Aside from the health care system, it arguably makes the general job market less efficient, by tying people more strongly to jobs that provide good health insurance, especially for people with chronic health conditions, or people with families.
It makes those people less likely to switch jobs, or start new self-employed projects of their own.
It's too easy to find facts and figures to support either side of the argument and I think the left finds a better argument in it simply being a human right and the moral thing to do, neither of which are easily refuted.
I don't agree or disagree with the claims, but they're not easily refuted because they're not falsifiable. They amount to "we should do this because I think it's better". It's not persuasive. A better argument would be, "We all want to take care of poor people and improve our economy--we can do both and here is the data". Of course there will still be lots of friction and lobbying and so on, but at least it's a compelling argument.
1) it has been made, but..
2) it doesn't naturally appeal to most people on the left, and everyone else knows it, so it comes off as unmotivating to the left and insincere to everyone else.
None of which means it isn't true (it is), or that it isn't important (it is), but that's why it doesn't get used as an argument very much.
I know a lot of small business owners who were only able to strike out "on their own"...because their spouse worked for a large corporation (or the government). They could afford to spend a few years getting it off the ground, supported by the family's other income (and health insurance). So, I suspect you're correct on this.
The only thing this demonstrates is the sheer idiocy of dividing ideas by "sides" or party lines. Real life has complex interactions that don't get captured by this.
I suspect the "right" is actually sincere. But it so happens that ideas giving more power to private businesses tend to disproportionally benefit larger businesses over the smaller ones (this is a natural advantage of having scale and capital). The ideas surgically targeted to benefit smaller businesses? The "targeted" aspect tends to pattern-match to the "left", so they get rejected. The end result looks like the "right" was dishonest, but IMO it's just the ass-backwards stupid fixation on ideology over problem solving that causes this. And the same thing applies to the "left".
This is all true, but I would add that many on the right are fully aware of the imperfections of the market, but believe the imperfections of government intervention are worse, and also less tractable. I agree with them on the first, although not the second.
Without government intervention there would be no law, there would only be anarchy and the law of the biggest and brutest. It would be Wild West all over again. Wild West of course is great for the fastest and biggest gun in town but less so for everybody else. I can already hear the fastest gun in town declaring "NO GOVERNMENT INTERVENTION !!!"
No. The same thing happens all around the world. Your "left" and "right" may be different than mine "left" and "right", but their problems still come from people fixating on ideology over solving problems.
I question your assumption on #2. I’ve specifically made this point on HN repeatedly (contracting 1-person outfits are common here) and you could label me as “left”.
It should be like the green new deal - the economics of eg Medicare4All is similar in that it’d greatly improve life for small business as well as families.
I've been working in my little corner of the world to re-frame the conversation. Socializing medicine isn't about restricting your freedom to choose your physician, it's the freedom from. Freedom from fear of losing your job, freedom from fear of having to change your doctor if you do, freedom to pick any doctor (they're all in-network), freedom from fear of starting a new business, freedom from fear of death and bankruptcy if anything goes wrong -- and it does, to all of us, eventually. Socialized medicine is freedom, and private medicine just isn't.
Socialized medicine is freedom until the government is the only provider of medicine and doesn't want to serve you for some reason, such as a shortage. Medicine is scarce, like food, and we've learned that it's dangerous to have the government be the sole provider of food (see: breadlines and starvation in various Communist nations like Venezuela today).
I have a real hard time agreeing with the concept that the government should have a monopoly on any necessary item, because then the government gets an unchecked choice about who gets the good and who doesn't.
Since we're talking in this thread about employer-provided healthcare, HMOs, I fail to see how recognizing that adding bureaucracy to healthcare didn't work leads to the line of thinking that the solution is to change the bureaucracy into a government bureaucracy and expect that to work better. To me this sounds like we passed a law that caused a problem (the employer mandate) and now think that more of the same kind of law that created the problem in the first place will resolve it?
No, we need a solution that is less encumbered with red tape and public policy, not one that is more tied to politics. Socialized medicine is just HMOs dialed up to 11 and with all choice (what little remains today) removed.
I'd like to just see the employer mandate repealed. Anyway, I'm ready for my downvotes for disagreeing with the hive, but I thought I'd try to contribute to the discussion. They're only imaginary internet points.
> Socialized medicine is freedom until the government is the only provider of medicine and doesn't want to serve you for some reason, such as a shortage. Medicine is scarce, like food, and we've learned that it's dangerous to have the government be the sole provider of food (see: breadlines and starvation in various Communist nations like Venezuela today).
This is obviously total and utter nonsense. Look at every other western country. Nobody is banning you (or your employer) from buying additional private health insurance. It's simply providing a basic level of service in this arena, just like roads, army, police, fire, health and safety, etc, etc, etc.
Comparing government provided healthcare to Venezuela is a straw man.
> This is obviously total and utter nonsense. Look at every other western country. Nobody is banning you (or your employer) from buying additional private health insurance.
It is in fact illegal in Canada under federal law: private clinics are not legally allowed to provide services covered by the Canada Health Act. I'm still for it, though, and the rest of your point stands. It's just like roads, army, fire, etc.
> Comparing government provided healthcare to Venezuela is a straw man.
Please explain how socialized will pay for it. Or more accurately, why. Treatment for some things is expensive, eventually we have to say that some treatment isn't worth it. Cancer can get expensive, and some treatments cost a lot of money while only adding a few weeks to lifespan. Why should those be paid for? Note that adding a few weeks is an average measure - some people die of treatment, some get "cured" and live for a few years.
Now turn the table, you are the one with cancer. There is an expensive treatment that might or might not work, but it is the only hope left. How much is this wroth to you?
With money. It's like insurance, except paid through an extra tax.
> Or more accurately, why.
I mean, are you really asking why someone sees human life to be roughly of equal value, regardless of said human's wealth? But let's look at it differently: I don't think public healthcare precludes people from access to private treatments and additional private medical insurance. Public healthcare is just another baseline service offered by the government, which happens to remove the need for most of the people to seek that service in private sector. Like many other government services, you could view it as a formalization of helping others in need.
> There is an expensive treatment that might or might not work, but it is the only hope left. How much is this wroth to you?
Obviously, all the wealth I can command at the moment - meaning what I have, + what debt I can get into. Which is precisely why healthcare needs to be regulated, and why public healthcare is useful - private providers know that true demand price for many medical issues is essentially "all that you have", and they will try to get all that money. Inserting the government between the healthcare provider and the patient means the provider doesn't get to "negotiate" with an individual under duress.
Same way it pays for car wrecks, house fires, ships sinking, satellites lost, etc etc. The world is awash with examples of the free market correctly pricing insurance. Give people cash vouchers for insurance, ramp up the tax rate so that the rich have to pay it and then some back. Let people buy their own insurance. Do some government re-insuring for companies that get hammered with too many sick people or go under. Done.
No, see you misunderstand the free market. Their goal isn’t to make the cheapest anything, their goal is to maximize shareholder value. And when the conversation is framed “pay up or die” well the amount people are willing to pay goes up. Explain to me if the free market objective is to make the cheapest goods possible why the iPhone exists and has a 60% profit margin?
Last time I was dealing with a hospital bill, they told me not to worry because it usually doesn't get resolved until the hospital and insurance company start threatening to sue eachother about it. 8 months after the procedure, my bill was resolved.
Socialized insurance isn't just my ability to pay, it is the willingness of everyone else to pay. If you need expensive treatment and have money this is an important distinction. With multiple players you in theory have the ability to decide if you want to be in the cheap payout pool that lets you die of concern, or the more expensive pool that covers chemo that can add years of life.
Of course what we have now with employers sponsored plans is the worst of both...
This assumes that you have $100,000 to treat it. The vast majority of people couldn't come up with that kind of money or talk an institution into lending it to them.
If you do have the money you can get your own supplementary health insurance that goes above and beyond. (This is common in Canada, not sure about England though.)
This is a false dichotomy. Setting aside the fact that the vast majority of Americans can't come up with $500 let alone $100,000 in the event of an emergency, socialized programs and the public purse ensure that care is made available to those in need in spite of the fact it's expensive. In fact, they can often negotiate it down. Further, if you can come up with $100K you can easily go to a private clinic or truthfully, another country where your money would go much, much, much further.
Everything bought and sold privately is rationed based on your ability to pay, including such vital resources as food, shelter, transportation, clothing, and higher education, so why is medical care to be treated so differently? If we agree that because medical treatment must be rationed because it is a finite resources, the debate is really comes down to who decides how this rationing is done and by whom.
Is the army not a necessary item? How about fire protection? How about police protection? How about criminal courts? This is a strange place to draw the line.
I'm really surprised to see this downvoted instead of rationally argued with. What is the disagreement here? We don't have universal single payer food, clothing, housing, etc. all because we know how inefficient and disastrous those things have turned out every time they've been attempted. Why do we expect medicine, especially in a country as large and varied as the United States to be any different?
Employer sponsored health care is just one example of a government sponsored incentive, one that was supposed to help, that turned out to be a terrible idea. In fact, most of the problems we have with healthcare in the US are the result of well intentioned government interventions. Is the solution really to have more government involvement? No, not just that, an entire government takeover? Is there really confusion as to why people are nervous about this idea? Other countries that have succeeded with single payer have populations smaller than some of our cities, and near zero diversity with regard to race, religion, individual cultural upbringing, etc. How do we know it will scale up to over 300 million people with widely differing politics, religion, culture, geography, population density, etc.?
Let’s turn that question around: It scales relatively well from countries with less than 1 million to countries with more than 80 million people, with the same variations in population and geography (although to be honest I don’t understand why race or culture would make a difference to a healthcare system). So why wouldn’t it scale further? Is there some fundamental limit at 100 or 200 million that would make it impossible?
Note that as long as you keep the bureaucracy mostly at state level, the argument of scale doesn't apply to the US - seen from the state level, the US is really just 50 small countries in a federation.
Race and culture being varied shouldn't be a propblem neither should having a big population size. I think having differing regulation in each and every state is the thing that will create complications.
Just as abortions aren't outlawed federally, I think making sozalized healthcare equally available will perhaps be similarily difficult as it is to make abortion equally available.
I'm not arguing that having more things regulated federally or having a completely federally regulated America is going to be better. It seems like you think of lawmakers and lobbyists as adversarial, not necesarily untrue, but it it is hard to argue in any direction since they will always be working against you to their benefit.
I was pointing out that this is what makes America "varied" compared to other countries and it will introduce complications and variations in how a healthcare system is going to work for it's citizens if they do try to mimick Canada, UK, etc.
I would also hope that the hospitals have a bit more autonomy and they aren't hamstrung by congress deciding they aren't allowed to spend more than 5mn on sedatives or some other really narrow and specific budget.
And further you needn’t scale it beyond 30 million if you leave it to each state to build a system that meets federal minimum requirements, which is what Canada does.
I'm 100% opposed to federal health care, but would be in favor of letting the states do whatever they want. How about that?
Like you said, small countries already do this. When 2/3 of the states can agree on a system then we make it federal. This is more like what Sweden does, their counties finance and administer health care according to agreed upon federal standards.
The U.S. government has already made a huge mess out of health care- the biggest in the world it appears. I don't trust them. We've already been screwed by industry lobbyists. They need to take a back seat and let the states run with this for now. As per our constitution.
I am 100% in favor of various plans at a state level. Vermont was going to do single payer before Obamacare. That's what I want to see. States will copy successful systems, and an amendment can eventually be passed once enough states agree on a federal system.
So if one state offers free health care for all, how do they avoid the freeload problem? When I lived in Washington near the Oregon border, we Washingtonions loved shopping sales tax free in Oregon. What prevents us all from going to Vermont as soon as we get cancer and overwhelming their system?
That would seem to be a concern, but it didn't stop Massachusetts from implementing Romneycare, nor Vermont from passing a single payer system, nor NY and California making plans for the same. It was happening before the feds got involved.
Besides the fact that is how it's supposed to work in this country. The constitution doesn't give the fed the power to regulate health care. That is supposed to require an amendment, which requires something more than a 51% majority because it is a big deal.
Your argument is grounded in the idea that the US is somehow an exception to the economic behavior of other first world nations, due to size or diversity or whatever. But is that actually the case?
Counter-argument... this isn't simply a question of "capitalism" vs "socialism". There are a wide variety of models in use out there, from the mostly-socialist (Sweden) to mostly-market (Japan). What they all have in common, though, is that all of them are producing better coverage and better outcomes at lower costs than the American system. We pay twice as much as the rest of the world, for the privilege of millions going without coverage, millions more trapped in jobs they hate for the sake of health insurance, and millions of families bankrupted by medical costs outside of what their insurance (or lack of insurance) covers.
In other words, the existing American model that you're defending is uniquely bad. It's more expensive and less efficient than any other system in the industrialized world. It's not about whether we can do better. It's about whether we could possibly do any worse, at this point.
"In other words, the existing American model that you're defending"
Careful, those are fighting words! I am in no way defending the current American model. It sucks. Let's be clear here. I highly, highly doubt that anyone is arguing for status quo in America here.
I'm defending capitalism against single payer and medicare for all proposals that rely on magical thinking and trusting our government (that got us into this terrible status quo). If Japan has a mostly market-based solution then lets hear about that some more.
EDIT: "It's not about whether we can do better. It's about whether we could possibly do any worse, at this point." Yeah, that's the kind of cynicism that I'm also fighting against. "Yep, we are screwed, might as well try socialism" is not an attitude I'm inspired by.
Yes, but. Highly socialist systems are working well in other countries. Interestingly, they seem about as effective as highly capitalist systems in other countries (except, of course, for the American system). So I don't think "socialism" is the problem here, and I worry about the magical thinking of reactionary politics when I see that used as the argument against.
Medicare is, in fact, the largest single payer system in the world, and it's a large chunk of the American system. Criticizing single payer would do well to start by criticizing the current Medicare system. But that means separating it logically from the privatized employer-based insurance model, and that's a very difficult knot.
"Criticizing single payer would do well to start by criticizing the current Medicare system."
Will do.
I have spoken with doctors and they hate medicare. It doesn't pay on time, it pays below market rates, it dictates what they can do with their patients, etc. These doctors still see medicare patients out of compassion, but they are losing money on each one. Think I'm making this up? I just did a quick web search and here's a quote from someone else:
"Yet, thanks to the federal program’s low reimbursement rates, stringent rules and grueling paperwork process, many doctors are refusing to accept Medicare’s payment for services. Case in point: In 2000, nearly 80% of the Texas Medical Association’s doctors were taking new Medicare patients. By 2012, that number dropped to less than 60%.
Why are more and more doctors turning down Medicare? The answer is simple: Medicare typically pays doctors only 80% of what private health insurance pays. While a gap always existed, many physicians feel that in the past several years, Medicare reimbursements haven't kept pace with inflation (especially the costs of running a medical practice), while the rules and regulations keep getting more onerous, as do penalties for not complying with them." --https://www.investopedia.com/articles/personal-finance/10021...
So, if we all go only-medicare, how many doctors decide to retire early? <edit>How many potential doctors will decide to do something else instead?</edit> What quality of doctors and care are we left with?
> Also, criticizing socialism is not magical thinking. It's been a proven failure over and over. Yes, some tiny homogeneous countries have come together and made socialist medicine work, but I'd wager good money that that has more to do with their citizens having a general feeling of all being on the same team, avoiding freeloader problems by discouraging immigration, having larger more prosperous countries in the world to provide innovation and competition, and other factors that America is never going to be able to achieve.
If by that you mean the entire OECD then yes, some tiny homogenous countries have tried it. And it works great. Also, diversity has nothing to do with medicine.
> I have spoken with doctors and they hate medicare. It doesn't pay on time, it pays below market rates, it dictates what they can do with their patients, etc. These doctors still see medicare patients out of compassion, but they are losing money on each one.
Lowering reimbursement rates reduces costs, that's how it's supposed to work. Did you think costs just go down while people get paid the same or more? Where did you think the money was to come from? Sorry, America's costs are 2X Canada's, those doctors do need to be paid less.
> Why are more and more doctors turning down Medicare? The answer is simple: Medicare typically pays doctors only 80% of what private health insurance pays.
Great, now all programs will pay the same, much less than today. You do know doctors in Canada make $200-500K/yr right, they're not exactly starving. They don't need to make more, they're public servants.
In the US the mean salary for a doctor is just shy of $300K (range $200-663K). In Canada the mean salary $225K, ranging from $232 to $676. I think they'll manage with the pay-cut.
> So, if we all go only-medicare, how many doctors decide to retire early?
Those who scrape by on $250-500K/yr and save, then retire, like the rest of the 1%.
"Did you think costs just go down while people get paid the same or more?"
Isn't the whole argument that our system is inefficient and therefore expensive? Get rid of the inefficiency and doctors should still get paid the same, no? Again (I think we are going back and forth in different threads here), free markets are great at doing that. We should try it with health care.
There's a ton of inefficiency in the system: administrative, lack of preventative care, lack of continuity of care, that hospitals are forced to provide critical emergency care to anyone who walks in and can't afford it, cost of drugs, and yes, the amount doctors are paid, and the amount doctors have to pay for malpractice insurance (which is also socialized in Canada dramatically reducing cost).
Doctors become public servants. They should get paid relatively comparably to other first-world countries but the fact is what they're getting paid right now is unsustainable for us as a society if our goal is to cover everyone at a reasonable price -- and it should be. Preserving doctors top-0.5% pay is strictly a non-goal. Building a functioning public health system is a goal.
Yes, pure tyranny. It's not like they can get jobs in other fields. Nobody is entitled to make a certain wage in their field of choice. You're not entitled to a seven-figure salary in janitorial any more than doctors are to mid-six-figure salaries in their jobs.
"Also, criticizing socialism is not magical thinking. It's been a proven failure over and over."
That's just partisan nonsense, platitudes disguised as criticism. You need to do a lot better than that. I could come back with plenty of failure modes for capitalism as well, but I very much doubt you'd call them proof that capitalism is a "proven failure", and I wouldn't make that argument myself. There are many cases where socialism has worked well and continues to work well.
Also, criticizing socialism is not magical thinking. It's been a proven failure over and over. Yes, some tiny homogeneous countries have come together and made socialist medicine work, but I'd wager good money that that has more to do with their citizens having a general feeling of all being on the same team, avoiding freeloader problems by discouraging immigration, having larger more prosperous countries in the world to provide innovation and competition, and other factors that America is never going to be able to achieve.
It's not magical thinking, it's "I've spend too much time watching Fox thinking." Trust me, I watch Fox too. This is just partisan nonsense the rest of the world has disproven if you just took a look outside.
It’s weird because the US does have socialized food options (SNAP/food stamps), socialized housing - albeit limited (shelters, BMR housing), clothing I’m not sure. It also has socialized medicine for the old which everyone loves, but if it’s so great once you turn 65 why does it suddenly stop working when you’re 64? 60? 50? 20? It doesn’t. It works great. It controls costs better, it’s more efficient and doesn’t leave anyone out.
