High-Deductible Health Policies Linked to Delayed Diagnosis and Treatment
npr.org
npr.org
Try showing an NPR article about universal healthcare to Joe USA. I guarantee you'll get one or all of the following responses:
1: I don't want my taxes to go up
2: I don't want to pay for illegals to go to the doctor for free
3: My insurance will get worse
4: I like my doctor, I don't want to be forced to go to a worse one
5: I don't want the government deciding when I go to the doctor
6: I don't want to wait six months for a doctor appointment
7: NPR has a liberal agenda
Many of my family and extended social circles are quite conservative (in the USA sense) because of how I was brought up. I have heard all of these and more every time the concept of universal healthcare is brought up.
Most of the reasoning I hear is not based on facts, but on emotionally misleading arguments from the network of memes and punditry where they get their info. And when they vote, they vote for people who oppose universal healthcare on these fallacious bases.
How do you convince someone like this that universal healthcare is better for all of us?
Here is one approach.
1) Enumerate the different options.
2) For each option, enumerate the upsides versus the downsides, which includes cost of implementation and operations, along with their likelihoods. Every option has potential downsides -- are we willing to accept them for the potential upsides?
3) Rank the options by expected utility. Which one comes out on top?
Ironically, you may find that universal healthcare is not the top-ranking option or that we have not yet come up with a high-expected-utility option.
[1] https://en.wikipedia.org/wiki/World_Health_Organization_rank...
[2] https://www.oecd.org/unitedstates/Health-at-a-Glance-2017-Ke...
What I truly don't get about M4A advocates or believers is why they don't tolerate a public option. Just let the state compete in the open market, and if you like state run , you have your and thats it.
That said if health outcomes aren’t the utility of a medical system what on Earth is?
i.e. You can improve health outcomes and decrease utility by banning tobacco.
FWIW the big issue is that private companies don't want to compete with the state because the goal of the state is to provide quality care, not to maximize profit. None of the private insurers are lobbying for two-tier universal healthcare so they can show off their sheer superiority are they? You'd think if they were actually superior they'd love, or at least be neutral to, the introduction of an inferior competitor.
If you're so sure private cover is better why push back against the introduction of a public option at all? Welcome all comers with open arms.
Government also has an interest, in fact a huge interest. If healthcare were socialized entirely, dollar-per-dollar it would increase the federal government's size by ~ 10% of GDP. Currently its 21%! It would mean 50% bigger government!!
And that means HUGE cash, and HUGE political boons. Sanders could become president by promising people a healthcare service he does not pay for or he is not responsible for its failure. And the government now will have some omnipotent ways to levvy taxes and then short-change constitutents by cutting health spending or quality.
The government is also an interested party, and it's stands to gain more power than ever with such a ploy.
I also urge not to believe that the state "does thing for the people" because it either fails to do so or it just is plain false. Please look at the real results of public education: it has terrible results even though "its in the interest of the state to provide quality education".
It doesn’t increase the size of government, those are flow-through dollars, they go in one side and out the other. A huge amount of American healthcare is already socialized between Medicare and Medicaid. If anything consolidating these disparate services should represent an administrative efficiency. And even if, so what?
Yes the government can then change health policy, that’s the point. If they cut it, deal with it at the ballot box. Right now there’s zero transparency and accountability with private insurers, so it’s strictly worse. In other countries the government treats health programs as sacred just like Medicare.
The data shows it works everywhere else, it can work here too. Government works in other countries, it can work here too. I’m curious as a free market health aficionado why not pitch privatizing Medicare? How’d you think that’d go over?
This is just a plain criticism of capitalism in general. Does this logic apply to everything else? Like food? Housing? In practice we have a great example with public education: an expensive, unequal base level that americans avoid if they have the money to.
> It’s crazy that the government was able to shirk it’s responsibility to look after people and place that unfair burden on businesses. > . It’s time to relieve businesses of the burden of dealing with their employees health
I agree, although I would like to note that historically this made sense from an administrative standpoint. Back in the 20's, administrative work of insurance was like half the cost. It wouldn't be so expensive today with electronic payments and all. Its the same logic behind payroll taxes (those that work pay it) mostly because its easy to do, not because its fair or good.
Its true that businesses would love not to manage training people about healthcare, but then the government will have to do it and that won't come cheap. That will be an interesting challenge. The M4A plan of no copays no nothing, that would eliminate that instruction is a pipe dream.
> It doesn’t increase the size of government, those are flow-through dollars, they go in one side and out the other.
Hey come in.
<They are in a federal bank account.>
<They are processed by a claims office that decides what to pay and what not to pay> They come out.
Whatever claims are not paid, its money leftover for spending in whatever initiative the government wants. In fact advocates for socialized medicine like Sarah Kliff want that to happen so the government can set prices. Since its your only employer (no competition with private insurance) you say you accept it or you close down.
> If anything consolidating these disparate services should represent an administrative efficiency
And if it doesn't, whats the way out?
> Yes the government can then change health policy, that’s the point.
Maybe thats your point, but I don't want in on that. I dont want the government deciding for me.
So I dont want to go thing by thing: we disagree, you envision a government administration to be great and fantastic, and I see it as unfair and oppressive. Lets compromise on our different of beliefs: lets advocate for a public option. Government offers something, insurance offers theirs, they compete in the open market, you get what you want and I dont need to confront.
I do want some other things though!
The reason public education is bad is because Americans have decided to hate their government (which is an extension of themselves) and not invest in services in the public interest. It's not inherent to the system, it's a product of what you put into it: apathy and distrust. The same just isn't true in other countries.
In your criticism of public education you actually make a case for two-tier healthcare: I'd rather have a base level of schooling I can buy my way to "better quality" than leave anyone who can't afford private school out on the street with no education.
Not everything needs a profit motive. Some things, the ones that lay a foundation for a free and fair society, such as police, fire, roads, railways, water, education and health, should be provided. This allows individuals to rise to the level of their abilities and merits without relying on the largesse of their family. This is the meritocratic American dream, in a lot of ways. There are plenty -- and I do mean plenty of ways to make money out there, it's not like socializing this eliminates capitalism. If anything, it bolsters it by allowing more people to pursue entrepreneurship.
> Its true that businesses would love not to manage training people about healthcare, but then the government will have to do it and that won't come cheap.
