I apologize for not reading this whole thread (the sniping gets tiresome) so maybe this has already been discussed, but how does the promise to eliminate private insurance square with fact that over a third (and rapidly growing) of Medicare coverage is now Medicare Advantage, run by private insurance companies?
Correct. In Ontario the “premium” is collected as a tax and is deposited into the provinces general revenue fund along with all other provincial income taxes. It is not deposited into any specific fund, and there are no restrictions at all as to how it must or even should be spent. It could be spent on medically treating a person, or building a hospital, or paying a clerk to issue drivers’ licences in the Ministry of Transportation, or to buy a police car.
In other words, it was a way of explaining a small increase in general income tax, but calling it a health premium made it a lot more palatable to the public.
And to preempt the naysayers, remember that when compared to Americans, Canadians live longer, live healthier for longer, pay less through their taxes for health care, and pay less out of their personal pockets for health care.
As far as medications outside the hospital go, in Ontario you are covered if you are 24 or under, or 65 or over, of if you spend more that 4% your net after-tax income. That 's a pretty sweet deal. Private insurance is also available for medications.
Sorry, I was not clear. That 4% qualifier to get into the plan is your deductible for the plan. After that, you pay the first $2 per prescription and the rest is covered.
The distinction between traditional Medicare and Medicare Advantage is part of the hugely complex quagmire that is US health care and is far from being as simple as the way you’ve presented it, but maybe I can provide – to the best of my understanding – a few insights into why this is not an argument for private insurance vs. direct public single-payer.
Traditional Medicare is so far removed from true comprehensive single-payer in terms of its limitations and inadequacies that it’s not surprising that there can be better models, but that says nothing about the effectiveness of MfA in which those barriers are removed and you have a universal single-payer system like in Canada and many other countries in which no private insurers are involved. Secondly, MA is less a system “run by private insurance companies” than a government funded and regulated system that provides managed health care on a capitation basis rather than fee-for-service. Moreover, many of the plan providers, called sponsors, are various forms of non-profits and by no means necessarily traditional insurance companies. And to the extent that capitation can offer benefits over traditional fee-for-service, such models can be and have been developed within single-payer systems – I know that we have them right here in Ontario within public single-payer where no private insurance is allowed for medically necessary services.
I would also note in passing that I have my suspicions about the impartiality of the Healthcare Leadership Council as it’s largely made up of the CEOs of health insurers, pharma companies, medical manufacturers, and for-profit hospitals, and their objective is really the complete privatization of Medicare. My skepticism is also triggered by statements like that US health care is “already the best in the world” – very far from true according to objective rankings like that of the OECD – or that the key to making it better is “consumer choice and competition” – a traditional mantra of free-market conservatives. And as I keep saying, no, when it comes to health care plans, consumers don’t need “choice” – they simply need a plan that will pay for all the essential health care they need, fully and unconditionally. The citizens of other advanced countries get this as a basic human right; Americans never have.
No. 90% of those “insurance workers” wouldn’t be needed in a single-payer system.
What does a health insurance company do? It needs a vast army of executives and their minions to creatively design a plethora of different insurance “plans” that will appear attractive to the public while generating maximum profit. It needs an army of actuaries to analyze risk factors and price the plans for every single individual. It needs an army of marketeers to flog these plans to the public. It needs any army of executives to set up and negotiate provider “networks”. It needs an army of claims adjusters to scrutinize every claim with a view to reducing it or denying it. And on the other side of the fence, health care providers have to employ an army of accounting clerks to fight with the claims adjusters through the echelons of their bureaucratic hierarchy.
Not a single one of those functions exists in a single-payer system, which, as someone already noted, is not really “insurance” at all but, at its core, simply a tax-funded public service that pays for all essential health care.
An interesting post but not one that has to do with the post it is supposed to be responding to. To be very clear: I was making no argument or any comment about the effectiveness of MfA.
It was an honest question. Medicare currently utilizes the private industry to no small degree. To what degree will a switch from private to Medicare coverage be a switch from one form of private to another by way of Medicare?
My apologies if I gave the impression I was arguing with you. I was really trying to respond to the proposition that Medical Advantage is “run by private insurance companies”. That phrase gives a somewhat inaccurate impression as it’s really run by so-called “sponsors” under contract to the federal CMS and operate according to their rules; many of those sponsors are insurance companies or their spin-off organizations but many are not. You can appreciate that this is a completely different situation than, say, the feds giving you some cash for buying an individual insurance plan for yourself on the open market, where the insurers really would dictate the terms of service.
