As much as dissapointment the Affordable Care Act was, at least someone tried something. If only we could learn from those mistakes and make incremental changes. Politicians are to obsessed with either tearing it all down or healthcare for all for "free", no middle ground
We have a single-payer system - Medicare. ACA is just a jobs program for the insurance industry, perpetuating 2 types of bullshit jobs: medical billing and medical underwriting.
Medical "insurance" companies actually don't do much underwriting any more. Most policies are self insured by large employers. The insurance company just manages the provider network and administers claims.
Even medical billing is gradually going away with the shift to value-based care and accountable care organizations (ACOs).
Not free and no one's saying that. Free at point of service, like the NHS or the Canadian health care system, yes, but obviously everyone knows we'd pay for it with taxes.
We could just do it, cover everyone, for less than we're paying now, by rejiggering the system under a "medicare for all" banner. There aren't any other serious options on the table. (replace and repeal, or whatever, is not a serious option.)
Medicare currently pays less than what it costs to provide for a lot of services. And providers are either declining medicare alltogether or recouping the missing funds from the other patients. Where would all those other patients come from if medicare will be "for all"?
After having dealt with billing from hospitals for services they never delivered or obscenely overpriced I am inclined not to trust them on statements about their actual cost. In my view the billing practices of most hospitals are very dishonest and intentionally confusing and opaque.
Check out some hospital bills for major procedures and there is a good chance that you will find things like charges for services nobody remembers or a doctor who was in the room for 3 minutes charged $1200 or receiving an aspirin costs $80. Maybe my experiences are all anecdotal but when I put my own experiences together with what I hear from others and things I read I am pretty convinced that something is going very wrong.
> For Medicaid, hospitals received payment of only 88 cents for every dollar spent by hospitals caring for Medicaid patients in 2016.
Is that the actual cost of the item or the obscene markup? Is medicare only paying $2.20 for the $2.50 saline bag, or are they only paying $176 of the $200 charge?
As a taxpayer I would be in favor of a more equitable system where everyone has a line item brought to their attention. There may be a use case for UBI here, everyone gets a stipend or a tax cut that they can use to either get healthcare or not. I'm getting tired of all of the taxes and how easy it is to paint tax payers as evil rich people who need to give more with their hard earned money
I agree with you, I'm saying we should learn from the mistakes and iterate on the current instead of fighting for extremes that will never work or be passed
One thing the Republicans could have done was to iterate on Obamacare instead of trying to repeal it for 8 years and now that they are in power they show that they have no ideas and no interest in improving anything.
While I think there's something to your point here, I wish for the sake of avoiding flamewars per the HN guidelines you could put it in less partisan terms. (For example by avoiding naming specific political parties.)
I would have liked to see more experimentation on price transparency.
Totally agree about price transparency. Everybody but the people in the medical system who benefit from opaque pricing should be able to agree with this.
I don't think my comment was partisan but it was a description of the last 10 years. Republicans voted to repeal Obamacare several times a year but never introduced anything for improving it. And now that they are in power they seem have no idea how to proceed.
I am not saying that Obamacare was a good law. Actually it was pretty half assed but it could probably be made to work with some changes. I would have loved it opponents of it would have introduced steps for improvement but they never did.
If we avoid finger-pointing it is easier to find common ground.
I like the concept of the ACA as integrating markets and competition, as opposed to price fixing. Healthcare is a terrible example of market failure which requires some amount of regulation -- I wish we could iterate on which regulations were worthwhile. Instead we have this all-or-none regulation-vs-no-regulation. :(
PPACA is the incremental change. There wasn't the political capital to effectively destroy the health insurance industry by leaving only VIP insurance (really it's not insurance, it's a "pay extra to cut in front of the line" product).
Democrats apparently didn't have the votes to even make Medicare or Medicaid an optional buy-in, to compete with marketplace insurance. This in particular is necessary in a huge land area of the U.S. where there's only one or two insurance providers.
Democrats had the only votes and the only say in every element of "Obamacare". Republicans were not even allowed to see the bill before the vote was taken, hence zero Republicans voting for it.
> Democrats had the only votes and the only say in every element of "Obamacare".
