I know people in HN hate to talk about politics, but this is a political problem.
People, please vote for medicare for all candidates, it might not affect your life now, but you don't know what the future holds for you.
People, please vote for medicare for all candidates, it might not affect your life now, but you don't know what the future holds for you.
Some subsets of the health care industry have price elasticity and seem to work fine in the free market, such as Lasik and liposuction etc. But stuff that gets called medically necessary don't work in a market, there is an entire branch of economics dedicated to it: Health Care Economics. Ironically pioneered by an American, Kenneth Arrow. Won him a Nobel Prize.
A Bismarck system (nonprofit govt sponsored insurance companies that all charge the same and are taken by all doctors) would be fine too, but that's not on the table in the US
There's no such thing as a healthcare system where nobody profits in some way. Lots of people working in "non-profit" organizations are still lining their pockets.
> A Bismarck system (nonprofit govt sponsored insurance companies that all charge the same and are taken by all doctors) would be fine too, but that's not on the table in the US
You must be alluding to the German system. We actually have two-class healthcare: Private insurance for those who are self-employed or who earn well enough to afford it and public insurance for everyone else (15% of income).
Those with private insurance get preferred treatment at almost any level, because while price controls exist for both public and private treatment, the amount of money doctors get for public patients is a joke.
It doesn't stop there of course, salaries for all healthcare workers are extremely low, as is the budget for cleaning personnel. Pretty disgusting, but also dangerous. Our rates of MRSA are extremely high, for instance.
Lots of German healthcare workers are moving to Switzerland (private system, but compulsory), being replaced by Eastern-Europeans. That doesn't bother me per se, but if we didn't have that kind of cheap labor, the system would just collapse.
In effect, I can tell you how to get "affordable" healthcare, whether it is public or private: Just pay your healthcare workers dramatically less money. Instate price controls. You'll have a lot of frustrated workers in a system constantly working at the brink of collapse, but it does work.
The difference in payment between US and European health care workers isn't large enough to make much of a dent in US healthcare expenses. The big sources of costs is the US massive bureaucracy dealing with bills, insurance and negotiation, as well as the medical inefficiency and overprovision inherent in the system. Also high drug prices.
For example, a US medical doctor makes about 100 000 $ more than the European average, although a few countries pays doctors more. There are about 1 million doctors working in the US. So thats 100 billion. US overspending is about 1 500 - 1 800 billion.
Germany today has a public/private mixture, Switzerland and Netherlands is fully private. I'm making this distinction because private profits do exist in these system, while the original comment I replied to lamented them.
> The difference in payment between US and European health care workers isn't large enough to make much of a dent in US healthcare expenses. The big sources of costs is the US massive bureaucracy dealing with bills, insurance and negotiation, as well as the medical inefficiency and overprovision inherent in the system. Also high drug prices.
Are you sure about this? Last time I looked it up, I came to a different conclusion: Administrative overhead (~8%) is neither a huge part of costs, nor is it massively different than in Europe. Drugs prices also only account for 10%.
Salaries for workers on the other hand are a significant chunk, and those are easily double than those in Germany in most cases. Note that I'm talking about all salaries, doctors, nurses, clerks, cleaners...
I agree with the overprovisioning being much costlier, but those are due to legal liabilities being more expensive in the US in general. In Germany, even if you win a malpractice suit, you get a pittance.
> There are about 1 million doctors working in the US. So thats 100 billion. US overspending is about 1 500 - 1 800 billion.
Again, this disregards the vast majority of worker salaries involved.
Private insurance in those countries works because those markets are highly regulated, and they don't have a corporate culture of trying to rip off people as much as they can.
If you don't have insurance in Germany you'll have to pay for that yourself as well. That's rare, but it happens especially with the precariously self-employed.
The issue with the US system is that you can't have it be both non-compulsory but also that coverage must be offered to everyone, no matter their state of health. Then you'll have a few healthy people pay huge premiums to finance treatment for those who never bought insurance until they're sick.
It is my understanding that a compulsory purchase (as in Switzerland) would be unconstitutional, so I guess "Medicare for all" in the form of a tax would actually be the next best thing. Just keep in mind that with US levels of healthcare salaries, that wouldn't come cheap.
