I'd go with MoneyCaid. Health run care by big bureaucratic business deeply intertwined with big bureaucratic government. So there's lots of money flowing, but not as much care.
Germany too has large businesses providing health care and mucho government. When I had my tonsils removed a few years ago, a €>1b/y organisation did the knifework, another organisation with an even bigger budget paid, and neither of them set the rates.
So why does this combination work in Germany and fail so spectacularly in the US?
As someone who got a peak into some of the intimate details of a large Hospice services provider, I have to agree. The fact that there are, no matter what they call themselves, salesmen who wine and dine hospital and senior home officials so that their employer can be made a part of their hospice pipeline is sickening. What’s worse is when you discover how many “palliative” patients will routinely temporarily leave care for surgeries, then cycle back on, for years.
Not to mention that many of my relatives, and myself, have been egregiously misbilled or convinced to purchase very expensive, extremely unnecessary devices/treatment. I’m sure a lot of people in healthcare are good, but the people calling the shots - including even some doctors - don’t give a shit
Yep. It's also important to understand that doctors - rightfully - still do pretty well by themselves in countries with single payer or other systems. It's all the extra insurance infrastructure that doesn't exist/rake in money hand over fist.
Well, yes... but it's not really the insurance companies fault. They're regulated and can only make a percentage of total costs so they need spending to increase so they can deliver growth to their stockholders. They negotiate higher prices for the consumer with the large medical services and drive out low cost providers so they can provide stable dividends. They make collecting benefits or reading a bill impossible and renege on agreed payments so that they can pay their employees to live in the style they are accustomed to.
Actually, I hate the player as much as the game. It's disgusting.
Do republican politicians, and others in charge of maintaining this healthcare farce we have, have some sort of training in "convince the downtrodden to vote for things that make their lives harder" or is it just something natural?
I say this as a Wisconsin emigrant that watched my home state shoot itself in the face time and time and time again.
So the democrats are not to blame for implementing it? I don't see how you can single out any particular party for this situation and if I had to, I'd go with the people that actually jacked up my premiums (democrats).
Oh, they’re entirely to blame and I’m just as angry as anyone for them furthering this broken system.
But their choice of doing so was guided by right-wing ideology. The Democratic Party is a center-right party. You might not be able to single out any one party for this problem, but you can certainly indict those who further this kind of thinking in the face of its demonstrable moral and economic failure.
I'm sorry but the sheer amount of regulation around healthcare is not a right-wing ideology. Let's get the free market in here and watch costs come crashing down. Do away with mandatory coverage, subscription windows, the government run "marketplace" and costs will come down. There's nothing right-wing about any of those features.
Yes, removing this reduces costs - by creating a category of people who can't get insurance at anything resembling a price they can afford, and therefore either have to suffer, go bankrupt, die, or all three.
The democrats big mistake was trying to compromise with the republicans, who still refused to work on it. it's clear the whole system is borked, and I only see one party at least trying to do something about it.
It was watered down to make it a "budget bill" under the Senate rules so it could withstand filibuster. (In doing this, the ACA had to be stripped of almost all its cost-containment features.)
It's incredible to witness, real-time, people such as who you're replying to trying to change the facts of history mere years after the thing occurred.
This is in line with my original point - since when did facts become so malleable?
> The rest of the developed world shows that anything short of national healthcare system is an expensive mistake.
Of "the rest of the developed world", only one country (the UK) has a "national healthcare system", and even that's a bit of a stretch, because England, Scotland, Wales, and Northern Ireland all have different systems.
Canada runs healthcare at the provincial level. France, Germany, Spain, the Netherlands, etc. - all of those countries use private systems that cannot reasonably be called a "national healthcare system", unless you're going to stretch the definition so far as to say that countries like India (and the US) also have national healthcare systems.
> Of "the rest of the developed world", only one country (the UK) has a "national healthcare system", and even that's a bit of a stretch, because England, Scotland, Wales, and Northern Ireland all have different systems.
England, Wales, Scotland and Northern Ireland makes 4 countries, just FYI.
> England, Wales, Scotland and Northern Ireland makes 4 countries, just FYI.
...yes, that's the point. When people talk about "the NHS", as they usually do on HN, they're conflating four different systems (or, more commonly, thinking only of NHS England).
The point, in case you missed it is that nobody outside the UK has what can reasonably be called a "national healthcare system" in this context.
I agree that it failed to achieve that goal but it also didn't make the rising health care costs worse.
You are making the big (and very american) mistake to attribute all problems to the party or president you don't like while overlooking the systemic problems that are there long term no matter who is in power.
Democrats wanted a much better of the ACA, but let's not forget that Republicans were walking around talking about how they'd "oppose anything Obama did," without even reading the texts of the bills
I would have much more respect for the Republicans if they had actually come up with some reality based proposals how to improve things for not wealthy patients instead of pretending that getting rid of Obamacare is the only thing needed to fix the "best healthcare system in the world".
All the Obamacare horror stories paraded in 2010 were easily debunked. Everyone acknowledged that some people would be hurt in the transition. The surprising fact was that it was so hard to find someone who was convincingly, demonstrably hurt.
You also realize that medical bankruptcies almost ceased to exist once The Affordable Healthcare Act started to work.
Source: I've been in the Medical Field for 20+years.
We used to get 3-4 bankruptcy notices a month for our small single practice office, the bankruptcies were not usually from us, but because if you're in my office you're usually deep in the medical system. Now we get one or two a year because those people still choose not to have medical insurance.
The problem is we have higher than average healthcare costs, but it's not the doctors fault, it's the 15 million employees in the US that are nothing but middlemen, look into the Buffet, Bezos, Dimond project and their stance on Healthcare, it's the future.
1. The discussion is about US healthcare costs compared to the rest of the world which is different to your monthly payments.
2. "Obamacare" seems to an outsider to have been a hellish compromise - the only thing that could get passed considering the political balance of power at the time. It was far from the legislation that was originally intended - and that even legislation (what was deemed politically possible in advance) is probably far from what would be needed to fix the US healthcare system.
So it's entirely possible you ended up with a terrible outcome instead of the merely inadequate outcome that might have transpired in a different climate.
Health care costs were (and are) increasing. The rate of increase slowed under the last administration. [1] Your costs may have gone up if you were part of a low risk group because under Obamacare, low risk individuals were made to share the cost of other insureds who were stupid enough to get old, be poor or have existing health issues that made them unprofitable for insurance companies to insure. Obamacare also removed the low price "scam" insurances that would deny coverage on flimsy "pre-existing condition" pretenses.
If I'd kept the same program that I had under the Obama administration, my costs would have doubled under the current administration (800->$1600mo).
"..the average premium for single coverage through employers has gone up 28 percent “under Obama” That’s right again, but much lower than the growth of individual premiums during Bush’s first six years. That increase was 72 percent."
> low risk individuals were made to share the cost of other insureds
Yes, that's a huge part of the problem right there. If I'm healthy and work hard to be healthy, I have zero interest in paying for someone else's health problems. I have my own family to feed and we're talking about massive amounts of money that I get no direct benefit from.
>massive amounts of money that I get no direct benefit from
If your value system is "let the lepers die in the street," our value systems are so far removed from each other that the best thing we can do is respectfully not engage.
But because we're both already here, and you seem to care a lot about money, maybe we should talk about money?
Do you like living in a city, country, state with high GDP? This can improve the price of goods locally as your country has a stronger bargaining position in international trade agreements. This means higher paying jobs are available because bigger companies are willing to play ball to set up shop locally.
The health of the general population is tied directly to GDP. Healthier population, better GDP. If you like $$$, support universal healthcare. It's a good long term investment.
Do democratic politicians have some sort of training in maintaining the farce that more things should be handled by government, when governments in Illinois, California, New York, etc.--democratic strongholds where Republicans cannot be pointed to as the scapegoats--are on the verge of bankruptcy?
I don't think, deep down, republicans think the current system is better. They just don't trust whatever replaces it won't be much worse. It's easy to say "if we were just like <X European country> we could offer universal healthcare and also save money!" But <X European country> probably has trains that are vastly better than ours despite costing less to operate. They have schools vastly better than ours that they spend less money on. Clearly there is more to the equation.
It doesnt matter. These are just the general American talking points.
Fortunately since this is a global forum, people can point out that the situation in AMerica is farce.
The basic stats are just solid - every first world country does better.
You guys have the worst of all worlds, and because of America's prediliction for everything market oriented, and the absurd partisanship - you have no solutions, and are ok with people getting cured in the ER.
Not to mention the fact that companies can write off insurance contributions against tax, and individuals can recieve that benefit without paying income or payroll tax on it. In effect that's a subsidy in favour of the middle classes and 1% to the tune of "between $174 billion and $429 billion over a six-year period".
You say this like it's some special provision in the tax code, but it's not. Companies pay taxes on profits, not revenue. And insurance contributions (like many many other things) are an expense that reduces profits.
Ah, I was wondering if you meant to mention that health care benefits are (in most cases) not taxable and I see with your edit that you did. I agree with you on that point. It's a big problem.
Interestingly, McCain proposed fixing this during the 2008 election and was slammed for it by Obama.
