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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 ar

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.
galeaspablo 9y ago
That is conjecture. I could similarly hypothesize that things would improve under a single payer system, even for the rich... because of the compounding scientific advances of government backed healthcare. BUT we could go back and forth all day with conjecture... Give me some apples to apples numbers; that's what I joined HN for.
asah 9y ago
Actually, the 1% would have private healthcare, i.e. pay twice. This is directly analogous to private primary education: the wealthy still pay taxes to fund public schools, while paying addition for private schools as well.
- seanmcdirmid 9y ago
  Something else the conservatives want to fix with school vouchers....
inopinatus 9y ago
This is not true, and can be trivially observed to be not true by counterexample, viz. looking at other countries that have a hybrid public/private system e.g. here in Australia. Incidentally, "level of care" is almost meaningless in most first-world systems. The difference I experience, due to my private health insurance here, is not in outcomes, but in time to service for elective procedures, and access to private facilities (most notably a private room for overnight/extended hospital stays). And that time-to-service difference vanishes for emergency care. EDIT: additional insider tip. If you have private health cover in such a system, and are being treated for a major medical issue, ask for a private room in a public hospital, because that is where our clinicians spend most of their day-to-day. If you are in a room in a private hospital, there are often no specialist clinicians on site. Whilst this may make no difference for most cases, any sudden complication may be dealt with much more quickly. This is possible in our hybrid system because the hospital is a separate institution from the state and happily does both public and private billing.
specialist 9y ago
Word salad. Our system (the USA) maximizes rent seeking, thru obfuscation, disjoint regulation, spotty oversight and enforcement.
abalone 9y ago
> They will undoubtedly receive worse care You're going to have to provide a lot more support for that claim. All you've really provided is the implication that "most expensive" = "best". But expense is also a result of inefficiencies, and we "undoubtedly" have a less efficient system (more administrative overhead.. I can cite sources if anyone doubts it). Other single-payer systems, for example, also provide complementary or supplementary private options.[1] And since these private options have to compete with a baseline of quality public care, they may be more affordable. [1] https://en.wikipedia.org/wiki/Two-tier_healthcare https://en.wikipedia.org/wiki/Two-tier_healthcare
- inopinatus 9y ago
  > And since these private options have to compete with a baseline of quality public care, they may be more affordable. In such a hybrid system the public hospitals also experience competitive pressures. I can confirm pretty much first-hand[1] that this is why pathology turn-around times in a major metropolitan Australian public health service are measured in hours, whilst in the UK they are measured in weeks. [1] I am married to the medical director of this service.
makomk 9y ago
Indeed. One of the core ways single payer systems achieve such great results in terms of bang-for-buck is by not covering treatments that offer bad value for money, and this is almost certainly not politically viable in the US. For example, I understand the ACA specifically forbids assessing the cost-effectiveness of treatment based on dollars per QALY, which is how the NHS in the UK rations care to reduce costs. It simply does not follow that, because single payer systems offer better value in terms of benefit gained for the dollars spent, those efficiency improvements mean it's possible for everyone to come out ahead. Those last few iotas of healthcare improvement are a lot more expensive than the lower-hanging fruit.
- inopinatus 9y ago
  This is flat wrong mis-statement of both the facts and the outcomes. The NHS does not assess cost-effectiveness of treatment in the UK in that fashion, and does not deny it on that basis. Cost-effectiveness by QALY is one factor included in assessments by a separate body, NICE, which a) is not part of the NHS and b) does not inhibit NHS bodies from offering any particular treatment. If NICE gives a treatment option the green light, then the NHS trusts are obliged to offer it in applicable circumstances. If NICE does not, then individual (local) NHS trusts can make their own assessment. If there is a local cost constraint, that is considered as a matter of simple necessity. It is a common falsehood often repeated by opponents of single-payer systems that doctors in such systems are directly prevented from offering treatments by faceless beancounters. It simply isn't so. Quite the opposite. The assessors may say "you must offer this treatment". They do not say "you must not". However, QALY itself is IMO a terrible metric mainly because it is sufficiently describable to non-practitioners to become a political football.
  - makomk 9y ago
    Part of running an "efficient" healthcare system is that cost constraints are always a factor. Sure, NHS trusts are legally allowed to offer treatments that aren't approved by NICE, but they have piles of money lying around to do expensive things beyond the basics that are required of them at the best of time, and this isn't the best of times - like many countries the UK has a healthcare funding crisis right now. At best, requiring a treatment rejected by NICE leaves your fate up to a postcode lottery where your location determines whether you have access to it. At worst, nowhere will cover it. Also, cost per QALY is one of the main factors NICE uses, and the ACA means it and similar measures cannot be used as any kind of factor at all in the US.