What's weird? That we have food stamps for those who are temporarily (at least that's how it's supposed to be) in a bind, yet not everyone uses food stamps? Why do you think that is?
Does everyone love medicare? Every doctor I've talked to hates it. It doesn't pay on time, it pays below market rates, it sometimes just doesn't pay at all, it doesn't let the doctors choose what care they think is best, etc. Doctors tell me that the rest of us are all subsidizing medicare patients right now, that if they could get away without seeing any medicare patients they would. How is that going to work out when we are all on medicare?
> What's weird? That we have food stamps for those who are temporarily (at least that's how it's supposed to be) in a bind, yet not everyone uses food stamps? Why do you think that is?
Because it's means-tested?
You're describing a two-tier health system, which many countries operating under a "socialized" model follow including Australia. That's fine, too. The government provides a safety net of basic coverage and then those who want more or whose employers want to lure them with the promise of better care can opt for private care. This would still work if Medicare were an open enrollment for anyone who wanted it.
> Does everyone love medicare? Every doctor I've talked to hates it. It doesn't pay on time, it pays below market rates, it sometimes just doesn't pay at all, it doesn't let the doctors choose what care they think is best, etc.
You can't on the one hand complain about the rising price of healthcare in the US, how it's moving further out of reach for everyone, and at the same time complain that the socialized program "pays below market rates." That's the definition of lowering costs, something the US has to do more than literally every other country in the world. That's a good thing. In fact, that's an argument for the system we're proposing.
> Doctors tell me that the rest of us are all subsidizing medicare patients right now, that if they could get away without seeing any medicare patients they would.
That's kinda hilarious. Medicare patients are the most expensive, worst customers for a medical program. They're all old, sick, dying or about to. That's facts. If the private system had to bear the burden of treating those patients their margins would implode or costs would balloon. The Medicare program as it exists right now is a huge subsidy to the private sector -- especially as it's forbidden from negotiating drug prices like any other sane system permits.
> How is that going to work out when we are all on medicare?
It's going to work fine like it does in every other country in the OECD. It's not like we're proposing something wildly outrageous and unheard of. Every other developed nation does this and has better health outcomes across the board with half the cost.
A two tier system actually sounds pretty good to me. I've mentioned in other comments that government probably should provide emergency care (like fire and police).
"You can't on the one hand complain about the rising price of healthcare in the US, how it's moving further out of reach for everyone, and at the same time complain that the socialized program 'pays below market rates.'"
I think that American people (probably more than any other country) value freedom of choice more than "cost cutting." Also, the idea of reducing costs by a government simply taking over the market really stinks of tyrannical authoritarianism in these here parts. It's distinctly un-American (like it or not).
Strangely enough, freedom of choice (i.e., increased supply along with low switching costs and price/value transparency) generally also leads to cheaper prices. I'm pretty sure that reforms in those types of areas are what would most easily get support from American people.
Yes, we could just go along with what other countries have done, but dang it, America is a leader. America champions freedom. If you want a better system (and I'm sure just about everyone in America does, I know I do) those are the things you have to sell.
> I think that American people (probably more than any other country) value freedom of choice more than "cost cutting." Also, the idea of reducing costs by a government simply taking over the market really stinks of tyrannical authoritarianism in these here parts. It's distinctly un-American (like it or not).
That's a false choice because the vast majority can't afford the choice and never will. The rest the choice of physician is made for them by their employer.
> Strangely enough, freedom of choice (i.e., increased supply along with low switching costs and price/value transparency) generally also leads to cheaper prices. I'm pretty sure that reforms in those types of areas are what would most easily get support from American people.
No, it doesn't. Not when your life is on the line. That's what the OECD and WHO data shows.
> Yes, we could just go along with what other countries have done, but dang it, America is a leader. America champions freedom. If you want a better system (and I'm sure just about everyone in America does, I know I do) those are the things you have to sell.
Not in this case. It's an abject failure here. It's the world's most expensive per capita -- by a country mile. It costs twice as much as Canada, has the same level of health outcomes, covers far fewer people. It's a bad system. America has lots of positive things but it's by no means a world leader in everything. For instance, not being obese.
Just because you're in front doesn't mean you're going in the right direction.
When there are 250M adults in the US, and 130M of them have had financial strain due to health costs, it's blatantly obvious that our highly privatized care system is falling down.
On the other hand, other first world governments adds strong government involvement in healthcare markets and average half the cost we do in the US. If you look at say the NHS in UK, it's pretty clear that government involvement results in a much smaller amount of bureaucracy from healthcare compared to the US.
The way I see it, either side's solution would be better than this mash-up of private insurance heavily encumbered by government regulations and subsidies. Single-payer would be much more efficient and cost-effective, while on the other hand, massively de-regulating the market would open it up to cost and treatment innovations.
The biggest downside to socialized care is stagnant innovation and a slow-moving bureacracy, and the major drawback to private care is unlimited catastrophic consequences for major health issues, and the fact that cost-comparison isn't possible for emergency care.
If I were decider for a day, I'd flip a coin for either option over what we have currently.
To be fair the 'cost innovation' would be 'how do we make cover yet more expensive' because private insurers have you in a bit of a bind, don't they? It's 'pay up or die.' That's the alternative you're proposing, is it not?
No, not at all. Look at Kaiser Health System and other subscriber networks, those are clear cost innovations. Also, urgent care centers, which are vastly cheaper than ERs. And CVS, Kroger minute clinics.
edit: Also, in the future, maybe we'll have AI doctors, and we're presently seeing remote health care through apps. I'm not talking specifically medical treatment technology, but so many other methods of health care which would greatly be encumbered by heavy-handed government regulations.
And yet if you walk in without money in an unregulated market, to a company whose goal is to maximize shareholder value will they (a) treat you out of the kindness of their hearts or (b) do what they always did and tell you to pay up or die? It’s like walking into an Apple store and asking for a free laptop. But you know, with your life.
Kaiser isn’t much of an innovation it’s just a scaled down model of any socialized health system. It’s exactly what Canada has but smaller.
> Using emergency services for the core of your argument is a strawman, as vastly more medical services are non-emergency or life threatening.
No, it isn't. It's the reason health insurance isn't insurance. Literally everyone will at some point come down with an emergency or life-threatening condition, and 100% of us will eventually die of one. It's not insurance if it's going to happen to you.
> Also, in the US, Kaiser is an innovation. Comparing a voluntary, private organization to a forced, tax-funded system is a false comparison.
That doesn't make it innovating. Cloning a system that works elsewhere isn't innovation. Get over the "forced tax funded" nonsense too, unless you want to relinquish all social services like education, fire, water, etc.
Believe it or not, most doctors get into the field because they truly enjoy helping people. It's interesting to me how often arguments in favor of socialism devolve into "but people are greedy, selfish, jerks." And then the solution to that is to put those greedy selfish jerks into government jobs providing the same services.
Most people are good, folks, otherwise no society is going to work!
Exactly why they would be okay with a reasonable pay cut for the public good. Because they're in it for the public good and helping people. So lets put them in a position they can help everyone who comes through the door without demanding their visa card first.
No, it would be monopsony; there would be lots of providers but just one payer. If someone suggested that we have "VA for all" I would think that was dumb, but it's not what we're talking about.
I upvoted you even though I disagree (downvoting is only for meaningless stuff). However, I think you are not getting a lot of love from the crowd because you are just complaining about how bad socialized medicine could be. But you are not offering a better solution that what we have today which clearly is pretty bad. The day we are not scared of medical bills or going to the doctor is the day I would consider that we have got something right about healthcare.
Especially - freedom to pick any doctor as they are all in-network.
Family had experience with California PCIP insurance (bridge for pre-existing condition after ACA was voted in, but before it took effect). The PCIP was amazing - PPO-like benefits, using MediCare network (close to 100% doctors take it) and quality services. Of course, unfortunately, the ACA/exchange provided policies are nowhere close to how good PCIP was.
If we could get the PCIP-like option, it would truly change lives for the better.
Any doctor? Doctors can take so many patients. Though it may benefit a large number of people, some may end up worse. Those who have the best doctors currently (because they can pay) may no longer be able to have those doctors.
First, it's unlikely that an influx of new patients due to opening networks and increasing coverage would lead to doctors dropping existing patients. On what grounds would that happen?
Second, you're at best arguing that we shouldn't go to a fair system of rationing because it would hurt the beneficiaries of an unfair system of rationing.
And to take this sideways... my favorite health care model is the Japanese system. It's actually quite similar to the American system (private employer-provided insurance, private providers), but with one key difference... a government commission fixes the prices for all medical goods and services. No more negotiating between providers and insurers. So no "networks".
It leads directly to the situation you described. It also leads to costing half as much as the US, for universal coverage and better outcomes. I'll take that trade, thank you.
> it's unlikely that an influx of new patients due to opening networks and increasing coverage would lead to doctors dropping existing patients.
It wouldn't, but if I needed to get a doctor, I might no longer be able to get a very good one.
Remember that cheaper prices for medical care means the smartest, best people may not become doctors.
> you're at best arguing that we shouldn't go to a fair system of rationing because it would hurt the beneficiaries of an unfair system of rationing.
I don't believe the current system is "unfair". Why is it? Most Americans like what they have; it is the bottom few percent who are unhappy. Is that "unfair"? At what percentage does that become the case? Must most of society change to accommodate a small, dissatisfied minority?
Without government regulation, health care would be much cheaper. Why must I purchase coverage for a hysterectomy or for birth control as part of a plan? I will never need these services. Wasted money.
What of experimental treatments? I know a person who is alive thanks to an experimental treatment that was reasonably priced. All it amounted to was an antibiotic regimen far outside the bounds of the CDC-recommended one, out-patient. The problem with single-payer is that I cannot do that, because there is a single payer - the feds. I may not pay for my own procedures (and my friend would not have been able to do so), even though this was quite affordable, because it was not on "the list".
Fixing prices is a possibility (albeit not one of which I am as fond), though we would need to allow procedures to be done out side of that (for those which were not approved, or for those who could not get availability and could pay). It is basic economics that price ceilings create shortages; who gets treatment? We are back at square one: I think it should be ordered by those who should pay. I trust dollars to be "fairer" than an opaque system, and would rather the coverage I can get be a known quantity than be at the mercy of the whims of a bureaucrat.
My biggest question: why do you want to force those who can pay onto the same plan? That is a part of single-payer that makes no sense. Why not let those who like their existing coverage keep it, as most Americans still do? [0]
There was an article that surfaced about an Indian hospital that had industrialized common health-care procedures. A four-year degree is not essential for these; why is it required? If we commoditize common and routine procedures via removal of barriers to entry, we can greatly increase the benefit without forcing those who like what they have to become worse off and without hurting more complicated situations.
Lastly, the problem with socialized medicine is that it cannot afford to spend beyond a certain amount per-person on average. End-of-life care is enormously expensive in America, but is better than in other places. [1]
Many of us may say it is foolish to spend upwards of a million dollars for a few more years of life, but having spoken to a few dying people, most say something to the effect of that they would give every thing they have for a few more weeks (the exception being those in exceptional pain, those with loss of senses, etc.).
Access to the best doctors isn't a function of how they're paid for now, unless you're saying the current system is giving them slack in their schedules by keeping patients away. Meanwhile, people are being denied access to good doctors with capacity now, because of a lack of insurance, or in-network restrictions. I've seen friends choose between life-threatening illness and bankruptcy due to networks, many times.
As for the "smartest, best" people becoming doctors... I don't think medicine is a path chosen simply because it's lucrative, in most cases. It's chosen because it's challenging (or sometimes, because it's expected). And those in it for the money are in paths of lucrative-but-socially-useless things like cosmetic surgery. High pay is incidental here.
Why pay coverage for things you'll never use? Same reason I'm paying for your broken arm. That's how insurance works. Spreading the risk.
Single payer systems - like Medicare, for example - are quite capable of covering experimental treatments. Why are you saying they can't? You're ignoring plain facts here. And it's possible that your experimental coverage might not be covered by your private insurer, either. I've been in that boat myself.
Fixed pricing is a far, far more transparent system than the current system of negotiating prices for the same things between different providers/insurers, so the same hospital charges $1.10 for aspirin here and $1.25 there. It also solves the problem of localized monopolies, such as rural hospitals, that can charge whatever they want because insurers have no alternative.
Why force people onto the same plan? Single payer doesn't do that, necessarily. Again, Medicare. There's a HUGE market for Medicare supplemental insurance (I work in that market). Wealthier people can afford additional coverage above and beyond single player. The single payer provides a guaranteed baseline, and covers basics so private insurers can focus on corner cases, extremes, and luxuries.
"End of life care is enormously expensive in America, but it is better than other places." Yeah, Medicare is single payer, right?
> Why pay coverage for things you'll never use? Same reason I'm paying for your broken arm. That's how insurance works. Spreading the risk.
Insurance is supposed to hedge against risk. You might need a broken arm; I will never need a hysterectomy or birth control (especially not the type covered by insurance).
> localized monopolies, such as rural hospitals, that can charge whatever they want because insurers have no alternative.
And if the rural hospitals then shut down due to not being able to cover costs?
> Why force people onto the same plan? Single payer doesn't do that, necessarily. Again, Medicare. There's a HUGE market for Medicare supplemental insurance
The definition of single-payer is in the name - there is a single entity which pays for insurance. A single payer. That means, definitionally, no private/supplemental insurance, no cash payments, no nothing. Experimental treatment may not be covered by private insurance, but at least it can be purchased with cash. A single-payer system definitionally precludes a cash option.
> Yeah, Medicare is single payer, right?
Wrong; see above. Medicare is also subsidized in no small part by higher-paying patients; because it often reimburses at below-market rates, private coverage is necessary to pick up the slack.
I take it, then, that you're totally ok with Medicare for All as a plan, as it's not single payer?
I'm guessing not, actually.
The point is, you're using such a narrowly defined, pedantic definition of "single payer" as to make what you're railing against a total strawman. Not even the most socialist systems in the world, (Norway, Medicare, etc) come anywhere close to your extreme.
> I take it, then, that you're totally ok with Medicare for All as a plan, as it's not single payer?
Nope. I am also not okay with Medicare, Medicaid, Obamacare, and any sort of transfer payment from the feds.
> I'm guessing not, actually.
How remarkably prescient of you.
> you're using such a narrowly defined, pedantic definition of "single payer" as to make what you're railing against a total strawman. Not even the most socialist systems in the world, (Norway, Medicare, etc) come anywhere close to your extreme.
Gee whiz, I interpreted "single-payer" as meaning there was a single payer in the medical system? What sophistry!
I believe it was Senator Harris that recently said that "Medicare for All" included abolishing all private health insurance, and this has seemed to get traction among the far left. Senator Sanders has similar ideas; he would allow a small amount of private insurance, but only in addition to mandatory enrollment in his plan.
Show me the part of the constitution where it says the government may sell health care. Show me the part that justifies transfer payments of any kind.
I proposed something of a solution above: remove the onerous regulations and allow industrialization of common procedures. This would cut out the bulk of health-care expense.
We're in a hole, financially speaking. America has about ninety-five trillion dollars in about household value; the "one percent" hold about forty percent of that. Seizing all the money they have, thirty-eight trillion dollars, would just about cover the costs of this "medicare for all" thing for a decade. What do you do then? We're spending too much, not taking too little.
> Show me the part of the constitution where it says the government may sell health care. Show me the part that justifies transfer payments of any kind.
No that's fine, you can tell grandma why she's not going to get that hip replacement or cancer treatment. It's because of your free market principals and she should have made more money when she was young. See, grammy, it says so right here in the constitution - and The Fountainhead!
If only there was a way to update or modernize or uh, what's the word, amend the constitution.
> I proposed something of a solution above: remove the onerous regulations and allow industrialization of common procedures. This would cut out the bulk of health-care expense.
Yes, it's the regulations, for sure. Like the ones that keep the air and water clean, and the rivers not-on-fire. And drugs safe. See if we just got rid of that, we'd be in great shape. You know what would make it really cheap? Let's get rid of medical licensing requirements. Now that's a money saver.
That's absurd. Even a Koch funded study showed MFA would be +/- 5% of what it costs right now, but would cover everyone, accidentally showing the unit economics to be much better. [1] You take all the money employers are currently spending on employee cover via a combination of payroll and personal taxes, direct it to the Medicare pool and enroll everyone. This isn't some sort of new wild plan. Other OECD member states do that right now.
By the way, the paper I link is the one the WSJ article cites (your link is broken) and if you read anything past the first page it clearly states that not only would everyone be covered it would cost less per capita and in total. Another study recently showed that Medicare and Medicaid do a better job of controlling costs than the private sector setting us up for success in the longer term, too. [2]
> you can tell grandma why she's not going to get that hip replacement or cancer treatment
I'll ignore the flame-bait. I honestly believe that we could reduce regulation and make the poorest better off. I referenced above an example: an Indian hospital has essentially mass-produced procedures for low cost. Things like hip replacements do not take a brilliant surgeon with eight years of medical training; I think breaking the monopoly of the AMA and lowering regulation will allow cheap procedures at prices reasonable to almost all. For those last few, I believe Churches and states ought to shoulder the responsibility. I said nothing of "no health-care", I said that the feds shouldn't do it and that single-payer is a bad solution.
> amend the constitution.
Be careful with amending our founding document to push a policy agenda. This has been rarely done in the past, because if one side does it to suit one agenda, the other will reciprocate once re-elected. Maybe the far left could get socialized medicine, but the right might repeal the 14th amendment birthright citizenship next election.
> Yes, it's the regulations, for sure. Like the ones that keep the air and water clean, and the rivers not-on-fire. And drugs safe. See if we just got rid of that, we'd be in great shape.
What did I say of environmental regulations? We have them to protect the rights of others, and they are important.
With respect to drug safety, I do believe rules could be somewhat loosened, but I also believe some regulation is necessary.
> Even a Koch funded study showed MFA would be +/- 5% of what it costs right now
This is an "alternative fact" pushed by Senator Sanders and Congresswoman Ocasio. [0]
> You take all the money employers are currently spending on employee cover via a combination of payroll and personal taxes, direct it to the Medicare pool and enroll eveyrone.
Americans are generally leery of just "taking the money", "directing it", and "enrolling everyone". That's too heavy-handed an action for the feds to take. I would appreciate a different source for your cost, as the one you mentioned was not correctly represented.
With respect to unit economics, that does not account for quality. Note that the study you cited above mentions the outrageous cost in the abstract. It also mentions that Medicare reimbursement rates are roughly 40% lower than private insurance; where will the extra money come from? That doesn't make the unit economics cheaper, that means private health insurance costs are currently subsidizing low medicare reimbursement rates. The bulk of the "cost reduction" to which you are referring (over 85% thereof) came from provider payment cuts, which assumes the current 40%-below-market rate. That's not better unit economics, that's monopolizing an industry and fixing prices. The remaining <15% came from better drug prices. I will concede that a monopsony tends to lower prices for certain things, but this is not nearly what you claimed.
