prices were cut in half or less? Put another way, how much money do investors stand to lose in this scenario. This is the biggest issue that I've yet to see addressed with the single payer idea - investors have hundreds of billions tied up in these companies and to diminish or destroy an enormous revenue stream could be devastating.

 

[MJ12666]

Since price controls have not destroyed the EU market or Canada (which have set drug prices for decades), I find it hard to believe that price controls would destroy the US market either.

Calculating the impact on revenue would be very difficult to calculate as even in the US prices are heavily discounted as it is. Very rare that a "customer" pays full retail.

Would price controls impact R&D? Probably but it also might make R&D more efficient.

 

[drayer54]

1) Ban advertising of prescription medicine. The swamp won't support this because big pharma is deep here.

2) No borders. Import drugs, let people buy drugs/plans on other markets.

3) No mandates. It's unamerican.

4) Put those with the burning homes on a government plan so everyone else isn't getting f'd on premiums to cover them.

Just my thoughts.

 

[woolybug25]

1) Ban advertising of prescription medicine. The swamp won't support this because big pharma is deep here.

2) No borders. Import drugs, let people buy drugs/plans on other markets.

3) No mandates. It's unamerican.

4) Put those with the burning homes on a government plan so everyone else isn't getting f'd on premiums to cover them.

Just my thoughts.

1) What would that accomplish?

2) Ok, flood the market with ripoff drugs from other countries and see how much R&D our pharma companies invest in. Watch as they all leave the US for countries that have cheaper labor and more lax regulations.

3) ahh... the "American" justification. Deep.

4) I actually agree here.

 

[drayer54]

1) What would that accomplish?

2) Ok, flood the market with ripoff drugs from other countries and see how much R&D our pharma companies invest in. Watch as they all leave the US for countries that have cheaper labor and more lax regulations.

3) ahh... the "American" justification. Deep.

4) I actually agree here.

Direct to consumer advertising adds a lot of cost to the drugs that shouldn't be advertised anyways. This isn't an uncommon thing to ban and it used to be restricted until the 90's. Cuts costs.

The US market is huge. Opening competition benefits the consumer. I've had drugs in other countries and was just fine.

Yes, mandating the purchase of a product in a free country is a bad idea. One of the biggest lobbies in the country convinced our congress to mandate the purchase of their product by every American. I think it is a corrupt violation of our commerce clause. The simple idea of telling everyone that they must buy a commodity is just simply un-American. Yes.

Thanks

 

[woolybug25]

Direct to consumer advertising adds a lot of cost to the drugs that shouldn't be advertised anyways. This isn't an uncommon thing to ban and it used to be restricted until the 90's. Cuts costs.

The US market is huge. Opening competition benefits the consumer. I've had drugs in other countries and was just fine.

Yes, mandating the purchase of a product in a free country is a bad idea. One of the biggest lobbies in the country convinced our congress to mandate the purchase of their product by every American. I think it is a corrupt violation of our commerce clause. The simple idea of telling everyone that they must buy a commodity is just simply un-American. Yes.

Thanks

- What? How do you think most drugs get noticed? I think private companies know better than us what investments are better for the bottom line. There is no negatives for them to be able to let the public know of the benefits of their products.

- I bet you've had good drugs in other countries. Drugs researched, developed and then copied by other countries.

- Let me know when I can choose to stop paying for road repairs and schools. After all, it's un-American for them to force me to pay for it.

 

[drayer54]

- What? How do you think most drugs get noticed? I think private companies know better than us what investments are better for the bottom line. There is no negatives for them to be able to let the public know of the benefits of their products.

- I bet you've had good drugs in other countries. Drugs researched, developed and then copied by other countries.

- Let me know when I can choose to stop paying for road repairs and schools. After all, it's un-American for them to force me to pay for it.

