SENATE BILL: Reforming Atlasian Public Health Act of 2014 (Debating)

[Southern Senator North Carolina Yankee]

I had planned to do some work on Part III, being Memorial day and such, but I got on to late.

I am in need of some ideas for the various savings component as well. Duke, the singapore plan had a savings component, based on your research how did the savings component function in that and could it work with a few alterations of course, in more broadly market based system then that of Singapores?

[Southern Senator North Carolina Yankee]

I think there are three ways to handle Part III.

1 Use Fritzcare in a medicare like form to cover the veterans and those with mental illness, maybe even those with pre-existing conditions.

2. Use the main subsidized pre-medium sysrem for as many of those as possible with some kind of fall back for the rest.


3. Some kind of self-contained VA like system branched off of the Fritzcare public option.


I think three is the most complex, expensive and considering the recent RL information, it might wall them into an inferior model and we don't want that. They should get the best not the worse. So maybe some combination of 1 and 2.

[Southern Senator North Carolina Yankee]

I think there are three ways to handle Part III.

1 Use Fritzcare in a medicare like form to cover the veterans and those with mental illness, maybe even those with pre-existing conditions.

2. Use the main subsidized pre-medium sysrem for as many of those as possible with some kind of fall back for the rest.


3. Some kind of self-contained VA like system branched off of the Fritzcare public option.


I think three is the most complex, expensive and considering the recent RL information, it might wall them into an inferior model and we don't want that. They should get the best not the worse. So maybe some combination of 1 and 2.

I would personally recommend using the first one. Much as I support introducing more and more free market elements (like the Health Savings accounts), I believe the least we could do for the veterans is to have them covered (mental illness is also a tricky issue). And, from a political point of view, it might give this bill a great chance if keep those benefits. Still, I recall that an earlier TNF bill stated that the health care benefits of the veterans were to be increased, perhaps it was one of the anti-imperialism bills?

Yea, even two eventually becomes one with the "fall back measure anyway" and three would be even more complex. For simplicity sake, since this will have several moving parts, I think you are right.

[Southern Senator North Carolina Yankee]

The "used car salesman" thing is taken care of by establishing exchanges. It prevents people from basing all of their healthcare decisions on advertising or whatever. By having a simple, side-by-side comparison of insurance plans, we counteract the used car salesman. That solves that problem.

Choice in insurance is plentiful. The variety of insurance networks also creates a sort of backdoor choice in providers. Empowering patients to pick insurance that is cost effective and is what they need while allowing them to save would work wonders. It addresses the vast majority of cost drivers in healthcare.

I agree with you about the exchanges, and the effect they have and that along with some necessary regulation helps to keep those excesses in check.


The problem is that we cannot just go back to 2009 and startover with healthcare and for five years we have had Frizcare. While the choice is plentiful in RL, it is not here as a result of us having had a system like Fritzcare designed so that we would be lucky if the hospitals are still open at this rate, more or less private insurers of any kind. Granted, options would be come available, but you cannot just erase ANHC from a page and expect to be able to formulate a plan as if it never existed. That is one of the main reason why I am looking to convert it to a market competing public option, but keep it nonetheless.

[Southern Senator North Carolina Yankee]

For one thing, insurance plans are very very complicated, by launching a brave new world where consumers (horrible word) choose their own care policy you'll leave behind the vulnerable, who'll be preyed upon by used car salesman who sell flashy but useless schemes. People don't want choice, they just want not to have to worry about paying for healthcare when they're suffering serious illnesses, and not be crippled with huge costs.

I said back in February and I meant it, that the poor, the veterans, mentally ill and those with pre-existing conditiosn would be taken care of and that preventative care had to be maintained as accessible. Any plan I formulate will do this and any plan that will get my vote has to as well.

To an extent though we have to get people more focused on their healthcare not necessarily for the sake of wanting them to desire a choice, but to get them to make more responsbile choices lest it bankrupt the system. Anyway I have to go again.

Damn it, I never have enough time... 

[Southern Senator North Carolina Yankee]

The savings component in the Singapore model functions much like a 401K. Employees and employers make contributions to an individuals account, which they can draw on whenever they receive medical treatment. These accounts are all pooled and maintained by a government run entity, and they can be shared amongst extended family members if one account is not sufficient. These accounts are mandatory.