That's not actually true (Republicans had a significant say, even though thet universally ended up voting no), but even if it was the public option had long been controversial among Democratic politicians despite it (and even moreso simple single payer, which had a majority support ) long being overwhelmingly popular among Democrstic voters and having stronger support nationally than the purchase mandate w/o public option approach.
> Republicans were not even allowed to see the bill before the vote was taken,
Yeah, they were, they were also involved in the Committee process in the Senate in which it was drafted. They also filibustered it for quite a while, which gave them even more time in which to read it.
And of course Republicans in the House had still more time to read it, since it was voted on in the House after the vote in the Senate.
There are lots of reasons you can argue might have been behind Republicans voting against, not being allowed to read it is not one of them.
In the US, if you can pay, you pay more for the same or poorer care. You don't get the best anymore. It is shown elsewhere, not in this article.
Obamacare killed the US as a medical mega-power. Economics 101: if you force the same prices for a much larger demand, then either the product sells out, or the service is watered down.
The US system is only "cheap" if you don't have any major medical issues. Once you get sick there is a good chance that copays, out of network bills and other charges will bankrupt you.
From my own research, this is not true - the US system is a little bit cheaper for an average software engineer, with much higher quality. We have to co-pay things in Europe as well; only basic ("medically necessary") care is free and of course you have to wait, sometimes years, and I'm not even speaking about the quality. E.g. my braces were more expensive than in the USA, in absolute money, not relative! And don't forget that a public system carries zero accountability of anyone ("you know, that's just how it is" is a perfectly acceptable argument here - even if you're paying out of pocket, even if someone died).
Deal with health care in the US and you will quickly learn that "you know, that's just how it is" too. There is a huge wall of inscrutable bureaucracy that's pretty much impenetrable.
My only experience in Europe is Germany and I much prefer that system over the US. I don't know how it is in other countries.
From my own experience coming from the French system to dealing with the Romanian one, it was for sure a hassle. Just getting them to fill paperwork in order to get my sick leave for work was pain and asking for a paper so my insurance could refund me was akin to setting the whole building on fire ( which wouldn't be bad ).
The problems is that the US system is unnecessarily expensive and inefficient. That means that more people could afford it if it were cheaper. Right now the system is only good for very well off people. Others are in danger of either not being able to afford it or going bankrupt if they actually get sick.
The methodology here is not good. All they're doing is comparing average health care cost vs life expectancy. They don't measure standard of care, accessibility of treatment, etc.
This is especially important when looking at end-of-life care, which I speculate affects these both of these metrics the most. A hospice with private rooms, friendly staff, and social engagement will score lower than a hospital that keeps someone alive in a coma.
The vast majority of the large scale increase in human lifespan you can put down to improvements in medical knowledge. People used to get their teeth knocked out and replaced with wooden ones as a wedding present, the idea being that the lucky couple would then have less risk of being killed by a tooth infection before the age of 40, as was common.
Could you indicate which health care systems you think are skewing the results in this manner? As it would seem to require keeping large numbers of the very elderly alive in comas while also not providing widespread elderly care, which seems an unlikely policy to pursue.
OECD has published data where you can compares 5-year survival rates after major cancers, heart attack 30-day survival after hospitalization, stroke, ischemic stroke etc. They also keep track of infant mortality, maternal mortality etc. http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT#
Data shows that Japan, South Korea, Israel and Nordics are have the best healthcare quality using these measures. US is often in top 10, or at least mid-tier. Beast cancer is treated very well in US.
But what is wrong with the US and infant mortality and perinatal mortality? How can the US be so low?
In the US, we make services used by the poor inconvenient and ineffective in order to (ahem) motivate people to not be poor. Lousy results are to be expected for that segment of the population.
That strikes me as an overly simplistic view, largely because it implies a unity of motivation across the various persons involved in U.S. healthcare policy-making and delivery.
If you're sure of your statement, it would be helpful to cite some supporting evidence.
The best example is work requirements for Medicaid as implemented by some states (Kentucky for one), which end up making it difficult to stay eligible for Medicaid.
Motivate? Most definitely yes. Equip? Not at all. The American Dream (especially that pesky part about "opportunity") died long ago. If you're born with a chronic condition such as diabetes or your parents can't afford an education giving you the chance of a decently paying job, better go die.
That being said, just looking at the raw numbers I'd dare to say that health care in the US is just about as inconvenient and ineffective for rich people as it is for poor...