It is cheaper in every other country, and there's no reason it wouldn't be cheaper here. Analysis in a Koch-backed study showed it would be +/- 10% (either 10% cheaper or 10% more expensive depending on ability to control costs while covering 12% more people) -- so less per capita no matter what. [1]
> Whatever claims are not paid, its money leftover for spending in whatever initiative the government wants.
That's not how governments work, that's how private companies work. Private companies take left over money and distribute it to their shareholders. Whenever a private insurer denies a claim someone makes money. Governments distribute it back to the people. Their goal is not to make money, to have money left over, it's to provide service. If they can do it for less, they'll lower their budget.
Not that it matters, single payer setting prices works just fine in Canada. You know that price transparency everyone in America is demanding? Here's Ontario's entire list of prices: http://www.health.gov.on.ca/en/pro/programs/ohip/sob/physser... PET scan? That's $237.50 (vs. $5000 in the US).
> And if it doesn't, whats the way out?
Voting?
> Maybe thats your point, but I don't want in on that. I dont want the government deciding for me.
By voting you decide. That's government. It's an extension of the people's will. You are in fact deciding. I'm sorry you feel like that doesn't work here, and that in fact you'd rather a faceless, un-accountable corporation with an interest in making a profit decide than a transparent, public good service you can control the leadership of. The government "decides" for you in so many other ways, it's ridiculous to draw the line here but even if you were to, offering a public plan strictly increases your options.
[1] https://www.nytimes.com/interactive/2019/04/10/upshot/medica...
Thats not going to change with socialized medicine. So shouldn't you be against it? Because americans still "hate government" and if that breaks government programs, it will break socialized medicine as well.
> In your criticism of public education you actually make a case for two-tier healthcare
US already has this. Namely Medicaid.
> It is cheaper in every other country,
We have had this argument before. Making it socialized will not make it cheaper, it will fundamentally change the way its funded. I haven't seen the details of the Koch study, but there are things that won't change: the shortage of doctors, the cost of pharma, the amount of hospitals, malpractice insurance costs etc. The cost of administration is exaggerated because that administration also provides value: it checks expenditures, medical reasearch etc.
In any case, again, if gov will be so efficient, it can start with a public option and see how that goes.
> By voting you decide. That's government.
I dont want to vote to see if I can see the doctor I want to see or pick the service I want to use. If you wish to vote your treatments go your own way, and you don't need me to achieve that. Advocate for a public option you can opt-in, and if it is truly better and cheaper and all that, now we know. I believe it will be worse and more expensive and I don't want to be locked in to that.
> The government "decides" for you in so many other ways,
That doesn't make me feel any better.
Maybe I'm just optimistic but I hope that this could be the thin edge that changes it. When in a democracy, attacking the government is attacking yourself and your country. It hurts you and your fellow citizens to approach social services like this, IMO.
That said I'd rather a low-quality baseline everyone gets that people can buy out of as necessary than leaving 10% of Americans un-insured and fending for themselves. Now ideally, I'd like a high-quality baseline everyone gets but even a low-quality program is better than the bupkis we have today.
> US already has this. Namely Medicaid.
Well, if private cover is the be-all and end-all why do we need this? Why don't we just privatize Medicare and Medicaid if they're so much worse? That plan enjoys little support, even from Republicans. Turns out the aged are all about socialized medicine for themselves, just not for anyone under 65.
You know that Medicaid may put a lien on your house for the amount of money spent on your care right? It's not socialized cover for the poor, it's death-prevention for the destitute.
> We have had this argument before. Making it socialized will not make it cheaper...
It does, though. Accessible preventative care is cheaper than dealing with problems down the line. You don't have huge marketing budgets, you don't have CEO compensation, you don't have claims denial departments, you have simple, stream-lined payout processes and pricing structures. You drive down drug prices because the states form bulk buying groups and negotiate. That's what makes drugs in Canada so much cheaper even though unless administered at a hospital, you have to pay out of pocket -- negotiation. Your incentive as the government is to make people well to drive down the cost of healthcare. Just axing coverage will not get you re-elected. (Imagine the optics of being the politician that cut spending on healthcare causing their constituents to die publicly?)
You send everyone through a primary care physician so they're not wasting the time of specialists via self-referrals. The list goes on and on. Medicare is objectively more efficient than private care. [1]
Then if you go all-in you can do what Canada does and socialize malpractice insurance too. It costs a fraction there of what it does here.
> In any case, again, if gov will be so efficient, it can start with a public option and see how that goes.
I'm down.
> By voting you decide. That's government. I dont want to vote to see if I can see the doctor I want to see or pick the service I want to use.
You don't get it. It's the other way around. In a public system 100% of doctors are in-network. You can go see anyone you need. In the US you either go to the ones your employer has in-network or you go bankrupt trying to see someone else. Change jobs? You may well have to change doctors. This whole narrative represents a false choice.
It's the other way around: Socialized cover represents a large cluster of freedoms: The freedom to pursue self-employment or liberal arts or stay-at-home parenting without fear of death or bankruptcy. The freedom to pick any job regardless of medical coverage. The freedom from worry about dying in the streets. The freedom from fighting your insurer over legitimate claims. The freedom to pick your own doctor regardless of what your boss wants -- and keep them if you change jobs! The freedom from having to pay more than you can afford for medical coverage. It's the freedom from having to be required to create profits for the insurance companies, by law (the individual mandate).
> The government "decides" for you in so many other ways, That doesn't make me feel any better.
Fair.
[1] https://www.modernhealthcare.com/article/20190211/NEWS/19021...
It's like offering government fire insurance only to buildings already on fire, in high-risk areas and below-code, leaving all the not-on-fire up-to-code buildings for the "free market." It's insane.
Medicare is funded by payroll taxes. So it already works as in "the young pay for the old". Its true insurances have incentives not to have diseases before patients to go medicare (for example, if they knew something has high risks at old age, but low risks before, they have an incentive to do that). Working in the industry I have yet to see an example of this, so I think its a greatly exaggerated claim.
OTOH, hospitals are forced to take medicare patients, and the reimbursement rate is up to half of what regular insurance pays. It is often below cost of care. This implies a cross-subsidy from private to medicare.
I think the final math on this topic is ambiguous. I would not make a claim either way without some stronger analysis.
