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Let’s pretend that we are starting from scratch on the health care overhaul push – that none of the existing proposals will be used as the template for a reform bill. In other words, let’s assume that the plan outlined in President Obama’s speech is the primary blueprint for the reform bill that Congress will have to consider. As I predicted he tried to strike a balance between being bold and rocking the boat too much calling both better and worse plans than his “a radical shift” that would be too much for something as economically large as the health care industry.
Now that I have read the entire speech I have four non-starters, one gem, two contradictions, and five questions after his speech that deserve public reaction. I’ll start with the non-starters because they are not non-starters put together, each one must be addressed before anything he proposes can be considered in any degree.
Non-Starters
- Even if I believe and agree with the whole plan outlined in the speech I have to read the bill that is supposed to implement the plan to see if I believe that the bill does what the speech said it would do.
- “This exchange will take effect in four years, which will give us time to do it right.” If it will take four years to get it right, why must we pass the bill now before the details can even be examined? I would never give a used car dealer $1000 when he promises to come back in 3 weeks with the best used car he can find for that price – that only guarantees that in 3 weeks he will hand me the keys to the cheapest car he can lay his hands on. In other words, if it will take four years to get the exchange right then it had better take at least three and a half years of debate over the details before we pass a bill authorizing such an exchange (so that the exchange can go live a few months after the bill, with details, is passed).
- “Businesses will be required to either offer their workers health care, or chip in to help cover the cost of their workers.” One of the major flaws of our current system is the expectation that employers must provide coverage – that is what drive higher prices for individual policies and loss of coverage with a change of employment. Obama’s plan not only allows that, but seeks to expand that flaw.
- “We’ve estimated that most of this plan can be paid for by finding savings within the existing health care system” While I beleive that the current system is full of waste – enough top pay for this plan even – I’m not foolish enough for the line “pass this bill and then I’ll find the savings in the current system. I say “start finding savings in the current system so that you can afford anything like this bill.”
Some might expect that an individual mandate would be a non-starter for me. In a nod to the necessity of compromise and political expediency (I do have a pragmatic bone in my body – somewhere) I will keep it out of the non-starter category and say that if it is extremely limited, as liability-only car insurance is, I could accept an individual mandate. For example, the a plan that I could support for an individual mandate would be one where the insurance offers absolutely no coverage for bills under $5000 except for preventive care. Such a policy would deter bankruptcies but should be available at extremely low rates.
Even the gem in his speech carries caveats, but I basically agree with the idea expressed here:
. . . it will be against the law for insurance companies to drop your coverage when you get sick or water it down when you need it most. They will no longer be able to place some arbitrary cap on the amount of coverage you can receive in a given year or a lifetime. We will place a limit on how much you can be charged for out-of-pocket expenses, because in the United States of America, no one should go broke because they get sick. And insurance companies will be required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies . . .
My caveats are that a cap on expenses paid during a given year can be perfectly reasonable so long as the cap is spelled out in the plan in advance and that “no extra charge” can be implemented by charging more for everything to cover the costs of the preventive care. The fact that we feel it necessary to mandate coverage for preventive care is a testament to the perverse incentives built into the current system.
Questions
- Will the “insurance exchange” cross state lines or will people still be limited to purchasing insurance regulated by their state only?
- “All insurance companies that want access to this new marketplace will have to abide by the consumer protections I already mentioned.” This implies that some insurance companies may not be required to abide by those consumer protections . . .
- “The public insurance option would have to be self-sufficient and rely on the premiums it collects.” How is it going to offer plans below the cost of private non-profit insurance companies if it must reply on the premiums it collects? I know the claim that it will do so “by avoiding some of the overhead that gets eaten up at private companies by profits, excessive administrative costs and executive salaries” – the only problem is that “excessive administrative costs” could be spelled faster like this – G-O-V-E-R-N-M-E-N-T. How do they expect to save on executive salaries if they replace five executives making $1 Million per year each and one executive making $3 Million a year in a private company with fifty bureaucrats making $200,000 per year each?
- “We believe that less than 5% of Americans would sign up.” These are the same people that predicted that $1 Billion in Cash for Clunkers would last for 4 months only to find that $3 Billion kept the program open for less than 3 weeks. When the government opened up a health insurance lifeline for people in 1965 they found that 12% of the population was signed up within a year. (Here are details about this and other facts.) What makes anyone believe that this public option will attract less participation than Cash for Clunkers or the original Medicare/Medicaid programs?