Private companies want to make money and find customers. They don't give a damn about me unless I can be convinced that my life would be better with some product that I must pursue a doctor to prescribe.
If I need it, my doctor will prescribe it to me. I think this why drugs are expensive and Americans or overmedicated. The main negative is the cost impact.

I generally prefer open markets and competition that benefit the consumer. To each their own.

Not everyone is driving on my health plan nor are they educated about it. Me buying a plan from Cigna is not for the common good. Healthcare is a commodity (not a right) and should be treated as such. Compelling the purchase of a product for the profit of a private company is theft. Taxation is theft. But so is this.

 

[Veritate Duce Progredi]

Private companies want to make money and find customers. They don't give a damn about me unless I can be convinced that my life would be better with some product that I must pursue a doctor to prescribe.
If I need it, my doctor will prescribe it to me. I think this why drugs are expensive and Americans or overmedicated. The main negative is the cost impact.

I generally prefer open markets and competition that benefit the consumer. To each their own.

Not everyone is driving on my health plan nor are they educated about it. Me buying a plan from Cigna is not for the common good. Healthcare is a commodity (not a right) and should be treated as such. Compelling the purchase of a product for the profit of a private company is theft. Taxation is theft. But so is this.

What sort of regulation is involved with imported drugs? How does the US police this? Is it truly open market, ie - we can mail order from any laboratory? I'm fairly certain that doesn't end well.

Do we demand global drug manufacturers submit sample tests every 3 months? 1 year?

How do we ensure the public is safeguarded from rip-offs? Diluted product? Are we comfortable with reduced R&D budgets in pharma? I don't necessarily think there is a right answer to this last question, just curious.

 

[Goldedommer44]

True, this functions as major medical, however, these folks don't tend to seek early medical care because of the out of pocket cost. The people with no insurance and paying a tax penalty... I think they would be happy to go back a few years.

The affordable healthcare act works at some level, no doubt. But it would seem we could do better. Also I do not think AHCA is sustainable. Market cost is heading up. Good luck with rates, especially the "market place" plans down the road.

I agree 100% that we could do better and I would also agree that the people who are paying the fine would much rather go back when they didn't have to pay it.

 

[Legacy]

How Will Trump Change The FDA? (National Law Review)

One of Trump's initial considerations for the head of the FDA, which regulates the process of drug approvals, was an advocate of a “post-marketing approval” paradigm to shorten the time it takes new drugs to get to market. New drugs would only have to pass Phase 1 in which they are proved safe, then jump to Phase 4 in which they could be marketed. The drugs would not have to be proven effective. That would be determined over time as patients took them. Meanwhile, those meds could be advertised and prescribed.

Trump ended up nominating Dr. Scott Gottlieb, who has previously worked in the FDA. (See link above for how Gottlieb may change the FDA) He spent more than a decade in Washington rotating between the worlds of government, health policy consulting and political think tanks. Gottlieb is a partner in New Enterprise Associates, the venture capital firm is currently or has been invested in 188 health care companies.


By The Numbers: Trump’s Choice For FDA Chief Is Versatile, Entrenched In Pharma

 

[pkt77242]

Here's the bipartisan path forward on health care: Andy Slavitt

An interesting article on some ways to improve the ACA.

 

[Legacy]

Single-Payer Health Reform: A Step Toward Reducing Structural Racism in Health Care (Harvard Public Health Review)

Racial and income equality are too often absent from conversations about health care financing. Research continually exposes alarming health disparities in the United States, particularly impacting African Americans and Native Americans. These groups have lower life expectancies than non-Hispanic white Americans, and experience higher rates of most major causes of death including infant mortality, trauma, heart disease, and diabetes.(1234567) Yet despite their greater need, access to care is worse for minority populations by most measures. (8)
Unequal medical care is often viewed as a consequence of broader social inequalities, but the current health financing system also reinforces and institutionalizes inequality; unequal care may be viewed as a form of structural racism. .....