How does that compare to like the way the savings accounts operate in Chile for instance?

Remember even if we don't keep a Medicare like model overall, chances are a similar model will be used for Part III as Lumine and I discussed.

[Southern Senator North Carolina Yankee]

People to need to understand that healthcare inflation is caused by three things.

1. Increased Usage - The alternative of denying coverage is not really desirable. In the modern era, people should want to be healthier and we should design a system that makes that possible. One thing we can do is to reduce unnecessary usage by encouraging more responsbile behavior by putting a current term costs with those current actions. With the plan that shua and I are working on, you could give a financial incentive if you utilize prevenative care (which is still going to be provided free), or perhaps join a wellness program similar to what Riley's original bill contained. This will reduce the costs long term and you cannot do it as well with a free at the point of use system.

2. Tuition Inflation - Means that doctors have to earn more to pay off the loans that got them through John Hopkins and Harvard Medical School, so it gets passed from the education sector to the healthcare sector. And we should refrain from bashing doctors, for wanting to earn a decent living for doing brain or heart surgery. To do otherwise would cuase a severe skill reduction, we have seen what has happened from short changing teachers, you end up with the lower academic performers in the profession with the top performers beocming doctors, engineers, lawyers or going to make a killing on wall street.

3. Liability Insurance Inflation - Another pass through from the rising cost of insurance to protect against malpractice suits. Another risk from short changing the doctors is the likelihood that less skilled doctors will make more mistakes of course, which are a cost in and of themselves. There is also of course the cost of unnecessary procedures being done simiply to protect against such lawsuits (which can be tacked back on to number one). It is difficult fordoctors to give people only what they think they need when they have to constantly guard against the lawsuit to follow and at the very least pay for the insurance against such.

[Southern Senator North Carolina Yankee]

I very strongly support the formation of Singapore-style Medisave accounts. I very strongly support Singapore-style anything, but their healthcare model in particular is a model to be followed. Central Provident Fund and all. Indeed, I'd support repealing healthcare taxes and having it be completely paid out of Medisave funds, with means-tested subsidisation when necessary funded through transfers and direct subsidies from the general fund to the ANHC.

Can you explain this I am confused. If you repeal the healthcare taxes, how do you pay for the subsidization? If you take it out of the general fund that would require something rather substantial to be cut in the rest of the budget, no?

[Southern Senator North Carolina Yankee]

Surely the answer to having too few doctors is to accredit more schools, not to throw the baby out with the bathwater?

I can guarantee that if we allow anything to go in the training of doctors in a few years there will be countless scandals involving poorly trained doctors killing their patients.

Certainly there is some middle ground between too few and too many, one that preserves that academic rigor, yet meets our needs.


I think we are moving too far afield though and will need several bills to deal with some of these other aspects, important though they may be.

[Southern Senator North Carolina Yankee]

Be prepared to have it hit the floor soon if you do. Clogging rule and all that.

[Southern Senator North Carolina Yankee]

For one thing as I have stated, the competition to ANHC will not just be private insurers and those private insurers will look much different. I was figuring that with our likely co-operative developement Act going to pass, that you might them and other non-profit health insurers come online that would provide an alternative as well giving three types of options potentially.

And yes, if a region wanted to, they decide against allowing any to compete against ANHC, giving them the equivalent of the Vermont exemption from Obamacare (meaning single-payer).

Superique, I can use your assistnace on some of the other elements as well. You are familiar with your own contries' various programs  that are built around saving's components I assume and you already have clearly read the framework that shua and I have put together so far, how would recommend crafting the savings component?

[Southern Senator North Carolina Yankee]

Does anyone know anything about this "paying based on outcomes" as opposed to by the number or procedures. I recall hearing about in various discussions but I have forgotten the details. Isn't that what they do at the Mayo clinic?

From what I can remember it sounded like a good way to boost quality, cut costs and reduce those unnecessary procedures we discussed, whereas most measures do one at the expense of the other like tort reform requires balancing the need to guard against mal practice whilst trying to reduce unnecessary procedures and costs and a lot of cost cutting can also come at the expense of quality and so for.

So how does this process work, can it be done on a large scale or should it be done experimentally first?

[Southern Senator North Carolina Yankee]

If we cannot achieve tangible progress in the thread, we can at least keep discussing these other related factors and thus seeding bills in the process that can be offerred whilst I work out issues behind the scenes.