- Why must this all come as one omnibus package? You have multiple ideas that you claim have bipartisan support – why not pass each of them individually? If they are each such good ideas would not passing some of them be better than killing all of them together?
Contradictions
- “In 34 states, 75% of the insurance market is controlled by five or fewer companies.” I have no doubt that Utah is among those 34 states and the dominant player is “some places, like the Intermountain Healthcare in Utah . . . offer high-quality care at costs below average.”
- “Some of the same folks who are spreading these tall tales have fought against Medicare in the past, and just this year supported a budget that would have essentially turned Medicare into a privatized voucher program.” Funny, Medicare as a system of vouchers for use in the private market would almost certainly be a vast improvement in our health care system. That would probably be a good start to trimming some of the excessive costs of the current system.
22 replies on “Takeaways From the Health Care Speech”
From my reading and understanding(however limited that maybe)(not meant as endorsement of the bill)
1. No the exchange won’t work across state lines, As much as the republican’s would like to see this it is likely not possible. You would have to kill the differing regulations in all 50 states. This isn’t a federal regulation issue.
2. I am pretty sure the new regulations applie to all insurance company’s
3. Medicare operates with around a 3% overhead, most private insurers operate with around a 28% overhead. the public option which is basically the ability to buy into medicare before you age 65, except that the public option pay rates to doctors and hospitals is set 20% higher then the medicare pay rate. The public option really is a blunt tool to beat private insurers over the head with if they don’t get their own overhead down.
4. Their are criteria you have to hit before your aloud to buy into the public option even if you have access to the exchange which requires you to hit several criteria in the first place.
for the exchange
a. small business less then 20 persons employed
b. employer does not provide insurance
c. independently employed
d. employer option is greater then 11 percent of your gross salary.
for the public option
a. insurance in exchange would cost more then 11 percent of your gross salary after any subsidy payed by government if you make less then 4x the poverty line
Basically if I understand correctly the 5% quoted by the president refers to the number of people that would qualify not the number of people that would potentially buy into the public option.
5. Health care is a political bloody bath, no politician wants 5-6 separate slightly smaller blood baths.
As to you contradictions
1. IHC owns something like 94% of the utah market, they own the hospitals, doctor offices,etc. while we may get a slightly better deal this has more todo with economies of scale then being treated better then other states. And we still pay way to much. My dad’s employer provided coverage($650 month) costs more then the payment on his house.
2. We have a seen what happens with a medicare “voucher” system, which is what we passed in 2003 in the form of medicare advantage(option to buy private insurance with your medicare dollars) and the medicare drug plan(privately ran drug coverage). Both have been enormous failures, The house bill would fill in the medicare drug “donut” hole and end medicare advantage, this will fund the first $500 billion or so of the reform bill.
Ron, I’d be very interested to know where you got some of your numbers (they were not in the speech as far as I could find).
I assumed that the exchange would not be across state lines, but if it isn’t then I don’t know how it offers any real advantage nationally. The Federal government is not going to be better at managing 50 smaller markets than it is in managing one large market. Also, I am confident that Obama intends for all insurers to comply with the new regulations, but what he said implies otherwise – he should not have pretended like it would be some accomplishment that insurers int eh exchange would comply with the regulations if all insurers would be complying.
Here is where we get into your numbers which I am unable to verify. I don’t intend to dispute the numbers with you but I do want to share the perspective of someone who claims no inside information. What is the Medicare overhead in dollars? Probably higher than any insurance company. How much of that 3% is a direct result of not actually being able to see the overhead because it is in other places on the government balance sheet? (Companies shuffle overhead all the time, I doubts governments are any different.)
The criteria you list for the exchange and the public option are interesting, but again, what is their source?
I think the Intermountain Healthcare contradiction is very interesting. (Disclaimer for those who were not aware – I work for Intermounting in an extremely non-clinical role.) How is it that the President cites competition as a crucial element to lowering costs and yet he cites an health care company that has as little competition within its market as a model for high-quality, low-cost care? It seems to break his argument and casts doubt on the idea that he even understands the real forces that are straining our system to the breaking point.
Your right many of the numbers I quoted are not in the speech.
If we take Michigan as a model for what a state exchange will do in the face of mandatory insurance coverage we should see the price lower a little bit, not by any amount to write home about however. So yea you are pretty much right on this one. Further in states like Utah why ever would IHC negotiate better rates to their hospitals through other insurance company’s then what they will offer to themselves. This is the argument democrats use for the Public option being one of the options on the health exchange.