I think that is part of it. I also think a lot of it has to do with size & diversity.
- The US is ~4x more populous than Germany (most populous in Western Europe)
- The US is ~15x larger than France (largest in Western Europe)
- The US is significantly more racially diverse than any country in Europe which is a huge advantage in many ways but also comes with more challenging governance particularly when you factor in the US's legacy of slavery & racism towards blacks (~12% of the population).
- The US also has greater financial inequality (much, but not all of which is due to government policy of course)
I could list a few more bullet points, but you get the gist. The US is just bigger and more complicated that other places. It makes us harder to govern efficiently.
Quite a few US states are bigger than EU countries which manage to run their own decent systems. (e.g. NY: 19 million, Switzerland: 8 million.) What's the argument against letting them run it?
Maybe there have to be some federal ground rules. But having wider experimentation would seem like a good thing, for discovering good ways to run a system.
It could work but you'd probably have at least a moderate free loader problem with it being so easy to move from state to state.
There would be nothing to prevent a healthy person from living in a low tax/no gov't health care state until they get sick and then moving to a high tax state/state paid for care.
The issue is that a big % of medical expenses come from a small % of people. It would only take a relatively small number of these people moving to make a big difference in expenses. And it's the people with the highest expenses who would have the most incentive to move.
Sounds like, if true (I was under the impression that a big % of medical cost is due to artificial cost inflation due to the existence of insurance companies), the people costing the system the most amount of money are the least able to move, because they're, you know, dying. Or have some other debilitating condition that requires them to stay with the doctors that know what's going on.
You're slicing the expense on a different axis than he is. Stipulate any amount of overhead and overpricing due to a given health care regime (fully public and managed like the VA, public/private like Medicare, private insurance, whatever). Within that regime, a very small percentage of health care consumers will make up a disproportionate amount of the expense. It doesn't matter how you fund it or how efficiently you deliver it, because the disparity is on the demand side. 5% of BCBS TN's customers made up over 75% of their total expense!
Those customers are perfectly capable of moving. Many of them are simply chronically ill, with things like kidney disease. But anyone who's been on a plane in the US lately can tell you that the elderly have no trouble getting around, either.
You're really disconnected from reality of you think California and New York, the two most dynamic and wealthiest states that actually fund directly and indirectly most of the other states, are on the verge of bankruptcy. Try coming back to the real world and examining the facts. There's a very good reason why certain states are high tax and high growth while others are welfare operations that unfortunately can leverage their two senators into a kind of ransom business model.
California and Illinois have two of the worst fiscal conditions in the country, ranked #43 and #49 (by GMU) among states respectively, based on cash on hand vs. immediate obligations, debt to income, and liabilities to assets. California's unfunded guaranteed pension obligations alone add up to almost half its personal income. Don't even ask about Illinois.
New York isn't much better. It's #39. New Jersey, home to a huge percentage of the NYC workforce, is #50!
California is the 5th fastest growing state economy. This is despite already being the largest state economy by far. That is simply remarkable and to call such a state of affairs "verge of bankruptcy" is just stupid.
Further the noise around pension obligations is mostly meaningless alarmism from people who don't know any better. If California is on the verge of bankruptcy why is California's bond rating at AA-? Why is New York's bond rating is AA+? Why are investors all over the world, particularly sovereign wealth funds, in fact standing in line to loan money to these high-tax, high-growth US states? Ex-real estate and ex-China, these economies are in fact the engines of growth for pretty much the Western hemisphere.
We'll see how long it lasts though. The thesis here is that when you combine the nonsense alarmism around debt and the cherished American belief that governments can do no right you get a recipe for enormous underinvestment and malinvestment. And Americans are so disconnected from reality that they probably will vote for any idiot who starts crying about "fiscal responsibility" and cuts public investment in these economies.
Those bond ratings are a measure of short-term solvency (if it heads off another unproductive exchange: the ratings agencies work with a very different of "long term" than GMU does). California does reasonably well (11th nationally) on that axis. We're talking about long-term structural solvency.
I don't understand what California's bond rating has to do with the impact of its unfunded pension obligations.
If we really are talking long term structural solvency, I think it's bad faith to start arguing any given state is "objectively worse" than any others - obviously we don't know, because we can't even predict the recessions that keep happening every ten years. (we being the majority of the population and law makers - obviously some people are screaming their heads off about it, fruitlessly)
I didn't start arguing that. The Mercatus Center at GMU did. Mercatus has an ideological bias (and not one I share), but they're serious people with real reputations. It's also a little weird to suggest that the fiscal outlooks of different states aren't comparable. Some states have pension obligations that consume an outsized fraction of their projected income, and others don't. What's complicated about that?
The idea that bond investors only care about "short-term solvency" and therefore ignore unfunded pension obligations doesn't make any sense at all. I don't even... Also this idea that California, the 5th largest economy in the world, is ranked "11th nationally" in terms of debt ratings doesn't make any sense. Nobody actually compares an economy like California (GDP 2.5T) with Arizona (GDP 2.5B). There's so much wrong here -- from the pure ideological nonsense that California is "on the verge of bankruptcy" to the idea that bond investors only think 6-10 years into the future -- that it's really not worth continuing this conversation. (It's also quite clear that the legion of downvoters, hard pressed to actually defend their ideological nonsense, can always just suppress the facts. So much for free speech uber alles.)
That's literally what a bond rating measures: whether a particular bond is likely to be repaid. A short-term bond is generally anything that comes to maturity before one year, and long-term is anything else.
> short-term bond is generally anything that comes to maturity before one year, and long-term is anything else.
Yeah that's now how any of this works. First, average muni bonds duration is 10+ years. Short-term debt is inherently safer than long-term debt but all investors will look far beyond a particular bond. Especially when dealing with sovereign entities who can't go bankrupt they are much more concerned about the risk of default (on anything, not just bonds). That's actually what the credit ratings measures -- a comprehensive evaluation of ability to service all debts. They are not at all bond-specific.
Logically, if investors really did believe these states were doomed then they would also be forced to conclude that the states themselves know they are doomed (all information is public) and at any moment the states will take measures before they are destroyed to prevent their own destruction. These measures will inevitably be some form of default. So if you're lending money to an entity who everybody knows will default at some point in the future it would be naive to think any one particular debt instrument is safe. Defaults, by their very nature, are very unpredictable. That's why investors will demand a real risk premium even for extremely short-term debt (30 days) from borrowers with low credit ratings. This isn't economic theory btw, this is economic fact, supported by two centuries of market data.
Suffice to say, Cali and NY bonds are actually set to out perform so the market does not believe that either state is going to default in the next 10 years or even the next 30 years.
Your first point needs expansion before it can be accepted.
Whether or not California is "on the verge of bankruptcy" is questionable. There's a lot of pension to pay out, sure, but the United States is over a trillion dollars in active debt about to add hundreds of billions more, and nobody describes the USA as "on the verge of bankruptcy."
Furthermore, you automatically assign this "on the verge of bankruptcy" aspect to a political party in power, ignoring the very important fact that you just named three states with the biggest, oldest metropolitan areas in the nation. And just because I'm expecting "but HOUSTON!", as a former houstonian, I say let's just hold tight and see what happens when the oil runs out, because the last time it did I was juggling hundreds of unemployed engineers living in houses they couldn't afford driving an hour to get to one interview.
You'll note in my post I never tried to argue the Democratic party was better - although if we want to I can argue about the value of leftist policy until I'm blue in the face. I will say this - if I walk into my house and the stove is on fire, but my dog has crapped ok the carpet, I put the stove fire out first.
We could spend a lot less money on un-needed things. For one, why are we the police of the world? What if we shut down ALL military bases abroad, docked most of our carriers except in times of war, put half the military on reserves.
What if we capped politician benefits across America at what the average American's is?
One big thing is-- if we ended Healthcare's ability to 'lobby' washington... made it illegal to spend healthcare money in lobbying endeavors, they could divert that to r/d and other worthwhile endeavors...
All insurance companies are --are companies that take our money and pay medical companies...couldn't the medical companies become the insurer?
What if instead of single-payer hospitals would take 'subscribers' locally, they'd pay 6% of their income. Make it a requirement that every American needs to signup with a hospital, and that all hospitals need to take anyone regardless of income or lack thereof.
Hospitals would then have a guaranteed monthly residual income they can track/chart and use to figure out their budget. We'd no longer be wasting ANY money on insurance CEO's, etc...
When traveling your host hospital pays the guest hospital, or other providers. The hospitals could work with each other to bring prices/costs down.
There are solutions and there's ways to pay for things, like maybe dropping progressive income taxes for consumption/vat instead... a vat would be paid by anyone in the country regardless of legal status, citizen or immigrant. So everyone would contribute.
> What if instead of single-payer hospitals would take 'subscribers' locally, they'd pay 6% of their income. Make it a requirement that every American needs to signup with a hospital, and that all hospitals need to take anyone regardless of income or lack thereof.
Unrealistic ideas are easy to throw around. In Germany, health insurance premiums are a mandatory 15.5% of income. Are we ready to impose a new 15.5% tax on everyone?
> We'd no longer be wasting ANY money on insurance CEO's, etc...
