I don’t doubt that US single-payer will happen within my lifetime on a state-by-state basis, but I don’t know to what extent (if any) the political will will ever exist to enact a national SP plan. More than likely, what you’ll have over the next 20-50 years is an augmented form of the ACA (dictated by whichever administration is in the WH) coupled with a patchwork system of state-based SP plans. Now, taken together the results of that scenario would still effectively result in a US version of UHC, but it’ll be more disjointed & inefficient than a national SP system.
Hell, I can even envision a regional scenario of SP in the US. Here, you’d have a system in which the bluest of blue states like California, Oregon, & Washington all adopt SP and band together to form the West Coast SP Cooperative (or whatever you’d like to call it); whatever financing mechanism they choose would be consolidated so that the legal residents of all three states would have this regional SP coverage which would provide for any HC tendered within those states.
I mean, that might even be a more palatable & practical alternative to singular state-based SP plans, given that multiple states would come together to alleviate any financial & sociopolitical hurdles. Similar cooperatives could exist across other liberal states.
Right now, however, a lot of these prognostications are contingent upon Vermont. Seriously, it’s enormously important that that state get its system up and running by 2017 (as scheduled) and before Obama leaves office. Although the Shumlin administration up there is still struggling to come up with a suitable financing mechanism for SP, I don’t foresee the effort collapsing in the same way it potentially could in other states.
But yeah, assuming VT pulls it off I’ve no doubt that CA would soon after fall in line and follow suit. Don’t forget: CA actually passed SP and got it to the Governor’s desk TWICE when Arnie was still in charge. Moreover, there’s been talk of putting SP on the 2016 ballot here, where it would probably have the best chance of passing. For now, however, the state is infinitely more concerned with making sure that the ACA is successful here, and so SP in CA - at least LEGISLATIVELY - has taken a backseat to shore up Covered CA.
We are still doing it because private insurance companies make around $900 billion per year.
And private insurance companies spend a couple hundred million per year, give or take, to influence our elected officials to keep that horrible socialist medicine away.
That’s why we still do it. That’s also why we have the ACA instead of real single-payer.
That’s likely how it will happen, and it’s not necessarily a bad thing, depending on the form it takes. Canada has a culture of relative provincial autonomy similar to the principle of states’ rights, and single-payer health care here was indeed implemented on a province-by-province basis. The federal government got involved only later, and only in the form of a set of health care principles that provinces have to meet in order to qualify for annual health care transfer payments. So each province runs its own separate single-payer system which it funds out of its own budget, with help from the feds. Each system is slightly different in some details of coverages and funding models, but the same in basic principle, and with similar reciprocal coverages for out-of-province residents. So it’s a “national” health care system with respect to that common compliance with the Canada Health Act, but with province-level management.
If you want insurance not to be tied to employers, you had better support Obamacare. In the pre-ACA period there were a lot of reasons that non-employer provided insurance was a problem.
1 - pre-existing conditions. They were never a problem with employer provided insurance, and a big problem without.
2 - purchasing clout. Big employes could negotiate good rates. Individuals could not. Now with exchanges individuals have a lot more information and there is more competition than before.
I’d love it if a law forced employers to pay employees the part of healthcare costs they cover. It would make the gap between employers with good benefits and without a lot clearer. But the cheapskates would just scream.
I agree. A good analogy is pensions. When I started to work, pensions were the norm, which was fine for lifers at big companies. But IEEE magazines were full of calls for portable pensions from engineers who would switch jobs every five years or so and never get vested. 401Ks, whatever their drawbacks, are vested and portable. Pensions for private industry are just about gone. Portable health insurance with dollar funding by companies (as opposed to them buying the insurance) might be just the ticket.
I’ve just been reading a Slashdot thread about a Motley Fool thread ( the MF being an extreme anti-capitalist communist propaganda group ) regarding broadband, Sweden and America compared.
Due to a network of municipalities, Swedes pay less:
For example, my brother pays $40 a month for his 100-megabit broadband connection in Karlstad, Sweden. He can take his pick from 19 different service providers, all using a common last-mile infrastructure and competing on price and features. For $70 a month, he could upgrade to a full gigabit.
Me, I’m stuck paying $83 a month for a 50-megabit connection. Moreover, my upload connection rarely goes past half the speed Verizon (nyse: vz) promised. So I’m paying more and getting less, and if I wanted Verizon’s fastest available FiOS connection, I’d be paying $300 a month (plus taxes!) for half a gigabit.
