That’s a fairly accurate assessment. However the “hard” part was that it was politically hard, not particularly administratively hard. Remember that in 1948, the UK established the entire National Health Service and completely transformed their health care system as part of post-war reforms. The US established the entire Medicare system in one fell swoop, and Canadian provinces moved quickly from private insurance to single-payer, mostly in the 60s.
As for the ACA, it’s noteworthy that the health insurance lobby practically wrote the thing, which is why it’s little more than a veneer of regulations on top of the broken private insurance system, and the truly progressive measures, notably the public option which could have offered a tremendously promising path forward, never had a chance. Republicans of course were vehemently opposed to all of it and are still trying to kill it because … well, because they’re Republicans.
I got to keep my doctor, which is why I rejected the Medicare Advantage plans, which would have forced me to move. They are the ones run by private insurance companies. My clinic is a high class one, which started in Palo Alto which tells you something.
I understand about the billing. My ex-stepbrother was a psychiatrist for the rich, and his wife complained bitterly about Medicare payments. He lived in La Jolla. Being a doctor (not a GP, I assume) is one of the best ways of getting into the 1%. They should be well paid, sure, but that much?
Like I said, my private insurance was good, but they frequently bugged me to prove that my wife didn’t have her own insurance - and then ignored my response and bugged me again. And my company was self-insured and so I suspect I had it better than most. Medicare is still better. And cheaper now though I did pay a bundle to it over my work career.
As for VA, surely you don’t expect them to build facilities 20 miles from all vets? I have no idea how VA works, my father was a vet but he had his own excellent insurance and never used the VA for medical care.
[Edit by Bone: Please note that bolded text in quote box was added by gtyj and not written by wolfpup. I’ve left it here so as to preserve the original post by gtyj]
My reasons for thinking that we shouldn’t do this in the US have been mentioned on other posts, and specifically on Post #159. That’s where I put it as succinctly as possible. Our politics & special interests & everything that would have to come together to make it happen would produce something that’s a complete mess…and it’s likely to never happen. I’m talking about the US, and not other countries.
I don’t know how many times I have said it, but I’ll say it one last time: I don’t have anything against Government healthcare, including various types of UHC schemes. But for the US (for many reasons I’ve laid out), I just want to keep what we have, and tweak the ACA to get us to our own version of UHC. I don’t want single-payer. I want what we have, but just working better, which is the easiest for us politically and technically.
You completely ignored the Medicaid expansion in your description of the ACA. I don’t know why you did that, maybe just overlooked it. But that was a huge part of the law, and it’s important to this day.
What the insurance lobby wrote was actually a law that would work reasonably well, if our politicians would allow it to work. There’s enough regulation and logic behind it, to where the ACA is fine. It just needs a few adjustments, like any large law. In normal times, the two parties would get together and make technical fixes. But that won’t happen in today’s climate. There was well more than just a veneer of regulation. And it was gradually doing its job, moving the uninsured % down over time, until Trump came in.
Our politics in the US was different in the 60’s when Medicare and Medicaid were both established. Both parties were able and willing to govern in a reasonably good-faith manner. There were demagogues. There were fights and problems. But the two parties would work together for the good of the country when they had to. That’s no longer the case, as the Republican party has gone off the deep-end since about 2008.
So, what you’re talking about, moving to something that’s single-payer, is a pipe dream that will not happen in the US. Not in my lifetime. And even if they did, it would likely be a mess. I have no faith that our political system can put together something like single-payer in the US without making a huge mess out of it.
The Republicans went berzerk over the ACA, and they will go berzerk a million times over on Medicare for All. The left’s insistence on this issue will just hand the right something to use as a sledge hammer against them politically.
Do not modify quotes inside of the quote box. This applies even in the way you have done so as bolded responses. See rules here. I’ve left the post alone because to properly edit it I’d have to move your comments outside of the quote box and it would be too similar to me putting words in your mouth. Since we don’t typically delete posts, I’m leaving it alone with a editorial note inserted describing what happened.
