4 ms·

> Cheaper, and more terrible. Medicaid is not something anybody wants and in many ways is worse than the ER as a measure of last resort for acquiring care. So

> Cheaper, and more terrible. Medicaid is not something anybody wants and in many ways is worse than the ER as a measure of last resort for acquiring care. So here is what I do not understand. Why does the US not do what many European nations do and split healthcare into two problems? You have a few large insurance pools (single payer for lack of a better term) that is government run, mandatory participation and that covers emergency care and basic health services. And then separately to that you run a free market private healthcare system that sits on top of that governmental system and covers the better care? It's absurd that insurance companies in the US pay for everything. The cost do not add up for me as a customer. I do want choice in the non life threatening cases but I sure as hell do not want to ever have money concerns when it's really critical.

fatbird 9y ago
The problem in the U.S. isn't that costs are hidden--in Canada, with fully socialized insurance, health care consumers are actually much less wasteful of resources because they pursue health care in the degree they feel they need it, irrespective of money. Some are constant complainers craving attention, some are tough-as-nails cowboys who don't need a doctor to pull the bullet out; overall, Canadians are pretty reasonable about their as-needed consumption, as demonstrated by per-capita health care spending. The problem in the U.S. is that health care costs are directly tied to your employer, mostly, because the employer is the cost-savings insurance pool you join. This creates a lot of terrible situations where people are stuck in jobs they can't afford to leave for medical reasons; or are stuck with medical problems that prevent them from getting hired. What was originally supposed to be a social contract where you work hard to have a good career, and your boss takes care of the ugly bits of life like cancer, has turned into a tight coupling of disjoint life issues that usually creates the worst possible outcome in both cases. Medicaid is terrible largely because it's legislatively hobbled to prevent it exercising market power (like negotiating bulk pricing for pharmaceuticals, because doing so would embarrass capitalism somehow), and otherwise regulation driven for political purposes, like capping payments for procedures at below market rates, causing them to be excluded from a large number of health care providers who don't need to submit to price controls. The U.S. health care system is like a graduate thesis in perverse incentives.
- rosser 9y ago
  I'd read that the way healthcare became tied to employment had less to do with some beneficent interpretation of the "social contract" than it did taxes. That is, when the two were first tied, income tax rates (especially for higher, including "professional", brackets) were much higher. Employer-sponsored insurance was first offered as a tax-free perk companies could use to draw talent. It's easy to see how that could become an expectation, and then a requirement, despite its helping create incentives that are ultimately aligned against the employee/patient.
  - eric_the_read 9y ago
    In 1943, the War Labor Board ruled that wage freezes due to WWII did not apply to fringe benefits, which included health insurance. So you couldn't pay your employees more money, but you could pay their health insurance.
- alacombe 9y ago
  > The problem in the U.S. isn't that costs are hidden--in Canada, with fully socialized insurance, health care consumers are actually much less wasteful of resources because they pursue health care in the degree they feel they need it, irrespective of money. Which lead to a 6 month delay to get an MRI in BC (which proud itself to be no. 1 province). Not to mention that the public insurance does NOT include dental, or if it does, only the bare minimum. I had to personally pay for a root canal because only a complete extraction was being reimbursed. Moreover, all my cleaning have been out of MY pocket, on top of MSP/RAMQ. I really don't get why Canadian think their healthcare is so star sprangling awesome... It's not.
  - the_mitsuhiko 9y ago
    > Which lead to a 6 month delay to get an MRI in BC (which proud itself to be no. 1 province). Not to mention that the public insurance does NOT include dental, or if it does, only the bare minimum. I had to personally pay for a root canal because only a complete extraction was being reimbursed. Moreover, all my cleaning have been out of MY pocket, on top of MSP/RAMQ. But isn't that what makes it great? I have no experience with Canada but Austria is not very different in that regard. My state insurance costs me (purely medical) around 5000 Euro per year independent if I self insure or through my employer. It gives me about what Canada gives you. No copays for employees and there is a 10% or 20% copay for self employed or management. In addition I pay about 3000 EUR a year extra for private insurance. I did not feel like waiting 2 months for an MRI so I decided to use my private insurance at a private carrier. Paid 500 EUR for that out of my pocket and the private insurance reimbursed everything but the contrast agent. I could also decide not to pay for my private insurance at all but I did the math and the plan I have now seems a pretty good way to spend money for later in life. It gives me the freedom to chose what I want. The cost for most non covered procedures is laughably cheap here. It seems like a better deal for my money.
ianai 9y ago
That sounds like a really great option. And like everything it's the republicans that keep it from happening.
pjc50 9y ago
This is actually the British system: the NHS covers everything, but you have to deal with their opinion of your need and may have to wait quite a long time. Quite a lot of higher-paid working people in the UK either buy insurance or get it as an employment benefit, because it can enable you to get back to work quicker if you have a serious accident or illness.
friendzis 9y ago
Public healthcare is sadly no silver bullet. In ideal private insurance scenario you pay some amount and get increasing credit for healthcare expenses, so the user is incentivised to chose best cost performing treatment (cheapest option providing adequate treatment) and providers are incentivised to obey free market rules and keep fees under control (sans cartels/antitrust, market segmentation). In publicly funded scenario without coupling between payments and usage, user is incentivised to seek the most "premium" treatment and providers are not incentivised to reduce operational costs. If the public system covers anything more than emergency care (patch a patient up and let them go) it automatically creeps into all service levels (have a basic cough? maybe that's bacterial pneumonia, better issue referrals for microbiological analysis and a CT scan. /s) if an answer to the question "if family doctor/general practitioner cannot appoint diagnosis and/or treatment and refers patient to a specialist and/or analyses, scans, etc. are those covered too?" is yes. The payer (government, taxpayers) probably has 3 mechanisms to keep [total] costs from skyrocketing all with their disadvantages: 1. Reduce usage count (doctor visits) - free visit quotas (possibly dependant on service level), fixed or percentage mandatory user fee, etc; 2. Fix service costs - e.g. 100$ for a GP visit from public pool; 3. Auction paid service quotas. While option 3 provides most incentives to optimise costs, it greatly punishes small players.
- crdoconnor 9y ago
  The only place I've ever seen private healthcare provision work about as well as public (Singapore), it was with price controls and a public at-cost option that competed with private options. The idea that price controls don't work in America is, of course, an article of faith in the free market religion. It wouldn't fly there. Spiraling costs is a much bigger risk in private "free market" systems, which is largely how America gets to spend 2x more of its GDP on roughly equivalent healthcare outcomes (mortality rates, etc.) to European single payer systems.
- vertex-four 9y ago
  > If the public system covers anything more than emergency care (patch a patient up and let them go) it automatically creeps into all service levels (have a basic cough? maybe that's bacterial pneumonia, better issue referrals for microbiological analysis and a CT scan. /s) No. In the UK, if you go into a GP's office with a cough, you'll be told to go home and rest. In fact, most likely, you'll be denied from making an in-person appointment. This is FUD in its plainest form.

