I am now firmly in the single payer camp. Medicare for All, I guess. To the insurance companies and medical billing industry, and even doctors, I say: "Sorry, not sorry, when this train comes through try to remember you did it to yourself."

Correct me if I'm wrong, but Medicare-for-All is just public insurance. It's not a state take over of all private hospitals.

But instead of negotiating a price with you, the hospital will be negotiating with the state. Hospitals can still compete on prices and likely the state will grant contracts for non-urgent services to the cheapest provider..

Modulo, whatever level of free choice is left and what capacity is available, etc..

Disclaimer: In full support of single payer/government managed healthcare

It's not like there is any competition right now? You can't even get a price quote for elective surgery.

Also I wouldn't be so sure that your children don't have significant leverage over you, hehe :) (They probably don't realize how much leverage they have)

You'd think they'd be a bit more invested in the process of healing, but I haven't found much evidence of that. I hope I'm horribly wrong here.

Personally, I don't think doctors are the answer. I used to really like the idea of high-deductible. But eventually, I just came around to the idea that only the gov't can fix it (with lots of tradeoffs in that fix, obviously).

I think they could, but more people would need to be in them and try to do what you did. It needs to be enough people to eliminate the problem where insurance companies like the system being too complex because then you use them instead of paying for it our of pocket.

Insurance companies clearly have nothing to worry about. I might be able to put in extra effort to negotiate my costs down by paying out of pocket, but then it would not count towards my deductible or out of pocket maximum. Even with HDHP, I am still clearly incentivized to just pay whatever the insurance company thinks I should.

It's a great racket to be in, really. They can negotiate the pricing in advance so that they appear to be useful in making my costs lower, while not actually incurring any costs other than paperwork. They hold all the cards and they have captured the regulatory authorities.

I've never had to wait for an elective procedure because I can choose to privately pay for care on a schedule more convenient to me. I have private health cover which tries to compete on this basis.

But if I had any emergency needs, then I'd be treated immediately at any hospital by the public system, which I pay into with taxes. And the waiting list for those elective procedures, if I couldn't afford private care, is a priority list - based on need.

The idea that shortages don't exist in the US is absurd - sure they do, you can't afford critical care then you just don't get it. The US waiting list is infinite.

So if everybody was covered by Medicare, either the providers would be going bankrupt left and right, or the Medicare reimbursements would have to rise - i.e., the price to the government would increase, and the only thing to do about that is to pass it on to the taxpayers.

It's a common misconceptions that Medicare is more efficient than commercial insurance, because on paper it looks that way. But in fact they're hiding their administrative expenses by forcing the providers to do much of their bookkeeping. (Source: my wife used to manage the department in the hospital that did that Medicare financial stuff)

Kaiser, who has a plausible claim to expertise in this field, puts the overhead cost of Medicare at 2%. The raw number is more like 1.4% but Medicare does get to piggyback a lot of the administrative workload on Social Security so perhaps that is why Kaiser's number is higher.

Insurance industry advocates, who are incentivized to provide the lowest number that can be defended, put private insurance overhead at 17%.

The rest of your suggestion -- that Medicare doesn't even pay for the actual cost of service -- is hard to really reason about accurately. Prices and costs are so completely distorted now that I am very skeptical of anybody's estimates of 'actual value.' Things will change dramatically if we eliminate the insurance industry and medical billing field.

Having just experienced first world level healthcare in another country and paying for it out of pocket at 1/20th or less of what it runs in the US, I am certain we are getting shafted.

This is exactly what I'm talking about. I'm sure that number is accurate, if you're looking at Medicare's books. I'm telling you that when you look at the way Medicare forces the industry to handle their charges, it makes the industry much less efficient, both in terms of administering the provision of care to Medicare's "customers" as well as more generally across how the industry handles its accounting in general.

Every hospital (and skilled nursing facility) has a small team of people whose job is to compile the statistics that Medicare demands, and report it annually in what's called "The Medicare Cost Report". Add up 1 or 2 or 5 FTEs across every hospital and SNF facility in the country, Medicare's claimed efficiency is quickly turned upside down. There is some work that providers have to do for other payers, but its scale doesn't approach the order of magnitude of what Medicare forces. This isn't a matter of opinion (like my wife's); this is absolutely factual and objective.

