* Poor people either get hit with huge bills because they're uninsured, or, if they know how to navigate the system, sometimes get these bills written off through "financial aid."
* Middle class people frequently have insurance, but get hammered by deductibles and out of pocket maximums, rarely qualifying for "financial aid." This can be ruinous.
* The rich still get what they want.
If the rich are "subsidizing" things anymore, it's not to a great enough extent to benefit the poor and middle class. The system has been broken over the past 40 years by medical and insurance costs that have risen much faster than the rate of wage growth for the average worker.
Switching from fee-for-service to prevention (capitation) would give us another 25% savings.
But I'm newly interested in notions related to cost disease. Am keen to hear anything anyone has to say about mitigation.
[0] https://time.com/5759972/health-care-administrative-costs/
Repeating myself:
Another low hanging fruit is transition from free-for-service to rewarding wellness (capitation). Some are already doing this.
I'd like to understand if, how, why cost disease is a factor. https://en.wikipedia.org/wiki/Baumol's_cost_disease I have zero understanding, intuition about this. Feels like black magic. But some of the experts I've read say it's important.
There's no shortage of management efficiency and quality of care innovations to explore. In the spirit of Atul Gawanda's book Better, like specialized clinics for cystic fibrosis, diabetes, and whatnot. And whatever we're calling people traveling for procedures. Like USA people going to Thailand and Mexico clinics.
USA's R&D and regulatory overhead (FDA) carries the world. That first adopter expense might be easier to accept if the accounting was transparent.
Any way.
I designed, implemented, supported 5 regional healthcare exchanges. Even in our little corner of the problem space, there was so much room for improvement. Alas, most of it was prevented, because our participants were competitors, so the incentives were all wrong. A single payer system (or rough equivalent) completely moot most of those roadblocks.
2. Nobody has a right to earn a living by causing suffering to others.
2. Is a good slogan, but understand that most of those people don’t think they’re doing a bad thing. Spending too much time demonizing the line level workers at insurance companies is probably counterproductive.
But the principal still stands, no matter how much I may sympathize with someone they don’t get any right to make income from causing other people suffering.
All 3 are connected and make healthcare absurdly expansive.
One such common thread is the financialization of consumer debt.
I recently learned (from Michael Lewis' Against The Rules podcast) that removing ban on usury debt (high interest rates) opened the flood gates. Sorry, I forget which episode.
They can be absurdly expansive because there is an expectation that students will indebt themselves with this one kind of debt you can't default on. So doctors have to earn more to be able to pay it back.
Then you have lawsuits where cost of lawsuit is paid by both sides, no matter who is at fault. So if it takes 2 years and costs 100 000 USD to determine you weren't at fault - you are still going to default (except yo ucan't default on your student's debt). So doctors are expected to be insured against lawsuits. Which is expansive. So they have to earn more.
Then there is a system where one drug company has 100 insurance provider customers who have to buy that drug. Who has more power in that relationship :) ? So you pay absurdly high prices.
re lawsuits, I advocate a specialized healthcare court for adjudicating those cases.
Our current system of legal precedent does not recognize progress of science. So we end up with nonsense like unnecessary c-sections for decades because a jury of laypersons determined vaginal births increases cerebral palsy.
https://web.archive.org/web/20090424115607/http://www.nytime...
We already have separate specialized courts. Bankruptcy, youth, etc. My local judges have innovated by creating separate courts for vets, addicts, and so forth. Much more fair, efficient, and effective.
re education. Yup, totally on board. We (society) need more healthcare workers, of all flavors.
re big pharma. I don't know enough to comment.
If someone ruled once that Indians aren't people and can be expelled from their property is that still a law? It can't be, right?
Or how about when you legalize something?
Precedent isn’t really about outcomes, it’s about lines of reasoning. If the law says that something has to be purple, the courts may need to decide what standard to use for purpleness. If another case then comes along that requires something to be green, the courts will try to make their greenness test work the same as the earlier purpleness test as much as possible. That way, everyone can get an understanding about how the courts reason about color. If the legislature disagrees with the court, they can amend the law to specify more precisely which color they wanted.
There’s a little bit of extra subtlety in that the US court system is hierarchical, and precedent is only controlling if it came from a court in your part of the tree. Different circuits may apply different reasoning for the same issue, and that’s probably the most common kind of case for the Supreme Court to take: two competing standards are in use, and they need to decide which one the whole country should use.