> What if we capped politician benefits across America at what the average American's is?
Feel-good moves that would save little real money, because at the end of the day what costs money are the salaries for all the middle class people involved in the health care system (doctors, nurses, administrators).
> progressive income taxes for consumption/vat instead... a vat would be paid by anyone in the country regardless of legal status, citizen or immigrant.
Except the people who want universal healthcare want the tax system to be even more progressive.
> Are we ready to impose a new 15.5% tax on everyone?
If at the same time pre-tax salaries increase by 15-30 percent when the employer no longer has to pay $16k for insurance, most employees would probably prefer it. (Apart from people earning 6 digits -- and in Germany those people can opt for private gold-plated insurance instead, too.
How does this math work? Those numbers are for salaried employees at large companies, but most Americans work for smaller companies. The new tax has to make the system work for everyone.
I want universal healthcare, but I want to use technology/common sense and end bloated programs. Military for instance could be cut in half or more (close the bases, keep the carriers, but dock unless during war). Focus on domestic defense, and let the rest of the world figure out their own shit.
End income tax, move to consumption tax/vat. (A modified version that would be sort of a negative tax). Basically, you'd have basic income making everyone who has a physical address (must spend some of the $$ on residence) would receive a check for whatever the poverty level is divided by 12.
Then everyone is a tax payer and pays consumption tax, we'd also have a land value tax, which would be more even on what land is 'worth' regardless of if you're using it for it's total 'worth'.. E.G. -- 2 people own same amount of land, same location, one builds a skyscraper, one doesn't, they both pay what the land/property would be worth if the area was 'fully developed', encouraging people to not just 'hold' land but 'use' it, or pay as if they did, so they might as well develop or sell it to someone who will.
We'd have to figure out ways of getting more off the top of the pile, as consumption does take a bit from the lower classes and funnels it up, but they're getting it back in terms of GBI + Healthcare.
Consumption tax could be tied to a citizen ID, ID = 10%, no ID = 15% tax rate. Could work in a +5% for college grads who used free education grants, until they're > 30 to pay for free college (State/Community schools). This way they pay back when they shop, but it's not permanent and it hurts a lot less than normal loans/etc...and doesn't affect credit. Or could just have a 'twenty's' tax of +5%, whether you go to college or not you pay an extra 5% from 20-30 to on goods, to pay for those who 'took' the advantage to go to school.
I like to believe that there's 'out of the box' ways to do things... I'm a social democrat with some techno-libertarian ideas, I feel the government needs to work and support all people, but it needs to do so in a way that can eliminate the most 'bureacracy' as possible, and drive down costs. I'd be happy if govt could be ran completely by AI and have maybe 10 people over-seeing / auditing the machines.
I'd like to see bills submitted like github issues - small, easily enacted/reversed 'pull requests' that only change small bits of law/codes. Instead of 10-100+ page omnibuses, everything would need to be < 5 pages (or something rudimentarily agreed upon - I'm not a lawyer/politician), and it must only effect a specific item or items that relate to each other. No combining other things for political 'fancy' or posturing.
I'm no fan of high military spending, but an aircraft carrier kept at the dock is worse than useless. Carrier operations are tremendously complex and the crews need constant practice in realistic scenarios (foreign deployments, fleet exercises with allies). When those skills and institutional knowledge are lost they take decades to rebuild.
Firstly the wars/fighting our military is currently 'engaged' in is mostly useless. We haven't 'won' a war since ww2.
Carriers are like bases that can easily be deployed as needed. Maybe keep 2 or 3 carriers off the coast not necessarily 'docked', to run maneuvers to keep 'training' up, reserves could come and run ops maybe every few months to stay 'fresh'... Ideally, we'd not need to call any up until WE are under direct imminent threat.
Furthermore, I think a lot of our future wars will be fought with technology, drones, robots, and not need as much military personnel anyways.
Our military budget should be on par with Russia, instead we're equivalent to the next 7 largest militaries combined. There's no need for that much expense (except to pad lobbyist coffers).
So for carriers you are essentially proposing the status quo. At any given time only about ⅓ are actually deployed. The others are docked for refit, or doing training close to bases. If they're going to deploy at all the costs are about the same regardless of where they operate. And to maintain proficiency they have to constantly practice operating in all over the world. These are not skills that can be picked up in just a few months. A carrier is not even remotely like a floating base; it's an order of magnitude more complex.
I am all for fighting fewer wars. But until that actually happens our carrier forces are over stretched.
Yes? Combined with the bizarre Democrat insistence on trying to play bipartisanship with people who aren't interested in reciprocating. That's what led them to push for "national Romneycare", the most conservative possible solution.
Republicans have no interest in the possibility of any kind of functioning public option, nor any kind of pro-consumer market reform that would actually deliver healthcare. It's simply not in the list of things they talk about.
So I like to think I'm pretty darn on the liberal side of the spectrum, but the (ACA if Democrat) (Obamacare if Republican) was overall a giant handout to the health insurance companies while carrying forward almost all of the pre-existing problems with health care in the US (see the charts in the original article). Both parties share substantial amount of blame for the current state of health care in the US.
It is honestly such an entrenched and complex problem I do not see any way it is going to be fixed (or get better) anytime soon.
This is it. Both parties have failed with healthcare - Republicans through complete inaction, and Democrats through pushing through legislation that simply expanded insurance coverage. While I think the ACA made things better than before (it got a lot more people insured and thus no longer easily susceptible to medical bankruptcy), it was a very imperfect and inefficient solution.
Because of the donors to each side - small government boosters like the Koch’s for the Republicans, insurance and pharmaceutical companies to the Democrats - it’s going to be very hard to move to a single payer solution. Even if you don’t think that’s the right way to handle it, you must admit that there is not much money behind it
I'm actually surprised there has not been more pressure by the business community to decouple health care/health insurance from employment. Health insurance costs, and the administrative effort to provide it, are an enormous burden on businesses/employers. From small business to giant corporations, it is an extraordinary burden that is only going to increase and at some point is going to start seriously impacting the competitiveness of US business. It should be an issue the Republicans have front and center.
Actually, businesses love healthcare coverage. The most costly thing in a business (esp. tech) is recruitment. If you give awesome benefits, a lot of people might decide it's 'safer' to stick with your company even though they're burned out and would rather work for an exciting startup, or something.
Benefits are a tool to turn workers into slaves, and stop job mobility. Sure there are other benefits, but healthcare is the biggest and most costly. The better health a company gives the more likely employees are to stick with it.
> While I think the ACA made things better than before (it got a lot more people insured and thus no longer easily susceptible to medical bankruptcy), it was a very imperfect and inefficient solution
Could they have done better?
Normally a big bill like this would pass the House. Then the Senate would make several changes in order to get enough votes to pass there. Then it would go back to the House, where the House would make another round of changes...then back to the Senate, and so on.
But in this case, that stopped early. It came from the House. Changes were made in the Senate that were able to get it through, 60-39 (60 were needed because Republicans were filibustering). One of those 60 was from the person temporarily filling the seat of the recently deceased Senator Kennedy.
It went back to the House, and while it was there the special election to fill Kennedy's seat was held, and a Republican won, and the Democrats lost the ability to break a filibuster.
So the Democrats in the House went with the bill as it came from the Senate, because that was the only thing they could pass that would not have to get past a Senate filibuster. (They were able to make some changes separately, because some of the changes they wanted, such as some relating to subsidies, because those counted as budgetary changes, and there is a separate procedure for reconciling budget changes between the House and Senate that is not subject to filibuster).
I don't understand how the "downtrodden" who rejects help from the government is somehow naive, but the billionaire who votes to have his taxes increased is somehow smart, noble, and a patriot. At the end of the day everyone votes for the policy initiatives that they prefer - whether the program is trying to help them or not.
The thing about lots of "downtrodden" people is they want opportunity - not support from the government. They want to be able to stand on their two feet to support their wives and kids - not to have Warren Buffet pay for their meals.
As someone who was once downtrodden, I completely disagree with your second part. I also sense a whiff of self defeating hypocrisy - if everyone votes for what benefits them, why wouldn't the downtrodden try to get as much as possible?
Poor people want a fucking break. When I was poor we'd watch all the rich people on TV get arrested and let off with a slap on the wrist and ask ourselves, "what the fuck?" We'd see pics of OJ partying with cocaine and porn stars in expensive clubs, then get away with murder. I don't know where you get this sense of "righteous wholesome poor people just trying to skip coffee for a day so they can put two more pennies in the savings account and one day be able to support their kids," poor people want to support their kids today, right now.
Please can someone explain the USA's lack of free healthcare to me? Every time i see it suggested or attempted its immediately sabotaged by just about everyone.
The NHS is one of the greatest things to come out the UK but you guys seem so opposed to the notion.
The abridged version is that they were working on it but the head of Kaiser convinced Nixon that private health insurance was a better option. Fast forward a few decades and there is too much at stake for the companies providing the care^insurance for a graceful change. Large companies also don't give a hoot because they're able to offer corporate self-insured plans which constitutes a competitive advantage against smaller employers.
