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Why Single-Payer Health Care Saves Money

140 points by frgtpsswrdlame 9y ago

prostoalex 9y ago
> One is that administrative costs average only about 2 percent of total expenses under a single-payer program like Medicare, less than one-sixth the corresponding percentage for many private insurers. That story needs to come with a caveat that Medicare's anti-fraud efforts are covered by law enforcement budgets, namely FBI https://news.google.com/news/search/section/q/medicare%20fraud/medicare%20fraud?hl=en&ned=us https://news.google.com/news/search/section/q/medicare%20fra...
- martinald 9y ago
  And that doesn't happen with private companies? There's loads of fraud that goes on there too.
  - prostoalex 9y ago
    Which is why those companies hire entire departments dedicated to fraud. If a government agency stepped in and instead offered to do fraud investigation for free, that would provide a rather nice reduction to their overhead costs.
    - martinald 9y ago
      Really? So all private insurance fraud is covered by those companies. I find that hard to believe.
  - nostromo 9y ago
    That's his point. The story doesn't include fraud prevention for Medicare because it's paid for by another agency.
- bradleyjg 9y ago
  Further it is not a good argument by itself. One could imagine a program with no administrative overhead that because of that lack of administration ended up costing far more than a program with higher administrative overhead. I'm not saying that's the case here, but the argument needs to be made that it isn't.
- dv_dt 9y ago
  Anti-fraud enforcement is a tiny nit compared to the overall poor performance of US healthcare compared to other single payer nations. We pay roughly double per capita, cover fewer people (which means the people who do pay in our system are paying more than double), and have lagging health measures such as life expectancy and infant mortality rates (2-3x higher in the US!). https://ourworldindata.org/the-link-between-life-expectancy-and-health-spending-us-focus https://ourworldindata.org/the-link-between-life-expectancy-... Anti-fraud measures can be evaluated for cost-benefit in isolation, but when the fundamental cost structures are so completely out of whack then we should prioritize discussion of the fundamental problems - which is lack of single payer universal healthcare in America.
  - prostoalex 9y ago
    > infant mortality rates (2-3x higher in the US!). https://www.theatlantic.com/health/archive/2014/10/why-american-babies-die/381008/ https://www.theatlantic.com/health/archive/2014/10/why-ameri... "The researchers compared data on infant health and mortality in the U.S.; Austria, whose rate of 3.8 is roughly average among European nations; and Finland, whose rate of 2.3 is one of the lowest in the world. One of the biggest differences, they found, was in the definition of what could be considered a live birth. “Extremely preterm births recorded in some places may be considered a miscarriage or still birth in other countries,” they wrote. Although the chance of survival for babies born before 23 weeks is low (the American Academy of Pediatrics recommends that doctors don’t resuscitate babies born before that point), they’re recorded as live births in the U.S."
    - dv_dt 9y ago
      This is often brought up, so show the corrected or aggregate miscarraige and mortality numbers to get some point of comparison. Leaving it just open seems incomplete... Edit: Absent more aggregated numbers, it looks like Canada records similar to the US, while also having some similar issues with a higher pre-term birth rate, and US rate is still 50% higher than Canadas. http://data.worldbank.org/indicator/SP.DYN.IMRT.IN http://data.worldbank.org/indicator/SP.DYN.IMRT.IN
- tvchurch 9y ago
  Here's the other thing about administrative costs: Medicare's patients cost a lot more per person than private insurance. In other words, if it costs you $500 in administration costs and one patient has care that totals $5,000 and another has care that totals $10,000, then their administrative costs are 10% and 20%. And yet we think that if we shifted more people onto a Medicare-like system, we'd save money.
  - hirsin 9y ago
    I've always read that the problem with Medicare is that it's unfair to hospitals because they pay lower than the average rate (but can't negotiate on medicine). Do the savings from lower care costs not balance out the higher drug costs? (From a steady state of 1 surgery can lead to a lifetime of drugs, I'd guess the balance isn't great)
  - jefurii 9y ago
    Medicare patients are more expensive because of who it currently covers: elderly and disabled people, two groups that use more services than the general population. The whole point of a single payer AKA Medicare for all system is to cover the entire population, which would (because math) bring down the average cost per person.
  - dv_dt 9y ago
    Medicare is also currently prevented by law from negotiating for drug prices. If we shift more people onto Medicare, we need to fix that problem too. The overall structure of a single payer/administrator is most likely to save money, but we need to be vigilant about the specific rules it is imposed with too.
- specialist 9y ago
  Switching to a single payer would reduce fraud. Because simplified rules are easier to adult. A cynic might even say the USA's healthcare system is purpose built to maxmize fraud. https://www.amazon.com/Healthcare-Fraud-Auditing-Detection-Guide-ebook/dp/B007P6UTX0/ https://www.amazon.com/Healthcare-Fraud-Auditing-Detection-G...
yegle 9y ago
I find it hilarious that this article uses state government taking over road maintenance as an analogy and claim it will save money, while it's known that California has a bad reputation in road repair, due to funding problem. http://www.latimes.com/politics/la-pol-sac-road-funding-problems-20160512-snap-story.html http://www.latimes.com/politics/la-pol-sac-road-funding-prob...
- luxuryballs 9y ago
  Yeah plus what a terrible analogy. The road is shared equally by everyone for the most part, my car tools along in a single lane. However if I smoke cigarettes and get cancer or eat myself into heart disease, this still doesn't cost any more for the road. It's something that can be mostly shared in a fair way. Healthcare cannot be shared in a fair way. Plus if I don't play well with others the government will take away my license so I can't drive anymore. I don't want the government standing between me and healthcare in any sense of the term. If they are the ones in charge of a limited resource that means they are also the ones that have to say 'no' when there isn't enough to go around.
- undersuit 9y ago
  >“I think the missing element in this is Republican votes and identified Republican support,” said Brian Kelly, secretary of the California State Transportation Agency. >California’s reliance on gas taxes to repair its transportation network is becoming less and less tenable. Increased fuel economy standards have led to less spending on gasoline Why stop at saying it's a funding problem? (Allegedly) Obstructionist Republicans won't allow the government to react to changing conditions to update laws needed to fix the funding problem.
  - DrScump 9y ago
    Republicans have no power in CA. Democrats hold the governorship and have supermajorities in both the Assembly and Senate. CA infrastructure doesn't have a funding problem. It has a spending problem.
    - 9y ago
necessity 9y ago
Time for the daily confirmation bias on HN! Sponsored contend? I wonder...
- jopsen 9y ago
  Yeah, even with all the inefficiencies added up, the top 5-10% will likely end up pay more for less. But that's still no reason to let poor people die...
fleitz 9y ago
A big part of this to is drs in places like Canada get training on how to save costs which generally means not providing service. I had to switch to a private system in Canada to get drs who would take a proactive approach.
- hfourm 9y ago
  Yea, I am all for more government cost controls, and maybe a public option for a more tiered system. But it seems like universal single payer is not really realistic for the US.
- vkou 9y ago
  Oftentimes, not providing any service is better for patient outcomes then providing unnecessary services. Especially if those services are surgeries. [1] [1] https://www.usatoday.com/story/news/nation/2013/06/18/unnecessary-surgery-usa-today-investigation/2435009/ https://www.usatoday.com/story/news/nation/2013/06/18/unnece...
  - fleitz 9y ago
    I'm talking about ordering an ultra sound / MRI and running other tests. I'm talking about sinuses so collapsed they couldn't be scoped so the ENT Dr just assumed they were fine.
- johnny99 9y ago