But I agree generally with this approach. Nearly every developed country has dramatically lower costs for the level of health outcomes, but they do it in a variety of different ways. There are clearly possible affordability improvements (even if we only try to catch-up to where other countries are at). But certain approaches may be more feasible to implement or may have less downside if things don't go perfectly.
Healthcare is already melting down, for patients.
https://www.quora.com/Who-or-what-controls-the-number-of-med...
Govt cost per capita for medicare is a measure of its efficiency, but not that its already funded for everyone.
Almost all of those in that list are fear-based, and fear is a big emotion. I don't know how you get past that, but the 'freedom' factor somehow should be focused on.
Freedoms to bring up:
* The freedom to move between employers and not have to concern yourself with tying your ability to get specific health service based on an employer's ability (or whim).
* The freedom to move geographically and not be concerned that you won't be able to afford access to health services. My own health insurance has a decidedly different monthly premium based on county, and I'd be saving probably $150/month if I lived 3 miles to the south.
* The freedom to start your own business (purportedly the backbone of 'US conservative thinking') without worrying about crippling debts.
Right now, instead of an elected/representative Congress controlling what services/procedures/medicines you have access to, you have a for-profit private company, with no recourse to change their leadership or focus via election/recall. "Vote with your feet" is basically impossible in this system.
"Insurance" is an odd product in this space too, at least for basic health care. Insurance is typically something we might get to reduce our exposure to risk for activities we engage in which are voluntary. Choose to buy a car? Get some insurance to help cover replacement costs, or incidental costs to others you may harm. Buying a house? Or renting? Get insurance to help cover replacement costs of things. You can choose to not buy a car, or a house. No one chooses to be born.
Untie anything related to medical care from employment. By what measure is tying someone's ability to access healthcare to the beneficence of their employer remotely morally good? Someone has no employment (through whatever or no fault) and we decide that they are somehow fundamentally unworthy (or perhaps just 'less worthy'?) of access to health services?
What never seems to get talked about after "your taxes will go up!!!" is "other things you pay for will go down!". Employer paying $1000/month for your health insurance policy? That expense will go away, and they'll either pay you more with that money or pay more in taxes.
Really... break ties between "employment" and "health insurance". It's a massive distortion of the 'free market', which is typically a conservative crowing point.
b) just divorce 'insurance' from being something which people expect to be tied to employment. whatever falls from that would likely be better.
I think that would be the most painful change to healthcare in America, but I don't think anything can improve until it happens.
Good comment a consultant we hired said. He and his wife had insurance for 25 years, then lost their jobs. Then his wife needed surgery.
It's a dick outcome when someone pays in for 25 years for a service and then gets denied because the economy tanked and they got laid off.
> The freedom to move between employers and not have to concern yourself with tying your ability to get specific health service based on an employer's ability (or whim).
It is the government that subsidizes employer insurance (a 260 billion tax subsidy for the richer part of society) and has made it mandatory. Repeal laws and this would naturally stop happening.
> The freedom to move geographically and not be concerned that you won't be able to afford access to health services.
This is not solved by socialized medicine: in a full government control scheme, the government decides where the doctors and hospitals are through the payment model. And the government will pay differently based in location as it already does for federal grants to hospitals.
> The freedom to start your own business (purportedly the backbone of 'US conservative thinking') without worrying about crippling debts.
Just crippling taxes. Its not that the cost dissapears, its that its mandatory to finance it with taxes.
> Repeal laws and this would naturally stop happening
I agree. I think there are regulations that could be changed to immediately economically favor individuals purchasing individual insurance plans vs employer-provided insurance stuff. I'd probably be in favor of that, but would prefer single-payer. Regardless, I'm definitely against employer involvement in employee healthcare at all.
If you're a minority in a society with universal healthcare, you will have to constantly fight for your rights. The second the rest of society decides your diet or your hobbies are too dangerous, they'll be pushing to ban you from partaking in them.
Also for #2, most democrats seem to support giving healthcare to illegals so I don't know why you act like that's a myth. And for #1, it's true for tens of millions of people that they will pay more in universal healthcare than they do currently. This is inherently true of all socialism (make no mistake, universal healthcare is socialist healthcare). If somebody is getting something for free, the money to pay for it is coming out of somebody's else pocket.
Instead, healthcare companies charge more if you're at risk. They're implementing solutions to discourage bad behaviors. Worse, this is all packaged up in various apps designed to take your data and sell them to others to make even more money off of every single person they rip off.
Don't even get me started on how the insurance industry abused pre-existing conditions as a catch-all term for denying coverage for things that weren't even a result of life style choices. So how is this different from the horror scenario you bring up?
I’m in agreement that the current situation is hot garbage, and it’s shitty for a lot of people. However, my insurance now is good enough for me and my family. Sure, it’d be nice if it was cheaper, but whatever. As I get older I find I can’t be bothered to lay awake at night worrying how everyone in the country gets healthcare anymore. I’ve simply accepted that this is the world we’ve been dealt and everyone needs to find their own way to survive.
My main concerns are 3,4,5,6. I don’t see them as “fallacious”, I think it’s naive to assume universal healthcare will work exactly as planned with no unforeseen consequences, and I’m generally suspicious of people who do not list the risks along with the benefits.
With that said, having a massive middle man (private health insurance) to act as bloat and added friction on the economy is bad for everyone. You may not be directly affected but you are definitely affected in other ways that aren't as obvious.
I find this sort of thing is common in America. There is always an industry set up as a middle man that needs to get paid.
The Obamacare tax was something like 3%, and only for the extremely wealthy.
In contrast, 33% of US healthcare costs go to insurance overhead, and >17% of our GDP goes to health care, so nearly 6% of the gdp goes to private insurance middle men.
Source on 17%: https://www.statista.com/statistics/184968/us-health-expendi...
Now, the entire federal government is currently spending 37% of GDP (though that includes deficit spending), so you posit that at least ~ 1/6th (6/37) of government spending is some healthcare program.
Source on 37%: https://tradingeconomics.com/united-states/government-spendi...
Medicare and health costs ~ $1T of the government’s $3.8T budget, which is a bit over 1/4th of the federal budget. That does meet the threshold of your claim, but only if much less than half of Medicare spending goes to actual health care.
Source on 1T Medicare, etc spending: https://www.nationalpriorities.org/budget-basics/federal-bud...
