Author Topic: Obamacare Repeal and Replacement  (Read 13499 times)

Gaoics79

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Re: Obamacare Repeal and Replacement
« Reply #50 on: March 26, 2017, 03:11:43 PM »
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If it's "no cost" to me on a trans-oceanic flight(particularly over the Pacific)? Yes I would. Now if we're talking a flight that lasts only a few hours, I'd be there in coach right beside you with all 6 feet of me.

I just came back from a Beijing trip a couple weeks ago. We flew direct to Beijing from Toronto. For a single round trip coach ticket on Hainan Airlines, the ticket cost us about $1,100 all-in. The same ticket first class would have cost us around $5,100 all-in. So basically that's near a 5x premium for first class. It was a 12-13 hour flight.

For the record, the leg room in coach was fine for me, and I am 6' tall. When I say "fine" I mean that there was ample space in front of my legs (probably 3-4" between the front of my knee and the seat in front) and I did not feel squeezed at all. Granted, I have had bad transatlantic flights where there was not this legroom, but on this flight, legroom was a non issue. And the plane appeared to be full.

The only time it made a significant difference was when I needed to grab something from under the seat and it was awkward. We were flying a nice 787 with modern amenities, we had individual video screens with lots of good movies and outlets and cellphone chargers at every seat.

What does your $4,000 get you for first class? Well you get on the plane first. Slightly pleasing - although something we take for granted as we usually fly with our toddler. You get leg room of course - alot more leg room. As I passed by I noted that the seats were more akin to what you get on a nice train - in coach mind you, but still not terrible. Not 5 star executive suites, but okay. Beyond that, I'm guessing that the food is better. But really, how good is first class food? I really really really doubt it's very good at all. I would be shocked if it were. Unless they have a chef up there preparing meals as you fly and a real kitchen - then it can't be anything other than more TV dinner garbage - probably made with better ingredients, but still TV dinner garbage. I imagine it's on par with the first class meals you get on the train - fancy TV dinners. I'd probably just eat at the airport anyway.

But let's say that you get an amazing 5 star restaurants quality meal (which is impossible on a plane, but whatever, let's pretend anyway), so what exactly am I paying $4,000 more for? More complimentary towels? That extra leg room? More attentive service? Where is that $4,000 of value coming from one wants to know? Is the flight shorter? Does jet lag not matter when you pay more for your ticket? Does getting a minivan to drive you to the gate make that extra difference compared with going in a bus? $4,000 was more than the cost of our entire trip, which included a 7 night stay in a 5 star Beijing hotel.

The only person who could rationally justify first class at a 5x premium  is 1) Someone not paying for his ticket; or 2) Someone who is so rich that $4,000 doesn't matter to them.

I sincerely doubt there are enough people in column 2 to make this a viable business at that price. Column 1 is, I strongly believe, where the customers are coming from. Take away column 1 and I sincerely believe there would be no first class, or if there was - it wouldn't be close to that price.

My cousin is a partner at a big Toronto accounting firm. She used to fly regularly to China. She only flew business class. She sincerely believed (and said) that her clients of course want her to fly first class. Something about productivity and being in top form when she arrived yadda yadda. I never heard such self-serving rationalizing, it was funny. Of course the people who were paying for her were no doubt flying first class themselves (and I'm sure charging it to someone else up the ladder too). Do you think my cousin flies first class on her own dime when she's not flying for work? (HA!). And her income with her husband's is scratching close to seven figures annually (not exactly a pauper). You get the picture.

Regarding the insurance premiums, what Letterip says makes perfect sense to me. The prices on the bills for US hospitals seem impossible - they come across as fantasy numbers. Somewhere down the line somebody is lining his pockets. Either that or it's smoke and mirrors.

« Last Edit: March 26, 2017, 03:16:08 PM by jasonr »

Gaoics79

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Re: Obamacare Repeal and Replacement
« Reply #51 on: March 26, 2017, 03:22:46 PM »
Just to add one last point: It's only smoke and mirrors so long as you play the game and pay the premiums. The prices are fantasies to those within the system, but for outsiders there is no magic trick. You pay the full price, however insane or ludicrous it may be. As a Canadian, I have always always always bought insurance when I have traveled to the USA. I do not so much as stick my pinkie toe across the border without insurance. Every Canadian knows has heard a horror story about someone crossing the border and getting appendicitis or breaking a leg and ending up with a $100,000 bill at the end.

Just because the prices are basically mirages and tricks of clever accounting, doesn't mean they can't hurt people.

JoshCrow

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Re: Obamacare Repeal and Replacement
« Reply #52 on: March 26, 2017, 04:22:09 PM »

Why would it cause the same effect in a single payer scenario?  In a single payer scenario you don't have the multiple and independent lines of bill payers (ie government, collective an individual).  You have a single-payer and they pick the price they will pay (again, often without regard to the actual costs of the service). 

Our formula is related to the prevailing price of a service (what is supposed to be the market price).  The government finds it convenient to lower the rate of reimbursement when it needs to control costs, without regard to whether this results in fair compensation.  That's what causes an incentive to force the prevailing price ever higher (so that this declining reimbursement percentage results in a similar sized payment).  Keep in mind this is a problem with central government, they can not effectively monitor whether a fair price is being paid for every service at every location in the country so they have to pass one size fits all prescriptive rules to try and limit the ability of locals to manipulate them.  A problem that is completely fixed by having the consumer make the pricing decisions.

Wait... what? You're telling me it's beyond the ability of government to monitor fair prices at a local level? That doesn't sound like a particularly challenging task for a team of researchers. I think you're overstating the difficulty there.

I also would challenge your assertion that government picks prices without regard to compensation. Negotiating prices that are fair and provide ample margins to vendors and providers is *exactly* how other countries have done it successfully for generations now. I think that you're really fixated on the ineptitude of (specifically) American government. If so, then so be it, but this isn't really a problem in peer countries. Your argument may well rest on simply a skepticism that the US can have a capable government operation.

JoshCrow

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Re: Obamacare Repeal and Replacement
« Reply #53 on: March 26, 2017, 04:24:09 PM »

TheDeamon

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Re: Obamacare Repeal and Replacement
« Reply #54 on: March 26, 2017, 09:02:28 PM »
What does your $4,000 get you for first class? Well you get on the plane first. Slightly pleasing - although something we take for granted as we usually fly with our toddler. You get leg room of course - alot more leg room. As I passed by I noted that the seats were more akin to what you get on a nice train - in coach mind you, but still not terrible. Not 5 star executive suites, but okay. Beyond that, I'm guessing that the food is better. But really, how good is first class food? I really really really doubt it's very good at all. I would be shocked if it were. Unless they have a chef up there preparing meals as you fly and a real kitchen - then it can't be anything other than more TV dinner garbage - probably made with better ingredients, but still TV dinner garbage. I imagine it's on par with the first class meals you get on the train - fancy TV dinners. I'd probably just eat at the airport anyway.

At least the couple of times I snagged a "space available" upgrade to First class on a several hour flight, the seats were much larger. While coach was 3 seats across, first class was 2. Leg room was significantly increased as well.  The seats were of a higher quality/more comfortable, and reclined back further. The service was much better as well, and (alcoholic) drink service was available, something coach didn't have on that flight. Yes, the flight attendants were also much more attentive. On a comparable flight with that airline in coach, IIRC, drink service only happened once. As a first class passenger, they came by three times. The (snack) food service was also very slightly upgraded, but you're correct, it isn't a significant improvement. But it's also been 10 years since I last boarded a plane.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #55 on: March 27, 2017, 10:18:14 AM »
Seriati,

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You have a single-payer and they pick the price they will pay (again, often without regard to the actual costs of the service).

Actually it is generally negotiatied, and the negotiated prices reflect actual time and material estimates based on research.

Prices being set by research and prices being set through free negotiation are contradictory concepts.  Which is the case?

Single payers win expense reduction by refusing to pay more than they want and expecting the suppliers to become more efficient (but not really caring if they do), basically they act like Walmart.  The suppliers meanwhile (if they are for profit) look for what ever places they can find higher margins and maximize those services.  You can watch service change patterns align very rapidly towards the highest margin services (regardless of medical need).  Usually, the way they work around this is by nationalizing parts of the system - like doctors no longer work for themselves for profit - or by abusive threats - produce medicine x for 1/10 its price to others or we will nationalize its formula as a matter of national necessity.

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Overcharging is dozens of things, but its root is government manipulation of the pricing market.  You're misidentifying symptoms as causes in the below:

No, it is predominantly those two things I listed.  It is unbridled greed and gaming of the system.

It's really not.  See I can say nuh uh too. 

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And why are they set up to do that?  The insurance company that is paying the bill makes more money if they pay less, why would they pay a third party a fee just to get to a higher price themselves (before you even consider the fee)?  Does that sound like a rational decision?  Do you really believe that some of the best predictors of financial results in the world (ie insurance companies) voluntarily create a system when they have higher expenses than they have to?

I think you misread or misunderstood.  Insurance companies make the most money when prices to uninsured are artificially high and when prices to the insured look high and they appear to be providing major value.

