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Old 16th May 2017, 04:40 PM   #1
jhunter1163
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Single-Payor Healthcare in the US: A Proposal

Hello, all. My friend Terry and I have been working on a proposed single-payor health insurance plan. This plan is designed to cover all Americans, from cradle to grave, soup to nuts, whatever you want to call it. This is a work in progress at this point; stay tuned for future updates. We welcome any feedback or constructive criticism.

General Plan Provisions

The plan year runs January 1 to December 31. Each year, there will be an open-enrollment period running from January 1 to February 28: during this time, individuals may opt to change their coverage without incurring a waiting period. After open enrollment, there will be a 90-day waiting period for plan changes. There are no referral or authorization requirements; any licensed medical provider (including MDs, DOs, APRNs, PAs, chiropractors and physical therapists) may provide services under this plan.

Level One Coverage

Services designated as Level One are required as part of base plans.

Men Aged 18-64: Covered services include: Doctor visits, inpatient and outpatient hospital services, emergency services, laboratory services, diagnostic testing, prescription drugs, mental health/rehab services, vision and dental checkups, screening colonoscopy after age 50

Women Aged 18-64: Covered services include: Doctor visits, inpatient and outpatient hospital services, emergency services, laboratory services, diagnostic testing, prescription drugs, mental health/rehab services, vision and dental checkups, maternity services, annual gynecological exams, screening mammograms after age 40, screening colonoscopy after age 50

Family Coverage: Covered services include: Doctor visits, inpatient and outpatient hospital services, emergency services, laboratory services, prescription drugs, mental health/rehab services, maternity services, annual gynecological exams, screening mammograms after age 40, screening colonoscopy after age 50, pediatric services including vision and dental, childhood immunizations, sports exams up to age 18

Age 65+: Additional services covered include nursing-home services, Alzheimer's treatment, hospice/palliative care (available before age 66 with doctor's certification)

Level Two Coverage

Services designated as Level Two can be purchased as riders to a base plan. There is a 90-day waiting period before coverage purchased under these riders takes effect if not purchased during the open enrollment period.

These services include: dental services, orthodontics, eyeglasses, hearing aids, infertility treatment, bariatric (weight-loss) surgery, smoking-cessation treatment, LASIK and similar vision services.

Level Three Coverage

Services designated as Level 3 are optional; individuals may purchase these coverages as riders to the base plans. There is a 90-day waiting period before coverage purchased under these riders takes effect if not purchased during the open enrollment period.

These services include: cosmetic surgery (non-reconstructive), Botox and similar procedures, Viagra, Rogaine, hair transplantation, cosmetic dental procedures.

Non-Covered Services

Services not covered under the plan include:

Massage therapy, naturopathy, religious practitioners (Christian Scientists), homeopathy, acupuncture, acupressure, hypnotherapy, biofeedback.

We have considered a variety of funding mechanisms; we are leaning towards having each person contribute towards a "nut", an amount which would be intended to cover expected health expenses over one's working lifetime; credits would be given against this for national service, military service, and possibly other categories of exemptions.

Again, this is a work in progress, and we welcome any and all constructive criticism. Thanks in advance.
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Old 16th May 2017, 05:21 PM   #2
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I'm going to go back and actually read the proposal after posting this but:
You'd have a lot more credibility if you spelled "payer" correctly.
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Old 16th May 2017, 05:30 PM   #3
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Originally Posted by Trebuchet View Post
I'm going to go back and actually read the proposal after posting this but:
You'd have a lot more credibility if you spelled "payer" correctly.
ETA:
Open enrollment should be before the plan year, like Medicare.
Level one may be a bit high. Probably should be some level of deductible. Nice to see the inclusion of dental, however, which isn't covered at any level of Medicare.
Level two: Some of that would actually reduce costs of level one.
Level three: Too much cosmetic/vanity stuff. Skip it.
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Old 16th May 2017, 08:18 PM   #4
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Originally Posted by Trebuchet View Post
I'm going to go back and actually read the proposal after posting this but:
You'd have a lot more credibility if you spelled "payer" correctly.
"Payor" is the legal term:

