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>ER wait-times aren't 2-4 hours just because.

ER wait times are long because ERs are the only place in the country where we effectively have medicare for all, albeit in a particularly perverse and dysfunctional form. Everyone gets treated at the ER even if they're broke & uninsured as long as they're willing to wait long enough. Now imagine if those folks could go to any primary care doc or even use One Medical, CVS walk-in clinic etc. That would go a long way toward fixing our overloaded ERs. We've legislated quazi-medicare for all but only in the most inappropriate part of the system.

Agreed. We all collectively understand that we can't allow people to die in the streets because of their lack of health insurance. We already have universal healthcare, we just have the worlds dumbest way to pay for it.

> Do you really need to go to the ER because you stubbed your toe?

Where else are some people supposed to go? Maybe that toe is starting to change colors… is it broken? Do I need to have it set? Is that possible for toes?

People have valid medical questions and don’t want to wait weeks to see their primary care. They might not live near an urgent care. The urgent care may have terrible hours, or they made the mistake of mentioning chest pain for their heartburn incident and now they are forced to the ER.

It’s a chicken and egg problem. Faster medical answers will lead to reduced ER wait times. Reducing ER wait times lead to faster medical answers.

Who would you choose not to cover? The sick?

I hate to break it to you but insurance is meant to be a tax on the entire risk pool. What changed after the ACA is we couldn’t kick anyone out of the risk pool for getting sick.

> Who would you choose not to cover? The sick?

You didn't read the post.

The sick are mostly the old (if you're looking at total spending), and they are already covered by Medicare.

The sick young are a minority, and are often times covered by Medicaid.

If the state covers the tail end and assuming they aren't covered already by Medicaid, there just isn't that much spending remaining.

They can get private insurance to cover the under $10k per year - but there's not really a product that covers that effectively - so unless a new insurance evolves, it still wouldn't make much sense.

The sick, young, non-medicaid tail is VERY small compared to the rest of the tail the state already covers. Just add it in. A 1% global tariff could easily cover it. You've still got 9-14% left to spend on more bombs, tax breaks for the rich, paying people to get underwater basket weaving degrees, whatever.

The premium charged for the sick, young is high enough that your math doesn't make sense. ACA plans have to pay out 80%. Since I'm paying $11k/yr for my ACA plan they are clearly paying out at least an average of $9k in claims for the average member of my cohort. (And the reality is worse as they are limited in the ratio between young and not so young, this effectively makes the young subsidize us not so young.)

I’m not understanding how this is better than just putting everyone in one risk pool and having the young and healthy subsidize the old and sick? You’re basically saying if you’re healthy don’t carry any insurance and just rely on the government and taxes for catastrophic coverage. And then as soon as you get sick you’re supposed to apply for this coverage that only applies when you’re sick? The biggest problem with Medicaid is that you have to prove you can’t get the means to pay for healthcare which is essentially impossible without paying for healthcare.

So now you have this huge apparatus for intake and for rejecting people who are not sick enough or old enough but who can’t conventionally afford care. And you have to pay for that apparatus. Why would that be any better for the young people, other than seemingly using their taxes to make cruel decisions about a portion of the old and sick instead of simply providing care?

And what’s worse is a lot of those sick people wouldn’t have gotten that sick if they could pay for preventative care. So now in your system you have this huge group of people who have through lack of means let their illnesses and maladies get so severe that they can’t afford to treat. The whole point of preventative care is to keep people healthy so they don’t become a cost burden to the insurer. That’s why we pay more relative to what it costs. And it’s a hedge for us. We might find ourselves among the desperate ill some day without the means to pay for treatment.

Breaking the existing system will be extremely difficult. I have decade-long relationships with all of my doctors. The thought of a health plan that forces me to change all my doctor relationships is anger-provoking and exhausting. New doctors don't know me, they don't know my history, and haven't seen the medical shit show you've been through and why your treatment is the way it is. Then they think they can change your treatment to something that has already failed because "I didn't give it a long enough trial" or "That's a rare side effect," it won't happen to you.

I highly recommend you read the book "We've Got You Covered." It's an economist's view of health systems and how we can rearrange government spending to provide coverage for everybody and prevent medical bankruptcies.

One Medical looks interesting, but I wonder how they keep the price that low. Is it subsidized? Are they putting constraints on physicians and what they can do in the same way BetterHelp messes with the therapists? Are they servicing only the young and healthy?

