I think most people around here know that our healthcare payment structure is totally whack. However, we're not the people who need to know this.
Try showing an NPR article about universal healthcare to Joe USA. I guarantee you'll get one or all of the following responses:
1: I don't want my taxes to go up
2: I don't want to pay for illegals to go to the doctor for free
3: My insurance will get worse
4: I like my doctor, I don't want to be forced to go to a worse one
5: I don't want the government deciding when I go to the doctor
6: I don't want to wait six months for a doctor appointment
7: NPR has a liberal agenda
Many of my family and extended social circles are quite conservative (in the USA sense) because of how I was brought up. I have heard all of these and more every time the concept of universal healthcare is brought up.
Most of the reasoning I hear is not based on facts, but on emotionally misleading arguments from the network of memes and punditry where they get their info. And when they vote, they vote for people who oppose universal healthcare on these fallacious bases.
How do you convince someone like this that universal healthcare is better for all of us?
> How do you convince someone like this that universal healthcare is better for all of us?
Here is one approach.
1) Enumerate the different options.
2) For each option, enumerate the upsides versus the downsides, which includes cost of implementation and operations, along with their likelihoods. Every option has potential downsides -- are we willing to accept them for the potential upsides?
3) Rank the options by expected utility. Which one comes out on top?
Ironically, you may find that universal healthcare is not the top-ranking option or that we have not yet come up with a high-expected-utility option.
What I truly don't get about M4A advocates or believers is why they don't tolerate a public option. Just let the state compete in the open market, and if you like state run , you have your and thats it.
Totally fine with it, it’s the MO for many European states, including France. Australia too. The issue for me isn’t puritanical, I don’t need single payer, what I want is everyone’s basic needs met.
That said if health outcomes aren’t the utility of a medical system what on Earth is?
Right, I don’t disagree. I’m still not sure how the utility of the health system isn’t health outcomes. You can make a case that they are interlinked, smoking and health, but that doesn’t really answer my question. If anything, to me, you're making the case that (abuse of) substances such as alcohol, cigarettes and all 'illicit' narcotics should be under the full control of the health system and not the criminal justice system. Similar to how Portugal handles it.
FWIW the big issue is that private companies don't want to compete with the state because the goal of the state is to provide quality care, not to maximize profit. None of the private insurers are lobbying for two-tier universal healthcare so they can show off their sheer superiority are they? You'd think if they were actually superior they'd love, or at least be neutral to, the introduction of an inferior competitor.
If you're so sure private cover is better why push back against the introduction of a public option at all? Welcome all comers with open arms.
Insurance companies should abhor any kind of state competition, regardless of the case for it, its in their interest. But being an interested party does not make you evil.
Government also has an interest, in fact a huge interest. If healthcare were socialized entirely, dollar-per-dollar it would increase the federal government's size by ~ 10% of GDP. Currently its 21%! It would mean 50% bigger government!!
And that means HUGE cash, and HUGE political boons. Sanders could become president by promising people a healthcare service he does not pay for or he is not responsible for its failure. And the government now will have some omnipotent ways to levvy taxes and then short-change constitutents by cutting health spending or quality.
The government is also an interested party, and it's stands to gain more power than ever with such a ploy.
I also urge not to believe that the state "does thing for the people" because it either fails to do so or it just is plain false. Please look at the real results of public education: it has terrible results even though "its in the interest of the state to provide quality education".
The idea that this is going to be more expensive/isn’t paid for is ridiculous because it eliminates all of the money spent by private corporations on what should be a public service. It’s crazy that the government was able to shirk it’s responsibility to look after people and place that unfair burden on businesses. That makes it harder to run a business, harder to start a business, and increases your total cost of doing business in America. It’s time to relieve businesses of the burden of dealing with their employees health. The money they were paying to provide that service is going to pay for it. Isn’t that what America is all about — small business?
It doesn’t increase the size of government, those are flow-through dollars, they go in one side and out the other. A huge amount of American healthcare is already socialized between Medicare and Medicaid. If anything consolidating these disparate services should represent an administrative efficiency. And even if, so what?
Yes the government can then change health policy, that’s the point. If they cut it, deal with it at the ballot box. Right now there’s zero transparency and accountability with private insurers, so it’s strictly worse. In other countries the government treats health programs as sacred just like Medicare.
The data shows it works everywhere else, it can work here too. Government works in other countries, it can work here too. I’m curious as a free market health aficionado why not pitch privatizing Medicare? How’d you think that’d go over?
> The idea that this is going to be more expensive/isn’t paid for is ridiculous because it eliminates all of the money spent by private corporations on what should be a public service
This is just a plain criticism of capitalism in general. Does this logic apply to everything else? Like food? Housing? In practice we have a great example with public education: an expensive, unequal base level that americans avoid if they have the money to.
> It’s crazy that the government was able to shirk it’s responsibility to look after people and place that unfair burden on businesses.
> . It’s time to relieve businesses of the burden of dealing with their employees health
I agree, although I would like to note that historically this made sense from an administrative standpoint. Back in the 20's, administrative work of insurance was like half the cost. It wouldn't be so expensive today with electronic payments and all. Its the same logic behind payroll taxes (those that work pay it) mostly because its easy to do, not because its fair or good.
Its true that businesses would love not to manage training people about healthcare, but then the government will have to do it and that won't come cheap. That will be an interesting challenge. The M4A plan of no copays no nothing, that would eliminate that instruction is a pipe dream.
> It doesn’t increase the size of government, those are flow-through dollars, they go in one side and out the other.
Hey come in.
<They are in a federal bank account.>
<They are processed by a claims office that decides what to pay and what not to pay>
They come out.
Whatever claims are not paid, its money leftover for spending in whatever initiative the government wants. In fact advocates for socialized medicine like Sarah Kliff want that to happen so the government can set prices. Since its your only employer (no competition with private insurance) you say you accept it or you close down.
> If anything consolidating these disparate services should represent an administrative efficiency
And if it doesn't, whats the way out?
> Yes the government can then change health policy, that’s the point.
Maybe thats your point, but I don't want in on that. I dont want the government deciding for me.
So I dont want to go thing by thing: we disagree, you envision a government administration to be great and fantastic, and I see it as unfair and oppressive. Lets compromise on our different of beliefs: lets advocate for a public option. Government offers something, insurance offers theirs, they compete in the open market, you get what you want and I dont need to confront.
One last point of interest: it's not an open market right now. Medicaid pays for the poor, Medicare pays for the old and sick. In any other insurance system, the young and healthy pay for the old, sick and poor. However, literally all the worst customers in US healthcare have been socialized away. This is probably the biggest cash giveaway to private enterprise in history.
It's like offering government fire insurance only to buildings already on fire, in high-risk areas and below-code, leaving all the not-on-fire up-to-code buildings for the "free market." It's insane.
This is a common criticism but I don't think it checks out:
Medicare is funded by payroll taxes. So it already works as in "the young pay for the old". Its true insurances have incentives not to have diseases before patients to go medicare (for example, if they knew something has high risks at old age, but low risks before, they have an incentive to do that). Working in the industry I have yet to see an example of this, so I think its a greatly exaggerated claim.
OTOH, hospitals are forced to take medicare patients, and the reimbursement rate is up to half of what regular insurance pays. It is often below cost of care. This implies a cross-subsidy from private to medicare.
I think the final math on this topic is ambiguous. I would not make a claim either way without some stronger analysis.
> This is just a plain criticism of capitalism in general. Does this logic apply to everything else? Like food? Housing? In practice we have a great example with public education: an expensive, unequal base level that americans avoid if they have the money to.
The reason public education is bad is because Americans have decided to hate their government (which is an extension of themselves) and not invest in services in the public interest. It's not inherent to the system, it's a product of what you put into it: apathy and distrust. The same just isn't true in other countries.
In your criticism of public education you actually make a case for two-tier healthcare: I'd rather have a base level of schooling I can buy my way to "better quality" than leave anyone who can't afford private school out on the street with no education.
Not everything needs a profit motive. Some things, the ones that lay a foundation for a free and fair society, such as police, fire, roads, railways, water, education and health, should be provided. This allows individuals to rise to the level of their abilities and merits without relying on the largesse of their family. This is the meritocratic American dream, in a lot of ways. There are plenty -- and I do mean plenty of ways to make money out there, it's not like socializing this eliminates capitalism. If anything, it bolsters it by allowing more people to pursue entrepreneurship.
> Its true that businesses would love not to manage training people about healthcare, but then the government will have to do it and that won't come cheap.
It is cheaper in every other country, and there's no reason it wouldn't be cheaper here. Analysis in a Koch-backed study showed it would be +/- 10% (either 10% cheaper or 10% more expensive depending on ability to control costs while covering 12% more people) -- so less per capita no matter what. [1]
> Whatever claims are not paid, its money leftover for spending in whatever initiative the government wants.
That's not how governments work, that's how private companies work. Private companies take left over money and distribute it to their shareholders. Whenever a private insurer denies a claim someone makes money. Governments distribute it back to the people. Their goal is not to make money, to have money left over, it's to provide service. If they can do it for less, they'll lower their budget.
Not that it matters, single payer setting prices works just fine in Canada. You know that price transparency everyone in America is demanding? Here's Ontario's entire list of prices: http://www.health.gov.on.ca/en/pro/programs/ohip/sob/physser... PET scan? That's $237.50 (vs. $5000 in the US).
