Taxpayers spend 22% more per patient to support Medicare Advantage
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Also, healthcare isn't the only industry suffering this pain though obviously a very important one.
Also, there's a question of how much of this is a cultural problem. How has this sort of thing been addressed in the past? Is the same solution even possible now with the power imbalance created with the current state of capitalism and technology?
A limited number of physicians, especially general practices? High cost therapies and treatments? Capital-intensive diagnostic devices? Lack of access outside of cities?
There are certainly a lot of things that could be done better, but this isn't 1950 -- some available medical technology is incredibly expensive.
Simply unshackling Medicare/aid and allowing it more freedom to negotiate costs would go a long way towards reducing US health care expenditures.
I.e. doing for more payments what the Inflation Reduction Act allowed Medicare to do for (a limited number of) drugs: https://www.cms.gov/files/document/fact-sheet-medicare-selec...
every single other country has free healthcare, lower costs, and better outcomes than USA.
> every single other country has free healthcare, lower costs, and better outcomes than USA.
Aside from those first two being mutually exclusive, no, they don't all.
There are a large variety of funding methods, ultimate out of pocket costs, and outcomes throughout the world.
You'd probably find this an interesting read: https://ourworldindata.org/financing-healthcare
The US is certainly an outlier based on {total spent of healthcare}:{health outcomes}, but it's generally in the middle of the pack in terms of GDP-adjusted out-of-pocket costs. (Mostly as a consequence of private insurance + Medicare/aid)
usa has by far highest cost and worst outcomes. practically speaking, most americans don't have access to medical care.
It's easiest if you sort by decreasing coverage, then look at all the 100% coverage countries, which tend to be developed.
To summarize though, aside from single payer, mandatory public-private hybrid and private are also used.
And you should look into the numbers before making absolute statements.
The facts, in contrast to how you stated it:
- The US spends more per capita on healthcare than many (all?) other countries
- Of that, an average amount is out of pocket (relative to developed country peers)
- The US has some poor metrics, particularly in maternal mortality and lifestyle diseases, but is average on others (relative to developed country peers)
- Because of EMTALA [0], all Americans within range of a hospital (that accepts Medicaid) have access to emergency care, whether or not they're insured. The primary problem with access is the scarcity of rural doctors, especially generalists (an AMA/federal-government problem because of limits put in place in the 80s)
[0] https://en.m.wikipedia.org/wiki/Emergency_Medical_Treatment_...
Yea, fixing this would require decades long effort that is extremely difficult without catalyst. Most of European Health Care came about after periods of extreme difficulty like WWI, Great Depression or WWII. Closest US ever came was Great Depression and unlike Europe, US didn't experience massive hardship after WWII.
What metrics are you looking at?
Also, police has already said that they are concerned about the lack of cooperation from the public at large when it comes to success of the manhunt. The people who usually jump onto that kind of stuff are explicitly disengaging.
You can argue that this all does nothing wrt navigating the politics that would actually lead to change. But I think that, at the minimum, it creates some incentive for the people who work with those structures on a day to day basis to do so. If CEOs of healthcare companies are now a socially approved assassination target, apparently, what does it say about healthcare lobbyists?
> News will move on
it's not up to the news (the media and their owners) to tell us what is important...
i'd prefer to think people care about themselves and others, and are otherwise distracted by trivialities to take their mind off of things, sometimes (hopefully less than 49% of the time) to excess
that's my "tuesday" :) (infra)
Look forward to alarming levels of healthcare privatization in the next four years unfortunately with players like Dr Oz (who is explicitly looking to make Medicare Advantage more the default) and Jay Bhattacharya in leading key healthcare roles
https://prospect.org/health/2024-11-26-dr-oz-stealth-destruc...
> A key part of that strategy is to expand the private Medicare Advantage program and push more and more Medicare recipients into it, leading to a death spiral of traditional public Medicare. The details are spelled out in the Project 2025 blueprint.
Not really. ACA, Medicare, Medicaid, and VA's health insurance programs are all extremely popular among voters.
There are lots of issues on the ballot, and approximately no one was voting for Trump's nonexistent "concept of a plan" for healthcare. Feel free to post evidence of "an overwhelming majority" of people voting for Trump's healthcare plan to back up your initial claim, if you'd like.
