Yes, as the quality of a doctor service in Paris and in New York I found no difference but the cost. Paris, it is not known to be a cheap city.
Economies of scale if you have the single market. But for some strange reason the pretended market oriented american right wish to be irrational in this area and choose the deliberately less economic structure that deliberately knocks down their greatest advantage, the creation of the largest and one of the most flexible common markets in the world for some ideological fetishisation of a narrow interpretation of the federalism (although other federal systems with states jealous of the perogatives have maged to understand the economic efficiency advantage of the common standards even if there is regional variation).
It is very odd.
It is funny to see Americans writing “best health care” when by all the objective data it is “most expensive for the most mediocre results”
But it is the lack of exposure of the certian political tendency to the alternative models and having the disinformation…
I don’t think I do. For instance, Medicare administrative costs per beneficiary are higher than for the private insurance patient.
We also pay doctors more, pay more for drugs, and Americans receive more health care - for instance, Americans with heart disease are more likely to receive open heart surgery than in other countries like Canada (cite). Yes, we could reduce that, but that’s rationing, which I already recommended.
Or we’re giving people heart surgery who don’t actually need it. In which case, reducing it is NOT rationing, it practicing better healthcare.
Overtreating IS a problem in the US, from people getting unneeded medical testing and scans (which can be quite expensive) to insisting that routine testing be done by specialists (you don’t need an OB/GYN to do a pap smear), to people undergoing unnecessary surgery or other procedures.
Sometimes the hardest thing to do is to do nothing - when my husband was dying and his kidneys failed I had one busy-body doctor really leaning on my to get him on dialysis. This, for a man with a life expectancy of days (it turned out to be 3.5), where dialysis would not correct the main thing killing him, which was cancer. So… a doctor pushing an expensive, intrusive, misery-inducing treatment on a patient that would in no way benefit from it. Me, I was strong enough to say “no” and keep repeating it, but many are not.
More care does not mean better care. The attitude “more is better” is something we need to correct in our society, particularly at the end of life.
Well, it is rationing. Because we are giving heart surgery to a bunch of patients, some of whom benefit from it and a lot who don’t. My main point is that if we decide, on a cost-benefit analysis, that we won’t do heart surgery on that group of patients, most will do just as well (or as poorly) as they do now but some small percent will do worse. And we are deciding that we will accept that small percent because we want to save money. And when, as is inevitable, doctors do a study showing that X number of lives can be saved by doing surgery, we need, as a society, to say “tough luck - we aren’t going to cover that.”
I don’t disagree with any of this. I would even widen the point to say that “more is not better” needs to be applied across the board, not only in end-of-life cases. As in “no, we won’t pay for your mammogram because you are under fifty. No, we won’t pay for your statin drugs, because they don’t save lives overall. No, you can’t have an MRI. Your back hurts? Go home and take aspirin. You keep showing up in the ER demanding treatment for every imaginary thing? GOMER- even if you wind up dead.” Etc.
Because, as you so rightly state, not everyone refuses unnecessary treatment. Why should they? They have already paid for it, thru insurance, or someone else already paid for it thru taxation, and sunk costs are sunk costs.
That isn’t going to be addressed thru single payer.
You are entirely correct - we overtreat in the US, and that costs a lot of money. And if we stop overtreating, people are going to scream. If the government is more capable than insurance companies of saying, “tough shit”, then I’m all for it. I’ve seen no indication that this is true - government health care plans are always being sold that “you can keep your doctor, you can keep your plan, we can cover everybody and you will save $2500 a year, we will reduce inefficient ER visits, we will save money with preventative care, we will cut out waste, fraud, and inefficiency, etc., etc.”
A single payer system that works is one that nobody will like. Doctors will not like having their income reduced, hospitals will not like having their revenue stream reduced, patients will not like getting less care, taxpayers will not like having their taxes raised. But it will reduce costs.
Regards,
Shodan
PS- Again, my condolences on the loss of your husband, and my apologies if any of this sounds accusing.
Some patients will get less care, but far more patients will get more care. And the increase in tax will be far more than offset by the absence of insurance premiums. And doctors and hospitals will spend a lot less time doing paperwork and more time doing medicine. So it’s not all downsides.