As to the hidden costs in medicare, I give yea that if we adjust for some of the cost shifting it comes to 5.2% healthcare-economist.com Given this is an article from 2006 but it should be good enough.
The criteria for the Health exchange are from the bill listed under “SEC. 202. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS.” HR 3200 I should note that it sounds like the rules for this are going to get stricter before the bill is put up for a vote.
As to your last comment in reference to Contradiction 2, Health care is a grossly atypical market where many of the common market principals are non-functional. Insurance removes consumer price pressure, and demand is a function of the disease rate not the price or supply of a curative or treatment.
I distrust purely market(aka regulation) based approach’s on this for a few reasons. Republicans like to deregulate selectively, if we pass a purely regulation based market system how long is it until someone removes the consumer protections while leaving the industry benefiting regulation in place(example Telephone industry). Don’t read the public option as purely the lefts distrust of the insurance industry(it is that), It’s also the lefts distrust of government is as a regulator.
It is sad that the government has failed and abused its position of trust so much that even those who favor government no longer trust them to be a fair regulatory entity.
I recognize that health care is not like other normal market transactions (there is an element of emotionality and irrationality that is much more prevalent in health care decisions than other large financial decisions) but on top of that the already special market has been warped away from the one thing that, even more than effective and fair regulation, can fix the problems and that is consumer price pressure. One of the fundamental flaws with all the health care proposals I have ever seen is that they never actively work to reinstate that crucial force into the equation.
You blame insurance for its absence, but that same disconnect does not warp the car market despite the fact that car owners are required to have car insurance – the difference is that what we call health insurance is not actually insurance. If it were truly insurance for most people they would have incentives to prevent injuries and illness as much as they could and insurance companies and other actors in the health care system would have incentives to maintain health. As it is doctors and hospitals have incentives to prescribe treatments – maintaining health is almost foreign to the industry because of the market warping effects of what we call health insurance.
apples or oranges comparison, Car repair costs are no where near health care costs, and Car insurance coverage is generally limited to accidents. And a car dieing doesn’t tug on anyone’s heart strings. Cars are expendable, I can’t argue the same for humans.
And I agree incentives in the health industry are screwed up, Tho I guess we disagree on the exact cause.
I have yet to hear a practical way to put price pressure back into the market that won’t have wide ranging negative impacts to the health care system. I would add to this that any system that increases the bankruptcy rate(due to “moral hazard”) would have wide reaching effects into the financial markets that would negatively effect the economy as a whole, The medical bankruptcy rate as it is right now is devastating in it’s effect. Any system that increases adjacent market collateral damage is unacceptable.
It is apples to oranges – but the apples to oranges has more to do with the structure of the “insurance” than it does with the cost. Are there more people able to afford a $1500 car repair than are able to afford a $400 minor surgery? $1500 is not a major car repair and I have had a $400 surgery this year (no, $400 is not what I actually had to pay out of my pocket – it’s the full cost of the surgery before the insurance reduced the cost with their volume price reduction).
The difference is that people expect to pay for new tires, oil changes, paint jobs, etc. unless they have a real accident -then the insurance kicks in. For health care they think they should be able to go to the doctors office for a $15 copay (or whatever their particular copay is) rather than paying for the full visit except when they have a serious health issue that costs real money – like the same car accident that required them to have the insurance pay for the car repairs.
I don’t see what’s impractical about having people change their expectations so that they take the price of a doctor visit into consideration when they decide to live unhealthy lifestyles or abuse the emergency room.
Insurance should be to protect against bankruptcy, not to cover every prescription we feel like pouring into our bodies (we don’t need many of the drugs we prescribe, but “why live with a bit of pain or discomfort when my insurance company is paying for it, what’s the value of those premiums if I don’t get anything out of it?” You don’t hear that about car insurance except when a claim is denied – not when someone is thinking of filing a claim) or every simple elective medical procedure we have the option to avail ourselves of.
My Dad is an auto mechanic so I just happen to be somewhat familiar with this field. Most people given a $1,500 dollar cost to repair their $4,000-$8,000 car are going to trade it in.
