At e21 Charles Blahous reviews the alternatives for paying for the health care of people with pre-existing conditions. He considers four alternatives:
1) Leave sick people to face the costs of their own treatment, whether out of pocket or through high-cost insurance, no matter how ruinous those costs become.
2) Mandate that other, healthier people overpay for the value of their own health insurance, so that sick people can underpay for the value of theirs.
3) Spread the costs of paying expensive health bills throughout society, for example by having taxpayers pick up the tab.
4) Require a targeted group to shoulder the costs.
My own preference is for a version of #3 but I would ask another question. Who should capture the economic surplus in health care? Consumers or producers? Right now producers capture the economic surplus.
Who should capture the economic surplus in health care?
I do not think it is a fair question. It does not account for the health surplus of advanced medical treatments and drugs. I think that this is the point that @steve makes. I do not know enough to have an informed opinion, but I think it should be included.
I would go with #3. It is really a question of what type of country want to have. Do we only want citizens who are healthy or who are rich?
An aside: For health insurance, allowing states to set their own rules and selling across state lines mutually exclusive. A free-marketer might prefer no rules by the states or federal government. While not desirable, rules by the federal government would allow “a level playing field” and selling across state lines.
It is easy to pout, stomp your feet, and hold your breath for almost 8 years, but as the Republicans have proven, doing something is not quite so easy.
That’s exactly what it accounts for. We are paying for care not health. Under the circumstances it’s not surprising that health care prices doubling or trebling do not result in even vaguely proportional improvements in health.
Real health care prices are a multiple of what they were years ago. Improvements in outcomes that can be attributed to improvements in care (e.g. rather than attributable to quitting smoking, etc.) are tiny by comparison.
Most of the low-hanging fruit in health care was harvested long ago and is handled by public health measures or infant or child health care. To my eye increases in prices are geometric while increases in life expectancy or any other measure of health I can think of are hyperbolic. That obviously can’t go on indefinitely.
It stands to reason the patient ought to come out the winner, otherwise medicine has no purpose. The best way to do that is a national health system (not based on the Canadian model, which I think is beset by a number of problems) that prioritizes keeping citizens healthy.
#3 is clearly, to me, the only route. It would be unfair, but as a practical matter its the only thing I see as politically possible.
Its unfair because people should suffer risk premium adjustment for their sins, and simply because life isn’t always a pure and fair model. I imagine there are very few who couldn’t have gotten themselves grandfathered in by buying insurance before their diagnosis. That they didn’t should to an extent be their responsibility. One of our own, Michael, who regales us with stories about how he doesn’t need or want tax cuts, on this very blog informed us all that his desire to see Obamacare pass was rooted primarily in the desire to have someone else pay for his statins. As for unfairness, I was subjected to unspeakable insult as a child, have disc disease (3 herniations) that runs in the family and a family history of diabetes. Is that “fair?” Should I have never paid a lick in premiums and then asked ‘society” to pay for my cervical fusions and 3 years of therapy for PTSD? I don’t think so.
But that’s all mumbo jumbo. That worldview will never get legislated, even if modified to have some bear at least a portion of the costs of their own actions or misfortune; and in the extreme case, we really don’t want to bankrupt or seriously financially harm, say, 5% of the population. From where I sit, grandfather everyone and establish one risk pool, not a 95% and a 5% preexisting conditions. Have the Treasury – the taxpayers – pay out to insurance companies a one time sum for embracing the pre-existing condition population, and on a go forward basis price everyone as they would normally. It will be messy and imperfect. So what? The current system is much worse and it scrapes away a huge issue. (Add portability and you are well down the road to a real fix of the insurance issue, although not the cost issue.)
This should pass in a heartbeat. I’m taking all the action I can that the Democrats would find a way to invoke #1 and attempt to scuttle the whole thing.
I imagine there are very few who couldn’t have gotten themselves grandfathered in by buying insurance before their diagnosis.
With household incomes flat for nearly forty years it becomes a matter of priorities. A lot of people just can’t afford insurance on top of daycare and transportation costs and housing.
I don’t really care about people’s sins. There’s far too much moralizing and holier-than-thouing in this country from liberals and conservatives and the religious and libertarians and god knows who else. Let’s put the judgement aside for once and make a choice that matters: should people be allowed to die for lack of medical care or should they not?
Mark Cuban suggests tax-paid catastrophic care for everyone with individual plans on top. Even those invincible kids pay.
I was a healthy kid once (with a policy) riding with the cutest curly-haired boy in a ’68 Mustang when it was T-boned by a Mark III.
For a first step, everybody needs to admit that health insurance is not and has no relation to insurance. It is a healthcare policy thingy. For real insurance, read your auto or homeowner’s policy. With good brake, I can stop sooner and decrease potential accidents, but Allstate does not pay for brake jobs for my car.