>If you're born with a chronic condition such as diabetes or your parents can't afford an education giving you the chance of a decently paying job, better go die.
This has always been the case. Most of these people just died before while today we have methods to keep them alive.
Rektang was being facetious with that comment, as tipped off by the “(ahem)”, implying the real reason we make services for poor inaccessible so they won’t be able to use them and thus drive up costs for them.
That's part of it. But there are other factors at work including political concerns -- for example in exempting rural majority-white counties in Kentucky from Medicaid work requirements while imposing them full-force on urban majority-black counties.
life expectancy is a bad measure of healthcare effectiveness
1) infant mortality heavily impacts life expectancy. The us has a few subpopulations that have very high infant mortality regardless of socioeconomic status.
2) The us has a high teen murder rate
3) The US has very high levels of obesity
4) There is a tremendous genetic component to life expectancy. Some sub populations (asians) have very high life expectancy, their home countries reflect that. Little dogs for example can live 20 years, where large breeds die at 15.
If you pull out 1 and 2, we are up there with other euro nations.
Better measures are things like life expectancy after <pick an age where you think we start needing lots of healthcare>
The sad thing is that the people who are experts in this know these things, but still push the narrative that it is our medical system.
The above commenter mentioned demographic and lifestyle discrepancies not adequately accounted for in this comparison of outcomes among countries... not health care problems, as you're implying.
An infant mortality rate far above other first world nations isn't a health care problem?
We're talking about kids too young to be be gunned down, so they're not part of America's remarkable teen-gun-death statistics.
They're predominantly kids from poor families, who don't live healthy lifestyles or have good health insurance. If the family doesn't have access to good healthcare, the kid's chances of survival are lessened.
Maybe Russia could improve its placement on the list if they ignored the health care issues caused by alcoholism.
And then America could improve its position by declaring obesity, and the health problems that come with it, a lifestyle issue instead of a health issue.
You're conflating health issues with health care issues.
What health care system now implemented in any country, or proposed for implementation in America by anyone, controls how people eat, how much alcohol, tobacco, and other harmful drugs they consume, how often they exercise, how much they sleep, whether they provide healthy environments for their children, etc.?
Just as schools and teachers are simply one factor in educational outcomes, the medical system is simply one factor in health outcomes. You must consider lifestyle, environmental, and genetic/epigenetic factors to get a full picture. You must equalize for these factors - as far as this is possible - to fairly compare the effect of the medical system and associated policies alone on health outcomes in different countries.
Properly accounting for genetic and lifestyle differences in different sub-populations is largely taboo, and this prevents a fair comparison of medical systems across countries.
Over 23,000 infants died in the United States in 2016. The five leading causes of infant death in 2016 were:
Birth defects.
Preterm birth and low birth weight.
Sudden infant death syndrome.
Maternal pregnancy complications.
Injuries (e.g., suffocation).
While the medical system can intervene, these causes all seem far more dependent on genetics, the mother's (and to a lesser extent the father's) behavior during pregnancy and the infancy of the child.
In 2016, infant mortality rates by race and ethnicity were as follows:
Non-Hispanic black: 11.4;
American Indian/Alaska Native: 9.4;
Native Hawaiian or other Pacific Islander: 7.4;
Hispanic: 5.0;
Non-Hispanic white: 4.9;
Asian: 3.6
Compare white Americans with European countries, and the discrepancy drops significantly. There's something beyond the medical / health care system playing a role here.
Points 1 - 3 are all public health issues. When you talk about healthcare you can't neglect that part.
By the way, physicians will say the proper measure for healthcare efficiency is disability-adjusted life years. The point is not to be alive but to live well. Getting shot in adolescence is a public health problem. Hanging around for 10 more years with full-strength Alzheimers is no advance.
Enslaving the population of doctors would improve the index, since it reduces salaries drastically. Halfway between slavery and market wages is where you find Spain.
I always look at these types of reports, and it makes me laugh. It doesn't tell the whole story, and it doesn't tell the true story. We left Canada precisely because of its healthcare system and came to the US. Canada would have require substantially more out of pocket (10s of thousands) with a much longer wait (years), whereas in the US, the out-of-pocket was substantially less ($500) and substantially less time (-2 weeks) to receive assistance. And that was without using insurance from my job.