> Show me the part of the constitution where it says the government may sell health care.
That's not an argument against the policy, it's an argument that if the policy is desirable it should be pursued by means which include a Constitutional Amendment.
Constitutional Amendments were not designed to directly contradict the purpose of the constitution; why would you do so if not for a blatant power grab? Why not allow states to do it for themselves? Broad-brush national solutions do not always work well. Labor costs are higher in certain places, conditions vary, etc. Why do it federally?
> Constitutional Amendments were not designed to directly contradict the purpose of the constitution
Constitutional Amendments were designed to give each generation the power to decide both the specific content and the purpose of the Constitution; which was not ever intended to be a vehicle by which the long dead dictate the form of government to the living.
Not, of course, that national health insurance costs the original purpose of the Constitution, which is laid out in the preamble, however much one might argue it violates the details of the design.
> Why not allow states to do it for themselves? Broad-brush national solutions do not always work well.
Why not do it nationally? Isolated local solutions do not always work well.
> Labor costs are higher in certain places, conditions vary, etc. Why do it federally? My
National programs can, and do, account for local variations of the type you describe, and state-level programs aren't immune to having to deal with them, anyway.
Would you please stop using HN for ideological battle and flamewar? You've been doing it a lot, and we ban accounts that do this. We have to, because it has the effect on curiosity that salt has on a slug, and curiosity is what this site exists for.
> Insurance is supposed to hedge against risk. You might need a broken arm; I will never need a hysterectomy or birth control (especially not the type covered by insurance).
Hedge against group risk. Why should I pay for your house burning down because it started on your deck? I don't have a deck. That's a terrible way of looking at it. The bigger the group/risk pool, the cheaper it is for everyone.
> And if the rural hospitals then shut down due to not being able to cover costs?
Sorry, that's not how socialized programs work. If there's particular need in communities they receive more funding. Or, the government flies people to nearby communities to seek treatment (see Northern Canada, Svalbard, etc).
> The definition of single-payer is in the name - there is a single entity which pays for insurance. A single payer. That means, definitionally, no private/supplemental insurance, no cash payments, no nothing. Experimental treatment may not be covered by private insurance, but at least it can be purchased with cash. A single-payer system definitionally precludes a cash option.
That's fine. Two tier is also fine. What's not fine is the status quo.
> Wrong; see above. Medicare is also subsidized in no small part by higher-paying patients; because it often reimburses at below-market rates, private coverage is necessary to pick up the slack.
Medicare subsidizes the private market by taking literally all the worst customers out of the risk pool. You've got this completely backwards. Without Medicare private cover would be astronomically expensive or have no margin.
If the US goes "single payer" aka "paid through taxes" I'm retiring at whatever age I am when that goes into effect. I would have enough money to retire early except I can't estimate future health care expenses.
I tried to downshift in 2017 but ended up having a $1400/mo health ins. payment for my family and me and that was more than my mortgage, which was about $650/mo. At least with the mortgage you know your future costs. I have since paid off the mortgage, so if we stay put, I have only property taxes to worry about.
Now, the last question is: What will taxpayers bearing the cost of everyone'se healthcare do to my taxes? The US is $21 Trillion in the hole and counting. I won't be paying much income tax, only taxes on capital gains and dividends.
My only other concern is that food prices keep rising like crazy, so do things like car insurance, homeowners' insurance, bills, etc.
I don't like private health ins--I work at a major provider and I know full well how billions get wasted. However, I think government taking it over is going to be the worst thing the US has seen since probably the Civil War. I'm certainly not paying for it all, you can go figure it out for yourselves.
> If the US goes "single payer" aka "paid through taxes" I'm retiring at whatever age I am when that goes into effect. I would have enough money to retire early except I can't estimate future health care expenses.
Do it! We've got more people than jobs necessary anyways, certainly once automation enters full swing.
> I tried to downshift in 2017 but ended up having a $1400/mo health ins. payment for my family and me and that was more than my mortgage, which was about $650/mo. At least with the mortgage you know your future costs.
This sounds like single payer will provide you with freedom.
> Now, the last question is: What will taxpayers bearing the cost of everyone's healthcare do to my taxes? The US is $21 Trillion in the hole and counting. I won't be paying much income tax, only taxes on capital gains and dividends.
Even a Koch funded study found that the cost of providing cover is +/- 5%-ish the amount we're spending on medical cover right now, and other studies have shown Medicare does a better job of controlling costs than private insurers. The way the system would be executed is that the amount employers are currently paying private insurers would be redirected to the public purse, either via payroll tax or via personal income tax, or both. No new money needs to suddenly appear from thin air, it's just getting re-allocated.
You won't be paying much income tax, others will. Dividends are usually treated as ordinary income, FWIW.
> I don't like private health ins--I work at a major provider and I know full well how billions get wasted. However, I think government taking it over is going to be the worst thing the US has seen since probably the Civil War. I'm certainly not paying for it all, you can go figure it out for yourselves.
And yet you were planning to go on Medicare right? People in America seem to like Medicare. Why is it socialized medicine only becomes "good" once you hit 65? It's like parents trying to explain alcohol to children: It's really really bad until you turn 21 then suddenly its really really good.
Here's the Koch study btw: https://www.mercatus.org/system/files/blahous-costs-medicare... and if you read anything past the first page the study is a fairly scathing indictment of the current system, indicating not only would everyone be covered but it would actually likely lead to a net decrease in spending.
Common misconception. Medicaid kicks in when you’re down on your luck but they’ll try and recover their costs by taking a lien against your house. It’s the ultimate cruelty.
A multi-hundred thousand dollar lien for someone who's already too low income to afford medical insurance? Where exactly do you think they'll get the money from?
And if they recover? You know in every other country in the OECD if you get sick, you go to the hospital, then they cure you and you walk out. That’s it! No liens, no debt, no bankruptcy. If you give it a chance you might just like it and if not, you can always go back.
I don't think it is entirely unreasonable that medicaid - a medical program for poor people - has the right to put a lien on someone's estate. Normally people on medicaid don't even have estates (or else they wouldn't meet the asset test), but for some reason we don't count house equity for the asset qualification criteria. Very unfair for renters - this at least somewhat equalizes things.
> Do all other OECD countries cover nursing homes for free until death? That's the case when liens apply - not hospitalization.
The NHS in the UK does, yeah [1]. In Ontario, end-of-life care is also provided and long-term care is provided for ~$1800CAD per month if you can afford it, and it may be free if not via a combination of CPP, social security and income-based subsidies. [2] In 2002, France introduced universal, income-adjusted, public long-term care coverage for adults 60 and older [3]. The Netherlands does too [4]. The rest of the OECD I'm not sure. Most developed systems do offer something.
The health system really is better pretty much everywhere else in the OECD. And remember! Every one of the systems I mentioned spends less per capita than the US. In some cases like Canada half.
> I don't think it is entirely unreasonable that medicaid - a medical program for poor people - has the right to put a lien on someone's estate. Normally people on medicaid don't even have estates (or else they wouldn't meet the asset test), but for some reason we don't count house equity for the asset qualification criteria. Very unfair for renters - this at least somewhat equalizes things.
While I don't believe in inter-generational wealth I'd argue this furthers the cycle of debt and poverty by taking an estate away from those who could most benefit - the poorest.
I've personally been trying to push this for years. About how much freedom would be had if we weren't basically in slavery to our job-granted insurance. I've found the right-wing people in my family don't like to hear it...
They are so focused on helping those without they forget the powerful argument that small business has to do part time shennanigans to avoid paying healthcare costs
As a liberal, this sort of thing drives me nuts. It's like my side has completely ceded the ground of both economic liberty and economic opportunity to conservatives, because neoliberalism has made "capitalism" such a dirty word on the left. As liberals, we should own the conversation about small business. Sigh.
Being trapped as the vassal of a giant corporation just to not-die is in direct opposition to the very concept of liberty. Being able to quit your job and create your own business is an essential freedom. But liberal politicians are unwilling to market that way, and so the neoliberal political class gets to argue for the preservation of a system that benefits the wealthy and the corporate at the expense of the liberty (and wallets!) of ordinary people as the "free market". Feh.
I'm amazed that no one the liberal side of single payer has made this argument: single payer would help create more small businesses.
This argument has in fact been made by a great many liberals and moderates, many times, going back to Clinton's (failed) attempt to pass a single-payer health system.
How about someone on the conservative, rah rah free-markets will solve all our problems, side? Oh yeah, they're getting campaign contributions from big business.
Anecdotally I know people who were running a small business and moved to Canada partially because how much of their revenue was going towards insurance. I think they pay more in taxes now but it still is a lot less than they were paying in insurance.
> But Canada lets business owners do a lot of income splitting with family members across different share classes. Particularly if you have children >18.
Thankfully, they're finally closing the loophole. Many doctors with private practices were reducing their tax burdens significantly by stating that their 14 year children were "medical receptionists". It's ridiculous to grant further tax avoidance loopholes to the already wealthy.
And big corporations are getting a discount on health insurance due to the volume of employees. Tell me why I can't find 100 more relatively healthy people and have our own "insurance" where we pitch into a account and do payouts. Oh yeah, the high barrier of entry these insuracne companies created and we would have to pay the Obamacare penalty for "not having insurance."
Yes fresh faced 20 somethings that all look, act the same who have this weird problem almost sick obsession with (EQ). Being a nice person who is a hard worker no longer good enough in today's New economy. I am over 40,unemployable because I needed to take some time off. Self studying front and back end development, having an accounting degree means nothing because I am an introvert and act nervous etc.. So don't interview well
That tax penalty no longer exists. I'd also like to point out that when it did exist, it was less than one month of my current un-subsidized insurance premium.
You might want a bigger pool. I'm 40 and was healthy until October when I was diagnosed with head and neck cancer. That was treated and two months after my last radiation/chemo treatment they did another PET scan only to find that the cancer has spread to my liver. I just finished up radiation for my liver a few weeks ago and on Thursday start immunotherapy. As far as I know immunotherapy is a ongoing thing for the rest of my life and it isn't cheap.
I stopped counting when my medical bills hit $750,000. It is probably double that by now. Again, normal healthy 40 year old guy that rode his bike everywhere who woke up one day with a sore throat that ended up never going away.
Canada has been taking Automotive sector jobs from U.S. workers. Detroit has seen a real cost savings by not covering health care for their Canadian workers.
US employers also seem to have a strong preference for young single employees - my theory is that this is because older employees with families are much more expensive to employ due to insurance.
Plus you get people are less interested in “work life balance”, and generally don’t have as high of salary expectations.
I’ve been involved in hiring decisions where HR brought up the healthcare costs to complain, then stated clearly we can’t use that as a criteria for hiring.
I have doubts that human brains can separate out that kind of statement from our actions.
Yes under 30 white with great social skills also known as good fit. Come to the Boston area, everyone looks the same and self segregates based on race outside of the office
This is true only if the company's health insurance is group-rated rather than community-rated. Large employers who self-insure (the employer is actually paying the claims; the insurance company is just providing administration and financing) have premiums set based on the cost of caring for their group of employees and will see their costs go up (and their employees' premiums likely go up too) if their employees are collectively sicker.
Under the ACA, small businesses all end up lumped together in the same state-wide risk pool, so if my small business hires old or sick people it's very unlikely to affect our premiums. In most places this risk pool is larger and somewhat less morbid than the individual market.
I'm not sure how health insurance is different than any other benefit a job offers when analyzing market efficiency.
It's not hard to put a dollar amount on the value of employer provided health insurance, and then use that when calculating your total compensation at one job versus another. Functionally I don't see how it's any different than your employer paying you the amount you would need to buy insurance.
Could you expand on what makes health insurance special in this regard?
Under the current system, you can't get the same insurance costs vs benefits as an individual or small business, even through the Obamacare exchanges, that you can get from a large, stable employer that has leverage to negotiate with insurance companies and health providers. In turn, that is an incredible amount of leverage that big employers have over certain employees who need to be part of a shared insurance negotiating pool. This is obviously not as relevant when comparing jobs at Google, Apple, or Microsoft, who all have equivalent health benefits, but it definitely matters when considering jobs at startups, nonprofits, or for being self-employed.
Is there solid data out here that this is true? My COBRA premiums last year were quoted at a bit over $1700; a Gold PPO (a slightly better plan) on Covered CA goes for $1900. This is in the range of "not that different".
What is a bit annoying for start-up founders is that health insurance premiums are only tax deductible/paid with pre-tax money if the plan is offered by your employer (may be you).
> it arguably makes the general job market less efficient
I didn't understand this until I started my own business. I was desperately trying to find a job during the '08 crash to get health insurance for my family but was unable to find one.
As a last resort I started my own consultancy which turned out to be a fantastic opportunity.
Self paying for health care was a massive barrier to starting my own business.
Once I hired people health care benefits were frequently top of their list in interview questions.
Not arguably, it definitely makes the "free market" for labor less free when workers have to think about possible gaps in coverage before changing jobs. And prior to Obamacare the first year(s) of self-employment were a huge risk.
Compared to what? Nationalized insurance? Nationalized insurance plus inclusion of private clinics?
I would argue the lack of transparency in the marketplace and the inability for anyone to make an informed choice of hospitals or what it will cost them (the linked article seems to indicate the consumer has a choice to go to a "nice" hospital or a "not so nice" hospital, but most times we don't have the choice when we need care - it's close to our home. The times we do have the choice (sometimes for birth, cancer treatment, etc) is where you see hospitals investing heavily to get high margin services from consumers.
Does Employer-provided care make medical care unfair? One could argue that employer-provided care with the tax incentive might lead to better resources for an employed person electing that care, but any time money is involved you will likely get better care. EDIT: More succinctly - There will always be some inequality / unfairness in care because there will always be inequality of wealth. I'm not sure explicitly here that employer-provided is the problem or that any subsidized care will create this kind of inequality.
I'm not sure you can argue effectively that granting the same medical care to all as a matter of law will fly because people will always find a way to get better care if they can afford it. Does employer-provided do this at a larger scale? Maybe?
The best way to ensure fairness and efficiency is to get the data out there and available, and make healthcare more like a market instead of a black box.
> I don't think you can argue effectively that granting the same medical care to all as a matter of law will fly. People will always find a way to get better care if they can afford it.
I’m not sure anyone is arguing that. In almost any country with single payer health care you’ll also find a thriving market in private health care, but they’re typically competing on things like providing private rooms and maybe a shorter waiting list rather than whether you get to live or die.
According to a 2009 study, 45000 people die annually due to lack of health insurance in the US[1]. Due to the ACA there are now more people who are insured but it's still a massive segment of the US population (not to mention that healthcare plans have been covering less and less over time).
The number of people who die due to lack of healthcare is ZERO for countries that have universal healthcare.
My point was that the hospitals don't turn you away if you are in need of urgent care. That statistic is looking at patients who avoided regular healthcare due to lack of insurance. Which is a problem.
And if we're looking at that, you have to look at the other side of the coin. Socialized healthcare systems have much larger wait times and you can find deaths attributed to those, so it's disingenuous to say ZERO people died in countries that have universal healthcare.
More research needs to be done before enforcing such a system on a wide scale in America. There has been data suggesting deaths and suffering related from long wait times in Canada. Then you have the increase of Canadians coming to America to escape the wait times. As well what we've seen with VA and ObamaCare wait times.
> 25,456 and 63,090 Canadian women may have died as a result of increased wait times between 1993 and 2009
Basically you trade the fear of going into debt and not getting healthcare vs wanting to get healthcare and not being allowed to for an arbitrary amount of time. There are more pros and cons to each system, but my point is that socialized healthcare systems has it's fault and certainly does cause deaths in some instances.
> 19.8 weeks between referral from a general practitioner and receipt of treatment
> across the 10 provinces, the total number of procedures for which people are waiting in 2018 is 1,082,541
> Socialized healthcare systems have much larger wait times.
That's because in the US, a very large proportion of people go to the ER instead of the normal in-patient process that universal healthcare countries use for non-emergency problems. US hospitals have very long waiting times for ER for this reason. Here in Australia, I've needed to go to the ER before and there wasn't a waiting time (though obviously this depends on the time of day and what hospital you go to).
This is all due to lack of funding and staffing for hospitals, not for any other reason.
> More research needs to be done before enforcing such a system on a wide scale in America.
I'm pretty sure the existence of this system across the developed world is sufficient research to show that it works. Even with these worries you have, the healthcare system would be orders of magnitude better than what you have now.
>The number of people who die due to lack of healthcare is ZERO for countries that have universal healthcare.
The design of any health care system needs to acknowledge the fact that people are going to get sick and die even with an unlimited budget, and there is not an unlimited budget.
We can't all get billionaire treatment for our ailments, no matter what system we have in place. We should be adults and accept that
In universal healthcare systems, the government negotiates prices of treatments and drugs -- so there are very few treatments that cost so much that you can't be covered by public (or private) insurance.
Obviously people will still get sick and die, that's unfortunately part of the human condition. But I reject the argument that life-saving treatments being impossible to afford by ordinary people is something we should accept.
I didn't mean to make the case that we should forget about the whole thing because we're all going to die anyways.
It's just that in this whole debate it seems we never have the honest discussion about how to deploy limited resources - i.e. how to ration care under a socialized system, or how to subsidize care under a free market system.
I believe that if we discussed it from this perspective perhaps the two sides of this debate could find some common ground.
That is a conversation worth having, though I hasten to note that the "limited resources" discussion (assuming you're talking about money) only ever turns up when talking about progressive policies such as universal healthcare or free college.
It's curious that nobody ever complains about limited resources when discussing increasing the military budget or "corporate welfare" through tax breaks and bank bail-outs. It leads me to wonder whether it's actually a significant problem in the first place or if it's just another talking point (there is quite a bit of evidence that deficit-spending is not necessarily a bad thing in-of-itself, what matters is what that money is being spent on).
Or you put off getting care because you don't want to spend a four-figure sum only to find out it's a problem that will resolve itself. I know people, with insurance and without, that have done just that.
It's definitely live or die in America. If you need a stem cell transplant to avoid dying from leukemia, they won't do it unless you can afford the medications you will need after the transplant, which almost no one can afford without insurance.
Agreed. I guess my point, more succinctly is that this will always be the case, regardless of from whom folks obtain their insurance. A better question might be "does employment-based insurance make medical care MORE or VERY inefficient / unfair".
>The best way to ensure fairness and efficiency is to get the data out there and available, and make healthcare more like a market instead of a black box.
Markets without perfect information are neither efficient or fair; I think it's reasonable to say that no healthcare market can have anything approximately resembling perfect information.
Also the idea of efficiency in healthcare is problematic. Does efficient healthcare means refusing care to old people and to people who need heroic interventions and instead focusing care only on interventions that provide a high return of healthy productive years per $?
I would like a clear articulation of efficient and fair in this context.