  Cost saving measures can also result in better care. We use Kaiser Permanente, and they often use nurse practitioners and physicians assistants to initially screen patients. It may sound like that's a lower level of care than seeing an MD, but in practice, it's much easier to be seen by someone quickly, and every single one of the providers we've seen has been excellent. Another point: health care outcomes are better in Canada. There may be more than just health care working there (ie, lower obesity), but it's worth noting.
- larrywright 9y ago
  It's also worth noting that more than a few Canadians come to the United States for treatment because they can either get treatment faster, or they can get treatments that aren't available in Canada.
nostromo 9y ago
I imagine both single-payer and a truly free market health care system would be substantially cheaper than the current system -- which has none of the benefits of either approach. With the federal government unable to act, turning healthcare back to the states to test a number of different solutions seems entirely reasonable. Let California try single-payer and Texas try something different -- after a few years see if we've found a solution that could work for the whole country.
- ravitation 9y ago
  > a truly free market health care system would be substantially cheaper Why would you imagine that? Regardless... You must also then ask the question, whether a "truly free market health care system" would be ethical.
  - warcher 9y ago
    It's a fun thought experiment, but we'd never do it. A free market would look something like this: 1) everybody buys their own insurance in a genuinely free marketplace (this is ENTIRELY not the case now and would probably require significant gov intervention to defeat cartel-seeking behavior from insurance co's. There are good reasons insurance is so highly regulated, only the first of which is that insurance companies are highly incentivized to not pay out since they already have your money, and you can't go elsewhere with your claim.) 2) if you can't pay, you die in the gutter.
    - warcher 9y ago
      Point two would be a hell of an incentive to get insurance, by the by. Beats the hell out of some candy-ass tax penalty. "Young invincible bet wrong, got caught in some freak skateboarding accident? Sucks to be you. You an organ donor by any chance?"
      - magicalist 9y ago
        > Point two would be a hell of an incentive to get insurance, by the by. Beats the hell out of some candy-ass tax penalty. "Young invincible bet wrong, got caught in some freak skateboarding accident? Sucks to be you. You an organ donor by any chance?" It wasn't before, so it probably wouldn't serve as one in the future. The issue is that people aren't very good at estimating risk. I'm young, healthy, and no one in my family has been in a serious car accident/gotten cancer/had a heart attack in the last 15 years. Obviously that happening is a low risk compared to the financial penalty of maintaining insurance today, so why should I worry? Besides, I'm sure I can get some kind of plan from an insurance company if something bad does happen[1] [1] I'll be sure to look into the feasibility of this statement as soon as I finish all the other important things on my todo list...
peterhadlaw 9y ago
The word "negotiation" is a euphemism here: > The most important source of cost savings under single-payer is that large government entities are able to negotiate much more favorable terms with service providers. If there are no other options for clients, it's essentially the government telling doctors how much their services are worth.
- leepowers 9y ago
  Yes, it's a euphemism for price controls. Which may or may not be a no-go depending on your political bent. Another issue here is termination shock - if a provider comes up under the current system, getting into massive student debt in anticipation of a highly remunerative medical career, how will price controls effect him?
  - tanderson92 9y ago
    By my back of the envelope account it might cost about $36 Billion to forgive the student debt (say $200k average) of a fifth (early career) of all physicians in the US (28 patient care docs per 10,000)
- dv_dt 9y ago
  It's not just doctors, its drug and health insurance companies, etc... but really? Is the argument is that we as a nation should pay double what other modern nations pay so doctors can be well paid? Edit: Here's a deal, lets pay for doctor's educations, implement universal healthcare and call it even.
  - peterhadlaw 9y ago
    You're still telling people what their time and efforts are worth rather than if there were no artificial restrictions.
    - dv_dt 9y ago
      No, if we're implementing universal healthcare, they're negotiating in a labor market which has decided to collectively bargain for the purchase of services. Consider it the physcians version of labor globalization. Or workers labor negotiations vs ever larger corporations. Only this time its for a public good.
leepowers 9y ago
> It thus makes no sense to reject single-payer on the grounds that it would require higher tax revenues. That’s true, of course, but it’s an irrelevant objection. > The most important source of cost savings under single-payer is that large government entities are able to negotiate much more favorable terms with service providers. I agree these objections are not relevant for the overall system. But certain individuals and groups within the current system will get screwed. The wealthy and upper middle-class will oppose any tax increases, as it will decrease their take-home income. Plus the resentment of having to pay for someone else (the moochers). Providers will oppose any haircut that comes with single-payer rates and price controls. No more millionaire doctors, specialists, or dentists. And of course the overhead of health insurance middle-men and the huge administrative bureaucracy costs. This is the crux of the problem. We could have a reasonably good system for everyone. But it requires a lot of people with heavily vested interests into a less ideal situation.
- luxuryballs 9y ago
  Yeah, and we ban people from public roads for bad behavior. Will we ban people from public healthcare for bad health choices? Do we really want to give the government that kind of exclusive control over a service while giving up control of our bodies?
  - ML_God 9y ago
    There are limited resources, somebody has to make hard decisions - e.g. if a given patient must live or die. Is a privately owned insurance company a better choice maker, than the government in this case?
  - coredog64 9y ago
    Smokers typically exhibit compressed mortality. Yes, they die younger than non-smokers, and yes, they have health issues. But the health issues are typically of the sort that get deadly in short order and so actually save money.
    - camiller 9y ago
tabeth 9y ago
The article makes the assumption that the goal is to save money. Perhaps the way things are keeps the status-quo alive for those who make the rules, and that's why we don't have single payer. I hate to be the conspiracy theorist, but I can't help but think that's the truth.
- cortesoft 9y ago
  Anytime one person saves money, it is also costing someone else money (the person or people that money was going to). Saving money on healthcare will cost money for people who are currently making money from the excessive costs of healthcare. This is not a secret, and not really a conspiracy; the groups that make money from the current system are always the ones opposed to change. It just sucks because there aren't nearly as many of them as the rest of us, but they just have more to lose than the rest of us have to gain - a classic example of concentrated benefits and diffuse costs.
  - luxuryballs 9y ago
    But the 'rest of us' can only gain for as long as those people stick around to pay for it. There is a lot of wealth in this country, for now. If you wanna really see things go down hill then watch the wealth scramble out of the country as soon as we tell them they're going to have to fund the healthcare of everyone else.
    - cortesoft 9y ago
      I was talking about people making money off of the health care industry, not wealthy people in general. We aren't asking them to fund the healthcare of everyone else, just not make profit off of waste. Also, scramble out of the country.... where? There are very few places they can 'run off to' that don't already have a single payer health care system. People don't seem to be 'fleeing' those countries.
      - luxuryballs 9y ago
        Those countries have way less population who can't contribute. The US is huge, there's so many more people who need healthcare but don't pay any taxes.
galeaspablo 9y ago
