VA System: Better Care with Less Profit Incentive

[airborne18]

I agree insurance is a bad way to attend to chronic conditions. By definition, insurance is for covering the unexpected. Insurance is not the way to address, say, wrecks from pile ups in the Demoltion Derby every Saturday night. For health care, high risk pools with government subsidies seems to be the way to go for chronic conditions - not run by government doctors, only subsidized by it. The US had a good version of risk pools on the table with McCain's campaign in my view.
http://www.politico.com/news/stories/0510/37013.html
Obamacare version:
http://www.healthinsurance.org/risk_pools/

I actually don't agree with your definition of insurance. But I don't think that auto or health coverages are insurance anymore. Once states mandated car insurance it became a subsidy to insurance companies. It is a tax if it is required. And there is no point in having private companies profit from a mandated product. The government should run it at that point.

Everyone will use medical care. So let's forget how it gets paid for, how do we extend health care to everyone in society? We give elderly unlimited access to care. So why do we limit access to care for younger people who actually would benefit.

And I don't understand the function of private insurance companies. They don't accept risk, they push high risk patients out of the pool. Health care is not an "unlikely" event in life. Health insurance is something everyone eventually uses, so it does not fall into your definition of insurance. So again the taxpayers are stuck with the people they push out of the risk pool, so the taxpayers are subsidizing their profits and pushing medical costs to the government. So they are not helping control costs, they are cost shifting to the government. Not a very efficient or fair system.

 

[airborne18]

Relevant question: what do people think about the idea of doing away with traditional* US malpractice suits altogether and avoiding the expense and defensive medicine? If the answer is no, then why is ok for the US VA?


http://veteranmedicalmalpractice.com/faq.html

* meaning no jury trials, and you have to seek an administrative solution before suing only in federal court.

Active duty cannot sue, that is the VA's role. And individual health professionals have no liability. The government picks up any negligence. Veterans can seek damages and it is actually good that we don't have to go through the US legal system. Veterans court actually operates contrary to the US Justice system. The rules of evidence don't apply, and Veterans have special standing. Any medical evidence that is favorable to the veteran gets in, and it outweighs any government evidence.

You are right there are no juries, thankfully. And the case can be reopened at any time, and new evidence is allowed on appeal.

I know the legal community has been trying to get into the VA, to make fees off Veterans. But they cannot make any sense of the system, because it is not adversarial in the traditional sense.

Plus veterans get free representation.


Private doctors should have personal liability. They are driven by profit. And they prescribe treatments based on kickbacks from 3rd parties, like drug companies. SO they should assume risk. They don't want the government regulating them, and they don't want liability.. Yet they accept payments from HMO's to limit treatment to patients..

Too bad, but that is the risk of being a business person and not a medical professional.

We need to focus on care, and not protecting profits.

 

[airborne18]

I will explain the lawsuit issue this way.

I have injuries due to my service in the military. I had to basically file with the VA to get it covered, so I had to take legal action. They assume all of my medical and they pay me.

Since I am totally disabled already, there is no benefit for me to file against them. There is nothing more to gain. Actually I have something to lose. If I accept a payoff because they made a mistake, then they no longer have to medically treat it.
So why release them from medical liability?

You have two options with negligence. Either the VA will pay you off, or they will give you medical care and an increased pension. So for someone who is maxed out, it makes no sense to ever sue.

Now on the other side. Say you punch me in the face and break my nose. The VA takes care of it, since I am essentially a ward of the VA. If I sue you for damages, the VA gets the money because they are the ones providing the treatment.

 

[mheslep]

I actually don't agree with your definition of insurance.

My definition? insure: to guarantee against loss or harm, i.e. used not on anything chronic: constant; habitual; inveterate

 

[mheslep]

I will explain the lawsuit issue this way.

I have injuries due to my service in the military. I had to basically file with the VA to get it covered, so I had to take legal action. [...]

The above quote and my point was about medical malpractice liability, not eligibility, two completely different things.

 

[airborne18]

My definition? insure: to guarantee against loss or harm, i.e. used not on anything chronic: constant; habitual; inveterate

That was not your definition before. So when I my chronic condition was profitable, they held up their contract, when it was not profitable they could break the contract. That is not insurance.

And a big component of insurance is assumption of risk, and aggregation of risk.

So at least you agree that health insurance does not facilitate care and is a liability to the US health care system. If people want to fund insurance company profits, fine, but we need to really focus on providing care and not looking out for doctor's and insurance company profits.

At least now we are on track to single payer. Dropping insurance for children in response to the preexisting conditions will just help the process.

 

[airborne18]

The above quote and my point was about medical malpractice liability, not eligibility, two completely different things.

Well you are trying to fit the VA system into the private model, and it does not work that way. Veterans are given very specific rights that don't translate into the private sector.
It just is not designed that way. And standing and eligibility are key issues.

There was plan floated to allow the VA to buyout veterans with disabilities to get them out of the VA cost structure. Veterans shot it down. Personally if the VA offered me 2 million, I would turn it down. In cash the VA will pay me 700,000 to 1,000,000 until I die. And that does not include care. Which the taxpayers are on the hook for all of my care, even nursing home, and organ transplants.

 

[Zefram]

Not taxing employer-provided health insurance which causes distortions, not allowing people to purchase health insurance across state lines, mandates from various state governments on what health insurance companies must cover, etc...there are other aspects I am not thinking of right now.