Plus the presence of single-payer doesn’t exclude the possibility of a two-tier system. Even single-provider Britain has private health insurance and private medical care available for those who want shorter waits, better hospital accommodations and a wider range of elective procedures. And since it doesn’t need to cover emergency care, even the upper tier is affordable to many. So middle- and upper-class Americans who want to wallow in all the extras can buy them and feel special, doctors can make bigger bucks and nobody dies purely for lack of access to basic care. Win-fucking-win.
Correct. But everybody will have to get used to less care, or else we won’t save money.
Almost by definition, that can’t be the case. Either we cover the same people thru taxpayer-funded healthcare, in which case taxation has to be the same as the insurance premiums, or we cover more, in which case taxes will be higher. And my Medicare example shows that administrative costs will not necessarily go down.
People will have to get used to less treatment, even if it doesn’t affect outcomes overall. I mentioned this before - some years ago, it was discovered that releasing a new mother from the hospital after 24 hours did not lead to any different outcomes than after 48 hours. So they tried to start doing that, with the predictable screaming. One legislator said new mothers needed to be in the hospital to rest up before going home with a new baby. Maybe that’s true - name the best hotel in town, and show that the nightly rates are anywhere close to that of a hospital bed. That’s not cost-efficiency.
It didn’t work either, did it?
The ACHA isn’t going to work any better than the ACA. Neither bill addresses the main issues. If either did, they wouldn’t pass. People want what they want, and they will vote for people who tell them they can have it. Then when they don’t get it, they vote for someone else. Maybe after the ACHA fails, we will get single-payer. Unless we implement the kind of rationing I have been discussing, single-payer won’t work either. Then what? Republicans will say it needs to be repealed and replaced, and Democrats will just say it is working fine and we just need to spend more. As always, on both sides.
That’s not unscrupulous - it’s a rational choice. Somehow the idea that the under utilizers should overpay to subsidize the over utilizers took hold, as if that is how insurance is supposed to work. It’s not. Insurance could work that way, but it doesn’t have to. Insurance could group people with similar risk, and through a large enough pool determine the premium necessary to cover that risk.
If the pool of people I was priced with were all similar in risk factors, the associated premium would probably be a fair representation of the risk involved. However, if I, the super under utilizer was grouped in with high utilizers, like longshoremen, roofers, and stunt performers, my premium would likely be higher than my actual risk. I wouldn’t want to participate in that pool if I could help it.
I think you misunderstood me - it’s not that “some small percent will do worse”, it’s that many doctors are biased towards intervention and in a definite number of cases surgery has no effect on outcome, or may even pose higher risks than doing nothing. That is why rigorous studies and evidence-based care is so important.
One notable area where this occurs is childbirth - FAR too many C-sections are performed. But also things like back pain - absent definite trauma it’s almost always better to go with non-surgical treatment and only *consider *surgery if that doesn’t work (because the truth is sometimes there isn’t anything that can be done to fix back pain).
Well… I’m going to put a small caveat on some of those things:
No, we won’t pay for your mammogram because you are under fifty unless you are at high risk or showing symptoms of breast cancer.
No, we won’t pay for your statin drugs, because they don’t save lives overall unless you are in a group where the benefits have been proven to outweigh the side effects/negatives.
You comment about MRI has some validity - it’s probably not needed for most back pain, for sprained ankles, and so forth unless there is no improvement or there are additional symptoms to warrant it. The US has an oversupply of MRI, CAT, and other imaging machines which makes it all too easy to order them when not needed.
It’s also helpful if records are digital and available - when my husband was undergoing treatment ALL of his providers has easy access to the digital records and thus were less inclined to order scans over and over, since the results from the prior one were so readily available.
These expensive modalities do have a role to play - but there needs to be both better education of the public and better gatekeeping by the system.
And no, I will NOT call it rationing - it’s appropriate treatment. You say you’re “rationing” something quite a few people will want it even more. Say “that’s not appropriate for your condition” and that’s less likely to happen. It’s not being denied because of cost, it’s being denied because it’s not appropriate.
Not true - not as long as insurance has co-pays, deductibles, and so forth. 20% of a PET scan might be $4000, which is enough for most Americans to notice. But if you understand that in this particular case a PET scan is not going to provide much more information or change the course of treatment then it becomes easier to say “no” and save yourself $4k and the system the balance of the bill.