So about the billing by result instead of procedure?

[Southern Senator North Carolina Yankee]

If we cannot achieve tangible progress in the thread, we can at least keep discussing these other related factors and thus seeding bills in the process that can be offerred whilst I work out issues behind the scenes.


So about the billing by result instead of procedure?

I've been researching the "paying based on outcomes" as you describe it, and so far my reaction is rather mixed after seeing some of the downsides (which involve both results and implementation). If we assume our current Health Care system has not butteflied this, there should be a growing number of clinics in the United States using the system, with the Mayo Clinic being the prime example. It's supposed to increase quality (a Mayo Clinic Doctor said: "you get what you pay for") and provide a far better service, but the initial experiments in the United States never accounted for the cost, which apparently shot through the roof.

Now, the results in Hospitals and Clinics were initially better, but as time went on and the rest of the Hospital catched up with other programs there was virtually no difference. Paying based on outcomes also has to rely on independent organizations to check on the results, organizations that we are going to have to pay for (and I suspect the cost will be  rather high in light of how many Hospitals and Clinics they will have to follow). One of the sources I checked (http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=78) also stated that some Hospitals feared to be "shamed" (as such a method was bound to hurt poorer zones and such).

I still have to do more research on this, but so far it seems overtly complicated and expensive to implement (this is still an experiment since there's no Obamacare, so it will definetly require more experimentation if we want to go forward).

Why did the costs go up? What were the quality downsides that you referenced

Also what forms of experimentation woudl you be willing to support?

[Southern Senator North Carolina Yankee]

Also, any discussion on cost containment should also include discussion of intellectual property. We need to embark on a liberalization of our copyright laws in order to foster competition and innovation. By opening up the intellectual property market and allowing small businesses and individuals to capitalize on their ideas and knowledge, we can push medical technology and pharmaceuticals to new heights with competition. Many times, people say care continues to increase in cost because of medical tech's march forward. It is not a good solution to slow that march, but rather increase it. By devaluing the current technology that is very effective, we raise the bar for care across the board and expand access to today's technology.

I would recommend pursuing that Intellectual property issue through a seperate bill, like Bore did on the doctor shortage. Chances of it passing are higher and it will decrease the size of this, which is already seeking to be large.

[Southern Senator North Carolina Yankee]

We address the first one with limits on damages, and maybe some sort of government guaranteed liability insurance for medical providers. Reforming the way we go about medical liability will release the amount of unnecessary procedures and bankruptcies among medical providers. This cuts back those useless procedures.

Like Deus said, the medical device providers need to be considered as well. How would such a gov't guarrantee liability insurance be structured?

The second one is a bit tricky but I proposed it earlier. Create a tax variable for institutions that coordinate care and promote efficiency. The Health Efficiency Tax Deduction would either decrease or increase your tax liability depending on whether the cost of providing care increased or decreased during the previous year. This creates a strong incentive to coordinate care and reduce costs.

How would it be to structured to not go too far. If cost cutting is poorly done or done in a way that puts the short term over the longer term, we could end up worse off overall.

[Southern Senator North Carolina Yankee]

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Reforming Atlasian Health Care (Working bill) The following is intended to replace F.L. 32-12  Section I: Establishing MediSave  Part I: Framework
1. All employers who employ citizens of the country of Atlasia on a full-time basis are hereby required to establish, for each full-time employee, an interest bearing MediSave account. Any self-employed individual earning more than $6,000 a month is also required to open and contribute to a MediSave account. The federal government will set the contributions required by the self employed based upon reported income.

 2. The MediSave account shall be funded by both employee and employer contributions where the employer matches the contributions made by the employee at a 1:1 ratio. 

3. Saving accumulated in MediSave accounts are not considered taxable either at the time of contribution nor at the time of withdrawal. 

4. MediSave accounts are capped at a maximum of $60,000. Any further contributions shall go to an individual’s retirement fund. 

5. Individuals aged 65 and older must hold a balance of at least $32,000; failure to meet this criteria will require funds be transferred from other retirement accounts into the MediSave account. 