Quote:
In legal documents payor is used to describe a person required by law to make specific payments such as child support.
https://www.reference.com/business-f...990f6aaad7636b
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Old 16th May 2017, 08:22 PM   #5
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Originally Posted by Trebuchet View Post
ETA:
Open enrollment should be before the plan year, like Medicare.
Level one may be a bit high. Probably should be some level of deductible. Nice to see the inclusion of dental, however, which isn't covered at any level of Medicare.
Level two: Some of that would actually reduce costs of level one.
Level three: Too much cosmetic/vanity stuff. Skip it.
Thanks for the feedback. We're trying to be fully inclusive, cover everything under the sun; that's why we included Level Three as a buy-up. If you want to have a tummy tuck or a nose job, fine, but you'll have to pay extra premium for it.
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Old 16th May 2017, 08:23 PM   #6
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Perhaps you could fill in more details. What will the plan cost? Who will pay how much? How will fees for service be determined?
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Old 16th May 2017, 08:25 PM   #7
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Level one looks a lot like Medicare in Australia. Levels two and three can be covered by additional private health insurance, which I have. I have no problem with ancillary and elective medicine being covered by additional insurance premiums.
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Old 16th May 2017, 08:31 PM   #8
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Originally Posted by Startz View Post
Perhaps you could fill in more details. What will the plan cost? Who will pay how much? How will fees for service be determined?
We're contemplating plan premiums in the neighborhood of the Medicare Part B plus D premium (around $170 per month per person, with a family cap). Physician fees would be based on the current Medicare fee schedules with geographic adjustments. Pharmaceuticals would be a bit of a sticky wicket; we don't want to disincentivize R&D, but the skyrocketing cost of drugs has to be addressed. As a stopgap we would set drug reimbursements at average sales price plus 6% markup (Medicare's rate) but shorten patent protection from ten years to five in order to increase competition (generics would be available sooner).
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Old 16th May 2017, 08:57 PM   #9
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That's a clear answer. And no one would expect every detail to be worked out.

But aren't almost all the items you propose to cover now paid for by Medicare Part A, not Part B?

The U.S. spends something like $10,000/person/year on healthcare now. Some argue that a single payer plan would have significant cost savings. But surely not on the order of 80%.
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Old 16th May 2017, 09:25 PM   #10
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Originally Posted by Startz View Post
That's a clear answer. And no one would expect every detail to be worked out.

But aren't almost all the items you propose to cover now paid for by Medicare Part A, not Part B?

The U.S. spends something like $10,000/person/year on healthcare now. Some argue that a single payer plan would have significant cost savings. But surely not on the order of 80%.
Actually, no; Medicare A covers hospital charges, while B covers physician charges, most diagnostic testing, laboratory charges, and so on. There would certainly be cost savings under a single-payor plan, due to the leverage a single payor would have in setting reimbursement rates as well as administrative streamlining; we estimate those savings at around 30% of current healthcare expenditures. So instead of $10,000 per year per person, we'd be spending around $7,000. We'd still have the most expensive system in the world, but the gap wouldn't be nearly as wide as it now is.
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Old 17th May 2017, 05:53 AM   #11
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(Well, you did include hospital care as being covered. I'm not trying to nitpick though.)

Let's say that your figure of $7,000/year is right. Suggesting a 30% reduction isn't unreasonable, and some of the costs that make up the $10,000 aren't included in your basic plan.

