Derived from “That’s more than my job’s worth” in response to any request for a bit of latitude in interpreting the rules, so pretty much what you describe (see also our immigration and benefits agencies, but when it comes to the NHS you’re dealing directly with doctors and nurses - though receptionists often had a bad reputation).
This is a bigger part of it than most people want to admit. The folks making the decisions all have GOOD U.S. insurance. That means they get lots of treatment easily and cheaply (for them, doh). They don’t want to risk UHC, which is “broader but shallower”.
I’m a huge fan of the Canadian system, having grown up there and having family and of course many friends there. But I’ve seen several specific instances where I could see huge differences between care in the U.S. with good insurance vs. what Canadians get. Not “worse” care in a medical sense, just less…optimal? desirable?
Let me cite some specifics.
15 or so years ago, my wife tripped and hurt her shoulder. A few days later, she went to the ortho. He did an x-ray and said he couldn’t see anything, but it could be a small fracture or a small rotator cuff tear. If it was a fracture, it would heal in a couple of weeks; if a tear, it would need surgery if it didn’t resolve on its own. “I can send you for an MRI if you want.” She did, she got the MRI, and it was also inconclusive. So beyond even the lack of meaningful results, the more logical approach would have been “Take NSAIDs and see me in a few weeks”. But no, we had good insurance, so she got the MRI.
A friend up in Canada had colon cancer. He was operated on within a few days of diagnosis, sent home with a colostomy bag. When healed, he then had to wait for the stoma to be repaired. Like six months. Can you imagine an American with good insurance waiting six months for an unnecessary colostomy to be closed up? I don’t think so.
Several years ago, I had a ganglion cyst removed from my foot, under local anesthetic. After he pulled it, the doc showed it to me; I said, “Are you going to send that to the lab?” and he said “Absolutely!” When I returned for followup, he told me that it was benign, that he’d known it was benign, but he volunteered that that was defensive medicine: "In med school, they told us that if someone EVER says ‘Are you going to send that to the lab?’, the only possible answer is ‘Absolutely!’, because if you don’t and that’s the one time you’re wrong, you’re toast.
Finally, I suffer from occasional BPPV (vertigo). I’m also bradycardic, have been for years. Last time I went to the doc for something else and mentioned that the BPPV was back, she sent me for a full cardiac workup. Which came back fine. When I saw her next, I asked her, and she admitted that that was 100% defensive medicine: vertigo+bradycardia=full workup, full stop, because if she’s wrong, again, she’s toast. Even though both of those conditions are chronic in my case.
Anecdotes aren’t data, but they can be illustrative. The above are examples of probably > $10K in wasted medical resources here in the U.S., none of which would happen in Canada. Nor, of course, would the Canadian incident happen here.
This is getting long, but for all the scaremongering BS about “People waiting years for emergency surgery with UHC!!!”, there’s a grain of truth to it in that people MAY wait longer for NON-critical procedures. And while I find that entirely just and reasonable, it is, well, kinda on the socialist end of things, and as DrDeth notes, many people are in the “I got mine” camp (and don’t get me started on the “socialism is a dirty word” thing).
I don’t know how anyone can make hay out of this revelation to promote UHC–I don’t quite think a campaign saying “Don’t be selfish about your healthcare” would help!–but recognizing it is, I think, beneficial in understanding why some people are so strongly opposed despite all the evidence of its goodness.
That (the whole post) is a cogent analysis and I completely agree. All OECD and similar countries all implemented UHC a long time ago. In Germany, it essentially goes back to the time of Bismarck, and in the UK, to the sweeping post-war social reforms. In Canada, Saskatchewan implemented hospitalization coverage at around the same time, and evolved it to universal coverage for all health care services in the early 60s. With the demonstrated success of this working model right in our own homeland, it quickly expanded to all other provinces and territories with federal funding and oversight.
The US, meanwhile, continued implicitly to believe that free markets can solve everything and that governments can solve nothing. They continued to believe Ronald Reagan when he told them that government doesn’t fix problems, government IS the problem, and they continued to believe it even though it was the same guy who had told them earlier that if Medicare was enacted, it would be the end of “freedom” and the end of America as we know it. And, cheerleading in the background, the big and ever-growing health insurers heartily agreed.
