I’m not saying anything bad at all about Canada. I have no interest in slamming your healthcare in the country where you live. I do know that Japan, Singapore, Thailand, and the US all have private supplemental plans that wrap around government plans. This is because the government plans aren’t rich enough and leave too many holes. There are other countries that have this as well. Private insurance has a place, even in some countries where the government provides basic UHC via single-payer.
I do know that there are many types of UHC systems. Some are full-blown government-owned, including the hospitals & doctors. Others are much more oriented to a mix of public & private. I don’t begrudge you for whatever Canada has.
It’s not conciliatory words I’m after here, it’s just accurate information. Your comments about supplemental insurance could be construed to mean that it’s widely necessary, since you state that so many of these countries (to use your words) “also have a big private supplemental system riding beside it, because the government system isn’t rich enough in benefits”. I’m not aware of that being the case in Europe, and it’s certainly not the case in Canada. I don’t know about the system in Japan, but I gather that they have fairly hefty co-pays ranging from 10% to 30% of total medical costs depending on income level, though I understand that there are monthly caps on that.
So there may be situations in some health care systems where supplemental insurance makes a lot of sense. But it’s certainly not a widespread characteristic of UHC. I’m not sure if you’re fully aware of the scope of health care coverage under the Canada Health Act. Co-pays are zero. There are no deductibles. Basically, by law, all medically necessary services have to be covered by the public UHC plan, and not a dime can be charged out of pocket. And the whole system costs half as much per capita as the US spends on health care. Does that sound like a system that’s so poor in benefits that it needs extra help from private supplemental insurance? If there are systems that you feel offer poor benefits, you should be specific and name them and tell us why they’re poor, instead of floating vague innuendoes about UHC in general.
What vague innuendos? I’ve named specific countries that have UHC that also have private supplemental plans, including Japan, Thailand, and Singapore. I’ve talked about the US, with our mix of public and private. I’ve talked about Switzerland, which has UHC with private plans combined with government subsidies. I believe that the Netherlands also uses private plans as part of their UHC system. There are other countries beyond the countries I’ve specifically mentioned that use private insurance to varying degrees.
I keep saying that I have no issue with government healthcare, and that I’m not arguing against other countries, including Canada. I’m simply showing where private fits in, where it can fit in, where it’s being used, and why it’s being used. That may not be the case in Canada. But Canada is one country with a small population, not the entire world.
So, boiling it all down, what is your beef? What exactly am I saying that you don’t agree with?
Just to build on this a bit, since it’s an area in which I have some expertise (I’ve had several of the Blues as clients):
Originally, all BCBS licensees had to be not-for-profit corporations, and each one was restricted to operating in a specific state or geographic region (i.e., Blue Cross and Blue Shield of Illinois couldn’t be owned by the same company that owned Blue Cross and Blue Shield of Indiana).
In the 1990s, the Blue Cross Blue Shield Association (the national company, and licensor of the brand name to the individual plans) changed their bylaws, allowing Blues to operate on a for-profit basis if desired, as well as allowing companies to own the Blues in multiple markets. There are now several large companies which own multiple Blues – some of them are for-profit (such as HCSC and Anthem), while others are not-for-profit (such as Highmark); a lot of the Blues are still independent companies still only operating in one state or region, and many of those are still not-for-profit.
The response here can only be cynical. As there are no real [non-maniacal] arguments against giving people the best health care that scientific technology can muster. So, the argument against Medicare for all, is that a society that is sick and stuck in a perpetual state of fear – the fear of medical ‘bill shock’ being one of many fears that enthral the majority U.S. – is that much easier to control through the emotional leavers of its populace and, thereby, subjugate.
The U.S. is by far the greediest nation the world has ever known – even greedier than the triilionaire oil sheikh gulf states (…for some of them have universal basic income!). This is because the measure of pure greed is not only a measure of wealth disparity, but also in how a nation (i.e., its rich and powerful) treat its most vulnerable. Therefore, given the U.S. values the likes of its trillion-dollar-per-annum military, its $10M+ per diem “aid” to Israel, the hocking of its weapons of death to murderous regimes etc. ad infimitum, far, far more than the basic health of its own burgess, the invidious U.S. clearly takes the mantel of the most greedy national entity in recorded history… and there is daylight to the next contender. Sure – Rome had its prefects and India has its caste system. But the former is millennia removed from modern-day analogy, and the latter is a Third World “shit house” *(property of Donald “Trump™” – all rights reserved) doing a Bollywood jig in a “superpower by 2020” veil.
