> we have no idea where the money is actually going
This is what auditors do. If anyone in government really gave a shit some auditors could get to the bottom of it in a matter of months.
This is what auditors do. If anyone in government really gave a shit some auditors could get to the bottom of it in a matter of months.
FWIW the government gets a better deal for healthcare than private insurers do (e.g. Medicaid is cheaper per person than if they were covered in a private plan). So I would say they do give a shit and have gotten to the bottom of it. It would be cheaper still if Medicaid covered everybody.
Medicare on the other hand is much better, though still not all that great (it's better than private insurance in many if not most cases). It is universal coverage for folks over a certain age in this country. There aren't any good reasons I've seen to not lower that age to 0 (i.e. covered from birth).
So here is what I do not understand. Why does the US not do what many European nations do and split healthcare into two problems? You have a few large insurance pools (single payer for lack of a better term) that is government run, mandatory participation and that covers emergency care and basic health services. And then separately to that you run a free market private healthcare system that sits on top of that governmental system and covers the better care?
It's absurd that insurance companies in the US pay for everything. The cost do not add up for me as a customer. I do want choice in the non life threatening cases but I sure as hell do not want to ever have money concerns when it's really critical.
The problem in the U.S. is that health care costs are directly tied to your employer, mostly, because the employer is the cost-savings insurance pool you join. This creates a lot of terrible situations where people are stuck in jobs they can't afford to leave for medical reasons; or are stuck with medical problems that prevent them from getting hired. What was originally supposed to be a social contract where you work hard to have a good career, and your boss takes care of the ugly bits of life like cancer, has turned into a tight coupling of disjoint life issues that usually creates the worst possible outcome in both cases.
Medicaid is terrible largely because it's legislatively hobbled to prevent it exercising market power (like negotiating bulk pricing for pharmaceuticals, because doing so would embarrass capitalism somehow), and otherwise regulation driven for political purposes, like capping payments for procedures at below market rates, causing them to be excluded from a large number of health care providers who don't need to submit to price controls. The U.S. health care system is like a graduate thesis in perverse incentives.
That is, when the two were first tied, income tax rates (especially for higher, including "professional", brackets) were much higher. Employer-sponsored insurance was first offered as a tax-free perk companies could use to draw talent. It's easy to see how that could become an expectation, and then a requirement, despite its helping create incentives that are ultimately aligned against the employee/patient.
Which lead to a 6 month delay to get an MRI in BC (which proud itself to be no. 1 province). Not to mention that the public insurance does NOT include dental, or if it does, only the bare minimum. I had to personally pay for a root canal because only a complete extraction was being reimbursed. Moreover, all my cleaning have been out of MY pocket, on top of MSP/RAMQ.
I really don't get why Canadian think their healthcare is so star sprangling awesome... It's not.
But isn't that what makes it great? I have no experience with Canada but Austria is not very different in that regard. My state insurance costs me (purely medical) around 5000 Euro per year independent if I self insure or through my employer. It gives me about what Canada gives you. No copays for employees and there is a 10% or 20% copay for self employed or management.
In addition I pay about 3000 EUR a year extra for private insurance. I did not feel like waiting 2 months for an MRI so I decided to use my private insurance at a private carrier. Paid 500 EUR for that out of my pocket and the private insurance reimbursed everything but the contrast agent. I could also decide not to pay for my private insurance at all but I did the math and the plan I have now seems a pretty good way to spend money for later in life.
It gives me the freedom to chose what I want. The cost for most non covered procedures is laughably cheap here. It seems like a better deal for my money.
I wonder what's up with all those MRI shortages in some places? I got my last MRI a couple of years ago in Germany, fully covered by public insurance, had to wait like 2 weeks for my appointment.
Sounds like some places are in dire need of more MRI capacity?
But so is Germany's? I didn't get that MRI because "I just felt like it", it was due to decade long migraine problems and I had to see a neurologist before getting the MRI.
I still don't understand these massive waiting times in some places, sounds more like a lack of capacity than anything else.
For a lot of things, MRIs are a medical convenience, not a necessity. When they're medically necessary, you get in within hours--my nephew got driven to the hospital with a head injury, and an MRI was the first thing they did. But if it's elective, you go on a waiting list, which might be short, but might be long. This is probably the most complained about aspect of Canadian health care, with some justice, but it's not obvious that eliminating all wait times with sufficient capacity for immediate access would yield better medical outcomes for the extra cost.
In Austria it's largely because the insurer wants people not to do MRIs unless necessary. So they typically sens you to an doctor first to confirm you need one, the approve from the insurer and then you get to wait a bit.
There are plenty of MRI machines in Austria because the place I got mine also takea publicly insured patients.
Quite a lot of higher-paid working people in the UK either buy insurance or get it as an employment benefit, because it can enable you to get back to work quicker if you have a serious accident or illness.
