Hospitals mergers do not improve quality: study
wsj.com
wsj.com
No matter how many people say "but a well regulated mandatory multi-payer type of system is working in Germany" or "nationalized medicine is working in Canada" it's all just ignored and the argument continues anew.
I mean, at one point for the hospitals to continue to operate at ever more profits you basically have to stop curing people and make them come back. You can combat that with more choices, but nobody is breaking up the banks, so why would they break up the big hospitals?
https://3.bp.blogspot.com/-XZHRqu2UjeE/U7LUMgY49HI/AAAAAAAAP...
Practically nobody is saying that a single payer system or tightly regulated multi-payer system hasn't worked anywhere (we all know Canada exists) or can't work in the US.
Everyone is arguing about the specific implementation because those are the details that make or break it. Anything would work on paper. Even free market with some good regulations to promote competition would probably work. It's the specific details of actually implementing something that works (and the ability of the people who would be doing the implementing to get those details right and not be corrupted by existing interests) that everyone is arguing over.
Everyone with a brain realizes that when it comes to big systems involving lots of moving parts the fine tuning is what makes or breaks them. Look at all the various social services programs that were kneecapped over the years because someone came along and made a few small changes or some key feature was compromised out of existence. Everyone is bickering over every detail because every detail has the ability to cause massive amounts of hardship when applied at a societal level if said detail is done wrong.
Simply put, healthcare is a hard issue because the stakes are so high that nobody is apathetic about it making compromise and consensus hard to reach.
One of the really interesting things about US healthcare is how much is spent on bureaucracy.
Consider, the average surgeon does ~400 operations per year and they generally make less than 600k/year. That’s 1,500$ per operation for the surgeon. Even with support staff, infrastructure, and materials, the average surgery should be under 10k.
Now let’s take an insurance that’s paying say 80% of it’s premiums for medical care. That’s 1 / 0.8 = a flat 25% price increase directly on top of whatever they add to healthcare provider’s costs in terms of additional paperwork and negotiation.
Similarly, before it goes to insurance the cost is inflated at the healthcare provider level to cover administrative costs like unpaid bill collections etc.
A junior programmer costs $250/hr from booz allen or whatever and I think a lot of people here understand why that is. They might not be able to fizz buzz so well but we expect the system to fizz and buzz eventually and expensively.
You can't add up what a plumber spends on beer or pays an apprentice and try to say what he should charge for his business.
What sucks is that despite the rhetoric theres actually no market. Want a market? Let people actually choose and make costs transparent.
Cosmetic surgery prices are generally reflective of costs including advertising etc. It’s not cheap by any means, but you simply avoid overhead occurring in other parts of US healthcare. Dentistry is another example where prices are generally reflective of costs, at least compared to say hospitals.
That's not a free market then. This is the hardest part of the entire discussion: everyone is attempting to not exercise political power because they have these grand notions that politics can be done for the benefit of all. I'm not saying M4A is impossible (in fact, I would prefer it if I still lived in the states), but the fact of the matter is that the donor class will feel the sting of this transition, so we go off and Chase fairy tales where both the donors and the people rationing insulin can both coexist.
Ultimately you end up with contradictory notions like a regulated free market.
Or stuff you eat or medicine. Or occupational products. Or... actually I think more things are regulated than aren't.
I guess my point is that when regulations apply to everything around us, is that really the sticking point or is it the potential for regulatory capture and limited user choice?
I think we're talking about different definitions of a free market then. To me, a free market is a market which is self-regulating or free from external regulation. It would seem to me that you define a free market as having some, arbitrary amount of regulation. If the amount of regulation is "under," that arbitrary bar, then it would be free. I don't really think this definition works, as the bar for what's "free" is arbitrary and would vary person-to-person, nation-to-nation, so it becomes a meaningless term.
There are severe limits on what any of us can buy and/or sell and how we talk about it. A good kick starter for discussion would be an example of a free market as you see it.
If you are doing things with widespread societal impact generally society will have some things to say about that and their (perhaps slow and ham-fisted) means of expressing opinions about that is law and regulation.
As a consequence of seeing all fields as essentially regulated, I have a pretty low bar for free markets which is mostly "multiple parties can meaningfully compete and politicians do not completely determine that. Also consumers have a genuine choice.". This excludes China but kind of includes the USA, in many fields. But health care is weird.
As an example of my point of view, I think we can have laws that regulate carbon, material waste or other externalities and might be "onerous" but still have "free markets".
They are certainly arguing that such systems won't be effective in ths US in this discussion:
> Many on the left despise mergers and consolidation, and anything that has a hint of monopoly power. Except when it comes to government, education, and healthcare! Doesn’t a single centralized monopoly providing everyone’s healthcare seem like a bad idea? Why is it so bad in business and so good for health?
> That is very bad reasoning. Most things don't get cheaper when they get nationalized. There is some evidence healthcare may be different in this regard, but the point is: costs are not invariant under nationalization.
