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?