UHC: Has to be affordable, high-quality, and also *not* have long wait times

Great Debates
41

Just a few days ago I had a long conversation with a friend who is a U.S. veteran and is a very satisfied customer of VA healthcare. They’ve given him totally free bypass surgery, a free pacemaker, free convalescence in a nice nursing home, and much more. They even paid for a taxi to take him home from the nursing home. Delays have been short; medical care has been excellent; one of his surgeons is world-renowned. (He lives in Thailand and must return to the U.S. to use VA, but he gets free medicines delivered here, and his American VA doctor sends him personal letters to keep up with his status.)

Anecdote is not the singular of data, but Googling shows that VA patients are, on balance, as satisfied with their care as Americans with good health insurance or HMOs.

Yet “popular wisdom” is that VA Healthcare is inferior with major problems and delays.

What’s the moral of the story? Fake News promulgated by kleptocrats and right-wing haters and liars is now ubiquitous in post-rational America. Even those smart enough to never watch FoxNews are victimized by the lies. How often have you read about the problems with VA healthcare? It’s become a cliché, and the reality of those problems is taken for granted; yet it all developed from a few stories exaggerated by opinion-makers who are paid to tell lies that make citizens hate government.

My recommendation is to compensate by moving to the opposite extreme: Assume anything you hear that fits a right-wing agenda to be a Lie!

TL;DR: If the U.S. somehow switches to single-payer healthcare it will be better than what we have now. Less delay. Lower co-pays, if any at all. Less cost. Higher quality.

HTH.

42

The coverage I had in the US was always worse than the coverage I had in Spain at the same time; the coverage I’ve had in Swtzerland, France, the UK and Costa Rica have been consistently better than what I had in the US. Are you sure that you want your coverage to “not change”?

43

America actually has fewer doctors per capita than most other wealthy nations.

However I think a bigger % of our doctors are specialists. Either way, waittimes are in part due to a shortage of labor and technically the US has a shortage of doctors compared to other OECD nations. We’ve got 26 doctors per 10,000 people while places like Germany have 42 doctors per 10,000 people.

Having said that, there are systems that hit all 3 of your metrics. Taiwan for example has affordable, high quality health care with short waittimes. Its entirely possible to have all 3. Also in Taiwan you don’t need a GPs referral to see a specialist, which I like.

Also every other wealthy nation spends around the same % of GDP on health care, around 8-12%. Many western nations hover in the 10-12% of GDP range despite having different plans. Some have single payer, some have multipayer, some have single payer with optional private insurance, some have public plans on the multipayer system, etc. but they all end up costing the same.

Also wait times in the US are comparable to wait times in Germany & Switzerland, which have health systems that cost at least 30% less than ours.

https://askepticalhuman.com/politics/2018/9/10/debunking-right-wing-healthcare-myths-wait-times-rationing

44

Yes, any time there’s a discussion here on UHC and the issue of wait times comes up, the assumption from some US posters seems to be that wait times aren’t an issue in the US. That’s not the case. But because wait times are caused by the private insurance system ( e.g. Only a few specialists in your insurers’ network, as Kayaker mentioned), that seems to be okay. It’s only wait times in a UHC system that are seen as a problem.

45

Its the same way that spending trillions of dollars on tax cuts for the rich or trillions of dollars on war are perfectly acceptable, but when people want to spend trillions on health care, education and infrastructure people start yelling ‘we can’t afford it’.

People weren’t saying that when we spent multiple trillions of dollars on tax cuts for the rich and the war in Iraq over the last 20 years.

46

One of the reasons for this is that cartels like the AMA have successfully lobbied to limit the number of new doctors, lest current doctors face any kind of downward pressure on their incomes.

47

Wait times, like everything else, depend on your insurance coverage, even for seeing general practitioners. I’ve had shitty insurance from former employers that few doctors in my area accept. I had a dental plan years ago where there was literally only one dentist in DC that was taking new patients with that insurance. It took months to get an appointment. Another employer offered insurance that was only taken by a for-profit clinic chain. The type of place you go when you need a pre-employment drug test. This was in Baltimore, and when my employer switched to the new insurance, I could no longer go to the high quality university hospital system on my street, but had to drive to a redeveloped industrial park on the other side of town to go to a low quality, slow, and unfriendly place.

