Universal health coverage could save $1T and 114k lives a year: study
ysph.yale.edu
ysph.yale.edu
The authors derive the $1T number from $1.3T in total cost savings and $304B in incremental spend (incremental spend is due to insuring more people). The $1.3T in cost savings come from five big buckets: lower pharmaceutical prices, Medicare-level payments to providers, reduced administrative overhead, less fraudulent billing, and fewer avoidable emergency department visits and hospitalizations.
The buckets themselves don't necessarily survive much scrutiny.
Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
The line item of "fewer avoidable emergency department visits and hospitalizations" assumes greater insurance coverage leads to greater access to primary care. It's true that great primary care prevents hospitalizations, and can be a net cost saving under certain assumptions [1]. But, we're actually in a primary care shortage. Existing insurance payments for primary care are low enough that private practices are going out of business and fewer residents are going into family medicine. Cutting rates (the paragraph above) would make this worse.
For "less fraudulent billing," a lot of people in the industry believe that Medicare has a large amount of undetected fraud. That's unfortunately the flip-side of reduced administrative overhead. The authors assume an 8% savings here, but the 2003 paper they cite uses the word "fraud" only twice and doesn't give a number.
Healthcare reform is hard.
[1] Reasonable breakdown on the economics of advanced primary care models: https://olearykm.medium.com/the-cost-equation-for-new-primar...
[1] https://pubmed.ncbi.nlm.nih.gov/25092774/ [2] https://doi.org/10.3322/caac.21732
It is fine to look only at patients with insurance/ access to refute the claim that US doctors dont cure cancer so they can make more money.
"Airplanes that get shot in the wing always survive" logic. People _do not get diagnosed and die_ because the US healthcare system is inaccessible to close to 50% of your population. A diagnosis easily reaches a few hundred dollars for the best cases (and several thousand if you need multiple tests/blood tests/operations like colonoscopies). And when you do get diagnosed, then you've just entered a world of having to pay hundreds of thousands of dollars.
>we get those numbers in part by diagnosing earlier and that our outcomes are broadly similar
lmao no you simply don't diagnose people and they just "die of natural conditions" early because they couldn't afford the treatment even if they were diagnosed.
So you have no idea what you're talking about. What is the point of making comments like this that are both verifiably false with about 2 seconds of online research and just sound incorrect based on anecdotal data to anyone living in the US.
For infant mortality specifically, in the US we count every baby with a sign of life, regardless of the age. In many developed countries, they simply don't count too premature (under 22 weeks or 500 grams, iirc) and therefore don't consider them in the metrics. It makes for an apples to oranges comparison.
You're right on "preventable and treatable deaths" with heart disease and diabetes being the biggest contributors. The question for that comes down to "is that a result of systemic issues or individual choices?" because we can do lots about one of those.
When I Googled life expectancy by ethnic group in the United States, it gave me the following numbers:
Asian: 85.2 years
Hispanic: 81.3 years
White: 78.4 years
Black: 74.0 years
American Indian and Alaska Native (AIAN): 70.1 years
Along with a source. (https://www.kff.org/racial-equity-and-health-policy/racial-d...) (Note: Based on the source, these numbers are for 2023.)
Overall, life expectancy in the United States in the last few years is around 79ish per the sources listed here in this Wiki article: (https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...)
This means that the average life expectancy of white Americans is actually slightly below the average life expectancy of all Americans.
Incidentally, while a lot of developed countries do not track life expectancy by ethnicity, the UK seems to have a few some studies. (https://www.ons.gov.uk/peoplepopulationandcommunity/birthsde...) Though the data is very old (2011-2014), and the data is broken out by sex with no summaries, whites actually fare the worst. Black African females came out at the top, with a life expectancy of 88.9. I asked Google's search what the comparable black American female life expectancy was in 2011, and it gave me 78.2, along with a link. (https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6244a8.htm)
Our overall ranking generally is below all "developed countries" that I can see, which range from Germany (~80) to the ~84 of "developed" countries like Japan, Switzerland, and Sweden (along with a few countries still classified as "developing" like Kuwait). It's not completely terrible, but considering how much the United States spends on health care, that's quite a poor value.
There are multiple identified factors for explaining life expectancy, but access to healthcare is identified as a very significant factor. In a system, like America, that is very expensive (likely due to highly inefficient, over-bureaucratic, overly complex, and over-quasi-monopolized systems) and without universal coverage, it follows that those who are poorer may not have the same access to healthcare and may succumb to entirely curable illnesses. So I don't think it's a coincidence that the racial breakdown above almost matches the median ethnic household income (the median white American household earns more than the median Hispanic household, but elsewise it aligns).
On infant mortality, at least one link I found -- https://www.healthsystemtracker.org/chart-collection/infant-... -- which adjusted data due to the reported difference, and still found significantly higher infant mortality in the United States. Though the data is a little old (2016).
You'd want to be looking for a scholarly source that puts numbers on this. It's been done! As I noted elsewhere on the thread, the study we're commenting on is based on 1990s numbers about differing mortality of the uninsured. But here you're looking breakdowns of all mortality causes and tying them to insurance, a trickier proposition. Will be interested in whatever you come up with.
Nope, that's not the reason.
> The U.S. infant mortality rate was still higher than for most Europeancountries when births at less than 22 weeks of gestation were excluded.
https://www.cdc.gov/nchs/data/databriefs/db23.pdf
Statistical hustling is common, but the most usual form is that the US excludes uninsured individuals to make itself look like it belongs in the developed country cluster.
* Car accidents, because we drive much more and are much more spread out than other countries.
* Drug overdoses, though other countries are starting to catch up to us there.
* Homicide, because of our gun policy and the universality of firearms (which also bears on our suicide stats).
* CVD.
That last item sounds like an indictment of the US health care system, but it isn't. If you break CVD out by state, northeastern states like Massachusetts have outcomes resembling the Nordics, and Mississippi has outcomes like a developing country. But the structure of the health care system is the same in both places.
I believe a single payer system is a matter of when not if. It works just fine in other countries. In our country, the healthcare industry has evolved into extracting as many dollars as it can from the economy. This is because when someone is sick and needs treatment, healthcare providers hold all of the cards.
Europe has several universal coverage systems without single payer. The original sin of the US system isn't private insurance, it's employment-based coverage; that's the thing nobody else has.
The second most common cancer is Breast Cancer. The USA is "top-tier" but so is pretty much every other Western Country. Australia, also famously single-payer is a mere 0.4% behind the USA.
This is the only source of modern survival statistics by country:
https://pmc.ncbi.nlm.nih.gov/articles/PMC5879496/
Compiled into an easier to read format:
https://worldpopulationreview.com/country-rankings/cancer-su...
Take note of two things: First, some states weren't even included in the study and second, there is no mention of insurance. The statistics are only tracking people who were diagnosed with cancer. It's reasonable to assume that some people who had cancer symptoms did not seek treatment because they didn't have insurance and died without being diagnosed.
I'm not saying that the US is better than every other country. I explicitly said somewhere else on this thread that there's a common critique of our outcomes that we just do detection better, and that our life expectancy outcomes aren't materially better.
What I am saying is that it's difficult to make a case that US life expectancy is materially altered by our health insurance system. You won't be able to use cancer to make that case, because the US has in fact quite good cancer outcomes. That's it: that's the whole argument.
Again, though: this repeated claim that "the uninsured aren't included in survival statistics" --- I don't know where that's coming from. It's not true.
I'll restate my argument so it's clear: CONCORD-3 does not mention insurance status anywhere in the paper. It does state that the statistics require diagnosis. It's reasonable to assume that if you can't afford healthcare, you're less likely to seek treatment or diagnosis.
You understand that CONCORD-3 is about tracking people who enter the healthcare system. Isn't it reasonable to assume that if healthcare is free or very affordable, there would be higher participation? And on the flipside, if it's outrageously expensive, there would be lower participation?
You're argument that uninsured are included is just as axiomatic. Zero evidence or sources. I guess we'll agree to disagree.
Somewhat off-topic, but I think this explanation of the car accidents misses the mark. It might be part of the cause, but car accident deaths were dropping in the US and Europe until around 2010 when they kept dropping in Europe, but flatlined and then rose back up in the US.
I don't think we were driving less and less and are now driving more and more. We changed policies. (I think it's mostly bigger cars, plus less focus on traffic infra/systems/rules that prevent fatalities.)
There's no way a Chairman/CEO would ever reduce the operating margin by just giving themselves and their buddies a raise is there?
They may have 4.2% margins knocked down to 4% by exec comp but I don't see that how that fact would change OPs point.
- Base salary
- Bonuses
- Stock options
- Perquisites (perks) like company cars or private jet usage
Just to be clear - I like my private jet(s) on call in case I want to get away for the weekend. TYSM
The GDP of the US is $32T. Saving $1T will essentially make 3% of the US economy vanish. You don't vanish 3% of an economy without wide ranging repercussion, it would be a crisis similar in scale to that of 2008.
With such numbers we are not "saving money", these are about rebuilding an entire economy, a painful process. So either the effect will be much smaller than that, or there will be riots.
These people will now have to do the "something else" that will be spent on, let's say gardening. But you don't turn a nurse into a gardener just like that, that's the kind of "wide ranging repercussions" I mentioned, and the painful transition period where nurses become gardeners. "Nurse to gardener" is just a random example, it can be "drug researcher to petrochemist", and some transitions we may be happy to see, like "health insurance lawyer to burger flipper", but overall, many good people will suffer in transition, many powerful people too, which make such transition unlikely.
Usually big change doesn't happen without a catastrophic event, like a war, a coup, or an economic crisis, or maybe more optimistically, a technical or scientific breakthrough. So when an article mentions trillions without hinting at such an event, to me, it is incomplete, or wrong.
The French revolution would be an extreme example. It is a win for freedom and democracy, but the period following it is called "the reign of terror", for good reasons.
I don't know the solution, but do you agree that the problem is basically one of individuals not being able to accurately model the tradeoffs in their head?
Shrinking US health expenditure by 3% of GDP while roughly maintaining health outcomes is eminently, obviously doable.
The US is in a class of its own when it comes to health spending. The second highest OECD country (per GDP) is Germany which is 5 points lower than the US (and BTW these figures include public and private spending).
You are clutching at straws to discount clear evidence that shows just how ideologically driven the US System status quo is...
"'No Way to Prevent This,' Says Only Nation Where This Regularly Happens"
https://www.oecd.org/en/publications/health-at-a-glance-2025...
"Sorry kids, can't turn off the Orphan Grinder 9000, there's a whole supply chain behind it that would have to restructure."
If we're taking the $1T figure seriously, let's take the other figure seriously too. Let's slash it to be more conservative while we're at it and say it would only save 90k lives. Do you think 3% of your economy is worth sacrificing to prevent the equivalent of 30 9/11s? And that's before considering that other people here already explained how these 3% are offset by other gains - if not completely then still substantially.
You can't touch the legions of people who exist to make things more expensive.
One reason hospitals have such low margins is many people simply can't pay. If you have a payment guarantee like a medicare for all system, this will increase the stability of hospitals. In fact likely bring back some hospitals in places that didn't make sense like rural areas, which have been struggling via hospital closures.
If you are worried a low cost system will reduce doctors and hospitals per capita you don't need to, as countries that have universal healthcare often have more per capita.
https://worldpopulationreview.com/country-rankings/doctors-p...
I don't see you complaining that the US military has a low operating margin, so maybe we can just agree that some things are just normal expenses for a population. Which therefore leads to step 2: nationalize every single hospital.
>cutting salaries for doctors/nurses/etc
Considering that over 50% of the money that goes into healthcare is just siphoned off by middlemen, no, just getting rid of these means that your health workers do not have a worse salary.
>But, we're actually in a primary care shortage.
Because people do not even go see their GP since there's a chance it leads to life ruining expenses.
> fewer residents are going into family medicine.
Because they're going where money is. Remove that from the equation, and all you have is a public service with public servants.
>a lot of people in the industry believe that Medicare has a large amount of undetected fraud.
Aside from the fact that "people in the industry" have a financial interest in making you believe Medicare is a net negative, there's a great thing that comes from making healthcare a public service: there's no longer any fraud. And those "fraudulent" expenses you used to have that were costing you millions anyways have just had their costs cut in half.
>Healthcare reform is hard.
It's the easiest thing in the world when you have the amount of money the US does. Healthcare reform isn't a financial or infrastructure problem, it's a political one. Cuba has a working healthcare system despite being under US embargo. Botswana has a working healthcare system. Rwanda has a working healthcare system. Azerbaijan, Sri Lanka, Turkey, Serbia, and the list goes on.
Once you grow the balls to nationalize everything, even a first year economy student could make a plan that works.
In practice what we would see under a single-payer system is that many doctors would opt out and shift to a cash payment model. So the shortage of doctors would get even worse for patients who can't afford to pay out of pocket.
I mean, admin costs at hospitals are ~25%, around half of that is directly linked to billing. Administrative costs in the US (because of course you have the same costs on the other side in the insurance side) are around 30% of cost in general, which is pretty insane.
The lack of regulation around pricing transparency and generally the lack of one-price-per-code (which the government uses to its "advantage" to get lower medicaid/medicare rates for sure) is what has caused this stupid arms race on both sides.
Most of the savings in these kinds of reports simply comes from paying doctors less (or delivering fewer procedures, which is also a problem we have.)
It's really the overhead costs that are so Byzantine that they can't be quantified properly. Hospitals have teams of coders, insurance companies have teams of counter-coders, physicians have to waste their time on calls with insurance companies, etc.
"Medicare for all" would alleviate a _lot_ of this. It already works for the elder population, and pretty much every senior has health conditions. So extending it for everybody would result in savings. This is a no-brainer from a purely fiscal point of view.
Another way to fix the mess is to lean on the free market side: prohibit employer-sponsored insurance. Completely. All the health insurance plans must be sold on the open market to everyone.
BIR is 8.5% of provider spending, once you add the multiple cells up that constitute providers.
I don't think your argument is going to survive contact with the numbers here.
I have a bit of personal experience here. I had a partner working as an endocrinologist, one of the higher-compensated medical professions. They were spending at least 1 _hour_ every day on calls with the insurance companies for prior authorization instead of seeing patients.
Some things are also weirdly broken down:
> Net Cost of Health Insurance Expenditures - 6.2% > Administration and Net Cost of Health Insurance - 7.4%
Why are they split?
I also suspect that they included some admin personnel cost in the physician/nurse salary. For my partner, their office employed a person just to deal with insurance. There is no easy way to break down these costs for small practices.
And they're not split: one row is an aggregate of subsequent rows, as you can see by simply adding them up.
This is just a colorized table view of a spreadsheet Medicare publishes every year.
Very curious where this comes from and how accurate it is. For example the $37 a provider charges for an Aspirin seems like more than 2-5% margin.
All of which are willing to fight tooth and nail to preserve "their" fat slices of the obscenely bloated pie.
And on top of that you've got synergies like the horrific cost of housing in the US - which drives up the cost of every employee, no matter how essential they might be to providing actual medical care.
The $37 for an aspirin offsets huge costs elsewhere for (non-NP) nurses, receptionists, janitors, orderlies, etc., who can’t bill directly to medicare.
ER’s for example are money pits, but society really needs them.
https://www.definitivehc.com/resources/healthcare-insights/h...
And while that law is obviously humane and reasonable, my only gripe is that the rest of our system is so backwards that it increasingly forces people to leverage that. There was a story about a woman who needed dialysis but had no insurance. So basically, she had to wait every couple weeks until she started breaking down, go to the ER, get emergency dialysis, get sent home. Rinse, repeat.
I don't blame her but really just the system that made this her best possible option.
https://kdvr.com/news/local/every-week-this-woman-nearly-die...
Do you have any citations for this? I've heard this rhetoric before, but every time I look into it, searching around for studies on google scholar or the web, I can only find studies and reports indicating that health outcomes trend better in countries with more universal coverage. There are think pieces with anecdata of course, but no actual peer reviewed publications I can find.
Heck when I went to college in Ohio's capital, the recommendation on how to get psychiatry or therapy as a new patient was to call the suicide helpline and claim that you were suicidal. That would get you a new patient appointment within 72 hours versus over 3 months on average for patients looking to get into care through normal channels.
The US maintains the highest hardware capacity of the three nations with roughly 43 scanners per million people and performs around 245 to 290 scans per 1,000 residents per year. non-emergency wait times are 1 to 7 days. The UK has 10 scanners per million people and ~100 scans per 1,000 residents, using centralized triage to keep non-emergency wait times between 1 and 6 weeks for NHS targets. Canada does 160 scans per 1,000 residents and 14 to 15 scanners per million, with wait times of 5 to 9 weeks.
When you consider that the US population is not fully covered by insurance, the number of scans is even higher
> Among patients undergoing cancer surgery, waiting times to initiation of first-course therapy have steadily increased since 2012, particularly at high-volume academic centers and among patients referred for definitive care. With continued consolidation and expansion of health systems, system-level strategies are urgently needed to monitor and mitigate delays in the delivery of surgical care for cancer.
> Delays were more pronounced at academic compared with community hospitals and among patients referred for care. Predictors of longer waiting time included Medicaid insurance (5 of 6 cancers), lowest-quartile income (6 of 6 cancers), Black race (5 of 6 cancers), increased travel distance (4 of 6 cancers), care in the West region (6 of 6 cancers), and treatment at academic institutions (6 of 6 cancers). Receipt of robotic operations was linked with longer waiting times for nonbreast malignancies (5 of 5 cancers).
Why would I want to trade my top tier private insurance for that?
And who was in the country illegally so she couldn't use Medicare or Medicaid. Still a terrible situation, but not representative of the typical American.
When you see $37 aspirin on the line, nobody actually pays $37 for it. The billed amount is replaced with whatever insurance rate is allowed for that. If someone is cash paying they get a large discount.