Sometimes people are demanding treatment because they simply don’t know better, they don’t really understand what is or isn’t given by the test or procedure. Or a doctor is pressuring them to get the test or procedure (as was the case with the doctor wanting to put my dying husband on dialysis). We can’t lay the blame entirely with the public because the public is not educated enough in medicine to make decisions unassisted. Even if a procedure is “free” to a given person that doesn’t mean they want it - a lot of medical stuff is uncomfortable or painful.
There is a sub-segment of the population that won’t go to a doctor even if someone else is paying for it.
No. It’s a complicated problem where society and education intersect. Maybe someone else would make that claim but I wouldn’t.
However, single-payer would lead to much greater consistency in what is and isn’t covered. Provided coverage decisions are made with evidence of efficacy in mind that should improve outcomes and reduce some unnecessary expenditures.
Are they?
Well, sure, if you just cut them off from treatments they’ve been told for years are necessary or beneficial. Try educating them - “we’ve found this is not really effective for your condition, we should do X, or stop Y so you don’t have to put up with these side effects anymore and save your copay for something that might actually benefit you.” Of course, it would help a great deal if we paid doctors for educating their patients. Currently, no one gets compensated for “doing nothing”, or counseling a patient to do nothing or discontinue a treatment. Maybe we should allow doctors to bill 15 or even 30 minutes (within limits) under “patient education” so they WILL be compensated for taking 15 or 30 minutes to talk to their patients and explain WHY this pill or that surgery is not appropriate and might even cause harm. Damn few people WANT surgery, or to be on a pill for life.
I was lucky to have a doctor in my family who could did take the time to explain why this or that - pushed by another doctor - wasn’t useful for my husband and might even cause greater harm than doing nothing. Most people don’t have that. If I hadn’t had that I might have made some very poor decisions due to bad advice from people who are better educated in some areas of medicine (but not, alas, in all areas).
Look at the health systems in other first world nations who have better outcomes for less cost per person than the US system. Yes, it CAN be done.
If doctors, hospitals, ambulance companies, and all those other providers no longer have to worry about chasing down patients to pay bills, or patients who won’t or can’t pay their bills, then their overall incomes might remain the same. The current billing system in the US is terribly inefficient, involves a lot of duplication of effort, and is a drain on the entire system.
Hospitals and, especially, ERs, bleed money because of all the uninsured care in the US. Obamacare did, in fact, reduce the amount of people whose bills were completely unpaid. That was a positive under the program, however much there are some people unwilling to admit any positive to the ACA.
He is arguing that you need to adjust for Medicares unfair advantage through the economies of scale. And that you need to include collecting tax money as part of Medicares administrative expenses. What is more, he is explicitly assuming that there is no difference beyond cost between Medicares patients and private insurance. In other words he is ignoring things like multiple conditions, greater prevalence of long-term issues and longer medical histories.
Further, extraordinary claims require extraordinary proof. A claim that the US does not spend far more money on bureaucracy and administration than other countries is extraordinary indeed.
Do you know how these systems work?
The US system isn’t just Medicare. There is also Medicaid, VA, IHA, and a very large number of private insurance companies. There is little standardization. There is gatekeeping, billing, credit checking, liaising with payers, bill writing, negotiations with insurers/payers, chasing down people for money… all sorts of positions that mostly don’t exist in other systems.
Shodan, this is fundamental information. Fundamental. It should be obvious from a glance at the systems, but there are a lot of studies out there showing the same thing.
Yes, you pay your doctors more, but its not enough to make much of a difference. You do overprovision healthcare, that is one of the other big factors in the cost. Bureaucracy, medical inefficiency and overprovision.
But the last is because you ration by ability to pay rather than medical need.
Good catch - you are correct. And the same factor will operate if there are deductibles and copays with single payer.
He is saying that when you talk about administrative costs of Medicare vs. private insurance, you need to compare apples to apples. When you do that, you find that a switch to “Medicare for everybody”, which is a model I have heard recommended, is not necessarily going to save enough in administrative costs to reduce the cost of health care overall.
Yes, I do. I worked for a large hospital system for more than a decade, and DRGs and HC/PCS and CPT codes and procuren billing and doctors gaming the system to maximize revenue were the stuff of my life. Ask me about the howling when the anesthesiologists were going to be replaced by Certified Registered Nurse Anesthetists to save money, or the doctors who did not want the DNR sticker on the outside of the medical records chart, because they did not want to know whether or not the patient wanted treatment no matter what.