Every criticism I hear about a public healthcare system ignores everything terrible about the current system. When my son was diagnosed with asthma, he was admitted to the hospital, we stayed overnight. He was covered by my wife’s insurance, but the hospital billed my insurance, who refused it, and then I got a bill. It was astoundingly high, and took months to work out. In the end I payed the hospital around $50, because I was so sick of disputing charges, and it was the last bit of the original bill.

48

I remember when some of my coworkers were saying " Do you want some government bureaucrats deciding whether you can get treatment? " I usually asked them why they didn’t have a problem with an insurance bureaucrat deciding, since at least the government workers wouldn’t profit personally by denying treatment. ( I also pointed out that said coworkers were government bureaucrats themselves)

49

I usually respond, why do you want that ass in HR deciding whether you can get treatment?

50

And that is why a public UHC system is more efficient than the “market” system in the US - because part of what US health insurance premiums pay for is for the insurance companies to hire bureaucrats to contest your bills. Their salaries come out of your premiums. We just don’t have that in the Canadian system. The medicare programme and the doctors work out in advance a schedule of what is covered (hint: pretty much everything) and how much medicare will pay the doctors. Then, when your doctor provides services, they are compensated according to that schedule. There’s no medicare bureaucrat who reviews the individual bills.

Now, there could be doctors who milk the system. That’s possible with any funding system. But the way to control that is that the medicare system monitors the overall billings of each doctor. If their billings are out of line for the average profile for a doctor in their specialty, the medicare officials will review that doctor’s billings in detail, and possibly claw back if the billings weren’t appropriate, or even refer to the police if they think there’s been fraud. But that in no way affects the health care you got, and you will never see a bill. You’ve got more important things to do, like look after your son. :slight_smile:

51

Your co-workers don’t appear to understand the fundamental difference between UHC and the US “market” system. That’s not how it works, at least in Canada. They’re transposing their experience with a private insurance company, whose goal is to save money by denying claims, with a public system, whose goal is to provide health services.

52

Well, now that’s an excluded middle. So, I can have that hip replacement tomorrow for $10x, but if I wait a year, I can have it for x? There is no reason why we cannot come to somewhere in the middle as a compromise, and have it for $8x in a month, or $5x in 6?

The two times that I had a major healthcare expenditure (once for wisdom teeth, and once for some sciatic issues), the doctor was waiting for the insurance company to approve the claim. It was not the doctor that was the hold up, once the claim was approved, which took nearly 2 months in the case of my wisdom teeth, I scheduled the surgery within a week.

What value added was there? What cost savings were generated by my wait?

What we have is of lower quality, much higher prices, and depending on how much you are worth financially, something between slightly faster to much, much, much slower, if ever.

The system that we have has an entirely separate entity acting as a parasite, adding to costs, lowering quality of care, and causing delays or even denials in coverage. It contributes nothing to the care received.

If I say I need it in two weeks, and you say you can’t do that, but you can have it in a month, for twice the price and of substandard quality, but your competitor can do it in the two weeks I ask for, with acceptable quality, and at a lower price, then I would be a fool to go with your company.

Yet that is exactly what we do in healthcare.

53

I don’t think you can call them bureaucrats. They are not supporting a bureaucracy, they are clerks working for a private firm.

54

Decriers of medicare seem similar to deniers of evolution and climate change. Their faith trumps everything else. Even reason and observation.

Those in the US who oppose medicare most vociferously seem to believe in their hearts that not only is their cause noble, but that it is vital. They use this type of faith-based ‘reasoning’ not just in their opposition to medicare and ‘socialism’ more generally, but to justify their opposition to evolution or addressing climate change. As ever, their faith calls for them to repudiate the faith of others.

Deep faith is particularly ugly in its American incarnation.

55

Not to hijack, but this is an area where in the US government intrusion has caused the issue. Insurance law used to be (more or less) the simple law of contracts. If I have a contract with the insurance company to insure my health care expenses and it dawdles or tries to “save money by denying claims” it has violated the good faith and fair dealing implicit in every contract.

Further, most (all?) states enacted consumer protection law with regard to insurance so that this duty was enhanced in an insurance contract. People facing huge losses in insurance whether replacing your house, or car, or health were in a bind and were in a poor position to enforce their contractual rights at that time. The violation of the duty of good faith was an additional tort for which hefty verdicts were rendered, reducing the incentives to near zero that companies would engage in this sort of thing.