> And if it doesn't, whats the way out?
Voting?
> Maybe thats your point, but I don't want in on that. I dont want the government deciding for me.
By voting you decide. That's government. It's an extension of the people's will. You are in fact deciding. I'm sorry you feel like that doesn't work here, and that in fact you'd rather a faceless, un-accountable corporation with an interest in making a profit decide than a transparent, public good service you can control the leadership of. The government "decides" for you in so many other ways, it's ridiculous to draw the line here but even if you were to, offering a public plan strictly increases your options.
> The reason public education is bad is because Americans have decided to hate their government...
Thats not going to change with socialized medicine. So shouldn't you be against it? Because americans still "hate government" and if that breaks government programs, it will break socialized medicine as well.
> In your criticism of public education you actually make a case for two-tier healthcare
US already has this. Namely Medicaid.
> It is cheaper in every other country,
We have had this argument before. Making it socialized will not make it cheaper, it will fundamentally change the way its funded. I haven't seen the details of the Koch study, but there are things that won't change: the shortage of doctors, the cost of pharma, the amount of hospitals, malpractice insurance costs etc. The cost of administration is exaggerated because that administration also provides value: it checks expenditures, medical reasearch etc.
In any case, again, if gov will be so efficient, it can start with a public option and see how that goes.
> By voting you decide. That's government.
I dont want to vote to see if I can see the doctor I want to see or pick the service I want to use. If you wish to vote your treatments go your own way, and you don't need me to achieve that. Advocate for a public option you can opt-in, and if it is truly better and cheaper and all that, now we know. I believe it will be worse and more expensive and I don't want to be locked in to that.
> The government "decides" for you in so many other ways,
> Thats not going to change with socialized medicine. So shouldn't you be against it? Because americans still "hate government" and if that breaks government programs, it will break socialized medicine as well.
Maybe I'm just optimistic but I hope that this could be the thin edge that changes it. When in a democracy, attacking the government is attacking yourself and your country. It hurts you and your fellow citizens to approach social services like this, IMO.
That said I'd rather a low-quality baseline everyone gets that people can buy out of as necessary than leaving 10% of Americans un-insured and fending for themselves. Now ideally, I'd like a high-quality baseline everyone gets but even a low-quality program is better than the bupkis we have today.
> US already has this. Namely Medicaid.
Well, if private cover is the be-all and end-all why do we need this? Why don't we just privatize Medicare and Medicaid if they're so much worse? That plan enjoys little support, even from Republicans. Turns out the aged are all about socialized medicine for themselves, just not for anyone under 65.
You know that Medicaid may put a lien on your house for the amount of money spent on your care right? It's not socialized cover for the poor, it's death-prevention for the destitute.
> We have had this argument before. Making it socialized will not make it cheaper...
It does, though. Accessible preventative care is cheaper than dealing with problems down the line. You don't have huge marketing budgets, you don't have CEO compensation, you don't have claims denial departments, you have simple, stream-lined payout processes and pricing structures. You drive down drug prices because the states form bulk buying groups and negotiate. That's what makes drugs in Canada so much cheaper even though unless administered at a hospital, you have to pay out of pocket -- negotiation. Your incentive as the government is to make people well to drive down the cost of healthcare. Just axing coverage will not get you re-elected. (Imagine the optics of being the politician that cut spending on healthcare causing their constituents to die publicly?)
You send everyone through a primary care physician so they're not wasting the time of specialists via self-referrals. The list goes on and on. Medicare is objectively more efficient than private care. [1]
Then if you go all-in you can do what Canada does and socialize malpractice insurance too. It costs a fraction there of what it does here.
> In any case, again, if gov will be so efficient, it can start with a public option and see how that goes.
I'm down.
> By voting you decide. That's government.
I dont want to vote to see if I can see the doctor I want to see or pick the service I want to use.
You don't get it. It's the other way around. In a public system 100% of doctors are in-network. You can go see anyone you need. In the US you either go to the ones your employer has in-network or you go bankrupt trying to see someone else. Change jobs? You may well have to change doctors. This whole narrative represents a false choice.
It's the other way around: Socialized cover represents a large cluster of freedoms: The freedom to pursue self-employment or liberal arts or stay-at-home parenting without fear of death or bankruptcy. The freedom to pick any job regardless of medical coverage. The freedom from worry about dying in the streets. The freedom from fighting your insurer over legitimate claims. The freedom to pick your own doctor regardless of what your boss wants -- and keep them if you change jobs! The freedom from having to pay more than you can afford for medical coverage. It's the freedom from having to be required to create profits for the insurance companies, by law (the individual mandate).
> The government "decides" for you in so many other ways,
That doesn't make me feel any better.
Most of the high ranking health care systems would probably be considered "universal healthcare", in that everyone has access to care. Many of them are not single payer though (in the sibling comment's WHO ranking link, France, a multi-payer system, was ranked #1 for "overall system performance").
But I agree generally with this approach. Nearly every developed country has dramatically lower costs for the level of health outcomes, but they do it in a variety of different ways. There are clearly possible affordability improvements (even if we only try to catch-up to where other countries are at). But certain approaches may be more feasible to implement or may have less downside if things don't go perfectly.
A good first step would be to kill the "single payer" meme. Thats not how it works in the really high performing health systems, which have competing insurance entities. It has been shown that the single-payer system is worse than those. Good and practical systems are always hybrids, not pure.
The book The Healing of America by T.R. Reid compares the systems of Canada, the UK, France, Germany, and Japan. According to the book, the latter three get among the top results in the world, measured by international organizations on various objective criteria like survival rates after diagnosis of major disease. They have various costs, with Japan being especially low at 5% GDP. All three have competing nonprofit insurance companies, mandates, and price controls. At the time the book was written, they were performing significantly better than the UK and Canada (which were doing better than the U.S.).
The UK would be a weak hybrid "Beveridge Model" system, not single payer. The Scandinavian strong hybrid systems are even better. Just another instance of localism winning over centralisation.
Tell them that the US pays MORE in taxes to fund Medicare and Medicaid than other countries spend for Universal. Tell that that with Universal we can let go a whole army of parasites living off the Health Care Industry.
The later argument is not going to get buy in from someone who is in or is related to someone in the health insurance industry, no matter how good it would be for society in general.
Obama said to Trump, during the transition, something to the effect of "I don't care what you call it -- make some tweaks and call it Trumpcare. Take me out of the equation; I don't care. But this is helping millions of people. You can make this a win."
Unless you mean "you already pay enough to fund a modern universal Healthcare system" which statistically would be true. US govt spending on Healthcare is now per capita than many universal systems.
Controlling for PPP? Try paying US doctors UK wages and see them all leave the industry. We’re already on the cusp of an intractable doctor shortage, try putting more down pressure on their wages and watch the healthcare meltdown.
The AMA intentionally limits the amount of doctors that can practice. If there is an intractable shortage it’s because 25% of the current practicing doctors like things the way they are.
Looks like this is not entirely true. Looks like Congress simply created bad regulations limiting the funding for residencies in the US. A simple formula could have been created to determine residency funded limits instead of a simple hard cap.
How many people have the talent to become doctors, but decided against it because of the working conditions? Limit the working week to 40 hours (including during training), and you won't need such extreme wages.
Do you mean PPP? Prices tend to be lower in the US (outside of Healthcare anyway...) so if anything I would expect adjusting for PPP to make the difference starker.
My point was that it happens that right now the US government spends a per capita amount on healthcare (for Medicare, Medicaid, VA, Military etc) that does not provide universal coverage but would be sufficient to provide universal coverage at the per capita cost of it in other western countries. It's an artefact of the substantially higher healthcare costs in the US.
Often universal healthcare isn't universal. In Germany, for example, it's illegal not to have health insurance. If you can't afford it then you'll only get emergency care (but you would get that in the US too). If you don't have health insurance then you'll have to pay back the months you didn't have it.
Don't even try. Trying to convince someone in a straightforward fact based approach only works on someone who comes looking for that information. Bringing it to someone who isn't looking for it causes them to dig in even further, it is not a rational behavior and can't be dealt with rationally either. This is not a dig at these peoples position either, for all I care they are in the right here. People are not Vulcans expected to rationalize every aspect of their lives.
> How do you convince someone like this that universal healthcare is better for all of us?
You have to show that the government is competent enough to create universal healthcare. If people thought the government were more competent in general, they'd be more amicable to having the government choose a doctor for them.
Huh? I'm in a public system, and I can change to any doctor I choose if they have space to take me. And choose to show up at any hospital in the country.
When I look at government services (where they have a monopoly and often where they have the full force of law to compel me to bend to their whims), I don't immediately think of a smoothly functioning, well-oiled, supportive machine such as I might want for my health care needs. Instead, I think of the DMV, the IRS, our public transportation systems, the FCC, traffic court, etc.
I don't love my current healthcare, but I'd rather muddle through 5 additional doctor visits than 1 additional DMV visit.
In my experience, sufficiently large corporations can become indistinguishable from government once they achieve total regulatory capture. That's where we are now in the US. If a company could disrupt the way healthcare is paid for, that would be great.
I find it helps to go into the details when trying to sell people on health care reform (I've also had these discussions with conservative family members).
First of all "universal healthcare" itself is pretty vague. Most developed countries have universal access to health care for less money but they do it in a lot of different ways, from NHS like systems to multi-payer systems like in France and Germany.
