As two quick examples, both Switzerland and France have private healthcare providers and insurers. I think that’s enough to falsify your assumption :)
Also FWIW France and Switzerland both have universal healthcare, under different systems where France splits payments 3 ways and covers more with the govt[1], and Switzerland seems to have a system like the ACA in the US where it's compulsory, but they also set caps on the deductibles and maximum price.
[1]: https://en.wikipedia.org/wiki/Health_care_in_France
[2]: https://en.wikipedia.org/wiki/Healthcare_in_Switzerland
You said private healthcare/insurance were to blame. Switzerland has private health insurance.
Universal healthcare is a separate goal post. For what it’s worth, I’m unclear its comprehensive iteration is compatible with America’s immigration model. (It absolutely is for life-saving measures.)
> You said private healthcare/insurance were to blame. Switzerland has private health insurance.
Private business in all western countries operates within the regulations and laws that cover them. The health insurance industry in Switzerland operates under a very different set of regulations and laws than the same industry in the USA. If you want to blame the OP for not being more explicit - "private healthcare/insurance and the regulatory framework are to blame" - then fine, but ... this is actually the crux of the issue.
I'm not sure it is. Universal healthcare is orthogonal to private health insurance. That's the lesson of Switzerland's example. I don't believe this is commonly known or accepted in American politics. Instead, any attempt at reform is pitched and vilified as an attempt to end private health insurance and healthcare.
However, "private health insurance" is not, in and of itself, really "a thing". Only "private health insurance plus a regulatory structure for it". It is in this department that the US falls over so badly, while, for example, Switzerland gets it (mostly) right.
Switzerland's compulsory private health insurance is nothing comparable to other countries' private insurance. There is "additional private insurance" in Switzerland (covering alternative medicine treatments, access to single bed rooms in hospitals, etc.) which do operate as private insurances elsewhere.
So does the US: https://www.healthcare.gov/glossary/minimum-essential-covera...
> there are treatments and operations (e.g. congenital defects and invalidity-related) that are directly billed to the public social insurance (funded by salary deductions) to help health insurances reduce their risk.
> Switzerland's compulsory private health insurance is nothing comparable to other countries' private insurance. There is "additional private insurance" in Switzerland (covering alternative medicine treatments, access to single bed rooms in hospitals, etc.) which do operate as private insurances elsewhere.
You're mistaken, Switzerland has no centralized social insurance — it is fully privatized (for real medicine as well as alternative medicine), and is decentralized among its Cantons. It's just that the private Swiss insurers tend to be non-profits (same holds true for the US, e.g. Blue Cross, Kaiser, etc) and the for-profit insurers' profits are heavily capped/regulated (same holds true for the US).
I don't know if you legitimately do not know that.
I did not talk about federal/cantonal to avoid writing a thesis in a comment. I never said it was centralized.
Salary deductions pay for subsidies to lower income beneficiaries to purchase the same private health insurance (KV) as everyone else. This is more or less identical to the US's ACA, and in fact the ACA was modeled after the Swiss healthcare system.
The one big difference between the US's ACA and the Swiss healthcare system is that the ACA also included an employer mandate and stimulated a regime in which the majority of working-age adults receive their private health insurance from their employers as opposed to the individual market, which is not how the Swiss KV works.
I am not conflating anything, you have a superficial understanding that makes you think it is privatized. If you dig into the spending public & private and the actual details you would see that Switzerland is not privatized as people generally think.
Even the US uses Medicare for certain congenital diseases as well (as well as end-stage renal disease).
The Swiss private KV system accounts for the vast majority of health expenditure, even more so than the US where half of health expenditure is nationalized in Medicare and Medicaid.
The intention of my comments was to make clear that in that regard, Switzerland is not an efficient free market private insurance paradise. There are lots of nuances to it, and the private insurance system in fact brings in inefficiencies, namely, a very complex and costly cost itemization and enormous amounts of paperwork and stress for doctors, customers, employers, and the insurances (for example, if there is an accident in a public place involving a car, there are at least one or two days worth of people's times just filling in forms)
In Switzerland (and also the Netherlands), the vast majority of this is covered by private health insurance, not via any sort of public health insurance. That's what sets Switzerland and the Netherlands apart from other peer developed countries, and they have results to show for it.