Not taxing employer-provided health insurance is why most health insurance in America is provided by employers, which makes it where if a person loses their job, they lose their health insurance. It also bankrupts businesses (like GM).

I don't know of any specific studies on this, but I know each state provides different levels of mandates on health insurance companies, so I wouldn't find it surprising if this affects healthcare costs.

It sounds like you're generally asking for some degree of simplification and standardization (i.e. federalization) of at least a regulatory floor for health insurance, the fostering of new marketplaces where individuals and even people with employer-sponsored coverage can choose from any of the plans available in the state and buy a plan that truly belongs to them (similar in some respects to the way http://www.deseretnews.com/article/700062069/Health-Exchange-opens-to-all-small-businesses-in-Utah.html works), and diminishing the relative tax advantages that employer-sponsored plans enjoy.

On the other hand, the call for across-state-lines purchasing usually implies an absence of federal standards and is thus usually just a coded way of asking for (potentially disastrous) deregulation of the health insurance industry. So I'm not entirely sure I see where you're coming from yet.

 

[mheslep]

Just curious:

On the other hand, the call for across-state-lines purchasing usually implies an absence of federal standards and is thus usually just a coded way of asking for (potentially disastrous) deregulation of the health insurance industry. So I'm not entirely sure I see where you're coming from yet.

Do you actually mean an absence of state standards? If not, why does across-state-lines mean no federal standards any more than buying food across lines would somehow eliminate (the copious) federal food standards?

 

[Zefram]

Federal legislation encouraging interstate insurance sales doesn't inherently imply the absence of federal standards; I'm talking about the actual proposals favored by conservatives today, which are built upon the idea of a single state's laws being enforced in 49 other states. That is, I'm talking about Shadegg's Health Care Choice act, the Republican repeal-and-replace bill (which lifts the text for the interstate purchasing section right out of H.R. 3217), Ron Paul's H.R. 5444, etc.

These are based on the notion of insurers choosing a "primary state" in which to be licensed and then operating in that primary state as well as in up to 49 other "secondary states," subject only to the insurance laws of the primary state. Moreover, the primary state is responsible for enforcing its state laws in every other state in which a primary state-licensed insurer is selling products ("IN GENERAL- Subject to subsection (b), with respect to specific individual health insurance coverage the primary State for such coverage has sole jurisdiction to enforce the primary State’s covered laws in the primary State and any secondary State.").

The object, of course, is deregulation--states are empowered and encouraged to circumvent each other's laws, sparking a race to the regulatory bottom. And they do so in the absence of a federal floor to that bottom.

Shadegg's bill (and the repeal-and-replace) bill don't completely pull the carpet out from underneath insurance regulations; since their effect is to overturn state insurance laws governing individual insurance policies, their damage is mostly confined to the individual market. It's when you take the more expansive conservative proposal--found in Ron Paul's bill and many conservative proposals--of also changing the tax treatment of health insurance to eliminate the advantages employer-sponsored plans enjoy (i.e. by offering a standard tax credit for health care costs to everyone) that things get dicey. Most people are currently in employer-sponsored plans and thus they do have federal protections under HIPAA and ERISA. When you couple de-regulation of individual markets at the state level with a gradual transition of virtually everyone into the individual market (stripping them of most of the federal protections they have today), that's when a misguided idea becomes a disastrous idea.

On the other hand hand, you could foster responsible interstate purchasing in multiple ways:

• Interstate compacts in which states willingly (unlike in the above proposals) enter into agreements with other states to allow interstate purchasing.
• The creation of national plans, subject to federal standards, that can be sold in any state.
• The voluntary merging of different states' health insurance exchanges.
• Setting uniform federal minimum standards and requiring that states allow the sale of any plan meeting those standards in their state.

The first three options have been accounted for in ACA. The last option is not currently law--i.e. states are not required to allow any plan from other states that meets the minimum standards of exchange eligibility to be sold in their exchange--but by setting federal minimums it does pave the way for that possibility. So no, interstate purchasing isn't inherently deregulatory. It just happens to be in the political context in which it's most often used today.

 

[Al68]

It sounds like you're generally asking for some degree of simplification and standardization (i.e. federalization) of at least a regulatory floor for health insurance, the fostering of new marketplaces where individuals and even people with employer-sponsored coverage can choose from any of the plans available in the state and buy a plan that truly belongs to them...

Those two things are contradictory when the "regulatory floor" outlaws plans that "truly belong to them". The type of medical insurance that "truly belongs" to many is the kind that covers only unexpected major medical expenses.

That's what the word "insurance" means. The rest of what is contained in an "Obamacare" plan is comprehensive health care coverage, not insurance. And it constitutes the bulk of the cost.

It's very misleading to even use the term insurance when talking about forcing people to buy much much more than just medical insurance. It's like forcing everyone to buy a diamond-encrusted Rolex and outlawing all other watches, while claiming "well, everyone ought to own a watch".

 

[loseyourname]

Apparently. I was looking for examples of each. For instance, Walter Reed takes both Vets and active duty, so what would its classification be?

The VA is a separate organization from the DOD. VA hospitals consistently rate pretty highly in quality of care surveys and DOD hospitals consistently rate pretty terribly. I don't know if this is the difference and I hate to trash my own profession, but DOD hospitals are staffed mostly by military officers; VA physicians are civilians (I'm an Army officer, not a doctor).

It kind of gets at the fallacy of people talking about "the government" as if it's all one agency with one set of equally competent managers and employees.