So reform could be a lot of things from a public option on insurance exchanges to single-payer with government-run hospitals like some other English-speaking developed countries. Honestly, I feel like people who are worried about second being actually implemented well are not necessarily just ignorant, for example the VA system in the US is structured in a similar way and a lot of people have terrible experiences with it. So at that point I usually acknowledge their concerns and point to other developed country systems that don't have the same single point of failure.
When you say "universal healthcare" are you trying to sell them on single payer specifically? I think the argument is stronger by letting go of that and just focusing on the costs and results compared to other countries.
I don’t believe in universal healthcare, and none of these approaches do much to convince me.
I’m in agreement that the current situation is hot garbage, and it’s shitty for a lot of people. However, my insurance now is good enough for me and my family. Sure, it’d be nice if it was cheaper, but whatever. As I get older I find I can’t be bothered to lay awake at night worrying how everyone in the country gets healthcare anymore. I’ve simply accepted that this is the world we’ve been dealt and everyone needs to find their own way to survive.
My main concerns are 3,4,5,6. I don’t see them as “fallacious”, I think it’s naive to assume universal healthcare will work exactly as planned with no unforeseen consequences, and I’m generally suspicious of people who do not list the risks along with the benefits.
FWIW, some views from Norway, which has universal healthcare.
3: Don't need health insurance so I'd say that's better.
4: We can chose our own primary doctor from the pool of available GPs. Available just means that some GPs have too many patients on their list already and don't have any slots available. You can switch primary GP once a month (IIRC). I switched a few times until I found one which I liked. Repeated the process when I moved.
5: I can see my GP whenever I feel like it, just need to set up an appointment. If you mean to see a specialist then yeah, I'd need my GP to refer me. Sometimes this can feel a bit unnecessary but mostly it's not a big issue IMHO.
6: If my GP doesn't have time for me, I'd just switch and find one who does.
Its not private/public that makes healthcare expensive in the US. Medicare is also public and fairly unlimited and also way more expensive than Norway health.
There's a big group of other issues at play. And universal healthcare in the US would be so massive that you can't compare it to a small country.
> 3: Don't need health insurance so I'd say that's better.
You do have health insurance, it's just provided by the government with premiums paid through taxes. When people express the concern that their insurance would get worse, they mean that the insurance provided by the government would be worse than what they currently have. There are a number of different things that people think make plans worse or better, which is a major contributor to the difficulty in having a clear discussion about this.
I mean, you do have to worry about that. It's just that you're happy with what it covers, so you don't worry about it. Despite all the well known awful problems we have, most people in the US actual feel the same about our plans as you do about yours. I don't have to worry about what my insurance covers because it is a good plan, and if it becomes worse, I can look for a better one. This is true for most people in the US - mostly those of us fortunate enough to have good employer sponsored plans - it just isn't true for enough of us in a lot of peoples' opinion (which I share).
One thing I'm way more afraid of with a single payer system (but not necessarily all universal coverage systems) is that if the coverage became worse, I would have no recourse; it would be a monopoly, I wouldn't be able to look for a better competitor. Even worse, it would be a monopoly run by a political bureaucracy, so coverage decisions could become political. For example, coverage for birth control is a very political topic here. I'm certain that the first incarnation of a single payer system would cover that, because it would be set up by the politicians who favor it, but once the system is enshrined, whoever is in power would be able to change it however they think best. Coverage policy could easily become a political football.
Are you against universal access to health care (why?) or just against single payer?
Plenty of developed countries like Germany and France have better access to health care (that costs a lot less) while still being multi-payer with private insurances. Although in the US we just seem to only pay attention to Canada and the NHS so universal health care and single-payer are tied together.
Honestly I think people's expectations have gotten much too high about single-payer solving all our problems. Clearly other developed countries have gotten their health care (relatively) in order without doing single payer. And we basically already have single payer for age 65+ and the costs there still aren't nearly in line with everyone else. The US definitely spends much more (as a % of GDP) than everyone else (to not dramatically better results) but single-payer or not doesn't seem to be the key difference.
For sure. From having lived in Germany, it's not the payor that makes it cheap, it's the regulated prices. There is simply a (low) price that everyone pays when they go to the hospital.
We also have something similar in the U.S., given that roughly half of medical care is paid for by the government. Medicare sets prices for each CPT code, and they do it through a formula that depends on geography, and something called Relative Value Units.
This is done nominally by the Center for Medicare Services, but they rubber stamp the work of the Specialty Society Relative Value Scale Update Committee, which is a group of doctors appointed by their respective medical societies to decide how much Medicare should pay them. When doctors can simply tell the government how much they should be paid, what do you think is gonna happen?
People really do not get that the rotten core of the healthcare market is regulatory capture, and that a bigger healthcare system will mean bigger regulatory capture.
This. I'd love if public policy researchers could find ways to end or dramatically reduce the (basically corrupt) regulatory capture the health care industry orchestrates.
Forgive me for asking, but do you personally deal with the paperwork generated by you and your family’s health care?
At my last N employers, I’ve been lucky enough to choose between literally the best HMO in the US (on multiple metrics), and top-end insurance plans from a range of multiple companies (e.g., a $0 annual deductible plan or an HSA + high deductible plan, where the employer’s HSA contribution matches the annual deductible).
The paperwork for the high deductible plan took multiple letters per doctor visit spread over multiple months, and more than doubled the paperwork we had to track for income taxes. This is completely unacceptable.
The HMO is, well, an HMO, we have limited choices of doctors and specialists, but I swipe my credit card when I check in or pick up medicine, and that’s 100% of the paperwork, even for extended hospital stays.
The only people in the US with better health care plans have what I have, and also a personal assistant (or heroic spouse) to abstract away how messed up the system is.
For these reasons, I argue the US health care system has failed all but top <1%, and those people can already afford to fly to Europe and buy specialist care, I don’t see why they won’t be able to do so in the US after the rest of us get universal healthcare.
I agree. This system is no secret. We all know this is how it works so why do people make poor choices and then later complain about their insurance?
With that said, having a massive middle man (private health insurance) to act as bloat and added friction on the economy is bad for everyone. You may not be directly affected but you are definitely affected in other ways that aren't as obvious.
I find this sort of thing is common in America. There is always an industry set up as a middle man that needs to get paid.
The massive middle man is the state, not private insurance. For all the complaints about private health insurance profits, all combined are a blip of the federal health expenditures.
What “federal health expenditures” are you talking about?
The Obamacare tax was something like 3%, and only for the extremely wealthy.
In contrast, 33% of US healthcare costs go to insurance overhead, and >17% of our GDP goes to health care, so nearly 6% of the gdp goes to private insurance middle men.
Now, the entire federal government is currently spending 37% of GDP (though that includes deficit spending), so you posit that at least ~ 1/6th (6/37) of government spending is some healthcare program.
Medicare and health costs ~ $1T of the government’s $3.8T budget, which is a bit over 1/4th of the federal budget. That does meet the threshold of your claim, but only if much less than half of Medicare spending goes to actual health care.
Note that the 20% Medicare waste number from the NBER study is not apples to apples with the 33% administrative overhead number, since it includes ineffective medical care (and all other wasted spending) that did not improve patient outcomes in the 20%, but the 33% number for insurers only counts useless paper pushing, and not ineffective care, etc, etc.
So, private insurers really are squandering many more healthcare dollars, and are also much less efficient than the federal government.
> In contrast, 33% of US healthcare costs go to insurance overhead, and >17% of our GDP goes to health care, so nearly 6% of the gdp goes to private insurance middle men.
6% of GDP to private insurance? Math doesn't add up on this back-of-the-napkin math. That's an entire Apple of operating costs every year.
The biggest insurance company, UnitedHealthcare, is worth 200 bill in the market. The gov could buy the big 5 insurance companies with half its yearly medicare budget.
Don't confound paying to insurance and paying to providers!
> So, private insurers really are squandering many more healthcare dollars, and are also much less efficient than the federal government.
I will answer seriously in a second, but for real: how is it so obvious that the private market beats the government on almost anything at any time, even this very government (for example, education) and still, the level of debate is "government is more efficient". Government is never more efficient, because it doesn't care about efficiency.
The comparison of efficiency between medicare and private insurance is grossly misrepresented by Bernie Sanders. First of all, there are some disingenuous numbers: it uses a measure of efficiency of total cost/admin costs, but that skewes severely in favor of medicare bacuse it has an older population that has more expensive treatment.
Some economists looked into this and the cost of administration per patient is similar.
Second, a great part of why medicare has less admin burden is that its collections are done through payroll taxes. This means the admin staff is included in other government agencies. This is not a public-advantage, because you can also use payroll taxes to pay for private insurance if you wish so, something that exists in some other countries. ( to my dismay, for the following topic).
Another trick here is that medicare collects from everyone and pays for a few. That is a great way to never have to market, administrate or manage people on your plan: you are not going to use it? tough luck. You dont like it? tough luck. You don't have quality coverage in your area? Tough luck.
This trick is so pervasive that even Bernie Sanders claims how medicare patients are so happy: why wouldn't they, the premium they should pay to maintain it is about 1k a month, and they pay 150!
Forth, it is key to understand that medicare offerings are not market competitive. They pay half of what private insurance pays, and there is no way in hell you make that work. Private insurance subsidizes medicare patients, and doctors would abandon the network if they were forced to accept medicare rates.
