Saturday assorted links

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#3. Especially for a country like Ecuador that sounds sketchy. The central government will be able to monitor all electronic transactions of all citizens. Who is buying goods and services from regime opponents when they are supposed to be trading with supporters? The government will know. And who thinks Correa would have been above using such information? And is this going to give the Ecuadorian central bank the ability to print electronic dollars? Some are certainly reading this as one more step in the end of dollarization:

http://www.investors.com/politics/editorials/ecuador-weakens-us-dollar-as-its-official-currency/

While it's debatable *how* the "dinero electrónico" platform will be used in time (just as it's debatable how any government will manage its currency), there is no debating that the system, as it is laid out in law and as it is currently operating, is *not* a "new kind of electronic money," but rather something more like M-Pesa in Kenya: a cell phone-enabled mobile payments system whose transactions are denominated entirely in US dollars (the official currency of Ecuador). The difference is that the Ecuadorian Central Bank has taken the lead in designing and implementing the system as a public service. To my mind at least, the key question is not about the system's effects w/r/t money creation (or even its potential to facilitate surveillance, considering the very small amounts of money involved), but about whether or not it will achieve its stated goals re: financial inclusion and payments interoperability.

2. Some very good ideas, which serves only to emphasize the difference between good ideas and the reality of what was/is achievable given all the interests that were/are affected by health care reform. This is Cowen's best idea: "opt for universal coverage if the elderly agree to give up Medicare, moving us to a version of the Swiss system and a truly unified method of coverage". Unless and until everyone is under the same health care system, we can continue to expect the different systems (individual market, group market, Medicare, etc.) to compete (i.e.., game health care) for preferred treatment, coming at the expense of the other systems. But as Cowen indicates ("[b]ut don't bet on that ever happening") it won't happen given that people are self-centered ("death panels!") and the politicians willing to exploit it.

Tyler just proposed a total government takeover of the entire health care industry with government dictating and rationing everything.

Not radical at all.

Nothing in Obamacare tanks HSAs, but in fact, the complaint is that the $5000 deductibles require too much out of pocket spending. But that spending is required by people who could not afford to have $100 per pay period diverted to an HSA.

Tyler's proposal was radical. Everyone without employer coverage would end up on Medicaid unless healthy and in no need of health insurance.

Federal Medicaid will be Medicare. It's an admission the "laboratory of the States" failed to lower medical costs by efficiency, but only by rationing.

Medicare has means tested reductions of premiums and deductibles, while Medicaid is means tested to qualify, varying by State.

Medicaid expansion has been a huge, letting states run not so great, will turn into future TANF like banks in the future.

HSA seem to be doing well.

War-Mart health clinics is a horrible idea and the only reason they are spreading is facility charges. What we need is a crack down on hospitals.

The big failure is there is no price information in the system. I have a HSA, and close to 12K in in. I have a sore and potentially broken elbow. Is it worth trying to sort out how much an x-ray would cost? Seeing an actual doctor would sort out the issue but I'd have to wait 4 weeks to see one.

What we need is a system to gets patients into doctors, and we have one that is designed to separate the two. And no, a nurse practitioner is not the same.

Where do you live where it is a 4 week wait to see a doctor?

He's a man. That means urgent requires blood gushing from a cut main artery.

Besides, it's been bothering him for 2 years already....

I'm a man, so I know.

Of course, HSAs are doing well because co-pays and deductibles have gone way, way up. Since I'm nearly old and pay the maximum premium for coverage, I have opted for a high deductible plan (HDP); indeed, my annual out of pocket expenses exceed $15,000 before I receive the first dollar of benefits (i.e., my combined premium and deductible is about $15,000). Charlie's post reveals the fallacy of the argument that people should personally bear out of pocket costs so they will shop for the lowest price; what they do instead is defer care, and by deferring care turning what was a minor injury into a major one. Go to your primary care physician and get an x-ray.