How do we compare apples to apples (between countries)? Compare health expenditure per capita (public and private) with multiple health indexes. I.e. get the bang for buck. In the list of nations with the best bang for buck healthcare programs, you will notice that top 20 healthcare programs are mostly single payer. http://www.who.int/healthinfo/paper30.pdf http://www.who.int/healthinfo/paper30.pdf But there are single payer healthcare systems with bad health indexes, you might say... Well, combine single payer healthcare systems and add some transparency in healthcare and you now have an unmissable correlation. https://www.transparency.org/whatwedo/publication/global_corruption_report_2006_corruption_and_health https://www.transparency.org/whatwedo/publication/global_cor... The top 20 bang for buck healthcare programs (mostly single payer systems), have an average ranking in terms of healthcare transparency of 18.7. Are you from the USA? Notice the countries with universal healthcare, who have a similar healthcare transparency ranking to that of the USA: Luxembourg, Canada, Germany, France, Belgium, Ireland, and Chile. Their bang for buck rankings are 16, 30, 25, 1, 21, 19, 33 respectively. All of these countries have a better bang for buck ranking than the USA's 37. In one sentence... Universal and transparently managed healthcare consistently gives more bang for buck. And now to quote the original article... "It is a bedrock economic principle that if we can find a way to do something more efficiently, it’s possible for everyone to come out ahead." EDIT: Check page 18 in the first source. Check chapter 11 in the second source.
- frgtpsswrdlame 9y ago
  This is a really good point. One problem I think though is that not everyone will come out ahead in a single payer system. Our system is explicitly organized around the fact that you must pay for care and we have the best and most expensive care in the world. Our system is setup so that those at the top of the economic ladder can buy a level of care they could not get anywhere else. They will undoubtedly receive worse care were the US to switch to a system which diminished the effect of personal wealth.
  - learc83 9y ago
    >They will undoubtably receive worse care were the US to switch healthcare systems. If the US switches to mostly single payer, but still allows for private insurance and private doctors to exist, the wealthy will probably have to pay more to access them, but they'll still be able to access them.
caseysoftware 9y ago
> "The most important source of cost savings under single-payer is that large government entities are able to negotiate much more favorable terms with service providers. In 2012, for example, the average cost of coronary bypass surgery was more than $73,000 in the United States but less than $23,000 in France." A more useful comparison would be the average cost of coronary bypass surgery for someone with a employer-provided health plan versus the cost that Medicare, Medicaid, or the VA pays. And then compare the average wait times of each along with recovery time/effectiveness. Out of pocket is only one "cost" in this picture.
- krath94 9y ago
  I feel like the numbers they picked are intentionally misleading. Is the $73,000 the cost for no insurance or with insurance? I know it says average, but average out of which group?
vowelless 9y ago
I personally think Medicare for all could potentially be a good system. But this article doesn't make a good argument at all. > Voters need to understand that this cost objection is specious. That’s because, as experience in many countries has demonstrated, the total cost of providing health coverage under the single-payer approach is actually substantially lower than under the current system in the United States. Not a valid comparison. They literally give examples of three liberal states where there were cost concerns. And the response? It is not to compare to states where single payer actually worked, bit compare it to different countries with widely different budgets and levels of centralization from medical research, medical school to employment of doctors. Just not a valid comparison at all. > It is a bedrock economic principle that if we can find a way to do something more efficiently, it’s possible for everyone to come out ahead. Useless fluff statement > By analogy, suppose that your state’s government took over road maintenance from the county governments within it, in the process reducing total maintenance costs by 30 percent. Your state taxes would obviously have to go up under this arrangement How is this an "obvious " point? Need some justification for this very important point ! Hence this statement doesn't follow as the premise is not established > Likewise, it makes no sense to oppose single-payer on the grounds that it would require additional tax revenue. . > One is that administrative costs average only about 2 percent of total expenses under a single-payer program like Medicare, less than one-sixth the corresponding percentage for many private insurers. Single-payer systems also spend virtually nothing on competitive advertising, which can account for more than 15 percent of total expenses for private insurers. Finally, some relevant fact and justified points. These are good points in favor of single payer. > The most important source of cost savings under single-payer is that large government entities are able to negotiate much more favorable terms with service providers Ah this is infuriating. The link compares USA to other countries. Why not given evidence of Medicare compared to private insurers? That would be such a strong point in favor of Medicare. I just don't think you can compare the entirety of the American healthcare system to other countries without controlling for the wide disparity in the systems as mentioned above. > In 2012, for example, the average cost of coronary bypass surgery was more than $73,000 in the United States but less than $23,000 in France Sad reality but again this comparison is meaningless without controlling. Why not compare states with single payer with states that don't have it? Or why not compare Medicare bypass surgeries with those of private? If none of those support the argument for single payer, then at least control for the variables when comparing countries... Otherwise the comparison is just lazy (or worse, just narrative building ). > In short, the evidence is clear that single-payer delivers quality care at significantly lower cost than the current American hybrid system. It thus makes no sense to reject single-payer on the grounds that it would require higher tax revenues. That’s true, of course, but it’s an irrelevant objection. I agree with this point, I am willing to take a higher tax hit to support single payer but the tax question is not an irrelevant object at all! Anyway, sorry if I sound bitter. I really want to see the US have a robust single payer system that respects it's ability to innovate with drugs and provide great healthcare to everyone. I just hope defenders of single payer (especially economics professors like the author ) can build a better case for it. I hope.
sailfast 9y ago
> "Of course, having to pay taxes is itself a mandate of a sort, but it’s one the electorate has largely come to terms with." Some taxes maybe? The whole "mandate vs. tax" argument was at the core of the opposition to the Affordable Care Act. I would argue that this issue is not decided by a long shot and a great deal of people are still upset by this. Further, this article addresses aggregate costs but doesn't acknowledge that costs of the change to single payer will impact people in much different ways. Some folks will be asked to pay a lot MORE, and some will be asked to pay LESS, and it may settle out to be cheaper in aggregate, but cheaper to whom? These impacts (especially felt in the short term) need to be considered and mitigated.
- DrScump 9y ago
  I would argue that this issue is not decided by a long shot On the contrary. The SCOTUS defined this already. ObamaCare still exists only because it is a tax and, therefore, pre-emption applied.
  - sailfast 9y ago
    Certainly, the legal issue of a tax vs. a mandate is decided, but Americans' comfort with this tax to cover other Americans as a matter of preference is not.
warcher 9y ago
It's still absurd to me that we make the false differentiation between taxes and insurance premiums. If you've got a family, neither is negotiable. If you have a job that pays, I promise you it affects your check in nearly identically the same way as payroll taxes do. There's a tradition in America where the price isn't actually the real price, we artificially advertise fake prices to get you in the door and stuff a bunch of surcharges on the back end. I wish we'd cut it out-- our taxes aren't crazy, but the way they're presented make people flip their shit.
- Joeri 9y ago
  Whenever I've visited the U.S. this drives me crazy. I always wonder how people shop for anything, given that the only time you find out the actual price of things is when you're about to pay for them. Do you just in your head have to tack on 10 to 20 percent (depending on the context)?
  - warcher 9y ago
    Basically yeah. I bought a car last month and I paid an extra... twenty percent before I walked out the door. Drives me nuts. That and fucking tipping, man. Enough already. Just put the price on the menu- I'm good for it, I swear.
