The problem with both those arguments (doreen, I understand that this is not your argument but that of your co-workers) is that in single-payer and equivalent UHC systems, government bureaucrats do not and cannot do those things, because the whole system is structured differently than conventional insurance. It’s easy to lose sight of that if one is accustomed to the workings of ordinary insurance companies. No insurance bureaucrat is going to deny surgery to someone because of their age for the simple reason that, by design, no mechanism exists in single-payer for adjudicating individual claims. It’s unnecessary and completely redundant because there is no contractual fine print that determines someone’s qualification for coverage; if it’s on the fee schedule and a doctor says it’s medically necessary, then it’s covered, by definition. This is a truly fundamental difference from the insurance model.
Of course, bureaucrats can always impose restrictions as a matter of system-wide policy, but those kinds of things affect everyone and tend to receive a great deal of public scrutiny. So it’s politically much harder, say, to announce that you’re going to cut off certain coverages at a certain age, as compared to screwing one individual patient the way insurance companies do all the time.
Yes, some large organizations self-insure, as you just acknowledged, and the reason many others don’t bother is because it doesn’t really save that much. The nuance that you’re missing here is that when I blame health insurers for the costs, denials, and all the other problems with health care in America, it’s not because of their mere existence, or their profits, it’s because the entire health care system is fundamentally structured around private insurance as the primary coverage mechanism. See, for instance, my immediately preceding post for one example of the consequences of that: the extremely costly and potentially life-threatening bureaucratic meddling with each and every claim in an effort to minimize medical payouts, which creates a costly mass of paperwork, claims denials, and non-payments to practitioners. And since there is no central regulatory policy to standardize and control costs, medical costs keep soaring. No individual private organization or even a very large insurer can do anything transformative about this mess. It takes government intervention to establish a fundamentally different system, one that is universal and community-rated, whether or not the government actually runs the health insurance system.
See above. What’s the difference between the US system and the systems everywhere else which cost so much less and whose costs are generally rising more slowly? They are not all public single-payer, but they all have a high degree of government regulation and generally streamlined and unconditional payment systems. US medical costs are high and rising fast because (a) they have to cover a ridiculous amount of administrative overhead, and (b) there is absolutely no means of cost control.
Sorry I wasn’t more clear- they were talking about system-wide policies (although not necessarily related to age) not individual cases. While I’m sure that UHC systems cover medically necessary treatment, I’m also pretty sure that medically futile treatment isn’t covered, even if it’s the doctors making the decision about what is and isn’t futile. That’s what my coworkers objected to - they were apparently living in some fantasyland where the insurance company would pay for any treatment/test a doctor was willing to provide* whether it was necessary or not, even if it was futile.
I knew that wasn’t true - about 15 years ago my daughter had been having headaches and the doctors wanted to do some very new type of MRI or CT (not sure which). Insurance wouldn’t cover it. As I was trying to figure out how to come up with the $20K, I asked what the alternative was. I was told a lumbar puncture, which was much less expensive. I asked if it would give them the same information and they told me it would. I can only assume they wanted the other test because they wanted either to play with/or pay for their new toy.
Judging from my own experience in single-payer, including as a patient advocate for elderly relatives, I would say the more correct statement is not that “medically futile treatment isn’t covered”, but that, as you say, “it’s the doctors making the decision about what is and isn’t futile” – which is a completely different statement. The operative principle in single-payer, as I’ve said before, is that doctors are the trusted gatekeepers to the medical system, as distinctly opposed to insurance bureaucrats. And the difference of course is that doctors make their decisions on medical grounds, whereas insurance bureaucrats do it on mercenary grounds.
That said, my elderly mother who lived well into her 90s received amazing medical care throughout her old age, her advanced age making absolutely no difference to the many medical amenities she received, including several major hospitalizations and home care. The degree of care and attention actually surprised me, even though I already had a very positive view of our medical system.
We’ll be substantially closer to a working form of universal health care once its proponents acknowledge that:
taxes will go up considerably, for most people, not just The Rich, and estimates of the total cost will almost certainly be way too low,
while care will be high quality, there will be longer waiting times for certain procedures/care and even denials of some requested services,
political pressures will ensure that non-evidence based therapies will be covered, so (for example) you may wind up paying for your neighbor’s reiki treatments (although hopefully not for her distance healing sessions),
many will find the new system to be more frustrating and less satisfying than their current private plans,
UHC overall will be messy and disruptive, at least early on until the worst bugs get worked out,
it’s worth doing for the overall public benefit.
The odds of proponents being honest and acknowledging these points (except for #5) is roughly the same as the odds of a million armadillos flying in perfect formation over the U.S. Capitol while playing “The Battle Hymn Of The Republic” on electric kazoos.
Or only #5 is true, and the rest of it has been debunked over, and over, and over, and over, and over. I’ll give you partial credit on #4, but only because people will insist upon it being messy and disruptive, and complain about any slight change, even if for the better.
