How do people envision cutting medical cost?

[edpell]

Hi folks. The original question is how will we lower the cost of medical care in the US. Does anyone support a lifetime limit to the dollar amount of medical care we give to one person? Say $100,000 per lifetime? Or some other number?

 

[Zefram]

What is the point of digit records? Is it just fraud detection?

There's a lot of potential upside to health information exchange: cost savings from administrative simplification, error reductions, quality improvement. A great deal of the delivery system reforms on the horizon are possible only if electronic records are in use.

No, the Republican legislators opposed the Democratic plans for reform; they repeatedly proposed many of their own, some of them in form of actual draft bills.

This is true but many of the elements in http://rules-republicans.house.gov/Media/PDF/RepublicanAlternative3962_9.pdf appear in some form in the Democratic proposals (e.g. allowing dependents to remain on their parents' coverage into their mid-20s, encouraging the interstate sale of insurance policies, high-risk pools, wellness promotion programs, some sort of pooling mechanism to allow buyers in the individual and small group markets to leverage greater purchasing power, etc). However, with these Republicans, winning policy concessions doesn't necessarily translate into voting for legislation. But don't be fooled into thinking the Democratic bills aren't heavy with conservative or Republican ideas.

There is no way to increase coverage and increase spending and simultaneously shrink the deficit and no healthcare bill has ever shrank the deficit.

Of course there is: accompany those things with a revenue source that more than pays for the coverage expansions. Both the House and Senate bills do this, which is why they reduce the deficit.

While the Republicans were not kind to the Democrats when in power, to say they have refused to participate in honest debate over this current bill is incorrect.

They've purposefully distorted the bills' contents and attempted to make a joke of the legislative process at every turn. So it doesn't seem too incorrect to say that.

Remove the law preventing people from being able to purchase health insurance across state lines

There's no federal law that does this. State laws are what prevent interstate insurance sales.

end the WWII-era price control that is the tax credit for employer-provided health insurance

Politically this would be exceptionally difficult to do, even if it is a good idea. The Senate bill's excise tax effectively caps this tax exemption at a fairly high level and even that's been very unpopular among the public.

 

[mheslep]

...This is true but many of the elements in http://rules-republicans.house.gov/Media/PDF/RepublicanAlternative3962_9.pdf appear in some form in the Democratic proposals ...

[...] encouraging the interstate sale of insurance policies, high-risk pools,

This one in particular - interstate sale of private insurance policies by any insurance company to any individual regardless of borders - is not in the Democratic bills (Senate or House). The http://www.opencongress.org/bill/111-h3962/text" empowers the individual, allowing "each individual to use the refundable tax credit toward the purchase of health insurance in any State", end of story.

[...] However, with these Republicans, winning policy concessions doesn't necessarily translate into voting for legislation. But don't be fooled into thinking the Democratic bills aren't heavy with conservative or Republican ideas.

I'll try not to be fooled by anyone, and I'm still looking for the conservative ideas in the Democratic bills.

Of course there is: accompany those things with a revenue source that more than pays for the coverage expansions. Both the House and Senate bills do this, which is why they reduce the deficit.

My reading of the CBO scoring (Senate bill) is the opposite: for a given year of actual benefits and spending (when indeed it starts), the revenues in the same year fall short.

There's no federal law that does this. State laws are what prevent interstate insurance sales.

Correct, but the federal government has the authority via the commerce clause to trump the state laws in this regard. Republicans favor the idea, Democratic legislators rejected it.

 

[mheslep]

...Politically this would be exceptionally difficult to do, even if it is a good idea.

Agreed. But there have been attempts at more pallatable solutions. McCain in the '08 campaign proposed moving the tax break dollar for dollar away from the employer-employee to the individual, a start at least to eliminate the madness of being forced to get high price health care only through an employer. The 08 Obama campaign, especially Biden, demagogued the idea heavily, so now for Congress to even mention the idea the political barrier was much higher.

The Senate bill's excise tax effectively caps this tax exemption at a fairly high level and even that's been very unpopular among the public.

http://www.nypost.com/p/news/national/unions_get_pecial_treatment_in_health_AB053CwqPIJlIxXAm37DOM" , then you get a pass on the Cadillac plan tax.

 

[Zefram]

This one in particular - interstate sale of private insurance policies by any insurance company to any individual regardless of borders - is not in the Democratic bills (Senate or House). The http://www.opencongress.org/bill/111-h3962/text" empowers the individual, allowing "each individual to use the refundable tax credit toward the purchase of health insurance in any State", end of story.

