And I find it extremely frustrating that you gloss over really key details, details critical to understanding how the system works at all without runaway costs or other issues. I had to look up much of this stuff myself since it was just left unsaid.
You are very tightly focused on the patient experience, which is fine, and obviously important for a healthcare system, but it’s not really what I care about at a systemic level. I want to know the mechanisms that keep the system stable and affordable, maintaining a certain level of care even in the presence of fraud and over diagnoses and such, and so on.
Co-pays exist for example not to make a profit but to reduce the moral hazard of providing a totally free product. By assigning a nominal price to something, people are much less likely to waste or overuse it, even if that price is small compared to the real price. Canadians seem to deal with that problem by mostly charging for prescriptions. That’s fine, and actually an even more practical way of dealing with the moral hazard, but that fact was not apparent early in the thread!
Honestly, this kind of blah-blah stuff is just not interesting. Just meaningless declarations, like something from the UN. I want to talk to the engineer that built the machine, not the PR lackey trying to sell it to me.
Probably a subject for another thread. It’s true, but not nearly as true as it’s made out to be. If you correct for the fact that Americans are uniquely rich, fat, violent, and car-obsessed, the US doesn’t look like nearly as much of an outlier.
America also counts more things as live births (rather than stillbirths) which depresses our total life expectancy and increases our infant mortality rates. That is, every country makes different choices as to how to code deliveries of nonviable infants, and the US is unusually generous in when to code them as live births who immediately die.
Neither our infant mortality nor our lifespans are especially outliers. (And a lot of the difference that’s left is due to racism, which universal healthcare won’t fix.)
Hmmm … that statement was a direct paraphrase of the first part of the Canada Health Act. It explains why the federal guidelines for health care coverage that follow have been established. In this particular case, the operative principle is that financial means should never be an obstacle to having access to health care, and eliminating user costs was deemed the simplest and most cost-effective way of achieving that. It’s also the reason that extra-billing by health care providers is explicitly prohibited.
You may not be interested in the “why” but it’s an important part of understanding the basic philosophy driving the implementation of single-payer. As for the “how”, the basic way that single-payer controls costs has been explained in this thread several times (see post #227, for example) and many more times in other threads.
Given that per-capita health care costs in Canada are less than half of what they are in the US and medical outcomes are generally the same or sometimes even better, clearly the system is working. If there are other things about single-payer that aren’t clear to you feel free to ask the folks who have a lifetime of experience with it. That would seem to be preferable to making incorrect dogmatic statements like this:
This is a favourite myth promulgated by armchair theorists and insurance industry apologists, and it’s simply not true. You may know people who go to doctors or emergency rooms simply to amuse themselves, but I don’t. User costs like deductibles exist in health insurance for exactly the same reason they exist in home and auto insurance; they act as intentional obstacles to access and lower the insurer’s costs. This of course is the norm throughout the industry, but many feel that morally it should not apply to health care.
Ironically, while overuse is not generally a problem in Canadian single-payer, I’ve seen arguments that it’s a problem in the US health care system, primarily because factors like medical liability fears and profit-seeking drive an excess of diagnostic and testing procedures which incur costs and tie up resources while yielding no better medical outcomes than anywhere else.
And finally, the idea that single-payer in Canada uses prescription drug costs as a means of controlling access to doctors is ridiculous. Who pays out of pocket for prescription drug costs? I’ll take Ontario as an example because I know it best. Everyone under 25 is covered by the public drug plan. Everyone 65 and over is covered. Everyone on social assistance, on a disability program, in a long-term care facility, or enrolled in a home care program is covered. Almost everyone between 25 and 64 is probably working and receiving coverage as a supplemental benefit, and if they’re not, they may fall into a low-income category that gives them coverage. Even those who don’t qualify under any of these criteria but have exceptionally high drug costs relative to income can still get coverage. So who pays out of pocket for prescription drug costs? Almost no one.
The ethics of health insurance as well as the ethics for all of medicine should not be a “for profit” enterprise. I sympathize with the health care agencies to some extent because the outrageous cost of drugs and sophisticated medical care is what they have to deal with. The key culprit is the medical establishment in general and Big Pharma in particular.
The definition of Capitalism in this country has become, “All you can get and no regret.” Things like ethics, compassion, fairness, etc. play no part.
Which – interestingly – is hurting the ShitFood industry:
The survey also noted a marked decrease in the consumption of carbonated soft drinks, candy, salty snacks, chocolate, and alcohol among some of the people who use a GLP-1 type drug.
