Ditto with socializing healthcare instead of making sure corporations provide it.
It’s not an argument that I agree with at all, to clarify.
If their employees have their back against the wall and are literally unable to do anything to change their situation, that is a more general societal problem.
UBI is, in my opinion, a monumentally superior solution than trying to micromanage the nature of contracts that people are capable of negotiating between one another.
The consequences of the $15 per hour minimum wage will be felt in due time. Anyone running a business in the context of a global economy knows this with absolute certainty.
This isn’t about greed, it’s about a mathematical reality and a destructive positive feedback loop: We keep doing one dumb thing after another to push jobs, businesses and industries towards China. Our consumers lose jobs and income and, as a result, apply downward pricing pressure to the goods and services they consume. Sector by sector, over time, pricing structures become such that it is impossible for these businesses to exist in the US or Europe. The Chinese government knows this, they apply further pricing pressure and very soon they own one sector after another. And so continues our positive feedback loop, deepening economic wounds that assure bad long term outcomes.
I really wish we actually taught kids from K-12 and into university a lot more about business and entrepreneurship. It is truly sad to watch young adults get behind some of the most destructive ideas this nation has had at the table in quite some time.
Simple example: Medicare for All.
Despite what people believe, this is already the largest private property grab by a government in, perhaps, world history. It certainly will be if we end up with Medicare for All.
Why?
Because Medicare is NOT insurance!!! After 55 years if age YOU OWE THE GOVERNMENT FOR EVERY PENNY OF MEDICAL CARE YOU RECEIVE.
Don’t take my word for it, read this and do your own research:
https://www.nolo.com/legal-encyclopedia/how-medicaid-recover...
So, if everyone was on Medicare/Medicaid the government would eventually have liens and the power of asset forfeiture on EVERY ESTATE IN THIS NATION.
Now, stop and think about that for a moment before you support politicians using the general ignorance of facts by the public to generate votes. This is a travesty, and everyone supporting it is a participant in what would be the largest private property grab by a government in history.
Think.
This clearly sets aside assets that are dedicated to a beneficiary or if the assets are jointly owned. I'm not a lawyer, so if someone is please chime in, but this would exclude pretty much anyone has a will or is still married.
I think this not a valid reason to exclude Medicare for all as an alternative to our disjointed and dysfunctional system of medicine. Also what about this precludes us from changing this feature if it was rolled out for everyone?
-Medicare does not kick in until 65+
-While you are on Medicaid you accumulate debt after age 55
-Medicare has an expenditure limit, after which you are kicked back into Medicaid, which is, effectively, after 55, a debt you have to pay and the State has the ability to place liens on your estate and grab your property for payment. In fact, they are required to do so by law.
As I said in another comment one of my friends is dealing with exactly this scenario right now. In fact, I just spoke to him a few minutes ago and learned his father died this morning.
While he was on both Medicaid and Medicare (due to the aforementioned ping-pong effect) he now owes the government a pile of cash, hundreds of thousands. My friend has power of attorney over the estate and will be traveling back to his home town to sell the assets and pay the government.
Again, like I said in my other comment, I am not saying these things because they occurred to me. This is reality in the US today: The crap they are trying to sell us will, in fact, turn into the largest private property grab by any government in the history of the world.
In my friend's case the Medicare lifetime limit was $120K. His father burned through that very quickly --probably in a single hospital stay. He was then kicked back into Medicaid, where he already owed money (from 55 to 65). All of his care after the $120K Medicare limit then became a debt the government is required, by law, to collect. And they intend to do so. This will cause the sale of his father's estate for payment. He is dealing with this nasty reality right now.
These things are NOT insurance. That's the greatest lie people are being told.
EDIT:
In Q&A form...
How do you get to Medicare?
Through Medicaid.
Is Medicaid insurance?
No.
Is it free?
After 55 years of age you owe the government for your medical care. It's a loan.
Are they required to collect on that debt?
Yes, by law. Some states are a little more lenient, but the law says they have to collect.
