Cheaper, and more terrible. Medicaid is not something anybody wants and in many ways is worse than the ER as a measure of last resort for acquiring care.
Medicare on the other hand is much better, though still not all that great (it's better than private insurance in many if not most cases). It is universal coverage for folks over a certain age in this country. There aren't any good reasons I've seen to not lower that age to 0 (i.e. covered from birth).
> Cheaper, and more terrible. Medicaid is not something anybody wants and in many ways is worse than the ER as a measure of last resort for acquiring care.
So here is what I do not understand. Why does the US not do what many European nations do and split healthcare into two problems? You have a few large insurance pools (single payer for lack of a better term) that is government run, mandatory participation and that covers emergency care and basic health services. And then separately to that you run a free market private healthcare system that sits on top of that governmental system and covers the better care?
It's absurd that insurance companies in the US pay for everything. The cost do not add up for me as a customer. I do want choice in the non life threatening cases but I sure as hell do not want to ever have money concerns when it's really critical.
The problem in the U.S. isn't that costs are hidden--in Canada, with fully socialized insurance, health care consumers are actually much less wasteful of resources because they pursue health care in the degree they feel they need it, irrespective of money. Some are constant complainers craving attention, some are tough-as-nails cowboys who don't need a doctor to pull the bullet out; overall, Canadians are pretty reasonable about their as-needed consumption, as demonstrated by per-capita health care spending.
The problem in the U.S. is that health care costs are directly tied to your employer, mostly, because the employer is the cost-savings insurance pool you join. This creates a lot of terrible situations where people are stuck in jobs they can't afford to leave for medical reasons; or are stuck with medical problems that prevent them from getting hired. What was originally supposed to be a social contract where you work hard to have a good career, and your boss takes care of the ugly bits of life like cancer, has turned into a tight coupling of disjoint life issues that usually creates the worst possible outcome in both cases.
Medicaid is terrible largely because it's legislatively hobbled to prevent it exercising market power (like negotiating bulk pricing for pharmaceuticals, because doing so would embarrass capitalism somehow), and otherwise regulation driven for political purposes, like capping payments for procedures at below market rates, causing them to be excluded from a large number of health care providers who don't need to submit to price controls. The U.S. health care system is like a graduate thesis in perverse incentives.
I'd read that the way healthcare became tied to employment had less to do with some beneficent interpretation of the "social contract" than it did taxes.
That is, when the two were first tied, income tax rates (especially for higher, including "professional", brackets) were much higher. Employer-sponsored insurance was first offered as a tax-free perk companies could use to draw talent. It's easy to see how that could become an expectation, and then a requirement, despite its helping create incentives that are ultimately aligned against the employee/patient.
In 1943, the War Labor Board ruled that wage freezes due to WWII did not apply to fringe benefits, which included health insurance. So you couldn't pay your employees more money, but you could pay their health insurance.
> The problem in the U.S. isn't that costs are hidden--in Canada, with fully socialized insurance, health care consumers are actually much less wasteful of resources because they pursue health care in the degree they feel they need it, irrespective of money.
Which lead to a 6 month delay to get an MRI in BC (which proud itself to be no. 1 province). Not to mention that the public insurance does NOT include dental, or if it does, only the bare minimum. I had to personally pay for a root canal because only a complete extraction was being reimbursed. Moreover, all my cleaning have been out of MY pocket, on top of MSP/RAMQ.
I really don't get why Canadian think their healthcare is so star sprangling awesome... It's not.
> Which lead to a 6 month delay to get an MRI in BC (which proud itself to be no. 1 province). Not to mention that the public insurance does NOT include dental, or if it does, only the bare minimum. I had to personally pay for a root canal because only a complete extraction was being reimbursed. Moreover, all my cleaning have been out of MY pocket, on top of MSP/RAMQ.
But isn't that what makes it great? I have no experience with Canada but Austria is not very different in that regard. My state insurance costs me (purely medical) around 5000 Euro per year independent if I self insure or through my employer. It gives me about what Canada gives you. No copays for employees and there is a 10% or 20% copay for self employed or management.