It is not that difficult to fix the problem. In New Orleans, the indigent went to Charity Hospital, and they were means tested. Then, you were billed on a sliding scale, and for most, they paid nothing. There were clinics for outpatient ongoing healthcare, and there were open wards for inpatient incidental/accidental healthcare.
If anybody thinks people were running down to Charity Hospital to get their free bed, you really should learn about wards, and anybody who enjoys waiting would love the clinics. Private insurance meant you could stay out of Charity. You did have to forego your free goodies.
As to other taxpayers bearing the burden, I am bearing a lot of burden for shit I will never use. Russia, China, or terrorists are not coming to my neighborhood any time soon, but I have to pay for the military. I am not going to be using the civil court system any time soon, but I have to pay for it so that companies can use it to screw me. I have not been on the road in years, but I have to pay for the FAA and TSA.
Here is an idea, pay for what you use. If you want a large military, there should be a box on tax papers for your share of the level you want. Every other public service should be billed as used. That goes for all the free riders on the public school system. You can start paying for your children’s education and stop taxing the non-breeders.
Holding forth “essential expenditures” with the specter of catastrophic harm if someone else doesn’t pay them is an old debating tactic. Its also pure bullshit. Eating vs certain death from disease is just a childish and false dichotomy. Everyone prioritizes their expenditures as they see fit and their circumstances dictate. Businesses do it. families do it. People do it.
The general issue here is the extraordinary escalation of an expense category – health care. (Education is another. I don’t think its just chance that payments for both are very influenced by government.) The specific issue is what to do about a tiny fraction of the population who for whatever reason haven’t made provisions for their health care. I advocate simply rolling over the problem with a payment. In the scheme of things it won’t break the bank and deals with a real issue. And for those unaware, many states, for years if not decades have covered the uninsured with pre-existing conditions.
The current debate is just an emotional, and for some a cynical, plea, as so much of politics is. I cant think of a better reason to not adopt a government run health care system.
Merely honing in on the categories listed in this thread, #3 sounds like the best choice. However, access to good healthcare for all is complicated by so many variables. And, usually when one variable is satisfied another coexisting one is put into Jeopardy.
Cost, however, is always a primary factor to consider, as is the fair/adequate disbursement of good healthcare services across the socioeconomic, metropolitan vs rural spectrums in this country. I’m not even going to hazard a way forward, except to say janis’s post about providing tax-paid catastrophic health insurance for everyone struck a good note with me.
#3 would be the worst, since i would require non-believers in insurance, like me and the Amish and Mennonites, to contribute to the religious superstition of others.
Been busy but just a few comments. First, high risk pools have never worked especially well. Most were pretty expensive (high deductibles also), most had waiting lists and then once you got coverage they would not pay for pre-existing illnesses for 6-12 months. So, a lot of people went w/o insurance, and it didn’t help a lot of people if they could get it. Really, if high risk pools worked well we probably would not have had the ACA to begin with.
When Dave poses the question as he does, most people are choosing #3. However, when you look at the policies they actually support, #1 is the default position of the GOP and the Dems would like to do #4, but also have to include bits of #2 and #3.
Assume that places like the UK, Singapore, France, etc. which have have world class health care also have world class (low) prices. No matter what you do health care is going to be expensive. A big chunk of people won’t be able to afford health care w/o insurance of some sort and many won’t be able to afford insurance. This i snot just an issue for those “other”people. Lose your job and you lose your insurance is the case for most of us.
Steve
This is not intended to disagree with what steve wrote above and while I recognize that he’s using the ordinary diction I genuinely wish that people wouldn’t refer to that as insurance.
What’s really being said is that somebody else will need to pay for it, i.e. that health care requires subsidies be paid to somebody by somebody else on behalf of yet somebody else. We’re calling that “insurance” but it really isn’t insurance in any technical sense.
Some people, mostly Republicans, think that we would be better off with a real insurance plan. Others, mostly Democrats, want to preserve the present system, just with ever-increasing subsidies. I disagree with both of those views. My thinking is more in line with Ben’s expressed above.
Besides the 4 options, there are a least two others:
1. Set up a medical savings plan for folks to invest in their future health care needs, much as they do for retirement.
2. Institute a plan for folks to borrow against future earnings or their estate much as they now do for college tuition, houses, and medicaid.
In this way, we can eliminate health insurance altogether along with the typical fees for insurance that amount to 25% tax on every healthcare dollar.
Here in Nebraska medical institutions typically shift unpaid medical bills to collection agencies within three months. Small claims only charges them $25 to file, sick people typically don’t show up for court, they know it’s useless, so with a judgement in hand, most medical bills are resolved through garnishment, which I’ve heard, is grounds for dismissal by most employers. After you lose your home or apartment, and job, you become difficult to locate, so collectors turn to automated dialers dialing disconnected numbers into infinity and beyond. Problem solved.
Basically, medical costs unreimbursed are sold at discount to willing brokers, collection agencies, who then willingly hound debtors to their graves and beyond.