Make no mistake: Gordon Gekko is the eternal president of the “United” tate of A̶v̶r̶a̶h̶a̶m̶ “America”; with Mammon as its patron deity / daemon-god. 'Twas always thus and always thus will be.
Now you’re just rambling all over the map and randomly conflating “private insurance” with “supplemental insurance”. Those are two different things. Virtually all countries have both public and private insurance systems, and a person is typically enrolled in one or the other. This has nothing to do with “supplemental insurance”, and the implication that it’s a common practice to have to buy supplemental coverage because the public system just isn’t good enough is simply false when applied to the majority of the industrialized world, particularly Europe and the Commonwealth countries.
Germany, for instance, has a public/private system so segregated that you can only get into the private system at a certain income level (only about 10% of the population bothers) and once you’re in it’s very hard to switch back. Canada has no private insurance at all for medically necessary services, only supplemental insurance for peripheral services. Conversely, your example of Switzerland has no public insurance at all, only mandatory, highly regulated private insurance with subsidies, which incidentally is one of the reasons that Switzerland has the second highest cost of health care in the OECD. But of course it’s still far lower than the US which has neither a public option or meaningful regulation like Switzerland, or the social solidarity and widely subscribed public plan like Germany.
So my beef is that I don’t think you fairly presented the role of supplemental insurance in the health care systems of other advanced nations, where the vast majority of the population is well served by whatever way their countries have chosen to structure their UHC system, most often as an either/or choice of public or private, and generally with caps and subsidies geared to income.
And while I’m on a roll here, quite frankly in a discussion where it’s important to be able to substantiate one’s claims, you’ve made a bunch of other assertions that are at best highly questionable or just flat-out wrong, such as:
[ul]
[li]In post #107 - that UHC wouldn’t save much money at all, might even cost more (all the evidence is to the contrary)[/li][li]that private insurance drives innovation (sure, where it’s profitable, except public systems drive innovation to the patient’s benefit)[/li][li]#110 - that what worked in Saskatchewan (and subsequently in the rest of Canada) couldn’t work in the US (because the US is apparently inhabited by a different species of being)[/li][li]that private insurance “controls costs” (so explain why US costs are twice as much as everyone else’s)[/li][li]that the limitations of insurance “networks” are somehow beneficial to the patient (because every patient loves to be told that he can’t see the doctor he wants to see)[/li][li]that employment-based insurance is good for everyone (because everyone loves indentured servitude, and if you lose your job you can always jump off a cliff)[/li][li]#123 - that private insurers are awesome because they “help with preventative type care” (yes, we’re repeating ourselves here; I showed you a specific example where UHC does it better; sometimes prevention is more expensive than subsequent remedial treatment, but it adds to quality of life. Do you think your private insurers are up for spending more money for your quality of life?)[/li][li]#132 - that government bureaucrats deny claims (so they’re no better than private insurers! I’ve already dissected this fallacy at length)[/li][li]that private insurers “do good work that benefits society” (so explain why conscientious political leaders have been trying for nearly a century to fix all this “good work” that is leaving millions without health care, killing tens of thousands annually from preventable causes, and leaving thousands bankrupt every year from medical expenses. And I still want to know, per my question above, whether your favorite health insurer – what with all the good work that they do for the benefit of society – is willing to spend their money to improve your quality of life.).[/li][/ul]
Wow. OK, that’s a lot of stuff that I need to respond to. But I don’t have the time to address all of this right now. You will hear back from me in the next few days.
That’s an effect of charging for each item of service. If you have a system based on a per capita block budget (in effect what I understand is sometimes called in the US a “concierge” doctor) and a system-wide patient database, that sort of fraud becomes more or less pointless.
I agree, and this is what I was alluding to earlier – if you have a system-wide patient database and only one payer, you have a comprehensive picture of the entire system and patterns of fraud are much easier to detect. And the reality is that fraud is simply not a significant problem in the UHC systems that I’m familiar with, and it’s actually rather astonishing how low the incidence is.
