Build Your Own ‘Medicare for All’ Plan. Beware: There Are Tough Choices
nytimes.com
nytimes.com
She said when you go to a hospital or medical office in Europe they generally look like an American junior high school. When you go to a hospital in the US, they often look like a resort hotel, especially the new ones. Such amenities are unrelated (or even counter-indicative) to the quality of medical care provided. The average European receives better care on average.
This also resonates with one area of my own medical care experience here in America: dentistry. My current dentist operates out of a modest office in an old strip mall in an unglamorous part of town. No fancy monitors hovering over every dental chair. No efforts to upsell me on cosmetics or prescriptions every visit. Just solid reliable affordable dental care.
I recognized in retrospect an anxious subtle almost subliminal feeling I would get whenever I walked into most dental offices before finding my current dentist. All these fancy state-of-the-art amenities, the giant saltwater aquarium, who knows how much in loans to pay off for a newly graduated dentist: somebody's gotta pay for these niceties somehow.
I wouldn't be surprised to find out the majority of patients were, unfortunately, impressed and reassured by such superfluities.
This resembles the "crisis" in education, where Univesities are spending huge sums of money from rising tuition fees on fancy facilities and amenities even as full professors are replaced with adjuncts.
The question you should be asking is, will fewer people die of preventable medical causes.
Most dying people I've seen choose to live the best quality of life they can rather than attempt to extend their lifespan with procedures that likely will not help.
https://www.deathwithdignity.org/news/2018/12/impact-of-deat...
Thing is, that is 90% of the population which isn't getting quality care.
Canada: https://torontosun.com/2017/02/16/canada-has-worst-erreferra...
Ireland: https://www.irishtimes.com/news/health/new-record-of-more-th...
There's more, but lets get real. The U.S. system has it's problems, but at least I can get treatment. That's why it's a difficult subject and why we should be cautious on how to proceed. Perhaps run trials per state or something as well.
Canadian here - yep, there are sometimes wait times, especially for specialists, especially if it's something that is unpleasant but not urgently life threatening. That sucks. I'd still take that over some percentage of the population just not having access to care, or having a huge number of medical bankruptcies.
As for the ER - it even says in the article you link, that's largely people who could have gone to their primary care physician. Those are the people waiting. If you go in with a stroke, you're not waiting. I've (luckily) never been to the ER for a life-threatening situation, but I have for injuries where I needed urgent care, and got excellent treatment - and yes, once I had to wait for the guy ahead of me who had a stroke. I'm ok with that.
Yup. I'd rather wait 10 hours in ER for something non-life-threatening than get immediate care and spend the next 10 weeks fighting with insurance companies or filing for bankruptcy.
What? Where does it say that in the report? The figure is 24% of Americans and _56%_ of Canadians!
Patients who waited 4 weeks or longer to see a specialist, after they were advised or decided to see one in the last 2 years: Country results from highest to lowest
Canada, 56% (below average); Norway, 52%; New Zealand, 44%; Sweden, 42%; United Kingdom, 37%; Commonwealth Fund average, 36%; France, 36%; Australia, 35%; Germany, 25%; United States, 24%; Netherlands, 23%; Switzerland, 22%
Also, here's a quick guide to health insurance systems around the world. As a Canadian, I would urge all Americans to be extremely suspicious of the National Health Insurance model that Canada has. Wait lists are very real. The Bismarck model seem like a better fit for US culture and needs (still universal access).
http://www.pnhp.org/single_payer_resources/health_care_syste...
If you have a cold, you find a PCP or a "health clinic" and make an appointment for same-day or later-that-week. And sure it's hard to find that PCP, but with my PCP in the US I have to book appointments three weeks in advance!
I'd argue "75%ile time waiting in the ER" is not a great metric. That neither tells you how easy it is you are to get preventative or routine treatment, nor how well your ER is able to handle a mass-shooting type catastrophe.
