…is this absolute? I won’t find any poor people with no insurance? I won’t find any middle class people with no insurance?
The near poor don’t.
Except you were near poor: and you say you do have insurance.
This isn’t making any sense. The question wasn’t about insurance. You could be paying for insurance but in certain circumstances not be able to access the healthcare you need. Would you care to try answering this again?
What about the millions of Americans who are unable to “pay extra”? What options do they have? What do the near poor do if they are unable to pay extra to access the level of healthcare that you are able to access?
Specialist physicians surveyed report a median waiting time of 19.8 weeks between referral from a general practitioner and receipt of treatment—shorter than the wait of 21.2 weeks reported in 2017. This year’s wait time is 113% longer than in 1993, when it was just 9.3 weeks.
There is a great deal of variation in the total waiting time faced by patients across the provinces. Saskatchewan reports the shortest total wait (15.4 weeks), while New Brunswick reports the longest (45.1 weeks). There is also a great deal of variation among specialties. Patients wait longest between a GP referral and orthopaedic surgery (39.0 weeks), while those waiting for medical oncology begin treatment in 3.8 weeks.
…so correct me if I’m wrong here: but in order to access (what most in the western world would consider adequate healthcare) you had to work 3 jobs?
If you can’t work 3 jobs, or if you are unable (for whatever reason) to work 3 jobs and you qualify as “near-poor” then what is the mechanism for thes “near-poor” people to access a reasonable level of healthcare?
Those are pretty scary numbers! My question to you is, have you read and understood a single thing I’ve been saying? The implication from that article is if, for instance, someone gets a sudden pain that could indicate a serious condition like a cancerous tumor, they get to wait (on average) 4.3 weeks (30.1 days) for a CT scan just to diagnose it, by which time they might be dead. This is the typical American conservative image of health care in Canada, and it’s not surprising to see it coming from the Fraser Institute, a conservative Canadian think tank (lobbyists, really) that have been pushing for years for the privatizaton of health care and reversing half a century of progress.
Remember what I said about triage and priorities? They seem to be totally ignoring this aspect of it, and only considering the lowest priorities averaged across the country, or else they may (slightly more honestly, perhaps) be weighting the numbers in terms of the fact that most patients are healthy with only minor non-critical issues that can be put in Priority 4 with no risk.
Here are the real numbers for CT scan waits in Ontario:
If you are in a hospital ER: Immediate
If you are a hospital inpatient: Immediate
Doctor’s referral as Priority 1: Immediate
Priority 2: 1 day
Priority 3: 18 days
Priority 4: 39 days
If you want to always have immediate or next-day service, then you need to have large numbers of these million-dollar machines sitting around idle along with all the staff and technicians needed to operate them, waiting for the occasional patient to come by, and still be able to make a profit by charging exorbitant amounts for the service. The US does all of those things: excess capacity and exorbitant fees, even when there’s no medical urgency. They also like to throw in unnecessary testing whenever possible, because why leave money on the table (doctors are often co-owners of these centers).
It is absent in the Canadian system, based on my own experience; I can’t speak for other systems.
When I’ve needed a referral from my GP, he discusses with me which specialists in the area are available to do the procedure. I’ve then decided which one I want to be referred to, and he enters it into his computer terminal, right then in the examining room, and says “Done. Dr So-and-so’s office will contact you to set up an appointment.”
Same for tests. If my GP thinks I need a test, he enters it in the computer, hits “print”, and hands me a requisition that I can take to any of the local labs. Cost of the test is paid for by the government medicare system.
This is one of the major differences in professional care between the two systems. The Canadian single-payer system leaves these questions to the professional judgment of the doctors themselves. The US provides that insurance adjusters, who are motivated to keep costs down, get to second-guess the professional judgment of the doctors.
Doctors in Canada have greater professional freedom to provide health-care than do their US counterparts. That’s been documented in numerous studies; I’ve seen some cited on the many other threads on health care here on the SDMB.
But to pick up the general question above about what is or isn’t a feature of a single-payer or public service system: it all depends on how you choose to design your system. There is no off-the-peg international rulebook.
Note that in this approach, it’s purely an issue between the medicare agency and the doctor. Even if the doctor has been found to be over-billing, it doesn’t affect that doctor’s patients. The medicare agency sues the doctor to recover the over-billed amounts. It might be your doctor who has over-billed, but you’re not involved, and the medicare agency doesn’t come after you for re-payment. It’s just between the agency and the doctor.
Your commentary is just that. MRI’s are not sitting around idle in the US. They’re being used on the people who would be waiting for 18-39 days. It’s impossible to know what is wrong until the MRI test is performed. If you have to wait that long then treatment is delayed by at least that amount of time. Assuming you survive the wait and the condition hasn’t deteriorated.
In my own example none of the previous tests showed the real problem so nobody knew how serious it was. I didn’t think the prognosis was correct so went to my family doctor who was able to schedule a new test that day. I didn’t have to clog up an ER room or go on waiting list for a test.
