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Comment by ScottBurson | Hacker News Reader

You've repeated this claim in several places so I'll just link to my rebuttal: https://news.ycombinator.com/item?id=16979565

While you may have a good argument against a "single-manager" health care system, this doesn't seem like an argument against a single-payer system. In fairness, I guess a lot of existing universal-coverage systems, such as the UK's NHS, are also single-manager (someone will correct me if I'm mistaken), but the very existence of Medicare Advantage shows an alternative possibility. I think that, far from being an argument against single-payer, it shows how single-payer can be made to work even better, through premium subsidies (and, I would guess, reinsurance for catastrophic losses) to private insurance companies, for those who are willing and able to pay additional premiums for better care.

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The NHS is what is called a Beveridge style system. I think that is what you mean by single managed. Similar systems are used in Spain, the Nordics, etc. They are often managed at local levels though and may include private hospitals and treatment that gets reimbursed by the payer at the same level as public ones. The VA is an example of this type of system although other nations have far more oversight and performance control than the VA does.

A competing setup is the Bismarck style of insurance company administered management, either for-profit or non-profit. Germany, the Nederland's, Switzerland, etc runs this sort of system. Always with a lot of legislation and safeguards to ensure that people do not fall outside the system. It is similar to the US employer-provided insurance setups.

Other systems are National Insurance, as used in Canada and Japan. Similar to Medicare. Canada is fairly unique in its hostility to private provision.

And then there is out of pocket, like rural Africa does it. That's basically like being uninsured and not qualifying for Medicaid.

Thing is, the US accumulated massive bureaucracy and costs by h\trying to run every system at the same time with little attempt at standardization and lots of billing and gatekeeping. Everyone else picked one system and stuck with it, letting private providers fill in the gaps. (Except Canada for the last)

> I guess a lot of existing universal-coverage systems, such as the UK's NHS, are also single-manager (someone will correct me if I'm mistaken), but the very existence of Medicare Advantage shows an alternative possibility. I think that, far from being an argument against single-payer, it shows how single-payer can be made to work even better, through premium subsidies (and, I would guess, reinsurance for catastrophic losses) to private insurance companies, for those who are willing and able to pay additional premiums for better care.

I don't think you understand how Medicare Advantage works. There's really nothing about it that suggests a single-payer system would work. The premiums are not subsidized. (Reimbursements are, but that's a separate matter.)

Medicare is the fullest extent to which people can legally opt out of Medicare, short of claiming religious exemptions (rare), working for a foreign government while in the US (rarer and legally questionable for citizens), or surrendering US citizenship altogether (drastic). Medicare Advantage outperforms Original Medicare on the top performance indicators (medical outcomes, cost, patient satisfaction), though underperforms the same exact private insurers on those same metrics, despite the latttermost also being saddled with the burden of subsidizing Original Medicare reimbursements.

If you still want to advocate for single-payer healthcare on philosophical grounds, okay. But from an empirical standpoint, Medicare is not the place to look for data to support that stance.

I already quoted from medicare.gov [0], but I'll repeat: Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans.

How is that not a premium subsidy?

[0] https://www.medicare.gov/sign-up-change-plans/medicare-healt...

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