Sure, but, like, changing the fundamental cost structure of our health care system seems like a pretty big add to the already absurdly big policy change of a basic income.
(Which is not to say that I disagree with you, though I do think that there are actually three different cost categories of health care:
1. Routine/preventative/minor care. Probably best dealt with as out-of-pocket costs.
2. One-time catastrophes, like "I broke my arm" or "I got pneumonia." Probably best dealt with as insurance.
3. Long-term or lifelong large expenses, like "I have HIV" or "I have MS." Probably best dealt with as a government program.
But then you'll have a lot of problems with the boundary cases.)
Just want to point out that making routine/preventative care an out-of-pocket cost is probably one of the worst things you can do. I expect there's a reason many companies emphasize and encourage their employees take advantage of 100% free preventive care under their insurance plans. You can save a ton of money later by catching and treating issues early, and even a small personal cost can encourage people to ignore warning signs and not seek aid until the problem has become severe and expensive.
Yeah, this is deeply off-topic, but my reading of the evidence is that preventative or diagnostic care is typically not cost-effective or even outcome-enhancing, with a few specific exceptions like vaccinations.
I have heard this as well, but I think the point still stands. Things like annual physical's might not be a net positive, but you don't want to deter people from going to the doctor when they think something could be wrong.
Interesting. I'd love to see support for this view. Everything I've heard suggests the opposite. Especially if you consider worker productivity in addition to healthcare costs.
It's a complex subject, and a few articles aren't the final word one way or the other. My opinion is based on various things I've read over the past couple of decades (most of which I can't summon up right now) and conversations with various medical professionals in my family and social circle, and my overall worldview (as anyone's must be).
Ok, this is interesting. Some of this fits my intuitions, and some was a surprise to me, so yes, this does modify my view, but only slightly.
It seems there are preventative measures that are cost effective, and there are others that are not. So really, this indicates a need to determine a threshold. Perhaps we determine that we can afford to pay up to $50,000 per QALY, and cover any care that falls within that limit. So, we'd have coverage based on its efficiency rather than whether it is considered preventative or treatment or maintenance. The idea being to get the maximum amount of healthy years of life out of whatever amount of money we as society are willing to put toward healthcare. This could also be extended to programs outside of direct care, like some of those articles suggest, which encourage and support healthy activity in a way that still falls within the $/QALY target.
Of course, I expect it would be a bear to fairly study every possible treatment and program to determine its efficiency, especially factoring in a changing environment which is bound to change the efficiency of any given treatment from year to year.
Still, at a minimum, we should be grabbing those low-hanging fruits, where we can gain healthy years for a very low cost.
I'm going to say this because I'm in a similar situation now.
For weeks, I've been having pains in my chest, back and sides. I know for sure something is wrong. And I fear I may be dying.
But being unsure where my next meal will come from, I can't even visit a clinic to get a test done.
I keep praying to get some money so I can go check myself before I leave my young family without a caregiver.
So yes, whatever you guys argue here today. Make sure people like me in future can be cared for. And that they don't have to worry about food, shelter, Healthcare.
However, that small personal costs may very well help not fill up a queue to the doctor for mundane, trivial crap that would have gone away in a day or two. Care quality is improved when the doctors are less stressed and can spend more time with their patients.
Free-as-in-beer health care ensure more people going to the doctor for more crap, reducing availability and quality for the average person.
I expect there's a reason many companies emphasize and encourage their employees take advantage of 100% free preventive care under their insurance plans.
Yeah, it is called brainwashing. I worked in insurance and was all tickled to see them offering "wellness" benefits. I was all "Oh, yay, the world is turning into a better and more clued place!" Then I went to the meetings. These were purely a sales gimmick. That's it.
You encourage people to go to their annual check up and they feel like you actually care. It breeds employee loyalty. It mostly does very little for actual health outcomes. If you actually want better health, you are better off promoting exercise, healthy eating, sanitation, etc. in place of preventive medical screenings.
> 1. Routine/preventative/minor care. Probably best dealt with as out-of-pocket costs.
This is a pretty terrible idea. Even programs in the current day that are trying to make consumers feel their healthcare costs (like HSAs and their required high-deductible PPO plans) often or always cover preventative care at 100%.
Preventative care is precisely the kind of care that people are most likely to skip to save on some money, and at the system-level this just means much more costly healthcare. Regardless of how you structure your healthcare system, increasing the cost of the actual care itself is a horrible idea.
> Sure, but, like, changing the fundamental cost structure of our health care system seems like a pretty big add to the already absurdly big policy change of a basic income.
We already have a national individual mandate for health insurance with specific coverage rules which has made decisions about this; essentially, a mature BI would cover expected out-of-pocket costs plus insurance premiums in that system.
(That's not to say further reform of that system isn't possible or desirable, with or without BI, just that, given the existing system, there seems to be a fairly natural way that healthcare within that system fits into BI.)
Sorry, I misunderstood your previous comment to mean that you thought we should go to an India-like "out of pocket" system plus (optional) health insurance to handle catastrophic costs. Rereading, your intent is clear.
(Not sure why I jumped to that conclusion, except that perhaps a basic income system appeals to the same economic minimalism that an out-of-pocket health cost system does.)
> Routine/preventative/minor care. Probably best dealt with as out-of-pocket costs.
This seems like a terrible idea. If someone, for example, notices a new mole, they are much less likely to get it checked out if it is an out-of-pocket expense. Obviously, most of the time it'll be fine, but it could also be skin cancer that was easily treatable but has now metastasised and will be hugely expensive to treat.