My personal opinion is that the ACA was also complete garbage. Either go single payer (or at least an option to buy into a single payer) or don't go at all. The half assed approach we've ended up with is the worst combination as the individual is forced to purchase insurance in a market with perverse incentives on all sides and no real competition.
There are lots of other systems besides single-payer (like the NHS grandparent mentions liking) or the US. It isn't some law of nature that anything "in-between" is doomed to failure.
The ACA isn't all bad. One thing it did do was open the market to more providers. Prior to that every state had their own insurance companies (ie. BCBS-FL, BCBS-VA, BCBS-WA). And if you wanted it there were maybe 2-3 companies you could choose from.
A hefty portion of the population hates, fears, or scorns the government. They think putting healthcare (even more) in the hands of the state will either lead to worse results or give the state even more leverage to push them around.
Also, a big and influential portion of the citizenry is served just fine by the current arrangement. If you don't have any long-term medical conditions and you have a job good enough that your employer provides medical insurance, you're doing just fine, thank you.
Finally, there are large and influential groups that are making a lot of money under the current system, and expect they would make less under a more socialized system. Among these are doctors, insurance companies, and pharmaceutical companies.
All these factors add up to a formidable bulwark against large-scale change.
We Americans have a pathological fear of socialism and since the 1980s it's been ingrained in the collective psyche of the nation that government is bad. You'll hear people talk about how government can't do anything right but we have the greatest military in the world. Such contradictions are endemic to the right leaning people of the country. Left leaning people of the country have a differing set of contradictions.
There is also a coupled fear of a poor person getting something they don't deserve. This has foundations in religion and in the development of the nation. There was a time (over a hundred years ago) when a man(family) could do it on their own and live off the land. This inculcated in us the idea that being poor is associated with being a slouch. Such a time has long since passed but that ethos is still in the collective consciousness.
There is also a pathological fear of taxes. It is widely believed that government is always more inefficient than a privatized solution. We had a Vice-Presidential candidate laugh at the notion that paying taxes is patriot and this while her son was in the military during a time of war! A lot of people think of themselves as some sort of Daniel Boone character that can do it on their own if only government got out of the way.
We do have a national healthcare system for elderly, members of the military, and most children. Everyone else can fend for themselves.
The direct answer to your question is that it's a complicated historical thing, where American doctors in the 1950's wanted to retain more control over their practices and happened to have the political power to make that happen.
> Consumers, meanwhile, buoyed by insurance and tax breaks, have little idea how much they are really spending and little incentive to know underlying costs.
Almost weekly there's another post showing that consumers literally cannot find out costs usually because the provider cannot supply it. It's time to put a stake in the heart of the recurring blame-the-consumer trope.
I agree, but I think they are talking about a different aspect of "not knowing". Which is, I get health coverage from my employer, I go to the doctor, I get some sort of bill that seems high but not crazy, I assume that is the cost of visit. But I am not seeing the transactions behind the scene between doctor/insurer/employer that may be several times what I am directly out of pocket, but pay indirectly.
there are other kinds of problems. You are in the hospital, you feel queasy after surgery, nurse asks if you would like medication for that. "how much is it?" If you even think to ask that, usually they will not know, and can't or will not find out for you. So you can't make a rational decision about whether to deal with the discomfort or not.
Similarly, doctors often won't know the cost difference between various medication options, and those costs are always extremely difficult to figure out since there are usually various coupons that last for various amounts of time, which if you are willing to sort through you can game the system a lot. But in the long run it would be better if those games didn't exist. Switching asthma meds as you run through coupon time limits isn't really the healthiest thing anyway.
Or you are hit by a car, an amublance shows up "what will the bill be? Oh I'll call a different service" no, you can't do that while you are bleeding out, nor will you have any way of knowing which hospital will have the best rates to fix you, you don't even know what is wrong yet!
One might conclude that private, free markets don't make sense in this domain at all, perhaps.
> there are other kinds of problems. You are in the hospital, you feel queasy after surgery, nurse asks if you would like medication for that. "how much is it?" If you even think to ask that, usually they will not know, and can't or will not find out for you. So you can't make a rational decision about whether to deal with the discomfort or not.
followed by
> One might conclude that private, free markets don't make sense in this domain at all, perhaps.
is an odd conclusion to draw, since the agent primarily responsible for the inability for providers to provide transparent prices to privately insured patients is, ironically, Medicare.
>is an odd conclusion to draw, since the agent primarily responsible for the inability for providers to provide transparent prices to privately insured patients is, ironically, Medicare.
I'm not sure how you can be so certain that is the 1st order reason. The pricing situation seems to often be obfuscated by our private insurance companies as well. When people have different insurance plans, with different back room deals on rates, and different customer out of pocket rules, or none at all, how is the doctor to know what your price is going to be? How does erasing medicare from the equation fix that?
I don't read it as "blame the consumer" but "the system is opaque".
The consumer doesn't know and can't find out. Articles have been written for, I don't know, a decade or more decrying the opacity of the "Chargemaster", etc, and how if you call a hospital to ask the charge for a procedure, they probably can't give you a quote.
If you have certain kinds of insurance, you're not even incentivized to care - you tolerate the opacity. But I don't think it's really blaming the consumer so much as blaming a system way off the rails.
Additionally, the first thing you have to do when you go to the doctor in the US is sign that paper that basically says “I agree to be responsible for the bill, no matter what it ends up being.” Which is ridiculous given you can’t know what the bill is until after you’re charged.
Imagine going to the grocery store and there are no prices on anything. You load up your cart and walk out and the grocery store sends you a bill months later. The bill is enormous because the grocery store has a signed statement from you agreeing to pay whatever they want. That’s the system we have for healthcare.
The problem I have with the "blame the consumer" trope is that there's the implicit "and if consumers had full pricing knowledge, The Market(tm) would correct all of the other issues, and healthcare in the US would be fixed." I assert this mostly through anecdotal evidence based on where these conversations tend to go.
I also find it to be some of the most disingenuous handwaving I've seen in recent memory. No one is going to comparison-shop when they have a ruptured appendix. Worse, if they think they can just "tough out" the abdominal pain because they can't afford the doctor visit _or the treatment that might result from it_, they'll just die.
Just to head something off... if your answer to "What if people still can't afford healthcare?" is "If you can't afford healthcare, then you're not contributing enough to society to receive healthcare.", then I thank you for your candor and your ideological consistency, and have you considered that you might be a sociopath?
>The problem I have with the "blame the consumer" trope is that there's the implicit "and if consumers had full pricing knowledge, The Market(tm) would correct all of the other issues, and healthcare in the US would be fixed." I assert this mostly through anecdotal evidence based on where these conversations tend to go.
If the consumer had full pricing knowledge beforehand then the market would certainly correct some of the other issues, probably not all but certainly some. Take a look at dental for example.
>I also find it to be some of the most disingenuous handwaving I've seen in recent memory. No one is going to comparison-shop when they have a ruptured appendix. Worse, if they think they can just "tough out" the abdominal pain because they can't afford the doctor visit _or the treatment that might result from it_, they'll just die.
Getting ripped of because you couldn't afford the time to shop around is par for the course in many industries. Yes, some peoples' appendices will rupture without warning but many more people will have conditions that give ample warning and allow comparison shopping. I think this there is a very good comparison to automotive repair in these scenarios (albeit higher dollar amounts and consumers being more willing to have work done up front to avoid more later).
Obviously some situations are complicated or don't lend themselves to doing so in a timely manner, but my healthcare/insurance provider (UWHealth and Quartz) has a priceline and online message center for immediate quotes without insurance. I use it even though I have insurance, especially before appointments where I anticipate what tests the doctor is going to order. They're usually reasonable, at least by American standards. Surgery has been more difficult to pin numbers down for because of the facilities.
Even if you got complete disclosure of costs, there is no incentive for consumers to negotiate costs because of insurance coverage. Sure, rates go up but that's a detached and opaque process.
Actually there's at least 2 incentives: 1) even with insurance coverage you have a deductible, and unless you have a year with a lot of doctor visits or procedures, you're probably going to end up paying almost everything out of pocket, 2) higher medical bills drive insurance costs, if you can get lower bills you can reduce your insurance costs (not even negotiating with the insurance, but just simply switching to a different/cheaper plan with lower coverage).
A piece of anecdata on what happens when it's not as opaque: I took the script for a lumbar MRI to a standalone imaging chain advertising low costs. The phone quote was 1/10th the price quoted by the hospital. What puzzled me was that although the imaging place accepts my insurance it asked for $395 if I wanted payment to apply against my insurance deductible but only $275 if I paid without going through the insurer. Was the delta reflecting the imager's cost to file a claim? They couldn't tell me. I wish there were ombudsmen to turn to.
The price differential is based on the cost of filing an insurance claim, the risk that the insurer will deny the claim (or require changes before approval), and the delay in receiving payment. A cash payment today is a sure thing.
Recently I went in for a consult to see about an operation. Before the consult, they asked for a pee sample. After the consult I got a bill, including the lab work. I never got the operation.
The doctor never needed that lab for the consult. I don't think they even performed it that day. They just threw an extra step into the procedure, knowing that most patients would just accept it rather than interrogate the doctor or nurse as to why this was needed. The nicest way to view this is the office is operating with unnecessary procedures that drive up cost. A less charitable interpretation is they're jacking up their fees.