    - pas 9y ago
      Tipping is. Meh. If you're broke, don't do it. It's not compulsory/mandated by law. (There are states where waiters don't get compensated, if patrons don't tip enough, but you're still broke, so don't feel too bad.)
      - warcher 9y ago
        The problem with tipping is that it's spreading, as wages aren't keeping up with cost of living, but employers won't hand out raises. Uber driver? Tip. Sandwich shop? Tip. Coffee shop? Tip. Pizza delivery? Delivery fee plus tip. Have I been in drive-throughs with a tip jar? You better believe I have. Enough already, guys.
donmatito 9y ago
I would like to understand better what is meant by "single payer". I think I know what it should mean, but then I see France as an example of single-payer system. France has a complex system of insurance bodies (public entities, privates companies, some weird stuff in between)... If I understand correctly the biggest savings come from the mandatory nature of the coverage - everybody is covered at least partially by the State, + employees by their employers, + private offers for the others + universal coverage for immigrants and the most destitute. Risk is shared between the healthy and sick people, and prevention can be maximized.
- coredog64 9y ago
  When I see it in the NYTimes, I assume it means that the health care fairy pays for it. As you've noted, very few people are wonky enough to be able to discern any difference between the systems in the UK, France, Germany, and Switzerland. Instead, they're all lumped into "European single payer" regardless of the level of truth or correctness.
  - pas 9y ago
    That's just bad faith. There are pretty well graspable differences. Germany has both private and public krankenkasse-s (sick people funds, so healthcare insurance providers). The UK has NHS, a big public insurance system. And so on. The economics are pretty well understood, so like climate change, it's not 100%, because it's big and complex as fuck, but a lot more certain, than a 50-50 coin flip. Of course people will have to still pay. The question is, what's the fair amount to ask from people. And it seems a progressive healthcare tax would be fair.
- LensLarque 9y ago
  In France when you work you have to pay a percentage of your salary for the national healthcare to cover you and your family. This national healthcare reimburse you about 60 to 80% of the bills depending on the type of treatment. The remainder is paid by a private healthcare that your employer is chosing and paying for you. The difference between the many private healthcare is usually the amount reimbursed for dental treatment and eyeglasses. If you have no work, there is an universal healthcare to cover you, but you cannot get fancy glasses or good tooth implant. The prices are regulated by deciding the amount reimbursed by the national healthcare for each medical act. The private healthcare reimbursement are based on these prices. Doctors are free to ask more money, but you are going to pay the delta. Savings are mainly achieved by having both sick and healthy people paying. Also, the fact that any medical treatment is basically free encourages you to see your doctor everytime you are beginning to be sick, preventing complications leading to a stay in hospital. Note also that many private healthcare are mutual insurance which are lowering the rates if there is a profit.
erentz 9y ago
Dan Carlin also did an episode on these numbers recently. The numbers are undeniable. We get terrible value for our money on health care in the US. https://itunes.apple.com/us/podcast/common-sense-with-dan-carlin/id155974141?mt=2&i=1000382690497 https://itunes.apple.com/us/podcast/common-sense-with-dan-ca...
methodover 9y ago
Yes, a single-payer system would save money, but you have to be honest about the downsides. It's unfortunate that they are not honestly discussed in the article. Or, for that matter, almost anywhere. The vast majority of the savings come from government price fixing. This is what the article means by "large government entities are able to negotiate much more favorable terms with service providers." It's not really a negotiation; at least not like it is in the private sector. When the government controls an entire market, they set prices. They can (and should) take input from providers and drug/device developers, but at the end of the day, whatever they say goes. There are incredible risks when the government sets prices for a good/service. We should not take on those risks lightly.
- jellicle 9y ago
  Suppose the current price for "two tylenol handed to a patient in a paper cup" is $50, and a giant insurer^W^W EVIL GOVERNMENT says it will only pay $40 next year. What do you suppose will happen? Societal collapse?
  - camiller 9y ago
    I suppose the hospital will lay off a pharmacist, increasing the workload for the rest of the pharmacy team, and instead of your Tylenol showing up in 15 min it will show up in 45 min.
- ClassyJacket 9y ago
  How does a government control an entire market when private health insurance is still available?
- exelius 9y ago
  Pricing in health care is currently not a negotiation. The customer often doesn't know the price before services are rendered -- they're left to negotiate the bill after the fact. And in the case of life-saving care like chemotherapy, your choice is "pay or die". That's not a negotiation; that's an ultimatum.
- esturk 9y ago
blizkreeg 9y ago
The government (county, state, or federal) pays for infrastructure, safety, defense, (public) schools, and a lot of other things. All out of tax revenue. With the help of _private_ contractors. Through a bidding process for contracts and work - thereby getting the lowest price (even if not necessarily value). It blows my mind that health is treated differently. It seems to me a lot of middle-America mistakenly assumes it's socialist, which single provider is. Single-payer is similar to most systems we already enjoy. It's the only way prices will come down. You need negotiating leverage and a single-payer system that a majority of your population uses is the only way to have that kind of leverage over drug companies and healthcare providers. Single payer universal healthcare with more expensive private plans (for those who can afford) is the only system that can come close to fixing the broken healthcare system in this country.
al3xnull 9y ago
I'm still wondering if it's possible to little by little add single-payer. If we could agree for basic 6-month checks at a doctor for preventive heads-up, basic immunizations, a single child delivery, and potentially a few other things; I wonder whom would get on-board. If at least very basic healthcare is guaranteed, why couldn't we as a nation at least provide that? Interested to see what someone more knowledgable would say is wrong with trying that.
RichardHeart 9y ago
What is more likely, insurance companies beat more than 50% more care per dollar out of doctors/hospitals etc, or people would be better of getting rid of the giant middleman? Insurance companies don't heal you. Medicine does. Get rid of the 33% overhead of insurance and gain the free 50% extra money for healthcare. Then all the people in that industry can move on to better gainful employment.
kbutler 9y ago
What government-run service do you consider a model of efficiency and good management? Highways? Defense? Education? National parks? Why would single payer health care be the exception?
mcrad 9y ago
Agency costs. Fools (& idealistic Americans) be thinking of "administrative costs" as able to be managed like the phone center that books your appointment, mail shop that sends your test results or janitors that clean the floor. Yes, these kinds of costs are basically in proportion to medical services provided, and yes, economies of scale apply. But if you have worked for a giant corporation or government, you might understand the danger of agency costs: not only can't be controlled, but in time, you get a worse product. Sad! No, there's no perfect solution, but there must be a balance of market forces and semi-trustworthy regulators to make it work.
dogruck 9y ago
I'd like to see more about how that "negotiation" over costs would work. Would it be like retail suppliers negotiating with Walmart? Or like military suppliers negotiating with the Pentagon? There's also the tough questions, such as who gets access to the best doctors, at the best hospitals?
Aron 9y ago
"An underappreciated advantage of the single-payer approach is that it sidesteps the mandate objection by paying to cover everyone out of tax revenue. Of course, having to pay taxes is itself a mandate of a sort, but it’s one the electorate has largely come to terms with. Apart from fringe groups that denounce all taxation as theft, most people understand that our entire system would collapse if tax payments were purely voluntary." Seriously? This is the argumentation from someone that has absolutely no idea what the other side is thinking.