How do they collect?
They seize your estate, your assets, they can force a sale of assets, etc.
Are the children affected. In come cases the debt has affected the children (I don't remember details).
Is MediCARE insurance?
No.
Is is free?
No, you paid for it while working.
Does it cover everything?
No, there's a limit based on your contribution. In the case of my friend's father this limit was $120K, which is nothing in terms of US medical care.
For context, he was 95 at the time of death. His $120K of Medicare allowance was burned through three decades ago. He ended-up back in Medicaid very, very quickly decades ago. And the bills are massive.
What happens when you use-up this money?
You are kicked back into Medicaid.
What happens then?
You add to the debt you accumulated between 55 and 65.
Do you still have to pay for it.
Damn right!
How?
See above.
I have a friend who is currently going through the estate recovery process for his dying father. They are —the government— effectively forcing him to sell his childhood home in order to pay for the healthcare he and his late mother received.
This isn’t theoretical, this is very real.
Also note that people are shoved into Medicaid until 65+.
Far better would be for the government to take care of this (via single-payer health insurance, possibly even something like UBI), and tax companies an appropriately higher amount in order to fund it. This would of course require a major overhaul of the tax code in order to eliminate loopholes that allow companies to hide revenue/income and dodge paying their fair share.
Given all the issues around this in the first place, it is clear that expecting companies to provide for their employees isn't working. AB5 is just a band-aid that treats the symptoms and not the cause, and comes with a ton of negative unintended consequences.
As much as I don't like how Uber/Lyft run their businesses (and yet I still use them), they have completely revolutionized (in a good way) how I get around my city. Every driver who I've talked to about AB5 has reacted negatively to it. Either they believe it'll be the end of Uber/Lyft, or they just point out they won't want to drive for them anymore because their flexibility will be destroyed.
There used to be a long list of benefits companies would provide, like company cars, that all went poof right after they started getting counted as taxable income.
A combination of the endowment effect and inertia/status quo bias. When a Big Medicine lobbyist shows long government wait lines, that can be as effective, and as insidiously misleading, as a picture of immigrants waiting to gain admission to the country.
The link between employment and health insurance is, from my perspective as an external observer, America’s worst idea.
Not sure why the AHA didn’t fix things like this.
https://en.wikipedia.org/wiki/Health_care_prices_in_the_Unit...
This is the result of a longstanding bargain between unions and employers to provide some compensation as health care rather than salary, which was win-win for both sides until health care costs soared. Now there's no way to break that link without throwing off those negotiations.
The ACA wasn't actually a huge change, except in the sense that any change at all was nearly impossible given the stability of that equilibrium. It's widely agreed that there are many better ways to do it -- all of them dispensing with the link between employers and health care -- but there's no way to get to wide agreement on any one plan.
I got the OECD data directly from the OECD's website: https://www.oecd.org/media/oecdorg/satellitesites/newsroom/4...
Yes, but there's a limit. Incentives have diminishing marginal returns. At the end of the day, a $2B pharma company is still going to doggedly pursue a 20 year monopoly on a potential $1B drug, even if it otherwise would have been a $1.5B drug if there was no Medicare for All. Moreover, the vast majority of waste in healthcare is with hospitals, administrators, surgeons, insurance companies, and doctors, not the pharmaceutical industry.
Pharma is closer to software in that one company can produce one product with zero marginal cost that can trivially serve everyone on Earth with a given condition. We can even leave Big Pharma as is and still realize hundreds of billions in savings, though I still believe that there should be some single-buyer negotiation for drugs. We can use empirical evidence to negotiate on drug prices without drastically changing the incentive scheme. Ultimately, I believe pharma companies would increase prices abroad if we implement price controls in the U.S. The U.S. is subsidizing the world's healthcare.
Doctor/surgeon labor scarcity exists for the following reasons:
- Medical associations lobbied the government to restrict residency positions a long time ago, and continually lobbied to keep them down until just recently when the shortages have become too obvious. They were even warning of an impending doctor surplus in the 90's. Ya, right.