Regarding rare conditions, we agree — even the US has a public healthcare system alongside which covers rare conditions (e.g. end stage renal disease). US's Medicare Advantage system of private individual health insurance for senior citizens (with Original Medicare as a public option) is also a proven model with results to show for it. The CBO expects that by 2032, 61% of health insurance expenditure for senior citizens will be by the private sector (https://www.kff.org/medicare/issue-brief/medicare-advantage-...).
https://www.cbpp.org/research/social-security/ssi-a-lifeline...
Also "socialization" is very different from "nationalization". The general trend you're talking about is more to do with the fact that having society subsidize healthcare for the poor can lead to better outcomes. As it relates to who actually does the insuring, underwriting, and payment (public vs private), one isn't necessarily better than the other; each has its trade-offs. It's just that the US (in particular) has chosen the worst of both worlds.
I work in this industry, and from where I sit, the closest thing we have to a clean A/B test that controls for all of those confounding variables is actually being run in the US right now, with Medicare. When you turn 65, you have the option to enroll either in "Original Medicare", which is what we usually think of when we talk about "single payer healthcare in America", or you can enroll in Medicare Advantage (aka Medicare "Part C"), where the premiums that would go to the CMS instead go to private insurers like Humana, United, Oscar Health, Aetna, Clover, etc. These plans replace Original Medicare.
- 48% of Medicare beneficiaries are on private Medicare Advantage plans instead of the public "Original Medicare". Because everyone is entitled to "Original Medicare", this is purely voluntary. This number has been growing so rapidly that the CBO projects that by 2023, the majority of beneficiaries with choose the private over the public option. The CBO further projects this proportion to increase to 61%(!!) by 2032. (https://www.kff.org/medicare/issue-brief/medicare-advantage-...)
- For most beneficiaries, Medicare Advantage costs about 40% less than Original Medicare and are, on average, of higher quality than Original Medicare (https://healthpayerintelligence.com/news/medicare-advantage-...)
- In Urban areas, Medicare Advantage costs less per capita to administer than Medicare — and that's not including the extra Medicare Part D insurance that you would have to buy if you're on the Original Medicare plan (https://www.commonwealthfund.org/publications/issue-briefs/2...)
So no, you cannot look the cost difference between the US and other countries and simply conclude that it's because of private insurance, because the actual data tells a different story. And "universal healthcare" is not the same as "public" healthcare. It might help to think about it this way: universal access to food can be achieved without nationalizing the food industry, or the food payment industry.
> Medicare Advantage Plans are another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare. (emphasis added)
Those rules are, IIUC, substantively different than the ones that cover the non-medicare private insurance industry, and as a result I'm not sure what any of the (true) facts that you've quoted really mean in the context of the questions being asked here.
Also, from reading up about MA, it would seem that MA is operating on the "HMO" (health maintainance organization) model that started to be touted in the 1990s. AFAIK, the HMO model has not done much to contain consts in the broader US private health insurance world. It would be interesting to know if it is specifically the combination of the HMO model and Medicare rules that has allowed MA to apparently work better than OM.
> that must follow rules set by Medicare. (emphasis added)
Yeah, I'm not sure that anyone seriously believes that insurance companies should operate in a 100% unregulated fashion. Even the US's food industry (which is predominately privatized) is regulated in some capacity. The argument is whether regulated private insurance can deliver good outcomes. That is very much the case, as evidenced by Switzerland, the Netherlands, and Medicare Advantage.
> Those rules are, IIUC, substantively different than the ones that cover the non-medicare private insurance industry, and as a result I'm not sure what any of the (true) facts that you've quoted really mean in the context of the questions being asked here.