Thanks for tip re Canada's admin overhead. Will research.
The government tried to centralise and digitise the whole thing but because it was mismanaged, most of the project was abandoned and cost billions to the taxpayer https://en.wikipedia.org/wiki/NHS_Connecting_for_Health
Now we are in a bit of a catch 22 where the costs keep increasing, and the government is always under pressure to spend more but there doesn't seem to be a solution to slowing down the increasing costs.
Yes. I have a friend in tech (contractor, bay area) who doesn't have insurance. his plan is to just show at the ER without an ID if he needs anything and give a fake name.
^ why we can't have nice things..
How large are these OOP maximums and deductibles on average? I’ve always kept an emergency fund that’s well in excess of my OOP max. Is this unusual? Also, I’m off the impression that you can get onto payment plans if you can’t pay your bills right away? These aren’t rhetorical questions (although that won’t stop people from downvoting as though they are, I’m sure), I’m genuinely curious.
29% of households have < $1000 in savings, and the median is $11,700[1].
$1000 disappears almost immediately given deductibles, and $11,700 isn’t that far off either. People just don’t have the chance to “get ahead” when making <$15/hour.
[1]: https://www.google.com/amp/s/www.cnbc.com/amp/2018/09/27/her...
Unfortunately, it is unusual among Americans to have an emergency fund this large.
Pensions are in a way similar. When steelworkers retiring at 65 could expect on average a few golden years, then deciding how to pay for that wasn't such a huge deal. When they can expect a third of their lifetime to be in retirement, then it's very different.
The chart on [0] is incredible. I also shows how much that percentage has grown over the last 45 years.
[0] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea... [1] Source data OECD: https://stats.oecd.org/Index.aspx?DataSetCode=SHA
Whether it will come down, I guess that's partly a forecasting guess. Will the healthcare sector be a smaller part of the economy in 10, 20 years? Employ fewer people? I would be extremely surprised if this happened in any advanced country.
Something I'll note, Jay Gould, one of the wealthiest men of his time died of tuberculosis - something we now think of as a poor persons disease.
If insurance was gone tomorrow and there was a cap on how much a single payer system would pay I am pretty sure million dollar surgeries would go down significantly in price.
I mean surgeons are paid well but a million dollars for a few hours of their labor?
Constraints on how many people are permitted to become doctor's also reinforce this issue.
She also stole kids and let babies die from lack of care...
It's funny how today's most complex problems are so simply avoided by simple people.
Source?
By what definition? According to mainstream health organizations and even still government guidelines, they eat very poorly. Their diet is very high in saturated fat, which although healthy in reality, is not healthy according to the government. They also eat plenty of sugar, the other common scapegoat for dietary problems.
>don't drink or smoke,
They drink and smoke at lower rates, but they absolutely do drink and smoke.
If you want something better (and there are tiers), you pay more. You can buy insurance policies that pay for the more comfortable stay.
We have universal health care, but anyone is of course free to forego that and pay (or use their private insurance) for a private room rather than a ward, or just go to a private hospital instead.
I don't understand the debate about this in the US. It's as if the rich assume that things will change for the worse for them if universal health care is enacted.
Price controls on healthcare (socialization) has positive and negative impacts. The positive impact is universality. Everyone gets approximately the same basic level of care. In some countries you might be able to pay for a nicer room, or quicker service, but generally speaking it's all the same. The downside is that price controls stifle innovation. That's just basic mainstream economics and is the case in every industry, not just healthcare. The trick about stifling innovation is you don't feel it immediately. On day 1 of the price controls, the rich are about the same but the poor are better off. On year 50 of the price controls, everyone is worse off because of all of the innovation that never came to fruition.
I never hear advocates of universal healthcare have an adult conversation that they are trading long term benefits for short term gains. I think that's a reasonable position to hold, but if we just pretend that it's all benefits and no cost we're not having an adult discussion. It's not as if one side is right and one side is wrong. Once we accurately discuss the economics, it's easier to understand that this is a very difficult moral decision and not the trivial one that is sometimes portrayed in the political sphere.
My speculation is that the rich people you refer to are more likely to be trained in economics (formally or otherwise) and are more likely to have a long term mindset regarding cost benefit tradeoffs.
