Jan. 8th, 2017

hudebnik: (rant)
From this NY Times article:

"Holding up confirmations just for delay's sake is irresponsible and it is dangerous," said Senator John Cornyn, Republican of Texas.

Cornyn is concerned that Democrats might delay the full Senate's confirmation of all of President-elect Trump's cabinet nominees, many of whom have never served in government and haven't yet filled out the standard pre-confirmation-hearing conflict-of-interest paperwork, for perhaps as much as several weeks.

Just for context, Senator Cornyn sits on the Senate Judiciary Committee, which has held a Supreme Court seat open for a year by refusing to even hold a committee hearing on, much less report to the Senate or confirm, President Obama's thoroughly uncontroversial and already-vetted nominee Merrick Garland.

UPDATE: Somebody at Daily Kos found a letter from then-Minority Leader McConnell, dated Feb. 12, 2009, laying out the requirements any Obama nominee would have to meet before even having a confirmation hearing in committee, much less being voted on by the full Senate. I believe most or all of those requirements were met, and some nominees' hearings were in fact delayed until they could be met. Needless to say, the Republican Senate has changed its tune, and is now hoping to have all of Trump's top-level nominees not merely through their committee hearings, but confirmed by the full Senate, before Trump takes office on Jan 20. Having insufficient time to vet them for conflicts of interest or even criminal histories is a feature, not a bug.
hudebnik: (Default)
Just got another EOB in the mail from the health insurance company. We have fairly good health insurance, so I can't complain about the $25 co-pay we owe. But...

The envelope contained EOB's for four procedures or office visits. The care providers billed a total of $686.10. Of that amount, we owe $25, the insurance company paid $218.32, and the remaining $442.78 is paid by... nobody. I assume the doctors, hospitals, and medical labs aren't running at a loss, because if they did they would go out of business quickly. So they must be able to provide these services for $243.32 (35 cents on the dollar), consistent with paying the staff and the rent and the insurance and a reasonable profit margin. So where did that $686.10 figure come from? What purpose does it serve?

It could be psychological jiu-jitsu on the provider's part: "hey, insurance company, see what a generous discount we're giving you?" But the insurance company is in this business, and is not likely to be fooled by it. Or maybe it's psychological jiu-jitsu on the insurance company's part, with the collusion of the providers: "hey, patient, see what a generous discount we negotiated for you? Pity something should... HAPPEN to it... like if you switched to a different insurer...."

I assume that $686.10 is what they charge uninsured patients. Some of those actually pay the full amount, while others, unable to pay it, get chased down by collection agencies, which take a cut of the money (whether their cut comes out of the $686.10 or is in addition to it, I don't know). But uninsured patients are almost certainly a small fraction of all patients, and an especially unreliable group as far as paying their bills, so I doubt the providers are buying yachts on the extra money brought in by uninsured patients.

I guess the other option is government. Do government programs like Medicare and Medicaid actually pay the billed amount?

Anyway, I'm quite certain that these "discounts" don't actually save a penny on the total cost of providing health care, but merely serve to shift those costs from insurance companies onto somebody else -- uninsured patients and/or taxpayers. Indeed, as a form of rent-seeking, the practice of "insurer-negotiated discounts" almost certainly makes the whole system more expensive rather than less.

How would we make this system cleaner and fairer? My naive answer (as long as we're in the fee-for-service world) is "providers charge everybody the same amount for a given service, and disclose that amount publicly." (I could see charging patients on an income-sliding scale, but no "discounts" based on who your insurer is.)

Providers would presumably set this amount at a level that covers their costs, but not much higher because public disclosure would force them to compete on price with other providers. Insurance companies would have a less-valuable commodity to sell -- they'd only be covering a fraction of your expenses, rather than using their negotiating power to shift most of those expenses to somebody else -- so they would probably lose some business. And since the club with which insurance companies do those negotiations is "exclusion from our preferred network," preferred networks would become irrelevant, and patients would be able to use whatever doctor they wished, thus again fostering competition among providers.

Sounds like a win on all fronts to me. And any Republicans who actually believe in market-based reform should like it, because it encourages competition among providers. Health care providers might not enjoy facing more competition, but would probably enjoy getting out from under the thumb of insurance companies and being more transparent with their patients.

How would one make this happen? Start with a disclosure rule: if you are a health care provider, you have to disclose publicly how much you nominally charge for Service X, along with how much discount you gave to various insurance companies and to Medicare/Medicaid/etc. Once you have some of these data, you publicize them and stoke some public outrage. Then, in the name of saving taxpayers money, you add a rule that says Medicare and/or Medicaid won't pay more for Service X than whichever insurance company got the deepest discount. At that point, insurance company discounts become a money-losing proposition for providers, so providers stop offering them, and the rest falls into place.

The biggest loser in this system is insurance companies, so they'll lobby hard against it.
hudebnik: (Default)
Specifically "Camelot 3000", a DC comic-book series originally published 25 years ago or so. I mention it because the hardbound edition recently appeared on our dining room table, thanks to my collection-development-librarian wife.

What do you call a guy who stands and fights against vastly superior numbers and weaponry? In fiction, you call him a hero. In real life, you call him a corpse.

Anyway, this is the story of a hero. See, the world is going to hell, being invaded by murderous extraterrestrial aliens, and the human race is losing steadily, apparently because after giving up on space exploration, it lost its will to do much of anything else either. And one day a guy in funny clothes who calls himself Arthur Pendragon and whose chief qualification is his willingness to stand and fight against vastly superior numbers and weaponry (and whose notion of "strategy" is "OK, everybody, on three...") shows up out of nowhere and offers to save the world, if its current political leaders will just hand over all their power to him and declare him King of Earth. The current political leaders, of course, are transparently corrupt, so they take this as nothing but an opportunity to scheme and back-stab one another (and Arthur). Turns out those political leaders are being played by another political leader, name of Morgan le Fay, who gets played a bit herself. Naturally, this being a comic book, Morgan (1600 years old but doesn't look a day over 25) wears a metal bikini most of the time.

An early portion of the book deals with the gathering of the Knights of the Round Table: the spirits of several characters from the original Camelot have been reincarnated in the bodies of somewhat-ordinary people around the world, and they have to be awoken, reminded of their true identities, and brought together to form a fighting team. For example, Guinevere has been reincarnated in the (hot) body of a female army general, so she has a more active role this time around. More interestingly, the Sir Tristan (of "and Isolde" fame) has been reincarnated in a (hot) woman's body, and (s)he spends much of the book demanding, without much success, to be treated as a man. When Isolde is also reincarnated as a woman, things get even more uncomfortable: Tristan still loves and desires her, but he's totally not gay, much less lesbian. This was controversial stuff 25 years ago, and in some parts of the U.S. it still is.

But what makes me really uncomfortable is the "Great Man" trope. See, the problem with Great Men is that, however Great they may be, they're still Men, and therefore susceptible to such human failings as overestimating their own Greatness. Especially when they see disaster looming, and imagine themselves the only thing standing in its way: they act "by any means necessary", putting their own Great judgment above petty things like laws, Constitutions, and basic human decency. The whole reason we have democracy, laws, Constitutions, and slow-moving government bureaucracies is to protect society from the whims of self-proclaimed Great Men.


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