How does $170 per month, with a family cap, cover $7,000?
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Old 17th May 2017, 10:25 AM   #12
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Well, you have to remember that the $7,000 is an average; many people, perhaps even most, won't utilize remotely close to that amount in a year. The per-capita numbers are skewed by the extreme costs of catastrophic illness and injury; I'm at work so I can't post links, but according to the Kaiser Family Foundation the top 5% of healthcare consumers accounted for slightly over half of all healthcare expenditures. High-cost cancer drugs accounted for about one-third of Medicare Part D expenses last year. There will, obviously, need to be some kind of mechanism to account for this imbalance; we were contemplating a risk pool along the lines of the Minnesota plan, with a separate funding mechanism to cover it (perhaps a small payroll tax, or an earmark within the funds received from premiums.)
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Old 17th May 2017, 10:35 AM   #13
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Originally Posted by jhunter1163 View Post
"Payor" is the legal term
Industry-specific jargon is usually alienating to non-industry audiences. At best, the effect is, "this guy doesn't know how what he's talking about, or even how to spell it." At worst, the effect is, "this guy is setting himself apart from us, and obfuscating his meaning, on purpose."

Consider avoiding situations where you have to explain that you're technically correct, instead of creating them. It is better communication, and is more likely to encourage a positive view of your proposals.
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Old 17th May 2017, 10:37 AM   #14
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First of all, I'm not sure if what you suggested would be called 'single-payer'. It may be universal, but not single-payer since different people are paying into it at different rates.

Secondly, your plan is missing some important details:

- How do you guarantee that everyone joins in? Insurance plans only work with a broad base of subscribers; without some mechanism to force people to join you will run the risk of the plan failing because many healthy people won't sign up

- Who actually runs the scheme? Is it a government-owned insurance system, or will it be similar to the U.S. system (i.e. private insurance companies working on government mandates).
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Old 17th May 2017, 11:07 AM   #15
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Originally Posted by jhunter1163 View Post
Well, you have to remember that the $7,000 is an average; many people, perhaps even most, won't utilize remotely close to that amount in a year. The per-capita numbers are skewed by the extreme costs of catastrophic illness and injury; I'm at work so I can't post links, but according to the Kaiser Family Foundation the top 5% of healthcare consumers accounted for slightly over half of all healthcare expenditures. High-cost cancer drugs accounted for about one-third of Medicare Part D expenses last year. There will, obviously, need to be some kind of mechanism to account for this imbalance; we were contemplating a risk pool along the lines of the Minnesota plan, with a separate funding mechanism to cover it (perhaps a small payroll tax, or an earmark within the funds received from premiums.)
That makes sense, but how much would the risk pool cost? Let's take your numbers. Suppose everyone puts in $170/month (no family caps, no one who doesn't pay in). That provides $2,040 a year. So an average of $7,000 leaves $4,960 for the risk pool. The U.S. has about 320 million people, so I think you need another $1.6 trillion. I don't think that's going to get covered by a small payroll tax.

None of this means you don't have interesting ideas. I'm just trying to point out that being careful about how things get paid for is needed to design a realistic system.
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Old 17th May 2017, 11:39 AM   #16
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So. Is this a health insurance proposal, or a health care proposal?
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Old 17th May 2017, 02:45 PM   #17
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Originally Posted by Segnosaur View Post
First of all, I'm not sure if what you suggested would be called 'single-payer'. It may be universal, but not single-payer since different people are paying into it at different rates.

Secondly, your plan is missing some important details:

- How do you guarantee that everyone joins in? Insurance plans only work with a broad base of subscribers; without some mechanism to force people to join you will run the risk of the plan failing because many healthy people won't sign up

- Who actually runs the scheme? Is it a government-owned insurance system, or will it be similar to the U.S. system (i.e. private insurance companies working on government mandates).
This would be a government-run plan, along the lines of Medicare-for-all, but with a national-service component (so a VA expansion along with the Medicare expansion). Participation would be mandatory; there would be employer payroll deductions, like there are now for Medicare. There would naturally be exemptions for disability or unemployment, but for the most part it would be a pay-as-you-go system.

And yes, I'm aware of the problems with the VA, but those problems are not institutional; they are the product of years of budget cuts and underfunding. There wouldn't be any private health insurance; the buy-up premiums for Levels Two and Three would be paid to the government.
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Old 17th May 2017, 02:59 PM   #18
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Originally Posted by Startz View Post
That makes sense, but how much would the risk pool cost? Let's take your numbers. Suppose everyone puts in $170/month (no family caps, no one who doesn't pay in). That provides $2,040 a year. So an average of $7,000 leaves $4,960 for the risk pool. The U.S. has about 320 million people, so I think you need another $1.6 trillion. I don't think that's going to get covered by a small payroll tax.