The difference is GKV being the default, and opting out of that kind of hard. You have to earn €5,062+ per month, for a start [0]. And the step is intentionally hard to reverse. I consider that a decent compromise. At that point people have to actively shoot them self in the foot, and I've little pity for those.
If you didn't opt out, thus are still under the GKV, the system will cover emergency services. Even if you haven't payed (yet).
[0] https://www.bundesaerztekammer.de/weitere-sprachen/english/h...
It's not hard at all, just go self-employed and you have the option.
> And the step is intentionally hard to reverse.
Yes, so that people towards the end of their lives don't profit from a system they never paid into. You're stuck with expensive private insurance for the rest of your life. In the US however, you would qualify for Medicaid.
> At that point people have to actively shoot them self in the foot, and I've little pity for those.
It's actually not that uncommon for people to fall into the trap of working self-employed for most of their lives, then retiring poor because they never paid into the pension system and their private insurance costs them over 500€/month.
In Switzerland, it is compulsory to purchase insurance, there's a basic plan that all insurers must offer, and if cost exceeds a certain fraction of the income, the state chips in.
remember healthcare.gov? we were pretty glad we had other redundancies from day 1! it takes time to build a system and in my (granted unrelated) experience, big changes are best done in small steps
There is no healthcare system less complicated than "medicare pays for everything"
For example, the healthcare system the USA had for well past the first half of the 20th century was "pay workers a middle class wage and control costs so the average family can afford housing and pay for medical care for their 5 kids. And then send them to college after." Nothing is simpler than to be told the price of the service ahead of time and then pay for it. I know this because my father lived through it. He was the child of dirt poor immigrants, only got a high school diploma thanks to being drafted out of college, and still managed to pay for medical care for a wife and six children. He told me about how insurance started as just catastrophe coverage, and then just grew and grew until the entire system became the morass of red tape, inefficiency, and rent-seeking it is today. Just like with student loans, having the monetary sovereign spend money into existence (directly or through high interest loan guarantees) will inevitably wildly inflate prices in the affected sector. To an extent it already has.
This isn't a simple static system. If it were, then sure "government pays for everything, good to go" would be correct. Unfortunately the reality is that it's a dynamic system, and providing a payment guarantee with politically determined pricing is "government pays for everything, so now every middle-man, lobbyist, special interest, rent-seeker, and every other assorted grifter is going to wet his beak". And that's just the beginning of the higher order consequences. Maybe medicare-for-all is a good choice, I just don't know. And I won't know until I see a cogent, rigorous, and complete analysis of the second order and higher effects of the policy change. I'm not aware of anyone offering that analysis.
See https://www.youtube.com/watch?v=8q71hrwUcu0 and the more complete https://www.youtube.com/watch?v=rWlk9HreE7U.
He explains how regulation eventually results in a centrally planned setup that is less efficient than what used to happen.
The [majority of hospitals in the US are non-for-profit](https://www.aha.org/statistics/fast-facts-us-hospitals). Needless to say, they are not able to provide a cheaper service than the for-profit hospitals. So there is some factor, unrelated to profit, which makes healthcare expensive.
If profit was causing healthcare expenses to rise, then non-for-profit hospitals should be be able to maintain lower prices than for-profit ones. They can't. So what's driving up the cost? The answer is pretty simple: government intervention.
Sure, there aren't shareholders getting dividends. There are plenty of other motives that push non-profit hospital systems to want to make money. New buildings, fancy robotic surgery machines, cushy patient amenities to compete with the other system in town, expensive administrators and staff...
Even for the most urgent issues like universal healthcare that have been literaly implemented by all western countries a long time ago as well as in most developing countries, you say : "But me..."
Since you're not directly affected by the matter, you simply don't care. Even if you could be the next...
You're part of the problem and nothing will never get done in America because of people like you.
Selfishness will break America.
Before your country collapses under its own debt, America will be filled by slaves and a clique of companies and billionnaires owning them.
> You're part of the problem and nothing will never get done in America because of people like you.
You don't know me and you don't know what I do / do not vote for. I recommend you keep your insults to yourself.
Selfishness is healthy in moderation. It's what helps people come to the conclusion that they have a shared interest on which they can collaborate.