I didn't misread, you did.  In your first link there is more than one player on the insurance end.  There's the employer sponsored plan paying the bill, and a separate company that's getting the fee for negotiating the reduction.  Effectively, a broker is once again interfering in the price decision, but now we have more than one person being insulated from the real price.  Why is the broker there in the first place?  You guessed it, government regulations.  The government set up the complex tax rules that are what cause companies to make decisions about whether to use company funded plans or other plans, and the regulations for their administration are so complex that the companies have to retain specialists like the broker in order to ensure they comply with the regulations and protect them from innocent mistakes in selection of products.  There are many different fiduciary concepts at play here that force how that works.

In your second link, start at page 32 and re-read the section on incentives to overcharge.  Virtually every paragraph is tied into governmental regulation issues and/or percentage payment problems.  Look, for example, at the section where Obamacare forced insurers to pay for a portion of out-of-network emergency care - previously the patient's responsibility.  These are situations where there is no ability for the insurer to negotiate ahead of time.  What was the result of the change?  Virtually across the board increases in emergency rates, and some hospitals refusing to negotiate with insurers (as the fixed force rate is a better deal for them).  Heck they give an example of a hospital that went from failing to profitable by refusing to negotiate with insurers and living off of forced out-of-network payments.  Governmental regulation which causes an incentive for increased unrealistic prices because of a formula, generates increased list prices.

Look too at section d, which skips over the DRG calculation - which is still a current issue that does the same thing - to focus on the historical outlier payments.  It walks you through exactly what I said above, though it does so as a matter of history as the authors believe its been resolved.  But after you read it, take a look at the DRG calculation and you'll see it may not be as resolved as they imply (not to mention, they cite still occurring 2013 cases in this 2014 paper).

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Do you want insurance that pays 33% of a bill or that appears to save you 90% of the bill?

You as the consumer don't care, you only care about the co-pay.  The link was you cited was complaining about the apparently unsophisticated company paying for its company sponsored plan being tricked by an unscrupulous but more knowledgeable broker.  I can tell you flat out, the author is ignoring the risk calculation that goes into that process - probably because like many, he really doesn't understand why companies make the decisions they do.  Paying more to a broker who has medical expertise is a very strong defense to medical liability for the plan.  Seeking out and obtaining lower cost solutions by the company on its own, would almost certainly be taken as proof of a breach of duty to the plan holders in any case that has a bad result.  That's the governmental background that forces these results, if you want to change it, you have to look at fiduciary standards and liability standards - both court and regulatory.

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So an artificially high price that they don't actually pay gives the consumer the 'wow my insurance saved me so much' and a disincentive to not be insured 'wow if I'm not insured it will cost me far too much'.

Please re-read your own links.  There's nothing about the "consumer" in them.  The broker example is talking about the company not the consumer getting overcharged. 

I'll be happy to work through a model with you, after you have a chance to revise them.

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Tax deductions are deliberate governmental manipulation - trying to attribute them to private actors is beyond the pale.

I wasn't complaining about tax deductions.  I was talking about deliberately inflating costs to create a large deduction well beyond the cost of providing the care.  The tax deduction was created so that the 'must treat all that need care' wouldn't be burdensome and could be completely offset via tax deduction - what I find unreasonable is massive over inflation.

This is from your second link, and per the discussion in part c after page 32, the charitable deduction loophole has been closed.  Though I note it wasn't a tax deduction per se, it was used to allow hospitals to fill up their charitable service requirements with less care provided (if you have to provide $4m, but you can do it at $100k a pop (marked up price) versus $10k a pop (actual cost to provide) it makes a difference.

Definitely adds to the pressure, but honestly doubt it was the most material factor for any but the most high-end hospitals that wanted to avoid charity work at all costs.  You know the same ones that will "close" when there is an influx of uninsured patients and send them elsewhere.

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Your thesis appears to be that these manipulations are somehow the fault of the government - rather than the obvious deliberate abuses that they are.  Apparently in your reality businessmen never engage in shady practices to maximize profit and everything bad is due to wrong action of the government.  It truly impresses me the idealogical gymnastics you go through to blame the government and excuse the inexcusible behaviour of businesses.

I think when people fail to see the hand of the government its generally because they've never seen these decisions from the inside.  There are plenty of shady people in business, but you'd be surprised how many more there are that are not shady.  Businesses have an active incentive to catch and weed out offenders, and companies spending hundreds, thousands, or even hundreds of thousands to millions of hours on compliance to try and get it right (not to find shady ways around it).

Every single thing you've complained about is a specific corporate reaction to governmental incentives and forced obligations and risks.  When you add corruption and greed, which certainly exist, it gets even worse.

Maybe try to open your mind on this, and ask yourself why companies where good people are in charge who are honestly trying to do the right thing often end up in exactly the same place as those you think are acting solely because of greed.  The idea that "companies" are made up of a different type of people than the rest of the world is silly, as is the idea that they are not reacting to the big stick the government is wielding, but are solely out there generating brutally stupid models of business out of "greed."

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #56 on: March 27, 2017, 10:28:13 AM »
Wait... what? You're telling me it's beyond the ability of government to monitor fair prices at a local level? That doesn't sound like a particularly challenging task for a team of researchers. I think you're overstating the difficulty there.

I'm telling you its beyond the ability of a central government, at least for a large or disparate country.  You'll note these rules are federal rules and they deliberately have overwritten the local decision making process.

You want to know why?  Because when you devolve decision making with government funds to hundreds and thousands of low level employees the history of the government is to always have run away corruption.  The Housing authorities are infamous for their corrupt deals, as are government appropriations, military spending, pretty much every source of government cash has known issues with corruption and sweet heart deals. 

A policy that says to pay the doctors a fair local rate?  What do you get, thousands of decisions that are fair, and what hundreds that let in corruption?  When the decision makers are locale, do you think the price the government pays tends to go up or down?  You don't have to speculate, the history is not downward.

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I also would challenge your assertion that government picks prices without regard to compensation. Negotiating prices that are fair and provide ample margins to vendors and providers is *exactly* how other countries have done it successfully for generations now. I think that you're really fixated on the ineptitude of (specifically) American government. If so, then so be it, but this isn't really a problem in peer countries. Your argument may well rest on simply a skepticism that the US can have a capable government operation.

Fair criticism.  There's nothing about the American prices that is reasonable, that doesn't mean that prices in other countries with a single payer are not.  Honestly, what is the "price" for a doctor's time?  A bunch of these costs are just tied into what we think a doctor should earn.  If the doctors in a country are happy with their compensation and work load that seems like a good result.

I think its a different issue when we're talking about the advancement of medicine rather than the availability of treatment, and the US's insistence on mixing the two causes a lot of the good and the bad here.  I think you're ignoring the issue that the single payer government systems remove a lot of the incentive to innovate and slow the rate of medical advancement.

JoshCrow

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Re: Obamacare Repeal and Replacement
« Reply #57 on: March 27, 2017, 06:32:04 PM »

when you devolve decision making with government funds to hundreds and thousands of low level employees the history of the government is to always have run away corruption.  The Housing authorities are infamous for their corrupt deals, as are government appropriations, military spending, pretty much every source of government cash has known issues with corruption and sweet heart deals. 

A policy that says to pay the doctors a fair local rate?  What do you get, thousands of decisions that are fair, and what hundreds that let in corruption?  When the decision makers are locale, do you think the price the government pays tends to go up or down?  You don't have to speculate, the history is not downward.


And yet, generally speaking, US corruption is historically quite unremarkable, perceived as being in the middle of the first-world pack...
https://en.wikipedia.org/wiki/Corruption_Perceptions_Index

Without excusing the existence of corruption (since it obviously is part and parcel with governance), why is this more undesirable than the situation we have now, where we KNOW price fixing is taking place in order to line the pockets of private industry? It seems to me that one picks one's poison according to one's relationship with authority... the folks to dislike authority will claim that market forces will reduce unscrupulous private practices, and those (lefties) who prefer their bad guys to be corporate-flavored will claim that democracy/elections at least create a public accountability for corrupted government officials, who can be removed from office.

I know I am from the latter camp there and you the former... I still think government corruption in the US is more easily combated than it is in private industry. The existence of lobbying muddies the waters between these camps, though.

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Fair criticism.  There's nothing about the American prices that is reasonable, that doesn't mean that prices in other countries with a single payer are not.  Honestly, what is the "price" for a doctor's time?  A bunch of these costs are just tied into what we think a doctor should earn.  If the doctors in a country are happy with their compensation and work load that seems like a good result.

I think its a different issue when we're talking about the advancement of medicine rather than the availability of treatment, and the US's insistence on mixing the two causes a lot of the good and the bad here.  I think you're ignoring the issue that the single payer government systems remove a lot of the incentive to innovate and slow the rate of medical advancement.

I think you raise a good point here about innovation. I understand that recouping R & D costs is driving a lot of pricing, and that R&D itself is a very risky venture where the number of failures vastly outstrips successes. That being said, I've lately become personally rather dismissive of innovation efforts (and this as an engineer) because I am skeptical of (wait for it) how money is being appropriated and managed. For example, if a treatment for disease were developed that cost only $0.10 to produce you can bet it would go ignored over one that Martin Shkreli could jack up the price on. In this way, R&D in pharma has been corrupted away from cheap solutions that could help people.
Because of all the BS that results from profit-taking in medical R&D, I tend to think that it is more important to make efforts to affordably distribute current treatments than it is to develop new ones. That might just be me, though.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #58 on: March 27, 2017, 07:21:41 PM »
JoshCrow, when I read people complaining about "profits" as if they are evil it always gets me a little worked up.  Profits are not evil.  Pursuing profits in ways that harm people can be, but the left is filled with people who overestimate how much profit is in a product.