> We can't provide everyone with all the healthcare that they should get. There are never going to be enough doctors, equipment or hospitals. Sickness is literally an endless source of suffering and we all die of something - there cannot be enough medical assistance to deal with everything even if we devote everything we have to the healthcare industry. Rationing access to healthcare by people's economic contribution to society is just as fair as any other sort of rationing you care to come up with.
> There aren’t sufficient amount of people willing to do the highly undesirable work of caring for sick, contagious, handicapped, possibly dangerous people without money as the end goal.
Its difficult because the system has evolved to a place where the parasites in the relationship have grown so large that they can't be removed without serious damage to the host. Not overhauling the system is unsustainable, but doing so will absolutely incur huge economic consequences for a large part of the population.
I don't think their problem (at least of one side of the debate) is whether it will work or not.
Their issue is a moral one, whether they should ever pay into a health care pool for the benefit of other people.
Those that think they can manage on their own don't see why that should happen. And as a protestant inspired culture that took it even further than the original protestants, they find this appalling.
They'd rather see people die in the streets and step over them on the way to brunch, than have themselves, hardworking "good" persons that they are, contribute for the health of the poor and the "losers". Even more so if it's mandatory. Charity from their magnanimous heart, they can consider.
But in a lot of cases, it's like they will not (or can not) learn from what is going on in other countries. Maybe it's also US exceptionalism at play?
For a country that supposedly values small business, there are few things I could think of that would support small business more than public healthcare. Currently, large employers can get a group plan with very reasonable rates. Small employers are pretty much out of luck.
It stands to reason to me that the bigger the pool, the more predictable and lower the costs. It's ridiculous to me that arbitrary groups of people can't go in on a health plan together. If a company with 50k employees can do it, why can't a city / state / random assortment of people?
But it does increase the gap in wages between the big corporates and small businesses. It’s very hard for small businesses to hire good talent when they can work in the corporate world for a higher salary plus benefits.
I have a 1500/3000 family plan with a sticker price of $32,000 / year. I pay a third of that and my employer picks up the rest. I guess it's possible that this is about the going rate and most employers just pick up more of the cost than mine.
Either way, that seems like an unsustainable amount of money to be paying each year.
I mean, realistically, that's what all insurance is anyway. The trouble with the US system (vs other mandatory/psuedo-mandatory insurance systems) is more around the way it's regulated.
(It's not really voluntary... While you can opt out, if you have moderate income or better, you do so at your own financial peril)
That's ok, as long as it's voluntary (as a sibling comment wrote), and as long as private companies, and not the public pool, benefits. /s
I think his main issue with it is that he thinks they are wasteful with their budgets. I've never really figured it out.
People pay for services that benefit others all the time - why should health be any different?
Very rarely. Good schools attract paying parents with large families, leading to a self-reinforcing effect and affecting property values so much that it's one of the search facets on property sites like Zillow. So really they pay for their children, usually.
> They already pay for a local library, even if they never use it.
This is a relic of when people did use libraries more. A lot of library systems are dying out with the excuse of "but we prefer Kindles".
> They pay for a local fire department, even if their house never burns down. They pay for a local police station, even if they are never the victim of a crime.
They do this more out of fear of avoiding viscerally life-threatening consequences. Somehow healthcare has assumed the status of not such a thing in the States.
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For what it's worth, I am strongly opposed to these viewpoints, but just stating that there is not as much self-contradiction there as you think.
And if you’re not paying this directly, it’s probably because you rent (and you’re getting passed on the cost) or it’s hidden in income taxes.
I guess a nuanced version of what I mean is – they very rarely pay a lot for schools if they don't have children. Put another way, they do pay through the nose for schools if they do have children, which it sounds like you are doing.
Of course there are exceptions to this. Maybe you live in a district with great schools and have no children, in which case you are paying for a great school with no direct way you can take advantage of the benefits. My point was that this situation is relatively rare; perhaps it wasn't expressed too well.
If some people could have their way, they'd remove paying for those -- or for bridges, roads, federal infrastructure etc away from their area, too. Let the locals short it out.
But a difference with those things you've mentioned is that they were born with them existing. So they're some kind of default (though a minority still debates them). Whereas nationalized healthcare would be a new development for them....
Having children is a choice at a different level than the need for healthcare. If I had to pick between public education and public healthcare, I'd pick public healthcare every time.
I haven't verified it but a quick Google search shows "American taxpayers spent close to $649 billion on its K-12 schools in 2015".
I don't know how much the US spends on healthcare. iirc it is about 18% of GDP or roughly a fifth. If our GDP is USD 20T, then we already spend almost $4T on healthcare. We don't know if adopting a system similar to Germany's will allow us to get it down to what Germany has (11% of GDP) but we have to try.
We already do. It's called private insurance. We also pay into medicaid and medicare.
Even when you can afford it, an increasing number of doctors are refusing to accept insurance. These doctors tend to be more highly regarded and provide a higher standard of care because they’re not shackled to a computer doing insurance paperwork half the day.
So even with the system we have, insurance isn’t really worth it unless you have chronic health issues. This becomes a feedback loop of increasing prices and decreasing benefits for all but the most expensive patients.
