6 ms·

I think we're just experiencing the ultimate end game of the system. The ACA was nothing more than ointment on an infected wound. It worked for a time but it i

I think we're just experiencing the ultimate end game of the system. The ACA was nothing more than ointment on an infected wound. It worked for a time but it is becoming more and more obvious that this leg our economy needs to be amputated. We need a single payer system or at the very least a single body that negotiates the price of all drugs and health care services on behalf of all Americans. Frankly I'm surprised that the insurance companies aren't lobbying for such a thing as it could be their only hope for continued existence very soon. The pharmaceutical industry would practically go to war to prevent a single payer or a price-fixed system but they would lose if they're opponent was the insurance industry (and the American people; who have very low esteem for "big pharma"). A most interesting change resulting from an American single payer system would be the increase of drug prices for everyone else (other countries). As it stands right now the only reason drug companies can get away with some of their lower prices in single-payer countries is because the US can and will make up the cost. Lowering the cost of drugs in some countries really does result in higher costs for Americans.

maxerickson 10y ago
We need a single payer system or at the very least a single body that negotiates the price of all drugs and health care services on behalf of all Americans. Frankly I'm surprised that the insurance companies aren't lobbying for such a thing as it could be their only hope for continued existence very soon. What role do insurance companies have if there is a national body fixing prices?
- jefurii 10y ago
  Looks like not much of a role at all. After all of my experiences with insurance companies I'm quite okay with that. A NHS-style system would still need staff in order to function and I expect many rank-and-file insurance people would end up there. The executives can go to hell as far as I'm concerned.
  - maxerickson 10y ago
    Providers also have a lot of staff dedicated to working with the insurance companies. I'm pretty sure billing complexity is one of the things driving consolidation of physicians into large practices and health systems.
- DiabloD3 10y ago
  None. Which is America's end game: to end that apparent scam. This is why I actually had hope for the original draft of Obamacare: he straight up cloned the Netherlands system where insurance companies must insure x% of various classifications of sick people (cancer, AIDS, asthma, heart disease, overweight, etc), where x% approximates the national average... ... and they must spend ridiculous high levels of what they make on actual health care, AND the prices of health care are nationalized. In the end, they fight over sick people (have a rare sickness? insurance companies will give you a discount to get you, instead of trying to figure out how to lifetime ban you from insurance instead). And what happens if an insurance company can't get enough people to meet the strict guidelines? They're banned from selling insurance in the Netherlands until they do. This is essentially the original Obamacare, filtered through the American way of doing shit. What we got instead? Half of that, and maybe not even the good half. We got fucked.
- nlodnl 10y ago
  They'd still be providing insurance. A national body negotiating pricing doesn't necessarily mean any or all forms of healthcare would be affordable.
brightball 10y ago
The ACA was pretty much a terrible proposal from the start. The logic that lead people from "insurance companies are the problem!" to "force everybody to buy insurance!" required a mind blowing level of cognitive dissonance.
- riskable 10y ago
  You assume that this current broken state was unintentional. I believe this situation is intentional and was predicted and expected. Back when Obamacare was being debated I and many others argued that the best it could do would be to slow the meteoric rise of health care costs because it was painfully obvious (to me at least) that it didn't actually solve the problem. I have no doubt that the politicians knew this as well which was why Republicans fought so hard against it and why Democrats wanted it so bad. I believe they wanted it to come to this. They wanted to demonstrate that even if you force people to get insurance it still wouldn't be enough. It is a real-world application of how, "the compromise" (forcing people to get insurance) doesn't actually impact the price much because health care costs are not controlled by traditional market forces. What is the price, "the market will bear" when someone will die or suffer immensely without treatment?
  - brightball 10y ago
    Wouldn't surprise me, but among numerous other issues all it's doing is amplifying how everything gets worse when the federal government gets involved.
  - mason240 10y ago
    This is also what has been pretty clear to me all along.
kefka 10y ago
I'm also seeing something else here too, with the "screw you, raise price by *1000" executives, schrekli (sic) being one of many. What many of these comes down to, is they own a right of patent on something that allows them to set the price at will. Or, if they choose, to not license or sell it at all. Stated differently, why should someone or government tell me how much I should set my price on a patent I own? An answer, which I am not aware of being used, is eminent domain. We do as such for public good when it comes to roads, buildings, and similar. I know the Supreme Court had to rule back with Wilbur and Orville Wright because they kept avionics back for a decade whilst Europe was booming... because someone wouldn't sell the rights to do aircraft. Of course, the underlying problem is public institutions pay for the research, and drug companies get access to this and extract. The drug co's aren't researching; the public institutions do; and we do.
- jostmey 10y ago
  Except the drug "schrekli" priced gouged was out of patent. It should have been a commodity, so why weren't any competitors allowed on the marketplace? Take a look at Washington for your answer. There are lots of amazing companies trying to invent cures that don't otherwise exist, and need compensation for their work. Then you have Epipen and "schrekli" jacking up prices on 30 year old drugs.
  - kefka 10y ago
    Indeed. Whatever his name is, used the fact that the FDA has to "authorize" a drug, which is more akin to an indefinite patent. Then again, the deeper we dig, the more idiocy we see. How can we expect anyone to fix: insurance, pharmaceutical, device companies, FDA, AMA, government interference, medical schools - everyone has a part in the current system. And it is the combination of the worst that capitalism and socialism have to offer. And yes, I misspelled his name, because a google search was too much work to get his name correct (marque of disregard). But admittedly, probably was not the best case to explain.
msandford 10y ago