By the way, the popular vote had less than a 1.5% margin. There was no "overwhelming majority" in any sense.
This was the 49th largest "overwhelming majority" victory ever by popular vote and the 44th largest victory by Electoral College vote. That is to say: an extremely tight race by any measure.
Considering no Republican president has won the popular vote in 20 years, the relatively small majority popular vote margin is nonetheless quite dramatic in the context of recent history.
> um, that's kind of....the diametric opposite of what an overwhelming majority of Americans just voted for.
Please substantiate your claim. There was no overwhelming majority, and even if there were, it does not at all mean that people voted for this particular policy. Again: you're free to provide evidence otherwise.
There is no evidence of this claim.
If you have any, please provide it. You attempted to provide the election which is not valid evidence for several reasons.
There is no evidence of a mandate from the public in the direction you’re suggesting there is.
Point taken about the election outcome, but to quibble, it wasn't "an overwhelming majority of Americans". It was a bare majority of voters. Trump got 50% of the vote with 64% turnout, so it was under a third of the eligible voting population, and of course nobody under age 18.
overwhelming majority of Americans just voted for.
I suspect the reason why UHC has decided to deny so many claims is that this will allow them to marginally lower he price of their premiums relative to their competitors. This'll get them more money via method 1. The whole industry is working around the clock on method #2.
Anyone more informed, feel free to correct me.
From working on automation inside the system at insurers at the time, I can definitively say this spurred health insurers to streamline and lower operational cost overheads.
With regards to the denials, I think you're right too. People like to point at insurers and blame them, but it's easy to forget they're just the middleman.
There's "cost of care" on the other side of them. At the end of the day, premiums need to balance with costs... (somewhat, in aggregate)
There are probably some edge cases where there are opportunities to profit, mostly to do with privately-administered but publicly-funded areas of health insurance (read: FEP and Medicare Advantage), but generally it's trying to get premiums lower for competitive reasons.
Public system has strictly defined coverage and tightly regulated premiums that are explicitly decoupled from individual health conditions and tied to percentage of salary instead. But providers themselves are decentralized and one is free to choose any provider that complies with all the govt requirements. Private providers can and do exist.
In some cases - e.g. self-employment, or income above a certain threshold - one can opt out of the public system and go fully private. Switching back is then only possible if income drops below the threshold. In practice, 90% of the population is in the public system.
Many other aspects of healthcare follow a similar model, where parts are fully private, parts are non-government-but-quite-close-in-function (Ärztekammern and other things) and many to most are public in some sense.
It would be pretty funny if it ends up being another Shinzo Abe moment where the predominant takeaway is "wait a sec, that murderer kind of had a point".
100%: Nationalize all healthcare providers and facilities. Forgive any outstanding student loans. Expropriate all property used in healthcare delivery. Make medical licensing contingent on public employment. Set up compulsory public housing accommodations at healthcare facilities for every person involved in healthcare delivery. Establish healthcare unions to negotiate working conditions and wages. Use evidence based scientific measurement of expected quality of life years to justify any treatment allowed on a first come first served basis. Anything less is anti-ethical and unhuman.
It's clear that there needs to be some degree of nationalization, though. Middlemen are literally killing us (and now, in a shift that might actually induce a change, getting killed).
Like, "Expropriate all property used in healthcare delivery." wouldn't work for my old dentist who had an office in a retail mall. Or, what of a rural nurse who uses her personal vehicle (reimbursed) to make house calls. A car is property. Or the on-site medical office for a large factory? (True story: I feel off the bike on the way to work on day, doing some contract programming work for a large company. Not only did the medical office check me over, but I got a tetanus shot, both free since I was working there.)
Are acupuncturists part of healthcare delivery?
> Make medical licensing contingent on public employment.
The TV series "The Love Boat" taught me that a large oceangoing cruise ship has a doctor on board, and that seems to be true still. Will this doctor be a public employee? State or federal? Or perhaps a joint employee?
> compulsory public housing accommodations
That sounds like you want to force all health care people to live at their workplace. Plus, what does "involved in healthcare delivery" supposed to include: the janitorial staff? The IT support staff? The food services staff?