If I could choose which hospital to go to based on available data, pricing, luxury levels, outcomes, etc so that I understood the costs I would incur (at a high level) to get that care, and then get quotes from different places, I think that would go a long way to ensuring at a minimum that folks understood what they were getting, rather than being forced toward outcomes due to lack of information.
As for "efficient" and "fair" I would also be interested in a better definition there, one the article didn't quite provide to my satisfaction based on its question.
No market has perfect information, but many still work pretty well. Just knowing what a healthcare service would cost before you get it would be a huge improvement in the US. And how about requiring providers to charge everyone the same price for the same service, instead of radically higher prices for the uninsured.
The fact that the rest of the developed world has universal healthcare (in one form or another) and most have better health outcomes and overall public health than the US tells me that your theory is flawed.
It should be noted that the Bernie Sanders proposal actually does allow for supplemental private insurance (for elective surgeries, or shorter waiting times). Most countries with universal healthcare have a private insurance industry, it's just that you get a basic level of care from government-provided free insurance.
My theory is that no matter what there will be things that are unfair or inequal in healthcare any time folks have more resources than others to apply to treatment. I agree with you that based on overall spending and outcomes something needs to change a great deal. I admit that even after reading the original article I don't really understand why employer-provided care is creating these asymmetries except to say that typically employer provided care is more reasonably priced to the employee than comparable coverages to a private citizen, because of course it is. It's an incentive.
Look at Foucault's book "Birth of the Clinic" to see why the wealthy need less wealthy people to get health care to drive the volume that makes possible the services that the wealthy can afford.
For instance, if you were a billionaire maybe $1,000,000 for a coronary artery bypass operation would seem like a good deal.
Doing those operations in volume lowers the cost but it also makes it possible for doctors to get experience that makes the operations safe and effective. Studies have shown that the main factor for survival in CABG surgery is how many operations are done a year by the doctor and the clinic.
Similarly, you have to treat thousands of people to prove a drug is safe and effective. You just couldn't have advanced treatments for the ultra-rich without these treatments being developed and tested on a large volume of less wealthy people.
The U.S. healthcare system encourages the average person to
spend a lot more on health care than they would otherwise.
If it wasn't for health insurance (private or public), very few people could shell out for $250,000 worth of cancer treatment at end of life. Either they would go without, or the market price would be less.
I'm specifically interested in whether universal healthcare improves the quality of healthcare for everyone through this increased experience effect. I don't see the connection with what you're saying.
There is a difference between employment-based insurance and employer-based insurance. One is guaranteed by being employed the other is tied to a given company.
The bigger issue though is the impact on free market prices as the free market requires competition, but employer group plans force everyone into whoever their employer has chosen - and the employer cost selection is different from that of the employee.
It also drastically impacts the ability for people to create new businesses as getting the required standalone health insurance is exceedingly expensive - again because individual insurance purchasers are not the primary customers of health insurance companies.
At least Obamacare/ACA meant that insurance companies couldn't deny on the basis of pre-existing conditions.
I used to have a coworker that claimed all that was needed was to raise the maximum income for medicare and that would magically solved healthcare. Ignoring entirely that private health insurance companies could choose to deny coverage. My (now) wife literally was unable to get insurance - she was deny by literally every insurance company in CA because she had donated a kidney, and it turns out having a single kidney is a preexisting condition. This was despite her donating a kidney saving an insurance company money.
Yes. It disrupts market forces that may exist. As employee you have pretty much no choice and the incentives for employees and employees are totally different.
You do have a choice of the plan as an employee usually.
And the employer made the choice on the best provider they could get at the best wholesale price.
The employer is incentivized to get the best provider for the best price to attract employees.
Employers shop for insurance, employees shop for jobs with the perks they want (pay, insurance coverage, etc).
EDIT: you're usually given a packet before accepting a job that goes over their healthcare plans. At least in the two instances I have been in the job market, I was.
And it's good for the employer to pick a plan that has the best coverage for the best value because they want to attract employees to them over their competitor.
It is crazy that people who get their insurance from an employer get a tax break (indirectly), while those that purchase it on the individual market do not. Also, it messes up the risk pool: more affluent people who get their insurance from work are bound to be more healthier than the poor schlubs who are not affluent enough to get insurance from their job. As an insurance company, I could get away with charging group plans much less than individual plans.
Switzerland, which is basically where the heritage foundation copied what would become RomneyCare/ObamaCare from, does not allow for group plans. You simply don't get your insurance from work, everyone is shoved into the same individual plan market (with some weird probably overthought exceptions, like Post docs....). This very important aspect is missing from the ACA, but would be impossible to remove politically, full on universal healthcare is much more likely.
Something else I don't quite understand is why plans have drastically higher rates between tiny private-company and ACA bought. Lost my job at a small company, only three people with insurance, and wanted to purchase the same silver-level insurance through the ACA. I could've, for over 3x the total payment for the private plan. Even the lowest-level catastrophic was still $100 more than the total cost of the silver plan.
Then there was the dental. Same plan, same dental insurer... but hey guess who gets a 6-month waiting period on that filing?
Sadly there's a lockup period for most work besides standard cleanings within the first 90-180 days with a lot of providers. Mine had a 1 year hold on fillings and crown repair etc. Even then they only covered part of it at that.
I also have the highest plan available from the Provider (employer paid in full) with a nominal annual deductible for the whole plan. Understanding what's covered and not, how much etc. is tough. Planning your dental care involves the Dentists looking at Timelines and fitting procedures around timelines more than priority simply because of the billing issues noted above.
Not waiting for the dentist, waiting for the coverage. With a new dental plan, if you didn’t have dental before, you can get cleanings but not other work covered for the first 6 months.
Otherwise since most dental work is not an emergency, you would pay for one month of dental insurance in a year you had any work needed, and pay out of pocket for cleanings.
If you had prior coverage and are just switching plans because of employment changes, then I believe the waiting period is waived.
We used to have the same thing with “pre-existing conditions” in health care. You needed “prior credible coverage” to be able to get treatment for an existing condition in the first 6 months of a plan. Again, it’s to prevent people from only buying insurance after they get sick.
I interpret what seanmcdirmid wrote to mean it’s messed up that healthy (and usually economically productive) people can sequester themselves in groups that have lower health insurance premiums.
I don't fully understand. Are you saying that in Switzerland it is illegal to have a group plan?
This is something I felt would actually help the US move off of Employer based insurance for a while now.
If every person is charged the same amount for insurance regardless of being in a group then we can more easily break from employer based insurance. Especially when I can see X job offers me 100,000 but pays 500 a month for insurance. And Y job offers me 110,000 but pays 0 a month for insurance. I can do the math on which one is better if both plans are the same.
Anyway I'd love for the US to ban group plans completely. In the digital age it should be easy enough to administer a large plan with individuals instead of a group plan. I can see why after WW2 a group plan might have been better to administer, but I think at least most of those benefits no longer exist.
> Are you saying that in Switzerland it is illegal to have a group plan?
Yes, group plans are not allowed. All residents are in the same risk pool. Also, all health insurance premiums are paid post tax (unless you are poor and get a subsidy).
Employers themselves can only offer accident insurance.
I love it. That's a practical way to force a more egalitarian system (Single payer or not) while not removing insurance companies in the mean time. Thanks for sharing.
Given the fact that Switzerland is second in ppp adjusted health care costs (after the US, of course), I'm not sure modeling a system after the Swiss one is necessarily the best approach.
The link is for 2016, but iirc the 2017 trends are similar. Haven't seen 2018 numbers yet.
Being the second most expensive still puts them way ahead of the USA. Also, Switzerland is a very rich country, they do get better results for the money they put into it (as measured by life expectancies).
The insurance industry is what makes medical care unfair and inefficient. So long as we allow health care to be a rentier cash cow nothing is going to fix this. Not the “free market” and not sticking government with the bill.
If you think about it, insurance is there to protect you when something unlikely nonetheless occurs. Having your house broken into, your car stops functioning, or as in this case, getting ill.
So for the user (as opposed to the insurance company), the value of the insurance is not to on average be covered. The point is to always be ok if you get ill.
Where I'm getting at is that employment is a thing that isn't always a given. You're going to be between jobs at some point in your life, and you don't want a potential huge bill to wipe you out financially. Even if it is just for a short period, it ought to worry you that you aren't covered.
I get the feeling most of the debate just glosses over this with the average case, which is that most people are going to be just fine not being covered for a few months.
>You're going to be between jobs at some point in your life, and you don't want a potential huge bill to wipe you out financially. Even if it is just for a short period, it ought to worry you that you aren't covered.
Anyone who loses health insurance coverage due to losing their job has the option to buy COBRA within 60 days of losing their health insurance. If they do buy COBRA, it is retroactive to the day they lost their health insurance. So you really do not need to be worried about being wiped out (unless the cost of COBRA would wipe you out) as long as you get a different job within 2 months.
I've been in this situation and bought COBRA. It was a mistake. It's not nearly as good a deal as it sounds like. It's really expensive! It was double what I pay as an individual.
Sure, it probably had some additional benefits that my basic plan doesn't, because my employer got the extra super gold plus plan, but if you're only buying it for a few months to avoid being wiped out in case the worst happens, then you probably don't care about that.
My recommendation is to never buy COBRA, unless there is a specific element of the plan that you need, and you have a short timeline to getting a new full-time job with comparable coverage. Otherwise, it's just hundreds of dollars extra you're spending, for features you don't need, right at the time when money is tightest.
This thread began with the statement that insurance is "to protect you when something unlikely nonetheless occurs", like getting ill.
Obviously, if a person already has some condition, then they're buying health insurance for a very different purpose, and none of this applies to them.
>but if you're only buying it for a few months to avoid being wiped out in case the worst happens, then you probably don't care about that.
Right, as I said though, the coverage is retroactive to the day you lost your health insurance. So if you have a heart attack a month and a half after losing your job, you can buy COBRA after having the heart attack, and you won't have to pay for the heart attack.
That's a good point. The optimal strategy, not knowing the future but assuming the most likely outcome is for nothing terrible to occur, is to buy no insurance for just under 2 months, and then buy COBRA (if something occurred and you need to retroactively cover it), or then buy an individual plan (to have basic coverage going forward).
Not sure who is down voting you or why. Maybe because you (gasp) gave a recommendation on health insurance. Although I do not want to recommend anything to anyone, I will say that I DEEPLY REGRET the COBRA that I paid for and sincerely hope that folks will strongly consider that insurance != health.
I don't understand what you are saying. COBRA is not a different, more expensive type of insurance. It's a law that allows you to extend the insurance plan you received through your employer for 18+ months after your employment is terminated. However, you need to pay the full amount (the premium you paid before, plus what the employer had been contributing on your behalf) plus a 2% fee.
Get a different job or start paying for COBRA insurance.
COBRA coverage is 18-36 months, depending on circumstances.
Only long-term unemployment (or having no savings, which is of course a bug deal) prevents health insurance coverage after employment.
Agreed -- with the proviso that unemployment of various sorts isn't always a short-term condition. I've been working a lot recently, but I still don't have a regular "job" (which would provide me with health insurance benefits). Paying for my own insurance is really expensive.
The premiums are also increasing much faster than cost-of-living or inflation, too, even though the benefits are unchanged. It's like the insurance companies are trying to price individuals out of self-employment.
This is another instance of a common case: it's really expensive to be poor! Tying insurance to employment is a "hit 'em while they're down" situation.
Insurance is annoying, but Physicians and healthcare workers have a legal license that drives up costs.
Do we need a 200k/yr gatekeeper to basic antibiotics? Or would an experienced nurse be able to figure out the difference between bacterial and viral?
Do we need a nurse cleaning patients? Or is that a job for unskilled labor?
Government licencing has gone too far, and has created artificially low supplies of health insurance workers. This was driven by incumbent healthcare workers.
Sure charge $300 for a basic office visit with a $50 appointment setting fee if you are a cash paying patient and make sure the front desk person is as snarky and rude as possible toward people without commercial insurance
Experienced nurses already prescribe drugs for people. Walk into a random retail clinic and you will most likely be seeing a nurse, not a doctor. My PCP is not an MD. She has the legal authority to prescribe me any drug she wants, including highly controlled substances.
> Or would an experienced nurse be able to figure out the difference between bacterial and viral?
Pfft. Doctors will give out antibiotics to treat viral infections just to shut people up. E.g. somebody goes to the doctor for the flu and demands antibiotics.
I read somewhere once that showed that doctors generally can't tell one from the other, either. Im not a medical professional and I have no idea how easy or hard it is to tell, but they can't.
I went to a Dermatologist who looks for weird spots then cuts them off to send to lab. I'm pretty certain they dont need 10 years of training. $300 for a 5 minute job.
Yes it's a vicious circle. If you have any type of illness mental illness and have poor work history or worse currently unemployed then it is tough to impossible to find a full time job with insurance. I am 43 essentially unemployable due to a poor work history, on mass health which is second class coverage. The newest and better anti depressants are not covered so I continue on Prozac, Lexapro which make me unmotivated and indifferent.
I generally agree with the article’s point, but this:
> the contribution made by employers to the premium is exempt from the employees’ taxable income. This exemption cost the US Treasury an estimated $300 billion in 2018.
is just very disingenuous. Does the lack of an air or sunshine tax also cost them money?
There is a huge amount of age discrimination. If you are over 40 especially in most STEM fields, you may accounting especially. Most of the 'auditors' at the Big 4 look like they are just out of school (college).
For a full time middle class white collar job that provides health insurance,Employers want people under 40, white and have no gaps in employment.
Yup, am mid-40s and already tech employment is a crapshoot in a lot of ways. Not that the jobs are worth working at other than the pay being good. The expectations have gone through the roof.
"Oh, we pay you an inflation-adjusted equivalent of 1980s $50K a year so you should be absolutely devoted to us."
In 1985, making $50k would make you one of the highest paid engineers in the country. Now it's a much more common pay range. Is your issue that pay hasn't outpaced inflation at a high enough rate?
The thing about employer-funded healthcare after WWII is that for a few decades, that health care was restricted to the Blue Cross/Blueso Shield monopoly [1], which functioned as a semi-socialized monopolies in the sense that network members would take anyone and prices were somewhat controlled.
This situation gradually broke down in the 1970s and 80s as other insurance companies entered the health care field and offered insurance to only the healthiest individuals. Eventually, Blue Cross' nonprofit status was revoked and insurance became a free-for-all (where those with existing conditions were effectively thrown under the bus).
People don't realize that a lot of American industry in 1960s and 70s was "regulated monopolies" (Health care, airlines, trucking, telephone, etc). These provide a lot of the benefits that social democracy provides in Europe but was less obviously "socialized".
And similarly, the huge sea change that happened with Reagan breaking regulated industries wasn't and isn't noticed as the huge change that it was (and it is still reverberating through this society).
The thing is, health care is "natural monopoly", it's a situation where competition is meaningless at the point when a person shows up bleed at the emergency room. The process of "opening health care for competition" from the 1970s onward grew a hundred poisonous rent-seeks in every part of supply chain, from medical equipment operators to hospitals to insurance companies. Blaming just insurance companies is a bit misguided after all this. Certainly they play a part but the basic structure of private health care just naturally goes this way unless it either seriously regulated or nationalized.
"The thing is, health care is 'natural monopoly', it's a situation where competition is meaningless at the point when a person shows up bleed at the emergency room."
This is a bit of a false narrative. 99% of healthcare is not emergency room, imminent bleeding out. I believe we should have government provided true emergency care for everyone (just like we have fire and police, right?), but for non-emergency stuff (which is most of healthcare), people do have time to shop around and find the best deal for them. The best deal might involve joining a health club like Aetna or Kaiser (these are not insurance, by the way), or it might be saving your money in a bank and paying for stuff piece by piece by yourself, just like we do for just about everything else we need to survive in this world.
Supply and demand should take care of this though. A lifetime supply of food is pretty reasonable these days. A lifetime supply of common medications should be about the same, right? Too much regulation restricts supply and too much health care bureaucracy screws up demand.
Of course people should still have insurance (possibly government provided?) for the very rare and expensive surprises (just like a house fire is rare and expensive).
Much easier for consumers to control food spending than drug spending. Lots of cheap food to choose from. Many chronic illnesses require medications for which there is no good substitute. Too much regulation is not responsible for high drug prices, deregulation is. Companies are allowed to buy their competitors and then raise prices.
> Too much regulation is not responsible for high drug prices, deregulation is
> regulatory capture, intellectual property
Ostensibly would seem that relaxing regulation and (more importantly) abolishing or heavily weakening medical patents would help drive down costs.
Can you imagine if tech companies could patent their products the same way medical companies do today? Uber would no longer have to worry about finding a moat, their moat would simply be their patent on "digital ride sharing provided by dynamic pricing to predict demand and position supply" (or some similar conceit). Smartphones would all be expensive and Apple would have a monopoly on multi-touch phones with capacitive displays and built-in app-stores.
If food companies could patent food the same way drug companies can patent drugs that they prepare, bread would be expensive and you wouldn't have store brands and generics to keep the price of the fancy Whole Foods bread in check.
This is a bit of a false narrative. 99% of healthcare is not emergency room, imminent bleeding out.
Fine, it is a "dramatic illustration" but for even ordinary, ongoing medicine, the average consumer isn't in a position to evaluate the choices involved, there a natural advantage whatever health care provider is in the area, necessary regulation create severe barriers to entry and so-forth.
Yes, the situation we have now sucks. But that's where we should start questioning. Is all the regulation we have necessary? Why aren't average consumers in a position to evaluate the choices, just like we do for food (admittedly, we aren't doing the best job at choosing the best foods, but we like our freedom of choice, and the information and options are there)?
Why aren't average consumers in a position to evaluate the choices
How could a consumer be in a position to evaluate their physician (and the entire health care process)? The knowledge required is huge. Moreover, once you have an adversarial market situation where the competitors use any means available to present themselves well, the ability of the consumer to do these evaluations will further decline - after twenty years of ecommerce, determining if a random thing I buy on Amazon actually has value is still hard, still a crapshoot (I don't mind having to be careful buying a random thing on Amazon, that's reason tradeoff. For something that could threaten my life, it's not a reasonable tradeoff). But bad health care products and services can kill you.
The usual answer is "we'll find a third party to do the evaluating" but unless that's actually the state, at which point things pointless, you will still have all the corruption of today - insurance companies are the evaluators and aggregators of health care services but they ultimately can't control prices (they can limit services provided but aren't really limiting the price for the services - they don't have an incentive to do so since they take a cut of the services).
Sounds like fear-based decision making there. If things are that bad, that difficult to get right, then the government isn't going to save you. Sorry. The good news, whether you choose to believe it or not, is that things are not that bad. We can do this.
Sounds like fear-based decision making there. If things are that bad, that difficult to get right, then the government isn't going to save you.
Most advanced industrialized nations have a state-run health care system and pay on average half of what the US pays. Health is naturally quite complicated but it isn't impossible to get right. The fundamental problem is that an adversarial system, where every provider has an incentive to wrangle their presentation and to wrangle their position in the regulator system, means, in the specific case of health care, pseudo-competition plus regulation as we have now, doesn't lower costs or increase productivity, it just produces a tide of dubious opportunism as one can see from current conditions.