This is a long topic, but to re-frame the conversation: what makes healthcare in the us expensive is NOT private insurance. Most of the world has private insurance! even Canada! Even France! Spain, Norway, etc. US healthcare is expensive because it is one of the most tight regulated expensive markets in the US.
Right, a lack of regulations is why things are expensive. Deregulating has worked so well as a cap on prices for internet, mobile, finance, etc. If only we'd let the free market Porcupine fairy handle everything it would be better. You completely left out that Republican Congress specifically denied Medicare the ability to bring in cheaper drugs from other countries and isn't allowed to negotiate drug prices, oh and they've underfunded every single regulatory agency for ages to be able to claim government doesn't work. Why is it that other countries can somehow pay more for the same or better care of their public options and we don't. I can promise you it's not that they are less regulated in Europe. You're never going to have a cheaper private option with a profit motive on anything versus an option that doesn't require a profit motive.
> Right, a lack of regulations is why things are expensive.
You might guess right now that I will argue the exact opposite point.
> ou completely left out that Republican Congress specifically denied Medicare the ability to bring in cheaper drugs from other countries and isn't allowed to negotiate drug prices, oh and they've underfunded every single regulatory agency for ages to be able to claim government doesn't work.
Aren't you taking into the calculations that socialized medicine will have the same political risks?
> Why is it that other countries can somehow pay more for the same or better care of their public options and we don't.
The U.S. has a specific regulatory framework that is chaoticly expensive. Regulatory capture is grotesque in the healthcare market, and you can read up what health economists say if you want details.
You could aim to do a healthcare reform that just plain reduces the cost of care by 10, 20% easily by just doing less as a government.
> You're never going to have a cheaper private option with a profit motive on anything versus an option that doesn't require a profit motive.
1) Medicare is also more expensive than other countries socialized systems
2) Some of the biggest insurance companies are non-profits
3) The combined market value of the top insurance companies is less than half the yearly Medicare budget.
Without a strong profit motive would companies still have much incentive to pour 100s of millions of dollars into R&D for new drugs and treatments though? How much progress in healthcare is driven by the fact there’s a lot of money to be made, and how much does the US’s high prices basically subsidize cheaper healthcare for the rest of the world?
That is a sub-problem of the pharma industry, that while significant (15% of healthcare spending) is not the same debate as banning private insurance.
What people dont get is that private insurance fiercely competes to lower costs, while the government's only effective mechanism is to not pay anything at all. Socialized medicine in the us would usher a new era of Cash pay.
I was going to add to my comment but didn't that: This is all an incredibly privileged mindset. Many people don't start on the same level with the same chances, that we do. It's hard to blame poor choices when it's not a choice.
But at the end of the day that's a big appeal to emotion. The logical argument, is that the current system is a big honking added step in the system that adds nothing but subtracts a lot and whether or not "you've got yours" you are still affected by those who don't. Poor choices or not it's still in your own interest for the people to your left and right to be covered and get healthcare.
If that's something you accept, then you also must accept that the moment you get sick and your health insurance decides to screw you over, that no one will be there to help you. You'll go bankrupt. You'll become homeless at the later ages of your life. And you'll need to find your own way to survive on the streets.
For me, since I saw first hand what the healthcare system did to my parents? No one should go through that. They had 'good enough' healthcare and it still financially and physically destroyed them.
You think you have good enough health insurance? You don't.
> So what? I accept the risk, like any other risk in life
You say that now, but the reality is much different when it comes down to it.
Like everyone else, you'll scream and cry like a stuck pig when it's your Mother/Sister/Daughter/Son who get unbelievably sick through no fault of their own and die early because of a lack of money.
The system as it exists today is nothing short of disgraceful. It's sad that you just accept it and have no interest in improve it.
You are stating that this is the reality as if it’s a certain thing.
I don’t have reason to believe my insurance will suddenly drop coverage when I need it. I don’t think that’s a huge risk.
Your hypothetical world isn’t all that safe either, because when the government says no, that answer is final. There is no other option, there is no other way even if I wanted to pay. That’s just as bad as coverage being dropped, and perhaps much more likely given my faith in the government to do things efficiently these days.
> I don’t have reason to believe my insurance will suddenly drop coverage when I need it. I don’t think that’s a huge risk.
Even for lukemia, or lung cancer? and that's assuming you go to work for the rest of your life. What happens when you get so sick with one of the above you can't go to work and you no longer have insurance?
> Your hypothetical world isn’t all that safe either, because when the government says no, that answer is final. There is no other option, there is no other way even if I wanted to pay
That's simply not true. I've had personal experience in Australia, Canada and the UK, and in each of those systems you can choose to pay for private coverage & care if you so wish. I have never felt the need.
EDIT: Also, I thought of another reason.
You use the word "I" or "Me" 6 times. Does your grandmother have the same "bulletproof" coverage you do? Your nieces and nephews? Your Sister and her husband? How about your distant cousins? How about even your best friends, neighbors, and their loved ones. It's not all about you. Think about how your loved ones will be impacted, because they just might not have the same coverage you do.
> I don’t have reason to believe my insurance will suddenly drop coverage when I need it. I don’t think that’s a huge risk.
There's loads of cases, including one in this thread, about people who thought they were covered but weren't. This is really a bad situation to be in if it happens, and it should worry you every time there's an event. After all, the insurance company has direct interest in not covering you.
Now the government does as well, this is true. But those cases, eg in the UK it's talked about a fair bit, tend to be where there's a judgement that a treat is neither not sufficiently tested to be useable, or simply not worth the cost-benefit, eg it's expensive and only buys the patient a few more weeks of life. So it's true what you say, but it's worth considering what the balance of risks is: a healthcare co that has an interest against you every time, and has been shown to fight, or the government, which normally only denies treatment in rare borderline cases.
I'd say a big part of it is particular to US culture: the healtcare cos have been shown to not be that easy to get money out of. Somewhere like Switzerland also has private healthcare, but they don't compete in the same way. Everyone must have insurance, and you won't be paying out of pocket above some limit. The companies are not famous for screwing everyone, and compete to provide extra service (eg hotel-like rooms when you have a kid).
After all, the insurance company has direct interest in not covering you
Arguably their job is to not cover you. Paying actual medical expenses is referred to in the industry as "medical loss". To reiterate: paying for health care is considered a type of loss. Their goal is not your goal.
We didn't have reason to believe that we'd lose coverage either. Until my mother had her stroke, and the insurance company fought tooth and nail to not pay out, ultimately resulting in bankruptcy.
Are you confident you'll never go through a stroke?
I hear you, and have similar experiences with some family and some friends/colleagues. You probably also hear people bringing up anecdotes about someone in Canada waiting for 9 months for a hip replacement. Primary difference is that, in many cases, Canadians with enough money can get a procedure done elsewhere (or privately) at their own expense. Wait 9 months, and there's no out of pocket costs to you. US - you may still have to wait months anyway, and you may end up with debt you will carry for years.
Almost all of those in that list are fear-based, and fear is a big emotion. I don't know how you get past that, but the 'freedom' factor somehow should be focused on.
Freedoms to bring up:
* The freedom to move between employers and not have to concern yourself with tying your ability to get specific health service based on an employer's ability (or whim).
* The freedom to move geographically and not be concerned that you won't be able to afford access to health services. My own health insurance has a decidedly different monthly premium based on county, and I'd be saving probably $150/month if I lived 3 miles to the south.
* The freedom to start your own business (purportedly the backbone of 'US conservative thinking') without worrying about crippling debts.
Right now, instead of an elected/representative Congress controlling what services/procedures/medicines you have access to, you have a for-profit private company, with no recourse to change their leadership or focus via election/recall. "Vote with your feet" is basically impossible in this system.
"Insurance" is an odd product in this space too, at least for basic health care. Insurance is typically something we might get to reduce our exposure to risk for activities we engage in which are voluntary. Choose to buy a car? Get some insurance to help cover replacement costs, or incidental costs to others you may harm. Buying a house? Or renting? Get insurance to help cover replacement costs of things. You can choose to not buy a car, or a house. No one chooses to be born.
Untie anything related to medical care from employment. By what measure is tying someone's ability to access healthcare to the beneficence of their employer remotely morally good? Someone has no employment (through whatever or no fault) and we decide that they are somehow fundamentally unworthy (or perhaps just 'less worthy'?) of access to health services?
What never seems to get talked about after "your taxes will go up!!!" is "other things you pay for will go down!". Employer paying $1000/month for your health insurance policy? That expense will go away, and they'll either pay you more with that money or pay more in taxes.
> Untie anything related to medical care from employment. By what measure is tying someone's ability to access healthcare to the beneficence of their employer remotely morally good? Someone has no employment (through whatever or no fault) and we decide that they are somehow fundamentally unworthy (or perhaps just 'less worthy'?) of access to health services?
Good comment a consultant we hired said. He and his wife had insurance for 25 years, then lost their jobs. Then his wife needed surgery.
It's a dick outcome when someone pays in for 25 years for a service and then gets denied because the economy tanked and they got laid off.
yep. I've 'paid in' more than $100k in premiums in my lifetime to various insurance plans. And a similar amount in FICA taxes, at least. I would prefer all of that having gone in to a system which I could utilize even during times when I couldn't pay in.
You've done an excellent job explaining all the downsides of our current system. You have not explained why universal health care is the only way to solve those problems.
