Why should healthcare be tied to employment?
"Quit fucking around" and institute a national, single-payer plan that covers everyone, like every other modern industrialized country.
"Quit fucking around" and institute a national, single-payer plan that covers everyone, like every other modern industrialized country.
We detached this subthread from https://news.ycombinator.com/item?id=40566761.
Except we're not starting from a blank slate. So short of heavy-handed, dictatorial decisions how would you propose to get to a single-payer plan that covers everyone? You'll have to work with the existing hospital infrastructure, insurance companies, and citizens who don't want a single-payer system. They all get a say, too. People who act like its a straightforward solution don't really understand the problem. But to avoid sounding overly cynical, I'll throw out a couple of recommendations.
1) Expand the VA system to cover all vets, regardless of whether it's a service-connected health issue or not, without insurance. This is politically possibly the easiest step because its hard for a politician to stand up and say they aren't an advocate for better care for the troops. However, the VA is entwined with medical schools and you'd have ensure you expand the funding proportionately to avoid pissing off that constituency.
2) Gradually ratchet down the age for medicare, over decades.
(I'd also argue you'd have to get money out of politics first for any really change to have a chance)
Stroke of a pen I just fixed everything.
> existing hospital infrastructure
Hospitals already deal with medicare.
> insurance companies
Oh no the vultures in the system will go hungry whatever shall we do
> citizens who don't want a single-payer system
Buy premium insurance above and beyond the public option, same as every other modern industrialized country. If you don't like the offering for free, the market can cover whatever gap exists.
Considering Medicare/Medicaid are currently approaching $1T annually to serve less than 20% of the population how dues your stroke of the pen plan pay for the increase when everyone is enrolled?
Hospitals are forced to accept Medicare, but in many cases this is at a loss, subsidized by private charges elsewhere. So you’ll need to find out how to shore up that cost, too.
These types of naive solutions assume everyone else is very very stupid or very very corrupt (or else why didn’t such a simple solution get implemented already?)
We currently can almost get enough of those representatives in office to do it (and a president to sign it), if it weren't for things like the electoral college, gerrymandering, and grossly unequal representation in the Senate, things that currently give disproportionate power to the "team" that happens to oppose single-payer.
The US spends 2-3x what the rest of the OECD spends per-capita, with about the same outcomes. Our system is the least cost efficient system in the entire developed world. It’s hard to see how Medicare-for-all could manage to do worse.
However, they’re a saying in healthcare that you can optimize for quality, access, or cost but you only get two.
The US system is largely focused on optimizing for quality and access (although I admit the latter isn’t necessarily done well and generally relies on reactive care). So to open up access further, you’d probably need to address the other two levers, and I’m not seeing anyone discuss that. There’s also the disproportionate amount of R&D done by the US which effectively subsidizes the rest of the world to help keep their costs down. All that to say, none of the simple solutions bandied about really talk about those effects, let alone how to manage them.
Most countries manage on ~12% or less of GDP, the US takes ~17% of GDP to pay for healthcare [0]. For example, the UK manages to cover everyone for about 12% of GDP. If the US adopted a plan as ubiquitous as the UK, in the same manner as the UK, it'd be cheaper than the current system. Expense seems to be correlated more with the presence of insurance than with the ubiquity of healthcare.
For example, other countries get to keep drug costs low because the companies that make them get huge profits in the US. If the US charges the same, the profits and R&D also dry up unless you set up another system.
Also, the US tends to rely on extreme measures more often very late in life. I’ve heard (but can’t confirm) this drives a huge proportion of costs. This is rooted in cultural ideas of the sanctity of life. You can’t just pull the rug out unless you’re prepared for backlash about “death panels” and such.
There’s a lot of nuance and the “just do what other countries do” misses it completely.
> Seven of the 10 largest drugmakers by revenue in 2020 spent more money on selling and marketing existing drugs than on research and development for new drugs, according to an analysis published Oct. 27 by America's Health Insurance Plans.
> GlaxoSmithKline spent $15 billion on sales and marketing in 2020 compared with $7 billion on research and development. Bayer spent $18 billion on sales and marketing compared with $8 billion for research and development. Johnson & Johnson spent $22 billion on sales and marketing, compared with $12 billion on research and development.
https://www.beckershospitalreview.com/pharmacy/top-10-pharma...
Glib answers like "just do what other countries do" don't address any of that.
Singapore has an excellent system costing about half the proportion of GDP.
I very much doubt there are either large economies or diseconomies of scale in healthcare. Certainly no indication of it in spend western Europe I can see.
The UK has IMO created diseconomies of scale by having a monolithic system.
Would it outweigh the diseconomies of scale seen in the NHS? It is pretty clear that the less centralised systems in other western European countries are more efficient, nor can I see any evidence that smaller western European countries face consistently higher costs than larger ones.
Again, though, I think it’s an error to treat each country as if it’s interchangeable. In other words, we need to understand the systemic causes of those costs to understand the impact as it relates to other nations.