The House bill contains financial assistance to states that enter into such compacts. If they choose to, fantastic. Each state entering such a compact will get to decide whether the regulatory floor in the compact is desirable for its residents. The Republican alternative--the Shadegg proposal--doesn't allow states to have a say in the insurance policies sold within their borders. That is, the Republicans call for states to cede sovereignty to other states. It's one thing to impose a federal floor on states but to pull the floor our from underneath states and allow the lowest common denominator to dominate the regulatory environment is irresponsible and potentially dangerous.

The Democratic bills encourage states to decide the level of interstate insurance sales they're comfortable with and provides funding for planning and implementation to states that enter into compacts. You don't believe that's a reasonable compromise?

I'll try not to be fooled by anyone, and I'm still looking for the conservative ideas in the Democratic bills.

I've already specifically mentioned ideas from the Republican substitute that appear in the Democratic plans:

• Allowing dependents to remain on their parents' policies into their mid-20s.
• Ending rescissions.
• The elimination of annual or lifetime spending limits for insurance policies.
• An expansion of high-risk pools.
• Incentives for wellness programs.
• Again, encouraging interstate insurance sales.

Are these proposals identical in every respect between the bills? No. As we've gone through, the Democratic proposal for interstate insurance sales is designed to preserve state sovereignty over insurance markets. The high risk pools in the Democratic bills are designed to be temporary and eventually people in those pools will be transitioned to the health insurance exchange. But these are ideas that vary in the details but have common roots.

Other ideas that are conservative or at least have been endorsed by conservatives:

• Elimination of pre-existing conditions as a pre-text for denying coverage (mentioned in Bobby Jindal's op-ed)
• The individual mandate (Republican leaders have since reversed themselves on this). For example, the lead Republican negotiator on the Senate Finance Committee, Chuck Grassley, http://www.washingtonmonthly.com/archives/individual/2009_09/020072.php: "As recently as a month ago, Chuck Grassley, the same senator bashing the idea of a mandate yesterday, announced that the way to get universal coverage is 'through an individual mandate.' He told Nightly Business report, 'That's individual responsibility, and even Republicans believe in individual responsibility.' Earlier this year, Grassley told Fox News that there wasn't 'anything wrong' with mandates even if some may view them 'as an infringement upon individual freedom.'"
• The creation of health insurance exchanges (these figured heavily into the Republican Patient's Choice Act of 2009).
• Continuing the stimulus bill's support of health information exchange
• Subsidies to low income buyers in the individual private insurance market. Here's the http://www.heritage.org/Research/HealthCare/wm2448.cfm (from before the Democratic bills were released): "Moreover, as a general principle, Congress should provide tax relief for those who purchase coverage on their own and redirect other health care spending to help low-income individuals and families purchase private health insurance coverage." This also appears in the Republican Study Committee's H.R. 3400.
• An employer mandate to offer insurance. This appeared in the bipartisan "Crossing Our Lines: Working Together to Reform the U.S. Health System" proposal released by Howard Baker, Bob Dole, and Tom Daschle.
• Support for comparative effectiveness research. This, too, appeared in "Crossing Our Lines: Working Together to Reform the U.S. Health System."
• A tax credit aimed at encouraging small businesses to offer their employees health insurance.
• The excise tax in the Senate bill.
• Increased funding to fight waste, fraud, and abuse in Medicare.

I'm sure there are more but it's exceedingly late right now. The bottom line is that the pillars of the Democratic proposals (insurance market reform, the creation of health insurance exchanges, and assistance to lower income Americans to buy private insurance in the individual market) have been embraced by conservatives. There may be disagreement in the details but philosophically (or ideologically) there are no real conflicts at the core here. There are numerous compromises built into these bills. Indeed, the entire premise of the Democratic proposal is a compromise between the liberal and conservative positions. To overgeneralize a bit: liberals prefer a universal public system, conservatives prefer a non-universal private system. The Democratic bills build a near-universal (mostly) private system.

My reading of the CBO scoring (Senate bill) is the opposite: for a given year of actual benefits and spending (when indeed it starts), the revenues in the same year fall short.

The http://cbo.gov/doc.cfm?index=10868&type=1 (the table on Page 3 is what you want to look at here) shows two oppositely directed influences on the budget: increases in the deficit caused by coverage expansions and decreases in the deficit caused by reductions in outlays. The former is larger than the latter. But then you factor in the new revenue stream and in nearly every individual year this leads to a net reduction in the deficit. Over the first decade the aggregate net reduction in the deficit is sizable and CBO projects it will be even larger in the second decade.

Agreed. But there have been attempts at more pallatable solutions. McCain in the '08 campaign proposed moving the tax break dollar for dollar away from the employer-employee to the individual, a start at least to eliminate the madness of being forced to get high price health care only through an employer. The 08 Obama campaign, especially Biden, demagogued the idea heavily, so now for Congress to even mention the idea the political barrier was much higher.

