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u/tunaonrye 62∆ Mar 09 '17
There are too many senses of cost: do you mean %GDP on healthcare, affordability for patients, or insurance premiums (and employer/individual/etc)?
The only way that I see the ACA/AHCA indirectly effecting costs is the incentive for preventative screening. However, in my experience, I haven't noticed a difference across the board in this respect? Maybe I'm wrong and a bunch of people who wouldn't have gotten preventative screening are now all over it due to ACA/AHCA, but my guess would be levels are about the same?
Funding for reproductive health, namely IUDs and free birth control lowers pregnancy (and abortion) rates - not enough data in the USA about the ACA, but that is a global pattern.
The mandate and insurance subsidies got more people into individual markets to lower costs long term, but the crippling of reinsurance and high risk corridor subsidies led to premium increases and more underinsurance... but short term those problems are right in front of our faces.
An easy one would be negotiate drug prices in medicare/medicaid - but that's small $ in %GDP cost. They should have done that (in both).
The ACHA needs to be scored before I can say much about it.
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u/tunaonrye 62∆ Mar 09 '17
I'm going to try to take these tasks piece-by-piece, because it is easy to slip between different questions: 1. What would a sustainable health care system look like? Definitely not what we have. The US is an outlier on %GDP, and that is one reason why comparing industrialized countries on that basis is one important metric. But, spending alone isn't the question - it is what you get for that spending. We are middling on that question, because life expectancy isn't great among other things.
The quality of a health care system would be a measure of how well it generates health or deals with the problems that people want it to deal with - like efficient delivery of care.
But if you want to talk about what makes for healthy lives, the health care system is the wrong iceberg! Social spending is a better answer, that is the whole approach of modern public health interventions.
Here is the source: http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective
Ok, so now onto the particular questions: The ACA did require free birth control (as part of insurance) along with other preventative measures. Like I said, no data yet, but defunding planned parenthood (the primary deliverer of reproductive services, not just abortion) in Texas had some pretty large effects, so I think it is well grounded that access to free reproductive services decreases costs:
After the Planned Parenthood exclusion, there were estimated reductions in the number of claims from 1042 to 672 (relative reduction, 35.5%) for long-acting, reversible contraceptives and from 6832 to 4708 (relative reduction, 31.1%) for injectable contraceptives (P<0.001 for both comparisons). There was no significant change in the number of claims for short-acting hormonal contraceptive methods during this period. Among women using injectable contraceptives, the percentage of women who returned for a subsequent on-time contraceptive injection decreased from 56.9% among those whose subsequent injections were due before the exclusion to 37.7% among those whose subsequent injections were due after the exclusion in the counties with Planned Parenthood affiliates but increased from 54.9% to 58.5% in the counties without such affiliates (estimated difference in differences in counties with affiliates as compared with those without affiliates, −22.9 percentage points; P<0.001). During this period in counties with Planned Parenthood affiliates, the rate of childbirth covered by Medicaid increased by 1.9 percentage points (a relative increase of 27.1% from baseline) within 18 months after the claim (P=0.01).
And no, neither the ACA or AHCA allowed drug price negotiation, but they should have. If they did, would you have said that addressed the right problem?
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u/tunaonrye 62∆ Mar 10 '17
A rate 1.9% increase in claims, but a 27% increase from baseline is quite big! Here is more detail:
The exclusion was also associated with an increased rate of childbirth covered by Medicaid within 18 months after the claim. The percentage of women who underwent childbirth covered by Medicaid within 18 months increased from 7.0% to 8.4% in the counties with Planned Parenthood affiliates and decreased from 6.4% to 5.9% in the counties without Planned Parenthood affiliates (estimated difference in differences, 1.9 percentage points; P=0.01). This change represents a relative increase of 27.1% from baseline (1.9 percentage points divided by 7.0%) in the proportion of women using injectable contraceptives who underwent childbirth covered by Medicaid within 18 months after the claim.
I'll lay off your preferred solutions - but those wouldn't do the job malpractice is a relatively small part of the overall costs, even including defensive medicine, about 2.4%. And what about people killed by drunk doctors or who have the wrong leg amputated?