> Before your country collapses under its own debt, America will be filled by slaves and a clique of companies and billionnaires owning them.
So the answer is to bankrupt the billionaires so everybody is living a terrible life?
Both the situation before ACA and the reaction to it have shown that privatised health insurance is never going to work in the US. Medicare for All looks like the only practical way forward, and it's been gaining a lot of momentum as a result. Medicare itself also still needs some fixes; at the moment the government isn't even allowed to negotiate prices. That's a law that clearly needs to be repealed. But other than that, Medicare for All sounds pretty good, and I'm not aware of any other credible proposal that looks anywhere near as good.
What about the poor people who only have one hospital nearby that might not accept their insurance? What about people who go to a hospital that's in their network, but it turns out one of the many doctors was not? The people who have a time critical illness who can't afford to do the whole Free Market thing right after a accident?
How does anyone know that when they arrive somewhere the exact number of treatments needed to cure their illness? Are you expected to walk out of the hospital and refuse treatment because you've tabulated all of the prices for all of the services needed, then ask the ambulance to take you somewhere else?
The free market solution to health insurance simply does not work and it's insulting to see people suggest it time and time again. It ironically only works in heavily centralized areas where people actually have a choice, and not the more rural areas where hospitals are far more spaced out. There's far too many variables at play for even software engineers to manage unless you dedicate a significant amount of your free time to maintaining an excel spreadsheet of every hospital near you and their prices, formulate the exact cheapest plan on the fly according to your personal needs and can pull that out immediately when you have a medical emergency.
And that's assuming they didn't decide to go out of network the day before and delayed updating their database.
All of these only apply to time-critical procedures. Otherwise you should be able to use the doctor and hospital which is covered.
Let's assume that emergency medicine should be provided by cities in the same way as other emergency services like fire companies. What's the argument for doing it that way for all medical services, including the ones that are not time sensitive and allow you plenty of time to shop around and choose the provider with the best combination of price, distance, scheduling availability, etc.?
> There's far too many variables at play for even software engineers to manage unless you dedicate a significant amount of your free time to maintaining an excel spreadsheet of every hospital near you and their prices, formulate the exact cheapest plan on the fly according to your personal needs and can pull that out immediately when you have a medical emergency.
This is hardly the only circumstance where there are many variables. Should the government buy everyone the same car because there are so many different choices between prices and safety ratings and fuel economy and performance? How does that even help, since the solution space is the same and government knows less about your priorities than you do?
Because for a lot of people, there is no real choice involved. If there's one hospital around for hundreds of miles, they realistically don't have the option to go to one further out when their job expects them to be available for work every single day. Not to mention that requires every hospital to offer every service and to have every type of specialist for every type of disease.
Medical issues don't operate like a grocery store. You can't just walk into a hospital and choose between Name Brand MRI or Store Brand MRI. It requires a level of knowledge that most people don't have. It's knowledge I don't have! And something I'd prefer to never have to think about when I have other shit to deal with in real life.
> This is hardly the only circumstance where there are many variables. Should the government buy everyone the same car because there are so many different choices between prices and safety ratings and fuel economy and performance? How does that even help, since the solution space is the same and government knows less about your priorities than you do?
Your analogy falls apart because the government does make mandates for cars. Things like safety features. And you're trying to compare buying a car which is a fairly small subset of considerations for the average person versus trying to purchase medical assistance which is an incredibly wide field encompassing multiple types of examinations, surgeries, biopsies and more. When you're looking for a car, you have some properties of a car which are easily understandable. When you're searching for medical assistance, most people only vaguely know what's actually wrong.
Federal law requires employers to provide at least unpaid sick leave. That caps the premium a local hospital can charge over competitors at the loss of the day's wages and the travel costs, which are both dwarfed by the amount of money in medical expenses we're comparing them to for these bankruptcy-inducing procedures.
> Not to mention that requires every hospital to offer every service and to have every type of specialist for every type of disease.
Why would it require that? There are thousands of hospitals in the US. You don't need every hospital to do everything as long as there is some competition for any given thing.
And far away hospitals can provide competition even if people don't actually use them in practice. If it costs $1000 in travel and inconvenience to fly to another city for a procedure then people won't use a local hospital that tries to charge $10,000 more, so they charge only $900 more because it's all they can get away with. But that's only if there's price transparency -- if you can't find out ahead of time that it costs $10,000 more for the local hospital then people choose it anyway and there is no incentive for them to lower their prices, which is where we are now.
