Democracy - We had a good run

[The Progressive]

So you think its a good idea to have insurance made less affordable because of mandatory coverage of things like acupuncture, chiropractic, or birth control? I personally can't imagine anyone buying "chiropractic" insurance but hey, that's just me.

I know that of course we all could just look into a magic 8-ball and predict which coverages we might need in the future so that we could buy just that, but I think that it's a good idea that some standard level of health coverage is ensured in case we don't.

I know, I'm just crazy like that.

But you were criticizing the idea of pre-tax individual purchases as if that somehow increases the risk of bankruptcy over the current system, which is clearly not true.

I didn't say that it would increase the risk of bankruptcy, I simply demonstrate that it's insufficient to prevent bankruptcy in case of serious medical emergencies such as major accidents and/or cancer. Furthermore, people with pre-existing conditions are usually ineligible for these plans.

[Aemon Stark]

So you think its a good idea to have insurance made less affordable because of mandatory coverage of things like acupuncture, chiropractic, or birth control? I personally can't imagine anyone buying "chiropractic" insurance but hey, that's just me.

I actually agree that separate coverage for hospital/physician services and "extended" health care (routine dental, vision, etc.) is probably desirable. Note that the former in Canada is about 90-99% publicly insured and the latter is mostly private. (I don't follow why birth control is some sort of "frill" though.) The difference types of coverage contrast "medically necessary" services from "extended" services that are not provided by physicians.

But you were criticizing the idea of pre-tax individual purchases as if that somehow increases the risk of bankruptcy over the current system, which is clearly not true. In either case, if a plan has limits, you could bump up against them. In fact, people could just up the coverage levels for catastrophic and have higher threshholds. And look, the truth is that you can't eliminate the risk of bankruptcy unless you provide some form of guaranteed income for people who are unable to work due to the condition that led to their medical expenses.

That's true, and it's why people receive disability assistance if they're unable to work for medical reasons. (And it's why disability/life insurance is very important, as such social assistance is fairly meagre.)

[Former Lord of Winterfell]

I know that of course we all could just look into a magic 8-ball and predict which coverages we might need in the future so that we could buy just that, but I think that it's a good idea that some standard level of health coverage is ensured in case we don't. I know, I'm just crazy like that.

Well, under the current system, there isn't. There are 50 different standards. And the point you're missing is that even under the current system, insurers still offer a wide variety of different levels of coverage. They have to cover certain things under state law, but the level of coverage and coverage of things not mandated still varies widely. And if people are all about "choice", why not permit them to choose an insurance option that doesn't require them to pay for someone else's visits to a chiropractor?

I didn't say that it would increase the risk of bankruptcy, I simply demonstrate that it's insufficient to prevent bankruptcy in case of serious medical emergencies such as major accidents and/or cancer. Furthermore, people with pre-existing conditions are usually ineligible for these plans.

You're right. It doesn't absolutely prevent bankruptcies. But eliminating state-based mandatory coverages and permitting individuals to purchase their own coverage with with pre-tax dollaws will help reduce them because more people will be able to afford insurance.

[The Progressive]

Well, under the current system, there isn't. There are 50 different standards. And the point you're missing is that even under the current system, insurers still offer a wide variety of different levels of coverage. They have to cover certain things under state law, but the level of coverage and coverage of things not mandated still varies widely. And if people are all about "choice", why not permit them to choose an insurance option that doesn't require them to pay for someone else's visits to a chiropractor?

I think the point you're missing is that it's better to reduce the 50 different standards than to introduce 50x50 different standards. That would be an even worse administrative problem and would only benefit medical billers and administrators, while patients could be very seriously screwed if they didn't have the foresight to purchase the right coverage.

You're right. It doesn't absolutely prevent bankruptcies. But eliminating state-based mandatory coverages and permitting individuals to purchase their own coverage with with pre-tax dollaws will help reduce them because more people will be able to afford insurance.

Not really. This argument is fundamentally flawed due to an assumption on the elasticity of healthcare needs. As pointed out earlier in either this thread or other threads, healthcare needs are fairly inelastic.

[Former Lord of Winterfell]

I think the point you're missing is that it's better to reduce the 50 different standards than to introduce 50x50 different standards.

It's actually the opposite. Right now, insurers have to offer 50 different kinds of policies because each state has its own minimum requirements. If you eliminated that, insurers could cut down on all the variations that are required due to 50 different state mandates.

Not really. This argument is fundamentally flawed due to an assumption on the elasticity of healthcare needs. As pointed out earlier in either this thread or other threads, healthcare needs are fairly inelastic.