Go to an urgent care clinic and you will see a doctor same day and if indicated get an X-ray the same day. NOT the emergency room but an urgent care facility.

Also, the fee is way less than an Emergency Room. It's roughly $150 to use Urgent care. Though you'll pay any X-ray's you need of course.

The bashing of "Wal-Mart health clinics" is unsupported by anything. Wal-Mart is not the only concern doing this. (Is this just another form of Wal-Mart bashing?) In Northern Virginia clinics in strip malls are open all over the place. But why rely on anecdotes? Here's an examination done last year. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2015/rwjf419415 There was a damper on their growth during the recession, but they now number 1,800. By 2012 they represented 2% of the primary care interactions. Also, there are "minute-clinics" in many places. (That's the CVS brand name.) Many of the big retail drug store chains have them. Minute clinics are usually staff by nurses who are qualified to do procedures like vaccinations, collect blood, etc. I just took my 11 year old for a T-Dap shot at one.

Physicians' assistants and nurse practitioners are an ever expanding resource for patients. They are used for important jobs like pain management, and minor illnesses. This frees up doctors to perform real medical work.

15 years ago few people could give vaccinations. Now pharmacists in all 50 states can, thanks to the free market. By this I mean pharmacists saw a way to expand their income and lobbied state legislatures. They easily proved their qualifications.

All in all, a prescient list of suggestions. It may come more into play given the prediction of some reputable health economists (in this study, Uwe Reinhardt) that Obamacare is in a death spiral. http://www.vox.com/2016/8/25/12630214/obamacare-marketplaces-death-spiral

Yes, we need to eliminate most primary care provided by physicians and hand it off to NPs and PAs until such time as physicians end their death grip on provider supply or are willing to accept less money. Unfortunately, docs have used their significant political influence to pass state scope of practice laws that prohibit NPs, PAs and RNs from performing some services that could easily be delivered by these other kinds of providers.

Gross output in the medical and nursing sector is now about $2,050 bn. Typical annual compensation for physicians per the Bureau of Labor Statistics is $245,000 for primary care and $411,000 for medical specialties. About 30% of all physicians are primary care practitioners. Given that there are about 700,000 physicians, about 11% of the gross output in the medical and nursing sector is accounted for by the compensation of physicians and surgeons.

#2.

Some good ideas, not all of them in conflict with Obamacare.

Now that the rubes a world without preexisting condition clauses, how can we get them back on the farm?

Given that path dependency, I don't think government can offer Medicaid for the poor, and a free market for everyone else.

Not just the rubes.

Yes, Cowen's post from 2009 looks better by the day.

I hope you have sent your suggestions to Mr,Trump, there could be a job in it for you.

The real problem I see with the ACA was that it was attempting the hide the costs of the expanded coverage- something that is leading today to the failure of the exchanges- they can be hidden, but they must still be paid, and the designated payers have decided they don't want to pay, mandate or no mandate, taxes or no taxes. The real benefit of many Cowen's proposals in that post is that the costs are not hidden. This, of course, means Cowen's proposals were politically impossible in 2009, but more possible today as the ACA's failures mount.

Rayward, yes, the plans have evolved into high-deductible plans, almost like the old catastrophic coverage plans (a good thing, in my opinion), but without the benefit of the lower premiums that used to be attached to such plans, unless you just happen to qualify for the full subsidy.

Obamacare insureds are more costly, with greater health care needs, than the overall population. Not surprising since many haven't been insured in the past and have deferred health care needs. Insurers would prefer to segregate those insureds from (for example) insureds who have group coverage, avoiding as much as possible coverage of the former in favor of coverage for the latter. When critics say that Obamacare is in a death spiral, what they mean is that insurers don't want to cover insureds with greater health care needs unless somebody else (i.e., the public) pays the extra cost of coverage. Of course, that's not really "insurance", which is a way to share risk not avoid it. That's why Cowen's best idea is universal coverage where everyone is in the same risk pool including seniors (the implication of Cowen's idea that universal coverage be contingent on seniors giving up Medicare). Personally, I'd like to be in the risk pool with healthy people (so my premiums are low), even if I get sick and can't work and lose group coverage. I'd also like to win tonight's lottery.