The billed items also have to cover everything. It’s not directly $37 for the aspirin, or the $5 or whatever allowed coverage it ultimately gets billed it. That had to cover the facilities, the salaries of the pharmacy staff who reviewed the request and dispensed it, the staff who inventory and order the medications, and the cost of billing insurance.
The only part that nationalized health care would change are the allowable billed rate and maybe the administrative overhead of billing different insurances. Even nationalized health care systems have admin overhead though.
You can think of it like when you have to pay $11 for a single glass of wine from a bottle that the restaurant paid $10 for. You’re not just paying for the liquid, you are paying into a big bucket of charges that all need to add up to more than the cost of the supplies, staff, building, and everything that goes into running it. The margin on individual products doesn’t make the entire operation profitable.
That's the same as any? CVS charging $5 for aspirin has to cover their staff who stocked and checked out the item, the shelf space, the marketing, and the looting.
The comparison you make between a bottle of wine vs a glass is not the right one. It's two different stores selling the same product. What's different about hospitals?
The discourse also underestimates how much of our health care costs go to our significantly higher salaries throughout the medical system. No politician wants to propose reducing the salaries of doctors, surgeons, or even researchers making new medications. The only acceptable villains are the administrators and insurance companies, but even in this inefficient system that's a much smaller slice of the pie chart than most people imagine.
One of the reasons hospitals operate in this convoluted way and still barely clear a profit is that we require them to treat everyone and attempt to collect payment later. A lot of what you and I pay for health care goes to cover people who can't or won't pay.
Well, the salaries of medical personnel only account for about 20% of total healthcare spending. So even cutting those by half wouldn't change much.
> One of the reasons hospitals operate in this convoluted way and still barely clear a profit is that we require them to treat everyone and attempt to collect payment later. A lot of what you and I pay for health care goes to cover people who can't or won't pay.
If that was a major reason, then those who don't pay would balance out those who pay and the grand total of all healthcare spending in the US would be pretty average despite individual premiums and out of pocket costs being sky high. But in reality, the total healthcare spending is just as sky high (several times more per capita then median OECD country).
When the hospital charges you $37 for an aspirin, that singular pill might have a crazy profit margin in isolation. But your entire treatment could very well be losing the hospital money.
In my own anecdotal experience, the one hospital I know enough details about to comment on specifically, had something like 85% of patients costing the hospital more money than the hospital made. It was entirely funded by the relatively small number of people who had the “right” insurance and had the “right” procedures done.
Eg Kaufman: https://www.vizient.com/insights/reports/national-hospital-f...
Oops! We can't find the page you're looking for
Administrator pay scale is completely irrelevant to the point
Really need to step back and start from first principles.
When I go to urgent care I get 15 minutes with a doctor who on average makes about $300K and maybe another 15 minutes with a nurse assistant who might be making $100K (or less). So that is less than $50 in doctor+nurse salary. Of course there are then all the overhead of rent, utilities, etc, etc but those are not so different from any other business in the same strip mall. So let's say total cost for my visit is maybe $100. But I'm charged $500-$600 for the visit. Someone is pocketing a lot of money and it is not the doctor nor the nurse.
We could do the same exercise for surgery, the costs for surgeons and anestethicians is much higher, but you'll be hard pressed to find any realistic scenario where the cost of a two hour surgery is more than $100K.
My surgeon friends routinely complain about the inordinate amount of time they personally need to spend fighting with insurance, in the form of filling endless forms that insurance insists must be filled and signed by the doctor. This is in addition to whatever time/cost the hospital staff wastes fighting with insurance paperwork.
The surgeon time is not cheap, but the insurance companies expect these doctors to do all this paper pushing for free on top of their day job.
But if it's a team of nurses, doctors, and other healthcare specialists rushing around doing checklist work to make sure you get that aspirin, that's just evil.
The principle is only applicable to our industry and closely adjacent industries.
Yep. Hospital "bills" are a fiction. On one occasion I was presented with an "Explanation of Benefits" for a hospital stay where I was "charged" for being in two hospital rooms at the same time. As if that weren't enough I was also "charged" with having a "Pap smear"[0], even though I don't have a cervix.
I complained bitterly and after making a big stink was informed by the hospital my insurer that the items weren't actually "billed". Rather, the insurance company paid $1500/day regardless of the treatment provided.
It's disgusting!
A Pap smear[0] is a diagnostic test to detect (pre)cancerous cells on one's cervix[1].
This is one of the areas where more standardization would certainly help. If there were more standardization of which codes disallow which other ones (which can currently vary wildly by plan even with the same insurer, must less across insurers), then a lot of line items could actually get removed as truly redundant, vastly simplifying the bill.
I would be able to dispute a double room billing, but I was sedated and dying so I took whatever they offered, assuming good faith.
I’m making a serious point here: medical overspending is not just gobs of money ending up in a single pocket. The US medical system really is incredibly complex, and the money is moving all over the place and being spent on many things. Most of those cost centers may all zero or even negative value to the patient, but that doesn’t mean they don’t exist.
Also, then, of course, we need to cover the United Healthcare guy's salary, which decreases margins.
Its all coming out of revenue.
The margin built into the prices bulled is not the actual margin the hospital ends up with.
The flipside to fraudulent billing is that people that need care are denied. The fraudulent billing was perpetrated by the insurer.
I don't spend any healthcare money at the hospital. It's all all providers office, private clinic, etc.
It costs $300 for my primary care doctor to see me for about 7 minutes. An assistant takes my blood pressure, he asks me a few questions about my habits and diet, and then I come back next year.
If I actually need any services, I go to much more expensive specialist, or urgent care facility. A visit there is about $100 and then a couple bucks for whatever prescription they give me.
People tackle hard things for nothing, never mind billions in savings.
How does this work when many/most US hospitals operate as non-profits? Quick search shows the for-profits have operating margins nearly triple your figures. And the non-profits are beholden to the community to provide some level of "freebies" to maintain their status, right? IE, they're aren't really all operating on razor thin margins.
I'm curious where you got this figure, because it doesn't track with my own experience.
I used to work for a place that worked closely with hospital clients (and prospective clients) to resolve billing issues with a particular EMR system, and we regularly discovered that a given hospital was losing hundreds of thousands to millions of dollars weekly due to missing charges. The problem was, so much money was sloshing around that the hospitals were virtually always unaware of the missing charges, and many CIOs were more interested in saving face by shutting down further discussion than in walking through the collected data, how to fix the charging issues, and even claw back some of the lost charges (which you can generally do up to several months after the fact).
There are many others as well.
FWIW, your experience doesn't seem contradictory to the operating margin claims.
Your experience seems to be that hospitals are run very inefficiently, implying that if they were run efficiently that their operating margins would be much higher than 2-5%. That may be the case, but that still means the Yale paper's claims don't make sense (unless they also propose some mechanism by which to suddenly force all hospitals to start operating efficiently).
But I'm also skeptical of your claim that hospitals are leaving a huge amount of operating margin on the table. IME, very little can be explained by "everyone is stupid." Would I be surprised if a given hospital was run very inefficiently or if a given hospital had a particular poor CIO or administrator? Not in the slightest. Would I be surprised if ALL hospitals were run by idiots who were leaving 10% operating margin on the table? Yes, I would be.
That the hospitals didn't seem to notice the problem, and upon being told of it, often pushed back against moving to fix the problem, is what gave the impression that they must be running on much larger margins than advertised.
I am constantly told how much less Europeans pay for better health outcomes and all I can think about was the obesity crisis I grew up around in Texas.
Socializing healthcare isn’t going to get an huge portion of the population out of their cars and get them walking as a primary or secondary mode of transportation. Not when it’s 100° and the grocery store is five miles away.
Americans, in no small part, have worse health outcomes because we have dramatically worse lifestyles. I support German-style universal healthcare, but I’m not going to pretend it will suddenly give us German health outcomes.
Take Europeans, put them in Kansas. Fund their healthcare as though they were in Europe, and watch their health outcomes take a nosedive because the environment here is non-trivially worse for you health.
Unless I’m wildly misunderstanding these studies, it makes sense that we would need to spend more for the same outcomes because we are starting from a more unhealthy position, so the same results require more resources.
We need to at least be controlling for the 10%+ differences in obesity rates, and the enormous differences in UV index. That’s before even considering weekly exercise minimums that most European get when just walking to a bar.
I think the important bit in all these discussions is that "universal health care" and "single payer" aren't synonyms. Single payer is one way to do universal, and most universal systems don't do it. But this article conflates the two.
You're not wrong at all that the US has some systematic issues that place additional strain on the healthcare system, but it's a "yes and" situation here. Even accounting for those, we spend far, far too much because our system is extractive.
I would be curious as to the costs/benefits there.
You would think so but once healthcare cost becomes a government policy issue people complain about its spending and they are forced to try and bring that cost down. One of the ways they did that in my country was to promote biking to work and build bike ways.
I agree with you generally on the incentives, but it took us 70 years to paint ourselves into this corner, and we’re not going to get out of it because of a third-order incentive.
https://press.uchicago.edu/ucp/books/book/chicago/R/bo413854...
The first step to reforming US healthcare is actually understanding it, and understanding some international designs. Lying about it doesn't help.
They mean “free to the consumer at time of service”, which it is. Nobody is lying, everyone agrees, it’s just you who doesn’t understand.
You are incredibly optimistic about a large swath of the population's understanding, unfortunately.
> Nobody is lying
There are plenty of people in this discussion making statements of fact that are false. Call it whatever you want.
No, they mean free at time of service, which they are.
Don’t believe me? Great, then ask them, without doing word gymnastics to try to trick them.
Should medical equipment cost 0 dollars to produce? Should doctors not earn any salary or wage? They will say no, 100% of the time.
I don't think that's true France, Norway, New Zealand, or Switzerland. (And that's just developed nations. The GP's claim was every country other than the US.)
In every case costs have gone down and outcomes have improved.
You always build on what you have because you can’t pause healthcare for very obvious reasons.
Hence a lot of different systems all with the same aim. Controlled costs and universal coverage.
The idea the US is somehow different and cannot make the change is the result of propaganda and a mistaken belief that the current Us system is the worlds best despite its costs.
Healthcare reform is easy and there is an ocean of prior art.
Health care is an absolutely massive industry (everywhere, not just in the United States), and slashing compensation in a massive industry by top-down fiat is in fact not an especially easy thing to do.
Turns out when you have the choice of accepting lower payment per patient for Medicare or having a lot fewer patients, you choose the lower payment per patient.
I would expect the same situation here. Doctors would grumble, but no one would force them to accept patients on whatever “Medicare for all” would be called. Nothing other than market forces.
A number of things would probably have to change, including the cost of medical school. But the system right now is expensive and essentially unsustainable. So change is inevitable.
And I’m aware that medical debt is a big issue, but it seems like a chicken-or-the-egg type problem. Of course you can charge $500k for a medical degree when the doctor can make it back and then some in 5-10 years.
It's really easy now with Claude and GPT5; just ask them a question and tell them to answer it for you, with cites, from the NHE. (The data I argue from precedes widespread LLM research; I built a site for this a couple years ago and didn't bother to update my data, because I assume it didn't get much better.)
https://www.cms.gov/data-research/statistics-trends-and-repo...
if a "senior" software engineer can make half a mil, and an electrician can make 200k, of course doctor pay are high.
who is going to take 10-15 years of school and debt otherwise?
> "The electricians that I interviewed and met two months ago in a data center in Plano, Texas, all under 30 years old, all making $240,000 to $280,000 a year, all with as much overtime as they want, none with any debt, all three of whom were poached three times in the prior 18 months," Rowe said ...
Google AI summaries then pick up wealth/finance grifter social media clickbait about it and parrots it as a fact.
There are contract data-center electrical jobs paying $55-65/hr (some with signing bonuses, per-diems, and benefits on top), but they only come close to $200,000 takehome by working 12/7 with generous overtime. And these are 5+ years of experience, OSHA 30, journeyman license, bring-your-own-tools. They're also exceptional; most are still $25-40/hr.
It’s funny, because it’s a career that feels both overpaid and underpaid to me. I went to a college where almost half of the students were going for nursing - and you certainly don’t need to be especially intelligent.
At least to an outsider, some nursing fields seem damned easy. The nurse that sees me before my GP? Pretty easy job.
Other specialties? Like the nurses that needed to clean up my wife after she massively bled during/after a c-section and they had to give her medications that also caused all sorts of other fluids to intermingle with the blood? Or the nurses that had to stand there for 10 minutes squeezing our infant daughter’s heel in the NICU to try to get enough blood out while she screamed as hard as a little baby can?
$100k doesn’t seem like enough. Odd occupation. For $60k I’d rather work at Costco, that’s for certain.
this isn't really true though, if you look at survival rates of many diseases.
Any model that gets rid of these frees up a huge swath of capital and work from society, and can use that work elsewhere. Of course, that is easier said than done.
Each of those are companies worth billions of dollars that could be instead used to lower the individual cost of providing health insurance.
As you say, this would of course be unsavory in some respects as those companies employ a lot of people. It's not a very economically productive industry though, the main output seems to be consuming patients' and doctors' time, causing financial anguish, and causing stress among people as to whether or not if their condition will be covered.
(Medicaid & Medicare claims processors do the same thing. Medicaid claims processing is mostly handled by private, third-party insurers now, and seems to be able to do so more efficiently and cheaply than when it was being run directly by states; the savings is mostly in the area of catching fraud.)
Medicare is much cheaper because they have fixed rates and hospitals know what to bill.
We all contribute to the pool at a time when we don't need it so we can use the money when we do, not to make CEOs or stockholders rich. That is how an insurance pool should work. Any excess money at the end of the year should be moved to the pool for the next year, not as a bonus on CEOs' 100m+ salary.
> Any excess money at the end of the year should be moved to the pool for the next year, not as a bonus on CEOs' 100m+ salary
Under the ACA, excess money in the pool must be rebated to policy holders. In practice, this worked for a few years, but eventually insurance companies ended up increasing cost in order to increase the absolute amount they were allowed to keep. Maybe this is still good (more claims approved), but it is counter productive to the goal of reducing healthcare costs.
I had a recent doctor's visit, with very good healthcare coverage, that was an in-network facility but an out-of-network provider. Coverage would have kicked in if I had a referral from my PCP, but my PCP recently retired and I was advocating for my own health for a small dermatological issue. They said it was cosmetic, my old PCP said it was not. I got a stack of 10 bills over many months all stating different things -- everything from $0 EOB to over $2k in uncovered expenses. No one would take ownership of sorting out what I was on the hook for. No one I talked to was empowered to actually solve it. It wasn't an affordability problem over $2k (but would be for my elderly grandparents on fixed income). Even asking "If I give you $2k does that resolve the debt?" was answered with "we won't know until we apply the payment" type non-answers.
Burn the whole stack down -or- earn enough you can operate on cash for the tier of care you want. Nothing inbetween seems to be working.
Aren't their profits regulated regardless? If all insurance companies became non profit and let's say total prices dropped by 3-5% that still wouldn't change the situation dramatically?
There are many factors, e.g. amongst other things American doctors are better paid than just about anywhere else in the world.
Yes and no. It's sort of a weird thing where insurance is somewhat regulated nationally but also regulated in a piecemeal fashion state by state.
There's a non-government standards body called the NAIC which provided national guidance for insurers. Most (all?) states basically say that "if you follow NAIC standards, you are good".
> If all insurance companies became non profit and let's say total prices dropped by 3-5% that still wouldn't change the situation dramatically?
It's a huge mess. It's not even really a profit vs non-profit thing but rather "what's the motivation". One major issue is that the ACA put in a loss ratio of 80%. Which isn't a terrible thing in principle, it forces insurance companies to spend money on treatment. The problem is it also means that the profit of insurance companies is tied directly to how much they spend on healthcare. As a result, they are incentivized to spend more, not less, on medical treatments so they can justify higher premiums.
This is a big part of why I think universal public insurance is a must. Basically the only organization that's motivated to keep costs as low as possible is the government.
> American doctors are better paid than just about anywhere else in the world.
This is a problem, but the bigger issue and why doctors are paid so well is because becoming a doctor is one of the more costly and hard to do things in america. There are limited spots, schools, and residency requirements that severely restricts the number of possible doctors we add per year. That drives up the their salaries.
I have a nephew going to medical school in Idaho of all places, and he's looking at $500k in debt by the end of the whole ordeal.
Investors care about margins, not absolute dollar figures. If your non-medical costs are capped, the incentive would be to reduce your other costs to preserve or maximize profits.
So the 80/20 rule is unlikely to have caused anything. More likely it's too low, and the profit ratio that can extracted and passed to investors is still higher than most investing alternatives, which is why it keeps attracting more investment. Without the 80/20 rule we would have seen the same thing or worse, though perhaps slower premium increases but less treatment delivered.
Really this all points to structural problems in the market. Naively we might presume there's not enough competition, and there could be many reasons for that--over regulation, lack of transparency. But it's more complicated than just that because medical treatment, particularly the most costly treatments, presumably have very high price elasticity [citation needed]. Over the long term, investors are just gonna keep trying to draw as much from the well as they can. The problem with public single-payer is that the basic demand curve dynamic doesn't magically change, so rather than complain about high prices people complain about shortages, OR the government just keeps borrowing to maintain satisfactory treatment access until they can't borrow anymore.
Maybe the only solution to rising healthcare costs is to slow down the pace of medical advancements. People love to point out how cheap care is elsewhere, but the most advanced and costly treatments usually become available in the US first, taking years or even decades to spread. (Note, higher prices on pre-existing tech subsidize the cost of bleeding edge treatments, so comparing MRI prices isn't very helpful.) Moreover, people elsewhere don't really know about them so it doesn't detract from their perception of the quality of care they receive. If you're dying and the doctor says there's nothing he can offer you, then that's that and no ill feelings toward the medical establishment. If he says there is something but it's gonna be crazy expensive or there's a shortage/waiting list, now your pissed.