It really has nothing to do with the concept of single payer. It has to do with the money spent. Nobody objects to the simplicity of it.
I’m not talking about fraud. Absolutely nothing I described in my post is fraud.
I’m talking about how we have a healthcare system where absolutely no one has any incentive to manage cost. I’m talking about large healthcare systems that have “best practices” designed to maximize billing. I’m talking about devices and medications that are priced in the ridiculous way things are priced when the people that are using the product never see the bill.
And I have not seen any healthcare proposal that addresses ANYTHING other than whose going to pick up this outrageous tab. And I think serious cost reforms need to be part of any healthcare reform. And people aren’t going to like that, they’ve been conditioned to think that it’s wrong to think about MONEY when it’s YOUR HEALTH on the line. But I think they should.
And I’ve been shaking my tiny fist at this sky for years. I’ve rejected medications and treatments that I felt were overpriced, regardless of how much the cost to ME was. My pharmacist hated to see me walk in the door, because I was always
“Before I decide whether to fill this I not only need to know the cost to me, but the retail price and the cost to my insurer”. One time I had this prescription for an ear drop. The ingredients were acetic acid and hydrocortisone. My copay was $20, the insurers portion was $175. I laughed and took the prescription back, then went into the shelves and purchased a tube of hydrocortisone cream and a bottle of white vinegar.
I was really happy several years ago when MSK Cancer Center rejected a drug based on price, and I was hoping this would become a trend. But it didn’t.
Wow, that is much higher than I expected! My premium is about $6,000, but going by the rate sheet the most expensive age group, 65+, would pay about $18,000.
I have little insight into how insurance companies determine their rates, but I do know that location and tobacco use plays a big role.
In my opinion, the moral question depends on the economic question. Unquestionably, I want your wife to receive her life-saving surgery. That means she would have to have some sort of coverage.
But I do think healthcare is a scarce resource, at least for the time being. From a policy perspective, I cannot support just any plan that saves your wife’s life. (I feel like a horrible person for writing this to you.) From my perspective, to answer the moral question I have to consider whether some policy proposal meets other requirements, namely whether it is sustainable and whether it provides a net moral benefit.
If a plan is not sustainable, then while it might save your wife’s life in particular, it does not ultimately resolve the problems at hand. An unsustainable plan will probably have both economic and moral drawbacks, which factors into the second requirement.
A plan must also provide a net moral benefit. That is why I started this thread with a cost-benefit moral analysis - a very crude one, I admit. Now, for you, saving your wife might trump literally every other conceivable cost. (Again, I feel like a horrible person for writing this) I cannot fault you for that, but I do not give her life the same weight. So I have to do the whole analysis instead of cutting it short right there.
Liquidating your business is bad, on the economic side. So are preventable deaths. But so are crippling taxes or shuttered hospitals - if these are incident to the single-payer. I am still struggling to attach numbers to these concerns of mine.
Cite? I see patients with categorical exclusions as to certain treatments, and patients with categorical deductibles for certain types of treatment, and patients whose plans cover certain drugs, and patients whose plans only cover alternative drugs, and patients whose plans cover no drugs at all. There are plans that require days of hassle to cover certain procedures (prior auth), and those which do not.
My own health insurance has a drug formulary which is different than it was last year. How can you say that all health plans cover the same thing? If I were taking, say, some asthma medicine, I could exercise my discretion when shopping for plans and find one that covers that particular medicine. If I were diagnosed with some sort of disease that required regular administration of a biologic, I had better shop for a plan that covers the biologic, right?
That’s why it makes sense to do cost-benefit analysis across the whole population rather than worry about every individual’s coverage/entitlement.Then it doesn’t become a question of “Is this person worthy of this treatment?”, rather “Does this treatment do enough good to everyone for the service to be compelled to provide it for everyone?”.
But of course the devil is in the detail of how you assess benefits (we do it in terms of the amount of quality life it provides, valued at something over average annual household income, but no doubt you can slice it up any way you like), as well as costs, which appears to be a knotty area for the US.
In the USA hospitals are being shuttered, no single payer needed. And in a very ugly irony, taking place mostly in places where many conservatives live.
I see. I originally claimed that “in principle, a single-payer system would have the largest possible pool and therefore could be more efficient”.
You countered that a single-payer system would have"the largest pool of sick people but not the largest pool of financial contributors", therefore it is not more efficient.
We seem to have come to an agreement, in that a single-payer system does in fact have the largest pool of financial contributors. Therefore your counterargument rests on a false premise, and is invalid.
Now you present a new counterargument: a single-payer system “reduces the financial contributors in relation to the insurance costs”, therefore it is not more efficient.
Would you agree that “efficient”, in the context of an insurance system, means to spread expenses over the largest possible subset of the population? To have the least number of pools or individuals turn insolvent? For any given population, the most efficient system is to place the entire population into a single pool, assuming the population’s contributions can match its expenses. It is true, I could pool all of the low-risk people together. But pooling high-risk people together is a recipe for death spirals, or insolvency. And having people go without pooling is inefficient, because that means their expenses are not being spread at all.