None of this means you don't have interesting ideas. I'm just trying to point out that being careful about how things get paid for is needed to design a realistic system.
A fair point. Health care represented about 18 percent of GDP last year, so about $3.2 trillion. However, "health care" is an extremely broad umbrella. One of the largest items under the "health care" umbrella is, of course, health insurance premiums. Things like vitamins, health club memberships, exercise equipment and so on also come under that umbrella. The best information that we've been able to find (through the Kaiser Family Foundation) indicates that the actual cost of health care rendered or prescribed by physicians is around $1.5 trillion per year. So, if we're able to reduce that number by 30 percent, that brings us down to $1.05 trillion. Premium income, as you point out, would be around $600 billion; that would cover the lower 95 percent of utilization, with perhaps $50 billion left over for reserves against future claims. The catastrophic claims would be the rub; we'd probably have to have some form of government reinsurance to cover these services.
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Old 17th May 2017, 03:01 PM   #19
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Originally Posted by theprestige View Post
So. Is this a health insurance proposal, or a health care proposal?
It's a health insurance proposal; the government would not be in the business of providing health care, with the exception of the VA.
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Old 17th May 2017, 03:09 PM   #20
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I suspect your 1.5 trillion is a bit low. On the other hand, even if you're "just" $450 billion short, you ought to get "credit" for whatever the federal and state governments are currently spending on Medicare/caid.
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Old 17th May 2017, 03:31 PM   #21
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Originally Posted by jhunter1163 View Post
This would be a government-run plan, along the lines of Medicare-for-all, but with a national-service component (so a VA expansion along with the Medicare expansion). Participation would be mandatory; there would be employer payroll deductions, like there are now for Medicare. There would naturally be exemptions for disability or unemployment, but for the most part it would be a pay-as-you-go system.
Ok, 2 things...

The problem with payroll deductions is that you have to deal with 1) people that are self-employed, and 2) people that are part time/work minimal hours, and thus wouldn't be able to make their minimum payments. (Not insurmountable problems but still need to be considered.) You may almost be better to take things out of general tax revenue rather than payroll deductions.

More importantly... if its a government-run health care, are you also going to allow private hospitals to function along side the public (government funded) ones?

The best health care systems in the world seem to have some sort of mix of public and private. Although there are accusations that allowing private care is somehow "unfairly jumping the queue" (i.e. people who pay more get faster access), in practice it is a great benefit, since it allows your health care system to be more responsive. Canada has a (more or less) single payer system (funded through tax revenues, but delivered privately) , and we have significant problems with wait lists.
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Old 17th May 2017, 10:46 PM   #22
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Originally Posted by lionking View Post
Level one looks a lot like Medicare in Australia.
Australia's medicare system is very dishonest. The medicare levy is simply additional general revenue for the government but it doesn't raise anywhere near enough to cover the cost of government funded health care. From the outset it instantly resulted in lengthy queues for public hospital treatment and massive out of pocket expenses for private treatment.

The "medibank stage two" system introduced by the Fraser government appeared to provide the best compromise between public and private health insurance. People had to pay a medibank levy through their taxes (as they do today) and got a basic level of doctor and hospital treatment. People could opt out of this levy if they had private health insurance. At least private health insurance companies had to be competitive then. Some even offered a "basic hospital only" package that cost less than the medibank levy.

Unfortunately, the medibank levy didn't cover the cost of government provided health care (I believe). So the government had two options: increase the levy or restrict coverage. The government chose the latter. This was the beginning of a never ending series of frustrating changes to the health system. By the time Bob Hawke introduced the current system, everybody was saying "enough" and no government since has been game to change the system.