 

[irishroo]

Private companies want to make money and find customers.
Not everyone is driving on my health plan nor are they educated about it. Me buying a plan from Cigna is not for the common good. Healthcare is a commodity (not a right) and should be treated as such. Compelling the purchase of a product for the profit of a private company is theft. Taxation is theft. But so is this.

Okay so substitute "roads and schools" with "auto insurance." I'm no fan of the ACA at all but to say that government mandating the purchase of a product from a private company is "unAmerican" when we already do that exact thing (to great success, I might add) is disingenuous. I know the argument is that auto insurance is necessary to cover mitigate costs to others impacted by your own problems on the road, but that's exactly what health insurance does too. If somebody shows up to the ER with no insurance, it's everybody else paying for that person's treatment. Mandated health insurance for that person mitigates the costs to others. Note that I'm not advocating for the ACA because I believe it does a terrible job at mitigating those costs, but just pointing out that argument seems like it doesn't hold water.

 

[phgreek]

They're fair questions, and it's one of the main arguments used in favor of nationalizing -- there are efficiencies to going that way.

The reasons we don't do it within the current structure are varied, and not all of them are good reasons:
1) Status as "insurance" -- regulation of all forms of insurance has historically fallen within state police power;

Still can...I guess what I'm suggesting is basic standards and licensure, and if states find it important, they can provide for and enforce additional endorsements. So much can be done through online training...marketers could maintain certs at least regionally pretty easily I would think.

2) Some of the insurance variations reflect actual differences among the states -- the cost of insuring a resident varies wildly by state which means that an insurer needs a different level of capitalization to support the same population in different states;

This makes sense...hadn't thought about this much. However, this isn't much different than folks who are commercial builders in multiple states. Most anyone who delivers services nationwide deals with real and imaginary/contrived differences. The real differences tend to create capitalization/bond issues unique to the situation. At some point their competitive model determines they can invest in the internal systems to add said state, and someone finds a way to overcome the risk with potential reward. I'd say this is a real issue that would take time for insurers to deal with in order to create a true competitive market place...in those cases I can see a need for Federal government support...even state level tax breaks etc. to get over the hump

3) This feeds into the one above, but providers vary wildly among the states -- a state like Florida or Louisiana is going to have more rural providers and a better per-capita capacity to handle tropical diseases than a state like Minnesota. There's also a significant difference in both surge capacity and the need for such capacity in a coastal state than in an inland state. There are also wide variations in provider sophistication and capacity to operate as insurers or ACOs, which is typically regulated by insurance commissioners. These variations have a dramatic impact on the state insurance code (legal, not regulatory) governing the insurer-provider relationship;

Those are costs associated with choosing to live in an area...and just like how it cost me 2X as much to insure a car in Hoboken NJ, than in Rural PA...its pure choice.

4) The insurer-pharmacy relationship is highly variable and depends on the level of fragmentation of that market within a state -- where the state has high levels of independents it tends to be more heavy-handed with PBM regulation than in a state where chains predominate;

This kind of stuff should be aided by competition...but I don't understand it all that well either. Seems the problem, thus the solution is more political than market standardization and business systems.

5) Incentivizing national provider networks will require busting state oligopolies. In Louisiana, for example, the Blues and Medicaid are nearly the entire market. Same for a state like Alabama (I think Alabama may actually be the most monopolistic, but that's purely from memory). They will actively work to prohibit providers from contracting with foreign insurers. Nationalizing will also create intense pressure on state legislatures to pass price controls -- this happens in the pharmacy market already, where health insurers' use of national wholesale price lists as the basis for reimbursement creates pressure to implement state-level price adjustments.

We have IHC in Utah...used to be BRUTAL w/regard to competition. I think the ultimate reimbursement may have to do with cost of delivery and that has to do with local regulations, and distribution systems supporting the vending side. If we put a fixed fee, and have cost basis for it...it costs what it costs to put 20 pills in a consumer's hands. But the price of the pill doesn't change. So I get it...there are business reasons for saying hey, the locality cost of delivering is more....