But the business of a concierge doctor is something else, and I just want to mention it because it’s an excellent illustration of the direction that US medical care is going, namely that the heavily free-market oriented approach is always driving it in the direction of finding ways to make more money, while UHC systems tend to be driven in the direction of delivering more efficacious health care. The block budget approach you mention is called capitation here in Ontario and it’s one of the innovations that’s been happening in recent years, along with patient rostering, which is the formalized connection of a patient to one doctor or team to optimize the delivery and incentivization of preventative services.
But capitation is not what a concierge doctor refers to in the US. The block fee is just an access fee, like a club membership that grants fast access to high-end medical services unavailable to the ordinary person; medical fees and co-pays for actual services are on top of that. I can only shake my head in disbelief. Nothing about US health care surprises me any more. The New York Times has a good write-up on the practice:
Concierge practices, where patients pay several thousand dollars a year so they can quickly reach their primary care doctor, with guaranteed same-day appointments, have been around for decades. But these aren’t the concierge doctors you’ve heard about — and that’s intentional.
Dr. Shlain’s Private Medical group does not advertise and has virtually no presence on the web, and new patients come strictly by word of mouth. But with annual fees that range from $40,000 to $80,000 per family (more than 10 times what conventional concierge practices charge), the suite of services goes far beyond 24-hour access or a Nespresso machine in the waiting room.
Indeed, as many Americans struggle to pay for health care — or even, with the future of the Affordable Care Act in question on Capitol Hill, face a loss of coverage — this corner of what some doctors call the medical-industrial complex is booming: boutique doctors and high-end hospital wards.
“It’s more like a family office for medicine,” Dr. Shlain said, referring to how very wealthy families can hire a team of financial professionals to manage their fortunes and assure the transmission of wealth from generation to generation.
Only in this case, they are managing health, on behalf of clients more than equipped to pay out of pocket — those for whom, as Dr. Shlain put it, “this is cheaper than the annual gardener’s bill at your mansion.”
I’m not sure why you’d think I’m conflating supplemental and private, when I’ve been careful to label supplemental when I know it’s supplemental (Japan) vs where the basic plans themselves are private (Switzerland, US, Netherlands). But furthermore, just about all supplemental is bought from private insurers, including in countries with UHD. I’ve mentioned some countries already, and there are others, such as South Korea, Chile, Argentina. These are countries where the basic UHC plans are often not rich enough for some portion of the population, who try to purchase extra insurance. Maybe it’s because the public hospitals & facilities aren’t as good. Maybe it’s because the co-pays are too high, or the benefits in general aren’t as rich, or the government is increasing co-pays for budget reasons. You have a specific experience in Canada. Europe also has an experience. But there are other parts of the world that have different experiences, and I’ve listed many of these countries. Why is Canada & Europe’s experience dispositive of this whole issue about the existence of private insurance?
Anyway, you saying that I’m conflating something when I’m not actually conflating it is utter nonsense and/or confusion on your part, not mine.
As for your list of that you want me to answer you on, I will do that on another post. I need to go back and check if I already clarified some of them. That will take some time.
Wow, this list is something else. One #107, here’s my exact quote, which I stand by:
“I think the main argument against Medicare for All is that it wouldn’t save nearly as much as people think. Matter of fact, early on, it might cost more at least until it’s had a few years to settle. And it would be too disruptive to our current system.”
Here are some links that talk about this, and come to very similar conclusions/questions. And these are not hard-right kook websites that raise these same questions that I’m raising. The punchline is that the devil is in the details. The US has developed a patchwork system, and going from that to Medicare for All would be very disruptive and the cost savings might not bare out the way their proponents are advertising, partcularly when you factor in all the interested groups that might impact where we end up:
So, my view is to keep what we have, and make the ACA work better by getting all the states their Medicaid expansion, and increasing the subsidies so that middle-class people on the exchanges can afford their policies. I think we could closely approximate UHD if we did that, and I’m not unique in that view.