Take a look at the research on the cost to bring a drug to market in the US, and to get the required FDA approval.  There are recent estimates that put the costs at about $2.5 billion per drug.  That is an absolutely insane governmentally added cost.  Costs can be that high even where a drug has been on the market for years or even decades in Europe.  I don't get why you're worked up about out of control profits, but not out of control regulatory add ins?

I grant you Martin Shkreli should just be put in jail.  I'd love to see patent and copy right reform that brings those laws back in line with their true purposes and stopped them being an out of control corporate give away and abuse factory.

LetterRip

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Re: Obamacare Repeal and Replacement
« Reply #59 on: March 27, 2017, 07:44:10 PM »
Seriati,

I wasn't basing my information on those links, I was providing those links in addition to what I know from previous research from when I was thinking of setting up my own insurance company. Those links showed additional ways in which insurance companies were screwing over the public, rather than being redundant to what I said.

So yes you did indeed misread and misunderstand and I had neither misread nor misunderstood.
« Last Edit: March 27, 2017, 07:56:12 PM by LetterRip »

JoshCrow

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Re: Obamacare Repeal and Replacement
« Reply #60 on: March 27, 2017, 07:57:31 PM »
JoshCrow, when I read people complaining about "profits" as if they are evil it always gets me a little worked up.  Profits are not evil.  Pursuing profits in ways that harm people can be, but the left is filled with people who overestimate how much profit is in a product.

I hope you award me enough courtesy to recognize that I'm not some version of that "left" person you have described. I, too, believe capitalism is important. That being said, if the world were my plaything, I could see myself having market-based systems in some areas of life and state-managed efforts in others where I think the profit-motive inherently corrupts the proper function of the system (health care, for one... and I'm seriously considering adding "journalism" to that list given the essential role it fills). I do believe, as you do, that pursuing profits in ways that harm people can be evil - and I include "making life-giving services prohibitively costly to access" to that list.

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Take a look at the research on the cost to bring a drug to market in the US, and to get the required FDA approval.  There are recent estimates that put the costs at about $2.5 billion per drug.  That is an absolutely insane governmentally added cost.  Costs can be that high even where a drug has been on the market for years or even decades in Europe.  I don't get why you're worked up about out of control profits, but not out of control regulatory add ins?

I'll be perfectly honest in answering that - it's a lot easier for me to smell injustice in pursuit of profits than to identify a regulation that I disagree with. "Regulation" isn't a very good motivator for me simply because I imagine those regulations being there for a valid reason. I usually challenge people to point out a (specific) bad regulation, because I can then sometimes agree and say "yes, that's a bad/meaningless/inane one and should be removed". But in general I can't see them as a boogeyman simply because I think regulations in general are important.

Fenring

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Re: Obamacare Repeal and Replacement
« Reply #61 on: March 28, 2017, 12:49:33 AM »
And yet, generally speaking, US corruption is historically quite unremarkable, perceived as being in the middle of the first-world pack...
https://en.wikipedia.org/wiki/Corruption_Perceptions_Index

The problem with analysis like this is that not all corruption is created equal. In some countries you can't get anything done in the public sector without an appropriate kickback going to the people doing the work. In others you can't open a business without giving the local boss his cut. That is certainly a kind of inbred corruption that places like the U.S. don't see anymore. Even in first world countries there are no doubt some kinds of corruption that Americans would think of as third world crap. So on the basis of average day-to-day life the U.S. is rather devoid of blatant corruption. An obvious exception to this usually presents itself at the municipal level where one often finds blatant corruption in the mayor's office and in areas like construction and sometimes with the police. But it's still not the kind of thing that the average person sees in daily life for the most part. However the danger in a place like the U.S., with such a vast and powerful central government (and this is the prototypical argument against big government) is that even a small amount of corruption will yield massive effects when that kind of power is brought to bare. You can have a fairly clean nation overall, and even have the Congresspeople for the most part do their jobs correctly, and yet if certain very particular areas of their behavior are beholden to certain special interests, the effect will be so pervasive that it will dwarf all of the accumulated minor corruptions that pervade every transaction in a place like India.

There's a lot to say about how 'clean' some aspects of American life are, but I wouldn't use a study like the one you linked to try to show that the government is operating on a relatively decent basis.

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I still think government corruption in the US is more easily combated than it is in private industry. The existence of lobbying muddies the waters between these camps, though.

I hope Seriati would agree with my reply here, which is that the issue isn't whether the government or the private sector 'would be' more corrupt than the other if given the chance. The point is specifically the nature of the relationship between the government and the private sector. I very much doubt Seriati would take a hard libertarian stance and advocate for no government, but I, at any rate, would advocate for a government model divorced utterly from monetary influence from the private sector. I would go so far in that direction that I would prefer them not even being on speaking terms rather than offer the slightest chance they might collude together. I think that when some people blame "the government" for various problems, what they really mean is that there are levers attached to government that private interests can pull and cause damaging effects. Seriati seems additionally to believe that government is inherent incapable of operating anything properly even without these kinds of corruptions, but I would maintain that this theory has never been put to the test because so far our only observation of governments have been incorrectly designed ones quite open to various corrupting influences. I think that if these avenues were closed off the people in government trying to do their jobs would muddle through ok.

DonaldD

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Re: Obamacare Repeal and Replacement
« Reply #62 on: March 28, 2017, 07:16:33 AM »
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Even in first world countries there are no doubt some kinds of corruption that Americans would think of as third world crap.
What, like civil asset forfeiture, or threatening people who owe fines with prison?  Yes, that is a real problem in the USA.

Fenring

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Re: Obamacare Repeal and Replacement
« Reply #63 on: March 28, 2017, 10:05:52 AM »
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Even in first world countries there are no doubt some kinds of corruption that Americans would think of as third world crap.
What, like civil asset forfeiture, or threatening people who owe fines with prison?  Yes, that is a real problem in the USA.

You'll get no argument from me on that. I don't think the average citizen experiences these problems directly, but enough do that I'd call it pervasive. I did mention that one of the remaining significant corruptions in the U.S. lie in the area of police. I'm not well versed enough to be able to say whether the civil asset forfeiture tends to be conducted by municipal cops versus state troopers, though.

JoshCrow

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Re: Obamacare Repeal and Replacement
« Reply #64 on: March 28, 2017, 10:37:31 AM »
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Even in first world countries there are no doubt some kinds of corruption that Americans would think of as third world crap.
What, like civil asset forfeiture, or threatening people who owe fines with prison?  Yes, that is a real problem in the USA.
Wait... I'm not clear on why prison is a) inappropriate and b) "corruption" for people who refuse to obey the law.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #65 on: March 28, 2017, 12:22:50 PM »
Seriati,

I wasn't basing my information on those links, I was providing those links in addition to what I know from previous research from when I was thinking of setting up my own insurance company.

I don't know what to make of you then.  There's no way to set up an insurance company and not be driven mad from the regulatory burden, to not be aware of the inefficiencies of government requirements and have a basic knowledge of how many of the things you complained about are the result of a legally defensive decision making strategy.  Insurance companies are experts at making risk decisions, and that means covering off bad risk results where you can do so comparatively inexpensively - they always cover the risks.

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Those links showed additional ways in which insurance companies were screwing over the public, rather than being redundant to what I said.

Except the links didn't precisely show that and certainly did nothing to undermine my claims about this being the result of government policy.  If you think they did, then I have to question your interpretation of other facts not in evidence as well.

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So yes you did indeed misread and misunderstand and I had neither misread nor misunderstood.

What did I misread?  Seriously, that's a bizarre claim if you're justifying it by reference to information you didn't include in writing in your post.

Not sure you have reasonable claim to misunderstood either.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #66 on: March 28, 2017, 12:32:28 PM »
I hope you award me enough courtesy to recognize that I'm not some version of that "left" person you have described. I, too, believe capitalism is important.

Honestly, I bring it up because we're all flooded with it constantly, and propaganda works.  It's important to address it when it's leading to implications or appears to be the result of an unproven assertion working its way in as a "fact" upon which an argument relies.

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That being said, if the world were my plaything, I could see myself having market-based systems in some areas of life and state-managed efforts in others where I think the profit-motive inherently corrupts the proper function of the system (health care, for one... and I'm seriously considering adding "journalism" to that list given the essential role it fills). I do believe, as you do, that pursuing profits in ways that harm people can be evil - and I include "making life-giving services prohibitively costly to access" to that list.

Well me too.  I've advocated more than once for making care of extreme, expensive and fatal conditions solely the responsibility of the government.  The appropriate decision making process on those is almost certainly utilitarian and when its the government and the tax payers directly footing the bill they can make the choice how utilitarian they want to be.

What I don't like, is the government imposing those costs on third parties.  And arguments about unfair profits, are exactly why people think its "fair" to impose millions dollars on expenses on a risk pool that it never got paid to bear.  The whole system is deliberately designed primarily by the government, but also by the industry, to misdirect and hide the costs.