In the above example with Medicare, the cause is due to negotiating power through volume. So it’s pretty clear that scale matters there.
https://www.theguardian.com/society/2024/jan/11/uk-cancer-su...
Singapore has an authoritarian police state which prevents many of the chronic substance abuse problems that drive a significant fraction of US healthcare spending. I don't think Americans would be willing to accept that trade-off. Singapore is also nearly 100% urban which makes care delivery much more efficient.
The US healthcare system is a mess and needs reform. But we can't just copy other countries. We don't want to lose the best parts of our system or stifle innovation in (expensive) new drugs and medical devices.
I think their point is this would help solve the principal agent problem so consumers can shop for service.
And why is “national” a criteria? California doesn’t get single payer unless Montana also gets it? Neither Californians nor Montanans want that. It’s just political games.
No it's not. Most European countries that run private health insurance keep pretty strong regulatory regime where pricing and coverage is tightly controlled. In America, there is some basic regulatory scheme but pricing, coverage, limits and such is extremely open.
You're correct too: these countries have strong regulations where pricing and coverage is tightly controlled, though they do use private health insurance.
--unless I am wrong in my belief that there is nothing California voters can do to prevent US citizens from moving to California.
https://www.heritage.org/social-security/report/assuring-aff...
But you’ve got a point, it’s probably fairer to say that the ACA and the Dutch and Swiss systems are all modeled on common ideas regarding managed competition: https://jacobin.com/2016/02/gaffney-single-payer-sanders-hea... (“The 2006 Dutch reforms were based in part on a school of health policy thought associated with the US economist Alain Enthoven, a man who got his start analyzing military strategy for the Pentagon before becoming the foremost proponent of competing private-sector health plans (so-called ‘managed competition’). Outside the Netherlands, Enthoven’s ideas have influenced health reform efforts in both his home country — first under Bill Clinton, then President Obama.”)
ROMNEY: Actually, Newt, we got the idea of an individual mandate from you.
GINGRICH: That's not true. You got it from the Heritage Foundation.
ROMNEY: Yes, we got it from you, and you got it from the Heritage Foundation and from you.
The Heritage report (1989), now disowned, antedates both the Dutch reforms and the Clinton Administration. Obama namechecked Heritage at the time.
Seriously, we lived through this. ObamaCare came from the Heritage Foundation.
The two (real, non-politicians are corrupt) downsides to contend with:
- countries do this by limiting what they will spend; in the US you have access to unlimited treatment. E.g. in the UK the NHS will spend £30k for each good year it buys you
- this one isn't fair, but the US is where health innovation happens. Companies sell into it to make money to survive. They then sell into the other countries to make much less margin, and if those countries were all they had as customers, they wouldn't exist. The US is why we have the advancements we have, and all us non-US countries have silly smug citizens who think our countries are better at negotiating deals. If the US didn't do what it did, we'd be a lot worse off.
This is a ludicrous claim.
People will occasionally travel to the states for drug/therapy trials not available in Canada, or for treatments that are not proven effective. These people will then loudly bitch about Canadian healthcare.
If you want the proof of it, remember that a huge majority of Canadians live close enough to drive to the US for health care, but don’t.
It varies by province, but Alberta will do n heart surgeries per year, and who gets them is by triage
You will find that triage is a fact of medical care in most places. I have waited hours in a private ER in the states multiple times. You have to wait months to see specialists in the states as well.
The US also has a triage system for care. First they filter by ability to pay, then they filter by doctor and facility availability like Canada does.
An American with no ability to pay will wait far longer than an Albertan for heart surgery.
Won't they be covered by Medicaid?
I don't understand this point. Obviously Canada offers healthcare, and what it offers is no doubt good. That doesn't mean that it offers everything that can possibly be done. People just won't be aware of what can be done, and/or don't have US health insurance to pay for what can be done.
If people were actually having to wait that long that their health was seriously threatened, they would likely be engaging in medical tourism on a much bigger scale. If you needed surgery or you were going to die/be permanently disabled and the Canadian system wasn't able to provide it, people would be driving across the border, flying to Mexico/Thailand/wherever, or doing whatever else they needed to not die or have their life impacted.
But that doesn't happen. What it tells you is that, as much as some Americans paint a false picture to slander single payer healthcare, and as much as some Canadians complain about waiting, the Canadian system is still better than any alternative available to the participants, despite the alternative being a quick drive away for most of us.
https://www.cbc.ca/news/canada/newfoundland-labrador/william...
https://www.usnews.com/news/best-countries/articles/2016-08-...
Might be worth a quick Google before posting.
What does this mean? It's not free as long as you can drive to it.
With Canada rapidly approaching third-world status, this is hardly surprising. Most Canadians cannot even afford to cross the border, much less pay American prices.
Also, Healthcare companies are wildly profitable. If they were negotiating prices in the USA just like they do everywhere else, they would only be profitable. Woe is me.