The healthcare in the U.S. seems nuts because you are _billed_ for hundreds of dollars, but that's because they have to subsidize medicare patients AND insurance companies have negotiated rates based on percentages. So, they may only pay 40% of what is billed, but you are shown much more.
It's a scam everyone is involved in, which is why we need open pricing and open "how much insurance actually paid".
The US spends about 8% of GDP on private medical care, and another 8% on public care. Universal healthcare is about making the public, taxpayer-funded part of that expenditure more efficient, not about abolishing the private part of it.
Anybody who does this: "I have a medical issue but I'm not going to seek treatment for it because I'll get a bill for $10K" should be viewed as having infinite wait times, and counted in the stats thusly. But they aren't.
"Oh, I've got this giant infected cut on my hand and I'm not going to go to the doctor because I'll end up broke" simply doesn't exist in Canada or Ireland, or any other first-world nation.
And hey poster, I guess you didn't get to the bottom of your linked article: "Almost three-quarters of Canadians rated their quality of care as very good or excellent, well above the international average of 65%, she said."
But the main thing is this has nothing to do with the universality of healthcare, more about how it has been implemented in those two countries. Go look at the UK, France, Germany, Australia.
I’m assuming that you realise the singular first person in that statement is very much that: singular.
> Let’s get real
The New York Times sees “real” as under a Rawlsian veil: they imagine being any citizen. You seemingly disagree with that approach.
The German system, which is also the oldest universal healthcare system, would be the best/easiest fit to transition the USA towards that.
Three years ago Medicare for All was “politically infeasible”. Then it turned out when you presented a direct, clear policy that improved people’s lives and was clearly untainted by special interests, people started to sign up. And suddenly every democrat candidate who hopes to have a shot at least has to pretend to offer Medicare for All. (Pretend because obviously some are for “realistic” “politically feasible” plans that mostly maintain the status quo and keep lobbyists and the insurance industry happy.)
> But when people hear arguments against it, their support plummets. It turns out that most people don’t really know what Medicare for all means. Even asking three policy experts might yield three different answers.
I suspect most people think “medicare for all” means exactly what it says. Everyone gets Medicare, that thing that you currently only get when you’re over 65.
...That's despite the fact that earlier in the same poll, according to the methodology document, the questioner had asked their opinion about "having a national health plan, sometimes called Medicare-for-all, in which all Americans would get their insurance from a single government plan" and, separately, "creating a national government administered health plan similar to Medicare that would be open to anyone, but would allow people to keep the coverage they have if they prefer". Take from that what you will.
After noticing that weirdness, I looked for polls from other pollsters on the same subject. In an online poll from last October [3], when asked "When you hear candidates talking about 'Medicare for All', what do you think they are proposing?", 52% picked "A single, government-run health insurance program to cover all Americans", 21% picked "An optional government-run program that would compete with private insurance"... and 24% picked "Neither of these". That's roughly consistent with the other poll if you group "optional" and "neither" together, but I have no idea what people who picked "neither" think Medicare-for-all actually is.
Another relevant question is how many people support single payer or a public option when the choices are explained more clearly. Going back to the first poll, in the earlier question I mentioned before, 56% supported single payer, while 74% supported a public option. However, a later question asked "Would you favor or oppose a national Medicare-for-all plan if you heard that it would..." with a series of hypotheticals. One of those, "Guarantee health insurance as a right for all Americans", had 71% in favor; but "Require most Americans to pay more in taxes" and "Eliminate private health insurance companies" each had 37% in favor. (I suspect the authors of the NYTimes article had this poll in mind when they wrote "when people hear arguments against it, their support plummets".) Once again, the methodology is confusing: the question literally asks if the respondent would support (or oppose) Medicare-for-all as a whole if the hypothetical were true, but some probably responded based on whether they liked the hypothetical itself. That might help explain how "Eliminate private health insurance companies" polled worse than "having a national health plan [..] in which all Americans would get their insurance from a single government plan" from earlier. Another part of the explanation is probably just ignorance and people not thinking about the issue very hard.