You see, efficiency in the context of risk pooling does not mean more bang for your buck, it means more stability, more resilience, because that is the point of health insurance. So with regard to your new argument, the relation between the quantity of enrollees and gross costs is irrelevant when determining the efficiency of a system. Your conclusion does not follow, thus your counterargument is, again, invalid.
As far as I can tell, that chart doesn’t imply anything about changing per-capita costs. The chart reads “Total Health Spending per Capita”, “Source: OECD - 2010”, and lists the United States as having about $8,200 in total health care expenditure per capita (including both public and private spending).
There is a second graph, titled “Rising Health Care Costs” that shows U.S. “per capita cpending” at about $7,500 somewhere around 2008 or 2010, I guess. It is about $6,500 in 2005, and $4,600 in 2000. No source is given, but it also shows an “OECD Average” so I assume the source is the same. The blurb under that graph cites “a combination of factors, such as” an ageing population and the availability of more expensive health care treatments.
You could conclude that the upward trajectory of health costs over time suggests that per-capita costs will also rise over time, but I am not making a direct connection to my original post.
Nevertheless, those people do have families and they do require food, housing, clothes, etc. I would expect to see significant economic downturn in areas currently populated with insurance workers. For example, Cigna is the single largest employer in the city of Bloomfield, CT. I’m guessing that at least a million people would lose their jobs, possibly a million and a half. You cannot deny the short term detriment of such a loss of jobs. It would be irresponsible to leave this out of consideration.
The first search result is from the CBC, a 2017 article titled “Brand name drug sales soar in Canada, while R&D sags”.
"*The Toronto physician and York University professor said despite the industry’s claims, patented drug companies have been winding down their research presence in Canada for years now.
“One of the consequences of consolidating and merging[…]”
Since 2000, Merck, AstraZeneca, Sanofi-Aventis and Johnson & Johnson have either shuttered research facilities or laid off R&D staff. Canada now trails France, Germany, Sweden, the U.S. and U.K., in in-house R&D. These are all countries where large patented drug makers are headquartered.
[…]
Instead of relying on the pharmaceutical industry to conduct critical research, he wants the federal government to boost its spending on R&D.*"
Or, perhaps the page returned from the Department of Industry, which cites industry R&D spending as falling 27% from 2001 to 2017. They say “Total business expenditures on R&D by Canadian pharmaceutical companies have fallen below $1 billion since 2011.” But, R&D costs per drug average US$1.4 billion over 12-13 years.
One of the arguments which I have heard directly from pharma reps that visit my office (so take it with a grain of salt) is that countries like Canada force prices way down, below the break even point if you factor in R&D. This forces the manufacturers to raise prices in the U.S.
Obviously I don’t think R&D can account for all of the differences between U.S. and Canadian drug prices, certainly there’s some extra overhead involved getting these drugs covered by various insurance plans, and there are plenty of drugs with high prices that have been around for a hundred years - long enough to pay off any R&D costs.
That is nice.
But it doesn’t actually address my concern.
I don’t think every industrialized nation on earth can implement “UHC”, if “UHC” means providing universal health coverage for all medically necessary treatments. Specifically I doubt that the U.S. has the present capacity to provide all of that treatment. Being the “richest country in the world” does not imply having the necessary infrastructure to provide necessary healthcare for everybody who lives there. I don’t think we have enough medicine, or medical supplies, or hospitals, or nurses, or doctors. We certainly have the resources to build a robust medical system, but I don’t think that system is ready to handle everybody right now.
We don’t have a national priority system for specialists here in the U.S., but we do keep some space on the schedule in case a “priority” case comes in and needs to be seen immediately. Usually these are referrals from other doctors, occasionally they are patients our doctor consulted with at the hospital. I mean, yeah, the doctor is scheduled out for two weeks, but if it’s important we can probably see you today or tomorrow, maybe in our office the next town over, but at least it will be soon.
Cool. Our referral process is actually very similar, we’ll go over the specialists in the area or usually the doctor will just recommend one, then when we call to schedule the appointment we ask if they take the patient’s insurance. If two or three doctors refuse the referral, we just hand it to the patient and say good luck, we’ll be glad to fax it over somewhere if you provide a name. We can also try sending the referral back to the PCP.
Most patients know which laboratory facilities take their insurance - there’s really only a couple in the area: Quest Diagnostics, LabCorp, and the local hospital’s lab. We have order forms for all three, but only an electronic interface with Quest.
Nevertheless, there are guidelines even for U.S. Medicare as to what tests can be ordered and what diagnosis is required for coverage. I literally compile lists of “acceptable diagnoses” for the doctor, should he want to order a certain test. These are based on claims experience and official guidelines. Occasionally the doctor disagrees with Medicare guidelines, in which case he tells the patient he would like to order a test, but Medicare won’t pay for it, here is how much it costs, etc. The same thing happens with private insurers, but for different tests. I suspect that part won’t be going away with single-payer.
I would be interested if you remember the thread, if I haven’t read it already.