Profit is a moral hazard in health care.
Note: This is not my position on the matter. Just trying to explain the difference.
Edit: Regarding Medicaid and Medicare - believe me, people would love to see Medicaid go also. I think they're OK-ish with Medicare because they know they'll get old at some point.
And as a individual to be able to take the most optimal decision in complex systems is pretty difficult. What would we be without our choice and an AI or a higher power would take the decisions for us?
The fact people in general can barely maintain their own needs makes it even more of a struggle to sell helping everyone else in general (healthcare, fire departments, schools...). They, themselves, would like financial assistance but can't get it so have quite a bit of resentment (and who can blame them for that).
If most folks had more resources (e.g. money), I think you'd find the culture would shift a reasonable amount towards supporting things like universal healthcare, etc. In a culture driven by constant economic competition for survival, it makes sense that people don't want to help their potential economic enemies. If there's fewer people, there's less competition, less kids to grow up and displace them, etc.
There are still people who literally do not have any concern for the wellbeing of others and no amount of resources would change their perspectives but I argue those are relatively few in the general population.
Yet I've never once seen a "we should just pay costs" argument, since it would invariably lead to large scale preventable suffering and death.
> They'd rather see people die in the streets and step over them on the way to brunch, than have themselves, hardworking "good" persons that they are, contribute for the health of the poor and the "losers". Even more so if it's mandatory. Charity from their magnanimous heart, they can consider.
This is a great summary of the issue.
Americans pay about twice as much as all other western nations for the opportunity to turn people away. It's not about contributing for the health of losers, it's about being ok with paying double so that losers don't get anything.
This belief that it's about not wanting to pay needs to end. They are paying just as much as everyone else from taxes, and then paying another just as big amount out of their own pockets.
In short, we have a cost problem that's not being tackled. Pharmaceuticals are often targeted, but they're about 8% of our total healthcare costs. We really need politicians that will tackle the other aspects of cost.
The countries that finance public healthcare have tax systems that are considered regressive by US standards. Some states have sales taxes, but we have no national VAT. As I understand it, some countries like Sweden have income taxes on lower income workers, whereas in the US, roughly 45% of households pay no federal income tax.
You can only squeeze so much money out of the wealthy, but the numbers don't add up to cover the projected costs of nationalized healthcare in the US. Taxes would need to be raised across the board. It's easy for campaigning politicians to propose pie-in-the-sky plans, but proposing a financially plausible one would be political suicide.
[1] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
[2] https://en.wikipedia.org/wiki/List_of_countries_by_health_ex...
The reasoning goes like this:
The entrenched well funded (and money loosely translates to political power) interests influence the legislators doing the implementing in order to ensure a regulatory capture that allows them to continue swindling people at their current level but because it is now proxied through the additional overhead of government the net cost to the citizenry is greater than the current "get swindled directly" system and we have little/no net change in outcomes.
Basically people don't trust the government to not screw it up so badly that it actually costs more. I'm sure the cost would come down over time but with the high cost and uncertainty involved that's a tough sell.
Everyone who works in healthcare now would become a low-paid government employee. That seems like your source of opposition.
It isn't the only reason, but it is one of the biggest.
Healthcare costs have skyrocketed because of the negotiators. PBMs are the middlemen who negotiate healthcare prices between insurance companies and providers. I can't speak for hospitals and procedures, but in the pharmaceutical industry, it actually has led to a system where insurers and PBMs both benefit from drug prices increasing as opposed to decreasing. They aren't driving costs down, they are directly contributing to driving costs up.
Make all the prices public, and watch all the excuses disappear. No insurance company will be able to answer the government or employer when they find out another insurance company was able to obtain the same medicine or healthcare for a lower price.
One thing I learned from the episode is that insurance companies get a reward for the delta between their negotiated price and the price a uninsured person would pay. This creates incentive for hospitals to raise their base price tag. Of course their is more to it. I cannot recommend the episode strong enough.
To me the bottom line is that right now we don't have free market health care and we don't have socialized health care we have the worst of both. Maybe what we have is best received as crony capitalism health care.
Taking a look at their website and just seeing the prices for procedures is incredibly refreshing: https://surgerycenterok.com/pricing
Disagree completely.
US spent $3.65T on healthcare in 2018. or 3650 Billion.
Insurance Net Income was 23 billion. Or 0.63% of total US healthcare expenditures was 'profit' for insurance.
"But, public option will save the costs/salaries/buildings/etc that you pay to insurance." Yes, but not all costs. You'll need to make up a small difference.
But, let's assume we only count money paid to 'care'.
If we ignore all other costs associated with insurance and just pass the 'care' portion through. Insurance REVENUE was 706 bil - 600 bil (What was paid for care). or 106 bil.
So a maximum savings of 2.9%. So rather than spending $11,172 per person we're down to $10,836 per person for healthcare. A savings of $336. Still far and ahead above what other countries spend.
So realistically we'd see a savings of 0.6% to 3% savings.
https://naic.org/documents/topic_insurance_industry_snapshot...