“This trend has profound implications for the food industry, necessitating innovation and a move towards healthier, low-calorie, and low-carb alternative.”
For Og’s sake. Won’t somebody think of the children!!
This is quite likely resulting in an even greater Clash of the Titans in the States, since – without checking – my gut tells me that lobbying is a bigger corrosive force in the US than it is in Canada. I stand welcome to correction on this.
One thing that America does better than the other advanced economy nations: we profit from misery:
Crime and punishment
Health and disease
War and peace
Substance abuse
Environmental disasters
Illegal immigration
The for-profit “Angertainment” news industry
In pretty much every case, the bottom line of this is that we:
Privatize TREMENDOUS profits (ie, they inure to the benefit of the few), while we
Socialize significant loss (ie, the rest of us have to pay for the damage done)
See also: “perverse incentive”
THAT’s “American Exceptionalism.”
I would agree that a fundamental paradigm shift would be required to make major changes in our healthcare system, but that the monied interests work tirelessly to ensure that we never look at it in a different way than we do today.
17-20% of our GDP is at stake. The rest? Well, that’s just people, humanity, and endless heart-wrenching stories. Let’s not go there.
Here’s the thing though, if a person has a simple concussion, and the doctor orders trepanning (CPT 61105, so it’s a real life procedure), there’s GOT to be some sort of formal gatekeeping procedure that would catch that and say that drilling a hole in someone’s head for a concussion hasn’t been a thing for hundreds of years. Or for something less dramatic, if someone’s got an uncomplicated, non-severe skin infection, there’s got to be something that says the doctor shouldn’t admit the patient to the hospital and give them IV vancomycin, and that they should start with penicillin.
That’s what I’m getting at- just because the doctor orders it, doesn’t mean it’s actually the right treatment.
And I doubt it’s much different in Canada than the US in that sense, except that the penalty falls on the patient in the US far more than in Canada. By that I mean that if the Dr. screws up and orders something wonky here, the facility/provider/whoever may do it, but then the insurance may or may not pay accordingly. I assume in Canada, the provincial health authority pays, and then there’s some sort of feedback mechanism that disciplines the doctor for fucking up?
That’s where our loop doesn’t get closed well here in the US. Our state licensing boards require doctors to just about be mass murderers to lose their licenses or get disciplined, and insurance companies don’t really do it either. And patients are left holding the bag for payment. Which is shitty, but I can’t blame the insurance companies for not wanting to pay for a doctor’s fuckup, if they’ve published their standards of care and guidelines to doctors who are within their network.
Again, you’re hypothesizing an imaginary problem – a significant proportion of inveterately incompetent physicians – and then proposing a solution that’s much worse than the imaginary problem it purports to solve. Insurance adjudicators exist for one purpose and one purpose only – to save their employer money by reducing or denying claims. It’s the major cause of skyrocketing administrative costs, health-related bankruptcies, and even preventable deaths. Insurance claims denials are an immeasurably greater threat to patients’ health than hypothetical incompetent doctors. It’s recently been in the news that UnitedHealthcare denies 1 out of every 3 claims. Do you think 1 out of every 3 doctors is incompetent, or does this insurer have some other motivation?
In your examples, the procedures are in hospital settings where incorrect procedures are likely to be recognized by others. And insurance bureaucrats are completely the wrong mechanism for gatekeeping even if it occasionally worked because of their contrarian interests. Suppose, for instance, that a doctor prescribed a procedure or a medication that was similar to what was actually needed, but much less effective. And it cost half as much. Do you really think the insurer would intervene?
In real life, the problem that may occur is not medical incompetence so much as lack of sufficient specialized expertise or an unwarranted bias toward a particular medical intervention. The solution is for the patient or patient advocate to inform themselves and to work as a doctor-patient collaboration with the patient exercising informed consent, possibly seeking the advice of other doctors if necessary. No insurer is going to have any interest in doing that, and on the contrary, their incessant meddling is actively harmful to the crucially essential clinical independence of the doctor-patient relationship.
That’s absolutely not true. I am more familiar with the nuts and bolts of Workers Comp medical, as I was a workers’ comp actuary for many years. But we found, for instance, significant over-use of opioids in parts of the country, and quite a lot of care that wasn’t terribly helpful. We were a major player in proving this was a problem, and pushing doctors to prescribe less opioid drugs and try more other things first. Given the opioid epidemic in the US, much of which was triggered by initial medical use of opioid pain killers, I feel this was a benefit to society. Even if, for a while, we came across as the big bad insurance company that wouldn’t authorize that drug.