Their senior care plans tell an interesting story. They only work with Medicare Advantage plans, specifically those known for up-coding, excessive pre-authorization requirements, and high rates of care denials. Medicare Advantage is an interesting failure in the marketplace in that it costs the government significantly more than classic Medicare and provides worse-quality care.

For the rest of us, we can skip the ER by going to an urgent care. But around here, urgent care offices are owned by private equity, have deceptive billing and are part of the reason why medical care costs so much.

> I have decade-long relationships with all of my doctors. The thought of a health plan that forces me to change all my doctor relationships is anger-provoking and exhausting.

You are clearly not in the bottom 50% of health care spenders. You would be in the group that would keep private insurance and be happy.

> One Medical looks interesting, but I wonder how they keep the price that low. Is it subsidized?

No.

> Are they putting constraints on physicians and what they can do in the same way BetterHelp messes with the therapists?

The vast majority of their "doctors" are Physician's Assistants. You can see whoever you want for whatever you want (that they provide).

> Are they servicing only the young and healthy?

Mainly. It's a clinic. You can't go there for Open Heart Surgery and cancer treatments. They'll just (cheaply) refer you to a specialist (who will be expensive and require insurance).

What you can do is avoid huge wait times and get good enough treatment for ~90% of what the mostly healthy group of ~50% of the population needs for fair up-front prices - which previously did not exist.

That's a mighty big assumption you're making. I've had private insurance for years, and I've always been unhappy with it because of treatment delays, Treatment denials, pre-approvals, and unrealistic copay limitations.

Many of my health needs are not expensive, but my body's reaction to treatments is. Frequently, cheap drugs are all side effects and no benefit. Also, private insurance has bizarre coverage gaps. For example, ambulance costs. When I had a heart attack, I drove myself for 45 minutes to the nearest hospital with a cath lab rather than take an ambulance and end up with God knows how many thousands of dollars in uncovered ambulance fees. Then there are things like cardiac rehab, which go a long way toward restoring cardiac health. 12 weeks, three times a week at $50 copays, was an expense I wasn't counting on. When I qualified for Medicare, the quality of care improved significantly. Usually, wait times for service are much lower than with private insurance.

I also resent private insurance because my premium dollars go toward enriching stockholders rather than providing care for all policyholders.

Okay - so you could keep your private insurance and not be happy, or move to Medicare and also not be happy.

I think you want a third solution - but that seems highly unlikely to be available in the mid term - and it doesn't look like anything is changing in the short term.

Who knows, my crystal ball doesn't work any better than anyone else's.

> We simply do not have enough doctors

We're going to need to make more doctors. To do that we'll need to identify kids in high school that would be good candidates and offer full-ride scholarships where needed. And we need to improve science education at the high school level to help with all of this.

> To do that we'll need to identify kids in high school that would be good candidates and offer full-ride scholarships where needed. And we need to improve science education at the high school level to help with all of this.

We could import them.

We have tons of options. But the medical industry likes a shortage, because they like high wages, so I won't hold my breath.

They pick the rules. The rules favor them.

That's going to remain true for the foreseeable future, and on the list of problems, that's at the absolute bottom of things to fix that would actually move the needle.

The cost you spend on DIRECT HEALTHCARE is only ~20-30% of all spending. The rest is administration, drugs, insurance overhead, profits, ACTUAL insurance costs, cost overruns due to insurance making everything as expensive as possible to scrape 15% off the top, fraud, legal fees, etc.

The biggest benefit to moving to a centralized insurer is that fraud is centralized.

If you're a Republican and skeptical of government, you might assume the government will let massive fraud slip through to insiders, and you don't like that.

If you're a Democrat, and think the government can generally be good, you think the government can catch a lot of the fraud and cut total costs by 10% to get to fraud levels that are similar to other advanced countries (with similar systems).

Or, like, not haze kids in their 20s for residency and make them take hundreds of thousands of dollars in debt. Whereas in Europe and other countries, residents work something like 50 hours per week and graduate with zero debt.

I've watched friends go through it here in the US and I have zero interest in working 24 hour shifts and sleeping in break rooms, working 80+ hour weeks for years. There just is no need other than hazing and keeping artificial scarcity of doctors for inflated wages. There are plenty of brilliant, scientifically minded, hard working people that care about others that probably could be great doctors, but the US training system is just hostile towards most people.