TomAiello

She's saying that the doctors would have to explain the new system to the patients, including the patients right (and need) to shop around for services. In a lot of places, patients are currently unaware that they even have options, and just go wherever their doctor sends them. I've seen unethical doctors use this to pad their wallets (for example, sending patients for outpatient MRI's at a facility the doctor owns and never telling the patient there are other options). It's definitely an issue, but I agree with you that a little education goes a long way when people understand their self-interest and have their own dollars at stake. -- Tom Aiello [email protected] SnakeRiverBASE.com

Sure. Physicians and the other providers (like the labs). In some cases, they'd be advertising their services, to attract business, which might include include advertising prices. Sure. They're the ones paying for them. Of course, if you, as their physician, aren't happy with the choices they make, you can try to convince them otherwise, or even just "fire" them as a patient, and refuse to see them anymore, because you don't want to be responsible for their bad decisions. -- Tom Aiello [email protected] SnakeRiverBASE.com

Yes, generally. But if you wanted to make sure people used their federal contribution for healthcare, you might want to simply disallow withdrawals below the deductible amount for non-healthcare expenditures. Alternately, you could just say that if you receive a federal contribution to your HSA, you may not withdraw below that amount for non-health expenditures, but I think that might be prone to cheating. -- Tom Aiello [email protected] SnakeRiverBASE.com

Generally my own idea. Drawing on the research (and suggestions) in the Friedman article I linked. -- Tom Aiello [email protected] SnakeRiverBASE.com

And here I was going to post something about how we were actually having a productive discussion in SC, without the usual nonsense... -- Tom Aiello [email protected] SnakeRiverBASE.com

Until it exceeded the deductible on the federal policy. After that, I'd let people withdraw it for whatever they wanted. I'd prefer they be able to do that tax free, but I'd be ok with taxing it, too. -- Tom Aiello [email protected] SnakeRiverBASE.com

I'm a fan of physicans being organized as small businesses controlled by themselves (or small groups of doctors). My wife is now on salary, and one of the things she laments is that she can no longer give away her services to people who she thinks are deserving. Back when she was a greedy, money grubbing fee-for-service doctor, she saw indigent (or otherwise hard pressed) patients for free, and even took the time to make house calls. Now that someone else is in control of the financial reins, she can't do those things, and I know it bothers her. -- Tom Aiello [email protected] SnakeRiverBASE.com

They're not really insurance companies. They're more healthcare financing companies. And yes, they'd get scaled down a lot. Real insurance would still be an option (for non-emergency high cost procedures, for example). And I bet the healthcare financing companies would offer a version of their existing plans that would finance care below the federal deductible, marketing it toward people who are worried their HSA would fall short in any given year. But, yes, I think that the current employer based healthcare finance company system is pretty much rotten to the core, and needs to go. -- Tom Aiello [email protected] SnakeRiverBASE.com

Right now people are being hit with bills of that magnitude, and they are surviving, mostly because they can negotiate payment plans for them. Remember that under this plan, the government would be directly subsidizing the cost of care for lower income Americans. The only people who could be hit with $3000 in a year would be those making more than $50,000 per year, and I think they can handle it. People making less than $20k would never face any extra costs, and people between those two numbers would have a sliding scale, so that at 30k (for example) the most you'd ever have to face in a year would be $1000. Do you really think that $1000 is too much for someone making 30k/yr to handle (serious, not rhetorical, question)? I heard that piece too. It was very interesting. I wish there was a wider base of more recent data for it, but the data collection was pretty intensive, and I bet that it would never be allowed under the current federal regulations. Imagine the HIPAA violations. Which is why the patients need to be in the driver's seat for payment--they are the one's with the incentive to manage costs. I bet it would work. It just wouldn't make it past the lobbyists in DC. Look at how much money it would take from the mouths of starving "insurance" company CEO's. -- Tom Aiello [email protected] SnakeRiverBASE.com

You also have to debate what exactly the goal is (i.e. what it means to "fail"). And some people aren't going to agree with the goal that is set by those in power. Are they then "anti-American" if they cheer the failure of those goals (which they never shared to begin with)? Is it mandatory for them to fall in line and work to achieve the "national goals" even though they don't share them? -- Tom Aiello [email protected] SnakeRiverBASE.com

Generally I like it. The issue is going to be with the chronically ill, who use up 3k every month. But then, that's an issue now, and it's going to be better under your system than under a typical yearly deductible system. And they will get 12 months of free care for every 3k they have to pay out of their HSA. Plus, since those are people who would probably qualify for medicaid now, we'd be looking at giving them the whole 3k. Would you give that contribution (of whatever amount) every time the deductible re-set, or keep it yearly? -- Tom Aiello [email protected] SnakeRiverBASE.com

The idea for the sliding scale on the automatic contribution was to avoid the sliding scale on the deductible, by making it "fair" for everyone, because the lower income people got subsidized directly. You pretty much need to have a high deductible to encourage people to shop around, and exert downward (market) pressure on prices. I picked $3000 because I figured that's about the level that hospitals are already dealing with when they finance things out to payment plans for patients who have trouble paying. What if you had a moving average year for the deductible, to avoid the end of year issue? -- Tom Aiello [email protected] SnakeRiverBASE.com

Unfortunately, no. I just made it up a few minutes ago. It's largely based on this article, with some other ideas thrown in. -- Tom Aiello [email protected] SnakeRiverBASE.com

Obviously there is no "ideal" for everyone. What works for you will depend on your training, physical strength, and disposition, as well as your ability to practice regularly. -- Tom Aiello [email protected] SnakeRiverBASE.com

