The BG Health Care Thread: Decreasing the Surplus Population

[kuronosan]

I guess we can start talking about health care related stuff here now?

Universal Plan is going to almost become a necessity no matter what.

[Ragnus]

Only thing I know at the moment is that something meaningful needs to happen. I'm one of the "lucky" ones who gets healthcare through his work. It's completely disheartening to see my coverage get noticeably worse while seeing premiums increase every year.

[kuronosan]

As someone who helps run a clinic for the uninsured I would agree.

[Byrthnoth]

So here's where I stand on the issue:


Here is the groundwork

* Healthcare is a right. - The vast majority of Americans agree that people should get care in emergency rooms regardless of their coverage status, so we agree that there is a right to treatment. The rest is how to pay for it and whether someone has to make it to home base (a hospital) before they can be treated.

* Our healthcare system is inefficient. - We pay the most for insurance and get mediocre coverage on average relative to other nations. Our investments might drive some innovation that wouldn't have happened otherwise, but for Americans it's a pretty bad ROI.



How should it be implemented?

* Our healthcare sector is massive. - Related to the above point, one sixth of our economy goes towards healthcare. That is a ton of jobs that are directly or indirectly related to healthcare. Suddenly disrupting healthcare markets doesn't seem wise.

* Medicaid/Medicare are well-liked, effective, and economical for the services provided. - I think you know what's coming.

* Healthcare does not make a healthy person healthier. - Healthy people with healthcare go to the doctor more often, but their health outcomes aren't notably different from comparable people without insurance. This should be intuitive.

* Healthcare does help people who are more at risk of being unhealthy. - This should also be intuitive. People who need to go to the doctor are helped by having healthcare.

So given the pens of dozens of healthcare policy experts, I'd recommend adding a moderate deductible, high-copay Medicaid buy-in option with the current needs-based exemptions and additional exemptions for people going through a medical crisis (for instance, pregnancy/birth.)




How can we make our medical system more efficient?

* Basically, fuck the American Medical Association. - They have a monopoly on doctor production in this country and it hurts the fuck out of us. There's no evidence that our medical professionals are superior to other countries (like Germany) where the medical degree is essentially a Master's obtained in the 2 years following college (formally a 6 year program that takes place at universities in lieu of a traditional university program.) The tortuous, ineffective system that creates our doctors is a major problem that needs to be addressed.

* Allow collective bargaining and price setting in all situations for Medicare and Medicaid. - Why is this not already a thing?

* Set reasonable limits on care. - This is the hardest discussion to have and it might have to be changed at a cultural level. End of life medical interventions are expensive and often ~useless. We need to mandate a serious discussion before any procedure.

idk there are a lot more reforms you can toss in there but here's a start for me

[Yuri-G]

four posts in and we've reached death panel status


WELL THEN


although I like everything else you said

[Darus Grey]

four posts in and we've reached death panel status


WELL THEN


although I like everything else you said

I know you're being facetious, but other countries address this issue simply(France,Germany,Switzerland, the insurance based universal coverage systems). The government mandated care is a minimum. You want infinite life support? You're welcome to buy a policy that covers that.

IMHO the biggest issue we face on the issue is the employer based pseudo system, it is hard to have serious discussions about the health system, because for 70%~ the population, it's never an issue, they just get whatever junk their employer gives them and that's that, they never have to think about it.

That's a terrible place to approach a problem, where the majority have essentially little to no stake in the outcome, even if they're still taking it in the ass via premiums increases, most people don't analyze their paycheck or negotiate on this issue to care, they just take what they're given.

Because of this, I think we should consider getting rid of the tax breaks associated with healthcare coverage from employers, it's not going to be pretty, but we need to train society on the cost/benefit of healthcare, where right now they're divorced from it and experiencing grand scale moral hazard.

[Fiye]

I hate to use the 'finite' resources argument but if someone ends up like tom petty and is physical alive but no brain activity do you let them stay on life support for months on the slim chance they survive or do you pull the plug and save the resources for others.

Care for all should be a thing but there will be some limitation on what's offered.

[Byrthnoth]

I'm not saying we should mandate that anyone die, but for the sake of both the family and society, there should be a serious discussion had.

Current hospital EOL care is ridiculous. It delivers mostly unnoticeable benefits at massive material and emotional cost. Putting grandpa through a long-shot surgery for another hospital-bound week on the ventilator isn't doing anyone any favors.

[Fiye]

most people don't analyze their paycheck or negotiate on this issue to care, they just take what they're given.

My workplace doesn't allow unions so we literally can't negotiate our medical coverage. psure we're also not an exception.

[kuronosan]

Doctor production is more limited by residency programs (somewhere close to 10-15% of graduates won't get matched every year), and funding from that comes from the government.

I feel like the AMA has relatively little to do with that bottleneck, but I'm just a junior member so maybe I don't know as well.

[Byrthnoth]

Doctor production is more limited by residency programs (somewhere close to 10-15% of graduates won't get matched every year), and funding from that comes from the government.

Eh, food for thought:

The AMA via controlling basically every hospital's management structure: "Oh, we can't possibly place doctors in hospitals to deliver high value service at cutrate prices... but the ones that we can place have to work double shifts."