> One is that administrative costs average only about 2 percent of total expenses under a single-payer program like Medicare, less than one-sixth the corresponding percentage for many private insurers. That story needs to come with a caveat that Medicare's anti-fraud efforts are covered by law enforcement budgets, namely FBI https://news.google.com/news/search/section/q/medicare%20fraud/medicare%20fraud?hl=en&ned=us https://news.google.com/news/search/section/q/medicare%20fra...

martinald 9y ago
And that doesn't happen with private companies? There's loads of fraud that goes on there too.
- prostoalex 9y ago
  Which is why those companies hire entire departments dedicated to fraud. If a government agency stepped in and instead offered to do fraud investigation for free, that would provide a rather nice reduction to their overhead costs.
  - martinald 9y ago
    Really? So all private insurance fraud is covered by those companies. I find that hard to believe.
- nostromo 9y ago
  That's his point. The story doesn't include fraud prevention for Medicare because it's paid for by another agency.
bradleyjg 9y ago
Further it is not a good argument by itself. One could imagine a program with no administrative overhead that because of that lack of administration ended up costing far more than a program with higher administrative overhead. I'm not saying that's the case here, but the argument needs to be made that it isn't.
dv_dt 9y ago
Anti-fraud enforcement is a tiny nit compared to the overall poor performance of US healthcare compared to other single payer nations. We pay roughly double per capita, cover fewer people (which means the people who do pay in our system are paying more than double), and have lagging health measures such as life expectancy and infant mortality rates (2-3x higher in the US!). https://ourworldindata.org/the-link-between-life-expectancy-and-health-spending-us-focus https://ourworldindata.org/the-link-between-life-expectancy-... Anti-fraud measures can be evaluated for cost-benefit in isolation, but when the fundamental cost structures are so completely out of whack then we should prioritize discussion of the fundamental problems - which is lack of single payer universal healthcare in America.
- prostoalex 9y ago
  > infant mortality rates (2-3x higher in the US!). https://www.theatlantic.com/health/archive/2014/10/why-american-babies-die/381008/ https://www.theatlantic.com/health/archive/2014/10/why-ameri... "The researchers compared data on infant health and mortality in the U.S.; Austria, whose rate of 3.8 is roughly average among European nations; and Finland, whose rate of 2.3 is one of the lowest in the world. One of the biggest differences, they found, was in the definition of what could be considered a live birth. “Extremely preterm births recorded in some places may be considered a miscarriage or still birth in other countries,” they wrote. Although the chance of survival for babies born before 23 weeks is low (the American Academy of Pediatrics recommends that doctors don’t resuscitate babies born before that point), they’re recorded as live births in the U.S."
  - dv_dt 9y ago
    This is often brought up, so show the corrected or aggregate miscarraige and mortality numbers to get some point of comparison. Leaving it just open seems incomplete... Edit: Absent more aggregated numbers, it looks like Canada records similar to the US, while also having some similar issues with a higher pre-term birth rate, and US rate is still 50% higher than Canadas. http://data.worldbank.org/indicator/SP.DYN.IMRT.IN http://data.worldbank.org/indicator/SP.DYN.IMRT.IN
tvchurch 9y ago
Here's the other thing about administrative costs: Medicare's patients cost a lot more per person than private insurance. In other words, if it costs you $500 in administration costs and one patient has care that totals $5,000 and another has care that totals $10,000, then their administrative costs are 10% and 20%. And yet we think that if we shifted more people onto a Medicare-like system, we'd save money.
- hirsin 9y ago
  I've always read that the problem with Medicare is that it's unfair to hospitals because they pay lower than the average rate (but can't negotiate on medicine). Do the savings from lower care costs not balance out the higher drug costs? (From a steady state of 1 surgery can lead to a lifetime of drugs, I'd guess the balance isn't great)
- jefurii 9y ago
  Medicare patients are more expensive because of who it currently covers: elderly and disabled people, two groups that use more services than the general population. The whole point of a single payer AKA Medicare for all system is to cover the entire population, which would (because math) bring down the average cost per person.
- dv_dt 9y ago
  Medicare is also currently prevented by law from negotiating for drug prices. If we shift more people onto Medicare, we need to fix that problem too. The overall structure of a single payer/administrator is most likely to save money, but we need to be vigilant about the specific rules it is imposed with too.
specialist 9y ago
Switching to a single payer would reduce fraud. Because simplified rules are easier to adult. A cynic might even say the USA's healthcare system is purpose built to maxmize fraud. https://www.amazon.com/Healthcare-Fraud-Auditing-Detection-Guide-ebook/dp/B007P6UTX0/ https://www.amazon.com/Healthcare-Fraud-Auditing-Detection-G...

yegle 9y ago

I find it hilarious that this article uses state government taking over road maintenance as an analogy and claim it will save money, while it's known that California has a bad reputation in road repair, due to funding problem. http://www.latimes.com/politics/la-pol-sac-road-funding-problems-20160512-snap-story.html http://www.latimes.com/politics/la-pol-sac-road-funding-prob...

luxuryballs 9y ago
Yeah plus what a terrible analogy. The road is shared equally by everyone for the most part, my car tools along in a single lane. However if I smoke cigarettes and get cancer or eat myself into heart disease, this still doesn't cost any more for the road. It's something that can be mostly shared in a fair way. Healthcare cannot be shared in a fair way. Plus if I don't play well with others the government will take away my license so I can't drive anymore. I don't want the government standing between me and healthcare in any sense of the term. If they are the ones in charge of a limited resource that means they are also the ones that have to say 'no' when there isn't enough to go around.
undersuit 9y ago
>“I think the missing element in this is Republican votes and identified Republican support,” said Brian Kelly, secretary of the California State Transportation Agency. >California’s reliance on gas taxes to repair its transportation network is becoming less and less tenable. Increased fuel economy standards have led to less spending on gasoline Why stop at saying it's a funding problem? (Allegedly) Obstructionist Republicans won't allow the government to react to changing conditions to update laws needed to fix the funding problem.
- DrScump 9y ago
  Republicans have no power in CA. Democrats hold the governorship and have supermajorities in both the Assembly and Senate. CA infrastructure doesn't have a funding problem. It has a spending problem.
  - 9y ago

necessity 9y ago

Time for the daily confirmation bias on HN! Sponsored contend? I wonder...

jopsen 9y ago
Yeah, even with all the inefficiencies added up, the top 5-10% will likely end up pay more for less. But that's still no reason to let poor people die...

fleitz 9y ago

A big part of this to is drs in places like Canada get training on how to save costs which generally means not providing service. I had to switch to a private system in Canada to get drs who would take a proactive approach.

