> Having every person under the same plan that has the negotiating power of 327.2 million people will definitely drive costs down. Don't want to pay what the government says it is going to pay? Good luck finding customers then, because the government is bargaining on behalf of all of the customers in the US.

So my mom and her boyfriend are both under Medicare now, as was her late 2nd husband. My mom and I had both generally been Medicare For All supporters (with some reservations in my case), but I got an earful recently about how people who support Medicare For All don't know what they're in for...

The problem is with Medicare's system of billing codes. Sure, if a hospital doesn't like the reimbursement rate, they can't go find other customers. But they can - and will - find other procedures. Not making enough money from that doctor's visit? Well, we better do some tests, then, just to be sure there's no lurking problem. Oh, there was a spot on that X-ray - more tests. We didn't find anything serious, but there was a benign growth that you probably should get taken care of. Don't worry, it's a quick procedure, it could potentially be done as an outpatient but you might want to make it an overnight hospital stay just to be sure. Shit, you contracted an infection in the hospital? Gotta extend that stay until you're better.

Basically, if they can't raise prices, they will find ways to do more procedures. My mom's description of what modern American health care is like as a senior citizen is truly terrifying - basically they manufacture illnesses so that they can cure them and bill for it.

I came to the conclusion (reinforced by every corporate scandal you read about on HN, and my time in the financial and tech industries) that the problem isn't health care per se, but something is deeply broken in American culture. People don't give a shit about their fellow Americans as people, only as dollars, and as a result no matter what system you institute it will end up being gamed in harmful ways. The U.S. is falling from a high-trust to a low-trust society, and there are few if any ways to bring it back.

>But they can - and will - find other procedures. Not making enough money from that doctor's visit? Well, we better do some tests, then, just to be sure there's no lurking problem. Oh, there was a spot on that X-ray - more tests. We didn't find anything serious, but there was a benign growth that you probably should get taken care of. Don't worry, it's a quick procedure, it could potentially be done as an outpatient but you might want to make it an overnight hospital stay just to be sure. Shit, you contracted an infection in the hospital? Gotta extend that stay until you're better.

Right. This is exactly what we want (save the MRSA). The problem with the American healthcare system isn't just that it's expensive; it's expensive and still has worse outcomes than in other industrialized countries. Part of the reason for that is that patients cut off their care for financial reasons, and not because they've reached a satisfactory conclusion about their state of health.

The way you describe the mindset isn't a function of Medicare per se, but of the fact that there's still a profit motive involved, even when receiving Medicare funding, in a system that is largely privately-funded. Maybe releasing that source of pressure and competition and scarcity will change the way people on both sides of the doctor-patient relationship approach their care.

This sounds like an ignorant view of getting proper healthcare.

There are more things to check because older people have more medical problems, therefore more tests, more treatments, etc.

We would have to see what would happen if you gave a 25 year old medicare in this country, I doubt it would be the same experience that an elderly person would have.

There is a very strong correlation between which additional tests are requested and what the hospital can charge under Medicare reimbursement codes. (My mother's boyfriend is a former doctor, and intimately familiar with the health-care system from the other side of the table.) Both of them are also in fairly good health (my mom has no pre-existing conditions, her boyfriend has some issues with his back but nothing unexpected for an 80-year-old), and were definitely not treated like this while on private health insurance.

What do you think would be different between 25-year-olds and elderly people? The incentives are the same in both cases, produced by the billing code.

And yet for all that, Medicare is vastly cheaper per capita than private healthcare. You get more service for less money? Sign me up.

25 year olds have fewer health problems that need treatment than 80 year olds.

My point is that people are being treated for health problems that are not problems because the provider can then bill Medicare for it. That's not going to go away because there are fewer health problems; the whole issue is that it doesn't matter if there are health problems, the provider will find or create some that they can bill for.

Oh, okay. I can't speak to that specifically, that seems like an unethical healthcare provider if they're genuinely performing unnecessary procedures. They should probably be reported to the state medical board.

I think there is also a matter of what you view as 'necessary medical care'. Preventative medicine is vastly cheaper (and more effective) than reactive procedures to fix things that have become serious issues.

(It makes practical sense, right? You properly maintain your roof so it doesn't leak, that's cheaper than fixing the damage caused by the leaking roof).

This is particularly true with older people who have higher incidence of cancer, heart disease and major organ problems.

So yeah, they may send you for a battery of tests that they can charge the state for, but it might be preventing a much more expensive (and traumatic/painful) surgery down the line.