> Insurance Net Income was 23 billion. Or 0.63% of total US healthcare expenditures was 'profit' for insurance.
Profit is not the main source of the expense imposed by private health insurance, administrative costs are; Administrative costs are estimated at around $1.1 trillion nearly a third of the total, much of which, particularly billing and insurance-related (BIR) costs which account for about half of admin costs, would be eliminated in a single-payer or even public option systems, since the BIR costs imposed in current US public programs are far lower than private insurance (and some of those are still due to interaction with private insurance—e.g., coordination of benefits—and so would be erased even for public programs in a single-payer system.)
https://www.americanprogress.org/issues/healthcare/reports/2...
Which is why I included this piece.
>If we ignore all other costs associated with insurance and just pass the 'care' portion through. Insurance REVENUE was 706 bil - 600 bil (What was paid for care). or 106 bil.
>So a maximum savings of 2.9%. So rather than spending $11,172 per person we're down to $10,836 per person for healthcare. A savings of $336. Still far and ahead above what other countries spend.
Last year insurance spent $92 Bil on admin. Even if we 'save it by half' (comparing the 56 bil from your link) our best case savings of 106 bil drops to 60 bil. Or a reduction of 1.6% in healthcare spending or ~$160 per person.
And hospitals will still have admin as they still have to bill the government.
Missed responding to this piece before, but, sure: but, from the source I cited upthread, BIR costs imposed in the US big public programs (Medicare/Medicaid) is 2-5% of total cost, in the US private insurance system, it's 17% of cost. With single-payer admin will be nonzero, but it also won't be nearly 1/3 of total health expenditures, nearly half of which is related to billing and insurance.
>NAM report concluded that BIR costs totaled $361 billion in 2009—about $466 billion in current dollars
>12.3 percent of spending on private insurance; and 3.5 percent of public program spending, including Medicare and Medicaid
So a difference of 8.8%. A savings of 41 Billion. So we'll add it to the 106 bil for removing insurance. And we're at 147 Billion. Or 4% total.
Even if we use the other estimate they mention. You're still looking at less than a 6% savings.
(People also misleadingly claim that the UK system excludes private provision - it doesn't, it's just that only a small fraction of the population has it and the tax advantages are nonexistant. Optical and dental are also mostly private.)
The relatively few who “pay their own way” face incredible costs as few of the health providers actually compete for customers in an open and free market and so they charge crazy prices and get away with it.
So even though we have the second best healthcare system and pay an average price for it, people still want to nationalise our system and revert the privatisation. Because "privatisation bad". It truly baffles me that people think it will be for the best. Perhaps the price will go down to the 4100 USD per capita that the nationalised UK system has has but I'm sure our quality would also drop to UK levels (16th place in Euro Health Consumer Index).
Is the insurance provided by employers? In the US, most plans are provided and heavily subsidized by the employer (because the tax code makes that palatable vs paying employees more).
Do you have co-pays or deductibles? If so, how large are they? In past decades in the US, good plans had fairly low costs to the consumer ($20 GP visit, $50 ER visit was common). These days, because costs have gone up, many plans have converted to high deductibles with dedicated savings plans ($5000/year per individual OOP, but the person is allowed to save into a tax-deferred account that's a lot like our 401k retirement system, just used for health care).
Dental and physiotherapy are separate from general healthcare and have their own insurances and payment structures. They are all privately owned facilities. I usually pay my physiotherapist around €40 for a 30 minute session so I don't need insurance for it. But if you have regular appointments it would make sense to get private insurance for it.
We don't have a lot of co-pay (eigen bijdrage). There are some parts in regard to post-natal care where a co-pay is required. Also on hearing aids, dentures, orthopaedic shoes, medicine and non-ambulance transportation to a health facility.
In the US, when I need a doctor, I get to see one right away. If the doctor recommends an MRI or ultrasound, I get it right away. No six month waits, no cancelled surgeries, no doctor strikes (!), no government deciding how to prioritize my medical needs, etc.
What it ultimately comes down to is that medical resources are scarce (and always will be while medical technology is improving and thus some care is expensive), and having the government allocate them can be inefficient (governments are generally inefficient due to lack of competition, as are systems where the customer is disconnected from the cost).
And yes, I care more about my own health care and that of my kids than I do about the health care of some stranger thousands of miles away. I have okay corporate health insurance and so the system works better for me than for some. (Some would argue that regulation rather than economic freedom are to blame for those people's worse experiences, but I'm not going to get into that other than to acknowledge it.)
You might disagree with some of my perspective, but the snooty attitude that Americans are oblivious morons is unwarranted.
As a relatively wealthy and well-educated American with great insurance (and easy access to other jobs with benefit packages should my employment situation change), yes, I benefit from the American system. But I wouldn't vote for representatives that advocated it. We're not yet approaching something that's a little bit worse for 99% of the country and a lot better for the remaining 1%, and I'm sure we will have many fun debates as to where we should balance the equation as we approach that point. I would have to be pretty selfish to vote for something that's objectively worse for most people in my country.