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I'll be perfectly honest in answering that - it's a lot easier for me to smell injustice in pursuit of profits than to identify a regulation that I disagree with. "Regulation" isn't a very good motivator for me simply because I imagine those regulations being there for a valid reason. I usually challenge people to point out a (specific) bad regulation, because I can then sometimes agree and say "yes, that's a bad/meaningless/inane one and should be removed". But in general I can't see them as a boogeyman simply because I think regulations in general are important.

$2.5 billion, important?  More important that letting people choose to accept the risks rationally?  I can't see any reasonable cause not to let the fatally ill take a chance if they want to do so.  Honestly, the only issue here is one of whether people can really judge risks, and I don't see it as a $2.5 billion benefit to help people judge those risks (particularly when the process still lets massive side effects through regularly). 

Regulations are supposed to exist to make our lives better.  They should always be weighed against commercial reasonableness.

Personally, I think every regulation that is not affirmed by Congress and the President - and thus granted similar standing to law going forward - should be revocable by a majority of Congress without the President's involvement.

LetterRip

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Re: Obamacare Repeal and Replacement
« Reply #67 on: March 28, 2017, 02:12:46 PM »
Seriati,

in regards regulation - there are generally two types of regulation

1) regulations that were created because it was discovered how an industry was screwing over the public or endangering their employees
2) regulations that were implemented at the behest of industry in order to create barriers to entry for competitors or to screw the public

Almost all of the complaints about regulation by Republicans are in regards to 1 and generally Republicans are quite willing to implement #2 for industries.  I do think that in response to misbehavior by corporations that the correct regulation isn't always implemented and even at times there are useless 'seen to be doing something' regulations.  However, generally the reason for the regulation is sound.

Personally I'd like regulations annotated with the concern they are attempting to address and be revisited to examine their effectiveness for addressing the concern; and whether the regulation might be changed to more effectively address the concern while reducing compliance burden.

JoshCrow

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Re: Obamacare Repeal and Replacement
« Reply #68 on: March 28, 2017, 02:16:57 PM »

$2.5 billion, important?  More important that letting people choose to accept the risks rationally?  I can't see any reasonable cause not to let the fatally ill take a chance if they want to do so.  Honestly, the only issue here is one of whether people can really judge risks, and I don't see it as a $2.5 billion benefit to help people judge those risks (particularly when the process still lets massive side effects through regularly). 

Regulations are supposed to exist to make our lives better.  They should always be weighed against commercial reasonableness.

Personally, I think every regulation that is not affirmed by Congress and the President - and thus granted similar standing to law going forward - should be revocable by a majority of Congress without the President's involvement.

Well, I admittedly don't know where that number is from, but $2.5B works out to about $9 per person in the US. Is that an unreasonable imposition to support the public good of having people judge health risks better? It doesn't seem so to me, on the face of it. I suspect it makes a significant difference in actual health outcomes. And I'm a guy who thinks people should have the right to kill themselves as they see fit (my positions on many hot-button issues can be charmingly summed up as "pro-death")! But I view the common good as a high-value commodity that suffers heavy neglect under the "everyone-is-an-island-of-liberty" ideology. Profit-taking is essentially more like profit-scrounging for me - you make money where you can without impinging on the common good.

DonaldD

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Re: Obamacare Repeal and Replacement
« Reply #69 on: March 28, 2017, 04:05:16 PM »
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Wait... I'm not clear on why prison is a) inappropriate and b) "corruption" for people who refuse to obey the law.
Quite aside from how the threat of prison can be used selectively against particular populations, are you really in favour of debtor's prison?

But on the subject, yes; the threat of prison for debt is absolutely corrupt as implemented in the USA, and has lent itself to the creation of a cottage industry of for-profit mercenaries.  It is also, by the way, not constitutional; so again, only implemented against people without the ability to hire sufficient legal representation.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #70 on: March 28, 2017, 04:58:49 PM »
Seriati,

in regards regulation - there are generally two types of regulation

1) regulations that were created because it was discovered how an industry was screwing over the public or endangering their employees
2) regulations that were implemented at the behest of industry in order to create barriers to entry for competitors or to screw the public

You forgot:

3) regulations that have been implemented to advance a political agenda that can not pass through Congress.
4) regulations that have been implemented to increase the authority of the regulatory agency that implements them.

and of course:

2a) regulations that were implemented at the behest of [special interests] in order to [manipulate an industry and] to screw the public.

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Almost all of the complaints about regulation by Republicans are in regards to 1 and generally Republicans are quite willing to implement #2 for industries.

Most of the complaints by Republicans are about 2a, 3 and 4.  The fact is that administrative agencies routinely exceed their authority (which is specifically limited) and pass ideological mandates on as regulations that are supposed to balance the economics versus the benefits.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #71 on: March 28, 2017, 05:01:24 PM »
Well, I admittedly don't know where that number is from, but $2.5B works out to about $9 per person in the US. Is that an unreasonable imposition to support the public good of having people judge health risks better?

$9 per person, per approved drug.  How many approved drugs are there?  And almost none of them are used by "every American".  That costs is 350x higher if only one million people need a drug.  It's 100x higher if just 100 drugs get approved in a year.  For a family of 4 its 4x higher.

It's disingenuous to pretend that it's $9 one time.

JoshCrow

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Re: Obamacare Repeal and Replacement
« Reply #72 on: March 28, 2017, 08:22:03 PM »
Well, I admittedly don't know where that number is from, but $2.5B works out to about $9 per person in the US. Is that an unreasonable imposition to support the public good of having people judge health risks better?

$9 per person, per approved drug.  How many approved drugs are there?  And almost none of them are used by "every American".  That costs is 350x higher if only one million people need a drug.  It's 100x higher if just 100 drugs get approved in a year.  For a family of 4 its 4x higher.

It's disingenuous to pretend that it's $9 one time.

I wasn't being disingenuous, I just didn't even know where that $2.5B number was from or what it meant. Technically, I still don't, so I'm happy for a link.

linuxfreakus

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Re: Obamacare Repeal and Replacement
« Reply #73 on: March 28, 2017, 11:44:58 PM »
There is no freakin way it costs $2.5B or $5B per drug depending on what industry funded "research" you look at.  For starters all drug company R&D costs are tax exempt, thats a huge break.. not to mention all the other subsidies and thinly veiled money laundering schemes they engage in (playing shell games with overseas "investments").  All perfectly legal by the way... but IMO it is a huge rip off.  I'd be surprised if their actual cost is much more than a tenth of what they claim.  They probably spend more than that and line their pockets but it shouldn't cost that much.  Otherwise how is it that small biotech startups are able to develop things?  They don't start out with billions, but they still make things (often getting bought up by the big companies to avoid having any competition if they start making too much noise).

This is isn't an example of full development cost, but it is nevertheless an example of borderline criminal price gouging:
http://www.theeventchronicle.com/health/epipen-goes-300-30-3-opensource-3d-printing/
« Last Edit: March 28, 2017, 11:51:46 PM by linuxfreakus »

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #74 on: March 29, 2017, 10:48:50 AM »
This $2.5 billion claim, which is widely cited if you look for it, comes from a Tuft study, you can read about it here:

http://csdd.tufts.edu/news/complete_story/pr_tufts_csdd_2014_cost_study

The out of pocket costs are about half and the time value of the money spent is the other half.

Edited to add:  There also seems to be a Doctor's without Borders response claiming drugs can be developed for $50 -$180 million, but its a bit deceptive because it's doing that by getting more "free" money from the government, which its not counting.  By that measure, drugs could also be developed for "free".
« Last Edit: March 29, 2017, 10:55:06 AM by Seriati »

linuxfreakus

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Re: Obamacare Repeal and Replacement
« Reply #75 on: March 29, 2017, 11:36:26 AM »
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The Tufts Center receives unrestricted grants from pharmaceutical and biotechnology firms, as well as companies that provide related services to the research-based industry (e.g., contract research, consulting, and technology firms). These grants represent approximately 35% of Tufts CSDD’s operating expenses.

They are not objective, they are funded to a large extent by the drug industry. It is in the pharmaceutical industry’s best interests to have the public believe that it is very expensive to develop a drug. I suspect (although can't prove since they don't release data from the study, nor has it been peer reviewed) that their methodology is deeply flawed.

What I do know is that I have consulted for small biotech startups, and I know what their budgets were.  I have non-disclosure agreements, but I can promise you, they are nowhere near these type of numbers and they are doing great work.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #76 on: March 29, 2017, 12:41:37 PM »
But have they gone through the FDA process and brought a drug to market, or are they producing products to sell off to other vendors?

Of course it's an estimate, but it was based on a look at the costs of brining over 100 drugs to market.  Some may dispute the financial costs component, but when you need to raise over a billion dollars in direct expenses it's totally reasonable to include the opportunity costs. 

There is no such thing as objective on these matters, I agree they seem to have an industry focus and that should be considered.  In any event, its way too much to be spent.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #77 on: March 29, 2017, 01:40:25 PM »
Here's a link to an opinion piece by John Stossel that summarizes a lot of what I have been thinking on the how and why of the inefficiency of the government's interference in the health insurance market.

https://www.creators.com/read/john-stossel

He raised an interesting point, that I had not previously considered, in pointing out that what American's might expect from a single payer model - ie the same level of immediate response they feel entitled to now, just without any apparent cost - is not a hallmark of single payer systems, and may in fact cause a "US single payer model" to set whole new records in expense.