fatbird 9y ago

The problem in the U.S. isn't that costs are hidden--in Canada, with fully socialized insurance, health care consumers are actually much less wasteful of resources because they pursue health care in the degree they feel they need it, irrespective of money. Some are constant complainers craving attention, some are tough-as-nails cowboys who don't need a doctor to pull the bullet out; overall, Canadians are pretty reasonable about their as-needed consumption, as demonstrated by per-capita health care spending. The problem in the U.S. is that health care costs are directly tied to your employer, mostly, because the employer is the cost-savings insurance pool you join. This creates a lot of terrible situations where people are stuck in jobs they can't afford to leave for medical reasons; or are stuck with medical problems that prevent them from getting hired. What was originally supposed to be a social contract where you work hard to have a good career, and your boss takes care of the ugly bits of life like cancer, has turned into a tight coupling of disjoint life issues that usually creates the worst possible outcome in both cases. Medicaid is terrible largely because it's legislatively hobbled to prevent it exercising market power (like negotiating bulk pricing for pharmaceuticals, because doing so would embarrass capitalism somehow), and otherwise regulation driven for political purposes, like capping payments for procedures at below market rates, causing them to be excluded from a large number of health care providers who don't need to submit to price controls. The U.S. health care system is like a graduate thesis in perverse incentives.