- Medical associations and med schools have been smart about restricting the supply of doctors through our med school network and excessively tedious licensing system.
Additionally, the other OECD countries I've referred to have similar health outcomes for a much lower % of GDP. Clearly, universal healthcare did not worsen their population's health. If someone wants quicker healthcare, I'm almost certain the U.S. would allow supplemental insurance to get that hip transplant in 2 weeks instead of 6 months.
The problem is they don't know it's a $1B drug instead of a dud until they've actually done the research, and most of the candidates fail. And since the successes have to cover the failures, if the successes make less money, they can't cover as many failures and you don't get as many attempts.
> Moreover, the vast majority of waste in healthcare is with hospitals, administrators, surgeons, insurance companies, and doctors, not the pharmaceutical industry.
It is certainly a multifaceted problem and there is plenty of inefficiency that could be improved. Not just healthcare, but also the plague of zoning rules that inflate real estate costs in cities. Which is where hospitals are for legitimate reasons, but hospitals not only need a lot of real estate, they also then have to pay salaries there that allow their (already expensive) staff to live within reasonable distances.
And the subsidy issue isn't just drugs, it's also technology. A lot of the "hospital" cost goes to equipment, which is the same subsidization of international R&D as drugs -- other countries with price controls not paying their share of the cost.
Which is why cost comparisons to socialized systems in other countries are so uninformative. Not only are they not paying their share of R&D, they typically have lower real estate costs, lower salaries across all industries, lower (and this one surprises a lot of people) taxes if you count "health insurance" as a tax, and it goes on.
There is a lot of pure inefficiency in the US healthcare system -- the level of bureaucracy is madness -- but a lot of its costs are also external to the system itself and symptomatic of healthcare being at the intersection of several independent sources of price inflation that each have to be addressed on their own terms.
See here for an in-depth analysis: https://randomcriticalanalysis.com/2019/11/07/a-tale-of-two-...
Additionally, the government would be more invested in the population's health under a single-payer model. It would actively work to reduce the prevalence of obesity and lower its costs. That would include taxing consumable goods with a negative health externality, commensurate with the magnitude of that externality. That would also include incentivizing the consumption and production of goods with positive health externalities and investing in pro-health infrastructure.
Imagine if a city faced the following math: "A network of bike lanes would cost us $40 million and $10 million to maintain over the next 10 years. It would also save around $50 million in health expenditures every 10 years. After one decade, it will cost $10 million and continue to save us $50 million." All the bike lanes you could dream of would be built overnight, assuming there would be subsidies by a M4A healthcare program. I'm more excited at the prospect of converting roads into pedestrian walkways and scooter highways. That wouldn't seem like such an expensive proposition if the government would recoup the cost in healthcare savings.
It's my blog (RCA). My argument is that obesity substantially explains US health outcomes in relation to other countries. I never claimed obesity is the cause of high national health spending (as in, "inputs"). To the contrary, I have consistently argued US health spending is well explained by its wealth (technically income levels).
https://randomcriticalanalysis.com/2018/11/19/why-everything...
To a first approximation, national health spending is entirely explained by the average house income level in the long run. While time, healthcare technology, and other factors are assocatied with rising spending, these changes are ultimately very well explained by changing income levels. Amongst high-income countries, a 1% increase in income is robustly associated with a long run increase of about 1.8% (it's highly elastic).
https://i0.wp.com/randomcriticalanalysis.com/wp-content/uplo...
The US spends more than Canada because it's still a much richer country (which isn't to say Canada isn't a nice place!).
> That is beyond the realm of believability, even if I introduce the other population-induced causal factors which you implied but didn't specify.
Again, I never said this, but other population health risk factors such as age structure, disease rates, and the like are of negligible significance when it comes to long run aggregate spending. Such factors may be highly predictive within countries and may have some say in the short run (within budgetary constraints), but in the long run national picture the evidence suggests these factors amount to little more than noise. National household income levels trumps everything.
