Re:how do you manage? - crony capitalism (Score 1)

""In the long run, Medicare will probably be gradually extended to cover everyone, which will give us Single-Payer by default"" Hope not - the managed care we have today is starting to break already. Try getting insurance for your family without working for an employer (self-employed). Why? Well actually - before "managed care" set into the marketplace in early 80's from academics setting policy in 70's - and indemnity insurance was still the main way of getting health insurance for employers and private policyholders - mostly Medicare had rising costs within 10 years of implementation - i.e. starting in 1966. Cost containment measures (i.e. putting in limits) stabilized this eventually but efforts backfired due to horror stories about "heartless" insurance companies rationing, etc. At some point a "semi happy" medium was reached between quality, patient satisfaction and cost containment. Managed care kind of followed the same suit with a increase in the 80's and 90's. In the managed care environment - rising costs have a few key root causes -- increasing demand, lower supply (of clinics/doctors/facilities willing to take Medicare/Medicaid) and shifting costs from care dollars to administrative dollars. The largest disincentive to "manage demand" is lack of transparency to overall price and consequence which has a boomerang effect to premiums and member share of cost depending on utilization patterns in prior periods. Additionally, the increase in regulatory requirements are not to be discounted. Regulators have some major latitude under very broadly written laws (currently PPACA/HIPAA, etc) to make many changes - even on a quarterly basis - that the "private corporate" insurance and hospital and even small medical group industry must comply with. Instead of hiring the extra nurse, physician assistant or taking on the extra junior MD partner - a "healthcare institution" are hiring an analyst, compliance officer, administrator (i.e. non-medical or middle manager) who can navigate the complex regulations and oversee policy and billing. Extend that constantly shifting regulatory landscape onto the harsh reality of shifting "software requirements" - and you can see how these costs get amplified in terms of software vendors, IT, etc - i.e. more administrative costs. Payors, Providers and their outsourcing suppliers (i.e. software vendors, pharma, PBM's, TPA's, medical supply, etc) have always responded to increased regulation via consolidation. This means "less competition", not more of it. With PPACA (aka Obamacare) - we have increased participation (which is true) - but also increased risk and demand without truly changing the supply side of the equation. The other reality is that regulation increased by magnitudes under "government defined" healthcare and so less dollars go into competitive models and more consolidation has occurred. What we are left with is fewer and larger players that tweak regulation via "crony capitalism". Before people point to Kaiser as a model - please look up "Stark Law" and Kaiser - the current modern managed care based system has it's origins in crony capitalism. Basically it is not easy to "startup" a Kaiser competitor using Kaiser's model in the current day. There is no free market healthcare in the US. It hasn't been even close to free market since the advent of managed care. Regulations have created a barrier to new experiments in healthcare delivery. Regarding Single Payer - by illustration, Medicare is not really run by the government, rather government policies by regulators are "interpreted and implemented" via fiscal intermediaries - which are large insurance companies - i.e. crony capitalism. Single payer won't be any different. The government doesn't ever reduce the cost of anything except to deny it and limit the "private marketplace". Single payer has a huge potential to a massive failed social experiment that will be a slow moving disaster spanning 50 years. It is not small business/entrepreneur or even consumer friendly (lack of choice/options to me is anti-consumer). Any innovative solution must solve the supply side (more providers, more models, more choices) and reduce the administrative costs to less than 1% of the overall healthcare dollar spent. Within the current regulatory environment, that is next to impossible for any care/service covered (and therefore heavily regulated/micromanaged) under managed care or government programs.