The important point about the shutdown that everyone is missing

Great Debates
41

A long time ago, I went through every proposed theory of why our costs were too high and looked for supporting/conflicting evidence. These were things like profiteering, high doctor wages, low support for preventative medicine, etc.

In general, the only thing that I could support was that we paid more for physical goods. We bought more and more expensive hospital beds, for example. Our drugs cost more, for no particular reason. We buy significantly more high-end exam equipment like CAT scanners.

In theory, the latter supports some theories that, by being divided into lots of smaller insurance companies, collective bargaining isn’t working and so the pharmaceutical industry can raise the prices for Americans without fear that we’ll walk away. No one player’s money is big enough that Big Pharma cares if we try to play hardball.

But, that also doesn’t really work since there are almost certainly American insurance groups and etc. that are bigger than many European nations and those nations are able to buy drugs at half the price at us. Not to mention that the price of drugs has nothing to do with us buying more electronics.

Ultimately, it’s just a theory, but the only reason that I’ve been able to come up with for the US’s raised price of medicine, that doesn’t conflict with any evidence, is that we’ve simply decided to spend more and the industry has happily risen to match that willingness. Like if I tell my employees that I’m going to give them 30% more money, despite their not having done anything different than yesterday, it’s not like they’re going to refuse.

I believe - and again, it’s just a theory until we have some way to prove it - that the issue is that we were one of the first countries to form a health care system. We were progressive but progressive for the early 1900s, when just giving people anything was a radical move. So our system simply worked by giving employers tax breaks and incentives to set up health care plans as a part of being a worker.

While that seems like a good idea, I think that’s creates a reverse incentive for spending more on health care.

In Europe, the government budgets how much to spend after reviewing how effective various treatments are and how common various illnesses are. Prices are matched to effectiveness.

In the US, employers budget how much to spend after analyzing how much their competitors are offering, to try and steal away all the good employees. They recognize that offering “fertility care” has a certain emotional value to potential employees that “dollars” simply can’t replace. A worker has no idea how much “fertility” coverage is actually worth, or should actually be worth, in monetary terms. They just know that if company A has it and company B doesn’t, then maybe they’d rather go work for company A. And, from the vantage of company A, they go from offering $5k to the employer that would be taxed - so they need to increase it by 20% to make it actually equal $5k - or they could offer maybe $2k of “fertility care” that’s untaxed, and have a lock on all the young married workers who are thinking of starting a family.

In general, this all creates market incentives to push more money into the health care world, rather than less.

But so, unless you correct this, you can’t convert to universal coverage because we’ve allowed the bubble to grow too high. And converting to universal coverage, while still allowing employer-driven health care plans, could cause that to continue to worsen. And, worse, any sudden shock like moving to full government-managed health care could shrink spending so extremely that it could ruin the industry and put millions of people out of employment.

In general, you need to deflate the bubble as step 1. Prior to that, you’re never going to win a vote because everyone will look at the price tag and reject it. Modern progressives are continuing to try and shoot us in the foot by trying to skip past that whole topic and run straight to universal coverage without analyzing nor addressing the price problem.

42

The user may or may not care, but they often don’t have any idea of what the final prices is - even after the treatment. I get statements from Medicare and my Medigap plan about what they paid. There are multiple numbers, all inconsistent, and I don’t care since I pay 0. (I have a good Medigap plan.)

I do know how much I pay the dentist, because I don’t have insurance any more. I discovered that I could cut my bill in half by moving to another dentist in the same complex. I’ve observed that when a new dentist buys into a practice, the work you need suddenly increases. Going to an old established practice is much cheaper.

But I can ask how much a procedure is going to be before I do it. You can’t do that for many medical procedures. I walked out on my old dentist when I discovered it would cost me $1500 to fill a tiny cavity they found in the X-ray. You can’t do that in an ER when you have a heart attack.

43

This is complicated, justifying your long post.

Here is important context:

Compared to its peers, the U.S. has about half as many in-person doctor consultations per person

I believe the U.S. is almost (or totally) unique in most of its physicians being specialists/consultants. It is hard to get good statistics on this because medical specialties do not exactly map to primary care vs. specialist/consultant. But only 11 percent or so of U.S. medical graduates choose a residency in our most generalist specialty, family medicine.

So Americans hardly ever go to their overscheduled “regular doctor.” They wait a while without seeing any doc, and then skip right to a specialist, who is in business to provide complex care. Instead of the family med doc, that most Americans rarely see, who might give the bad news that none of the treatments for backache are all that good, they see an ortho who schedules them for surgery (that’s part of why we call them specialists, not consultants). I realize that insurers push back on this by requiring referrals and precerts, but it often doesn’t work.

And even when going to a specialist, Americans go to the one who does a bigger job. We get fewer angioplasties and more open heart surgery.

Consider:

American Journal of Medicine: Where Have the Generalists Gone? They Became Specialists, Then Subspecialists

The link above suggests patients see a physician assistant as an alternative to the short-in-supply primary care physician, but I’d question how many of us would trust a PA or nurse to tell us that we wouldn’t benefit from specialty care..

44

Nope. That’s why it’s in GD instead of P&E.

45

My Russian wife complains that she must see a General Practitioner and get a referral to a specialist if she thinks that she has a particular ailment.