However, it would in fact take an oblivious moron to advocate something that's simultaneously worse on average and also worse for them individually, and yet that's what we have in American politics today.
Interestingly, my wife -- who moved from the US to the UK a decade ago, and has had quite a bit of interaction with the healthcare system since she's been here -- feels exactly the opposite.
Here we finally got the MRIs that were recommended but family couldn't afford years ago. Sure, we had to wait for 3 months and the doctor's visit + MRI cost us a total of $35 (hadn't reached the $120 yearly out of pocket limit) but it was a known non-emergency.
My point is that these other systems work, maybe people working at the FAANG companies, in financial services etc. might see a slight decrease in their quality of care, but the systems would all still work and would be much less of a share of your GDP.
I do not have anything good to say about our "system" (except that the doctors and nurses themselves are many times exceptional), but I also have seen enough of government run systems to know that that is not not an answer.
There are many Canadians who have been convinced that our health care system is crap by the usual suspects. It isn't.
Yes, if you live in a major center in the US (like near John Hopkins or Stanford Medical) and have great insurance, you will get some of the best health care in the world. The cost is your less wealthy neighbours are dying and going bankrupt.
1 - A significant portion of our economy is healthcare middlemen. With single payer or nationalized care, all of our Blue Crosses and Cignas (and the jobs associated) would evaporate overnight.
I'm not arguing that we need trillions of dollars of our GDP locked up in middlemen, but it's very hard for a man to understand something when his salary depends on his not understanding it.
2 - We hear about long wait times in other countries. And the stories are mostly true. There's nothing wrong with waiting, but we've been conditioned to expect near-immediate resolutions.
People in the United States with high-quality private insurance* can usually be seen by a specialist within a few weeks regardless of how severe or immediate their problem is. The truth is that unless that person has some kind of advanced or rapidly progressing disease, they could wait for months without any problems. But that would be a major change to the way we think. It would mean allocating care based on need, not based on ability to pay.
*High-quality private insurance is usually one of the perks of working for a great company. I would argue that only a small minority of Americans have truly high-quality coverage. But all of the people who don't have high-quality coverage envy the others and vote with them, a la "temporarily embarrassed millionaire."
Are you sure? I have to schedule several days if not a week in advance just to go to my PCP, much less a specialist. I also live in an area with no shortage of medical services.
If it's emergent (like a severe allergic reaction), there's the ER.
If it isn't emergent but needs resolving sooner (like an ear infection), there are Urgent Care clinics everywhere. I've also had the experience that my GPs' assistants can find time in their schedules if my problem is one that (1) they can resolve and (2) does need a quicker resolution.
About the long wait time - I waited from 11pm until 8:30am (discharge) in the morning in ER of Strong Memorial hospital one day for falling and bleeding from my nose (I thought I broke my nose, but luckily, I didn't). I should have answered my pain level was 10 instead of being truthful about it and responding 3. This is not to mention that I got charged $250 from deductibles despite having the insurance.
My sister, who lives in Rochester, NY, is waiting until May 2020 to get an appointment for yearly physical checkup. There's a significant shortage of doctors in rural areas (Rochester isn't even that rural to be honest). And yet, AMA is happily restricting the supply of new doctors by putting up multiple hurdles including exam fees (not to mention the amount of money they charge for each USMLE exam is ridiculous) and requirement to go through 8 years of education when that could have been easily reduced to just 4 for any IM (internal medicine) physician.
This is how the system is supposed to work. Even if you had broken your nose, unless it's some gaping open fracture or the bleeding can't be controlled, it's probably not a higher priority than most of the cases they see.
> My sister, who lives in Rochester, NY, is waiting until May 2020 to get an appointment for yearly physical checkup. There's a significant shortage of doctors in rural areas (Rochester isn't even that rural to be honest). And yet, AMA is happily restricting the supply of new doctors by putting up multiple hurdles including exam fees (not to mention the amount of money they charge for each USMLE exam is ridiculous) and requirement to go through 8 years of education when that could have been easily reduced to just 4 for any IM (internal medicine) physician.
This is a complicated problem. Our current system incents people to become specialists. Why would I want to go to school for 8 years (taking on $200-300k in student loans if I'm lucky) and then do 1-3 years of 100-hour weeks making $50k to come out making less than a twentysomething software engineer?
The real supply bottleneck is in federal funding for additional residency slots. Every year students graduate from medical school but are unable to practice because they can't get matched to a residency program. The AMA is actively lobbying to fix that problem.
https://www.ama-assn.org/press-center/press-releases/ama-fun...
There's nothing wrong with forcing you to wait a few hours in the ER for a minor problem. If your vital signs are stable then you can wait.
This is why we can't have nice things.
If California wants to have socialized health care for all it's residents, literally nothing is stopping them. Many states already have 100% government medical insurance for the poor.
The reality is, government run systems are an absolute nightmare. Similar to government housing, you only use it if you can't afford the alternative.
Well done.
In the case of hospitals, a system occasionally takes over a bankrupt hospital. That isn't particularly worse for the people that continue to have proximity to the services available at the hospital.