You then brought up the fact that Saskatchewan went through a conversion without those problems, to which I said that Saskatchewan is not analogous to the overall US. Your characterization of what I said about Saskatchewan is very disingenuous. Saskatchewan has about 1 to 1.2 million people, which is roughly twice the size of Vermont in population (as you know, Vermont shitcanned their single-payer, because it was going to be too expensive). I don’t think that using Saskatchewan as an example would even come close to characterizing what might happen in a country with over 300 million people spread over 50 states with a huge patchwork of private and public coverages aimed at different populations. The challenges would be different and on a much larger scale.
I did not say that employer-based insurance is good for everyone. You’re making that up, because I didn’t say it. It’s been good for many. It’s been good for me. I didn’t say everyone.
Government bureaucrats absolutely do deny claims. Where on Earth did you get the idea that they didn’t deny claims? If they didn’t, then AARP wouldn’t provide the following:
Most of the rest of your list is stuff I’ve already talked about in more detail. And I’m not going to go through all of it in the interest of time. But let me just point out that there’s nothing wrong or evil about the profit motive. I don’t personally care what motivates my health insurer. I just want them to perform the service that I pay for. They do that well in my experience. There are millions of Americans that use private insurance and are happy with it. Providing a product that people want and like is a benefit to society.
Finally, I hope you never get a Donald Trump-like character in your country. If he decides to punish you by trashing your UHD, I hope you’ll have something else to fall back on. Governments absolutely do the wrong thing in many situations, and that’s when it’s good to have more than one way to skin a cat.
Most of your word salad nonsense demonizing the United States has been tolerated on the grounds that it provides insight into people who are more puffed up on their ability to type long, meaningless sentences just to hide their raw invective than they are in discussion.
However, blatant anti-semitism is not something we encourage.
This is a Warning that you are about to give up your posting privileges with this sort of nonsense.
I do not doubt your story. Since Medicaid had to be means tested and god knows what else, there is going to be a lot of red tape and plenty of opportunity for people to get screwed. That is exactly what would not happen in a Medicare for all system.
I’m on Medicare. I enrolled online, no means test, no red tape. Basic Medicare was trivial. Deciding on the supplemental plan was harder, but that was in exploring the options. When my wife went on it was fast.
I have the very best supplemental plan, and most expensive, and it is a hell of a lot cheaper than my Cobra was.
Of course we have to pay for supplemental care - the mess of our healthcare system in terms of high prices affects everyone.
I’m glad you have a good deal with Medicare plus supplemental. That’s the ticket for the age 65+ crowd. And I’m glad you don’t have to deal with the hassle of “qualifying”. I hope you don’t have problems getting a doctor. Some doctors don’t accept Medicare or Medicaid patients. My parents are on Medicare, as I mentioned, and they don’t have any problems in their hometown of finding doctors who will treat them.
And I would point out a few things from my own experience using employer-based coverage. I’ve never had any issues with eligibility, claims payments, premiums, or pharmaceuticals. I’ve had a very good deal for almost 30 years, and I’ve worked at a few places. My current plan covers me, my wife, and my two children. We’re overall healthy, but managing some chronic conditions that make us not a “zero claim” family. We have some co-pays & deductibles, but they are totally reasonable, and don’t stretch my budget at all. We use healthcare in my family, and my insurance has done well for us. I’ve never had anything at all like what my brother dealt with, or what my father-in-law dealt with under the VA, where he only had one facility to go to that was 90 miles from his house…scratch that, make it 60 to 70 miles, still a long haul.
Thanks for that clarification: I was clearly under a misapprehension! Interestingly, people in the UK do occasionally float the idea of a supplementary charge for GP visits, or at least for “no shows” to discourage them from doing it again. But it’s always been thought to be too much bother to administer. And they do charge for what you might call optional add-on services (e.g., writing a letter to confirm some medical condition for some other purpose, or travel vaccinations)
On the other hand, the idea of the “family doctor” is what is supposed to underly the capitation+registration system for GPs (that was the price of getting them to sign up to the system), even if development has been towards larger and larger group practices where you could be seen by any one of a dozen or more people. Some people get quite bothered about not seeing their named doctor all the time, or about the time it takes to get an appointment specifically for them, but since they have access to all the same information in the database (and I can also see a summary of it), personally I’m not bothered.
Back to the OP: if it’s a case of changing the basic assumptions most people have about a system that they’re used to (so much so that the discontented aren’t sufficiently up in arms about it to force a change), so as to embed an alternative instead, then there really only are two ways.