This study from 2001 concluded Medicare is about 80% efficient (20% waste): https://www.nber.org/papers/w8395
Note that the 20% Medicare waste number from the NBER study is not apples to apples with the 33% administrative overhead number, since it includes ineffective medical care (and all other wasted spending) that did not improve patient outcomes in the 20%, but the 33% number for insurers only counts useless paper pushing, and not ineffective care, etc, etc.
So, private insurers really are squandering many more healthcare dollars, and are also much less efficient than the federal government.
6% of GDP to private insurance? Math doesn't add up on this back-of-the-napkin math. That's an entire Apple of operating costs every year.
The biggest insurance company, UnitedHealthcare, is worth 200 bill in the market. The gov could buy the big 5 insurance companies with half its yearly medicare budget.
Don't confound paying to insurance and paying to providers!
> So, private insurers really are squandering many more healthcare dollars, and are also much less efficient than the federal government.
I will answer seriously in a second, but for real: how is it so obvious that the private market beats the government on almost anything at any time, even this very government (for example, education) and still, the level of debate is "government is more efficient". Government is never more efficient, because it doesn't care about efficiency.
The comparison of efficiency between medicare and private insurance is grossly misrepresented by Bernie Sanders. First of all, there are some disingenuous numbers: it uses a measure of efficiency of total cost/admin costs, but that skewes severely in favor of medicare bacuse it has an older population that has more expensive treatment. Some economists looked into this and the cost of administration per patient is similar.
Second, a great part of why medicare has less admin burden is that its collections are done through payroll taxes. This means the admin staff is included in other government agencies. This is not a public-advantage, because you can also use payroll taxes to pay for private insurance if you wish so, something that exists in some other countries. ( to my dismay, for the following topic). Another trick here is that medicare collects from everyone and pays for a few. That is a great way to never have to market, administrate or manage people on your plan: you are not going to use it? tough luck. You dont like it? tough luck. You don't have quality coverage in your area? Tough luck.
This trick is so pervasive that even Bernie Sanders claims how medicare patients are so happy: why wouldn't they, the premium they should pay to maintain it is about 1k a month, and they pay 150!
Forth, it is key to understand that medicare offerings are not market competitive. They pay half of what private insurance pays, and there is no way in hell you make that work. Private insurance subsidizes medicare patients, and doctors would abandon the network if they were forced to accept medicare rates.
This is a long topic, but to re-frame the conversation: what makes healthcare in the us expensive is NOT private insurance. Most of the world has private insurance! even Canada! Even France! Spain, Norway, etc. US healthcare is expensive because it is one of the most tight regulated expensive markets in the US.
What people dont get is that private insurance fiercely competes to lower costs, while the government's only effective mechanism is to not pay anything at all. Socialized medicine in the us would usher a new era of Cash pay.
You might guess right now that I will argue the exact opposite point.
> ou completely left out that Republican Congress specifically denied Medicare the ability to bring in cheaper drugs from other countries and isn't allowed to negotiate drug prices, oh and they've underfunded every single regulatory agency for ages to be able to claim government doesn't work.
Aren't you taking into the calculations that socialized medicine will have the same political risks?
> Why is it that other countries can somehow pay more for the same or better care of their public options and we don't.
The U.S. has a specific regulatory framework that is chaoticly expensive. Regulatory capture is grotesque in the healthcare market, and you can read up what health economists say if you want details. You could aim to do a healthcare reform that just plain reduces the cost of care by 10, 20% easily by just doing less as a government.
> You're never going to have a cheaper private option with a profit motive on anything versus an option that doesn't require a profit motive.
1) Medicare is also more expensive than other countries socialized systems 2) Some of the biggest insurance companies are non-profits 3) The combined market value of the top insurance companies is less than half the yearly Medicare budget.
For me, since I saw first hand what the healthcare system did to my parents? No one should go through that. They had 'good enough' healthcare and it still financially and physically destroyed them.
You think you have good enough health insurance? You don't.
Not sure why those risks mean I have to get on board with a complete overhaul to something I don’t believe will work, as if that will be less risky.
You say that now, but the reality is much different when it comes down to it.
Like everyone else, you'll scream and cry like a stuck pig when it's your Mother/Sister/Daughter/Son who get unbelievably sick through no fault of their own and die early because of a lack of money.
The system as it exists today is nothing short of disgraceful. It's sad that you just accept it and have no interest in improve it.
I don’t have reason to believe my insurance will suddenly drop coverage when I need it. I don’t think that’s a huge risk.
Your hypothetical world isn’t all that safe either, because when the government says no, that answer is final. There is no other option, there is no other way even if I wanted to pay. That’s just as bad as coverage being dropped, and perhaps much more likely given my faith in the government to do things efficiently these days.
Even for lukemia, or lung cancer? and that's assuming you go to work for the rest of your life. What happens when you get so sick with one of the above you can't go to work and you no longer have insurance?
> Your hypothetical world isn’t all that safe either, because when the government says no, that answer is final. There is no other option, there is no other way even if I wanted to pay
That's simply not true. I've had personal experience in Australia, Canada and the UK, and in each of those systems you can choose to pay for private coverage & care if you so wish. I have never felt the need.
EDIT: Also, I thought of another reason.
You use the word "I" or "Me" 6 times. Does your grandmother have the same "bulletproof" coverage you do? Your nieces and nephews? Your Sister and her husband? How about your distant cousins? How about even your best friends, neighbors, and their loved ones. It's not all about you. Think about how your loved ones will be impacted, because they just might not have the same coverage you do.
Are you confident you'll never go through a stroke?
There's loads of cases, including one in this thread, about people who thought they were covered but weren't. This is really a bad situation to be in if it happens, and it should worry you every time there's an event. After all, the insurance company has direct interest in not covering you.
Now the government does as well, this is true. But those cases, eg in the UK it's talked about a fair bit, tend to be where there's a judgement that a treat is neither not sufficiently tested to be useable, or simply not worth the cost-benefit, eg it's expensive and only buys the patient a few more weeks of life. So it's true what you say, but it's worth considering what the balance of risks is: a healthcare co that has an interest against you every time, and has been shown to fight, or the government, which normally only denies treatment in rare borderline cases.