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.

galeaspablo 9y ago

That is conjecture. I could similarly hypothesize that things would improve under a single payer system, even for the rich... because of the compounding scientific advances of government backed healthcare. BUT we could go back and forth all day with conjecture... Give me some apples to apples numbers; that's what I joined HN for.

asah 9y ago

Actually, the 1% would have private healthcare, i.e. pay twice. This is directly analogous to private primary education: the wealthy still pay taxes to fund public schools, while paying addition for private schools as well.

seanmcdirmid 9y ago
Something else the conservatives want to fix with school vouchers....

inopinatus 9y ago

This is not true, and can be trivially observed to be not true by counterexample, viz. looking at other countries that have a hybrid public/private system e.g. here in Australia. Incidentally, "level of care" is almost meaningless in most first-world systems. The difference I experience, due to my private health insurance here, is not in outcomes, but in time to service for elective procedures, and access to private facilities (most notably a private room for overnight/extended hospital stays). And that time-to-service difference vanishes for emergency care. EDIT: additional insider tip. If you have private health cover in such a system, and are being treated for a major medical issue, ask for a private room in a public hospital, because that is where our clinicians spend most of their day-to-day. If you are in a room in a private hospital, there are often no specialist clinicians on site. Whilst this may make no difference for most cases, any sudden complication may be dealt with much more quickly. This is possible in our hybrid system because the hospital is a separate institution from the state and happily does both public and private billing.

specialist 9y ago

Word salad. Our system (the USA) maximizes rent seeking, thru obfuscation, disjoint regulation, spotty oversight and enforcement.

abalone 9y ago

> They will undoubtedly receive worse care You're going to have to provide a lot more support for that claim. All you've really provided is the implication that "most expensive" = "best". But expense is also a result of inefficiencies, and we "undoubtedly" have a less efficient system (more administrative overhead.. I can cite sources if anyone doubts it). Other single-payer systems, for example, also provide complementary or supplementary private options.[1] And since these private options have to compete with a baseline of quality public care, they may be more affordable. [1] https://en.wikipedia.org/wiki/Two-tier_healthcare https://en.wikipedia.org/wiki/Two-tier_healthcare

inopinatus 9y ago
> And since these private options have to compete with a baseline of quality public care, they may be more affordable. In such a hybrid system the public hospitals also experience competitive pressures. I can confirm pretty much first-hand[1] that this is why pathology turn-around times in a major metropolitan Australian public health service are measured in hours, whilst in the UK they are measured in weeks. [1] I am married to the medical director of this service.

makomk 9y ago

Indeed. One of the core ways single payer systems achieve such great results in terms of bang-for-buck is by not covering treatments that offer bad value for money, and this is almost certainly not politically viable in the US. For example, I understand the ACA specifically forbids assessing the cost-effectiveness of treatment based on dollars per QALY, which is how the NHS in the UK rations care to reduce costs. It simply does not follow that, because single payer systems offer better value in terms of benefit gained for the dollars spent, those efficiency improvements mean it's possible for everyone to come out ahead. Those last few iotas of healthcare improvement are a lot more expensive than the lower-hanging fruit.

inopinatus 9y ago
This is flat wrong mis-statement of both the facts and the outcomes. The NHS does not assess cost-effectiveness of treatment in the UK in that fashion, and does not deny it on that basis. Cost-effectiveness by QALY is one factor included in assessments by a separate body, NICE, which a) is not part of the NHS and b) does not inhibit NHS bodies from offering any particular treatment. If NICE gives a treatment option the green light, then the NHS trusts are obliged to offer it in applicable circumstances. If NICE does not, then individual (local) NHS trusts can make their own assessment. If there is a local cost constraint, that is considered as a matter of simple necessity. It is a common falsehood often repeated by opponents of single-payer systems that doctors in such systems are directly prevented from offering treatments by faceless beancounters. It simply isn't so. Quite the opposite. The assessors may say "you must offer this treatment". They do not say "you must not". However, QALY itself is IMO a terrible metric mainly because it is sufficiently describable to non-practitioners to become a political football.
- makomk 9y ago
  Part of running an "efficient" healthcare system is that cost constraints are always a factor. Sure, NHS trusts are legally allowed to offer treatments that aren't approved by NICE, but they have piles of money lying around to do expensive things beyond the basics that are required of them at the best of time, and this isn't the best of times - like many countries the UK has a healthcare funding crisis right now. At best, requiring a treatment rejected by NICE leaves your fate up to a postcode lottery where your location determines whether you have access to it. At worst, nowhere will cover it. Also, cost per QALY is one of the main factors NICE uses, and the ACA means it and similar measures cannot be used as any kind of factor at all in the US.