Primary care that is the direct cost of doctors visits is about 10-12% of the cost of the system currently, far from serious, dropping the entire cost of these doctor visits on people will reduce the disease detection rates and cost us vastly more money(due to late detection of diseases) while reducing the quality of the outcomes and further reducing the number of doctors willing to be general practitioners because consumer price pressure will assure them better paying jobs doing something else in health care. The number of medical graduates going into general practice is a sad statistic that needs improving, their are provisions for this in the bill HR 3200 DIVISION C–PUBLIC HEALTH AND WORKFORCE DEVELOPMENT.
Ron is right to point out that health care does not function like other markets. If I don’t want to pay the price for a Mercedes, I can shop and get a Toyota, whereas if I want treatment for cancer, my choices for treatment become more limited and I can’t choose to have some disease that does not cost as much to treat. A “pure” market for healthcare will not work and there will have to be some level of government involvement.
But Obama Plan does little, if anything, to address the structural problems in the current system, that could be better corrected using a free-market approach. By this I mean an approach without government intervention in which the parties find the most efficient delivery systems.
Most people buy insurance thinking it is a package to cover all medical costs except co-pays and deductibles, which significantly masks the underlying costs. If the consumer was placed more in a position of being a concerned buyer of health/medical care then prices would eventually come down because insurance companies are not set up to be efficient purchasers of healthcare services on behalf. If insurance companies were set up to be our agents in the buying process, they would be able to bring costs down. Insurance companies are compelled to be in a broker arrangement between us and the provider. The insurance company makes money on the transaction and just like the provider, they make more money based on volume of transactions. Insurance companies also manage risk, which is a different transaction than a broker.
What we need to consider is to split the roles of broker and risk manager into different groups. Consumers who buy “health/medical” services could do their own homework and find the right doctor for the ailment, or they could use a “broker” to set up the relationship between the consumer and the appropriate provider. This will bifurcate the conflicting services that the insurance companies now provide. These are ways in which the “market” can implement efficiencies.
The government programs work more like a Wal-Mart operation, in which either because of buying clout or, more likely, mandate, they stipulate the price they will pay for a service. Medicare can just decide it will only pay $1,000 for a procedure—take it or leave it—even if the procedure actually costs $1500. But, if Medicare will pay for that procedure 20 times, then a hospital/doctor is going to order that procedure 20 times because if it is done 20 times, the hospital/doctor can spread fixed costs over more than one procedure, thus bringing the “average” cost down. For example, rent is fixed each period and it cost less per procedure for each incremental procedure. If Medicare truly participated as a competitor to insurance companies, then it would be compelled to pay a higher price for 1 treatment, but would then only authorize 1 treatment, not 20. Medicare also has laws behind it that insurance companies don’t relative to fraud. In one situation I worked in Medicare denied all the payments for a period of time. We determined it was easier to just let them do that rather than fight the ruling and we feared they would come in an audit other things—not that there was anything for them to uncover, but if they want, they can use the full force of criminal sanctions and just being jerks—similar to the IRS—to recover what they want.
Again, Obama Plan only exacerbates the fundamental design flaws. It is like building an airplane that may fly but has long-term structural defects. Pouring more money into it and demanding that the plane fly or else the government will take over ownership of the airplane does not address the fact that the plane was designed wrong.
Scott,
Your point about the need to separate the broker from the risk manager role is important. That is the difference between car insurance and health insurance. With car insurance the insurance company is only acting as the risk manager.
Ronald says that people paying for their own primary care will result in later detection of disease and thus higher cost. That sounds good on paper but it flies in the face of the evidence. Studies have shown that people who choose to self-insure or who choose high deductible plans are more careful about their health and more wise in their health spending than people with other forms of health insurance. His statement may well be accurate for those who can’t get insurance but for those who feel ownership for the health care dollars they spend (as opposed to those who feel that everything they spend on health care is out of their control) it is natural to find ways to stay healthy – including being very conscientious about primary care visits.
I hate to point this out (okay, no I don’t) but when people choose to trade their car in rather than pay for the $1500 repair they are, in fact, choosing to spend more than $1500 – and it still did not bankrupt them. Sorry – apples to oranges.
No matter what we like to believe when we make health care decisions we are making economic decisions and the laws of economics apply. The fact is that when we make economic decisions with other people’s money – whether it’s the insurance company or government money taken through taxes – we do not tend to be more wise in our decisions than when we are spending our own money. Whether we like to think of it that way or not the laws of economics will apply for those decisions – if we make poor decisions then poor results will follow. If we spend other peoples money unwisely it is entirely possible that we will not directly feel the effects, but in the end there is a limit to the money supply and somebody will be saying no to some treatment if we overspend. it might be doctors providing lower quality care because they are not getting properly compensated for their services, it might be the insurance company going bankrupt, it might be the nation going bankrupt, but one day the laws of economics will take what is due in some form. If we spend our own money we get to decide when it is time to say no – even if its a painful decision.