This does not take into account that taxation is different than insurance premiums. Taxes have dead weight loss that premiums don’t. This is because if you pay less in taxes you still get the same benefits but when you pay less in premiums you get worse health insurance. Since the profits for the health insurance companies are not a large part of total healthcare spending it is likely that the dead weight loss of the taxation would be more than savings from insurance premiums.
Sure, if you assume all other things remain equal. But remember that administration relating to health insurance is a large part of total healthcare spending. Some hospitals have up to thirty people just processing insurance paperwork, and there are people like that in every doctor’s office in the country. That eats up a lot of resources. And there are other considerations, such as the fact that being able to negotiate medicine prices from a system-wide standpoint mitigates the costs of predatory pricing.
The truth remains that systems with single payer or single provision are far more efficient than the US system and cost far less per capita. So your assumptions about the significance of deadweight loss are fundamentally flawed and ignore the downside of the alternative approach which is, literally, dead people.
If you have ever worked in government you would know that they still have paperwork there too. Some of the paperwork would go away but much of it would stay and medical fraud is already a huge problem that costs the government tens of billions per year.
Other countries have much more efficient systems but the question was not about whether a more efficient system is possible but rather we can get from the current system to a more efficient system. As you say it would be possible for a single payer system to negotiate lower prices for drugs, whether or not that is a good thing, but Medicare and Medicaid are already larger than most country’s health systems and they are not allowed to negotiate lower drug prices. As has already been pointed out the government spends more per patient on paperwork than private insurers. Thus in order to believe the government take over would save money you have to believe that the government would be better at running the entire system then it does at running half the current system. And then that it would be so much better that it could offset the deadweight loss of the new taxes needed to run the system. There would be dead people in any other system, healthcare reform would not grant immortality.
I am not an insurance actuary but it seems to me that insurance for healthcare is not well suited to risk pools. Attempting to do so leads to the mess we now have.
If I am in a high risk pool for auto insurance, I can move to a lower risk pool by improving my driving record, avoiding high performance cars, commuting by mass transit or simply being less young and foolish. To a large extent, I can directly control my risk factors.
On the other hand, I can be in a high risk for health insurance for things beyond my control. Sure, I could affect my risk profile to some extent. Eat healthy, change to a less dangerous career, have regular checkups, etc. but random chance, genetics or age would have a greater effect.
To me, the only fair way to deal with health risk factors is to average the costs over the entire population (or over an individual’s lifespan if you prefer to think of it that way).
The problem with this is that young, healthy people know they are getting a raw deal and choose not to participate. You can force them to participate but then it is the young and poor subsidizing the older and wealthier which seems like the opposite of fair.
The methodology you suggest is an available option for sure, but it’s not necessarily the only fair way. To me, the issue is informed by first principles. One of those is that people should be responsible for themselves - nothing is owed except that which is agreed. So while I accept that by random chance, one individual may have a greater risk of more expensive care, that doesn’t necessarily mean that a different person should pay for it. We may agree that that should be so, yes, but it’s not a given.
Let’s use one example from healthcare.gov. One of the principles is that premiums based on age can only be up to 3 times higher for older people than for younger ones. Why 3 times? I don’t know, but that’s what the rule is. Now, if the actual cost of care for older folks is equal to or less than 3 times the cost of care for younger folks, then that seems fine. I suspect that’s not true though. If that’s the case, and because the actual costs incurred wont change, then the only way the all in costs can be recovered is if the younger folks pay more than their actuarially determined costs would be. That doesn’t sound fair. If the young people were grouped in a risk pool with more similar demographics, then their costs would likely go down. The converse is that the older folks costs would probably go up by quite a bit.
So for lower income folks, they get a subsidy which narrows the inequity in their premium vs. their utilization. But for people who don’t get a subsidy, and are also low utilizers, they bear the burden of this inequity. Is that fair? Debateable.
Here’s an example:
Years ago (very pre ACA) I was responsible for the health plan of the company I was at with about 150 employees. We had a really good plan. No deductibles, very little to no co-pay, I think $5 or so, with zero employee contribution. It was the best plan I’d ever seen really. This is when rates were starting to really go up by 10-30% per year. We looked at the budget and realized it wasn’t sustainable so we had to change it somehow. There were a few levers we had to reduce the cost - we could increase co-pays, require employee contributions, implement deductibles, etc. When we looked at the stats of utilization, we found that most people actually didn’t use the services very much. If we were to implement a deductible of some amount per year, our overall premium would go down by a lot. The thing was though, most people didn’t use $1000 of service in our demographic pool, though some did. Mostly it balanced out, some used more, some less.