And a look at present US health would show things are pretty bad - costs are approaching 20% of GDP and given that this is double that of equivalent advanced industrialized nation, that means we're spending 10% of the entire GDP on some combination of waste and inefficiency.
This argument uses average income as proxy for what health care spending in the US should be.
That seems clearly wrong given that with US now having a GINI coefficient, high level of income inequality, median household income would be a better thing to measure health care spending, since every individual has to spend money on staying healthy.
The argument generally seems wrong too. The need for health care isn't elastic - if someone need care, they need care and people going without needed health care is a humanitarian crisis (a situation that the US is arguable in - see the people giving free dental in a stadium a few years back).
> This argument uses average income as proxy for what health care spending in the US should be.
> That seems clearly wrong given that with US now having a GINI coefficient, high level of income inequality, median household income would be a better thing to measure health care spending, since every individual has to spend money on staying healthy.
The author responds to that criticism in the following comment[1]:
>> Two, I don’t understand why you’re using mean rather than median AIC throughout.
> Several reasons.
> 1) We don’t have good internationally comparable statistics for income or consumption at various points in the distribution...
> 2) When I’ve looked into this I have not found measured differences in the distribution or the median to be particularly informative...
> 3) This makes sense because there is approximately no relationship between individual income and health spending in the developed world, including the United States...
As for your second argument:
> The argument generally seems wrong too. The need for health care isn't elastic - if someone need care, they need care and people going without needed health care is a humanitarian crisis (a situation that the US is arguable in - see the people giving free dental in a stadium a few years back).
I'm not sure I follow your argument. RCA is saying that, as a country, the U.S. spends more on healthcare because we consume more health care than other countries. The U.K. kept their prices low for a long time only because the NHS engaged in intense rationing[2].
1) Using average income, a clearly bad statistic, can't be justified by saying you could not find a good statistic. Unless you use a good statistic, your argument isn't justified. (cue story of drunk looking for glasses under lamp post etc).
Also, if there's no measured difference in individual household income versus health care spending, well then maybe his pet theory comparing average household income and health care spending isn't very applicable either.
2) "RCA is saying that, as a country, the U.S. spends more on healthcare because we consume more health care than other countries."
That argument is either wrong or tautological. The US spends more on health care for worse outcomes, as many studies have shown. If this person means we buy better outcomes, they are wrong. If they are saying we buy more stuff labeled health care, maybe true but that's because the system is bad, not good.
> 1) Using average income, a clearly bad statistic, can't be justified by saying you could not find a good statistic. Unless you use a good statistic, your argument isn't justified. (cue story of drunk looking for glasses under lamp post etc).
You're not responding to the complete argument. RCA has looked into finding median measure of income, and not found them relevant to the discussion because (as he says in the third point of the argument) the rich do subsidize health care for the poor.
> Also, if there's no measured difference in individual household income versus health care spending, well then maybe his pet theory comparing average household income and health care spending isn't very applicable either.
But again, mean income is relevant because the important thing is how much a society as a whole puts into the healthcare system. Average is meaningful when the rich subsidize the poor.
> 2) "RCA is saying that, as a country, the U.S. spends more on healthcare because we consume more health care than other countries."
> That argument is either wrong or tautological. The US spends more on health care for worse outcomes, as many studies have shown. If this person means we buy better outcomes, they are wrong. If they are saying we buy more stuff labeled health care, maybe true but that's because the system is bad, not good.
According to RCA, AIC isn't just correlated with spending, but also "the vast majority of socially relevant outcomes and their covariates." [1]
ADDENDUM: There are charts that show life expectancy to be lower in the U.S. than other developed countries, but that has to do with factors other than the quality of healthcare[2].
> "Using average income, a clearly bad statistic, can't be justified by saying you could not find a good statistic."
As lliamander already mentioned, I addressed this on my blog. Several quick points:
1) International comparisons of health spending overwhelmingly relate directly to mean health expenditures (e.g., per capita, % of GDP, etc). Even if you know nothing of this area it seems most reasonable to compare mean health spending to mean material living conditions (disposable income or consumption)!
2) Individual income and health expenditures on behalf of individuals (i.e., not just OOP) are effectively uncorrelated within countries in the developed world (including the United States). There are clearly large national level effects independent on one's place in the national income distribution, which are exceptionally well correlated with mean income (r^2>0.9), and we shouldn't expect to income of the median person to be terribly informative.
3) We know healthcare to be heavily socialized in the United States and throughout the developed world. Mean income is a much better indicator of overall financial wherewithal than median income. The median just doesn't make much sense from a theoretical point of view. Moreover, estimates of the income distribution and the medians are surely subject to greater measurement error and issues of comparability between countries, so there are practical issues with this as well.
4) More practically speaking, I've run many different regressions using medians, various indicators of income inequality, etc and found little to nothing to suggest the income distribution is an important independent predictor. The r-squared and various goodness of fit indicators suggest these metrics perform less well than the National Accounts-based means I have used for disposable income and consumption. In multiple regression on these necessarily smaller samples (which are easy to over-fit) the coefficient/effect size of these distribution-related indicators are rarely significant, don't significantly improve model fit, and would almost certainly be rejected in lasso or the equivalent.
5) With other aggregate consumption/expenditure statistics, such as food, housing, transport, entertainment, etc the fit is also (unsurprisingly) much better with my statistics than cross-sectional comparisons of median income, so I'm not sure why you would expect one of the most socialized and most elastic categories of expenditure at a national level (~1.4 as a function of GDP) to be any more favorable for the distributional perspective.
(1) National health expenditures are overwhelmingly determined by the resources available to households, as measured by consumption or disposable income (not individual income), and these same measures effectively explain why the US spends much more than other countries.
(2) The increase in health spending in the US, as in other countries, has overwhelmingly been driven by an increase in the volume or quantity of healthcare consumed. While healthcare prices have risen they have generally not risen much faster than incomes have in the long run (especially not overall, but even when disaggregated somewhat), and thus cannot substantially explain why the share of income or consumption allocated to healthcare has risen overtime (indeed, the indices published by CMS and BEA indicate that had the quantity of health per capita remained constant the share would have actually fallen over time). This is also mirrored by related indicators, such as the vast rise in the health workforce, slow growing wages in healthcare (average healthcare wage approximates national average and hasn't increased for decades), and so on.
> The US spends more on health care for worse outcomes
So-called health "outcomes" are substantially endogenous (lifestyle, social influences, etc) and these factors vary systematically between countries. Moreover, health expenditure is almost certainly subject to rapidly diminishing returns and there is little to nothing to suggest the broad outcomes people typically cite (e.g., life expectancy) improve systematically with expenditures amongst countries in the developed world.
The pattern of rising expenditure with little or nothing to show for it on the margins in these broad measures may be regrettable, but my point is largely being driven by increasing disposable income, as opposed to idiosyncratic features of the US healthcare system. It sure seems like people really don't like to cut spending in practice and ultimately reject aggressive rationing conditional on income levels.
Thanks for chiming in! I am fairly impressed with your analysis, but I am somewhat perplexed as to figuring out "what do we do now?"
It seems that if we want to fix our satisfaction with our healthcare situation (in the U.S.), we have to fix a couple of issues:
- we have to mitigate the "endogenous factors" that contribute to poor health outcomes (i.e. people have to live healthier lifestyles).
- we have have to find a way to encourage people to self-ration their own medical spending in a way that doesn't adversely affect their own health outcomes.
Do you think a more free-market based approach to healthcare consumption would fix these issues? How do we address lack of information? How do we address the motivational issues that lead us to both live unhealthy lifestyles and to spend money on unhelpful medical care?
> Health is naturally quite complicated but it isn't impossible to get right
We may never get it 'right' but we can aim for 'better', and have consensus on what the metrics are. By many measures the US isn't even in the top 10 for health metrics. Given what we pay (hard dollars and % comparison against other countries), that's crazy.
I still totally disagree with your narrative. There is no natural monopoly in health care. New hospitals continue to be built all the time. You can goto your CVS and see a doctor if you want. There are tons and tons of choices and competition.
>the average consumer isn't in a position to evaluate the choices involved
Why? Once again I completely disagree with this narrative as well.
There are many, many, many examples of people who go to a hospital and ask at every point whether the services being provided are "in-network" for their insurance company, and yet still find themselves being billed for "out-of-network" services because of some assistant to a doctor or someone who was consulted outside the patient's presence. It's a minefield, even for people with patience and a clear head, which doesn't describe the majority of people seeking medical care.
Everyone agrees that this is a problem. The debate is about how to solve the problem. One side says, "the government should just make our decisions for us." The other side says, "the government should intervene enough so that consumers have the information they need to make informed decisions on their own."
You don’t need to socialize medicine, just make all HMOs and providers non for profits which would mean they have to reinvest everything into their core services rather than posting returns for investors.
>The thing is, health care is "natural monopoly", it's a situation where competition is meaningless at the point when a person shows up bleed at the emergency room
Your natural monopoly claim is incorrect. People have choices as to where they get their healthcare, at least in the US. You can always claim a monopoly if you make the criteria strict enough but obviously in the US today people have a great deal of choice as to which healthcare providers they use. Even in an emergency (at least in larger metro areas) ambulances actually have choices as to which hospital they take the patient.
>The thing about employer-funded healthcare after WWII is that for a few decades, that health care was restricted to the Blue Cross/Blueso Shield monopoly [1]
You link to a wikipedia article which says
> In the 1960s the U.S. government chose to partner with Blue Cross and Blue Shield companies to administer Medicare.[6]
If somebody finds me unconscious on the sidewalk, bleeding from a head wound, they're going to rifle through my belongings to find my insurance card, and then magically know which ER to take me to?
Love some of the bracing analogies employed by this analysis:
* employer-based insurance being a 'Whole Foods'-like product best for the rich that's nonetheless been encouraged by the government, while the 'Wal Mart'-like alternative has been encumbered to the point of disappearing.
* how would we raise our $3.5T health costs if they were war reparations required of the US from a foreign conqueror?
This is like asking if employment base matching 401k retirement accounts make retirement unfair to those managing their own 401k. Of course it is unfair, because life is not fair in nature.
Let's be clear on one thing before starting, it's just a benefit for employees, just like any other kind of benefit offered, for example the aforementioned matching 401k retirement fund. Some employers have fabulous benefit packages, and that is fine. Another related topic here is how medical insurance used to be mostly about avoiding costly emergency room visits, which back in the old days would sometimes result in bankruptcy. And, that is fine, because bankruptcy has replaced debtors prison, and we maintain a civilized society, but I digress. Insurance used to be a safety net to avoid financial ruin in the event of an emergency, but somewhere along the way it morphed into an all-invasive pervasive part of medical maintenance care, I.E. yearly dental cleanings, or primary care physical exams, etc.. Consider this, Medical insurance used to be just like automotive liability insurance, it paid out when there was an expensive accident, but auto insurance does not pay for oil changes and windshield wiper fluid. Well that is kidna what happened to medical insurance, it's morphed into a pervasive maintenance plan, and at this point the maintenance aspect is what is most defining about medical insurance. Paying that small sum of money every month is super worth it when that ultra rare accident happens requiring an emergency room visit, but this same model does not apply well when it comes to maintenance, because then you get people with pre-existing conditions who are effectively uninsurable, because this is not a Hippocratic oath, it's insurance (I.E. business) for avoiding bankruptcy by way of emergency room visit.
Still, it was an interesting perspective on insurance as an employee benefit. Not sure about the foundations, but the analogies with grocery stores was amusing.
As far as 401k plans go, self-employed individual running their own 401k often have an advantage over employees who have to take whatever 401k plan is offered by their employer. The downside of not having any other members to share administrative overhead costs is more than dwarfed by the ability to ruthlessly optimize for favorable tax treatment on the combined "employee" and "employer" parts without regards to which entity gets what.
I run a small business and it costs about $2000/Month group premium for a family of 4 and mind you this is the discounted group rate. If you buy similar insurance individually, you will pay over $2500/Month. So give or take, $25K per year per family/employee. Yes the employer gets a tax deduction but if you really think about it, i would rather offer the employee say $35K extra and take a hit in Payroll taxes while the employee gets so much more money for themselves. If only, health insurance was not a scam in this country.
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[ 4.4 ms ] story [ 297 ms ] threadIt makes those people less likely to switch jobs, or start new self-employed projects of their own.
I don't agree or disagree with the claims, but they're not easily refuted because they're not falsifiable. They amount to "we should do this because I think it's better". It's not persuasive. A better argument would be, "We all want to take care of poor people and improve our economy--we can do both and here is the data". Of course there will still be lots of friction and lobbying and so on, but at least it's a compelling argument.
Or are you saying your observations of this country's value system leads you to believe that only economic arguments would be effective?
I don't think it is too easy, to find such facts and figures. Can you give us some links to them?
None of which means it isn't true (it is), or that it isn't important (it is), but that's why it doesn't get used as an argument very much.
How can we know? Because if they were pro small business they would be pro universal healthcare, so that it would be easy to start your own business.
I suspect the "right" is actually sincere. But it so happens that ideas giving more power to private businesses tend to disproportionally benefit larger businesses over the smaller ones (this is a natural advantage of having scale and capital). The ideas surgically targeted to benefit smaller businesses? The "targeted" aspect tends to pattern-match to the "left", so they get rejected. The end result looks like the "right" was dishonest, but IMO it's just the ass-backwards stupid fixation on ideology over problem solving that causes this. And the same thing applies to the "left".
It should be like the green new deal - the economics of eg Medicare4All is similar in that it’d greatly improve life for small business as well as families.
Edit: it's true. If you are a democrat candidate and this is the angle you push, it's not going to work. But you already know that.
I have a real hard time agreeing with the concept that the government should have a monopoly on any necessary item, because then the government gets an unchecked choice about who gets the good and who doesn't.
Since we're talking in this thread about employer-provided healthcare, HMOs, I fail to see how recognizing that adding bureaucracy to healthcare didn't work leads to the line of thinking that the solution is to change the bureaucracy into a government bureaucracy and expect that to work better. To me this sounds like we passed a law that caused a problem (the employer mandate) and now think that more of the same kind of law that created the problem in the first place will resolve it?
No, we need a solution that is less encumbered with red tape and public policy, not one that is more tied to politics. Socialized medicine is just HMOs dialed up to 11 and with all choice (what little remains today) removed.
I'd like to just see the employer mandate repealed. Anyway, I'm ready for my downvotes for disagreeing with the hive, but I thought I'd try to contribute to the discussion. They're only imaginary internet points.
This is obviously total and utter nonsense. Look at every other western country. Nobody is banning you (or your employer) from buying additional private health insurance. It's simply providing a basic level of service in this arena, just like roads, army, police, fire, health and safety, etc, etc, etc.
Comparing government provided healthcare to Venezuela is a straw man.
It is in fact illegal in Canada under federal law: private clinics are not legally allowed to provide services covered by the Canada Health Act. I'm still for it, though, and the rest of your point stands. It's just like roads, army, fire, etc.
> Comparing government provided healthcare to Venezuela is a straw man.
It 100% is a straw man.
Oh??
https://www.nytimes.com/2019/03/23/health/private-health-ins...
(EDIT Formatting)
Now turn the table, you are the one with cancer. There is an expensive treatment that might or might not work, but it is the only hope left. How much is this wroth to you?
With money. It's like insurance, except paid through an extra tax.
> Or more accurately, why.
I mean, are you really asking why someone sees human life to be roughly of equal value, regardless of said human's wealth? But let's look at it differently: I don't think public healthcare precludes people from access to private treatments and additional private medical insurance. Public healthcare is just another baseline service offered by the government, which happens to remove the need for most of the people to seek that service in private sector. Like many other government services, you could view it as a formalization of helping others in need.
> There is an expensive treatment that might or might not work, but it is the only hope left. How much is this wroth to you?
Obviously, all the wealth I can command at the moment - meaning what I have, + what debt I can get into. Which is precisely why healthcare needs to be regulated, and why public healthcare is useful - private providers know that true demand price for many medical issues is essentially "all that you have", and they will try to get all that money. Inserting the government between the healthcare provider and the patient means the provider doesn't get to "negotiate" with an individual under duress.
The insurance system is already bureaucratic as all get out. Creating one payer would actually streamline the experience.
The government has a monopoly on the national defense as well, a good that we all need. That works. Why wouldn't health care be the same.
Canadians and British folks seem pretty happy with their nationalized health care.
Sounds pretty efficient to me!
Of course what we have now with employers sponsored plans is the worst of both...
If you do have the money you can get your own supplementary health insurance that goes above and beyond. (This is common in Canada, not sure about England though.)
Employer sponsored health care is just one example of a government sponsored incentive, one that was supposed to help, that turned out to be a terrible idea. In fact, most of the problems we have with healthcare in the US are the result of well intentioned government interventions. Is the solution really to have more government involvement? No, not just that, an entire government takeover? Is there really confusion as to why people are nervous about this idea? Other countries that have succeeded with single payer have populations smaller than some of our cities, and near zero diversity with regard to race, religion, individual cultural upbringing, etc. How do we know it will scale up to over 300 million people with widely differing politics, religion, culture, geography, population density, etc.?
But I'm not convinced that it's a total explanation, either. Necessary but not sufficient.
Just as abortions aren't outlawed federally, I think making sozalized healthcare equally available will perhaps be similarily difficult as it is to make abortion equally available.
And having one federal system creates corruption - a one-stop shop for lobbyists.
Do you really want congress and the president deciding on budgets for various illness, prescription costs, what is covered, etc?
I was pointing out that this is what makes America "varied" compared to other countries and it will introduce complications and variations in how a healthcare system is going to work for it's citizens if they do try to mimick Canada, UK, etc.
I would also hope that the hospitals have a bit more autonomy and they aren't hamstrung by congress deciding they aren't allowed to spend more than 5mn on sedatives or some other really narrow and specific budget.
Like you said, small countries already do this. When 2/3 of the states can agree on a system then we make it federal. This is more like what Sweden does, their counties finance and administer health care according to agreed upon federal standards.
The U.S. government has already made a huge mess out of health care- the biggest in the world it appears. I don't trust them. We've already been screwed by industry lobbyists. They need to take a back seat and let the states run with this for now. As per our constitution.
I am 100% in favor of various plans at a state level. Vermont was going to do single payer before Obamacare. That's what I want to see. States will copy successful systems, and an amendment can eventually be passed once enough states agree on a federal system.
Besides the fact that is how it's supposed to work in this country. The constitution doesn't give the fed the power to regulate health care. That is supposed to require an amendment, which requires something more than a 51% majority because it is a big deal.
