>A single-payer universal health care system could cover every American, save more than 100,000 lives a year, and still cost $1 trillion less than the system it would replace, according to a new preprint study led by researchers at the Yale School of Public Health.
Total profits for US health insurance companies in 2025 were $50 billion. The other $950 billion has got to come from cutting:
1. money to providers
2. overall healthcare consumption
3. bureaucratic redundancy and waste
1 is going to piss off medical providers. 2 is going to piss of the general public. 3 is going to piss off the 20 million healthcare industry workers who are not direct care providers. So pick your poison. This is why it will never pass.
But think of all the health insurance jobs. They provide a service, it’s not like a government entity will deny enmasse enough people to cause their largest CEO to be assassinated.
FWIW, the methodology that produced this particular result is known to have significant issues. The claimed effect disappears after correcting for them. It also isn't the first time that these authors have published similar studies with these issues. They are not a credible source.
Universal health coverage may save lives and money but this study doesn't provide actual evidence for it.
"known" by whom, and documented where? if you're going to just parachute in and say this paper by domain experts is dead wrong, at least link to what you believe shows this to be the case.
This is why it doesn't happen: politicians get bought.
"Jeffries co-sponsored Medicare for All legislation between 2013 and 2021, but in August 2026, he stated he shifted his stance and stated that he no longer supports or co-sponsors the proposal." https://en.wikipedia.org/wiki/Hakeem_Jeffries#Healthcare
Quite weird to see such a study from Yale, Yale is the heart of the capitalistic western empire, and it exists to serve the oligarchy and the capitalists. So then what gives ? perhaps the person working on this report is still an innocent person and has not yet seen the reality of his situation :)
In a more sane world the Republican Party would be in favor of universal health coverage. How many potential entrepreneurs stay working at BigCorp because they need the health benefits? How many small businesses are crushed by the cost of providing healthcare to their employees? It would be great for business to remove any involvement they have in personal healthcare.
But I suppose they are the party of big business, not the party of business in general.
BigCorp gives money to politicians and gets to depress worker wages because they can't leave — sounds perfectly sane to tie your insurance to your employer under capitalism.
… in Massachusetts. New England Republicans are not the bulk of the party, and that’s not all bad - remember, the phrase was “banned in Boston”, not “banned in Bakersfield”.
Bill Clinton was a once-a-century skilled politician, but if you translated his policies without his extreme personal charisma to today it’s unlikely he would make it through the Dem primaries.
Decoupling health insurance from your job and going single payer are separate things.
You can have one without the other.
You can have a very healthy system with private insurers (like in Switzerland) and you can have completely dysfunctional single payer system (like in Poland and I guess many other countries).
Main problems are elsewhere: doctors gatekeeping the market, lack of transparency when it comes to pricing, regulation making it impossible to compete for smaller players etc.
> In a more sane world the Republican Party would be in favor of universal health coverage. How many potential entrepreneurs stay working at BigCorp because they need the health benefits?
If they published the plan, it was a normal rational one without carveouts for their friends, and they started pushing specific legislation now to implement it, they'd crush the Democrats, and Trump could declare himself God-Emperor.
All they'd have to do is cut a few friends (insurers) loose. They'd still even have the power of the contract to reward theoretically productive elements of the new health system in return for kickbacks, and there'd simply be more money sloshing around within government to take advantage of. They could continue to stomp the planet freely, because Americans don't care about anyone but themselves. The upper-middle class post-Obama "left" would evaporate. Give them free state college and they'd start calling Republicans the real left.
Another reminder that the US government spends more per-capita on health care than every country with universal health care, and then the population pays again.
One of the things usually cited to defend this waste of money is the massive excess army of people working in healthcare administration, half of whom are employed to file paperwork and the other half employed to throw it in the trash. Now that they're all soon to be replaced by AIs which will be able to simultaneously file and delete worthless paperwork at inhuman speeds, we can let go of that garbage excuse.
But in a more sane world the Republican Party would simply acknowledge slavery as being a real debt owed, and stop being racist, without changing anything else. Most black people are socially conservative Christians, and it would instantly become another God-Emperor situation. Democrats haven't won whites since Kennedy; they gave them entirely up for supporting basic civil rights for black people (an own-goal for the Republican Party, started as a single-issue antislavery party) and big business. Without guaranteed black support (the only other choice black people have to Democrats is not to vote, which is quickly increasing its share), the Democrats wouldn't be a viable party at any level. Republicans are not sane, they are short-termists like everyone else.
Picking out the Republicans is unfair, though. Democrats lobbied furiously and entirely dishonestly against single-payer healthcare in 2016 and 2020. They even tried to sell single-payer and its supporters as racist.
If spending drops by $1t, it will come out of someone's paycheck. Yes, some are greedy folks who will be just fine making 20% less a year. But many will be nurses or hospitals or some combination of providers.
it would not because the margins in the insurance industry aren't high. The OP is entirely correct, insurers are a source of payment, not a driver of cost. Insurers don't benefit from hospitals charging them high prices, they try to negotiate cost down, that is their service.
What is driving the actual cost is the high expenses hospitals have, and the biggest source of that is labour cost, as in any other industry. American healthcare workers, doctors and nurses, earn about 2-3x as much as their peers in the developed world.
they don't, for the simple reason that if they did all you'd need to do is go to the hospital and pay out of pocket, most US states don't require you to have health insurance. (or switch your insurance provider, as you pointed out there are many).
There's no logic in what you're trying to argue. Healthcare providers charge for their service, insurance companies negotiate that cost down, next to risk management that collective bargain power is the reason you buy insurance in the first place. Again if what you're saying is true all you'd need to do is just buy your healthcare from the hospital directly, if you end up in the ER take a look at the bill and tell me how that went
The United States government does not set prices for doctors bills, what are you talking about? Healthcare providers in the US operate privately and set prices based on market rates. Again, if you want to, you can go and purchase whatever healthcare you like already without a middleman, the point is, it isn't going to be cheaper, which is why people, voluntarily, purchase insurance.
What about quality of care tradeoffs? In Canada, for example, you are forced to use the government system, and if it doesn't deem you important enough, there is no private option.
There are private options for lots of things in Canada, depending on the province.
Without data on what proportion of people are denied and what the consequences are, this isn’t a good faith argument.
On the flip side, cases that would get care in Canada are denied in the USA by private insurance. Private options are far outside the means of most people.
The differences in life expectancy are due entirely attributable to vehicular accidents, homicide, and life style factors. It has nothing to do with medical care.
My dad, in the US on Medicare (one of the government funded systems), was denied a test. Because we have the option and had the money, he went and got the test himself on his own dime. That kicked off a series of events that led to a quadruple bypass, avoided an impending heart attack, and likely added many years to his life and his ability to remain and functioning member of society.
While I love the idea of never having to think about health care costs for a variety of reasons, I do like that some services are available to anyone with a wallet and not locked behind government controlled gates.
I don't know about Canada, but here in Spain you have both. You have public health guaranteed, but many people also have different levels of private coverages, usually to get quicker appointments.
As I understand Medicaid, it would just be open Medicaid for 100% of the US population regardless of the income, remove Medicare (they are now under Medicaid), leave the private sector as it is. Do you think Medicaid is too slow, too low quality, too terrible in general? Pay for private insurance, but you can still go to Medicare if needed.
This is what is never mentioned. Quality of care, access to cutting edge treatments, timely access to care are never discussed when moving to universal healthcare. There are examples of private and public systems out there, which would be a much better model.
First off, all Canadian provinces are different. Here in Quebec, there is a absolutely a private option. Not everyone likes that it exists, but most people seem to like having that option.
Canadians live better for longer on average (for cheaper healthcare overall). Any other metric is just a misguided attempt to justify the US status quo, which has nothing going for it unless you're rich.
In the US, you are forced to use the private for-profit system, and if you don't have enough money, you're shit out of luck, there is no other option. If I get cancer or some other serious condition my treatment will likely be a bottle of scotch and one 10mm dose of steel-jacketed chemotherapy.
I'm in Canada. The only time I ever needed a doctor in my life it was denied. I ended up having an issue that took ~5 years to resolve, which could have been prevented easily by any competent doctor in a 30 minute session.
I'm originally from Mexico. With what I have paid in tax here over the years I can afford to set up and operate my own small hospital over there, with new equipment, this is not an exaggeration.
"Free" healthcare, as with many other free things, turns out to be the most expensive kind of healthcare. Anyone who thinks otherwise doesn't really know what they're talking about or they're just stupid.
What could work, imo, and since we're all giving opinions here, is private healthcare with a ceiling on profits. Let players take 2x-5x, but not 50x which is what they do now, bring and enforce usury laws into healthcare.
In New Zealand we have private insurance and universal health care. Insurance kind of fills the gaps and usually has faster turn around time, like 1-day vs 1-month for an MRI.
But like insulin is free for everyone, so nobody is going broke while dying here rationing it.
We've been down this road. ACA was predicated on studies like this, to no avail (it turns out).
I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
I'm not saying that this is what is happening now, but I am saying that calls for universal health coverage, no matter how correct and well supported, are going to probably face the same obstacles they did last time, so we need new coalitions and implementation proposals if we're going to give it a go again. It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to.
These types of studies, and the goals they aim to support, always frustrate me as solving a surface-level problem rather than root cause.
The problem with US healthcare isn't who pays for it, its how damn expensive it is. As always there are multiple factors at play, my list would include corruption, lack of legal accountability/responsibility, and a population that is much less healthy than reasonable.
Go after any one of those and we'd make a lot more headway than trying to ram through a universal, government-run healthcare or insurance program. And yes, such a program could impact the above topics, but it doesn't have to and could make any of them worse.
I agree that this proposal would not solve all of the problems; absent more changes you would still see the creep up of healthcare costs at too high a rate. But slashing $1 trillion off of a $5.3 trillion costs is a pretty big bite of the apple. Even if you go with the more conservative $663 number, that is still a great first step. And both of those numbers are after adding the costs of covering currency uncovered people. So we are collectively getting more for significantly less money.
It does this by eliminating a very inefficient layer of our current system (insurance companies), and by having there replacement for that (the government) negotiate on drug prices (how much savings there is the reason there are two estimates). Currently insurance companies almost have a negative incentive to push down drug prices (their profits are limited to a percentage of total spending, and most large companies are pushing against that limit).
Most of the cost control pressures in our current system come out of Medicare/Medicade, and this would widen that out to the whole system. That in turn would wedge open the door to pushing on the other drivers of the cost spirals: hospital administration, new expensive drugs that are not worth the additional costs, doctor salaries ballooning, and the broken system between malpractice insurance and dysfunctional enforcement against malpractice.
I understand that theres an argument for removing private insurance companies in favor of thr government can cut costs. It can also increase them.
I'd argue that the primary issue with insurance costs today is the lack of market competition, obscurity of what costs and prices are, and government protections that prevent insurance companies from being legally liable for many of the problems they cause.
Corruption and monopolistic practices is a big deal in healthcare, for example. We'd be better off, in my opinion, by solving that rather than killing an entire private industry and hoping our government can continue to do it better indefinitely.
The "just" is doing some heavy lifting there. Clinicians aren't required to participate in Medicare. And there's no way that such a mandate could ever pass Congress, or be effectively enforced. Let's focus on reforms that are actually achievable in the real world.
It's extremely challenging to go after high costs in the current system, because the doctors who charge them are popular and the insurance companies who pay them are hated. There was a 2024 story that stuck in my mind (https://www.npr.org/2024/12/05/nx-s1-5217617/blue-cross-blue...) when Anthem tried to negotiate down the rate of certain anesthesia procedures; the public was absolutely outraged, successfully demanding that Anthem must back down and accept whatever the doctors feel is the appropriate pricing model.
The disconnect between prices and end consumers is itself a huge problem. I should know what care costs before I get it, and I should know how much my instance company is paying on my behalf before I get care.
For prices to be sane we need people being able to compare prices, decide what care they want and can afford, etc. Our prices are so high because its a closed market acting as though it were a free/open market being driven in part by customer decisions.
Preauthorization is a bit different, and yes I can see care providers hating it.
Its possible for a provider to know ahead of time that providing a saline IV costs $60, for example. Its also possible to have health care policies that approve any treatment deemed necessary at any healthcare provider, or at any healthcare provider in network if that concept was still a thing.
We don't have to have a preauthorisation step where doctors are expected to ask insurance companies if they will approve a certain treatment for a certain patient before it can be done. That is a particularly terrible implementation if you ask me.
I have a strong dislike for the industry as a whole. There's too many ridiculous situations I've been subject to, along with hearing of some from my friends.
My favorite was a friend who had to deliver her child, alone, in a hallway, because they forgot about her. And the hospital billed her for it. LOL.
> The problem with US healthcare isn't who pays for it, its how damn expensive it is
Exactly! There's so much paperwork that a doctor sometimes need two assistants just for the paper work. There's so much cost for independent practice that increasingly more doctors end up joining big hospitals. Charges with and without insurance have a huge difference. Just to name a few.
medicare is basically the biggest culprit for the "too much paperwork" stuff. A m4a plan that doesnt involve capitation would have even more paperwork than the current system does.
I haven't finished reading the paper and have no opinions on it (other than that most successful universal systems aren't single-payer) but if we start from actual numbers the discussion will be better.
"If your solution requires addressing the slow-burn civil war, your solution is just a campaign slogan".
Essentially, all solutions require addressing the slow-burn civil war, which is today capable of of subsuming any issue. Not a single policy issue can realistically be addressed while the rabid 800lb gorilla is in the room. That gorilla is not Trump, that gorilla is Heritage, Fox News, Koch, et al.
ACA has saved tons of lives. Due to the intense opposition, it was not structured in a way that could save money, but rather structured in the way that it could get through congress.
Additionally, as somebody who was around pre-ACA, I can not tell you how much better, in every single way, the post-ACA healthcare world is. Pre-existing conditions? Access to healthcare as an individual? These are life-changing possibilities, especially for entrepreneurs.
There's a very clear type of fallacy you are engaging in here that only works in politics: you're taking a vague general idea X, ignoring all particulars, and then lumping an idea Y together as if they identical and that any change in that general direction of Y could ever be different than what happened with X. There's no intellectual rigor or honesty in that sort of thinking, yet it somehow pops up throughout all of politics.
I lost my individual healthcare plan, and I couldn’t afford the new ones. Remember when they said you could keep your plan? Yeah, that’s the one I lost.
I'm curious as to how your experience actually using the plan for more than preventive coverage? IIRC, plans before the ACA had a ton of customer unfriendly provisions which made the insurance far less usable in practice. E.g. denying coverage for preexisting conditions.
No system that saves money can pass in congress: that's the real problem that we cannot actually avoid. Forget pressure from large companies: So many of US costs come from very high salaries, and a lot of bureaucratic positions that don't exist elsewhere. Every dollar we pay goes to someone, and it's not just some random mogul here or there that will be OK anyway. Reform that really lowers prices means loss of jobs, which them will be blamed on the politicians who signed the bill into law.
Yeah, since the ACA my coverage has remained the same while my costs have risen 10x; I'm in my 30s and my medical insurance costs 3x what my mortgage costs, and I still have $$$$ sized bills after a round of strep throat.
I would really like to just be able to get a true catastrophic policy which would cover unlikely risks such as cancer -- and then go on a cash basis for common meds and treatments. The ACA made this kind of insurance illegal, so my choice is to leave my family uninsured -- or let insurance soak up the money I might have saved for their college education.
Your blame is misplaced. Costs are increasing in spite of the ACA, not because of it. Pre-ACA your family insurance policy was likely worse in some key ways: it probably excluded coverage pre-existing conditions and had a lifetime maximum coverage limit.
Republicans finalized things to address medical costs and chiseling at hospital billing - regulations promulgated during Democrat regimes - so I would say there is bipartisan consensus for the actual arguments, if people listened to the actual arguments instead of seeing a no-vote as an opposite nonsensical ideology.
This has been one of the opposition points - don't just give a handout to insurance companies without addressing their billing practices
The original ACA did not have consensus for some of the proposals to address the billing practices such as existing and new state healthcare programs having collective bargaining. And yeah I think the original ACA was unworkable, compromise is taught as a good thing to children in this country, but it just means "the wrong answer".
The tweaks now, alongside the original democrat led ACA, alongside the parts that were stripped out I think could have better consensus
does need a rebranding though.
The only that will actually lower costs in our society is healthy people. And right now, everyone is unhealthy and not doing preventative measures due to expense.
And this is precisely why nothing will ever change. I tell everyone who will listen to me on my soap box, we will never get universal healthcare until we divorce healthcare from employment (by that I mean, make it to where businesses cannot offer benefits at all).
Personally, I would retire early. I have enough to cover bills and reasonable HC costs, but the way it is now, I'll just keep plugging away for a few more years.
Funny enough there's a very good chance I'm a Lost Canadian. I filed my application for proof of citizenship in February and am still waiting to hear back. Hopefully soon.
The real problem with universal healthcare is that it immediately completely eradicates religious charity.
Any single mom who works as a stripper can go see a doctor who doesn't have the slightest inclination to judge- you're just a number in a government database.
Everyone's getting free shit no questions asked.
I don't know that "inclination to judge" is a necessary component of religious charity. Religious charities beyond healthcare give out a lot of "free shit no questions asked," and usually without any attempt at proselytization. Catholic hospitals are not known for turning down patients due to moral judgements.
If there's a benefit to religious charity, it lies not in the "inclination to judge" but in maintaining a multiplicity of authorities. Combining everything under the government umbrella gives you a totalitarian society; a liberal democracy restrains the power of government while allowing for competing authorities in other spheres, like medicine, religion, academia, and the press. Giving the government the power to mandate or withhold medical treatment for political opponents (think Soviet "sluggish schizophrenia" as a diagnosis for removing dissidents from public life) seems more worrying than strippers getting free healthcare.