Unfortunately, this isn't true for the government either.
Source: personal experience of me and literally dozens of people that I know. I've briefly worked with my country's government, and in that time I personally experienced and got dozens of stories along the lines of "the government spent tens of thousands of dollars of aggregate government employees' time because a single employee booked a hotel that was less than one dollar above the approved rate while traveling".
There's a good reason for this, of course: bureaucracies' policies are mostly "scar tissue" from high-profile cases where a bad actor did something they shouldn't have but wasn't specifically against policy, and then a policy was written for that case and stands for the rest of time. And, bureaucracies are risk-averse, especially democratic governments, whose leaders are elected based on optics almost as much as policy.
But it doesn't change the facts. Not only are large bureaucracies inefficient, but government bureaucracies specifically are incentivized to optimize for optics and structure rather than improving that inefficiency, and anyone who has actually worked for a large government can tell you that.
Not really accurate if you look at the closure of rural and smaller city healthcare facilities. They don't have the base to charge "regular price" to make up for the aging, less healthy, rural populations.
We all pay for it, but some pay heavier costs than others.
Americans are constantly trying to exclude uninsured people from their statistics (and, worse, from the care itself) but the comparable countries don't do this so it is utterly ridiculous to propose that the correct statistical comparison is one in which the US excludes the undesirables while other countries don't.
https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
Total health spending per capita in PPP$
2024 2023 2022
United States 14,885 13,818 12,898
Switzerland 9,963 9,301 9,089
Norway 9,393 8,909 8,533
Germany 9,365 8,503 8,652
Netherlands 8,436 7,615 7,517
Austria 8,401 7,697 7,700
Luxembourg 8,087 7,173 6,854
Sweden 7,871 7,364 6,977
Ireland 7,813 7,027 6,748
Belgium 7,750 7,178 6,906
Australia 7,469 7,015 6,907https://www.oecd.org/en/publications/health-at-a-glance-2025...
https://data.worldbank.org/indicator/SH.XPD.GHED.PP.CD?locat...
According to the world bank it's closer to 40:60 (government spending still being the majority). So that puts it behind Switzerland but still more than combined spending in just about any other country.
Even if it's US Government only per capita with people the government insures, it makes sense it would be so high because only people on government insurance are the poor/disabled AND old. Two groups that have extremely high utilization.
That means that even though government insurance in the US only covers a relatively small percent of the population, we pay more than other countries that cover the whole population.
I say convert SSA to UBI, set a floor, and let the price of things find a new level with more people in the marketplace:
Your point is correct, but since the majority of healthcare spending occurs in the last 18 months of life, and the vast majority are on either Medicare or Medicaid during that time of their life (either due to age or ailment-related incapacity), it doesn't make a huge difference.
I could make observations about who tends to be there at either but that might rustle some jimmies.
Most patients never file a lawsuit, even if things don't go well, and most injuries that aren't deaths or newsworthy are not worth the trouble to an "overburdened" court system itself imposing a lot of burdens.
And the quality life years lost waiting to share a verdict with attorneys ought to count for everyone affected, not just those who spearhead a trial by catastrophe.
I think the solution is to make the practice of medicine more scientific, and less dominated by competitive incentives, but as long as research and development, reform, or even consumer choice, is strictly a cost, that will be considered "too expensive", if not "too risky".
When patients are harmed by medical errors caused by non-quacks, that's just tough luck. Not everyone can be saved. Creating a gigantic medical malpractice insurance industry so that a few hundred surviving families per year can have lottery jackpot settlements isn't a solution in any way, and has done very little to incentivize fewer errors.
I'm used to this though.
Somewhere there's a pareto-optimal frontier where one can't possibly save more lives without spending more, or spend less without more people having negative health outcomes ... and the question is whether universal health coverage would be a step towards that frontier (b/c we're all pretty sure we're far from the frontier today). And the fact that plenty of countries have both lower costs and better outcomes through such a system is highly suggestive that it is a more efficient policy regime.
Maybe the big quibble is whether the American penchant for creating corporate givewaways to powerful organizations that lobby politicians would create an especially toxic public-private-partnership monopoly in which the biggest existing private healthcare networks are granted regional monopolies and set crazy prices (or some other dystopian warping of an initially reasonable idea) so costs actually balloon. I do think that would be a risk and so we need to be careful about the specifics of how we implement this.
You arent considering
1. Hospitals eating the cost of the uninsured, which this would solve
2. Hospital spending tons on administrative duties fighting with insurers on coverage, which this would reduce
Wouldn't it just transfer the cost from the hospitals to the universal coverage agency? This would make the financial picture even worse for the proposed system.
The hospital can be paid less without reducing their margin if they can remove a cost from their balance sheet. It does not make the system cheaper overall, but it means the hospital does not have to bear those costs directly. They may not have to bear them at all, because hospitals are not the only things in the system.
About 8% of the population is uninsured. The uninsured population skews younger, with less healthcare utilization (Medicare already covers everyone 65 and older).
Another comment in this thread estimated billing overhead at 8.5%. Medicare for All would eliminate some, but not all of this, since Medicare is still a claims-based system. You would remove a lot of overhead around prior auths, which I agree is a good thing, but could be achieved with more focused legislation.
OP makes a good point. The studies assumes two diametrically opposed things will happen - doctors will take a 50% pay cut but access to primary care physicians will increase.
Why would we solve the primary care physician shortage by cutting their pay?
Would this go away, though? Instead of fighting with insurers they would be fighting with the government insurer?
I am very pro universal healthcare, I just don’t want to pretend there aren’t still going to be fights over what should be paid for.
No matter what, there are going to be disagreements on what medical procedures should be paid for and who needs them, as well as how much they should be billed for.
All of this was branded as "death boards" in the American healthcare debate.
1. I'd rather fight the non profit-motivated entity 2. We can probably compare to VA and Medicare and even other countries to see what the fight will be like. I'm willing to bet it will be a big improvement.
> No matter what, there are going to be disagreements on what medical procedures should be paid for and who needs them, as well as how much they should be billed for.
Government insurance has a service motive. Private insurance has a profit motive.
And government can just lower the definition of acceptable service rather than provide any accountability for not providing it.
but why would they? OTOH for-profit companies do this all the time.
This layer won't go without a fight. Maybe it _is_ the layer we're fighting against. The owners will still make profit, the providers still have jobs.. but the middle layers are useless bloat. They don't have skills to provide care, they don't operate at the capitalist layer. They are useless today, and even more useless tomorrow.
And that is likely useless layer is millions? of jobs.
How do we know? The experiment has been done multiple times, all over the world. In the worst case (Sweden), healthcare is a bit short of $5K per capita per year, or around $1.7T. We’ve actually got a nice margin to achieve $1T, even if we remain the worst.
I agree health care reform is hard, though. We have a clear roadmap on how it can work a lot better. But what’s the political path forward?
As someone who’s actually fiscally conservative, single-payer universal healthcare is an absolute no-brainer, but, ironically, the people who call themselves fiscal conservatives will fight it to the death (well, not that ironic — at this point we all understand that, in politics, what groups purport to believe and what they actually believe have little to do with each other).
This is a hoot. There is an entire cohort of people who use the emergency room as their non-urgent clinic. This is not a small demographic, it must be at minimum tens of millions of people, if not going above the nine digit mark. They do this because their parents did it, and it's the only thing they know, and their parents did it because it's the only thing they knew, and they did it because their parents did the same. It is a culture that no amount of education and public service announcements will ever change.
Heaping one perverse incentive after another on top of this mess won't change it either, but will almost certainly make things worse for everyone.
>For "less fraudulent billing," a lot of people in the industry believe that Medicare has a large amount of undetected fraud.
My grandpa when he was still alive would have one new fraud story with every visit to the doctor, and he wasn't in great shape towards the end, so this was too many to count, every year for the last few. Diabetic, they ordered him compression socks at one point... a dozen show up instead of the two pair that was ordered. He'd come home and wait for a bill in the mail, and a few days later would see itemization for tests and procedures he never underwent. Over and over and over. He was sharp, argumentative, and as far as I could tell, less confused than most his own age. His experience, I think, wasn't atypical.
https://www.miamiherald.com/news/politics-government/article...
Funny thing is: if you tell the hospital that you do not have an insurance they will charge you a price that actually sounds reasonable, say $700 for a CT scan (which is still like 2x more than in my home country, but then the US is a high cost of living place), but if you do have insurance they will try to extort as much money as possible from your insurer: initial bill will be like $10k, and then they will settle for, say, $6k.
That has not been my experience. Insurance negotiates lower rates and without insurance, the full fare price suggested price has always been higher.
Also, for beyond that, unspend premiums have to be refunded, which also cuts into the potential admin spend bucket, so it's best to always ensure your paying as much as possible in claims.
Plus, patients hate denied claims, because typically your forced to sign paperwork saying your responsible for anything insurance refuses to pay.
And with most health insurance spending being locked to employer benefits, the big market is the group market, which means your stuck with either getting your job's option(s), finding a new job, or not getting insurance basically.
In other words, you don't have a price choice as an individual in a group.
Now that is some sick shit. Making every doctor's visit a gamble you might lose, discouraging people from seeing a doctor.
Alot of insurers the past few years have actually gone bankrupt from ballooning costs and claims.
So, they want costs to go up, so the next year they can up the premiums, so they can then up their admin spend, but the costs still need to below the premium. And they can't just up the premium without an associated rise in cost, because groups are owed their premium money back if it isn't paid out.
All for profit insurance must by definition bring in more than it pays out. From cars to homes to health to pets.
If instead of paying all your premiums, you'd be far more likely to be able to afford the services that the insurers are supposedly paying for. Like, yeah, there's a chance you need a new engine, and a small chance that all of your monthly car insurance totals up to less than the cost of the engine, but the entire point of the company is that they know that it is far more likely that you will end up paying more for their service than you'd have actually payed for turns out the only thing that ever went wrong was a small crack in your windshield.
Why can't they just charge higher rates to more risky people. If you are a risky driver you pay more, and if you have a risky body you should also pay more.
Well yes, but you are paying for reduced variance, which itself has a value.
Last I heard healthcare is like the only employment sector that's seeing real growth right now.
Note that this is a Good Thing.
The issue with US (and privatized) healthcare delivery is that there is an incentive (by insurers) to deny treatment, as well as an incentive for healthcare suppliers (hospitals, doctors) to over-deliver treatment, as well as incentives to use more expensive solutions.
Demand in healthcare is inelastic, no one is ever "too healthy".
Supply is always insufficient, so there needs to be a mechanism to resolve that.
In the US, that mechanism is money, or the cost of insurance etc to provide a restriction on demand.
In universal healthcare, that mechanism is a combination of subsidizing medications based on results and waiting lists for limited supplies, prioritized by need (eg surgeries).
But you will lose endless billing departments at general/specialist practices, hospitals etc, because actual consumers would not engage. Hospital administrations will be driven by the government setting reimbursement rates for services that are transparent, so the argy-bargy between someone paying cash, someone getting insurance etc will disappear (mostly).
I'm in Australia, and the billing departments, even at private hospitals are minimal. Ditto at general practices. Reimbursements for GP/specialists that are not "bulk billed" (ie paid at the government rate) are automated into a nominated bank account and are usually instant.
Medicare for All in the US would move the 2/3rds that are not covered by Medicare, VA, etc into the same systems, with the reduction in overhead from 10-20% to the 2-5% of the current government run health systems.
Allowing Medicare to negotiate both drug prices (as a large purchaser) and health services will also dramatically reduce costs, because the government has the purchasing power to drive hard bargains.
You can't just conjure up a medical school out of nowhere though. That's extremely hard and expensive. You can do it if you relax your standards. Maybe by making the "hospital" part of the school optional or something. Students won't see patients but what does it matter.
Medicare, Medicaid and Tricare are all basically universal systems for segments of the population. None work well. And all are subsidized from what people with private insurance pay. And the UHC proponents rely on a stacked deck--UHC is "better" in a system that makes 20% of the score "fairness". That is, UHC. And one of the other yardsticks is life expectancy. Sounds fine--but dig deeper. A big factor in lowering life expectancy is infant mortality. Again, sounds fine--except you see a big difference in infant mortality across the developed world that is not reasonably explained by differences in their medical systems. But you see an inverse relationship between infant mortality and stillbirths. Most of what you're really seeing is whether the doctors consider it a live birth that promptly died, or consider it a stillbirth. (And, yes, we are still an outlier--but by only 1/3 of the amount claimed.)
Show me it's better without your thumb on the scale!
(A lot of people are going to be very mad at me about this comment, without having the awareness to understand that this is the inevitable conclusion to, "You wanna play rough, ah?!"ing people's access to life-saving treatment. Please grok that we can preclude any more assassinations by cutting profits and letting people get the care they need.)
Congress is our only hope, along with a president who signs reform.
Obama had a generational mandate and couldn't even pass a public option which, is far more moderate than a single payer approach. Even the abomination of the ACA that actually got signed into law was subsequently gutted to the bone in the following years.
There is room for more tweaking, but the system we're living with now is pretty close to what most voters prefer.
1) In the immediate aftermath of Thompson being shot, policies were deliberately briefly softened. Anecdotally, people were helped to live longer by this. It didn’t last long.
2) The response to Thompson’s assassination was the closest I’ve seen to a class consciousness almost forming in the US, as people from across the political divide who had suffered at the hands of the healthcare insurance companies found common ground.
The reaction was short lived while the insurance companies figured out how to bolster security and return to the usual.
Look at what's happening in California with the proposed wealth tax.
>Page’s co-founder, Sergey Brin, has poured at least $45 million into the Building a Better California Super PAC specifically dedicated to blocking the tax
The reason more CEOs getting shot might make a difference is that many CEOs care about status and being able to mention it in the right places. Historically many people love it so much that they call themselves CEOs and Presidents of companies that are small businesses.
If these same people can no longer be open about their role and status, which they value, there will be some kind of change. I'm not sure what it is, but security guards don't restore their freedom to feel thoughtless about their role and lifestyle.
Whereas with taxes... Maybe some people brag about dodging them or their suspect filings that get them big refunds. But they're mostly not public and not tied to identity the same way. And even the wealth tax isn't remotely the same as the public being vocal at large.
For it to be comparable we'd have to have modern highwaymen and Robin Hoods somehow stripping the wealth, not the tax man.
Because the weight of any changes or perceived need to change come from the social burden that public violence would create in the shooting case.
And that doesn't seem to exist near at all with the wealth tax.
This is still a possitive outcome brought from the presence of a threat to their lives. Not as positive as the healthcare thing, but it's still jobs and a "tax" in that they are forced to purchase the vehicles which do have to be built and driven by someone not in their tax bracket.
The solution is to have both a) mandatory voting and b) a voting holiday. This is done in many other democracies around the world, and it works. Personally I would prefer term limits and age limits for congress, the president, and federal judges. Diane Feinstein, Ruth Bater Ginsberg died in office. Mitch McConnell is working on it. We have age limits for lots of professions that require high performance - political leadership should not be an exception. But of course to make any of these changes young people have to vote, but they're mostly busy being poor and doomscrolling to block out the pain.
-The US has had a lot of success by letting businesses run pretty free. This has produced some of the largest and most powerful companies on the planet.
-The conservative party traditionally has been suspicious of a powerful, centralized government
-In the US, there is a common thread of "government workers are impossible to fire" as well as a common thread of "government moves at a snail's pace".
In light of just that, there are many people who would prefer that healthcare is run by a private industry, as private insurers are enormous companies in the US. Everyone knows Blue Cross Blue Shield, Aetna, or Kaiser Permanente. Many people give a benefit of the doubt that companies are doing things efficiently. Additionally, health insurance companies in the US have a requirement to spend a certain % of their revenue each year on medical care, and will sometimes send out small refunds when they simply cannot suppress costs in certain other regions of the company enough to keep their spending at the right rates.
Beyond this, states may provide additional benefits, and many do (some with the help of federal funding, even). You may find someone in one state where they are suffering greatly, while someone in an identical economic situation in another state is not suffering at all. It's easy to convince the first man to vote for a better healthcare situation. It's hard to convince the latter.
I could go on for ages, but this is getting long. There are like a billion reasons.
The grammar is a little ambiguous around this, but you seem to be claiming that this is a majority position. It isn't. Single payer polls over 50% basically every time it's tested (the exception being some spun partisan reframings you occasionally see pushed), and has for decades.
Sorry, that's ridiculous. Universal Health Care policies are an almost 100% partisan issue. I can literally count on one hand the number of federal lawmakers who cross party lines here.
The real problem is people like you refusing to vote for the people with the policy you want, as often as not as part of a bothsidesist stance designed to get more upvote in peer forums like HN.
The two party system may be flawed and unjust, sure. But people who want single payer are still democrats.
That's a lot of words they didn't say. It is a true statement that Congress did not give the USA single-payer healthcare nor even a public option.
Nothing about that says anything about who voted for whom, where anyone even lives for that matter, or anything about political parties.
To say this is the fault of "people like you" is out of line.
But that is what they didn't say! They said it wasn't "votable", in the sense I took that means that this isn't an issue you can get by voting. And it is, clearly. And was, in 2010, when they were within one senate vote for a "public option" in the ACA. It 100% boggles my mind that you'd look at that once again incredibly partisan voting result and decide "Oh well, I might as well vote republican" (instead of "damn Joe Lieberman").
Who said any of this? "I" said nothing of the sort
I don't think you're going to convince anyone of anything this way. If anything you'll probably end up turning people off who otherwise would have agreed with you
You quite clearly came in to defend someone who did, though. This is the second time you've tried this end-around strawman. Please engage with the discussion as it is.
> "I already have universal healthcare here in Canada"
I don't think I'm the one misreading the discussion as it is.