At the same time there were major changes in the health care landscape. As health care technology evolved, it became capable of fixing more and more health problems, but at ever-increasing cost. Health insurers flourished, becoming ever more powerful and more entrenched in the health care system, and today the combined health care interests as a whole are the most powerful aggregate lobby group in Washington. To make things even worse for health care reform, we now live in an age of disinformation where the lies promulgated by health insurers, misguided organizations like the AMA and hospital associations, and right-wing ideologues are more pervasive than ever, and facts hardly even matter any more – facts like how the entirety of the civilized world provides health care for all its citizens. So yes, truly meaningful health care reform in the US is a tall order indeed.
It’s worth noting that these different countries implemented UHC in many different ways, for reasons that are some combination of historical and socioeconomic. What they all have in common is the imperative of universal access, and the principle that health care is a basic human right, so that a person’s financial means should never be an obstacle to needed care. Those basic principles and their necessary corollaries, such as the public system insuring all participants as a common pool, the absence of discriminatory risk rating, and the clinical autonomy of medical practitioners, free of bureaucratic meddling, have achieved uniformly remarkable successes in providing high quality care while managing costs. It doesn’t seem to matter exactly how UHC is achieved; the benefits accrue as long as it’s built on those basic principles.
Except it’s not, because you can literally just copy everyone else. Hell, you’ve got (nearly) fully-metric Canada right next door, that you already trade with. Just use our packaging and cross out the French parts!
“Oh, but switching over is eXpEnSiVe!” Screw that, every company out there that’s embraced new Shrinkflation packaging in the last couple of years proves that switching packages is trivially easy.
Packaging is the least of it. As you rightly point out.
How many machines from cars to factory devices are built using US customary units and US customary fasteners and worked on with US customary tools.
We could get there. Via an obviously inconvenient, expensive transition process taking decades and driven from the top down. Or we can have the current not-at-all obvious inconvenient and expensive incremental PITA of being out of step with the whole world in our usual bottom-up fashion.
When choosing between top-down obvious inconvenience or bottom-up hidden inconvenience, there is no contest: your bog-standard American will choose Door #2 99% of the time. Even when Door #2 is vastly more expensive over time.
Agree overall.
What is critical to understanding about the US, is that if the UHC system was to have taxation as any significant element of its financing, that part would be chronically underfunded to extreme degrees incomprehensible in other first world civilized places. Worldwide, nobody loves taxes, but Americans are far more vocally tax-allergic than almost anyone else can imagine.
This is the rock on which it founders. If tax-supported it’ll be underfunded unto collapse. It not tax-supported, it’ll have to be very expensive for the comfy to pay for care for all the barely-getting-by to indigent who can’t pay but a pittance.
Everything comes down to deep-seated income- and asset-inequality plus the racial issue always buried just 1 micro-inch below the surface of the economic arguments.
Right, exactly, they each had their own situations, and found their own paths based on their situations. All of those different situations had a path to health care coverage. What makes the American situation so different? Why can’t we find a path to health care coverage, when everyone else in the world, with all their different situations, managed it?
It’s exactly as hard now as then. You just do it. Either way, you’ll have to put up with a generation of people grumbling about the Old Days, and either way, once that generation passes, it’s done.
That’s pretty much what I thought - but what I’m describing is something a little different. It’s not refusing to give any latitude in interpreting the rules (although that happens too) , it’s about how the entire system is set up for the convenience of the workers rather than customer/clients/taxpayers - for example, DMVs in my state used to be not only first come ,first served but they were open from 8;30am to 4:30 pm which meant whenever I needed to go in person , I had to take time off from work.
A good point, and underfunding is a risk and a big potential vulnerability in any UHC system. For that matter, it’s a risk to any health care system, because the money has to come from somewhere, and that somewhere may not always have or provide it in sufficient amounts.
But the US has a unique opportunity to work around this problem by taking advantage of the fact that today, employers and individuals are paying through the nose for health insurance and generally getting poor value for this extravagant rip-off. So don’t make it a tax, and certainly don’t fund it out of general revenues. How about setting up a federal or state-level health insurance fund that everyone pays into, with the efficiencies of UHC ensuring that they’re now paying far less than they used to? The poor, unemployed, etc would be subsidized by the rest; economic analyses show that payers still are financially way ahead in a UHC system even when they subsidize non-payers, provided the system is managed well enough to realize the inherent cost savings.