TheDeamon

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Re: Obamacare Repeal and Replacement
« Reply #78 on: March 29, 2017, 02:34:19 PM »
He raised an interesting point, that I had not previously considered, in pointing out that what American's might expect from a single payer model - ie the same level of immediate response they feel entitled to now, just without any apparent cost - is not a hallmark of single payer systems, and may in fact cause a "US single payer model" to set whole new records in expense.

Or alternately, turn it into "a very short lived experiment" that either is aborted entirely, or we get to watch as the secondary Insurance market doesn't go away(as I understand happened in Britain), and it suddenly becomes the new defacto standard insurance offering for those lucky enough to afford it. While everyone deals with the "affordable" (and low priority) single payer public option.

Edit to add: That actually is an outcome I'd be somewhat ok with as I think about it. So long as the preventative care side of things doesn't end up with waiting lists so long it isn't very preventative at all.

linuxfreakus

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« Reply #79 on: March 29, 2017, 03:08:17 PM »
But have they gone through the FDA process and brought a drug to market, or are they producing products to sell off to other vendors?

Of course it's an estimate, but it was based on a look at the costs of brining over 100 drugs to market.  Some may dispute the financial costs component, but when you need to raise over a billion dollars in direct expenses it's totally reasonable to include the opportunity costs. 

There is no such thing as objective on these matters, I agree they seem to have an industry focus and that should be considered.  In any event, its way too much to be spent.

In the companies I've been involved with, they are either still iterating, or they have been bought up by large pharma and are being brought to market still... none are actually available outside of special trials.... but the primary barrier in the FDA approvals is the insane amount of *time* it takes.... in most "studies" I've seen they attach huge monetary values to that time.  IMO, that is complete nonsense.  Sure, they could take that money and invest it in real estate or something else, but ultimately, if they are in business to produce pharmaceuticals, they have to realize that if they don't wait it out, they don't get to sell a product later, and just because they feel like they could be making more money if they did stuff differently doesn't make it valid to claim that as part of the development costs.  The actual costs are the people's salaries and various other overhead.

linuxfreakus

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Re: Obamacare Repeal and Replacement
« Reply #80 on: March 29, 2017, 04:00:20 PM »
Not to mention, once their dev (or acquisition -- since they get a lot of their stuff from acquisition) pipeline is full and producing things, they are selling things and making money all the time, so their claims about opportunity cost are sort of absurd in that respect too.

LetterRip

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Re: Obamacare Repeal and Replacement
« Reply #81 on: March 29, 2017, 05:59:45 PM »
Seriati,

in your article,

he says that ACA madates,

Quote
—Birth control.
—Alcohol counseling.
—Depression screening.
—Diet counseling.
—Tobacco use screening.
—Breastfeeding counseling.

Each unwanted child costs the state potentially 100,000's of dollars and will have pregnancy related costs of 20k+.  So birth control is a major net savings both for the government and the insurance provider.
Alcohol, Depression, Obesity, and Tobacco use are all major cost drivers of health care - so mandating those should save many billions of medicare spending.
Breastfeeding counseling is the only odd one out and it may also be a huge area of savings if it improves early childhood nutrition.

So he listed all negative cost items...

He states that stuff covered increased in cost, but stuff not covered (LASIK, plastic surgery) fell in costs.

Price of LASIK fell because the patent expired and economies of scale and huge amount of competition; and the price of plastic surgery fell because non-specialists started doing it. 

http://www.nytimes.com/2012/01/31/health/non-specialists-expand-into-lucrative-cosmetic-surgery-procedures.html

Since they are non critical they are subject to price competition.  Required medical treatment isn't subject to competition since the option is 'die' or get treated; (or 'be horribly disfigured' or get treated).  Luxuries have entirely different economics than necessities that have monopolies.

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Insurance is meant for catastrophic health events, surprises that cost more than most people can afford. That does not include birth control and diet counseling.

This is a fundamental misunderstanding.  It is also a way for negotiating group discounts; it is also for reducing future costs by engaging in prevention.  Also the government has an interest in birth control beyond health in that unwanted children are an expense born by the state - including education; possibly raising (via foster care); other expenses if the parent is poor; possibly incarceration etc.

Anywho the guy has a bunch of fundamental misunderstandings and a poor grasp of the topic in general and makes a variety of misleading statements...

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #82 on: March 29, 2017, 06:27:44 PM »
Some may dispute the financial costs component, but when you need to raise over a billion dollars in direct expenses it's totally reasonable to include the opportunity costs. 

In the companies I've been involved with, they are either still iterating, or they have been bought up by large pharma and are being brought to market still... none are actually available outside of special trials.... but the primary barrier in the FDA approvals is the insane amount of *time* it takes.... in most "studies" I've seen they attach huge monetary values to that time.  IMO, that is complete nonsense.  Sure, they could take that money and invest it in real estate or something else, but ultimately, if they are in business to produce pharmaceuticals, they have to realize that if they don't wait it out, they don't get to sell a product later, and just because they feel like they could be making more money if they did stuff differently doesn't make it valid to claim that as part of the development costs.  The actual costs are the people's salaries and various other overhead.

You think it's "complete nonsense" if I have to pay tens of millions of dollars a year to staff and develop a drug I can't sell for 15 or more years after I begin development to consider the opportunity cost?  Private Investment in medical products is in direct competition with other forms of private investment for resources.  Private money will absolutely compare the other things they could invest in over that same period, especially since almost every single one of those other investments provides greater liquidity. 

Would you send me your entire liquid net worth, on the promise that I may have a product to sell in 15 years (or may not)?  Government money moderates some of this impact, but the idea that no one should be in the game unless they can wait 15 years and sink over a billion dollars out of their own pockets into a product they may be able to sell is kind of odd.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #83 on: March 29, 2017, 06:57:41 PM »
Seriati,

in your article,

What article?  Seriously, I always label opinion pieces as such.

Quote
he says that ACA madates,

Quote
—Birth control.
—Alcohol counseling.
—Depression screening.
—Diet counseling.
—Tobacco use screening.
—Breastfeeding counseling.

Each unwanted child costs the state potentially 100,000's of dollars and will have pregnancy related costs of 20k+.  So birth control is a major net savings both for the government and the insurance provider.

The economics of "unwanted" children you are citing are such accounting scam.  Is it your view that each additional citizen is a net loser economically for the government?  If that's the case then you should favor slash and burn on entitlements, if its not the case then you are citing something that you must in fact believe is ultimately misleading.  In actuality in western countries with aging populations you're even more wrong about the economics as we need more young people to pay the taxes to feed the pyramid scheme that is our retirement system.

I agree with you its basic math that birth control pills cost less than a baby.  But if you're trying to make an economic argument that's only the tip of the ice berg, and it only gets you somewhere if it results in a net reduction in the average number of children born.  It actually has a gross negative effect if it's used to time shift children to later in life, as you end up with extremely costly fertility treatments and much higher risk and more expensive pregnancies generally.

That said, I have no issue with government paying for birth control, I have an issue with government requiring a third party like an insurance company to do so.  The government should provide condoms and birth control pills for everyone, and higher expense birth control options for those for whom the low cost solution has a medical conflict.  Very similar to how they handle vaccines if you want to treat it as a public good.

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Alcohol, Depression, Obesity, and Tobacco use are all major cost drivers of health care - so mandating those should save many billions of medicare spending.

You can achieve the same effect, if its economically justifiable as you imply, by simply allowing insurers to ask about usage, charge for and prohibiting them from kicking users off, as it will be in the insurers' interest to deal with it.  Of course the far more efficient solution is to allow the insurers to suppress abuse by charging the full cost of the abuse to the person making the decision to abuse.  Why do you feel its societies job to pick of up cost of someone harming themselves, but not to pressure them to stop?

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Breastfeeding counseling is the only odd one out and it may also be a huge area of savings if it improves early childhood nutrition.

And it may be a good idea, that doesn't make it a government responsibility (or even entitle the government to do it).

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So he listed all negative cost items...

He states that stuff covered increased in cost, but stuff not covered (LASIK, plastic surgery) fell in costs.

Price of LASIK fell because the patent expired and economies of scale and huge amount of competition; and the price of plastic surgery fell because non-specialists started doing it.

And?  That's what market forces are, people competing to get your business with a combination of price and quality.  The same process would work for most non-life threatening surgical situations.  Certainly would work for testing regimes that rely on the "expensive" machine more than any professional qualifications. 

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Since they are non critical they are subject to price competition.  Required medical treatment isn't subject to competition since the option is 'die' or get treated; (or 'be horribly disfigured' or get treated).  Luxuries have entirely different economics than necessities that have monopolies.

And there it is, the call to death and disfigurement.  The vast majority of covered surgical procedures are quality of life not directly life saving.  Sure heart surgery has an issue, but does knee surgery have the same considerations?  You already know I'm in favor of a pooled approach for fatal procedures because the market forces are unlikely to work well with them, so that seems non-responsive to the bigger point I was making.

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Insurance is meant for catastrophic health events, surprises that cost m
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ore than most people can afford. That does not include birth control and diet counseling.