Yes, they shouldn't have done that. But Congress has mentioned the idea before and since; Wyden-Bennett has been around for 3 years now and never seems to get much traction. The reality is that politically it's exceedingly difficult because people are afraid of anything that will alter their coverage, even if it involves a transition to a better system.

http://www.nypost.com/p/news/national/unions_get_pecial_treatment_in_health_AB053CwqPIJlIxXAm37DOM" , then you get a pass on the Cadillac plan tax.

...for four years after the opening of the exchanges. I hope you didn't mean to imply a pass in perpetuity.

 

[mheslep]

The House bill contains financial assistance to states that enter into such compacts. If they choose to, fantastic. Each state entering such a compact will get to decide whether the regulatory floor in the compact is desirable for its residents. The Republican alternative--the Shadegg proposal--doesn't allow states to have a say in the insurance policies sold within their borders. That is, the Republicans call for states to cede sovereignty to other states. It's one thing to impose a federal floor on states but to pull the floor our from underneath states and allow the lowest common denominator to dominate the regulatory environment is irresponsible and potentially dangerous.

The Democratic bills encourage states to decide the level of interstate insurance sales they're comfortable with and provides funding for planning and implementation to states that enter into compacts. You don't believe that's a reasonable compromise?...

No. As we know and you pointed out earlier, the reason the US doesn't have interstate health insurance now is because of the states themselves. Leaving it up to them means retaining the status quo, i.e. doing nothing. So I think that suggesting the D. bill will change anything regarding interstate sales is misleading.

Also while state sovereignty is important, it doesn't always trump everything else, especially not the individual. In this case I'd say that control is ceded to the individual, not other states. Auto insurance is sold across state lines; I don't see that as a attack on state rights.

Edit:

[...]The high risk pools in the Democratic bills are designed to be temporary and eventually people in those pools will be transitioned to the health insurance exchange. But these are ideas that vary in the details but have common roots.

Well we are talking past each other here. I see no intention to actually get behind pools in the D. bill when the plantgoing in is to get rid of them, but merely a political head fake to give the appearance of common ground, when in reality there is none.

 

[mheslep]

...
...for four years after the opening of the exchanges. I hope you didn't mean to imply a pass in perpetuity.

Agreed, it says four years now. We'll see if it stays that way. I doubt it.

 

[WhoWee]

It's funny how the Left has changed it's tune.

http://www.msnbc.msn.com/id/10609044/
"Three growing entitlement programs consumed nearly half of all federal spending in 2004, and budget analysts expect them to make up an even bigger share in the future.

Social Security, Medicare and Medicaid accounted for more than $1 trillion in the 2004 budget year, according to the Consolidated Federal Funds Report released Tuesday by the Census Bureau.

Overall federal spending was $2.2 trillion, an increase of 5 percent from 2003."


http://www.msnbc.msn.com/id/34415087/ns/politics-health_care_reform/
"Liberals had sought the Medicare expansion as a last-minute substitute for a full-blown, government-run insurance program that moderates insisted be removed from the legislation."

http://firstread.msnbc.msn.com/archive/2010/02/01/2191106.aspx
"The proposed FY2011 budget puts overall spending at $3.83 trillion dollars during the fiscal year, and projects a deficit of $1.27 trillion, or 8.3% of the Gross Domestic Product.

With the unemployment rate stuck at 10%, the administration has been under pressure to defend its spending decisions. Republican critics say efforts to pull the economy out of recession have done little to produce jobs and have added too much to the deficit. Obama has consistently argued the spending was necessary to prevent total economic collapse and has sought to remind people that he inherited an already huge $1.3 trillion deficit, was prepared to take steps to reduce it, and wants help from both parties."

Just saying

 

[Astronuc]

Start saving if one hasn't already.

The High Cost of Growing Older
http://finance.yahoo.com/focus-retirement/article/109070/the-high-cost-of-growing-older

No doubt, healthcare will be one of your biggest expenses in retirement. Qualifying for Medicare coverage at age 65 will quell some cost and coverage worries. But although Medicare is far more affordable than private health insurance coverage for seniors, the government health insurance program still leaves retirees with significant out-of-pocket costs.

Consider this: A typical 65-year-old married couple without chronic conditions will need $197,000 to pay for out-of-pocket medical costs throughout retirement, according to new calculations by the Center for Retirement Research at Boston College. That figure includes insurance premiums, services not covered by Medicare, and home healthcare expenses, but it excludes nursing-home care. Retirees also have a 5 percent chance that healthcare costs that are not covered by insurance will exceed $311,000, according to the study, which was underwritten by Prudential. "Regular ongoing out-of-pocket costs can really cumulate over the years," says Anthony Webb, associate director of research at the Center for Retirement Research at Boston College and coauthor of the study. "There is no substitute to having a lot of money stashed away."

