Memeology #4

Track record matters more than intentions. The track record of wealth taxes is pretty mediocre.

Those 4 countries used to be 12. Most countries stopped due to how costly & difficult administering the tax turned out to be.

Of the remaining 4, Switzerland gets the highest return, and it’s only 3-4% of revenues.

If you’re thinking this would somehow solve our debt problem, or give us breathing room to enact free X, you’re out of luck.

  1. Make the medical industry competitive so prices fall.

You can start by allowing people to buy insurance across state lines.

  1. High risk pool insurance.
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Regulation and buying in bulk through Medicare and medicaid has done that.
Congress has the ability to regulate INTERSTATE but not INTRA STATE commerce. Do you know my current insurer is based in California and I’m in Michigan yet it’s sold to meet the regional needs of Michigans west coast. What your really saying is deregulate have bottom basement insurers compete across state lines with no federal oversite making it hard to file claims during denials. You know you would get bare basement plans in Delaware where crap banks with 300% emergency loans exist right? They can sell those across stateliness unlawfully hoping you’re stupid enough to pay them back. They tried to collect on one with 300% interest here in Michigan our maximum interest rate was 33.3% they were laughed out of court. Yeah bottom basement fly by night insurance yeah that’s what Americans need.

I swear you’d sell your kids kidneys to make money.

So functionally; no:

https://help.ihealthagents.com/hc/en-us/articles/115003456874-Can-I-Buy-Health-Insurance-Across-State-Lines-

You need to make the broader market like this. Prices will fall that way, including for Medicare plans, as they are impacted by what the rest of the market is doing.

Incorrect, you just pointed it out yourself:

So it’s not a way around Federal oversight. It’s a way around State mandates.

If the State I live in requires pap smears in my plan, when I have no need for them, and there’s a cheaper plan the next state over that does not have pap smears, I would prefer to buy that plan. That plan is a better option for me.

“Pay for what you need” makes so much sense, yet in health insurance, we don’t get that.

Insurance doesn’t really work that way by nature, it’s not a specific service you’re buying. You’re buying access to a collective fund to cover whatever you might need done.

It’s not for you. It’s for your neighbors. Some of your money covers that and some of their money covers prostate exams. It’s not about an individual service, it’s covering the collective good and public health

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Yes it does:

Customize your plan to your particular use case. Not an average, not added expenses for things you don’t do; yours. Other sidelong industries are looking at health insurance, shaking their heads for it being so backwards.

My neighbor drives a car modified for his use, so he can park a wheel chair in the driver side.

Somehow, my car insurance doesn’t have to cover that, and he can still afford to get that modification. And the world turns just fine.

Equally, my property insurance doesn’t cover wildfires since I don’t live in the middle of a forest, but people here in Colorado who do can still find that coverage affordably.

Excuses; insurance in other industries shows that’s what they are. What’s more, they are harmful excuses that make the industry more, not less expensive.

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Health insurance isn’t like any other insurance. Do you want to cover chemotherapy? Do you realize that by not covering pap smears you could end up paying much more to cover cancer related costs that could have been prevented with regular screening? You can’t reliably plan for most health emergencies like you can wildfires or auto issues.

Yes it is; again, the Lodge practice era showed that.

History simply dealt health insurance a strange hand with the AMA monopoly, WWII making employer tax benefits the norm, and the messy Federal coding system demonstrating everything that is wrong with monopsony.

Byzantine requirements, vendor driven (not consumer driven) behavior, and high barriers to market entry.

An industry that lags because of it.

Have you checked on the cost of that lately?:

So we have nigh parity even if you’re paying out of pocket, and it can even be better that way.

Meanwhile, getting pap smears off plans for those who don’t want it would make it more affordable. Because cost efficiency at the level of industry is not won by negotiations.

It’s won by competition, and insurers/providers trying to offer you, the consumer, the best value.

Which we insulate current insurers from doing. The implicit bargain is that they agree to certain demands, and in return, we let them have their oligopolies. It’s a Faustian bargain.

My neighbor did not plan his spinal injury that made getting that wheel chair-driven van and it’s lift a necessity.

If you actually want to reduce the bloat and save money, then this is relevant:

That’s over 2 million employees, and doesn’t even touch that they’re so effective at denying coverage, your money went to covering their shareholder profits of around 30 billion dollars beyond that.

Made necessary by Government regulation, and their coding system.

Remember these guys? Guess who they threw out by moving to their model?

And implying Gov’t middlemen would be more efficient than private ones is… dubious.

What you’re arguing is that hard monopsony is better than soft(er) monopsony. True or not, I’m saying, quit with the monopsony. Make this an actual market again.

Only use Gov’t middlemen where the market actually can’t deliver. Which is why high risk pool programs exist.