A couple of points on the ACA – I’ve worked on advertising for a major regional health insurance company, including, specifically, their ACA policies, for the past 3 years.
Yes, the Medicaid expansion was an important part of the ACA, but it was optional for the states (which directly administer Medicaid, unlike Medicare). The gist of it was that the ACA included subsidies to help lower-income people (who made too much for Medicaid) to help buy ACA policies, but part of that plan was that there is an income “floor,” under which you can’t get an ACA subsidy. That “floor” is higher than the old Medicaid income ceiling; as part of the ACA, the federal government encouraged the states to increase their Medicaid income limits – initially, that change in Medicaid income limits was meant to be a mandatory part of the law, but a Supreme Court ruling made it optional for the states
To encourage the states to raise their Medicaid limits, the federal government offered to pay the states the difference (but only for a certain number of years); because it was optional (and because many “red states” didn’t like the ACA), there are seventeen states that didn’t raise their Medicaid limits, creating the “Medicaid Gap” – people who make too much money to qualify for Medicaid, but, absurdly, they don’t make **enough **money to qualify for a subsidy to buy an ACA policy. The Kaiser Family Foundation estimates that about 2 million people are in the Medicaid Gap; 89% of them are in the South (including the state where my client operates).
The insurance companies which offered ACA policies have, in many cases, been losing money on them; even with raising premium rates substantially on a yearly basis. With many healthy people electing to remain uninsured, it’s the “high utilizers” (i.e., people who need medical care frequently / expensively) who are buying, and using, the policies; many of them are people with pre-existing conditions, who weren’t able to buy individual coverage at all before the ACA. As a result of this, many major insurers have pulled out of offering ACA policies in some (or all) states, and some states now only have one or two companies offering the policies at all. This withdrawal from offering ACA policies was already occurring in 2016 (i.e., before Trump was elected).
I know! I was straight out worried about whether these insurance companies would even survive. But don’t worry! In 2017 Kaiser was up around 23% in profits of 3.8 billion, so you don’t have to pass the hat around for them just yet.
Yes, when SCOTUS made the Medicaid expansion optional, that really put some people behind the eight-ball in red states. I predict that eventually all of the states will accept it, because the ultimate Federal reimbursement will be 90%, which is a good deal, and people need it. But it might take another decade or so for all of that to flesh out.
The other items can be fixed by increasing the subsidies, making it more affordable for people. In the past, the two parties would get together and apply technical fixes on bills of this nature. Nothing is ever perfect the first go-round. But currently, there’s no way to get anything bipartisan done.
Matter of fact, the tax penalty you mentioned - i.e., the individual mandate - goes away under the Trump Tax Cut bill. Also, Trump has cut off one of the subsidies that was written into the original law, and companies have had to adjust how they price silver plans in order to keep everything hanging together. The Silver plans are important, as they determine the subsidies in some way. He also cut down on advertising for the ACA, and cut the enrollment period down, and cut down funding for navigators. Just a few days ago, the CMS announced they were freezing one of the risk adjustment programs built into the ACA, due to some court ruling a few months ago. On top of all of this, some red states are applying for work requirements for some Medicaid-eligible people, and the Trump CMS has approved some of them. His attack on the ACA and Medicaid is full steam ahead.
In the face of all of this, companies are still hanging in there, although some have left, as you mentioned. The companies that have done the best were companies that were familiar with managing care for medicaid-type populations. Those that were more familiar with employer groups have not fared so well.
In all of this, the population that’s benefits from the ACA is poor and near-poor. The lower-middle to middle class who don’t have policies need help with a better subsidy formula. But that’s not going to happen as long as Trump is in office.
Other countries systems cost less than the US system. That does not mean that the US can copy the other countries and achieve the same cost savings. Healthcare systems are an emergent phenomenon and are too complex to copy and expect the exact same results, think of Kruschev and the corn campaign. Most national health care schemes were started in the 40s, 50s, and 60s when the biggest hospital expenses were laundry. Over time, especially in the 80s, America’s costs started growing faster for a decade or so and then costs increases started matching the rest of the world’s in percentage terms but starting from a higher base. If the US had switched to universal healthcare back then it is probable that costs would be lower now.