If you take a deep breath and re-read, maybe you'll understand the point I've been trying to make is you're jumping down people's throats that aren't disagreeing with you, which at best does your own arguments a disservice. To put words in someone's mouth and say this is the fault of 'people like you' is out of line.
Have a good one
But I'm very happy you agree that health care policy in the USA is among the most directly partisan issues and know who to vote for given those priorities.
Edit: and even now you still put words in my mouth with your edit (so that's every message in this thread that does so). Best of luck to you
You just don't think I shouldn't have engaged with advocacy around the issue or taken offense that you and upthread commenters feel that this isn't something that can be... I guess "achieved by voting"[1]. I think that's a weird thing to troll a discussion this deep about, but OK.
[1] Does that match your understanding of the point? Genuine question! I think it's bonkers and wrong, but you seem attached to it and I'd like the opportunity to convince you.
In the 2020 debate, Joe Biden said he would veto Medicare for all*. Just this week, Hakeem Jeffries said he did not support Medicare for all and wouldn't vote for it. You already mentioned Joe Lieberman
None of what I just said implies "it's not partisan" nor does it imply "both sides are the same" -- multiple things can be true at the same time
It sure does, however, reinforce the original, plain statement: "The issue is that the people in Washington won’t make it a 'votable' decision."
*By April 8, 2020, Biden was the "presumptive Democratic nominee" -- at that time, 22 states still hadn't yet held their primary elections. As such, for those 22 states it was quite literally not a votable decision
As the joke goes, "how did God create the universe in 7 days? No installed base"
Oh for... Joe Biden was literally the tiebreaker vote in the senate when the public option was still part of Obamacare and was stumping for it like crazy. MfA is one particular proposal from one particular faction of the party. We aren't talking about MfA specifically, and that's quite clear all the way upthread.
This kind of dissembling and trickery is what's driving me crazy in this thread. You just don't seem to be arguing in good faith. No, Joseph Biden Jr. is very clearly not opposed to government-provided health care, nor is any democrat in office right now that I'm aware of.
"Mostly" partisan. Good grief.
Public option is not single-payer/universal healthcare. Medicare for All is generally used as a synonym for single-payer healthcare in the US. The article stated it models the results of implementing a plan like Medicare for All
"Public option" still results in a vast bureaucracy of "paying for healthcare machinery", and so is scarcely comparable. Note: that does not mean a public option would be a bad thing. But it is not the same thing
I've already wasted way too much time on this, against my better judgement. I tried to leave twice, but third time will be the charm. Be well
Indeed you've wasted too much time on this. And I still have no idea what it is you really are trying to argue about. You agree with me on everything I've tried to pin you down on, and want to dither over tone and jargon when challenged.
There would still be the option of people and businesses to buy 3rd party "extras" like private hospital rooms, vision care etc. on top the state plan, but some level of basic health care would be provided to all people paying into the state plan.
Would that work?
Probably important to point out here that leftists are looking to see a threat to a corporation's leadership change the behavior of a corporation, whereas right-wingers are looking to see a threat to a government's leadership change everyone's behavior ("overreaching government" in a democracy being the will of voters). They're not the same thing.
Reliable details are hard to come by, but some estimations are that more people in the industry are doing admin tasks than instead of providing care, admin tasks that will be reduced drastically once the industry is streamlined.
Once we get affordable care there will be less people who can... afford.
This just plainly isn't true. The US is unique in the way it doesn't have affordable public healthcare, but the rest of the western world doesn't have an affordability problem because of less bean counters scamming patients.
Feels like their job is mostly to enrich the corporations profiteering from these inefficiencies, they're doing admin fighting the sick and dying who also gained the job of admin of fighting them (a job thrown at them to - in a lot of cases - literally save their lives, financially and physically).
And, there’s also a lot of people who actually believe we have a superior system because M’urica and Europe is communist or something
-----
It's a n-tuple-whammy. Co-pays and deductibles discourage early diagnoses by preventing most people from visiting doctors for issues that aren't serious. The painful process of claiming the small amounts that would cover preventive care discourage people from getting it even if they've seen a doctor and been told to. Preventable conditions balloon into things that are very expensive and unpleasant. This process takes years though, and there are many, many insurance companies, plus people change jobs and coverage frequently. Odds are, the company denying preventive care won't be on the hook for the heavy costs down the road. If they are, they have ways to wriggle out of it. Also, with more people waiting until conditions get bad before seeking treatment, the whole system consumes more resources to keep people less healthy, on average, than if the system pushed preventive care effectively.
When governments assume responsibility for medical coverage, incentives start to be much less perverse. You pay taxes while you work. You work while you're healthy. So, the government wants you healthy. The government wants to do that as cheaply as possible, so they're incentivized, not just to provide preventive care, but to make sure you take advantage of it. I live in Canada. I have a genetic condition that could cause me problems if I don't get preventive care. One of my relations had those problems, so they tested her and found the problem gene. The government then tasked a genetic counsellor to seek out everyone related to her. I had the gene, so they now book me for the care I need to manage it. I don't have to pay for this. I don't have to fight insurance companies to prove I need preventive care. I just do what they ask me to do and I get to live longer. This is the kind of stuff that happens when the incentives are right.
Insurance companies need to be cut out of the loop entirely. They know they're what's wrong, so they employ expensive lobbyists. Americans need to realize this and start making it an election issue.
_______
EDIT: TIL that preventative and preventive are used interchangeably in the context of medicine, so I changed my very inconsistent use of them to just one.
Most of the things that are predictable and lead to long-term bad outcomes are behavioral (i.e. diet and exercise; smoking cessation; quitting drugs), and therefore both largely unaffected by medical care, and heavily confounded with socioeconomic status. Your doctor cannot make you eat better and exercise and quit smoking.
In the developed world, if you don’t die at birth or succumb to diseases of lifestyle (diabetes, heart disease, addiction) or accidents, you basically then die of cancer. The lifestyle diseases cannot be prevented by a doctor, and we have essentially no ability to prevent cancer. It’s all just acute treatment.
North Americans in particular hate to hear this, because they have an almost religious faith in doctors based on decades of bad TV. Honestly, though, doctors are pretty impotent when it comes to prevention of illness, and it is ironically this desire for treatment that is helping to balloon costs.
You've also included vaccines (which I explicitly mentioned) and "taxes" (which are not medical interventions), so you've completely missed the point.
[1] The NordICC trial found an impact of 0.03% on risk of death from colorectal cancer, which was insignificant. It did find an 18% risk reduction for getting colorectal cancer, but this didn't translate into a survival benefit.
I'm one of the 20% with the lipoprotein A gene. Mimics high cholesterol. Diet and exercise still help but that just slows the clogging.
GLP-1 drugs do seem to help people change their diet (or at least intake), even in this environment of unhealthy, hyperpalatable foods that we have created.
And the PE firms getting in to healthcare delivery space will take up that fight too, so they can keep more of what they make.
As individual, you buy basic insurance costing roughly $500/month with a $2500 yearly deductible (LAMal/KVG). Applicants must be accepted even with pre-existing conditions. Post-deductible, you pay 10% co-insurance capped at roughly $800/year (no medical bankruptcy). Insurers operate basic plans as non-profit. They make their profit on optional supplemental insurance (private hospital rooms, extra benefits...) The state subsidizes basic premiums for low-income individuals. A doctor's visit is a $150 minimum, similar to the US.
What was most surprising compared to here in the US is employers pay $0 toward premiums. Funding is entirely decoupled from employment. You don't lose coverage or change plans when changing jobs.
On the negative, basic insurance does not have dental, so dental stuff is out-of-pocket and expensive.
In terms of stats, the US spends 18% of GDP on healthcare vs. 12% for Switzerland and the gain is lower stress too. Not perfect but maybe the best of both worlds.
I’ll be lucky if I get a specialist for under 500 until I meet deductible of 3k+ for a family of 3. One emergency room visit and we reach it in one or two days.
[1]: If you have the CHF2500/year deductible, premiums are cheaper but you have to pay that amount out of picket before the insurance company reimburses your expenses
It's $20 to go to the doctor on similar priced insurance in the US.
Your $500/month is just a tax for healthcare. Your only advantage over the US is that it's not tied to employment. Ours is both a tax and a cudgel to force people to work.
We have the worst of all worlds because ours is a tax and a cudgel, but then we also have to pay tax to the state to fund the healthcare for others who can't or won't work. I wouldn't call yours the best of both worlds. It sounds like you're getting fleeced to a lesser extent, but still not great.
Same in Germany: private kids' insurance costs a fraction of the one for adults. Apparently it's very unlikely that they require expensive healthcare.
There are "problems" but overall it has had a net benefit with poor people who could not afford medical treatment just get it. If you are having an emergency, they just do whatever is needed and you are golden. I know hundreds of people in my neighbourhood who have had surgeries done on "card" and most could not otherwise afford it.
I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
I'm not saying that this is what is happening now, but I am saying that calls for universal health coverage, no matter how correct and well supported, are going to probably face the same obstacles they did last time, so we need new coalitions and implementation proposals if we're going to give it a go again. It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to.
The problem with US healthcare isn't who pays for it, its how damn expensive it is. As always there are multiple factors at play, my list would include corruption, lack of legal accountability/responsibility, and a population that is much less healthy than reasonable.
Go after any one of those and we'd make a lot more headway than trying to ram through a universal, government-run healthcare or insurance program. And yes, such a program could impact the above topics, but it doesn't have to and could make any of them worse.
Given that people constantly, literally AVOID care because they can’t pay for it until it’s such an absurd problem that it’s very, very expensive, I struggle to believe this, at all.
And money amount doesn’t matter in this evidence because, again, Americans regularly avoid care until it’s catastrophic because they literally can’t afford it and/or have to wait for insurance to meet a certain harm level threshold where it literally can no longer be argued (emergency care)
I think there are other reasons, e.g. they don't like doctors, or it's too inconvenient, or waiting times are too long. I have good insurance and haven't seen a doctor in probably 20 years.
I know people who are visiting the doctor for every sore throat, ache and pain or sneeze and sniffle, and that's not me at all.
> The survey showed that over nine in ten (92%) of insured respondents had delayed or avoided medical care because of concern about cost.
> In fact, 95% of those surveyed said a medical emergency would likely put them into serious debt even with insurance.
People get so hung up on the idea that they should have to pay for health care, when you have to pay for every other necessity in life.
The medical emergency debt statistic is just the usual thing of people not really understanding how medical insurance works.
A lot of medical care involves inelastic demand because your options are 1) pay this or 2) suffer and/or die.
"The market" does not function correctly with inelastic demand curves.
Yet another reason to socialize healthcare.
Then there's the people who bemoan "paying for someone else's healthcare" while completely ignoring that's what they're doing in the current system anyway.
Until public healthcare advocates understand this and make actual attempts to convince the majority of people who are satisfied with the current system that there are benefits, the status quo will remain.
I find it hard to believe that people who would like to seek care but are unable to do so because of limits on their existing coverage would say that they are satisfied with their medical insurance.
So we fail both ways at the same time: We avoid interacting with the medical system, but when we do, far more is done, at far higher price per intervention, so we end up with more interventions for the same outcome, even though we avoid doctors more!
Saving $1,000,000,000,000/yr is directly addressing how damn expensive it is.
Obamacare made wild claims about cost savings as well. That didn't work out for many reasons that could show up again with another universal healthcare push.
2. If you think this modeling is inaccurate or incomplete you can directly discuss that. That would be a much more interesting discussion than "it might be incorrect."
My hunch is that (a) this study over estimates on the cost reduction side and would not pan out, and (b) improving health should always be a better cost savings than reducing corporate overhead (especially given how piss poor our average health is today).
Cost of healthcare for individuals is not a good metric to judge by. The ecosystem of hospitals, patients, doctors, insurers, health systems, and the federal government is complex and you're not going to get a clear picture of the overall impact of the ACA by looking as something as simple as cost savings.
One example, hospitals are required to treat patients whether or not they hold insurance. The hospital foots the bill for that care and it's a major reason why hospitals shut down (especially in underserved communities). Getting more people on insurance plans was a direct factor is keeping many struggling hospitals and health systems afloat.
https://www.statnews.com/2019/03/22/affordable-care-act-cont...
https://www.networkforphl.org/news-insights/the-affordable-c...
https://www.cbpp.org/research/health/chart-book-accomplishme...
We will never know how costs would have changed if we didn't implement the ACA, and cost is not the only metric of success. But it clearly hasn't led us to a place where people feel okay with what the industry costs.
Also necessary to remember the ACA was only passed because of Democratic support in 2010. Republicans hacked away at the proposal before it became law, kneecapping any real institutional changes it had contained, and have effectively killed it since becoming the majority in the House and Senate in 2024. That bipartisan support piece is required in order for anything meaningful to happen.
At a minimum since we don't know what prices would be today without the ACA, prices have risen dramatically in recent years to a point that I think most agree its unaffordable.
- hospital reimbursement drops to medicare rates ($296 billion)
- pharma prices decline 51% ($378 billion)
- administrative overhead way down ($286 billion)
- fraudulent billing way down ($286 billion)
- people stop going to the ER and stop being hospitalized as frequently, so the expanded use of services only costs $198 billion
Those seem like extremely optimistic assumptions, and the paper gives 0 consideration to most knock-on effects. For instance I don't think it's reasonable to cut hospital funding by $296 billion, increase the access to these hospitals, and assume everything will work out just fine. They at least acknowledge not acknowledging this, but that one factor alone already is likely to dramatically reshape things. And there are many others.
You could have universal health with zero additional spending by the US government, but all that administrative overhead is someone’s income.
There’s multiple healthcare systems around the world, single payer results in vastly less administrative and thus overall spending and equal or better outcomes overall. So by objective criteria the average person massively benefits from single payer healthcare.
The problem is you either need to regular or nationalise. And neither of those are particularly “American”.
Regardless of "insurance", who is ultimately paying, or subsidies to provide a baseline of care - there needs to be reform that mandates simple up-front prices, constant per-provider regardless who is paying, and ruling out any other theory of billing. Doctors throw up their hands and act like they're dealing with some special problems, but there are plenty of other industries we can look at for the dynamics of how to handle routine procedures versus emergencies (and knowns vs unknowns) in a consensual and market-responsive manner.
https://www.cms.gov/priorities/key-initiatives/burden-reduct...
The good news is that CMS is working on an update to those standards which will at least make prospective claims technically possible. Although it may take years until that functionality is widely implemented.
(And "might take years" lol. How about eliminate whatever flagrant regulatory capture is allowing providers to create and enforce post-facto and downright fraudulent bills in the first place, and watch the system reform itself overnight)
If you have specific suggestions for fixing the regulatory capture problem then you can submit a petition for rule making under the Administrative Procedures Act.
https://www.govinfo.gov/content/pkg/USCODE-2011-title5/html/...
I don't know the specific legal details that allow doctors to make up these post-facto bills (often fraudulent) and send them to patients, but I feel it's probably at the state level rather than federal. Also the big problem with regulatory capture is that businesses paying off politicians makes that kind of citizen feedback meaningless.
[0] in fact I think another good angle of reform would be "if a patient has a health plan, providers are prohibited from billing the patient directly". Any copays, outstanding balances, etc should flow through the health plan.
https://www.cms.gov/medical-bill-rights/help/guides/good-fai...
https://www.cms.gov/priorities/healthplan-price-transparency...
Also the ambiguous place between the two cases - "you have a health plan but we didn't do the work to actually bill it" - is a common source of the fraudulent shakedown bills, and this does nothing to constrain those types of fraudulent bills!
In general, I don't need to request a "Good Faith Estimate" from a grocery store about my upcoming food purchase for when I go later in the week, nor for an oil change down at the mechanic. If I go to the mechanic with "something is making a noise", then they are upfront about any fixed diagnosis fee, and then give estimates routinely in terms of a shop rate and book hours. If there are still unknowns about what might need to be fixed/replaced, they are up front about that and readily communicate with the customer. All of this is straight up missing in the medical industry, even when you try to engage. Rather they shove "consent" forms at you that say nonsensical anti-contractual things like "we can bill you whatever we want and you're responsible" and when you start pushing back on them they look at you like you have three heads.
(and just to head off the inevitable drive by comments like "It's not practical to shop around while you're in an ambulance" - the vast majority of medical care is scheduled ahead of time rather than on an urgent basis)
Doctors can't say how much an insurance provider will cover or what a patient's out of pocket will therefore be, but that is a separate issue further downstream of clear pricing for treatment.
Today's model is great for the insurance company, it should be great for the patient. If one wants to offer an insurance product they should be considering average cost of care based on whatever factors their actuaries come up withz they shouldn't be demanding say into pricing so they can protect their bottom line.
You see the same problem in IT with hardware startups vs purely software ones. The moment you need to own something more than 1s and 0s, the risk grows exponentially.
Reducing regulation doesn’t solve that problem.
And that’s without even considering all the shady tactics that the incumbents can do to drive new ventures out of business.
And also how much is required. I bet a study investigating how much money and lives could be saved by reducing obesity would have 2x numbers
Similarly we could look into the likely cost of over medicating our people, and the atrocities we call food in grocery stores.
It does this by eliminating a very inefficient layer of our current system (insurance companies), and by having there replacement for that (the government) negotiate on drug prices (how much savings there is the reason there are two estimates). Currently insurance companies almost have a negative incentive to push down drug prices (their profits are limited to a percentage of total spending, and most large companies are pushing against that limit).
Most of the cost control pressures in our current system come out of Medicare/Medicade, and this would widen that out to the whole system. That in turn would wedge open the door to pushing on the other drivers of the cost spirals: hospital administration, new expensive drugs that are not worth the additional costs, doctor salaries ballooning, and the broken system between malpractice insurance and dysfunctional enforcement against malpractice.
I'd argue that the primary issue with insurance costs today is the lack of market competition, obscurity of what costs and prices are, and government protections that prevent insurance companies from being legally liable for many of the problems they cause.
