Even The Ideal Health Insurance Is NOT Like Car Insurance

So the end-result of the Parlor problem appears to be that the neighborhood isn’t going to budge on the parking variance, cardiologist check which means that another local business is in danger of going under unless the notoriously neighborhood-friendly Board of Adjustment suddenly becomes more responsible.
The end of the thread on the hydeparkaustin mailing list occurred when a member of the “Circle C in downtown Austin” party commented that a plan (in the works now for a long time and seemingly not close to fruition) to arrange for parking at the State Hospital (across Guadalupe) to be used for employees of businesses on Guadalupe would be the only way out of this mess.
I replied that it was unlikely that any customer or employee of those businesses would find it attractive to park at the state hospital, thumb rx walk out to Guadalupe, psychiatrist wait a long time for the light at 41st and Guadalupe to change, walk very quickly across the street, and then and only then arrive at their destination (as compared to parking on a side street or Avenue A).
The person replied (and was supported by the moderator, who then ended the discussion with the attached unpublished rebuttal in hand) that “the boss can make the employee park whereever they say”. This may be true in an abstract sense, I replied, but it’s unlikely that any such boss would want to spend the energy enforcing a rule which prevented employees from parking in PUBLIC spaces such as on Avenue A, even if they did want to keep employees out of their own private lot.
This goes back to thinking of a type which is unfortunately prevalent here in Austin and among many other progressive cities – that being that people will do things that are good, as long as we provide opportunities to do them. IE, build it and they will come. What you build, given this thinking, doesn’t have to be attractive compared to the pre-existing or forthcoming alternatives; its mere existence will suffice.
For instance, in this circumstance, they think that simply providing available parking in an inconvenient and unpleasant location will get people to park there who would otherwise park on neighborhood streets. Likewise, Capital Metro thinks simply providing any rail will get people to use it, even if the individual incentives are pretty awful, given the shuttle bus transfers.
I have a whole blog category analyzing ‘use cases’ which I think is a far more useful way to look at the problem. In this case, for instance, put yourself in the shoes of that potential parking consumer a few paragraphs back and remember that your boss probably (a) isn’t going to be able to stop you from parking on Avenue A, and (b) probably couldn’t catch you even if he tried.
But like with the naive pro-transit suckers that bought the MikeKrusee ScrewAustin Express, it’s unlikely that it’s possible to get through to these people. And so, the consequence is that another local business which probably would have improved Guadalupe as a place we actually want to be is thwarted. Good work, geniuses.
This is not to say that we should never build transit or highways. What it does mean is that somebody ought to spend at least a few minutes figuring out whether the thing you’re going to expect people to use is actually attractive enough for them to choose to use it. By that metric, light rail in 2000 was a slam dunk, despite the lies spread by Skaggs and Daugherty. But in this parking case and with this commuter rail line, nobody seems to have bothered to put themselves in the shoes of the prospective user.
my sadly now never-to-be-published response (remember, this is to somebody who said “But the Heart Hospital doesn’t let their employees park in their lot!” follows.

Those cases have some clear and obvious differences to the one
we’re talking about here — one being that the employees are being prohibited from parking in a private lot (which is still difficult to enforce, but at least defensible). You’re asking that these business’ employees not only refrain from parking in the business’ lot (private) but ALSO from the public spaces on Guadalupe and the street space on Avenue A. And nobody’s ‘requiring’ those state employees to park in Siberia – if they could find an open metered space somewhere else, for instance, they’re free to take it. Likewise, the Heart Hospital can’t force its employees to mark at the MHMR pool.
So it’s easy to prohibit people from parking in a given private lot. Unless you’re going to turn Avenue A into RPPP as part of this, though, they’d still park there instead of across Guadalupe. And any boss who tried to force them otherwise would probably be experiencing the fun world of employee turnover.