6) The provider network structure scales very poorly. It would really be better to do away with it entirely if you're going to nationalize. It's not a good or a bad option (okay, gun to my head, it's probably a good thing on balance to do away with it), just a reality

Why is that though? And help me understand why this is more than just a list of lists from a consumer perspective. By that I mean, yea, contracts can be complex, but they are in place...they deal with local and regional issues...but why does the approach need to change? Are they coding things differently?

I'm sure I can come up with more thinking through it further

No doubt.

I think there is serious complexity here. The government has a role to play in terms of oversight. No question. 1) they can't do it the way they have w/o breaking efficiency mechanisms 2) those mechanisms take time to work; 3) there are valid locality considerations...there is a cost consequence on literally every other facet of life based upon where one finds him or herself living. 4) locality considerations aren't so complex as to stop a corporation from developing some commodity offerings, and locality based adds...rather built into the sausage or priced separately.

I think our problem will always boil down to the time horizon for market solutions with correct oversight, and the time horizon of politicians. No republican has the political will to do this.

Thanks for the info...I learn form these exchanges.

 

[Veritate Duce Progredi]

My message is that the Council of Bishops has no right to try to push their agenda on the sitting Congress. And that they have no moral high ground to lecture from, because of their decidedly lacking response to the sexual abuse scandal.

The council of Bishops has no right to attempt getting their message through to sitting congress? Why? You don't believe faith informs every other part of life? You don't believe faith is the foundation from which many form their life's philosophy.

You believe faith should be compartmentalized? ie - not lived out in the public square?

And just so I'm understanding correctly: anyone with past transgressions, or transgressions by association can never attempt to make moral arguments for or against something?

Quoting this again to try and get a reply on this. These are genuine questions.

 

[kmoose]

Quoting this again to try and get a reply on this. These are genuine questions.

The council of Bishops has no right to attempt getting their message through to sitting congress? Why?

I never said that they have no right to express their message. What they don't have a right to do is demand that their agenda be included in legislation. From the letter:

Respect for life and dignity:* The Bishops of the United States continue to reject the inclusion of abortion as part of a national health care benefit.* No health care reform plan should compel us or others to pay for the destruction of human life, whether through government funding or mandatory coverage of abortion.* Long-standing "Hyde Amendment" protections must extend to any relevant health care plan in order to prevent federal funding of abortion, and federal resources—including tax credits—must not be used to assist consumers in the purchase of health care plans that cover abortion.* These protections ought not be in the form of a temporary fix or future promise; any legislation must be passed with these provisions in place for the sake of the most vulnerable among us.

Who are the Bishops to demand that Congress legislate that abortions cannot be covered by healthcare plans that are available to those with subsidies? They can certainly remind the Congress that they view abortion as a sin, but they have no right to demand that Congress leave it out of the healthcare law, anymore than a group of Muslim clerics have the right to demand that no Federal dollars go to insuring any disease that can be related to eating pork.

You don't believe faith informs every other part of life? You don't believe faith is the foundation from which many form their life's philosophy.

No. I believe that morals inform every other part of our life and are the foundation from which we all form our life's philosophy. You don't have to be religious to have morals. Just as morals are not required, to be religious.

You believe faith should be compartmentalized? ie - not lived out in the public square?

Yes! Yes! And even more YES! Think about how much more peaceful the world would be, if we didn't have religions fighting for followers. There would still be violence, sure. People will always covet. And the strong will always believe that they some kind of birthright to what is not theirs. But no one would be able to twist religion into some instrument of action, if more people kept their devotion to themselves and quit trying to make everyone else believe the same as they do. I'm not saying that you can't openly practice your faith, but when the open practice of one faith becomes a death sentence from another faith, then it has just gone too far.

And just so I'm understanding correctly: anyone with past transgressions, or transgressions by association can never attempt to make moral arguments for or against something?

