By definition, everyone literally has “skin in the game” in healthcare. The phrase sounds like the Atlantic City muscle approach to breaking, er, containing costs.

The “market” cure is malpractice.

Walker’s right, it’s STUPIDITY

I can accept the fact that we pay a higher premium to cover those people that are sicker or have no coverage, but I also feel that the people that maker their mission to live a better life and do the right things do not get any recognition.

Yep, I’m lucky I have coverage but it just went up $185.00 per month and I have to wait a yr to make any changes. It’s going to be close. If this is the richest nation in the world why isn’t health care free to everyone in Amerika, greed the bottom line. Oh order a new F-35 while Main Street is bleed to death slowly.

What does living a good life and doing the right things have to do with the rising costs of healthcare?

Honestly, people live good and try to be healthly all their lives. However, we are bombarded daily with chemicals and other shit that nobody has control over. Tell me, doesn’t everyone wish to be healthy and without pain or sickness?

I’ve got some skin in the game suggestions for Congress! Hopefully, one that voted for the NDAA will get to try it out.

The “market” cure is malpractice.

How so?

Not only did obama run the biggest con job on the American people during his campaign of “hope & change”, but his so-called “health reform” was simply a gift to the health insurance industry. From the beginning, single-payer was off the table, he pretended to be for a weakened public option, and then he wasn’t. He had the opportunity of a lifetime to give the American people single-payer and he didn’t take it.

To Jon: I have my own ideas as to why he didn’t fight for single-payer, but I would love to hear your opinion.

Thanks.

You partially correct, but their is a percentage of us that talk a good speech but don’t follow thru. It’s cheaper to try to stay healthy and I mean try, than to fix the problem after the fact. I have an example; cancer to me is probably one of the worst sickness that exist, I am very familiar, because of family history, the only people who would benefit from a cure would be the patients that have it. If a cure was found we would have massive unemployment and the ripple effect would be felt around the world. This cure will always be very elusive. So where is the incentive? We do the best we can, the only reward is no suffering!

Yes, I think we can agree that this one is obviously a scam.

This isn’t an issue I’m well-versed in, and others can make these points much better than I. Your post cites one data point (50% of health care spending goes to 5% of the population) and one gut-check about human behavior.

1. The gut-check about human behavior I don’t agree with. I’ve gone to the dermatologist many more times than necessary, and experimented with many types of largely-cosmetic skin prescriptions because there is essentially no cost to me. I’ve gone to mental health professionals quite a few times, even though I didn’t really need to — again, because it’s basically free, so might as well check it out. I don’t think these experiences are uncommon, and if the cost to me were higher (say, $100 per visit rather than $20, or whatever I pay), I might have bothered to weigh the costs versus the benefits, or made sure I squeezed as much as possible into each visit.

When it comes to more serious medical conditions, I think your gut-check analysis misses the point. Suppose I’m on my death bed and there is an expensive, low-probability “heroic” surgery that might prolong my life. If I had to weigh the cost to my family/heirs against the odds of heroic measures being successful, I’m more likely to skip the surgery than if there is practically no cost to me. It might be the case that it’s better social policy to require all other healthcare consumers to subsidize my heroic surgery without my having to make an economic cost/benefit analysis, but that’s not at all obvious and good arguments can be made on both sides.

2. Your data point (5% of the population use 50% of the spending) also isn’t dispositive of anything. First, there’s the other 50% of spending. Second, per the paragraph above, it’s not obvious that the best social policy is to have all healthcare consumers subsidize expensive treatments for sick people without the sick people having to make a cost/benefit analysis of their own.

Gut-instinct rebutted by a personal anecdote. Nice.

Cost/benefit? We’re not choosing between used Hondas.

“Skin in the game” means only one thing: you and me paying more out of pocket for routine, preventive, and exigent medical care.

I think the point is maybe you wouldn’t have your skin condition, albeit thankfully in your case mild, if we weren’t bombarded with chemicals that are contained in EVERYTHING that are there without our direct knowledge/consent/understanding.

“Suppose I’m on my death bed and there is an expensive, low-probability “heroic” surgery that might prolong my life.”

In medicine, high monetary costs go hand in hand with high human costs. Medical interventions get costly in money terms only insofar as they involve highly invasive procedures, and/or the intervention is so destructive that it requires intensive care support to give the patient a decent chnace of surviving the “cure”. People on their deathbeds don’t have much prospect of surviving the big-ticket interventions such as open-heart surgery, or liver or bone marrow transplants. Sure, sometimes people are offered such intervbentions when there is little chance that they will benefit, because there is little chance the cure won’t kill them. The screwed up money incentives our non-system puts on providers explains those incidents. And sometimes patients accept such interventions. But that’s not a rational calculation on their part. High monetary cost to medical interventions means that they extract a high human cost from the patient. There really is no moral hazard on patients from high-end medical interventions. No one wnats to spend their last days in an ICU on a ventilator after some heroic cure so invasive that it leaves them no prospect of a post-ICU future existence.

There is indeed some case to be made that there is moral hazard when it comes to some, scattered, low-intensity interventions, such as you allude to elsewhere in your post.