Also modern Apple devices are based on the NeXT's operating system and have nothing other than cosmetic and emulative compatibility with MacOS. OSX/macOS is NeXTStep on top of Mach.
source: bought $100,000 of APPL in 1997.
Not really to "bring back Jobs". Jobs was not considered any kind of wonder CEO or miracle worker at the time. They wanted a new OS, as their own traditional Mac OS successor attempt had failed.
They also looked and negotiated with Be (for BeOS), so it wasn't that they wanted Jobs particularly.
It would just be a nice "back to roots" publicity side benefit, but nobody considered Jobs especially their potential saviour at the time...
There’s even a joke of “how to go from billionaire to millionaire? Buy an airline”.
- Richard Branson
While there were more companies before the merger, verizon and at&t were dominating that a long tail of small companies was not true competition.
When tmobile merged, it started to add a true 3rd competitor to the scene and they were the first to do a lot of stuff with unlimited data. Many people attribute verizon and at&t following suit to their initial move.
Of course this is speculation as no one can prove casual linkage between these events, but it seems pretty plausible.
Sure, Sprint is a dead carrier waking, but T-Mobile is already a competitor to Verizon and AT&T.
T-Mobile doesn’t need Sprint to compete with the other two at this point. They have the spectrum. They also have a 5G network rollout out with the lowest frequencies, which means they’ll actually have a coverage advantage.
Back to Sprint, they essentially can’t afford to build out 5G. But for consumers, they’re the cheapest option by far, especially when you consider their MVNOs like Boost Mobile. They also have a tremendous mess of spectrum that isn’t a very good situation for device interoperability and availability, nor is it good for rolling out 5G at all.
In other words, Sprint needs T-Mobile, but T-Mobile doesn’t need Sprint.
If Sprint cut costs and declared that they are the cheap, forever on 4G network, that would benefit price-sensitive consumers. Sprint’s competitive advantage would be that it doesn’t have to spend a lot of money on bothering to upgrade anything, or the marketing budgets that Verizon and the rest spend (I’d love to know how much of our monthly bill ends up on TV), and that their 4G network is good enough if you mostly care about price.
In my view this is the alternative that the corporations won’t even suggest to the public because it’s not as profitable. The people who own Sprint maximize their investment returns by selling to T-Mobile.
Sprint going bankrupt or being sold in pieces or in whole may even benefit the consumer more than Sprint being absorbed by T-Mobile, but the big three are never going to admit that.
Finally, what’s happening here is that you are unintentionally parroting T-Mobile’s own PR and lobbying efforts. T-Mobile put out news stories and press releases describing this exact scenario and how it benefits the consumer. They claim that they will truly do 5G right if they own Sprint, but I think they just want Sprint’s customers to be tacked on to their own.
How come T-Mobile is consistently cheaper than ATT and Verizon? How come Verizon is the most expensive?
If the networks were the same, why would people opt to pay Verizon more? As far as I know, for coverage, Verizon > ATT > T-Mobile. It’s mostly a function of more towers, and I presume T-Mobile has the fewest.
Absolutely no one anywhere is suggesting doctors and nurses should work for free. Single payer advocates are only suggesting that we cut out the byzantine mechanism of the US medical billing regime, and let the American people pay health care professionals directly, with taxes, instead.
And good compensation for health professionals can happen in a non-profit context too.
Compare to an free or open source project. A project that pays some contributors, but not others is a rather unhealthy situation. Such a project would have more difficulties attracting and retaining developers.
Don't underestimate what people will do for other than financial compensation, given suitable conditions.
The analysis you present is not uncommon, where the businessman somehow gets to choose how much money he makes in a vacuum, a situation that doesn't really exist.
Ironically, lots of US regulations prevent providers from entering markets, letting providers that already have regulatory approval charge more. Some regulations are literally written with this as the goal (CONs, Medicare reimbursement rules designed to prop up small hospitals with emergency rooms).
It would be just as massive an overhaul to turn this sector into a truly competitive market as it would be to nationalize it.
Obviously having a single purchaser of so many services allows them a large degree of control, but it isn't even a single payer system, since many health services require extra funds (even a routine doctor's visit requires out of pocket costs for many people, like $30 — that isn't cheap) although that's a recent change. There's also private health insurance and extra fees you can pay for nice service (like a room of your own).
Because health shouldn't be run like a business, just like the fire department shouldn't be run like a business. The only metrics that should matter are patient outcomes and cost.
Option E is to run healthcare entirely as a business. Payment up front, and refusal to treat anyone without payment.
Option S is to take option E, but avoid immediately attributable deaths. Treat somebody at the emergency room, even if they don't have a line of credit with them. Patch them up enough to walk out the door, but don't treat the underlying issues without additional payment.
Option G is to treat patients before they reach death's door, when it is cheaper to do so. To give the preventative care that keeps costs down, even if somebody isn't able to pay for it. To treat public health as a public good, rather than as a series of purchases.
Option E is evil, to let people die unnecessarily. Option S isn't openly evil, but is stupid. It is where the US is now, and inflates the costs tremendously. Option G is to actually be good.