> Establish healthcare unions
I've learned that's entirely too underspecified. A company union isn't an effective at negotiating for workers, for example. Plus, repeal Taft-Hartley.
> to justify any treatment allowed on a first come first served basis
That too needs some examination. How does one measure 'quality of life years'? Do rich people have a higher quality of life than poor? Do blind people have a different quality of life than sighted? What about someone bedridden? In a coma?
How are error estimates incorporated? How do we justify a novel experimental treatment which has no use evidence?
Is cosmetic treatment included? How do we measure quality of life for a nose job? For Lasik surgery?
The goals are great, don't get me wrong, but the taskforce is going to need work out the details better than an HN comment, and you might use my feedback to tweak your wording.
If an activity requires a healthcare license, only allow the government to pay for it. Some things are required for healthcare delivery and are not of value outside of those activities. Apply imminent domain law to expropriate those things to prevent fraud on the part of their owners.
The examples of extra-scientific or optional healthcare activities are likewise simple. Establish a lottery for such procedures using any resources not expended to improve existing quality of life years. Current private provision of healthcare resources bids up the fixed pool of providers and causes us all to pay more for life-continuing care.
Ancillary nonmedical services are red herring. Charge back the cost of those services against provider payments. Much of health IT exists as an elaborate method by healthcare providers to justify payments from payors and can be eliminated.
I noticed, for example, that you haven't actually answered my questions.
How do we measure quality of life years in any operationally useful way?
Which healthcare is optional?
Is acupuncture - which requires a healthcare license in some states - included? Why or why not?
How does one expropriate the health care services provided on a cruise ship, and how does it prevent fraud when there is a sole provider of power, water, etc. to said services which can charge whatever they want? Surely you need strict cost controls, but in that case you don't need to expropriate in the first place.
I don't follow what you suggest by the solution to the red herring, so here's a concrete example. I was near-sighted, and paid for new prescription glasses every few years. I decided to get Lasix surgery, which I don't regret, though now I need to get (much cheaper) reading glasses every few years.
Is Lasix for this case non-medical? Who is the provider which would be charged? For that matter, are prescription glasses part of health care, and if so, do people only get basic glasses (like US Army slang "Birth Control Glasses"), or are fancier glasses included, and who pays for the cost difference?
Are breast implants ancillary nonmedical services? Some women find that having larger breasts improves the quality of their lives. Does that make it ancillary or not? What about for women who had a double mastectomy and are depressed about the loss of her breasts? What about gender affirming care for transwomen? What about that guy I saw on TV who got breast implants because he lost a bet?
There are similar issues for cosmetic dental treatment, where fixing a chipped tooth may depend on personal vanity and external perceptions - a model's career may be negatively affected by an ugly-looking tooth. Do we factor in the difference in potential earnings when figuring out quality of life years?
And on and on.
These are not simple problems, and there is no simple answer.
Life’s complications are certainly soluble through relatively simple algorithms. For example, what to do on a cruise ship? Start with “is the care under the jurisdiction of this healthcare regime?” If no, then it is not addressed and entirely up to the individual. If yes, then the person must make their way to the nearest government healthcare facility. I would expect a significant uptake in medical tourism in this form.
Examples like “birth control glasses”: just do the math. Minor likely benefit over a likely long time period for a medium cost. Same for any other example. Will people be unhappy because they value something at more than a standard deviation from the mean? Absolutely, same as people are unhappy now. Not very interesting.
0. https://en.wikipedia.org/wiki/Gish_gallop
I thank you for pointing out QALYs. I had not heard of it. I have read now a few journal articles, and none of them say that QALYs stand alone. For example, https://onlinelibrary.wiley.com/doi/10.1111/j.1524-4733.2009... says:
> Aggregate health gains, measured by conventional QALYs, are one of many inputs to the processes of individual clinical decision-making, societal or programmatic audit, or resource allocation. The other considerations, including equity and fairness, need to be considered separately in the conventional QALY approach.