The AMA via controlling basically every hospital's management structure: "Oh, we can't possibly come up with 50k/yr per resident... we should hire more PAs at 80k/yr instead!"

If there were only two unions to bust, it would be the police union and the AMA.

[Darus Grey]

Also as we've discussed in the past, don't forget the AMA is also a disincentive to people interested in going into medicine. I'd be interested in some research into this, but anecdotally I know lots of competent people who considered a career in medicine and basically said "naw, fuck that" due to AMA procedures(myself included).

Regardless, the evidence doesn't support that being significantly more discerning achieves actual results, doctors in Germany & France are essentially just as competent for significantly less hurdles to get them to patients. So we should be in favor of less grueling standards just based on that alone. It's meaningless suffering.

It's hard to see the AMA as anything more than pure protectionism masquerading as standards.

[Heavencloud]

Eh, food for thought:

The AMA via controlling basically every hospital's management structure: "Oh, we can't possibly place doctors in hospitals to deliver high value service at cutrate prices... but the ones that we can place have to work double shifts."

The AMA via controlling basically every hospital's management structure: "Oh, we can't possibly come up with 50k/yr per resident... we should hire more PAs at 80k/yr instead!"

If there were only two unions to bust, it would be the police union and the AMA.

PAs make quite a bit more than 80k a year though.

[Byrthnoth]

I googled, found 85k, and then lowballed it. Probably just regional variation.

[kuronosan]

PAs make quite a bit more than 80k a year though.

Which is sad, because they make about 90-110k a year at a Master's level while a post-doc PGY-1 or 2 makes almost half that. Working twice as much.

I mean, if it wasn't for the benefits they fork out I would probably also say fuck the AMA.

As far as controlling costs goes I feel like a lot of it stems from 1) hospital admins who aren't actually doctors and 2) insurance admins who aren't actually doctors making choices about the patient's care without actual input from doctors.

Having insurance companies hoard money and forcing patients to pay $400-500 a month for a policy they will either never use or have to pay money on top of anyway is silly. My wife and I the other day were talking about how essentially all the healthy and unhealthy people pay like $2000-5000 a year for health insurance on average only to have to pay like $2000-5000 in deductibles before insurance will start covering everything. And the worst part is, it makes sense from the standpoint of making sure you really need it before it pays out but the end result is making you pay out when you've already paid out, and then the even poorer population can afford neither and drive costs up because they get sick more often from receiving less care.

[Darus Grey]

On that last point, I've personally always thought a graduated/stepped co-pay makes a lot of sense in place of a deductible. First X services a year have essentially none, and then it rises past that with repeated use(up until the limit of what we now have as deductibles).

Goal being, don't put a barrier in front of people who need services(or are just being responsible with their checkups), put a disincentive to people using tons of services for no reason, and the people who pay the full deductible level fees are primarily those using tens of thousands of dollars+ of services.

I don't know how/if to address the issue of the person who is just legitimately chronically ill all the time, but even in that case, I think the above is still better than the status quo for them, and better for the population as a whole.

[Ragnus]

I remember growing up with my parents having a co-pay with their insurance, and even my first insurance plan was just a co-pay for most things. I'm not anywhere close to poor, but a deductible bill of a couple hundred dollars is enough to throw my finances off for a month or two. I swear my insurance coverage's quality to cost ratio plunged after the ACA got passed.

The last time I went to the doctor for my 100% covered check up, she made a follow up appointment for three months later. It was 15 minutes for a BP check, and a prescription. She also sent me to the lab for some blood work. Three weeks later I get around $400 worth of bills because the the follow up and blood work was only covered 20%.

[kuronosan]

That's the main issue I have in some cases - it makes sense to only order a Hemoglobin A1c, for example, every 3-4 months because it has no value (unless an erroneous result was suspected the first time, in which case it shouldn't be billed at all) otherwise. The problem is that umbrella covers things like X-Rays, where you need an absolute reason to do it when it isn't "algorithmically" indicated so the insurance company refuses to pay for it. That's largely the issue with algorithms in general (and a large problem I have with NPs/PAs) is that they need to be infinitely complex to be on the level of human intuition and training.

So many people think doctors can just be replaced by computers, but honestly without human interpretation of something an algorithm will ALWAYS miss it. That's something that annoys me greatly about insurance companies - some things are logical and should be controlled to control costs (ordering certain tests, for example). Others should be taken care of if there is medical justification for it. If someone comes in because I told them to follow-up because I was worried they might be developing diabetes complications, the patient shouldn't just be stuck with a bill.

I think Darus hit a good point too. We should be protecting people with chronic care issues and punishing people who just want to go to a doctor because they can. The current system essentially does the opposite - we punish people who don't go to the doctor because they can't and reward people who are healthy.

[Heavencloud]

Which is sad, because they make about 90-110k a year at a Master's level while a post-doc PGY-1 or 2 makes almost half that. Working twice as much.

I have a buddy who works as a primary care PA and he grosses 160k a year. It's insane. And the quality of PAs/NPs is so fucking variable. Some are absolutely great, but many are awful. They can make literally nearly as much as a pediatrician/family med physician who has 6+ more years of training.

[Seha]

I don't like Sam B much, but relevant to the discussion