I'd say a big part of it is particular to US culture: the healtcare cos have been shown to not be that easy to get money out of. Somewhere like Switzerland also has private healthcare, but they don't compete in the same way. Everyone must have insurance, and you won't be paying out of pocket above some limit. The companies are not famous for screwing everyone, and compete to provide extra service (eg hotel-like rooms when you have a kid).
Arguably their job is to not cover you. Paying actual medical expenses is referred to in the industry as "medical loss". To reiterate: paying for health care is considered a type of loss. Their goal is not your goal.
Plenty of developed countries like Germany and France have better access to health care (that costs a lot less) while still being multi-payer with private insurances. Although in the US we just seem to only pay attention to Canada and the NHS so universal health care and single-payer are tied together.
Honestly I think people's expectations have gotten much too high about single-payer solving all our problems. Clearly other developed countries have gotten their health care (relatively) in order without doing single payer. And we basically already have single payer for age 65+ and the costs there still aren't nearly in line with everyone else. The US definitely spends much more (as a % of GDP) than everyone else (to not dramatically better results) but single-payer or not doesn't seem to be the key difference.
We also have something similar in the U.S., given that roughly half of medical care is paid for by the government. Medicare sets prices for each CPT code, and they do it through a formula that depends on geography, and something called Relative Value Units.
This is done nominally by the Center for Medicare Services, but they rubber stamp the work of the Specialty Society Relative Value Scale Update Committee, which is a group of doctors appointed by their respective medical societies to decide how much Medicare should pay them. When doctors can simply tell the government how much they should be paid, what do you think is gonna happen?
At my last N employers, I’ve been lucky enough to choose between literally the best HMO in the US (on multiple metrics), and top-end insurance plans from a range of multiple companies (e.g., a $0 annual deductible plan or an HSA + high deductible plan, where the employer’s HSA contribution matches the annual deductible).
The paperwork for the high deductible plan took multiple letters per doctor visit spread over multiple months, and more than doubled the paperwork we had to track for income taxes. This is completely unacceptable.
The HMO is, well, an HMO, we have limited choices of doctors and specialists, but I swipe my credit card when I check in or pick up medicine, and that’s 100% of the paperwork, even for extended hospital stays.
The only people in the US with better health care plans have what I have, and also a personal assistant (or heroic spouse) to abstract away how messed up the system is.
For these reasons, I argue the US health care system has failed all but top <1%, and those people can already afford to fly to Europe and buy specialist care, I don’t see why they won’t be able to do so in the US after the rest of us get universal healthcare.
3: Don't need health insurance so I'd say that's better.
4: We can chose our own primary doctor from the pool of available GPs. Available just means that some GPs have too many patients on their list already and don't have any slots available. You can switch primary GP once a month (IIRC). I switched a few times until I found one which I liked. Repeated the process when I moved.
5: I can see my GP whenever I feel like it, just need to set up an appointment. If you mean to see a specialist then yeah, I'd need my GP to refer me. Sometimes this can feel a bit unnecessary but mostly it's not a big issue IMHO.
6: If my GP doesn't have time for me, I'd just switch and find one who does.
There's a big group of other issues at play. And universal healthcare in the US would be so massive that you can't compare it to a small country.
You do have health insurance, it's just provided by the government with premiums paid through taxes. When people express the concern that their insurance would get worse, they mean that the insurance provided by the government would be worse than what they currently have. There are a number of different things that people think make plans worse or better, which is a major contributor to the difficulty in having a clear discussion about this.
Yes, I had a line about being taxed quite heavily but deleted it for reasons I've forgotten, and I missed updating point 3.
I don't need to worry about my insurance though, what it covers etc.
One thing I'm way more afraid of with a single payer system (but not necessarily all universal coverage systems) is that if the coverage became worse, I would have no recourse; it would be a monopoly, I wouldn't be able to look for a better competitor. Even worse, it would be a monopoly run by a political bureaucracy, so coverage decisions could become political. For example, coverage for birth control is a very political topic here. I'm certain that the first incarnation of a single payer system would cover that, because it would be set up by the politicians who favor it, but once the system is enshrined, whoever is in power would be able to change it however they think best. Coverage policy could easily become a political football.
https://en.wikipedia.org/wiki/Health_system#International_co...
You have to show that the government is competent enough to create universal healthcare. If people thought the government were more competent in general, they'd be more amicable to having the government choose a doctor for them.
I don't love my current healthcare, but I'd rather muddle through 5 additional doctor visits than 1 additional DMV visit.
Anywho, I don't imagine my (public system's) doctor visits being any different than yours. Except less paperwork/billing work.
Long lines, onerous paperwork, generally unhelpful/not caring govt employees
That said, it's undeniable that NPR has a liberal agenda. They swung so much in that direction in the past few years I stopped listening to them and switched to audio books for my commute. Best switch ever.
I still have no idea why they think "Wait Wait Don't Tell Me" is a show that deserves air time though. Worst radio show I've ever listened to.
You will very likely be denied treatment if your condition is "only" a chronic one. And if you do show up with an acute+chronic condition, your acute condition (heart attack) will be treated, but no mandated follow-up for your chronic one (ongoing high blood pressure).
edit: watered down some of the absolute statements, you're all free to try your luck, don't take my advice blah blah.
The larger point is, the "crazy expensive", acute part is already "universal". We just need to mop up the remaining stuff, formalize the arrangement, and call it a day.
Adams also makes another point in that this can't happen without downward pricing pressure for drugs and services and there currently isn't much. If you have a fancy insurance plan it doesn't matter to you if something costs $1000 or $10K or $1M - you aren't the one paying. What he suggests is insurance companies should give you a kickback if you find a service for less than a predetermined threshold. You already see this happening in some cases.
I believe Trump will create that downward pressure for drugs (as he promised many times during his campaign), but services are going to be an issue for years to come, perhaps until automation takes over.
The "crazy expensive" part of health care is the long-term chronic conditions: they require a lot of care/tweaking/services over a long period of time. The lifetime costs of treating a diabetic exceeds the lifetime costs of the one-off hip replacement or hip fracture.
I dunno how Trump will create downward pressure on drugs without regulating prices on patented drugs or discouraging/defunding cost-ineffective interventions. That's how most other countries do it, but it seems incompatible with his philosophy.
For type 2 diabetics, most are in or will be covered by Part D, so the manufacturers do the same thing.
But for a one-off treatment for those the middle aged, like the new HepC treatments, manufacturers don’t have the same incentives.