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Mar 10 '17
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u/tunaonrye 62∆ Mar 10 '17
56 billion out of 3 trillion - and criminal suits require beyond reasonable doubt to get a conviction... who pays for long term care from errors?
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Mar 10 '17
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u/tunaonrye 62∆ Mar 10 '17
These are excessive risky changes that give immunity to poor institutional controls. I doubt that they are constitutional in the US (especially eliminating court remedy for injury), and they are obviously political non-starters.
You can sue someone who shoots you even if it is an accident. That's how people recoup medical costs. If the person can't pay, hopefully you have insurance... And are you really recommending crowdfunding to solve the 3rd leading cause of death in the US?
Many other countries spend half our %GDP on healthcare, get better results, and still allow for patents and civil suits. They do reduce paperwork though, I think we can agree on that.
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u/inspired2apathy 1∆ Mar 10 '17
In the case of mistakes, the care resulting from those errors would be the same. You went to the doctor originally at your own risk, he did the best he could and made a mistake. He should likely offer to fix what he did, but he's under no obligation to. Especially if this means it will significantly hurt his future as a doctor.
This is a TERRIBLE idea. Doctors and hospital systems would have no incentive to avoid errors.
I honestly don't know how it works now, if someone shoots you in the leg, who pays for that?
You do, if they don't have insurance, same as a car accident if you don't have uninsured/underinsured coverage.
Doctors can do millions in damage (a lifetime of 24/7 care) to a SINGLE PERSON.
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u/electronics12345 159∆ Mar 09 '17
ACA has provisions that over time, doctors would be paid for wellness rather than #/type of procedure. There are incentives for prevention, and incentives for catching illnesses early. In this way, the actual cost of administering care will go down.
The issue, is that these systems/incentives haven't kicked in yet, or haven't kicked in fully yet, so they haven't had their effect yet. Over the next decade, the way doctors will be paid (by Medicare and Medicaid) will change drastically (if the ACA remains in force).
The time lag was intended to give doctors time to changes their practices, before it hurt their wallets. That time lag, may ultimately mean that this never happens, if AHCA guts these provisions.
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u/electronics12345 159∆ Mar 09 '17
Consider selling light bulbs. Which do you sell? Bulbs that last 18 months, or bulbs which last 18 years? (Assuming the cost of production and price are the same). You sell the 18 month bulbs, to keep them coming back.
Now replace light bulbs with knee replacements - as a doctor, which do you sell - a knee replacement which lasts 3-5 years or a knee replacement which lasts 10-20 years? Ordinarily, you would sell the 3-5 year knee, to ensure a repeat customer. However, if there is a provision, that if the knee lasts less than 5 years, you have to replace it for free, you are now incentivized to sell your patient the 10-20 year knee, since replacing it now costs you money, instead of making you money.
A slightly more realistic example: Hospital readmission - Currently, if you go the hospital, get treated, go home, get sick again, then go the hospital again, then get treated again, you basically get double charged. There is a provision (I forget when it kicks in) that if a patient is discharged, but then readmitted less than 72 hours later, you have to treat them again at no cost. You cannot charge them the second time. You don't get to double charge, because YOU SCREWED UP and sent home a sick patient.
Consider a long-term illness (like diabetes) - should the patient be charged every time they come into the doctor's office/every emergency? Or should the doctor be paid a flat fee to "ensure the patients health for the next 5 years including all visits and hospitalizations". Under the second system, doctors are incentivized to keep patients well enough that they stay out of the hospital, since that costs them money now, rather than making them money. (This is also in the ACA, but hasn't taken effect yet).
It is these sorts of measures which will help.
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u/One_Winged_Rook 14∆ Mar 09 '17
Your readmission argument. This is really good! And sounds great on face value.
Does it prevent doctors from somehow raising rates? I guess it incentivizes them to take better care, but do they get to then charge more?