This is a fundamental misunderstanding.  It is also a way for negotiating group discounts; it is also for reducing future costs by engaging in prevention.

Sigh... really sigh.  It is NOT a fundamental misunderstanding.  That is what insurance means. 

yossarian22c

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Re: Obamacare Repeal and Replacement
« Reply #84 on: March 29, 2017, 08:36:02 PM »
But have they gone through the FDA process and brought a drug to market, or are they producing products to sell off to other vendors?

Of course it's an estimate, but it was based on a look at the costs of brining over 100 drugs to market.  Some may dispute the financial costs component, but when you need to raise over a billion dollars in direct expenses it's totally reasonable to include the opportunity costs. 

There is no such thing as objective on these matters, I agree they seem to have an industry focus and that should be considered.  In any event, its way too much to be spent.

In almost all of the pharma sourced costs for bringing a drug from idea to market include some averaging in of all the failed drugs.

Also you do realize that the most expensive part of the drug process is called phase 3 (the earlier phases make sure the drug won't kill or cause lasting damage to the body) clinical trials.  This is where the company actually tests to make sure the drug works. In other words to make sure the drug cures people better than a placebo or to measure how effective it is compared to existing treatments.  Without this phase your individual couldn't make a rational assessment of the efficacy of the drug because no data would exist for them to make a decision with.  Eliminating these costly regulations would turn pharmaceutical companies into modern day snake oil salesmen, there would be no science to validate or refute their claims.  I agree this is an expensive regulation but the alternative is much worse. 


On another note as to the budgets of small biotechs vs the big price tag, here is the reason for the discrepancy you are seeing.

The small biotech usually can't fund phase 3, therefore this is a reason why a bunch of small biotech companies can produce promising drugs but don't necessarily have the resources to get them to market.  The small firms don't have the staff, connections, and money to organize the kind of large scale human trials required to show a drug actually works.  The small firms also don't have the sales and marketing departments of the big companies so when they have a promising drug they either sale the rights, partner with a bigger company, or are bought outright.

LetterRip

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Re: Obamacare Repeal and Replacement
« Reply #85 on: March 29, 2017, 08:57:24 PM »
Seriati,

Quote
What article?  Seriously, I always label opinion pieces as such.

an opinion piece is a subset of the class articles. Essentially any piece of writing for a blog, newspaper, magazine etc. is an article.

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The economics of "unwanted" children you are citing are such accounting scam.  Is it your view that each additional citizen is a net loser economically for the government?

No.  Each unwanted pregnancy that results in a net economic positive is generally fungible with a wanted pregnancy (ie unwanted pregnancies that turn out with a well adjusted child are from women who generally want children but wanted delayed timing).  Also unwanted pregnancies are far more likely to have the mother engage in behaviours like drinking; drugs; or risk STDs.  Also those who forgo birth control for reasons of being unable to afford birth control are by far the most likely to have unwanted pregnancies that are a net drain on society.

Quote
I agree with you its basic math that birth control pills cost less than a baby.  But if you're trying to make an economic argument that's only the tip of the ice berg, and it only gets you somewhere if it results in a net reduction in the average number of children born.  It actually has a gross negative effect if it's used to time shift children to later in life, as you end up with extremely costly fertility treatments and much higher risk and more expensive pregnancies generally.

Actually you are mistaken.  A big reason for poverty is having children before finishing education.  By delaying pregnancy to a wanted time period, the women is much less likely to need government assistance and be in poverty and thus cost the government far less.  Also the child born when wanted will grow up in a likely far less stressful and resource constrained environment, far less likely to be exposed to drugs or alcohol during pregnancy, and thus more likely to grow up well educated and to not end up in jail. So there will be a similar cost to birthing and raising the child to the mother, but the chance of the child being a net burden on society will be far less likely.

Also IVF in Belgium costs 3K(USD about 2K euro) in the US 12k(USD).  It is another area of ridiculously overpriced medicine in the US.

Quote
That said, I have no issue with government paying for birth control, I have an issue with government requiring a third party like an insurance company to do so.  The government should provide condoms and birth control pills for everyone, and higher expense birth control options for those for whom the low cost solution has a medical conflict.  Very similar to how they handle vaccines if you want to treat it as a public good.

Fair enough.  It is logical for health insurance to cover birth control, since it is a net savings to the insurance companies as well.  Vaccines are generally covered by insurance for widely needed ones.

Quote
You can achieve the same effect, if its economically justifiable as you imply, by simply allowing insurers to ask about usage, charge for and prohibiting them from kicking users off, as it will be in the insurers' interest to deal with it.  Of course the far more efficient solution is to allow the insurers to suppress abuse by charging the full cost of the abuse to the person making the decision to abuse.

This is a fundamental misunderstanding of physiology and psychology.  Basically noone ever decided to be an alcoholic or addict.  These are diseases not choices.  People do decide to drink occassionally - nearly every person in the US has decided to do that.  Some people are unlucky and have genes and other risk factors that result in them becoming addicted others are lucky and don't have those genes and risk factors. Obesity is similar - we are beginning to understand that it is largely about other factors rather than 'choice' (ie the microbioata of the intestines; light exposre patterns; environmental stressors) - that to some degree can be overcome by choice (exercise can trigger hormones that can suppress and change the bacteria population; diet can influence the bacteria).

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And it may be a good idea, that doesn't make it a government responsibility (or even entitle the government to do it).

The SC ruled that the government has the right and authority to do so.  Or ignoring that the 'promote the general welfare' clause.

Also it is idiocy to have things like Medicare and Medicaid and then not promote stuff that can reduce those costs in a non intrusive way.

Quote
And?  That's what market forces are, people competing to get your business with a combination of price and quality.  The same process would work for most non-life threatening surgical situations.  Certainly would work for testing regimes that rely on the "expensive" machine more than any professional qualifications. 

Stuff that is needed 'immediately' for existing medical conditions are things that you must have, there is no reasonable way to go 'oh I probably can wait on that MRI 12 months and go to a cheap provider' like you can with LASIK surgery or simple cosmetic surgery.  Also there isn't objective criteria for most things LASIK - you can ask your friends if they see better and there are lots of people so you can get referals; cosmetic you can see if your friends nip and tuck worked or not - lay persons can't judge a skilled versus unskilled MRI or XRay provider - it takes medical expertise to judge the quality of the service for an MRI or XRay.

Also medical services is unable to be a free market, it lacks many fundamental features of a market.

https://www.forbes.com/sites/chrisladd/2017/03/07/there-is-never-a-free-market-in-health-care/

I'm all for 'government pays for the cheapest and most effective option, more expensive fancy is out of pocket'.  Basically things that effect survival, longevity, and employability should be covered.

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Sigh... really sigh.  It is NOT a fundamental misunderstanding.  That is what insurance means.

Insurance had that narrow meaning 200 years ago.  It has had the broader meaning for longer than you and I have been alive.

linuxfreakus

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Re: Obamacare Repeal and Replacement
« Reply #86 on: March 30, 2017, 12:14:25 AM »
You think it's "complete nonsense" if I have to pay tens of millions of dollars a year to staff and develop a drug I can't sell for 15 or more years after I begin development to consider the opportunity cost?  Private Investment in medical products is in direct competition with other forms of private investment for resources.  Private money will absolutely compare the other things they could invest in over that same period, especially since almost every single one of those other investments provides greater liquidity. 

Would you send me your entire liquid net worth, on the promise that I may have a product to sell in 15 years (or may not)?  Government money moderates some of this impact, but the idea that no one should be in the game unless they can wait 15 years and sink over a billion dollars out of their own pockets into a product they may be able to sell is kind of odd.

Yes, I do not find that doing R&D for stuff that might not earn money for 10 or 15 years is an unwise policy for a company that endeavors to stay in business long term.  Venture capital is all about funding promising things, many of which never pan out, but the ones that do more than make up for the ones that don't.  I maintain that the big drug companies do not need to spend nearly as much as they claim to spend, and in fact, I don't think they really do spend that much on R&D.  They cook the books to make it look that way.

yossarian22c

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Re: Obamacare Repeal and Replacement
« Reply #87 on: June 19, 2017, 10:09:57 PM »
I guess I really shouldn't be surprised that the party that blasted the Democrats for ramming a bill through that had been negotiated in public for a year and had multiple (public) legislative drafts has drafted a healthcare bill in secret, even from members of their own caucus. They are now planning bringing the bill to the floor for a vote all in a single day without anyone else getting to read it first.

When Schumer asked McConnell if they would get at least 10 hours to read and amend the bill, McConnell only responded there would be ample time to read and amend the bill.

Pete at Home

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Re: Obamacare Repeal and Replacement
« Reply #88 on: June 19, 2017, 10:59:25 PM »
Seriati, you don't see the problems inherent of a birth control regime where the persons with most resources that could be used to protect, raise, shelter, feed, and educate their kids are the only ones with easy access to birth control?  Do you really think that a generation of crack heroin and meth babies is going to provide that labor base to take care of an aging population?

TheDeamon

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Re: Obamacare Repeal and Replacement
« Reply #89 on: June 20, 2017, 11:30:32 AM »
Cheap/affordable/free access to birth control is an entirely different issue from comprehensive health care. You can have birth control access without comprehensive care. While the reverse may or may not apply depending on the (religious) convictions of the person in question.