ACA also greatly increased costs. As an entrepreneur at the time, insurance premiums increased 25% overnight for the same plan. Many people had similar experiences.
That the ACA forced a large number of people to pay a lot more for literally the same product is not a good outcome for those people. Too many people try to pretend this didn't happen.
I don't believe you. It wasn't the "same plan". I guarantee that the plan you had before the ACA had a lifetime benefit limit, perhaps as low as $1M. Read the fine print. A single complex episode of care could easily blow past that limit and leave the plan member functionally uninsured.
I agree with you about the ACA (as an opponent of single-payer). Prior to the ACA, members of my immediate family were uninsurable on the individual market --- not insurable at a higher rate, not insurable with exclusions, but literally uninsurable: their only options were employer-provided group coverage or state catastrophic safety net coverage programs. The twist: neither has any chronic health conditions. The underwriting refusals were based on symptoms reported in previous engagements with the health care system.
Before I went indie, prior to ACA requirements I researched private insurance and found plans for around $3K. This year I’ll pay over $20K for a bronze plan for my family. 700% increase in less than a decade. Aetna left the marketplace input state and no pediatrician in a 10 mile radius takes the most cost effective ACA plan. The pediatricians we found are actually just GPs who have training in pediatric medicine, but we bring in the only minors they see. This is in a top-5 market based on population.
All of the providers have consolidated. I don’t know if ACA affected that or not, but wait times for checkups went from later this afternoon to sometime 6 months from now.
Part of my experience is going from corporate health insurance to marketplace, but in the past 5 years, ACA plans have consistently gotten worse and more expensive while service for those plans has gotten significantly worse in almost every way.
Without the ACA it would have been even worse. And by worse I mean that even if the premiums were lower, we would still have horrible limitations like maximum lifetime coverage amounts or exclusions for pre-existing conditions.
There is a legitimate shortage of physicians in many areas, especially in primary care. This has a variety of causes including bottlenecks in the training pipeline, shitty working conditions that drive experienced doctors out of the profession, and an aging populace that has drastically increased demand. More and more doctors are opting out of taking any sort of insurance and shifting to concierge medicine or cash-pay models.
If that’s the only benefit couldn’t that have just been made a law and left out all the rest? Healthcare system is worse than ever, I don’t know the cause but with its current prices I can’t imagine subsidizing it further being the answer
I think it's generally gotten better for insurance companies, at the expense of both end customers and providers (with the exception of providers that have vertically integrated into the ecosystem, e.g. Aetna/CVS, etc. to capitalize on the advantages that brings).
Not debatable that it has gotten worse over the last decade, mostly due to one party in the government intentionally doing what they can to chip away at the efficacy of the program, which when it launched was incredibly compromise heavy and should have been viewed as a first step towards a better, long term solution.
I had a local primary care I really liked; I never saw the Dr. there, just the Physician's Assistant typically. They were independent, and last year they made the change to go to a membership model. Basically $50/month just to be able to be a patient of their practice, and then use your insurance for care. In their notification she laid out the economics of where they currently were and it wasn't sustainable for them, based on how much they were squeezed, mostly by not being also a facility to be able to double bill insurance for facility fees + care fees. Also mentioned that the other 3 independent doctors in our neighborhood had all closed in the last 2 years.
ACA is not Universal Health Coverage. So this would be different enough. And you don't need perpetual majority control, only sensible politicians for about a generation (like FDR/Truman/Eisenhower/JFK) to lock in a popular entitlement.
This is exactly the argument that gave us the Affordable Care Act. It was literally a republican plan from Massachusetts. It was supposed to be broadly acceptable and that's why it was implemented with a billion compromises.
But the Republicans called the Democrats commies anyway and refused to participate. And that has been their playbook ever since. That is what they are going to do, no matter what we propose.
So we may as well propose actual universal healthcare. But I agree with you that we need to create strong majorities to keep it in place until it reaches the kind of momentum it has in Canada or Sweden and opposition to it becomes a practical impossibility, like opposing social security.
Maybe someday we can have a system where losing health insurance isn't a motivation for not starting a company. Our current system is a complete disaster for entrepreneurial capitalism.
You mean obstacles from politicians who took money from the healthcare industry. That’s how we ended up with PPACA and they used it to justify massive cost increases and consolidations. They passed that junk to save face and now healthcare is far worse. But we “closed” the donut hole, right? Quite literally made everyone worse off and no one wants to talk about it.
I mean, the original plan for what became ACA was single payer. They didn't have the votes from the moderate democrats though, which is why the "private plans on public exchanges" became a thing instead.
You're not wrong at at least for the forseeable future, single payer does seem untenable politically, but I'd argue that dismissing studies like this on the basis that it needs solved before debating it on its merits is circular, because the only plausible political objection to a policy like this is financial. If you reflexively claim that nothing without broad consensus appeal at a given point in time is worth discussing, you're essentially arguing in favor of freezing our public policy to whatever the current public opinion is today. I don't think you need to go very far back in history to see some pretty striking examples of why that would be undesirable.
They had 59 votes from Democrats for the public option, not single payer. Public option is to let people choose either a non-profit government insurance plan or private insurers. They needed 60 votes to break a Republican filibuster. Joe Lieberman (Ind-CT) said he would filibuster the public option but would vote for the ACA without it.
Whoops, good correction, I did misremember public option versus single-payer, and I guess technically Liberman was not a Democrat at that point, but he had been for a while and still had committee chair positions from the Democrat leadership, so it mostly feels like a distinction without a difference.
I still think this is an important historical detail that seems to go under the radar a lot; if anything, it gives me yet another reason to disdain the filibuster!
George Bush Sr. made a deal with Democrats to raise taxes and cut spending. Ever since then the Republican strategy has been to oppose pretty much anything a Democratic President proposes. The ACA was a Republican healthcare idea and they didn’t support it because a Democrat proposed it.
There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think. If it gets implemented quickly enough then getting rid of it will be very difficult to do. People won’t give up free at the point of usage healthcare once they try it out.
> There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think.
It's worth keeping in mind that Eisonhower's cabinet argued against the idea of giving the polio vaccine away for free on the basis of it being a "backdoor to socialized medicine". We're over seven decades past the point where it makes sense to give a shit about what anyone says about "socialized medicine".
For what it's worth, Obama did actually initially consider a public option[0]; it was Congress who made it clear that they wouldn't pass it that caused him to pivot to what we have now.
[0]: edited from "single-payer" to reflect correction to a similar comment I made elsewhere in this thread
can someone tell me this. Right now level of care is rationed by type of insurance you can afford. eg: northwestern in chicago downtown is inaccesible to ppl below certain income level.
In universal everyone has access to every hospital ? Why would someone go to lower level hospital if they can go to northwestern. Now the acess to best hosptials is gated by a queue?
I am not saying this is right but ppl who already have access to northwestern its in their best selfish interst to oppose universal?
i am just countering the point that "ppl opposing it are merely brainwashed by foxnews or are stupid" .
> Now the acess to best hosptials is gated by a queue?
I mean, yes? Literally the same principle we all learned in kindergarten for how to make access to something fair. You didn't get to skip the line in lunch because your parents had a better job than someone else either.
Most of society also doesn't require paying for indirectly via employer subsidy (driving up the cost to people who are between jobs or have money by other means).
If your objection is to a system that operates differently than the rest of society, it's not clear why the hypothetical healthcare system is more of a bugbear than the very real one that doesn't resemble pretty much any other way that things get purchased. I don't really understand how you think spending time arguing against something that has very little chance of happening based on principles that ostensibly conflict with the actual version that genuinely does exist is a sign that people are not being misled by those with incentives to distract them in that way or otherwise are struggling to reason about an issue logically.
From my perspective, what you're saying sounds like nonsense. I'm not sure why you're more concerned with my karma than I am, but since you're curious: no, I did not spend much time thinking about the one singular downvote my comment received. It's pretty common for people to downvote for any number of reasons (downvoting for disagreement in particular is controversial but not against the HN guidelines), so I didn't really read into it at all. Sometimes a comment I make that receives a downvote will end up with upvotes a few days later, and sometimes it won't; sometimes a comment I make that initially receives some upvotes will end up neutral or worse. At the end of the day, I comment because I have something to say, and while others' opinions on that is potentially useful feedback, and a single upvote or downvote is literally the smallest possible signal that can exist about whether what I said has merit.
Sadly, this is a better comparison than you probably intended, because access to school lunch is still not universal in the US.
If a child cannot pay, there are some districts that serve cheaper alternative meals that don't meet the normal lunch standards, some that shame children by giving them hand stamps, and even some that will literally dump their tray in the trash.
You're right, it's not just that people opposing it are stupid or brainwashed: Some of them, to your point, are selfish and don't want others to have access to the nice things that they have.
Can you explain why those people DESERVE access to better care? Do they have more complex/rare diseases that require specialized treatment? Are there specialists who only work at that hospital? Those feel like warranted needs. But "I can pay more so I should have better things" is a ruinous worldview that, at its end, is just Might Makes Right.
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan
So you'll never vote GOP again. And you tacitly agree with Trump's repeated claim that conservatives will stay in the minority unless they _reform_ election rules -- https://www.theguardian.com/us-news/2020/mar/30/trump-republ.... Vote suppression and the "perpetual majority control of legislative, executive, and judicial branches," is Republican stated aim since the late 60s/early 70s when their party began its creep into permanent minority status
> It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to
What does this even mean? ACA was based on a GOP-governor-in-a-blue-state's successful implementation of HCR. Everyone loved it until Obama loved it, then the highly organized GOP minority hated it, fight it, wasted ~20 years claiming insanely to have a better solution they knew they never had nor will have
Back when Nancy's daughter Alexandra Pelosi used to make mini-doc shorts for the intolerable Bill Maher she made one about southern white Americans' opposition to ACA. She interviewed one fellow -- perpetually unemployed, alcohol/drug/legal problems etc -- who came well out of his chest against Democrats, socialism, The Gubmint and all the other typical lefty stuff that Fox News mentors him and so many others on. Then we find out he's on welfare. Then we find out he's on Medicare/medicaid. Pelosi's like "What?? Wait a minute ... I thought you didn't like this government stuff. Why're you all over it" and mans goes "WELL I DESERVE IT!!!"
Let's just call anti-UHC arguments what they are: wet bullshit from private healthcare industry stakeholders and the uninformed partisans who repeat Trumpist mantras
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
You mean like overturning Roe v. Wade? Can't ever happen, right?
> ACA was predicated on studies like this, to no avail
ACA was also predicated on broad participation. As with all insurance, the bigger the pool, the lower the premium. Insurance of any kind is primarily a risk arbitrage business and fundamentally relies on the presence of low risk consumers. ACA was designed with this in mind and made participation in the insurance pool mandatory(whether via the public marketplace, or via private).
Unfortunately for the ACA, the individual mandate was removed in 2017 via Trump's Tax Cuts and Jobs Act, which reduced the penalty to $0, while leaving intact the ban on denials based on preexisting conditions(on it's own a good thing). The elimination of the federal tax penalty caused health insurance premiums on the ACA individual marketplace to increase by an estimated 10% annually, as younger and healthier individuals dropped coverage and left behind a sicker, more expensive risk pool.
So, while it's fair to criticize the ACA, you simply can't expect a law to work if it's intentionally altered to engineer the worst case scenario specifically.
Here's the overall timeline
* March 23, 2010: President Barack Obama signs the ACA into law, establishing the individual mandate and its future financial penalties.
* June 28, 2012: The Supreme Court upholds the individual mandate's financial penalty, ruling it a valid exercise of Congress’s taxing power.
December 22, 2017: The TCJA sets the individual mandate penalty to $0. Lawmakers attached the repeal to a major federal tax overhaul package and used the budget reconciliation process that allowed the Senate to pass the measure with a simple majority vote, avoiding a filibuster.
January 1, 2019: The tax penalty officially drops to $0 nationwide, effectively eliminating the financial pressure to participate.
My favorite part of the ACA is that the nickname, Obamacare, was created by Republicans, thinking it would fail and the nickname would make that failure stick to Obama better. Problem was, the ACA helped a lot of people, particularly people in red areas. So, then Republicans started complaining that Obama and the Democrats were being arrogant for putting Obama's name on the ACA.
There's been tons of short interviews showing MAGA people having no idea ACA and Obamacare were the same things. They cheered when Obamacare got repelled even though they were beneficiaries of it. MAGA propaganda is powerful
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
At this point it says more about the state of our democracy than it does about any proposed solution. Even policies widely supported by the American public these days are met with obstructionists who care less about the welfare of the country than they do about scoring and blocking political "points".
I would never have had healthcare as an adult without the ACA due to an illness as a child that was expensive enough that I’m sure some insurance exec was only able to get a 26 foot yacht instead of a 30 footer.
It was a great success for people in my boat(no pun intended)
This doesnt need yet another study. Instead of narrating the problem we should figure out whats actually stopping it. And people saying the ACA was universal health coverage or even an attempt at it should stop intentionally derailing this discussion.
Look no further than the UK, with 24 month waiting lists, the shunning of experimental treatments (many high profile kill decision cases) and skyrocketing costs.
In the UK, a brain surgeon is paid less than the General Manager of a single Buc-ees Gas Station location in the United States. Absolutely diabolical.
The US, we ration too. We just do it in the most cruel way possible where the working poor doesn't get access to health care, because they can't afford it, and just lives with preventable and easily treated conditions until they die sooner and more miserably.
I'm honestly curious how we square this with the only experimental evidence we have on cost-sharing in the US, like the Oregon Medicaid Study and the RAND study which showed no impact on mortality or really any physical health outcomes at all.
I've become so cynical that I think even if universal health coverage would be passed, since it almost certainly would be run by the executive branch, it would become just another political football to be fucked with every 4 to 8 years.
Just think, if we had universal health care in the US today, the MMR vaccine would not be covered by it!
The US is far too broken for such a thing to ever come to be. Politicians are bought and paid for, and the impact on the insurance companies and their profits make this impossible.
US legislators will never, ever, ever put the needs of the people above the needs of corporations, not as long as corporations can wield their massive wealth as "free speech" in the form of lobbying and political donations.
The US has gone through a lot of changes since it's inception, so there's no reason we can't change this. Preferably to a system where people have the freedom to pay out of pocket for whatever level of care they want when they can afford it, avoiding the "death panels" and extended wait times that exist just about everywhere that already has a universal health system.
What UHC proponents never honestly admit is that these headline figures require incredibly optimistic assumptions and also much more rationing of care than our current model. We spend a lot on healthcare because we consume a lot of services. To save money, you have to buy fewer services. Yes, you can squeeze providers a little bit ("Medicare-level payments to providers" -- which they will absolutely hate, by the way), and you get another little bit by disposing of insurance provider profit margins ("reduced administrative overhead"). But the vast majority is coming from rationing, which people hate. And it would also cost massively increased taxes on the middle class, which voters also hate.
"Fewer avoidable emergency department visits and hospitalizations" -- sheer optimism. "Less fraudulent billing" -- no reason to believe this would be true. There could be even more fraudulent billing! Medicare fraud has been a big problem, and solutions are largely reactionary.
Since when has a government projection of costs ever been in any way realistic? The estimates for the costs of Medicare when it was established were low by a factor of 10.
You think they’re getting so much money from out current system that cutting out insurance companies would result in a 50% reduction in their pay? Have you ever looked up the size of the health insurance sector here?
You're being dishonest if you claim otherwise. UK brain surgeons get paid less than a Walmart general manager in the United States, let alone a like for like comparison.
Cut their pay by 50% and get rid of malpractice lawsuits. Have some other system that doesn't incentivize lawsuits where doctors are still held accountable but I think that's a deal most doctors would take in a heartbeat.
I'd like to believe this, but the study makes a bunch of really hasty assumptions.
The authors derive the $1T number from $1.3T in total cost savings and $304B in incremental spend (incremental spend is due to insuring more people). The $1.3T in cost savings come from five big buckets: lower pharmaceutical prices, Medicare-level payments to providers, reduced administrative overhead, less fraudulent billing, and fewer avoidable emergency department visits and hospitalizations.
The buckets themselves don't necessarily survive much scrutiny.
Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's not necessarily a free lunch.
The line item of "fewer avoidable emergency department visits and hospitalizations" assumes greater insurance coverage leads to greater access to primary care. It's true that great primary care prevents hospitalizations, and can be a net cost saving under certain assumptions [1]. But, we're actually in a primary care shortage. Existing insurance payments for primary care are low enough that private practices are going out of business and fewer residents are going into family medicine. Cutting rates (the paragraph above) would make this worse.
For "less fraudulent billing," a lot of people in the industry believe that Medicare has a large amount of undetected fraud. That's unfortunately the flip-side of reduced administrative overhead. The authors assume an 8% savings here, but the 2003 paper they cite uses the word "fraud" only twice and doesn't give a number.
Even if universal health coverage lost money it would be better than the current system that is based on a "causing cancer is better for the GDP than curing it" mentality.
Are you saying that most hospitals have 50% profit margins, of which 90% are paid to the chairman leaving only a thin margin? That seems difficult to believe.
They may have 4.2% margins knocked down to 4% by exec comp but I don't see that how that fact would change OPs point.
I'm saying if you think that administrative expenses (among others) can't be inflated for a profitable company, I would like to run your company and demonstrate what executive compensation can include:
- Base salary
- Bonuses
- Stock options
- Perquisites (perks) like company cars or private jet usage
Just to be clear - I like my private jet(s) on call in case I want to get away for the weekend. TYSM
Yes, I consider big numbers like this to be red flags.
The GDP of the US is $32T. Saving $1T will essentially make 3% of the US economy vanish. You don't vanish 3% of an economy without wide ranging repercussion, it would be a crisis similar in scale to that of 2008.
With such numbers we are not "saving money", these are about rebuilding an entire economy, a painful process. So either the effect will be much smaller than that, or there will be riots.
