I can’t speak for @Chronos, but when the final phase of universal single-payer health care was introduced in Canada back in the 60s, health insurers had to haul their sorry asses out of the country because there was no business here for them. Blue Cross and a few others are still here offering supplemental forms of insurance, but it’s illegal to try to make money by insuring medically necessary health care. The opportunities to make big bux are gone, and so are most of the big health insurers.
That has nothing to do with health care funding. It’s a worthwhile discussion, but a completely different topic. Again, to take Canada as an example, health care services are provided by a mix of non-profit (mostly large hospitals) and for-profit (doctors, clinics, and labs) organizations. They all bill the same single-payer health care system.
I want to close the companies whose purpose is to charge people to deny them health coverage. Those companies serve no good purpose and do considerable harm. I have nothing against for-profit hospitals.
I seem to recall that we had a thread on this a few years ago: “What did private health insurers do when Canada introduced single-payer health care?”
The answer, as I recall, was that they diversified. They could offer supplementary health insurance (dental, vision, prescription, etc.); and/or they offered whole and term life assurance; and/or they even got into casualty insurance–Aetna was known in Canada as “Aetna Life and Casualty” for a number of years after single-payer was introduced; during which, it also started offering sureties on construction projects. Now that’s diversifying!
Point is, that today’s American Aetnas and Cignas and Humanas and Kaisers need not go out of business, if UHC is introduced. All they need to do is diversify their products.
Some did diversify, yes. Here in Ontario one of the major former health insurers got into an interesting sideline business when the first Ontario public health plan was introduced, because the government was not yet equipped to handle large-scale payments processing, so the insurer did it for them, for a fee, of course. Eventually the Ontario government got their own payments system together, which today pays all health care providers through electronic transfers.
Isn’t that true of any law firm’s partners though? That whole structure (and that of consulting firms) seems to have been cribbed straight from the Mafia- everybody above gets a cut.
One of the problems is that many people have a large portion of their premiums paid out of secret money that they never had their hands on, so it doesn’t actually feel like money that they’re “paying.” That can be replicated with taxes (the “employer” portion of Social Security works much the same way) but that would add complexity to both the legislation and the argument.
If Joe currently pays $7,700 a year for insurance, but $6,200 of that is the hidden employer contribution, he is not going to be happy if his overall bill is reduced to $6,000 but the hidden portion is reduced even more to $4,000. To Joe, that is $500 less in his pocket, and even if he gets a raise out of the money the employer isn’t contributing, you’ll be pushing uphill to explain it.
Except, say you live in a town of a thousand people, where everyone has a net worth of $10,000 except for that one guy who has a net worth of a hundred million, which means the average net worth of the townsfolk is $109,990, or almost eleven times what it is for almost everybody. Averages can be quite non-meaningful.
That depends entirely on how you design and specify your UHC system: regulated (how and to what degree?) insurance, or public service funded from taxation (levied on what or whom and to what degree?)
Coming from a country that’s had the latter for 75 years, and is always debating the boundaries and funding levels (but virtually never the founding principle) of a public service system, I can say that my (very rough, back of an envelope) calculations are that the amounts of tax going into the NHS are about 4-6% of gross income for most people on average household income up to £150k a year - plus just under 4% VAT on whatever goods and services are VAT-able.
Depending on how you structure your tax system, you pay more the more you earn (and vice versa). You pay in (whether you like it or not) when you’re healthy and get back according to your clinical need (within the budget of the relevant NHS facility treating you and whatever treatment protocols the clinical system recommends). In my case, being retired I no longer pay the payroll-related National Insurance tax, so my contribution is below 4% of gross income (after 40 years of payment in, with minimal call in the service): I also (currently) pay nothing for my prescriptions.
The advantage is that actuarial risk is pooled, and provision is based on one’s clinical need if it’s been judged cost-effective, across the whole population, rather than one’s individual status.
The disadvantage is, as we repeatedly discover, that it’s not difficult for governments to let budgets lag behind rising costs and to trade on staff goodwill to avoid generous pay increases. It was remarked years ago that the NHS is a cost-control system.
It may or may not be relevant that it was touch and go whether the system could be set up in the first place, until as the founding minister said “We stuffed their mouths with gold”. The hospitals and senior clinicians were mostly relieved (after all the difficulties of WW2) to be nationalised (especially once the senior clinicians were allowed to spend a proportion of their time on private practice); but GPs resisted till almost the last, being bought off by being made the linch-pin of the system as the first port of call and gatekeepers, while retaining the status of self-employed contractors.
