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2020 Policy Talk: Healthcare

bad_teammate

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bad_teammate

bad_teammate 13481

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First off, if you're a conservative/Republican, this thread isn't really about the 2020 Republican healthcare policy debate. Because there isn't one. And if there was, it would be extremely stupid. So sorry, my Republican friends, but you suck and so do all of your terrible ideas.

On the Democratic side, there are two competing visions starting to materialize. I've linked to a VOX explainer for each.

Medicare for All (Single-Payer)

Medicare for America (Obamacare w/ Public Option)

Ideally, I'd like for us to be able to talk about these healthcare plans without reference to candidates specifically so it doesn't devolve into a(n open) feud between the calf-crampers and the shower-door-distrusters.

--------------------------

Medicare for All basics:

For the citizen:
- Everyone has Medicare.
- Free at the point of access.
- No enrollments. No deductibles. No co-pays. No premiums.
- Probably higher taxes for everyone, especially those with means.
- Private insurance allowed as luxury/supplemental, but not in competition with the national single-payer plan.

For the policy-maker/wonk/pundit/nerd:
- Various methods of funding, generally involving higher taxes
- Phased in over time (Jayapal's (I love her, she's awesome) House bill is faster than Sanders's Senate bill)
- Elimination of private insurance from core healthcare question greatly reduces administration and complexity
 

Medicare for America basics:

For the citizen:
- "If you like your health care plan, you'll be able to keep your health care plan." - Employers will still be able to offer private health insurance plans per usual or they will be able to pay into the Medicare system for their employees.
- If employer insurance isn't available, you're on Medicare.
- You still have out-of-pocket expenses, but there's a max, depending on how much money you make.
- Still have enrollments, co-pays, deductibles, and premiums.
- You can opt out of your employer's insurance and get on Medicare.
- Probably higher taxes for everyone, especially those with means.

For the policy-maker/wonk/pundit/nerd:
- Various methods of funding, generally involving higher taxes.
- Phased in over time.
- No elimination of the private insurance system, meaning the administration costs are not reduced

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Skyline

Skyline 325

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Thanks for the write-up. A lot of countries have shot for their version of M4A but usually end up around a public option. So for those of you in the M4A camp, what would the timetable for phasing in people? 

I really liked that you brought up Jayapal, she brought up a lot of interesting arguments in favor of M4A on Ezra's show. Link 

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Lagunamadre

Lagunamadre 1975

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We need to treat pharmaceutical companies as public utilities. The government controls rates on utilities because of their de facto monopolies in their respective regions means they could gouge consumers who need to keep their lights and heat on. How is a hedge fund buying insulin manufacturers, driving out competition and jacking up the price 10 fold to gouge people who need it to live any different. 

Convince me I'm wrong. 

Edited by Lagunamadre
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bad_teammate

bad_teammate 13481

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4 minutes ago, Hank Scorpio said:

What if I like my doctor? Can I keep my doctor? 

A very huge concern I have with this kind of public option approach is that it's not a "bridge" to single-payer/actual universal coverage.

1) Some people (those who profit) don't want us to go to single-payer.

2) We don't remember the lessons from ACA's failure. Which you reference beautifully here.

Any major reform, even one that allows employer-based private insurance, will cause changes in policies. Plans didn't even stay the same year-to-year before the ACA, so telling people that you can keep your plan/doctor if you want is an impossible promise to keep and reusing it now is just insane. It's a lie and it's going to piss people off again in the exact same way it already did.

I really don't understand the point of keeping employer-based insurance. I just don't know why.

1 minute ago, CooterBrown said:

If you consider the elimination of health insurance costs and out of pocket health expenses, it’s probably a decrease in overall costs even if technically your taxes go up.

Oh yeah, of course, but tax hikes can't be ignored.

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Grandioso

Grandioso 2592

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There is a minor urgent care place near me that basically bills my insurer what it can and eats anything that is denied by my carrier, i.e., doesn't balance bill me. Longest I've ever waited to see a doctor was maybe 20 minutes, I've never paid a dime out of pocket, and the place is nice AF. I had cellulitis on my neck that required IV antibiotics and an incision to drain it (PM me for pics). I had to stay for a night and it was free and amazing. 

Though I don't think this experience illustrates the beauty of the market as much as it does the insanely inflated cost of healthcare. I have a friend who is deeply invested in these urgent care type joints, and he said some shit like one of his clinics can see like 8 patients in a day and just with that money cover that day's entire overhread: pro rata rent, payroll, fucking everything. They have mushroomed up EVERYWHERE in Houston, which has a medical center people literally travel from all over the WORLD to get treatment.