"The real problem I see with the ACA was that it was attempting the hide the costs of the expanded coverage-"

No, it was an attempt to use the existing system of individual health insurance policies for those not getting employer, Medicare, Medicaid, military.

Which is the system laid out by a few Republicans in response to Democrats in the early 90s, and then brought up by candidate Dole in 1996, then signed by Mitt Romney as goverror.

It's roots in the Republican playbook is the reason Republicans can't come up with a replacement.

Unless by "costs" you mean lost rent seeking opportunity by the insurance industry. The lost fees to insurance agents selling policies was a big deal to the insurance agents.

#1 - seems FARC going away is a net plus, despite the continuing existence of armed drug gangs. Put another way: would you, US citizen, prefer the Cold War and threat of nuclear annihilation over today's fear of terrorism (about as likely has harming you as being struck by lightening)?

Article: "“This may be the future of crime in Colombia,” said Adam Isacson, a senior associate at the Washington Office on Latin America (WOLA). “These groups are hard to fight because they don’t want to fight. They would much rather bribe and penetrate.”

WOLA has long been a collecting pool of red haze fools.

Problematic levels of street crime are a given in Colombia and, in fact, in all but two or three Latin American countries. There's nothing new in that, and Colombia used to be in worse shape than it is now, with a homicide rate twice what it is today. What's new is the cease fire with the reds, but acknowledging something straightforward is not what poseurs can manage to do because they cannot present themselves as clever in doing it.

"What should we do instead of Obamacare?"

Two simple things:
1. Create a single decent health insurance plan and use it for all government workers (to insure that the plan is a good one and to equalize health insurance so that the bureaucrats don't have the cadillac plan and the rest of us the Cheverolet plan. Let the insurance be offered by any and all insurance companies/providers at the same cost to everyone (employer, individual, poor rich, etc.)
2. Subsidize the cost for the poor with a single simple tax change; end the charity exemption and all tax free entities to include churches. This alone is probably 100's of billions and possibly in excess of $1 trillion a year.

Perfect solution. A plan so good that all government employees would embrace it and make sure it stays good. Same cost to everyone; to employers who provide insurance for their employees, to individuals who pay for their own insurance and to the old and poor whose insurance is subsidized by taxes today. The plan would not be run or provided by the government it would be 100% capitalist with a single premium for all that will allow the plan to remain solvent and profitable for the insurance companies.

"...and all tax free entities to include churches."

I imagine that is an explicit Constitutional violation and would require an Amendment to enact. It would probably be far more straightforward to just cap deductions at some number across the board (say 10% or 5%) and let people use the deductions as they so choose. I'm sure a cap would also raise a Constitutional question, but it would be far more likely to survive a POTUS decision, because it's not directly in conflict with Constitutional legal precedent.

Make an all-out attempt to limit deaths by hospital infection and the simple failure of doctors to wash their hands and perform other medically obvious procedures.

This all-out attempt has been underway for several years now. What is "medically obvious" does not always reduce in-hospital infections. There are strong incentives to get this right, so the fact it hasn't been done yet -- even at the best organized hospitals -- might suggest that it's really, really hard.

Recall also the MR cited paper by TC that washing hands really doesn't clean the hands as much as the drying with paper towels (not air drying) and also the paper I once saw that said hot water is no better than cold. I don't believe either paper completely but there may be some truth that for simple bacteria in a non-hospital setting, 'washing your hands' (however you do it) gets rid of these germs, and that's 'good enough' for a healthy person, but for a hospital setting it doesn't really 'do anything that important'.