Yes, it will, but think about the supply side. If people spend $1T less on health, health professionals will earn $1T less, it means, as GP said, layoffs, cutting salaries, etc... Not just doctors and nurses but also drug researchers, medical equipment manufacturers, etc...
These people will now have to do the "something else" that will be spent on, let's say gardening. But you don't turn a nurse into a gardener just like that, that's the kind of "wide ranging repercussions" I mentioned, and the painful transition period where nurses become gardeners. "Nurse to gardener" is just a random example, it can be "drug researcher to petrochemist", and some transitions we may be happy to see, like "health insurance lawyer to burger flipper", but overall, many good people will suffer in transition, many powerful people too, which make such transition unlikely.
I don't understand why we always pay attention to only the jobs side of decisions like this. Why is the main concern always preserving existing jobs? The extreme version of that is obviously silly. The savings is real and lowers prices, increasing social mobility and spending elsewhere. How many people are locked out of moving for a job that matches them better, or taking some training for a better job and so on just because of medical debt leaving them no flexibility? And if we could save that trillion by eliminating jobs, doesn't that kind of imply those jobs (or at least the system requiring them) were terrible allocation of human capital?
I am not saying it is a bad thing. What I am saying is that when we are talking about trillions we are talking big changes, and big change doesn't come without suffering, and people don't like suffering.
Usually big change doesn't happen without a catastrophic event, like a war, a coup, or an economic crisis, or maybe more optimistically, a technical or scientific breakthrough. So when an article mentions trillions without hinting at such an event, to me, it is incomplete, or wrong.
The French revolution would be an extreme example. It is a win for freedom and democracy, but the period following it is called "the reign of terror", for good reasons.
I see. But I think that's kind of the same diffuse vs. visible problem that underlies a lot of impedents to progress. The jobs thing is one example. We focus on one set of workers because we can picture being in their position. We can't internalize and "feel" the diffuse but greater benefit of a more efficient healthcare system, which I'm 100% would be a net positive, just spread out over the whole population.
I don't know the solution, but do you agree that the problem is basically one of individuals not being able to accurately model the tradeoffs in their head?
Yes, but it's a different group of Americans, and the ones who are currently thriving in this broken system will fight tooth and nail to preserve their way of life.
The money doesn't vanish. It stays in the hands of people. People who would spend it on other things, feeding it into the wider economy instead of the pockets of a small number of corporations. There's zero reason to think this would result in anyone rioting except maybe insurance company CEOs.
Sure, it's possible in principle. But the US also has a much higher GDP per capita than the UK. The UK is a (relatively) poor country and is increasingly being left behind.
The US is in a class of its own when it comes to health spending. The second highest OECD country (per GDP) is Germany which is 5 points lower than the US (and BTW these figures include public and private spending).
You are clutching at straws to discount clear evidence that shows just how ideologically driven the US System status quo is...
"'No Way to Prevent This,' Says Only Nation Where This Regularly Happens"
This is broken window fallacy. The $1T not wasted on healthcare inefficiencies would be spent/invested on other things, creating jobs there. Yes, there would be churn because a good number of people involved in the bureaucracy of private health insurance would lose their job and possibly their career. But these things get smoothed out.
I mean there's flavors of contributions to gdp. Spending money on make work for people digging holes still counts. I wouldn't mind 1 trilly being freed up for more effective use. I imagine we could get pretty good returns on it just paying it against the debt as a simple idea, effectively a tax cut.
Only the American mind can comprehend leading to the deaths of tens of thousands of your own people for the sake of 3% of your economy. As long as the line goes up.
If we're taking the $1T figure seriously, let's take the other figure seriously too. Let's slash it to be more conservative while we're at it and say it would only save 90k lives. Do you think 3% of your economy is worth sacrificing to prevent the equivalent of 30 9/11s? And that's before considering that other people here already explained how these 3% are offset by other gains - if not completely then still substantially.
We're quick to want to automate trucking, manufacturing, even knowledge jobs and say "ooh but the horse shoe maker became the tire installer" but the pointless middleman jobs making everyone's health worse seems to be the line in the sand for job automation.
You can't touch the legions of people who exist to make things more expensive.
Yes, these cost savings would be a deflationary event. Most layoffs will come from insurance companies and administration necessary to satisfy them in hospitals.
One reason hospitals have such low margins is many people simply can't pay. If you have a payment guarantee like a medicare for all system, this will increase the stability of hospitals. In fact likely bring back some hospitals in places that didn't make sense like rural areas, which have been struggling via hospital closures.
If you are worried a low cost system will reduce doctors and hospitals per capita you don't need to, as countries that have universal healthcare often have more per capita.
I don't see you complaining that the US military has a low operating margin, so maybe we can just agree that some things are just normal expenses for a population. Which therefore leads to step 2: nationalize every single hospital.
>cutting salaries for doctors/nurses/etc
Considering that over 50% of the money that goes into healthcare is just siphoned off by middlemen, no, just getting rid of these means that your health workers do not have a worse salary.
>But, we're actually in a primary care shortage.
Because people do not even go see their GP since there's a chance it leads to life ruining expenses.
> fewer residents are going into family medicine.
Because they're going where money is. Remove that from the equation, and all you have is a public service with public servants.
>a lot of people in the industry believe that Medicare has a large amount of undetected fraud.
Aside from the fact that "people in the industry" have a financial interest in making you believe Medicare is a net negative, there's a great thing that comes from making healthcare a public service: there's no longer any fraud. And those "fraudulent" expenses you used to have that were costing you millions anyways have just had their costs cut in half.
>Healthcare reform is hard.
It's the easiest thing in the world when you have the amount of money the US does. Healthcare reform isn't a financial or infrastructure problem, it's a political one. Cuba has a working healthcare system despite being under US embargo. Botswana has a working healthcare system. Rwanda has a working healthcare system. Azerbaijan, Sri Lanka, Turkey, Serbia, and the list goes on.
Once you grow the balls to nationalize everything, even a first year economy student could make a plan that works.
Every country with nationalized healthcare systems has lower wages for clinicians. So the notion that this wouldn't lower salaries is just ludicrous. That might be an acceptable trade-off but let's not pretend it doesn't exist.
In practice what we would see under a single-payer system is that many doctors would just opt out and shift to a cash payment model. So the shortage of doctors would get even worse for patients who can't afford to pay out of pocket.
Those countries also just have lower salaries for all sectors. The USA is just exceptional in salaries for many professionals. Just look at software engineers pay in Europe Vs US....
> Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
I mean, admin costs at hospitals are ~25%, around half of that is directly linked to billing. Administrative costs in the US (because of course you have the same costs on the other side in the insurance side) are around 30% of cost in general, which is pretty insane.
The lack of regulation around pricing transparency and generally the lack of one-price-per-code (which the government uses to its "advantage" to get lower medicaid/medicare rates for sure) is what has caused this stupid arms race on both sides.
Billing and insurance ("BIR") is reported at around 8.5% of revenue --- admin isn't just BIR, as you note. But replacing private insurance with Medicare doesn't drive BIR to zero; Medicare is also a claims-based system. Estimates are that you'd cut BIR by somewhere around 30-40% (of 8.5%).
Most of the savings in these kinds of reports simply comes from paying doctors less (or delivering fewer procedures, which is also a problem we have.)
Physician/nurse salary is not the major driver of the cost of healthcare. It's around 12-15% spending, depending on the methodology. Even if you force doctors to work for free, it won't meaningfully affect the cost.
It's really the overhead costs that are so Byzantine that they can't be quantified properly. Hospitals have teams of coders, insurance companies have teams of counter-coders, physicians have to waste their time on calls with insurance companies, etc.
"Medicare for all" would alleviate a _lot_ of this. It already works for the elder population, and pretty much every senior has health conditions. So extending it for everybody would result in savings. This is a no-brainer from a purely fiscal point of view.
Another way to fix the mess is to lean on the free market side: prohibit employer-sponsored insurance. Completely. All the health insurance plans must be sold on the open market to everyone.
I just don't believe that it's correct. The Kraken hides here: Hospital Expenditures - 31.2%
I have a bit of personal experience here. I had a partner working as an endocrinologist, one of the higher-compensated medical professions. They were spending at least 1 _hour_ every day on calls with the insurance companies for prior authorization instead of seeing patients.
Some things are also weirdly broken down:
> Net Cost of Health Insurance Expenditures - 6.2%
> Administration and Net Cost of Health Insurance - 7.4%
Why are they split?
I also suspect that they included some admin personnel cost in the physician/nurse salary. For my partner, their office employed a person just to deal with insurance. There is no easy way to break down these costs for small practices.
I don't think a price transparency reform would be hard. Other than in terms of political will. We did go part of the way there a few years ago, though it's not common knowledge yet.
Hand-waving numerous details, but - That $37 isn't the price in the hospital's gift shop. It's n=1 pricing, hand delivered to your bedside by a nurse with a whole hierarchy of higher-level medical & admin staff behind her, and documented out the wazoo. Aspirin could be free & unlimited at the hospital pharmacy's receiving dock, and it wouldn't affect the @bedside price.
... and in other countries, medical administrative costs are far lower because they don't need to build entire divisions around correctly coding the same condition and procedure 11 different times before insurance approves it, because the insurance is universal and self-consistent by comparison to our private fractured mess.
Ever hear of loss leaders? Some parts of a typical hospital make money while others lose it hand over fist. The overall margin isn’t across the board, it’s after everything hopefully balances out.
ER’s for example are money pits, but society really needs them.
That's true, but obscuring the true costs through hidden cross-subsidies isn't helping anyone in the long run. We would probably be better off with state and local governments setting requirements for ER capacity in each region, and then running an annual reverse auction system where hospitals can bid on maintaining that capacity in exchange for cash payments.
Exactly this. They need to offset the areas where they lose money. And we have federal laws (justifiably so, IMHO) that ERs must provide stabilizing services regardless of insurance and ability to pay.
And while that law is obviously humane and reasonable, my only gripe is that the rest of our system is so backwards that it increasingly forces people to leverage that. There was a story about a woman who needed dialysis but had no insurance. So basically, she had to wait every couple weeks until she started breaking down, go to the ER, get emergency dialysis, get sent home. Rinse, repeat.
I don't blame her but really just the system that made this her best possible option.
Nationalized healthcare might help with certain things but it can't create capacity out of thin air. Just because the government theoretically covers everyone doesn't mean that services are actually available when needed. In general the countries with the highest levels of nationalization also have the most problems with shortages. When everything comes straight out of the government budget there's always a political tendency to cut costs by reducing provider payrolls, imposing waiting lists for expensive treatments, or refusing to cover certain treatments at all.
> In general the countries with the highest levels of nationalization also have the most problems with shortages.
Do you have any citations for this? I've heard this rhetoric before, but every time I look into it, searching around for studies on google scholar or the web, I can only find studies and reports indicating that health outcomes trend better in countries with more universal coverage. There are think pieces with anecdata of course, but no actual peer reviewed publications I can find.
Those studies have all, to my knowledge of them, shown no system mode that is better or worse than any other. The USA for many categories of care has often in those studies had worse wait times compared to nations with fully nationalized healthcare.
Heck when I went to college in Ohio's capital, the recommendation on how to get psychiatry or therapy as a new patient was to call the suicide helpline and claim that you were suicidal. That would get you a new patient appointment within 72 hours versus over 3 months on average for patients looking to get into care through normal channels.
Interesting you weren't able to find any examples. Here are some quick ones for CT scans in US Canada and UK.
The US maintains the highest hardware capacity of the three nations with roughly 43 scanners per million people and performs around 245 to 290 scans per 1,000 residents per year. non-emergency wait times are 1 to 7 days. The UK has 10 scanners per million people and ~100 scans per 1,000 residents, using centralized triage to keep non-emergency wait times between 1 and 6 weeks for NHS targets. Canada does 160 scans per 1,000 residents and 14 to 15 scanners per million, with wait times of 5 to 9 weeks.
When you consider that the US population is not fully covered by insurance, the number of scans is even higher
Okay, but that again seems to just be a few selected data points, rather than an actual trend, backed by peer reviewed study? Japan, Australia, and Iceland all have CT units per capita that exceed the US (~ 112, 70, and 50 /MM respectively), and all of three have universal care, two are full on single payer.
> Among patients undergoing cancer surgery, waiting times to initiation of first-course therapy have steadily increased since 2012, particularly at high-volume academic centers and among patients referred for definitive care. With continued consolidation and expansion of health systems, system-level strategies are urgently needed to monitor and mitigate delays in the delivery of surgical care for cancer.
> Delays were more pronounced at academic compared with community hospitals and among patients referred for care. Predictors of longer waiting time included Medicaid insurance (5 of 6 cancers), lowest-quartile income (6 of 6 cancers), Black race (5 of 6 cancers), increased travel distance (4 of 6 cancers), care in the West region (6 of 6 cancers), and treatment at academic institutions (6 of 6 cancers). Receipt of robotic operations was linked with longer waiting times for nonbreast malignancies (5 of 5 cancers).
There was a story about a woman who needed dialysis but had no insurance.
And who was in the country illegally so she couldn't use Medicare or Medicaid. Still a terrible situation, but not representative of the typical American.
Insurance pays the higher of their negotiated rate or the billed charge. Medical facilities set their billed rates so high that they’re guaranteed to be higher than all negotiated rates, ensuring that they get paid.
When you see $37 aspirin on the line, nobody actually pays $37 for it. The billed amount is replaced with whatever insurance rate is allowed for that. If someone is cash paying they get a large discount.
The billed items also have to cover everything. It’s not directly $37 for the aspirin, or the $5 or whatever allowed coverage it ultimately gets billed it. That had to cover the facilities, the salaries of the pharmacy staff who reviewed the request and dispensed it, the staff who inventory and order the medications, and the cost of billing insurance.
The only part that nationalized health care would change are the allowable billed rate and maybe the administrative overhead of billing different insurances. Even nationalized health care systems have admin overhead though.
You can think of it like when you have to pay $11 for a single glass of wine from a bottle that the restaurant paid $10 for. You’re not just paying for the liquid, you are paying into a big bucket of charges that all need to add up to more than the cost of the supplies, staff, building, and everything that goes into running it. The margin on individual products doesn’t make the entire operation profitable.
> The billed items also have to cover everything. It’s not directly $37 for the aspirin, or the $5 or whatever allowed coverage it ultimately gets billed it. That had to cover the facilities, the salaries of the pharmacy staff who reviewed the request and dispensed it, the staff who inventory and order the medications, and the cost of billing insurance.
That's the same as any? CVS charging $5 for aspirin has to cover their staff who stocked and checked out the item, the shelf space, the marketing, and the looting.
This is like that thing about about $15,000 toilets at DoD. What's actually happening is a cost allocation function where an agreed-on list price for a whole project is getting distributed pro-rata over as many different line-items as possible.
Sure, it's more expensive, but is it thousands of times more expensive? That $5 bottle probably has 50-100 pills in it. A single dose for $37 is 740X more expensive. And its not just that the apsrin is expensive to cover salaries, EVERYTHING is similarly inflated.
It’s more like a politically palatable Rube Goldberg machine for transferring costs to those (well-insured through their jobs, the Federal government, rich supporting institutions and donors) able to pay.
All healthcare systems have administrative overhead, including completely nationalized systems. The US discourse on health care overestimates the administrative overhead by a large amount. We could remove all insurance company profits and adjust our administrative overhead to be in line with countries with nationalized systems and it wouldn't change health care costs by an appreciable amount.
The discourse also underestimates how much of our health care costs go to our significantly higher salaries throughout the medical system. No politician wants to propose reducing the salaries of doctors, surgeons, or even researchers making new medications. The only acceptable villains are the administrators and insurance companies, but even in this inefficient system that's a much smaller slice of the pie chart than most people imagine.
One of the reasons hospitals operate in this convoluted way and still barely clear a profit is that we require them to treat everyone and attempt to collect payment later. A lot of what you and I pay for health care goes to cover people who can't or won't pay.
> The discourse also underestimates how much of our health care costs go to our significantly higher salaries throughout the medical system.
Well, the salaries of medical personnel only account for about 20% of total healthcare spending. So even cutting those by half wouldn't change much.
> One of the reasons hospitals operate in this convoluted way and still barely clear a profit is that we require them to treat everyone and attempt to collect payment later. A lot of what you and I pay for health care goes to cover people who can't or won't pay.
If that was a major reason, then those who don't pay would balance out those who pay and the grand total of all healthcare spending in the US would be pretty average despite individual premiums and out of pocket costs being sky high. But in reality, the total healthcare spending is just as sky high (several times more per capita then median OECD country).
That number might be true across all health spending, which includes hospital plant, home health care, all public health work (including animal control), and medical equipment. But if you zoom in on clinical and specialist practice, the parts of the health care equation where payer-structure actually enters the picture, compensation for practitioner shoots up; it's the dominant cost of running a health provider.
Hospitals, now that private equity is involved, do this weird cost shifting accounting BS with shell companies etc, as such their books aren’t straight forward and the 2-5% thing is likely greatly underestimated given the amount of understaffing PE has driven in that space and how much gouging there is from PBM etc.
You can search for more reports, because they do vary based on methodology. But the median hospital in the US makes between -1% (yes, negative, they lose money, because a huge percentage are non profits) and 4% depending on the source.
When the hospital charges you $37 for an aspirin, that singular pill might have a crazy profit margin in isolation. But your entire treatment could very well be losing the hospital money.
In my own anecdotal experience, the one hospital I know enough details about to comment on specifically, had something like 85% of patients costing the hospital more money than the hospital made. It was entirely funded by the relatively small number of people who had the “right” insurance and had the “right” procedures done.
How do the salaries of administrators at such hospitals compare to for profit hospitals? How do they compare to non-medical institutions of similar size? Without a lot more information, your statement doesn't mean anything.
It is a system where all prices and costs are so far detached from reality for multiple reasons, that looking at any current profit margins is not going to be very realistic either.