In addition I pay about 3000 EUR a year extra for private insurance. I did not feel like waiting 2 months for an MRI so I decided to use my private insurance at a private carrier. Paid 500 EUR for that out of my pocket and the private insurance reimbursed everything but the contrast agent. I could also decide not to pay for my private insurance at all but I did the math and the plan I have now seems a pretty good way to spend money for later in life.
It gives me the freedom to chose what I want. The cost for most non covered procedures is laughably cheap here. It seems like a better deal for my money.
>I did not feel like waiting 2 months for an MRI so I decided to use my private insurance at a private carrier.
I wonder what's up with all those MRI shortages in some places? I got my last MRI a couple of years ago in Germany, fully covered by public insurance, had to wait like 2 weeks for my appointment.
Sounds like some places are in dire need of more MRI capacity?
Because Canada's approach to universal coverage is socialized insurance, it controls costs overall with price controls and with funding big ticket medicine carefully. MRIs are very expensive to buy and operate, comparatively, so for elective use (which includes a doctor treating someone with headaches and wants one to rule out a brain tumour), you're on a waiting list that could be six months or longer. For emergency use (like my nephew who fell and hit his head) you get it right away.
>Because Canada's approach to universal coverage is socialized insurance
But so is Germany's? I didn't get that MRI because "I just felt like it", it was due to decade long migraine problems and I had to see a neurologist before getting the MRI.
I still don't understand these massive waiting times in some places, sounds more like a lack of capacity than anything else.
Yes, it's a deliberate lack of capacity for a common form of big ticket medicine, which reduces costs overall. If you have migraines in Canada, you'll likely end up getting an MRI at some point, and you might wait six months to get it (though there are private options, and there are also ways to get in before your appointment like being ready on the cancellation list).
For a lot of things, MRIs are a medical convenience, not a necessity. When they're medically necessary, you get in within hours--my nephew got driven to the hospital with a head injury, and an MRI was the first thing they did. But if it's elective, you go on a waiting list, which might be short, but might be long. This is probably the most complained about aspect of Canadian health care, with some justice, but it's not obvious that eliminating all wait times with sufficient capacity for immediate access would yield better medical outcomes for the extra cost.
> I wonder what's up with all those MRI shortages in some places?
In Austria it's largely because the insurer wants people not to do MRIs unless necessary. So they typically sens you to an doctor first to confirm you need one, the approve from the insurer and then you get to wait a bit.
There are plenty of MRI machines in Austria because the place I got mine also takea publicly insured patients.
This is actually the British system: the NHS covers everything, but you have to deal with their opinion of your need and may have to wait quite a long time.
Quite a lot of higher-paid working people in the UK either buy insurance or get it as an employment benefit, because it can enable you to get back to work quicker if you have a serious accident or illness.
Public healthcare is sadly no silver bullet. In ideal private insurance scenario you pay some amount and get increasing credit for healthcare expenses, so the user is incentivised to chose best cost performing treatment (cheapest option providing adequate treatment) and providers are incentivised to obey free market rules and keep fees under control (sans cartels/antitrust, market segmentation). In publicly funded scenario without coupling between payments and usage, user is incentivised to seek the most "premium" treatment and providers are not incentivised to reduce operational costs.
If the public system covers anything more than emergency care (patch a patient up and let them go) it automatically creeps into all service levels (have a basic cough? maybe that's bacterial pneumonia, better issue referrals for microbiological analysis and a CT scan. /s) if an answer to the question "if family doctor/general practitioner cannot appoint diagnosis and/or treatment and refers patient to a specialist and/or analyses, scans, etc. are those covered too?" is yes.
The payer (government, taxpayers) probably has 3 mechanisms to keep [total] costs from skyrocketing all with their disadvantages:
1. Reduce usage count (doctor visits) - free visit quotas (possibly dependant on service level), fixed or percentage mandatory user fee, etc;
2. Fix service costs - e.g. 100$ for a GP visit from public pool;
3. Auction paid service quotas.
While option 3 provides most incentives to optimise costs, it greatly punishes small players.
> If the public system covers anything more than emergency care (patch a patient up and let them go) it automatically creeps into all service levels (have a basic cough? maybe that's bacterial pneumonia, better issue referrals for microbiological analysis and a CT scan. /s)
No. In the UK, if you go into a GP's office with a cough, you'll be told to go home and rest. In fact, most likely, you'll be denied from making an in-person appointment. This is FUD in its plainest form.
