There's hundreds of things that can be done to chip away at them.

A pet peeve of mine is certificate of need laws:

http://www.ncsl.org/research/health/con-certificate-of-need-...

The notion is to reduce capital expenditures and save costs, but they are a big part of why the hospital in the article can get away with charging so much for cat scans -- there's no competition. Of course it is going to be difficult to go to an outside imaging center during an emergency room visit, but when the outside imaging center advertises $500 prices, the patient will at least know there is something a bit fishy about the $3000 bill from the hospital.

They probably make a lot of sense for something like an ER, where there is a high up front cost and a lot of staffing costs and you can make reasonable predictions about demand. They don't make any sense for equipment that only used to be expensive.

Seems like what you're saying is, we're damned if we do and damned if we don't. If we allow hospitals to build out as much as they want, they'll be underutilized and will have to raise prices to cover their capital costs; if we restrict them with CON laws, lack of competition will allow them to raise prices anyway.

Given that, I don't see how CON laws are either the problem or the solution. The problem seems to be more that patients just have no leverage to negotiate with providers.

I acknowledged that some; I'm pretty sure they shouldn't apply anymore to CT machines. Creates a profit center for the hospital with little or no offsetting benefit to the public.

Whole hospitals is harder to say, but build out will be treated like any other investment, not done willy-nilly, and a hospital going out of business is probably better over the medium term than a hospital being propped up by limiting market entry.

There are good reasons to maintain levels of service geographically, but for stuff like that we should be doing direct grants, not obstructing markets and hoping it works out the way we want.

A great book on this is Healing America by T.R. Reid, who saw doctors in eight countries about his bum shoulder and wrote about their healthcare systems. Interestingly, single-payer isn't the only good option, or even necessarily the best.

Canada was the only country with single-payer like we talk about in the U.S. The U.K. is single-payer but also single-provider, the doctors work for the government-run healthcare system.

But the best results were in France, Germany, and Japan. They function a lot like Obamacare (multiple insurance companies, though all non-profit, and mandates to buy insurance). However, they add several critical features:

- Government controls on the price of services. Doctors make a lot less money than in the U.S.

- No claim denials allowed for anything on the national price list. If a doctor prescribes it, prompt payment is guaranteed.

- Good digital medical records.

According to Reid, a lot of German doctors don't bother hiring office staff. They swipe your medical card, get all your records, prescribe what they want, and get paid in a week. They can charge less because their costs are lower.

At least one of those countries also has subsidized tuition for medical school, I think Japan. Japan has the lowest costs (only 5% GDP on healthcare, with great outcomes despite an aging population of smokers), and the tightest cost controls; e.g. they make do with simple MRI machines without a lot of bells and whistles, but they do the job, and an MRI costs $100. Japan implements their mandate in an interesting way: you're free to not pay, but if you go to the doctor and you want it covered, you have to pay your back premiums.

Anyway, it's a fascinating book if you're interested in this stuff.

I've never been to a doctor in Germany that doesn't have office staff (though I suspect that it would be possible). You still need someone to deal with incoming calls, organizing the file cabinet and looking through the insurance rule changes of the week. Usually this is done by people who do limited medical work on patients as well (think nurse). Having one employee per doctor is not uncommon.

Doctors only send their bills once every three months and payment takes a while after that - a week would be a dream. Insurance can deny payment if they determine it wasn't medically necessary (and they do checks if they find a trend) but that comes out of the doctor's pocket. And for expensive things (like psychotherapy or dental) it needs to be preapproved by the insurance but they are are very limited in what they can deny.

And good digital health records? I don't think I will live long enough to see that in Germany. The only thing that leaves your doctor's office digitally (within they are free to work with paper or computer or whatever they wish) are the procedure and a short code for the diagnosis. If you need to see a specialist, paper still gets send around.

Edit: I just read the Germany chapter of that book. While it contains some (not really significant) errors and is a bit outdated (now six years old) I would still recommend that book based on this chapter.

> Japan implements their mandate in an interesting way: you're free to not pay, but if you go to the doctor and you want it covered, you have to pay your back premiums.

That's a brilliant solution!

Routine medical care should be like food and shelter: something you are expected to pay for yourself. That would put price pressure on providers. Insurance should be a backstop for catastrophic accident or illness. It should be sold by competing local and national providers. It should be untangled from employment as a benefit. You should buy it like car insurance.