A mandate to receive emergency care is not universal healthcare. You still die from the cancer you get and can't afford to treat because it is not emergency care.
NPR doesn't have a liberal agenda, who knows what you're talking about. If anything, they bend over backwards to hit "both sides" and corporate narratives.
They are my main source of news, but there is a lot of truth to "you report what you see", and most of the reporters are liberal, so they cover liberal issues. I agree that they go out of their way to correct for that bias, and I appreciate that they do.
His main point was, _we are already paying_ for universal healthcare, since everyone who _really_ needs the expensive stuff done, gets healthcare care. It's hard to argue with this.
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case "styleguidist":
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case "next":
case "apollo":
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case "nest":
case "vuepress":
case "styleguidist":
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return "src/index.js";
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if (config.template) {
return config.template;
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} catch (e) {}
}
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return "gridsome";
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if (totalDependencies.indexOf("vuepress") > -1) {
return "vuepress";
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if (totalDependencies.indexOf("ember-cli") > -1) {
return "ember";
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return "sapper";
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return "gatsby";
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}The Right Wing has it figured out. Democrats think they are showing up to a debate club when the other side has been out for blood for the last 50 years.
Energize the base, and the moderates will eventually fall in line (just look how small and ineffectual the "Never Trumpers" turned out to be). The base drives things now. You can't just fire up the base and then slap a Romney or Clinton on top and expect to win elections anymore.
Where what you said comes into that is that Democrats think they can win just by nature of Republicans being incompetent. Republicans are out there, like you said, doing the dirty work to win elections and mind/vote-share, because while they disagree with Democrats, they know they can't just rest on their smug sense of superiority.
First of all "universal healthcare" itself is pretty vague. Most developed countries have universal access to health care for less money but they do it in a lot of different ways, from NHS like systems to multi-payer systems like in France and Germany.
So reform could be a lot of things from a public option on insurance exchanges to single-payer with government-run hospitals like some other English-speaking developed countries. Honestly, I feel like people who are worried about second being actually implemented well are not necessarily just ignorant, for example the VA system in the US is structured in a similar way and a lot of people have terrible experiences with it. So at that point I usually acknowledge their concerns and point to other developed country systems that don't have the same single point of failure.
When you say "universal healthcare" are you trying to sell them on single payer specifically? I think the argument is stronger by letting go of that and just focusing on the costs and results compared to other countries.
I'm very supportive of universal healthcare but even I doubt in the governments capability to pull it off, we couldn't even pull off healthcare.gov without massive waste.
Regardless I will continue to support it even if it means a generational hit to get it right.
I don't see why healthcare is any different. People wanted roads, so we built roads. People want healthcare, so we should build healthcare. It's the same exact thing.
American conservatism is authoritarian. The only way to reach an authoritarian is to shame them. Because they are family, you shouldn't insult them or anything, but you need them to be on the defensive about those ideas.
Go through each one and ask them why they think that, but don't leave it open-ended, make it clear that you're asking why they think that despite all the evidence.
Example for response 1:
Why do you believe your taxes going up is a problem when you will be paying much less overall? How many dollars are you willing to spend to avoid one dollar in taxes?
The clarifying factor where you hold the cards and knowledge, and they don't (and therefore feel shame) is the simple fact that universal, taxpayer-funded healthcare is far cheaper than private healthcare.
Because they are authoritarian and this line of thinking disagrees with the authority, there's a very good chance that this will not work, at all. Instead, they will try to change the subject. Don't let them. Patiently guide them back to the question at hand, make them explain how much money they're willing to spend to avoid paying taxes, make them deal with the fact that they will save money.
Depending on the person, they will just trudge out or start insulting you. If you're lucky, they might listen a little. It's rare that anyone will change their mind on the spot, let alone an authoritarian conservative, whose entire identity is predicated on believing nonsense given by a chosen authority. But, if you do it enough times, it can start to sink in. Alternatively, if they start insulting you, that's when you have to bring out the less polite shaming, because it's what they respond to.
Best of luck.
That's funny, I don't see how you got there though. Liberals seem to engage in authoritarian tactics quite often from what I can see. Demands for censorship seems to come from there.
>Why do you believe your taxes going up is a problem when you will be paying much less overall?
And then they counter with: If people will get better healthcare then somebody will have to pay for it. I like my current healthcare, so I'm going to be the one that has to pay for those other people.
Now the onus is on you to prove to them that their costs won't increase. You'll find it very difficult, because those costs probably will increase.
>The clarifying factor where you hold the cards and knowledge, and they don't (and therefore feel shame) is the simple fact that universal, taxpayer-funded healthcare is far cheaper than private healthcare.
What's your evidence for that? Because if you're going to cite other countries then you also have to keep in mind that they have a completely different structure for healthcare outside of whether the government pays for it or not. The US does more biomedical research than other countries, doctors are paid more, more treatments are available etc.
I don't think it's nearly as easy to try to convince someone that universal healthcare is cheaper or better. Also, when you say universal what do you mean? Universal, where everyone gets it or the 'universal' that some (many?) countries do, where you have to be employed and pay over a certain amount of tax to get healthcare or healthcare is predicated on you having mandatory insurance?
Tell them that the government should get out of the road business, and you should only drive on roads where your employer has paid the toll for you.
And many of the things you mention are factually correct statements on for example, M4A.
When you say "convince" you actually show militancy, not understanding. I get it though, the topic is very complex and people lean very differently. I think the best way to deal with this political will is to do a public option. More choices to the people: if public truly is better, then it will promptly show it in the open market. If its not, then we know socialized solutions will not work.
And that's exactly what happened, most developed countries have got variants of socialized healthcare
Also, market failures happen all the time, it is never a good idea to rely on "Free Market Fanaticism" as that easily leads to catastrophe without oversight
At least by the accounts of the Social Transformation of american medicine, european health systems were pretty much top down, but the AMA was so politically powerful that it was able to fight it effectively.
There are many cases where a somewhat expensive treatment saves a very expensive hospitalization.
For instance, a steroid inhaler for asthma costs about $200 a month, maybe you have two $200 specialist visits a year. So for $2800 a year (not covered by high-deductible insurance) you can probably be symptom free or you can take your chances and have an exacerbation and a $28,000 hospitalization (which insurance will pay some of after the deductible)
Docs hate them too.