The only ones left with anything to complain about would be morons who prefer to be uninsured because nothing bad will ever happen to them. They can be ignored. The other group is the super-wealthy who are accustomed to luxury-class medical care. In the US zeitgeist these cannot be ignored, but there are already concierge-style medical services that cater to them, and those could be allowed to continue as a regulated tier that is strictly out-of-pocket for those with very deep pockets.
In fact it would theoretically be possible to continue to utilize today’s private insurers, provided that the government regulated the living daylights out of them as it does in Germany’s statutory public system, so that they become essentially just payment processors. IOW, they’d have to adhere to the basic principles of UHC I indicated previously: everyone pays the same rates (no risk rating), everyone gets the same services, every service provider gets the same fee, and operates with clinical autonomy (no meddling by insurance bureaucrats), and every service provider gets paid in full without hassle or question, excepting only in a case of provable fraud. This is literally how single-payer works. The eminent late health care economist Uwe Reinhardt advocated such a system as the most realistic model for UHC in the US.
That’s what we call a tax.
I don’t know, maybe you could sell it better by coming up with some other word for it, but I don’t think it’s going to work.
Oh, I’m sure there would be lots of whining to that effect, particularly since a central premise of UHC is that everyone participates in it. But surely even the most obtuse could recognize that they’re paying through exactly the same mechanism as before, except they’re paying less and getting greater benefits. No doubt a great many ideologues would strongly object anyway (because “freedom”, or something).
There’s no getting away from the fact that many aspects of UHC stand in direct opposition certain deep-rooted American beliefs like the virtue of free markets and freedom of choice and a fundamental distrust of government. You either plow ahead against those biases or you continue to endure a truly shitty and increasingly unsustainable health care system fiasco. UHC is unabashedly socialist, but so is every other public service. It’s also the only feasible way to manage health care, because health care fundamentally ** is ** a public service, and the free-market model has never worked there and never will.
Not always. My understanding is that in the UK, most service providers are salaried, and don’t get paid for services at all, ever. This removes a great deal of administration from the system.
I believe that’s true for the NHS public system in the UK. Most systems, like the ones in Canada, are primarily fee-for-service, although they’re sometimes augmented with alternative models like Comprehensive Care and capitation based models.
What I was getting at, though, is the propensity of health insurers to insinuate themselves between doctor and patient, meddling in the clinical decision-making in the interest of minimizing payouts, such as requiring pre-approvals and/or demanding less costly treatment, and thereafter potentially delaying or denying claims, sometimes on the flimsiest or irrational excuses. A well-managed single-payer system based on fee-for-service really doesn’t have “a great deal” of administration associated with it. The provider submits procedure codes electronically and receives payment electronically; there’s really very little administration compared to the bureaucracy of private insurance, mainly because there’s no bureaucracy incentivized to avoid payment.
If it’s fee for service, with no oversight, how do you avoid unscrupulous doctors performing unnecessary procedures to line their banks accounts? Few patients are qualified to know what healthcare they need.
I didn’t say there was no oversight. I mentioned examples of onerous administration that is intrinsic to the operation of private health insurance that is minimal or unnecessary with single-payer UHC.
I’m not familiar with the specific methods that the health ministry uses here in Ontario to prevent health insurance fraud by medical providers, and indeed the ministry probably doesn’t want to publicize its methods for obvious reasons. But there is definitely oversight, and I can mention a combination of facts and educated guesses to provide some insight.
First and foremost, the incidence of medical fraud is very low. According to some figures I was looking at, fraud recoveries were less than 0.01% out of the $16.6 billion expenditures of the Ontario Health Insurance Program. Some have argued that a lot of fraud goes undetected, but even the most pessimistic estimates put it at less than 0.04%. The question then arises, how much would it cost, considering diminishing returns, to reduce that to near zero, and would it cost far more than it’s worth? By contrast, Medicare fraud in the US is estimated at over 9%.
As to methods of oversight, I can only guess, but the fact that single-payer manages payments to all doctors in Ontario means that systematic behaviour monitoring is possible, via automated and even AI systems – i.e.- how does this practitioner’s billing patterns compare to others in the same practice; how do they compare to previous months? Then, just like with tax audits, individual investigations are based on a mix of random selections and those targeted by unusual billing patterns or other red flags. Anything suspicious is turned over to the Ontario Provincial Police Anti-Rackets Health Fraud Investigation Unit.
