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 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.
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.
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.
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.
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.
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
(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)
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.
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?
I think his main issue with it is that he thinks they are wasteful with their budgets. I've never really figured it out.
We already do. It's called private insurance. We also pay into medicaid and medicare.
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.
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.
> 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.
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."
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.
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.
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.
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.
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
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.
(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.
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.
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.
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.
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...
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.
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.
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.
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.
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.
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".