I haven't crunched the numbers on jhunter1163's proposals but I suspect that underfunding will also be a recurrent problem with his proposals.
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Old 17th May 2017, 10:52 PM   #23
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Originally Posted by jhunter1163 View Post
......... shorten patent protection from ten years to five in order to increase competition.......
Aren't you frightened that this would stifle medical research by halving the incentives? You might make existing drugs and those in the pipeline cheaper, but turn off the supply of new drugs.
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Old 18th May 2017, 04:04 AM   #24
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Thank you all for your feedback.

Quote:
The problem with payroll deductions is that you have to deal with 1) people that are self-employed, and 2) people that are part time/work minimal hours, and thus wouldn't be able to make their minimum payments. (Not insurmountable problems but still need to be considered.) You may almost be better to take things out of general tax revenue rather than payroll deductions.

More importantly... if its a government-run health care, are you also going to allow private hospitals to function along side the public (government funded) ones?

The best health care systems in the world seem to have some sort of mix of public and private. Although there are accusations that allowing private care is somehow "unfairly jumping the queue" (i.e. people who pay more get faster access), in practice it is a great benefit, since it allows your health care system to be more responsive. Canada has a (more or less) single payer system (funded through tax revenues, but delivered privately) , and we have significant problems with wait lists.
You could be right about simply taking the money from general revenues. The current Medicare deduction is 1.45% for employees and employers, and raises about $800 billion annually. We'd have to increase that to something on the order of 4% each, but the tradeoff would be that there wouldn't be any health insurance premiums, so most employees (and employers, for that matter) would see a decrease in costs.

I might not have been clear earlier; the government will not be running healthcare itself, except for the VA and any expansion of that system needed to accommodate the national-service program. Most hospitals and medical facilities would still be privately owned, but would be paid by the government. So, yes, public and private facilities would be side-by-side.

Quote:
I haven't crunched the numbers on jhunter1163's proposals but I suspect that underfunding will also be a recurrent problem with his proposals.
As above. You may well be correct; this is a work in progress and we are continuing to discuss possible funding designs.

Quote:
Aren't you frightened that this would stifle medical research by halving the incentives? You might make existing drugs and those in the pipeline cheaper, but turn off the supply of new drugs.
This is a good point, and one that we have considered. Granted, it might stifle some R&D, or, conversely, it might make drugs more expensive in the short run as manufacturers try to recoup more costs in the shorter patent period, but we believe that opening the drug markets to generics sooner will be a net positive.
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Old 18th May 2017, 05:34 AM   #25
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Originally Posted by jhunter1163 View Post
) but shorten patent protection from ten years to five in order to increase competition (generics would be available sooner).
You might want to check that:

Quote:
Orange Book Frequently Asked Questions*
1. What is the difference between patents and exclusivity?
Patents and exclusivity work in a similar fashion but are distinct from one another and governed by different statutes. Patents are a property right granted by the United States Patent and Trademark Office anytime during the development of a drug and can encompass a wide range of claims. *Exclusivity refers to certain delays and prohibitions on approval of competitor drugs available under the statute that attach upon approval of a drug or of certain supplements.* A new drug application (NDA) or abbreviated new drug application (ANDA) holder is eligible for exclusivity if statutory requirements are met.* See 21 C.F.R. 314.108, 316.31, 316.34 and sections 505A, 505E, and 505(j)(5)(B)(iv) of the FD&C Act.* Periods of exclusivity and patent terms may or may not run concurrently.*Exclusivity was designed to promote a balance between new drug innovation and greater public access to drugs that result from generic drug competition.
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2. How long is a patent term?
Patent terms are set by statute.* Currently, the term of a new patent is 20 years from the date on which the application for the patent was filed in the United States.* Many other factors can affect the duration of a patent.
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3. How long does an exclusivity period last
It depends on what type of exclusivity is at issue.
Orphan Drug Exclusivity (ODE) – 7 years
New Chemical Entity Exclusivity (NCE) – 5 years
Generating Antibiotic Incentives Now (GAIN) Exclusivity– 5 years added to certain exclusivities
New Clinical Investigation Exclusivity – 3 years
Pediatric Exclusivity (PED) – 6 months added to existing Patents/Exclusivity
Patent Challenge (PC) – 180 days (this exclusivity is for ANDAs only)
See 21 C.F.R. 314.108, 316.31, 316.34 and sections 505A, 505E, and 505(j)(5)(B)(iv) of the FD&C Act.
https://www.fda.gov/Drugs/Developmen...longpatentterm
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Old 18th May 2017, 07:35 AM   #26
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Originally Posted by Aber View Post
You might want to check that.. <snip>
Thanks for the info. To clarify, I meant five years after FDA approval; the issues that MikeG identified would still apply.
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Old 18th May 2017, 10:09 PM   #27
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Originally Posted by jhunter1163 View Post
Thanks for the feedback. We're trying to be fully inclusive, cover everything under the sun; that's why we included Level Three as a buy-up. If you want to have a tummy tuck or a nose job, fine, but you'll have to pay extra premium for it.
Why do you want to cover everything under the sun? That boosts costs for everyone, and insurance coverage of elective care reduces price competition. Why should completely optional services like Lasik or tummy tucks be covered by insurance?