> Additionally, the government would be more invested in the population's health under a single-payer model.
US government programs, namely Medicare and Medicaid, spend more on healthcare than most other high-income countries do in total (even more so comparing public-to-public). Just how much more incentive do we need before these magical effects kick in? Higher health spending predicts higher obesity rates in time series and cross-sectionally (though this is likely ultimately mediated by long-run income levels and by time).
https://i0.wp.com/randomcriticalanalysis.com/wp-content/uplo...
Where is the evidence that these programs have large, sustained effects and are cost effective? Most data indicate these programs have negligible effects in the long run and they almost always cost more than they save (which isn't to say we shouldn't necessarily do it, but the economic rationale is v. weak).
~ RCA
It's telling that, whenever the government (rarely) enacts laws that tax or ban consumables with negative externalities, they actually target the right thing. After troves of empirical evidence, they heavily taxed smoking and banned trans fat (I'm aware of the government's misguided early endorsement of trans fat vs. saturated fat, but science has progressed a lot since then). Recently, local governments have tried to tax excess added sugar. That has been less successful, but it's guided by the right thinking. Excess sugar in our food supply is unequivocally, empirically bad. The government has less of a basis to tax it since it's not paying for all our healthcare, but that would change under M4A. Moreover, there would be more money behind nutritional/health research, because that research would have a more tangible payoff: an approximate dollar amount saved in public healthcare expenditures.
Nothing is perfect, but most experts believe this has little to do with healthcare today because healthcare interventions tend not to be effective causes of long-run weight loss and most countries aren't doing enough of the stuff likely to have large effects (e.g., surgical interventions) to explain much of the variance. Even if you could argue it might explain something, say 0.5 mean BMI points, other factors are clearly highly important. Cultural * and genetic factors are likely to play a significant role amongst high-income countries. Further, obesity rates rise with time and income levels despite higher health spending.
https://i0.wp.com/randomcriticalanalysis.com/wp-content/uplo...
> socialized healthcare does a better job of controlling obesity with preventative health measures
evidence?
> As it is now in the U.S., patients only go to medical professionals when there is a problem
The US spends more on preventive medicine than almost any other country, though preventative medicine generally has very-small-to-modest effects on outcomes and rarely, if ever, saves money (usually quite the other way around)
~ RCA
note: * some of these "cultural" factors may be residual economic influences... the US escaped the malthusian trap long before almost all other high-income countries and this may have latent effects on attitudes towards food, diet, etc)
The problem is we do have "allowing drug companies to keep researching new drugs" to show for it. We're subsidizing the rest of the world because they impose price controls on patented medications. We could do the same thing, but then where does the money to do the R&D come from?
People like to point out that they spend more on advertising than research, but the advertising generates more revenue than it costs or they wouldn't do it, which means without the advertising they would have less money for research.
It should come from other countries who have been free riding with price controls, but how do you get them to do that? The status quo is giving them a trillion dollar a year subsidy.
Somewhat related, but Jennifer Doudna, a government employee, co-discovered CRISPR. CRISPR will prove to be one of the biggest step changes in health outcomes in the history of mankind, or, at some point, supermankind. Now hundreds of pharma companies will try to monetize on the government’s discovery: CRISPR for sickle-cell anemia, CRISPR for congenital retinal defects, CRISPR for lactose intolerance, etc... Should we have to reimburse drug companies for the value of the drug, or should we, recognizing the government’s contribution and the immense value of life, put a reasonable cap on reimbursement? I say the latter. A company developing CRISPR drugs is on record saying they plan to charge over $100,000 for their treatment. I’m not convinced that the drug would not have been developed if they stood to make much less than that per person. We trust the government to grant 20 year monopolies on drugs, and I believe we can also trust the government to reasonably modulate drug reimbursement without ruining incentives for development.
Health spending is almost entirley explained by income levels, especially in the long-run. The US spends much more because the US is much richer than most and because health spending is highly elastic at a national level.