Corruption and monopolistic practices is a big deal in healthcare, for example. We'd be better off, in my opinion, by solving that rather than killing an entire private industry and hoping our government can continue to do it better indefinitely.
I don't see why you'd need to do that. Just expand medicare to everyone and if people want to also buy private insurance they can.
They'd just need to be more competitive and add significant value, which they don't currently do.
Actually I thought that was already the case.
https://www.cms.gov/medicare/enrollment-renewal/providers-su...
Every other developed country has managed it so why don't you look to see how they achieved it?
Wouldn't you like to never worry about healthcare costs again?
For prices to be sane we need people being able to compare prices, decide what care they want and can afford, etc. Our prices are so high because its a closed market acting as though it were a free/open market being driven in part by customer decisions.
You can and I do solve that annoyance with an HMO, where the doctors and insurance can communicate more effectively because they’re part of the same organization. But that also means it’s difficult or impossible for me to get the kind of care that a normal insurance company would hesitate to approve.
Its possible for a provider to know ahead of time that providing a saline IV costs $60, for example. Its also possible to have health care policies that approve any treatment deemed necessary at any healthcare provider, or at any healthcare provider in network if that concept was still a thing.
We don't have to have a preauthorisation step where doctors are expected to ask insurance companies if they will approve a certain treatment for a certain patient before it can be done. That is a particularly terrible implementation if you ask me.
My favorite was a friend who had to deliver her baby, alone, in a hallway, because they forgot about her. And the hospital billed her for it. LOL.
Exactly! There's so much paperwork that a doctor sometimes need two assistants just for the paper work. There's so much cost for independent practice that increasingly more doctors end up joining big hospitals. Charges with and without insurance have a huge difference. Just to name a few.
https://nationalhealthspending.org/
I haven't finished reading the paper and have no opinions on it (other than that most successful universal systems aren't single-payer) but if we start from actual numbers the discussion will be better.
I think once universal health coverage is established, it amounts to political suicide to try to take it away again.
Heck, we still have SNAP, even though it's almost universally hated by republicans.
These are the same ones who currently would be able to repeal the ACA tomorrow if they felt like it. You're essentially asserting that the reason they aren't is that they like the policy, and I don't think it's crazy to expect more justification for a claim like that if you want people to find it compelling.
Essentially, all solutions require addressing the slow-burn civil war, which is today capable of of subsuming any issue. Not a single policy issue can realistically be addressed while the rabid 800lb gorilla is in the room. That gorilla is not Trump, that gorilla is Heritage, Fox News, Koch, et al.
Additionally, as somebody who was around pre-ACA, I can not tell you how much better, in every single way, the post-ACA healthcare world is. Pre-existing conditions? Access to healthcare as an individual? These are life-changing possibilities, especially for entrepreneurs.
There's a very clear type of fallacy you are engaging in here that only works in politics: you're taking a vague general idea X, ignoring all particulars, and then lumping an idea Y together as if they identical and that any change in that general direction of Y could ever be different than what happened with X. There's no intellectual rigor or honesty in that sort of thinking, yet it somehow pops up throughout all of politics.
It was the Medicaid expansion that has been cited as saving lives [0]. An expansion that has almost nothing to do with the rest of the ACA.
> "There's a very clear type of fallacy you are engaging ... There's no intellectual rigor or honesty in that sort of thinking"
So you're claiming that the person who posted that is not only falling into a fallacy, but they are neither intellectually rigorous or honest? I think you're reading a lot into their comment which seemed pretty benign, but possibly contrary to your viewpoint?
[0] https://news.uchicago.edu/story/new-research-shows-medicaid-...
That's a very strange assertion, it's literally "the ACA medicaid expansion" and was a key part of the whole thing.
I'm saying most political argumentation is dishonest and not intellectually rigorous, and that's what the comment was doing. It wasn't arguing based on facts or data or actual specifics, but rather according to vague political ideologies.
That's one reason that I believe politics are discouraged on HN. It turns off our brains and we start using less interesting or useful ways of thinking.
Medicaid expansion was a big part of the ACA.
> "Their findings show that Medicaid expansions led to a 12% increase in enrollment and significantly reduced mortality—not just among older adults, but also younger ones, who accounted for nearly half of the life-years saved."
Huh? Did you read it? My point was that we could have just expanded Medicaid to achieve this.
Laws need votes.
If we are going to be unbound by reality then we could "just" put a medbed to cure all diseases, reverse ageing, and regrow limbs using quantum space-age tech in everyone's home.
The major GOP complaint about the entire thing was that it was the federal government forcing people to buy a product from companies. The Supreme Court ruled that it had that power.
If they are down for it, I can make a call and it would be a near unanimous vote.
Republicans fought hard to discredit their own plan. They just wanted to move to the right of whatever it was that the black man championed.
How are we paying for that? Debt.
On top of that, the ACA provides $100 billion a year to subsidize the healthcare markets.
Medicaid expansion saved lives. That is true and not in dispute. Other lives were saved too. It wasn’t just poor people who obtained life saving care from ACA. In an alternate world where only Medicaid expansion occurred fewer lives would have been saved than were saved with ACA as it exists now.
Well see, first you narrowly define the ACA to be "everything that didn't help"...
First, it involves twisting correlation and causation into an Escher knot. Secondly, it's not even what cited source says.
Yes, "reduced mortality along a timeline for a certain demographic" is a good and desirable statistic, but there is no way that it translates into the self-aggrandizing and sensationalistic "ACA/Medicaid saved tons of lives" (whatever "tons" is supposed to mean, in terms of lives. Perhaps grossly obese people died less.)
Edit: I will never understand why people think ACA was so great. It was a bad policy because they couldn’t get it through whole. They passed it with all the compromises that made it DOA. You can’t fix something when you are still in denial about it being bad. ACA is not a transition to universal healthcare when you allowed massive consolidation in the space with some of the biggest companies in this country. Good luck deconstructing that mess.
I would never have healthcare without it due to pre existing conditions from childhood. I literally was going to be locked out of healthcare barring becoming wealthy enough to afford everything out of pocket until it passed. And that’s really wealthy not just software engineer money. I know a lot of doctors are offering routine services for cash at a discount in increasing amounts but if you need anything with a hospital or a specialist it’s a nightmare to even find out the price before agreeing to the service.
I agree that "To no avail" could be read as "was worthless" to an adversarial reader, but trust me when I say it was meant as "which didn't save it from being opposed and stripped over time". As in "the studies and facts don't move the politics"
It should be obvious the messaging is oppositional along party lines. Every chip away at ACA makes it a worse program, and is celebrated by half the electorate. This is a core problem with the legislation. A second iteration on top, or in place, would have to learn from this and work to make the program stickier.
The failures and politicization of the ACA have caused us to be a little too dismissive of its successes and popularity.
Protections for pre-existing conditions and allowing children to stay on family plans until 26 in particular have made an incredible difference in a lot of people's lives and are wildly popular. So much so that it would be close to political suicide to try to remove them as evidence by Republicans controlling all three branches of government including both chambers of Congress and there is no serious talk of repealing them.
There is belief among a lot of its supporters that universal healthcare would have a similar wave of support if enacted and that the opposition is mostly irrational political arguments rather than people's true feelings about an actual policy. This is why the "ACA" polls higher than "Obamacare" despite those being two terms for the same legislation.
The details matter. If you're a single person living alone at an income of $70,000.00, you're below the median household income and "picking up" other people's subsidies, but that's not indicative of the country.
[1] https://www.healthcare.gov/lower-costs/
[2] https://www2.census.gov/programs-surveys/demo/tables/p60/286...
And for the record, it was not as high a deductible as most “silver” plans on the exchange currently.
Why do you believe that the ACA would have wanted such plans cancelled? There's a very straightforward public health reason that's reminiscent of why states require drivers to have car insurance.
> And for the record, it was not as high a deductible as most “silver” plans on the exchange currently.
The plan would have been in effective over 18 years ago. Does your internet plan look the same now as it did 18 years ago? Your cell phone plan?
This is such an important point. There's been ~40% of cumulative inflation over that period.
Also, anyone who was already buying insurance for years before the ACA knew the price has always gone up every year, often by double-digit percentages. Simple compounding plus the fact that insurance is always more expensive for people 18 years older are confusing a lot of people in this discussion.
My point about the current plans is that if you want to call them a “scam” because they are high deductible, you have to call almost all current plans scams.
My afib ER trip three years ago cost me $7k out of pocket even though I left the hospital still in afib.
Today in my 50s, my deductible is now $8,500. My partner doesn't have insurance because she's not poor enough or rich enough.
We had an insurance rep come to my work last year who said after ACA they had some people whose premiums went up 900%.
So yeah, ACA is better in your world, but not in mine.
I would really like to just be able to get a true catastrophic policy which would cover unlikely risks such as cancer -- and then go on a cash basis for common meds and treatments. The ACA made this kind of insurance illegal, so my choice is to leave my family uninsured -- or let insurance soak up the money I might have saved for their college education.
Imagine car insurance regulations changing in such a way to force underwriters to blanket-assume everyone has had a couple speeding tickets this year. I understand why we do it. We are ok with speeders paying more for insurance, and not ok with someone born with diabetes forced to pay more for health insurance. But it is the end result in any case.
)which is why as a percentage of GDP, Americans, European costs are remarkably similar, just distributed differently).
This has been one of the opposition points - don't just give a handout to insurance companies without addressing their billing practices
The original ACA did not have consensus for some of the proposals to address the billing practices such as existing and new state healthcare programs having collective bargaining. And yeah I think the original ACA was unworkable, compromise is taught as a good thing to children in this country, but it just means "the wrong answer".
The tweaks now, alongside the original democrat led ACA, alongside the parts that were stripped out I think could have better consensus
does need a rebranding though.
The only thing that will actually lower costs in our society is healthy people. And right now, everyone is unhealthy and not doing preventative measures due to expense.
I would quit my day job and completely focus on my side business if I didn't have to worry about healthcare.
The "well of course" moment took me a day longer than it should have.
https://news.ycombinator.com/item?id=47161587 (expat resources for those potentially interested)
https://relocateme.substack.com (a product of andrewstetsenko here, no affiliation, I just like resources that can help humans achieve their success criteria)
https://healthcareinfusion.org/ (for healthcare workers interested in Canada, likely does not apply to many here, but please share with others who might be seeking a path)
(i see this problem as a vulnerability management and exposure exercise to attempt to solve for, ymmv, no affiliation with any resources recommended)
This is one major reason why most of the world's universal systems make private insurance work, and it doesn't blow up the way ours does. But I don't think employers are any happier about it than you are!
Can we afford it? Doesn't stop trillions of dollars for DoD spending for middle east wars or tax cuts for the wealthy, so that isn't an argument, that's subjective cover for not fixing it, we do lots of things we cannot afford (current sovereign debt outstanding is ~$40T, as of this comment). Can't be done? Almost every other OECD country has solved this in some way. Therefore, as a scholar of systems, the root cause I am left with via Occam's razor is "This is an active choice to not fix this suboptimal system, where the fix would be both more economically efficient and humane, For Reasons while the electorate is lied to or paid lip service."
Employers, who supposedly are unhappy with their healthcare costs, could form a coalition and lobby for legislation and fund PACs to fund candidates who would fix this state by state with universal healthcare systems (Canda's universal healthcare system started in a single province as an experiment, for example). Why don't they? Are the costs not high enough yet? They can't argue they don't have enough power, they already, in many ways, bend the US government to their will. They have the power, they actively choose to not use it to fix this system failure.
https://en.wikipedia.org/wiki/The_purpose_of_a_system_is_wha...
https://usafacts.org/government-spending/
https://usafacts.org/articles/how-much-of-the-federal-budget...
https://www.militarytimes.com/news/pentagon-congress/2025/12...
What an idle comment - where is the AMA on record saying that we should spend more on healthcare? Here's all the work they do to describe our increasing costs:
https://www.ama-assn.org/about/ama-research/policy-research-...
Also, when people invoke the bogeyman of 'AMA' they treat it like the lobbies that tech companies belong to. The AMA is not enriching physicians or hospitals (which have their own lobby!) but generally espouses consensus perspectives among doctors while making money from administering things like a residency program application system.
It's frustrating for someone like you to make this statement which feels quite divorced from any fact when you would not do the same about a security topic.
I have to say: you can go either way on the AMA, I guess, but it's a weird hill to die on, isn't it? They're a trade group, not a public health organization. They exist for the benefit of their members.
> The AMA orchestrated the capping of residency slots through CMS/Medicare,
This has very little to do with the AMA, though it is true that in 1997 the AMA was predicting an oversupply of physicians. CMS funding is the role of Congress and the AMA has supported increases in residency seats since the prediction of oversupply was found incorrect.
If there's a problem with an advisory group suggesting that the US not overspend, then I think we'll not agree on much.
I take their 1997 position as one in good faith; the graduate training component of medicine is very resource-intensive (and honestly dangerous!) so it should not be expanded without good reason.
> Doctors in the US make integer multiples of what they do in Europe in part as a result of this.
Doctors in the US make mulitples of what they do in Europe because we do not have a single-payer. You even say this earlier in the thread!
> They're a trade group, not a public health organization. They exist for the benefit of their members.
I assure you, no physician feels their needs are reflected by the AMA. It's an odd duck that probably made sense in the era of PCPs owning their own firms. The AMA has several structural roles in medical training (they administer application programs, primarily) so they're not going away any time soon, no matter what I may wish.
https://www.hrsa.gov/sites/default/files/hrsa/advisory-commi...
It's weird to hear someone in medicine say this, because it was a big deal at the time and it comes up in many health care economics discussions (it's a commonly stated reason we can't just make more medical schools to create more doctors, and in that way bring the cost of medical education down). And: if you feel that physicians are alienated from the AMA, OK, why are you defending the AMA?
"Single payer" can't be the reason doctors make more here, because they make far less in systems like Germany which aren't single payer. There's a really widespread misconception on the left in the US that "universal care" elsewhere in the world automatically connotes "single payer", but most universal systems aren't single payer.
A quick caution: if you write to me as if I'm a defender of the US system, you're going to miss me consistently, because I am not that. I just think the reflexive position that the answer to our problems is to universalize medicare is bad policy. We could do guaranteed issue, community rating, price transparency, and means-tested subsidy and land essentially where Germany is without essentially ratifying permanently the perverse protectionist premium paid to providers.
Personally, I would retire early. I have enough to cover bills and reasonable HC costs, but the way it is now, I'll just keep plugging away for a few more years.
Any single mom who works as a stripper can go see a doctor who doesn't have the slightest inclination to judge- you're just a number in a government database. Everyone's getting free shit no questions asked.
If there's a benefit to religious charity, it lies not in the "inclination to judge" but in maintaining a multiplicity of authorities. Combining everything under the government umbrella gives you a totalitarian society; a liberal democracy restrains the power of government while allowing for competing authorities in other spheres, like medicine, religion, academia, and the press. Giving the government the power to mandate or withhold medical treatment for political opponents (think Soviet "sluggish schizophrenia" as a diagnosis for removing dissidents from public life) seems more worrying than strippers getting free healthcare.
That the ACA forced a large number of people to pay a lot more for literally the same product is not a good outcome for those people. Too many people try to pretend this didn't happen.
But when we talk about the ACA's impact on cost, we're always talking in a macro sense. Every program has individual winners and losers.
That's because NY had enacted a coverage mandate even before the ACA, so insurance companies were forced to offer policies to everyone. This resulted in a runaway spiral where only sick people were getting insurance.
The ACA forced all large employers to buy insurance, greatly increasing the risk pool.
in the 2000s (pre ACA); * Employer plans averages 6-10% increase per year * Individual plans averages 10-15% increase per year
Rollout (2010-2017) * Employer plans averaged 3-5% increase per year * Individual plans averages 0-10% the first couple of years, but spiked hard to 25%+ from 2016-2018.. with lots of volatility (one stat I found shows 130% increase between 2013-2019)
Post (2018 to today) * Employer Plans averages 4-6% increase per year * Individual plans were generally stable but with huge volatility; also expansion of gov't subsidies absorbed much of the increases for those earning up to 400% of fed poverty level
The ACA has killed a whole lot more lives than it has saved by causing healthcare costs to spiral up.
If you begin with something that is obviously incorrect and trivially debunkable, perhaps that's indication that you should review your priors.
All of the providers have consolidated. I don’t know if ACA affected that or not, but wait times for checkups went from later this afternoon to sometime 6 months from now.
Part of my experience is going from corporate health insurance to marketplace, but in the past 5 years, ACA plans have consistently gotten worse and more expensive while service for those plans has gotten significantly worse in almost every way.
Who is it better for?
You are paying more because a lot more healthcare is being delivered, to people who never used to either due to exceeding maximum benefits (we have the opposite today with out of pocket maximum), or being denied for pre existing health conditions.
So to answer:
>Who is it better for?
My 4 year old, who has received hundreds of thousands of dollars of cancer treatment, and will need a bunch more over the coming years.
Then turn it into a tax and be done with it. I don't shop for my tax collector and I don't pay taxes to companies with the biggest buildings in the city. Companies that don't actually provide health care, but just collect their pound of flesh from patients and providers, driving up costs for everyone.
I'm glad your child has received care. I'm very much behind the idea that pre-existing conditions should not preclude anything from receiving _care_. I'm completely opposed to mandating a private 3ᴿᴰ party be between me and my provider.
Democrats tried, they did not get 60 votes in the Senate between Jan 2009 and Jun 2009. What we have is because at least 41 other legislators, including all Republicans, decided not to offer the US public this option, and since then Democrats have had nowhere near the numbers to enact any further reaching legislation, except the No Surprises Act in 2021.
https://en.wikipedia.org/wiki/Public_health_insurance_option
There is a legitimate shortage of physicians in many areas, especially in primary care. This has a variety of causes including bottlenecks in the training pipeline, shitty working conditions that drive experienced doctors out of the profession, and an aging populace that has drastically increased demand. More and more doctors are opting out of taking any sort of insurance and shifting to concierge medicine or cash-pay models.