One is some catastrophic change in circumstances shaking up most people’s thinking and expectations (in our case WW2). The other is something gradual, as proposed above; but it looks as though there’d have to be an equally gradual and carefully balanced effort at cost control, maybe by freezing prices over an extended period.
Conversely, in Spain the biggest providers tend to be the regional governments. When it comes to primary care, that’s the case everywhere - but this was a gradual evolution. When I was little, we’d go to the pediatrician at the public healthcare center if it was in the morning, in his private office if it was during the afternoon; by the time my brothers were at the end of their pediatrical years, pediatricians were available in the PHC during the afternoon. GPs had pushed to do all their work through the PHC even earlier; it was more convenient both for them and for the patients, so the question wasn’t “why” but “why the heck not.”
Most private clinics offer specialist work; in general, they focus on procedures which are considered elective and therefore not covered by the public system. Many of them have agreements with the public system, so you can be treated in a private hospital under the public system if that’s considered the best choice, or be sent from a private clinic to the public system for a test the clinic doesn’t have available and the public system does.
But in the end, both patients and doctors have the choice to go private or go public. The amount of people who choose each varies by region, specialty and procedure (is it covered by the public system or not, will it truly be more convenient to go private or not).
Oh: employees of both private and public hospitals, clinics and day centers are salaried. That includes the doctors: working at a hospital is a job, not a privilege. They get bonus pay for things such as shift duty, standing guards etc. Partners in private clinics split any benefits or not as in any other business. And payments between private centers, private insurance and the public system are by procedure but, depending on the specific contract, a private center being paid by the public system may just get a sum based on estimates rather than having to count every cut and stitch.
In our case, most of the fraud is linked precisely to the private clinics and to insurance schemes which promise better! faster! shinier! access - and then funnel patients through the public system and double-charge. Fraud in the public system, by users entering directly from the public system, isn’t so much unheard of as inconceivable. Considering how much some people like to spend more time finding ways to cheat than learning how to win straight, if it was possible to do it someone would have.
Think about how hard it was just to get the ACA implemented. The ACA left most of the pre-existing healthcare system in place. Employer-based, existing Medicaid, Medicare, S-Chip, VA, and the like was mostly not touched, just some minor things around the edges. All they did was expand Medicaid, and put some order into the true Individual Health Insurance sector, in order to get the last 15 to 20% of uninsured down to near zero. And Republicans acted like it was the most gigantic “takeover” of healthcare that’s ever been engineered, and they’re still (8 years later) trying to kill it.
Imagine all of that multiplied by a million, and that’s the backlash you’d get from Medicare for All. People on this board who live in other countries might have a very good experience with their own system. But our political system, IMO, would end up with a very kludgy, inefficient, expensive, unsatisfactory “medicare for all”, that would still be subject to Republican sabotage. The US is just not in a place where we need to go through all of that.
We should instead try and get some Democrats elected, and once and for all put the ACA on the footing that it needs. The existing ACA (even without the insurance mandate) could get us down to near-zero uninsured if they beefed up subsidies on the exchanges, if the remaining 17 or so states would accept the Medicaid expansion, and if more states would actually try and publicize the exchanges and get people enrolled. The only people who wouldn’t have coverage would be some young invincibles, who think they’ll never need to see a doctor, some lazy-asses who won’t be bothered to sign up for programs that they qualify, and illegal immigrants. It would be 97 to 98% insured, and that would be good enough in my view. Right now, we’re at around 90%.
Read what you just wrote. Go on, read it carefully. You start talking about supplemental insurance, saying that “just about all supplemental is bought from private insurers”, then carelessly segue into “private insurance”, once again blurring the distinction. In most of the cases that I know of in Europe and the Commonwealth – there are a few exceptions – private insurance is an alternative, an "either-or"proposition with the public plan with respect to medically necessary procedures, not a supplement to it.