Counter-argument... this isn't simply a question of "capitalism" vs "socialism". There are a wide variety of models in use out there, from the mostly-socialist (Sweden) to mostly-market (Japan). What they all have in common, though, is that all of them are producing better coverage and better outcomes at lower costs than the American system. We pay twice as much as the rest of the world, for the privilege of millions going without coverage, millions more trapped in jobs they hate for the sake of health insurance, and millions of families bankrupted by medical costs outside of what their insurance (or lack of insurance) covers.
In other words, the existing American model that you're defending is uniquely bad. It's more expensive and less efficient than any other system in the industrialized world. It's not about whether we can do better. It's about whether we could possibly do any worse, at this point.
Careful, those are fighting words! I am in no way defending the current American model. It sucks. Let's be clear here. I highly, highly doubt that anyone is arguing for status quo in America here.
I'm defending capitalism against single payer and medicare for all proposals that rely on magical thinking and trusting our government (that got us into this terrible status quo). If Japan has a mostly market-based solution then lets hear about that some more.
EDIT: "It's not about whether we can do better. It's about whether we could possibly do any worse, at this point." Yeah, that's the kind of cynicism that I'm also fighting against. "Yep, we are screwed, might as well try socialism" is not an attitude I'm inspired by.
Medicare is, in fact, the largest single payer system in the world, and it's a large chunk of the American system. Criticizing single payer would do well to start by criticizing the current Medicare system. But that means separating it logically from the privatized employer-based insurance model, and that's a very difficult knot.
Will do.
I have spoken with doctors and they hate medicare. It doesn't pay on time, it pays below market rates, it dictates what they can do with their patients, etc. These doctors still see medicare patients out of compassion, but they are losing money on each one. Think I'm making this up? I just did a quick web search and here's a quote from someone else:
"Yet, thanks to the federal program’s low reimbursement rates, stringent rules and grueling paperwork process, many doctors are refusing to accept Medicare’s payment for services. Case in point: In 2000, nearly 80% of the Texas Medical Association’s doctors were taking new Medicare patients. By 2012, that number dropped to less than 60%.
Why are more and more doctors turning down Medicare? The answer is simple: Medicare typically pays doctors only 80% of what private health insurance pays. While a gap always existed, many physicians feel that in the past several years, Medicare reimbursements haven't kept pace with inflation (especially the costs of running a medical practice), while the rules and regulations keep getting more onerous, as do penalties for not complying with them." --https://www.investopedia.com/articles/personal-finance/10021...
Here's another link a quick web search turned up: https://www.verywellhealth.com/doctors-accept-medicare-insur...
So, if we all go only-medicare, how many doctors decide to retire early? <edit>How many potential doctors will decide to do something else instead?</edit> What quality of doctors and care are we left with?
If by that you mean the entire OECD then yes, some tiny homogenous countries have tried it. And it works great. Also, diversity has nothing to do with medicine.
> I have spoken with doctors and they hate medicare. It doesn't pay on time, it pays below market rates, it dictates what they can do with their patients, etc. These doctors still see medicare patients out of compassion, but they are losing money on each one.
Lowering reimbursement rates reduces costs, that's how it's supposed to work. Did you think costs just go down while people get paid the same or more? Where did you think the money was to come from? Sorry, America's costs are 2X Canada's, those doctors do need to be paid less.
> Why are more and more doctors turning down Medicare? The answer is simple: Medicare typically pays doctors only 80% of what private health insurance pays.
Great, now all programs will pay the same, much less than today. You do know doctors in Canada make $200-500K/yr right, they're not exactly starving. They don't need to make more, they're public servants.
In the US the mean salary for a doctor is just shy of $300K (range $200-663K). In Canada the mean salary $225K, ranging from $232 to $676. I think they'll manage with the pay-cut.
> So, if we all go only-medicare, how many doctors decide to retire early?
Those who scrape by on $250-500K/yr and save, then retire, like the rest of the 1%.
Isn't the whole argument that our system is inefficient and therefore expensive? Get rid of the inefficiency and doctors should still get paid the same, no? Again (I think we are going back and forth in different threads here), free markets are great at doing that. We should try it with health care.
Doctors become public servants. They should get paid relatively comparably to other first-world countries but the fact is what they're getting paid right now is unsustainable for us as a society if our goal is to cover everyone at a reasonable price -- and it should be. Preserving doctors top-0.5% pay is strictly a non-goal. Building a functioning public health system is a goal.
That's pure tyranny. Stop it. People are paid what the market dictates, not what some government bureaucrat decides.
That's just partisan nonsense, platitudes disguised as criticism. You need to do a lot better than that. I could come back with plenty of failure modes for capitalism as well, but I very much doubt you'd call them proof that capitalism is a "proven failure", and I wouldn't make that argument myself. There are many cases where socialism has worked well and continues to work well.
What's weird? That we have food stamps for those who are temporarily (at least that's how it's supposed to be) in a bind, yet not everyone uses food stamps? Why do you think that is?
Does everyone love medicare? Every doctor I've talked to hates it. It doesn't pay on time, it pays below market rates, it sometimes just doesn't pay at all, it doesn't let the doctors choose what care they think is best, etc. Doctors tell me that the rest of us are all subsidizing medicare patients right now, that if they could get away without seeing any medicare patients they would. How is that going to work out when we are all on medicare?
Because it's means-tested?
You're describing a two-tier health system, which many countries operating under a "socialized" model follow including Australia. That's fine, too. The government provides a safety net of basic coverage and then those who want more or whose employers want to lure them with the promise of better care can opt for private care. This would still work if Medicare were an open enrollment for anyone who wanted it.
> Does everyone love medicare? Every doctor I've talked to hates it. It doesn't pay on time, it pays below market rates, it sometimes just doesn't pay at all, it doesn't let the doctors choose what care they think is best, etc.
You can't on the one hand complain about the rising price of healthcare in the US, how it's moving further out of reach for everyone, and at the same time complain that the socialized program "pays below market rates." That's the definition of lowering costs, something the US has to do more than literally every other country in the world. That's a good thing. In fact, that's an argument for the system we're proposing.
> Doctors tell me that the rest of us are all subsidizing medicare patients right now, that if they could get away without seeing any medicare patients they would.
That's kinda hilarious. Medicare patients are the most expensive, worst customers for a medical program. They're all old, sick, dying or about to. That's facts. If the private system had to bear the burden of treating those patients their margins would implode or costs would balloon. The Medicare program as it exists right now is a huge subsidy to the private sector -- especially as it's forbidden from negotiating drug prices like any other sane system permits.
> How is that going to work out when we are all on medicare?
It's going to work fine like it does in every other country in the OECD. It's not like we're proposing something wildly outrageous and unheard of. Every other developed nation does this and has better health outcomes across the board with half the cost.
"You can't on the one hand complain about the rising price of healthcare in the US, how it's moving further out of reach for everyone, and at the same time complain that the socialized program 'pays below market rates.'"
I think that American people (probably more than any other country) value freedom of choice more than "cost cutting." Also, the idea of reducing costs by a government simply taking over the market really stinks of tyrannical authoritarianism in these here parts. It's distinctly un-American (like it or not).
Strangely enough, freedom of choice (i.e., increased supply along with low switching costs and price/value transparency) generally also leads to cheaper prices. I'm pretty sure that reforms in those types of areas are what would most easily get support from American people.
Yes, we could just go along with what other countries have done, but dang it, America is a leader. America champions freedom. If you want a better system (and I'm sure just about everyone in America does, I know I do) those are the things you have to sell.
That's a false choice because the vast majority can't afford the choice and never will. The rest the choice of physician is made for them by their employer.
> Strangely enough, freedom of choice (i.e., increased supply along with low switching costs and price/value transparency) generally also leads to cheaper prices. I'm pretty sure that reforms in those types of areas are what would most easily get support from American people.
No, it doesn't. Not when your life is on the line. That's what the OECD and WHO data shows.
> Yes, we could just go along with what other countries have done, but dang it, America is a leader. America champions freedom. If you want a better system (and I'm sure just about everyone in America does, I know I do) those are the things you have to sell.
Not in this case. It's an abject failure here. It's the world's most expensive per capita -- by a country mile. It costs twice as much as Canada, has the same level of health outcomes, covers far fewer people. It's a bad system. America has lots of positive things but it's by no means a world leader in everything. For instance, not being obese.
Just because you're in front doesn't mean you're going in the right direction.
https://www.nbcnewyork.com/news/national-international/Ameri...
On the other hand, other first world governments adds strong government involvement in healthcare markets and average half the cost we do in the US. If you look at say the NHS in UK, it's pretty clear that government involvement results in a much smaller amount of bureaucracy from healthcare compared to the US.
The biggest downside to socialized care is stagnant innovation and a slow-moving bureacracy, and the major drawback to private care is unlimited catastrophic consequences for major health issues, and the fact that cost-comparison isn't possible for emergency care.
If I were decider for a day, I'd flip a coin for either option over what we have currently.
edit: Also, in the future, maybe we'll have AI doctors, and we're presently seeing remote health care through apps. I'm not talking specifically medical treatment technology, but so many other methods of health care which would greatly be encumbered by heavy-handed government regulations.
Kaiser isn’t much of an innovation it’s just a scaled down model of any socialized health system. It’s exactly what Canada has but smaller.
Also, in the US, Kaiser is an innovation. Comparing a voluntary, private organization to a forced, tax-funded system is a false comparison.
No, it isn't. It's the reason health insurance isn't insurance. Literally everyone will at some point come down with an emergency or life-threatening condition, and 100% of us will eventually die of one. It's not insurance if it's going to happen to you.
> Also, in the US, Kaiser is an innovation. Comparing a voluntary, private organization to a forced, tax-funded system is a false comparison.
That doesn't make it innovating. Cloning a system that works elsewhere isn't innovation. Get over the "forced tax funded" nonsense too, unless you want to relinquish all social services like education, fire, water, etc.
Most people are good, folks, otherwise no society is going to work!
What you are describing is not proposed.
Especially - freedom to pick any doctor as they are all in-network.
Family had experience with California PCIP insurance (bridge for pre-existing condition after ACA was voted in, but before it took effect). The PCIP was amazing - PPO-like benefits, using MediCare network (close to 100% doctors take it) and quality services. Of course, unfortunately, the ACA/exchange provided policies are nowhere close to how good PCIP was.
If we could get the PCIP-like option, it would truly change lives for the better.
Any doctor? Doctors can take so many patients. Though it may benefit a large number of people, some may end up worse. Those who have the best doctors currently (because they can pay) may no longer be able to have those doctors.
Second, you're at best arguing that we shouldn't go to a fair system of rationing because it would hurt the beneficiaries of an unfair system of rationing.
And to take this sideways... my favorite health care model is the Japanese system. It's actually quite similar to the American system (private employer-provided insurance, private providers), but with one key difference... a government commission fixes the prices for all medical goods and services. No more negotiating between providers and insurers. So no "networks".
It leads directly to the situation you described. It also leads to costing half as much as the US, for universal coverage and better outcomes. I'll take that trade, thank you.
It wouldn't, but if I needed to get a doctor, I might no longer be able to get a very good one.
Remember that cheaper prices for medical care means the smartest, best people may not become doctors.
> you're at best arguing that we shouldn't go to a fair system of rationing because it would hurt the beneficiaries of an unfair system of rationing.
I don't believe the current system is "unfair". Why is it? Most Americans like what they have; it is the bottom few percent who are unhappy. Is that "unfair"? At what percentage does that become the case? Must most of society change to accommodate a small, dissatisfied minority?
Without government regulation, health care would be much cheaper. Why must I purchase coverage for a hysterectomy or for birth control as part of a plan? I will never need these services. Wasted money.
What of experimental treatments? I know a person who is alive thanks to an experimental treatment that was reasonably priced. All it amounted to was an antibiotic regimen far outside the bounds of the CDC-recommended one, out-patient. The problem with single-payer is that I cannot do that, because there is a single payer - the feds. I may not pay for my own procedures (and my friend would not have been able to do so), even though this was quite affordable, because it was not on "the list".
Fixing prices is a possibility (albeit not one of which I am as fond), though we would need to allow procedures to be done out side of that (for those which were not approved, or for those who could not get availability and could pay). It is basic economics that price ceilings create shortages; who gets treatment? We are back at square one: I think it should be ordered by those who should pay. I trust dollars to be "fairer" than an opaque system, and would rather the coverage I can get be a known quantity than be at the mercy of the whims of a bureaucrat.
My biggest question: why do you want to force those who can pay onto the same plan? That is a part of single-payer that makes no sense. Why not let those who like their existing coverage keep it, as most Americans still do? [0]
There was an article that surfaced about an Indian hospital that had industrialized common health-care procedures. A four-year degree is not essential for these; why is it required? If we commoditize common and routine procedures via removal of barriers to entry, we can greatly increase the benefit without forcing those who like what they have to become worse off and without hurting more complicated situations.
Lastly, the problem with socialized medicine is that it cannot afford to spend beyond a certain amount per-person on average. End-of-life care is enormously expensive in America, but is better than in other places. [1]
Many of us may say it is foolish to spend upwards of a million dollars for a few more years of life, but having spoken to a few dying people, most say something to the effect of that they would give every thing they have for a few more weeks (the exception being those in exceptional pain, those with loss of senses, etc.).
EDIT: Downvoters care to comment?
[0] https://news.gallup.com/poll/245195/americans-rate-healthcar...
[1] https://www.forbes.com/sites/cjarlotta/2016/01/19/end-of-lif...
As for the "smartest, best" people becoming doctors... I don't think medicine is a path chosen simply because it's lucrative, in most cases. It's chosen because it's challenging (or sometimes, because it's expected). And those in it for the money are in paths of lucrative-but-socially-useless things like cosmetic surgery. High pay is incidental here.
Why pay coverage for things you'll never use? Same reason I'm paying for your broken arm. That's how insurance works. Spreading the risk.
Single payer systems - like Medicare, for example - are quite capable of covering experimental treatments. Why are you saying they can't? You're ignoring plain facts here. And it's possible that your experimental coverage might not be covered by your private insurer, either. I've been in that boat myself.
Fixed pricing is a far, far more transparent system than the current system of negotiating prices for the same things between different providers/insurers, so the same hospital charges $1.10 for aspirin here and $1.25 there. It also solves the problem of localized monopolies, such as rural hospitals, that can charge whatever they want because insurers have no alternative.
Why force people onto the same plan? Single payer doesn't do that, necessarily. Again, Medicare. There's a HUGE market for Medicare supplemental insurance (I work in that market). Wealthier people can afford additional coverage above and beyond single player. The single payer provides a guaranteed baseline, and covers basics so private insurers can focus on corner cases, extremes, and luxuries.
"End of life care is enormously expensive in America, but it is better than other places." Yeah, Medicare is single payer, right?
Insurance is supposed to hedge against risk. You might need a broken arm; I will never need a hysterectomy or birth control (especially not the type covered by insurance).
> localized monopolies, such as rural hospitals, that can charge whatever they want because insurers have no alternative.
And if the rural hospitals then shut down due to not being able to cover costs?
> Why force people onto the same plan? Single payer doesn't do that, necessarily. Again, Medicare. There's a HUGE market for Medicare supplemental insurance
The definition of single-payer is in the name - there is a single entity which pays for insurance. A single payer. That means, definitionally, no private/supplemental insurance, no cash payments, no nothing. Experimental treatment may not be covered by private insurance, but at least it can be purchased with cash. A single-payer system definitionally precludes a cash option.
> Yeah, Medicare is single payer, right?
Wrong; see above. Medicare is also subsidized in no small part by higher-paying patients; because it often reimburses at below-market rates, private coverage is necessary to pick up the slack.
I'm guessing not, actually.
The point is, you're using such a narrowly defined, pedantic definition of "single payer" as to make what you're railing against a total strawman. Not even the most socialist systems in the world, (Norway, Medicare, etc) come anywhere close to your extreme.
Nope. I am also not okay with Medicare, Medicaid, Obamacare, and any sort of transfer payment from the feds.
> I'm guessing not, actually.
How remarkably prescient of you.
> you're using such a narrowly defined, pedantic definition of "single payer" as to make what you're railing against a total strawman. Not even the most socialist systems in the world, (Norway, Medicare, etc) come anywhere close to your extreme.
Gee whiz, I interpreted "single-payer" as meaning there was a single payer in the medical system? What sophistry!
I believe it was Senator Harris that recently said that "Medicare for All" included abolishing all private health insurance, and this has seemed to get traction among the far left. Senator Sanders has similar ideas; he would allow a small amount of private insurance, but only in addition to mandatory enrollment in his plan.
Reason Magazine corroborates the general definition: https://reason.com/2019/01/24/new-poll-shows-medicare-for-al...
Show me the part of the constitution where it says the government may sell health care. Show me the part that justifies transfer payments of any kind.
I proposed something of a solution above: remove the onerous regulations and allow industrialization of common procedures. This would cut out the bulk of health-care expense.
And how would you pay for such a plan? Even doubling taxes wouldn't do it: https://www.wsj.com/articles/even-doubling-taxes-wouldnt-pay...
We're in a hole, financially speaking. America has about ninety-five trillion dollars in about household value; the "one percent" hold about forty percent of that. Seizing all the money they have, thirty-eight trillion dollars, would just about cover the costs of this "medicare for all" thing for a decade. What do you do then? We're spending too much, not taking too little.
No that's fine, you can tell grandma why she's not going to get that hip replacement or cancer treatment. It's because of your free market principals and she should have made more money when she was young. See, grammy, it says so right here in the constitution - and The Fountainhead!
If only there was a way to update or modernize or uh, what's the word, amend the constitution.
> I proposed something of a solution above: remove the onerous regulations and allow industrialization of common procedures. This would cut out the bulk of health-care expense.
Yes, it's the regulations, for sure. Like the ones that keep the air and water clean, and the rivers not-on-fire. And drugs safe. See if we just got rid of that, we'd be in great shape. You know what would make it really cheap? Let's get rid of medical licensing requirements. Now that's a money saver.
> And how would you pay for such a plan? Even doubling taxes wouldn't do it: https://www.wsj.com/articles/even-doubling-taxes-wouldnt-pay....
That's absurd. Even a Koch funded study showed MFA would be +/- 5% of what it costs right now, but would cover everyone, accidentally showing the unit economics to be much better. [1] You take all the money employers are currently spending on employee cover via a combination of payroll and personal taxes, direct it to the Medicare pool and enroll everyone. This isn't some sort of new wild plan. Other OECD member states do that right now.
By the way, the paper I link is the one the WSJ article cites (your link is broken) and if you read anything past the first page it clearly states that not only would everyone be covered it would cost less per capita and in total. Another study recently showed that Medicare and Medicaid do a better job of controlling costs than the private sector setting us up for success in the longer term, too. [2]
[1] https://www.mercatus.org/system/files/blahous-costs-medicare...
[2] https://www.modernhealthcare.com/article/20190211/NEWS/19021...