From the second poll, when asked which option they would favor most, single payer, public option, and "neither" were all roughly tied, at 34%, 33%, and 30% respectively. The first two add up to 67% preferring either single payer or a public option. This is close to the 74% who supported a public option in the other poll, which makes the results roughly consistent, assuming that respondents to this poll who preferred single payer would still prefer a public option to nothing.
Anyway... it's certainly true that single payer has substantial support, and that it seems a lot more politically feasible today than it did in 2016, in large part due to the efforts of Bernie Sanders and others. But it's likely all downhill from here. Medicare-for-all has become such a popular rallying cry on the left that it doesn't have much room to grow. And for any variant of Medicare-for-all (like anything else), once a concrete policy is on the table and its costs and downsides are available to criticize, support will fall; and once conservative figures leap on the opportunity to rally the base with that criticism, what bipartisan support currently exists will evaporate. That doesn't mean it can't maintain enough momentum to become a reality: it could. But it will help to have a higher starting point of popularity, and so evaluations of "political feasibility" do matter.
[1] https://www.kff.org/slideshow/public-opinion-on-single-payer...
[2] http://files.kff.org/attachment/Topline-KFF-Health-Tracking-...
[3] https://www.axios.com/medicare-for-all-poll-midterm-election...
No country on earth with single payer or other universal coverage has anywhere near the number of citizens nor geographic or social diversity as the US.
Now, that doesn't mean we can't learn from those countries, but our own smaller scale federal health care systems (medicare, VA, tricare) are already large enough to compare with and done so.
It's quite unfortunate, but the entire federal system has to change in order to lay the groundwork for a single payer system.
That's both not true (the PRC exists, and alone is sufficient to disprove that no country with universal coverage exceeds the US on any of the measures you listed) and not relevant, as none of those are significant per-capita or per-GDP healthcare cost drivers.
The PRC has universal healthcare coverage entitlement by national policy, financed and administered largely by local governments under national standards (with central subsidies to poorer regions), and has over 95% of the population covered through public-funded programs. [0]
> 2. that it's something that is to be imitated?
The claim was no country with certain features exists; being worthy of imitation was not one of the features.
I never advocated emulating the PRC either in general or in the specifics of their mechanism of addressing universal healthcare access; in fact, I specifically pointed out that, as well.as being false, the claim about countries sharing those features was irrelevant to the healthcare discussion (which implies that a country meeting the supposedly unmet description has no particular reason to have special status as a model for the US.)
[0] https://international.commonwealthfund.org/countries/china/
That's saying nothing of its outcomes or service level by the way. Simply in reference to its structure.
It's not even in the same ballpark.
This argument is so bizarre. Larger population sounds like better economies of scale to me. And social diversity? I mean we're talking about Homo Sapiens here. A kidney is a kidney is a kidney, no matter your cultural background.
Healthcare also hasn't shown that it can scale or that margins increase with more centralized services, while maintaining service levels. Said another way: doctors (the bottleneck for service) are expensive to grow, take a long time to make, in high demand, and work serially (no parallel service provided).
It's a structural problem, not just a policy one.
Why is this relevant?
The UK for example has a population of 60+ million (v US's 300+ million), if that figure doubled or halved, I don't think that would fundamentally change how the NHS operates. Just like it doesn't fundamentally change how it operates in central London or the Scottish highlands.
I'm tired of "political feasibility" being a euphemism for negligence, incompetence and lack of creativity.
What we have right now with deductibles and co-insurance is ludicrous though, that shit needs to go.
Plus, it offers a minor incentive to actually be healthy. Health should be a personal responsibility just as much as a government responsibility. I don't support subsidizing unhealthy habits.
For example one asks:
> Do you support replacing individually purchased private coverage, like Affordable Care Act plans or Medicare Advantage?
What's odd even on the face of it is that Medicare Advantage works VERY differently than traditional private insurance (one being supplemental and the other being primary coverage).
Many countries have a mixed system. A basic level of healthcare with supplemental plans built on top to provide improved benefits, reduced OOP costs, and so on.