It gets even worse than that. Because the care paid for by Medicare together with that of Medicaid (which is a separate program, but rides on Medicare's coattails for a lot of its reporting mechanics) dwarfs any private payer, hospital information systems (at least the parts that deal with finance) are structured around the way statistics need to handled for Medicare. That squeezes out the ability to do any more traditional cost accounting. This is the reason that the fee for a given service varies so wildly from hospital to hospital: because they're not doing normal cost accounting (but instead tracking Medicare statistics) the don't actually have a good idea of what any given thing costs, so their fee schedules are all over the place. (I'm generalizing here, there are hospitals that do it better, but my anecdata from hospitals we've had close association with show that this problem is quite widespread.)

It's important to note that this industry is a complete bullshit industry with complete bullshit jobs. Their only job is to say no, to stop money from going out of the insurance companies, in any way possible. That is their entire purpose.

Your medical insurance money props up this industry. Every person working in this industry and receiving a salary, and every person owning shares of companies in this industry receiving profits, are taking money that should have been spent on producing healthcare for themselves.

So however many billions of dollars of revenue this industry makes, we would instantly save most of it by getting rid of this industry.

We are, but not by insurance companies. Their profit margins are thin. The issue is hospitals.

Sarah Kliffs idea to reduce the cost of hospitals is price controls: for the government to tell them they cant choose a price, and to ban them from accepting other insurance.

Less than half; US healthcare spending was around 8.5% GDP public, 8.8% GDP private in 2016.

https://www.healthsystemtracker.org/chart-collection/health-...

Even if we take the value to be 50%, my point stands -- the gov't is already heavily involved in funding healthcare in this country. Implementing single payer at this point would simplify quite a lot of bureaucracy.

I propose the other thought experiment: why doesnt medicare just compete in the market with other insurance plans: it charges X and provides the service. If its truly more efficient it will beat all the rest.

Eventually, as this started to be more widely known the Conservative government "fixed" it. Not by paying nurses more, not by lowering the immigration income requirement to match what they pay skilled workers like nurses, but by specifically exempting nurses.

Sorry wasn't awake enough when I first wrote this.

If not, what do you think is currently happening to those people who need mental health care or routine surgery in a non-single-payer system?

Can you help me understand why if everyone is paying for everyone's healthcare in a socialize system - how that reforms the transparency and stops the abuses?

I actually agree w/ overhead limits, but you also need other efficiency metrics to keep the anti-optimization in check. Or, personally I think we should go to some form of universal healthcare and wipe out private health insurance as it's currently constituted.

Why wouldn't insurers argue for better prices now?

Even in our own VA system, their negotiated prices are lower for drugs than the Medicare part D program, barred from negotiating (and with large pieces managed by private companies).

I think your skepticism should primarily be directed to wondering if private systems can ever negotiate a fair price in healthcare products and services.

The rest of the OECD has universal healthcare, but not necessarily fully public healthcare (the model vary considerably.)

Which just means that there are lots of good proven models that the US could adopt.

https://ourworldindata.org/the-link-between-life-expectancy-...

The most recent life expectancy numbers are the hardest to interpret, the US has the only three-year-running negative life expectancy growth in the first world nations - but some argue we should separate healthcare from the suicide numbers that are a big contributors. I don't know that I agree with that as there is a fuzzy line between healthcare and social care efforts.

Age-adjusted all-cause death rate is the better stat for measuring life-saving outcomes.

Child mortality is certainly a useful stat for its purpose, though.

Are there sources of that stat over time and between nations that you would recommend?

http://apps.who.int/gho/data/view.main.1360?lang=en

It probably still supports the point you are trying to make, I just get grumpy about statistic selection.

I think "only (any large organization) can negotiate a better price" is a little misleading on the surface. On a macro level it should, in theory, be true, and should already be happening with private insurers; when I've looked at my own EOBs, they consistently will list a service, a coding, a billed price, an "allowed" price that is always much less than the billed price, and the amount paid (which predictably matches the "allowed" price). And yeah, when we're watching politicians pontificate, we end up having strong opinions about the total price of healthcare and its effect on the economy.