So you're saying that permitting insurers to offer plans that cover fewer conditions won't make cheaper policies available? Well, I think that's self-evident, but we apparently disagree. Anyway, you asked me for three "conservative" ideas, and you got them.

[Andriy Czarchenko]

It's actually the opposite. Right now, insurers have to offer 50 different kinds of policies because each state has its own minimum requirements. If you eliminated that, insurers could cut down on all the variations that are required due to 50 different state mandates.

So you're saying that permitting insurers to offer plans that cover fewer conditions won't make cheaper policies available? Well, I think that's self-evidence, but we apparently disagree. Anyway, you asked me for three "conservative" ideas, and you got them.

You´re finewith "race to the bottom" then?

[Former Lord of Winterfell]

You´re fine with "race to the bottom" then?

We don't have a "race to the bottom" now, so why would we have it then? Under the current system, employers have no obligation to offer insurance at all. A "race to the bottom" would mean offering nothing, yet the majority of American workers who are covered by employer health insurance clearly are getting a lot more than "nothing". That means there are good economic reasons why employers don't "race to the bottom" by providing only minimum coverage. Namely, its part of a compensation package that attracts and retains employees.

If you got rid of those state minimums, those same incentives would still be in place to offer insurance coverage as part of a package to attract employees. The difference is that they wouldn't have to comply with all those state-coverage mandates, so there would be the option to offer different coverages. For example, an employer might decide that it doesn't want to cover acupuncture, chiropractic, or birth control, but will instead offer, higher lifetime caps and lower deductibles by purchasing a policy that operates that way instead. And it can get greater administrative efficiencies because it can administer that same policy in all 50 states, which current law does not permit.

But I think the real benefits come on the margins. Right now, there are a lot of jobs out there that don't produce enough value to justify insurance coverage that complies with state minimums, so the employees get no coverage at all. This would allow those employers to offer at least something, maybe catastrophic coverage or whatever. Some insurance is better than no insurance, and the current system of state mandates doesn't permit that.

[Aemon Stark]

So you're saying that permitting insurers to offer plans that cover fewer conditions won't make cheaper policies available? Well, I think that's self-evidence, but we apparently disagree. Anyway, you asked me for three "conservative" ideas, and you got them.

So... just which "conditions" should not be covered by mandatory insurance? Best to make it simple - like this:

Insured health services are medically necessary hospital, physician and surgical-dental services provided to insured persons.

Insured hospital services are defined under the CHA and include medically necessary in- and out- patient services such as accommodation and meals at the standard or public ward level and preferred accommodation if medically required; nursing service; laboratory, radiological and other diagnostic procedures, together with the necessary interpretations; drugs, biologicals and related preparations when administered in the hospital; use of operating room, case room and anaesthetic facilities, including necessary equipment and supplies; medical and surgical equipment and supplies; use of radiotherapy facilities; use of physiotherapy facilities; and services provided by persons who receive remuneration therefore from the hospital, but does not include services that are excluded by the regulations.

Insured physician services are defined under the Act as "medically required services rendered by medical practitioners." Medically required physician services are generally determined by physicians in conjunction with their provincial and territorial health insurance plans.

Insured surgical-dental services are services provided by a dentist in a hospital, where a hospital setting is required to properly perform the procedure.

Extended health care services as defined in the CHA are certain aspects of long-term residential care (nursing home intermediate care and adult residential care services), and the health aspects of home care and ambulatory care services.

[The Progressive]

It's actually the opposite. Right now, insurers have to offer 50 different kinds of policies because each state has its own minimum requirements. If you eliminated that, insurers could cut down on all the variations that are required due to 50 different state mandates.

Actually, what we have right now is insurers offering about 100 different kinds of policies, 2 for each states. Each insurers basically offer two plans, one basic and one higher, with different premiums and caps accordingly; this does not include dental and vision plans. What you're proposing would chop that into several even smaller pieces, with employers shredding through them to find the least expensive one for their employees.

We don't have a "race to the bottom" now, so why would we have it then?

We already does, the trick is that more of the cost burden is being shifted to the employees in the forms of higher premiums and deductibles. With your proposal, it would get even worse since insurers would just all relocate to the state with the least regulations.

[Former Lord of Winterfell]

So... just which "conditions" should not be covered by mandatory insurance?

Well, I don't think insurance should be mandatory period, so I guess I'd say all of them. But the real question is a bit different. If an employer is going to offer health insurance to its employees through a group insurance policy, should the various state governments mandate that certain conditions be covered, which is inherently going to vary from state to state? My answer to that is no.