Your restated question, “To what degree will a switch from private to Medicare coverage be a switch from one form of private to another by way of Medicare?” seems like a different question. I have no idea of the answer to that one, but frankly the MfA proposals at this point are so very, very far from any kind of realistic implementation that what finally emerges will likely be totally unrecognizable from the current political rhetoric, as usually happens with this stuff. The solid facts that I’m trying to bring to bear on the subject are about how health care actually works, as actually implemented, in other countries, and the general picture is that it either involves single-payer or a multi-payer system that is so tightly regulated that it’s indistinguishable, and free-market private insurance is usually just a small component of the total health care system in terms of participation.
I’m sure that, regardless of political rhetoric, the US will eventually end up with such a two-tier public/private system. This has nothing to do with the capitation system of payment, which is the defining characteristic of Medicare Advantage, and to which both public and private systems are amenable. For example, here are the alternative payment methods to traditional fee-for-service in Ontario, which as about as pure a single-payer system as you’ll find anywhere, and where the Family Health Network (FHN) and Family Health Organization (FHO) models are primarily capitation-based models.
Wolfpup has already addressed this point, but I’ll chime in: one of the areas where US health costs are way more than in other countries is the administrative cost. Single payer eliminates much of the administration costs, nameky the salaries of all those administrators.
A simple example is claims procedure. As I understand it, each US insurer has its own coding system for each procedure, and its own claims interface. That means doctors need to have staff to enter all those claims, each day, using different systems. It may all be computerised, but the multiplicity of systems means more people are needed.
That’s not the case in single payer. There’s one set of codes within the province, and one interface. That reduces the administrative cost, because your staff just needs to be proficient in one billing system.
And there’s no need for pre-approvals, and no need to have someone to fight with the insurance company when they disallow the claim. That eliminates more administrative layers.
I’ll have to take your word for it. I don’t know how the typical insurance company is organized. Just seemed to me that most of their workaday activity was enrolling new members and processing claims, both of which would still need to be done under single-payer.
Given that the healthcare industry currently employs somewhere between 15 and 20 million people, a loss of 2 million jobs in the sector is not trivial. If half of those jobs are on the insurers’ side, that suggests that over 10% of the total work currently done by health insurance industry employees is just the bureaucratic red tape associated with a for-profit multi-player system, and would become unnecessary in a more efficient single-payer setup.
In the Canadian single-payer system, I’ve been enrolled exactly once: by my parents when Medicare was brought in by the Douglas government. Now, most Canadians are enrolled at birth. You only have to change your enrolment if you move to another province. That doesn’t take a lot of employees in the provincial Medicare offices.
As for processing claims, other consists of the doctor or hospital sending in a bill. Our system doesn’t have the yin and yang of insurance adjusters challenging a claim, and the doctor’s office arguing why it should be paid.
It depends on the proposal, and there’s no reason to think it would be enacted as-is, but the Sanders bill (the most commonly-discussed version of Medicare For All) doesn’t put anyone on the current Medicare system, which is actually abolished in the plan, and replaced by a whole new and entirely public system also called Medicare.
So as stands the pitch is to take away what you now have, be it private or Medicare, and replace it with a something different unknown exactly what except that it is single payer?
To be fair, the Sanders plan is not exactly “unknown” – it’s been fairly well fleshed out. Nor is single payer really much of mystery – one has only to look north to Canada, read the terms and principles of the Canada Health Act, and say “it will look a lot like this in its broad outlines”.
Rather more definitive, I’d say, than Trump’s election promise to replace Obamacare with “something terrific”, which turned out to be good enough to get him elected. And which turned out to mean “replace Obamacare with nothing” and he couldn’t even do that. I believe that option will be offered again in 2020 for those who prefer that sort of thing.
Except that it what his website states the is blatantly misleading, aimed at promulgating a false narrative that it is an expansion of Medicare. To quote
As detailed above a third of Medicare right now is administered by private companies and utilizes panels that operate under value-based care (VBC) payment models. Canada and many other nations are moving more towards these approaches as well.
No that doesn’t flesh anything out and it is not honest in that it does not at all make clear that Medicare as is will be removed as an option.
He states that patients can see whoever they want but that is not how the Canadian system works. You need a referral from the GP to see a specialist.
