Single payer works well in the US. Despite claims and the continuously driven narrative of government inefficiency and waste, Medicare and Medicaid are easily the most efficient and effective health care options in America.

It would take a one line act of congress...removing the income cap...to make America a defacto single payer state. The only problem is that it would disrupt a huge capitalist market, and our society has judged the protecting markets is more important than protecting people.

Medicaid and Medicare are heavily subsidized in practice by private insurance covered patients.

Hospitals that have too high of a proportion of Medicare patients get a bonus subsidy from the government to cover up the fact that the coverage alone can't financially sustain the provider.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Paymen...

If we implemented single-payer in the form of Medicare as it is now, the healthcare industry would quickly collapse.

> Medicaid and Medicare are heavily subsidized in practice by private insurance covered patients. If we implemented single-payer in the form of Medicare as it is now, the healthcare industry would quickly collapse.

In addition to everything you said (which is true), Medicare's apparent success is also boosted by the portion of Medicare patients who receive their non-pharmaceutical Medicare benefits through a private insurer.

Original Medicare (which is the part of Medicare that is purely government-run[0]) has dramatically lower ratings for both medical outcomes and patient satisfaction scores[1] than Medicare Advantage, which is privately run. Medicare Advantage also consistently outperforms Original Medicare on cost as well.

Unfortunately, when statistics are cited for Medicare as a whole by laypeople and in mass-media, Original Medicare and Medicare Advantage are lumped together, giving the impression that Original Medicare is much more effective and well-liked than it actually is.

The same applies to Medicaid, but because that's state-run, the exact details vary from state-to-state. Overall, though, nearly ever state has some form of private management for Medicaid plans, and those consistently outperform the state-run counterparts, for reasons which are immediately clear to anybody who's experienced both firsthand.

[0] except for drug benefits under Part D

[1] In 2015, Original Medicare's patient satisfaction scores were lower than the very worst Medicare Advantage provider - they were literally the bottom of the rung.

But this is because Medicare reimbursement rates are set by a panel of specialists (I believe there is one internal medicine doc and then every specialty is represented, so getting a stent sure does get reimbursed well while counseling a diabetic about keeping that A1c down or working on the toe of a homeless guy get reimbursed approximately not at all) who don't necessarily care if Medicare is that fair.

Tangentially, note Medicare spends about 3% on overhead, compared to private industry's previous 30%. (There are now caps on overhead expenditures -- trying to keep it to 20% or less.)

> But this is because Medicare reimbursement rates are set by a panel of specialists... who don't necessarily care if Medicare is that fair.

The problem is that Medicare has no incentive to ensure that their rates are sustainable (without the indirect subsidies that come from private insurers).

Medicare can balance their budget either by increasing their revenue (ie, asking Congress for more money) or by lowering their costs (ie, cutting reimbursements). They have no mandate to ensure that their reimbursements cover the marginal costs of care (and as a result, they don't). On top of that, private insurers are guaranteed by law to pay more than Medicare does, so they can set their reimbursement rates as low as they want.

This is also why the best providers almost never accept Medicare - or, if they do, they do it through a separate practice from their main one. Accepting Medicare means that you're likely going to run a loss on those patients (unless you're operating out of a CAH). So, the best doctors either segregate their Medicare patients into a separate practice (which allows them to manage their losses by capping the number of Medicare patients they see, but also dramatically reduces doctor availability from the patients' perspective), or they just drop Medicare altogether.

The US government spends more on health care than some other G7 nations, not including private insurance.

http://visual.ons.gov.uk/how-does-uk-healthcare-spending-com...

If you include both government spending and private insurance the US leads the G7 in spending on healthcare (but doesn't seem to get results that match the massive spending); if you only include government spending the US pays more than Canada, the UK, Italy, and the OECD average. It pays about the same as (a bit less than) France.

> If we implemented single-payer in the form of Medicare as it is now, the healthcare industry would quickly collapse.

This is because of the pisspoor state of US healthcare that insists on huge amounts of over testing, over diagnosis, and over treatment - causing excess harm at every step.

To amplify your last statement, I recently had a kid. It was a low-risk pregnancy and in the end a fast and boring birth -- could have had the kid in a clean barn with some qualified attendants, in the end. But to get this boring, normalish (breech) birth I had to spend some hours researching providers and my insurance options to work with someone who practices low-intervention, evidence-based medicine -- and I had to drive to another state to work with this guy. Everyone within 40 miles wanted to throw a lot of resources and a C-section at me -- for no mortality or morbidity benefit that persists after about 10 minutes. (Breech babies born the old-fashioned way generally have low 1-minute Apgar scores.) I saved my insurance company a ton of money, I have to say.

The whole experience of pregnancy was an experience of reading the medical literature and then trying to evade the "care" of obstetricians in the standard US care model. I'm glad we have the facilities to deal with all the complications that arise, but we don't have to use them just because they're there when they're not appropriate care.