Or https://www.valueinhealthjournal.com/article/S1098-3015(24)0... is more recent article, from earlier this year, titled "Quality-Adjusted Life Years, Quality-Adjusted Life-Year-Like Measures, or Neither? The Debate Continues"
> The assessment of effectiveness is not and can never merely be a technical exercise. Whatever measure of effectiveness is chosen—even one that has the seeming appeal of being “objective,” such as a clinical endpoint—implies a value judgement about the importance of the various aspects of treatment outcomes.
> It is also important to remember that QALYs and their use to estimate incremental cost-effectiveness ratios inform, rather than dictate, decisions. Limitations of QALYs—or, indeed, any chosen alternative to them—can in principle be handled via careful deliberative processes or addressed by the consideration of other kinds of evidence and decision rules, as is typically the case in the HTA processes of many jurisdictions.
My gallop gave specific examples which require value judgements, and therefore cannot be made with "relatively simple algorithms".
"Same for any other example."
You don't seem to understand that no matter what system is used, it's fundamentally driven by political decisions of what is appropriate.
We know that politics means some healthcare systems will prohibit gender affirmation therapy. Can the person go elsewhere, where that is allowed, and pay for said therapy, or does the other system have to accept anyone who shows up, on a first-come-first-served basis?
Your proposal seems to say that there can be no healthcare outside the government system, so those who want chiropractic treatment, those who want acupuncture, etc. are forbidden by law from even using their own money. (I picked these two because while the science doesn't support their efficacy, often require licensed practitioners because doing it wrong can kill people.)
There are not simple solutions, and the longer you insist it's true the more cold shoulders you'll receive.
What’s always missing from these calls to action is: what are you replacing it with? There are a number of healthcare programs across the world and every country has a variety of different problems. There are no silver bullets.
If you want a great read about a few different countries, I recommend The Healing of America by T.R. Reid. It has some suggestions, but in general it is great at illustrating how treating the same illness in different countries can be varied in terms of treatment and cost.
For example: https://www.kff.org/health-policy-101-international-comparis...
But a basic google search returns hundreds of sources
And the US is near the top of the GDP rankings.
https://www.kff.org/health-policy-101-international-comparis...
The metrics the US does poorly on seem like they're more of an access problem (than acute care being bad), which suggests broadening access to affordable healthcare would be the best redress -- i.e. universal healthcare.
The US health system seems like it would be better served by explicitly breaking it into a multi-tier one.
Basic tier: universal health care for basic access and procedurings, including proactive health measures
Everything else: private health insurance available (not attached to an employer)
It really does matter. I'm no fan of our current system either, but by and large people do receive quality healthcare on it. If you rip out that system, you need to replace it with something that's at least meets the same standard.
Instead of US-style employer + individual paying insurance premium...
... you increase taxes and fund universal insurance directly from those revenues.
In the end, it should hypothetically balance out ($1 for healthcare == $1 for healthcare), except employment would no longer be a precondition for having access to affordable insurance.
Not in any meaningful sense.
https://www.noahpinion.blog/p/paycheck-to-paycheck-and-five-...
> In other words, a number of government surveys just contradict LendingClub’s survey. Why does [politician] choose to believe a survey by a payday lender with a secret methodology, instead of multiple surveys by the U.S. government with transparent methodologies? I guess being ...
Living paycheck to paycheck has low bearing on savings. The LendingClub survey is self reported, and includes people whose finances fluctuate seasonally (they overall live paycheck to paycheck but wind up with random windfalls) and people who maintain a small pile of cash but are always counting on the next paycheck to avoid dipping into their savings. The report even mentions that a chunk of the paycheck to paycheck people are superprime credit consumers, but Noah refuses to stop and think about why that is the case.
I personally know people who very well off who are riding the razor’s edge so to speak- they have huge savings but 100% of income does straight to bills.
Or to put it another way, any insurer offering a "better" policy (in terms of more coverage for less money) will attract the highest-consuming patients, individually.
If they sign up groups with less choice, they're more likely to get a balanced cohort of consumers / non-consumers, young / old, etc. etc.
Fire many administrators and managers over there, put a lot of them in prison and tell them to start again.
You just can't beat O(2) function with linear policies. You must make it cost less - but making it costing less means everyone in the healthcare is making less. So there will be massive resistance to any kind of change. You could achieve slightly more healthcare for money spent, but you can't meaningfully reduce costs.