Fostering innovation is of course important. Which is why you can deduct a lot of your R&D expenses from your taxes. Again, each country has its own tax code, so generalization might not be possible, but in a lot of cases, the hard work of finding new drugs is funded by the citizens, through tax breaks or research grants. The public sector, via universities and public labs, is a major player (although not the only one, of course) in the medical field.
Let's not forget that forcing people to stay with their employer to maintain insurance coverage is also a way to stifle innovation. How many of those workers could have and would have started a business, if not for the fear to loose everything in case of medical issues ? Surely the republicains would love to remove those kind of barriers to worker movement and innovation, wouldn't they ?
The universal healthcare system obviously isn't free. Altough some studies, and real life examples elsewhere in the world, showed it wouldn't be the money pit some imagine, it certainly doesn't run on love and compassion and fresh water only. The taxes in my country can show you that. But the social benefits and the peace of mind I enjoy are, in my very own and somewhat biased opinion, worth the cost.
We're talking about changing the velocity of innovation. Let's do a thought experiment about what innovations might be missing today if we implemented price controls everywhere in the globe 50 years ago. We might be missing the HPV vaccine leading to many cases of cancer for women. We might not have CRISPR. We might not have HIV treatments. High prices, profits, however you wish to put it, incentivized people to create these thing and go through the extremely difficult process of bringing them to market.
Now that's just a thought experiment about the past. It's impossible to know exactly what would have happened then, just like it's impossible to imagine the things that won't get invented 50 years from now. But we do know, according to basic mainstream economics, that price controls change the velocity of innovation. Since the velocity decreases, the farther you go into the future the more harm you cause through the lack of innovation.
I'm glad you brought up the fact that healthcare is tied to your employer. If you look up the history of this situation, you can see that it's the result of price controls enacted by the government on wages. Dumb things happen when we implement price controls.
HPV vaccines were first developed by the University of Queensland in Australia [1] and further improved by the the University of Queensland, Georgetown University Medical Center, University of Rochester, and the U.S. National Cancer Institute [1].
CRISPR was discovered by several researchers from the University of California, Berkeley, the Broad Institute of Harvard and MIT [2].
The public helped in the discovery of those treatments (through tax payer subsidies), and as such, in my view, are entitled to some kind of retribution. Having a form of universal healthcare, where the public can put pressure on companies to decrease the price of different treatment, is exactly that.
Regarding the velocity of innovation, I don't think it is hurt by a universal healthcare system. Everyone has access to those treatments, and so the profit on each instance of the treatment can be lowered while keeping the same total profit for the company manufacturing the pills.
What is the point to discover insuline if the price asked for a shot makes it impossible for some people to buy it ?
Even if some treatments, like drugs, can be made generic, and through that, have their price descrease in the futur, what about medical procedure ? Hip replacement won't suddenly or magically become cheaper in 5 years. Look at the price of stitches in the USA (For patients without health insurance, stitches typically cost $200-$3,000 or more, depending on the provider, the injury and the complexity of the repair [3]).
I do not propose to slash the profit of pharma companies. Like you said, academic studies consistently show that a reduction in current drug revenues leads to a fall in future research and the number of new drug discoveries [4]. Forbidding them one way or another to make a profit would be a net negative on the long term. But were our differences arise are in the implementtion of this principle. You propose, and correct me if I misunderstood, to let them set the price, and those how can will buy it. I propose to contain the cost so that all who need can afford it. The net result could be the same.
Price controls, like other types of controls, are a necessary evil in lots of case. It would be cheaper to allow companies to pollute everything and everyone, but we decided that society as a whole is better off with environmental controls. It would be cheaper to not test all those drugs and just let the market sort out which pills are working and which ones are dangerous, but we decided against it.
[1] https://en.wikipedia.org/wiki/HPV_vaccine#History [2] https://time.com/time-person-of-the-year-2016-crispr-runner-... [3] https://health.costhelper.com/stitches.html [4] https://itif.org/publications/2019/09/09/link-between-drug-p...
There's no such thing as a new drug that reaches the market without massive investment from private companies to do things like pay for FDA certifications, drug trials, etc. These are different categories of activities besides research. I don't think we're in conflict here.