Wayward Son

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Re: Obamacare Repeal and Replacement
« Reply #90 on: June 20, 2017, 01:22:37 PM »
I hear you, yossarian.  Why is it that Republicans insist on doing what they criticized the Democrats of doing, but only worse?

For Obamacare, there were 50 hearings, roundtables, etc. in the Finance Committee, 47 in the Health and Education Committee, 25 days of debate on the Senate floor, and a dozen Republican amendments incorporated into the final bill, and it was considered by Republicans to have been done without enough review.  So in response, the Republicans now are holding secret meetings with no hearings, roundtables, etc., not even informing their own members, taking no Democrat amendments (much less letting them in on the process), and want the bill passed within 13 days, before the Fourth of July, once they get around to submitting the final draft.

As one Senator put it:

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“This is a very important issue. You know, we shouldn’t try to do it in the dark. And whatever final bill is produced should be available to the American public and to members of the Senate, certainly, for enough time to come to grips with it. And we are going to insist — and the American people are going to insist — that it be done in a transparent, in a fair and open way.”

Is this, in any universe, "a transparent, ... fair and open way?"  ::)

It's like the Senate leadership said to themselves, "We'll show them why doing this stuff in secret is so bad, by really, really doing it in secret.  That'll teach 'em!" :)

Yeah, it teaches us, all right, just not the lesson they think we'll learn. ;)

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #91 on: June 20, 2017, 02:01:32 PM »
I hear you, yossarian.  Why is it that Republicans insist on doing what they criticized the Democrats of doing, but only worse?

For Obamacare, there were 50 hearings, roundtables, etc. in the Finance Committee, 47 in the Health and Education Committee, 25 days of debate on the Senate floor, and a dozen Republican amendments incorporated into the final bill, and it was considered by Republicans to have been done without enough review.


Lol, maybe because it was a campaign promise by the great Obama that it would be pubilically posted for comment before passing it?  Maybe because the Democrats that passed it didn't know what was in it, and as well evidenced by the great Nancy Pelosi?

Silly to keep pretending there were any real concessions to Republicans.

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So in response, the Republicans now are holding secret meetings with no hearings, roundtables, etc., not even informing their own members, taking no Democrat amendments (much less letting them in on the process), and want the bill passed within 13 days, before the Fourth of July, once they get around to submitting the final draft.

Rushing it is bad business for something this important.  Maybe they're doing it this way because of the Democratic planning to delay it.  I mean its more than Ironic that you posted this on a day when the NY Times has a headline that reads, "Democrats will try to run out clock on G.O.P. Health Bill."

Democrats have made it clear that they will not assist in any way with Healthcare reform on the Republican model, which is I suppose an instance of turnabout being fair play.  However, if you care at all about the final healthcare model, wouldn't it make sense to encourage say a large block of Democrats to join in a grand bill to get some compromises built in?  Of course it would, there's just to many positions from which neither side will retreat to reach a "best for the country" plan.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #92 on: June 20, 2017, 02:03:11 PM »
Seriati, you don't see the problems inherent of a birth control regime where the persons with most resources that could be used to protect, raise, shelter, feed, and educate their kids are the only ones with easy access to birth control?  Do you really think that a generation of crack heroin and meth babies is going to provide that labor base to take care of an aging population?

Want to walk me through how you got from my quote below to your analysis above?

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That said, I have no issue with government paying for birth control, I have an issue with government requiring a third party like an insurance company to do so.  The government should provide condoms and birth control pills for everyone, and higher expense birth control options for those for whom the low cost solution has a medical conflict.  Very similar to how they handle vaccines if you want to treat it as a public good.

Pete at Home

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Re: Obamacare Repeal and Replacement
« Reply #93 on: June 20, 2017, 02:36:57 PM »
Seriati, you don't see the problems inherent of a birth control regime where the persons with most resources that could be used to protect, raise, shelter, feed, and educate their kids are the only ones with easy access to birth control?  Do you really think that a generation of crack heroin and meth babies is going to provide that labor base to take care of an aging population?

Want to walk me through how you got from my quote below to your analysis above?

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That said, I have no issue with government paying for birth control, I have an issue with government requiring a third party like an insurance company to do so.  The government should provide condoms and birth control pills for everyone, and higher expense birth control options for those for whom the low cost solution has a medical conflict.  Very similar to how they handle vaccines if you want to treat it as a public good.

 I similarly "have no objections" to your argument that it makes more sense to have the state provide BC directly rather than putting it on insurance.  What I said was a direct and immediate response to the pyramid scheme argument against provision of birth control that I saw in these other paragraphs:

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The economics of "unwanted" children you are citing are such accounting scam.  Is it your view that each additional citizen is a net loser economically for the government?  If that's the case then you should favor slash and burn on entitlements, if its not the case then you are citing something that you must in fact believe is ultimately misleading.  In actuality in western countries with aging populations you're even more wrong about the economics as we need more young people to pay the taxes to feed the pyramid scheme that is our retirement system.

I agree with you its basic math that birth control pills cost less than a baby.  But if you're trying to make an economic argument that's only the tip of the ice berg, and it only gets you somewhere if it results in a net reduction in the average number of children born.  It actually has a gross negative effect if it's used to time shift children to later in life, as you end up with extremely costly fertility treatments and much higher risk and more expensive pregnancies generally.

I absolutely agree with you that the program you describe would be better.  But the reason isn't just because of third party issues (since insurance companies wrote half of the freaking ACA they are hardly a third party) but with respect to economically selective birth control, the invisible hand tends to diddle us all.
« Last Edit: June 20, 2017, 02:49:13 PM by Pete at Home »

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #94 on: June 20, 2017, 02:46:43 PM »
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The economics of "unwanted" children you are citing are such accounting scam.  Is it your view that each additional citizen is a net loser economically for the government?

No.  Each unwanted pregnancy that results in a net economic positive is generally fungible with a wanted pregnancy (ie unwanted pregnancies that turn out with a well adjusted child are from women who generally want children but wanted delayed timing).

Not sure where you're going with that.  The fact is even unwanted pregnancies are economic winners, particularly on average, from the government's point of view.  If you want to make a utilitarian argument on this point you're stuck with the actual facts.

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Also unwanted pregnancies are far more likely to have the mother engage in behaviours like drinking; drugs; or risk STDs.  Also those who forgo birth control for reasons of being unable to afford birth control are by far the most likely to have unwanted pregnancies that are a net drain on society.

So in summary, people who are net drains on society will have pregnancies that increase the net loss on that mother?  I may agree, but you're making a huge assumption that even such a mother is a net drain on society - it's based on overweighting easy to digest numbers (like welfare costs) and not considering tough to calculate impacts.  Certainly, those of you who accept the basic income arguments can not turn around and label any consumer, even this one, as a net loss and be consistent with the logic behind the concept that consumption of resources provided by the government results in a gain.

In any event, you should look at the numbers, those kids may start at a disadvantage, but even they are net positives to society from an economic point of view on average.

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It actually has a gross negative effect if it's used to time shift children to later in life, as you end up with extremely costly fertility treatments and much higher risk and more expensive pregnancies generally.

Actually you are mistaken.  A big reason for poverty is having children before finishing education.  By delaying pregnancy to a wanted time period, the women is much less likely to need government assistance and be in poverty and thus cost the government far less.

This is a much larger topic, but I want to pull this part out separately because you are actually being non-responsive.  Nothing I said is incorrect, I included a specific qualifier on it.  Your criticism is literally incorrect, as you are talking about a circumstance that is specifically not covered by me.  Do you really think I would object to the idea that time shifting to a better time to raise kids would cause an economic harm (even if I would, it'd still be better for the children)? 

My point was taking notice of the fact that there has been a marked shift to pushing pregnancy well past the ideal time for  pregnancy, with a big impact on costs of that pregnancy and overalll health.  People have the that right of course, but it does undercut your "economic" argument.

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Also IVF in Belgium costs 3K(USD about 2K euro) in the US 12k(USD).  It is another area of ridiculously overpriced medicine in the US.

Yes, forcing everything through our ridiculous government manipulated market increases the costs.

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Fair enough.  It is logical for health insurance to cover birth control, since it is a net savings to the insurance companies as well.  Vaccines are generally covered by insurance for widely needed ones.

Vaccines are heavily subsidized directly and indirectly (tort relief) by the government, which is why they are covered.

I agree it makes perfect sense for birth control to be covered if its a net benefit, but if that's the case there is no reason to force it. 

I also find it fascinating that most people who make this argument do a very poor analysis.  Why is it efficient to cover birth control?  Just to stop pregnancy?  What about the savings on the STD front is that not efficient?  Why would we cover anti-pregnancy measures (pills, Iuds) and not anti-disease measures (condoms)?

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This is a fundamental misunderstanding of physiology and psychology.  Basically noone ever decided to be an alcoholic or addict.  These are diseases not choices.


Bull crap.  Plenty of people have decided to become alcoholics and addicts.  And even more have decided not to seek treatment.

Many things can impair personal responsibility but you're delusional if you think that everyone who is an addict, alcoholic or obese is subject to a genetic condition that meant they couldn't control themselves.

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And it may be a good idea, that doesn't make it a government responsibility (or even entitle the government to do it).

The SC ruled that the government has the right and authority to do so.

