Healthcare Reform Thread II

[KrazyHorse]

You've made this assertion a few times, by the way...

[rah]

I'll admit to liking Charles Krauthammer since politically we share a lot of common beliefs but even I know better than to accept his comments as truths. He is usually quite biased and twists things to make his point. But he always provides me entertainment.

[Ramo]

There are large up front costs in setting the system up. Getting the health insurance exchange up and properly running, paying for comparative effectiveness research, and above all, getting the uninsured poor coverage is going to cost money. And I don't think expecting similar economic patterns to pop here as everywhere else in the developed world qualifies as "magic."

It's important to note that CBO scoring is pretty conservative. For example, comparative effectiveness would probably yield a significant pot of money, but the CBO is effectively ignoring the effect. Same thing with universality, but that's a bit more speculative. It also hasn't scored things that would likely be part of reform only because they weren't part of the initial House or HELP bills, i.e. MedPac reform. A major positive step would be to limit the employer tax deduction, and that's what Finance is trying to do (and CBO has implied that they would score the step agressively).

[Kuciwalker]

Getting the health insurance exchange up and properly running, paying for comparative effectiveness research,

And when we're done paying these the system will be so much cheaper?

and above all, getting the uninsured poor coverage is going to cost money.

Why would this cost disappear in 10 years?

[KrazyHorse]

There are large up front costs in setting the system up. Getting the health insurance exchange up and properly running, paying for comparative effectiveness research, and above all, getting the uninsured poor coverage is going to cost money.

The first two are extraordinarily small costs. The last is an ongoing cost, not a fixed cost.

And I don't think expecting similar economic patterns to pop here as everywhere else in the developed world qualifies as "magic."

I have seen nothing to indicate that the dynamics present in many other developed countries which contain their cost of medical care relative to that of the US will be introduced by any politically feasible measure. Can you explain specifically which measures you're thinking of?

It's important to note that CBO scoring is pretty conservative. For example, comparative effectiveness would probably yield a significant pot of money

Comparative effectiveness RESEARCH won't do ****. Only a mandate to restrict care based on comparative effectiveness research might do something. Is this likely to pass?

Same thing with universality

Explain what you mean here in a straightforward way.

i.e. MedPac reform

What do you mean by "MedPac reform"? You're just throwing around buzzwords when you say **** like this.

A major positive step would be to limit the employer tax deduction

Yes. Or to simply eliminate it.

[Ramo]

And when we're done paying these the system will be so much cheaper?

Probably.

Why would this cost disappear in 10 years?

Where did I say that? Getting people into a universal system means that you can tweak the incentive structure to minimize expensive, acute care through preventative measures. That effect would be minimal over ten years.

[Ramo]

The first two are extraordinarily small costs. The last is an ongoing cost, not a fixed cost.

Yes, hence the above all.

Comparative effectiveness RESEARCH won't do ****. Only a mandate to restrict care based on comparative effectiveness research might do something. Is this likely to pass?

Really? You think that Medicare+Medicaid+VA has a small market share?

As for regulation, that is exactly the sort of thing that a health insurance exchange can facilitate.

Explain what you mean here in a straightforward way.

As I told Kuci, a universal system would help to diagnose problems early on that would otherwise be left for an expensive operation in an emergency room, picked up on the public tab. This is something that you'd see more gains from later.

What do you mean by "MedPac reform"? You're just throwing around buzzwords when you say **** like this.

I brought it up in a number of previous health care posts. The idea is that the entity that controls Medicare disbursement rates is subject to heavy Congressional intervention. My favorite example of this is that Ted Stevens landed a 35% increase in disbursements for Alaskans last year. So you have a body that can make a set of recommendations (subject to some metrics wrt cost control and quality) and Congress only has the power to accept or reject them. So you get a much less parochial basis for how Medicare operates. Fed vs. Treasury. And changes there can propagate to the private sector.

Yes. Or to simply eliminate it.

I agree, but it's not politically realistic. Harry and Louise.

[Ogie Oglethorpe]

Why would this cost disappear in 10 years?

More to the point why wouldn't this cost explode in light of universal coverage. If illegal immigration is a concern now...

[Ramo]

I have seen nothing to indicate that the dynamics present in many other developed countries which contain their cost of medical care relative to that of the US will be introduced by any politically feasible measure. Can you explain specifically which measures you're thinking of?