#1 is slightly true, in that taxes will go up, but will go up less than what people are paying in premiums right now. #2 is half untrue and half irrelevant. Yes, some elective procedures may have a bit of a longer wait, but procedures deemed as non-elective will actually be a shorter wait, and there would be no denials of any covered services.
Your #3 is just BS, though I suppose if you were trying hard enough, you could try to claim that denial of Reiki healing justifies your claim on #2.
The odds of your concerns being true are far less than the odds of your armadillo parade.
ETA:
I see that you have 2 #3’s, but both are BS.
If you think that there is anything more frustrating than the current system, then you have obviously not ever had to use it.
Since I’ve been living with single-payer UHC for most of my adult life and have some direct knowledge of its early days, perhaps I can comment on some of your prognostications.
That’s possible of course, since it all depends on how the system is structured. But since per capita health spending everywhere else in the first world averages about half of what the US spends, even if some cost savings take a while to kick in, surely one can expect that the typical middle-class taxpayer’s tax component of health care costs will be less than today’s total cost of taxes plus insurance premiums. IOW, how can the average taxpayer NOT save money overall? The most likely losers here will probably be the rich, because they already have the best health care that money can buy, and are the most likely to be hit with higher taxes under a progressive tax scheme. And since the rich basically own Congress, this helps explain why calls for UHC get so little traction in the US despite the obvious benefits. That, and the massive health insurance lobby.
See my post #61. How can you predict that there will be denials of some services when single-payer UHC – at least as implemented in Canadian provinces – has no mechanism for denying claims for listed procedures that have been deemed medically necessary? This is fundamental to how the system works. There is in fact no formal line of communication between me and the province’s health insurance system at all, in contrast to the blizzard of forms and phone calls going back and forth all the time with private insurance. When I go to the doctor or hospital, I present my health card and that’s the first and last that I ever deal with payment issues in any way. Payment processing is pretty much fully automated and electronically paid directly to the provider. I don’t even have a way of finding out how much was billed, nor do I care. Medical care is essentially a non-monetary event for the patient.
Maybe, but that’s absolutely not the case in Canada. As a matter of fact, I was reading a commentary recently from the Ontario Ministry of Health about the importance of a strong case for efficacy when approving the addition of a novel therapy to the fee schedule.
Maybe, but I rather suspect that most of this will be baseless whining from the same crowd currently fearmongering about “socialized medicine”. Like a poster on another board whose arguments in favor of private insurance made it sound like the greatest thing since sliced bread, and he apparently never had a single problem or issue with it of any kind. Until you found some of his other posts in a different forum in which he whined about being denied coverage and ripped off by hospitals.
It’s a big change on a large scale, so this is possible. But again, looking at the transition in Canada, the biggest disruption was the doctors’ strike in Saskatchewan, aided and abetted by both the US insurance lobby and the AMA, who were heavily engaged in the process informally known as “shit-disturbing”. Once that was settled, I’m not aware of too many problems as single-payer rolled out to other provinces. I know that in Ontario, there was concern that the government didn’t have a fully operational payment system in place, so they outsourced the payments processing to one of the former big health insurers that was still around. There were complaints that payments were often slow in the early days, but that all got resolved, and the private insurer soon packed up and left when they had no more business.
True, dat.
I’m more than happy to be honest. I think I have been. I don’t think it’s dishonest to point out that few or none of the things you predict actually ever happened in Canada in the course of the transition from private insurance to single-payer.
It’ll get you into the top 1%, but not the true echelon of the rich.
If you study a specialty and move to a high demand area, maybe pick up a 2nd medical job you can make half a million a year. Good money, but thats barely getting into the top 1%.
My impression is that to get into the truly rich categories (the 0.1% or higher) you have to work in finance, own a business, or come from a family that did one of the two.
Or you can own a concierge medical business like this. The total incursion of money into health care as the primary determinant of quality appears to be never-ending, and everyone should be both concerned and disgusted. This is what happens when you let the “free market” run wild in health care because people have become indoctrinated to have a mindless fear of “socialized medicine”.
That’s why I said top 1%, not top 0.1%, which indeed has lots more money, as they get an even bigger share of their gains.
And you underestimate what they get paid:
Now I don’t know how accurate this is, but a median salary of $450K is a lot more than you seem to expect.
I certainly don’r mind doctors making reasonable amounts of money, but is a median salary of $450K reasonable, and does it come from the fact that many doctors have the power of life and death. The exception in the list above are plastic surgeons, who are more market based.
From here the average salary of Canadian doctors is $225,000 (Canadian dollars.) I don’t know if GPs make less there like they do here, but UHC doesn’t seem to be hurting too much.
ETA: BTW, the salary that gets you in the top 1% (family) is $421,926, so $500K or even the median for orthopedic surgeons puts you right smack dab in it.