First of all, the non-Medicare private insurance industry is heavily regulated, often more so than Medicare Advantage private insurers. In fact, you raise an important point: it's important to consider which specific regulations are helping and which are hurting. Outside of Medicare Advantage, there are regulations that strictly control insurance company's profit margins, how much of premiums can be spent on collecting medical claims (see: the 80/20 rule and Medical Loss Ratio rules), the fact that every beneficiary must be treated exactly the same (ERISA, parts of ACA), a minimum amount of coverage required (the ACA added this), the employer mandate (ACA), etc.
To give you a sense for some of the unintended consequences that have been created by regulations on non-Medicare Advantage health insurance plans, due to Federal mandates and tax incentives, health insurance is predominately provided by employers rather than the individual market (unlike Switzerland, Germany, or the Netherlands). What we're seeing in healthcare costs is analogous to what you might see happen to airline ticket costs if we all got our air tickets through our employers: the vast majority of us would fly business class, while the unemployed would be simply unable to pay for business class fares out of pocket. A big reason for this is that employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals. If you take this behavior and combine it with the fact that health insurers' profit margins are capped by law, insurers pay more absolute dollars for treatments (which doctors happily accept), charge more to employers (who are generally less price conscious vs individuals), thus bring in more absolute revenue, and therefore more profit because a capped profit percentage of a higher revenue is higher than a capped percentage of lower revenue. It's somewhat counter-intuitive, but the policy combination of an employer mandate and insurance profit cap results in increased prices.
This cocktail of regulations does not exist for Medicare Advantage insurers — even though they are still regulated in different ways. That's a very important distinction. Currently, Medicare Advantage insurers are allowed to return 50 percent to 70 percent of any cost savings to beneficiaries in the form of reduced premiums or expanded benefits — whereas with employer-sponsored insurance, even if such cost savings existed, they would accrue to employers (unbeknownst to worker beneficiaries) — and that's assuming there are cost savings for employers; there aren't, due to the aforementioned regulatory concoction. A big part of why Medicare Advantage actually works really well is because it's effectively a basic income for health insurance, it's just that individuals are empowered to use those dollars to buy whichever healthcare plan meets their needs (including a public option), as opposed to being forced to choose among a small selection of plans curated by an employer.
> Also, from reading up about MA, it would seem that MA is operating on the "HMO" (health maintainance organization) model that started to be touted in the 1990s. AFAIK, the HMO model has not done much to contain consts in the broader US private health insurance world. It would be interesting to know if it is specifically the combination of the HMO model and Medicare rules that has allowed MA to apparently work better than OM.
Medicare Advantage plans can both be HMOs as well as PPOs (https://www.medicare.gov/types-of-medicare-health-plans/pref...), it's just that there happen to be many MA plans that are HMOs. HMOs can have very good outcomes with significant cost savings (think of the pre-2010 UK NHS as a public HMO), but can also have bad outcomes if managed poorly (think of the 2022 NHS or US's VA as poorly managed public HMOs). With Medicare Advantage, seniors have the option to choose.
I don’t really understand why anybody would be against introducing this in the US.
> A dead simple “this is how much you’re allowed to charge”.
This has its own set of unintended consequences, including physician rationing (it's a huge crisis of the NHS right now), and a reduction of investment in new medical research. There are many good reasons to be against introducing this in the US.
Switzerland does not have price controls on medicines, treatments, etc. and the reason why it is so often cited is because it enjoys a comparable level of healthcare innovation to the US while still ensuring universal access (through its ACA-like subsidies). It also costs a lot per capita (among the highest in the OECD), but it actually gets what it pays for (https://pubmed.ncbi.nlm.nih.gov/26766626/) (https://www.theweek.in/news/world/2022/05/07/7-reasons-why-s...)
In fact, of the countries that usually make up the global leaders in health/medical innovators, all but 1 (the UK) engage in price controls (https://immigrantinvest.com/insider/the-best-healthcare-coun...), and the UK's NHS is suffering from a rationing crisis, and (ironically) a cost crisis.