The point is that employers are going to spend a certain amount on insurance, and no more. Regardless of what specific conditions they are required to cover by a state, they can always mix/match premium contributions, copays, etc. to get to the same cost. So when the state requires that certain conditions be covered, that requires a corresponding drop somewhere else in the equation.

It becomes, in part, a big lobbying game. Manufacturers of birth control devices, chiropractors, acupuncture folks, etc., all will push to have their particular speciality mandated by state law. And everytime that lobbying is successful, the cost of policies go up, and employers and insurers look to make cuts elsewhere. Personally, I think employees and employers would do a much better job of figuring out what is worthwhile to them than will the government.

[Former Lord of Winterfell]

Actually, what we have right now is insurers offering about 100 different kinds of policies, 2 for each states. Each insurers basically offer two plans, one basic and one higher, with different premiums and caps accordingly; this does not include dental and vision plans. What you're proposing would chop that into several even smaller pieces, with employers shredding through them to find the least expensive one for their employees.

This is such a pointless argument....okay, fine. They go to 10 different policies instead of 2 -- and I think that 5-1 ration is ridiculous, but you can have it -- which still makes only 10 policies instead of 100 because they can have the exact same policies in every state, which current law does not permit.

We already does, the trick is that more of the cost burden is being shifted to the employees in the forms of higher premiums and deductibles. With your proposal, it would get even worse since insurers would just all relocate to the state with the least regulations.

You misunderstand the nature of the laws at issue. For the most part, state laws don't mandate certain premium levels or copays -- they mandate coverage of certain conditions. Just because they'd have the right to write policies covering fewer conditions doesn't mean those "barebones" policies are the only ones they'd offer. The current market proves that.

[Aemon Stark]

Please stop lumping in contraception with chiropractors and acupuncturists. I don't think IUD manufacturers represent a terribly significant lobby group. For that matter, insurance mandates should not (and don't really to my knowledge) pertain to specific conditions but to types of services. But if you want to reduce the overall cost of insurance, a compulsory mandate for everyone is the way to go about it. Pool the maximum risk, achieve the lowest unit cost.

[The Progressive]

This is such a pointless argument....okay, fine. They go to 10 different policies instead of 2 -- and I think that 5-1 ration is ridiculous, but you can have it -- which still makes only 10 policies instead of 100 because they can have the exact same policies in every state, which current law does not permit.

News flash: most states have somewhat similar standards. That's why your argument is quite pointless in the first place; it seems to be mostly a disguise for the real argument of eliminating any basic coverage altogether.

You misunderstand the nature of the laws at issue. For the most part, state laws don't mandate certain premium levels or copays -- they mandate coverage of certain conditions. Just because they'd have the right to write policies covering fewer conditions doesn't mean those "barebones" policies are the only ones they'd offer. The current market proves that.

You misundestood the facts. The current market have proved that employers would opt for the cheapest plan as dictated by laws. Additionally, your argument that there isn't a race to a bottom given that employers aren't required to provide insurance is seriously flawed given the fact that employers receive huge tax breaks as incentive for doing so.

[Former Lord of Winterfell]

Please stop lumping in contraception with chiropractors and acupuncturists. I don't think IUD manufacturers represent a terribly significant lobby group.

I think it deserves to be lumped in there, along with whatever other mandates are out there. And its nice that you picked IUD's, but what about monthly oral contraceptives?

[Former Lord of Winterfell]

News flash: most states have somewhat similar standards. That's why your argument is quite pointless in the first place; it seems to be mostly a disguise for the real argument of eliminating any basic coverage altogether.

Do you have any evidence that most states have somewhat similar standards, or did you just make that up?

You misundestood the facts. The current market have proved that employers would opt for the cheapest plan as dictated by laws.

Wow, you did it again. Do you have any evidence proving that employers opt of the "cheapest plan directed by law", or are you just making that up too? Because the "cheapest plan directed by law" actually is no plan at all, and the majority of employers don't opt for that. And if they all opted for the cheapest plan, it seems that each employer would have the exact same insurance -- the cheapest one, from the exact same company, which anyone who has any familiarity with health insurance knows isn't true. So I'm going to be really interested to see you back up that one.

[Aemon Stark]

I think it deserves to be lumped in there, along with whatever other mandates are out there. And its nice that you picked IUD's, but what about monthly oral contraceptives?

I'd say that there's room for variation in the types of drug plans available. These are mainly private here and you pay out of pocket unless it's covered by your private/group insurance. These plans typically don't cover anything that has not been prescribed by a physician.