The subject is much more nuanced than that, but yes. Hillary Clinton doesn't get to lecture people about corruption or the evils of sexual assault. Actually, she is allowed to, but her words ring hollow. The same with Donald Trump and being foolish.

 

[Valpodoc85]

http://www.economist.com/blogs/econ...n/fb/te/bl/ed/whydrugpricesinamericaaresohigh

I'll just park this here...

 

[BleedBlueGold]

http://www.economist.com/blogs/econ...n/fb/te/bl/ed/whydrugpricesinamericaaresohigh

I'll just park this here...

Cory Booker contributions from Pharma. Just saying...

Find Contributions | MapLight - Money and Politics

And obviously, he's not the only one.

 

[Valpodoc85]

seems like the system is needlessly complicated making it difficult to track who benefits. Typical bureaucratic mess. System was designed that way to plenty of politicians have a hand in it.

 

[Legacy]

New Analysis Finds Out-of-Pocket Prescription Drug Spending Decreasing on Average, But More People Spending in Excess of $1,000 a Year (Kaiser FF)
Oct, 2016

A new Kaiser Family Foundation analysis finds that average annual out-of-pocket prescription drug spending for workers and family members decreased from a recent high of $167 in 2009 to $144 in 2014. Most of the decline in out-of-pocket spending occurred between 2009 and 2012 and is likely due to generic substitution for popular drugs that lost patent protection. The decline in out-of-pocket-spending continued from 2012 to 2014 with nearly two-thirds of the decline during this period attributable to the Affordable Care Act provision requiring most plans to cover contraception without cost sharing.

At the same time, the relatively small share of people spending more than $1,000 a year out-of-pocket on prescription drugs rose in the past decade, from 1 percent in 2004 to 2.8 percent in 2014, and their spending accounted for a third (33%) of all out-of-pocket drug spending by enrollees in large-employer plans in 2014, the study finds.

One of the studies linked in above:

Examining high prescription drug spending for people with employer sponsored health insurance

This analysis examines trends in drug spending for people who have insurance coverage through their or a family member’s large employer, with a particular focus on those with high total drug spending or high out-of-pocket drug spending. The analysis is based on a sample of health benefit claims from the Truven MarketScan Commercial Claims and Encounters Database to calculate the amounts paid by insurance and out-of-pocket on prescription drugs from 2004 – 2014. We use a sample of between 785,000 and 15.3 million enrollees per year to analyze the change from 2004 to 2014 in average prescription drug spending for covered prescriptions overall, the average amount paid by health benefit plans, and the average amounts attributable to deductibles, copayments, and coinsurance.

 

[Veritate Duce Progredi]

I never said that they have no right to express their message. What they don't have a right to do is demand that their agenda be included in legislation. From the letter:



Who are the Bishops to demand that Congress legislate that abortions cannot be covered by healthcare plans that are available to those with subsidies? They can certainly remind the Congress that they view abortion as a sin, but they have no right to demand that Congress leave it out of the healthcare law, anymore than a group of Muslim clerics have the right to demand that no Federal dollars go to insuring any disease that can be related to eating pork.

I just read the quoted blurb again and I have yet to see a demand. They stated very clearly, if you want to protect the most vulnerable among us, you should follow our recommendations. Did they state demands somewhere else?



No. I believe that morals inform every other part of our life and are the foundation from which we all form our life's philosophy. You don't have to be religious to have morals. Just as morals are not required, to be religious.

I suppose the above was supposed to have meaning. If you believe faith serves as a foundation for many, then you'd understand why it's incomprehensible for them to "leave their faith at home"

Yes! Yes! And even more YES! Think about how much more peaceful the world would be, if we didn't have religions fighting for followers. There would still be violence, sure. People will always covet. And the strong will always believe that they some kind of birthright to what is not theirs. But no one would be able to twist religion into some instrument of action, if more people kept their devotion to themselves and quit trying to make everyone else believe the same as they do. I'm not saying that you can't openly practice your faith, but when the open practice of one faith becomes a death sentence from another faith, then it has just gone too far.