What we elected to do was make a contribution to all employees for $1000 to go towards that deductible, that they could carry over. It turned out that even with this contribution, the offsetting lower cost saved the company money. The company could hold back the tide of rising costs, and most employees wouldn’t feel the difference because even though there was a deductible, the contribution the company was making would cover it. We didn’t have to charge people more out of pocket, and the company was able to save money. Win/win. Except for one person - that person had various medical conditions that required medication and they were a high utilizer. They would need to pay more out of pocket and would exceed the company contribution amount. They were upset that their costs would go up under the new plan, and they were right - their costs did go up by a not insignificant amount. We could have preserved the plan but the company would have paid more, or forced all the employees to start contributing. What would be fair in that scenario? Should the rest of the employees be forced to pay every paycheck to preserve the old plan? I don’t know, but I do know I made the decision knowing it would have a negative impact on that person.
Sometimes due to circumstances completely out of a person’s control they will be negatively impacted. It could be health, meteors, whatever. That doesn’t mean everyone else has a duty to minimize that impact. We could choose to if we want, but it’s not the only way nor do I think it’s the most fair in all cases.
Their disagreements aren’t based on fairness, quality of life, or cost, but the idea of paying for other people’s healthcare and the hazards of government intervention. You can explain how other countries do it until you’re blue in the face, it won’t do any good.
They also have a host of rationalizations to disregard comparisons, such as:
Other countries can only have UHC under the umbrella of American military might. They act as if Europe is a demilitarized zone and incapable of standing up for itself. “Keep the sea lanes open” could be on this bingo card. Besides, someone has to spend trillions on Middle East boondoggles.
UHC would destroy American medical innovation that other countries rely on. Americans eat the costs so other countries can benefit. America is just so magnanimous.
America is a special snowflake. What works elsewhere won’t work here. There’s too much “diversity,” whatever that means.
Did you think American society was one that would vote Trump? America may be closer to dismantling the rest of the New Deal and repealing the EMTALA than anything approaching reasonable healthcare policy.
The current system is hugely inefficient, but denying care to poor people does, as I understand it, save it money. Play it out a little :
Person A has the good insurance all his life. He gets twice a year checkups like clockwork (like maintaining a car), and as he ages and gets various minor problems, they are treated with the best available preventative medicine. He gets statins for his cholesterol and prostate meds and blood pressure pills and the effects of all this are checked on a regular basis.
Eventually, person A will still have a medical emergency, perhaps at age 75. He is taken to the hospital in an ambulance and given both emergency care but also followup care, both in the hospital wards and as an outpatient. Several surgeries are performed, and he lives to age 80, where this happens again, then at age 85, where he is taken once last time to the hospital, and he lives for a few weeks in the ICU and then dies.
Person B has no coverage. He gets no help. Eventually, at age 60, he is taken to the hospital for a heart attack and given a stent. He declares bankruptcy and this wipes out any assets he has. At age 62 he has additional heart problems, and is taken to the ER where he is futilely treated and he is now dead, costing no more money.
It’s heartless but I think the reason America spends so much money on health care is not needless emergency care on poor people - what I’ve read is that preventative care does not save money overall, it just extends lives - but sky high price inflation. Prices inflate so high because of restricted supply :
a. The government restricts the supply of doctors by refusing to spend enough on residency slots to train them. (that’s where the bottleneck is, not med school)
b. The government restricts the supply of medicine by requiring FDA approval and clinical trials even for generic medicine. Also, it costs a billion dollars or more to get a drug past the FDA.
c. The government restricts the supply of hospitals, nurses, and everything else through numerous (probably necessary) regulations.
With restricted supply, the almost complete inability of consumers of healthcare to actually make any meaningful choices on the demand side (since they don’t even know what something will cost until they get the bill and often are in no condition to make decisions on cost), and so on, it’s a mess.
And as you can see, no “free market” solution can work if the government restricts supply like it does. I’m not saying this would be a good idea - but if you really wanted a ‘libertarian’ healthcare system, you would need to make the government relax regulations on healthcare. Any doctor with a license anywhere in the world would be able to come to America, with a guaranteed visa, and start practicing. Any generic drug would be importable, as long as the manufacturer is licensed in their host country. And so on.