Really need to step back and start from first principles.
When I go to urgent care I get 15 minutes with a doctor who on average makes about $300K and maybe another 15 minutes with a nurse assistant who might be making $100K (or less). So that is less than $50 in doctor+nurse salary. Of course there are then all the overhead of rent, utilities, etc, etc but those are not so different from any other business in the same strip mall. So let's say total cost for my visit is maybe $100. But I'm charged $500-$600 for the visit. Someone is pocketing a lot of money and it is not the doctor nor the nurse.
We could do the same exercise for surgery, the costs for surgeons and anestethicians is much higher, but you'll be hard pressed to find any realistic scenario where the cost of a two hour surgery is more than $100K.
> a department to argue with insurers, etc cost the hospital?
My surgeon friends routinely complain about the inordinate amount of time they personally need to spend fighting with insurance, in the form of filling endless forms that insurance insists must be filled and signed by the doctor. This is in addition to whatever time/cost the hospital staff wastes fighting with insurance paperwork.
The surgeon time is not cheap, but the insurance companies expect these doctors to do all this paper pushing for free on top of their day job.
It's the salaries. That's where all the money is going. So that 37$ asperin, the profits... most of it is going to pay salaries. Not just of the doctors but administrators and all that.
The old saw about the engineer who says that the $100,000 bill was $1 for the bolt, and $99,999 for knowing which bolt it was... that's just funny AND true!
But if it's a team of nurses, doctors, and other healthcare specialists rushing around doing checklist work to make sure you get that aspirin, that's just evil.
The principle is only applicable to our industry and closely adjacent industries.
Hospital billing practices are often terrible or even fraudulent, but stories about the $37 aspirin are generally misleading. Most hospital claims and bills are actually coded around day rates and DRGs, so even if the aspirin shows up as a line item it doesn't actually impact the patient's financial responsibility or the amount allowed by their health plan. (I'm not trying to defend such a confusing system, just explaining how it works.)
To be clear, they are billing for all the coded line items at the listed prices, it is just that the agreements with the insurance company will disallow many of the line items in favor of other ones. They bill everything, because they may accept some insurance that has not negotiated a day rate, and in that case, the day rate code would be disallowed and some of the other line items will be paid at relevant negotiated rates instead (with others still likely disallowed). It needs to be the same bill in both cases, so they need to include everything, and the list prices need to be greater than or equal to what any insurance would pay, or they might lose out on the difference.
This is one of the areas where more standardization would certainly help. If there were more standardization of which codes disallow which other ones (which can currently vary wildly by plan even with the same insurer, must less across insurers), then a lot of line items could actually get removed as truly redundant, vastly simplifying the bill.
I have the best health plan available (as a lifelong heart patient) from my provider, which owns the hospital. I've been charged 250$ for a covid vaccine, which was administered when I was recovering from a surgery to stop Sepsis. My hospital bill was itemized and I called to verify it.
I would be able to dispute a double room billing, but I was sedated and dying so I took whatever they offered, assuming good faith.
Medicare has been playing a shell game with reimbursements for decades. They cut the base rate for an office visit or hospital stay to below the cost of the actual service, but allow for separate charges for various things that make up the difference so that doctors don't just stop accepting Medicare in mass. That's why you get billed $37 dollars for aspirin, $15 for drug administration, $50 for IV placement, $10/bag for saline drips, $75 for vitals checks, etc. That way the hospital can make up the money lost from the actual visit charge, this also requires more administration overhead, to both keep track of all the additional charges, and to make changes as the rules change.
On the occasions that I’ve watched a hospital go through the actual process of selling a small amount of inexpensive medication for a large amount of money, there is a ridiculous amount of ceremony involved. I can easily imagine that it costs that hospital 2 cents for the pill, $5 in amortized capital plus operating expense for the facility that stores that pill, plus $25 in labor and IT expenses to get that pill to the patient.
My wifes a doctor and i can assure you they are gouging you. What it is is that the insurance companys are really in the purchase processing business. So what they do is institute fees on every possible charge and the hospitals in our area mark everything up as a result. Thats part of the problem.
You understand that hospitals have more costs than just aspirin, right? Depreciation, amortization, utilities, rent, taxes, maintenance, salaries, etc...
It comes from the fact that lots of the charges they bill (both of the patient share billed to insured patients and of all costs billed to uninsured patients) end up written down or off because they are uncollectable.
The margin built into the prices bulled is not the actual margin the hospital ends up with.
I don't spend any healthcare money at the hospital. It's all all providers office, private clinic, etc.
It costs $300 for my primary care doctor to see me for about 7 minutes. An assistant takes my blood pressure, he asks me a few questions about my habits and diet, and then I come back next year.
If I actually need any services, I go to much more expensive specialist, or urgent care facility. A visit there is about $100 and then a couple bucks for whatever prescription they give me.
How does this work when many/most US hospitals operate as non-profits? Quick search shows the for-profits have operating margins nearly triple your figures. And the non-profits are beholden to the community to provide some level of "freebies" to maintain their status, right? IE, they're aren't really all operating on razor thin margins.
I'm curious where you got this figure, because it doesn't track with my own experience.
I used to work for a place that worked closely with hospital clients (and prospective clients) to resolve billing issues with a particular EMR system, and we regularly discovered that a given hospital was losing hundreds of thousands to millions of dollars weekly due to missing charges. The problem was, so much money was sloshing around that the hospitals were virtually always unaware of the missing charges, and many CIOs were more interested in saving face by shutting down further discussion than in walking through the collected data, how to fix the charging issues, and even claw back some of the lost charges (which you can generally do up to several months after the fact).
FWIW, your experience doesn't seem contradictory to the operating margin claims.
Your experience seems to be that hospitals are run very inefficiently, implying that if they were run efficiently that their operating margins would be much higher than 2-5%. That may be the case, but that still means the Yale paper's claims don't make sense (unless they also propose some mechanism by which to suddenly force all hospitals to start operating efficiently).
But I'm also skeptical of your claim that hospitals are leaving a huge amount of operating margin on the table. IME, very little can be explained by "everyone is stupid." Would I be surprised if a given hospital was run very inefficiently or if a given hospital had a particular poor CIO or administrator? Not in the slightest. Would I be surprised if ALL hospitals were run by idiots who were leaving 10% operating margin on the table? Yes, I would be.
To be fair, my experience has been exclusively with hospitals running a specific EMR with a relatively new-ish (at the time) and difficult to configure billing system. Still, we were expecting to see shortfalls nearly an order of magnitude smaller than what we found.
That the hospitals didn't seem to notice the problem, and upon being told of it, often pushed back against moving to fix the problem, is what gave the impression that they must be running on much larger margins than advertised.
There is a ton of ideology baked into naive-level analysis of this stuff.
I am constantly told how much less Europeans pay for better health outcomes and all I can think about was the obesity crisis I grew up around in Texas.
Socializing healthcare isn’t going to get an huge portion of the population out of their cars and get them walking as a primary or secondary mode of transportation. Not when it’s 100° and the grocery store is five miles away.
Americans, in no small part, have worse health outcomes because we have dramatically worse lifestyles. I support German-style universal healthcare, but I’m not going to pretend it will suddenly give us German health outcomes.
>Socializing healthcare isn’t going to get an huge portion of the population out of their cars and get them walking as a primary or secondary mode of transportation
You would think so but once healthcare cost becomes a government policy issue people complain about its spending and they are forced to try and bring that cost down. One of the ways they did that in my country was to promote biking to work and build bike ways.
Did I mention the 100° summers or the fact that people usually live 20+ miles from where they work?
I agree with you generally on the incentives, but it took us 70 years to paint ourselves into this corner, and we’re not going to get out of it because of a third-order incentive.
Thats not every where nor is it everyone. Im not saying it will specifically be bikes but the government will be incentivized to have a healthier population. It could be higher tax on cigs, or sugars, it could be more annual leave it could be any number of wellbeing policies.
But it is many places. You can't just magically hand-wave away the fact that the demographics between these places are wildly different, and that changes the burdens on the systems in place.
From a political philosophy standpoint, this is exactly why many people oppose a single-payer healthcare system. When the government is paying for everything it creates a financial incentive for an intrusive nanny state. We can argue about the positives and negatives, and maybe we would be healthier overall, but many Americans simply don't want the government telling them what to do.
One wonders what the lowered stress vis a vis healthcare concerns that a reformed system would take care of would do for our ability, as an electorate, to make better decisions in other arenas.
People wouldn't be externalities if healthcare costs money. Next thing you know you would have to pay attention to the environment or god forbid the food. It would eat away the budget for overthrowing countries and bombing children. Watch them elect a democrat to do the bombing next round and a new republican after that. It sounds like a joke but it isn't funny.
The US' healthcare model is not unique, and almost no countries have zero-cost-to-consumer healthcare systems (and none of them are free -- they're just paid by taxpayers instead of consumers). "Free" healthcare is the exception rather than some kind of international norm you incorrectly make it out to be.
No, they’re not false, you’re just misunderstanding. When people say “free” healthcare they do not literally mean all healthcare is zero dollars. They don’t mean nurses earn a wage of 0 dollars an hour.
No, they mean free at time of service, which they are.
Don’t believe me? Great, then ask them, without doing word gymnastics to try to trick them.
Should medical equipment cost 0 dollars to produce? Should doctors not earn any salary or wage? They will say no, 100% of the time.
> No, they mean free at time of service, which they are.
I don't think that's true France, Norway, New Zealand, or Switzerland. (And that's just developed nations. The GP's claim was every country other than the US.)
The vast majority of those 8 billion people do not have single payer healthcare. A lot of Americans get confused on this, because we're the only country in the Anglosphere that doesn't do single payer, but it's far from universal globally.
I didn’t say they did. I said they understand that free healthcare is not literally free, but comes from taxes. Do not underestimate them, they understand very basic things.
Healthcare reform isn’t actually hard. Every advanced country has done it bar the United States.
In every case costs have gone down and outcomes have improved.
You always build on what you have because you can’t pause healthcare for very obvious reasons.
Hence a lot of different systems all with the same aim. Controlled costs and universal coverage.
The idea the US is somehow different and cannot make the change is the result of propaganda and a mistaken belief that the current Us system is the worlds best despite its costs.
Healthcare reform is easy and there is an ocean of prior art.
Yeah, and they all generally get there by paying practitioners much less than the US does (by integer multiples). Single-payer, which this working paper equates with "universal coverage", is in fact not the norm among universal systems; besides using Medicare to ration the supply of practitioners, the original sin of our system is employer-based coverage, not payer structure.
Health care is an absolutely massive industry (everywhere, not just in the United States), and slashing compensation in a massive industry by top-down fiat is in fact not an especially easy thing to do.
Funny how one of the arguments against Medicare in the 60s was that providers wouldn’t accept it.
Turns out when you have the choice of accepting lower payment per patient for Medicare or having a lot fewer patients, you choose the lower payment per patient.
I would expect the same situation here. Doctors would grumble, but no one would force them to accept patients on whatever “Medicare for all” would be called. Nothing other than market forces.
A number of things would probably have to change, including the cost of medical school. But the system right now is expensive and essentially unsustainable. So change is inevitable.
Nope. More and more providers are dropping out of Medicare, or imposing limits on the number of Medicare patients that they're willing to see. It's tough to sustain a financially viable medical practice on Medicare rates, especially for primary care in HCOL areas. Medicaid is even worse. There are a lot of patients who nominally have coverage but in practice are functionally uninsured because they can't find a local doctor to take them on.
Why do doctors need to be paid integer multiples more in the US than every other country on earth? This is not rhetorical, I mean it sincerely.
And I’m aware that medical debt is a big issue, but it seems like a chicken-or-the-egg type problem. Of course you can charge $500k for a medical degree when the doctor can make it back and then some in 5-10 years.
They don't! It's a huge problem! It's probably the problem in US health care, which, despite my own belief that single-payer is bad policy, is in fact a total shitshow.
We have numbers for this, we don't need to derive them axiomatically. Practitioner compensation is the largest component of health provider spending. Liability coverage is the second largest component of admin spending, which is 25% of provider spending.
“We have numbers” is always refreshing, especially in a shell game.
Cost of all licensed medical practitioners? Or overweighting incomes of outlier CEO physicians?
25% is a steep tax on health in any case.
Fair enough, but it is a political topic, and there are different and more confusing slices of the healthcare system exposed to patients than org spending breakdowns. Not sure how many of this thread's comments could hold water if falsification were universally applied.
Just so that people reading this thread know that there is the medical expense version of the Bureau of Labor Statistics, and it lives inside Medicare (CMS), and it publishes data. Most things people are trying to derive axiomatically on this thread, you can just look up.
It's really easy now with Claude and GPT5; just ask them a question and tell them to answer it for you, with cites, from the NHE. (The data I argue from precedes widespread LLM research; I built a site for this a couple years ago and didn't bother to update my data, because I assume it didn't get much better.)
No, that's not why. Doctors also make drastically more than the median wage. Doctors make so much in the US because we have artificial scarcity of doctors.
No it isn't! The median wage for an electrician in the United States is about $65,000. It's nowhere near $200,000. The median general skilled wage is lower than that.
"Gen Z electricians making $240-280k in data centers" was a viral ploy by Mike Rowe on a podcast to promote his trades-training hustle.
> "The electricians that I interviewed and met two months ago in a data center in Plano, Texas, all under 30 years old, all making $240,000 to $280,000 a year, all with as much overtime as they want, none with any debt, all three of whom were poached three times in the prior 18 months," Rowe said ...
Google AI summaries then pick up wealth/finance grifter social media clickbait about it and parrots it as a fact.
There are contract data-center electrical jobs paying $55-65/hr (some with signing bonuses, per-diems, and benefits on top), but they only come close to $200,000 takehome by working 12/7 with generous overtime. And these are 5+ years of experience, OSHA 30, journeyman license, bring-your-own-tools. They're also exceptional; most are still $25-40/hr.
Nurses are also highly-paid in the USA (relative to other developed countries), and they make up a large part of the wage expenditure in the system. This may not make a difference to your point, but it is important to note that doctors are not the whole problem.
For those that have never looked it up, the median RN salary in the US is about $100k a year. Germany and the UK are more like $60k.
It’s funny, because it’s a career that feels both overpaid and underpaid to me. I went to a college where almost half of the students were going for nursing - and you certainly don’t need to be especially intelligent.
At least to an outsider, some nursing fields seem damned easy. The nurse that sees me before my GP? Pretty easy job.
Other specialties? Like the nurses that needed to clean up my wife after she massively bled during/after a c-section and they had to give her medications that also caused all sorts of other fluids to intermingle with the blood? Or the nurses that had to stand there for 10 minutes squeezing our infant daughter’s heel in the NICU to try to get enough blood out while she screamed as hard as a little baby can?
$100k doesn’t seem like enough. Odd occupation. For $60k I’d rather work at Costco, that’s for certain.
I think for the math to work you have to consider the bigger bulk of work that could be eliminated by universal healthcare: the payer industry. Insurers, PBMs, and all the smaller sectors that support them. The utility provided to society is fairly low — basically, just selective claims denial.
Any model that gets rid of these frees up a huge swath of capital and work from society, and can use that work elsewhere. Of course, that is easier said than done.
Truly. Aetna, United Healthcare, Anthem, etc are examples of industry that does not need to exist, and exist only to serve the status quo.
Each of those are companies worth billions of dollars that could be instead used to lower the individual cost of providing health insurance.
As you say, this would of course be unsavory in some respects as those companies employ a lot of people. It's not a very economically productive industry though, the main output seems to be consuming patients' and doctors' time, causing financial anguish, and causing stress among people as to whether or not if their condition will be covered.
They do perform one useful service: forcing a hospital that tries to issue a $100,000 bill that should be $10,000 to reissue it, and not leave the patient saddled with a giant debt.
(Medicaid & Medicare claims processors do the same thing. Medicaid claims processing is mostly handled by private, third-party insurers now, and seems to be able to do so more efficiently and cheaply than when it was being run directly by states; the savings is mostly in the area of catching fraud.)
Companies do this because it's massive song and dance by everyone. Hospitals issue big bills to insurance companies knowing they will want a discount so there is plenty of wiggle room. Also, it's free marketing for insurance companies because people see 100k, see all discounts for their insurance and are happy it's only 10% of true cost. It's like car buying except with your healthcare.
Medicare is much cheaper because they have fixed rates and hospitals know what to bill.
A lot of the reason hospitals have to charge so much is that they take massive losses on uninsured people in emergency rooms. Medicare for all means they don't have to treat anyone for free.
They are not taking any losses; they just charge the regular price with a very tiny profit margin. US healthcare costs are heavily inflated. Insurance is a scam that lets the rich get richer. All insurance should be non-profit.
We all contribute to the pool at a time when we don't need it so we can use the money when we do, not to make CEOs or stockholders rich. That is how an insurance pool should work. Any excess money at the end of the year should be moved to the pool for the next year, not as a bonus on CEOs' 100m+ salary.
It doesn't matter what they charge if the patient doesn't pay it; which is what often happens with uninsured people showing up at the ER.
> Any excess money at the end of the year should be moved to the pool for the next year, not as a bonus on CEOs' 100m+ salary
Under the ACA, excess money in the pool must be rebated to policy holders. In practice, this worked for a few years, but eventually insurance companies ended up increasing cost in order to increase the absolute amount they were allowed to keep. Maybe this is still good (more claims approved), but it is counter productive to the goal of reducing healthcare costs.
It often happens with insured people showing up at the ER as well. Many patients don't pay their bills, either because they can't afford it or are just deadbeats. As overall healthcare costs have increased, insurers and employers have shifted more costs to plan members through higher deductibles / co-pays / co-insurance. So hospitals end up with a lot more bad debt, and this in turn causes further price inflation.
Carriers and providers don't make this easy, either.