6. The interest rate for interest bearing MediSave accounts shall be set by the Health Directorate each quarter. 

 Part II: Usage 1.    https://uselectionatlas.org/FORUM/index.php?topic=191318.msg4166361#msg4166361  https://uselectionatlas.org/AFEWIKI/index.php/Atlasian_National_Healthcare_Act  https://uselectionatlas.org/AFEWIKI/index.php/The_New_Atlasian_Healthcare_Act https://uselectionatlas.org/AFEWIKI/index.php/Comprehensive_Drug_Reform_Act https://uselectionatlas.org/AFEWIKI/index.php/Equality_in_Healthcare_Act https://uselectionatlas.org/AFEWIKI/index.php/TRICARE_Reform_Act_of_2013 https://uselectionatlas.org/AFEWIKI/index.php/Senior_Care_Act 


Damn thing kept crashing. IE 8 is not even four years old and everywhere I look, it is being deemed non-compatible. Previous browsers had a much longer lifespan. OF course the dirty little secret is that its Micro$hits way of pushing us to give up XP. They can suck my...

[Southern Senator North Carolina Yankee]

First off, did I get all of it? It looks cut off at the bottom


That said, what will the allowed withdrawals be?

[Southern Senator North Carolina Yankee]

I am waiting MR. PResident?


I think I have the basics down for Part III, I just got to committ them to a text. It will probably be shorter then either of the others.

We just need to lay out the framework for those sub groups and figure out how the mechanics of it will function. We will use the exchanges and since everyone is starting off with ANHC anyway, it won't be as complex as I first thought.

One big variable I am facing is how much is covered in real life. For instance, I assume Veterans are fully covered through the VA Tricare, etc? How does that work, how are family members treated with regards to such, etc?

[Southern Senator North Carolina Yankee]

Well I am going to fill in Part III, but until we can figure out the savings component, the other sub section gaps in my framework (near top of page 3 or 4 I think), will have to wait until this weekend.

Also, I might need a seperate bill to do this (several parts need seperate bills), but there are some adaptations to the Fritzcare Cards that I definately want to make for Veterans and the like as well. Once I see how big Part III gets I can decide on the best approach.

I also recommend that all healthcare related policy that is not directly related in some way the public system or reform thereof, be pursued through independnet legislation like bore did with the Doctor thing, which is now law. The same could be done with Riley Efficiency Deduction thing, Malpractice and liability reform and the like that have been discussed.

[Southern Senator North Carolina Yankee]

These cut-outs really help to keep the main text post manageable in size.

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I am uncertain as whether to put pre-existing conditions in Part One or in here. Also it might be that these changes to the Fritzcare cards might need to be done in a seperate bill. Section 3, clause 3 needs to be beefed up, I know it is a just a place holder for now.

[Southern Senator North Carolina Yankee]

Putting this here so that I don't have to keep changing pages.

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I do like Section 1, Clause 7, on the other hand we have a problem with children getting lost, falling through the cracks of the system has they become adults, progress gets lost and the patients end up regressing. We need to balance protecting privacy (which can boomerang around and hurt the patient if it is not  protected) and ensuring that they don't fall through the cracks of the system.

[Southern Senator North Carolina Yankee]

Ah, TNF that is the Healthcare Modernization Act of 2014 passed back in February. I put it there for cross referencing. Are seeking to replace the current text (see OP) with an amendment to said Act?

[Southern Senator North Carolina Yankee]

I very strongly support the formation of Singapore-style Medisave accounts. I very strongly support Singapore-style anything, but their healthcare model in particular is a model to be followed. Central Provident Fund and all. Indeed, I'd support repealing healthcare taxes and having it be completely paid out of Medisave funds, with means-tested subsidisation when necessary funded through transfers and direct subsidies from the general fund to the ANHC.

Can you explain this I am confused. If you repeal the healthcare taxes, how do you pay for the subsidization? If you take it out of the general fund that would require something rather substantial to be cut in the rest of the budget, no?

It would come out of general taxation revenues. The assumed savings would keep the scheme revenue-positive.

The savings would have to rather substantial to cover 100% of its own cost.

[Southern Senator North Carolina Yankee]

I get that thE Medisave accounts, people would contribute to instead of paying taxes basically. Then the general revenues would be used to cover the difference for those who cannot afford to contribute enough to their account, and savings reaped from the general system would then be expected to defray that cost in turn, no?

Seems kind of thin, though.