People with pre-existing conditions. They were literally uninsurable before the ACA.
The insurance costs are also skyrocketing in the employer-sponsored insurance.
Not debatable that it has gotten worse over the last decade, mostly due to one party in the government intentionally doing what they can to chip away at the efficacy of the program, which when it launched was incredibly compromise heavy and should have been viewed as a first step towards a better, long term solution.
I had a local primary care I really liked; I never saw the Dr. there, just the Physician's Assistant typically. They were independent, and last year they made the change to go to a membership model. Basically $50/month just to be able to be a patient of their practice, and then use your insurance for care. In their notification she laid out the economics of where they currently were and it wasn't sustainable for them, based on how much they were squeezed, mostly by not being also a facility to be able to double bill insurance for facility fees + care fees. Also mentioned that the other 3 independent doctors in our neighborhood had all closed in the last 2 years.
But the Republicans called the Democrats commies anyway and refused to participate. And that has been their playbook ever since. That is what they are going to do, no matter what we propose.
So we may as well propose actual universal healthcare. But I agree with you that we need to create strong majorities to keep it in place until it reaches the kind of momentum it has in Canada or Sweden and opposition to it becomes a practical impossibility, like opposing social security.
Maybe someday we can have a system where losing health insurance isn't a motivation for not starting a company. Our current system is a complete disaster for entrepreneurial capitalism.
You're not wrong at at least for the forseeable future, single payer does seem untenable politically, but I'd argue that dismissing studies like this on the basis that it needs solved before debating it on its merits is circular, because the only plausible political objection to a policy like this is financial. If you reflexively claim that nothing without broad consensus appeal at a given point in time is worth discussing, you're essentially arguing in favor of freezing our public policy to whatever the current public opinion is today. I don't think you need to go very far back in history to see some pretty striking examples of why that would be undesirable.
I still think this is an important historical detail that seems to go under the radar a lot; if anything, it gives me yet another reason to disdain the filibuster!
There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think. If it gets implemented quickly enough then getting rid of it will be very difficult to do. People won’t give up free at the point of usage healthcare once they try it out.
It's worth keeping in mind that Eisonhower's cabinet argued against the idea of giving the polio vaccine away for free on the basis of it being a "backdoor to socialized medicine". We're over seven decades past the point where it makes sense to give a shit about what anyone says about "socialized medicine".
[0]: edited from "single-payer" to reflect correction to a similar comment I made elsewhere in this thread
In universal everyone has access to every hospital ? Why would someone go to lower level hospital if they can go to northwestern. Now the acess to best hosptials is gated by a queue?
I am not saying this is right but ppl who already have access to northwestern its in their best selfish interst to oppose universal?
i am just countering the point that "ppl opposing it are merely brainwashed by foxnews or are stupid" . Its no different than ppl preventing outsider kids from going to your school.
I mean, yes? Literally the same principle we all learned in kindergarten for how to make access to something fair. You didn't get to skip the line in lunch because your parents had a better job than someone else either.
most of the society doesnt operate in the way that you described.
If your objection is to a system that operates differently than the rest of society, it's not clear why the hypothetical healthcare system is more of a bugbear than the very real one that doesn't resemble pretty much any other way that things get purchased. I don't really understand how you think spending time arguing against something that has very little chance of happening based on principles that ostensibly conflict with the actual version that genuinely does exist is a sign that people are not being misled by those with incentives to distract them in that way or otherwise are struggling to reason about an issue logically.
> I am not saying this is right
in my original comment.
If a child cannot pay, there are some districts that serve cheaper alternative meals that don't meet the normal lunch standards, some that shame children by giving them hand stamps, and even some that will literally dump their tray in the trash.
Can you explain why those people DESERVE access to better care? Do they have more complex/rare diseases that require specialized treatment? Are there specialists who only work at that hospital? Those feel like warranted needs. But "I can pay more so I should have better things" is a ruinous worldview that, at its end, is just Might Makes Right.
i dont get why ppl responding to me think i do when i already said this
> I am not saying this is right
i am merely saying that the angle i described should be considered because a big portion of population thinks along those lines ( my guess)
Describes everything the GOP offers as “solutions.” Theirs tend to strip rights while Democrats tend to provide rights.
We’re still waiting on the GOP’s “concepts of a plan” for healthcare promised on the last campaign trail.
So you'll never vote GOP again. And you tacitly agree with Trump's repeated claim that conservatives will stay in the minority unless they _reform_ election rules -- https://www.theguardian.com/us-news/2020/mar/30/trump-republ.... Vote suppression and the "perpetual majority control of legislative, executive, and judicial branches," is Republican stated aim since the late 60s/early 70s when their party began its creep into permanent minority status
> It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to
What does this even mean? ACA was based on a GOP-governor-in-a-blue-state's successful implementation of HCR. Everyone loved it until Obama loved it, then the highly organized GOP minority hated it, fight it, wasted ~20 years claiming insanely to have a better solution they knew they never had nor will have
Back when Nancy's daughter Alexandra Pelosi used to make mini-doc shorts for the intolerable Bill Maher she made one about southern white Americans' opposition to ACA. She interviewed one fellow -- perpetually unemployed, alcohol/drug/legal problems etc -- who came well out of his chest against Democrats, socialism, The Gubmint and all the other typical lefty stuff that Fox News mentors him and so many others on. Then we find out he's on welfare. Then we find out he's on Medicare/medicaid. Pelosi's like "What?? Wait a minute ... I thought you didn't like this government stuff. Why're you all over it" and mans goes "WELL I DESERVE IT!!!"
Let's just call anti-UHC arguments what they are: wet bullshit from private healthcare industry stakeholders and the uninformed partisans who repeat Trumpist mantras
You mean like overturning Roe v. Wade? Can't ever happen, right?
ACA was also predicated on broad participation. As with all insurance, the bigger the pool, the lower the premium. Insurance of any kind is primarily a risk arbitrage business and fundamentally relies on the presence of low risk consumers. ACA was designed with this in mind and made participation in the insurance pool mandatory(whether via the public marketplace, or via private).
Unfortunately for the ACA, the individual mandate was removed in 2017 via Trump's Tax Cuts and Jobs Act, which reduced the penalty to $0, while leaving intact the ban on denials based on preexisting conditions(on it's own a good thing). The elimination of the federal tax penalty caused health insurance premiums on the ACA individual marketplace to increase by an estimated 10% annually, as younger and healthier individuals dropped coverage and left behind a sicker, more expensive risk pool.
So, while it's fair to criticize the ACA, you simply can't expect a law to work if it's intentionally altered to engineer the worst case scenario specifically.
Here's the overall timeline
* March 23, 2010: President Barack Obama signs the ACA into law, establishing the individual mandate and its future financial penalties.
* June 28, 2012: The Supreme Court upholds the individual mandate's financial penalty, ruling it a valid exercise of Congress’s taxing power.
December 22, 2017: The TCJA sets the individual mandate penalty to $0. Lawmakers attached the repeal to a major federal tax overhaul package and used the budget reconciliation process that allowed the Senate to pass the measure with a simple majority vote, avoiding a filibuster.
January 1, 2019: The tax penalty officially drops to $0 nationwide, effectively eliminating the financial pressure to participate.
I suspect Social Security would have met that definition at one point in time. Perhaps even paid overtime, the 40-hour work-week, etc.
At this point it says more about the state of our democracy than it does about any proposed solution. Even policies widely supported by the American public these days are met with obstructionists who care less about the welfare of the country than they do about scoring and blocking political "points".
It was a great success for people in my boat(no pun intended)
1. It detaches health insurance from the employment market. This means those minimum wage walmart jobs just became more feasible, or any low end job really, since their is no pressure to provide "benefits" anymore. This would seriously lubricate the labor market, because the friction to providing, taking, and changing a job is reduced.
2. It ends a bias for group plans. If you are poor or are a trades worker and need to buy insurance outside of a group plan, you are going to be in an expensive high risk pool.
3. Its a benefit we can fund socially with taxes that will immediately have a positive impact on lower income workers, as well as poorer regions of the country (e.g. red states).
I think it's easy to shout free healthcare as a slogan but I think the important bit is how it's implemented.
I don't think anyone from any country thinks their healthcare system is perfect or even sufficient. It all kind of stinks although some countries it is easier to solve problems with above average money (but not if you are average). We need to fundamentally figure out how to do more with less, automation (AI) could help out a lot here and I don't care about purists who want hand crafted artisanal advice about how they need to lose weight or they will die of a heart attack. But otherwise, a lot of problems exist just due to bad incentives.
US legislators will never, ever, ever put the needs of the people above the needs of corporations, not as long as corporations can wield their massive wealth as "free speech" in the form of lobbying and political donations.
Sounds nice, though.
“Thankless job” is a crazy way to describe United Healthcare.
No one cares about insurance companies and their profits?? This doesn’t even make sense, so many people rely on insurance and many stakeholders profit off the American insurance system.
I mean, you can do that here. The system just restricts what you can do until you've spent more time commenting.
His annual compensation was over $10 million.
People say they don’t like the ACA. But if you try to revoke its grants, it’s political suicide. Which is why republicans don’t even try.
Bring back denying insurance for pre-existing conditions? Lower the age for parent-child plans? Can you even grasp just how wildly unpopular either of those would be? Or what about marketplace plans? Congratulations, you’ve just destroyed every small business and entrepreneur in the country. I’m sure that will go over well.
The ACA is universally loved. Yes, everyone likes it. They won’t say that because they don’t know exactly what it gave them, and they’ve taken it for granted. Many of you would be uninsurable without the ACA.
And that’s why, despite people complaining, the republicans do not dare repeal even parts of the ACA. It’s too popular, whether people know it or not.
I suspect a single payer system would be equivalent. It would be contested hard, but once it’s passed, it’s passed. It would become so unbelievably popular for a majority of the population that suggesting a repeal would immediately end your political career.
That's another lie you've been told and believed.
With Universal Healthcare the government just provides the funding. Medical decisions are made by Doctors.
For example, let's say you're in England and your doctor decides you need Enhertu or proton beam therapy. That decision is meaningless because the NHS won't pay for them.
See my other reply in this thread.
To quote from my other reply:
They don't fund everything. They don't fund anything in particular.
They provide the funding and the medical professionals decide how best to allocate that funding for the best results.
And what makes you think that they fund everything? I support universal healthcare as well (I'm literally Canadian), but I can accept that there are tradeoffs associated with it.
They provide the funding and the medical professionals decide how best to allocate that funding for the best results.
It's a bit different in Canada to my situation in Scotland since there is also the choice of private healthcare here if you want to pay more to skip queues etc.
[0]https://web.archive.org/web/20110925050527/http://www.nice.o...
[1]https://web.archive.org/web/20151225115559/http://www.pancre...
That's exactly my point. How on earth are you still missing this?
We can and should expect a lot out of the people around us and especially the ones who choose civil service.
Our grandparents ended slavery, got votes for women, established a merit-based civil service, fought fascism, passed equal rights legislation, and created the most dynamic large economy in history.
We have problems, too, but we are not powerless to fix them.
It's literally everywhere. So much negativity. Sometimes I wonder how much is enemy action and how much is just depression or some other mental illness.
It's a serious requirement for despots. You don't need a large and supportive group. You don't need 80% of the population expressing support for your acts.
All you need is like 20% of the population absolutely Ride-Or-Die levels of support for you, willing to do violence and hate on your behalf, and everyone else just kind of apathetic, unsure, or oppressed enough to stay down.
Indeed. Even as some of the more mainstream methods to address our current problems become less effective, we should be open to other ways change can come about. Among your list, many of those achievements had their roots in various approaches that didn't involve legislators.
I would still get private insurance for VIP car but it would cost less than what i am paying now.
But I suppose they are the party of big business, not the party of business in general.
It's also well known from leaks that the first Obama administration selected his cabinet using recommendations from Citigroup.
Bill Clinton was a once-a-century skilled politician, but if you translated his policies without his extreme personal charisma to today it’s unlikely he would make it through the Dem primaries.
Main problems are elsewhere: doctors gatekeeping the market, lack of transparency when it comes to pricing, regulation making it impossible to compete for smaller players etc.
Oh hi. That is me.
All they'd have to do is cut a few friends (insurers) loose. They'd still even have the power of the contract to reward theoretically productive elements of the new health system in return for kickbacks, and there'd simply be more money sloshing around within government to take advantage of. They could continue to stomp the planet freely, because Americans don't care about anyone but themselves. The upper-middle class post-Obama "left" would evaporate. Give them free state college and they'd start calling Republicans the real left.
Another reminder that the US government spends more per-capita on health care than every country with universal health care, and then the population pays again.
One of the things usually cited to defend this waste of money is the massive excess army of people working in healthcare administration, half of whom are employed to file paperwork and the other half employed to throw it in the trash. Now that they're all soon to be replaced by AIs which will be able to simultaneously file and delete worthless paperwork at inhuman speeds, we can let go of that garbage excuse.
But in a more sane world the Republican Party would simply acknowledge slavery as being a real debt owed, and stop being racist, without changing anything else. Most black people are socially conservative Christians, and it would instantly become another God-Emperor situation. Democrats haven't won whites since Kennedy; they gave them entirely up for supporting basic civil rights for black people (an own-goal for the Republican Party, started as a single-issue antislavery party) and big business. Without guaranteed black support (the only other choice black people have to Democrats is not to vote, which is quickly increasing its share), the Democrats wouldn't be a viable party at any level. Republicans are not sane, they are short-termists like everyone else.
Picking out the Republicans is unfair, though. Democrats lobbied furiously and entirely dishonestly against single-payer healthcare in 2016 and 2020. They even tried to sell single-payer and its supporters as racist.
They don't give any shits about free market economics or struggling entrepreneurs. They care about protecting their own money.
And it isn't about big business; that's the Democratic Party. It is about hoarding wealth and gaining more.
Cars, clothes, TVs, Labubu dolls. People will use the savings to buy things. In massive quantities.
I would argue the government case is actually much worse because at least the CEO has the feedback mechanism of revenue because the company <> customer relationship is entirely voluntary on both sides. The public vote is supposed to restrain the government in the same way, but in practice it seems to be much less effective in restraining politicians than the customer is at restraining companies.
It was not for a lack of motivation or a lack of cut-throat pursuit, consequences be damned.
1. A number of other developed countries have UHC while also allowing a private system as well - what is unique about the US that other countries' existing approach couldn't work here?
2. Less importantly, in this world where everyone has medicare, but a smaller fraction have private coverage, your argument is that the existing healthcare providers would choose to give up most of their (medicare) patients? If so, why wouldn't providers choose to stop serving medicare patients under the pre-2026 system, where giving up medicare patients would be a far smaller loss than in a world where everyone has medicare?
Mainly, expectations. I understand that UHC in European countries doesn’t cover all the things Americans assume it does.
Japan apparently keeps costs down by not using cutting-edge drugs. That’s not going to happen in the US.
The US Congress just isn’t good at keeping costs down.
> 2. ... why wouldn't providers choose to stop serving medicare patients under the pre-2026 system, where giving up medicare patients would be a far smaller loss than in a world where everyone has medicare?
They absolutely do. Many providers don’t accept Medicare. Very few providers accept Medicaid. The payments just aren’t high enough.
> Many providers don’t accept Medicare. Very few providers accept Medicaid.
1. About the same percent accept Medicare as private insurance (85-90%, while ~70% accept Medicaid - is that "very few"?).
2. "Medicare for all" is one of the primary proposals being discussed.
3. Previous smaller expansions of government healthcare resulted in expanded provider capacity to handle them, not less, but your argument is that we'd see the opposite results from further expansion?
4. And in this new world where everyone had Medicare or similar, your argument is that providers would choose to ignore most patients, where they don't under the existing system where government-sponsored healthcare makes up a significantly smaller portion of the customer base?
5. And your argument is that if the government finds that healthcare providers contract to the point that outcomes remain the worst among every developed country, as they are today, that the government would be unwilling to make any changes (such as reimbursement rates) to address this?
The argument is that the US system has a much lower floor, which leads to the bad health outcomes, but also generates a lot of people who expect and demand more than most universal healthcare systems would give them. An Uber driver with the cheapest marketplace plan he could find would benefit greatly from any universal healthcare system; a guy with really bad ulcerative colitis (https://www.propublica.org/article/unitedhealth-healthcare-i...) would likely not be able to get a prescription for a cocktail of drugs at non-FDA-approved doses costing $2M/year.
I remember when President Obama suggested “maybe you’re better off not getting the surgery but taking the painkiller” ( https://youtu.be/rin4h4cRs6Y ). That seemed to surprise many of the people who wanted a single payer option. He stopped suggesting that kind of cost-cutting that very quickly.
I also remember when a few people received anthrax in the mail. Every news story said that people who had any contact with the letter had received Cipro to avoid developing an infection. After a couple of weeks, the government actually announced that other (cheaper) antibiotics were effective against anthrax, but it was obvious that no company was going to hand their employees something other than Cipro.
Incidentally, my autistic adult son has Medicaid. I don’t think I’ve yet found a doctor who will accept it. Luckily he’s also on my health insurance.
There's this idea that there are no upsides to the American system, only downsides.
1. money to providers
2. overall healthcare consumption
3. bureaucratic redundancy and waste
1 is going to piss off medical providers. 2 is going to piss of the general public. 3 is going to piss off the 20 million healthcare industry workers who are not direct care providers. So pick your poison. This is why it will never pass.
Like I would love to go to law school but I can't afford it. So many possible but inherently unattainable futures. We'll get there.
Universal health coverage may save lives and money but this study doesn't provide actual evidence for it.
So well known you neglected to state or cite them? I'd invite you to do so now.
America: Sounds like communism
Paying 40 dollars for lozenges in the ER is insane.