>What is the point to discover insuline if the price asked for a shot makes it impossible for some people to buy it ?
What is the point to avoid discovering ways to create insulin altogether just because some people might not be able to afford it while the patent is active? What are the regulatory hurdles preventing generics?
>Hip replacement won't suddenly or magically become cheaper in 5 years.
Regulatory capture by medical unions is a separate topic.
>I propose to contain the cost so that all who need can afford it. The net result could be the same.
The net result is NOT the same if the new treatment is never created in the first place. That's the whole point.
>Price controls, like other types of controls, are a necessary evil in lots of case.
Again, this whole thread is about making sure we acknowledge the "evil" part, which is long term increase in death and suffering but short term reduction in death and suffering. After that, you can decide on your own whether or not things are "necessary."
The most innovation I am seeing coming up from the US health system these days is in finding ways to extract more wealth.
Innovative things like "let's make a cartel, increase the price of insulin by 1000%, and use some of that money to buy politicians so they don't stand in our way".
2.) With this theory, if it is true, you are basically volunteering American patients to pay for innovation worldwide. That is quite a bad deal for quite a lot of American people.
3.)
> My speculation is that the rich people you refer to are more likely to be trained in economics (formally or otherwise) and are more likely to have a long term mindset regarding cost benefit tradeoffs.
They have also different interests. Good cost benefit tradeoffs for one group is often very bad deal for another group.
2) America doesn't have to let this happen. We could charge other countries for our innovations or otherwise demand reciprocation.
3) For people rich enough to have serious political power, the short term price difference is negligible or perhaps even cheaper under price controls.
An MRI cost me about 0€.
A 4000€ test which tests for nearly any rheutmatic diseases markers and the visit to the hospital for that test cost me 0€, both things got done within two weeks.
Even if you are poor and want to go to a private doctor it will cost you not nearly as much as in the usa. For me it was about 100€, for one visit and that was on the higher end.
Socialized healthcare is always cheaper.
My mom is a doctor, she worked ICU, ER, etc, board certified in 10 states and holds a medical license in 3 countries(yes, she did residency three times, it's a long fascinating story for another time). Eventually she decided to open a private practice for family medicine bec it was less stress, but she's got tons of experience, and is highly regarded, and she charged less than $40 a visit for the uninsured. She would spend ages talking patients out of procedures that were harmful or simply unnecessary. You got high end care from her each time.
The gist of this is: you have no idea what you're talking about and individual anecdotes don't prove one system is better then another.
I'll just add as food for thought: nothing is free, avg effective tax rate in EU is 50%
Avg ETR in the US is less than 30%.
If there is demand for private healthcare affordable to the middle class, the demand will be met with supply.
And if that fails, they should be taught about democracy.
That if it turns out that socialised healthcare doesn't work for most Americans most of the time, then the country can revert to the system it currently has.
Well, it depends on the implementation, but Bernie Sanders has been on record numerous times as stating that his Medicare-for-All proposal would absolutely ban private insurance. Elizabeth Warren is another Democratic front-runner who indicated that she's on board with that, though her proposals didn't necessarily reflect it.
For what it's worth, the M4A _plan_ from Bernie's camp that I've seen didn't actually specify that it would eliminate private insurance, but he's also been keen on reminding us that he wrote it, and knows best what's in it.
So while it seems unlikely to me that political reality in America would prohibit banning private insurance, there are definitely those who espouse banning it for the greater good, so perhaps that fear isn't wholly unwarranted.
I think it's fair (if a bit naive) to take politicians at their word on occasion. Moreover, I think it's more than a bit disingenuous to assert that plans that are disallowed by law from competing with Medicare services still being allowed to exist for only elective operations as "not banning them." If I disallowed Netflix from streaming any videos longer than a minute in length, I guess technically I have not banned Netflix, but in practice, I have totally banned Netflix, and that's exactly the scale of disallowance we're discussing here.
Do you understand the difference between primary and secondary / supplemental insurance coverage?
Again, I'm not making the claim that it's what's in the policy, but it's what Bernie has said, and others have echoed. Reasonable people can disagree on what policies are practicable or likely, but if you're a person who believes their health insurance might change based on those statements, then it seems like a warranted fear.
For any of the services covered by Medicare. Quoting the Kaiser Family Foundation, "private insurance would be prohibited from duplicating the coverage under Medicare."