I had a recent doctor's visit, with very good healthcare coverage, that was an in-network facility but an out-of-network provider. Coverage would have kicked in if I had a referral from my PCP, but my PCP recently retired and I was advocating for my own health for a small dermatological issue. They said it was cosmetic, my old PCP said it was not. I got a stack of 10 bills over many months all stating different things -- everything from $0 EOB to over $2k in uncovered expenses. No one would take ownership of sorting out what I was on the hook for. No one I talked to was empowered to actually solve it. It wasn't an affordability problem over $2k (but would be for my elderly grandparents on fixed income). Even asking "If I give you $2k does that resolve the debt?" was answered with "we won't know until we apply the payment" type non-answers.
Burn the whole stack down -or- earn enough you can operate on cash for the tier of care you want. Nothing inbetween seems to be working.
Aren't their profits regulated regardless? If all insurance companies became non profit and let's say total prices dropped by 3-5% that still wouldn't change the situation dramatically?
There are many factors, e.g. amongst other things American doctors are better paid than just about anywhere else in the world.
The bigger factor in the American system is taxes. If everyone in the healthcare industry stack, from suppliers to nurses, is exempt from federal and state taxes, healthcare costs could come down by 70%+.
Yes and no. It's sort of a weird thing where insurance is somewhat regulated nationally but also regulated in a piecemeal fashion state by state.
There's a non-government standards body called the NAIC which provided national guidance for insurers. Most (all?) states basically say that "if you follow NAIC standards, you are good".
> If all insurance companies became non profit and let's say total prices dropped by 3-5% that still wouldn't change the situation dramatically?
It's a huge mess. It's not even really a profit vs non-profit thing but rather "what's the motivation". One major issue is that the ACA put in a loss ratio of 80%. Which isn't a terrible thing in principle, it forces insurance companies to spend money on treatment. The problem is it also means that the profit of insurance companies is tied directly to how much they spend on healthcare. As a result, they are incentivized to spend more, not less, on medical treatments so they can justify higher premiums.
This is a big part of why I think universal public insurance is a must. Basically the only organization that's motivated to keep costs as low as possible is the government.
> American doctors are better paid than just about anywhere else in the world.
This is a problem, but the bigger issue and why doctors are paid so well is because becoming a doctor is one of the more costly and hard to do things in america. There are limited spots, schools, and residency requirements that severely restricts the number of possible doctors we add per year. That drives up the their salaries.
I have a nephew going to medical school in Idaho of all places, and he's looking at $500k in debt by the end of the whole ordeal.
> One major issue is that the ACA put in a loss ratio of 80%. Which isn't a terrible thing in principle, it forces insurance companies to spend money on treatment. The problem is it also means that the profit of insurance companies is tied directly to how much they spend on healthcare. As a result, they are incentivized to spend more, not less, on medical treatments so they can justify higher premiums.
Investors care about margins, not absolute dollar figures. If your non-medical costs are capped, the incentive would be to reduce your other costs to preserve or maximize profits.
So the 80/20 rule is unlikely to have caused anything. More likely it's too low, and the amount of profit that can extracted and passed to investors is still higher than most investing alternatives, which is why it keeps attracting more investment. Without the 80/20 rule we would have seen the same thing or worse, though perhaps slower premium increases but less treatment delivered.
Really this all points to structural problems in the market. Naively we might presume there's not enough competition, and there could be many reasons for that--over regulation, lack of transparency. But it's more complicated than just that because medical treatment, particularly the most costly treatments, presumably have very high price elasticity [citation needed], are long-term investors are just gonna keep trying to draw as much from the well as they can. The problem with public single-payer is that the basic demand curve doesn't magically disappear, so rather than complain about high prices people complain about shortages, OR the government just keeps borrowing to maintain satisfactory treatment access until they can't borrow anymore.
> Basically the only organization that's motivated to keep costs as low as possible is the government.
Unfortunately, this isn't true for the government either.
Source: personal experience of me and literally dozens of people that I know. I've briefly worked with my country's government, and in that time I personally experienced and got dozens of stories along the lines of "the government spent tens of thousands of dollars of aggregate government employees' time because a single employee booked a hotel that was less than one dollar above the approved rate while traveling".
There's a good reason for this, of course: bureaucracies' policies are mostly "scar tissue" from high-profile cases where a bad actor did something they shouldn't have but wasn't specifically against policy, and then a policy was written for that case and stands for the rest of time. And, bureaucracies are risk-averse, especially democratic governments, whose leaders are elected based on optics almost as much as policy.
But it doesn't change the facts. Not only are large bureaucracies inefficient, but government bureaucracies specifically are incentivized to optimize for optics and structure rather than improving that inefficiency, and anyone who has actually worked for a large government can tell you that.
I'm not necessarily opposed to making all health plans non-profit, but that's kind of a red herring. Many of the largest insurers, like most Blue Cross Blue Shield Association members and EmblemHealth, are already non-profit. They generally don't charge plan members any less than their for-profit peers.
Not really accurate if you look at the closure of rural and smaller city healthcare facilities. They don't have the base to charge "regular price" to make up for the aging, less healthy, rural populations.
We all pay for it, but some pay heavier costs than others.
The fun part is when you break those numbers down between government and non-government expenditure. You’ll find that US governmental spending on health care per capita is higher than every other country’s entire (gov and non-gov) spending per capita.
That number seems hard to believe? Specifically that non government spending would be this low. Presumably "compulsory" includes way more than direct government spending.
According to the world bank it's closer to 40:60 (government spending still being the majority). So that puts it behind Switzerland but still more than combined spending in just about any other country.
In that link, government/compulsory for the United States seems to indicate times when an insurance company covered it. Voluntary/Out of Pocket is when insurance company wasn't required to cover and did or person paid out of pocket.
Even if it's US Government only per capita with people the government insures, it makes sense it would be so high because only people on government insurance are the poor/disabled AND old. Two groups that have extremely high utilization.
The spending per capita, unless I’m mistaken, is just “per person in the country” not “per person insured by the government”.
That means that even though government insurance in the US only covers a relatively small percent of the population, we pay more than other countries that cover the whole population.
Per capita stats are computed based on population, not per treatment or per person eligible for treatment. The US spends more per head on giving only a fraction of them subsidised healthcare than other nations manage on universal health, [more years of] education, [more generous] welfare payments etc. Some of that is down to medical professional salary discrepancies, but some of it is down to a terrible system...
>"Per capita stats are computed based on population, not per treatment or per person eligible for treatment. "
Your point is correct, but since the majority of healthcare spending occurs in the last 18 months of life, and the vast majority are on either Medicare or Medicaid during that time of their life (either due to age or ailment-related incapacity), it doesn't make a huge difference.
That claim is at odds with the working paper's methodology, which gets a good chunk of the $1T in savings it discussed by assuming very sharp cuts to practitioner compensation.
It also means that emergency rooms can be used just for emergencies and ongoing and preventative care can happen in clinics. Cheaper to operate and preventing preventable emergencies lowers the load.
Here's what happens in my locale. If you show up in an ER, they quickly decide whether you need emergency care, or regular urgent care, delivered in the same facility. And medicine is anything if not statistical, so they know the amount of each kind of service that they need to plan for.
My jimmies are hard to rustle. I'm fortunate that I have flexible hours, and can leave work if I need to visit a clinic. If either of my adult kids gets sick, they start making calls to find someone who can take their shift. So I suspect it boils down to individual or family circumstances.
A lot of the rest of the reasons are carrying the deadweight of administering regulation, and dancing with the existing and prospective malpractice suits that randomly benefit the system sometimes, but always cost everybody, and warp the practice of medicine and patient healthcare experiences.
So what's the solution? Some states have already limited malpractice liability but that hasn't done much to hold down costs. When patients are harmed by preventable medical errors they should be compensated.
The solution is NOT to decide on one problem at a time to all agree on solving by incremental compromise, or trust free market competition driving what is in reality a non-free market.
Most patients never file a lawsuit, even if things don't go well, and most injuries that aren't deaths or newsworthy are not worth the trouble to an "overburdened" court system itself imposing a lot of burdens.
And the quality life years lost waiting to share a verdict with attorneys ought to count for everyone affected, not just those who spearhead a trial by catastrophe.
I think the solution is to make the practice of medicine more scientific, and less dominated by competitive incentives, but as long as research and development, reform, or even consumer choice, is strictly a cost, that will be considered "too expensive", if not "too risky".
That's a non answer. The medical profession is already embracing evidence-based medicine as well as specific tools such as checklists and EHRs to reduce preventable errors. But there will always be some providers who are simply sloppy or incompetent or even malicious. Nothing else you proposed is actionable, just vague complaints and hand waving.
When patients are harmed by quacks, it is a true problem and those quacks should be incarcerated and never allowed near medicine again. If there are too many quacks, then this is a systemic problem that needs to be addressed completely separately from malpractice and professional insurance.
When patients are harmed by medical errors caused by non-quacks, that's just tough luck. Not everyone can be saved. Creating a gigantic medical malpractice insurance industry so that a few hundred surviving families per year can have lottery jackpot settlements isn't a solution in any way, and has done very little to incentivize fewer errors.
That's a silly comment. There's a huge difference between establishing civil liability versus a criminal conviction, and rightly so. The quacks aren't going to be incarcerated.
I think instead of my comment being silly, it's just difficult for you to understand because your Overton window only allows people who agree with you but differ on how much compensation should be allowed and the particulars of how that compensation is decided and doled out.
You can quibble with the specific projected savings, or the projected lives saved. But it kinda doesn't matter? If we can have net savings of half what this paper said, or a quarter, and still have more lives saved, that would still be a strong argument to do it.
Somewhere there's a pareto-optimal frontier where one can't possibly save more lives without spending more, or spend less without more people having negative health outcomes ... and the question is whether universal health coverage would be a step towards that frontier (b/c we're all pretty sure we're far from the frontier today). And the fact that plenty of countries have both lower costs and better outcomes through such a system is highly suggestive that it is a more efficient policy regime.
Maybe the big quibble is whether the American penchant for creating corporate givewaways to powerful organizations that lobby politicians would create an especially toxic public-private-partnership monopoly in which the biggest existing private healthcare networks are granted regional monopolies and set crazy prices (or some other dystopian warping of an initially reasonable idea) so costs actually balloon. I do think that would be a risk and so we need to be careful about the specifics of how we implement this.
>> Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
You arent considering
1. Hospitals eating the cost of the uninsured, which this would solve
2. Hospital spending tons on administrative duties fighting with insurers on coverage, which this would reduce
How would this change solve: "Hospitals eating the cost of the uninsured..."?
Wouldn't it just transfer the cost from the hospitals to the universal coverage agency? This would make the financial picture even worse for the proposed system.
>>> Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance.
The hospital can be paid less without reducing their margin if they can remove a cost from their balance sheet. It does not make the system cheaper overall, but it means the hospital does not have to bear those costs directly. They may not have to bear them at all, because hospitals are not the only things in the system.
Those are two real effects, but together they wouldn't compensate for the rate cuts.
About 8% of the population is uninsured. The uninsured population skews younger, with less healthcare utilization (Medicare already covers everyone 65 and older).
Another comment in this thread estimated billing overhead at 8.5%. Medicare for All would eliminate some, but not all of this, since Medicare is still a claims-based system. You would remove a lot of overhead around prior auths, which I agree is a good thing, but could be achieved with more focused legislation.
> .. 8% of the population is uninsured. ..
this is Bogus, one of the first argument hospitals make for inflated pricing is that they have to cover the cost of uninsured. if the uninsured doesnt exist then the whole line of BS argument falls.
What hospitals makes has nothing to do with physician pay - those are separate categories. Hospitals aren’t going to magically start giving some of their profit to doctors to help cover their lower fees.
OP makes a good point. The studies assumes two diametrically opposed things will happen - doctors will take a 50% pay cut but access to primary care physicians will increase.
Why would we solve the primary care physician shortage by cutting their pay?
> Hospital spending tons on administrative duties fighting with insurers on coverage, which this would reduce
Would this go away, though? Instead of fighting with insurers they would be fighting with the government insurer?
I am very pro universal healthcare, I just don’t want to pretend there aren’t still going to be fights over what should be paid for.
No matter what, there are going to be disagreements on what medical procedures should be paid for and who needs them, as well as how much they should be billed for.
The way a lot of other countries deal with this is that the government calculates out a benefit vs cost assessment for every new treatment and only covers ones that come out ahead. But, that ends up with things like new targeted chemotherapies being unavailable for years after their initial release, vs in the US where they are available to much of the population once the right prior auth is filed. There is also more top down management of costs, such as long term life support for people in vegetative states.
All of this was branded as "death boards" in the American healthcare debate.
People hate it when faceless bureaucrats decide that some health care expense is too expensive for the large faceless bureaucracy to cover, when they have a medical issue that they would like the large faceless bureaucracy to spend money on. Perhaps in that world, some insane guy with a back injury who's unhappy about the quality of his care assassinates the Secretary of Health and Human Services, rather than the CEO of a medical insurance corporation (and hey, a lot of people hate RFK Jr. anyway, so maybe that assassin still becomes a folk hero for doing it).
This is already how Medicare works and it covers 70 million Americans. I’m not aware of any of these hypothetical violent outcomes being a huge problem for the program.
> Instead of fighting with insurers they would be fighting with the government insurer?
1. I'd rather fight the non profit-motivated entity
2. We can probably compare to VA and Medicare and even other countries to see what the fight will be like. I'm willing to bet it will be a big improvement.
> No matter what, there are going to be disagreements on what medical procedures should be paid for and who needs them, as well as how much they should be billed for.
Government insurance has a service motive. Private insurance has a profit motive.
> 2. Hospital spending tons on administrative duties fighting with insurers on coverage, which this would reduce
This layer won't go without a fight. Maybe it _is_ the layer we're fighting against. The owners will still make profit, the providers still have jobs.. but the middle layers are useless bloat. They don't have skills to provide care, they don't operate at the capitalist layer. They are useless today, and even more useless tomorrow.
And that is likely useless layer is millions? of jobs.
There’s essentially zero doubt that universal healthcare would save over $1T per year.
How do we know? The experiment has been done multiple times, all over the world. In the worst case (Sweden), healthcare is a bit short of $5K per capita per year, or around $1.7T. We’ve actually got a nice margin to achieve $1T, even if we remain the worst.
I agree health care reform is hard, though. We have a clear roadmap on how it can work a lot better. But what’s the political path forward?
As someone who’s actually fiscally conservative, single-payer universal healthcare is an absolute no-brainer, but, ironically, the people who call themselves fiscal conservatives will fight it to the death (well, not that ironic — at this point we all understand that, in politics, what groups purport to believe and what they actually believe have little to do with each other).
>"fewer avoidable emergency department visits and hospitalizations" assumes greater insurance coverage leads to greater access to primary care.
This is a hoot. There is an entire cohort of people who use the emergency room as their non-urgent clinic. This is not a small demographic, it must be at minimum tens of millions of people, if not going above the nine digit mark. They do this because their parents did it, and it's the only thing they know, and their parents did it because it's the only thing they knew, and they did it because their parents did the same. It is a culture that no amount of education and public service announcements will ever change.
Heaping one perverse incentive after another on top of this mess won't change it either, but will almost certainly make things worse for everyone.
>For "less fraudulent billing," a lot of people in the industry believe that Medicare has a large amount of undetected fraud.
My grandpa when he was still alive would have one new fraud story with every visit to the doctor, and he wasn't in great shape towards the end, so this was too many to count, every year for the last few. Diabetic, they ordered him compression socks at one point... a dozen show up instead of the two pair that was ordered. He'd come home and wait for a bill in the mail, and a few days later would see itemization for tests and procedures he never underwent. Over and over and over. He was sharp, argumentative, and as far as I could tell, less confused than most his own age. His experience, I think, wasn't atypical.
There are many studies from reputable sources (one being the CBO) that say it would result in almost no savings or potentially even higher costs, just like there are many studies like this one that say there will be massive savings with no reduction in quality of care.
I support universal health care, but each side just lobs whatever data supports their position at the other without any real thought. Most people in support of a universal health care system seem to be completely unaware that the vast majority of households are happy with their current coverage (whether they should be or not isn't relevant really) and are not looking for someone who claims to know better to "improve their medical care" through a entity (the US federal government) that is generally not known for improving almost any situation it interacts with.
I personally would like to see Medicare opened up to the public as an option. It's simple, doesn't require anything of anyone who doesn't want to participate, and should be a reasonable test for the claims of cost savings. If it's truly a better option, people will move to it. If not, then the conversion will not happen.
Barring some sort of catastrophic financial or medical event, there is a 0% chance that anyone can make a radical change to the status quo.
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[ 0.20 ms ] story [ 17.1 ms ] thread1. money to providers
2. overall healthcare consumption
3. bureaucratic redundancy and waste
1 is going to piss off medical providers. 2 is going to piss of the general public. 3 is going to piss off the 20 million healthcare industry workers who are not direct care providers. So pick your poison. This is why it will never pass.
Universal health coverage may save lives and money but this study doesn't provide actual evidence for it.
So well known you neglected to state or cite them? I'd invite you to do so now.
America: Sounds like communism
"Jeffries co-sponsored Medicare for All legislation between 2013 and 2021, but in August 2026, he stated he shifted his stance and stated that he no longer supports or co-sponsors the proposal." https://en.wikipedia.org/wiki/Hakeem_Jeffries#Healthcare
Maybe extreme but what prevents that entity from becoming the decider regarding who lives and dies?
But I suppose they are the party of big business, not the party of business in general.
Bill Clinton was a once-a-century skilled politician, but if you translated his policies without his extreme personal charisma to today it’s unlikely he would make it through the Dem primaries.
Main problems are elsewhere: doctors gatekeeping the market, lack of transparency when it comes to pricing, regulation making it impossible to compete for smaller players etc.
https://kffhealthnews.org/news/nixon-proposal/
Oh hi. That is me.