The blame falls on me here because I put blind faith in the doctor's office and did not fully investigate everything being done and approve or deny things based on my questions.
Now, do I think I should have to do this? Hell no. I'm not qualified to speak to their procedures. But the only way I can see doctors change how they operate is to start demanding it, in addition to regulatory change to provide a fee breakdown before doing anything. I know this would probably only make everything more expensive and slower, but I don't have a better idea. Hopefully somebody else does.
> The blame falls on me here because I put blind faith in the doctor's office and did not fully investigate everything being done and approve or deny things based on my questions.
The thing you are describing is not the problem. In a normal healthcare system patients aren't expected to second-guess and interrogate doctors.
Sure, but we don't have a normal healthcare system, and we can't just convert it into a normal one, either.
It's a bit like big distributed systems. Before it is built, you can design it the way it should be done. After it is built, you can completely rebuild a new one from scratch, and migrate over to it over time. But it is incredibly costly, difficult, and impractical to retrofit the existing system to the point that it operates in a completely new ideal way. You can patch it, but the more patches you add, the more of a Frankenstein's Monster it becomes, getting slower, uglier, costlier, and buggier.
As much as it would be great to just upgrade the system per-state, the medical industry (as I understand it) is basically a national monolith. What I'm proposing, unfortunately, is patches. But I don't see a way around it other than rebuilding from scratch.
Agreed this needs done asap. Benefits hold unsatisfied workers captive, get rid of this bandaid -- and maybe we can afford Medicare for all.
One other option -- make Hospitals be both insurer/provider. They get recurring monthly income, they'd pay 'other' providers when you're travelling out of network, but they'd be more able to bring down costs, the government should set limits though on surgeries and their needs to be more transparency in pricing.
You'd subscribe to your local hospital and pay a % of your income to the hospital they'd take everyone regardless of income level.
If this is all that's done and companies stop paying for insurance, I would expect employers to use the opportunity to pocket most of the savings and only pass on a pittance to their employees.
Also, uninformed consumers will opt for cheap plans without checking for (or realizing their personal susceptibility to) major pitfalls that the ACA used to protect against before the Republicans pulled it apart.
> The health-care industry overtook the retail sector as the nation’s largest employer in December, giving local economies and their workers a stake in the industry’s growth. Health jobs surpassed manufacturing jobs in 2008.
This seems to me the biggest source of the problem. As the saying goes it’s hard to get someone to understand something when their salary depends on them not understanding it.
These days healthcare jobs - technicians and clerks and so on - are the new factory line work. Ie readily available good paying jobs that you can get (in many cases) without a college degree. These personal care jobs are also hard to replace with automation since the entire point is to deal with other humans.
Thus most people agree “the system” is broken but any specific proposal made to change it meets a big backlash of people who imagine - perhaps rightly so - “that could cost my job!”
Healthcare costs are by far the #1 reason why I want to move out of the U.S. as soon as possible.
I am well off, but due to recent experience I have a major anxiety about going bankrupt from another unexpected health issue. I had emergency spine surgery last year and despite coordinating everything I could to stay in network prior to entering the hospital - surgeon was in network, hospital in network, etc... - the monitoring group that was in the surgery room was NOT in network and neither was the assisting physician. Their fees were so high, that insurance refused to negotiate with them and so I was responsible for the charges despite meeting my out of pocket maximum for out of network charges.
Basically out of network maximums are worthless! If it's set at 10k and the bill comes back 100k, insurance can pay up to the 10k (if even that) and you will be responsible for 90k afterwards. It's a mess. I did some reading on this and it turns out to be a huge problem across the US, especially in states like Texas where finding in-network providers and facilities is less likely.
I remember when I started working in the early 2000s at a gas station. I was getting 100% paid medical benefits through Aetna and coverage was 90% through the insurance. As time went on and I got better jobs (in IT), that turned into a small monthly premium. Then the premiums just kept growing every year until it became a significant chunk of my monthly take-home check. Starting a few years ago, they've introduced reduced coverage all the way down to 70% as premiums continue to climb and with huge deductibles and higher out of pocket maximums. How long can they continue doing this before the whole system collapses?
> How long can they continue doing this before the whole system collapses?
The system is working as designed. Regulation ensures the corporations are getting rich and you're going broke.
When the government decided to make insurance a mandatory product, what did you really think the outcome was going to be? Insurance companies acted in their own interest: lowered payments to providers which forced providers out of their 'networks.'
I know, I know. The insurance companies (that formed 'non-profit' entities) are 'losing' money. But, thankfully, the laws provided for subsidies in case of 'losses.' It's all smoke and mirrors.
So sorry for what happened to you. Can relate a bit. A few months ago, when we learned that my wife would have to get a C-section, we tried getting an estimate for how much it would cost - asked doctors, nurses, hospital staff, insurance company, etc. No one could or would tell us, not even give us a range. Our best guess was to read online articles, which don't really help very much (unless you are into stressing yourself out). It's been 5 months after the C-section now and we still haven't gotten the bill. Our insurance agent told us it looks like it's going to be $85k total before coverage, and we have no idea how much we'll have to pay out of that. Btw, this was in SF which apparently is the most expensive city in the US where to give birth :(
That's really frustrating, sorry. I would think a c-section is such a relatively routine procedure that estimating the costs would be a trivial matter, but I guess that just shows how seriously complicated the healthcare system is overall.
> Healthcare costs are by far the #1 reason why I want to move out of the U.S. as soon as possible.
Hope you and your family are in perfect health if you plan to immigrate to a country with socialized healthcare. Most such countries will reject families with an autistic child, for example, based on the notion that said child will be heavily dependent on govt/health services.
Good to know, I did not consider that. It doesn't necessarily have to be socialized healthcare for me as long as private healthcare prices and treatments are reasonable.
Did they move there with an already-diagnosed kid?
There was a professor in the news for leaving New Zealand (I think) recently for exactly this reason. Because his kid was autistic (or something) the authorities were highly reluctant to grant him residency & hence lifelong care.
The charts are not really "Why Americans Spend Much on Health Care", just "Americans Spend Much on Health Care (or More than Others and More than They Used To, Anyway)". Believable causes that I have read being suggested are "demographics", "lack of single payer health care", "unhealthy lifestyle", "inefficient allocation of resources towards terminally ill patients", "Americans pay for drug research that inhabitants of other countries get for free", "expensive safeguards against malpractice lawsuits". Lobbying, taxation and opacity to consumers seems like a poor explanation of why healthcare in the US is so much more expensive than in other countries, and more expensive than in the past.
Americans spend too much on nearly all government provided services. Anyone who thinks that more government spending is the solution really doesn’t understand the underlying issues at all.
When it costs 5x as much to build a new subway line in NYC compared to Paris [1], spending 20% more on infrastructure isn’t going to do anything. Arguably it will make things worse, allowing the existing inefficiencies to continue.
This problem occurs in all the areas where America lags behind other first world countries. Education, healthcare, infrastructure - spending is equal or greater than comparable nations, but the returns on each dollar spent is much smaller.
People try to simplify this issue in a partisan manner to having bigger government (Democrats) vs having more free markets (Republicans), but when you look at each of these areas in greater depth you realize that it’s not that simple. There are a multitude of causes unique to America that contributes to costs being so high, as exemplified in this thread’s article. In the case of health care, elsewhere in the world there exist both free market and government provided solutions that deliver better outcomes than the American system.
I wish we didn't overpay compared to other first world countries, but although that is very annoying it is probably sustainable. Furthermore, we have several examples of other first world countries paying much less, using systems ranging from full socialized medicine (the UK) to almost fully private systems with some government regulation (Switzerland), so that fixing this is not a matter of figuring out something that works. It is a matter of getting enough people to agree on the same fix.
What worries me more is how the costs keep going up, and that's when measured as a percentage of GDP, so you can't just hand wave it away as part of everything going up over time due to inflation.
That's not sustainable.
Worse, the same thing is happening in other first world countries, with the costs going up at similar rates as they are here, so unlike the overspending problem this is not just a matter of getting the will to adopt one of the known solutions.
Uncheck the "latest data available" box, and that will enable the year range sliders. Set them to 1970-2017 and the graph will show the growth over time for several countries. Mouse over the lines on the graph and it will give you number.
The common refrain that we will improve healthcare by keeping the government away and relying on the free market ignores the fact that most people are unable to shop for healthcare. Consolidation, price obscurity and immediate need makes that impossible. Even if it were possible, will there be uniform methods for describing the services and total price of services so that people can shop around?
137 comments
[ 2.9 ms ] story [ 133 ms ] thread1. Find link to article on Twitter ( https://mobile.twitter.com/WSJ/status/1024306968029224960 )
2. Click it.
Yes, that worked.
So why does this combination work in Germany and fail so spectacularly in the US?
Not to mention that many of my relatives, and myself, have been egregiously misbilled or convinced to purchase very expensive, extremely unnecessary devices/treatment. I’m sure a lot of people in healthcare are good, but the people calling the shots - including even some doctors - don’t give a shit
Actually, I hate the player as much as the game. It's disgusting.