[0] The full quote here is "If you support Medicare for All, you have to be willing to end the greed of the health insurance and pharmaceutical industries. That means boldly transforming our dysfunctional system by ending the use of private health insurance, except to cover non-essential care like cosmetic surgeries."
[1] - https://www.bloomberg.com/news/articles/2019-07-05/harris-ke...
That's correct. Supplemental insurance can still cover copays and other out of pocket expenses. It can also cover procedures not covered by Medicare.
Now, tell me, how is that "banning private insurance" if insurance companies can still sell those policies?
Q: "Does private insurance go away under Medicare for All?"
A: "Yes, it does, because you're not going to a have a need for private insurance"
A tweet[1] from Bernie Sanders: You're damn right we're going to get rid of greedy health insurance companies.
CNBC describes Bernie Sanders plan as "Bernie Sanders is pushing a “Medicare for All” bill, which would create a government-run program and end private insurance."[2]
The Hill's headline covering Bernie's policy is "You're Damn Right Health Insurance Companies Should Be Eliminated"[3] and references a quote in an interview from MSNBC in which Bernie says universal health care can't be achieved "unless you get rid of the insurance companies."
So feel free to quibble over the nuances of what "eliminate," "end," and "abolish" mean as much as you like, but if you're a person who is concerned that your private insurance is going to be eliminated, and you're listening to Bernie Sanders talk about it, it seems like his statements would reinforce that fear.
[1] https://twitter.com/berniesanders/status/1111363118867927040...
[2] https://www.cnbc.com/2019/07/18/these-2020-democrats-want-me...
[3] https://thehill.com/policy/healthcare/436033-sanders-youre-d...
> In other words, while Sanders' plan doesn’t ban supplementary coverage from private insurers, it does offer such generous coverage by the government that there's not much room left for private coverage to fill any gaps. This is the logic upon which both conservative critics — and supposedly nonpartisan mainstream reporters and pundits — hang the logic that Sanders' plan would "ban" private coverage. It's a dramatic "gotcha" question.... [0]
You're essentially reinforcing a right wing talking point that completely mischaracterizes what Bernie's M4A plan actually does.
---
[0]: https://theweek.com/articles/850638/no-really-wants-ban-all-...
"I could whack pharmaceutical companies, and I don’t need Medicare for All to do it, but I do need Medicare prices for all to deal with what the real profits are — whether you call them profits or not — which is hospitals."
https://www.politifact.com/factchecks/2020/jan/15/bernie-san...
You're reaching. Why are you trying to push a right wing spin on M4A, when studies show that it would reduce costs and increase access to care?
But to the point of why people might be wondering about changes to their healthcare policies, well, perhaps it's because they've been listening to the politicians. If folks would like to obliquely sidestep what I feel was a rather small, simple point and have an argument about efficiency gains in healthcare, you're free to, but I'm not trying to participate in that argument.
Edit: Actually, consider this my last post on the topic at hand, as I'd rather not engage in any argument where reputably sourced facts and direct quotes are regarded as "right wing spin."
I did not do that
> Yours are exactly the words I would expect to hear from scaremongers
I quote the author and it's scaremongering? Yeah, count me out of this conversation altogether. You've uncharitably interpreted what I'm saying, and are doubling down on the sort of rhetoric I explicitly stated having no interest in.
And, as for the conversation, you were supposed to be out already. It would be better if you stayed out rather than amplifying false statements. If you want to critique M4A, then quote the actual policies put out, not the rhetoric.
b) I've made no critiques of M4A.
c) You're wrong to the point of malice, perhaps deliberately.
That said, answering your question, they would presumably not ban it because a) the aforementioned arguments upthread make it pretty silly to do, and because b) it seems impossible to me that banning a wholly legal service just because it competes with the government would ever be deemed as constitutional.
Well, not ever -- but not today, and not with the direction that the Supreme Court has been taking for decades now in regards to government power. Licensure seems possible, but I think even prohibitive licensure intended to dissuade private entities from competing with the government would be tossed out, and we already have such programs for insurance providers anyway.
What you are talking about is that rich people don't need insurance at all. They just pay out of pocket.
If you want private health insurance for say $50 a month[1], then insurance gives access to procedures more quickly and the rooms are much nicer than the public health care system. It may give access to rare but expensive procedures.