As to why the fraud rate is so low, I can venture several reasons. One is that few doctors want to risk the consequences, which would involve criminal charges, possible jail time, and the permanent loss of their license. Another is that that health care economics are different in Canada. Because medical providers incur such low overhead with single-payer, fees are also correspondingly lower, so it’s less of a big-money game. Also, there is much less tendency here for doctors to own spin-off businesses like their own labs, so there is no financial incentive for them to engage in the boondoggle of unnecessary testing.
I was in a conversation with someone a few years ago about the health care in his province , and it turned out that we were talking past each other. When he was talking about “No oversight” ( or “no investigation” , not sure of the exact wording) , he meant that there wasn’t anyone looking at individual claims to deny payment and leave the patient on the hook for the doctor’s fee. Instead, the authorities looked at the doctor’s billing and if they decide that the doctor is overbilling they get the money back from the doctor and the patient is unaffected.
Yes, which helps explain our current system somewhat. Employer-based insurance, which I have nothing against in theory, is funded by huge tax-deduction on premiums that employers pay. This is the engine that covers about 50% of all Americans. The same people who raise Holy Hell about the working poor getting tax credits to fund their ACA policy are being subsidized to a huge degree for their own employer-based insurance. They have no issue with the corporate tax subsidy that funds their own insurance, but scream “Marxism” when the poor try and access the same treatment in the tax code.
There is another issue though that people around the world don’t understand about America. We (as an aggregate) detest one-size-fits-all. Americans just don’t like to go along with anything if it means everyone is required to do it. You saw it in the pandemic. You see it in every facet of life in this country. Sometimes, it’s a great thing. Other times - like during the pandemic - it’s a very bad thing. I think our patchwork healthcare system has evolved along the same lines, where everyone gets a different deal, depending on where you are on the food chain. And I don’t see that ever going away. So, however we achieve UHC, which I hope happens before I die, it will probably still keep a little bit of that patchwork quilt. Not efficient, more costly, yes. But we will have to incrementally slug away at this until we finally cover everyone. The ACA cut our uninsured in half, and it appears the ACA has lowered the trajectory of cost growth somewhat. More is needed. Politically, not sure how we’ll get there. We do have the GOP to deal with, and they’re completely bad-faith actors in this topic, as well as many other topics. The Dems will have to try to do it themselves, which is extremely hard to do.
When we get to UHC, we’ll still probably be the most expensive version in the world. And some people will still probably be underinsured somewhat. I just hope we make incremental progress and make a bad situation better.
Theoretically, I think we would save money. But we have to be careful in making those assumptions, because US politics is a messy thing. So, it wouldn’t surprise me if some got a better deal than they had before, and some got a worse deal. Whatever we do that finally gets us to UHC, it will probably be messy, and chock full of rube goldberg device inefficiency.
I do think any UHC solution in the US will involve private insurers. I think the Swiss and Netherlands do a good job of “ACA On Steroids” approach. I think that could work in America, if the politics of it would subside. The crazy thing is that the original ACA-like idea was cooked up in the Heritage Foundation, which is a right-wing think tank. They had differences from the final ACA, but the same basic structure. Back then, it was a conservative way to UHC. The idea was that everyone had to buy (individual mandate), medicaid would be expanded, companies had to sell, the government had to subsidize for people that wouldn’t afford. It’s the three-legged stool.
Then, Mitt Romney, Republican governor in Mass, implemented it in his state. Still a conservative idea. Then, Obama tried to implement the same basic concept nationwide, and all of the sudden, it was labeled as a Bolshevik plot…just goes to show how crazy our politics are.
Here’s the Heritage Foundation paper that, IMO, was the original inspiration of the Bolshevik ACA Plot:
If it does, I’m sure they’ll seek every possible way to extract as much money out of the public and the government as they can. As an example of how they will do this, here is a gift link to an October 2022 article from The New York Times about how private insurers (like UnitedHealth, Kaiser Permanente, Humana, etc) work to extract more money from Medicare Advantage. (For example: “The health system Kaiser Permanente called doctors in during lunch and after work and urged them to add additional illnesses to the medical records of patients they hadn’t seen in weeks. Doctors who found enough new diagnoses could earn bottles of Champagne, or a bonus in their paycheck.”) As a result, Medicare Advantage plans cost more than traditional Medicare plans.