With real insurance, you have maybe a $20 copay you pay at time of service and they know they are going to get paid by the insurance.
With fake insurance, they don't know what you are going to pay until months later when the insurance gets around to telling them. Then you get a bill that says you owe $291.44 for some unspecified service you got 6 to 18 months ago.
(They can't tell you what it was because that would violate your privacy)
Needless to say they have a big accounts receivable this way, many people don't pay or they pay late (e.g. a few months after getting a bill they don't understand as well as something that says "THIS IS NOT A BILL" they don't understand). This is not good for their finances or their state of mind.
In theory high-deductible plans might lead you to shop around between providers to get a better price but in practice nobody can or will tell you what things costs and it doesn't work.
It's a perfect example of the neoliberal mind at work.
Do you have a citation for this? If this were true, why would they aggressively negotiate lower costs and offer discount Rx cards?
In the US, higher premiums mean fewer subscribers. I'm a co-founder of an auto-insurance company, and all we ever try to do is lower premiums in order to compete.
> The 80/20 Rule generally requires insurance companies to spend at least 80% of the money they take in from premiums on health care costs and quality improvement activities. The other 20% can go to administrative, overhead, and marketing costs.
Basically, if you want to make more profits, you have to increase the raw size of that 20%. There's really only one way to do that - raise premiums. You can't really lower costs, as you risk having to pay back your subscribers for having shrunk the costs side too much.
Unfortunately, a properly functioning insurance market would require dumping everyone on the market, not just those who aren’t lucky enough to have it from their employer, who tend to be in better health anyway.
That's true if it's just your costs that are unnecessarily high. But you can encourage policies and regulation that raise the total cost of healthcare for everyone.
If people had doctors and hospitals competing to offer standard procedures like births, broken bones, fevers, etc at lower costs, then that’s what will bring prices down.
This is an enormous oversimplification unless you are taking such a broad view of "low supply" that it loses usefulness.
>I’m not aware of any insurance industry effort to keep those supplies down.
I don't know every policy that insurance industry lobbyists push. I do know that they lobby against price transparency--the lack of which almost certainly plays a role in healthcare costs.
>If people had doctors and hospitals competing to offer standard procedures like births, broken bones, fevers, etc at lower costs, then that’s what will bring prices down.
For elective procedures like plastic surgery and LASIK sure, but overall medical care is full of such extreme examples of market failures that you need more than just free market competition to control costs.
https://www.wsj.com/articles/hospitals-insurers-set-to-resis...
I agree it’s a huge nightmare dealing with the bills and claims processes, but I’m not sure that goes away with high deductible plans.
At the end of the day we have to get medical costs under control and I don’t think there are any great ideas for that right now. Public single payer will help, and it could at least end the billing nightmare, but I don’t see it actually solving the underlying problem of skyrocketing health care costs because the problem is too big and people are too politically invested in the way things are now.
The insurance company is coming out ahead on me, even when I had a kid I still paid them more money than they paid out, but a coworker’s wife had a heart attack and had some extraordinary care that the insurance was ultimately paid more than a million dollars for. These major health events and chronic illnesses are completely through the roof in terms of costs.
The reason for that is adverse selection. If you don't expect to go to the hospital then you can save money with the HDHP. Only very sick people will choose the more reasonable deductible.
- Regular annual checkups are still free
- You get access to an HSA account, which is effectively the most tax-advantaged retirement account available. You can deposit income pre-tax, invest the balance (minus a few hundred), and withdraw tax-free as well for either health expenses (at any time) or for any purpose (after 65).
I used to think employers would love to have to be able to stop offering insurance. But then I realized for the most part, employers love the current situation. Offering health insurance keeps employees chained to their desks. They'll moan every now and then about costs going up, but the current system ultimately serves them well.
You cant make a pizza larger by cutting it in different ways.
The top level comment gave a perfect example why. Preventative care is cheaper than emergency care. When everyone (including the unemployed) can get preventative care, total costs go down.
That unemployed person with no insurance still gets emergency care. The hospital doesn't turn them away to die in the street. They don't pay the bill. They go into bankruptcy instead. The hospital makes it up on all the paying customers (the insured). Your $10k is already paying for the ones who don't have insurance. Medicine is already socialized!
Now, if we can acknowledge that, can we do the fiscally responsible thing and make sure everyone can get preventative medicine?
A trope without rigour. The health community is even putting into question the value of yearly checkups (i.e. https://www.health.harvard.edu/blog/a-checkup-for-the-checku...).
It's not "flipping a switch".
> When everyone (including the unemployed) can get preventative care, total costs go down.
This is one side of the coin: when everyone goes to the doctor on a cold, total costs go way up. Its an economic problem, it requires economic solutions. Private insurance, for all its bad rep, has very strong incentives to have proper utilization. More so than government: when a patient gets hospitalized, insurance loses money. Govt never loses money!
> Your $10k is already paying for the ones who don't have insurance. Medicine is already socialized!
No need to change it then...
"when a patient gets hospitalized, insurance loses money...." and the patient gets the treatment they need. you seem to have forgotten that part.
"Proper utilization", in a private sense, is the same as "maximize shareholder value". Anything that damages shareholder value is not "proper".
Sick people have very strong incentive to want treatment. HEALTHY people have very strong incentive to want treatment for sick people. Private insurance has very strong incentive to take in as much money and pay out as little as possible.
Access - Quality - Cost. Somebody has to make a choice. If what you care about is unabated and unrestricted access, get ready to pay more than what you pay today.
Not necessarily, you may just need to ensure that insurance companies put the needs of their patients before the need of the shareholders.
Don't complain to your car insurance company that cars are expensive!
If I have to shop in a market full of confusing terms, exceptions, reams of paperwork (I am not a medical expert) the solution is already crap. When it comes to health care, the a provider should not have an opportunity to gain advantage by segmenting the market into different groups or risk pools, or hiding behind long and complex policies that require a subject matter expert to understand.
The HDHP + HSA are great for those that can afford them AND are in good health overall. Good employers also add to your HSA each year to help with the initial costs.
The HSA is a lot better than the FSA, which creates bad incentives on use it or lose it money.
The problem becomes when HDHP is used without a well funded HSA and with insufficient income to handle the deductible, together with health problems.