I say this as a Wisconsin emigrant that watched my home state shoot itself in the face time and time and time again.
The rest of the developed world shows that anything short of national healthcare system is an expensive mistake.
But their choice of doing so was guided by right-wing ideology. The Democratic Party is a center-right party. You might not be able to single out any one party for this problem, but you can certainly indict those who further this kind of thinking in the face of its demonstrable moral and economic failure.
Yes, removing this reduces costs - by creating a category of people who can't get insurance at anything resembling a price they can afford, and therefore either have to suffer, go bankrupt, die, or all three.
And then, when coverage was revoked, why would any other person insure this new cancer patient?
[1]: http://www.washingtonpost.com/wp-dyn/content/article/2010/03...
> The House voted 219 to 212 to approve the measure, with every Republican voting no.
[2]: http://www.washingtonpost.com/wp-dyn/content/article/2009/12...
> Vice President Biden presided over the 60 to 39 party-line vote, ...
This is in line with my original point - since when did facts become so malleable?
Of "the rest of the developed world", only one country (the UK) has a "national healthcare system", and even that's a bit of a stretch, because England, Scotland, Wales, and Northern Ireland all have different systems.
Canada runs healthcare at the provincial level. France, Germany, Spain, the Netherlands, etc. - all of those countries use private systems that cannot reasonably be called a "national healthcare system", unless you're going to stretch the definition so far as to say that countries like India (and the US) also have national healthcare systems.
England, Wales, Scotland and Northern Ireland makes 4 countries, just FYI.
This handy graphic explains in case of confusion: https://upload.wikimedia.org/wikipedia/commons/thumb/2/28/Br...
...yes, that's the point. When people talk about "the NHS", as they usually do on HN, they're conflating four different systems (or, more commonly, thinking only of NHS England).
The point, in case you missed it is that nobody outside the UK has what can reasonably be called a "national healthcare system" in this context.
You are making the big (and very american) mistake to attribute all problems to the party or president you don't like while overlooking the systemic problems that are there long term no matter who is in power.
You opened the can of worms, now eat it.
Healthcare costs were always increasing. That trend slowed under Obama.
https://www.factcheck.org/2015/02/slower-premium-growth-unde...
Democrats wanted a much better of the ACA, but let's not forget that Republicans were walking around talking about how they'd "oppose anything Obama did," without even reading the texts of the bills
http://swampland.time.com/2012/08/23/the-party-of-no-new-det...
So back to my original point - Republicans, why they be like they do?
"premium increases averaged about 60 percent from 2013, the last year before ACA reforms took effect, to 2017"
https://www.forbes.com/sites/theapothecary/2017/03/22/yes-it...
https://www.factcheck.org/2015/02/slower-premium-growth-unde...
Source: I've been in the Medical Field for 20+years.
We used to get 3-4 bankruptcy notices a month for our small single practice office, the bankruptcies were not usually from us, but because if you're in my office you're usually deep in the medical system. Now we get one or two a year because those people still choose not to have medical insurance.
The problem is we have higher than average healthcare costs, but it's not the doctors fault, it's the 15 million employees in the US that are nothing but middlemen, look into the Buffet, Bezos, Dimond project and their stance on Healthcare, it's the future.
2. "Obamacare" seems to an outsider to have been a hellish compromise - the only thing that could get passed considering the political balance of power at the time. It was far from the legislation that was originally intended - and that even legislation (what was deemed politically possible in advance) is probably far from what would be needed to fix the US healthcare system.
So it's entirely possible you ended up with a terrible outcome instead of the merely inadequate outcome that might have transpired in a different climate.
If I'd kept the same program that I had under the Obama administration, my costs would have doubled under the current administration (800->$1600mo).
[1] https://www.factcheck.org/2015/02/slower-premium-growth-unde...
"..the average premium for single coverage through employers has gone up 28 percent “under Obama” That’s right again, but much lower than the growth of individual premiums during Bush’s first six years. That increase was 72 percent."
Yes, that's a huge part of the problem right there. If I'm healthy and work hard to be healthy, I have zero interest in paying for someone else's health problems. I have my own family to feed and we're talking about massive amounts of money that I get no direct benefit from.
If your value system is "let the lepers die in the street," our value systems are so far removed from each other that the best thing we can do is respectfully not engage.
But because we're both already here, and you seem to care a lot about money, maybe we should talk about money?
Do you like living in a city, country, state with high GDP? This can improve the price of goods locally as your country has a stronger bargaining position in international trade agreements. This means higher paying jobs are available because bigger companies are willing to play ball to set up shop locally.
The health of the general population is tied directly to GDP. Healthier population, better GDP. If you like $$$, support universal healthcare. It's a good long term investment.
I don't think, deep down, republicans think the current system is better. They just don't trust whatever replaces it won't be much worse. It's easy to say "if we were just like <X European country> we could offer universal healthcare and also save money!" But <X European country> probably has trains that are vastly better than ours despite costing less to operate. They have schools vastly better than ours that they spend less money on. Clearly there is more to the equation.
Fortunately since this is a global forum, people can point out that the situation in AMerica is farce.
The basic stats are just solid - every first world country does better.
You guys have the worst of all worlds, and because of America's prediliction for everything market oriented, and the absurd partisanship - you have no solutions, and are ok with people getting cured in the ER.
https://www.nytimes.com/2017/07/07/health/health-insurance-t...
(Edited to include the missing point about income/payroll)
Interestingly, McCain proposed fixing this during the 2008 election and was slammed for it by Obama.
Maybe it's your political class that's broken.
- The US is ~4x more populous than Germany (most populous in Western Europe)
- The US is ~15x larger than France (largest in Western Europe)
- The US is significantly more racially diverse than any country in Europe which is a huge advantage in many ways but also comes with more challenging governance particularly when you factor in the US's legacy of slavery & racism towards blacks (~12% of the population).
- The US also has greater financial inequality (much, but not all of which is due to government policy of course)
I could list a few more bullet points, but you get the gist. The US is just bigger and more complicated that other places. It makes us harder to govern efficiently.
Maybe there have to be some federal ground rules. But having wider experimentation would seem like a good thing, for discovering good ways to run a system.
There would be nothing to prevent a healthy person from living in a low tax/no gov't health care state until they get sick and then moving to a high tax state/state paid for care.
Those customers are perfectly capable of moving. Many of them are simply chronically ill, with things like kidney disease. But anyone who's been on a plane in the US lately can tell you that the elderly have no trouble getting around, either.
New York isn't much better. It's #39. New Jersey, home to a huge percentage of the NYC workforce, is #50!
Further the noise around pension obligations is mostly meaningless alarmism from people who don't know any better. If California is on the verge of bankruptcy why is California's bond rating at AA-? Why is New York's bond rating is AA+? Why are investors all over the world, particularly sovereign wealth funds, in fact standing in line to loan money to these high-tax, high-growth US states? Ex-real estate and ex-China, these economies are in fact the engines of growth for pretty much the Western hemisphere.
We'll see how long it lasts though. The thesis here is that when you combine the nonsense alarmism around debt and the cherished American belief that governments can do no right you get a recipe for enormous underinvestment and malinvestment. And Americans are so disconnected from reality that they probably will vote for any idiot who starts crying about "fiscal responsibility" and cuts public investment in these economies.
I don't understand what California's bond rating has to do with the impact of its unfunded pension obligations.
Yeah that's now how any of this works. First, average muni bonds duration is 10+ years. Short-term debt is inherently safer than long-term debt but all investors will look far beyond a particular bond. Especially when dealing with sovereign entities who can't go bankrupt they are much more concerned about the risk of default (on anything, not just bonds). That's actually what the credit ratings measures -- a comprehensive evaluation of ability to service all debts. They are not at all bond-specific.
Logically, if investors really did believe these states were doomed then they would also be forced to conclude that the states themselves know they are doomed (all information is public) and at any moment the states will take measures before they are destroyed to prevent their own destruction. These measures will inevitably be some form of default. So if you're lending money to an entity who everybody knows will default at some point in the future it would be naive to think any one particular debt instrument is safe. Defaults, by their very nature, are very unpredictable. That's why investors will demand a real risk premium even for extremely short-term debt (30 days) from borrowers with low credit ratings. This isn't economic theory btw, this is economic fact, supported by two centuries of market data.
Suffice to say, Cali and NY bonds are actually set to out perform so the market does not believe that either state is going to default in the next 10 years or even the next 30 years.
Whether or not California is "on the verge of bankruptcy" is questionable. There's a lot of pension to pay out, sure, but the United States is over a trillion dollars in active debt about to add hundreds of billions more, and nobody describes the USA as "on the verge of bankruptcy."
Furthermore, you automatically assign this "on the verge of bankruptcy" aspect to a political party in power, ignoring the very important fact that you just named three states with the biggest, oldest metropolitan areas in the nation. And just because I'm expecting "but HOUSTON!", as a former houstonian, I say let's just hold tight and see what happens when the oil runs out, because the last time it did I was juggling hundreds of unemployed engineers living in houses they couldn't afford driving an hour to get to one interview.