Instead of starting from scratch, why not build on existing models? Medicare generally works pretty well and is well understood. Medicaid can work well if states fund it properly. Even good corporate health insurance generally works pretty well; the key issue is how to pay for the same coverage for everyone. Federal government workers can choose from a wide array of health plans, with varying options, premiums and deductibles.

And what, by the way, is wrong with the basic Obamacare model, with more generous subsidies to users and guarantees to insurance companies?

And health care systems abroad range from the British NHS (like our VA) where all hospitals and doctors are part of the government system, to Canada (like our Medicare), where a national or provincial government pays private providers, to Germany, Switzerland, Japan etc., where private insurers pay private providers, but all are closely regulated like public utilities.

But all of this could come after you decide how to pay for it: increased FICA taxes, private premiums with government subsidies, etc., etc. Start with the money question before you debate coverage details.

Last edited by Bob001; 18th May 2017 at 10:11 PM.
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Old 19th May 2017, 03:27 AM   #28
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Originally Posted by Bob001 View Post
Why do you want to cover everything under the sun? That boosts costs for everyone, and insurance coverage of elective care reduces price competition. Why should completely optional services like Lasik or tummy tucks be covered by insurance?

Instead of starting from scratch, why not build on existing models? Medicare generally works pretty well and is well understood. Medicaid can work well if states fund it properly. Even good corporate health insurance generally works pretty well; the key issue is how to pay for the same coverage for everyone. Federal government workers can choose from a wide array of health plans, with varying options, premiums and deductibles.

And what, by the way, is wrong with the basic Obamacare model, with more generous subsidies to users and guarantees to insurance companies?

And health care systems abroad range from the British NHS (like our VA) where all hospitals and doctors are part of the government system, to Canada (like our Medicare), where a national or provincial government pays private providers, to Germany, Switzerland, Japan etc., where private insurers pay private providers, but all are closely regulated like public utilities.

But all of this could come after you decide how to pay for it: increased FICA taxes, private premiums with government subsidies, etc., etc. Start with the money question before you debate coverage details.
Fair questions. We want to cover everything in the interest of completeness; we intend this to be a true single-payor system, where people don't have to pay at all for medical services (beyond their premiums, that is.) Also, the plan does charge extra for those completely elective services; it's basically a voluntary tax to cover those things.

Medicare is, as you said, well understood, by far the largest health insurance plan in the country, and quite efficient. Medicaid also is a fairly efficiently run program. We have based our model on the concept of Medicare-for-all, with some expansions to cover things that are currently excluded. We're not trying to re-invent the wheel here, but we are trying to think in a different direction as far as coverage and provider reimbursement.