Now the US doctors make more, nurses make more, administrators make more, more technology is used, more tests are used, and more drugs are prescribed. If you try to bring costs down to match the rest of the world quickly all of those things will need to change and all of those factors have powerful groups supporting them so cutting them will be politically impossible.
You are claiming that more people can be treated for the same amount of money by getting rid of the people checking for fraud. That is just not possible. The only way possible is to apply pressure to reign in spending so it grows by 4% each year instead of 5% and in 20 to 25 years it stays so the influx of new patients increasing their usage will be made up for.
This is one of the worst straw man arguments I’ve ever seen. I never said you could “copy other countries” and get “the exact same results”, which is completely meaningless because every UHC system in every first-world country is different. In fact it’s incredible how different they are, ranging from single-payer with a government-run provider system, like the NHS, to regulated private insurance like in Switzerland, and likewise, there are no “exact same results”.
But what you’re missing or ignoring is the remarkable fact that, despite vast structural differences, these systems all have manageable costs roughly in line with each other, especially when adjusted for relative cost of living. The one outlier is the US, whose costs by any measure are so enormously greater than anywhere else that there is clearly some underlying fundamental difference(s) not present in any other country.
The issue, then, is addressing those fundamental differences, not “copying” some other country’s system. And broadly speaking, those fundamental differences are the lack of universality and the lack of regulation and government oversight that enables universality, including things like common rate structures, subsidies, cost controls, and simple guaranteed coverage rules. The lesson that can be gleaned from other countries is that those things matter more than the implementation details, such as whether the system is single-payer or multi-payer, public or private, or whether the provider system is public, private, or mixed.
This is a glaringly huge fallacy, the “laundry” snark aside. Just look at the first graph in this article comparing the US to the rest of the world. US health care costs have not only been outpacing the rest of the world in the last half century, they have also been greatly outpacing GDP growth. That means the system is fundamentally unsustainable. It’s not just a “higher base”, it’s also, over most time periods, a higher rate of growth, too, and all while suffering from lack of universality and lack of guaranteed access even for the insured, because of the constant risk of revenue-motivated claims denials.
The problem isn’t that it’s too late to change a broken system, which has to change because it’s obviously a disaster in the making. The problem is the worsening political climate is making it more and more difficult. You’re right that if UHC had been introduced in the 60s or before, costs today would be at about the same level as the rest of the world. But that was a time when Ronald Reagan was telling Americans that if the horrible socialist scourge called “Medicare” were ever to be passed, “one of these days you and I are going to spend our sunset years telling our children and our children’s children what it once was like in America when men were free.” This kind of blathering nonsense was widely accepted even back in the days when Republicans were relatively sane. Today, Medicare itself wouldn’t have a hope in hell against even more reactionary Republican extremism.
It’s not the practical aspects of solving the problem that are so hard, it’s the politics.
One can at least recognize that there are two major contributors to these astronomical provider costs. One is that providers have been charging more because they can, because there are no effective means of cost control. The other is that they charge more than in other countries because they have to cover the administrative costs of processing claims and collecting from insurance companies, as well as subsidizing the losses of not getting paid. Just eliminating the latter overhead alone – the administrative costs and losses – would enable providers to make just as much from significantly lower fees. That’s a start.
This is the kind of paraphrase that causes you to lose all credibility. Where on earth did I say anything that could even remotely be interpreted as cost savings due to “getting rid of the people checking for fraud”? Here is exactly what I said, emphasis added:
Here’s a good warning about pursuing single-payer in the US from Harold Pollack, who is a well-known healthcare economist:
Here’s the punchline from the link, and a guy who is no enemy of government healthcare:
*Some progressives hope that single-payer could provide an attractive replacement for the grubby, path-dependent logrolling that now dominates our $3 trillion health care political economy. No viable single-payer program will replace these grubby politics. That’s logically impossible, because such a program must be produced through that very same process. Barring a historically comprehensive defeat of Republicans at every level of American government, advocates for expanded health coverage will face this discomfiting reality.