If the public system covers anything more than emergency care (patch a patient up and let them go) it automatically creeps into all service levels (have a basic cough? maybe that's bacterial pneumonia, better issue referrals for microbiological analysis and a CT scan. /s) if an answer to the question "if family doctor/general practitioner cannot appoint diagnosis and/or treatment and refers patient to a specialist and/or analyses, scans, etc. are those covered too?" is yes.
The payer (government, taxpayers) probably has 3 mechanisms to keep [total] costs from skyrocketing all with their disadvantages:
1. Reduce usage count (doctor visits) - free visit quotas (possibly dependant on service level), fixed or percentage mandatory user fee, etc;
2. Fix service costs - e.g. 100$ for a GP visit from public pool;
3. Auction paid service quotas.
No. In the UK, if you go into a GP's office with a cough, you'll be told to go home and rest. In fact, most likely, you'll be denied from making an in-person appointment. This is FUD in its plainest form.
The idea that price controls don't work in America is, of course, an article of faith in the free market religion. It wouldn't fly there.
Spiraling costs is a much bigger risk in private "free market" systems, which is largely how America gets to spend 2x more of its GDP on roughly equivalent healthcare outcomes (mortality rates, etc.) to European single payer systems.
They can "seek" it, but in the public system you don't really have a route for doing that. You might want a CT scan, but if your doctor doesn't think you need it you're not going to get it.
Your list left off (4) queueing. In the UK public system, if your condition is not urgent you'll have to wait, possibly for months. Unless you have private top-up insurance which will cover the specialist you're waiting for.
(It's difficult to estimate how much money the NHS saves by people on queues for non-urgent operations dying from something unrelated in the meantime - e.g. dying of a heart attack while waiting a year for a hip replacement)
See e.g. https://books.google.co.uk/books?id=RyJfEbwGwgkC&pg=PA4&lpg=...
(random googling found confirmation of this in someone's FOI request: www.heartofengland.nhs.uk/wp-content/uploads/FOI4797.docx )
Medicaid is almost entirely state run and varies radically from state to state, but in all cases subsumes and goes beyond ER care, so in no way is it "worse than the ER".
> Medicare on the other hand is much better, though still not all that great (it's better than private insurance in many if not most cases).
Basic Medicare is worse than private insurance (and even, in some ways, most state Medicaid plans) in a number of ways (especially in the way that it is segmented, particularly the separate prescription drug portion), and deliberately kept worse to promote publicly-subsidized, privately-run (often for-profit) “Medicare Advantage” plans, which (unlike basic Medicare) are comprehensive and integrated, rather than segmented.
Tell that to the people in states with Republican governors who won't expand Medicaid to cover them...
> in many ways is worse than the ER as a measure of last resort for acquiring care
What are you talking about? If you are in an emergency and on Medicaid you can go to the ER[1]. ERs give great care, they are just expensive. Medicaid is not expensive, so if their patients are getting ER quality care that is an amazing deal.
[1] https://www.medicaid.gov/medicaid/cost-sharing/out-of-pocket...
Not only can you go, you won't be charged unlike almost all private insurance plans.
> Out of pocket costs cannot be imposed for emergency services, family planning services, pregnancy-related services, or preventive services for children.
My Dad has a $750/month plan but only pays $150 because of the medicaid subsidy in PA from the ACA for his income bracket.
That said, the Medicaid expansion definitely puts people on Medicaid! That's a big part of the reason why it's politically suicidal to repeal the ACA.
http://www.kff.org/medicaid/issue-brief/what-coverage-and-fi...
> Between Summer 2013, just prior to the ACA, and September 2016, there was a net increase in Medicaid and CHIP enrollment of 15.7 million people.
It isn’t that simple. Medicare saves lots of money because of their lower reimbursement rates and many of the smaller medical practices near me won’t accept any more medicare patients. Even with that, the Part A trust fund (covers hospital costs) is expected to be completely depleted in roughly 10 years.
What is really amazing is that it also returns Emergency Rooms back into a place where you go in an emergency so you can actually get treatment in 15min rather than wait for a few hours at 3am as you drip blood on the floor through the towel you've wrapped your arm in, and watch in horror as the lady next to you screams and shakes on the floor as she passes kidney stones (yes you would recognize the world renowned hospital where this happened).
No there isn't, unless you go private, speaking of which France has pretty much made private "mutuelle" mandatory.
> What is really amazing is that it also returns Emergency Rooms back into a place where you go in an emergency so you can actually get treatment in 15min rather than wait for a few hours at 3am as you drip blood on the floor
You have obviously never been in an emergency room in Canada, and I really hope you have not to, ever. My friend got a whiplash injury and got told to go back home, and I had to walk 3 days on a broken foot in Quebec because the ER turned me down (and incidentally asked me to pay CAN$1k to have my foot looked at).
OTOH it would be easier in a completely government managed system, because there would be fewer entities and they could all have full reporting imposed on them by design.