It fundamentally comes down to a large public role with less overhead, that bargain with providers, and can more effectively restrict treatment that has a marginal benefit. We're not going to see that immediately, but we might see something resembling that in a decade.

[KrazyHorse]

Yes, hence the above all.

I have no idea what this sentence means. You claimed that there are large upfront expenses which skew the CBOs numbers because they only go 10 years out. You then gave some upfront expenses (which appear to be relatively small) and an ongoing expense (which has nothing to do with your claim).

Really? You think that Medicare+Medicaid+VA has a small market share?

WTF does this have to do with what I said?

As for regulation, that is exactly the sort of thing that a health insurance exchange can facilitate.

Uhhhh....what?

As I told Kuci, a universal system would help to diagnose problems early on that would otherwise be left for an expensive operation in an emergency room, picked up on the public tab. This is something that you'd see more gains from later.

Do you have any evidence at all that there are large gains to be had from preventative care? Or that anything currently being proposed will LEAD to these large gains being picked up? Because right now it looks like an underpants gnome argument.

I brought it up in a number of previous health care posts. The idea is that the entity that controls Medicare disbursement rates is subject to heavy Congressional intervention. My favorite example of this is that Ted Stevens landed a 35% increase in disbursements for Alaskans last year. So you have a body that can make a set of recommendations (subject to some metrics wrt cost control and quality) and Congress only has the power to accept or reject them. So you get a much less parochial basis for how Medicare operates. Fed vs. Treasury.

Do you have any reference available for how widely medicare disbursement rates (I'm assuming you mean disbursement rates for a given procedure?) vary geographically, and how far from the ideal this is?

And changes there can propagate to the private sector.

Errrr....what?

[KrazyHorse]

I literally CANNOT understand what your arguments are when it comes to health care reform, Ramo. You are not expressing yourself clearly.

[Ramo]

I have no idea what this sentence means. You claimed that there are large upfront expenses which skew the CBOs numbers because they only go 10 years out. You then gave some upfront expenses (which appear to be relatively small) and an ongoing expense (which has nothing to do with your claim).

I was making the point that there are cost savings here that are not likely to be realized over a short time period.

WTF does this have to do with what I said?

Huh? What exactly do you think is stopping Medicare from telling doctors to pay for procedure x with marginal benefit? We're talking about a HUGE portion of the market that comparative effectiveness research has immediate applicability.

Uhhhh....what?

The health insurance exchange is a regulated marketplace. It provides an avenue for imposing these kinds of controls. But the hope is that the private sector would follow Medicare's lead.

Do you have any reference available for how widely medicare disbursement rates (I'm assuming you mean disbursement rates for a given procedure?) vary geographically, and how far from the ideal this is?

IIRC, the Stevens appropriation was an increase in aggregate disbursement. And yes:

http://www.dartmouthatlas.org/interactive_map.shtm

How far from ideal? Dunno, but you can look at a more micro comparison (similar demographic towns), and see the same thing. McAllen and El Paso, TX for example.

Do you have any evidence at all that there are large gains to be had from preventative care? Or that anything currently being proposed will LEAD to these large gains being picked up? Because right now it looks like an underpants gnome argument.

In my initial post, I said that this was more speculative.

Errrr....what?

If the government makes efforts at limiting disbursements for a certain class of procedures, private insurers have that leverage when negotiating with providers.

[Ramo]

KH, I'll make a full argument later today. Busy right now.

[KrazyHorse]

It fundamentally comes down to a large public role with less overhead

a) I'm not convinced that there is less overhead
b) I have no idea why you believe that the size of the public provider in the US would approach the size of the public providers in other developed countries, given the proposals being floated. In those countries everybody's given basically free access to the "public option". This is not what will be passed in the US.

, that bargain with providers, and can more effectively restrict treatment that has a marginal benefit. We're not going to see that immediately, but we might see something resembling that in a decade.

a) The government has been exercising monopsony power on health care for old people for many decades. Where are the savings?

b) How much of health care for under-65s is currently public in the US? How high do you think it will go? Will this be sufficient to exercise monopsony?

c) I have no idea why you think it is reasonable to claim that the gov't will be able to restrict care based on cost effectiveness when it hasn't proven its ability to do so in the past.

[Jon Miller]

KH, what do you think are the reasons why other countries pay less for their health care, but have a more cared for populace compared to the US?

I know one is doctors education. But that is a one time cost that should just increase costs just slightly on a per service basis over the course fo the doctors life time.

JM