> We need a single payer system or at the very least a single body that negotiates the price of all drugs and health care services on behalf of all Americans. Frankly I'm surprised that the insurance companies aren't lobbying for such a thing as it could be their only hope for continued existence very soon. Insurance companies are legally obligated to pay out 80-90% of their receipts for treatment. Since they can't become more profitable on a percentage basis, they have every economic incentive to drive the cost of medicine up. What's better than making $500/year/customer? Making $1000/year/customer because medicine costs twice as much. You don't even need to get more customers! There's definitely a whole slew of market failures piled up on top of one another in the healthcare system here in the US. There are people who are afraid of single payer for silly reasons, but there are also people who are scared of rationing. That's a legitimate fear! And it's not one that can really be assuaged because we've seen that while it's very difficult to get laws passed today, that's nothing compared to rolling them back. So everyone could go into single payer with the best of intentions but it only takes a few changes of administration for things to start to go off the rails, and then it'll be nearly impossible to get the mess sorted out. I mean, look at the ACA! The whole thing was done with the best of intentions but even before it made it to being a law it got all messed up. And now that it is a law, it's maybe not necessarily having the intended effect. Couple that with the idea that everyone in the US is about to "make it" or that everyone thinks they're middle class or upper middle class and fears about rationing can seem entirely well founded. Anecdotally I had a prof who was from Vancouver who had a knee problem and needed an MRI to make sure it wasn't cancerous before they operated. 9 month wait list fo r the MRI or a half day excursion to Seattle and about a grand and he had his imaging. It doesn't prove that everyone in Canada experiences rationing the same way, but it does mean that fears aren't completely unfounded.
- mgkimsal 10y ago
  " but even before it made it to being a law it got all messed up" Requiring legislators to read legislation (and maybe even take a test on bills that are larger than 10 pages?) before they vote on it might help. Being told "we have to pass it before we can look inside of it" is... I can't think of anything less sane. Re: Canada and other countries. I know in the UK you can get private insurance and "go private" for most services, or you can take the public option, which may involve waiting. Why we think here it's going to be 100% one thing... I don't understand. Your canada story already demosntrates that - someone with more money paid for faster service. I have a strong suspicion he could have had that done privately someone in canada for $x, but seattle was closer/easier (?)
rayiner 10y ago
Having a single entity negotiating prices would obviously lower them--it'd establish a monosopny. But would that be a good thing? I mean, we could lower prices for everything that way. Have a single entity negotiate prices for cars, or construction services, for example. That'd lower prices too. Why don't we do that for everything?
- mgkimsal 10y ago
  arguably not everyone needs everything - many people can get by just fine without a car, or construction services, or other things you might list. Not too many people get by (for long) with poor/ailing health. Some aspects of health care - basic stuff like getting people insulin they need and whatnot - does that not potentially get justified under "general welfare" clause? Many other countries seem to get by just fine with a baseline "health service" provided to everyone, with "premium" service paid for out of pocket or via private insurance. People should not have to face bankruptcy (or just extreme debt) because they happened to be born with the wrong genes.
  - harryh 10y ago
    There are other things that people need by: food, housing, clothing. We don't use the government as a single entity for purchasing those goods. What makes them different from drugs?
  - rayiner 10y ago
    That's an argument for the government paying for healthcare. But why is it a good idea to achieve lower consumer prices via centralized price negotiation for health care but not for other things?
    - enraged_camel 10y ago
      Healthcare is a human right. Cars aren't. https://en.m.wikipedia.org/wiki/Right_to_health https://en.m.wikipedia.org/wiki/Right_to_health
mgkimsal 10y ago
"It worked for a time" It's only been in effect for a few years - what "time" did it "work"?
- xienze 10y ago
  What, you don't remember those articles immediately after Obamacare went into effect gloating about how everything was going fine?
- calvano915 10y ago
  The big successful aspects of the law remain in my mind: Elimination of lifetime caps, pre-existing conditions. Allowing children to remain on plans until 26. Insuring millions more via expansion of Medicaid or subsidies of premiums with initially more competitive plans. By and large I think it was a success, albeit a completely temporary bandaid to a system that requires massive re-thinking
neffy 10y ago
I agree - a lot of the issue in the US is that there isn´t any effective competition (or control of) the drug companies and price gouging. A single payer will help tackle that. But the key question is, why is American healthcare so expensive, and for such poor outcomes - measured by life expectancy at least? You can lop off a few percent as the cost of running the insurance company infrastructure, but it still doesn´t explain all of it. Nor is it the case that US patients are subsidising other patients drug costs - not all drugs are researched or manufactured by US drug companies. There is a supply element to all this as well, and it´s not just drugs. Let me give you one example from the UK, since I don´t know the US figures. One of the problems in the UK is that doctors are very expensive, and there aren´t enough of them - this isn´t because of their student loans, it´s because there´s a shortage of doctors. The NHS imports a lot of doctors from abroad to cover this (causing issues in their home countries), the US does the same. (If you´re a doctor from a country with low cost medical training the markup for working in the US is insane. I digress.) Dig into the statistics for medical training in the UK, and it becomes clear that the number of places has been held more or less constant, while the base population has increased significantly, and you can put whatever fudge factor you like on the population needs more healthcare because of obesity/ageing/excessive tea drinking, etc. http://dera.ioe.ac.uk/16155/1/medical-and-dental-school-intakes.pdf http://dera.ioe.ac.uk/16155/1/medical-and-dental-school-inta... (p11) Finally - this year: https://www.gov.uk/government/news/up-to-1500-extra-medical-training-places-announced https://www.gov.uk/government/news/up-to-1500-extra-medical-... Which unfortunately won´t have any real impact for at least 6 years or so. To solve the american health care problem requires essentially a large scale attack on the cost of the health provisions, and that has to be across the board, and it´s going to take years just because of the lag times involved. Personally I would start with simply doubling the number of medical school places - maintain standards on admission - and work on dropping the salary levels. Provide scholarships so students don´t need big loans. Attack the anti-competitive practices of the drug companies directly, etc. In other words, remove artificial supply bottlenecks, let the market sort it out... and have some kind of bailout ready for the existing medical professionals, and medical providers, who then can´t repay their loans. Making the rest of the world pay US prices...isn´t going to happen. Sir Alexander Fleming was Scottish.
- maxerickson 10y ago