hfourm 9y ago
Yea, I am all for more government cost controls, and maybe a public option for a more tiered system. But it seems like universal single payer is not really realistic for the US.
vkou 9y ago
Oftentimes, not providing any service is better for patient outcomes then providing unnecessary services. Especially if those services are surgeries. [1] [1] https://www.usatoday.com/story/news/nation/2013/06/18/unnecessary-surgery-usa-today-investigation/2435009/ https://www.usatoday.com/story/news/nation/2013/06/18/unnece...
- fleitz 9y ago
  I'm talking about ordering an ultra sound / MRI and running other tests. I'm talking about sinuses so collapsed they couldn't be scoped so the ENT Dr just assumed they were fine.
johnny99 9y ago
Cost saving measures can also result in better care. We use Kaiser Permanente, and they often use nurse practitioners and physicians assistants to initially screen patients. It may sound like that's a lower level of care than seeing an MD, but in practice, it's much easier to be seen by someone quickly, and every single one of the providers we've seen has been excellent. Another point: health care outcomes are better in Canada. There may be more than just health care working there (ie, lower obesity), but it's worth noting.
larrywright 9y ago
It's also worth noting that more than a few Canadians come to the United States for treatment because they can either get treatment faster, or they can get treatments that aren't available in Canada.

nostromo 9y ago

I imagine both single-payer and a truly free market health care system would be substantially cheaper than the current system -- which has none of the benefits of either approach. With the federal government unable to act, turning healthcare back to the states to test a number of different solutions seems entirely reasonable. Let California try single-payer and Texas try something different -- after a few years see if we've found a solution that could work for the whole country.

ravitation 9y ago
> a truly free market health care system would be substantially cheaper Why would you imagine that? Regardless... You must also then ask the question, whether a "truly free market health care system" would be ethical.
- warcher 9y ago
  It's a fun thought experiment, but we'd never do it. A free market would look something like this: 1) everybody buys their own insurance in a genuinely free marketplace (this is ENTIRELY not the case now and would probably require significant gov intervention to defeat cartel-seeking behavior from insurance co's. There are good reasons insurance is so highly regulated, only the first of which is that insurance companies are highly incentivized to not pay out since they already have your money, and you can't go elsewhere with your claim.) 2) if you can't pay, you die in the gutter.
  - warcher 9y ago
    Point two would be a hell of an incentive to get insurance, by the by. Beats the hell out of some candy-ass tax penalty. "Young invincible bet wrong, got caught in some freak skateboarding accident? Sucks to be you. You an organ donor by any chance?"
    - magicalist 9y ago
      > Point two would be a hell of an incentive to get insurance, by the by. Beats the hell out of some candy-ass tax penalty. "Young invincible bet wrong, got caught in some freak skateboarding accident? Sucks to be you. You an organ donor by any chance?" It wasn't before, so it probably wouldn't serve as one in the future. The issue is that people aren't very good at estimating risk. I'm young, healthy, and no one in my family has been in a serious car accident/gotten cancer/had a heart attack in the last 15 years. Obviously that happening is a low risk compared to the financial penalty of maintaining insurance today, so why should I worry? Besides, I'm sure I can get some kind of plan from an insurance company if something bad does happen[1] [1] I'll be sure to look into the feasibility of this statement as soon as I finish all the other important things on my todo list...

peterhadlaw 9y ago

The word "negotiation" is a euphemism here: > The most important source of cost savings under single-payer is that large government entities are able to negotiate much more favorable terms with service providers. If there are no other options for clients, it's essentially the government telling doctors how much their services are worth.

leepowers 9y ago
Yes, it's a euphemism for price controls. Which may or may not be a no-go depending on your political bent. Another issue here is termination shock - if a provider comes up under the current system, getting into massive student debt in anticipation of a highly remunerative medical career, how will price controls effect him?
- tanderson92 9y ago
  By my back of the envelope account it might cost about $36 Billion to forgive the student debt (say $200k average) of a fifth (early career) of all physicians in the US (28 patient care docs per 10,000)
dv_dt 9y ago
It's not just doctors, its drug and health insurance companies, etc... but really? Is the argument is that we as a nation should pay double what other modern nations pay so doctors can be well paid? Edit: Here's a deal, lets pay for doctor's educations, implement universal healthcare and call it even.
- peterhadlaw 9y ago
  You're still telling people what their time and efforts are worth rather than if there were no artificial restrictions.
  - dv_dt 9y ago
    No, if we're implementing universal healthcare, they're negotiating in a labor market which has decided to collectively bargain for the purchase of services. Consider it the physcians version of labor globalization. Or workers labor negotiations vs ever larger corporations. Only this time its for a public good.

leepowers 9y ago

> It thus makes no sense to reject single-payer on the grounds that it would require higher tax revenues. That’s true, of course, but it’s an irrelevant objection. > The most important source of cost savings under single-payer is that large government entities are able to negotiate much more favorable terms with service providers. I agree these objections are not relevant for the overall system. But certain individuals and groups within the current system will get screwed. The wealthy and upper middle-class will oppose any tax increases, as it will decrease their take-home income. Plus the resentment of having to pay for someone else (the moochers). Providers will oppose any haircut that comes with single-payer rates and price controls. No more millionaire doctors, specialists, or dentists. And of course the overhead of health insurance middle-men and the huge administrative bureaucracy costs. This is the crux of the problem. We could have a reasonably good system for everyone. But it requires a lot of people with heavily vested interests into a less ideal situation.

luxuryballs 9y ago
Yeah, and we ban people from public roads for bad behavior. Will we ban people from public healthcare for bad health choices? Do we really want to give the government that kind of exclusive control over a service while giving up control of our bodies?
- ML_God 9y ago
  There are limited resources, somebody has to make hard decisions - e.g. if a given patient must live or die. Is a privately owned insurance company a better choice maker, than the government in this case?
- coredog64 9y ago
  Smokers typically exhibit compressed mortality. Yes, they die younger than non-smokers, and yes, they have health issues. But the health issues are typically of the sort that get deadly in short order and so actually save money.
  - camiller 9y ago

tabeth 9y ago

The article makes the assumption that the goal is to save money. Perhaps the way things are keeps the status-quo alive for those who make the rules, and that's why we don't have single payer. I hate to be the conspiracy theorist, but I can't help but think that's the truth.

cortesoft 9y ago
Anytime one person saves money, it is also costing someone else money (the person or people that money was going to). Saving money on healthcare will cost money for people who are currently making money from the excessive costs of healthcare. This is not a secret, and not really a conspiracy; the groups that make money from the current system are always the ones opposed to change. It just sucks because there aren't nearly as many of them as the rest of us, but they just have more to lose than the rest of us have to gain - a classic example of concentrated benefits and diffuse costs.
- luxuryballs 9y ago
  But the 'rest of us' can only gain for as long as those people stick around to pay for it. There is a lot of wealth in this country, for now. If you wanna really see things go down hill then watch the wealth scramble out of the country as soon as we tell them they're going to have to fund the healthcare of everyone else.
  - cortesoft 9y ago
    I was talking about people making money off of the health care industry, not wealthy people in general. We aren't asking them to fund the healthcare of everyone else, just not make profit off of waste. Also, scramble out of the country.... where? There are very few places they can 'run off to' that don't already have a single payer health care system. People don't seem to be 'fleeing' those countries.
    - luxuryballs 9y ago
      Those countries have way less population who can't contribute. The US is huge, there's so many more people who need healthcare but don't pay any taxes.