All they'd have to do is cut a few friends (insurers) loose. They'd still even have the power of the contract to reward theoretically productive elements of the new health system in return for kickbacks, and there'd simply be more money sloshing around within government to take advantage of. They could continue to stomp the planet freely, because Americans don't care about anyone but themselves. The upper-middle class post-Obama "left" would evaporate. Give them free state college and they'd start calling Republicans the real left.
Another reminder that the US government spends more per-capita on health care than every country with universal health care, and then the population pays again.
One of the things usually cited to defend this waste of money is the massive excess army of people working in healthcare administration, half of whom are employed to file paperwork and the other half employed to throw it in the trash. Now that they're all soon to be replaced by AIs which will be able to simultaneously file and delete worthless paperwork at inhuman speeds, we can let go of that garbage excuse.
But in a more sane world the Republican Party would simply acknowledge slavery as being a real debt owed, and stop being racist, without changing anything else. Most black people are socially conservative Christians, and it would instantly become another God-Emperor situation. Democrats haven't won whites since Kennedy; they gave them entirely up for supporting basic civil rights for black people (an own-goal for the Republican Party, started as a single-issue antislavery party) and big business. Without guaranteed black support (the only other choice black people have to Democrats is not to vote, which is quickly increasing its share), the Democrats wouldn't be a viable party at any level. Republicans are not sane, they are short-termists like everyone else.
Picking out the Republicans is unfair, though. Democrats lobbied furiously and entirely dishonestly against single-payer healthcare in 2016 and 2020. They even tried to sell single-payer and its supporters as racist.
They don't give any shits about free market economics or struggling entrepreneurs. They care about protecting their own money.
And it isn't about big business; that's the Democratic Party. It is about hoarding wealth and gaining more.
And nothing will come of it. Too many entrenched interests, regulatory capture, and lobbying + political donations.
What is driving the actual cost is the high expenses hospitals have, and the biggest source of that is labour cost, as in any other industry. American healthcare workers, doctors and nurses, earn about 2-3x as much as their peers in the developed world.
There's no logic in what you're trying to argue. Healthcare providers charge for their service, insurance companies negotiate that cost down, next to risk management that collective bargain power is the reason you buy insurance in the first place. Again if what you're saying is true all you'd need to do is just buy your healthcare from the hospital directly, if you end up in the ER take a look at the bill and tell me how that went
Without data on what proportion of people are denied and what the consequences are, this isn’t a good faith argument.
On the flip side, cases that would get care in Canada are denied in the USA by private insurance. Private options are far outside the means of most people.
https://commons.wikimedia.org/wiki/File:Life_expectancy_vs_h...
While I love the idea of never having to think about health care costs for a variety of reasons, I do like that some services are available to anyone with a wallet and not locked behind government controlled gates.
As I understand Medicaid, it would just be open Medicaid for 100% of the US population regardless of the income, remove Medicare (they are now under Medicaid), leave the private sector as it is. Do you think Medicaid is too slow, too low quality, too terrible in general? Pay for private insurance, but you can still go to Medicare if needed.
First off, all Canadian provinces are different. Here in Quebec, there is a absolutely a private option. Not everyone likes that it exists, but most people seem to like having that option.
Canadians live better for longer on average (for cheaper healthcare overall). Any other metric is just a misguided attempt to justify the US status quo, which has nothing going for it unless you're rich.
I'm originally from Mexico. With what I have paid in tax here over the years I can afford to set up and operate my own small hospital over there, with new equipment, this is not an exaggeration.
"Free" healthcare, as with many other free things, turns out to be the most expensive kind of healthcare. Anyone who thinks otherwise doesn't really know what they're talking about or they're just stupid.
What could work, imo, and since we're all giving opinions here, is private healthcare with a ceiling on profits. Let players take 2x-5x, but not 50x which is what they do now, bring and enforce usury laws into healthcare.
I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
I'm not saying that this is what is happening now, but I am saying that calls for universal health coverage, no matter how correct and well supported, are going to probably face the same obstacles they did last time, so we need new coalitions and implementation proposals if we're going to give it a go again. It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to.
The problem with US healthcare isn't who pays for it, its how damn expensive it is. As always there are multiple factors at play, my list would include corruption, lack of legal accountability/responsibility, and a population that is much less healthy than reasonable.
Go after any one of those and we'd make a lot more headway than trying to ram through a universal, government-run healthcare or insurance program. And yes, such a program could impact the above topics, but it doesn't have to and could make any of them worse.
It does this by eliminating a very inefficient layer of our current system (insurance companies), and by having there replacement for that (the government) negotiate on drug prices (how much savings there is the reason there are two estimates). Currently insurance companies almost have a negative incentive to push down drug prices (their profits are limited to a percentage of total spending, and most large companies are pushing against that limit).
Most of the cost control pressures in our current system come out of Medicare/Medicade, and this would widen that out to the whole system. That in turn would wedge open the door to pushing on the other drivers of the cost spirals: hospital administration, new expensive drugs that are not worth the additional costs, doctor salaries ballooning, and the broken system between malpractice insurance and dysfunctional enforcement against malpractice.
I'd argue that the primary issue with insurance costs today is the lack of market competition, obscurity of what costs and prices are, and government protections that prevent insurance companies from being legally liable for many of the problems they cause.
Corruption and monopolistic practices is a big deal in healthcare, for example. We'd be better off, in my opinion, by solving that rather than killing an entire private industry and hoping our government can continue to do it better indefinitely.
I don't see why you'd need to do that. Just expand medicare to everyone and if people want to also buy private insurance they can.
They'd just need to be more competitive and add significant value, which they don't currently do.
Actually I thought that was already the case.
Every other developed country has managed it so why don't you look to see how they achieved it?
Wouldn't you like to never worry about healthcare costs again?
For prices to be sane we need people being able to compare prices, decide what care they want and can afford, etc. Our prices are so high because its a closed market acting as though it were a free/open market being driven in part by customer decisions.
Its possible for a provider to know ahead of time that providing a saline IV costs $60, for example. Its also possible to have health care policies that approve any treatment deemed necessary at any healthcare provider, or at any healthcare provider in network if that concept was still a thing.
We don't have to have a preauthorisation step where doctors are expected to ask insurance companies if they will approve a certain treatment for a certain patient before it can be done. That is a particularly terrible implementation if you ask me.
My favorite was a friend who had to deliver her child, alone, in a hallway, because they forgot about her. And the hospital billed her for it. LOL.
Exactly! There's so much paperwork that a doctor sometimes need two assistants just for the paper work. There's so much cost for independent practice that increasingly more doctors end up joining big hospitals. Charges with and without insurance have a huge difference. Just to name a few.
https://nationalhealthspending.org/
I haven't finished reading the paper and have no opinions on it (other than that most successful universal systems aren't single-payer) but if we start from actual numbers the discussion will be better.
I think once universal health coverage is established, it amounts to political suicide to try to take it away again.
Essentially, all solutions require addressing the slow-burn civil war, which is today capable of of subsuming any issue. Not a single policy issue can realistically be addressed while the rabid 800lb gorilla is in the room. That gorilla is not Trump, that gorilla is Heritage, Fox News, Koch, et al.
Additionally, as somebody who was around pre-ACA, I can not tell you how much better, in every single way, the post-ACA healthcare world is. Pre-existing conditions? Access to healthcare as an individual? These are life-changing possibilities, especially for entrepreneurs.
There's a very clear type of fallacy you are engaging in here that only works in politics: you're taking a vague general idea X, ignoring all particulars, and then lumping an idea Y together as if they identical and that any change in that general direction of Y could ever be different than what happened with X. There's no intellectual rigor or honesty in that sort of thinking, yet it somehow pops up throughout all of politics.
My afib ER trip three years ago cost me $7k out of pocket even though I left the hospital still in afib.
Today in my 50s, my deductible is now $8,500. My partner doesn't have insurance because she's not poor enough or rich enough.
We had an insurance rep come to my work last year who said after ACA they had some people whose premiums went up 900%.
So yeah, ACA is better in your world, but not in mine.
I would really like to just be able to get a true catastrophic policy which would cover unlikely risks such as cancer -- and then go on a cash basis for common meds and treatments. The ACA made this kind of insurance illegal, so my choice is to leave my family uninsured -- or let insurance soak up the money I might have saved for their college education.
)which is why as a percentage of GDP, Americans, European costs are remarkably similar, just distributed differently).
This has been one of the opposition points - don't just give a handout to insurance companies without addressing their billing practices
The original ACA did not have consensus for some of the proposals to address the billing practices such as existing and new state healthcare programs having collective bargaining. And yeah I think the original ACA was unworkable, compromise is taught as a good thing to children in this country, but it just means "the wrong answer".
The tweaks now, alongside the original democrat led ACA, alongside the parts that were stripped out I think could have better consensus
does need a rebranding though.
The only that will actually lower costs in our society is healthy people. And right now, everyone is unhealthy and not doing preventative measures due to expense.
I would quit my day job and completely focus on my side business if I didn't have to worry about healthcare.
Personally, I would retire early. I have enough to cover bills and reasonable HC costs, but the way it is now, I'll just keep plugging away for a few more years.
Any single mom who works as a stripper can go see a doctor who doesn't have the slightest inclination to judge- you're just a number in a government database. Everyone's getting free shit no questions asked.
If there's a benefit to religious charity, it lies not in the "inclination to judge" but in maintaining a multiplicity of authorities. Combining everything under the government umbrella gives you a totalitarian society; a liberal democracy restrains the power of government while allowing for competing authorities in other spheres, like medicine, religion, academia, and the press. Giving the government the power to mandate or withhold medical treatment for political opponents (think Soviet "sluggish schizophrenia" as a diagnosis for removing dissidents from public life) seems more worrying than strippers getting free healthcare.
That the ACA forced a large number of people to pay a lot more for literally the same product is not a good outcome for those people. Too many people try to pretend this didn't happen.
The ACA has killed a whole lot more lives than it has saved by causing healthcare costs to spiral up.
If you begin with something that is obviously incorrect and trivially debunkable, perhaps that's indication that you should review your priors.
All of the providers have consolidated. I don’t know if ACA affected that or not, but wait times for checkups went from later this afternoon to sometime 6 months from now.
Part of my experience is going from corporate health insurance to marketplace, but in the past 5 years, ACA plans have consistently gotten worse and more expensive while service for those plans has gotten significantly worse in almost every way.
Who is it better for?
There is a legitimate shortage of physicians in many areas, especially in primary care. This has a variety of causes including bottlenecks in the training pipeline, shitty working conditions that drive experienced doctors out of the profession, and an aging populace that has drastically increased demand. More and more doctors are opting out of taking any sort of insurance and shifting to concierge medicine or cash-pay models.
People with pre-existing conditions. They were literally uninsurable before the ACA.
The insurance costs are also skyrocketing in the employer-sponsored insurance.
Not debatable that it has gotten worse over the last decade, mostly due to one party in the government intentionally doing what they can to chip away at the efficacy of the program, which when it launched was incredibly compromise heavy and should have been viewed as a first step towards a better, long term solution.
I had a local primary care I really liked; I never saw the Dr. there, just the Physician's Assistant typically. They were independent, and last year they made the change to go to a membership model. Basically $50/month just to be able to be a patient of their practice, and then use your insurance for care. In their notification she laid out the economics of where they currently were and it wasn't sustainable for them, based on how much they were squeezed, mostly by not being also a facility to be able to double bill insurance for facility fees + care fees. Also mentioned that the other 3 independent doctors in our neighborhood had all closed in the last 2 years.
But the Republicans called the Democrats commies anyway and refused to participate. And that has been their playbook ever since. That is what they are going to do, no matter what we propose.
So we may as well propose actual universal healthcare. But I agree with you that we need to create strong majorities to keep it in place until it reaches the kind of momentum it has in Canada or Sweden and opposition to it becomes a practical impossibility, like opposing social security.
Maybe someday we can have a system where losing health insurance isn't a motivation for not starting a company. Our current system is a complete disaster for entrepreneurial capitalism.
You're not wrong at at least for the forseeable future, single payer does seem untenable politically, but I'd argue that dismissing studies like this on the basis that it needs solved before debating it on its merits is circular, because the only plausible political objection to a policy like this is financial. If you reflexively claim that nothing without broad consensus appeal at a given point in time is worth discussing, you're essentially arguing in favor of freezing our public policy to whatever the current public opinion is today. I don't think you need to go very far back in history to see some pretty striking examples of why that would be undesirable.
I still think this is an important historical detail that seems to go under the radar a lot; if anything, it gives me yet another reason to disdain the filibuster!
There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think. If it gets implemented quickly enough then getting rid of it will be very difficult to do. People won’t give up free at the point of usage healthcare once they try it out.
It's worth keeping in mind that Eisonhower's cabinet argued against the idea of giving the polio vaccine away for free on the basis of it being a "backdoor to socialized medicine". We're over seven decades past the point where it makes sense to give a shit about what anyone says about "socialized medicine".
[0]: edited from "single-payer" to reflect correction to a similar comment I made elsewhere in this thread
In universal everyone has access to every hospital ? Why would someone go to lower level hospital if they can go to northwestern. Now the acess to best hosptials is gated by a queue?
I am not saying this is right but ppl who already have access to northwestern its in their best selfish interst to oppose universal?
i am just countering the point that "ppl opposing it are merely brainwashed by foxnews or are stupid" .
I mean, yes? Literally the same principle we all learned in kindergarten for how to make access to something fair. You didn't get to skip the line in lunch because your parents had a better job than someone else either.
most of the society doesnt operate in the way that you described.
If your objection is to a system that operates differently than the rest of society, it's not clear why the hypothetical healthcare system is more of a bugbear than the very real one that doesn't resemble pretty much any other way that things get purchased. I don't really understand how you think spending time arguing against something that has very little chance of happening based on principles that ostensibly conflict with the actual version that genuinely does exist is a sign that people are not being misled by those with incentives to distract them in that way or otherwise are struggling to reason about an issue logically.
> I am not saying this is right
in my original comment.
If a child cannot pay, there are some districts that serve cheaper alternative meals that don't meet the normal lunch standards, some that shame children by giving them hand stamps, and even some that will literally dump their tray in the trash.
Can you explain why those people DESERVE access to better care? Do they have more complex/rare diseases that require specialized treatment? Are there specialists who only work at that hospital? Those feel like warranted needs. But "I can pay more so I should have better things" is a ruinous worldview that, at its end, is just Might Makes Right.
i dont get why ppl responding to me think i do when i already said this
> I am not saying this is right
i am merely saying that the angle i described should be considered because a big portion of population thinks along those lines ( my guess)
Describes everything the GOP offers as “solutions.” Theirs tend to strip rights while Democrats tend to provide rights.
We’re still waiting on the GOP’s “concepts of a plan” for healthcare promised on the last campaign trail.
So you'll never vote GOP again. And you tacitly agree with Trump's repeated claim that conservatives will stay in the minority unless they _reform_ election rules -- https://www.theguardian.com/us-news/2020/mar/30/trump-republ.... Vote suppression and the "perpetual majority control of legislative, executive, and judicial branches," is Republican stated aim since the late 60s/early 70s when their party began its creep into permanent minority status
> It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to
What does this even mean? ACA was based on a GOP-governor-in-a-blue-state's successful implementation of HCR. Everyone loved it until Obama loved it, then the highly organized GOP minority hated it, fight it, wasted ~20 years claiming insanely to have a better solution they knew they never had nor will have
Back when Nancy's daughter Alexandra Pelosi used to make mini-doc shorts for the intolerable Bill Maher she made one about southern white Americans' opposition to ACA. She interviewed one fellow -- perpetually unemployed, alcohol/drug/legal problems etc -- who came well out of his chest against Democrats, socialism, The Gubmint and all the other typical lefty stuff that Fox News mentors him and so many others on. Then we find out he's on welfare. Then we find out he's on Medicare/medicaid. Pelosi's like "What?? Wait a minute ... I thought you didn't like this government stuff. Why're you all over it" and mans goes "WELL I DESERVE IT!!!"
Let's just call anti-UHC arguments what they are: wet bullshit from private healthcare industry stakeholders and the uninformed partisans who repeat Trumpist mantras
You mean like overturning Roe v. Wade? Can't ever happen, right?
ACA was also predicated on broad participation. As with all insurance, the bigger the pool, the lower the premium. Insurance of any kind is primarily a risk arbitrage business and fundamentally relies on the presence of low risk consumers. ACA was designed with this in mind and made participation in the insurance pool mandatory(whether via the public marketplace, or via private).
Unfortunately for the ACA, the individual mandate was removed in 2017 via Trump's Tax Cuts and Jobs Act, which reduced the penalty to $0, while leaving intact the ban on denials based on preexisting conditions(on it's own a good thing). The elimination of the federal tax penalty caused health insurance premiums on the ACA individual marketplace to increase by an estimated 10% annually, as younger and healthier individuals dropped coverage and left behind a sicker, more expensive risk pool.
So, while it's fair to criticize the ACA, you simply can't expect a law to work if it's intentionally altered to engineer the worst case scenario specifically.
Here's the overall timeline
* March 23, 2010: President Barack Obama signs the ACA into law, establishing the individual mandate and its future financial penalties.
* June 28, 2012: The Supreme Court upholds the individual mandate's financial penalty, ruling it a valid exercise of Congress’s taxing power.
December 22, 2017: The TCJA sets the individual mandate penalty to $0. Lawmakers attached the repeal to a major federal tax overhaul package and used the budget reconciliation process that allowed the Senate to pass the measure with a simple majority vote, avoiding a filibuster.
January 1, 2019: The tax penalty officially drops to $0 nationwide, effectively eliminating the financial pressure to participate.
I suspect Social Security would have met that definition at one point in time. Perhaps even paid overtime, the 40-hour work-week, etc.