You believe the world would be less violent without religion? How does one maintain a serious faith but also keep it to themselves? In the case of the bishops: All human life has dignity. The Church should work to protect the weakest and infirm among us. Who are the weakest? I imagine a 19 week old child has to be on the short list, no?

The subject is much more nuanced than that, but yes. Hillary Clinton doesn't get to lecture people about corruption or the evils of sexual assault. Actually, she is allowed to, but her words ring hollow. The same with Donald Trump and being foolish.

Ok. But it's not just Hillary, it's all politicians right? How about da gubment? Technically they are all the same so they can't say sh!t about sh!t because they've had all manner of transgressions. So continuing to follow your logic, we arrive at: any person in the Catholic church can't speak about healthcare cuz pedophilia.

.

 

[NOLAIrish]

Still can...I guess what I'm suggesting is basic standards and licensure, and if states find it important, they can provide for and enforce additional endorsements. So much can be done through online training...marketers could maintain certs at least regionally pretty easily I would think.

I don't think states would object to federal control of basic licensure requirements, but I think most commissioners would simply point out that NAIC standards are essentially universal already and the fed taking that over wouldn't accomplish much. It'd be similar to federalizing the Uniform Commercial Code -- to the extent states have generally adopted its principles, the change won't fix outstanding differences, and to the extent those differences are problematic, states will want to retain control.

This makes sense...hadn't thought about this much. However, this isn't much different than folks who are commercial builders in multiple states. Most anyone who delivers services nationwide deals with real and imaginary/contrived differences. The real differences tend to create capitalization/bond issues unique to the situation. At some point their competitive model determines they can invest in the internal systems to add said state, and someone finds a way to overcome the risk with potential reward. I'd say this is a real issue that would take time for insurers to deal with in order to create a true competitive market place...in those cases I can see a need for Federal government support...even state level tax breaks etc. to get over the hump

I would agree that it's not an impossible problem -- just an issue that insurers would need time to incorporate. But it is a real problem and it's one of the hindrances to expansion of the market -- meeting requirements in one state can impose overhead on the company without making it any more efficient in its home state; that's a real problem in terms of competition, and these variations can have a significant annual cost.

Those are costs associated with choosing to live in an area...and just like how it cost me 2X as much to insure a car in Hoboken NJ, than in Rural PA...its pure choice.

Regional differences are a choice and do account for some variation in price. Price is not what I was getting at with that point, though; rather, it was intended to point out an issue in nationalizing insurance requirements. State insurance codes (and regs) aren't generally related to price with the exception of trying to avoid increasing cost; instead they're focused on defining the "stuff" of coverage: what does your product have to look like to be sold as insurance; is that different for large group, small group, and individual plans; can you cover things outside of health; how do you interact with bodily injury clauses in auto insurance; what does the provider network have to look like before we'll let you tell them they're covered; what do you have to cover; what solvency requirements are necessary to ensure you won't leave our residents in the lurch; what are you allowed to do to encourage providers to join your network; what can you do to recoup payments from providers; can you address balance billing; do you have to offer your product to any willing purchaser; how do you interact with employers; etc.

The answers to those questions vary based on the population you're covering. In a coastal state, we may want an insurer to cover non-network providers during a disaster. We'll pay a bit extra for that, but we may want that to be a mandatory part of what it means to insure us. In Nevada, maybe that's not as necessary. Maybe we also want to stay out of the balance billing issue and leave the up to insurers and providers to hash out themselves, where a state with a larger aged population or a more left-leaning governing style may want to be a bit more prescriptive. These kind of issues are far more variable than laws/regs aimed at price.

One place where price does come in though is with provider sophistication. In a state dominated by large, well-capitalized providers in urban settings, providers and insurers are largely left to negotiate between each other and the insurance code reflects that hands-off approach. In states with more rural or small providers, state legislatures (even the ostensibly fiscally conservative ones) tend to be much more willing to step in and tilt the scales a bit to keep rurals from getting crowded out of their markets.

