This is why there’s so much debate about Canada vs. the USA. Yeah, maybe overall the Canadian system is better (it’s argued), but for those of us with excellent insurance in the USA, the USAian system is indisputably better. And since those of us that have excellent insurance are the ones who are educated, work, vote, and run the economy, we’re not willing to give up our superior system, which is only a piece of the “overall worse” system.
In order to convince those of us who run the system, then, you have to convince us that we won’t get worse service as a result, which might mean a single-payer system is available to all, but unlike Ontario (or all of Canada), allow a separate, private system the right to exist. Unfortunately this raises accusations of elitism, but the fact is, we already have elitism as demonstrated in the previous paragraph.
If you read thru the Vox article that adaher cited, if we do the Medicare-for-all thing, and if, on average, hospitals and physician groups lose money on Medicare patients as previously cited, then either we jack up the premiums on those outside Americare, or raise taxes (or increase deductibles and non-covered costs).
Or else it is the same “buy at six, sell at three, make up the difference with volume”.
A key factor you are missing is that the government can simply force drug companies to take “3” as the going rate for their services, and licensed physicians as well. As long as the rate the government pays is above the marginal cost for actually manufacturing a drug (or about 5% of the current prices generally), and as long as the government offers enough reimbursement to physicians that they make more than quitting and getting a job in another field, they don’t have any choice but to take the price offered.
I agree that if the government does this, it will potentially have negative consequences in the long term that will cost more in some ways. Obviously, the government would need to start directly funding drug development, since drug companies could no longer afford to do so, and to start paying medical students to go to medical school. And obviously the quality of physicians might decline a little bit, and if the government doesn’t fund development of certain drugs, it won’t happen.
The government could also eliminate a huge number of bureaucrats by simply refusing to pay for their services. Hospitals wouldn’t need large numbers of billers, and they wouldn’t be able to pay high executives million dollar salaries.
That’s just the thing though,proponents of Americare THINK it will reduce private insurance use, but I just don’t see it at the rates they are offering. The better providers won’t take Americare, which will put Americare at a competitive disadvantage to private insurers. Americare will probably get a big share of the market, but I’m thinking private insurers will maintain 20-30% of the market, not the tiny percentage proponents think. Too many well off workers are going to demand the best doctors in their networks, and the best doctors ain’t working for a mere $100-200K.
You throw in the words “indisputably better” without basis, about a premise that is, at best, arguable and actually difficult to support. “Better” how? Medical outcomes in Canada (and the advanced countries of western Europe) are about the same as in the US and sometimes better, despite the fact that artificial structural differences encourage a system where Americans tend to get more – and largely unnecessary – medical testing. Wait times? Largely not a problem in Europe. Waits tend to exist in Canada for non-critical elective procedures but rarely for critical ones, and pretty much never for hospital in-patients; in the final analysis, the most effective way to schedule expensive resources is through queue management and not through wasteful replication. But medical staff and equipment in Canada is, in my experience, second to none in the world.
Against this scenario, the downside of even “excellent insurance” in the US is the ever-present possibility of a large claim being denied or an expensive treatment cheapened or severely cut back; this kind of clinical meddling is the hallmark of private insurance and for the patient it can be financially ruinous and medically catastrophic. And you are always going to have significant out-of-pocket payment requirements.
I would argue that “indisputably better” medical care applies in America to only one class of patient, and that is the storied 1-percenters, the phenomenally wealthy, for whom none of those things matter. Indeed, just as aside but deeply symptomatic of the entrenched problems with free-market health care, there has been a growing trend towards red-carpet “boutique” medical services that attract the best doctors, taking them out of circulation for ordinary people, even those with the best insurance, and offering first-class care to an elite clientele – the kind who can afford out-of-pocket annual fees of up to $40,000 for the privilege. And these are the folks who, in a more realistic sense, really have influence over public policy. So I think you do have a point but you’ve targeted entirely the wrong economic stratum.
IMHO, something like Americare is our best chance at something better. I am on Medicare (at long last) and happy for it. It continues to serve my parents well and I expect the same for my wife and me.
If 64% of providers lose money on it (as referenced upthread), then they need to either negotiate for better rates or get efficient. (The other 36% must be doing something right). After all, the other advanced nations have a myriad of examples of how government, pharma & healthcare provider committees can cooperate in setting prices so that no one loses like that.
Over 50 years ago, Kenneth Arrow demonstrated that free market forces fail when it come to healthcare costs. Since I, as an end consumer of healthcare can’t negotiate a deal with ‘Stents R Us’ while dealing with crushing chest pains - then I would rather have the government (state or local, I don’t care) negotiate prices for me than a for-profit insurer.
(The insurance industry doesn’t have to go away - it can be non-profit as in Germany and Switzerland - and continue to provide upgrade policies to those interested in that sort of service.)
There are other paths to universal care, ACA already pretty much gets us there is we consider universal to mean “everyone who wants health insurance can get it”. Which in America, is really all we should be shooting for.
“Premium” is a very misleading term in the Canadian health care context. It’s essentially a small tax surcharge that is earmarked for health care but has no relationship to whether you get health care or what level you get – health care is universal, period, and if you don’t pay the surcharge (if there is one) your problem is going to be with the income tax people. In Ontario it’s geared to income and currently looks like this. The most anyone will ever pay is $900 a year, and that’s if your net taxable income is over $200,600. Note that by law, there is zero deductible, zero co-pay, and no maximum on health care coverage. I suppose this is where the euphemism “free” comes from. Like when I had my first major hospital stay a few months ago, which involved heart surgery. My major responsibility when leaving was to say thanks to everyone as I walked out the door. Not a shred of paper or a single dollar was involved.
Until you need something they don’t cover. Of course, you’ll never know, because doctors won’t tell you about treatments not covered by the system. So you’ll be content not knowing that just across the border are other options.
Actually, what you need is multiple payers so that doctors can recommend care without having to account for what Medicare covers and doesn’t cover. For all they know you might have coverage for proton beam therapy when your chemo fails to halt the growth of your tumor.
Plus, British doctors are perfectly willing to discuss treatments that are not available on the NHS in those rare occasions such situations arise. It’s not like there’s a gag order on them.
I thought it was obvious I was speaking with “the voice of the class.” I don’t have data one way or the other, but what I say is suggestive of the arguments from the top 10% or so.
I’m not missing it - I just don’t think a law telling suppliers that they must charge less than it costs them to deliver a good or service will work out too terribly well.
For example, the current cost of bringing a new drug to market is $2.6 billion. If the government refuses to pay anything more than simply the cost of manufacture, how many new drugs do you expect will be developed?
We could certainly put a cap on how much we pay for patient care - we used to do something like this with DRGs, or Diagnosis Related Groupings (I used to work for a hospital system). The idea was to group patients into certain groups based on their diagnosis, complications and co-morbidities, and then say “we will pay X amount for each patient in this DRG. If you stay under, keep the change, if you go over, you have to eat the difference”. The thing is, they didn’t eat it - they charged other patients more.
Something like that could work - so long as we are willing to accept that there are no other patients to charge more, so we simply don’t spend the money. And I don’t mean doing the care for free - I mean saying “sorry, Charlie - you went over your limit, so go home - no more for you. If you die, you die.”
Do you think true costs have been going up by 10% or more a year (rough number) for decades? Or is that just more bureaucratic bloat and pocket-lining that suppliers *could *cut if they had an inducement to do so?