Employer-tied health insurance is also my main irritation with the current system. How you feel about the health insurance situation in America is directly tied to how large / well off your employer is.
I think that would be the most painful change to healthcare in America, but I don't think anything can improve until it happens.
Universal healthcare is a goal and a problem to be solved, not a plan in and of itself. There are many ways to achieve it that have been successfully practiced in many other countries. If you genuinely want an explanation instead of playing the tired old "just asking a question" rhetorical dodge, then I suggest you research how all the other countries are managing to cover most or all of their citizens for a nominal cost. Participate in the solution.
And they also don't tie (through culture and regulations) access to health insurance (and therefore care) to employment situations.
Really... break ties between "employment" and "health insurance". It's a massive distortion of the 'free market', which is typically a conservative crowing point.
You dont need socialized medicine to solve the problems you state.
> The freedom to move between employers and not have to concern yourself with tying your ability to get specific health service based on an employer's ability (or whim).
It is the government that subsidizes employer insurance (a 260 billion tax subsidy for the richer part of society) and has made it mandatory. Repeal laws and this would naturally stop happening.
> The freedom to move geographically and not be concerned that you won't be able to afford access to health services.
This is not solved by socialized medicine: in a full government control scheme, the government decides where the doctors and hospitals are through the payment model. And the government will pay differently based in location as it already does for federal grants to hospitals.
> The freedom to start your own business (purportedly the backbone of 'US conservative thinking') without worrying about crippling debts.
Just crippling taxes. Its not that the cost dissapears, its that its mandatory to finance it with taxes.
Nowhere did I or the OP say "socialized medicine". The OP said "our healthcare payment structure is totally whack." I advocated divorcing employer involvement in healthcare concerns, in whatever form that would take.
> Repeal laws and this would naturally stop happening
I agree. I think there are regulations that could be changed to immediately economically favor individuals purchasing individual insurance plans vs employer-provided insurance stuff. I'd probably be in favor of that, but would prefer single-payer. Regardless, I'm definitely against employer involvement in employee healthcare at all.
There are no facts that socialized medicine would be better for the US either.
And many of the things you mention are factually correct statements on for example, M4A.
When you say "convince" you actually show militancy, not understanding. I get it though, the topic is very complex and people lean very differently. I think the best way to deal with this political will is to do a public option. More choices to the people: if public truly is better, then it will promptly show it in the open market. If its not, then we know socialized solutions will not work.
> if public truly is better, then it will promptly show it in the open market.
And that's exactly what happened, most developed countries have got variants of socialized healthcare
Also, market failures happen all the time, it is never a good idea to rely on "Free Market Fanaticism" as that easily leads to catastrophe without oversight
> And that's exactly what happened, most developed countries have got variants of socialized healthcare
At least by the accounts of the Social Transformation of american medicine, european health systems were pretty much top down, but the AMA was so politically powerful that it was able to fight it effectively.
> How do you convince someone like this that universal healthcare is better for all of us?
American conservatism is authoritarian. The only way to reach an authoritarian is to shame them. Because they are family, you shouldn't insult them or anything, but you need them to be on the defensive about those ideas.
Go through each one and ask them why they think that, but don't leave it open-ended, make it clear that you're asking why they think that despite all the evidence.
Example for response 1:
Why do you believe your taxes going up is a problem when you will be paying much less overall? How many dollars are you willing to spend to avoid one dollar in taxes?
The clarifying factor where you hold the cards and knowledge, and they don't (and therefore feel shame) is the simple fact that universal, taxpayer-funded healthcare is far cheaper than private healthcare.
Because they are authoritarian and this line of thinking disagrees with the authority, there's a very good chance that this will not work, at all. Instead, they will try to change the subject. Don't let them. Patiently guide them back to the question at hand, make them explain how much money they're willing to spend to avoid paying taxes, make them deal with the fact that they will save money.
Depending on the person, they will just trudge out or start insulting you. If you're lucky, they might listen a little. It's rare that anyone will change their mind on the spot, let alone an authoritarian conservative, whose entire identity is predicated on believing nonsense given by a chosen authority. But, if you do it enough times, it can start to sink in. Alternatively, if they start insulting you, that's when you have to bring out the less polite shaming, because it's what they respond to.
That's funny, I don't see how you got there though. Liberals seem to engage in authoritarian tactics quite often from what I can see. Demands for censorship seems to come from there.
>Why do you believe your taxes going up is a problem when you will be paying much less overall?
And then they counter with: If people will get better healthcare then somebody will have to pay for it. I like my current healthcare, so I'm going to be the one that has to pay for those other people.
Now the onus is on you to prove to them that their costs won't increase. You'll find it very difficult, because those costs probably will increase.
>The clarifying factor where you hold the cards and knowledge, and they don't (and therefore feel shame) is the simple fact that universal, taxpayer-funded healthcare is far cheaper than private healthcare.
What's your evidence for that? Because if you're going to cite other countries then you also have to keep in mind that they have a completely different structure for healthcare outside of whether the government pays for it or not. The US does more biomedical research than other countries, doctors are paid more, more treatments are available etc.
I don't think it's nearly as easy to try to convince someone that universal healthcare is cheaper or better. Also, when you say universal what do you mean? Universal, where everyone gets it or the 'universal' that some (many?) countries do, where you have to be employed and pay over a certain amount of tax to get healthcare or healthcare is predicated on you having mandatory insurance?
Is there a successful example of the US government solving a Universal Healthcare type of problem? Perhaps at a much smaller scale? Maybe some of our military logistics, the space race, etc.?
I'm very supportive of universal healthcare but even I doubt in the governments capability to pull it off, we couldn't even pull off healthcare.gov without massive waste.
Regardless I will continue to support it even if it means a generational hit to get it right.
The government has successfully solved many large-scale infrastructure problems. Have you ever driven somewhere on a road? Was that road funded by you paying for a "road subscription" or as a benefit from your employer? Probably not. The government built it, and there are a lot of them.
I don't see why healthcare is any different. People wanted roads, so we built roads. People want healthcare, so we should build healthcare. It's the same exact thing.
Medicare is expensive per capita, and also is not self-sustaining: it needs people paying and not getting benefits to subsist. The entire social security paycheck wouldn't cover the cost of medicare per capita.
You say this like the free market people aren't already doing this. Despite how many bridges collapse they seem to think things are going just fine because the bridges haven't collapsed on the roads they use yet.
Start with Left-Wing newsletters. Infiltrate churches. Get some socialists on AM Radio. Start a propaganda Leftist cable network. Create partisan think-tanks. This will be a multi-generational fight.
The Right Wing has it figured out. Democrats think they are showing up to a debate club when the other side has been out for blood for the last 50 years.
Energize the base, and the moderates will eventually fall in line (just look how small and ineffectual the "Never Trumpers" turned out to be). The base drives things now. You can't just fire up the base and then slap a Romney or Clinton on top and expect to win elections anymore.
I appreciate your comment. A common theme I've seen through my politically conscious life (15 years maybe?) is that Democrats think Republicans are stupid, where most Republicans just think Democrats are misguided.
Where what you said comes into that is that Democrats think they can win just by nature of Republicans being incompetent. Republicans are out there, like you said, doing the dirty work to win elections and mind/vote-share, because while they disagree with Democrats, they know they can't just rest on their smug sense of superiority.
Democrats know most Republicans are stupid. Democrats just don't realize most of them are stupid too. Democrats try to play like it's an even playing field where everyone is playing by the same rules and are too afraid to get their hand dirty or be seen as having had to overcome issues in the past. Republicans see character flaws as a bonus just to spite the libtards because Rush told them right. The smart ones in the political sphere are just two sides of the same coin with slightly different opinions on the same issues to anchor what they think should matter in people's minds. I'd politics were rational we'd have significantly different political systems than we have now.
You're ignoring by the far biggest downside to state-sponsored healthcare: society now has a strong incentive to ban risky behaviors. If I'm paying for Joe Schmoe's healthcare, why should he be able to give himself liver disease by drinking alcohol or tear his ACL skiing? I don't ski or drink alcohol, so it's no skin off my bone if we ban alcohol and skiing.
If you're a minority in a society with universal healthcare, you will have to constantly fight for your rights. The second the rest of society decides your diet or your hobbies are too dangerous, they'll be pushing to ban you from partaking in them.
Also for #2, most democrats seem to support giving healthcare to illegals so I don't know why you act like that's a myth. And for #1, it's true for tens of millions of people that they will pay more in universal healthcare than they do currently. This is inherently true of all socialism (make no mistake, universal healthcare is socialist healthcare). If somebody is getting something for free, the money to pay for it is coming out of somebody's else pocket.
Your example already occurs, so I don't know why you're conveniently ignoring that fact.
Instead, healthcare companies charge more if you're at risk. They're implementing solutions to discourage bad behaviors. Worse, this is all packaged up in various apps designed to take your data and sell them to others to make even more money off of every single person they rip off.
Don't even get me started on how the insurance industry abused pre-existing conditions as a catch-all term for denying coverage for things that weren't even a result of life style choices. So how is this different from the horror scenario you bring up?
As Scott Adams said on Twitter the other day, we already have universal healthcare. You can't be denied treatment if you walk into a hospital and require treatment. That is, all the healthcare that covers everybody in the country is already paid for. What we don't have is universal healthcare _insurance_.
That said, it's undeniable that NPR has a liberal agenda. They swung so much in that direction in the past few years I stopped listening to them and switched to audio books for my commute. Best switch ever.