But a moral argument could certainly be made for option G.
I feel like it's not only a moral argument, instead it's a better alignment of those who pay and are served by the system. At present, the goals of insurers and providers are very different from patients, partly due to profit-seeking, partly due to the disconnect in who pays for it (49% of US population receives employer-covered healthcare).
in option G, how much $ do we spend on terminally ill patients in order for them to have a few more days with their loved ones?
or how about smokers who will as a result of their actions will cost spades more than "good souls"? or type 2 diabetics on dialysis?
this false trilemma is largely useless and only presents one side of a moral choice and even then ignores the other prickly of it (read: the people paying for this glorious utopia and where the lines are drawn when it comes to saying no)
We already pay for our healthcare in the US, we just do it predominantly via employer-contributed job benefits, and existing Medicare/Medicaid. The money for the bulk of healthcare is already there, but there are people falling through cracks all the time.
Is your position that bringing everyone's healthcare up to Medicare's baseline is too expensive? Where is the extra cost coming from?
That is very bad reasoning. Most things don't get cheaper when they get nationalized. There is some evidence healthcare may be different in this regard, but the point is: costs are not invariant under nationalization.
> Is your position that bringing everyone's healthcare up to Medicare's baseline is too expensive? Where is the extra cost coming from?
Cost of providing the existing service is not the only cost worth considering. The other issue is opportunity cost of innovation. Right now there are powerful incentives for people to innovate in the healthcare space, particularly in pharmaceuticals. But also in prosthetics and the procedural space. Nationalization is likely to crimp those incentives, and thereby lead to less innovation over time.
Zero. They would be explicitly avoided care if they are known being unable to return to work nor parent somebody (higher-order parenting such as grandparents, uncles, aunts count too).
Why not just tax the cigarettes and subsidise bike roads instead of car roads?
Efficiency matters, of course, and a higher fraction of GDP spent on healthcare isn't per se better, either.
One problem with private provision of anything is that a company only cares about the revenue it can actually capture itself. Nationalised provision, using tax as a revenue stream, can look at whether something is beneficial on the whole even if it isn't directly paid for.
Then why does the left assiduously avoids talking about student outcomes or per capita student spending?
my understanding is that at a macro level firefighters routinely "trade" regions for sake of better defending bigger or more important regions. it will have to be the same for health care: not everyone can afford a legion of 24/7 ICU nurses and ER physicians on standby when the end comes, even if .gov is footing the bill.
IIRC dems got killed for "death panels" when ACA was getting played up. there will always be death panels - someone who decides whether or not an additional dollar is warranted for any particular individual - so what inputs should we use to make those decisions in your opinion?
Multiple companies would show up at a house on fire, check insurance plaques, and then head home if they hadn't paid them.
If no one had paid them they'd let things burn, which sounds fine conceptually, but it's much cheaper to put out a fire early, and it has that awkward tendency to spread.
They were AARP supported voluntary sessions, paid for by Medicare, where people could discuss stuff like living wills and other end of life issues. https://www.politifact.com/truth-o-meter/article/2009/dec/18...
For instance, given that fire brigades are commonly city-level in the US and that American cities often have highly irregularly and interlocking shapes, it is plainly more efficient to trade a certain amount of funding to have the other city look after your dog leg. But there is a mandate on them to look after all structural fires in a certain area. They can pay someone else to look after it on their behalf, but the mandate remains. Territory and funds are exchanged. In other places, where fire brigades are run nationally or regionally, perhaps even individual stations will trade — "we specialise in rural fires and you specialise in urban fires, so you should take this newly urbanised region off our hands" "okay, but we will also take your newly urbanised funding off your hands". But it might also occur at the national or regional level and thus be central planning rather than business like.
But a fire brigade that is a private business will look after fires that are cheaper for them to put out than to burn. Perhaps they will put out a fire in a non-member's building since every neighbor is an important member — and then they might sue them for all their worth. But if they have no customers in an area because the people who live there do not have the money, then they might let the fire burn. Or they might say "we are liable for a hundred thousand dollars compensation if we don't put out this fire, but it will cost us at least a million to put out". (The local fire brigade will probably have to let some fires burn because they don't have the resources to put them out — it may be vastly too dangerous to get involved, but of a nature that, after a day of burning, it will be much safer. Here, the difference is the consideration — the question is the relative safety of attacking it vs waiting it out, rather than the relative costs of attacking it vs waiting it out.)
A mediate position could exist, where private corporations are allowed to get involved in the firefighting business, but if that were permitted, it would be a situation where the mandate remains and the private firefighters would be paid by mandatory payments from the property owners of the relevant territory. Unlike most businesses, they aren't free to pick what they do. A private supermarket can decide if they want to stock Mildew Milk or not. But a private regulated/mandatory firebrigade would have to put out the fire at Mildew Milk even though they've had a long running feud.
Exactly. Currently they're for-profit death panels in the insurance industry. And their metric is profit, not minimising death and suffering.