The only sustainable solution to our health care problem is to put consumers back in the position of paying for their health care so that they no longer think that someone else will pick up the final tab (this does not rule out buying health insurance, but it does mean that we must change the way we think of it – we must look at it like insurance).
I think we both pretty much saw the speech from the same perspective. Nothing changed. Government will be in charge. He should have just come out and outlawed insurance companies. To me, I just keep asking one question: do these folks really get it? If this is to be his legacy, then it will be a poor one. It could be titled, “How I Made a Bad System Even Worse” with a subtitle, “The Real Reason You Can’t Get Adequate Care”.
With respect to the point on Medicare and insurance company overhead, why is there such a huge difference in rates? I suspect it is not because insurance companies want to have so much overhead, but rather the cost of complying with significant regulatory burdens. Also, most hospitals and doctors factor in that Medicare is just going to pay a lower rate and this is subsidized by the insurance company reimbursements. As the CFO for a hospital, I have spent the last year working to bring down overhead. It is difficult because of all the things we have to provide patients that is not directly attributable to the treatments. Although my overhead burden is different from an insurance company’s overhead, the concept is the same and any company that competes against a government entity is going to have a disadvantage with respect to overhead. The factor that is always left out of any discussion of competition is that non-government enterprises absolutely must provide top-quality customer service whereas a government entity is totally and completely removed from that concept. If I am a hospital or an insurance company and can get away from providing customer service without the risk of losing my customers, then I could bring down my overhead very quickly. The government does not have to advertise for customers, it can just mandate.
That’s a very good point Scott that private health care entities (hospitals and insurance companies for example) are paying in overhead to comply with Medicare/Medicaid. If insurance companies could lower their overhead they would do so simply based on the profit motive.
Unfortunately our tax structure actually encourages our broken structure of employer provided care and cost shifting (artificially lowering costs on some procedures thus encouraging excess use of less regulated procedures). Now we want to fix that government manipulation with a government-centric solution.
The first solution is to remove the distortions and figure out what the market can actually provide without a public option. Then we can decide what is or might be necessary (which would probably be a business or technology solution rather than a government solution) to fix the system.
Exactly, and that is what is so frustrating to me about the whole healthcare reform. If they really want to reform it, then they need to really reform how it works, not just put a bigger government band-aid on it and scream about the evil insurance companies. This whole mess started out of the unintended consequences of tax laws back in WWII. It is broken because it is has fundamental flaw designs. Insurance companies are not truly insurance companies (as we think of auto and life insurance, or business insurance), almost every aspect of the system is distorted in its mechanisms to exchange goods and services for value. And although I am a cruel and uncompassionate republican-oriented, nihlistic, insane snob, I do think that everyone should have access to health and medical care and nobody should go broke to get that, but the parties to healthcare transactions need to be put back in contact with each other. The current plan and the Obama Plan is NOT the way to do it. The President said last night that we cannot go back and redesign the flawed system and that we have to work with what we have. That is the ultimate illogic to this debate!
$400 for the surgery, how many doctor visits did you get before the minor surgery, how many medications did you take before the minor surgery, yes a one separate item can be handled by an individual the total of all the costs that built up to that in many cases can not be. When I had a tube put into my right ear(also minor surgery tho a bit more expensive ($2k~ish)), I had 5 separate doctor visits, and 3 different antibiotics, one of these antibiotics being a $370 dollar expense due to a patent. Each of these items are very minor but taken together are devastating financially. If the entire cost of just the doctor visits and medication was left on my shoulders I would be deaf in my right ear and in pain.
Anything less the comprehensive health care just won’t work.
What is “comprehensive health care?” I’m not certain that I accurately recognize what your end goal is so I fear we may be talking past each other.
As for my minor surgery – two doctor visits before and one after plus no medications. Total bill less than $1000. (Again, that’s the total before insurance adjustments etc.)
We have good studies on what happens with debt in health care, UCLA health care debt study
Very high deductible insurance will result in a lot of health related debt. A 1% decrease in the cancer detection rate will eat the savings we can get from consumer price pressure in primary care.