Will be checking this thread often because (meaningful) affordable healthcare for every American is a fucking real possibility, which kind of blows my mind still and is about the only silver lining in this dark Trumpstorm.

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bad_teammate

bad_teammate 13481

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Just now, Hank Scorpio said:

Follow up question, if there are 2 people who are dying and only 1 healthcare, who decide which get the healthcare? Can I decide? 

you push the fat healthcare off the bridge to stop the train healthcare and save the two healthcares tied to the track

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Incredulity

Incredulity 11861

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14 minutes ago, bad_teammate said:

A very huge concern I have with this kind of public option approach is that it's not a "bridge" to single-payer/actual universal coverage.

1) Some people (those who profit) don't want us to go to single-payer.

2) We don't remember the lessons from ACA's failure. Which you reference beautifully here.

Any major reform, even one that allows employer-based private insurance, will cause changes in policies. Plans didn't even stay the same year-to-year before the ACA, so telling people that you can keep your plan/doctor if you want is an impossible promise to keep and reusing it now is just insane. It's a lie and it's going to piss people off again in the exact same way it already did.

I really don't understand the point of keeping employer-based insurance. I just don't know why.

Oh yeah, of course, but tax hikes can't be ignored.

The biggest failure of the ACA is it was never implemented.  That’s not an endorsement that it would of worked.  By the time the O Administration got off of the, “just kidding till next year” program they were leaving office.

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Skyline

Skyline 325

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16 minutes ago, bad_teammate said:

2) We don't remember the lessons from ACA's failure.

Any major reform, even one that allows employer-based private insurance, will cause changes in policies. Plans didn't even stay the same year-to-year before the ACA, so telling people that you can keep your plan/doctor if you want is an impossible promise to keep and reusing it now is just insane. It's a lie and it's going to piss people off again in the exact same way it already did.

 

Another thing to consider is that the GOP will look to sabotage whatever the newest healthcare changes are. Democrats/The President should have a better messaging strategy pre and post whatever law they can move forward. 

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bad_teammate

bad_teammate 13481

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2 minutes ago, Henry Hill said:

The best way to fix a heavily regulated, highly inefficient system with mixed incentives for patients, providers and payers is to increase regulation and inefficiency and remove incentives for patients, providers and payers.

lol this guy

Henry, buddy, spin us a yarn.

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Hank Scorpio

Hank Scorpio 17924

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35 minutes ago, Henry Hill said:

The best way to fix a heavily regulated, highly inefficient system with mixed incentives for patients, providers and payers is to increase regulation and inefficiency and remove incentives for patients, providers and payers.

What about synergy and market dynamics? How would those factors interplay with incentives? 

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Incredulity

Incredulity 11861

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6 minutes ago, Hank Scorpio said:

What about synergy and market dynamics? How would those factors interplay with incentives? 

It would rely on game changer technologies being implemented up and down the value-chain and wholistic embrace of category disruption by millennials.

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bolverk

bolverk 30244

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The idealist in me prefers M4A immediately.

The pragmatist in me knows that the entrenched hospital, insurance, pharmaceutical, and doctor lobbies wouldn't let that happen. Given what we know of corruption in our politics, they'll use whatever means they have at their disposal to defeat it. I'm fairly sure that most other countries that have single-payer, government-paid, universal healthcare never had to face this dynamic. The policy was implemented prior to the creation of these behemoths.

Because of this, I'd prefer a phase-in to introduce the concept and ensure that the vast majority of Americans can try on this new pair of shoes and see how it actually works.

My personal preference for that phase in would be to keep Medicare for seniors and add children under 18 and expectant mothers as phase one. Two reasons for that would be 1) it's the humane/Christian thing to do and 2) providing adequate care early is fairly cheap but also critical to lifelong wellness for better outcomes.

From there, I'd add pretty quickly a public option for all adults. I agree that there is no logical reason why my healthcare insurance should be tied to a specific employer, which places a burden on both him and me as it affects his costs of business and my labor mobility.

As stated above, the problem with the public option is the doctors/hospitals refusing to accept Medicare patients. My response is to say "Fuck them. They have to." You became a doctor to provide a public service, likely at a public school, likely with federally back student loans. As such, you have an obligation to serve the public you purportedly signed up to care for. This same principle applies to hospitals and pharmaceutical companies who are all heavily subsidized by the public.