maxerickson 10y ago

We need a single payer system or at the very least a single body that negotiates the price of all drugs and health care services on behalf of all Americans. Frankly I'm surprised that the insurance companies aren't lobbying for such a thing as it could be their only hope for continued existence very soon. What role do insurance companies have if there is a national body fixing prices?

jefurii 10y ago
Looks like not much of a role at all. After all of my experiences with insurance companies I'm quite okay with that. A NHS-style system would still need staff in order to function and I expect many rank-and-file insurance people would end up there. The executives can go to hell as far as I'm concerned.
- maxerickson 10y ago
  Providers also have a lot of staff dedicated to working with the insurance companies. I'm pretty sure billing complexity is one of the things driving consolidation of physicians into large practices and health systems.
DiabloD3 10y ago
None. Which is America's end game: to end that apparent scam. This is why I actually had hope for the original draft of Obamacare: he straight up cloned the Netherlands system where insurance companies must insure x% of various classifications of sick people (cancer, AIDS, asthma, heart disease, overweight, etc), where x% approximates the national average... ... and they must spend ridiculous high levels of what they make on actual health care, AND the prices of health care are nationalized. In the end, they fight over sick people (have a rare sickness? insurance companies will give you a discount to get you, instead of trying to figure out how to lifetime ban you from insurance instead). And what happens if an insurance company can't get enough people to meet the strict guidelines? They're banned from selling insurance in the Netherlands until they do. This is essentially the original Obamacare, filtered through the American way of doing shit. What we got instead? Half of that, and maybe not even the good half. We got fucked.
nlodnl 10y ago
They'd still be providing insurance. A national body negotiating pricing doesn't necessarily mean any or all forms of healthcare would be affordable.