Passing a single-payer plan requires precisely the same interest group bargaining and logrolling required to pass the ACA. The resulting policies will thus replicate some of the very same scars, defects, and kludge that bedevil the ACA. *
He’s right. Which is why I say (again) that we should just stick with what we have, and don’t fall for the pipe dream of the left. The ACA would do just fine if we simply beefed it up with a few technical fixes, and let the states eventually accept Medicaid expansion. We’d have almost full UHC with that, and no need for single-payer. Not to mention the fact that those of us with good private insurance could keep it.
no waiting for doctor, specialist, medical tests, or surgeons.
Example, when I had a kidney stone I saw my family doctor twice, specialist/surgeon 2 times in the space of two weeks. I had an x-ray and MRI within an hour of first sign of pain. after 2 weeks I was given the option of removal which happened within hours of that option.
Open heart surgery took a month of ever increasing tests to verify and then map out the procedure. I picked both the cardiologist and surgeon.
This little bit of surrender assumes that public opinion will not shift in favor of single payer. Not only is support growing, but there are also plenty of other examples where policies previously thought of as impossible to change have passed in Congress and state legislatures.
An argument against single payer is one thing, even if it’s been made pretty clear in this thread that they’re not very good, but an argument that the political will isn’t there to support it is just an ability to foresee how things constantly change.
It's great that you didn't have to wait when you were in pain - but one thing I don't recall being discussed in this thread is the cost of excess capacity. A good healthcare system needs the capacity to handle emergency situations without waiting. It doesn't need the capacity to handle non-emergencies without waiting - but people don't want to wait and in many cases they don't have to wait. But eliminating waiting costs money- if I can call today and get an appointment for a screening mammogram tomorrow , that means the technician wasn't fully booked. If it were a rare occurrence, that can't be avoided and probably doesn't add to much to the cost. But nearly every time I schedule something at the radiology center (and it's never an emergency) , I am asked if I want to come tomorrow. And if I don't want to come in tomorrow, they ask me which day I would like and then what time. That pretty much means they have more capacity than there is a demand for. It's never "We have an opening Tuesday at 10am and the next one is Thursday at 4pm". It costs money to have machines and technicians waiting around just in case someone calls on Monday and wants an appointment on Tuesday.
If anything, our politics have gotten more difficult on this issue than previously. I think that one party - which is currently in power - is doing all they can do to kill the ACA. And they will do the same, and then some, if single-payer is ever brought to the table. Democrats would have to take the house, the senate, and the White House, and probably hold the senate by a filibuster-proof majority, all of that at the same time. This is about as likely as Iceland becoming a world military power.
If Dems took the White House - or if they took the house & senate, and a non-insane person of either party won the Presidency - I think something could and would be done on the ACA, to make the minor fixes it needs, and to reinstate the things that Trump tried to kill it with. And keep in mind that the states will continue to accept the Medicaid expansion, however slow it may be, regardless of who’s in power in Washington.
Also, remember that Americans tend to like their own healthcare. They may talk about how much they don’t like the system, or they may bitch about the cost, or don’t like this or that, or want single-payer. But when asked about their own healthcare, 3/4 of them like it. On any other issue, that’s a big consensus. That’s another reason not to do single-payer, and just do ACA-fixes:
I’m in that 3/4’s. I have insurance through my employer that I like, and have had a good experience with. I like my doctors, and I’ve never had issues with getting claims paid or issues with super-long waits for anything. In the US, there are about 157 to 158 million people who get their insurance through their employer. Most of these people have a good deal, and they’re not asking to be “saved” from this condition.
Premiums are reasonable, co-pays are reasonable, you have a good choice of doctors, and they don’t reject every other claim so you have to appeal.