Right now the system has an opaque pricing structure which makes no sense.
Force hospitals to expose API's with transparent pricing.
Oh yes, and patient/coverage drop rates
Unless you're uninsured (which is a whole separate clusterfuck), the hospitals aren't the ones who decide how much you pay for any service - the insurance companies are. The sticker price that hospitals charge is almost meaningless and is intentionally high because it's used as the starting point for negotiations, which always bring the price down (never up). There isn't any expectation that any insurer is actually going to pay the billed amount as-is.
And I'm talking more specifically about a single entity selling to multiple customers. If two different retailers want to charge two different prices of course that's fine.
Also, if you're looking for treatment after you're sick, that's not health insurance.
Healthy people without concerns aren't looking for treatment, they're visiting their PCP once a year.
https://www.cms.gov/priorities/key-initiatives/hospital-pric...
This is an impossible ask. Truly impossible. The medical care providers have spent the last 50 years or more honing the art of making costs inscrutable. Not really to make it harder for you or I to know the costs, but for the insurance companies to know the cost. 50 years is a long time, that's not just one set of workers who have done this, it's 4-6 career spans now... the first to learn it taught it to their underlings and coworkers, who invented new sophisticated techniques and bureaucracies and taught that to the third career generation, who did the same and so on.
Even if we had universal healthcare, you're not getting rid of that. It's now a culture. A transmissible, everlasting culture.
For any political ask you might come up with, absurd and difficult and even intractable as it might be, this is light years beyond that. God himself couldn't make these prices transparent.
Read The Logic of Collective Action by Mancur Olsen. It wasn't written thinking of healthcare. but anyone looking at the US healthcare system will see that what is going on is stacks upon stacks of collective action beating overall societal efficiency, over and over and over again, in such a way that it's basically in none of the decision makers best interest to actually increase overall efficiency.
My mom's been dealing with an issue with her lungs for the better part of the past year, and trying to get help through any of the intended methods just gets her put on a 2 year wait list. At this point her plan is to pay tens of thousands of dollars out of pocket to see a specialist in America.
The current generation of elderly Canadians now having lived a long life spent most of that life in an entirely different Canada. My generation is going to die on a waitlist.
Gap between Canada and US life expectancy overall: ~3 years in favor of Canada
Gap between Canada and US life expectancy for top 10% economically: ~0
Income is also an assertion not supported by data. For simple procedures such as a knee or hip replacement, many people earning under $80K CAD opt for US treatment.
Likely because Canada has extremely bad waitlists which are continuing to deteriorate. That coupled with a lack of specialist medical options and lesser quality.
In Canada, a woman with breast cancer could be waiting 2 months to even start treatment. In the US, you'll be starting next week.
There's lots of places in America with spare hospital capacity. In those places, locals still cannot get affordable treatment, because our health insurance system is bad.
Meanwhile, plenty of places in the US have the absurdity of our broken healthcare system, and get to wait 4 months to see a doctor after having a stroke, like my mother had.
Or like my ex, who had to wait TWO YEARS for an MRI and neurology appointment, and that took so long that by the time her appointment was coming up, her situation had changed and needed other investigation and that appointment was not really a good fit anymore.
The situation is so mediocre in most of the US, that you have to travel hundreds of miles to see specialists anyway.
Nearly every single person in Maine who needs to see a specialist is waiting months. If you are in northern maine, you will have to wait months and travel to southern maine, or wait a year for a traveling specialist who has to fit a hundred patients into a timetable meant for 20. If you need to see a special specialist, you will be triaged on the same list as the entirety of New England for the one doctor in Boston who can actually do anything for that condition.
The same guild system that keeps US doctor compensation high is also keeping supply low! Someone is going to be waiting to see a doctor! If they weren't, US doctors wouldn't be paid as much!
You should see how long their surgery departments are backed up!
(For those not in the know, out of network means costs to the patient are much higher).
https://www.chiefhealthcareexecutive.com/view/hoping-to-see-...
ZocDoc isn't reflective of availability as a whole. It has a lot of depth in certain areas, like dentistry, dermatology, and primary care, and less in other specialties. Many of the providers are not physicians, they're NPs and PAs. Perfectly qualified for certain kinds of issues but not others.
ZocDoc is also, obviously, working only with the providers who are willing to pay for new patients, such as newer practices trying to build a patient base. An established practice that is booked out for the next two months obviously isn't going to use such a service.
Finally, you're not considering insurance and continuity of care.
So yeah, in an urban area, you can probably find someone to see you sooner than later if they're in network or you can afford to pay, and you're okay with seeing someone you might never see again or with whom there might not be continuity of care.
https://benchmarkcanada.org/Governing_Healthcare-Wait-Times....
The US does far better than the UK and Canada.
Somewhat related: a couple years ago my spouse had cancer, and the doctor could do surgery either 5 days after our insurance was changing companies, or 2 months after that, those were the next two openings. The insurance said that if we proceeded with the surgery, without the new insurance company giving us approval, but they couldn't start approving it until the insurance started, and the pre-approval from the other company didn't give us anything. We finally decided to go ahead with it and take on the risk of ~$70K if it was denied. Which we decided to do rather than my spouse spending a few months worrying. Turned out that was a really good call, because when they did the surgery it turned out that instead of the expected slow growth, it was actually growing extremely fast. That was probably the difference between it being fatal and it being treatable.
The US system is far from smooth.
"Oh, your septum is deviated ~90% on the right. Surgery? No, first you need to go on these nasal sprays for a few months so we can decide they didn't reshape the cartilage in your nose before your insurance will decide whether they want to "allow"[1] surgery."
[1] Insurers will always say, and have won in court, saying "We don't allow or deny anyone any care they need. We are just saying we won't pay for it."
I've flat out been rejected from a specialist because they had no availability at all. I actually tried again and got to be seen, but an appointment is months out, always.
Two months can be a luxury. With my insurance in the US, it usually takes longer for me to see an in-network specialist. For my kid, it has often taken over 6 months.
Of course, none of these were urgent, so it was fine. If it really was urgent as deemed by a medical professional, I likely could get a quicker appointment.
But my friend, who has even worse insurance, developed a condition and was having trouble getting a diagnosis. He got referred to neurology, and none of the in-network specialists had an appointment for over 2 months. His condition made it hard to sleep every night (averaging about an hour of sleep a night). Due to the lack of sleep, he couldn't function at work. Took a leave of absence, got a plane ticket to go to a relative's country, got to see a neurologist the next day, got treatment that day and had his first good night of sleep in a long time.
Lost his job because of it, though. Unsure what his medical insurance situation is while living on welfare...
For a lot of people it very much doesn’t. And the cost is very prohibitive for people getting any care at all when insurance doesn’t cover it, so they end up not getting necessary care and then ending up on disability for life.
A healthy population *makes money for taxes and buying things*, too.
It was a rhetorical question. I'm aware it doesn't.
So you’re free to pay for anything else if you want.
Without data on what proportion of people are denied and what the consequences are, this isn’t a good faith argument.
On the flip side, cases that would get care in Canada are denied in the USA by private insurance. Private options are far outside the means of most people.
https://commons.wikimedia.org/wiki/File:Life_expectancy_vs_h...
While I love the idea of never having to think about health care costs for a variety of reasons, I do like that some services are available to anyone with a wallet and not locked behind government controlled gates.
As I understand Medicaid, it would just be open Medicaid for 100% of the US population regardless of the income, remove Medicare (they are now under Medicaid), leave the private sector as it is. Do you think Medicaid is too slow, too low quality, too terrible in general? Pay for private insurance, but you can still go to Medicare if needed.
First off, all Canadian provinces are different. Here in Quebec, there is a absolutely a private option. Not everyone likes that it exists, but most people seem to like having that option.
Canadians live better for longer on average (for cheaper healthcare overall). Any other metric is just a misguided attempt to justify the US status quo, which has nothing going for it unless you're rich.
I'm originally from Mexico. With what I have paid in tax here over the years I can afford to set up and operate my own small hospital over there, with new equipment, this is not an exaggeration.
"Free" healthcare, as with many other free things, turns out to be the most expensive kind of healthcare. Anyone who thinks otherwise doesn't really know what they're talking about or they're just stupid.
What could work, imo, and since we're all giving opinions here, is private healthcare with a ceiling on profits. Let players take 2x-5x, but not 50x which is what they do now, bring and enforce usury laws into healthcare.
And nothing will come of it. Too many entrenched interests, regulatory capture, and lobbying + political donations.
What is driving the actual cost is the high expenses hospitals have, and the biggest source of that is labour cost, as in any other industry. American healthcare workers, doctors and nurses, earn about 2-3x as much as their peers in the developed world.
One of the biggest benefits of a national healthcare system for consumers is that the government becomes a monopsony buyer of healthcare workers. The British system is half as expensive because the government gets to set the prices for its healthcare workforce and that gets passed on to the patients.
There's no logic in what you're trying to argue. Healthcare providers charge for their service, insurance companies negotiate that cost down, next to risk management that collective bargain power is the reason you buy insurance in the first place. Again if what you're saying is true all you'd need to do is just buy your healthcare from the hospital directly, if you end up in the ER take a look at the bill and tell me how that went
In the UK it's about 20%.
Yet apparently the UK is mostly nationalised under the NHS, while in the US there is huge additional spending on private insurance.
Can somebody from the US explain to me how that's the case and why American's still put up with it?
With the UK spend roughly 80:20 government:private and the US spend about 50:50.
So as percentage of GDP government spend is about the same percentage of GDP but the much bigger private spend in the US what makes the difference.
[0] https://aspe.hhs.gov/reports/comparing-prescription-drugs
Typically health care is massively human capital intensive with like 50% on wages, and only 10% on drugs.
I suspect the blame lies with a broken market and inflated prices costs across the board ( ie the higher drug prices are a symptom of a wider systemic problem ).
It's not the entire reason, but when America pays 2-3x more for the same drug, it can blow out.
Reading the source I attached helps. "In 2022, U.S. prices across all drugs (brands and generics) were nearly 2.78 times as high as prices in the comparison countries. U.S. prices for brand drugs were at least 3.22 times as high as prices in the comparison countries, even after adjustments for estimated U.S. rebates."
I accept that the US pays over the odds for drugs. I don't accept that's the driving force behind overall health care costs - as 2.78x cost for something that's only 10% of overall costs doesn't get you to doubling the overall spend. ( If overall cost is 100 - then a 2.78 increase in 10% of that is = (10 * 2.78) + 90 = 117.8
That's a long way from double the cost - ie 200.
My contention is that the higher drug prices are a symptom, not a cause - and that's important to understand if you want a cure. Simply targeting drug pricing alone is an exercise in whack-a-mole.
The problem with insurance systems in markets that aren't operating properly is that it's actually in the insurance companies interests to increases costs.
Why? Because in the absence of proper competition in the market, insurance companies profits scale with the size of the thing they are insuring against as margins are % based.
So I would argue there is indirect collusions between all the parties involved ( insurance companies, doctors, hospitals, middlemen, pharma etc ) to escalate costs to increase the money flow they are all feeding on.
The idea of free markets driving ruthless competition is fine on paper - however in the real world there are all sorts of reasons why they don't happen in practice - so they have to be actively managed or in some cases acknowledge it's just not the best way - but that's a much longer post.
Maybe extreme but what prevents that entity from becoming the decider regarding who lives and dies?
1) 2 friends had to wait over a year for gallbladder surgery.
2) A friend with autistic child had to wait 2 years for any type of therapy. He couldn't afford the $80k/yr for private care. Ontario has 70,000 autistic children on the waiting list for treatment.
3) Another friend had to wait several years to find a PCP in Ottawa, the capital city of Canada. He has a golf ball sized lump on his head and he can't see anyone without a referral from his PCP but he has none and no one was taking new patients. He put himself on a list to get the first PCP available anywhere in the city. After that he has to wait a year for a consult and who knows when surgery is.
4) Another friend had to wait 9 months to get an MRI for a pain in his neck. After that it was another 4 months to see a neurologist.
You don't pay in money but you pay in time and suffering.
In most of the world it's the policy that cannot be touched, just in Europe, Canada and Australia its _existance_ is invoilable, in the US the _introduction_ seems to be the unwinnable war
The NHS can NOT be meddled with whatsoever.
Complete political suicide.
I can't help but think the picture looks very different now. There is growing awareness that chargemasters can not be secret. LLMs offer a way to overcome the complexity of choosing options, opening doors for real competition. I sincerely hope we can take advantage of this changed landscape to provide better care. Universal health care remains an interesting possible direction, but I now have hope that we can do a lot better within the existing laws.
I support universal health care, but each side just lobs whatever data supports their position at the other without any real thought. Most people in support of a universal health care system seem to be completely unaware that the vast majority of households are happy with their current coverage (whether they should be or not isn't relevant really) and are not looking for someone who claims to know better to "improve their medical care" through a entity (the US federal government) that is generally not known for improving almost any situation it interacts with.
I personally would like to see Medicare opened up to the public as an option. It's simple, doesn't require anything of anyone who doesn't want to participate, and should be a reasonable test for the claims of cost savings. If it's truly a better option, people will move to it. If not, then the conversion will not happen.
Barring some sort of catastrophic financial or medical event, there is a 0% chance that anyone can make a radical change to the status quo.
1) how much cost comes from "friction" like middleman, administrative bloat, shitty digitalization/note sharing, all the time the nurses and doctors have to spend on paperwork... Etc.
2) how much drug development is subsidized by the US patient via higher domestic vs. foreign pricing. Or even how much of the cost total is drugs?
3) how much roughly every added year of life past some marker of "high quality of life" is spent just keeping people alive. And if there's any trends there, cost going up or down total and per person.
4) some basic accounting of where the spend is actually going. A lot of people in this thread are talking about hospital margins. There's much more to health care than that. Labs, hospice, mental health, labs/diagnostics, drugs, r&d, nursing facilities and many things I probably don't even know about.
Basically an equivalent of david mackays "without the hot air" but for health care.
Also if anyone has some good reading on ideas around kind of SEZs for drug/treatment development where people opt in to riskier care. Not quite the same thing but I know for example that lots of medical device development and proving is done in spain to gather evidence for the FDA since the FDA process for devices is legitimately insane.
Oh and if there has been any proposals or even adoption of better health record management, digitization. Especially access to your own health record. Im not a crypto guy but it seems like maybe it could be an application for it?
And then ICU/end of life. Way too many Americans don’t ever talk about what will happen when they die and what they do or don’t want at the end of life. Then they become incapacitated, family pursues all advanced therapies because they don’t know what to do and they spend a long time in the ICU getting things done for an unclear goal
No politician is going to want to deal with the fallout of massive layoffs or millions of people having their coverage changed (e.g. no free chiropractor appointments or GLP-1s for weight loss), especially since the Democrats suffered one of the worst Congressional losses in US history the year the ACA was passed. There are ways to make this transition less painful, but the only people interested in health policy are those who make money from healthcare, so you generally only see solutions that involve throwing money at the problem. We need regular people to develop an understanding of health policy or else we'll end up with a policy that merges the worst parts of a planned economy and capitalism even more than today.
And I do know that you mentioned a real material reason why this isn't pushed harder by either political party despite the nearly inevitable massive savings if we pull it off. Causing an upheaval in the job market by removing a bunch of unnecessary admin work has real short-term impacts that will be hard for any US political party to weather well. That being said, I do think there are very real paths to achieving this and rhetoric about needing to copy-paste big parts from other countries distracts from how achievable it is. 90% of the work is already there with Medicare, and expanding the list of covered drugs and having a price negotiation with hospitals to make Medicare a good customer rather than a burden in some cases is definitely possible with some political will. A public option if it had been included in the ACA would have likely moved us a lot closer to universal coverage, especially if the mandate was still enforced, and likely would have spurred some of these necessary discussions.
When have you ever heard "rhetoric" that actually brings up the details of how universal healthcare would actually implemented in practice? If you have an idea at work and a coworker brings up a caveat that you missed, do you dismiss it as rhetoric? If you are to be worried about rhetoric, it should be about how the general public talks about policy like it's sports whereas corporations talk about policy like it's work.
It would fine if it were just internet comments. However, this article is talking about a paper from one of the most prestigious university in the world and yet it's devoid of meaningful analysis. It literally does the "copy-pasting" that I'm talking about.
> Hospital and clinical fees are paid at Medicare reimbursement rates, which are below the rates paid by commercial insurers and above those paid by Medicaid.
https://www.medrxiv.org/content/10.64898/2026.07.22.26358689...
Doctors see downsides of a universal coverage are mostly about loss of autonomy and increased demand because when care becomes free demand rises along with pressure to expand access without extra staff.
I’m in the hospital right now. My two year old had her tonsils and adenoids out this morning. Regular Dr visit lead to an X-ray on the same day, specialist appointment 3 weeks later, surgery 2 months later (would have been one month, but we pushed it back because timing and life).
Just talking about how my wife is coming off 18 months of maternity leave. Before that she quit and just didn’t work for 3 years because burn out. I’ve been self employed for 10 years earning about $20k a year.
This whole thing cost us exactly nothing. Would be the same if we’d never had jobs.
Mum got stage 4 cancer in another country where she lived. 2.5 years of radiation, chemo, X-rays, mri, and dozens and dozens of specialist appointments (which she got paid for transit and free accommodation in the capital city) not to mention the mountains of serious drugs.
Total cost $0.
Anyone that argues against this is either not very intelligent (easily manipulated by the propaganda) or does not want to help others (“freeloaders”), or is getting rich from the status quo.
A close relative of mine (who is single) also had cancer and had 100% of it paid for.
Transportation costs are also paid for, although we never needed overnight accommodation so far.
My prior experience was in Australia was a youngster under a particularly terrible universal care system in the 1989s, and then in the 2000s when I lived in Canada.
I get a little weary of the refrain about how American healthcare is terrible, esp. for poorer people - it’s actually very good.