The UK's difficulty lie in their leadership and political issues and in the economic consequences of Brexit. I'm not sure it's the best example for your argument.
Where you're correct is that the difficulty lies in leadership's inability to actually change the prices to attract the supply necessary to reflect the increase in demand — and that's because the Single Provider system is tied to politics rather than market forces. The NHS is a third rail of politics and real reform is extremely difficult given the political buy-in necessary. In contrast, the private sector can (and will) increase prices to overcome demand — we see this happening in Switzerland (https://pubmed.ncbi.nlm.nih.gov/26766626/).
> The system offers a high degree of choice and direct access to all levels of care with virtually no waiting times
So where we may agree to disagree is that the NHS's woes are in fact a very strong example of the greater argument, on net.
Indeed. It's basically the convenient bogeyman for opponents of the current government.
>The NHS is a third rail of politics and real reform is extremely difficult given the political buy-in necessary.
Private Eye on "24 Hours to Save the NHS <https://twitter.com/KulganofCrydee/status/833654730849136641>
And the US's problem is that the list prices it pays for GPs, nurses, and services are subject to market forces and thus are too high. The government is currently failing to address the service provision loss with little political will to decrease list prices (even though they would propagate through to consumers as decreased costs).
It seems to me that there's no getting around the need for good governance here. And that lack of it is no excuse for not governing at all.
Yeah that's completely untrue; the list prices that insurers pay for GPs are heavily inflated by the market distortions introduced by the Federal government. I don't know if you read any of what I've written up-thread, but I'll paste the relevant parts here for your benefit:
"First of all, the non-Medicare private insurance industry is heavily regulated, often more so than Medicare Advantage private insurers. In fact, you raise an important point: it's important to consider which specific regulations are helping and which are hurting. Outside of Medicare Advantage, there are regulations that strictly control insurance company's profit margins, how much of premiums can be spent on collecting medical claims (see: the 80/20 rule and Medical Loss Ratio rules), the fact that every beneficiary must be treated exactly the same (ERISA, parts of ACA), a minimum amount of coverage required (the ACA added this), the employer mandate (ACA), etc.
To give you a sense for some of the unintended consequences that have been created by regulations on non-Medicare Advantage health insurance plans, due to Federal mandates and tax incentives, health insurance is predominately provided by employers rather than the individual market (unlike Switzerland, Germany, or the Netherlands). What we're seeing in healthcare costs is analogous to what you might see happen to airline ticket costs if we all got our air tickets through our employers: the vast majority of us would fly business class, while the unemployed would be simply unable to pay for business class fares out of pocket. A big reason for this is that employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals. If you take this behavior and combine it with the fact that health insurers' profit margins are capped by law, insurers pay more absolute dollars for treatments (which doctors happily accept), charge more to employers (who are generally less price conscious vs individuals), thus bring in more absolute revenue, and therefore more profit because a capped profit percentage of a higher revenue is higher than a capped percentage of lower revenue. It's somewhat counter-intuitive, but the policy combination of an employer mandate and insurance profit cap results in increased prices."
Put simply, the US healthcare industry is not subject to traditional market forces.
> The government is currently failing to address the service provision loss with little political will to decrease list prices (even though they would propagate through to consumers as decreased costs).
It's quite clear that the reason the government is not doing this is because it would further exacerbate the staffing shortage and lead to even higher wait times. That's not a political problem, that's a hard economics problem.
> It seems to me that there's no getting around the need for good governance here. And that lack of it is no excuse for not governing at all.
There is a key governance difference between making the decision to lift distortionary regulations once & up-front so as to unblock efficient resources allocation vs actively having to continuously adjust resource allocation. With the former, you just have to trust that the "good governance" happens once, whereas with the latter, you have to trust that "good governance" happens forever (politics notwithstanding). The Swiss chose the former, whereas the UK struggles with the latter. Domestically in the US, Medicare Advantage is a proven model — and the governance prescription here is to have the entire private insurance industry look more like Medicare Advantage.