Given that, the public option would be equally, if not more, competitive to private insurance and will inevitably become the preferred option for most and will slowly eat away at the market share of private insurance providers who'll leave that sphere for mostly covering cosmetic surgeries and other elective shit.

If M4A was an immediately tenable goal, then go for it. But prove me wrong that it wouldn't come close to breaking the nation if that legislation were up to debate.

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bad_teammate

bad_teammate 13481

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23 minutes ago, bolverk said:

The idealist in me prefers M4A immediately.The pragmatist in me knows that the entrenched hospital, insurance, pharmaceutical, and doctor lobbies wouldn't let that happen. Given what we know of corruption in our politics, they'll use whatever means they have at their disposal to defeat it. I'm fairly sure that most other countries that have single-payer, government-paid, universal healthcare never had to face this dynamic. The policy was implemented prior to the creation of these behemoths.

They didn't let the public option happen. We are going to have to fight them. There is no avoiding it. We cannot be cowards.

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Because of this, I'd prefer a phase-in to introduce the concept and ensure that the vast majority of Americans can try on this new pair of shoes and see how it actually works.

Do you think they will sit on the sidelines and not fight this?? Were you around for the ACA debates? Do you know why the public option was killed?

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Given that, the public option would be equally, if not more, competitive to private insurance and will inevitably become the preferred option for most and will slowly eat away at the market share of private insurance providers who'll leave that sphere for mostly covering cosmetic surgeries and other elective shit.

They know that's what the public option will do. They're going to fight it. They fought it before (and won). They aren't going to give you a public option without a fight.

Quote

If M4A was an immediately tenable goal, then go for it. But prove me wrong that it wouldn't come close to breaking the nation if that legislation were up to debate.

You'll have to define what "breaking the nation" even means first.

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Henry Hill

Henry Hill 3156

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does the shift of our current hybrid model to that of some version of a medicare for all system better align incentives of patients, providers and payers to improve quality and outcomes and reduce cost? i’m not sure it does. will patients take more control of their health, make better, well-informed wellness decisions and treat the consumption of healthcare like they do for all other aspects of their life? will providers focus on delivering better quality care for better outcomes at a lower cost? will payers have any reason to work in concert with providers and patients to minimize care and process waste? my educated guess to all of these questions is likely no.

the healthcare policy options discussed here focus almost entirely on access and supply and very little on consumption, cost and unanticipated consequences (e.g., increasing clinician (namely nursing) shortages, decreasing physician supply, increasing hospital insolvency, stifling innovation and removing most choice and competition). i agree with this group that there are some serious issues with supply and access that need to be addressed that our current model likely will never fix.

i also agree with this group that each person should be able to have access to basic care but don’t believe every person has a right to receive whatever care they want for as long as they want, no matter the expense.

i want real policy that addresses core issues for both supply and consumption. not one...both. 

but hey, i just work in health finance and policy compliance for a living so tell me where i’m misguided. or continue with the ad hominems.

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bolverk

bolverk 30244

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There were enough of the public that were too scared of anything sounding like socialism in healthcare to allow for them to get away with killing the public option during the debates of 2009 over the issue. Now, ten years later, enough Americans have seen the positive of what was able to get passed then to want more government intervention in the market. In other words, today, they wouldn't be able to kill a public option like they were able to do then.

And, yes, I think Obama should've fought harder for it back then, and, yes, I was disappointed that he didn't. At the same time, the economy was going through the worst recession since the Depression and he was already getting enough pushback for pursuing ACA right out of the gate while also trying to provide the stimulus package.

Personally, I think a persistently and incrementally progressive approach is the best way to handle this position to win over the public. We can't force it down their throats. We have to win them over.

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bad_teammate

bad_teammate 13481

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3 minutes ago, Henry Hill said:

does the shift of our current hybrid model to that of some version of a medicare for all system better align incentives of patients, providers and payers to improve quality and outcomes and reduce cost?

It depends on what you mean by "some version of", but as far as reducing cost, absolutely. There is no first world universal system that costs more per capita than ours. It's not even close.

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will patients take more control of their health, make better, well-informed wellness decisions and treat the consumption of healthcare like they do for all other aspects of their life?

Maybe, maybe not. Basically everything you're saying there is (purposefully) vague.

Quote

but hey, i just work in health finance and policy compliance for a living so tell me where i’m misguided. or continue with the ad hominems.

