How would we implement UHC in the US (not a political discussion)

[Kimera757]

@Akaj

Two recent threads (this one and this one) have me convinced that:
[ol]
[li]Universal healthcare coverage would be better in almost all respects than the system we have now.[/li][li]Changing over to a UHC system will be a wrenching transition that could be catastrophic if handled wrong.[/li][/ol]
Let’s leave the red/blue politics out of this – assume we have elected leadership that wants to get it done with at least a clear majority of voters who support the change.

Further assumptions:
[ul]
[li]We have a multi-trillion dollar health insurance insudtry and millions of Americans who like their coverage as is. Wipiing all that out overnight is politically unfeasible.[/li][li]Our “clear majority of voters” understands that taxes may go up, but a drastic hike (say, 2x) will not go over well.[/li][li]Americans will be patient but only to a point. If things go badly for too long, the political will to transition to UHC may disappear.[/li][/ul]
Given all that, how do we get it done? Where do we start?

Canada implemented universal healthcare in the 1960s, before I was born. Obviously I don’t know how it was set up. Times were different then.

1. Canadian health insurance (which is really provincial) does *not wipe out the industry. It insures a lot of items, so obviously private companies don’t insure those. Visiting a doctor, getting your heart tested, getting an MRI, giving birth… none of that costs the patient any money (directly) in Canada. Prescription medication (and non-prescription medication) cost money. Prescription medication is covered by private insurance, if the patient has any.

I have private insurance, which I’ve only had for a few years, through work. (Some family members simply paid for their own private insurance.) That private insurance covers dentistry, which is not free (unless you’re a child, elderly, or sometimes if you’re very poor). It covers optometry, which is not free, but not opthamology, which is free. It covers prescriptions, which I already mentioned are not free. It covers audiology, massage, orthodontics, and … hospital stays? In Canada, staying in a hospital is free, but you need to pay for a private room (or share a room) and, of course, they try to make your stay short. The private insurance covers out-of-country care. I don’t know if it covers ambulance service. I was outraged when I heard that ambulances are not free in the US, and then outraged further when I found out they’re not free here, either.

My insurance covers 80% of the “minimal cost” of prescriptions. I have one prescription and it covers a bit less than that because the pharmacy I use isn’t the cheapest. Before I had to pay the entire thing; to this day I still rue having to pay $41 for an old (one-time) prescription more than a decade ago (when I was was working part-time at minimum wage). Fortunately even as a poor person I paid 0% (not 20%) for doctor visits and even the prescription was (barely) affordable.

Usually my private insurance reimburses me, rather than it paying for things up front.

Doctors make a profit (and are paid well, although maybe not as much as American doctors). Each province lists certain “tasks” (ranging from seeing a patient to injecting a patient with something) and pays $X for that task. I heard that doctors will try to do tasks that their nurses could do because they get paid more… but that could be a rumor. Naturally doctors try to see as many patients in as short a period of time as possible… which is what you would expect in any profit-driven system. That’s a negative, but not a negative that is associated with a universal health system. As a result, the system gets a certain level of support from doctors. They have one or more associations who negotiate with the provinces (over pricing, or how quickly they get paid), and sometimes threaten to go on strike.

Generally Canadian doctors are self-employed, even when there’s more than one doctor in a clinic (they’re essentially partners). However, those that work at a hospital might be employees. Some doctors have their own clinic and a hospital position. Doctors have to hire staff (receptionists, and sometimes nurses, dental hygienists, and so forth); the Canadian system has not done anything to free enterprise.

2. Canada has high taxes, due in part to healthcare. Many provinces have an employer health tax, usually around 2% of payroll, and there’s often a “discount” for smaller businesses (sometimes small businesses don’t have to pay anything). This tax is basically invisible to employees, who don’t make voting decisions based on this. Generally the provinces don’t bring in enough money, and so they’re always in debt. Sort of like the federal government, or the American federal government, or the British federal government…

One province (British Columbia) used to require its residents to pay a health premium on a monthly basis. It uses to be $75 per month, then they cut it in half, then it vanished. People who made below a certain amount of money (I think $30,000) didn’t have to pay it, but ironically would probably have paid it during the year and then get reimbursed afterward. Many employers actually paid the premium for the employees, but this became a taxable benefit. (At least it meant people who hated the premium couldn’t dodge it.) If residents didn’t do their taxes, then they couldn’t prove that their income was low enough.

Ontario introduced a health premium that is added directly to your tax return, costing most people a few hundred dollars for the year. If your income was very low, you wouldn’t have to pay anything. Ontario also had the “hidden” employer health premium.

One of the territories just added the tax to your tax return. I think it was either 1% or 2%. Well at least they’re honest.

3. I don’t think I’ve ever heard a Canadian say they hate our system. Of course, people will complain. It can be slow, bureaucratic, etc, and some people will leave to travel to the US to get treatment faster (since you can pay your way to the front of the line there, or so I’ve heard). Doctors complain, but the system is still for-profit, so they don’t complain too much. Doctors can easily travel to and from the States, so unsatisfied doctors have an easy escape valve. (For instance, last week I visited a specialist, and noted that they had been educated in the States. They were born outside of the country, too.)