(And opioids are actually cheap, this was not about saving money on the drugs. It was about saving money on workers who became permanently disabled, rather than the cheaper outcome of returning to work. But that also happens to be the better outcome for the patient.)
You done good. Seriously, kudos for that. But the fact remains, even by your own account, that one way or another, in the short or the long term, with private insurance the cost of claims is always the overriding factor. Doubly so for exchange-traded health insurance corporations that have a fiduciary responsibility to exploit every contractual avenue to limit medical payouts.
While there are occasionally – I would venture to say very rarely – good news stories like yours, the hard reality is that health insurance companies are not in the health care business despite their advertising claims. Put bluntly and cynically, given that their primary goal is to make money while rarely or never contributing anything of value, they’re more in the health care prevention business. UnitedHealthcare denying 1 in every 3 claims is a good illustration of the problem at its worst, and the industry average of 1 in 6 is almost as pathetic since single-payer essentially denies nothing at all as long as basic, simple rules are followed – rules that were developed with the advice and consensus of the medical community.
I think it’s fair to say that the reason this part is true is that, in the big picture, the previous part is true, too.
This is also not true. Before we head health insurance, we had unaffordable health care. I’m not sure if it’s this thread or another, but it seems that the history of why the US doesn’t have universal health care is racism, not corporate interests. (Wouldn’t want to have integrated hospitals!) Health insurance, properly administered, is a good.
I’m not saying it’s properly administered in the US. It’s not. But health insurance companies absolutely contribute something of value, and if they didn’t, no one would pay the premiums. So they are incentived to provide value, they need to in order to survive, let alone be profitable.
Well, yes, when the government drops the ball and there’s no other way of funding health care, insurance serves a purpose when there’s nothing else left, I suppose the same way that a stick of wood serves as a canoe paddle in an emergency. When I say they contribute no value, I mean that everything they do can be done better and much cheaper by single-payer (or by highly regulated non-profits, like the statutory system in Germany). The presence of a vast corporate empire that purports to insure people for medically necessary procedures and then as much as a third of the time fails to give it to them is an indictment of a government that has failed the people it was supposed to serve.
I agree with you that racism is a factor in the course that America took, but it’s not the only factor and probably not even the biggest one. I think the three other major factors that arose when health care became much more capable and expensive were (a) Americans’ pathological distrust of government (and concurrent faith in the miraculous power of free enterprise), (b) the corresponding rise of the powerful health insurance lobby, and (c) the rising power and political influence of the plutocracy – billionaires are prefectly happy with free-market health care, and therefore so should everyone else.
I think these are pretty much objective facts, but I admit to a certain bias because my (much) older brother was a young grad student in Saskatchewan when Tommy Douglas was leading the transformation from his single-payer hospitalization plan to a full-fledged Medicare system. It was vehementaly opposed by doctors and the American insurance lobby and the AMA came over the border and joined the fight to make sure it never happened.
My brother was on the front lines working with the Douglas team to help make it happen. I was just a kid at the time but I was proud of him. And of course it did happen, and eventually became a model that was adopted by the other provinces and its principles eventually entrenched in the Canada Health Act as federally mandated standards. And also, in a very practical sense, I was very impressed by the extraordinary care that my mother received in her final years from the single-payer system and its associated programs like home care. So, you might say that the single-payer philosophy is kind of a family legacy.
I get that. My statement wasn’t directed at you personally, but just that these vague declarations just don’t carry any water with me. Everyone wants a pony, too. The how and the what of what is desired is what matters. It’s the same thing with every other “positive right”. Fine, internet service is a human right. What does that mean? How does it work?
Yes, but that’s overuse on the part of the doctors, not the patients. That’s a problem, but not one that co-pays will stop/reduce. It’s a completely different type of moral hazard, but one that I agree is a problem.
I’m talking medicine, not doctors. And as best I can tell, most Canadian drug plans still have co-pays, either a fixed dollar amount or a percentage. Why is that if not to avoid the moral hazard problem?
Remember that the median US household income is 60% higher than Canada. Since medical care is a service industry, one would expect roughly that increase in cost just based on salaries.
Some of the rest comes from the observation that as income goes up, so does the share of income (or GDP) spent on health care. This isn’t specific to the US, though again the US is an outlier in this respect due to our wealth. I don’t know what the explanation is for this observation.