> You can't just walk into a hospital and choose between Name Brand MRI or Store Brand MRI. It requires a level of knowledge that most people don't have. It's knowledge I don't have! And something I'd prefer to never have to think about when I have other shit to deal with in real life.
And that option exists -- you buy an expansive low deductible insurance plan that covers everything. That necessarily comes at the cost of very high premiums, because it has to cover the cost of making you price-insensitive.
You can also buy a less expensive insurance plan that doesn't cover everything and then consider anything it doesn't cover as unavailable. That's what socialized systems generally do, because they do make people price-insensitive but still have budgetary requirements to meet. But there's no reason you can't get a private plan that does that either; just don't object when it doesn't cover everything. You pay for what you get, one way or another.
> Your analogy falls apart because the government does make mandates for cars. Things like safety features.
They also have mandates for medicine. There is a whole medical licensing system. That's independent from who pays for it.
> When you're looking for a car, you have some properties of a car which are easily understandable. When you're searching for medical assistance, most people only vaguely know what's actually wrong.
I don't see how it's different. There are plenty of subtleties when buying anything expensive that aren't readily apparent, like that car insurance can be more than the car payment, or that some models depreciate faster than others so you have to account for future resale value, or that some models have more frequent repairs, or more expensive repairs. Some people buy based on style and only later find out through experience the total cost of ownership is $40,000 higher than they expected.
It's the same thing with healthcare, but it's the same thing with healthcare either way. Regardless of who is paying, which doctor has the best patient outcomes? Which medication is more effective? What clinical trials are there for your condition? You can ask your doctor, but first you have to choose your doctor. And then, in the end, they only advise you what to do. It's still your decision and your life.
Not really. The law you're referring to is the Family and Medical Leave Act (FMLA), which only applies for childbirth and "serious health conditions". Most things you can shop around for also aren't serious enough to qualify, so you're not entitled to such unpaid sick leave.
But also, it's kinda a moot point because laws like that only apply to people that know them or can afford an attourney. Just like the person in the linked article didn't know she couldn't be harassed quarterly by the court system (rather, just yearly) due to being disabled, those who are most in need of that law are unlikely to know about it nor to have an attourney.
> If it costs $1000 in travel and inconvenience to fly to another city for a procedure then people won't use a local hospital that tries to charge $10,000 more
This assumes that people have both perfect knowledge of their procedure and the prices of all hospitals, and that people value money over convenience.
I know for a fact that I can fly to another country with free healthcare and get a procedure for cheaper than I can get it in the US, but hardly anyone does that regardless. It's just too inconvenient.
I also know for a fact that people rarely have even decent knowledge. Plenty of people buy incredibly overpriced cell-phone plans or internet. The free market hasn't been able to get those prices anywhere close what they should be even though people can switch providers, compare prices, and aren't stressed about their health.
But now you're not making an argument for socialized medicine, you're just making an argument for requiring unpaid sick leave for a scheduled medical procedure.
> But also, it's kinda a moot point because laws like that only apply to people that know them or can afford an attourney.
Are there many laws that don't work this way? Would the same people be any better off if the government would pay for their medical procedure but they didn't get it because they didn't know that?
> This assumes that people have both perfect knowledge of their procedure and the prices of all hospitals
Which is the point of requiring price transparency. Your doctor should provide you with a list of all the places that can do the procedure along with their locations and prices and any other information useful to choose between them.
> and that people value money over convenience.
But that is the mechanism by which it operates -- there is a point where the money is worth more than the convenience, and once people actually know the amount of money required, that limits how much providers can overcharge because past that the inconvenience is less than paying the money.
There is nothing wrong with choosing convenience. It's the thing that allows trade offs between price and convenience to exist. Maybe the clinic near the big city will always have the best price because it has the most patients to amortize fixed costs over, so the rural clinic can only stay in business by charging more per patient. If the higher price is worth not having to travel to the city -- and people know that -- then people will choose to patronize it, which is how we know its value exceeds its costs. If everybody chooses to travel to the city for the lower price then we know the rural clinic costs more than it's worth, which is the same mechanism that causes it to fold.