 

Where's the ad hom? do you know what that word means?

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bad_teammate

bad_teammate 13481

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2 minutes ago, bolverk said:

There were enough of the public that were too scared of anything sounding like socialism in healthcare to allow for them to get away with killing the public option during the debates of 2009 over the issue. Now, ten years later, enough Americans have seen the positive of what was able to get passed then to want more government intervention in the market. In other words, today, they wouldn't be able to kill a public option like they were able to do then.

On what do you base this?

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Personally, I think a persistently and incrementally progressive approach is the best way to handle this position to win over the public. We can't force it down their throats. We have to win them over.

Win who over? The people already support single-payer. Healthcare professionals support it.

You are never going to win over the private health industry. They're never going to say, "Ok fine, we get it, we're inefficient and a huge drain on public resources, we give up!"

That's not how capital works.

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bolverk

bolverk 30244

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@Henry Hill Agree with bad about the lack of ad hominems in this thread. Seems pretty civil by cloak standards. As he also pointed out, other countries get better results for about half the cost. I can't see any logical reason why we wouldn't be able to do the same following others' well-worn models, but I'll grant you that I'm no healthcare finance expert. At the same time, didn't the ACA attempt to set up means-tested standards to recommend best practices at the lowest costs but were hampered by the death panel accusations? Honestly, I think that's one of the best parts of an M4A approach because specific standards of care can best be tackled at that level. 

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Gil Bang

Gil Bang 26177

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nursing shortages my ass. 

At one point, my favorite watering hole in Dana Point CA had 3....THREE Registered Nurses waiting tables, because they couldn't find jobs. They would have sucked my dick to get a job in one of our surgery centers, but none of them had the necessary experience. 

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bolverk

bolverk 30244

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6 minutes ago, bad_teammate said:

On what do you base this?

 

 

The Republican/Fox News propaganda/spin machine that is consistently able to get people to vote against their own self-interests. Right now, I BELIEVE that public support is still too soft to be able to pull it off. 

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bolverk

bolverk 30244

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13 minutes ago, bad_teammate said:

You are never going to win over the private health industry. They're never going to say, "Ok fine, we get it, we're inefficient and a huge drain on public resources, we give up!"

Fine. Let's just go with your approach.

Sorry for the double quote.

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F250

F250 29178

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4 hours ago, Gil Bang said:

We need to be building medical schools.  If everybody can actually get the healthcare that they need, we will have a doc shortage.  

Maybe make PA's the first line of defense?

Maybe look into some of the barriers to entry that are currently in place for doctors and nurses. My mom's housekeeper was a nurse in Mexico and her husband was a doctor over there but worked as a landscaper here in the U.S. Seemed like a waste of talent not to use their training here in the U.S.

 

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bolverk

bolverk 30244

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5 minutes ago, F250 said:

Maybe look into some of the barriers to entry that are currently in place for doctors and nurses. My mom's housekeeper was a nurse in Mexico and her husband was a doctor over there but worked as a landscaper here in the U.S. Seemed like a waste of talent not to use their training here in the U.S.

 

There's a good argument to be made that a lot of the licensing requirements across multiple professions (not just healthcare) are unnecessary barriers that lead to wealth inequality in this nation. Yes, you need to be educated and qualified but, in many cases, these professional licenses only serve the purpose to protect existing job holders.

https://www.mercatus.org/system/files/McLaughlin-Regulation-Income-Inequality.pdf

I'm in no way suggesting that standards should be lowered but the certification/licensing requirements for many professions appear to be somewhat arbitrary (and very expensive).

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gmr548

gmr548 16681

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15 minutes ago, bolverk said:

There's a good argument to be made that a lot of the licensing requirements across multiple professions (not just healthcare) are unnecessary barriers that lead to wealth inequality in this nation. Yes, you need to be educated and qualified but, in many cases, these professional licenses only serve the purpose to protect existing job holders.

https://www.mercatus.org/system/files/McLaughlin-Regulation-Income-Inequality.pdf

I'm in no way suggesting that standards should be lowered but the certification/licensing requirements for many professions appear to be somewhat arbitrary (and very expensive).

There are a lot of professions where licence requirements are essentially the old boys club protecting itself. For example, I work for a firm that does appraisal work. Anyone half decent at math can competently appraise a property after a few months of guidance. Hell, a computer can do the work at this point if given good data inputs. Yet getting an appraisal license requires a burdensome amount of coursework, as well as a licensed sponsor, which many are reluctant to do because you are training your competition/replacement.