I would suggest the idea of private insurance is actually completely non-functional without such heavy regulation that you might as well just institute public provision — which also has the benefit that it does not heavily incentivize over-provision.
With a competitive insurance market, you charge people a premium related to their expected healthcare costs. Some people have chronic diseases, and their expected healthcare costs are way beyond what they can likely afford.
However you regulate, insurance companies will always try to find a way to cream off the lowest risk customers to offer them the cheapest deal, progressively chipping away at the idea of collective insurance until it breaks.
Private health insurance is broken not only in practice but also in theory.
For sure - it's kind of absurd because healthcare costs are an inevitability.
With car and home insurance, the products can go their entire lifecycle without burning down, being robbed, or smashing into a tree.
With healthcare, a person is going to need it, and it incapacitates them when they don't get it. Personally I'm for treating healthcare as we treat most regional monopolies that everyone needs - make it a public utility. You'll need healthcare just like you'll need water and electricity.
> With healthcare, a person is going to need it [...]
Not really, at least not at the current stage of technology.
During most of your life, healthcare is more like a lottery, ie you might never need it.
When you are old, something will eventually get you. And a lot of health care costs are spend on these end-of-life conditions. Alas, our massive spending at the end doesn't actually help very much: they mostly give you a few more month of suffering. (For things like cancer etc.)
For a lot of people hospice care is both cheaper and provides a better quality of life. (Some in-law of mine went from hospital care to hospice care when the cancer treatments got worse than the disease.)
So you're saying that you don't eventually need healthcare, except for when everyone needs it then it's the most expensive?
That's like saying you don't really need electricity until later in the day, when it's more in demand for everyone. Should we treat electricity use as a lottery?
In fact, people should be using healthcare more, as a preventative measure (for reasons you just said), but because we treat it like car accidents and house fires and lotteries it's stuck in remedial mode.
>When faced with a terminal illness, medical professionals, who know the limits of modern medicine, often opt out of life-prolonging treatment. An American doctor explains why the best death can be the least medicated – and the art of dying peacefully, at home
To be clear, there are a few different kinds of health care along multiple dimensions, like
- price
- expected mean utility (as measured in quality adjusted life-years gained)
- variance of utility (which I am ignoring here)
I am saying that at current state of technology, if we exclude the expensive stuff with near zero or even negative utility, the remaining demand for big items fits an insurance model rather well.
Yes, I agree that we should probably do more preventive interventions---like exercise, decent nutrition, vaccinations, etc. These are mostly cheap.
And even though they are good for people already, the insurance company might very well decide to just pay for them (and perhaps even pay people extra on top with discounts etcs to nudge them even more) to save itself money in the long run.
EDIT: There's of course also expensive treatments that provide a lot of quality adjusted life years, but the need for these are more like a lottery. (Eg treatment after a car accident or massive burn, or certain treatable cancers.)
So why not explicitly pass a subsidy (e.g. through the tax code) for the chronically ill? Disguising such transfers through regulatory costs is both inefficient and dishonest. It's also very unclear whether society would choose to subsidize all sick people. For example, those who are sick and rich enough to afford their insurance premiums (or who were lucky enough to obtain long-term coverage before they got an expensive medical condition, so their premiums are low), might not merit such transfers. If women have higher expected lifetime health costs due to pregnancy-related care, society might or might not want to have healthcare-related subsidies that amount to a transfer payment from men to women.
The proper way to make these sorts of decisions is by passing laws that make the transfer payments explicit, not disguising them in byzantine insurance regulations.
The system that exists now in the US is broken and already exactly what is described.
Those with money pay too much for insurance because those without insurance are only covered at the last stages, when it becomes inhumane (by anyone's definition) to deny them care (which is also the most drastic and expensive level of care for a problem) which is then 'written off' and padded in to the 'prices' asked for other services.
A LOT of medical costs are actually sunk fixed op-ex. Big expensive machines that cost deferentially little to use or not (but always coast a lot to have the option of using), drugs and other supplies that have shelf lifes, etc.
Labwork presently requires a lot of humans, but much of it could also be converted to automation and human review, lowering the per unit cost; if there were incentive to make such technology.
It's also a major bit of administrative overhead to have to haggle with different insurance companies, hound patients for billing, and in general worry IF someone will pay and how much.
Sorry to basically just negate your post but I do believe that you missed answering the last question in explaining details.
The poster asked, how would the provision of basic income further turn healthcare supply in the US to a negative sum game as compared to private insurance supplemented with corporate and government benefits?
Your response does a fair job of detailing some of the current issues with the US healthcare system but does not mention how basic income would make these issues worse. Would you kindly link the two for those of us who are not making the connection?
You're correct, I was explaining why it was /already/ a negative sum game.
I suppose the closest parallel is what I recall hearing happened to auto-insurance rates when those became mandatory.
Another close parallel would be what would happen if everyone in the San Francisco Bay Area were to suddenly receive an additional 500 USD/month housing allowance for living in the area. I would expect occupancy prices to go up by ~500 USD and the general quality of housing anyone current has to remain the same otherwise.
(And incidentally, that's a great argument for replacing almost all taxes with taxes on land rent: any extra money people have left over after paying taxes etc goes to bid up housing costs. Lower taxes and you get higher housing costs. A land tax can recover the lost revenue---and it's really hard to hide land and evade the tax.)
and looking at the After-tax Lease & R&D adjusted margin, The software industry is at 24% (8th place) and the Insurance industry is at 11.51% (37th place).
You can drive the cost of healthcare up without having large margins
Just like Hollywood never makes a profit, you can't use profit margin to measure what the cost savings would be in moving to national healthcare system.