I'll ignore the flame-bait. I honestly believe that we could reduce regulation and make the poorest better off. I referenced above an example: an Indian hospital has essentially mass-produced procedures for low cost. Things like hip replacements do not take a brilliant surgeon with eight years of medical training; I think breaking the monopoly of the AMA and lowering regulation will allow cheap procedures at prices reasonable to almost all. For those last few, I believe Churches and states ought to shoulder the responsibility. I said nothing of "no health-care", I said that the feds shouldn't do it and that single-payer is a bad solution.
> amend the constitution.
Be careful with amending our founding document to push a policy agenda. This has been rarely done in the past, because if one side does it to suit one agenda, the other will reciprocate once re-elected. Maybe the far left could get socialized medicine, but the right might repeal the 14th amendment birthright citizenship next election.
> Yes, it's the regulations, for sure. Like the ones that keep the air and water clean, and the rivers not-on-fire. And drugs safe. See if we just got rid of that, we'd be in great shape.
What did I say of environmental regulations? We have them to protect the rights of others, and they are important.
With respect to drug safety, I do believe rules could be somewhat loosened, but I also believe some regulation is necessary.
> Even a Koch funded study showed MFA would be +/- 5% of what it costs right now
This is an "alternative fact" pushed by Senator Sanders and Congresswoman Ocasio. [0]
> You take all the money employers are currently spending on employee cover via a combination of payroll and personal taxes, direct it to the Medicare pool and enroll eveyrone.
Americans are generally leery of just "taking the money", "directing it", and "enrolling everyone". That's too heavy-handed an action for the feds to take. I would appreciate a different source for your cost, as the one you mentioned was not correctly represented.
With respect to unit economics, that does not account for quality. Note that the study you cited above mentions the outrageous cost in the abstract. It also mentions that Medicare reimbursement rates are roughly 40% lower than private insurance; where will the extra money come from? That doesn't make the unit economics cheaper, that means private health insurance costs are currently subsidizing low medicare reimbursement rates. The bulk of the "cost reduction" to which you are referring (over 85% thereof) came from provider payment cuts, which assumes the current 40%-below-market rate. That's not better unit economics, that's monopolizing an industry and fixing prices. The remaining <15% came from better drug prices. I will concede that a monopsony tends to lower prices for certain things, but this is not nearly what you claimed.
[0] https://www.factcheck.org/2018/08/the-cost-of-medicare-for-a...
That's not an argument against the policy, it's an argument that if the policy is desirable it should be pursued by means which include a Constitutional Amendment.
Constitutional Amendments were designed to give each generation the power to decide both the specific content and the purpose of the Constitution; which was not ever intended to be a vehicle by which the long dead dictate the form of government to the living.
Not, of course, that national health insurance costs the original purpose of the Constitution, which is laid out in the preamble, however much one might argue it violates the details of the design.
> Why not allow states to do it for themselves? Broad-brush national solutions do not always work well.
Why not do it nationally? Isolated local solutions do not always work well.
> Labor costs are higher in certain places, conditions vary, etc. Why do it federally? My
National programs can, and do, account for local variations of the type you describe, and state-level programs aren't immune to having to deal with them, anyway.
https://news.ycombinator.com/newsguidelines.html
https://news.ycombinator.com/newsguidelines.html
Hedge against group risk. Why should I pay for your house burning down because it started on your deck? I don't have a deck. That's a terrible way of looking at it. The bigger the group/risk pool, the cheaper it is for everyone.
> And if the rural hospitals then shut down due to not being able to cover costs?
Sorry, that's not how socialized programs work. If there's particular need in communities they receive more funding. Or, the government flies people to nearby communities to seek treatment (see Northern Canada, Svalbard, etc).
> The definition of single-payer is in the name - there is a single entity which pays for insurance. A single payer. That means, definitionally, no private/supplemental insurance, no cash payments, no nothing. Experimental treatment may not be covered by private insurance, but at least it can be purchased with cash. A single-payer system definitionally precludes a cash option.
That's fine. Two tier is also fine. What's not fine is the status quo.
> Wrong; see above. Medicare is also subsidized in no small part by higher-paying patients; because it often reimburses at below-market rates, private coverage is necessary to pick up the slack.
Medicare subsidizes the private market by taking literally all the worst customers out of the risk pool. You've got this completely backwards. Without Medicare private cover would be astronomically expensive or have no margin.
I tried to downshift in 2017 but ended up having a $1400/mo health ins. payment for my family and me and that was more than my mortgage, which was about $650/mo. At least with the mortgage you know your future costs. I have since paid off the mortgage, so if we stay put, I have only property taxes to worry about.
Now, the last question is: What will taxpayers bearing the cost of everyone'se healthcare do to my taxes? The US is $21 Trillion in the hole and counting. I won't be paying much income tax, only taxes on capital gains and dividends.
My only other concern is that food prices keep rising like crazy, so do things like car insurance, homeowners' insurance, bills, etc.
I don't like private health ins--I work at a major provider and I know full well how billions get wasted. However, I think government taking it over is going to be the worst thing the US has seen since probably the Civil War. I'm certainly not paying for it all, you can go figure it out for yourselves.
Do it! We've got more people than jobs necessary anyways, certainly once automation enters full swing.
> I tried to downshift in 2017 but ended up having a $1400/mo health ins. payment for my family and me and that was more than my mortgage, which was about $650/mo. At least with the mortgage you know your future costs.
This sounds like single payer will provide you with freedom.
> Now, the last question is: What will taxpayers bearing the cost of everyone's healthcare do to my taxes? The US is $21 Trillion in the hole and counting. I won't be paying much income tax, only taxes on capital gains and dividends.
Even a Koch funded study found that the cost of providing cover is +/- 5%-ish the amount we're spending on medical cover right now, and other studies have shown Medicare does a better job of controlling costs than private insurers. The way the system would be executed is that the amount employers are currently paying private insurers would be redirected to the public purse, either via payroll tax or via personal income tax, or both. No new money needs to suddenly appear from thin air, it's just getting re-allocated.
You won't be paying much income tax, others will. Dividends are usually treated as ordinary income, FWIW.
> I don't like private health ins--I work at a major provider and I know full well how billions get wasted. However, I think government taking it over is going to be the worst thing the US has seen since probably the Civil War. I'm certainly not paying for it all, you can go figure it out for yourselves.
And yet you were planning to go on Medicare right? People in America seem to like Medicare. Why is it socialized medicine only becomes "good" once you hit 65? It's like parents trying to explain alcohol to children: It's really really bad until you turn 21 then suddenly its really really good.
Here's the study that showed Medicare and Medicaid control costs better than private insurers: https://www.modernhealthcare.com/article/20190211/NEWS/19021...
Do all other OECD countries cover nursing homes for free until death? That's the case when liens apply - not hospitalization.
https://www.aarp.org/health/medicare-insurance/info-1996/are...
I don't think it is entirely unreasonable that medicaid - a medical program for poor people - has the right to put a lien on someone's estate. Normally people on medicaid don't even have estates (or else they wouldn't meet the asset test), but for some reason we don't count house equity for the asset qualification criteria. Very unfair for renters - this at least somewhat equalizes things.
The NHS in the UK does, yeah [1]. In Ontario, end-of-life care is also provided and long-term care is provided for ~$1800CAD per month if you can afford it, and it may be free if not via a combination of CPP, social security and income-based subsidies. [2] In 2002, France introduced universal, income-adjusted, public long-term care coverage for adults 60 and older [3]. The Netherlands does too [4]. The rest of the OECD I'm not sure. Most developed systems do offer something.
The health system really is better pretty much everywhere else in the OECD. And remember! Every one of the systems I mentioned spends less per capita than the US. In some cases like Canada half.
> I don't think it is entirely unreasonable that medicaid - a medical program for poor people - has the right to put a lien on someone's estate. Normally people on medicaid don't even have estates (or else they wouldn't meet the asset test), but for some reason we don't count house equity for the asset qualification criteria. Very unfair for renters - this at least somewhat equalizes things.
While I don't believe in inter-generational wealth I'd argue this furthers the cycle of debt and poverty by taking an estate away from those who could most benefit - the poorest.
[1] https://www.nhs.uk/conditions/end-of-life-care/hospice-care/
[2] https://www.ontario.ca/page/get-help-paying-long-term-care
[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462881/
[4] https://www.researchgate.net/publication/304653227_Long-Term...
http://fortune.com/2017/08/21/bernie-sanders-medicare-for-al...
Being trapped as the vassal of a giant corporation just to not-die is in direct opposition to the very concept of liberty. Being able to quit your job and create your own business is an essential freedom. But liberal politicians are unwilling to market that way, and so the neoliberal political class gets to argue for the preservation of a system that benefits the wealthy and the corporate at the expense of the liberty (and wallets!) of ordinary people as the "free market". Feh.
This argument has in fact been made by a great many liberals and moderates, many times, going back to Clinton's (failed) attempt to pass a single-payer health system.
Particularly if you have children >18.
And if they’re under 18, just make them directors and pay them $100 for attending each monthly board meeting.
Thankfully, they're finally closing the loophole. Many doctors with private practices were reducing their tax burdens significantly by stating that their 14 year children were "medical receptionists". It's ridiculous to grant further tax avoidance loopholes to the already wealthy.
I stopped counting when my medical bills hit $750,000. It is probably double that by now. Again, normal healthy 40 year old guy that rode his bike everywhere who woke up one day with a sore throat that ended up never going away.
I’ve been involved in hiring decisions where HR brought up the healthcare costs to complain, then stated clearly we can’t use that as a criteria for hiring.
I have doubts that human brains can separate out that kind of statement from our actions.
Under the ACA, small businesses all end up lumped together in the same state-wide risk pool, so if my small business hires old or sick people it's very unlikely to affect our premiums. In most places this risk pool is larger and somewhat less morbid than the individual market.
It's not hard to put a dollar amount on the value of employer provided health insurance, and then use that when calculating your total compensation at one job versus another. Functionally I don't see how it's any different than your employer paying you the amount you would need to buy insurance.
Could you expand on what makes health insurance special in this regard?
What is a bit annoying for start-up founders is that health insurance premiums are only tax deductible/paid with pre-tax money if the plan is offered by your employer (may be you).
I didn't understand this until I started my own business. I was desperately trying to find a job during the '08 crash to get health insurance for my family but was unable to find one.
As a last resort I started my own consultancy which turned out to be a fantastic opportunity.
Self paying for health care was a massive barrier to starting my own business.
Once I hired people health care benefits were frequently top of their list in interview questions.
I would argue the lack of transparency in the marketplace and the inability for anyone to make an informed choice of hospitals or what it will cost them (the linked article seems to indicate the consumer has a choice to go to a "nice" hospital or a "not so nice" hospital, but most times we don't have the choice when we need care - it's close to our home. The times we do have the choice (sometimes for birth, cancer treatment, etc) is where you see hospitals investing heavily to get high margin services from consumers.
Does Employer-provided care make medical care unfair? One could argue that employer-provided care with the tax incentive might lead to better resources for an employed person electing that care, but any time money is involved you will likely get better care. EDIT: More succinctly - There will always be some inequality / unfairness in care because there will always be inequality of wealth. I'm not sure explicitly here that employer-provided is the problem or that any subsidized care will create this kind of inequality.
I'm not sure you can argue effectively that granting the same medical care to all as a matter of law will fly because people will always find a way to get better care if they can afford it. Does employer-provided do this at a larger scale? Maybe?
The best way to ensure fairness and efficiency is to get the data out there and available, and make healthcare more like a market instead of a black box.
I’m not sure anyone is arguing that. In almost any country with single payer health care you’ll also find a thriving market in private health care, but they’re typically competing on things like providing private rooms and maybe a shorter waiting list rather than whether you get to live or die.
According to a 2009 study, 45000 people die annually due to lack of health insurance in the US[1]. Due to the ACA there are now more people who are insured but it's still a massive segment of the US population (not to mention that healthcare plans have been covering less and less over time).
The number of people who die due to lack of healthcare is ZERO for countries that have universal healthcare.
Fourty. Five. Thousand. Every. Year.
[1]: https://news.harvard.edu/gazette/story/2009/09/new-study-fin...
And if we're looking at that, you have to look at the other side of the coin. Socialized healthcare systems have much larger wait times and you can find deaths attributed to those, so it's disingenuous to say ZERO people died in countries that have universal healthcare.
More research needs to be done before enforcing such a system on a wide scale in America. There has been data suggesting deaths and suffering related from long wait times in Canada. Then you have the increase of Canadians coming to America to escape the wait times. As well what we've seen with VA and ObamaCare wait times.
> 25,456 and 63,090 Canadian women may have died as a result of increased wait times between 1993 and 2009
https://www.huffingtonpost.ca/bacchus-barua-/wait-times-cana...
Basically you trade the fear of going into debt and not getting healthcare vs wanting to get healthcare and not being allowed to for an arbitrary amount of time. There are more pros and cons to each system, but my point is that socialized healthcare systems has it's fault and certainly does cause deaths in some instances.
> 19.8 weeks between referral from a general practitioner and receipt of treatment
> across the 10 provinces, the total number of procedures for which people are waiting in 2018 is 1,082,541
https://www.fraserinstitute.org/studies/waiting-your-turn-wa...
That's because in the US, a very large proportion of people go to the ER instead of the normal in-patient process that universal healthcare countries use for non-emergency problems. US hospitals have very long waiting times for ER for this reason. Here in Australia, I've needed to go to the ER before and there wasn't a waiting time (though obviously this depends on the time of day and what hospital you go to).
This is all due to lack of funding and staffing for hospitals, not for any other reason.
> More research needs to be done before enforcing such a system on a wide scale in America.
I'm pretty sure the existence of this system across the developed world is sufficient research to show that it works. Even with these worries you have, the healthcare system would be orders of magnitude better than what you have now.
The design of any health care system needs to acknowledge the fact that people are going to get sick and die even with an unlimited budget, and there is not an unlimited budget.
We can't all get billionaire treatment for our ailments, no matter what system we have in place. We should be adults and accept that
Obviously people will still get sick and die, that's unfortunately part of the human condition. But I reject the argument that life-saving treatments being impossible to afford by ordinary people is something we should accept.
It's just that in this whole debate it seems we never have the honest discussion about how to deploy limited resources - i.e. how to ration care under a socialized system, or how to subsidize care under a free market system.
I believe that if we discussed it from this perspective perhaps the two sides of this debate could find some common ground.
It's curious that nobody ever complains about limited resources when discussing increasing the military budget or "corporate welfare" through tax breaks and bank bail-outs. It leads me to wonder whether it's actually a significant problem in the first place or if it's just another talking point (there is quite a bit of evidence that deficit-spending is not necessarily a bad thing in-of-itself, what matters is what that money is being spent on).
Markets without perfect information are neither efficient or fair; I think it's reasonable to say that no healthcare market can have anything approximately resembling perfect information.
Also the idea of efficiency in healthcare is problematic. Does efficient healthcare means refusing care to old people and to people who need heroic interventions and instead focusing care only on interventions that provide a high return of healthy productive years per $?
I would like a clear articulation of efficient and fair in this context.
As for "efficient" and "fair" I would also be interested in a better definition there, one the article didn't quite provide to my satisfaction based on its question.
It should be noted that the Bernie Sanders proposal actually does allow for supplemental private insurance (for elective surgeries, or shorter waiting times). Most countries with universal healthcare have a private insurance industry, it's just that you get a basic level of care from government-provided free insurance.
For instance, if you were a billionaire maybe $1,000,000 for a coronary artery bypass operation would seem like a good deal.
Doing those operations in volume lowers the cost but it also makes it possible for doctors to get experience that makes the operations safe and effective. Studies have shown that the main factor for survival in CABG surgery is how many operations are done a year by the doctor and the clinic.
Similarly, you have to treat thousands of people to prove a drug is safe and effective. You just couldn't have advanced treatments for the ultra-rich without these treatments being developed and tested on a large volume of less wealthy people.
The U.S. healthcare system encourages the average person to spend a lot more on health care than they would otherwise.
If it wasn't for health insurance (private or public), very few people could shell out for $250,000 worth of cancer treatment at end of life. Either they would go without, or the market price would be less.
https://www.thriftbooks.com/w/medical-industrial-complex_sta...
https://www.businessinsider.com/inside-indias-no-frills-hosp...
The bigger issue though is the impact on free market prices as the free market requires competition, but employer group plans force everyone into whoever their employer has chosen - and the employer cost selection is different from that of the employee.
It also drastically impacts the ability for people to create new businesses as getting the required standalone health insurance is exceedingly expensive - again because individual insurance purchasers are not the primary customers of health insurance companies.
At least Obamacare/ACA meant that insurance companies couldn't deny on the basis of pre-existing conditions.
I used to have a coworker that claimed all that was needed was to raise the maximum income for medicare and that would magically solved healthcare. Ignoring entirely that private health insurance companies could choose to deny coverage. My (now) wife literally was unable to get insurance - she was deny by literally every insurance company in CA because she had donated a kidney, and it turns out having a single kidney is a preexisting condition. This was despite her donating a kidney saving an insurance company money.
Did she donate the kidney to someone covered by the same company?
And the employer made the choice on the best provider they could get at the best wholesale price.
The employer is incentivized to get the best provider for the best price to attract employees.
Employers shop for insurance, employees shop for jobs with the perks they want (pay, insurance coverage, etc).
EDIT: you're usually given a packet before accepting a job that goes over their healthcare plans. At least in the two instances I have been in the job market, I was.
And it's good for the employer to pick a plan that has the best coverage for the best value because they want to attract employees to them over their competitor.
Best for the employer, not for the employee. In addition when you start a job you can’t really evaluate health insurance choices.
From the title was hoping to see employer-based insurance compared against better market-driven individual-based insurance.
Instead it's yet another privatized vs socialized insurance analysis. (Not that it's not interesting...was hoping for something new.)
It is crazy that people who get their insurance from an employer get a tax break (indirectly), while those that purchase it on the individual market do not. Also, it messes up the risk pool: more affluent people who get their insurance from work are bound to be more healthier than the poor schlubs who are not affluent enough to get insurance from their job. As an insurance company, I could get away with charging group plans much less than individual plans.
Switzerland, which is basically where the heritage foundation copied what would become RomneyCare/ObamaCare from, does not allow for group plans. You simply don't get your insurance from work, everyone is shoved into the same individual plan market (with some weird probably overthought exceptions, like Post docs....). This very important aspect is missing from the ACA, but would be impossible to remove politically, full on universal healthcare is much more likely.
Then there was the dental. Same plan, same dental insurer... but hey guess who gets a 6-month waiting period on that filing?
Otherwise since most dental work is not an emergency, you would pay for one month of dental insurance in a year you had any work needed, and pay out of pocket for cleanings.
If you had prior coverage and are just switching plans because of employment changes, then I believe the waiting period is waived.
We used to have the same thing with “pre-existing conditions” in health care. You needed “prior credible coverage” to be able to get treatment for an existing condition in the first 6 months of a plan. Again, it’s to prevent people from only buying insurance after they get sick.
> it messes up the risk pool
Only if you believe that it's "messed up" to pay for health care only for people who are economically productive...
This is something I felt would actually help the US move off of Employer based insurance for a while now.