The problem with private commercial insurance (as well as the Obamacare exchanges) is spiraling cost. Health insurance premiums have more than doubled since 2001, while average deductibles have quadrupled in the same period. We're paying a lot more for a lot less coverage, and this model is not sustainable over the long run. We need to address the money question, yes, but also the coverage question and the access question.
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Old 19th May 2017, 04:07 AM   #29
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Originally Posted by jhunter1163 View Post

I might not have been clear earlier; the government will not be running healthcare itself, except for the VA and any expansion of that system needed to accommodate the national-service program. Most hospitals and medical facilities would still be privately owned, but would be paid by the government. So, yes, public and private facilities would be side-by-side.
A similar arrangement appears to have resulted in massive inflation of higher education costs in the US.
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Old 19th May 2017, 04:09 AM   #30
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And why is completeness a good goal?
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Old 19th May 2017, 07:52 AM   #31
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Originally Posted by jhunter1163 View Post
......
The problem with private commercial insurance (as well as the Obamacare exchanges) is spiraling cost. Health insurance premiums have more than doubled since 2001, while average deductibles have quadrupled in the same period. We're paying a lot more for a lot less coverage, and this model is not sustainable over the long run. We need to address the money question, yes, but also the coverage question and the access question.
Insurance companies are basically the middlemen. They are certainly profit-motivated, but rising health care costs are largely the result of opaque pricing by providers, particularly hospitals. Journalist Steven Brill got quite a lot of attention a couple years ago with a Time magazine report, later a book, about the complexity and irrationality of hospital charges. And pharmaceutical companies charge whatever they can get away with.
https://www.nytimes.com/2015/01/11/b...ven-brill.html
https://www.amazon.com/Americas-Bitt...Pill%2C’

No single-payer system in the world covers everything everybody could possibly want, nor should it. But they all do have tough controls on how much providers can charge for covered services. That's the place to start.

Last edited by Bob001; 19th May 2017 at 07:53 AM.
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Old 19th May 2017, 08:44 AM   #32
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Originally Posted by jhunter1163 View Post
It's a health insurance proposal; the government would not be in the business of providing health care, with the exception of the VA.
So you're suggesting a government approved monopoly on health insurance, essentially expanding the risk pool to include all U.S. citizens.

Meanwhile, hospitals and other medical offices continue to be private, but are told what they have to charge for services? I assume they also have to accept this coverage? Or are they able to opt out and be private pay only?
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Old 19th May 2017, 08:54 AM   #33
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I foresee a lot of, "Here's what we (the single payer entity) will reimburse for an x-ray."

With a medical office saying, "We would have to take a loss on providing x-ray services, so we will no longer be providing those."

I don't know if this is necessarily a bad thing.

Canada has 8.8 MRI machines per 1,000,000 people.
The US has 34.5 MRI machines per 1,000,000 people. No doubt part of our cost issues reflect under-utilized capacity. Idle machines don't pay for themselves. But it is nice to have a machine available when you need it.
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Old 19th May 2017, 09:05 AM   #34
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Originally Posted by Bob001 View Post
Insurance companies are basically the middlemen. They are certainly profit-motivated, but rising health care costs are largely the result of opaque pricing by providers, particularly hospitals. Journalist Steven Brill got quite a lot of attention a couple years ago with a Time magazine report, later a book, about the complexity and irrationality of hospital charges. And pharmaceutical companies charge whatever they can get away with.
https://www.nytimes.com/2015/01/11/b...ven-brill.html
https://www.amazon.com/Americas-Bitt...itter+Pill%2C’

No single-payer system in the world covers everything everybody could possibly want, nor should it. But they all do have tough controls on how much providers can charge for covered services. That's the place to start.
While I don't disagree that hospital billing practices are ridiculously and unnecessarily complex (believe me, I know; dealing with this sort of thing is my day job), I feel I must point out that reimbursements to hospitals are dictated by the insurance companies. If you charge $100,000 to an insurance company for a cardiac procedure, and the insurer says "We'll give you $25,000 instead," the hospital gets $25,000 and is contractually barred from pursuing the patient for the balance. The horror stories regarding hospital billing arise from patients who are uninsured, who get the same bills that insured patients do. And you're correct about Big Pharma; the question is, how do we give patients relief from these skyrocketing prices without a) implementing price controls or b) cutting off the pipeline of new drugs?
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Old 19th May 2017, 09:09 AM   #35
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Originally Posted by Spock Jenkins View Post
I foresee a lot of, "Here's what we (the single payer entity) will reimburse for an x-ray."