You'll note in my post I never tried to argue the Democratic party was better - although if we want to I can argue about the value of leftist policy until I'm blue in the face. I will say this - if I walk into my house and the stove is on fire, but my dog has crapped ok the carpet, I put the stove fire out first.
What if we capped politician benefits across America at what the average American's is?
One big thing is-- if we ended Healthcare's ability to 'lobby' washington... made it illegal to spend healthcare money in lobbying endeavors, they could divert that to r/d and other worthwhile endeavors...
All insurance companies are --are companies that take our money and pay medical companies...couldn't the medical companies become the insurer?
What if instead of single-payer hospitals would take 'subscribers' locally, they'd pay 6% of their income. Make it a requirement that every American needs to signup with a hospital, and that all hospitals need to take anyone regardless of income or lack thereof.
Hospitals would then have a guaranteed monthly residual income they can track/chart and use to figure out their budget. We'd no longer be wasting ANY money on insurance CEO's, etc...
When traveling your host hospital pays the guest hospital, or other providers. The hospitals could work with each other to bring prices/costs down.
There are solutions and there's ways to pay for things, like maybe dropping progressive income taxes for consumption/vat instead... a vat would be paid by anyone in the country regardless of legal status, citizen or immigrant. So everyone would contribute.
Unrealistic ideas are easy to throw around. In Germany, health insurance premiums are a mandatory 15.5% of income. Are we ready to impose a new 15.5% tax on everyone?
> We'd no longer be wasting ANY money on insurance CEO's, etc...
> What if we capped politician benefits across America at what the average American's is?
Feel-good moves that would save little real money, because at the end of the day what costs money are the salaries for all the middle class people involved in the health care system (doctors, nurses, administrators).
> progressive income taxes for consumption/vat instead... a vat would be paid by anyone in the country regardless of legal status, citizen or immigrant.
Except the people who want universal healthcare want the tax system to be even more progressive.
If at the same time pre-tax salaries increase by 15-30 percent when the employer no longer has to pay $16k for insurance, most employees would probably prefer it. (Apart from people earning 6 digits -- and in Germany those people can opt for private gold-plated insurance instead, too.
End income tax, move to consumption tax/vat. (A modified version that would be sort of a negative tax). Basically, you'd have basic income making everyone who has a physical address (must spend some of the $$ on residence) would receive a check for whatever the poverty level is divided by 12.
Then everyone is a tax payer and pays consumption tax, we'd also have a land value tax, which would be more even on what land is 'worth' regardless of if you're using it for it's total 'worth'.. E.G. -- 2 people own same amount of land, same location, one builds a skyscraper, one doesn't, they both pay what the land/property would be worth if the area was 'fully developed', encouraging people to not just 'hold' land but 'use' it, or pay as if they did, so they might as well develop or sell it to someone who will.
We'd have to figure out ways of getting more off the top of the pile, as consumption does take a bit from the lower classes and funnels it up, but they're getting it back in terms of GBI + Healthcare.
Consumption tax could be tied to a citizen ID, ID = 10%, no ID = 15% tax rate. Could work in a +5% for college grads who used free education grants, until they're > 30 to pay for free college (State/Community schools). This way they pay back when they shop, but it's not permanent and it hurts a lot less than normal loans/etc...and doesn't affect credit. Or could just have a 'twenty's' tax of +5%, whether you go to college or not you pay an extra 5% from 20-30 to on goods, to pay for those who 'took' the advantage to go to school.
I like to believe that there's 'out of the box' ways to do things... I'm a social democrat with some techno-libertarian ideas, I feel the government needs to work and support all people, but it needs to do so in a way that can eliminate the most 'bureacracy' as possible, and drive down costs. I'd be happy if govt could be ran completely by AI and have maybe 10 people over-seeing / auditing the machines.
I'd like to see bills submitted like github issues - small, easily enacted/reversed 'pull requests' that only change small bits of law/codes. Instead of 10-100+ page omnibuses, everything would need to be < 5 pages (or something rudimentarily agreed upon - I'm not a lawyer/politician), and it must only effect a specific item or items that relate to each other. No combining other things for political 'fancy' or posturing.
Carriers are like bases that can easily be deployed as needed. Maybe keep 2 or 3 carriers off the coast not necessarily 'docked', to run maneuvers to keep 'training' up, reserves could come and run ops maybe every few months to stay 'fresh'... Ideally, we'd not need to call any up until WE are under direct imminent threat.
Furthermore, I think a lot of our future wars will be fought with technology, drones, robots, and not need as much military personnel anyways.
Our military budget should be on par with Russia, instead we're equivalent to the next 7 largest militaries combined. There's no need for that much expense (except to pad lobbyist coffers).
I am all for fighting fewer wars. But until that actually happens our carrier forces are over stretched.
Republicans have no interest in the possibility of any kind of functioning public option, nor any kind of pro-consumer market reform that would actually deliver healthcare. It's simply not in the list of things they talk about.
It is honestly such an entrenched and complex problem I do not see any way it is going to be fixed (or get better) anytime soon.
Because of the donors to each side - small government boosters like the Koch’s for the Republicans, insurance and pharmaceutical companies to the Democrats - it’s going to be very hard to move to a single payer solution. Even if you don’t think that’s the right way to handle it, you must admit that there is not much money behind it
Benefits are a tool to turn workers into slaves, and stop job mobility. Sure there are other benefits, but healthcare is the biggest and most costly. The better health a company gives the more likely employees are to stick with it.
https://promarket.org/donald-trumps-economic-policy-pro-busi...
Could they have done better?
Normally a big bill like this would pass the House. Then the Senate would make several changes in order to get enough votes to pass there. Then it would go back to the House, where the House would make another round of changes...then back to the Senate, and so on.
But in this case, that stopped early. It came from the House. Changes were made in the Senate that were able to get it through, 60-39 (60 were needed because Republicans were filibustering). One of those 60 was from the person temporarily filling the seat of the recently deceased Senator Kennedy.
It went back to the House, and while it was there the special election to fill Kennedy's seat was held, and a Republican won, and the Democrats lost the ability to break a filibuster.
So the Democrats in the House went with the bill as it came from the Senate, because that was the only thing they could pass that would not have to get past a Senate filibuster. (They were able to make some changes separately, because some of the changes they wanted, such as some relating to subsidies, because those counted as budgetary changes, and there is a separate procedure for reconciling budget changes between the House and Senate that is not subject to filibuster).
Wikipedia has a good, detailed, account: https://en.wikipedia.org/wiki/Patient_Protection_and_Afforda...
The thing about lots of "downtrodden" people is they want opportunity - not support from the government. They want to be able to stand on their two feet to support their wives and kids - not to have Warren Buffet pay for their meals.
It's pretty hard to stand on your own feet in a hospital bed.
Poor people want a fucking break. When I was poor we'd watch all the rich people on TV get arrested and let off with a slap on the wrist and ask ourselves, "what the fuck?" We'd see pics of OJ partying with cocaine and porn stars in expensive clubs, then get away with murder. I don't know where you get this sense of "righteous wholesome poor people just trying to skip coffee for a day so they can put two more pennies in the savings account and one day be able to support their kids," poor people want to support their kids today, right now.
The NHS is one of the greatest things to come out the UK but you guys seem so opposed to the notion.
My personal opinion is that the ACA was also complete garbage. Either go single payer (or at least an option to buy into a single payer) or don't go at all. The half assed approach we've ended up with is the worst combination as the individual is forced to purchase insurance in a market with perverse incentives on all sides and no real competition.
For example, read a bit about the Swiss system:
https://en.wikipedia.org/wiki/Healthcare_in_Switzerland
Also, a big and influential portion of the citizenry is served just fine by the current arrangement. If you don't have any long-term medical conditions and you have a job good enough that your employer provides medical insurance, you're doing just fine, thank you.
Finally, there are large and influential groups that are making a lot of money under the current system, and expect they would make less under a more socialized system. Among these are doctors, insurance companies, and pharmaceutical companies.
All these factors add up to a formidable bulwark against large-scale change.
There is also a coupled fear of a poor person getting something they don't deserve. This has foundations in religion and in the development of the nation. There was a time (over a hundred years ago) when a man(family) could do it on their own and live off the land. This inculcated in us the idea that being poor is associated with being a slouch. Such a time has long since passed but that ethos is still in the collective consciousness.
There is also a pathological fear of taxes. It is widely believed that government is always more inefficient than a privatized solution. We had a Vice-Presidential candidate laugh at the notion that paying taxes is patriot and this while her son was in the military during a time of war! A lot of people think of themselves as some sort of Daniel Boone character that can do it on their own if only government got out of the way.
We do have a national healthcare system for elderly, members of the military, and most children. Everyone else can fend for themselves.
Almost weekly there's another post showing that consumers literally cannot find out costs usually because the provider cannot supply it. It's time to put a stake in the heart of the recurring blame-the-consumer trope.
Similarly, doctors often won't know the cost difference between various medication options, and those costs are always extremely difficult to figure out since there are usually various coupons that last for various amounts of time, which if you are willing to sort through you can game the system a lot. But in the long run it would be better if those games didn't exist. Switching asthma meds as you run through coupon time limits isn't really the healthiest thing anyway.