Obama, Trump, Clinton. senators, representatives -- none (or very few) of these people have any medical background and really can do little else but screw it up as badly as if the government was the single provider of all software.

Maybe it should be that way, however in practice it doesn't work. The ACA specifically requires free preventive services because research has shown that when patients have to pay they often skip it. And when they skip preventive care that causes the spread of infectious diseases, and allows small problems to turn into serious problems that are more difficult and expensive to treat. So this is important from a public health standpoint regardless of concerns over economic efficiency or personal responsibility.

https://www.healthcare.gov/coverage/preventive-care-benefits...

Preventative care that actually works is super cheap and not controversial (mostly vaccinations). This idea that we can save vast sums via preventative care is a fantasy. You may find anecdotes to support it, but the serious literature doesn't bear it out.

> Preventative care that actually works is super cheap

The same's true about car maintenance, but plenty of people drive on dying brake pads and stretch oil changes anyways. A hundred bucks for a checkup is still more than many folks are willing to pay. As an example, here's a kid who died for want of a $80 dental procedure: http://www.washingtonpost.com/wp-dyn/content/article/2007/02...

> not controversial (mostly vaccinations)

LOL.

Well they usually want to do more expensive procedures along with the dental extraction. I've been delaying mine a bit because they want to take it out then put in a bridge, which will cost $1800 (normally $6700, but I have good dental insurance). In fact the extraction will be free, the cost is all in the bridge. But now you've got me paranoid again. Damn.

from a personal standpoint i often skip preventive care even if its free. I am either just lazy or scared my doctor will tell me something bad.

I agree with this. Obamacare should have created rules for a national minimum policy, largely targeted at catastrophic incidents. Remove the ability of employers to buy coverage for their employees (a holdover from WWII staffing shortages) and let be more open and market driven.

We also need to reform pharma. When even K-mart has a pharmacy it shows how much money could be removed there.

Lastly, we need to change our perspective about aging. If you live long enough, you will (most likely) get cancer. This is how the body works, not specifically a "disease". We need to stop paying $1M for the 75 year old who gets brain cancer so that they can live for 2 extra months. Feel free to spend your own money but Medicare won't. They already have laws like this in France, etc.

> should

and minimum wage should be enough to live on, housing should be affordable a reasonable distance from where you work. but for some strange reason, the world doesn't work that way.

I suspect many will skip it entirely...there was a reason car insurance was made mandatory.

Relevant quote from the article re: what an effective solution needs to achieve:

>The real issue isn’t whether we have a single payer or multiple payers. It’s whether whoever pays has a fair chance in a fair market. Congress has given Medicare that power when it comes to dealing with hospitals and doctors, and we have seen how that works to drive down the prices Medicare pays, just as we’ve seen what happens when Congress handcuffs Medicare when it comes to evaluating and buying drugs, medical devices and equipment.

> Stripping away what is now the sellers’ overwhelming leverage in dealing with Medicare in those areas and with private payers in all aspects of the market would inject fairness into the market. We don’t have to scrap our system and aren’t likely to. But we can reduce the $750 billion that we overspend on health care in the U.S. in part by acknowledging what other countries have: because the health care market deals in a life-or-death product, it cannot be left to its own devices. Put simply, the bills tell us that this is not about interfering in a free market. It’s about facing the reality that our largest consumer product by far — one-fifth of our economy — does not operate in a free market.

The article's list of actionables seem like a good first step:

> We should tighten antitrust laws related to hospitals to keep them from becoming so dominant in a region that insurance companies are helpless in negotiating prices with them.

> we should tax hospital profits at 75% and have a tax surcharge on all nondoctor hospital salaries that exceed, say, $750,000

> We should outlaw the chargemaster.

> Finally, we should embarrass Democrats into stopping their fight against medical-malpractice reform and instead provide safe-harbor defenses for doctors so they don’t have to order a CT scan whenever, as one hospital administrator put it, someone in the emergency room says the word head.

I agree with most of this, but

> We should outlaw the chargemaster.

I don't know how that would work. My thought was to require it to be published.

That's when we built pricepain.com in 2013 ... The article definitly inspired several efforts to allow market forces to operate by facilitating price transparency.

Or rather the chargemaster should at least be based on the price you could purchase an item on Amazon.