Right-wing slashdotters argue that Swedes pay higher taxes which subsidizes this useful thing contrary to morality and b/ government = bad.
Personally I would just note that Swedes get better results for less cost; and religious belief in the superior values of either the free market over government or vice versa doesn’t really matter. Chose that which brings the nearest to best result.
That quote of $387 billion in savings is from the website of the politician who sponsors HR676, the ‘medicare for all’ piece of legislation. Even he says about $400 billion in savings.
The study mentioned here however says closer to $592 billion.
Keep in mind if our system were as efficient as what they have in Europe, we would need to spend about a trillion less per year than we do now. If we spent 1.8 trillion instead of 2.8, that means health care would be about 11% of GDP rather than 18%.
And 11% is on the higher end of OECD averages. Places like Italy, Japan, UK, etc only spend about 8% of GDP on health care. 11% would put us in the same category as ‘expensive’ nations like Germany.
My point is, our system sucks and single payer is a good idea. But that alone will not make our health care as efficient as what they have in other OECD nations.
Why not? My point is that it can be and it should be – and it all depends on how it’s implemented. The reality is that control of provider costs is inherent in public systems everywhere, as it should be. Indeed, it’s precisely that control of provider costs that removes the need for clinical meddling at the claims level, which is one of the signature attributes of single-payer and all systems that effectively work like single-payer – letting patients get the health care they need while taking bureaucrats out of the criminally sordid business of clinical adjudication.
I hope so. But right now Vermont is the only state taking single payer serious. California’s democrats are just using single payer to rile up the base for votes and donations. They only got it passed through the legislature when they knew governor Arnie would veto it. now that they actually can get it passed (they have the governorship), they can’t get the votes. Same thing happened with the EFCA on the national level. As long as democrats knew it would never become law they could get it through congress. Once they actually could pass it, they couldn’t get the votes. It is all a scam and Vermont is the only one taking it seriously.
Having said that, states like Illinois and Pennsylvania have supposedly made attempts at single payer. But who knows how serious they are. Larger states with liberal governments (CA, PA, IL, NY) combined make up about 1/4 of the nation. Combined just those 4 states would put 1/4 of this country under state single payer system.
Single payer can be controversial (despite the fact that people love medicare) because some people feel it will take away their options.
A better stepping stone to single payer is a strong public option that lets people buy into medicare, VA or medicaid.
The guy who designed Vermonts single payer system, William Hsiao, came up with 3 policy ideas for Vermont. Two single payer plans, and a public option plan. He predicted the savings over a decade to be about 24% with the single payer and about 16% with the public option.
My point is, the debate isn’t ‘single payer or business as usual’. A strong public option is a good stepping stone, would be less controversial, would be easier to get passed legislatively and would provide 2/3 of the savings of single payer. It isn’t an end goal (massive reform is the end goal) but ACA could open the door to a public option, which could open the door to single payer, which could open the door to more meaningful reform on how our system is run.
A big reason our system costs so much is we didn’t enact reform in the past. Our health costs grew faster than other nations with better run systems. There were attempts to create a universal system in the 40s under FDR and Truman, but southern politicians were afraid it would lead to integrated hospitals and black people getting health care. Those fears (in dog whistle form) are still a major hurdle for health reform. You just portray reform as white working class people’s standard of living going down so blacks, latinos and poor people can see their standard of living go up.
I haven’t seen any evidence that single payer will trim a trillion dollars or more off our health spending. The figures I’ve seen range from $50 billion to $600 billion a year.
We need single payer combined with strong (public and private) market forces to drive down costs. Things like price transparency, comparative effectiveness, incentivizing lower cost measures, etc.
The business doesn’t save any money in switching systems. It’s paying a total compensation package that it has to in order to attract the workers it needs. If it stopped paying health insurance benefits, it would have to increase the amount it pays in cash salaries. In other words, workers would not be content to just absorb a significant pay cut.
Adverse selection: People actively seeking out health insurance are more likely to need it than the rest of the population.
If you know you have an expensive condition, then of course you’re more likely to justify the expense of insurance to cover as much of it as possible.
On the other hand, those getting it through work are less likely, as a whole, to use it. Insurance companies know this and offer better rates to such groups.
So it’s a win for the employers, employees, and insurance companies. It sucks for everyone left out.
I’m not convinced it really impact competition. I mean, if those employers weren’t offering healthcare, they would presumably offer better salaries instead, or else employees who elected to work for the company because it offered X dollars plus healthcare would just try to find a better deal.