We’d probably have to sift through a lot of data to pick out how much difference there is in the spread of doctor types, but I’d venture to guess that across all of the countries with some form of universal health care that there’s all of the variety that you can imagine and that none of them have the overall cost as us. Even Switzerland, last I looked, isn’t close coming in at the 2nd most expensive.

46

The referral requirement was a sounds-good-to-me reasonable effort to cut back on excessive specialty care. Here’s what happened: The hospitals, at least in my area, bought up most of the physician practices. So there is no longer a system-level financial incentive for the offices to require a real visit at which the primary doc can try to handle the problem themselves (such as with watchful waiting). Instead, I believe, the secretaries in our physician offices often hand out a referral on request.

I phrased the above sentence with “I believe” because my Blue Cross plan stopped requiring referrals many years ago. It wasn’t saving enough money to be worth it.

I wonder what the experience of dopers from universal care countries is on this. Can you go to a consultant without input from your primary care physician? For example, if your spouse says you are snoring, do you just call to make an appointment with a sleep medicine doc (or maybe pulmonary medicine consultant if your country does not have a separate sleep medicine specialty)? And if you see a dark spot on your skin, can you call to make an appointment with a dermatologist? Back pain, and just call an orthopedic surgeon? Or is there some sort of gatekeeping?

47

I suspect part of the problem is that the internet allows for a greater degree of self-diagnosis, so people believe they already know what is wrong with them before they go to a doctor. This causes them to be annoyed that they have to go to a regular doctor first.

48

Although this may be off topic with regard to the healthcare debate, I believe it is on topic within the thread (or at least it’s title) to take issue with the opening lines…

The shutdown isn’t really about healthcare, it’s about partisan power. Its about the Democrats needing to show that they can stand up to Trump and that they can not be completely ignored. And its about the Republicans asserting that they have supreme power and so don’t need to negotiate. Healthcare was just the battlefield that the Democrats chose to make their stand. If in an alternate history the Republicans had unilaterally decided to extend the ACA tax credits in their big beautiful bill. The shutdown would have still happened, it just would have been a different awful action that the Republicans took unilaterally that the Democrats would demand be changed and which the Republicans would be refusing.

49

I believe that in other insurance-based UHC countries (France and possibly Germany) you can go straight to.a specialist within the terms of their public system. In the UK, the NHS requires referral through a GP, or a hospital A&E if it’s an emergency. Or you can go private and pay for it. The key position of the GP in the NHS was the price for getting them to sign up to the service in the first place - they were already in that gatekeeper/advocate.position before, at least in relation to a specific local hospital, and they wanted to retain their status. The point is that they triage whatever’s being presented, and save the specialist hospital services time and money (it’s a commonplace that A’&E departments will grumble that X% of their cases are minor issues that should have gone to their GP or a pharmacy).

Don’t forget that NHS services aren’t funded per item of service, but by annual budgets based on all sorts of demographic criteria. They don’t have to bill for every bandage or aspirin, just make do within their budget.

50

AFAIK, in the public system here in Quebec (every province has its own rules) you have to be referred to a specialist. On the other hand, my wife went to a private clinic for a mammography (she had a very small lump). The mammogram showed cancer and two days later a surgeon in the clinic excised it (ductal carcinoma in situ) and did biopsies to show no spread. It would have taken months to get that mammography. On the other hand, they handed her off to a public hospital for further treatment (radiation and tamoxifam).

51

What we see happening among elected officials is pre approved performance.

The big money literally bought all three branches of government. There are enough wildcats in the mix to provide interesting theater but not change up the outcome. The big health insurers control the access to doctors and treatments they can prescribe. The health insurance companies own the pharmacies who can dictate which medications your drug insurance will cover. And the big health insurance companies have control over members of Congress, just like high finance controls their Congress. The only debates that happen are between the banks, the health insurance companies, the energy companies, defense industries, media, and big tech. It is within that debate where all the policy gets set up. Once those entities have agreed to the policy, they hand it off to Congress and they say “do it dog”.

52

America is a hybrid democracy-plutocracy, and health care is a 5 trillion dollar a year industry. Anything that improves health care would damage the businesses that run the US health care system, and they will fight like dogs to resist it. Thats why even in blue states like VT or CA, they talk endlessly about health reform but don’t actually do anything of substance. They’re trying to pretend they want to fix the health care crisis to keep their voters motivated, while not doing anything of substance.

When democrats do pass health reform, their solutions are generally to expand government subsidies for the private, overpriced health care system.

I don’t know how it gets fixed. Like the OP mentioned, ballot initiatives get shot down. Even if they pass, the government won’t implement health reform. Vermont passed health reform, then refused to implement it.

Sadly I think the best we can hope for is a system like the Netherlands or Switzerland. Basically we’d have universal health insurance, but it wouldn’t be nearly as good as these countries. In those countries the exchanges guarantee everyone coverage.

What may happen for health reform in the US is that the subsidies for ACA plans are expanded, and more people become eligible for medicaid.

53

I saw a bumper sticker. Can’t remember it exactly but it was something like:
If you are Pro-Life then literally the most important thing to you should be Universal Healthcare.

54

Weirdly, in South Africa, despite being elective surgery, I had to get a referral for my vasectomy. I mean, sure, a urologist is a specialist…

However, being South Africa, my medical aid breathed a sigh of relief because they already covered two child births, and a vasectomy is way cheaper than those. They paid.