> Do you support ending employer-based private coverage?
Again, lacks nuance.
Some plans outright ban employer involvement, whereas others allow employers to make pre-tax contributions to something akin to a HSA (which can be used on premiums torwards a plan of the employee's choosing).
> Do you support eliminating cost sharing — meaning co-payments, coinsurance, deductibles — for everyone?
All or nothing. We cannot talk about eliminating cost in some services/areas.
At least tell me the estimated cost for the choices available...
The argument against cost sharing is that it penalizes the poor, who are likely to put off treatment if they can't afford it.
The argument in favor of cost sharing is that it helps prevent people from taking advantage of the system.
I wonder if it might be possible to strike a balance using graduated (rather than fixed) cost sharing based on income.
So, let's say the cost sharing for a monthly prescription is normally $30.
But someone with an AGI below $50K might pay $20, and someone with an AGI below $30K might pay $10, and someone with an AGI below $10K might pay $5.
You would always have to pay something (because, as NYU's Glied points out, "the biggest effects are moving from zero to something"). But that something would be proportionate to your means.
1. Use previous year income.
2. Everybody pays the maximum copay and then gets some money back with their taxes.
Fund drug research through public-private hybrids and grants, instead of intellectual property monopolies for the first x years of the drug. You can then spread the cost of developing the drug over a generation or two, instead of making the first people to be treated foot the entire bill. The public will own the intellectual property, the government can decide what diseases to fund/fight, and private companies still have incentive to perform research. All the while, private research can still compete for other treatments, or rare diseases with funding.
There is a supply limit imposed by the AMA. Kill it.
The system isn’t undermanned, it said: It’s inefficient. We rely too heavily on physicians and not enough on midlevel practitioners, like physician assistants and nurse practitioners, especially because evidence supports they are just as effective in primary care settings. We don’t account for advances in technology, like telehealth and new drugs and devices that lessen the burden on physician visits to maintain health.
Source: https://www.nytimes.com/2016/11/08/upshot/a-doctor-shortage-...
I’ve been preaching this for ages, there’s a place for MD/DO’s but when you go in for a set of sutures, an annual physical, all sorts of basic procedures there’s simply no reason for anything but a PA or NPP to be involved.
Let mid level providers do their jobs without needing a physician to sign off on everything (many states have figured this out already) and encourage growth in these roles instead of saying “we don’t have enough doctors!”
Can you give some examples of how other modern countries use telehealth and similar technologies as the basis of their provision of affordable universal healthcare? It has seemed like those countries were able to provide cost-effective healthcare without hand-waving future tech by rather boosting the supply in supply and demand.
In BC, Canada, there is the 24/7/365 BC Nurse's Hotline. (Healthlink BC)
It's a phone number, that you can call, to get medical advice.
"I have peanut allergies, and I am having an allergic reaction to peanut butter. I've taken my emergency pills for it, and I have an epipen with me. My symptoms are such and such. It's 3 am, and I'm at a provincial park's parking lot, 20 km out of town. Should I inject myself? Should I wait it out? Should I drive myself to the hospital? Should I call an ambulance?"
The practitioner at the other end will, given the information presented, provide medical advice.
The American reaction to this situation would be to go straight to the ER, regardless of whether or not they actually need it.
PS. In the exact situation I described, the person in question was told that someone should drive them to the ER (It turned out that they would have died, if they hadn't.) But, people call the BC nurse's hotline for all sorts of reasons, many of which do not necessitate a trip to the hospital.
To that point, for me the question(s) is straightforward:
- which other countries are the healthiest, - and which have the best healthcare outcomes?
I understand those might not be objective questions / answers but let's start there. The idea that there are no baselines or reference points is absurd.
- everyone can go to any doctor without any payments or paperwork, all of that being done behind the scenes
- you'd get a tax refund (it is literally cheaper than you pay in taxes right now, you just don't get universal care for your taxes now)
- your health insurance costs would be eliminated