brightball 10y ago

The ACA was pretty much a terrible proposal from the start. The logic that lead people from "insurance companies are the problem!" to "force everybody to buy insurance!" required a mind blowing level of cognitive dissonance.

riskable 10y ago
You assume that this current broken state was unintentional. I believe this situation is intentional and was predicted and expected. Back when Obamacare was being debated I and many others argued that the best it could do would be to slow the meteoric rise of health care costs because it was painfully obvious (to me at least) that it didn't actually solve the problem. I have no doubt that the politicians knew this as well which was why Republicans fought so hard against it and why Democrats wanted it so bad. I believe they wanted it to come to this. They wanted to demonstrate that even if you force people to get insurance it still wouldn't be enough. It is a real-world application of how, "the compromise" (forcing people to get insurance) doesn't actually impact the price much because health care costs are not controlled by traditional market forces. What is the price, "the market will bear" when someone will die or suffer immensely without treatment?
- brightball 10y ago
  Wouldn't surprise me, but among numerous other issues all it's doing is amplifying how everything gets worse when the federal government gets involved.
- mason240 10y ago
  This is also what has been pretty clear to me all along.

kefka 10y ago

I'm also seeing something else here too, with the "screw you, raise price by *1000" executives, schrekli (sic) being one of many. What many of these comes down to, is they own a right of patent on something that allows them to set the price at will. Or, if they choose, to not license or sell it at all. Stated differently, why should someone or government tell me how much I should set my price on a patent I own? An answer, which I am not aware of being used, is eminent domain. We do as such for public good when it comes to roads, buildings, and similar. I know the Supreme Court had to rule back with Wilbur and Orville Wright because they kept avionics back for a decade whilst Europe was booming... because someone wouldn't sell the rights to do aircraft. Of course, the underlying problem is public institutions pay for the research, and drug companies get access to this and extract. The drug co's aren't researching; the public institutions do; and we do.

jostmey 10y ago
Except the drug "schrekli" priced gouged was out of patent. It should have been a commodity, so why weren't any competitors allowed on the marketplace? Take a look at Washington for your answer. There are lots of amazing companies trying to invent cures that don't otherwise exist, and need compensation for their work. Then you have Epipen and "schrekli" jacking up prices on 30 year old drugs.
- kefka 10y ago
  Indeed. Whatever his name is, used the fact that the FDA has to "authorize" a drug, which is more akin to an indefinite patent. Then again, the deeper we dig, the more idiocy we see. How can we expect anyone to fix: insurance, pharmaceutical, device companies, FDA, AMA, government interference, medical schools - everyone has a part in the current system. And it is the combination of the worst that capitalism and socialism have to offer. And yes, I misspelled his name, because a google search was too much work to get his name correct (marque of disregard). But admittedly, probably was not the best case to explain.

msandford 10y ago

> We need a single payer system or at the very least a single body that negotiates the price of all drugs and health care services on behalf of all Americans. Frankly I'm surprised that the insurance companies aren't lobbying for such a thing as it could be their only hope for continued existence very soon. Insurance companies are legally obligated to pay out 80-90% of their receipts for treatment. Since they can't become more profitable on a percentage basis, they have every economic incentive to drive the cost of medicine up. What's better than making $500/year/customer? Making $1000/year/customer because medicine costs twice as much. You don't even need to get more customers! There's definitely a whole slew of market failures piled up on top of one another in the healthcare system here in the US. There are people who are afraid of single payer for silly reasons, but there are also people who are scared of rationing. That's a legitimate fear! And it's not one that can really be assuaged because we've seen that while it's very difficult to get laws passed today, that's nothing compared to rolling them back. So everyone could go into single payer with the best of intentions but it only takes a few changes of administration for things to start to go off the rails, and then it'll be nearly impossible to get the mess sorted out. I mean, look at the ACA! The whole thing was done with the best of intentions but even before it made it to being a law it got all messed up. And now that it is a law, it's maybe not necessarily having the intended effect. Couple that with the idea that everyone in the US is about to "make it" or that everyone thinks they're middle class or upper middle class and fears about rationing can seem entirely well founded. Anecdotally I had a prof who was from Vancouver who had a knee problem and needed an MRI to make sure it wasn't cancerous before they operated. 9 month wait list fo r the MRI or a half day excursion to Seattle and about a grand and he had his imaging. It doesn't prove that everyone in Canada experiences rationing the same way, but it does mean that fears aren't completely unfounded.