If every person is charged the same amount for insurance regardless of being in a group then we can more easily break from employer based insurance. Especially when I can see X job offers me 100,000 but pays 500 a month for insurance. And Y job offers me 110,000 but pays 0 a month for insurance. I can do the math on which one is better if both plans are the same.
Anyway I'd love for the US to ban group plans completely. In the digital age it should be easy enough to administer a large plan with individuals instead of a group plan. I can see why after WW2 a group plan might have been better to administer, but I think at least most of those benefits no longer exist.
Yes, group plans are not allowed. All residents are in the same risk pool. Also, all health insurance premiums are paid post tax (unless you are poor and get a subsidy).
Employers themselves can only offer accident insurance.
The link is for 2016, but iirc the 2017 trends are similar. Haven't seen 2018 numbers yet.
https://data.worldbank.org/indicator/SH.XPD.CHEX.PP.CD?most_...
So for the user (as opposed to the insurance company), the value of the insurance is not to on average be covered. The point is to always be ok if you get ill.
Where I'm getting at is that employment is a thing that isn't always a given. You're going to be between jobs at some point in your life, and you don't want a potential huge bill to wipe you out financially. Even if it is just for a short period, it ought to worry you that you aren't covered.
I get the feeling most of the debate just glosses over this with the average case, which is that most people are going to be just fine not being covered for a few months.
Anyone who loses health insurance coverage due to losing their job has the option to buy COBRA within 60 days of losing their health insurance. If they do buy COBRA, it is retroactive to the day they lost their health insurance. So you really do not need to be worried about being wiped out (unless the cost of COBRA would wipe you out) as long as you get a different job within 2 months.
Sure, it probably had some additional benefits that my basic plan doesn't, because my employer got the extra super gold plus plan, but if you're only buying it for a few months to avoid being wiped out in case the worst happens, then you probably don't care about that.
My recommendation is to never buy COBRA, unless there is a specific element of the plan that you need, and you have a short timeline to getting a new full-time job with comparable coverage. Otherwise, it's just hundreds of dollars extra you're spending, for features you don't need, right at the time when money is tightest.
Obviously, if a person already has some condition, then they're buying health insurance for a very different purpose, and none of this applies to them.
Right, as I said though, the coverage is retroactive to the day you lost your health insurance. So if you have a heart attack a month and a half after losing your job, you can buy COBRA after having the heart attack, and you won't have to pay for the heart attack.
COBRA coverage is 18-36 months, depending on circumstances. Only long-term unemployment (or having no savings, which is of course a bug deal) prevents health insurance coverage after employment.
For many people, having no income means they cannot afford the $500+/month it will cost to continue their coverage.
Absolutely agreed, but it is peace of mind if you know you're going to be between jobs for 2 months or less.
But this affects everyone except the rich. Therefore government should step in and insure everyone even those without work.
Government should support people taking reasonable business risks such as starting their own business.
The premiums are also increasing much faster than cost-of-living or inflation, too, even though the benefits are unchanged. It's like the insurance companies are trying to price individuals out of self-employment.
This is another instance of a common case: it's really expensive to be poor! Tying insurance to employment is a "hit 'em while they're down" situation.
Do we need a 200k/yr gatekeeper to basic antibiotics? Or would an experienced nurse be able to figure out the difference between bacterial and viral?
Do we need a nurse cleaning patients? Or is that a job for unskilled labor?
Government licencing has gone too far, and has created artificially low supplies of health insurance workers. This was driven by incumbent healthcare workers.
Nurse practitioners are a 6 figure/yr job.
Pfft. Doctors will give out antibiotics to treat viral infections just to shut people up. E.g. somebody goes to the doctor for the flu and demands antibiotics.
> the contribution made by employers to the premium is exempt from the employees’ taxable income. This exemption cost the US Treasury an estimated $300 billion in 2018.
is just very disingenuous. Does the lack of an air or sunshine tax also cost them money?
Multiple protected classes? Sounds like a lawsuit.
"Oh, we pay you an inflation-adjusted equivalent of 1980s $50K a year so you should be absolutely devoted to us."
Yeah, whatever.
People don't realize that a lot of American industry in 1960s and 70s was "regulated monopolies" (Health care, airlines, trucking, telephone, etc). These provide a lot of the benefits that social democracy provides in Europe but was less obviously "socialized".
And similarly, the huge sea change that happened with Reagan breaking regulated industries wasn't and isn't noticed as the huge change that it was (and it is still reverberating through this society).
The thing is, health care is "natural monopoly", it's a situation where competition is meaningless at the point when a person shows up bleed at the emergency room. The process of "opening health care for competition" from the 1970s onward grew a hundred poisonous rent-seeks in every part of supply chain, from medical equipment operators to hospitals to insurance companies. Blaming just insurance companies is a bit misguided after all this. Certainly they play a part but the basic structure of private health care just naturally goes this way unless it either seriously regulated or nationalized.
[1] https://en.wikipedia.org/wiki/Blue_Cross_Blue_Shield_Associa...
This is a bit of a false narrative. 99% of healthcare is not emergency room, imminent bleeding out. I believe we should have government provided true emergency care for everyone (just like we have fire and police, right?), but for non-emergency stuff (which is most of healthcare), people do have time to shop around and find the best deal for them. The best deal might involve joining a health club like Aetna or Kaiser (these are not insurance, by the way), or it might be saving your money in a bank and paying for stuff piece by piece by yourself, just like we do for just about everything else we need to survive in this world.
A lifetime supply of insulin is much more expensive than setting a broken bone. We are not all equally likely to have cancer or respiratory disease.
Of course people should still have insurance (possibly government provided?) for the very rare and expensive surprises (just like a house fire is rare and expensive).
> regulatory capture, intellectual property
Ostensibly would seem that relaxing regulation and (more importantly) abolishing or heavily weakening medical patents would help drive down costs.
Can you imagine if tech companies could patent their products the same way medical companies do today? Uber would no longer have to worry about finding a moat, their moat would simply be their patent on "digital ride sharing provided by dynamic pricing to predict demand and position supply" (or some similar conceit). Smartphones would all be expensive and Apple would have a monopoly on multi-touch phones with capacitive displays and built-in app-stores.
If food companies could patent food the same way drug companies can patent drugs that they prepare, bread would be expensive and you wouldn't have store brands and generics to keep the price of the fancy Whole Foods bread in check.
Fine, it is a "dramatic illustration" but for even ordinary, ongoing medicine, the average consumer isn't in a position to evaluate the choices involved, there a natural advantage whatever health care provider is in the area, necessary regulation create severe barriers to entry and so-forth.
How could a consumer be in a position to evaluate their physician (and the entire health care process)? The knowledge required is huge. Moreover, once you have an adversarial market situation where the competitors use any means available to present themselves well, the ability of the consumer to do these evaluations will further decline - after twenty years of ecommerce, determining if a random thing I buy on Amazon actually has value is still hard, still a crapshoot (I don't mind having to be careful buying a random thing on Amazon, that's reason tradeoff. For something that could threaten my life, it's not a reasonable tradeoff). But bad health care products and services can kill you.
The usual answer is "we'll find a third party to do the evaluating" but unless that's actually the state, at which point things pointless, you will still have all the corruption of today - insurance companies are the evaluators and aggregators of health care services but they ultimately can't control prices (they can limit services provided but aren't really limiting the price for the services - they don't have an incentive to do so since they take a cut of the services).
Most advanced industrialized nations have a state-run health care system and pay on average half of what the US pays. Health is naturally quite complicated but it isn't impossible to get right. The fundamental problem is that an adversarial system, where every provider has an incentive to wrangle their presentation and to wrangle their position in the regulator system, means, in the specific case of health care, pseudo-competition plus regulation as we have now, doesn't lower costs or increase productivity, it just produces a tide of dubious opportunism as one can see from current conditions.
And a look at present US health would show things are pretty bad - costs are approaching 20% of GDP and given that this is double that of equivalent advanced industrialized nation, that means we're spending 10% of the entire GDP on some combination of waste and inefficiency.
The U.S. is not an outlier with regard to healthcare consumption when you factor in household income[1]. GDP is the wrong metric to measure against.
[1]https://randomcriticalanalysis.com/2018/11/19/why-everything...
That seems clearly wrong given that with US now having a GINI coefficient, high level of income inequality, median household income would be a better thing to measure health care spending, since every individual has to spend money on staying healthy.
The argument generally seems wrong too. The need for health care isn't elastic - if someone need care, they need care and people going without needed health care is a humanitarian crisis (a situation that the US is arguable in - see the people giving free dental in a stadium a few years back).
> That seems clearly wrong given that with US now having a GINI coefficient, high level of income inequality, median household income would be a better thing to measure health care spending, since every individual has to spend money on staying healthy.
The author responds to that criticism in the following comment[1]:
>> Two, I don’t understand why you’re using mean rather than median AIC throughout.
> Several reasons.
> 1) We don’t have good internationally comparable statistics for income or consumption at various points in the distribution...
> 2) When I’ve looked into this I have not found measured differences in the distribution or the median to be particularly informative...
> 3) This makes sense because there is approximately no relationship between individual income and health spending in the developed world, including the United States...
As for your second argument:
> The argument generally seems wrong too. The need for health care isn't elastic - if someone need care, they need care and people going without needed health care is a humanitarian crisis (a situation that the US is arguable in - see the people giving free dental in a stadium a few years back).
I'm not sure I follow your argument. RCA is saying that, as a country, the U.S. spends more on healthcare because we consume more health care than other countries. The U.K. kept their prices low for a long time only because the NHS engaged in intense rationing[2].
[1]https://randomcriticalanalysis.com/2018/11/19/why-everything...
[2] https://i1.wp.com/randomcriticalanalysis.com/wp-content/uplo...
Also, if there's no measured difference in individual household income versus health care spending, well then maybe his pet theory comparing average household income and health care spending isn't very applicable either.
2) "RCA is saying that, as a country, the U.S. spends more on healthcare because we consume more health care than other countries."
That argument is either wrong or tautological. The US spends more on health care for worse outcomes, as many studies have shown. If this person means we buy better outcomes, they are wrong. If they are saying we buy more stuff labeled health care, maybe true but that's because the system is bad, not good.
You're not responding to the complete argument. RCA has looked into finding median measure of income, and not found them relevant to the discussion because (as he says in the third point of the argument) the rich do subsidize health care for the poor.
> Also, if there's no measured difference in individual household income versus health care spending, well then maybe his pet theory comparing average household income and health care spending isn't very applicable either.
But again, mean income is relevant because the important thing is how much a society as a whole puts into the healthcare system. Average is meaningful when the rich subsidize the poor.
> 2) "RCA is saying that, as a country, the U.S. spends more on healthcare because we consume more health care than other countries."
> That argument is either wrong or tautological. The US spends more on health care for worse outcomes, as many studies have shown. If this person means we buy better outcomes, they are wrong. If they are saying we buy more stuff labeled health care, maybe true but that's because the system is bad, not good.
According to RCA, AIC isn't just correlated with spending, but also "the vast majority of socially relevant outcomes and their covariates." [1]
[1] https://randomcriticalanalysis.com/2018/11/19/why-everything...
EDIT: fixed wording in my first response
ADDENDUM: There are charts that show life expectancy to be lower in the U.S. than other developed countries, but that has to do with factors other than the quality of healthcare[2].
[2]https://randomcriticalanalysis.com/2016/11/06/us-life-expect...
As lliamander already mentioned, I addressed this on my blog. Several quick points:
1) International comparisons of health spending overwhelmingly relate directly to mean health expenditures (e.g., per capita, % of GDP, etc). Even if you know nothing of this area it seems most reasonable to compare mean health spending to mean material living conditions (disposable income or consumption)!
2) Individual income and health expenditures on behalf of individuals (i.e., not just OOP) are effectively uncorrelated within countries in the developed world (including the United States). There are clearly large national level effects independent on one's place in the national income distribution, which are exceptionally well correlated with mean income (r^2>0.9), and we shouldn't expect to income of the median person to be terribly informative.
3) We know healthcare to be heavily socialized in the United States and throughout the developed world. Mean income is a much better indicator of overall financial wherewithal than median income. The median just doesn't make much sense from a theoretical point of view. Moreover, estimates of the income distribution and the medians are surely subject to greater measurement error and issues of comparability between countries, so there are practical issues with this as well.
4) More practically speaking, I've run many different regressions using medians, various indicators of income inequality, etc and found little to nothing to suggest the income distribution is an important independent predictor. The r-squared and various goodness of fit indicators suggest these metrics perform less well than the National Accounts-based means I have used for disposable income and consumption. In multiple regression on these necessarily smaller samples (which are easy to over-fit) the coefficient/effect size of these distribution-related indicators are rarely significant, don't significantly improve model fit, and would almost certainly be rejected in lasso or the equivalent.
https://randomcriticalanalysis.com/2018/01/20/on-the-relevan...
5) With other aggregate consumption/expenditure statistics, such as food, housing, transport, entertainment, etc the fit is also (unsurprisingly) much better with my statistics than cross-sectional comparisons of median income, so I'm not sure why you would expect one of the most socialized and most elastic categories of expenditure at a national level (~1.4 as a function of GDP) to be any more favorable for the distributional perspective.
https://rpubs.com/random_critical_analysis/oecd_2014_consump...
There are two distinct claims here.
(1) National health expenditures are overwhelmingly determined by the resources available to households, as measured by consumption or disposable income (not individual income), and these same measures effectively explain why the US spends much more than other countries.
(2) The increase in health spending in the US, as in other countries, has overwhelmingly been driven by an increase in the volume or quantity of healthcare consumed. While healthcare prices have risen they have generally not risen much faster than incomes have in the long run (especially not overall, but even when disaggregated somewhat), and thus cannot substantially explain why the share of income or consumption allocated to healthcare has risen overtime (indeed, the indices published by CMS and BEA indicate that had the quantity of health per capita remained constant the share would have actually fallen over time). This is also mirrored by related indicators, such as the vast rise in the health workforce, slow growing wages in healthcare (average healthcare wage approximates national average and hasn't increased for decades), and so on.
> The US spends more on health care for worse outcomes
So-called health "outcomes" are substantially endogenous (lifestyle, social influences, etc) and these factors vary systematically between countries. Moreover, health expenditure is almost certainly subject to rapidly diminishing returns and there is little to nothing to suggest the broad outcomes people typically cite (e.g., life expectancy) improve systematically with expenditures amongst countries in the developed world.
https://i2.wp.com/pbs.twimg.com/media/DUwPBxoXUAEMCxy.jpg
The pattern of rising expenditure with little or nothing to show for it on the margins in these broad measures may be regrettable, but my point is largely being driven by increasing disposable income, as opposed to idiosyncratic features of the US healthcare system. It sure seems like people really don't like to cut spending in practice and ultimately reject aggressive rationing conditional on income levels.
It seems that if we want to fix our satisfaction with our healthcare situation (in the U.S.), we have to fix a couple of issues:
- we have to mitigate the "endogenous factors" that contribute to poor health outcomes (i.e. people have to live healthier lifestyles).
- we have have to find a way to encourage people to self-ration their own medical spending in a way that doesn't adversely affect their own health outcomes.
Do you think a more free-market based approach to healthcare consumption would fix these issues? How do we address lack of information? How do we address the motivational issues that lead us to both live unhealthy lifestyles and to spend money on unhelpful medical care?
edit: fixed formatting
We may never get it 'right' but we can aim for 'better', and have consensus on what the metrics are. By many measures the US isn't even in the top 10 for health metrics. Given what we pay (hard dollars and % comparison against other countries), that's crazy.
>the average consumer isn't in a position to evaluate the choices involved
Why? Once again I completely disagree with this narrative as well.
There are many, many, many examples of people who go to a hospital and ask at every point whether the services being provided are "in-network" for their insurance company, and yet still find themselves being billed for "out-of-network" services because of some assistant to a doctor or someone who was consulted outside the patient's presence. It's a minefield, even for people with patience and a clear head, which doesn't describe the majority of people seeking medical care.
A quick search turns up a few examples: - http://www.news-gazette.com/news/local/2019-01-20/wondering-... - https://www.consumerreports.org/health-insurance/states-work... - https://www.prlog.org/12766040-hbma-adopts-policy-framework-...
This is a very common issue, so common it is receiving legislative attention.
Oversimplifications don't serve anyone, and mischaracterizations are unhelpful and unwelcome.
https://youtu.be/Tct38KwROdw
1. Laws can correct this.
2. A large segment of consumers paying out of pocket would also result in competitive pressure for hospitals to disclose prices.
Fwiw, I don't have this problem with smaller medical clinics.
Your natural monopoly claim is incorrect. People have choices as to where they get their healthcare, at least in the US. You can always claim a monopoly if you make the criteria strict enough but obviously in the US today people have a great deal of choice as to which healthcare providers they use. Even in an emergency (at least in larger metro areas) ambulances actually have choices as to which hospital they take the patient.
>The thing about employer-funded healthcare after WWII is that for a few decades, that health care was restricted to the Blue Cross/Blueso Shield monopoly [1]
You link to a wikipedia article which says > In the 1960s the U.S. government chose to partner with Blue Cross and Blue Shield companies to administer Medicare.[6]
What about the 20 years before that?
* employer-based insurance being a 'Whole Foods'-like product best for the rich that's nonetheless been encouraged by the government, while the 'Wal Mart'-like alternative has been encumbered to the point of disappearing.
* how would we raise our $3.5T health costs if they were war reparations required of the US from a foreign conqueror?
Let's be clear on one thing before starting, it's just a benefit for employees, just like any other kind of benefit offered, for example the aforementioned matching 401k retirement fund. Some employers have fabulous benefit packages, and that is fine. Another related topic here is how medical insurance used to be mostly about avoiding costly emergency room visits, which back in the old days would sometimes result in bankruptcy. And, that is fine, because bankruptcy has replaced debtors prison, and we maintain a civilized society, but I digress. Insurance used to be a safety net to avoid financial ruin in the event of an emergency, but somewhere along the way it morphed into an all-invasive pervasive part of medical maintenance care, I.E. yearly dental cleanings, or primary care physical exams, etc.. Consider this, Medical insurance used to be just like automotive liability insurance, it paid out when there was an expensive accident, but auto insurance does not pay for oil changes and windshield wiper fluid. Well that is kidna what happened to medical insurance, it's morphed into a pervasive maintenance plan, and at this point the maintenance aspect is what is most defining about medical insurance. Paying that small sum of money every month is super worth it when that ultra rare accident happens requiring an emergency room visit, but this same model does not apply well when it comes to maintenance, because then you get people with pre-existing conditions who are effectively uninsurable, because this is not a Hippocratic oath, it's insurance (I.E. business) for avoiding bankruptcy by way of emergency room visit.
Still, it was an interesting perspective on insurance as an employee benefit. Not sure about the foundations, but the analogies with grocery stores was amusing.
And thats what doesn't really work. When your health is a "benefit for employees", you're in a bad spot.