With a medical office saying, "We would have to take a loss on providing x-ray services, so we will no longer be providing those."

I don't know if this is necessarily a bad thing.

Canada has 8.8 MRI machines per 1,000,000 people.
The US has 34.5 MRI machines per 1,000,000 people. No doubt part of our cost issues reflect under-utilized capacity. Idle machines don't pay for themselves. But it is nice to have a machine available when you need it.
Probably not so much on x-rays, as that's a mature tech, but I could see, say, MRI and CAT scan providers grouping up to save money on overhead and equipment if reimbursements are reduced. And as you say, that might not be an entirely bad thing; a lot of these services come under the heading of defensive medicine (that is, services performed to protect the provider against allegations of malpractice by misdiagnosis or nondiagnosis).
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Old 19th May 2017, 09:19 AM   #36
Bob001
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Originally Posted by jhunter1163 View Post
While I don't disagree that hospital billing practices are ridiculously and unnecessarily complex (believe me, I know; dealing with this sort of thing is my day job), I feel I must point out that reimbursements to hospitals are dictated by the insurance companies. If you charge $100,000 to an insurance company for a cardiac procedure, and the insurer says "We'll give you $25,000 instead," the hospital gets $25,000 and is contractually barred from pursuing the patient for the balance. The horror stories regarding hospital billing arise from patients who are uninsured, who get the same bills that insured patients do. And you're correct about Big Pharma; the question is, how do we give patients relief from these skyrocketing prices without a) implementing price controls or b) cutting off the pipeline of new drugs?
I don't think that's true. Uninsured patients -- and often insured patients who go outside their company's network -- can be billed the full retail cost of the services. In your example, the uninsured patients would be billed -- and ultimately sued -- for the full 100 grand. It would be a big step forward if providers were prohibited from charging uninsured people more than the standard Medicare reimbursement rate.

Of course, theoretically Obamacare -- properly executed and supported --would have eliminated the whole idea that anybody could be uninsured. But now we're going backward.
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Old 19th May 2017, 09:22 AM   #37
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Originally Posted by jhunter1163 View Post
Probably not so much on x-rays, as that's a mature tech, but I could see, say, MRI and CAT scan providers grouping up to save money on overhead and equipment if reimbursements are reduced. And as you say, that might not be an entirely bad thing; a lot of these services come under the heading of defensive medicine (that is, services performed to protect the provider against allegations of malpractice by misdiagnosis or nondiagnosis).
Free-standing MRI/CAT centers, dialysis centers etc. are big profit centers for their owners, who are often physician groups who refer their patients to their own businesses. They don't want to save money; they want to make money.
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Old 19th May 2017, 09:53 AM   #38
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Originally Posted by Bob001 View Post
I don't think that's true. Uninsured patients -- and often insured patients who go outside their company's network -- can be billed the full retail cost of the services. In your example, the uninsured patients would be billed -- and ultimately sued -- for the full 100 grand. It would be a big step forward if providers were prohibited from charging uninsured people more than the standard Medicare reimbursement rate.
In medical services, full retail cost is what the market will bear, and seems unconnected with the actual costs in providing the services.
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Old 19th May 2017, 01:05 PM   #39
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Originally Posted by Bob001 View Post
Free-standing MRI/CAT centers, dialysis centers etc. are big profit centers for their owners, who are often physician groups who refer their patients to their own businesses. They don't want to save money; they want to make money.
While that's true today, I'm not sure how that would work under a single payer, assuming the single payer has the power to establish the reimbursement rate, and the provider is required to accept said coverage, and prohibited from pursuing the patient for the difference.
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Old 19th May 2017, 02:22 PM   #40
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