> I know for a fact that I can fly to another country with free healthcare and get a procedure for cheaper than I can get it in the US, but hardly anyone does that regardless. It's just too inconvenient.
Because flying to another country is very inconvenient, and not at all inexpensive on its own. So the limit it places on overcharging is not very strict. Especially when you don't actually know how much you'll be charged, so you don't even realize that it would have been worth it to do that until after it's already done.
The inconvenience is much less to go to another town than another country, so that would provide a much lower limit on how much anyone can overcharge before people would do that. If they were actually provided with the price differences -- so why aren't we doing that?
https://www.menshealth.com/health/a19543406/50-most-overpric...
My state has the highest rate of uninsured residents in the country and also one of the states that did not expand medicaid and take in federal funds to cover 90% of that. I paid for the best health insurance plan I could find on healthcare.gov and went with a doctor that was listed as a preferred provider with my insurance explicitly because my insurance provider claimed that any lab work, referrals, etc from that preferred provider would be covered and that they partnered with them to ensure that there wouldn't be any surprise out of network bills that weren't covered. The best health insurance plan I could buy left me out to dry for ~$600 in bills that were supposed to be covered 100% by my plan.
The notion of the magic of the free market driving down healthcare spending is nothing more than a libertarian fantasy. By any objective measure we spend far more than any other country on the planet for a given medical service. The fact that doctors and hospitals can't even tell you how much a given service will actually cost beforehand should be enough to tell you that the free market clearly isn't working here.
How do prices not help? You at least know how much you'll have to pay, which is certainly relevant information. You still may not know which one is best (no guarantee that it's the one that costs more), but what solution are you proposing to that anyway? Even if the government was paying for your medicine, how would that help you choose which doctor to listen to?
> When you are under, you don't get to consent to the actions of the surgeons ,anesthesiologists or whomever else they decide to bring in to assist.
Which is why it may make sense to have an insurance plan that fully covers emergency services regardless of network. But emergency services aren't the majority of medical costs.
First things first, you probably have little choice in where you are going to get things checked out, as there may only be one place in town or one place your insurance covers or one place that works with the hospital your doctor goes to. It isn't like you can opt out if you suspect things like breast cancer, which might kill you, or if you are getting anything done in an emergency fashion. AT best, knowing the cost might give relief or stress and at worst, it'll cause some folks to die a slow death because they can't afford the cure.
IIRC, they aren't always upfront about this stuff during surgery. You simply don't know or there might not be folks in your network available for a variety of reasons (like your anesthesiologist being sick that day).
No, they don't. When you're out of breath with pain running down your left arm and are about to collapse, you're going to try to get to the nearest hospital, not first shop around to see which one has the most competitive rates like you're buying a new car or something.
A family friend, a very smart guy himself, was recently diagnosed with Parkinson’s Disease. Since I’m a neuroscientist, he asked me for advice. I work on brain stimulation, one of the better treatments for Parkinson’s Disease. My institute is a Parkinson’s Centre of Excellence, and I collaborate with movement disorders specialists. I have easy access to experts and tons of relevant training and literature. Nevertheless, I found it very hard to make a recommendation, even between the options his doctor had laid out—-and I wasn’t even considering price, since he has excellent insurance. This decision was smack in the middle of my wheelhouse too; helping with, say, a decision about kidneys would have been even worse.
There’s no way people, especially people in vulnerable situations, can reasonably be expected to catch up with experts that have a decade of advanced training and then second-guess them.
Sure, you technically have time to shop, but it seems to me that this is just an excuse and makes sick people suffer more.
1. Take 30 mins to find the most affordable option. 2. Ask for a lower price.
You also could just live in a country with a good single payer health service, and know that you'll be treated without any bullshit.
The fact that anyone would seriously suggest shopping around for treatment, as if there is a convincing and credible reason why anyone should even have to consider this, is beyond astonishing to me.
I have heard multiple stories now whete independent practices now just want cash, without insurance, payments for much cheaper, and they get paid more in the end.
We are expecting a baby, and one of the tests we had to get done early in the pregnancy was NIPT. There was 2-3 companies we could go with, and when we asked for the price they responded some number between >2.7K - I don't really recall - it could even be 8K. When asked for the cash price, they said 250$.