At this point it says more about the state of our democracy than it does about any proposed solution. Even policies widely supported by the American public these days are met with obstructionists who care less about the welfare of the country than they do about scoring and blocking political "points".
It was a great success for people in my boat(no pun intended)
A lot of people do not want it, and you've thus far failed to make them want it.
In the UK, a brain surgeon is paid less than the General Manager of a single Buc-ees Gas Station location in the United States. Absolutely diabolical.
There's literally over 7,000,000 Britons on a NHS waiting list right now.
Please clarify what I'm incorrect about.
[1] https://uk.indeed.com/career/neurosurgeon/salaries
[2] https://finance.yahoo.com/news/buc-ee-offering-275k-salaries...
[3] https://www.bma.org.uk/advice-and-support/nhs-delivery-and-w...
[4] https://old.reddit.com/r/ADHD/comments/1nz7dt2/if_your_in_th...
Just think, if we had universal health care in the US today, the MMR vaccine would not be covered by it!
US legislators will never, ever, ever put the needs of the people above the needs of corporations, not as long as corporations can wield their massive wealth as "free speech" in the form of lobbying and political donations.
Sounds nice, though.
I would still get private insurance for VIP car but it would cost less than what i am paying now.
"Fewer avoidable emergency department visits and hospitalizations" -- sheer optimism. "Less fraudulent billing" -- no reason to believe this would be true. There could be even more fraudulent billing! Medicare fraud has been a big problem, and solutions are largely reactionary.
That's the only thing that matters in Amerika.
The authors derive the $1T number from $1.3T in total cost savings and $304B in incremental spend (incremental spend is due to insuring more people). The $1.3T in cost savings come from five big buckets: lower pharmaceutical prices, Medicare-level payments to providers, reduced administrative overhead, less fraudulent billing, and fewer avoidable emergency department visits and hospitalizations.
The buckets themselves don't necessarily survive much scrutiny.
Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's not necessarily a free lunch.
The line item of "fewer avoidable emergency department visits and hospitalizations" assumes greater insurance coverage leads to greater access to primary care. It's true that great primary care prevents hospitalizations, and can be a net cost saving under certain assumptions [1]. But, we're actually in a primary care shortage. Existing insurance payments for primary care are low enough that private practices are going out of business and fewer residents are going into family medicine. Cutting rates (the paragraph above) would make this worse.
For "less fraudulent billing," a lot of people in the industry believe that Medicare has a large amount of undetected fraud. That's unfortunately the flip-side of reduced administrative overhead. The authors assume an 8% savings here, but the 2003 paper they cite uses the word "fraud" only twice and doesn't give a number.
Healthcare reform is hard.
[1] Reasonable breakdown on the economics of advanced primary care models: https://olearykm.medium.com/the-cost-equation-for-new-primar...
There's no way a Chairman/CEO would ever reduce the operating margin by just giving themselves and their buddies a raise is there?
They may have 4.2% margins knocked down to 4% by exec comp but I don't see that how that fact would change OPs point.
- Base salary
- Bonuses
- Stock options
- Perquisites (perks) like company cars or private jet usage
Just to be clear - I like my private jet(s) on call in case I want to get away for the weekend. TYSM
The GDP of the US is $32T. Saving $1T will essentially make 3% of the US economy vanish. You don't vanish 3% of an economy without wide ranging repercussion, it would be a crisis similar in scale to that of 2008.
With such numbers we are not "saving money", these are about rebuilding an entire economy, a painful process. So either the effect will be much smaller than that, or there will be riots.
These people will now have to do the "something else" that will be spent on, let's say gardening. But you don't turn a nurse into a gardener just like that, that's the kind of "wide ranging repercussions" I mentioned, and the painful transition period where nurses become gardeners. "Nurse to gardener" is just a random example, it can be "drug researcher to petrochemist", and some transitions we may be happy to see, like "health insurance lawyer to burger flipper", but overall, many good people will suffer in transition, many powerful people too, which make such transition unlikely.
Usually big change doesn't happen without a catastrophic event, like a war, a coup, or an economic crisis, or maybe more optimistically, a technical or scientific breakthrough. So when an article mentions trillions without hinting at such an event, to me, it is incomplete, or wrong.
The French revolution would be an extreme example. It is a win for freedom and democracy, but the period following it is called "the reign of terror", for good reasons.
I don't know the solution, but do you agree that the problem is basically one of individuals not being able to accurately model the tradeoffs in their head?
Shrinking US health expenditure by 3% of GDP while roughly maintaining health outcomes is eminently, obviously doable.
The US is in a class of its own when it comes to health spending. The second highest OECD country (per GDP) is Germany which is 5 points lower than the US (and BTW these figures include public and private spending).
You are clutching at straws to discount clear evidence that shows just how ideologically driven the US System status quo is...
"'No Way to Prevent This,' Says Only Nation Where This Regularly Happens"
https://www.oecd.org/en/publications/health-at-a-glance-2025...
"Sorry kids, can't turn off the Orphan Grinder 9000, there's a whole supply chain behind it that would have to restructure."
If we're taking the $1T figure seriously, let's take the other figure seriously too. Let's slash it to be more conservative while we're at it and say it would only save 90k lives. Do you think 3% of your economy is worth sacrificing to prevent the equivalent of 30 9/11s? And that's before considering that other people here already explained how these 3% are offset by other gains - if not completely then still substantially.
You can't touch the legions of people who exist to make things more expensive.
One reason hospitals have such low margins is many people simply can't pay. If you have a payment guarantee like a medicare for all system, this will increase the stability of hospitals. In fact likely bring back some hospitals in places that didn't make sense like rural areas, which have been struggling via hospital closures.
If you are worried a low cost system will reduce doctors and hospitals per capita you don't need to, as countries that have universal healthcare often have more per capita.
https://worldpopulationreview.com/country-rankings/doctors-p...
I don't see you complaining that the US military has a low operating margin, so maybe we can just agree that some things are just normal expenses for a population. Which therefore leads to step 2: nationalize every single hospital.
>cutting salaries for doctors/nurses/etc
Considering that over 50% of the money that goes into healthcare is just siphoned off by middlemen, no, just getting rid of these means that your health workers do not have a worse salary.
>But, we're actually in a primary care shortage.
Because people do not even go see their GP since there's a chance it leads to life ruining expenses.
> fewer residents are going into family medicine.
Because they're going where money is. Remove that from the equation, and all you have is a public service with public servants.
>a lot of people in the industry believe that Medicare has a large amount of undetected fraud.
Aside from the fact that "people in the industry" have a financial interest in making you believe Medicare is a net negative, there's a great thing that comes from making healthcare a public service: there's no longer any fraud. And those "fraudulent" expenses you used to have that were costing you millions anyways have just had their costs cut in half.
>Healthcare reform is hard.
It's the easiest thing in the world when you have the amount of money the US does. Healthcare reform isn't a financial or infrastructure problem, it's a political one. Cuba has a working healthcare system despite being under US embargo. Botswana has a working healthcare system. Rwanda has a working healthcare system. Azerbaijan, Sri Lanka, Turkey, Serbia, and the list goes on.
Once you grow the balls to nationalize everything, even a first year economy student could make a plan that works.
In practice what we would see under a single-payer system is that many doctors would just opt out and shift to a cash payment model. So the shortage of doctors would get even worse for patients who can't afford to pay out of pocket.
I mean, admin costs at hospitals are ~25%, around half of that is directly linked to billing. Administrative costs in the US (because of course you have the same costs on the other side in the insurance side) are around 30% of cost in general, which is pretty insane.
The lack of regulation around pricing transparency and generally the lack of one-price-per-code (which the government uses to its "advantage" to get lower medicaid/medicare rates for sure) is what has caused this stupid arms race on both sides.
Most of the savings in these kinds of reports simply comes from paying doctors less (or delivering fewer procedures, which is also a problem we have.)
It's really the overhead costs that are so Byzantine that they can't be quantified properly. Hospitals have teams of coders, insurance companies have teams of counter-coders, physicians have to waste their time on calls with insurance companies, etc.
"Medicare for all" would alleviate a _lot_ of this. It already works for the elder population, and pretty much every senior has health conditions. So extending it for everybody would result in savings. This is a no-brainer from a purely fiscal point of view.
Another way to fix the mess is to lean on the free market side: prohibit employer-sponsored insurance. Completely. All the health insurance plans must be sold on the open market to everyone.
BIR is 8.5% of provider spending, once you add the multiple cells up that constitute providers.
I don't think your argument is going to survive contact with the numbers here.
I have a bit of personal experience here. I had a partner working as an endocrinologist, one of the higher-compensated medical professions. They were spending at least 1 _hour_ every day on calls with the insurance companies for prior authorization instead of seeing patients.
Some things are also weirdly broken down:
> Net Cost of Health Insurance Expenditures - 6.2% > Administration and Net Cost of Health Insurance - 7.4%
Why are they split?
I also suspect that they included some admin personnel cost in the physician/nurse salary. For my partner, their office employed a person just to deal with insurance. There is no easy way to break down these costs for small practices.
And they're not split: one row is an aggregate of subsequent rows, as you can see by simply adding them up.
This is just a colorized table view of a spreadsheet Medicare publishes every year.
Very curious where this comes from and how accurate it is. For example the $37 a provider charges for an Aspirin seems like more than 2-5% margin.
The $37 for an aspirin offsets huge costs elsewhere for (non-NP) nurses, orderlies, etc., who can’t bill directly to medicare.
ER’s for example are money pits, but society really needs them.
https://www.definitivehc.com/resources/healthcare-insights/h...
And while that law is obviously humane and reasonable, my only gripe is that the rest of our system is so backwards that it increasingly forces people to leverage that. There was a story about a woman who needed dialysis but had no insurance. So basically, she had to wait every couple weeks until she started breaking down, go to the ER, get emergency dialysis, get sent home. Rinse, repeat.
I don't blame her but really just the system that made this her best possible option.
https://kdvr.com/news/local/every-week-this-woman-nearly-die...
Do you have any citations for this? I've heard this rhetoric before, but every time I look into it, searching around for studies on google scholar or the web, I can only find studies and reports indicating that health outcomes trend better in countries with more universal coverage. There are think pieces with anecdata of course, but no actual peer reviewed publications I can find.
Heck when I went to college in Ohio's capital, the recommendation on how to get psychiatry or therapy as a new patient was to call the suicide helpline and claim that you were suicidal. That would get you a new patient appointment within 72 hours versus over 3 months on average for patients looking to get into care through normal channels.
The US maintains the highest hardware capacity of the three nations with roughly 43 scanners per million people and performs around 245 to 290 scans per 1,000 residents per year. non-emergency wait times are 1 to 7 days. The UK has 10 scanners per million people and ~100 scans per 1,000 residents, using centralized triage to keep non-emergency wait times between 1 and 6 weeks for NHS targets. Canada does 160 scans per 1,000 residents and 14 to 15 scanners per million, with wait times of 5 to 9 weeks.
When you consider that the US population is not fully covered by insurance, the number of scans is even higher
> Among patients undergoing cancer surgery, waiting times to initiation of first-course therapy have steadily increased since 2012, particularly at high-volume academic centers and among patients referred for definitive care. With continued consolidation and expansion of health systems, system-level strategies are urgently needed to monitor and mitigate delays in the delivery of surgical care for cancer.
> Delays were more pronounced at academic compared with community hospitals and among patients referred for care. Predictors of longer waiting time included Medicaid insurance (5 of 6 cancers), lowest-quartile income (6 of 6 cancers), Black race (5 of 6 cancers), increased travel distance (4 of 6 cancers), care in the West region (6 of 6 cancers), and treatment at academic institutions (6 of 6 cancers). Receipt of robotic operations was linked with longer waiting times for nonbreast malignancies (5 of 5 cancers).
Why would I want to trade my top tier private insurance for that?
And who was in the country illegally so she couldn't use Medicare or Medicaid. Still a terrible situation, but not representative of the typical American.
When you see $37 aspirin on the line, nobody actually pays $37 for it. The billed amount is replaced with whatever insurance rate is allowed for that. If someone is cash paying they get a large discount.
The billed items also have to cover everything. It’s not directly $37 for the aspirin, or the $5 or whatever allowed coverage it ultimately gets billed it. That had to cover the facilities, the salaries of the pharmacy staff who reviewed the request and dispensed it, the staff who inventory and order the medications, and the cost of billing insurance.
The only part that nationalized health care would change are the allowable billed rate and maybe the administrative overhead of billing different insurances. Even nationalized health care systems have admin overhead though.
You can think of it like when you have to pay $11 for a single glass of wine from a bottle that the restaurant paid $10 for. You’re not just paying for the liquid, you are paying into a big bucket of charges that all need to add up to more than the cost of the supplies, staff, building, and everything that goes into running it. The margin on individual products doesn’t make the entire operation profitable.
That's the same as any? CVS charging $5 for aspirin has to cover their staff who stocked and checked out the item, the shelf space, the marketing, and the looting.
What's different about hospitals?
The discourse also underestimates how much of our health care costs go to our significantly higher salaries throughout the medical system. No politician wants to propose reducing the salaries of doctors, surgeons, or even researchers making new medications. The only acceptable villains are the administrators and insurance companies, but even in this inefficient system that's a much smaller slice of the pie chart than most people imagine.
One of the reasons hospitals operate in this convoluted way and still barely clear a profit is that we require them to treat everyone and attempt to collect payment later. A lot of what you and I pay for health care goes to cover people who can't or won't pay.
Well, the salaries of medical personnel only account for about 20% of total healthcare spending. So even cutting those by half wouldn't change much.
> One of the reasons hospitals operate in this convoluted way and still barely clear a profit is that we require them to treat everyone and attempt to collect payment later. A lot of what you and I pay for health care goes to cover people who can't or won't pay.
If that was a major reason, then those who don't pay would balance out those who pay and the grand total of all healthcare spending in the US would be pretty average despite individual premiums and out of pocket costs being sky high. But in reality, the total healthcare spending is just as sky high (several times more per capita then median OECD country).
When the hospital charges you $37 for an aspirin, that singular pill might have a crazy profit margin in isolation. But your entire treatment could very well be losing the hospital money.
In my own anecdotal experience, the one hospital I know enough details about to comment on specifically, had something like 85% of patients costing the hospital more money than the hospital made. It was entirely funded by the relatively small number of people who had the “right” insurance and had the “right” procedures done.
Eg Kaufman: https://www.kaufmanhall.com/insights/research-report/nationa...
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¹ https://en.wikipedia.org/wiki/Hollywood_accounting
Administrator pay scale is completely irrelevant to the point
Really need to step back and start from first principles.
When I go to urgent care I get 15 minutes with a doctor who on average makes about $300K and maybe another 15 minutes with a nurse assistant who might be making $100K (or less). So that is less than $50 in doctor+nurse salary. Of course there are then all the overhead of rent, utilities, etc, etc but those are not so different from any other business in the same strip mall. So let's say total cost for my visit is maybe $100. But I'm charged $500-$600 for the visit. Someone is pocketing a lot of money and it is not the doctor nor the nurse.
We could do the same exercise for surgery, the costs for surgeons and anestethicians is much higher, but you'll be hard pressed to find any realistic scenario where the cost of a two hour surgery is more than $100K.
My surgeon friends routinely complain about the inordinate amount of time they personally need to spend fighting with insurance, in the form of filling endless forms that insurance insists must be filled and signed by the doctor. This is in addition to whatever time/cost the hospital staff wastes fighting with insurance paperwork.
The surgeon time is not cheap, but the insurance companies expect these doctors to do all this paper pushing for free on top of their day job.
But if it's a team of nurses, doctors, and other healthcare specialists rushing around doing checklist work to make sure you get that aspirin, that's just evil.
The principle is only applicable to our industry and closely adjacent industries.
A Pap smear[0] is a diagnostic test to detect (pre)cancerous cells on one's cervix[1].
[0] https://en.wikipedia.org/wiki/Pap_test
[1] https://en.wikipedia.org/wiki/Cervix
This is one of the areas where more standardization would certainly help. If there were more standardization of which codes disallow which other ones (which can currently vary wildly by plan even with the same insurer, must less across insurers), then a lot of line items could actually get removed as truly redundant, vastly simplifying the bill.
I would be able to dispute a double room billing, but I was sedated and dying so I took whatever they offered, assuming good faith.
Also, then, of course, we need to cover the United Healthcare guy's salary, which decreases margins.
Its all coming out of revenue.
The margin built into the prices bulled is not the actual margin the hospital ends up with.
The flipside to fraudulent billing is that people that need care are denied. The fraudulent billing was perpetrated by the insurer.
I don't spend any healthcare money at the hospital. It's all all providers office, private clinic, etc.
It costs $300 for my primary care doctor to see me for about 7 minutes. An assistant takes my blood pressure, he asks me a few questions about my habits and diet, and then I come back next year.
If I actually need any services, I go to much more expensive specialist, or urgent care facility. A visit there is about $100 and then a couple bucks for whatever prescription they give me.
People tackle hard things for nothing, never mind billions in savings.
How does this work when many/most US hospitals operate as non-profits? Quick search shows the for-profits have operating margins nearly triple your figures. And the non-profits are beholden to the community to provide some level of "freebies" to maintain their status, right? IE, they're aren't really all operating on razor thin margins.
I'm curious where you got this figure, because it doesn't track with my own experience.
I used to work for a place that worked closely with hospital clients (and prospective clients) to resolve billing issues with a particular EMR system, and we regularly discovered that a given hospital was losing hundreds of thousands to millions of dollars weekly due to missing charges. The problem was, so much money was sloshing around that the hospitals were virtually always unaware of the missing charges, and many CIOs were more interested in saving face by shutting down further discussion than in walking through the collected data, how to fix the charging issues, and even claw back some of the lost charges (which you can generally do up to several months after the fact).
There are many others as well.
FWIW, your experience doesn't seem contradictory to the operating margin claims.