> You can't be denied treatment if you walk into a hospital and require treatment.
You will very likely be denied treatment if your condition is "only" a chronic one. And if you do show up with an acute+chronic condition, your acute condition (heart attack) will be treated, but no mandated follow-up for your chronic one (ongoing high blood pressure).
edit: watered down some of the absolute statements, you're all free to try your luck, don't take my advice blah blah.
As someone with hypertension, it costs something like $10/mo to treat with generic drugs. I know because I had to buy lisinopril out of pocket when I was between jobs. Not a good example. A better example would be something like diabetes, but I don't know if insulin can be denied or not (or whether there are other means for the poor to obtain it), maybe someone can clarify.
The larger point is, the "crazy expensive", acute part is already "universal". We just need to mop up the remaining stuff, formalize the arrangement, and call it a day.
Adams also makes another point in that this can't happen without downward pricing pressure for drugs and services and there currently isn't much. If you have a fancy insurance plan it doesn't matter to you if something costs $1000 or $10K or $1M - you aren't the one paying. What he suggests is insurance companies should give you a kickback if you find a service for less than a predetermined threshold. You already see this happening in some cases.
I believe Trump will create that downward pressure for drugs (as he promised many times during his campaign), but services are going to be an issue for years to come, perhaps until automation takes over.
Right, generic drugs are cheap, but you still have to find someone to prescribe it. If you show up in ED without insurance with a hypertensive crisis, they'll give you blood pressure drug doses to resolve/stabilize it, but I don't think they have to give you a prescription to fill. They might charitably do so, but what do you do on Day 29 of that prescription?
The "crazy expensive" part of health care is the long-term chronic conditions: they require a lot of care/tweaking/services over a long period of time. The lifetime costs of treating a diabetic exceeds the lifetime costs of the one-off hip replacement or hip fracture.
I dunno how Trump will create downward pressure on drugs without regulating prices on patented drugs or discouraging/defunding cost-ineffective interventions. That's how most other countries do it, but it seems incompatible with his philosophy.
Perhaps that's the part we really need to fix. I mean at least at the low end of the wealth spectrum it shouldn't cost like three hundred dollars to go to a doctor to prescribe a $10/mo drug. Heart disease is one of the leading causes of death, and it sounds to me like we could get a lot of bang for the buck, statistically speaking, by deregulating this and making prescribing blood pressure meds a "grocery store doctor" thing that doesn't cost much at all. As far as I can tell, the selection of drugs is really narrow for most people. I do agree it's tragic if someone who could be taking care of their hypertension can't do so just because doctors cost so much. I havent heard much about people dying due to lacking access to insulin, though, which leads me to conclude that it can be obtained even by those who don't have the means to pay the full price.
30.3 million people in the US have diabetes. Not all of them need insulin, but even those that do are millions of people, and lots of them are poor. It'd be a major cause of death if they couldn't get insulin. This means they are getting it somehow.
Most Type1 insulin-dependent diabetics start young, so it’s in the manufacturer’s interest to get you on their insulin for free in hopes that you get coverage later in life.
For type 2 diabetics, most are in or will be covered by Part D, so the manufacturers do the same thing.
But for a one-off treatment for those the middle aged, like the new HepC treatments, manufacturers don’t have the same incentives.
Scott Adams has no idea what he's talking about and is reaching for a pithy and wrong oversimplification, per usual.
A mandate to receive emergency care is not universal healthcare. You still die from the cancer you get and can't afford to treat because it is not emergency care.
NPR doesn't have a liberal agenda, who knows what you're talking about. If anything, they bend over backwards to hit "both sides" and corporate narratives.
Nonetheless, if you were to come down with an acute illness that requires hospitalization, or break a leg (god forbid), you will get care whether you have the means or not. That is, by definition, "universal" healthcare. I did say he simplified the situation, but not by much. He did it for the purposes of persuasion, as he often does.
His main point was, _we are already paying_ for universal healthcare, since everyone who _really_ needs the expensive stuff done, gets healthcare care. It's hard to argue with this.
import { INormalizedModules } from "codesandbox-import-util-types";
import { ITemplate } from "codesandbox-import-util-types";
export function getMainFile(template: ITemplate) {
switch (template) {
case "vue-cli":
return "src/main.js";
case "angular-cli":
return "src/main.ts";
case "create-react-app-typescript":
return "src/main.tsx";
case "parcel":
case "static":
return "index.html";
case "gatsby":
return "src/pages/index.js";
case "gridsome":
return "src/pages/Index.vue";
case "mdx-deck":
return "deck.mdx";
case "styleguidist":
case "nuxt":
case "next":
case "apollo":
case "reason":
case "sapper":
case "nest":
case "vuepress":
case "styleguidist":
return "package.json";
default:
return "src/index.js";
}
NPR tries to show both angles of stories that tend to be primarily on the liberal radar.
They are my main source of news, but there is a lot of truth to "you report what you see", and most of the reporters are liberal, so they cover liberal issues. I agree that they go out of their way to correct for that bias, and I appreciate that they do.
I think public radio in general leans left of the location's center. Living in a purple / red state, that seems to put it at a pretty happy medium. Also you just need to read between the lines a bit. They do try a lot more to be balanced than many news outlets.
I still have no idea why they think "Wait Wait Don't Tell Me" is a show that deserves air time though. Worst radio show I've ever listened to.
These are going to be recognized as a policy disaster.
There are many cases where a somewhat expensive treatment saves a very expensive hospitalization.
For instance, a steroid inhaler for asthma costs about $200 a month, maybe you have two $200 specialist visits a year. So for $2800 a year (not covered by high-deductible insurance) you can probably be symptom free or you can take your chances and have an exacerbation and a $28,000 hospitalization (which insurance will pay some of after the deductible)
Docs hate them too.
With real insurance, you have maybe a $20 copay you pay at time of service and they know they are going to get paid by the insurance.
With fake insurance, they don't know what you are going to pay until months later when the insurance gets around to telling them. Then you get a bill that says you owe $291.44 for some unspecified service you got 6 to 18 months ago.
(They can't tell you what it was because that would violate your privacy)
Needless to say they have a big accounts receivable this way, many people don't pay or they pay late (e.g. a few months after getting a bill they don't understand as well as something that says "THIS IS NOT A BILL" they don't understand). This is not good for their finances or their state of mind.
In theory high-deductible plans might lead you to shop around between providers to get a better price but in practice nobody can or will tell you what things costs and it doesn't work.
It's a perfect example of the neoliberal mind at work.
My premiums and deductible are north of 10k. This is why I laugh when some one tries to scare me with the old "with Medicare for all, your taxes will go up!" I'd gladly and enthusiastically pay more in taxes to rid myself of the current system.
I used to think employers would love to have to be able to stop offering insurance. But then I realized for the most part, employers love the current situation. Offering health insurance keeps employees chained to their desks. They'll moan every now and then about costs going up, but the current system ultimately serves them well.
What if someone suggests your taxes would rise by 10k? Are you concerned because that much money is an expenditure you can’t afford, or is it just behavioral and you’d rather prepay in the expense in your taxes than choose to spend it?
If you get access to the same level of health care even during periods of unemployment - meaning, you might be paying no taxes at all - I wouldn't mind a bit.
The top level comment gave a perfect example why. Preventative care is cheaper than emergency care. When everyone (including the unemployed) can get preventative care, total costs go down.
That unemployed person with no insurance still gets emergency care. The hospital doesn't turn them away to die in the street. They don't pay the bill. They go into bankruptcy instead. The hospital makes it up on all the paying customers (the insured). Your $10k is already paying for the ones who don't have insurance. Medicine is already socialized!
Now, if we can acknowledge that, can we do the fiscally responsible thing and make sure everyone can get preventative medicine?
> When everyone (including the unemployed) can get preventative care, total costs go down.
This is one side of the coin: when everyone goes to the doctor on a cold, total costs go way up. Its an economic problem, it requires economic solutions. Private insurance, for all its bad rep, has very strong incentives to have proper utilization. More so than government: when a patient gets hospitalized, insurance loses money. Govt never loses money!
> Your $10k is already paying for the ones who don't have insurance. Medicine is already socialized!
>Private insurance, for all its bad rep, has very strong incentives to have proper utilization. More so than government: when a patient gets hospitalized, insurance loses money.
"when a patient gets hospitalized, insurance loses money...." and the patient gets the treatment they need. you seem to have forgotten that part.
"Proper utilization", in a private sense, is the same as "maximize shareholder value". Anything that damages shareholder value is not "proper".
Sick people have very strong incentive to want treatment. HEALTHY people have very strong incentive to want treatment for sick people. Private insurance has very strong incentive to take in as much money and pay out as little as possible.
> and the patient gets the treatment they need. you seem to have forgotten that part.
> "Proper utilization", in a private sense, is the same as "maximize shareholder value".
Access - Quality - Cost. Somebody has to make a choice.
If what you care about is unabated and unrestricted access, get ready to pay more than what you pay today.
Insurances don't provide medical care: they don't have patients, they have clients that wish to not pay doctors directly and be protected from the risk of sudden high costs.
Don't complain to your car insurance company that cars are expensive!
As long as the other ways require less effort for the patient/care receiver to worry about where to find quality health care, I'm game.