rosser 9y ago
I'd read that the way healthcare became tied to employment had less to do with some beneficent interpretation of the "social contract" than it did taxes. That is, when the two were first tied, income tax rates (especially for higher, including "professional", brackets) were much higher. Employer-sponsored insurance was first offered as a tax-free perk companies could use to draw talent. It's easy to see how that could become an expectation, and then a requirement, despite its helping create incentives that are ultimately aligned against the employee/patient.
- eric_the_read 9y ago
  In 1943, the War Labor Board ruled that wage freezes due to WWII did not apply to fringe benefits, which included health insurance. So you couldn't pay your employees more money, but you could pay their health insurance.
alacombe 9y ago
> The problem in the U.S. isn't that costs are hidden--in Canada, with fully socialized insurance, health care consumers are actually much less wasteful of resources because they pursue health care in the degree they feel they need it, irrespective of money. Which lead to a 6 month delay to get an MRI in BC (which proud itself to be no. 1 province). Not to mention that the public insurance does NOT include dental, or if it does, only the bare minimum. I had to personally pay for a root canal because only a complete extraction was being reimbursed. Moreover, all my cleaning have been out of MY pocket, on top of MSP/RAMQ. I really don't get why Canadian think their healthcare is so star sprangling awesome... It's not.
- the_mitsuhiko 9y ago
  > Which lead to a 6 month delay to get an MRI in BC (which proud itself to be no. 1 province). Not to mention that the public insurance does NOT include dental, or if it does, only the bare minimum. I had to personally pay for a root canal because only a complete extraction was being reimbursed. Moreover, all my cleaning have been out of MY pocket, on top of MSP/RAMQ. But isn't that what makes it great? I have no experience with Canada but Austria is not very different in that regard. My state insurance costs me (purely medical) around 5000 Euro per year independent if I self insure or through my employer. It gives me about what Canada gives you. No copays for employees and there is a 10% or 20% copay for self employed or management. In addition I pay about 3000 EUR a year extra for private insurance. I did not feel like waiting 2 months for an MRI so I decided to use my private insurance at a private carrier. Paid 500 EUR for that out of my pocket and the private insurance reimbursed everything but the contrast agent. I could also decide not to pay for my private insurance at all but I did the math and the plan I have now seems a pretty good way to spend money for later in life. It gives me the freedom to chose what I want. The cost for most non covered procedures is laughably cheap here. It seems like a better deal for my money.

ianai 9y ago

That sounds like a really great option. And like everything it's the republicans that keep it from happening.

pjc50 9y ago

This is actually the British system: the NHS covers everything, but you have to deal with their opinion of your need and may have to wait quite a long time. Quite a lot of higher-paid working people in the UK either buy insurance or get it as an employment benefit, because it can enable you to get back to work quicker if you have a serious accident or illness.

friendzis 9y ago

Public healthcare is sadly no silver bullet. In ideal private insurance scenario you pay some amount and get increasing credit for healthcare expenses, so the user is incentivised to chose best cost performing treatment (cheapest option providing adequate treatment) and providers are incentivised to obey free market rules and keep fees under control (sans cartels/antitrust, market segmentation). In publicly funded scenario without coupling between payments and usage, user is incentivised to seek the most "premium" treatment and providers are not incentivised to reduce operational costs. If the public system covers anything more than emergency care (patch a patient up and let them go) it automatically creeps into all service levels (have a basic cough? maybe that's bacterial pneumonia, better issue referrals for microbiological analysis and a CT scan. /s) if an answer to the question "if family doctor/general practitioner cannot appoint diagnosis and/or treatment and refers patient to a specialist and/or analyses, scans, etc. are those covered too?" is yes. The payer (government, taxpayers) probably has 3 mechanisms to keep [total] costs from skyrocketing all with their disadvantages: 1. Reduce usage count (doctor visits) - free visit quotas (possibly dependant on service level), fixed or percentage mandatory user fee, etc; 2. Fix service costs - e.g. 100$ for a GP visit from public pool; 3. Auction paid service quotas. While option 3 provides most incentives to optimise costs, it greatly punishes small players.

crdoconnor 9y ago
The only place I've ever seen private healthcare provision work about as well as public (Singapore), it was with price controls and a public at-cost option that competed with private options. The idea that price controls don't work in America is, of course, an article of faith in the free market religion. It wouldn't fly there. Spiraling costs is a much bigger risk in private "free market" systems, which is largely how America gets to spend 2x more of its GDP on roughly equivalent healthcare outcomes (mortality rates, etc.) to European single payer systems.
vertex-four 9y ago
> If the public system covers anything more than emergency care (patch a patient up and let them go) it automatically creeps into all service levels (have a basic cough? maybe that's bacterial pneumonia, better issue referrals for microbiological analysis and a CT scan. /s) No. In the UK, if you go into a GP's office with a cough, you'll be told to go home and rest. In fact, most likely, you'll be denied from making an in-person appointment. This is FUD in its plainest form.