Sanders belief is that paying providers less per service by being able to dictate pricing is the key to getting greater value. How the ACA has delivered is by encouraging the systems that work smarter thereby avoiding preventable admissions and stays that too long because there is not the incentive to organize the processes efficiently. The evolution in progress is a move away from being paid more by doing more and to population wide outcome measurements. I can’t find that in his bill.
All I can say is that our opinions on this differ. Medicare will have to be substantially rejigged in order to function as a viable UHC system, and whether this is an “expansion of Medicare” or something entirely different is a matter of opinion. Presenting it as an expansion of something people are already familiar with is a useful way of communicating the intent.
VBC (or VBHC) is related to the capitation model I described previously. It’s not the same thing but rather is a feature that can work with capitation models. And, again, it has little or nothing to do with private insurance except coincidentally. In Canada it works under the government single-payer model, and in the US, under Medicare Advantage, the administering “sponsors” (which may also be non-insurance organizations) operate as contractors to the federal Centers for Medicare and Medicaid Services, and must conform to their rules and standards.
Well, it’s many pages of detailed information, and it should be obvious that Medicare and Medicaid as we know it today would become totally redundant. I don’t understand why you keep going on about this. Is there any other way you could possibly imagine MfA could work?
It absolutely is how the Canadian system works. I can see any doctor I want, or go to any hospital or clinic I want. It’s true that you need a referral the first time you see a specialist, but it would be hugely misleading to see this as some kind of obstacle rather than what it is, a matter of medical protocol to direct patients to the appropriate resources, collaboratively with the patient’s wishes. In many cases the patient might have no idea what specialist she needs, or who the most qualified ones are for a particular condition. Just recently I told my doctor that I wasn’t happy with the cardiologist that the hospital had set me up with for followups after my surgery and I wished I could see the wonderful cardiologist who had looked after me in the hospital, and that’s exactly what was done.
Efficiencies and negotiated, transparent, uniform provider fees are both essential to a viable and sustainable health care system. Let me make a general comment about an important aspect of this using length of hospital stays as an example. All health care systems strive for efficiencies, and perhaps more accurately, all strive to minimize costs. The problem is that private insurance – and unfortunately Medicare, too, because it operates as a parallel system in the same costly environment – often do it in ways that are counterproductive to the patient’s interests. Thus both private insurance (often) and Medicare have arbitrary limits on length of hospital stays*** irrespective of what the patient actually needs***. You can literally have sick patients dumped out into the street because their time is up. This has never occurred in the single-payer system in Canada, ever, to the best of my knowledge, and indeed would be contrary to its fundamental patient-centric principles. But to an insurance company focused on costs and profits, it’s just business.
Presenting it as an expansion of something that people know and are comfortable with instead of the taking that system away and replacing it is untruthful IMHO. It may or may not be that the new system would be better but it not expanding Medicare to all.
Agreed that it is unfair to portray requiring referrals to specialists as obstacles rather than medical protocols that direct patients to the appropriate resources. But that process has long been demonized as such and claiming that a plan eliminates that when it does not is being untruthful.
Your understanding of how the shift to Value Based Care has been playing out in the United States is very incorrect. No there are not arbitrary lengths of stay. There are benchmarks that organizations have for populations, normed by scores for the population that account for levels of comorbid conditions and with incentives for achieving various quality metrics. Improve your complete system, invest more in keeping the population from having the complications or diseases that lead to admissions and readmissions and in better more seamless outpatient support seamlessly provided and you achieve better outcomes with fewer admissions and shorter lengths of stay across the population as a whole. Kicking someone out while still sick because of and arbitrary guideline is NOT how it is done and would be counterproductive to those goals, and the bonuses for hitting those goals are the only way to not lose money in the process.
Single payer has many advantages. But selling it by misrepresenting both what it actually is and what the system in America is transitioning into with the ACA as the catalyst is wrong.
The ACA has, despite continuous major kneecapping by the GOP, been hugely successful. It has improved the access, improved quality, and decreased costs. No question that it is as is far from a finished product. Expanding Medicare as an option to all, expanding Medicaid, and yes working on pricing and pharmacy benefits reform, are all part of it.
Just to be clear on this point, I wasn’t talking here about the Value Based Care model. I was saying that in traditional insurance models, there are pressures from insurers, hospital administrators, and – due to out-of-pocket costs – sometimes from the patients themselves, for early discharge to a point that is sometimes unsafe.