The best part of the HSA is that you can save your receipts and reimburse for those expenses 30 years later instead of right away so that you can pay with gains rather than principal.
My current insurance is something like $35k / year premiums for a 3k/6k family plan (which is actually a 6k/12k plan since 3k is when they start covering anything, and it isn't until 6k / 12k that they actually start picking up the whole bill)
There is no way I could afford a "low deductible" plan.
I’m saying as a society/country/large group of people, we are choosing to pretend to offer affordable healthcare options, but in reality using specialty products designed for relatively wealthy and healthy people as a mainstream option.
For financial/healthcare situation described, we need a true affordable option, not an exotic instrument.
As a society we did the same thing with exotic mortgages and pretended they were affordable.
Paying monthly installments on your insurance plan, only to have to pay for your healthcare costs anyway (first the deductible, then this new maximum out of pocket they added to me this year), that's the scam.
Why are there doctors in Europe then?
As I've read, it doesn't seem that the cost of healthcare is dramatically higher in the USA because we pay our doctors more, it's because of the insurance industry, and how much money people have to spend figuring it out (hospitals have to have staff specifically to deal with it, as their whole job).
Regarding insurance, I believe since ACA was enacted there's now a limit on how much profit an insurance company can make, as a percentage of the money they pass through. I'm not a specialist in this field, but this seems to have only made matters worse.
Ok, to be clear, you seem to be suggesting that everyone would live in the USA by default if they could, and the only thing stopping them is inconvenient immigration and the cost of a plane ticket?
I feel like I must be misunderstanding you because it seems a bit silly.
>> you seem to be suggesting that everyone would
>> live in the USA by default if they could
How about this - if America didn't exist, and doctors got paid what they got paid in Europe right now, why are there doctors in Europe?
The problem with health insurance is that "rare but catastrophic" is not the only health-related expense that people have. It covers that case quite well, so isn't really a scam, but it also doesn't give people exactly what they want -- seek medical attention whenever and for anything with no financial outlay.
I fit most of those checkboxes, but I take PrEP (preventative HIV med) that is something like $1500/month before deductible, and the math for HDHP vs traditional plan does not check out in that case at all.
Pay for medical care/medicine with after tax, save the receipts, and let the HSA contribution with pre tax money grow tax free in a Fidelity HSA (since it’s free) and then withdraw it whenever you want, and just pay yourself whenever you need the money.
1) complete lack of price transparency, which means virtually no price competition between clinics / doctors 2) artificially low supply of doctors to jack up prices 3) corrupt regulation to prevent consumer health startups from existing
Fixing these issues is going to take a lot more than just taxing people for not buying high deductible health insurance.
There's no fundamental reason why most doctors should get paid more than airplane mechanics for example. Either way if they mess up, people die.
I used to have a couple imaging facilities that I went to because their rates were low. In the past few years they have all been bought up by some sort of conglomerate and prices have gone up. It’s not advertised, so I literally have to call the place, talk to the back office and find out if they’ve been bought. So last year I go to the one place that hasn’t been bought, rates were good, I go this year and the bill was a surprise. Even my blood test rates have gone up this year, I’ve asked several doctors and they’re like “Yeah, it’s pretty much Quest or Labcorp now.” So my rule now is, if the back office has no clue what they're doing, they will likely be cheap, and they will likely either get bought up or go out of business.
Many years ago when I’d go to the doctor I think I was literally the only one with an HDHP, and the allowable amount would come out to $200, and they’d go “Oh, that’s not right. How about $60?” And just take $60 from me and call it a day. Now when I ask “Will this test cost me more than $200?” No one has an answer or seems to care like we are in some crazy bureaucracy.
I’ve always contributed the annual maximum into the HSA so there was never a question for me of running out of money to pay for care, and it hasn’t held me back from seeking medical care or treatment.
However, it’s perfectly possible for someone to elect the HDHP and not contribute to their HSA, in which case you could be facing a $3000 or higher bill without the money to pay for it. It seems like this is the case described in the article.
With a fully funded HSA I almost feel like I have the opposite problem, which is I don’t feel a need to attempt to shop around and compare prices.
In general it feels like the HSA/HDCP experiment has failed although I’ll keep using it for as long as it’s offered, as I like the ability to build up my savings every year in the HSA and eventually use it as a second retirement account unless I have a huge medical problem in the future.
Why?
The US has the best health CARE in the world, but with a crappy health insurance system. The health insurance has been regulated to a hot mess by cronies and politicians that is slowly destroying the care system.
An HSA gives you more control of your care.
Rationing care is not the answer to solve the insurance problems. I'm not interested in waiting for long periods of time for rationed care, such as what is seen in Canada.
https://www.fraserinstitute.org/studies/waiting-your-turn-wa...
For all its faults, at least I can get an MRI within a day or two, and can see a specialist within a day or two. That's way better than waiting on rationed care.
and we are starting to see pressure on drug companies and medical care (epic pen issue for example) as consumers push for reform now that they are feeling it in their pocketbooks more directly.
Part of the problem here is a lack of price transparency. That's what's stopping consumer choice driving any price reduction. It's very difficult to shop medical expenses. In the end it seems like the main choice they give you is really either to do it now or delay.
I have never understood how this is supposed to work.
I can imagine shopping around for things that are a) have perfect substitutes and b) aren’t urgent. For example, maybe you’d pay a bit more for an MRI of your painful knee if it were at a convenient time or in a nicer facility, vs. 5am in a cold bore with no movie or other frills. Perhaps you opt for a cheaper generic or a twice-a-day pill instead of the more expensive extended-release version.
Everything else comes with some fairly tricky cost-benefit analysis. How badly do I need to be screened for this or that? If something is missed now, how much worse will it be later—-and how much will it cost then? I’m skeptical that a half hour on WebMD will do much to improve on a trained doctor’s recommendation.
A doctor visit starts at $139 and may be from $300 to $500 depending on the diagnosis. One cannot determine the cost in advance. Any lab work is extra. Is it worth $1000 every year to have a doctor do standard blood tests?
Like anything that suddenly becomes very expensive, it makes one look at things differently and question whether they are necessary. Some people put off doctor visits longer until things seem unbearable. Some research online and try to self medicate with over the counter things.
And don't even get me started on FSA and forfeiture. That's MY money. What the hell do you mean the amount is forfitted?
Apologies for my language. The policies are making me go crazy.