# TL;DR https://i0.wp.com/randomcriticalanalysis.com/wp-content/uplo...
# Long explanation
https://randomcriticalanalysis.com/2018/11/19/why-everything...
> and we don't have better outcomes to show for it
Norway and Luxembourg also spend 2x Spain and Italy and don't have more to show for it either despite the fact that they're also much richer, have larger welfare states, etc.
https://i1.wp.com/randomcriticalanalysis.com/wp-content/uplo...
Countries increase health spending because they can, not necessarily because they need to. Evidence strongly suggests returns to health spending are falling everywhere and the US isn't particularly unique in this regard.
https://randomcriticalanalysis.com/2019/11/07/a-tale-of-two-...
My findings strongly agitate against the notion that high US health spending is a product of idiosyncratic features of our system. Presumably most of these critics believe we'd spend much less if only our system looked more like other countries, but my evidence indicates we'd spend very similar amounts in the long run regardless. Further, we'd likely have similar outcomes and many other similar healthcare attributes (prices, intensity, health worker density, etc). Most of the things about US healthcare people believe to be important and unique (i.e., not explained by income) just aren't.
> The more money is in the pot, the greater the incentives to pilfer it, and, in lieu of adequate controls, the more it will be pilfered
I wouldn't argue there's no "pilfering" or that more money doesn't create more opportunity for this, but the high income elasticity likely has little to do with pilfering. Where are these ill-gotten gains going? I certainly don't think you'd have much success in showing this if you look at, say, the growth in physician incomes, pharma/biotech industry profits, and so on. The data are much more consistent with mundane explanations like rising technological sophistication, higher intensity, and so on (ultimately much of this being driven by some combination of patient/family demand and providers' "spare no expense" approach to caring). I mean, if you look at the economic data it's quite obvious most of the increase can be arithmetically attributed to a swelling of health workers (density or share of workforce) and that most of these workers have lower-to-middle income levels (especially on the margin).
https://twitter.com/RCAFDM/status/1193949748841111552
> I surmise that the accelerating nature of health expenditures... is due to the rapid inflation of disposable income relative to overall income at the higher levels.
I'm not sure what you mean by this exactly, but a better, more parsimonous way to understand high income elasticity is that higher income countries are usually inherently more productive countries. We can spend substantially smaller shares of our income on food, clothing, shelter, and other "necessities" because we are able to produce these things so much more efficiently (or otherwise procure on the market) than we did decades earlier or than OECD countries of more significantly more modest income levels while still consuming more of these things in real terms. This frees up resources to be spent on higher order wants like health, education, recreation, culture, and so on. Many of these growth areas, meanwhile, are inherently subject to less productivity growth, meaning prices tend not to fall relative to incomes nearly as quickly as we observe in other sectors.
https://randomcriticalanalysis.com/2019/12/03/no-means-no-th...
> I say this with no irony: a linear regression between income and amounts extorted during kidnapping, controlling for other variables, would show similar results.
I doubt that's true, though we're talking about the total spending (kidnapping ransom) per capita here. It's pretty clear the price per transaction (as in, health inflation) explains very little in US time series or cross-sectionally. Now maybe if kidnapping started to become a high amenity affair in developed countries (presuming this sort of thing happened with measurable frequency here) and 25% of the population worked delivering these services.....
At roughly the same time, Harry Truman had a (possibly) better model, but business groups and the AMA prevented adoption (because "socialism").
The employer-sponsored model of the US wasn't that bad during the 1940s, but I was clearly obsolete by the 1960s. What keeps it alive, ironically, may be Medicare: it removed the most expensive pool of patients (seniors) from the risk pool. This staved off the government needing to come in and heavily subsidize private insurance and set up nation-wide care provider networks.