If I have to shop in a market full of confusing terms, exceptions, reams of paperwork (I am not a medical expert) the solution is already crap. When it comes to health care, the a provider should not have an opportunity to gain advantage by segmenting the market into different groups or risk pools, or hiding behind long and complex policies that require a subject matter expert to understand.
Before the ACA, a colleague with a small consultancy (IIRC ~10 people) discussed how ridiculous the term “market” was: none of the companies would even tell him the coverage details for the plan (“each member will get a booklet”) so the idea of shopping around was positively Kafkaesque, lacking basic information and having substantial time and cost penalties if you realized you made a mistake and wanted to switch.
I'm proposing we don't accept higher taxes and/or universal health care as foregone conclusions. I think we can do better than just sitting here on hacker news and smugly mocking those who "don't get it."
If you take away my 20k health insurance premiums (many commenters are not counting employer contributions), tax me an extra 20k, and now I have no deductible and can switch jobs fearlessly, how am I not better off?
I hate my HDHP but as far as I can tell it’s ultimately driven by the massive increases in medical care costs. My total premium cost (counting employer contribution) is a little more than 20k and I have a 7k deductible. How much higher would the premium be with a more reasonable deductible? You pay one way or another.
I agree it’s a huge nightmare dealing with the bills and claims processes, but I’m not sure that goes away with high deductible plans.
At the end of the day we have to get medical costs under control and I don’t think there are any great ideas for that right now. Public single payer will help, and it could at least end the billing nightmare, but I don’t see it actually solving the underlying problem of skyrocketing health care costs because the problem is too big and people are too politically invested in the way things are now.
The insurance company is coming out ahead on me, even when I had a kid I still paid them more money than they paid out, but a coworker’s wife had a heart attack and had some extraordinary care that the insurance was ultimately paid more than a million dollars for. These major health events and chronic illnesses are completely through the roof in terms of costs.
If HDCP and other plans exist on an open market, then the difference of the cost between them tends to be the amount of the deductible. This is what I have seen on the Obamacare exchange and also in prices for employer provided plans.
The reason for that is adverse selection. If you don't expect to go to the hospital then you can save money with the HDHP. Only very sick people will choose the more reasonable deductible.
In my experience at three different employers the lower deductible plans are more expensive by more than the difference in the deductible. That is, in my experience, it has always been more rational to choose the higher deductible plans because even if I assumed I would always meet the deductible the cost of the deductible plus the premium was always less on the HDHP.
More or less this. I am a person who exceeds not just the deductible but the out of pocket max more years than not. The out of pocket max on the bronze plan is something like $7k and the out of pocket max on the platinum was still $5k, but the premium difference is $900/mo. There are certainly cases where you come out ahead on the platinum but I think they are unlikely for most people.
While not applicable for everyone (such as your asthma inhaler example), HDHPs aren't bad for people who don't have regular health expenditures. I like my HDHP for two main reasons:
- Regular annual checkups are still free
- You get access to an HSA account, which is effectively the most tax-advantaged retirement account available. You can deposit income pre-tax, invest the balance (minus a few hundred), and withdraw tax-free as well for either health expenses (at any time) or for any purpose (after 65).
Why I was 25 I hardly ever got sick. Now I'm double that age, and I'm in good shape but eventually something will happen. When I was 25, I could have had a hdhp then, but I was a super poor grad student and got whatever my university offered, a regular plan. Eventually I got a real job, there was no hdhp offered and I had regular insurance. The thing was, by being part of a larger pool, I was helping make insurance reasonable for everyone. That's as it should be. I do think ubiquitous health insurance that everyone has will save money in the end, and it's a humane necessity.
You are right that the HSA is a nice complement for the HDHP. If your employer has an HDHP and puts a good chunk in your HSA for you that could be a better option than a conventional plan.
Policy disaster? On the contrary, insurance companies love this. They have a counterintuitive conflict of interest - that is, they make more money when health costs are more expensive, through higher premiums.
> they make more money when health costs are more expensive, through higher premiums
Do you have a citation for this? If this were true, why would they aggressively negotiate lower costs and offer discount Rx cards?
In the US, higher premiums mean fewer subscribers. I'm a co-founder of an auto-insurance company, and all we ever try to do is lower premiums in order to compete.
> The 80/20 Rule generally requires insurance companies to spend at least 80% of the money they take in from premiums on health care costs and quality improvement activities. The other 20% can go to administrative, overhead, and marketing costs.
Basically, if you want to make more profits, you have to increase the raw size of that 20%. There's really only one way to do that - raise premiums. You can't really lower costs, as you risk having to pay back your subscribers for having shrunk the costs side too much.
Assuming you have competing insurance companies, then you can’t just raise premiums if your costs are unnecessarily high.
Unfortunately, a properly functioning insurance market would require dumping everyone on the market, not just those who aren’t lucky enough to have it from their employer, who tend to be in better health anyway.
>Assuming you have competing insurance companies, then you can’t just raise premiums if your costs are unnecessarily high.
That's true if it's just your costs that are unnecessarily high. But you can encourage policies and regulation that raise the total cost of healthcare for everyone.
The main factors keeping cost high is low supply of doctors, hospitals, and medicines. I’m not aware of any insurance industry effort to keep those supplies down. If anything, seeing a doctor who charges $200 for a 5 minute visit to prescribe antibiotics for a fever or a hospital that charges $7.5k for a no complications birth is what keeps prices high.
If people had doctors and hospitals competing to offer standard procedures like births, broken bones, fevers, etc at lower costs, then that’s what will bring prices down.
>The main factors keeping cost high is low supply of doctors, hospitals, and medicines.
This is an enormous oversimplification unless you are taking such a broad view of "low supply" that it loses usefulness.
>I’m not aware of any insurance industry effort to keep those supplies down.
I don't know every policy that insurance industry lobbyists push. I do know that they lobby against price transparency--the lack of which almost certainly plays a role in healthcare costs.
>If people had doctors and hospitals competing to offer standard procedures like births, broken bones, fevers, etc at lower costs, then that’s what will bring prices down.
For elective procedures like plastic surgery and LASIK sure, but overall medical care is full of such extreme examples of market failures that you need more than just free market competition to control costs.
I’m not aware of them lobbying against price transparency. I can easily search procedure codes on my insurance website and get the cost back. What I can’t get are the procedure codes from the doctors or the hospitals, somehow not a single person that works there knows what procedure codes will be billed.
This is starting to feel like the mortgage crisis again - specialty tools that are not in themselves bad, are being misused to bolster affordability and in the process create very bad financial situation.
The HDHP + HSA are great for those that can afford them AND are in good health overall. Good employers also add to your HSA each year to help with the initial costs.
The HSA is a lot better than the FSA, which creates bad incentives on use it or lose it money.
The problem becomes when HDHP is used without a well funded HSA and with insufficient income to handle the deductible, together with health problems.
We took a HDHP just in order to qualify for the HSA. It probably doesn't save us money on the health-care side, but the HSA as stealth additional retirement account more than makes up for us.
The best part of the HSA is that you can save your receipts and reimburse for those expenses 30 years later instead of right away so that you can pay with gains rather than principal.
You phrase that as if the people choosing HDHP without a funded HSA could actually afford a traditional low deductible plan.
My current insurance is something like $35k / year premiums for a 3k/6k family plan (which is actually a 6k/12k plan since 3k is when they start covering anything, and it isn't until 6k / 12k that they actually start picking up the whole bill)
There is no way I could afford a "low deductible" plan.
I’m saying as a society/country/large group of people, we are choosing to pretend to offer affordable healthcare options, but in reality using specialty products designed for relatively wealthy and healthy people as a mainstream option.
For financial/healthcare situation described, we need a true affordable option, not an exotic instrument.
As a society we did the same thing with exotic mortgages and pretended they were affordable.
The health care system in this country is a crime. It is structured to take advantage of people at their weakest and most helpless. We spend 3 times as much per capita as most other industrialized nations and get worse outcomes overall.
That is correct. I am originally from Israel and moved to California 7 years ago. I'm very healthy but on the rarest of occasions, when I do need to get SOMETHING done, it has proven to be an absolute nightmare, and I always walk away feeling like I've been scammed.
The one time you aren't being scammed is when you get something done and actually get to bill the insurance company.
Paying monthly installments on your insurance plan, only to have to pay for your healthcare costs anyway (first the deductible, then this new maximum out of pocket they added to me this year), that's the scam.
In reality, if you're spending ANY money on healthcare in the US you're getting scammed. The healthcare you'll find in Israel and Europe is the modern standard of care and the US is on the opposite side of the spectrum with our corrupt for-profit "healthcare" industry. We pay more for generic crap (generic only has to be 80% as effective as brand) than modern countries pay for 'Made in USA' brand names.
One thing people miss is, we're paying our doctors _several times_ as much. If that doesn't change (and nobody wants the doctors to earn as much as they do in Europe: there just won't be any doctors), there's really no way to achieve the same cost structure without replacing doctors with something like machine learning in a lot of capacities (radiology/imaging most immediately, other diagnostics in the longer term).
> (and nobody wants the doctors to earn as much as they do in Europe: there just won't be any doctors),
Why are there doctors in Europe then?
As I've read, it doesn't seem that the cost of healthcare is dramatically higher in the USA because we pay our doctors more, it's because of the insurance industry, and how much money people have to spend figuring it out (hospitals have to have staff specifically to deal with it, as their whole job).