That said, does anyone _really_ make personal healthcare decisions based on the macro effect on the economy? I personally doubt it.

I posit that the vast majority of US citizens and residents wouldn't care if the annual healthcare spend changed by US$200 million, but any individual American cares A WHOLE LOT if you bill them personally for US$100,000 and their insurance doesn't cover it (or much of it).

It seems to me that a much better approach to this entire conversation is "let's drastically reduce the number of Americans forced into bankruptcy because they or their dependent got sick". My own inclination is that that'll require government intervention, because the incentives for a for-profit insurance company are to pay out as little as possible, but I'm open to anything that addresses that problem.

The proposed alternative is to give tremendous power to an organization with less conflicted responsibilities.

In a larger system, we get lower prices via several mechanisms: - Preventative care replacing ER care due to universal coverage - Larger risk pool lowers per-participant costs - Single payer has more leverage and depth of time/knowledge to regulate/negotiate with individual hospitals

The reality of a competitive landscape, hand of market, etc, that just didn't happen.

That one entity can unilaterally refuse to do business with abusive vendors. They can negotiate for lower prices. They can notice and investigate discrepancies in pricing between similar cases. They are in a position to judge which types of care are and are not cost effective and can refuse to cover the latter.

So that explains why having an insurance company helps, but it doesn't explain why a private insurance company can't perform the same role. For that, we have to introspect a little into how insurance firms work.

An insurance company is, in essence, a mechanism for transferring funds from lucky people to unlucky ones. If your car gets totaled then, in essence, a bunch of other people with working vehicles have all volunteered to chip in a couple of bucks toward buying you a new one. The insurer is mostly facilitating the transfer and skimming just enough off in the process to cover their administrative costs.

The private insurance market works well enough for most types of property because the volunteers can't predict in advance whether they're going to be lucky or not and because there's a realistic upper bound on how much money the unlucky ones will need to be made whole. Neither of these assumptions are true for healthcare. Many people were born into pre-crashed cars, to stretch the metaphor, and at least for the foreseeable future it's not possible to decide to replace a body instead of attempting to repair it.

So we need* some non-market mechanism to incentivize or compel insurance companies to cover the already unlucky: people with pre-existing conditions. But that introduces a new problem. The lucky people are being asked to volunteer to chip in more, and at least some of them will stop volunteering. That causes the prices to go up even more, which causes a few more volunteers to leave, which causes the prices to go up again, and so on. Pretty soon there's no volunteers left to transfer funds from.

So we also need* some non-market mechanism to incentivize or compel healthy people to contribute to our insurance system. And with those two requirements (needs to cover everyone and everyone needs to contribute) we are left with a problem space that the State is really the only entity with the ability to implement a solution. It doesn't have to be socialized medicine, per se, but it does basically have to be big government of one stripe or another.

\* Yes, we do technically have the option of compelling innocent people to suffer and die from otherwise treatable diseases that they're not wealthy enough to afford to cover out of their own pocket. If you're aware of that fact and comfortable with it then okay, but please do understand that it is the societal tradeoff that we would have to make to avoid some sort of serious state involvement in provisioning medical care.

That doesn't always work out as well as you might think. A number of years back Medicare told hospitals they'd no longer pay for UTI treatment, unless the provider could prove that the patient had the UTI when they were admitted. This made sense, because hospital-acquired UTI is a big thing.

The thing is, what hospitals had to do to defend against this was to test everybody being admitted to prove that they already had the UTI. So from Medicare's point of view they were saving, but from a broader perspective they were pushing unnecessary costs (unnecessary tests) onto providers which increased the total amount being spent on healthcare.

It's also worth pointing that what you're describing is an illusion of efficiency arising from Medicare implicitly pushing costs off onto non-Medicare patients. That wouldn't be able to happen if there weren't any non-Medicare patients.

Having worked for companies that do government contract work (DoD, in particular), this line of reasoning always makes me laugh.