Really, where did they do that?  I'd like to see you provide the language on that.

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Or ignoring that the 'promote the general welfare' clause.

Or understanding what it means, and more importantly doesn't include.

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Also it is idiocy to have things like Medicare and Medicaid and then not promote stuff that can reduce those costs in a non intrusive way.

It is idiocy to insulate anyone from the harmful costs of decisions they personally control.  if you agreed to pay any speeding tickets your friend earned and made a law that he couldn't lose his license so long as the tickets were paid, what would happen?

Would you be on here claiming that his rampant speeding was a result of a genetic inability to go slow (ala Ricky Bobby)?

Once you decide the government is responsible for people's results, they accrete to themselves the ability to control those costs - ie your life.

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And?  That's what market forces are, people competing to get your business with a combination of price and quality.  The same process would work for most non-life threatening surgical situations.  Certainly would work for testing regimes that rely on the "expensive" machine more than any professional qualifications. 

Stuff that is needed 'immediately' for existing medical conditions are things that you must have, there is no reasonable way to go 'oh I probably can wait on that MRI 12 months and go to a cheap provider' like you can with LASIK surgery or simple cosmetic surgery.

Why would you have to?  DO you understand the least thing about market forces?  Open up  MRI's to the market and your wait time will go down, your costs will go down and the technology itself will improve. 

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Also there isn't objective criteria for most things LASIK - you can ask your friends if they see better and there are lots of people so you can get referals; cosmetic you can see if your friends nip and tuck worked or not - lay persons can't judge a skilled versus unskilled MRI or XRay provider - it takes medical expertise to judge the quality of the service for an MRI or XRay.

Lay persons can't judge, responsiveness and wait time?  Costs and professionalism?  They can't communicate that an MRI provider's results were rejected by their doctor?

I'll ask you specifically, are you incompetent to evaluate whether you should use a specific doctor?  Most people are not in fact incompetent at identifying qualify medical providers, even if they have no basis for direct evaluation of their skill.

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I'm all for 'government pays for the cheapest and most effective option, more expensive fancy is out of pocket'.  Basically things that effect survival, longevity, and employability should be covered.

Yep, just like I said the whole time.  Government control leads to rationing and lower services level.

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Sigh... really sigh.  It is NOT a fundamental misunderstanding.  That is what insurance means.

Insurance had that narrow meaning 200 years ago.  It has had the broader meaning for longer than you and I have been alive.

It really doesn't unless you qualify it with one additional word "medical."   Insurance works the same way, and far more efficiently in virtually every other context.

I get we made a choice to force medical insurance to be "health plans" instead of insurance.  But you have to live with the actual results of that government manipulation when you make your arguments.  You can't pretend the harmful consequences you are looking at are not the direct results of that governmental interference.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #95 on: June 20, 2017, 02:49:07 PM »
I similarly "have no objections" to your argument that it makes more sense to have the state provide BC directly rather than putting it on insurance.  What I said was a direct and immediate response to the pyramid scheme argument against provision of birth control that I saw in these other paragraphs:

That wasn't an argument on substance, that was pointing out the falsity of making an "economics" argument that says birth control is cheaper than pregnancy, which inherently ignores the total economics picture (ie that a new citizen is a net economic advantage).  I tire of cherry picking arguments on topics like this.

Pete at Home

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Re: Obamacare Repeal and Replacement
« Reply #96 on: June 20, 2017, 02:52:49 PM »
Seriati, I have no malice to you and I'm not so vain as to seek score on you or to make you look bad.  I honestly do not understand how you can make the argument you just made to LR within the last 15 minutes and then ask me why my own arguments apply to what you said.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #97 on: June 20, 2017, 03:03:46 PM »
I honestly, don't understand your confusion.

The fact that unwanted pregnancies have a net positive economic impact, would only control if economics is the only consideration.  Maybe the unstated criticism is what's confusing?  Economics should not be the sole basis for these decisions.  However, if you're going to make a utilitarian argument, you should include a full consideration of utilities not a cherry picked set.

Am I missing something?

Fenring

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Re: Obamacare Repeal and Replacement
« Reply #98 on: June 20, 2017, 03:08:42 PM »
So in summary, people who are net drains on society will have pregnancies that increase the net loss on that mother?  I may agree, but you're making a huge assumption that even such a mother is a net drain on society - it's based on overweighting easy to digest numbers (like welfare costs) and not considering tough to calculate impacts.  Certainly, those of you who accept the basic income arguments can not turn around and label any consumer, even this one, as a net loss and be consistent with the logic behind the concept that consumption of resources provided by the government results in a gain.

I just wanted to mention that this is a very good point. As someone who is adamantly supportive of a basic income, and also believes that it will be inevitable in one form or another, I think it's good to make clear that by stating that people should have a baseline level of income guaranteed we acknowledge that life has intrinsic value that exists outside of quantifiers. That being said, I believe that a basic income is economically advantageous as well. However in context of this thread I agree with you that even if an unwanted pregnancy was somehow a net economic loss that is still not a solid argument against it happening. Looking at the 'value' of a birth is only one metric, and as you point out it's a shady one at that since it's very hard to measure the actual economic value of a given birth. You need to effectively look backward over the person's entire lifetime, and even then it's not very promising as a final result.

And how can one measure how social change affects political and economic change? Since I'm still reading De Tocqueville (and likely will continue to do so for a while since it's a slog) I'll throw in another thing he mentions, which is that he observed that in America a lot of economic and political habits seem to emerge from social mores, and not the other way around. By having 'unwanted' births, even in the case of having to support such lives to a certain extent through basic income or welfare or whatever else, maybe this hypothetically shifts public sentiment towards esteeming more dearly the value of life in general. Maybe it shifts public perception of the value of lives in other countries and shifts polling on foreign policy. Maybe it increases the need for and therefore the availability of support structures in culture to take care of people who need it (something lacking at this time). Now maybe none of this happens and there's some other effect. My point is that one cannot foresee what effect a pattern of choices will have down the road, and using tunnel-vision metrics to assess the value of something in an oversimplified way is more of a cheat than anything else in going after the issue.

Wayward Son

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Re: Obamacare Repeal and Replacement
« Reply #99 on: June 20, 2017, 03:24:46 PM »
I hear you, yossarian.  Why is it that Republicans insist on doing what they criticized the Democrats of doing, but only worse?

For Obamacare, there were 50 hearings, roundtables, etc. in the Finance Committee, 47 in the Health and Education Committee, 25 days of debate on the Senate floor, and a dozen Republican amendments incorporated into the final bill, and it was considered by Republicans to have been done without enough review.


Lol, maybe because it was a campaign promise by the great Obama that it would be pubilically posted for comment before passing it?  Maybe because the Democrats that passed it didn't know what was in it, and as well evidenced by the great Nancy Pelosi?

Silly to keep pretending there were any real concessions to Republicans.

Well, I won't argue about whether there were "real concessions" or not, but at least Republicans had the chance to make amendments--and did so, with a vengeance.

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Of the 788 amendments filed, 67 came from Democrats and 721 from Republicans. (That disparity drew jeers that Republicans were trying to slow things down. Another explanation may be that they offered so many so they could later claim—as they are now, in fact, claiming—that most of their suggestions went unheeded.) Only 197 amendments were passed in the end—36 from Democrats and 161 from Republicans. And of those 161 GOP amendments, Senate Republicans classify 29 as substantive and 132 as technical.

How many amendments will Republicans accept from Democrats before July 4? ;)

And tell me, how much better informed will the Republicans be come July 4?

As I said, Republicans complain about how unfair Democrats were with Obamacare, and to show how unfair it was, they plan on being even more unfair, just to prove their point!  ::)

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So in response, the Republicans now are holding secret meetings with no hearings, roundtables, etc., not even informing their own members, taking no Democrat amendments (much less letting them in on the process), and want the bill passed within 13 days, before the Fourth of July, once they get around to submitting the final draft.

Rushing it is bad business for something this important.  Maybe they're doing it this way because of the Democratic planning to delay it.  I mean its more than Ironic that you posted this on a day when the NY Times has a headline that reads, "Democrats will try to run out clock on G.O.P. Health Bill."

Democrats have made it clear that they will not assist in any way with Healthcare reform on the Republican model, which is I suppose an instance of turnabout being fair play.  However, if you care at all about the final healthcare model, wouldn't it make sense to encourage say a large block of Democrats to join in a grand bill to get some compromises built in?  Of course it would, there's just to many positions from which neither side will retreat to reach a "best for the country" plan.

And, of course, Republicans didn't use any delaying tactics when Obamacare was on the table, right? ;)

Republicans knew they wouldn't get help from Democrats on repealing Obamacare.  But the whole point is political, so of course Democrats aren't going to cut their own throats to give Republicans political points.

They are rushing it because they know the only way they'll get it passed without Democratic cooperation is by through budget reconciliation with the House, which requires only 51 votes.  And apparently, if they miss the July 4 recess, they'll have to wait until August to try again (if I understand it correctly).

Now, sure, if Republicans want to fix or modify Obamacare, the Democrats have already said they have plenty of ideas they would love to discuss.  But they won't.  Because they want a win, and that's the most important thing.

Let's hope the Democrats are successful in delaying the vote, so we can all see the details of what they are trying to foist on us.