In essence, yeah that’s what I’m saying. I’ve personally never had a choice in healthcare provider anyway, it’s always whichever provider my employer uses. In terms of making it an actual market, there’s a piece I think we may disagree on: in my mind, for profit healthcare coverage cannot exist as it is innately unethical and incentivizes not covering patients. It’s the same reason I’m opposed to for-profit prisons. The cost of healthcare itself is another issue separate to but intertwined with coverage.

How they fix it here in Korea is setting price caps. Way oversimplified: say a pap smear costs $25-$125? Cool, looks like you can make money at $25, so it’s now illegal to charge more than $30 for one. Cost going up and you’re losing money on pap smears? Prove it in a request to reevaluate the price cap. The insurance part comes in where the government says they will pay the provider half the cost and the patient will pay the other half.

For the record insurance here is pretty across the board 50% coverage. They just make covering 50% out of pocket manageable by capping prices.

That sounds worse than what we have here in the states, with medicaid as long as you refuse hours you can buy into our Cadillac Care system. Some providers refuse to take it out of spite, none the less I love the system here wish they would define poverty differently.

This restricts access. Not every place can charge the same price as not every location has the same costs. Overhead, utilities, prevailing wage for the employees, etc. will all differ.

The end result is less places offering the service.

Instead of Gov’t boards, it should be competition that sets prices. As competition does not stop you from offering a higher price, but it will mean you need to justify it to your consumers who will otherwise go somewhere else.

That will sort out justified vs unjustified costs rather quickly. Especially for a low margin service like this one.

We did this with airlines. The end result was prices of faires going up year after year. Your study shows Korea is no different when it comes to drug prices.

Airlines in the 60s had no interest in being competitive. Prices only fell, after the board controlling prices went away, and we forced them to compete.

Ergo, even with the best of intentions, regulatory capture still occurs. Because the regulatory board, has to take industry assumptions on-board.

In healthcare we are seeing the objection go somewhere already. How can $30+ billion in industry profit be morally justified on the back of denying anyone needed coverage?

Perhaps, but I don’t think healthcare and medicine have ever been or should be a true marketplace. Demand for drugs don’t rise to the point of buying them out of stock because prices lower, there’s a gatekeeper to buying, physicians and prescriptions. Demand does go up when prices lower, sure. Doctors are more likely to prescribe them if they know it will be more affordable to patients, but they’re not prescribing them unnecessarily (at least not good doctors). So we’ll never be dealing with a pure and open marketplace.

Unless they also mandate offerings (license them for a set of drugs that go together) or give prices flexibility regionally based on the factors you described. The latter seeming more realistic.

As a related aside, ever heard of the rural doctor crisis in the U.S.?

How does a small rural town compete? In a pure marketplace, why bother trying to supply a small town with anything?

It shows that it was going up year after year anyway, and the rate at which it was rising was brought under control.

For the record, airlines are still a joke. Even in my lifetime they’ve become significantly worse, though I may be biased as a person well over 6 foot.

Since this is the meme thread though:

Except in other forms of insurance we have a marketplace, and costs go down. Including life insurance.

If healthcare operated in the same way, prices would go down the same way. Plans would right-size to what people actually want in their plans, consumer-driven trends would dominate.

  1. Yes they do. Shortages of drugs do happen.

  2. The relationship on the right.

Most drugs do not need to be gated this way. Making them a required item in insurance drives up the cost of both the drug, and the insurance.

If I don’t want my plan to include them, it shouldn’t be there.

There are also many drugs which should be made available over the counter that are not, simply because it allows the manufacturer to drive the price up when selling to a 3rd party.

Doesn’t need to be, but current restrictions don’t add anything and keep prices high. Again, we have the precedent. Both past American history, and services that are paid for out of pocket or by something other than insurance.

That still means you have less providers. If costs and requirements are higher, it means less can afford to be in the market segment that requires it, or in the business altogether.

“Flexibility” to be approved by a council means you’re still gating who can do the providing.

You’ve removed the choice from consumers, and put it in the hands of bureaucrats who have to make assumptions. Assumptions which reflect what the largest industry stakeholders want.

DPC handles this. Indeed, they expanded under COVID because of their flexibility to handle patients in telemedicine formats in far-flunged areas.

Larger towns can be the hubs where they base themselves and compete in; that already happens. If we need to dish out contracts to ensure a provider is in a given place, that’s fine with me.

Nope. It’s a Faustian bargain where you don’t address why the price is going up. You just accept it, while demanding certain things in return.

The price should be going down, and it would be if this was a market.

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Not in terms of price, destinations, or capacity. It is immensely better.

FedEx was not able to take full advantage of what it could do until post-deregulation. It dramatically changed parcel delivery and air mail; lowering costs, expanding service, making Air mail on time for the first time in decades.

A high cost airline in the 60s that could offer a better travel experience, is no replacement for a low cost carrier that people can actually use, that goes to where they need, and less chance of forcing a connecting flight.