galeaspablo 9y ago

How do we compare apples to apples (between countries)? Compare health expenditure per capita (public and private) with multiple health indexes. I.e. get the bang for buck. In the list of nations with the best bang for buck healthcare programs, you will notice that top 20 healthcare programs are mostly single payer. http://www.who.int/healthinfo/paper30.pdf http://www.who.int/healthinfo/paper30.pdf But there are single payer healthcare systems with bad health indexes, you might say... Well, combine single payer healthcare systems and add some transparency in healthcare and you now have an unmissable correlation. https://www.transparency.org/whatwedo/publication/global_corruption_report_2006_corruption_and_health https://www.transparency.org/whatwedo/publication/global_cor... The top 20 bang for buck healthcare programs (mostly single payer systems), have an average ranking in terms of healthcare transparency of 18.7. Are you from the USA? Notice the countries with universal healthcare, who have a similar healthcare transparency ranking to that of the USA: Luxembourg, Canada, Germany, France, Belgium, Ireland, and Chile. Their bang for buck rankings are 16, 30, 25, 1, 21, 19, 33 respectively. All of these countries have a better bang for buck ranking than the USA's 37. In one sentence... Universal and transparently managed healthcare consistently gives more bang for buck. And now to quote the original article... "It is a bedrock economic principle that if we can find a way to do something more efficiently, it’s possible for everyone to come out ahead." EDIT: Check page 18 in the first source. Check chapter 11 in the second source.

frgtpsswrdlame 9y ago
This is a really good point. One problem I think though is that not everyone will come out ahead in a single payer system. Our system is explicitly organized around the fact that you must pay for care and we have the best and most expensive care in the world. Our system is setup so that those at the top of the economic ladder can buy a level of care they could not get anywhere else. They will undoubtedly receive worse care were the US to switch to a system which diminished the effect of personal wealth.
- learc83 9y ago
  >They will undoubtably receive worse care were the US to switch healthcare systems. If the US switches to mostly single payer, but still allows for private insurance and private doctors to exist, the wealthy will probably have to pay more to access them, but they'll still be able to access them.

caseysoftware 9y ago

> "The most important source of cost savings under single-payer is that large government entities are able to negotiate much more favorable terms with service providers. In 2012, for example, the average cost of coronary bypass surgery was more than $73,000 in the United States but less than $23,000 in France." A more useful comparison would be the average cost of coronary bypass surgery for someone with a employer-provided health plan versus the cost that Medicare, Medicaid, or the VA pays. And then compare the average wait times of each along with recovery time/effectiveness. Out of pocket is only one "cost" in this picture.

krath94 9y ago
I feel like the numbers they picked are intentionally misleading. Is the $73,000 the cost for no insurance or with insurance? I know it says average, but average out of which group?

vowelless 9y ago

I personally think Medicare for all could potentially be a good system. But this article doesn't make a good argument at all. > Voters need to understand that this cost objection is specious. That’s because, as experience in many countries has demonstrated, the total cost of providing health coverage under the single-payer approach is actually substantially lower than under the current system in the United States. Not a valid comparison. They literally give examples of three liberal states where there were cost concerns. And the response? It is not to compare to states where single payer actually worked, bit compare it to different countries with widely different budgets and levels of centralization from medical research, medical school to employment of doctors. Just not a valid comparison at all. > It is a bedrock economic principle that if we can find a way to do something more efficiently, it’s possible for everyone to come out ahead. Useless fluff statement > By analogy, suppose that your state’s government took over road maintenance from the county governments within it, in the process reducing total maintenance costs by 30 percent. Your state taxes would obviously have to go up under this arrangement How is this an "obvious " point? Need some justification for this very important point ! Hence this statement doesn't follow as the premise is not established > Likewise, it makes no sense to oppose single-payer on the grounds that it would require additional tax revenue. . > One is that administrative costs average only about 2 percent of total expenses under a single-payer program like Medicare, less than one-sixth the corresponding percentage for many private insurers. Single-payer systems also spend virtually nothing on competitive advertising, which can account for more than 15 percent of total expenses for private insurers. Finally, some relevant fact and justified points. These are good points in favor of single payer. > The most important source of cost savings under single-payer is that large government entities are able to negotiate much more favorable terms with service providers Ah this is infuriating. The link compares USA to other countries. Why not given evidence of Medicare compared to private insurers? That would be such a strong point in favor of Medicare. I just don't think you can compare the entirety of the American healthcare system to other countries without controlling for the wide disparity in the systems as mentioned above. > In 2012, for example, the average cost of coronary bypass surgery was more than $73,000 in the United States but less than $23,000 in France Sad reality but again this comparison is meaningless without controlling. Why not compare states with single payer with states that don't have it? Or why not compare Medicare bypass surgeries with those of private? If none of those support the argument for single payer, then at least control for the variables when comparing countries... Otherwise the comparison is just lazy (or worse, just narrative building ). > In short, the evidence is clear that single-payer delivers quality care at significantly lower cost than the current American hybrid system. It thus makes no sense to reject single-payer on the grounds that it would require higher tax revenues. That’s true, of course, but it’s an irrelevant objection. I agree with this point, I am willing to take a higher tax hit to support single payer but the tax question is not an irrelevant object at all! Anyway, sorry if I sound bitter. I really want to see the US have a robust single payer system that respects it's ability to innovate with drugs and provide great healthcare to everyone. I just hope defenders of single payer (especially economics professors like the author ) can build a better case for it. I hope.

sailfast 9y ago

> "Of course, having to pay taxes is itself a mandate of a sort, but it’s one the electorate has largely come to terms with." Some taxes maybe? The whole "mandate vs. tax" argument was at the core of the opposition to the Affordable Care Act. I would argue that this issue is not decided by a long shot and a great deal of people are still upset by this. Further, this article addresses aggregate costs but doesn't acknowledge that costs of the change to single payer will impact people in much different ways. Some folks will be asked to pay a lot MORE, and some will be asked to pay LESS, and it may settle out to be cheaper in aggregate, but cheaper to whom? These impacts (especially felt in the short term) need to be considered and mitigated.

DrScump 9y ago
I would argue that this issue is not decided by a long shot On the contrary. The SCOTUS defined this already. ObamaCare still exists only because it is a tax and, therefore, pre-emption applied.
- sailfast 9y ago
  Certainly, the legal issue of a tax vs. a mandate is decided, but Americans' comfort with this tax to cover other Americans as a matter of preference is not.

warcher 9y ago

It's still absurd to me that we make the false differentiation between taxes and insurance premiums. If you've got a family, neither is negotiable. If you have a job that pays, I promise you it affects your check in nearly identically the same way as payroll taxes do. There's a tradition in America where the price isn't actually the real price, we artificially advertise fake prices to get you in the door and stuff a bunch of surcharges on the back end. I wish we'd cut it out-- our taxes aren't crazy, but the way they're presented make people flip their shit.