A massive percentage of the population don’t have and/or can’t afford healthcare.
By definition, that is not a good system.
We’re checking out of hospital right now after an overnight stay for my 2 year olds surgery.
Never a single piece of paper, and of course no bill. They’re sending us home with the pain meds we need for the next week, plus a stack of yogurt and jello for the little one.
Life is pretty simple when you want it to be.
I know plenty of people who are eligible and simply don’t want to apply.
[1] https://petrieflom.law.harvard.edu/2022/03/15/ama-scope-of-p...
The way that universal health coverage saves money is by rationing care. You do not save lives when you ration care.
> private equity acquisition was associated with a 25.4% increase in hospital-acquired conditions, which was driven by falls and central line–associated bloodstream infections
https://pmc.ncbi.nlm.nih.gov/articles/PMC10751598/
> Medicare beneficiaries in the emergency departments of private equity hospitals experienced seven additional deaths per 10,000 visits after acquisition relative to hospitals that were not acquired by private equity, the team found. This rise represented a 13 percent increase from a baseline of 52 deaths per 10,000 visits
https://hms.harvard.edu/news/deaths-rose-emergency-rooms-aft...
Cuba has one of the highest doctor-to-population ratios in the world—roughly 6 to 8 physicians per 1,000 people: https://www.reddit.com/r/dataisbeautiful/comments/r468au/oc_...
Alas...
The real question is then: since corruption seems to be everywhere, which system is the most resistant to it in terms of the price + quality for the end user.
And the real real question is: what can be done so that every country has a political class that has the same strict rules of law for corruption etc... as Singapore does?
Real lives don't factor into their decisions, even if there are more than enough to fill a large city in this country - every year.
2) I believe the U.S. is willing to go to greater lengths to save people. So they will spend obscene amounts of resources keeping a cancer patient alive for an additional six months, or saving a borderline case of a premature baby, etc.
I'll pass on mandated, outlaw-private-insurance government healthcare, thanks.
The UK has a single payer healthcare system but folks may purchase (or obtain through work) private insurance.
https://ballotpedia.org/Sen._Bernie_Sanders%27_Medicare_for_...
1. This means large new taxes for everyone. For those on lower incomes, they might end up better off. For those on middle-upper+ incomes, they will unequivocally end up paying more.
2. The U.S. already has unbelievably high deficits and debt. This would make that worse without significant spending cuts elsewhere, and without very large new taxes. And before someone says "just tax the rich!", even if every billionaire in the U.S. had all their wealthy confiscated today, it would barely cover U.S. federal spending for *one year.* Then the party's over and the government collapses. "Just tax the rich" is an absurdly superficial position. European taxation is broad and deep. Everyone pays high tax - even those who do not earn much.
3. U.S. society is built on rugged individualism. Acceptance of immigrants under the premise that they will work hard and contribute. For this reason, U.S. success at integrating immigrants is better than anywhere else in the world, by a wide margin. Our issues re immigration in Europe are numerous and unbelievably contentious. Should the U.S. become a "welfare state," like European countries, it would no longer have a natural filter for immigrants. It would realise the type of immigration that we get in Europe, where for many groups, a majority refuse to work - for life. For this reason, it would require a MUCH tougher filter on immigrants - much more so than what the current administration is doing.
I do not see the U.S. materially reducing spending in other areas, including the military. I do not see general public support for large taxation increases across the board. I do not see public consensus on strict new immigration requirements and enforcement. For these reasons and more, I do not think public health care is a realistic prospect for the foreseeable future.
If the US could spend healthcare dollars as efficiently as the UK, the US could pay for a single payer healthcare system covering every resident using only existing Medicare + Medicaid spending.
Is the US willing to reduce the price of healthcare? I observe a large appetite in congress to increase the visibility into US healthcare spend. I observe rather more limited effort spent to use this data to reduce the aggregate costs (e.g. negotiating drug prices [1]).
The math:
The US spends $2 Trillion dollars on Medicare + Medicaid a year [2][3]. $2 Trillion dollars / a population of 342.7 million [4] = ~$5800 per resident per year.
NHS (UK's universal healthcare system) costs ~£3,500 or ~$4800 per person per year [5].
[1] https://www.kff.org/medicare/key-facts-about-medicare-drug-p...
[2] https://www.cms.gov/data-research/statistics-trends-and-repo...
[3] https://www.kff.org/medicaid/medicaid-financing-the-basics/#...
1. Universal health care reduces the total cost of healthcare across the nation. If the bill is $x now, the total cost would be $x-0.2 (or whatever).
2. This is EXTREMELY expensive FOR THE GOVERNMENT. They would need to either raise taxes considerably (broadly and deeply, as in Europe), or deficit spend.
For some people, the increased taxes would be offset by not having to buy health insurance. For some people, they would be spending more.
My point is that we already pay $2 Trillion dollars for existing single payer healthcare (Medicare/Medicaid). I think it's fair to call that extremely expensive.
You say that universal single payer healthcare would have a huge price tag, my point is that we are already paying a huge price tag ($2 Trillion) but just not getting universal single payer healthcare as a result of this spending.
My point is that we could have universal single payer healthcare without raising taxes if it cost less than or equal to ~$5800 per person per year.
UK spends ~$4800 per person per year on their single payer healthcare.
Note: This just considers existing taxes spent on existing single payer healthcare. This doesn't consider other healthcare spending. The majority of the US get's their insurance through employment-based plans. Some pretty reasonable percentage buy their plans directly through the marketplace. And some pretty reasonable percentage don't have health insurance.
The number of politicians that conflate healthcare and health insurance (notwithstanding the actual convergence of the two through payers’ purchasing provider entities) is mind boggling.
Striking the word “healthcare” from the conversation would make this much more digestible for folks afraid of the “socialism boogeyman”…
But the bigger problem is the current system is really profitable for the millionaire and billionaire owners of those companies. They're well connected in Congress. Attempting to change the system is extremely difficult when it means so many rich people might lose their gravy train. These people go to expensive campaign dinners. Even when the ACA came out and the first versions had universal healthcare provisions those were quickly and quietly eliminated.
* Billing and claims management
* Compliance
* Customer service
* Operations
* IT
You can drive billing all the way down to zero and you're still going to be spending a lot of money on administration just like any large enterprise does. Those jobs aren't really "corporate welfare" and they exist in every system, although the single-payer systems get a bit of a break on them because they can and do trade responsiveness off for customer service (at likely little cost to outcomes, to be fair!)
The people providing actual healthcare end up being a minority in the system.
Inappropriate application of capitalism. A market failure of epic proportions.
Do something about it! You live in a democracy, act like it!!
It has to be one of the most bureaucratic and paperwork overloaded systems of all time. It's hard to imagine somebody who've had an actual health crisis would think otherwise, unless they can afford people who can shield them from the BS.
/sarc
"Fewer avoidable emergency department visits and hospitalizations" -- sheer optimism. "Less fraudulent billing" -- no reason to believe this would be true. There could be even more fraudulent billing! Medicare fraud has been a big problem, and solutions are largely reactionary.
Did you notice the gorilla walk by? They sure didn’t.
get rid of medicare etc, then let it be handled on a city / state level. if some states wanna provide for public hospitals clinics - let them do so. even more if cities too wanna provide for public healthcare. then we can gladly reduce taxes too. the amount spent on medicare vs outcomes is already scam level.
trying to solve this at a national level won't work - too many middleman, too much politics and perverse incentives.
This is why almost every wealthy country and most middle income countries and many poor countries have universal health Canada,UK, Australia, almost every European country, Cuba, Costa Rica, Kyrgyzstan, Sri Lanka, and Rwanda.
There are a few minor weird oligarch run kleptocratic exceptions like America, but in the global context they are irrelevant.
Universal health care by country: https://en.wikipedia.org/wiki/Universal_health_care_by_count...
A lot of people do not want it, and you've thus far failed to make them want it.
Taxes here are high. They pay for a lot of things. Is it the best of the best? No. There’s private insurance for that. But does it work? Yup. And it’s just another thing we don’t think or care about while we take all of August off. ;-)
DOGE 2.0 will destroy it overnight
because somehow funding is not exempt from executive manipulation
look at what they did to ACA (and everything else)
all it takes another apathetic Congress and poof it will be gone so billionaires can get a few million off their taxes
there's absolutely no way to harden it against that
Also - given the rate of AI progress, shouldn't we see this cost go to zero essentially.
Just think, if we had universal health care in the US today, the MMR vaccine would not be covered by it!
The USA spends the equivalent of about $10 per citizen per year on Israel. Medicaid spends about $10,000 per recipient per year. But antisemite math has its own rules.
I'm not opposed to a peaceful transition, but we'll need a big surplus and more idealism to make it happen.
Do away with the finance ledger.
Accurately measure where the people are.
Ensure enough resources flow there.
Special interests with a social moat to protect can pound sand or be hung from ports as a warning.
I would like to be free from hallucinated social belief Jeff Bezos is meaningful to humanity when mfer just gonna die and be forgotten like everyone else.
The truth is once systems like this are implemented they change the dynamics of the study and as such could hurting lives.
As a simple example, the biggest cost to the healthcare system in the US is dialysis. Many of those folks already have health issues, and by both dialysis and for all the issues that caused the need for dialysis in the first place is a massive strain. The direct cost of dialysis is $33B annually [1], but indirectly is probably at least another doubling.
Further, the way the government has imposted monopolies in the space already has caused costs to balloon. While making it "universal" could mean the government gets control, and can limit the explosion. It can also could result in weird incentives like Canada, where they're promoting MAID.
That's the only thing that matters in Amerika.
https://www.cato.org/blog/who-will-pay-democratic-socialisms...
Quantify the impact on productivity
With their health expenditure potential liabilities reduced by universal health coverage, people would be more able to take good risks in developing small businesses for example.
This is the harsh reality. No system (private or public) can save all of the lives.
We are debating who will make the decision of who gets to get a chance to live longer.
My country has universal public healthcare, and nobody forces you, or even your children to get vaccinated, monitors what you eat, or any other form of control that you're worried of. Organ donations are voluntary too, you can opt-out easily. And if you think the system sucks, nothing prevents you from taking extra insurance and using whatever private healthcare provider you want.
We are so desperate that someone murdered a Healthcare CEO - ie resorting to violence
We are so desperate that many is (myself included travel to cheaper countries for dental and other healthcare)
Its a simple calculus but one that is obtuse to conservatives and richer people
The attempts by the current republican admin to seize control of certain 'illegal' bodies has caused so so much harm, I'd agree there. But even operating at 10x the nominal level of the past and ICE still haven't been able to exert temporary control over a single American city that resisted them, much less everyone in America.
You should figure out specifically what you are scared of and deal with that, rather than catastrophizing about things that cannot physically happen on any near timeframe.
Because none of the things you said have ANYTHING to do with "universal healthcare" and everything to do with "bad actors worming their way into positions of authority to enrich themselves". Surly you can't believe that "let every induvial person figure it out themselves in an unbalanced capitalist system" is a better answer, right? This isn't just about "if too many people are in the system then MY healthcare quality goes down", right?
reply1: "The alternative is bad, and Trump is evil" reply2: "Uhhh, source for that? /reddit" reply2a: "I bet he subscribes to the wrong politics" reply3: "Americans are idiots" reply4: "I bet you have a personality disorder" reply5: "You're dumb but I'm not going to expound" reply6: "WTF dude" (proceeds to uphold a murderer as an example)
Can no one explain why the ideas the OP fears will not come to fruition? Can anyone explain the safeguards of the UHC system? Or do discussions about policy now all fall under the teamsport known as modern politics?
Is this what hackernews has become? It wasn't like this a decade ago.
We're talking about families that are provably not lazy or sucking up handouts: taxpaying citizens with beautiful, healthy children. The job creators and professionals driving America, securing their future and their children's future.
If the government were to focus on these first-class citizens, who knows what could be accomplished once the drag is taken off the system of the useless eaters and the welfare queens.
Systems thinkers may try to push notions of connectedness in societies, and moralists may try to push notions of universal equality of human dignity, but in the end, both are overwhelmingly outnumbered by tribal thinkers, who wish to harm the outgroup at absolutely any cost.
> Medicare available for free for households making over $100,000 annually
Sure, why not try it? It's still 50% of America getting coverage.
After a few years maybe they'll realize that not having to think about health care insurance is a good thing actually (tm) and start supporting it for lower brackets of the population too.
"Jeffries co-sponsored Medicare for All legislation between 2013 and 2021, but in August 2026, he stated he shifted his stance and stated that he no longer supports or co-sponsors the proposal." https://en.wikipedia.org/wiki/Hakeem_Jeffries#Healthcare
I don't think anyone perceives a flip-flopper as anything except unprincipled. There's nothing "moderate" about corruption.
Also, ~150M people with employer coverage plus seniors on Medicare fear disruption more than they value expansion.
Ergo the reason they didn't support the ACA and won't do this is something other than it covering hormones and abortion.
When a similar bill was voted down years ago, someone I was with laughed and said, 'no way were we paying for healthcare for the Blacks'. It fits the divide and conquer strategy to divide poorer people with hate so that they don't unite and vote for all these things - why do you think leaders promote hate?
The key word here is "currently". When did Democrats ever propose or pass single payer when they were in power?
Moreover, when the leaders of both parties are opposed to single payer, how in the world do you expect it to ever pass? Jeffries wants to be Speaker of the House after the midterms. If he's opposed to single payer, then there's no hope for it.
The majority of Democrats support single payer. That's why I'm pointing the finger at a Democratic leader. I don't expect Republicans to support single payer. What I expect is for Democrats and Republicans to have opposing views, not the same views.
I don't. However, if I were a betting man, I'd bet on the Democratic leadership to come around well before the Republicans. Not least because a significant, non-zero fraction of their politicians are already in favor of it (compared to the other side, which has close to zero).
Without a 60-strong majority in the Senate, which must necessarily include some Republicans, it'll never happen. So ultimately Republicans are the bottleneck.
Jeffries was already around. He supported single payer but now rejects it, so he's moving backward.
> Without a 60-strong majority in the Senate, which must necessarily include some Republicans, it'll never happen.
Democrats had 60 during Obama's first term. They'll always find a rotating villain to oppose it, Joe Lieberman, Joe mansion, etc. Anyway, the filibuster can be eliminated. In 2013 Democrats eliminated the filibuster for most nominations, and in 2017 Republicans eliminated the filibuster for Supreme Court nominations.
So what do you propose? Is there a 3rd party that has a reasonable chance of doing it?
Maybe if you flip a few Republicans (to supporting UHC) it might go easier. It'll give their leadership something to think about at least.
No, I propose calling out Democratic leaders for corruption, removing corrupt leaders from their leadership positions, and running primary challenges against them.
As you said, Republican leaders are calling single payer "Communist". When the Democratic response is, "I no longer support single payer", they're essentially allowing Republicans to win the argument. That's political malpractice.
I would note that the Republican House Majority Leader Eric Cantor lost a primary challenge in 2012, yet as you noted, this hasn't stopped Republicans from taking control of the House and the entire government. "Vote blue no matter who" is not necessarily a winning strategy.
Godspeed.
Why even bother asking me what I propose then? What do you propose?
I can certainly understand pessimism, but if you're going to be a pessimist, asserting that there's nothing we can do, then at least be consistent in your pessimism. Don't pretend that you somehow have a better answer than I do. The only possible "plan" I've seen from you is "wait around for Republicans to support single payer", which IMO is vastly less feasible than challenging corrupt Democratic leaders, since the majority of Democratic voters already do support single payer, while the majority of Republican voters do not. And if the debate is one-sided, "Communist" vs. "I don't support single payer", then voters will never be persuaded to support it. Leaders need to lead, persuade, not just take a current poll. If you don't persuade, the other side certainly will.
> The only possible "plan" I've seen from you is "wait around for Republicans to support single payer"
That and blame Republicans more. Don't let them off the hook and make it "corrupt Democrats" who are solely to blame. The median, disengaged, nominally-independent voter hears that and assumes it means "don't vote D".
I apologize if I assumed incorrectly.
> That and blame Republicans more. Don't let them off the hook and make it "corrupt Democrats" who are solely to blame. The median, disengaged voter hears that and assumes it means "don't vote D".
But how can Democrats possibly blame Republicans for not supporting single payer when the top Democratic leaders don't either? That's the dilemma. What's the "Do vote D" reason? Biden didn't support it. Schumer doesn't support it. Now Jeffries doesn't support it. And Harris flip-flopped too, supporting single payer in 2020 when she ran for President but as the 2024 nominee became a Biden parrot (which obviously did not turn out well). In 2016, Hillary Clinton sent her own daughter out on the campaign trail to fearmonger about Bernie's single payer plan. That's why I point the finger at Democratic leaders. You're correct that Democrats are the only hope for passing single payer, but the leadership of the party is actively hostile and working to prevent it from ever happening.
I'm not sure that the "disengaged" voter would even hear this debate, but in any case, voters seemed attracted to the "drain the swamp" concept, despite the irony that it was proposed by the swamp creature.
Many Democratic politicians are moving away from progressive positions, including Ocasio-Cortez. They seem to be following the old (and failed) Democratic Party tactic of moving to the center to get elected.
Look at his health PAC contributions over time:
https://www.opensecrets.org/profiles/hakeem-jeffries/us_cong...
You need to pay rock bottom wages to doctors to make it work, so guess what all the good doctors leave for private healthcare and you end up with the dregs from the third world.
(Thanks for catching this! I had no idea.)
This is super weird, isn't it? Some of it is obviously overprescription on the US side, but also: Canada could just get more machines.
America is a wild outlier, and unless you have data to back that those machines are put to good use, I'd trust the rest of the world who decided the sweet spot is 15-30 mer million, not 60.
The gap between Canada and the United States is immense. Canada could add quite a large number of machines and not come even within the line of sight of where the US is.