Why is this important? It’s important because it shows that your argument that public insurance is generally inadequate is bullshit, since it generally covers everything that is medically necessary as independently determined by the patient’s doctor(s), often with little or no monetary contribution from the patient. The fact that you can find examples of UHC systems that are underfunded or otherwise mismanaged is not an argument against the efficacy of the UHC model. It’s not hard for me to find examples of private health insurers that are not just criminally unethical but downright evil. And lest you try to misinterpret or distort that reference, it’s not about the company being ruthlessly arrogant, it’s about the fact that they literally killed a young girl by denying her life-saving health care, something that happens every single day across America as insurers strive to cut their “medical loss ratios”.
I took exception to that first sentence because it’s extremely deceptive when taken at face value. Clearly, from the all the data among countries that have UHC, as illustrated in the chart I’ve posted twice now, UHC (aka “Medicare for All”) provides enormous cost savings. Your argument is that UHC would be politically and administratively difficult to achieve in the US. I agree, it’s a big job, in its totality at least as big an initiative as Medicare itself. But that’s a completely different argument. I’m talking about the end state, not about the challenges of the transition. Lots of things are difficult but well worth doing, and in the end, when properly done, the same cost savings the rest of the world experiences would be there for Americans, too. Therefore your statement is wrong.
You continue to make the assumption that the US federal government would run the whole UHC system. It probably could (it runs Medicare, which is far more complicated) but that would be far from optimal. It’s been pointed out to you several times that the logical way to run it is at the state level under federal guidelines and subsidies, and you’ve chosen to studiously ignore this fact despite it being repeated for you several times now. What worked fine in Saskatchewan works fine today in Ontario, which has more than twice the population of the average US state, and more diversity than you can shake a stick at. Your silly argument is just more of the head-in-the-sand and fingers-in-the-ears type of “it works everywhere in the world but it won’t work in the US” specious rejection of proven fact.
You said (in #110) in which you itemized the alleged terrific benefits of private insurers, that the system has “allowed different employers to attract good employees”, which implies pretty widespread benefits, and then you doubled down on it (in #132) by saying about these useless parasitic leeches on the health care system that “the great majority … do good work that benefits society.” So I think my paraphrase pretty accurately portrays your belief that health insurers are a boon to employers, employees, and society as a whole.
I find myself wondering if you’re simply not understanding what I’m writing, but I think the real problem is that you just don’t understand how single-payer works.
I’ve repeated it again and again, to no avail.
I already acknowledged that sure, government bureaucrats can do nasty things – and that includes denial of access to Medicaid, or denial of Medicare claims due to any of the vast myriad of conditions not being met. Are you able to understand that that has nothing whatsoever to do with single-payer?
Here is how single-payer works, for about the third or fourth attempt at explaining it. Paying all valid claims per the fee schedule, unconditionally and without exception, is structurally intrinsic to single-payer, one of whose foundational principles is lack of meddling in individual cases and delegation of trust to the medical professional and guaranteeing the autonomy of the doctor-patient relationship. In simple words, single-payer doesn’t deny claims for agreed-upon covered services, ever. By design, it has no ability to do so. Your implications that the bureaucratic denials that you know about somehow apply to single-payer are misleading nonsense which reveal only that you don’t understand the fundamental economic model of single-payer.
As already noted just above and several times in preceding posts, you ought to care that their motives are not aligned with yours and often diametrically opposite, which is why private business is a horrible and unethical model for health care coverage even under the best of circumstances, why thousands of Americans get their health claims denied – sometimes in life-critical situations – and suffer health care costs as the #1 cause of personal bankruptcies. You ought to be very concerned that insurance bureaucrats are constantly coming between you and your doctor, interfering with the health care the medical system is able to provide, and you ought to be concerned that you’re paying through the nose for that unconscionable counterproductive meddling, about twice as much as the residents of any other advanced country in the world, and getting less for it, and then still getting dinged with enormous deductibles and co-pays while health insurers make out like bandits.
Why do I have to keep repeating myself? As I said before, that’s a failed argument because we’ve had such right-wing governments. The former Prime Minister of Canada was a right-wing climate change-denying evangelical nutjob. The present Premier of Ontario is a right-wing fanatic just like his late brother, the former mayor of Toronto. No one even remotely considers single-payer to be at risk. It’s not just that it’s popular, it’s that it’s now entrenched as a national value, a defining national characteristic. These are the kinds of nuances that might escape an outside observer, but they’re there, and they’re foundationally important. Single-payer and UHC aren’t going anywhere.