Read the study again – that’s not what it says. It says that those with health debt are more likely to put off treatments (they are rationing themselves to avoid more debt) thus increasing costs to the system. What it says about high deductible plans is this:
There is no proof – only a suggestion. They show that many who purchase insurance privately purchase high deductible plans but they do not demonstrate that those choosing high deductible plans have a higher likelihood of carrying medical debt than those without insurance or those with lower deductibles. If that data is actually there then someone should call it out. Until then you have only a suggestion with no proof.
With respect to the UCLA study, I once again see a problem with statistics, damn statistics and lies. I don’t doubt the numbers, but let’s look past those to truly identify the issues before we start making conclusions. I ask one question: how much medical debt is attributable to true medical needs that the people could not pay versus how much is medical debt due to people being maxed out on credit cards, mismanaged funds, lack of savings for emergencies, etc.? There may be “medical” related debt because they had not properly managed their financial resources so they could have cars they could not afford, homes they could not afford, or lifestyles they could not afford at the cost of additional medical debt.
This does not mean there is not a legitimate issue that needs to be looked at relative to paying for the cost of medical care beyond what insurance pays, I merely suggest we have to look behind the figures for what is really going on.
Forgive me while I am confident that what I am about to say will sound indelicate or insensitive but Scott has a point here. While there are doubtless cases where people have been as wise as we could reasonably expect with their finances and they are still ending up bankrupt due to medical bills we do need to tease apart those cases from among the doubtless many others who have many forms of unnecessary debt which cause them to take on medical debt when they then have a medical problem. The medical debt then becomes an issue that will generate sympathy in bankruptcy court while glossing over the fact that the case is really an issue of poor financial management.
I think it is safe to suggest that the vast majority of those with less than $10,000 in medical debt who are in real financial trouble are likely suffering more from poor financial management than from a broken health care system. As Scott said, this does not mean there is no problem (nothing could be further from the truth) but until we hone in on the actual problem, unhindered by other issues, we will not be able to solve what is really broken in the system. We will be left putting band-aids on our broken bones and tourniquets on our scraped knees.
I was referring to $10-$20k very high deductible plans proposed as a method to reconnect consumer price pressure(this is the most commonly cited method to do this). And I don’t think accusing the 2 million people(of which 78% had insurance at the onset of their disease) who declare medical bankruptcy each year of being bad with their finances is constructive to solving that problem. That is to wide a generalization.
That UCLA study shows that Medical debt results in delays in care. That doesn’t just mean the persons current problem’s are not being properly handled, this also means that the person is more likely to delay seeing the doctor for other indirectly related issues as well. As to the validity of the UCLA study, I have always considered University research to be good but I do suppose UCLA does tend to be a bit on the liberal side, I wouldn’t call that a reason to disbelieve that study however.
I find the Scott’s idea’s interesting on the subject, but I also wonder if separating things the way he suggests would just add more bureaucrats(I see no difference between industry bureaucrats and government bureaucrats both are bad) to the equation.
Really trying to wedge a non-market entity into a market model has always smelled funny to me, If it comes down to it and my choice is between having a privately ran socialism or a publicly ran socialism I will pick the public ran socialism every time. Not saying that I see that as being the case yet, I won’t discount the possibility of a market system being made to work. I will remain highly distrusting of regulation based approaches.
*unrelated note. The comments on this blog seem to be appearing out of order missing a “ORDER BY” clause in your SQL somewhere maybe?
I acknowledged that what I said would be viewed as insensitive. I also said that there are legitimate cases of medical bankruptcy. With those acknowledgments it is still important for us to tease apart the legitimate cases from the ones that are actually based on poor choices. Without that analysis we won’t know the true scope of the problem to accurately address it with our solutions.
There is no doubt that delays in care lead to higher costs. The doubt is whether high deductibles lead to delays in care (what has been shown is that medical debt leads to those delays). I never said that I did not believe the study, I said that you are implying a claim that they never made – and I have no inclination to try to make sense of their numbers (statistical analysis not being my forte) to prove or disprove that unmade claim.
More bureaucrats does not always mean higher costs, especially if the new bureaucrats are untying such an obvious conflict of interest as having the roles of broker and risk manager combined where the broker is has incentives to raise volume rather than managing risk.
As to your unrelated note – I have comment threading turned on and we have exceeded the threshold for comment depth – I’m a bit conflicted about whether it is best to remove threading, or to muddle through this case where we went deeper than the threshold.