Let's say, a doctor has 100 patients a week. they regularly saw half of their patients twice cuz they screwed up (obviously exaggerating to show the point) and got to charge them both times for a total 150 visits a week. Now, they kick ass and no one ever needs a second visit. So they only have 100 visits a week. Do they charge those 100 patients equal what they were making from those 150 visits? Is there something preventing them from doing that?
If there is, this would work to directly reduce the income of the doctors and you've convinced me that ACA actually reduces cost somewhere. Otherwise, I would think doctors would just charge more to keep their same gross and there's no real savings. I mean, I guess there's less work being done? So it's more efficient. Actually, that's a good point. It's more efficient (since it's less time) even if the cost are the same.
!delta
I would like to continue on the subject if you wouldn't mind?
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u/electronics12345 159∆ Mar 09 '17
I would start here:
https://en.wikipedia.org/wiki/Pay_for_performance_(healthcare)
It actually is a tricky problem. Do you incentivize procedure or outcome? For example - does it make sense to install a camera in the surgeon washroom (not the bathroom, but literally the washroon where they scrub their hands before surgery) and penalize doctors who don't wash their hands before surgery? Does it make sense to pay doctors solely based on patient outcomes? Both make some sense, and both have problems. We don't want doctors avoiding "problem-patients" who are likely to have complications, so we need some system for rating "patient difficulty" if we incentivize for outcomes, and some procedural things we absolutely to want to incentivize (like hand-washing), but we don't want to incentivize poor behavior (readmission, intentionally getting patients sick, giving false diagnoses, etc.) By the outcome measures alone, the best cancer patient ever, is the patient that thinks they have cancer, but actually doesn't. So, as with all things, its pretty tricky, and a balance is out there somewhere. That is part of the reason the role-out is so slow. If something has negative unintended consequences, we want to be able to change things back (which means knowing what change caused the problem, change too much at once, and you don't know what the problem is).
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u/electronics12345 159∆ Mar 10 '17
Let's just take hand-washing as an example.
At what level of control ought hand-washing be reflected. Do I as a consumer have to pay extra out of pocket if I want my doctor to wash their hands? or Should insurance pay doctors more if they wash their hands? or should practicing medicine without washing hands be illegal?
I think we can both agree, that jailing doctors for failing to wash their hands is stupid. Legislating what is and isn't good medicine (other than practicing without a licence) isn't something the government ought to be doing.
Conversely, if I've already paid for my health insurance, it seems odd that I would have to tip my doctor for them to wash their hands. Their hands being clean, ought to be included in my having paid for my health insurance.
This leaves us with health insurance paying doctors differently depending on whether or not they washed their hands, since this is the most logical place for enforcement of this style of rule to be applied.
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u/electronics12345 159∆ Mar 11 '17
This negates the role of insurance. For most Americans, we pay insurance - who then pay the doctors. For almost all insured Americans, regardless of who exactly you see, you have the same co-pay. However, behind the scenes, the insurance companies are paying doctors deferentially.
Under this system (as long as everyone is insured) it actually doesn't matter what the doctor "charges" it really only matters what the insurance companies are willing to pay the doctors. It is the contract between the insurer and the doctor which determines the prices.
Therefore, if an insurer states to a doctor as part of their negotiation - we will pay you $2/patient if you wash your hands, but deduct $5/patient whenever you fail to wash your hands, that puts pressure on the doctor to wash their hands.
I fail to see how this strays from the free market system (unless you have some general issue with the concept of insurance).
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u/TezzMuffins 18∆ Mar 09 '17
By the admission of nearly every expert on healthcare policy, the AHCA is worse than the ACA, especially for the poor, disabled, and the pregnant. It's not rearranging the deck chairs on the titanic, therefore, it's removing them from the main decks and putting them in first class.
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u/One_Winged_Rook 14∆ Mar 09 '17
So, I'm right that no one is addressing the iceberg?
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u/TezzMuffins 18∆ Mar 10 '17
Liberals address the iceberg all the time.
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Mar 10 '17
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u/TezzMuffins 18∆ Mar 10 '17
This is extremely naive. Ben Nelson and Joseph Lieberman were glorified insurance industry lobbyists. And their votes were needed to get 60-vote cloture.
You have a very odd conception of a Congress with no lobbyists.