Other researchers have come up with similarly large numbers. Fidelity Investments estimates that a couple, both age 65 in 2009, will need approximately $240,000 to cover medical expenses throughout retirement. And the Employee Benefit Research Institute determined that a 65-year-old couple in 2009 will need $210,000 to have a 50 percent chance of affording their retiree health expenses and $338,000 to have a 90 percent chance of being able to pay all their medical bills.

These eye-popping numbers are generally a tally of small expenses that add up throughout retirement. Here are the latest estimates of the health expenses most Americans will face.

. . . .

Don't get sick, or at least not seriously ill. It helps to be a millionaire or better.

 

[mheslep]

A typical 65-year-old married couple without chronic conditions will need $197,000 to pay for out-of-pocket medical costs throughout retirement,

With an average lifespan of 75 (and they might be using 80 in the future), that's ~$20k/ year for a couple, age 65-75 that includes hip / knee replacements, etc, etc. One hardly needs to be a millionaire to afford those kind of out of pocket costs. Frankly I can't imagine using a trained medical staff and facilities that cost much less than that.

 

[Astronuc]

With an average lifespan of 75 (and they might be using 80 in the future), that's ~$20k/ year for a couple, age 65-75 that includes hip / knee replacements, etc, etc. One hardly needs to be a millionaire to afford those kind of out of pocket costs. Frankly I can't imagine using a trained medical staff and facilities that cost much less than that.

Closer to 80 years (or high 70's). I was thinking that ~$1 million in investments so that one lives of the interest. Otherwise, one is looking at a sinking fund. Although one might expect to live 80 years, what happens if one is still alive and manages to live to 90 or 100. My mother in law is 89 this year, and her sister lived to about 93, but spent the last 3 years in a nursing home with Alzheimers/dementia.

A lot depends on where one lives. My parents looked at place on the E. Coast, and the planned retirement communities were pretty expensive. The question becomes one of when assisted living will be required.

It also depends on how much travel one might want to do. Of course, one could just stay local and wait to die.

 

[mheslep]

Closer to 80 years (or high 70's). I was thinking that ~$1 million in investments so that one lives of the interest. Otherwise, one is looking at a sinking fund.

<shrug> Can't take it with you.

A lot depends on where one lives. My parents looked at place on the E. Coast, and the planned retirement communities were pretty expensive. The question becomes one of when assisted living will be required.

Yes though living expenses are a separate issue, not included in the article.

 

[Count Iblis]

How do you think the U.S. will cut medical cost?

For the US, it is actually very simple. The government can give people money for successfully losing weight and staying at their new weight.

 

[edpell]

For the US, it is actually very simple. The government can give people money for successfully losing weight and staying at their new weight.

I have not carefully reviewed all the posts but I think this is the first positive constructive answer to the question! Thank you.

My grandmother is 101 years old and showing no signs of dying.

 

[ThomasEdison]

More medications should be over-the-counter and not require a doctor's approval or a visit to a pharmacy to get them.

 

[edpell]

More medications should be over-the-counter and not require a doctor's approval or visit to a medical center to get.

I agree.

In fact as a Libertarian I would have all medical services, drugs and devices be available in the free market. Not being a prefect Libertarian I would have regulation to the extent that no one may make fraudulent claims (i.e. lie about their training or lack of training).

 

[adrenaline]

Provide more primary care physicians,they provide lower cost medical care, many times with even better outcomes.

Eliminate defensive ordering of tests estimated at 300 billion a year. There are two things that go through every doc's mind.

1. what test do I need to order to confirm or rule out a diagnosis?
2. What test do I need to order so I don't get my a$$ sued.

It is number two that adds to cost

( Also, right now doctors cannot use evidence based medicine to defend their practices, they have to use standard of care ( many times the standard of care is no longer the best practice and actually more expensive).

single payer, saves 400 billion a year in clerical and administrative costs but that is as likely as hell freezing over

Third, change the lifestyle of americans, something as simple as making sure there are adequate bike lanes and side walks ( I bike in a very bike unfriendly city Atlanta) people may start to bike or walk more to work.
Change expectations that more expensive is better or that quick fixes are the answer to everything. . For example, we are finding out that verteboplasty is no better than placebo, much of the times, yet many americans still want a quick fix for their compression fracture pain and studies are out there that show non invasive, medical and diet management of heart disease is as good as aggressive more costly interventions( ,( depending on the type of heart disease of course!)

Change the fee for service, especially in the general medicine fields ( not surgeons) , right now an family practioner gets paid more to take care of an ingrown toenail in 10 minutes than he would to spend 45 minutes educating patients on diet, excercise, disease avoidance , how to manage exacerbations of disease, how to modify treatment plans in emergencies etc. ( of course, the latter is being relegated to nurse practioners right now already) or an internist spending 35 minutes of cognitive effort sorting out a complex disease diagnosis.