I’ve been on an HSA for about six months now (only choice at current job). Ironically, angina the primary reason I had to leave the last job, pestilence which I liked a lot, ophthalmologist was a benefits cut that hit our family very hard, with no accompanying increase in salary. They (previous company) left us with choosing between a “high” plan which was ALMOST as good as the previous-years’ plan, except a couple hundred bucks more a month; a “medium” plan for a few bucks more in which all copays were nontrivially hiked and coinsurance cut; and a “low” plan which was basically a HSA, too.
The HSA works pretty much like an FSA (which we were already using), except a bigger pain in the butt, since the years’ money isn’t all available on day one, like in an FSA. (In fact, I ‘bounced’ payments-by-mail twice because I mailed in the bill response without double-checking to see how much had flowed in, each time with a delightful $20 charge tacked on). You also get to enjoy looking like a deadbeat to doctors’ offices as you quite frequently fall into the “31-60 days overdue” bill categories since they first have to file with insurance, then insurance tells them what they’re supposed to charge you, and then you get sent a bill. The tax savings are no greater than with an FSA, which is to say that they depend on your marginal tax rate, which for most of the people who were having trouble with health care before isn’t likely to be high enough to be worth the difficulty of setting aside this money in the first place.
Now, for us, it still makes sense (even though unlike most people on HSA’s, we actually hit our deductible last year; i.e., we actually use health care). And it makes a hell of a lot of sense for a high-earning person that doesn’t use health care. But it doesn’t do squat to help out people who are unable to afford insurance today – the benefits disproportionately accrue to those with the highest marginal tax rates, not the poor. The poor, sadly, probably remain better off going to the emergency room than using this thing.
Even libertarians who have been exposed to single-payer or socialized medicine seem to finally get it, as I got it a few years ago. Medicine is not a case where the market works like it does in computers or groceries or whatever else; nor will it ever be. It’s more like providing a police force and firefighters.
And no, switching to an HSA has not given us any incentive to reduce our usage of medical care at all, because, like pretty much everybody who works for a living, I only go to the doctor when I need to because it’s such a pain in the ass. The theory that we can save money on healthcare with this “ownership society” crap rests on the questionable premise that most money is being spent by people who can use HSAs, when, in fact, most money is spent on the elderly, the premature, and other heroic interventions.
This is really becoming an issue in which the center is ready to move, and only the far, far, far right balks. There’s just no sensible reason not to pick the best socialized system (appears to be France or maybe Germany) and just get it over with.

from that liberal rag “The Economist”, information pills an article on our health care dilemna, more about including this tidbit on why HSA’s won’t do squat to control costs:

To an administration that believes the answer to every problem is lower taxes, the appeal of these ideas is obvious. Many health experts, however, are deeply sceptical, both about whether the shift to higher-deductible plans will actually reduce health-care inflation and, even if it does, whether the government should encourage this trend with more tax cuts.
The logic of consumer-driven health care assumes that unnecessary doctor visits and procedures lie at the heart of America’s health-care inflation. And it assumes that individual patients can become discerning consumers of health care. Both are questionable. Most American health-care spending is on people with chronic diseases, such as diabetics, whose health care costs many thousands of dollars a year, easily exceeding even high deductibles.
Instead, critics worry that greater cost-consciousness will deter people, particularly poor people, from essential preventive medical care, a trend that could even raise long-term costs. A classic study by the Rand Corporation in the 1970s showed that higher cost-sharing reduced both necessary and unnecessary medical spending in about equal proportion.

In other words, somebody who already has diabetes isn’t going to save you any money when you stick him on an HSA, but somebody who might GET diabetes without preventative care will be even less likely to get that care, since now he’s got to pay for 100% of the cost himself.
This backs up what I said yesterday – that the people who think HSAs will make people spend less on health care are fooling themselves. People who can get HSAs are primarily the employed, and those with a fair amount of money. None of those people are likely to go get unnecessary medical treatments – most of the money we spend in this country is on heroic interventions and on inefficient health care provided to the poor at emergency rooms. We clearly aren’t going to stop spending so much on the elderly, and they clearly still have plenty of time to sit in doctors’ offices anyways. The poor who clog up emergency rooms either aren’t going to be able to get insurance at all (just like today), or won’t be able to afford to contribute anything into the attached HSA anyways. No change, except that the wealthy employed get a bigger tax break.

Continuing my oddball string of non-transportation rants, cialis there’s an analogy which has been bugging me for a while now, ed and I just finally figured out why it’s so crappy.
There’s a lot of folks out there who argue that old-style health insurance really isn’t ‘insurance’ because it pays first-dollar stuff (i.e. you get coinsured on essentially everything after you meet a small annual deductible). Car insurance and home insurance, these people say, don’t pay for oil-changes and gutter-cleaning. They only cover catastrophic conditions. Fair enough. (Google on “health insurance” and “oil changes” to see how widespread this meme has become).
But then you take a look at their proposed solution – HSA’s (paired with high deductible plans). You have to meet a large annual deductible, and then most stuff is covered. Sounds like a better match, right?
Except for this little problem: in both car and home insurance, the deductible is per-event, not per-year. By that metric, traditional insurance actually maps better to car and home insurance!. Hint: the ‘copay’ is sort-of a per-event deductible. If you visit the doctor and it costs a hundred bucks, and your copay is $20, then your insurance covers $80 (although unlike car and home insurance, it probably doesn’t cover 100% of that $80). Likewise, if my roof needs a $2000 repair, and my deductible is $1000, you could call that my co-pay.
Maybe a table is a better way to present this. I’m using what I remember of my old PPO, my current HSA, and my automobile insurance as examples here.

Clearly the high-deductible plan isn’t any more like “insurance” if you define it as “how homes and autos are covered”, despite the rhetoric you hear. A PPO isn’t perfect either, due to coinsurance rarely being 100%, but one could imagine a similar auto/home policy being floated and still being called “insurance”. On the other hand, I have yet to see an automobile insurance company ever offer a policy where you had to meet an “annual deductible” in addition to a “per-event deductible”.