In the case of the HSA, you could spend it on almost anything (even non-prescription medications, for example). In the case of the high deductible policy? It would be covering the typical catastrophic stuff that you see bankrupting people (trauma, birth complications, etc). You have to roll it over. That's the only way you can eventually exceed the deductible and be allowed to withdraw the cash. Rewarding people for saving money is one of the key components of this plan. No. And no one. The idea of empowering the patients (i.e. making it a first party payer system) is that they will then be incentivized to shop around and pay lower prices for those parts of their healthcare (routine treatments, outpatient labs, primary care) that aren't urgent. The high deductible policy eliminates that need in the case of urgent care, so that you're not trying to price shop in the midst of a multi-trauma MVA. I actually think it would. It will address the daily costs by reducing the overhead associated with "insurance" companies, and also by encouraging price shopping (by letting people take home the excess for their own uses). You are correct that it doesn't really address the escalation of costs in the "high deductible" world. Major surgeries, for example, might actually become more expensive if it was known that the government was footing the bill. You could address this in the short term with a system that regulated the prices on things like that, but in the long term it's always better to design the underlying system to exert downward pressure on prices over time (like the low cost end of this proposal). Do you have any ideas on how to do that for the high cost emergency stuff? In terms of high cost non-emergency care (surgery for ruptured disks and the like), I think we'd be ok to leave that to a private, secondary insurance market. People would price shop those policies, and if the policies had cost limits, people would price shop their surgeons, too. -- Tom Aiello [email protected] SnakeRiverBASE.com

I agree. One advantage of the 9 over the .45 could be the potential for faster and more accurate follow up shots. Given that a handgun is basically stopping people based on shot placement (not caliber), it makes sense to use the most controllable handgun, with the largest magazine, to maximize the chance of getting a well placed shot. 9mm in a full size pistol fits the bill nicely, for that. Which is also a good rationale for using 9mm handguns for back-line troops and .45 for the more highly trained SOCOM types, which is more or less what the US military is doing now. I always get confused when people cite the FBI study to show that "bigger holes is better," because when I read it what I get is "shot placement is the paramount consideration--everything else is secondary." For personal defense with a handgun, then the real answer would be "use what you shoot well." -- Tom Aiello [email protected] SnakeRiverBASE.com

Here's a pretty good proposal: a) create a national health insurance policy with a high deductible (say $3000) b) create a tax free health savings account for each citizen c) deposit some amount into the health savings accounts (or just those of people under a certain income level) every year (for example $1000) d) allow people to withdraw (tax free) any amount in their HSA that exceeded the deductible (in this example $3000) Such a plan would encourage each consumer to mind costs, and motivate them to save money. It would also reward them for doing those things. At the same time, it would eliminate the catastrophic medical costs that can bankrupt people. It would also scale back the influence of the health "insurance" companies (really, I think that "healthcare finance companies" is a more accurate term for them), bring medical decisions back to the level of doctor and patient, and streamline the (massive) payment bureaucracy. You could even use such a program to eliminate medicare, medicaid, and the VA health system (saving trillions of dollars) by simply deciding to deposit the full deductible amount ($3000) into the HSA of people who qualify for medicare/medicaid/VA care. If you did that, you might want to tax the amount they withdraw at the end of the year, although personally I think the system would work marginally better without that extra taxation of benefits. You can then adjust the amount of the automatic contribution, and the rules for qualifying, to match your personal social engineering preferences. That could go all the way from giving the full $3000 to every American to eliminating the HSA contribution, and everywhere in between. A middle of the road proposal could give people with less than $20k/yr in income the full $3000 contribution, phasing that out as income went up, by $100 for each $1000 of yearly income (so that at $50k, the government made no contribution to their account). Enacting such a plan would: a) Create an incentive to save money on the part of every patient b) Create substantial savings over the current system c) End the problems resulting from our current employment based system d) Provide universal coverage for every American e) Substantially reduce the (massively expensive) influence of the health care finance companies (health "insurance" companies) What do you think? -- Tom Aiello [email protected] SnakeRiverBASE.com

Did he comment on muzzle blast, relative to blinding or deafening yourself in an indoor environment? That's really the only good argument I've heard against the 12 gauge (generally from people who like handgun caliber carbines for home defense, but also from some AR folks who like AR's in the new calibers, like 6.8, with suppressors). -- Tom Aiello [email protected] SnakeRiverBASE.com

I'm loyal to neither. Imagine the question with the names changed, and asked to an Iranian who supports a reform candidate. I mean, the reform candidates are just fomenting unrest, right? Are you so loyal to the reformists that you'd be disloyal to your country? Despite your protestation, that's definitely a "trick" question. -- Tom Aiello [email protected] SnakeRiverBASE.com

In general, I think it's almost impossible to characterize a success or failure as belonging to "America." Successes or failures belong to individuals, and are measured relative to their personal goals. It's very easy to hope an individual fails in attaining a personal goal you find repugnant, even (or perhaps especially) if they are in a position of authority in a government you are subject to. -- Tom Aiello [email protected] SnakeRiverBASE.com

Can anyone, please, explain how Obama is more deserving than Tsvangirai? Anyone? -- Tom Aiello [email protected] SnakeRiverBASE.com

Why's that good? Because he's an American? Because he's president? -- Tom Aiello [email protected] SnakeRiverBASE.com

I'm an individual. How about you? I'm against group identity politics. -- Tom Aiello [email protected] SnakeRiverBASE.com

It's their million bucks, they can spend it how they want. Where did all the libertarians go? Are Libertarians also not allowed to comment on the Oscars? Hey, it's their Oscar, they can give it to Yor, Hunter from the Future if they want, right? Give me a break. -- Tom Aiello [email protected] SnakeRiverBASE.com

You have to ask? -- Tom Aiello [email protected] SnakeRiverBASE.com