In 2017, the median income of households in the US was 61'000 $.

Meaning half the population has to pay half their income (maximum) into this healthcare plan. And 61'000$ income isn't being dirt poor either. In some economic models this is the lower middle class in terms of income.

For people who only graduate high school and no college, this is 80% of their income. If they go to some college about 70% (14'000$ left of the income). This group makes up about 30 to 40% of the US population.

In my own country, I would pay 350€ a month for a 60'000€ yearly income. The equivalent of an ER visit copay for you and it covers all my medical needs for a month.

With a multi-person household and $60k income, you would qualify for subsidies to reduce the premiums and out of pocket costs.

The key idea in the ACA that addresses this problem is subsidies: you get tax credits and (ostensibly) CSRs to offset the cost of health insurance if you're within some multiple of the Federal poverty line. Unfortunately, this is exactly the part of the system Congressional opponents of the ACA have taken direct aim at.

The ACA reduced the rate of growth in health insurance premiums, but health insurance premiums continue to grow and have been for decades --- spiraling health care costs were a part of the Republican Party platform... in 1980.

Guaranteed issue, community-rated health insurance is a necessity for a private health care system, and the ACA brought those badly-needed features here. But the big problem with US health care is simply that it costs too damn much to stay healthy, and those problems are structural more than they are a function of how we fund the system.

Saying the ACA reduced the rate of growth in healthcare spending is arguable. The last time I looked at this there was indeed a reduction in the rate of growth by my understanding is that it predated the ACA by several years.

The most interesting thing I've seen about health care inflation is what it looks like in the U.S.A. vs. the other developed countries. The answer is not that different. There was a huge increase in the 80's but after that the growth rate of the U.S. is somewhere in the middle.

But aren't those structural problems directly caused by the way we fund the system?

No, I don't think that's even partially true. Medicare also overpays for care and responds to the same structural wackiness the rest of us deal with. Medicare has lower administration costs, but those costs are still higher than administration elsewhere in the world, and administration is not actually where most of our dollars go.

So maybe I don't know what you mean by structural problems. I assumed you meant agency problems, administrative costs, medical professional pay, liability costs, over care & end of life care.

All of which are directly impacted by how we fund the system.

Two examples of structural problems with our health care systems:

1. We lead the world in transitioning from inpatient to outpatient care; for instance, I read a source last night that said the majority of hernia repairs in the NHS were inpatient, and the overwhelming majority of them in the US were outpatient. That's good, but an unintended consequence of it is that it's easier to route a patient to a surgical procedure if it's done outpatient, and as a consequence US patients get a lot more of these procedures, some of them (cardiac stents being a recent well-publicized example) of dubious utility. Our relative overconsumption of services doesn't lead to better outcomes, and thus represents misallocation.

2. Our health provider systems are more decentralized, delivered in smaller clinics and hospitals. Our hospitals generally, nationwide, have poor utilization. Not only do we therefore overspend on plant and salary costs (which we do, relative to Europe) but coupled with our price transparency problems we end up with the situation Atul Gawande described a year or two back, when he noted the insane difference in prices for an MRI at different imaging centers in a small region of (iirc) Texas.

Our system right now isn't good and some of it (but by no means all of it) is related to how we regulate the way it's funded. But Medicare overspends on many of the same things. The structural problems will need to be corrected no matter how we design the rest of the system.

Ultimately I think the problem in the US is a sort of perfect storm of badnesses.

(Good sources: Kauffman's health cost explorer, the McKinsey report, the Health Care Cost Institute annual breakdowns).

Both of those are classic examples of the outcomes being directly related to how we fund our medical care.

In the first instance it's a tension between the providers trying to maximize service, insurers trying to minimize risk and the user having little agency in the outcome.

The second example is a straight up agency problem.

None of that changes the argument, it is a perfect storm of badness and even if nationalized healthcare was politically feasible it wouldn't fix all of these issues.

I just want to get to the point where my insurance doesn't come from my employer...

There are a bunch of ways to rebut that argument. First, you can look at private systems that don't have these problems (ie: all the rest of the private systems). Second, you can note that Medicare, our single-payer system, interacts with the same structurally inefficient provider system. And, of course, if we switch to single-payer tomorrow, we're still going to be doing most care on an outpatient basis (because we should), and are still as a result going to be overprescribing procedures to patients.

> Second, you can note that Medicare, our single-payer system,

Medicare is not a single payer system, but a partial-subsidy voucher system for highly-regulated private insurance with (for the core inpatient and outpatient components) a fully-paid public option.

Fair enough. Consider my rebuttal so revised.