Joeri 9y ago
Whenever I've visited the U.S. this drives me crazy. I always wonder how people shop for anything, given that the only time you find out the actual price of things is when you're about to pay for them. Do you just in your head have to tack on 10 to 20 percent (depending on the context)?
- warcher 9y ago
  Basically yeah. I bought a car last month and I paid an extra... twenty percent before I walked out the door. Drives me nuts. That and fucking tipping, man. Enough already. Just put the price on the menu- I'm good for it, I swear.
  - pas 9y ago
    Tipping is. Meh. If you're broke, don't do it. It's not compulsory/mandated by law. (There are states where waiters don't get compensated, if patrons don't tip enough, but you're still broke, so don't feel too bad.)
    - warcher 9y ago
      The problem with tipping is that it's spreading, as wages aren't keeping up with cost of living, but employers won't hand out raises. Uber driver? Tip. Sandwich shop? Tip. Coffee shop? Tip. Pizza delivery? Delivery fee plus tip. Have I been in drive-throughs with a tip jar? You better believe I have. Enough already, guys.

donmatito 9y ago

I would like to understand better what is meant by "single payer". I think I know what it should mean, but then I see France as an example of single-payer system. France has a complex system of insurance bodies (public entities, privates companies, some weird stuff in between)... If I understand correctly the biggest savings come from the mandatory nature of the coverage - everybody is covered at least partially by the State, + employees by their employers, + private offers for the others + universal coverage for immigrants and the most destitute. Risk is shared between the healthy and sick people, and prevention can be maximized.

coredog64 9y ago
When I see it in the NYTimes, I assume it means that the health care fairy pays for it. As you've noted, very few people are wonky enough to be able to discern any difference between the systems in the UK, France, Germany, and Switzerland. Instead, they're all lumped into "European single payer" regardless of the level of truth or correctness.
- pas 9y ago
  That's just bad faith. There are pretty well graspable differences. Germany has both private and public krankenkasse-s (sick people funds, so healthcare insurance providers). The UK has NHS, a big public insurance system. And so on. The economics are pretty well understood, so like climate change, it's not 100%, because it's big and complex as fuck, but a lot more certain, than a 50-50 coin flip. Of course people will have to still pay. The question is, what's the fair amount to ask from people. And it seems a progressive healthcare tax would be fair.
LensLarque 9y ago
In France when you work you have to pay a percentage of your salary for the national healthcare to cover you and your family. This national healthcare reimburse you about 60 to 80% of the bills depending on the type of treatment. The remainder is paid by a private healthcare that your employer is chosing and paying for you. The difference between the many private healthcare is usually the amount reimbursed for dental treatment and eyeglasses. If you have no work, there is an universal healthcare to cover you, but you cannot get fancy glasses or good tooth implant. The prices are regulated by deciding the amount reimbursed by the national healthcare for each medical act. The private healthcare reimbursement are based on these prices. Doctors are free to ask more money, but you are going to pay the delta. Savings are mainly achieved by having both sick and healthy people paying. Also, the fact that any medical treatment is basically free encourages you to see your doctor everytime you are beginning to be sick, preventing complications leading to a stay in hospital. Note also that many private healthcare are mutual insurance which are lowering the rates if there is a profit.

erentz 9y ago

Dan Carlin also did an episode on these numbers recently. The numbers are undeniable. We get terrible value for our money on health care in the US. https://itunes.apple.com/us/podcast/common-sense-with-dan-carlin/id155974141?mt=2&i=1000382690497 https://itunes.apple.com/us/podcast/common-sense-with-dan-ca...

methodover 9y ago

Yes, a single-payer system would save money, but you have to be honest about the downsides. It's unfortunate that they are not honestly discussed in the article. Or, for that matter, almost anywhere. The vast majority of the savings come from government price fixing. This is what the article means by "large government entities are able to negotiate much more favorable terms with service providers." It's not really a negotiation; at least not like it is in the private sector. When the government controls an entire market, they set prices. They can (and should) take input from providers and drug/device developers, but at the end of the day, whatever they say goes. There are incredible risks when the government sets prices for a good/service. We should not take on those risks lightly.

jellicle 9y ago
Suppose the current price for "two tylenol handed to a patient in a paper cup" is $50, and a giant insurer^W^W EVIL GOVERNMENT says it will only pay $40 next year. What do you suppose will happen? Societal collapse?
- camiller 9y ago
  I suppose the hospital will lay off a pharmacist, increasing the workload for the rest of the pharmacy team, and instead of your Tylenol showing up in 15 min it will show up in 45 min.
ClassyJacket 9y ago
How does a government control an entire market when private health insurance is still available?
exelius 9y ago
Pricing in health care is currently not a negotiation. The customer often doesn't know the price before services are rendered -- they're left to negotiate the bill after the fact. And in the case of life-saving care like chemotherapy, your choice is "pay or die". That's not a negotiation; that's an ultimatum.
esturk 9y ago

blizkreeg 9y ago

The government (county, state, or federal) pays for infrastructure, safety, defense, (public) schools, and a lot of other things. All out of tax revenue. With the help of _private_ contractors. Through a bidding process for contracts and work - thereby getting the lowest price (even if not necessarily value). It blows my mind that health is treated differently. It seems to me a lot of middle-America mistakenly assumes it's socialist, which single provider is. Single-payer is similar to most systems we already enjoy. It's the only way prices will come down. You need negotiating leverage and a single-payer system that a majority of your population uses is the only way to have that kind of leverage over drug companies and healthcare providers. Single payer universal healthcare with more expensive private plans (for those who can afford) is the only system that can come close to fixing the broken healthcare system in this country.

al3xnull 9y ago

I'm still wondering if it's possible to little by little add single-payer. If we could agree for basic 6-month checks at a doctor for preventive heads-up, basic immunizations, a single child delivery, and potentially a few other things; I wonder whom would get on-board. If at least very basic healthcare is guaranteed, why couldn't we as a nation at least provide that? Interested to see what someone more knowledgable would say is wrong with trying that.

RichardHeart 9y ago

What is more likely, insurance companies beat more than 50% more care per dollar out of doctors/hospitals etc, or people would be better of getting rid of the giant middleman? Insurance companies don't heal you. Medicine does. Get rid of the 33% overhead of insurance and gain the free 50% extra money for healthcare. Then all the people in that industry can move on to better gainful employment.

kbutler 9y ago

What government-run service do you consider a model of efficiency and good management? Highways? Defense? Education? National parks? Why would single payer health care be the exception?

mcrad 9y ago

Agency costs. Fools (& idealistic Americans) be thinking of "administrative costs" as able to be managed like the phone center that books your appointment, mail shop that sends your test results or janitors that clean the floor. Yes, these kinds of costs are basically in proportion to medical services provided, and yes, economies of scale apply. But if you have worked for a giant corporation or government, you might understand the danger of agency costs: not only can't be controlled, but in time, you get a worse product. Sad! No, there's no perfect solution, but there must be a balance of market forces and semi-trustworthy regulators to make it work.

dogruck 9y ago

I'd like to see more about how that "negotiation" over costs would work. Would it be like retail suppliers negotiating with Walmart? Or like military suppliers negotiating with the Pentagon? There's also the tough questions, such as who gets access to the best doctors, at the best hospitals?

Aron 9y ago

"An underappreciated advantage of the single-payer approach is that it sidesteps the mandate objection by paying to cover everyone out of tax revenue. Of course, having to pay taxes is itself a mandate of a sort, but it’s one the electorate has largely come to terms with. Apart from fringe groups that denounce all taxation as theft, most people understand that our entire system would collapse if tax payments were purely voluntary." Seriously? This is the argumentation from someone that has absolutely no idea what the other side is thinking.