Because coming to the US is a hassle and we'd force them to basically re-qualify to be allowed to practice. Some European doctors do move here and go through the hassle nevertheless.
Regarding insurance, I believe since ACA was enacted there's now a limit on how much profit an insurance company can make, as a percentage of the money they pass through. I'm not a specialist in this field, but this seems to have only made matters worse.
Ok, to be clear, you seem to be suggesting that everyone would live in the USA by default if they could, and the only thing stopping them is inconvenient immigration and the cost of a plane ticket?
I feel like I must be misunderstanding you because it seems a bit silly.
??? I'm trying to, hence my attempt to clarify. Could you please help me understand what you were saying? I'm trying to read it as anything but how I've restated it, but I genuinely can't.
How about this - if America didn't exist, and doctors got paid what they got paid in Europe right now, why are there doctors in Europe?
Are you getting "scammed" because you have homeowners insurance and you didn't burn down your house? No. The money is to pay for the worst-case scenario.
The problem with health insurance is that "rare but catastrophic" is not the only health-related expense that people have. It covers that case quite well, so isn't really a scam, but it also doesn't give people exactly what they want -- seek medical attention whenever and for anything with no financial outlay.
This shouldn't be surprising. If you're on an employer-based healthcare plan, a HDHP only makes sense if you're young, healthy, have no dependents, don't take expensive medication, and your employer pays most of the annual cap into your linked HSA.
I fit most of those checkboxes, but I take PrEP (preventative HIV med) that is something like $1500/month before deductible, and the math for HDHP vs traditional plan does not check out in that case at all.
If the difference between the premiums for a non HDHP and the HDHP deductible is not too big, I can very well see it being worth it to go HDHP just to take advantage of the triple tax advantage of HSA.
Pay for medical care/medicine with after tax, save the receipts, and let the HSA contribution with pre tax money grow tax free in a Fidelity HSA (since it’s free) and then withdraw it whenever you want, and just pay yourself whenever you need the money.
There's a whole thing with the $0 copay coupons on many expensive drugs like this, it usually just depends on which insurance you have. In many cases the drug companies have actually set up charities which will donate your entire max out of pocket on an HDHP regardless of income.
Obamacare is unfortunately a band aid solution and does nothing to address the fundamental issues:
1) complete lack of price transparency, which means virtually no price competition between clinics / doctors
2) artificially low supply of doctors to jack up prices
3) corrupt regulation to prevent consumer health startups from existing
Fixing these issues is going to take a lot more than just taxing people for not buying high deductible health insurance.
There's no fundamental reason why most doctors should get paid more than airplane mechanics for example. Either way if they mess up, people die.
I got an individual HDHP as soon as I turned 18 in 2004. Shopping around on these plans is not easy, I'm really the only one to do it. I thought it would get easier as more people got HDHPs, it got a little bit better over the years and then drastically went downhill after the ACA. Two main reasons: reduced competition, and our bizarro culture where no one blinks at an $800 surprise bill.
I used to have a couple imaging facilities that I went to because their rates were low. In the past few years they have all been bought up by some sort of conglomerate and prices have gone up. It’s not advertised, so I literally have to call the place, talk to the back office and find out if they’ve been bought. So last year I go to the one place that hasn’t been bought, rates were good, I go this year and the bill was a surprise. Even my blood test rates have gone up this year, I’ve asked several doctors and they’re like “Yeah, it’s pretty much Quest or Labcorp now.” So my rule now is, if the back office has no clue what they're doing, they will likely be cheap, and they will likely either get bought up or go out of business.
Many years ago when I’d go to the doctor I think I was literally the only one with an HDHP, and the allowable amount would come out to $200, and they’d go “Oh, that’s not right. How about $60?” And just take $60 from me and call it a day. Now when I ask “Will this test cost me more than $200?” No one has an answer or seems to care like we are in some crazy bureaucracy.
I was on high-deductible plan a couple of years ago, and went in for an allergy test. After the test, I got a bill for $750 ish. Insane. This was in November as well, so two months later the deductible would reset in 2 months. In the same year I had a whole array of expensive dental work done, and I almost exhausted my HSA. I swore off high-deductible plans ever since then. Even though I'd selected a HDHP at the beginning of open enrollment (in Nov) that year, I was able to call HR in December and switch me to a normal PPO plan (which just had copays).
I’ve always contributed the annual maximum into the HSA so there was never a question for me of running out of money to pay for care, and it hasn’t held me back from seeking medical care or treatment.
However, it’s perfectly possible for someone to elect the HDHP and not contribute to their HSA, in which case you could be facing a $3000 or higher bill without the money to pay for it. It seems like this is the case described in the article.
With a fully funded HSA I almost feel like I have the opposite problem, which is I don’t feel a need to attempt to shop around and compare prices.
In general it feels like the HSA/HDCP experiment has failed although I’ll keep using it for as long as it’s offered, as I like the ability to build up my savings every year in the HSA and eventually use it as a second retirement account unless I have a huge medical problem in the future.
When selecting from health insurance options, I only ever consider HSA plans, which typically have large deductables.
Why?
The US has the best health CARE in the world, but with a crappy health insurance system. The health insurance has been regulated to a hot mess by cronies and politicians that is slowly destroying the care system.
An HSA gives you more control of your care.
Rationing care is not the answer to solve the insurance problems. I'm not interested in waiting for long periods of time for rationed care, such as what is seen in Canada.
For all its faults, at least I can get an MRI within a day or two, and can see a specialist within a day or two. That's way better than waiting on rationed care.
i hope this is a transitional cost. i am on the fairly liberal end of things but was hoping high deductible plans would force prices lower by getting consumers involved while still protecting against catastrophic events.
and we are starting to see pressure on drug companies and medical care (epic pen issue for example) as consumers push for reform now that they are feeling it in their pocketbooks more directly.
> but was hoping high deductible plans would force prices lower by getting consumers involved
Part of the problem here is a lack of price transparency. That's what's stopping consumer choice driving any price reduction. It's very difficult to shop medical expenses. In the end it seems like the main choice they give you is really either to do it now or delay.
I have never understood how this is supposed to work.
I can imagine shopping around for things that are a) have perfect substitutes and b) aren’t urgent. For example, maybe you’d pay a bit more for an MRI of your painful knee if it were at a convenient time or in a nicer facility, vs. 5am in a cold bore with no movie or other frills. Perhaps you opt for a cheaper generic or a twice-a-day pill instead of the more expensive extended-release version.
Everything else comes with some fairly tricky cost-benefit analysis. How badly do I need to be screened for this or that? If something is missed now, how much worse will it be later—-and how much will it cost then? I’m skeptical that a half hour on WebMD will do much to improve on a trained doctor’s recommendation.
It is more an issue of supply. The inflow of new doctors and new healthcare business is constrained by the incumbent system. Besides the cartel network that has established, the new potential disruptors are prevented to enter the market all in name of regulation and safety measures. Now it is a positive feedback loop when the current players are incentivized to lobby for a new safety regulations to prevent new market entrants rather than improving the service.
Switching from a co-pay based insurance to an HDHP + HSA was a big change. My deductible is quite high, so all normal, non-catastrophic medical costs are paid for without insurance.
A doctor visit starts at $139 and may be from $300 to $500 depending on the diagnosis. One cannot determine the cost in advance. Any lab work is extra. Is it worth $1000 every year to have a doctor do standard blood tests?
Like anything that suddenly becomes very expensive, it makes one look at things differently and question whether they are necessary. Some people put off doctor visits longer until things seem unbearable. Some research online and try to self medicate with over the counter things.
I'm exhibit A. I signed up for an HDHP because I didn't want to pay a monthly premium and thought and HSA sounded like a great way to save for health expenses. I had a bout of rhabdomyolysis after pushing myself while at the gym, after doing some research and learning that it probably wasn't life threatening I decided to wait it out and self treat instead of going to the ER.
In what way are they putting downward price pressure? every tried to get prices for a treatment so you can pick a cheaper provider? It's close to impossible to get any numbers.
I have found that by paying the same amount as the premium of the PPO into my HSA that I come out even, if I end up spending the whole deductible, or ahead (i.e. building savings), if I don't. In other words, I don't see any disadvantage to HDHP+HSA vs. PPO plan.
A little off track rant but the tax and health policies of USA are super freaking unbelievable. Why on Earth can one not be eligible for a HSA when they don't have a HDHP? The healthcare is screwed up. The least you could let people do is use their pre tax monies for the health treatments.
And don't even get me started on FSA and forfeiture. That's MY money. What the hell do you mean the amount is forfitted?
Apologies for my language. The policies are making me go crazy.
Try showing an NPR article about universal healthcare to Joe USA. I guarantee you'll get one or all of the following responses:
1: I don't want my taxes to go up
2: I don't want to pay for illegals to go to the doctor for free
3: My insurance will get worse
4: I like my doctor, I don't want to be forced to go to a worse one
5: I don't want the government deciding when I go to the doctor
6: I don't want to wait six months for a doctor appointment
7: NPR has a liberal agenda
Many of my family and extended social circles are quite conservative (in the USA sense) because of how I was brought up. I have heard all of these and more every time the concept of universal healthcare is brought up.
Most of the reasoning I hear is not based on facts, but on emotionally misleading arguments from the network of memes and punditry where they get their info. And when they vote, they vote for people who oppose universal healthcare on these fallacious bases.
How do you convince someone like this that universal healthcare is better for all of us?