But in the mid-1970s, for some reason,the feds passed ERISA which among other things, eliminated this type of lawsuit in health care insurance leading to this type of foot dragging and refusal to cover certain things.

But my point is that there is nothing unique about an insurance “service” contract that simple regulation designed to keep the playing field fair cannot achieve. Your objection that it would lead to have a goal to deny the service would seem to apply on its face to any service contract, and hence the need for government intervention in all of them.

56

This is a very important point that I frequently mention and will do so again. It’s what I mean when I refer to the single-payer payment system as “streamlined” and “unconditional”. There’s a real irony in anti-government types being fearful of public insurance plans because they think they will entail “government bureaucracy”, but in reality the way single-payer is intrinsically structured removes the bureaucracy between doctor and patient. It’s a completely different model from conventional insurance. And yes, one reason it’s cheaper is because you, the patient, are not paying for bureaucrats who work hard to find ways to deny your claim.

57

Then explain to me why large companies or organizations don’t self insure and get rid of private insurance middle men? Google, Apple, the city San Francisco, and Facebook could administer their health plans in-house and save tons of money. The truth is that many organizations already self-insure and don’t have greedy middle men. They use Blue Cross/ Shield which basically handles the paperwork and cuts the checks.

One of the big hurdles I have for single payor or medicare for all is that I have not been supplied with a reasonable explanation as to why healthcare costs keep rising so much and well as why are they so high. Somebody, somewhere explain it to me.

58

No, they understood that. The “government bureaucrats” they were referring to were those who might decide that performing a triple bypass on a 97 year old with terminal lung cancer is not the best use of health care dollars.

59

Sorry for the double reply, but at least in the U.S., the government bureaucrats are typically not just guided by their stated goal. They have budgetary constraints and middle managers looking to make it to the next level by showing how cost effective they have been in managing their departments. So to the extent that people are acting in bad faith, those same pressures are there in a public system just as in a private system. The only difference is that because of sovereign immunity, you can (almost) never sue the government for anything. At least you can sue private actors for something.

As an aside, here is my problem with “Medicare for All.” As you know, I am a criminal defense attorney. Criminals, by and large, do not have money. I make my money when mom, dad, or grandma pays my fee to get their wayward child out of trouble. I make a decent living doing that. But there are not enough of those people, especially in a poor state like West Virginia, to be able to pay the bills with just that. So, I voluntarily take appointments from the courts to represent defendants to fill in the rest of the day (usually a 10 to 12 hour day) to supplement that income and justify paying my staff and still being able to do a quality job. But that pay is a pittance. It is far, far short of what a private person pays for an attorney.

Now, imagine the government instituted “Public Defenders for All” and that nobody paid in private and that my entire practice had to rely on the state payment rate. I would have to go into another type of law or become a farmer. I could not pay myself, let alone staff, on that rate.

I know and have talked to many doctors and their experience with Medicare is EXACTLY the same. They make money off of private pay and insurance pay and accept Medicare to supplement the income and the Medicare rates are grossly reduced. They could not survive on taking Medicare only.

If we have Medicare for all, we would need to dramatically increase the cost of the program to keep doctors in business. I don’t think that anyone has addressed that issue. They seem to only take the Medicare patients, multiply to reach 100% and think that will be the cost. It is not.

60

Part of the high costs in the US system are due to economic inefficiency that results from all the middlemen. The spectre of lawsuits also has a pervasive and expensive influence on health care.

In any developed nation, health care costs can rise because of some combination of:

  • increasing expectations by the population (sometimes for what is essentially unlimited care)
  • aging and hence sicker population
  • increased lifespan of the chronically ill (and thus increasing numbers of people who have expensive care needs)
  • the cost of new interventions (nothing comes on the market cheaply anymore and sometimes new treatments are fantastically expensive; and sometimes for pure economic gain without health benefit as in Martin Shkreli)
  • the law of diminishing returns for many interventions (i.e. except for rare instances, many new therapies and treatments lead to small, often low single-digit percentage gains in some hopefully meaningful endpoint or outcome). Simply put, you pay more for less
  • and don’t forget that much of medicine in the developed world deals with effects, not causes. Phrased differently, hugely more is spent treating disease than preventing it. This ass-backwards approach would seem to lead inexorably to increasing costs.