I hate meta comments, but I love how posting facts gets voted down here just because people don't like the facts. That's why autism support in Canada is a shit-show.
You look at the list of most efficient health care systems across the globe and they are not nearly as large as the US. They are typically small and homogeneous. I like the concept of single payor in the US but I do see big hurdles even if we get through the politics which is a big if. I'd point to heterogeneous population and a very wide range of care quality across the country and sometimes even within MSAs.
You look at any list of anything across the globe relating to countries and they are not nearly as large as the US.
For the very simple reason that most countries are smaller and more homogeneous than the US, so I don't think it really proves a lot. Unless you're suggesting US only compare itself to Russia and China in future?
China is number twenty and climbing. People in China could say it is not fair to compare health care in China to the US because the China is four times as big, but I have never heard that.
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[ 3.0 ms ] story [ 124 ms ] threadEven medical billing is gradually going away with the shift to value-based care and accountable care organizations (ACOs).
We could just do it, cover everyone, for less than we're paying now, by rejiggering the system under a "medicare for all" banner. There aren't any other serious options on the table. (replace and repeal, or whatever, is not a serious option.)
Is that even true? Personally I have my doubts.
FINDINGS
In the aggregate, both Medicare and Medicaid payments fell below costs in 2016:
- Combined underpayments were $68.8 billion in 2016. This includes a shortfall of $48.8 billion for Medicare and $20.0 billion for Medicaid.
-For Medicare, hospitals received payment of only 87 cents for every dollar spent by hospitals caring for Medicare patients in 2016.
- For Medicaid, hospitals received payment of only 88 cents for every dollar spent by hospitals caring for Medicaid patients in 2016.
- In 2016, 66 percent of hospitals received Medicare payments less than cost, while 61 percent of hospitals received Medicaid payments less than cost.
[0] https://www.aha.org/data-insights/2018-01-03-underpayment-me...
Is that even true? Personally I have my doubts.
Is that the actual cost of the item or the obscene markup? Is medicare only paying $2.20 for the $2.50 saline bag, or are they only paying $176 of the $200 charge?
I would have liked to see more experimentation on price transparency.
I don't think my comment was partisan but it was a description of the last 10 years. Republicans voted to repeal Obamacare several times a year but never introduced anything for improving it. And now that they are in power they seem have no idea how to proceed.
I am not saying that Obamacare was a good law. Actually it was pretty half assed but it could probably be made to work with some changes. I would have loved it opponents of it would have introduced steps for improvement but they never did.
I like the concept of the ACA as integrating markets and competition, as opposed to price fixing. Healthcare is a terrible example of market failure which requires some amount of regulation -- I wish we could iterate on which regulations were worthwhile. Instead we have this all-or-none regulation-vs-no-regulation. :(
Democrats apparently didn't have the votes to even make Medicare or Medicaid an optional buy-in, to compete with marketplace insurance. This in particular is necessary in a huge land area of the U.S. where there's only one or two insurance providers.
That's not actually true (Republicans had a significant say, even though thet universally ended up voting no), but even if it was the public option had long been controversial among Democratic politicians despite it (and even moreso simple single payer, which had a majority support ) long being overwhelmingly popular among Democrstic voters and having stronger support nationally than the purchase mandate w/o public option approach.
> Republicans were not even allowed to see the bill before the vote was taken,
Yeah, they were, they were also involved in the Committee process in the Senate in which it was drafted. They also filibustered it for quite a while, which gave them even more time in which to read it.
And of course Republicans in the House had still more time to read it, since it was voted on in the House after the vote in the Senate.
There are lots of reasons you can argue might have been behind Republicans voting against, not being allowed to read it is not one of them.
Obamacare killed the US as a medical mega-power. Economics 101: if you force the same prices for a much larger demand, then either the product sells out, or the service is watered down.
My only experience in Europe is Germany and I much prefer that system over the US. I don't know how it is in other countries.
Germany has its own set of problems but it's still better than the US for most people. The US should compare itself against the best.
This is especially important when looking at end-of-life care, which I speculate affects these both of these metrics the most. A hospice with private rooms, friendly staff, and social engagement will score lower than a hospital that keeps someone alive in a coma.
That aside, you can't tie all of life expectancy to health care. For example, diet, life style, genetics, and environment are all factors too.