I also think that because over here healthcare is paid for by a tax on salaries (partly paid by the employer, partly by the employee) for historical reasons . However, when people talk about a lack of competitiveness of French companies, I never heard this cost mentioned as an issue. Presumably, a Frenchman gets a lower salary than, say, an Englishman (who will later pay for the British UHC with his regular taxes) and the labour cost, all other things being equal, is about the same in both countries. If it weren’t the case, I’m pretty sure French employers would cry a river to get rid of this burden.
I really can’t imagine that American employers could get by with offering the same salaries if they stoped also offering health insurance. People agree to work for them because of this perk. It might even be that it would cost them more, since they now have “captive” employees who needs the insurance, who might suddenly become more willing to leave on a whim if this isn’t an issue any more and more difficult to retain.
(*)The French healthcare system was build on a system where employers provided health insurance, so basically they generalized the concept at the time by having all employers/employees paying in. Before becoming universal it covered only employed people, recently unemployed people, and retirees.
American companies have been shedding health insurance even from existing employees for some time now, even before Obamacare came into being. Sometimes these companies will offer subsidies to existing employees to assist them in purchasing health insurance through the marketplace. Not always. I don’t hear about employees being offered their salaries when care is dropped or for salaries for new employees doing the same work without health care.
Of course, this is also a symptom of how the game is rigged for employers these days much more than workers. Though I fear how that changing dynamic would impact workers if we did attempt to untie health insurance with employment.
Not exactly. Insurance companies offer “better” rates to such groups because a) they are very large, and the risk is spread around thinly per member, or b) the groups are self-insured and only using the insurance company to administer processing the claims and to access the company’s network of providers.
Also, we are going to see costs paid out by employer insurance actually go UP.
Why?
The ACA gives incentives to companies that provide insurance and offer “workplace wellness plans”. And as a result, the data crunched actually is finding that instead of reducing costs, it’s actually increasing them.
Why?
Because many of these wellness plans involve “health fairs” where blood is drawn and the wellness vendor has lab tests run, and anyone who has anything out of whack with the norm has to go for more tests and more doctor’s office visits. This leads to unnecessary testing, additional specialist visits, and a shitload of meds prescribed that may or may not be necessary. All to hit numbers to make the wellness vendor able to demonstrate a good ROI.
Not just the hidden subsidy. My employer pays a large chunk of my insurance premium. I already checked, and I could get an equivalent or better plan on Healthcare.gov for less total cost - but not for less than my share of the premium for my employer-based plan.
You’re missing the point. If my employer pays $7000 and I pay $3000, and then I have to pay FICA, Medi, federal and state income taxes on the $7000 as well (say $2500), I’d be very willing to go out into the marketplace instead and shell out $3000 for a high deductible plan if I’m healthy and young. Even if I got no subsidy at all. The $2500 tax bill is more than the increased coverages are worth, because I’m really subsidizing older and sicker employees.
Adverse selection will then kill the employer plan. The employer will get sick of paying tens of thousands more for old and sick employees than young healthy ones. In fact the employer will start attracting old and sick employees.
This will never happen, of course, because killing the tax deduction is political poison for left, right and center. Everyone is looking for the free lunch and to shift costs to someone else. That’s why we are in the mess we are in in the first place.
My company used to be one of the country’s largest providers of those sorts of services, and I worked in the IT group that supported that business unit, and I haven’t ever heard of there being mandatory doctor visits based on the rinky-dink physicals that we used to do all the time.
Typically, the wellness screenings don’t actually translate into mandated doctor visits, but they often do translate into discounts if your numbers are below some threshold. So if you had BP under say… 120/80, you got $20 per month off your premiums. If it was under 130/90, you got $10 off per month, and you paid full freight for anything above that. There are usually a small set of tests that worked for this, and some automatic crash landings- if you were too fat, or you smoked, you didn’t qualify for full discounts, no matter what your numbers were.
They also do questionnaires and based on the results of those, may try and coerce you into doing ‘health coaching’ which is basically having to meet with some chump who is called a “health coach” or something like that, and they basically tell you what you already know- to eat healthier, don’t smoke, don’t drink so much, and exercise more.
Of course, they’ll suggest that you go see a doctor if your numbers are in certain ranges- for example, my company had 4 ranges, IIRC for BP- there was the “Awesome!” range, which was 120/80 or below, the “OK, but you should see a doctor”, which was like 121/81 to like 135/90, the “You REALLY need to see a doctor” range, which was higher than 135/90, and the “HOLY SHIT! Your brain is about to burst” range, which was something absurd and life threatening, and IIRC, they usually offered to call an ambulance for those people.