The US system is convoluted enough that I wouldn't be surprised if they're bringing negative value simply by existing.
Especially since with computerization, there's no need to have an entire company to track and route paper.
The seemingly inevitable part-privatization we're now facing for Social Security and Medicare is nothing more than the wealthy looting the public purse.
This is patently untrue. The entity that paid for my 2yr college was a public-private partnership. It was administered by the Dept of Labor. The private end was a mix of businesses and philanthropy that wanted to better align education and careers.
Funding was predicated on students completing degrees and a period of related employment. It was tremendously successful. It was also immediately axed when the 'Contract with America' took effect.
But my question is: why does college cost anything? Particularly more vocational courses, which 2 year Associate's degrees tend to be.
We have a model for this: the military. You pick a job, they train you to do that job and then you do that job. There is absolutely no reason why education can't be this accessible to everyone.
Public private partnerships at the Federal level have historically just been elaborate grafts to enrich the already wealthy at everyone's expense.
Ever read The Shock Doctrine?
In almost all cases, it's better for the state to build themselves, then lease/rent to private companies, or operate themselves in some cases.
Basically free market is shit at central planning, and the state is shit at offering diversity and finding out preferences.
There are an awful lot of people who are either the wealthy who are exploiting the working class or, way more likely, they think they someday will be:
> “John Steinbeck once said that socialism never took root in America because the poor see themselves not as an exploited proletariat but as temporarily embarrassed millionaires.
Why else would people fight so hard against Jeff Bezos paying slightly more in taxes? Jeff would use you as fertilizer or reactor shielding if it ticked up profits. You are not and will never be Jeff Bezos.
HN just skews to people who aspire to be the exploiters.
We REALLY should have learned our lesson after what happened with the broadband rollout in the early 2000s.
https://www.nytimes.com/2017/02/16/business/dealbook/unitedh...
Also, here's a longer read about the same topic. The fraud wasn't limited to a single insurer, but some have been more blatant than others.
https://www.newyorker.com/magazine/2019/02/04/the-personal-t...
"Medicare Disadvantage" is an HMO scheme, with limited doctor lists and lots more limiting rules. Avoid.
Some people qualify for a tax subsidy that can be anywhere from $0 to the entire cost of a plan, depending on their income. A unique feature is that the subsidy is based on your expected income for the upcoming year, but if you make less than that (are laid off for example) or more (independent contract gets an unexpected contract), the subsidy is adjusted when you file your taxes.
Currently the ACA does not accept anyone who has a policy through work. IMO, every should have the option of getting ACA healthcare coverage. If their work coverage is better or cheaper, they can stick with that, but if their work coverage is worse or more expensive, employees should be allowed to get ACA coverage, with the employer paying part or all of the subsidy (what they would have paid to a private insurance company for the employee) instead of just the government.
From the underlying report that's cited [0]:
>> We include uncorrected coding intensity and favorable selection in our analysis so that the MA and FFS populations are comparable. Because benchmarks do not account for these adjustments, it is also unlikely that plan bids assume the effects of uncorrected coding and favorable selection. With these adjustments, we project that benchmarks in 2024 are 132 percent of [traditional Medicare fee-for-service / FFS] spending (i.e., the amount that would have been spent on MA enrollees if they were in FFS).
>> Overall, plan bids — 14 percent of which are projected to be nonmedical expenses for administration and profit — in 2024 are an estimated 101 percent of FFS spending.
>> Thus, though MA plans have lower medical costs than FFS, these projected efficiencies are offset by plans’ projected administration costs and profits.
>> In total, we project that plans will offer the standard Medicare benefit at about the same cost as FFS in 2024, which implies that the majority of extra benefits for MA enrollees are not financed by plans offering the benefit at lower costs than FFS, but rather by the taxpayers and beneficiaries who fund the program. Overall, we estimate that coding and selection cause MA payments to be 22 percentage points above FFS spending in 2024. That difference translates into MA payments that are a projected $83 billion above FFS spending in 2024.
[0] p373 https://www.medpac.gov/wp-content/uploads/2024/03/Mar24_Ch12...
So you might want to be more specific in what you're talking about in your original comment, re: Medicare.