Your experience seems to be that hospitals are run very inefficiently, implying that if they were run efficiently that their operating margins would be much higher than 2-5%. That may be the case, but that still means the Yale paper's claims don't make sense (unless they also propose some mechanism by which to suddenly force all hospitals to start operating efficiently).
But I'm also skeptical of your claim that hospitals are leaving a huge amount of operating margin on the table. IME, very little can be explained by "everyone is stupid." Would I be surprised if a given hospital was run very inefficiently or if a given hospital had a particular poor CIO or administrator? Not in the slightest. Would I be surprised if ALL hospitals were run by idiots who were leaving 10% operating margin on the table? Yes, I would be.
That the hospitals didn't seem to notice the problem, and upon being told of it, often pushed back against moving to fix the problem, is what gave the impression that they must be running on much larger margins than advertised.
I am constantly told how much less Europeans pay for better health outcomes and all I can think about was the obesity crisis I grew up around in Texas.
Socializing healthcare isn’t going to get an huge portion of the population out of their cars and get them walking as a primary or secondary mode of transportation. Not when it’s 100° and the grocery store is five miles away.
Americans, in no small part, have worse health outcomes because we have dramatically worse lifestyles. I support German-style universal healthcare, but I’m not going to pretend it will suddenly give us German health outcomes.
You would think so but once healthcare cost becomes a government policy issue people complain about its spending and they are forced to try and bring that cost down. One of the ways they did that in my country was to promote biking to work and build bike ways.
I agree with you generally on the incentives, but it took us 70 years to paint ourselves into this corner, and we’re not going to get out of it because of a third-order incentive.
https://press.uchicago.edu/ucp/books/book/chicago/R/bo413854...
They mean “free to the consumer at time of service”, which it is. Nobody is lying, everyone agrees, it’s just you who doesn’t understand.
You are incredibly optimistic about a large swath of the population's understanding, unfortunately.
> Nobody is lying
There are plenty of people in this discussion making statements of fact that are false. Call it whatever you want.
No, they mean free at time of service, which they are.
Don’t believe me? Great, then ask them, without doing word gymnastics to try to trick them.
Should medical equipment cost 0 dollars to produce? Should doctors not earn any salary or wage? They will say no, 100% of the time.
I don't think that's true France, Norway, New Zealand, or Switzerland. (And that's just developed nations. The GP's claim was every country other than the US.)
In every case costs have gone down and outcomes have improved.
You always build on what you have because you can’t pause healthcare for very obvious reasons.
Hence a lot of different systems all with the same aim. Controlled costs and universal coverage.
The idea the US is somehow different and cannot make the change is the result of propaganda and a mistaken belief that the current Us system is the worlds best despite its costs.
Healthcare reform is easy and there is an ocean of prior art.
Health care is an absolutely massive industry (everywhere, not just in the United States), and slashing compensation in a massive industry by top-down fiat is in fact not an especially easy thing to do.
Turns out when you have the choice of accepting lower payment per patient for Medicare or having a lot fewer patients, you choose the lower payment per patient.
I would expect the same situation here. Doctors would grumble, but no one would force them to accept patients on whatever “Medicare for all” would be called. Nothing other than market forces.
A number of things would probably have to change, including the cost of medical school. But the system right now is expensive and essentially unsustainable. So change is inevitable.
And I’m aware that medical debt is a big issue, but it seems like a chicken-or-the-egg type problem. Of course you can charge $500k for a medical degree when the doctor can make it back and then some in 5-10 years.
It's really easy now with Claude and GPT5; just ask them a question and tell them to answer it for you, with cites, from the NHE. (The data I argue from precedes widespread LLM research; I built a site for this a couple years ago and didn't bother to update my data, because I assume it didn't get much better.)
https://www.cms.gov/data-research/statistics-trends-and-repo...
if a "senior" software engineer can make half a mil, and an electrician can make 200k, of course doctor pay are high.
who is going to take 10-15 years of school and debt otherwise?
> "The electricians that I interviewed and met two months ago in a data center in Plano, Texas, all under 30 years old, all making $240,000 to $280,000 a year, all with as much overtime as they want, none with any debt, all three of whom were poached three times in the prior 18 months," Rowe said ...
Google AI summaries then pick up wealth/finance grifter social media clickbait about it and parrots it as a fact.
There are contract data-center electrical jobs paying $55-65/hr (some with signing bonuses, per-diems, and benefits on top), but they only come close to $200,000 takehome by working 12/7 with generous overtime. And these are 5+ years of experience, OSHA 30, journeyman license, bring-your-own-tools. They're also exceptional; most are still $25-40/hr.
It’s funny, because it’s a career that feels both overpaid and underpaid to me. I went to a college where almost half of the students were going for nursing - and you certainly don’t need to be especially intelligent.
At least to an outsider, some nursing fields seem damned easy. The nurse that sees me before my GP? Pretty easy job.
Other specialties? Like the nurses that needed to clean up my wife after she massively bled during/after a c-section and they had to give her medications that also caused all sorts of other fluids to intermingle with the blood? Or the nurses that had to stand there for 10 minutes squeezing our infant daughter’s heel in the NICU to try to get enough blood out while she screamed as hard as a little baby can?
$100k doesn’t seem like enough. Odd occupation. For $60k I’d rather work at Costco, that’s for certain.
this isn't really true though, if you look at survival rates of many diseases.
Any model that gets rid of these frees up a huge swath of capital and work from society, and can use that work elsewhere. Of course, that is easier said than done.
Each of those are companies worth billions of dollars that could be instead used to lower the individual cost of providing health insurance.
As you say, this would of course be unsavory in some respects as those companies employ a lot of people. It's not a very economically productive industry though, the main output seems to be consuming patients' and doctors' time, causing financial anguish, and causing stress among people as to whether or not if their condition will be covered.
(Medicaid & Medicare claims processors do the same thing. Medicaid claims processing is mostly handled by private, third-party insurers now, and seems to be able to do so more efficiently and cheaply than when it was being run directly by states; the savings is mostly in the area of catching fraud.)
Medicare is much cheaper because they have fixed rates and hospitals know what to bill.
We all contribute to the pool at a time when we don't need it so we can use the money when we do, not to make CEOs or stockholders rich. That is how an insurance pool should work. Any excess money at the end of the year should be moved to the pool for the next year, not as a bonus on CEOs' 100m+ salary.
> Any excess money at the end of the year should be moved to the pool for the next year, not as a bonus on CEOs' 100m+ salary
Under the ACA, excess money in the pool must be rebated to policy holders. In practice, this worked for a few years, but eventually insurance companies ended up increasing cost in order to increase the absolute amount they were allowed to keep. Maybe this is still good (more claims approved), but it is counter productive to the goal of reducing healthcare costs.
I had a recent doctor's visit, with very good healthcare coverage, that was an in-network facility but an out-of-network provider. Coverage would have kicked in if I had a referral from my PCP, but my PCP recently retired and I was advocating for my own health for a small dermatological issue. They said it was cosmetic, my old PCP said it was not. I got a stack of 10 bills over many months all stating different things -- everything from $0 EOB to over $2k in uncovered expenses. No one would take ownership of sorting out what I was on the hook for. No one I talked to was empowered to actually solve it. It wasn't an affordability problem over $2k (but would be for my elderly grandparents on fixed income). Even asking "If I give you $2k does that resolve the debt?" was answered with "we won't know until we apply the payment" type non-answers.
Burn the whole stack down -or- earn enough you can operate on cash for the tier of care you want. Nothing inbetween seems to be working.
Aren't their profits regulated regardless? If all insurance companies became non profit and let's say total prices dropped by 3-5% that still wouldn't change the situation dramatically?
There are many factors, e.g. amongst other things American doctors are better paid than just about anywhere else in the world.
Yes and no. It's sort of a weird thing where insurance is somewhat regulated nationally but also regulated in a piecemeal fashion state by state.
There's a non-government standards body called the NAIC which provided national guidance for insurers. Most (all?) states basically say that "if you follow NAIC standards, you are good".
> If all insurance companies became non profit and let's say total prices dropped by 3-5% that still wouldn't change the situation dramatically?
It's a huge mess. It's not even really a profit vs non-profit thing but rather "what's the motivation". One major issue is that the ACA put in a loss ratio of 80%. Which isn't a terrible thing in principle, it forces insurance companies to spend money on treatment. The problem is it also means that the profit of insurance companies is tied directly to how much they spend on healthcare. As a result, they are incentivized to spend more, not less, on medical treatments so they can justify higher premiums.
This is a big part of why I think universal public insurance is a must. Basically the only organization that's motivated to keep costs as low as possible is the government.
> American doctors are better paid than just about anywhere else in the world.
This is a problem, but the bigger issue and why doctors are paid so well is because becoming a doctor is one of the more costly and hard to do things in america. There are limited spots, schools, and residency requirements that severely restricts the number of possible doctors we add per year. That drives up the their salaries.
I have a nephew going to medical school in Idaho of all places, and he's looking at $500k in debt by the end of the whole ordeal.
Investors care about margins, not absolute dollar figures. If your non-medical costs are capped, the incentive would be to reduce your other costs to preserve or maximize profits.
So the 80/20 rule is unlikely to have caused anything. More likely it's too low, and the amount of profit that can extracted and passed to investors is still higher than most investing alternatives, which is why it keeps attracting more investment. Without the 80/20 rule we would have seen the same thing or worse, though perhaps slower premium increases but less treatment delivered.
Really this all points to structural problems in the market. Naively we might presume there's not enough competition, and there could be many reasons for that--over regulation, lack of transparency. But it's more complicated than just that because medical treatment, particularly the most costly treatments, presumably have very high price elasticity [citation needed], are long-term investors are just gonna keep trying to draw as much from the well as they can. The problem with public single-payer is that the basic demand curve doesn't magically disappear, so rather than complain about high prices people complain about shortages, OR the government just keeps borrowing to maintain satisfactory treatment access until they can't borrow anymore.
Unfortunately, this isn't true for the government either.
Source: personal experience of me and literally dozens of people that I know. I've briefly worked with my country's government, and in that time I personally experienced and got dozens of stories along the lines of "the government spent tens of thousands of dollars of aggregate government employees' time because a single employee booked a hotel that was less than one dollar above the approved rate while traveling".
There's a good reason for this, of course: bureaucracies' policies are mostly "scar tissue" from high-profile cases where a bad actor did something they shouldn't have but wasn't specifically against policy, and then a policy was written for that case and stands for the rest of time. And, bureaucracies are risk-averse, especially democratic governments, whose leaders are elected based on optics almost as much as policy.
But it doesn't change the facts. Not only are large bureaucracies inefficient, but government bureaucracies specifically are incentivized to optimize for optics and structure rather than improving that inefficiency, and anyone who has actually worked for a large government can tell you that.
Not really accurate if you look at the closure of rural and smaller city healthcare facilities. They don't have the base to charge "regular price" to make up for the aging, less healthy, rural populations.
We all pay for it, but some pay heavier costs than others.
https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
https://www.oecd.org/en/publications/health-at-a-glance-2025...
According to the world bank it's closer to 40:60 (government spending still being the majority). So that puts it behind Switzerland but still more than combined spending in just about any other country.
Even if it's US Government only per capita with people the government insures, it makes sense it would be so high because only people on government insurance are the poor/disabled AND old. Two groups that have extremely high utilization.
That means that even though government insurance in the US only covers a relatively small percent of the population, we pay more than other countries that cover the whole population.
I say convert SSA to UBI, set a floor, and let the price of things find a new level with more people in the marketplace:
Your point is correct, but since the majority of healthcare spending occurs in the last 18 months of life, and the vast majority are on either Medicare or Medicaid during that time of their life (either due to age or ailment-related incapacity), it doesn't make a huge difference.
I could make observations about who tends to be there at either but that might rustle some jimmies.
Most patients never file a lawsuit, even if things don't go well, and most injuries that aren't deaths or newsworthy are not worth the trouble to an "overburdened" court system itself imposing a lot of burdens.
And the quality life years lost waiting to share a verdict with attorneys ought to count for everyone affected, not just those who spearhead a trial by catastrophe.
I think the solution is to make the practice of medicine more scientific, and less dominated by competitive incentives, but as long as research and development, reform, or even consumer choice, is strictly a cost, that will be considered "too expensive", if not "too risky".
When patients are harmed by medical errors caused by non-quacks, that's just tough luck. Not everyone can be saved. Creating a gigantic medical malpractice insurance industry so that a few hundred surviving families per year can have lottery jackpot settlements isn't a solution in any way, and has done very little to incentivize fewer errors.
I'm used to this though.
Somewhere there's a pareto-optimal frontier where one can't possibly save more lives without spending more, or spend less without more people having negative health outcomes ... and the question is whether universal health coverage would be a step towards that frontier (b/c we're all pretty sure we're far from the frontier today). And the fact that plenty of countries have both lower costs and better outcomes through such a system is highly suggestive that it is a more efficient policy regime.
Maybe the big quibble is whether the American penchant for creating corporate givewaways to powerful organizations that lobby politicians would create an especially toxic public-private-partnership monopoly in which the biggest existing private healthcare networks are granted regional monopolies and set crazy prices (or some other dystopian warping of an initially reasonable idea) so costs actually balloon. I do think that would be a risk and so we need to be careful about the specifics of how we implement this.
You arent considering
1. Hospitals eating the cost of the uninsured, which this would solve
2. Hospital spending tons on administrative duties fighting with insurers on coverage, which this would reduce
Wouldn't it just transfer the cost from the hospitals to the universal coverage agency? This would make the financial picture even worse for the proposed system.
The hospital can be paid less without reducing their margin if they can remove a cost from their balance sheet. It does not make the system cheaper overall, but it means the hospital does not have to bear those costs directly. They may not have to bear them at all, because hospitals are not the only things in the system.
About 8% of the population is uninsured. The uninsured population skews younger, with less healthcare utilization (Medicare already covers everyone 65 and older).
Another comment in this thread estimated billing overhead at 8.5%. Medicare for All would eliminate some, but not all of this, since Medicare is still a claims-based system. You would remove a lot of overhead around prior auths, which I agree is a good thing, but could be achieved with more focused legislation.
The Kaiser Family Foundation estimates about 26.7 million people ages 0-64 were uninsured in 2024 (9-10% of that population segment): https://www.kff.org/uninsured/key-facts-about-the-uninsured-...
OP makes a good point. The studies assumes two diametrically opposed things will happen - doctors will take a 50% pay cut but access to primary care physicians will increase.
Why would we solve the primary care physician shortage by cutting their pay?
Would this go away, though? Instead of fighting with insurers they would be fighting with the government insurer?
I am very pro universal healthcare, I just don’t want to pretend there aren’t still going to be fights over what should be paid for.
No matter what, there are going to be disagreements on what medical procedures should be paid for and who needs them, as well as how much they should be billed for.
All of this was branded as "death boards" in the American healthcare debate.
1. I'd rather fight the non profit-motivated entity 2. We can probably compare to VA and Medicare and even other countries to see what the fight will be like. I'm willing to bet it will be a big improvement.
> No matter what, there are going to be disagreements on what medical procedures should be paid for and who needs them, as well as how much they should be billed for.
Government insurance has a service motive. Private insurance has a profit motive.
And government can just lower the definition of acceptable service rather than provide any accountability for not providing it.
but why would they? OTOH for-profit companies do this all the time.
This layer won't go without a fight. Maybe it _is_ the layer we're fighting against. The owners will still make profit, the providers still have jobs.. but the middle layers are useless bloat. They don't have skills to provide care, they don't operate at the capitalist layer. They are useless today, and even more useless tomorrow.
And that is likely useless layer is millions? of jobs.
How do we know? The experiment has been done multiple times, all over the world. In the worst case (Sweden), healthcare is a bit short of $5K per capita per year, or around $1.7T. We’ve actually got a nice margin to achieve $1T, even if we remain the worst.
I agree health care reform is hard, though. We have a clear roadmap on how it can work a lot better. But what’s the political path forward?
As someone who’s actually fiscally conservative, single-payer universal healthcare is an absolute no-brainer, but, ironically, the people who call themselves fiscal conservatives will fight it to the death (well, not that ironic — at this point we all understand that, in politics, what groups purport to believe and what they actually believe have little to do with each other).
This is a hoot. There is an entire cohort of people who use the emergency room as their non-urgent clinic. This is not a small demographic, it must be at minimum tens of millions of people, if not going above the nine digit mark. They do this because their parents did it, and it's the only thing they know, and their parents did it because it's the only thing they knew, and they did it because their parents did the same. It is a culture that no amount of education and public service announcements will ever change.
Heaping one perverse incentive after another on top of this mess won't change it either, but will almost certainly make things worse for everyone.
>For "less fraudulent billing," a lot of people in the industry believe that Medicare has a large amount of undetected fraud.
My grandpa when he was still alive would have one new fraud story with every visit to the doctor, and he wasn't in great shape towards the end, so this was too many to count, every year for the last few. Diabetic, they ordered him compression socks at one point... a dozen show up instead of the two pair that was ordered. He'd come home and wait for a bill in the mail, and a few days later would see itemization for tests and procedures he never underwent. Over and over and over. He was sharp, argumentative, and as far as I could tell, less confused than most his own age. His experience, I think, wasn't atypical.
I support universal health care, but each side just lobs whatever data supports their position at the other without any real thought. Most people in support of a universal health care system seem to be completely unaware that the vast majority of households are happy with their current coverage (whether they should be or not isn't relevant really) and are not looking for someone who claims to know better to "improve their medical care" through a entity (the US federal government) that is generally not known for improving almost any situation it interacts with.
I personally would like to see Medicare opened up to the public as an option. It's simple, doesn't require anything of anyone who doesn't want to participate, and should be a reasonable test for the claims of cost savings. If it's truly a better option, people will move to it. If not, then the conversion will not happen.
Barring some sort of catastrophic financial or medical event, there is a 0% chance that anyone can make a radical change to the status quo.