How about capping the salaries of doctors at, say, 100,000 and nurses at 60,000? US salaries in health care are incredibly high. Administration and the like could be capped at the nurse level. Only a very small minority could realistically get higher paying jobs outside the US anyway. If your main motivation is to make a lot of money, choose a different career.

Also, cap profits to almost zero while moving to a completely not-for-profit system.

Capping admin salaries makes a lot of sense. Maybe not at nurse level, but at doctor level for sure.

Capping doctor's salaries at $100,000 is probably a bad idea. Some cap might make sense, but definitely not $100,000.

$100,000 may sound like a lot, but keep in mind that US doctors take on a lot of debt -- both actual and in terms of opportunity cost. And they also take on a lot of personal risk up until the point where they become doctors. And sometimes even after thatn.

So you're not really saying that should make "around what a software dev makes". You're actually saying that doctors should make significantly less than your average software developer.

Driving smart and driven people away from medicine doesn't seem like a great idea.

The idea that Trump is unencumbered by campaign contributions is a pipe dream, because he has to buy the loyalty of Congress in order to pass laws, and they are more encumbered than ever.

It is immoral for someone to profit from denying someone healthcare. As I see it healthcare is a scare good and the Canadian system is the way to go. But socialism and all that... won't happen in the U.S. any time soon.

I'm for single payer but it will never happen until Democrats get the White House and congress. Paul Ryan is planning on privatizing Medicare asap

The public option was removed from the eventual Affordable Care Act when it passed in 2010. The Democrats did have both houses of congress and the white house at the time, but that part of the law was brought down by a filibuster threat from a small group of 'blue dog' democrats. Had it passed, it would surely have been a trojan horse for universal coverage.

The public option had the support of all 59 Democrats. It was Lieberman, an Independent who often voted with the Democrats, who got the public option removed.

I don't know that Paul Ryan's opinion matters too much at this point.

I also am not sure the Democrats could do single-payer even if they had the White House and Congress. They take plenty of money from the special interests too.

The democrats couldn't do it when they had WH and Congress... they had to go with Plan B - "Obamacare".

Personally, I believe that Plan B was written to fail. Government creates problems. How do you solve the problem? More government.

Obamacare, imho, was created as the groundwork for single payer. I just don't think they expected it to fail so hard and so fast.

I have no faith in single payer... for example, look at the VA. Months of wait times for those who need the help... while those at the top get lavish bonuses.

Single payer works well in many places other than the US.

People on private insurance plans in the US die or suffer while waiting for care their plans allegedly offer, while executives of those private insurance companies get "lavish bonuses".

The US is the wrong level of government for a healthcare system. If a place like California wanted to offer free healthcare to its residents, that's fine, but the federal government should only be responsible for war, negotiating trade deals, handling immigration, and other external issues.

Keep in mind that "many other places" are smaller than a single US state.

Your view went out of fashion with the Articles of Confederation; the ultra-limited "only for a handful of external-facing issues" federal government was an abject failure.

Consider that Californian's pay about $290 Billion to the Feds and the state collects about $70 billion. Do other small countries pay most of their taxes to a larger central organization? Much of that Federal money gets shunted to other states.

For consistency, I also support repealing the 16th amendment and removing the interstate commerce clause. Then California would have more direct control over its citizens' tax money.

Why stop there?

You seem to want not a nation of 50 states, but 50 completely independently sovereign nations which will somehow miraculously also agree to cooperate on the handful of things that you personally feel they should.

This has been tried, and failed, and was replaced with the Constitution we have now.

The reality is in the middle. We are ONE Nation AND FIFTY Nations.

> which will somehow miraculously also agree to cooperate on the handful of things that you personally feel they should

That's what the constitution is for... it states what the Federal Government does... everything else SHOULD be state issues.

Those clearly drawn lines have been eroded over the years and is one of the larger points of contentions between the "Constitutionalists" who think that we should have a government actually limited by those rules... and those who think the government has all the answers and should have no limit

At one time it was more common to use "These United States of America" and "the United States are …"

https://en.wikipedia.org/wiki/United_States#Etymology

the people who die, i assume are the ones that cant afford that care and need to knoww beforehand its going to be completely covered?

Plenty of things require referrals and authorizations and those can be processed at a glacial pace, yes.