But people seem to focus on the collective bargaining and price aspect of everyone having proper healthcare, which is weird because it shouldn't be about that, it should be about increasing the efficiency of the overall system and quality of life of the people involved.

You're not wrong they are deeper problems, but you say these things as if M4A would cause them when they are happening now. I was recently asked by a dentist if I wanted a special kind of cleaning. She then nervously admitted that it wasn't necessary, but she "wanted to make sure." M4A won't fix all the problems, but it would definitely make things better, and hopefully, lead to people demanding more.

So your conclusion is that we shouldn’t fix the part that we can fix because people will still be assholes?

> Having every person under the same plan that has the negotiating power of 327.2 million people will definitely drive costs down.

Why do you think this would be true? Why do you think the bargaining power would work the way you think it would?

If you were correct, then cop cars must be fairly cheap compared to normal cars. Is this the case?

What about other goods? Laptops? Cruise missiles? etc.

Actually is it true for any good which the US Gov is the sole buyer? Can you think of even a single good where your supposition is true?

Perhaps this is a good reason:

>Literally, every Industrial Nation has addressed this problem for much lower costs with better out comes.

But why those nations have lower costs isn't so simple. If you remove all profit and admin overhead from the US system, its still something like $5000/person more expensive than other countries (I think that that was vs Canada).

A large component of healthcare cost in the US is simply healthcare use. We are deeply, deeply unhealthy with 75% overweight rates and absurd levels of pre/diabetes, which are the largest comorbidities of all, and comorbidities of each other. Costs will never be comparable until overweight/obesity rates and usage are comparable too. They are not.

High prices in the US are very unfortunately largely explained by usage, and no amount of profit-reducing or cost cutting will work unless you are cutting usage itself:

https://randomcriticalanalysis.com/2016/09/25/high-us-health...

It's not just about cutting usage, it's about cutting the right kinds of usage as well.

Lots of Americans, anecdotally, skip out on regular checkups or checking on minor ailments because of anxiety about paying copays. And then eventually something that could've been easily treated when detected initially blows up into an expensive ER visit or requiring specialists.

A good chunk of this could be solved if we stopped using the ER as the catch-all emergency net for literally everything.

In the UK the NHS negotiates prices for drugs. NICE have to approve all drugs and if a drug is too expensive, the manufacturer either has to lower the price so that the benefit outweighs the cost, or they lose a large market.

This is why hand waving away "bargaining power" ignores one of the sources of high costs.

The other is that our doctors are mostly either employed by the NHS, or employed by a private provider who is paid by the NHS ... yes, there are doctors who do private only work, but they are fairly small in number.

Perhaps our student loans system also helps - fees are £9k a year, but you start paying them back at 9% of income over £25k ... so it's essentially a graduate tax and they are fully written off after a set number of years if you don't pay them off.

The difference in drug spending between countries amounts to a small fraction of overall healthcare spending. $1200 a year in the US versus $900 in Switzerland or $800 in Germany, Canada, and Japan.

It's incidental what the numbers are. Given how effed the US system is, I would fully expect that $1200 being spent on the entirely wrong things, like a few super expensive drugs, and a lot of antibiotics which should have been dirt cheap getting a ridiculous markup, or on Oxycontin.

Doctors should earn enough to pay the loan off

Really? So there are zero people from other industrial nations that come into the US for health care?

Zero people from other nations come to the US to save money on health care. The ones that do come are looking for specialists for some exotic condition, not because they love the level of care or the price tags.

And do you think those specialists would exist here if we had medicare for all? no, evidence: all those other countries that have that and no such specialists.

Yes they would. The Americans also go to other countries to seek treatment in special cases.

Also, if our healthcare works well to treat rich foreigners in special cases, but sucks otherwise — I say, we should scrap it.

But sure, we can cherrypick metrics all day long.

This is a great point more people should make. There’s nothing “America first” about preserving the inefficiencies of a system just so that very wealthy people from everywhere can get care and leave (and ultimately specialists would anyway still exist, even if their treatments aren’t covered by Medicare)

Actually, that's completely what "America first" means by those who say it, at the least the ones who are in on the deal.

if everyone had that specific knowledge, there would be no specialists. no, different countries develop different specialties. famously, Kobe Bryant went to Germany (a country with national healthcare) to get a knee procedure from a specialist.

It's not a one way street, though. Americans go to other countries like Canada or Cuba for health care, including, famously, GOP Congressman Paul Ryan.

Cop cars aren't collectively bought. For one its on a state by state basis, and then in some states individual PDs are responsible for their own vehicles, they just get a budget to buy and fix them.