I agree my comment was an oversimplification but I think it is fairer to say that "the health care industry as we know it would change"

I think you are unlikely to see immedaite adoption but over time you would have many other/new/different problems to address just as we have many problems now. It is worth mentioning that it would like cause significant employment reductions in the non-governmental insurance providers which are not without an impact.

But for starters, both medicare and medicaid are effectively a concentration of very high risk/high cost customer pools (the elderly and the low income). Opening it up would likely positively impact that cost calculation as well

It's a valid solution that will never happen. Why?

https://www.google.com/finance?q=NYSE%3AUNH&fstype=ii&ei=QD1... $184B in revenue and 230k jobs gets eliminated

https://www.google.com/finance?q=NYSE%3AAET&fstype=ii&ei=Zj1... $63B in revenue and 49.5k jobs get eliminated

https://www.google.com/finance?q=NYSE%3AANTM&fstype=ii&ei=yj... $84B in revenue and 53k jobs get eliminated

https://www.google.com/finance?q=NYSE%3AHUM&fstype=ii&ei=7j1... $54B in revenue and 51k jobs get eliminated

That's just 4 companies that total $385B and 383,500 jobs. More broadly, healthcare spending is about 20% of the US's GDP.

What about drug R&D in those countries?

For all the issues of the US healthcare system, one thing it has going for it is most of the new developments in medicine comes from the US.

Great for pharma stockholders, terrible for American citizens.

Let's stop subsidizing drug R&D for the world on the backs of US citizens who are being squeezed to death by Washington and a for profit healthcare system.

Hell, how much of the money is spent on marketing, not actual R&D? It seems like there is a lot of Hollywood accounting in pharma.

Only $5 billion a year.

https://www.statnews.com/2016/03/09/drug-industry-advertisin...

> Ad spending soared more than 60 percent in the last four years, hitting $5.2 billion last year.

> And there’s no sign it’s slowing. On the contrary: Nine prescription drugs are on pace to break $100 million worth of TV ad time this year.

That's a fair argument but I'm more interested in how much R&D happens under single payer systems.

Does the NIH and NSF not provide a pipeline for drug research in the US?

Did you know the CEO of Mylan, the company that makes epipens made $98 million last year? Is that reasonable?

http://money.cnn.com/2017/05/31/investing/epipen-mylan-chair...

Well the board felt it was reasonable, and I'd expect the board of a publicly traded company to know more about its finances than me.

The question was about how much R&D happens in single-payer counties, not how much one particular CEO made. I am a proponent of single-payer health care in the US but responding to unrelated, valid questions with, "yeah, but this one person made a lot of money and that makes me mad!" is ridiculous.

That CEO only made that amount because of FDA regulations related to the manufacture of generics, as well as her family connections.

http://amp.timeinc.net/time/money/4502891/epipen-pricing-sca...

My point is that the entire for profit healthcare system in the US is broken, and it's time to burn it to the ground.

> responding to unrelated, valid questions with, "yeah, but this one person made a lot of money and that makes me mad!" is ridiculous.

Waste is waste, and must be eliminated from the system with extreme prejudice.

Excessive profits are waste.

Reminds me of a good SSC post.

> The problem with the pharmaceutical industry isn’t that they’re unregulated just like chairs and mugs. The problem with the pharmaceutical industry is that they’re part of a highly-regulated cronyist system that works completely differently from chairs and mugs.

http://slatestarcodex.com/2016/08/29/reverse-voxsplaining-dr...

> That's a fair argument but I'm more interested in how much R&D happens under single payer systems.

Half of all medical and pharmaceutical research in the world is directly funded by the US. That number doesn't include indirect funding which takes place as well - for example, pharmaceutical companies that are based in Europe (such as Astra Zeneca) often receive the funding for their research from the US, and use additional indirect funding methods to essentially subsidize their research that takes place outside the research with the money they make in the US.

The US's market share of medical research has dropped a bit in recent years, but not because countries with single-payer systems are picking up the pace - it's because the research industries in China and India have grown incredibly fast in the last five years.

GSK is British. Novartis is Swiss. Roche is Swiss. Bayer is German. In short: plenty.

What about it? What R&D has been done, for example, in the past few decades for routine doctor exams and to combat obesity?

Outside of niche drugs for rare diseases, what has R&D done to reduce costs?

Sure but why do i as a American consumer subsidize drug invention for England or India?

If the goverment wants to pay for R and D awesome. Dont put it on my bill to see the doctor.

> Sure but why do i as a American consumer subsidize drug invention for England or India?

You don't. You subsidize the massive advertising budgets of the companies in the US.

Drug advertising -> Drug Sales -> Drug Profits -> Profit for Drug Company -> More R&D For Next Drug

If all drug advertising went to 0, it would not significantly impact drug prices in the US. It might in fact increase prices as there would be less users per drug. (Which of course may be a better result for society, but I digress)

It works so well in Australia that entire elections are basically predicated on who will protect it the best.