I'm going to call you on this point, because what you're hinting at, whether you realize it or not, is that employers need to step up their medical care spend management game, which if implemented, looks damn near dystopian. As someone that works in insuretech, the number of times I've raised concerns about revealing too much about the shape of medical spend to employers is scary to quantify, because once you start going down that road, it isn't that far to "huh, 20% of our workforce is 80% of spend" hrrrm...
We do not want to be going down the road where employers are singled out as the appropriate optimizers there.
What I'm suggesting is that the proven private sector model is one where employers are simply not involved, not a part of the equation. Private insurance purchased on the individual market. That's exactly how it works in Switzerland, the Netherlands, and also how it works in Medicare Advantage (seniors directly buy their insurance plans using dollars they theoretically set aside over the course of their lifetime through Medicare FICA taxes).
The most practical way to get there, in America, would be to either enact Medicare Advantage For All, or to tweak the employer mandate to only include ICHRAs rather than group health insurance. ICHRAs are employer-sponsored funds (in lieu of employer sponsored insurance) that the employee-beneficiary uses to buy health insurance on the individual market.
For example, if someone makes a pill that cost $1 million to live one more day, they can sell it, but most national health services won't buy it.
In the US, the national health services and insurance companies are mandated to buy it, and a byzantine system of price controls ensure we only pay 900k.
This is of course already happening since, most of the world has price controls. The US market is probably financing most of the world's medical research, and if we stop paying so much, it may shrink a lot.
For example I just got a 900€ dentist bill recently. By default the sécurité sociale would just reimburse 300€ of it, for the essential care as well as a standard deductible on dental crowns. With my current mutuelle there's only 3€ left for me to pay.
One of our largest problems right now is that our system is failing and can’t keep up.
The solutions being rolled out by the provinces to fix the huge backlog of people waiting for care is to privatize more of the service delivery (while keeping single payer).
You also haven't given even a hint of proof for this alleged trend.
Maybe there is a trend, but let's look at some serious data before we just assume it's an obvious fact.
Last time I checked, Canada, for example, spent 1/3rd less than the USA and Canadians lived a few years longer.
IIRC, of the "universal coverage" systems, Switzerland's ACA-like system had the highest per capita, but still less than USA's system.
Much has changed these last few years. eg Our life expectancy in the USA has fallen.
A much bigger factor is GDP per person.
I think of it as: The more material wealth you have, the better your life is, and you get less risk of bad health.
You’re far better to look at things like “survival after cancer diagnosis” where the US has some of the world’s best outcomes.
https://www.healio.com/news/hematology-oncology/20180131/us-...
Only if we assume public health is unrelated to individual health.
Using life expectancy to judge the quality of a healthcare system or quality of public health efforts is like judging car quality by how nice the body work is. It's a component, but a relatively minor one in overall quality.
https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...
Western Europe does better, Eastern Europe does worse. Pretty much as one would expect.
--
Your prior "5 year cancer survival rate" was pretty random. The cherry picking of one favorable stat while ignoring the mountain of counterfactuals.
I was confused.
Then I spotted this.
https://www.aei.org/carpe-diem/us-vs-europe-life-expectancy-...
Aha. Just another "libertarian" talking point. Good grief.
First I argued that life expectancy isn't a good measure because of lifestyle, then you say "public health should address those", then I argued Europe does worse than the US on several public health metrics like smoking rates and alcohol consumption, then you go back to life expectancy.
I have no idea the point your making because you're failing to actually provide counterfactuals.
In an analysis we published in 2011, the ratio of social service spending to medical care spending was significantly associated with better health outcomes across 34 OECD (Organization for Economic Cooperation and Development) countries between 2000 and 2005.
and
When comparing state-to-state spending between 2000 and 2009, those states with higher ratios of social service spending to health care spending had better outcomes on average.
[1] https://qualitysafety.bmj.com/content/20/10/826.abstract
[2] https://www.rwjf.org/en/blog/2016/08/how_social_spending.htm...
[3] http://content.healthaffairs.org/content/35/5/760.abstract