Let me expand on that: Medicare has recognized the problems you mentioned and has, fairly recently, begun directing efforts through payment system at the first broad class (inefficient interventions) through adoption of a variety of quality-incentive payment systems. But those aren't going to be as broadly effective, even for Medicare fee-for-service patients, as they could be if delivery systems and practice is shaped by conflicting incentives from different payers (who may be involved in covering some of the same claims, because coordination of benefits is a real thing, and even when they aren't for the same claims, will often over time be for treatment of the same patient.)

The VA is the best example of single payer system in the US, it does not suffer from either of these problems (though for demographic reasons it suffers from a host of others).

As for the private options do any of them have the weird employer provided health care indirection?

I think employer-provided insurance at scale is a uniquely American problem, and agree that it is problematic, but I don't see how it produces more overconsumption and less centralization than a purely individual market would. In fact, if you maintain a system of private providers (even with a public payer), I don't see a connection between funding and these structural problems at all.

Nearly 150 million people in the states get their medical funding chosen for them by an HR analyst III & their favorite consultant buddy. Then it gets paid for in a combination of literally hidden payments, pre-pay deductions & tax subsidies. The idea that there isn’t a connection between this and costs is incredible. That’s before talking about the impacts on small businesses, long term care & the like.

Lack of price transparency is a problem. But by what I (off the top of my head) understand to be an overwhelming margin, Americans who get their health insurance from their employers like that insurance; it's also hard to see how the HR rep at your company is influencing decisions about how many hospitals to build or how many MRIs to prescribe.

I'd probably report I liked my car insurance if it included a twice a year detailing and paid for my lyft rides from the bar. Especially if the real cost of it was hidden from me. That is to say, the consumer of health care being unable to accurately judge the quality and efficiency of the funding of that care is at the heart of the problems with the market based approach to health care funding.

The fact that one of the major players in the funding space have an intermediary as a customer instead of the health care recipient is a further distortion of the market.

Imagine if we got our car insurance the way we get our health insurance. What impact would that have on efficiency of that industry?

Our health insurance system is inefficient, and some of that inefficiency does come from the way employer-provided private health insurance works. My point though is that the numbers suggest that there are larger structural factors that operate independently of that inefficiency.

It's possible that the pathologies of our system created those other structural flaws; like, if we had an NHS instead of private insurers, we wouldn't have built all these inefficient hospitals. But whatever the cause, we are where we are, and switching to single payer won't undo those problems.

Which sums up my concern about single-payer: it might be a good way to lock in a lot of structural problems for a long time. Meanwhile, if you just directly address the problems themselves --- stabilize the markets, enact strong price transparency rules, aggressively incentivize efficiency --- you might not need single-payer (an immense, disruptive change) in the first place.

Also, if we want cost outcomes approaching that of the NHS, we have to do more than simply enact single-payer. We also have to aggressively set rates, reduce compensation for doctors, fire a lot of nurses, and make people wait years for knee surgery.

You’ll note most of my commentary centers around employee provided health insurance. That’s because it’s the outlier. Other countries have similar systems to ours on the provider, Medicare & Medicaid side. Employee provided insurance is, as far as I know, unique. And it’s a dramatically stupid way to fund health care.

Further, it’s a less dramatic thing to change. We’ve already been through a much more impactful change in living memory in the form of moving away from pensions.

My position is that changing that are of funding brings price transparency to the biggest segment of the population & it derisks the migration.

It's not clear to me how it does that.

> Medicare also overpays for care and responds to the same structural wackiness the rest of us deal with.

Medicare isn't a closed system, and isn't the majority of funding, so it has to deal with the structural results of the rest of the system, which is majority private pay (and heck, Medicare itself is a partially-subsidized private-insurance voucher system with a public option for it's core services, which exclude prescription drug coverage, which is provided through an optional partially-subsidized private voucher with no public option.)

Help me understand what exactly, in broad strokes, a single-payer system adopted in the US in 2019 would do to correct those structural problems?

(I asked roughly the same question upthread a few minutes earlier, so if you answer there, I'll see that answer and consider it an answer to this question too. Thanks!)

If Medicare overpays, then the entire system is really broken. The reason you see fewer and fewer private doctors hanging a shingle for a private practice is because you can't break even. Those that do, don't accept medicare, many don't even accept insurance anymore. They can't take medicare because they'd operate at a loss. They don't take insurance because they're a pain to work with and don't like to pay.

> But aren't those structural problems directly caused by the way we fund the system?

Yes. Almost entirely.

If that's true, and we stipulate that the two specific problems I called out are major contributes to the inefficiency of our system, you should easily be able to explain how switching to an alternate funding system would remediate them. Can you provide more detail?