Countries with private insurance industries that didn't bifurcate the risk pool in this manner ultimately did a better job of controlling costs for everyone
Medicare itself is a bit of compromise: it was suppose to be for everyone, but it ultimately just became for seniors. And while Medicare for All is back in the zeitgeist today, it was a consistent policy plank until the 80s, with the more conservative position being an approach where private companies would just sell medicare coverage (effectively creating a system like Switzerland or Germany, minus the public care providers).
I'm tired of this model too. People should pay what they're costing. It's just that, the costs should be reasonable. I work out, I eat extremely healthy, I'm never sick, and I don't require medication to keep my heart pumping. Why am I still paying a fortune on healthcare, including premiums and deductibles? I have a great insurance plan, ffs!
But half the country either smokes or is obese, and I shouldn't have to incur the cost of other people's conditions.
The biggest problem is that the entire existing system is so convoluted and bureaucratic that the cost of everything is ten times what it ought to be.
They should just delete every single piece of federal healthcare law with two years of notice for the states to be ready to pick up the ball. Then let fifty states try fifty different ways to clean up the mess. Some will get it right and some won't, and then the losers can copy the winners, but even the screw ups can't be much worse than the status quo.
I'm not sure it's a good idea to ban other options, but it'd be great if everyone was covered by default.
Also, what happens when nationalized health care is implemented, since employers will stop offering medical insurance in many cases?
The fact that gig economy companies can get away with paying people less than minimum wage shows that it's not working.
Because we, as a society, decided decades ago that this is important to do for the good of the nation and that's why it was codified into law.
You’ll have to excuse me if I don’t think that we should celebrate giving the government more power over what consenting adults are allowed to do when it doesn’t invade another person’s rights.
The government added new rules to the market. Some players like those rules: some don’t.
If you answered "yes" to these, then I expect people like you and people like me will fundamentally never have a productive discussion about this, as our values just don't match up.
No, at a certain level, if you are a highly compensated employee, you should be able to negotiate that you won't compete with your employer for x months after you leave the company in exchange for a certain amount of money.
Do you reject the notion of the minimum wage?
I reject the concept of a "livable wage". It's not the market's responsibility to provide a "livable wage" since that varies based on your situation -- a teenager staying at home vs a single mom with three kids. The "safety net" is the responsibility of government. That was the original thought behind the Earned Income Tax Credit, disability, etc.
Do you think we shouldn't have required unemployment insurance payments?
No, I should be able to negotiate that I want to be a 1099 employee (and I have) and know that I won't get UI in exchange for a higher hourly rate to allow me to "self insure".
Do you think we should allow companies to force workers to sign contracts banning union membership?
What I do outside of company's time is none of their business. However, if they pay me enough in exchange for me not being in a union (which I wouldn’t want anyway), sure I’ll take the money. If I don’t want the government coming in between negotiations between myself and my potential employer, why in the heck would I want a union?
Free will is great isn't it?
The government has nothing to do with the market. They exist to complicate it and take their cut.
Are there stats on how many Uber drivers have a second job vs. for how many it's their primary source of income.
Regardless, I reject the notion that someone should be required to hold down more than one job in order to make ends meet. If they like to have more than one job, and the total hours work out to something reasonable, sure, but my impression of this is that we see people working multiple jobs out of necessity, at significantly north of 40 hours per week, and are still living paycheck-to-paycheck.
- As of 2015, 69% of Uber drivers drove for Uber on the side.
- 97% were satisfied with the flexibility of their schedule
- 16% drove for a set amount of time, as opposed to setting an earnings goal or "it just depends on my schedule"
- 50% drive fewer than 10 hours a week, on average
AB5 throws a wrench in all of that. The trend from 2014-2015 was towards more flexible workers, so the above numbers may have gone up since then.
Source: Benenson Strategy Group, as shared via USA Today https://bit.ly/2PyO1uq
AB5 seems aimed at addressing the vulturism that emerged in the wake of the Great Recession, where the economic collapse was used as an excuse to undo all kinds of more stable arrangements and protections, privatize costs onto workers, and grab an even greater share of wealth for the rich.