This kind of stuff should be aided by competition...but I don't understand it all that well either. Seems the problem, thus the solution is more political than market standardization and business systems.

Pharmacy is one of the weirdest markets in the country. Historically, insurers contracted with pharmacy benefit managers to negotiate drug prices with pharmacies. In turn, the independent pharmacies would contract with a third party contract manager to pool their negotiating power when dealing with the PBM. In addition, chain pharmacies have a strong interest in the major PBMs -- CVS/Caremark is one of the largest PBMs in the country; Walgreens used to own one of the PBMs that became Catamaran, which was subsequently bought up by UnitedHealth and incorporated into its captive PBM, OptumRx. Clear as crystal, eh? Anyhow, the upshot is that states with high concentrations of independents tend to see much more lobbying against PBM authority (especially around steering patients to PBM-affiliated pharmacies) and for "any willing provider" requirements in the pharmacy industry.

We have IHC in Utah...used to be BRUTAL w/regard to competition. I think the ultimate reimbursement may have to do with cost of delivery and that has to do with local regulations, and distribution systems supporting the vending side. If we put a fixed fee, and have cost basis for it...it costs what it costs to put 20 pills in a consumer's hands. But the price of the pill doesn't change. So I get it...there are business reasons for saying hey, the locality cost of delivering is more....

I actually don't know how much the unit cost varies nationally for medical services. I mean, I know there's some -- even Medicare DRGs show that there's wide variation -- I just don't know how much of a driver it is relative to, say, efficiency of care delivery (e.g. Minnesota is famous for reducing care costs by reducing excess care) or venue appropriateness (e.g. using urgent care over EDs where appropriate, building and using an adequate primary care network, etc). And of course you've got the massive variation from non-medical cost drivers in health.

Why is that though? And help me understand why this is more than just a list of lists from a consumer perspective. By that I mean, yea, contracts can be complex, but they are in place...they deal with local and regional issues...but why does the approach need to change? Are they coding things differently?

Oh, I know it looks like a list by the time it's down to the patient level, but it represents so much more. These are individual agreements with providers governing what's reimbursable, how much the insurer reimburses for care, whether unreimbursed costs can be charged to the insured, what requires prior authorization with the insurer before treatment, what can be post-authorized and for how long, what the bill must look like, which policies include the physician, and so on. To answer your direct question, I guess from a patient-facing perspective, this will govern how long you have to wait for care (prior auth), the amount of your premium, the amount of your coinsurance, and whether you get balance billed.

The reason that it's inefficient at a national level is that the terms of network participation aren't ubiquitous and it becomes impossible to efficiently negotiate new terms for multiple coverage plans in widely disparate regions with different conventions of coverage for each of several thousand providers who are themselves in a constant state of flux. I can think of simpler methods if we had an interstate insurance model, but the cost component of switching off of the network model is out of my depth. I would add that this isn't really an issue for government to solve -- it's just an issue that industry must confront before progress is possible.

No doubt.

I think there is serious complexity here. The government has a role to play in terms of oversight. No question. 1) they can't do it the way they have w/o breaking efficiency mechanisms 2) those mechanisms take time to work; 3) there are valid locality considerations...there is a cost consequence on literally every other facet of life based upon where one finds him or herself living. 4) locality considerations aren't so complex as to stop a corporation from developing some commodity offerings, and locality based adds...rather built into the sausage or priced separately.

I think our problem will always boil down to the time horizon for market solutions with correct oversight, and the time horizon of politicians. No republican has the political will to do this.

Thanks for the info...I learn form these exchanges.

This is a great post overall. I would add a 5) to your list -- the issues we face are symptomatic of the system we've built and not of the nature of health care. It's not that they're insurmountable problems, it's that solving them requires alterations to the system far more significant than granting corporations permission to participate in multiple markets.