[Akaj]

@Translucent_Daydream

Corporations are better at seeing the long view and doing what you said. Most people don’t work for corporate conglomerates anymore though, they work for small businesses, and small businesses will pocket the money, they always do. I am part owner of a small business, and have worked for over 15 in my career. My brother owns a small business. They will always pocket the money because “today’s numbers” are “today’s numbers” and if they have to let some of what they put in their pocket back out at a later date, it will have been in their pocket for quite a while. You are assuming too much. Restaurants are terrible at paying minimum wage differentials, and they are required to do so by law.

You generally drag people up a mountain kicking and screaming, not down as they say.

Yes, you’re probably right about this. But (as much as I didn’t want this to be a thread about politics), I wonder if allowing employers freedom to make “bad” choices like this wouldn’t be part of how this all gets sold. E.g., “Yes, we’re replacing a theoretically free market health insurance system with one that’s centrally controlled, but in doing so we’re letting businesses take advantage of a free market in other areas.”

Better example: I’ve always maintained that reliance on employer-funded health insurance is a barrier to entrepreneurship. Set up a working UHC system and that barrier disappears.

[Red_Wiggler]

@Horatius

Start cutting off the for-profit system at both ends, while poking holes in it in the middle.

That is, gradually expand medicare coverage by lowering the age at which you are eligible to join it. Say, lower the age by one year for every two years that pass.

Hooray, I no longer feel like a voice crying in the wilderness.

[Akaj]

@Horatius

Start cutting off the for-profit system at both ends, while poking holes in it in the middle.
That is, gradually expand medicare coverage by lowering the age at which you are eligible to join it. Say, lower the age by one year for every two years that pass.

Also expand it by making kids born today eligible. Who could object to babies being given care? These kids will then grow up having always had coverage, so by the time they’re voting age, it will just be normal to them. Also consider adding in their older siblings in a gradual way, similar to how we’re getting older people on to medicare.

And then poke holes in the middle. Don’t force anyone to switch to medicare. If they like their coverage, let them keep it. But make it easy to switch to the public option. The one thing I would mandate is that employers make healthcare costs explicit - show people how much of their paycheck is going to these plans, and then do the same with their tax bill when they switch. When enough people do the math on how much the public option costs as compared to the private system, the rate of people switching will likely accelerate.

It will likely take decades to completely convert to a public system, which gives the insurance companies more than enough time to adjust to the change, so there won’t be major employment losses all at once.

@Red_Wiggler

Hooray, I no longer feel like a voice crying in the wilderness.

I somehow missed this response from **Horatius **yesterday, but I like these ideas a lot!

[Translucent_Daydream]

@Akaj

Yes, you’re probably right about this. But (as much as I didn’t want this to be a thread about politics), I wonder if allowing employers freedom to make “bad” choices like this wouldn’t be part of how this all gets sold. E.g., “Yes, we’re replacing a theoretically free market health insurance system with one that’s centrally controlled, but in doing so we’re letting businesses take advantage of a free market in other areas.”

Better example: I’ve always maintained that reliance on employer-funded health insurance is a barrier to entrepreneurship. Set up a working UHC system and that barrier disappears.

I think that the important thing if you implement UHC is that the money that employers are paying towards private healthcare gets put back into the pocket of the employee, because his tax bill will go up. If politicians tell the electorate, “You’re gonna save money because you are getting back more than you have to pay, being cash positive in the end,”, they had better not let the employer pocket that money, because if it costs more money for the employee in the end and the boss man gets a windfall, you would have lied.

It gets to be another “keep your doctor if you like him or her” situation you know what I mean?

There has to be a control on this aspect or the whole house of cards starts to fall.

[Shodan]

@Akaj

For example … I’ve heard it proposed on these boards that the age of eligibility for Medicare simply be lowered by some increment each year until everyone is covered. Is that possible? Feasible? A good idea?

There are penalties if you don’t sign up for Medicare as soon as you are eligible. I don’t know if those would continue to apply as the eligible age drops - i.e. drop the age to fifty, and every fifty year old has to sign up or pay increased premiums.

@Icarus

Well, that has to be addressed. What employers are spending on health insurance is already considered employee compensation, but it doesn’t go to the employee directly. Many modern employers provide their employees with information on how much they are paying for the individual employee’s health insurance. “See, I’m paying you $60,000 in salary, plus $12,000 in insurance costs, so your total compensation is $72,000.” My proposal is that by eliminating insurance costs, employers turn that compensation amount over to employees as salary. Now, in real life, employers would most likely try to muck with that and keep that money themselves, so that is why I’m saying we (the gov’t) would have to force their hands on this issue to make the whole transition work.

Maybe we’re not talking about the same thing.

I am making $60K, plus $12K in insurance, of which I pay $6K and my employer pays $6K. OK, now we eliminate private insurance. Do my payroll taxes go up by $6K, or $12K? Or do my payroll taxes go up by $6K and my employer’s corporate taxes go up by $6K? If they both go up, there isn’t any extra money to give me. If only one goes up, and you want me to have it, then don’t raise payroll taxes - raise corporate taxes.

And if M4A can deliver the same level of coverage to a larger number of people at half the cost, that sounds great but rather optimistic. Because the costs of Medicare right now aren’t anywhere near half those of patients with private insurance.

Doctors won’t lose money, supposedly, because administrative overhead drops from 10 to 2%. OK, but now we are only bringing in half as much.

Regards,
Shodan