When we’re dealing with serious, life-threatening problems, there is no moral hazard for patients because the human cost of the high intensity interventions keeps them from wanting them unless they are strictly indicated, will probably do more good than harm. Patients with coronary artery disease (CAD) have no incentive to want the most expensive intervention — open heart surgey — over number two on the intensity parade — angioplasty — over the least invasive alternative — medication and life-style changes — unless their disease is worse than the cure. Very, very few people have CAD that presents a greater chance of killing them (At least, a greater chance that can be reduced by the surgery! The greater the time horizon we consider, the less advantage surgery has over medication.) than open heart surgery. Open heart surgery isn’t going to break the bank, because no one but a very “select” few with exactly the right CAD risk profile, would see potential beneifts outweighing the huge risks and other human costs.

But when we turn to the treatment of less serious conditions, we can indeed get down to a point where all of the available treatments have such low human costs that patients might choose the more expensive option systematically, out of vanity or convenience, or other motivations that are usually swamped by the fear of death and suffering that dominates choices when the problem is more serious. Surgery isn’t really justified for myopia, not when we have eyeglasses, a safer, cheaper alternative. But corrective surgery is so non-threatening, so much unlike open-heart surgery in that repsect, that vanity can often triumph over the very mild fears raised by the dangers of corrective surgery, and many patients want the more expensive intervention.

But, not only are such problems fairly easy to sort out, and address with a system of having the insurance only pay for the reasonable cheap alternative (e.g., eyeglasses), but these non-serious problems aren’t going to break the bank either. Even if we err on the side of being overly generous in suppporting vanity, myopia corrective surgery just isn’t that expensive.

What patients want, what choicees they make, is not the problem behind our high medical costs. We could give every patient every intervention they really need and really want, and still have a quite affordable system. But we can’t go on doing as we now do, and tolerate monopolies and cartels among providers and insurers, and have anything but out-of-control costs. The money people who diddle in the middle in medicine have a fiduciary duty to their shareholders to gouge us for as much as we will let them. Their depredations will grow without control as long as we do not impose that control.

andreww: Your first point isn’t coherent (responding to an intuition with a personal counterexample and related explanation *is* a logical way to reply) your second two points are too flippant to respond to. You, like the original poster, should spend some time learning what the other side’s arguments actually are before laughing them off.

gtomkins: You’re getting beyond my ability to respond — like I said, I’m not well-versed on the factual specifics of the health care industry. My point was that blog posts like this one make liberals look bad because they suggest we aren’t capable of understanding the other side’s positions, so instead we just knock down straw men with bad arguments and pat ourselves on the back, saying, “Those Republicans are so dum, lulz.”

Well, there is never going to be a case where the people on the wrong and foolish side of an argument fail to cloak their error in some or other point that actually makes sense. But I think you have to look at where and how these little snippets of sense are deployed to distinguish between mere error, and intentional obfuscation and deception. I would argue that the biggest problem with blanket and lazy assertions that the Rs are “dum”, is that we’re letting them off too easy by not sharpening our analysis of what they say to the point that we’re talking about their knavery rather than their folly.

I would concede they have a point about patient moral hazard, not having enough “skin in the game”, to a limited extent, and only for low-end medical problems. But that’s not a point that, however theoretically valid, an honest participant in the debate would be interested in making, for two reasons:
1) we’re not hemorrhaging money on the low end — We don’t have patient moral hazard on the high end, where all the money is spent. It only exists on the low end, where there isn’t much money at stake.
2) we’re already addressing patient moral hazard on the low end — Insurers, both private and public, like Medicare, already are vigilant about not paying extra for interventions with cheaper alternatives, or interventions for problems that aren’t really medical. You want Botox, you’re already going to have to pay for it yourself out of pocket.

Their scam works this way. They find some theoretical mechanism for a public policy problem that has some plausibility at least in the abstract. Maybe it’s the idea that fear of malpractice lawsuits causes providers to practice defensive medicine, and that’s why costs are out of control, or maybe it’t this idea that it’s people who seek excessive treatment for their acne who are to blame. Those mechanisms make sense in the abstract. Concretely, we probably all know people who seek medical interventions for their acne beyond reason, and the industry has made sure we all have heard several anecdotes about unreasonable malpractice awards.

But the math just doesn’t add up for any of these mecahnisms to even come close to making any meaningful contribution to the problem. But while we are busy fending off these ideological gnat-bites, they get to avoid discussion of where the system really hemorrhages money, to the monopolies and cartels. And insofar as these bright ideas of theirs aren’t purely a diversionary tactic, their real purpose is to advance an agenda that has nothing to do with controlling costs. They want tort reform to make it harder to sue providers. They want these vouchers or these medical accounts, these ways of getting patient “skin in the game”, in order to tempt the healthy majority into unburdening themselves of folks wiht medical conditions. They want the healthy to stop voting to share the risks of illness in common, but instead to let the insurers make easy money collecting premiums from beneficiaries who never make claims, while sick people get fobbed off onto the public dole because they are forced into some high-risk pool whose premiums Bill Gates would have trouble paying, that only Uncle Sugar could afford.

They’re not “dum”. They are very effective and cagey advocates for shareholder value. If that advocacy leads them to oppose the public good, then the public good be damned. That’s not dumb, that’s evil.

Sadly, we will probably never adopt proven solutions to reduce our huge levels of health care spending until our political leaders admit this “skin in the game” theory is nonsense.

Concern for what is sense or nonsense has zero to do with it. The job of the politicians–as they see it–is to be salesmen for the special interests that fund their campaigns and undeservedly profit at our expense.

You get medical treatment you don’t need just to “check it out”?

Yeah, I’m going to go ahead and assert that that’s uncommon.

Shorter gtomkins: Cost controls work (cf. every other industrialized nation).