I don't know what the system looks like for foreign doctors - I see no reason a credentialed and practicing physician from another country should not, at the very least, be able to sit for the USMLE and enter a residency.

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TwiceHorn

TwiceHorn 31994

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13 minutes ago, gmr548 said:

There are a lot of professions where licence requirements are essentially the old boys club protecting itself. For example, I work for a firm that does appraisal work. Anyone half decent at math can competently appraise a property after a few months of guidance. Hell, a computer can do the work at this point if given good data inputs. Yet getting an appraisal license requires a burdensome amount of coursework, as well as a licensed sponsor, which many are reluctant to do because you are training your competition/replacement.

I don't know what the system looks like for foreign doctors - I see no reason a credentialed and practicing physician from another country should not, at the very least, be able to sit for the USMLE and enter a residency.

I don't know what's involved in "converting" foreign credentials, but at least half the doctors on my shitty Molina medical plan did not attend medical school in the US and probably like 2/3 of the PCP/Internal/Family Medicine docs. It is not my sense that it's overly difficult.  The AMA, which has nothing to do, specifically, with medical licensing, is an extremely effective lobby on behalf of the medical profession.

The real barriers to entry posed by licensing aren't for professionals, they are for more prosaic jobs.

Some food for thought:

  • Percent of national health expenditures for hospital care: 32.4% (2016)
  • Percent of national health expenditures for nursing care facilities and continuing care retirement communities: 4.9% (2016)
  • Percent of national health expenditures for physician and clinical services: 19.9 (2016)
  • Percent of national health expenditures for prescription drugs: 9.8% (2016)

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

Also, assuming this is accurate. doctors are paid 2x as much here as in other wealthy countries.  https://www.politico.com/agenda/story/2017/10/25/doctors-salaries-pay-disparities-000557  Also has more talk about licensing and physician supply controls.

 

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Larry T. Spider

Larry T. Spider 1747

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Medicare for all is very similar to what I would prefer. Everybody has health coverage no matter what. People or employers can add on additional coverage if they want. The money that goes to paying for health insurance now will cover most of the costs but it will be through taxes. I think it should be partly a corporate tax and partly an income tax. Right now, corporations are spending a metric shit ton on purchasing health insurance plans for their employees. This could be great for business even if their taxes go up some.

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BillyBadAss

BillyBadAss 197

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I don't understand why every industry in the US not associated  with healthcare is not lobbying hard for universal, single-payer coverage. It has to be a big drain on every employer to administer and pay for the plans. Someone educate me why this is not the case. 

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Dnaguy

Dnaguy 12575

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I’m going to preface this with the fact that I havent really thought that hard on my proposal.... but here it is.

Instead of CHIP and instead of letting the states administer it, why not have the federal government insure every child without cost to parents... at all.

No copay. No deductible. All costs for a child’s healthcare are free. All healthcare for pregnant women, free. If you’re under 18 it’s all gratis. Pregnant women and mothers up to the baby’s 1 year birthday, free.

It’s the perfect Trojan horse for those who want single payer. It’s a judo move.

1.) Opposition can be cast as anti-child / anti-family

2.) It helps the unborn

3.) It gets people used to having all costs covered (used to single payer)

4.) Its less expensive than a single payer for all.

5.) It helps middle class people.... who vote and who will like it.

6.) It’s actual good policy because no kid should ever be sick because their parents can’t. Afford it.

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Larry T. Spider

Larry T. Spider 1747

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I don’t disagree with your plan, I just don’t know if it serves the biggest need. I’ve worked in a lot of poor schools. The kids were always able to get healthcare when they needed it. The parents had to go sit in an ER to get care if they were just above the cutoff for Medicaid. Obviously that’s about the least cost efficient way to treat a person with a cold.

Your plan would certainly paint Republicans in a bad light when they go nuclear on it. But they would, and their supporters would cheer them on, and nothing would change. I know it sounds defeatist but I have watched them do the same to education funding, especially early childhood programs for over a decade now. 

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David Dennison

David Dennison 19441

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15 hours ago, Henry Hill said:

The best way to fix a heavily regulated, highly inefficient system with mixed incentives for patients, providers and payers is to increase regulation and inefficiency and remove incentives for patients, providers and payers.

Or just institute Medicare for everyone, not just people 65 and older.

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