If you don’t want insurance, then the default is the public healthcare system, which is paid for by taxes. You will usually be in a ward with other patients. You pay small amounts on use (to prevent abuse, and even those amounts are reduced to nearly free if you are poor). The level of care is reasonable, but can be slow for non-urgent elective surgery, and extremely expensive procedures are not available. The public healthcare system handles ongoing chronic conditions much better than a private system could.
[1] You can see a quote from https://www.southerncross.co.nz/ if you give your age, gender and tick whether you smoke. Note that Southern Cross is a nonprofit co-op, most premiums get returned to members (on average, less an approx 10% administrative overhead).
Germany allows people to opt out entirely, although there are a bunch of conditions and limitations. Most people don't, so the public system can still pay for itself.
If you're avoiding paying into a system because you don't want to claim from it then letting you hop back on whenever you need it would destroy the system very quickly.
So if you were self-insured and broke a leg, then decided to switch back to insurance, you'd still be on the hook for the costs of the ongoing physiotherapy until it is healed back up. The insurance doesn't have to actually pay anything that happened before a switch (switching from public to public insurance or private to private doesn't have this limit, private to public and the other way round but you don't pay, your old insurance pays).
The only universal way to switch is to marry someone in public insurance.
Severe health problems don’t bankrupt NZers, and you are not locked into a job just to (a) keep your insurance, or (b) keep your insurance benefits.
How many recently unemployed in the US have lost cover for their pre-existing conditions?
I expect you can find the benefits list document for Southern Cross, if you wished to check out the details of cover for cancer or pre-existing conditions.
He couldn't afford to go to hospital, so never did. I was visiting from Australia at the time and was utterly horrified, having no idea the US worked like that. Now years later his shoulder is still screwed.
Of course people in the US avoid going if at all possible, it's horrendously expensive, and medical bills are the number one cause for bankruptcy in the US [1]
In a stack of OECD countries (all the other ones?) nobody has ever gone bankrupt from medical bills, because that's impossible.
[1] https://www.thebalance.com/medical-bankruptcy-statistics-415...
There are people that cannot afford insulin. THAT is a problem. But the fact that he took a risk, for fun, and suffered the consequences, rather than having everyone paying for it? That sounds a bit reasonable...
Note: important that the risk is voluntary, optional and recreational rather than professional. Why would the collective bear the costs, in those circumstances? Why is that fair?
Or use physical therapy, it's cheap.
Now imagine that was scaled up to a whole country. That's New Zealand. Check out the Accident Compensation Corporation. All medical costs related to accidents are automatically covered!
But who pays the costs! Everyone, via levies. How much? $2000 on a $150K IT income.
But how do you control costs? Who is entitled? Who is at fault? Surprise! It's a no-fault accident insurance system that covers all accidents.
In exchange for that, we gave up our right to sue in accidents for medical damages. Why pay a lawyer when they're not required?
If monthly, the answer is still no, but only because testing for covid is a significant public good.
Otherwise, yes, sure?
It is an unpredictable, low probability event, with not so big an impact (the payment, I mean, not covid)
I am not suggesting this explains all of it. Our health care system is definitely overpriced and overloaded with badly designed bureaucracy, but it definitely explains some of it.
I’m not sure how that’s different from today, other than the exorbitant costs that exist today.
Like just chopping off a leg instead of spending a 12 hour operation and months of physiotherapy to save it.
Letting people die from chronic conditions instead of managing them.
Letting old people die, because the cost of medical treatment was too high.
Not performing operations for heart disease, so people got one heart attack and then died a year later.
Which we could totally go back to, it really is a lot cheaper.
Part of it is patent law, part of it is dysfunctional American healthcare system that drives prices up, but big part of that is that medicine just got much better and much more inherently expansive.
> I asked my literal grandmother, a 95 year old former nurse, how health care worked in her day. She said it just wasn’t a problem. Hospitals were supported by wealthy philanthropists and religious organizations. Poor people got treated for free. Middle class people paid as much as they could afford, which was often the whole bill, because bills were cheap. Rich people paid extra for fancy hospital suites and helped subsidize everyone else.
In other words... allow rampant inequality in the healthcare system. The rich would pay for their designer surgeries, and let that subsidize the rest.