The only place I've ever seen private healthcare provision work about as well as public (Singapore), it was with price controls and a public at-cost option that competed with private options.
The idea that price controls don't work in America is, of course, an article of faith in the free market religion. It wouldn't fly there.
Spiraling costs is a much bigger risk in private "free market" systems, which is largely how America gets to spend 2x more of its GDP on roughly equivalent healthcare outcomes (mortality rates, etc.) to European single payer systems.
> user is incentivised to seek the most "premium" treatment
They can "seek" it, but in the public system you don't really have a route for doing that. You might want a CT scan, but if your doctor doesn't think you need it you're not going to get it.
Your list left off (4) queueing. In the UK public system, if your condition is not urgent you'll have to wait, possibly for months. Unless you have private top-up insurance which will cover the specialist you're waiting for.
(It's difficult to estimate how much money the NHS saves by people on queues for non-urgent operations dying from something unrelated in the meantime - e.g. dying of a heart attack while waiting a year for a hip replacement)
Queues are a result of mentioned instruments. Say a hospital has a CT scanner capable of 10 scans per day, 3,5k scans per year. NHS pays for 500. A hospital can fully utilise the scanner and blow their yearly budget of publicly funded scans in two monts, do 10 free scans a week or do 8 scans and save 2 for emergencies. Placing more scanners does not reduce queues.
The CT scanner is usually owned by the NHS trust, which makes the marginal cost of using it rather small. It's almost the other way round: having bought a big capital asset, the incentive is to make sure it's kept busy being used effectively. The NHS "internal market" obfuscates this hugely, but there is still no incentive to over-provision because the system can't drive up external insurance costs.
> Medicaid is not something anybody wants and in many ways is worse than the ER as a measure of last resort for acquiring care.
Medicaid is almost entirely state run and varies radically from state to state, but in all cases subsumes and goes beyond ER care, so in no way is it "worse than the ER".
> Medicare on the other hand is much better, though still not all that great (it's better than private insurance in many if not most cases).
Basic Medicare is worse than private insurance (and even, in some ways, most state Medicaid plans) in a number of ways (especially in the way that it is segmented, particularly the separate prescription drug portion), and deliberately kept worse to promote publicly-subsidized, privately-run (often for-profit) “Medicare Advantage” plans, which (unlike basic Medicare) are comprehensive and integrated, rather than segmented.
Tell that to the people in states with Republican governors who won't expand Medicaid to cover them...
> in many ways is worse than the ER as a measure of last resort for acquiring care
What are you talking about? If you are in an emergency and on Medicaid you can go to the ER[1]. ERs give great care, they are just expensive. Medicaid is not expensive, so if their patients are getting ER quality care that is an amazing deal.
Not only can you go, you won't be charged unlike almost all private insurance plans.
> Out of pocket costs cannot be imposed for emergency services, family planning services, pregnancy-related services, or preventive services for children.
The partial medicaid expansion coverage of the ACA isn't actually putting people on medicaid, it is subsidizing private insurance at a percentage of cost. If you hit 100% of the ACA subsidy you are in medicaid territory, if you are up to 4x poverty you get a diminishing % of your insurance bill paid by the state.
My Dad has a $750/month plan but only pays $150 because of the medicaid subsidy in PA from the ACA for his income bracket.
How it works depends on the state because a lot of Republican governors wanted to stick it to Obama and poor people by not expanding Medicaid as intended under the ACA.
That said, the Medicaid expansion definitely puts people on Medicaid! That's a big part of the reason why it's politically suicidal to repeal the ACA.
>...There aren't any good reasons I've seen to not lower that age to 0 (i.e. covered from birth).
It isn’t that simple. Medicare saves lots of money because of their lower reimbursement rates and many of the smaller medical practices near me won’t accept any more medicare patients. Even with that, the Part A trust fund (covers hospital costs) is expected to be completely depleted in roughly 10 years.
Medicare on the other hand is much better, though still not all that great (it's better than private insurance in many if not most cases). It is universal coverage for folks over a certain age in this country. There aren't any good reasons I've seen to not lower that age to 0 (i.e. covered from birth).