Nowadays, it’s the staff, at all levels, and particularly GPs, who are the most passionate defenders of the system as it is.
But that’s us. Up to you how you design what would suit you.
Yes, the thing to realize is that hospitals and insurance have different goals, even if they can both be summed up as “profits”. Hospitals make profits when they treat a patient. Insurance companies make a profit when they refuse to treat a patient. The goals are inherently mutually opposed, even if they’re both “profit-driven”.
I think a huge money saver in UHC is not the premium vs taxes question. It’s the fact that, despite paying premiums, more often then not you still have to pay copays, medicine, 20% of tests up until your deductable, equipment costs, etc. Hell if you told me we will quadruple your premiums but you never pay out-of-pocket, my response would be, “Where do I sign up for that?!”
If you quadruple my SHARE of the premiums it would be more than 40% of my gross salary. Any my salary is over the 80th percentile and 2.5 times the median for full time employees in my very large company.
If you quadrupled the total premium (i.e. including what my employer pays) it would be more than my entire gross salary.
Too much treatment can be worse than not enough treatment. In theory, the people saying “no” are looking at appropriate care, not just cost.
Now, i am currently paying out-of-pocket for an expensive estrogen patch because my drug insurance has decided that a daily cream is good enough, and doesn’t want to pay for the patch, which is much more convenient and doesn’t risk giving estrogen to my husband and my cat. I’d that a fiscally responsible choice or an inappropriate denial of care?
But i don’t really think this is a point where universal health care different from private health care. For years the argument against universal health care was that the government would impose that kind of limit. And in practice, government-funded universal health care DOES limit what’s available, much as private healthcare does.
I can’t find info on the version I’m taking, but it looks like Medicare doesn’t cover the version i would want when i get my IUD removed.
I also scrolled through the formulary for Medicaid, and they do cover a generic, but the generic i tried didn’t work. Even when it didn’t fall off (it often did) i got hot flashes for the first time since I’ve been on estrogen. That may be a problem with the generic approval process (my problems were far from unique, the internet is full of complaints just like mine) because in general, generics are a good thing. But it suggests that universal health insurance is not the solution.
I think it would be valuable to analyze what limitations are imposed by various systems, especially comparing across nations and various types of health payment systems. (Many nations have managed competition to provide universal coverage, rather than a single payer system.) I haven’t seen anything like that in more than a decade, and there’s a lot more healthcare potentially available now than in the past.
But I believe that every healthcare funding system will have both a “pay” and an “avoid paying too much” component. That’s a lot wrong with our wildly expensive, inconsistent, wasteful, and inequitable healthcare payment system in the US, but “someone is paid to say ‘no’” is not really on the list.
FWIW, politicians over here don’t legislate on what is or isn’t clinically desirable*, and the NHS does allow for a variety of means of delivery for HRT, according to the patient’s preferences.
There is an NHS organisation that investigates what treatments are cost-effective across the whole population, and produces treatment/guidance protocols: but it too is expert-led. Unfortunately these aren’t available to readers outside the UK so I can’t link to it.
That would be NICE: “Evidence-based recommendations developed by independent committees, including professionals and lay members, and consulted on by stakeholders.”
Of course, that’s a matter of policy with any individual UHC system, but yes, in general private insurance loves to ding you with both co-pays and deductibles, as well as of course scrutinizing all the details of each claim to see if they can weasel out of paying altogether.
One great thing about the UHC systems we have in Canada is that there are no out-of-pocket costs for medically necessary health care. Whether it’s a routine doctor visit or a major hospitalization, the patient never owes a single dime. The Canada Health Act provides for a uniform set of standards across all the provincial systems, one of which is that the practice of what used to be called “extra-billing” (essentially, any kind of co-pay) is prohibited.
I’ve seen arguments that modest co-pays prevent medical overuse, but those seem to be artificially contrived arguments with no basis in fact. I’d be surprised if anyone can find me a person who visits their doctor just for fun, but it’s an actual fact that there are people who would be discouraged from seeing their doctor because even a small co-pay would be a hardship. The elimination of extra-billing was based on one of the fundamental principles of federal health care policy, that financial means should never be an obstacle to accessing health care. Whereas with private insurance, health care is a business; it’s all about money, from start to finish.
Now that’s diversifying!