The UK approach to this is a board called NICE, which measures effectiveness and tries to set a cost-benefit level. What this means is that the UK is behind on leading-edge cancer drugs which cost a fortune for a few extra months of life, but makes sure that everyone has insulin. The US system is the other way round: some people get the life extension, some people die from lack of insulin.
(A surprising amount of healthcare rationing in the UK is simple waiting)
But the reason fire departments aren't run like a business is because fires spiral out of control and affect neighbours. That is not really the problem when we are talking about patient outcomes. Obviously we should all get exactly what we want without having to worry about physical constraints. But when we go from what should happen to what will happen the whole physics-and-reality problem sets in.
We can't provide everyone with all the healthcare that they should get. There are never going to be enough doctors, equipment or hospitals. Sickness is literally an endless source of suffering and we all die of something - there cannot be enough medical assistance to deal with everything even if we devote everything we have to the healthcare industry. Rationing access to healthcare by people's economic contribution to society is just as fair as any other sort of rationing you care to come up with.
What's the thought process for the "fairness" of income based rationing? This doesn't seem that rational from either utilitarian or deontological angles. From my perspective it's a very unfair strategy compared to providing equal care to all people.
How else do we ration healthcare? Best looking people first? Oldest first? Youngest first? They all have terrible edge cases that are as bad as richest first.
We can't give everybody what they need because that is physically impossible. I don't want to die, so if we are going by needs I need permanent life support :(. That isn't even slightly practical, so we can't do that either - someone has to do without.
We could directly build more hospitals, train more doctors, etc. It is hard to see what would really change - there would still be horrible stories about edge cases where the system failed and there would still be a great need for more people. We have to draw a line somewhere - why not here? If we can justify going beyond the economic equilibrium, at what point do we stop pouring money into the healthcare system? A serious question which in my view has no satisfactory answer.
In parts of the US, fire departments are run like a business http://www.nbcnews.com/id/39516346/ns/us_news-life/t/no-pay-...
Many a hospital has gone under due to the rising costs of ERs.
You don't see the difference between an entity designed for profit and an entity of the people, by the people, and for the people?
You might not agree its the most efficient solution, but its not a logical contradiction to be against private monopolies but for public entities.
Because a business is answerable to shareholders and a government is (theoretically) answerable to the electorate. This keeps the incentives between politicians and people aligned much more than between a monoploy business and people.
No. It doesn’t “seem” like a bad idea. Go look at actual countries that do it - it works fine and it’s vastly cheaper than the US’s failed “system”.
That said, you don’t have to go all the way and have a single healthcare provider: a single insurer will do just fine - it works for Germany!
Also: what the heck is a non-monopoly government even supposed to be? Of course a government is a monopoly (it is all of us), you want lots of competing governments running the same things? Now that does seem like a bad idea.
And while the Swiss system is expensive, can you really put a price on your health? I'd rather have a good system (Switzerland) than a cheap system (UK).
The services are also much cheaper than the US in general, even though Switzerland has some of the highest costs of living in the world. A routine visit at your doctor will cost at most a couple hundred dollars. Your deductible may be ~1000-2000 dollars and co-pay 10% up to ~7000 dollars after which your insurance must cover everything.
Swiss insurance will only cover you outside of your home canton up to twice the cost of having the procedure done in that canton, and only in emergencies. For that reason Swiss people are warned about needing emergency procedures in the US and Japan because it can bankrupt them.
This bifurcation of billing makes an easy trap into falling into dilliquency because youre inundated with so many bills for the same visit that, even if you can afford to pay, you're like, "didnt I already pay for this?"
Seriously, the hospital near me seems to be a racket for Bill collectors. It seems no one is employed by the hospital proper and that theyre effectively all subcontractors that submit their bills directly to the end client, despite never being notified of that.
I cannot imagine a process like this where I hire a contractor to build a house at X rate, and they agree, and then all of the subcontractors bill me directly outside of the initial agreement. Maybe not the best analogy...
I fucking hate medical billing practices.
(I'm in the US)
Too often hospital care involves out-of-network doctors, that will bill directly as they may not have contract with your insurance. Knowing who'll be on duty ahead of time is not always if at all possible.
The whole podcast is worth listening to, not just this one episode, especially if you are frequently involved in the medical system.
[0] https://armandalegshow.com/episode/can-they-freaking-do-that...
Didn't read the article but the headline is absolutely not a surprise.
Quality :)
This is the real reason for rising healthcare costs.
Pro tip: go to a smaller clinic or hospital and save $$
For profit (in my exe) has always been lower quality.
If you want competition to work you have to have sufficient excess capacity in the system to allow entities to fail and fail fast.
Not so much a case of big enough to cope, but small enough not to matter that much in the grand scheme of things.
That ought to be the rule of thumb for any competition authority - if this new entity went pop, would we notice?
Capitalism without the threat of bankruptcy is like Catholicism without the threat of hellfire. It no longer works as a concept.
Excellent material for those interested, an actual cash only, price listed, customer facing hospital. Shiver ye comrades for the devil capitalist is and has been here.
https://www.econtalk.org/keith-smith-on-free-market-health-c...