That would only apply if you have an inbuilt system of reviewing costs per patient and per item of service in order to second-guess clinicians’ judgements. Hand the doctors a budget and general guidelines as to value-for-money, and that issue simply becomes one more factor in their judgement.
In the Spanish system while the doctor determines whether a procedure or a medication is appropriate for a specific patient, the definition of “covered” and “not covered” is usually at the procedure/active ingredient level and doesn’t include an exam of whether it’s futile or voluntary by somebody else unless there are accusations of possible criminal activity; hospitals and ambulatory centers have periodic reviews of procedures, but these are after the fact and do not affect a patient that’s already in treatment (they may lead to changes in protocol going forward). Some specific procedures are in a “must be decided on a case by case basis” area due to their very nature: braces for medical reasons are covered, braces for aesthetic reasons are not. Whether to do or not a specific procedure in a specific case is determined by the doctor (who defines whether it is appropriate or not and acts as the first gatekeeper), the patient and the patient’s family; the patient has ultimate say unless considered incapable, but having a family that’s all in agreement makes things easier. If Dad had chosen to have surgery for his aortic aneurysm, it would have been covered; the surgery might have killed him sooner than the aorta eventually did, due to the weakened state produced by the cancer and its treatment, but “bypasses and stents are covered” means they are.
Just a couple of points on the US-Canada salary comparison. The CIHI data cited in the article actually speaks of the average Canadian doctor salary being around $307,000, then later adjusts that to $225,000 after deducting overhead expenses. It’s not clear whether the data you cite for US doctors is similarly adjusted, though it probably is. But also, the US data is median salary while the Canadian data is average salary.
Here is another source for US doctors’ salaries which might be a better basis for comparison. It cites average salary, not median, and makes it clear that this is net pre-tax after expenses. It’s even closer to the Canadian figures; net CAD $225,000 average for Canadian doctors, net US $299,000 average for American doctors. Plus I would hazard a guess that absence of any regulatory cost controls whatsoever enables in-demand top specialists to crank up their fees to astronomical levels, creating a “millionaire class” of top specialists in the US which artificially skews the average salary figure. Since Canadian doctors are all paid according to a standard fee schedule, there are no such extreme incomes.
The average overall physician salary—including primary care and specialties—is $299,000. The profession saw a modest increase in earnings over last year: In 2017, primary care physicians earned $217,000, compared with $223,000 in 2018; specialists earned $316,000 in our 2017 report compared with $329,000 this year. For employed respondents, compensation includes salary, bonus, and profit-sharing contributions. For partners and solo practitioners, it includes earnings after taxes and deductible business expenses but before income taxes. https://www.medscape.com/slideshow/2018-compensation-overview-6009667#2
One thing that should also be mentioned is that the cost of running a medical practice in the US is much, much higher than in Canada because of the clerical staff (and some amount of the doctor’s own time) necessary to deal with the enormous insurance overhead – not just the extra staff in the doctor’s office, but the entire insurance bureaucracy (which mostly exists in order to deny or reduce payments). Add to that the absence of any regulatory cost controls and the much higher cost of malpractice insurance, and the need to subsidize instances of non-payment, and there in a nutshell you have the high cost of US health care explained.
I know. I guess my point is that I don’t consider the 1% and the 0.01% the same for various reasons.
For one, the top 1% are still salaried, so they pay a large tax burden (which is fine). a physician making 500k may pay 200-250k a year in taxes.
Also at that level of wealth, you have more than enough to live comfortably, but not enough to bribe politicians or bend society to your will.
The top 0.1% or 0.01% may only pay a 10-15% tax rate since their incomes come from capital gains and dividends, not salaries. And have enough money to bribe politicians, buy up media empires, brainwash the public, etc.
But yes I agree, medicine seems to be the best path to getting into the top 1%. I know someone who is a specialty physician and he said in high demand areas, jobs are paying about $240/hr. That alone would put someone in the 1%.
However I really don’t know how people get into the top 0.1% or 0.01%. I assume that only comes from finance, owning a business, or coming from a family that did one or the other.
Canadians, Britsh people, do you ever get stories like this one near you? Valaraiso (Valpo) is a town in Indiana not far from me.
“I was in a cell fit for a murderer,” she recalled. “I slept on disgusting mat on a concrete floor in a tiny room, next to a musty water drain that was more like a sewer. I was treated like a dog from staff members, served food through a door hole, and showered in an open area with actual felons.”
“I had nothing to do but stare at the four concrete walls and listen to catcalls from felons down the hall, or the vomiting from inmates going through drug withdrawals,” she said. “All this because I failed to pay off an ambulance bill. My crime was having a heart attack.”
Single mother goes from traffic stop to bench warrant to jail over unpaid medical bill: ‘It just isn’t right’