So the actual, corrected difference is probably more like 10-20%, not 100%. We should still reduce costs. But it’s not as bad as you imply.
I had earlier said “We have a system where there is no cost to the patient for all medically necessary procedures – no co-pay, no deductible, no “claim” at all in the insurance sense – you just receive the service and then you go home” and you responded by talking about the “moral hazard” of cost-free access to health care. I don’t see the relevance here of prescription drug coverage.
And your statement about that is wrong, anyway. No doubt private drug plans have co-pays (it’s been a long time since I had supplemental coverage) but in Ontario the public drug plan (ODB) does not. So I’ll turn your question around: why is private insurance so awesomely concerned about “moral hazard” but public insurance is not? Maybe the motivation behind private insurance co-pays is not the noble one you think it is!
Full details for the sake of accuracy: the ODB has a $100 annual deductible, which is waived for low income earners. Most pharmacies also charge a small dispensing fee of a few bucks, though some won’t even bother. None of those are co-pays, and none act as disincentives for patients to not fill their prescriptions!
I didn’t realize I was living in a third-world country! There is so much wrong with that analysis – aside from being numerically incorrect – that I barely even know where to begin. For the sake of brevity I’ll cut to the chase.
The fact that US health care costs are a huge outlier among all advanced economies is a well-established fact and the reasons for it are quite well understood. For example, it’s off the charts in competently executed comparisons like those of the OECD where costs are normalized in US dollars per capita based on economy-wide parity purchasing power (PPP). .It’s also a huge outlier by any other meaningful metric, including health care spending as a percentage of GDP, which is really saying something considering how huge the US GDP is.
You’re right, actually. My point was that @Dr.Strangelove was arguing that co-pays are a necessary systemic mechanism imposed by the insurer specifically to act as a disincentive for preventing abuse of services, and a couple of bucks that may or may not be charged by a pharmacy hardly seems like a disincentive for patients to get their prescriptions filled.
A co-payment of up to $2.83 is made for each prescription dispensed from an outpatient hospital pharmacy.
And of course every province/territory is totally different. Ontario seems to be one of the cheaper ones; others can have quite high co-pays, often depending on the income of the patient. Jeez, at least with American health insurance my fees don’t go up when I get a raise.
The U.S. Census Bureau reports that the 2023 real median household income for U.S. families was $80,610.2 In Canada, the median household income in 2022 was C$70,500 (about $50,656 USD), according to the latest report.3
80610 / 50656 = 1.59. Ok, that actually compares 2023 to 2022, but I can’t imagine Canada jumped by more than a few points in one year. And just to be clear, that’s median income, not distorted by a bunch of billionaires.
The rest of the world rather underestimates how rich Americans are.
Yes, again because rich countries in general spend not just more money in absolute terms but as a share of their GDP. It’s not just an American trend, but because America is a huge outlier in income it suffers the worst for it. If you correct for both these factors, America is on the same trendline that other countries are on:
At work, when I first started ~25 years ago, they had free soda just stocked in the fridges. Nice perk for a while, but every so often, and with increasing frequency, the fridges would just be emptied out overnight. They eventually tracked it down to just a few people, but they ruined it for everybody. They switched to vending machines that charged a quarter, and also gave a free can every few dispensings, so it was really more like 20 cents. Still trivially cheap but it fixed the problem.
The whole point is that almost any nominal fee, even a tiny percentage of the total, eliminates the moral hazard of having really, truly free-for-the-taking stuff. Sorry, but humans suck. And it only takes a few to ruin things for everyone.
Just to pull back a little from the various rabbit-holes that we’re verging on descending into, let me return to a question I asked before. How many people do you know who go to doctors or emergency rooms just to amuse themselves – or, to put it less sarcastically, for entirely frivolous reasons? I don’t know of any. ISTM that the “moral hazard” in the case of health care – which is not the same as free soda – is largely a fabrication of armchair theorists and insurance industry proponents. It’s the sort of theory that sounds good, but just doesn’t play out in practice.
I’d sure like to know how many Canadian doctors and ERs are plagued by frivolous patients who should just have taken an aspirin and gone to bed. In all my time here, I’ve never seen any. What evidence do you have that it’s a huge number?
And how do you assess the “moral hazard” of people who are left to die because they don’t see a doctor in the early and treatable stages of a disease because they can’t afford it? Or most importantly, those who die because their insurer has found a loophole allowing them to deny coverage?
Sorry. Long day, eyes glazed.