My employer insurance was good. Medicare is even better.
Mercifully, I’ve never had a kidney stone but I imagine that would be treated with all appropriate urgency. But from my own experience and that of others I can relate stories very similar to yours, which would be considered unremarkable in Canada, under single payer. In my case I could have had bypass surgery done promptly, as you did, but I was very anxious to see if there was a less drastic alternative. My cardiologist met with the relevant surgical specialists, and it turned out that this hospital had been doing clinical research in advanced forms of stenting that in many cases were viable alternatives to bypass with equivalently good outcomes. It took them about 24 hours to decide I was a good candidate, at which point the surgery was scheduled for that same afternoon, and I was home the next day.
So I have no complaints about any of it, neither the promptness, nor the excellence of the technology (about which I’ve been doing a lot of curious reading). But I do have some questions for you. You say that you “picked both the cardiologist and surgeon”, as if this was something remarkable. Did they just happen to be in your insurer’s network? Do you have in-network and out-of-network issues to worry about? Because I don’t. The concept is unknown here. Every doctor, every hospital, is accessible to every patient, and I can choose whoever and whichever I like. This is just taken for granted.
And secondly, what did this experience cost you – in co-pays, deductibles, and other costs? Here is a fellow with a similar experience who is out $4000 for hospital costs (after insurance coverage), and another $2000 in ambulance costs. What I can say is that my medical event cost me absolutely nothing – not one dime. What can you say about yours? And maybe even more importantly, there was never any question, and never any possibility, that some insurance bureaucrat would question or jeopardize the coverage of any particular procedure. Everything was guaranteed to be covered, and decisions that were made were made 100% on the basis of best medical judgment, not some faceless insurance bureaucrat trying to score a bonus by improving his company’s bottom line.
So, I would say, compared to my experience with single-payer and what I anticipate your answers would be to my questions above, no, I would say you do NOT have good insurance.
This is an important point that I’ve made frequently. It’s critically important to have the capacity to treat urgent cases with appropriate urgency, and to triage cases into the appropriate medical priorities. But it’s downright wasteful to have an excess of expensive resources sitting idle, waiting for some casual non-critical user to show up just so he can have an appointment tomorrow instead of Friday. And that’s why moderate queues which promote full utilization are an important aspect of cost management. Modern diagnostic imaging technology, for instance, can cost millions, and many hundreds of thousands in annual operating costs and staffing. That such facilities can sit idle in the US health care system is testimony to the enormous fees that are charged when they’re actually used. From figures that I’ve seen, a typical MRI in the US can cost as much as ten times what the exact same MRI would cost in other countries.
That question sounds a lot like it was referring to quality of health care services provided, not quality of the overall system. Moving down to the other questions, there was far less satisfaction with what it was costing them, and this telling assessment of the system as a whole:
Most Americans say the U.S. healthcare system is troubled: Nearly three-quarters of employed Americans (73%) say the healthcare system is “in a state of crisis” or “has major problems” in Gallup’s most recent survey.
You don’t find that extremely concerning?
Finally, two surveys here in Canada show that (1) there is overwhelming support – 86.2 percent – for strengthening public health care rather than expanding for-profit services, and (2) most Canadians (85.2 percent) aged 15 years and older reported being “very satisfied” or “somewhat satisfied” with the way overall health care services were provided.
So, your preference for “not doing single payer” seems to be based, as before, on personal bias rather than hard facts.
Oops – I screwed up one of my links. It points to an SDMB forum instead of the specific thread I intended. First sentence in the third paragraph, with corrected link:
And secondly, what did this experience cost you – in co-pays, deductibles, and other costs? Here is a fellow with a similar experience who is out $4000 for hospital costs (after insurance coverage) …
Honestly, when I read about someone experiencing a significant medical event and then being out thousands of dollars despite being supposedly “well insured”, I find it both shocking and disgusting. It’s just immoral. Somehow hospitals playing negotiating games makes it seem even worse, and insurers denying or downgrading coverage is just criminal.