mgkimsal 10y ago
" but even before it made it to being a law it got all messed up" Requiring legislators to read legislation (and maybe even take a test on bills that are larger than 10 pages?) before they vote on it might help. Being told "we have to pass it before we can look inside of it" is... I can't think of anything less sane. Re: Canada and other countries. I know in the UK you can get private insurance and "go private" for most services, or you can take the public option, which may involve waiting. Why we think here it's going to be 100% one thing... I don't understand. Your canada story already demosntrates that - someone with more money paid for faster service. I have a strong suspicion he could have had that done privately someone in canada for $x, but seattle was closer/easier (?)

rayiner 10y ago

Having a single entity negotiating prices would obviously lower them--it'd establish a monosopny. But would that be a good thing? I mean, we could lower prices for everything that way. Have a single entity negotiate prices for cars, or construction services, for example. That'd lower prices too. Why don't we do that for everything?

mgkimsal 10y ago
arguably not everyone needs everything - many people can get by just fine without a car, or construction services, or other things you might list. Not too many people get by (for long) with poor/ailing health. Some aspects of health care - basic stuff like getting people insulin they need and whatnot - does that not potentially get justified under "general welfare" clause? Many other countries seem to get by just fine with a baseline "health service" provided to everyone, with "premium" service paid for out of pocket or via private insurance. People should not have to face bankruptcy (or just extreme debt) because they happened to be born with the wrong genes.
- harryh 10y ago
  There are other things that people need by: food, housing, clothing. We don't use the government as a single entity for purchasing those goods. What makes them different from drugs?
- rayiner 10y ago
  That's an argument for the government paying for healthcare. But why is it a good idea to achieve lower consumer prices via centralized price negotiation for health care but not for other things?
  - enraged_camel 10y ago
    Healthcare is a human right. Cars aren't. https://en.m.wikipedia.org/wiki/Right_to_health https://en.m.wikipedia.org/wiki/Right_to_health

mgkimsal 10y ago

"It worked for a time" It's only been in effect for a few years - what "time" did it "work"?

xienze 10y ago
What, you don't remember those articles immediately after Obamacare went into effect gloating about how everything was going fine?
calvano915 10y ago
The big successful aspects of the law remain in my mind: Elimination of lifetime caps, pre-existing conditions. Allowing children to remain on plans until 26. Insuring millions more via expansion of Medicaid or subsidies of premiums with initially more competitive plans. By and large I think it was a success, albeit a completely temporary bandaid to a system that requires massive re-thinking

neffy 10y ago

I agree - a lot of the issue in the US is that there isn´t any effective competition (or control of) the drug companies and price gouging. A single payer will help tackle that. But the key question is, why is American healthcare so expensive, and for such poor outcomes - measured by life expectancy at least? You can lop off a few percent as the cost of running the insurance company infrastructure, but it still doesn´t explain all of it. Nor is it the case that US patients are subsidising other patients drug costs - not all drugs are researched or manufactured by US drug companies. There is a supply element to all this as well, and it´s not just drugs. Let me give you one example from the UK, since I don´t know the US figures. One of the problems in the UK is that doctors are very expensive, and there aren´t enough of them - this isn´t because of their student loans, it´s because there´s a shortage of doctors. The NHS imports a lot of doctors from abroad to cover this (causing issues in their home countries), the US does the same. (If you´re a doctor from a country with low cost medical training the markup for working in the US is insane. I digress.) Dig into the statistics for medical training in the UK, and it becomes clear that the number of places has been held more or less constant, while the base population has increased significantly, and you can put whatever fudge factor you like on the population needs more healthcare because of obesity/ageing/excessive tea drinking, etc. http://dera.ioe.ac.uk/16155/1/medical-and-dental-school-intakes.pdf http://dera.ioe.ac.uk/16155/1/medical-and-dental-school-inta... (p11) Finally - this year: https://www.gov.uk/government/news/up-to-1500-extra-medical-training-places-announced https://www.gov.uk/government/news/up-to-1500-extra-medical-... Which unfortunately won´t have any real impact for at least 6 years or so. To solve the american health care problem requires essentially a large scale attack on the cost of the health provisions, and that has to be across the board, and it´s going to take years just because of the lag times involved. Personally I would start with simply doubling the number of medical school places - maintain standards on admission - and work on dropping the salary levels. Provide scholarships so students don´t need big loans. Attack the anti-competitive practices of the drug companies directly, etc. In other words, remove artificial supply bottlenecks, let the market sort it out... and have some kind of bailout ready for the existing medical professionals, and medical providers, who then can´t repay their loans. Making the rest of the world pay US prices...isn´t going to happen. Sir Alexander Fleming was Scottish.

maxerickson 10y ago