OECD has published data where you can compares 5-year survival rates after major cancers, heart attack 30-day survival after hospitalization, stroke, ischemic stroke etc. They also keep track of infant mortality, maternal mortality etc. http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT#
Data shows that Japan, South Korea, Israel and Nordics are have the best healthcare quality using these measures. US is often in top 10, or at least mid-tier. Beast cancer is treated very well in US.
But what is wrong with the US and infant mortality and perinatal mortality? How can the US be so low?
If you're sure of your statement, it would be helpful to cite some supporting evidence.
That being said, just looking at the raw numbers I'd dare to say that health care in the US is just about as inconvenient and ineffective for rich people as it is for poor...
This has always been the case. Most of these people just died before while today we have methods to keep them alive.
http://www.nber.org/papers/w20525
Big recent declines are due to safer sleeping practices reducing SIDS / asphyxiation.
Education about safe sleeping is a factor, and also if you are in a household that can't afford a crib, that's going to have an impact too.
https://www-m.cnn.com/2018/01/04/health/infant-mortality-by-...
Yet US govt healthcare spending is absurdly high and far out of line with the rest of the world either per person or by gdp.
Seems to suggest that efficiency is terrible and that's still ignoring the out of pocket costs to the end consumer.
Some of these are definitely mediated by the quality of the health care system, but culture, public policy, and economics have impacts too.
https://www.webmd.com/mental-health/addiction/news/20180816/...
1) infant mortality heavily impacts life expectancy. The us has a few subpopulations that have very high infant mortality regardless of socioeconomic status.
2) The us has a high teen murder rate
3) The US has very high levels of obesity
4) There is a tremendous genetic component to life expectancy. Some sub populations (asians) have very high life expectancy, their home countries reflect that. Little dogs for example can live 20 years, where large breeds die at 15.
If you pull out 1 and 2, we are up there with other euro nations.
Better measures are things like life expectancy after <pick an age where you think we start needing lots of healthcare>
The sad thing is that the people who are experts in this know these things, but still push the narrative that it is our medical system.
That's convenient.
We're talking about kids too young to be be gunned down, so they're not part of America's remarkable teen-gun-death statistics.
They're predominantly kids from poor families, who don't live healthy lifestyles or have good health insurance. If the family doesn't have access to good healthcare, the kid's chances of survival are lessened.
Maybe Russia could improve its placement on the list if they ignored the health care issues caused by alcoholism.
And then America could improve its position by declaring obesity, and the health problems that come with it, a lifestyle issue instead of a health issue.
Just as schools and teachers are simply one factor in educational outcomes, the medical system is simply one factor in health outcomes. You must consider lifestyle, environmental, and genetic/epigenetic factors to get a full picture. You must equalize for these factors - as far as this is possible - to fairly compare the effect of the medical system and associated policies alone on health outcomes in different countries. Properly accounting for genetic and lifestyle differences in different sub-populations is largely taboo, and this prevents a fair comparison of medical systems across countries.
Edit: Consider this article by the CDC on infant mortality: https://www.cdc.gov/reproductivehealth/MaternalInfantHealth/...
Over 23,000 infants died in the United States in 2016. The five leading causes of infant death in 2016 were: Birth defects. Preterm birth and low birth weight. Sudden infant death syndrome. Maternal pregnancy complications. Injuries (e.g., suffocation).
While the medical system can intervene, these causes all seem far more dependent on genetics, the mother's (and to a lesser extent the father's) behavior during pregnancy and the infancy of the child.
In 2016, infant mortality rates by race and ethnicity were as follows: Non-Hispanic black: 11.4; American Indian/Alaska Native: 9.4; Native Hawaiian or other Pacific Islander: 7.4; Hispanic: 5.0; Non-Hispanic white: 4.9; Asian: 3.6
Compare white Americans with European countries, and the discrepancy drops significantly. There's something beyond the medical / health care system playing a role here.
By the way, physicians will say the proper measure for healthcare efficiency is disability-adjusted life years. The point is not to be alive but to live well. Getting shot in adolescence is a public health problem. Hanging around for 10 more years with full-strength Alzheimers is no advance.
For the very simple reason that most countries are smaller and more homogeneous than the US, so I don't think it really proves a lot. Unless you're suggesting US only compare itself to Russia and China in future?