Hospitals have dispensers of antibacterial solution everywhere - in the hallways, in the rooms, in the bathrooms. It was about a decade ago I first noticed doctors making compulsive use of the stuff. The place I used to work has posters everywhere with the hospital director and nurses urging everyone to use the solution.

2. None of Tyler's suggestions addresses one of the main impetuses for universal coverage (no one should go bankrupt to pay for his/her medical care) and none of his proposals addresses one of the main impetuses behind ACA (people with preexisting conditions should not be frozen out of coverage). "C" level undergrad blog post.

1. Construct a path for federalizing Medicaid and put it on a sounder financial footing; call that the "second stimulus" while you're at it. It's better and more incentive-compatible than bailing out state governments directly and the program never should have been done at the state level in the first place.

Why? Are there important economies of scale in a public medical insurance program when the number of households covered exceeds 200,000 or 2,250,000. How about the long-term care portion of Medicaid? Would there be economies of scale with that? Given that setting up public insurance programs of this sort is not an enumerated power of Congress, what purpose is served by ignoring the Constitution in this respect?

2. Take some of the money spent on subsidizing the mandate and put it in Medicaid, to produce a greater net increase in Medicaid than the current bill will do, while still saving money on net. Do you people like the idea of a public plan? We already have one!

The purpose of this is what?

2b. Make any "Medicare to Medicaid" $$ trade-offs you can, while recognizing this may end up being zero for political reasons.

??

3. Boost subsidies to medical R&D by more than the Obama plan will do. Establish lucrative prizes for major breakthroughs and if need be consider patent auctions to liberate beneficial ideas from P > MC

Yeah, more swag for professors. Make it less obvious that you work in higher education.

4. Make an all-out attempt to limit deaths by hospital infection and the simple failure of doctors to wash their hands and perform other medically obvious procedures.

And how many deaths are there from this 'simple failure'?

5. Make an all-out attempt, working with state and local governments (recall, since the Feds are picking up the Medicaid tab they have temporary leverage here), to ease the spread of low-cost, walk-in health care clinics, run on a WalMart sort of basis. Stepping into the realm of the less feasible, weaken medical licensing and greatly expand the roles of nurses, paramedics, and pharmacists.

Again, physicians' compensation accounts for 11% of gross output in the medical and nursing sector. That aside, what is a 'WalMart' sort of basis? What do you expect to get from a nurse, pharmacist, or paramedic that you might ask a doctor for now?

6. Make an all-out attempt, comparable to the moon landing effort if need be, to introduce price transparency for medical services. This can be done.

What? A vast engineering program to induce 'price transparency'? Why not just attempt (starting with ICD-9) to promote controlled vocabulary in medical billing with a federal commission producing a model vocabulary and have federal legislation which compels hospitals with a presumptively multistate clientele (say, those in greater Washington and greater New York) to publish their chargemasters. The state governments might just pick up the ball re the general run of hospitals and clinics.

7. Preserve current HSAs. The Obama plan will tank them, yet HSAs, while sometimes overrated, do boost spending discipline. They also keep open some path of getting to the Singapore system in the future.

8. Invest more in pandemic preparation. By now it should be obvious how critical this is. It's fine to say "Obama is already working on this issue" but the fiscal constraint apparently binds and at the margin this should get more attention than jerry rigging all the subsidies and mandates and the like.

Sorry, the CDC is preoccupied with treating gun ownership as a public health problem.

9. Establish the principle that future extensions of coverage, as done through government, will be for catastrophic care only.

Sounds reasonable. Quite a challenge in a world where all the women in your office want to visit the doctor and fork over a $20 co-pay.

10. Enforce current laws against fraudulent rescission. If these cases are so clear cut and so obviously in the wrong, let's act on it. We can strengthen the legal penalties if need be.

11. Realize that you cannot tack "universal coverage" (which by the way it isn't) onto the current sprawling mess of a system, so look for all other means of saving lives in other, more cost-effective ways.

What, the WalMart model?

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