Or you are hit by a car, an amublance shows up "what will the bill be? Oh I'll call a different service" no, you can't do that while you are bleeding out, nor will you have any way of knowing which hospital will have the best rates to fix you, you don't even know what is wrong yet!
One might conclude that private, free markets don't make sense in this domain at all, perhaps.
followed by
> One might conclude that private, free markets don't make sense in this domain at all, perhaps.
is an odd conclusion to draw, since the agent primarily responsible for the inability for providers to provide transparent prices to privately insured patients is, ironically, Medicare.
I'm not sure how you can be so certain that is the 1st order reason. The pricing situation seems to often be obfuscated by our private insurance companies as well. When people have different insurance plans, with different back room deals on rates, and different customer out of pocket rules, or none at all, how is the doctor to know what your price is going to be? How does erasing medicare from the equation fix that?
The consumer doesn't know and can't find out. Articles have been written for, I don't know, a decade or more decrying the opacity of the "Chargemaster", etc, and how if you call a hospital to ask the charge for a procedure, they probably can't give you a quote.
If you have certain kinds of insurance, you're not even incentivized to care - you tolerate the opacity. But I don't think it's really blaming the consumer so much as blaming a system way off the rails.
Imagine going to the grocery store and there are no prices on anything. You load up your cart and walk out and the grocery store sends you a bill months later. The bill is enormous because the grocery store has a signed statement from you agreeing to pay whatever they want. That’s the system we have for healthcare.
I also find it to be some of the most disingenuous handwaving I've seen in recent memory. No one is going to comparison-shop when they have a ruptured appendix. Worse, if they think they can just "tough out" the abdominal pain because they can't afford the doctor visit _or the treatment that might result from it_, they'll just die.
Just to head something off... if your answer to "What if people still can't afford healthcare?" is "If you can't afford healthcare, then you're not contributing enough to society to receive healthcare.", then I thank you for your candor and your ideological consistency, and have you considered that you might be a sociopath?
If the consumer had full pricing knowledge beforehand then the market would certainly correct some of the other issues, probably not all but certainly some. Take a look at dental for example.
>I also find it to be some of the most disingenuous handwaving I've seen in recent memory. No one is going to comparison-shop when they have a ruptured appendix. Worse, if they think they can just "tough out" the abdominal pain because they can't afford the doctor visit _or the treatment that might result from it_, they'll just die.
Getting ripped of because you couldn't afford the time to shop around is par for the course in many industries. Yes, some peoples' appendices will rupture without warning but many more people will have conditions that give ample warning and allow comparison shopping. I think this there is a very good comparison to automotive repair in these scenarios (albeit higher dollar amounts and consumers being more willing to have work done up front to avoid more later).
> a system way off the rails.
I agree.
Recently I went in for a consult to see about an operation. Before the consult, they asked for a pee sample. After the consult I got a bill, including the lab work. I never got the operation.
The doctor never needed that lab for the consult. I don't think they even performed it that day. They just threw an extra step into the procedure, knowing that most patients would just accept it rather than interrogate the doctor or nurse as to why this was needed. The nicest way to view this is the office is operating with unnecessary procedures that drive up cost. A less charitable interpretation is they're jacking up their fees.
The blame falls on me here because I put blind faith in the doctor's office and did not fully investigate everything being done and approve or deny things based on my questions.
Now, do I think I should have to do this? Hell no. I'm not qualified to speak to their procedures. But the only way I can see doctors change how they operate is to start demanding it, in addition to regulatory change to provide a fee breakdown before doing anything. I know this would probably only make everything more expensive and slower, but I don't have a better idea. Hopefully somebody else does.
Copy what works well in the rest of the world?
The thing you are describing is not the problem. In a normal healthcare system patients aren't expected to second-guess and interrogate doctors.
It's a bit like big distributed systems. Before it is built, you can design it the way it should be done. After it is built, you can completely rebuild a new one from scratch, and migrate over to it over time. But it is incredibly costly, difficult, and impractical to retrofit the existing system to the point that it operates in a completely new ideal way. You can patch it, but the more patches you add, the more of a Frankenstein's Monster it becomes, getting slower, uglier, costlier, and buggier.
As much as it would be great to just upgrade the system per-state, the medical industry (as I understand it) is basically a national monolith. What I'm proposing, unfortunately, is patches. But I don't see a way around it other than rebuilding from scratch.
Your company doesnt pay for your car insurance or home insurance, why does it pay for your health insurance?
One other option -- make Hospitals be both insurer/provider. They get recurring monthly income, they'd pay 'other' providers when you're travelling out of network, but they'd be more able to bring down costs, the government should set limits though on surgeries and their needs to be more transparency in pricing.
You'd subscribe to your local hospital and pay a % of your income to the hospital they'd take everyone regardless of income level.
Also, uninformed consumers will opt for cheap plans without checking for (or realizing their personal susceptibility to) major pitfalls that the ACA used to protect against before the Republicans pulled it apart.
http://facebook.com/l.php?u=https://www.wsj.com/articles/why...
This seems to me the biggest source of the problem. As the saying goes it’s hard to get someone to understand something when their salary depends on them not understanding it.
These days healthcare jobs - technicians and clerks and so on - are the new factory line work. Ie readily available good paying jobs that you can get (in many cases) without a college degree. These personal care jobs are also hard to replace with automation since the entire point is to deal with other humans.
Thus most people agree “the system” is broken but any specific proposal made to change it meets a big backlash of people who imagine - perhaps rightly so - “that could cost my job!”
I am well off, but due to recent experience I have a major anxiety about going bankrupt from another unexpected health issue. I had emergency spine surgery last year and despite coordinating everything I could to stay in network prior to entering the hospital - surgeon was in network, hospital in network, etc... - the monitoring group that was in the surgery room was NOT in network and neither was the assisting physician. Their fees were so high, that insurance refused to negotiate with them and so I was responsible for the charges despite meeting my out of pocket maximum for out of network charges.
Basically out of network maximums are worthless! If it's set at 10k and the bill comes back 100k, insurance can pay up to the 10k (if even that) and you will be responsible for 90k afterwards. It's a mess. I did some reading on this and it turns out to be a huge problem across the US, especially in states like Texas where finding in-network providers and facilities is less likely.
I remember when I started working in the early 2000s at a gas station. I was getting 100% paid medical benefits through Aetna and coverage was 90% through the insurance. As time went on and I got better jobs (in IT), that turned into a small monthly premium. Then the premiums just kept growing every year until it became a significant chunk of my monthly take-home check. Starting a few years ago, they've introduced reduced coverage all the way down to 70% as premiums continue to climb and with huge deductibles and higher out of pocket maximums. How long can they continue doing this before the whole system collapses?
The system is working as designed. Regulation ensures the corporations are getting rich and you're going broke.
When the government decided to make insurance a mandatory product, what did you really think the outcome was going to be? Insurance companies acted in their own interest: lowered payments to providers which forced providers out of their 'networks.'
I know, I know. The insurance companies (that formed 'non-profit' entities) are 'losing' money. But, thankfully, the laws provided for subsidies in case of 'losses.' It's all smoke and mirrors.
Hope you and your family are in perfect health if you plan to immigrate to a country with socialized healthcare. Most such countries will reject families with an autistic child, for example, based on the notion that said child will be heavily dependent on govt/health services.
There was a professor in the news for leaving New Zealand (I think) recently for exactly this reason. Because his kid was autistic (or something) the authorities were highly reluctant to grant him residency & hence lifelong care.
Edit: here's the story, 13-year-old stepson in fact: https://www.theguardian.com/world/2016/feb/16/prestigious-ac...
When it costs 5x as much to build a new subway line in NYC compared to Paris [1], spending 20% more on infrastructure isn’t going to do anything. Arguably it will make things worse, allowing the existing inefficiencies to continue.
This problem occurs in all the areas where America lags behind other first world countries. Education, healthcare, infrastructure - spending is equal or greater than comparable nations, but the returns on each dollar spent is much smaller.
People try to simplify this issue in a partisan manner to having bigger government (Democrats) vs having more free markets (Republicans), but when you look at each of these areas in greater depth you realize that it’s not that simple. There are a multitude of causes unique to America that contributes to costs being so high, as exemplified in this thread’s article. In the case of health care, elsewhere in the world there exist both free market and government provided solutions that deliver better outcomes than the American system.
For a more in depth coverage on this topic, I highly recommend: http://slatestarcodex.com/2017/02/09/considerations-on-cost-...
[1] https://www.nytimes.com/2017/12/28/nyregion/new-york-subway-...
What worries me more is how the costs keep going up, and that's when measured as a percentage of GDP, so you can't just hand wave it away as part of everything going up over time due to inflation.
That's not sustainable.
Worse, the same thing is happening in other first world countries, with the costs going up at similar rates as they are here, so unlike the overspending problem this is not just a matter of getting the will to adopt one of the known solutions.
There's a great interactive view of the data at the OECD health spending page: https://data.oecd.org/healthres/health-spending.htm
Uncheck the "latest data available" box, and that will enable the year range sliders. Set them to 1970-2017 and the graph will show the growth over time for several countries. Mouse over the lines on the graph and it will give you number.