Crazy.
We're not talking about the life and death part though. There are already laws requiring emergency rooms to see anyone who shows up. The question is how to pay for it, which is a matter of economics.
Medical providers not being able to provide the total cost for a non-emergency procedure up-front but then expecting people to pay whatever price they make up after the fact is practically fraud. The fact that it leads to outrageous costs is entirely predictable.
I’d like to turn the question around and ask folks who believe that the healthcare problem is one of not enough market freedom: what’s an example of a country that gets a free market in medical care right, from your perspective?
We universal healthcare advocates have a couple of dozen examples lined up to support our perspective, what about from the other side?
But the primary reason you don't see more successes is the lack of attempts. It's not as if there is a long list of countries with failed free market healthcare systems, either.
I don't know in what meaningful sense Israel is a "hybrid" system, it functions almost exactly like a 'Medicare for all' type proposal would.
"Houses keep people warm, they should not cost anything" etc." I'm not sure who is arguing this, but it isn't a stretch for folks to agree that everyone should have access to shelter, even if you cannot afford it. I personally wouldn't mind standard and basic housing being free (Small kitchen/living room, bathroom, and bedroom or bedrooms)
I'd also point out that cross state competition would only help a little. Your laws need to be the same state to state, minimally, and most of the providers wouldn't change. Most insurance is provided through a job anyway, and I'd like to mention that most people's "tech company", besides social media, are ISP's with little to no competition.
So, no, "insurance" will never under any circumstances be the correct model to work from. (And no, I don't know what is.)
No thank you. I've helped people with medicare and it's the worst health insurance I've ever encountered, with insane rules and brain-twisting billing practices.
I have absolutely no desire to inflict this on the entire country.
When you are promoting medicare - have you actually tried it? Are you speaking from a position of knowledge?
I have, it's terrible.
But worst of all it doesn't fix anything!!! The problems with healthcare in this country are that hospitals and doctors will need to take a pay cut, and we'll need to fire a lot of people in order to save money.
Medicare for all, at current payment rates, will just cause havoc.
And I wouldn't trade my current system. I'd rather have medicare than nothing, and know that the issues it has can be fixed. Just because something has problems doesn't mean that it isn't better than nothing and doesn't mean that it isn't a good starting point.
It might not be so bad being a doctor if we fixed some supply issues: For example, making sure doctors (and everyone else) doesn't have tons of student debt. We can do things about how expensive malpractice insurance is: My dentist here in Norway would like to live in the US, but won't because of the malpractice suits. We can do things to simplify the office work, such as standardising payment scales and coding. We can make good use of nurse practitioners, especially for children who generally have run-of-the-mill infections THese things make it cheaper to be a doctor and cheaper to run an office.
You'd think we might need to fire a lot of people... but not really. Single payer health care means we can do things differently because our resources are pooled. Norway, at least where I live, will send a home nurse to your house for free up to 6 times a day. Even if you are in a cabin in the mountains or living on a little island. This is all because overall, this is cheaper than a nursing home... which costs 80% of your retirement, no matter how much you make.
There is also a private system, which mostly gives bells and whistles. You might get into a non-urgent MRI sooner and so on.
Also my wife is a Dentist. She works 4 days a week and does extremely well. If malpractice and costs were an issue for Dentist's in the US, they would work more. I know a lot of dentists but not a single one that works 5 days a week. And of course no residency required. Its got to be the best career choice in the US today.
As for firing people... I agree probably not. But most Hospitals _do_ run on a tight margin (like 5% or less), and the majority of their costs are staff.
But overall, if you've experienced the system at all, you know how utterly wasteful and unorganized it is. Its difficult to fathom a system with more waste, which is especially ironic since there's so many smart people running around. I think single payer, whatever the flaws, would absolutely be a major change in the right direction.
This is the part people don't understand when they promote Medicare for all - it's a really really bad plan, that people don't use unless they have no choice.
This should be the death nail in these proposals, except the people proposing it typically don't even realize the difference.
Medicare for all is a horrible idea.
Government funded private health insurance for all is a good idea.
So to add on to what you've said, yes medicare is nightmarish. Hopefully this offers me a new chance to live a life.