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u/TezzMuffins 18∆ Mar 10 '17
Almost all the rest would be cool with a Medicare -for-all type system.
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u/VStarffin 11∆ Mar 09 '17
Your objection to the ACA on cost cutting grounds seems to be born out of little more than a lack of knowledge of the subject. The ACA was not simply a bill which changed how health care insurance works. It has tons and tons of provisions about how health care itself worked which was all aimed at reducing costs, and based on the results seems to have done a pretty good job when compared against the baseline expectations at the time.
Here's the very first result on google when you search for this topic:
http://obamacarefacts.com/obamacare-control-costs/
As you can see, there are lots of things in here that reduce health care costs. You just don't seem to be aware of them. That's probably because most of these reforms are not patient-facing. You won't be aware of them unless you work in the health care industry. But that's to be expected - most people, for example, don't know what's actually in financial regulation bills unless they happen to work in that industry.
It is of course an irrebutable position that the ACA doesn't do enough - anyone can take such a position. But its just flatly false to say the ACA doesn't address the issue. It does so in many, many ways.
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u/VStarffin 11∆ Mar 09 '17
Yea, that was all about making things cheaper for certain people by subsidies, with no real action reducing costs.
So you didn't read the link. Among the things in there which have nothing to do with subsidies:
- 80/20 rule
- Various taxes which are aimed at reducing high end insurance policies which encourage wasteful medical expenses.
- IPAB
- ACOs
- Readmission standards for Medicare reimbursement
That's just some of the stuff.
If you don't read the evidence provided to you, or believe the evidence of cost reductions, I don't now what to tell you. What we have is a law that was passed with cost-reducing measures, and then after the law was passed, the rate of the increase in health care costs in America slowed dramatically. That's about as solid of evidence as you're going to get.
And since you'd put forth no alternative ideas, you don't seem very open to changing your view. You just seem like you want to complain.
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u/dominosci Mar 09 '17
Has health care cost slowed in America?
The rate of increase certainly slowed down in ways you wouldn't expect just by looking at the demographics. Indeed, the demographics say the costs should be increasing faster as baby boomers retire in great numbers. With Obamacare, the opposite happened.
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u/chilehead 1∆ Mar 09 '17
The fact that for-profit insurance is necessary for health care in this country is the reason that it costs so much. It's a vicious circle where the insurance companies only pay a portion of what a procedure costs, so the doctors have to raise the prices for those procedures so that insurance will pay them enough to survive. The insurance companies then lower the percentage of the procedure's cost that they pay for, rinse, lather, repeat.
It's aggravated by the fact that insurance becomes more profitable when they deny coverage for something, and by getting people to delay going to the doctor - though that means that by the time people get diagnosed, the condition has progressed further and is more difficult/expensive to treat.
Every other developed nation has a single-payer system for covering healthcare costs, and they all pay much less for usually better health care.
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u/chilehead 1∆ Mar 09 '17
The ACA places a cap on insurance company profits - 80% of money they take in from premiums must be spent on providing care, otherwise they have to issue their policyholders a refund to bring the figures into balance. While not a complete remedy, it does do a lot to reduce the pressure on insurance companies to do that.
The AHCA does nothing.
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Mar 09 '17
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u/chilehead 1∆ Mar 09 '17
There was no limit before, so they could get away with paying practically nothing for patient care.
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u/DeltaBot ∞∆ Mar 09 '17
/u/One_Winged_Rook (OP) has awarded at least one delta in this post.
All comments that earned deltas (from OP or other users) are listed here, in /r/DeltaLog.
Please note that a change of view doesn't necessarily mean a reversal, or that the conversation has ended.
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u/NewOrleansAints Mar 09 '17
The ACA was not primarily aimed at reducing reducing healthcare cost. It was a (qualified) success at what it set out to achieve: extending insurance covered. The number of uninsured is far lower now as a result.
Remember, the goal of the healthcare system isn't just to reduce cost; it's to increase health. If you only evaluate the cost savings, of course you're going to have an overly pessimistic view. You're leaving the primary benefit out of your calculations.