  1. Yes, but not nearly in the same way as if iphones were suddenly free. You can’t have a “run” on the market in the same way non-restricted products are.

  2. The relationship on the right is pretty uniquely American. In Korea it’s basically already the left. Everyone pays the same insurance fund, that insurance is accepted everywhere, I go wherever I want and make appointments directly with the doctor. All costs are transparent, upfront, and cheap.

I agree to an extent, but people are seriously morons and can’t be trusted to get whatever meds they want. Even with prescription gating we saw shortages of hydroxychloroquine, which negatively impacted patients who actually needed the drug.

Just in terms of quality and customer satisfaction.

I just want to make clear, I see universal coverage and access, even at a higher personal cost, as a good thing. You have to think beyond “me me me” for something like this.

And Direct Primary Care does this, and has the capability to become cheaper because it’s a market.

The only way the Korean system will remain cheap, is if it has a mechanism where you’re encouraged to shop around for the best price, which in Singapore they do. Do you?

That becomes a self-fulfilling prophecy when you don’t start by trusting people to make their own decisions.

I trust people, and their clinicians more than I trust bureaucrats to make those decisions for them. For as I just told you, many of those decisions made by regulatory bodies were made in bad faith. Producers fight against it until it goes generic, then they suddenly don’t care.

Nope, as again, the comparison is no service, or one that doesn’t go where you need. So long as the ride is safe, that’s what matters.

In Singapore we see this very tradeoff made in their system, with the tiers of service. If you want the extra amenities, you’ll have to pay extra for them. And this works.

I’d also easily take the bet that the worst airline in 2021, is better than the worst airline in 1979.

Except that’s what you’re doing Gene. You want something you don’t have to pay for.

I want efficacy.

I want a system that lasts (as in doesn’t go broke, and breaks down, like it has in France), and updates best practices on a time scale that’s not decades. And is not horrible, like our current public system the VA. Which my mother as a veteran has wonderful stories to tell. C section when you’re dehydrated, and there’s no pain killers on hand. Glorious.

And certainly not a system that makes mediocre promises like this:

Under the NHS Constitution, if your GP refers you for a condition that’s not urgent, you have the right to start treatment led by a consultant within 18 weeks from when you’re referred, unless you want to wait longer or waiting longer is clinically right for you.

… and then doesn’t even meet it.

“me me me”.

More like I just don’t buy the bull crap Gene. Or your excuses.

70% of Koreans have private insurance to lower their wait times. 90% of hospitals there are privately operated, whereas here in the U.S, its 1 in 3.

And in the U.S, we’ve yet to deploy a successful public model at the State level. Despite years of posturing on the issue, the left can’t convince their own localities to back it for some reason.

A plan which to me, doesn’t look necessary. You can have a commoditized market, have it cover 95% of the population, and then create a smaller public system to assure access for the rest.

Just like with Food Stamps. Or to complete the airline example, the Essential Air Service.

For healthcare, yes. You can go wherever you want. They do an odd thing though where pharmacies are only allowed to prescribe for doctors in their neighborhood. So of you preffered a certain pharmacy for some reason, you’d have to go to a doctor in that neighborhood.

Singapore is a strange case. While they have market principles in mind, they also have heavy regulation and have had to scale back their healthcare market’s freedom due to prioritization of high paying patients to the detriment of the poor.

Hospitals are also largely publicly owned and doctor salaries are tightly controlled.

I’d agree, but the end result in airlines is that the experience is horrible for anyone that can’t afford the expensive seats (most people). While that’s acceptable in the airline industry, as was shown in Singapore, you can’t generalize only rich people getting good service to healthcare.

We’ve yet to deploy your style on a state level too. That doesn’t mean it’s bad, just that there’s a lot of pushback from the established players, which of course there is.

First of all, what Slim said; eschewing a private middleman for a bureaucratic middleman is easily going from bad to worse. Second, I don’t like the idea of insurance in the first place; essentially, it’s gambling at house odds.

I notice that with regulation that stifles entrepreneurship, many types of service and products are hard to find in rural and small town areas. The Soviet Union was a classic case of this. If you’re ever of a mind to, I would recommend reading a book (which I’ve mentioned and quoted from on occasion) called MiG Pilot by John Barron. It’s the true story of a Soviet fighter pilot (Viktor Belenko) who defected to the U.S. by flying his MiG-25 to Japan in 1976. He noticed the contrast in availability of goods and services in rural areas in the U.S. and U.S.S.R.

So we invite the government to do their thinking for them and trust them not to take advantage of the situation?

Which is, to a large degree, exactly what happened in the Soviet Union. You’re never going to have a parity between the rich and poor when it comes to quality of healthcare. But I’ll argue to the death that government “solutions” are guaranteed to make it much worse in the end.

Amen.

Ditto amen.

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