That means they usually end up in an imbalanced power relationship of small 20-30 person local PD force approaching Ford / GM asking for their police cruisers.

Some states, of course, do collectively bargain their service vehicles like that, the USPS is probably the most prominent example of collective bargaining on a national scale - the post office bought 140,000 of them over 7 years for below consumer grade vehicle pricing. Even nowadays when they are reevaluating replacing their fleets it only averages out to about 41k per truck for a new model and that includes having to refit garages and post offices to accommodate them.

I'm also pretty sure there are licensing deals between US auto makers and various state bureaucracies to price control service vehicle costs, but its still never like a private automaker is getting an order for 80k cop cars from one entity.

What other goods is the US Gov the sole buyer of, for which the sellers can't easily shift to other customers? Cop cars clearly doesn't apply, as carmakers have other customers. Doctors, hospitals, and pharmaceuticals will face true monopsony, which means sell at gov rates or quit entirely. Some suppliers will quit entirely, but most won't.

Wait, how much are you paying for cruise missiles? I always feel like my cruise missile guy is ripping me off.

This is how the NHS functions and it has far better rates.

Sure, the government can say they'll only pay half as much as they do now, so providers will only provide half the care. Have you ever actually done any government procurement? Saying the government can just wave a magic wand and lower prices because "they said so" will only hurt the quality of care patients receive in the US.

The 'quality of care' you receive in the US is entirely dependent on your wealth and it's only the upper class that actually benefit from it.

You know what quality care I got as a poor person? Nothing, because my family couldn't afford it. I was given the privilege of going through highschool and college with teeth quite literally broken down to the gumlines and abscessed because it was either that or not being able to have a future.

I'm tired of hearing nonsense about quality of care because for a lot of people the quality is set to null.

Every time I read arguments online of people defending the American system, I almost always get hints that they are wealthy people, usually because they admit they can actually afford the care instead of essentially going broke over it. Healthcare debt is the leading cause of personal bankruptcy in the US, so it is statistically true that it is too much for the people below the median. Even for people in the middle class.

Did something happen to your teeth that basic maintenance like brushing and flossing wouldn't have prevented?

What you're describing doesn't sound very normal, even if you never went to the dentist in your life.

Genetics and diet seem to be large factors in dental health.

Poor people tend to not be able to afford healthy foods and will often eat foods high in sugars, which are terrible for your teeth. Perhaps their parents couldn't afford toothpaste regularly, or floss at all, or could only replace their toothbrushes once a year or two. Perhaps the parents work all the time, and don't have as much time or energy to instill strong daily tooth hygiene habits in their kids or police their brushing.

As an anecdotal data point, a friend of mine always goes for regular dental checkups, and brushes and flosses daily, but still has tartar buildup and gum issues. He had to get a deep-clean, and was in pain and bleeding for several days afterward. I (foolishly) avoided going to a dentist for many, many years, and in that time did a mediocre (at best) job of daily maintenance. When I finally started seeing a dentist again, I got away with two minor fillings (my first ones, and they didn't even numb me at all for the drilling) and a deep cleaning, where I had no bleeding issues and the pain was gone within a few hours (aside from tenderness around the anesthetic injection sites). My gums aren't in great shape, but are better off than my friend's. Unknown as to why the outcomes are so different. I can't imagine what my friend's teeth would be like if he didn't go to the dentist and didn't have good hygiene habits.

The quality of care is already so low that you're better off financially and health wise just flying to Europe, or fleeing to Canada.

Thailand. Some of the best medical care of any developing nation, at around 10% of the price for most procedures. A night in a very clean, modern Thai hospital can be less than $100/night.

> Having every person under the same plan that has the negotiating power of 327.2 million people will definitely drive costs down. Don't want to pay what the government says it is going to pay? Good luck finding customers then, because the government is bargaining on behalf of all of the customers in the US.

That explains our highly competitive, low profit margin defense industry.

Peter Attia discussed this issue pretty extensively Mart Makary on his podcast. It seems like most of the medical community agrees this would drive down costs in the near-term. The issue is what happens to care, choice, and price long-term in a single-payer system.

I think is we force the disclosure of what every company or individual pays for specific treatment or medication, this transparency alone should be a big step in the right direction to normalize costs.

There are 60 million people on Medicare. If you can’t negotiate with twice the population of Canada I don’t think the problem is not enough beneficiaries.

You know Medicare sets separate prices from normal insurance, right? See [1]. For most procedures, there's the "we make up a number to charge to insurance companies" price and then there's the negotiated Medicare price with associated billing codes.

[1] https://www.healthcaredive.com/news/cbo-reports-show-private...