If there's any point to that information, it's simply that there's so much variation possible in the organization of insurance plans. The patchwork of drug coverage in Canada is one of the most significant policy problems in our system - lower prices notwithstanding, it can still be very expensive. Of course, we have the benefit of being able to compare private and public care side-by-side in some respects. Dental care is a good example; there's nothing more "efficient" about it (takes longer to get an appointment usually than a non-urgent specialist referral) and they have a habit of charging more than is reimbursed by insurance companies. Optometry is worse - they do the refraction and exam (providing screening that, to my knowledge, is not necessarily evidence-based), then hand you a prescription so you can pick out frames and lenses from their very own opticians. It's really quite the racket, not altogether different from a group of physicians shunting their patients to fill all their prescriptions at a pharmacy they own. Generally speaking, private out-of-pocket or privately insured health care is not "better", but there's certainly more of it.

[The Progressive]

Do you have any evidence that most states have somewhat similar standards, or did you just make that up?

Actually I was wrong. Further research did revealed that nearly 100 different benefit mandates are on the books in various states.

http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2009/Jun/Setting%20National%20Minimum%20Standards/1292_Frey_setting_nat_minimum_standard_hlt_benefits_ib_v5.pdf

But instead of reducing them into a comprehensive one like a federal minimum benefit standard, you would opt for each state to slash the mandates further, or maintain the status quo, or eliminate them all together and let the free market takes care of itself.

Do you have any evidence proving that employers opt of the "cheapest plan directed by law", or are you just making that up too? Because the "cheapest plan directed by law" actually is no plan at all, and the majority of employers don't opt for that.

This is quite self-evident. Employers fight the increasing cost of health insurance by either choosing a lesser plan or one that raise premiums and deductibles.

And if they all opted for the cheapest plan, it seems that each employer would have the exact same insurance -- the cheapest one, from the exact same company, which anyone who has any familiarity with health insurance knows isn't true.

Right, because there are nearly 100 different state mandates on the book, remember?

[Cuellar]

Couple items I'd like to point out since I actually worked at a health insurance company:

- Most plans are administered at a state level. Meaning each insurer has a division that deals with a state, and they really only know that 1 state. Typically 2-3 health insurers dominate a given state, IE California has Blue Cross, Blue Shield, and Kaiser which I believe make up over 70% of all insured (at least 5 years ago). Most of that stuff like chiropractic service is very very low cost, and really was never even a minor concern.

- A large number of states actually still have not-for-profits running their blue cross and blue shield health insurance plans. Typically these are run like shit, since even government is better run than not-for-profits. A lot of hospitals are not-for-profits as well, hence THEY are run like shit too.

- Probably 10-20% of all insurance is actually administration only. That means Insurers just manage claims and crap and have absolutely no incentive to manage costs, since the cost/risk is passed on to the company seeking insurance (I'd guess almost every company over 50,000 employees does this).

- Biggest cost to healthcare is not random stuff like birthcontrol, rather it is OLD PEOPLE, heart disease, and very very expensive drugs for cancer and such. If you had a group for under 40 and over 40, I'd guess health insurance would be $100 a month for the first group and $1000+ for the second group.

I'm a big proponent of universal healthcare, but people simply don't understand how insurance works. People forget that insurance and pre-existing conditions and all that shit exists because IF YOU WILL COST MORE YOU MUST PAY MORE. It's like a 16 year old who's totalled 3 cars in 6 months saying "OMG WHY AM I PAYING $5K A YEAR IN CAR INSURANCE", it's because they're a total disaster and will cost a lot more. Same goes for grandma taking $1,000 a month in cancer pills.. she pays a lot for health insurance because SHE COSTS A LOT. When I worked in health insurance the key to everything we did was PRICING RIGHT. You figure your margin and admin costs and add it directly to the expected cost to insure someone... and we had hundreds of actuaries who calculated it for us (they call it actuarial science for a reason). If you got Jim the 22 year old not on any medications vs Aunt Thelma on $1K a month in medications, who should pay more for healthcare? Aunt Thelma is a train wreck, therefore it will cost a lot more to insure her unless you really want to fuck over Jim and want to make him pay for Aunt Thelma. That is the EXACT reason insurance rates are skyrocketing this year, since all the Jims drop coverage, but Thelma is medicating her way to heaven therefore is keeping her coverage.

[Aemon Stark]

Precisely. And while Jim is generally healthy, that'll change as he ages, and being young does not mean immune to accidents, infections, or a variety of cancers. No one can be a free rider.

[Swordfish]

Fascinating...........