7 ms·

Medicare for All – How Can We Pay for It?

29 points by howard941 8y ago

sjg007 8y ago
It's pretty simple, through taxes. Most of the tax we would pay would be akin to the premiums we pay for private insurance... remember that we already pay medicaid and medicare taxes now.
- deleted 8y ago
  [deleted]
- martinald 8y ago
  The US pays more as a percentage of GDP for Medicaid/Medicare/Veterans healthcare than the UK spends on the entire NHS (which covers 100% of people).
  - qasdf 8y ago
    This is often overlooked in the health care debate. If the US paid European prices for health care, the government could give everyone free healthcare without raising taxes at all.
    - berbec 8y ago
      I think they could lower taxes. [1] 1: Citation needed
gammateam 8y ago
Would it be that hard of a stretch to convince people that a healthy population is more important and productive than how much you trust your neighbor’s work ethic and role in a darwinism nightmare?
awinder 8y ago
I don’t understand the reasoning / appeal of a new national sales tax for half of the new funding, as opposed to making this financed through payroll taxes exclusively. Maybe it’s to emphasize the 8% cost savings right off the bat to get private companies on board, but man, solving the escalating cost problem is a gift on its own. And we have already done the dance of trickle down, how about we directly deliver cost relief to the worker one time...
- howard941 8y ago
  I don't really wanna defend it but I'll try. If it's payroll taxes then it's only workers paying, but financed partially by sales tax broadens the base to include trust fund babies as well as retirees and public aid recipients.
bko 8y ago
> So we say by shifting everything to a single-payer system, with the government being the Medicare equivalent for everybody, we’re going to get about 9 percent savings for the whole system. Then we say, well, in Europe, on average they pay 50 percent less for drugs than we do. And we say, OK, well, we’ll take a more conservative number. We’ll say 40 percent less as opposed to 50 percent less. Cutting reimbursements for drugs by 40% is going to have impacts on everything from R&D to what drugs are available. Drug companies median profit margin varies widely but its about on average 12-14% [0]. I don't think you can just wave a magic wand and say now you get 40% less and you'll just deal with it. It's also naive to believe you can just export some reimbursement model from another country to the US and just plug and play. > That gives us 6 percent total savings in the system. Then we say Medicare rates for all providers, all doctors, hospitals, dentists. Everybody gets the Medicare rate. And that saves about 7 percent savings for the system cost. Same problem here. Paying doctors and hospitals 7% less will have an impact. Prices aren't just some arbitrary number you can change on a whim and have no effect. > And then finally we have high levels of inefficiency with so-called doctor-induced demand, where there’s too many procedures using high tech when you don’t need it, because they can charge more. This is just a change from bottom up (doctor) to top down (some medicare committee). I agree that there is a problem with over-treatment but I'm skeptical that a rule based system would be the ideal way to address this problem. > And there’s fraud. And so there’s a lot of estimates at very high levels of fraud and excessive costs. We took that service delivery savings as modest, maybe 1 to 2 percent. Add them all up, you get 19 percent savings. Traditionally government services are more susceptible to fraud as there is less of an incentive to address fraud. I'm not sure why a single federal agency would be more effective at rooting out fraud than smaller private insurers. Overall I'm skeptical of a top down approach primarily because they mainly address the problem by lowering prices by fiat rather than addressing the systematic issues of high costs. [0] https://yourbusiness.azcentral.com/average-profit-margin-pharmaceuticals-20671.html https://yourbusiness.azcentral.com/average-profit-margin-pha...
- hnmonkey 8y ago
  If you're the only customer for their businesses, yes you can waive a magic wand and say now you'll get 40% less and deal with it. Especially if you're the government and it's a law. It's like Walmart with their suppliers. If you're the biggest baddest around you can kinda do what you want. Certainly it will have impacts on R&D but are you suggesting that new drugs won't get created anymore? Don't drugs get created all throughout the EU?
reasonablemann 8y ago
I don't understand why there's so much resistance to having everybody save a huge amount of money while at the same time allowing everybody to be healthier. Boggles the mind.
- hnmonkey 8y ago
  It's not as lucrative for some people that way.
- adamnemecek 8y ago
  "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!"
- berbec 8y ago
  Part of it is distrust of government. Part of it is status quo. Part of it is belief they will be worse off in the new system. Part of it is not wanting to have to supliment other's heath care. Those are the real underlying reasons, as far as I can tell.
  - ams6110 8y ago
    For me, it's that I can't think of anything the government really does a good job at while also controlling costs.
    - hnmonkey 8y ago
      Really? For the most part, the government is pretty functional at all levels and while costs generally rise it seems like they do less so than compared to the privatized version. I'm sure there are many cases where they do a bad job and costs rise, but I'd imagine the things government has done well and that keep costs somewhat okay far outweighs it and I also imagine you never hear about 99% of the stuff where things are humming along.
    - charlesism 8y ago
      The good news is that government only needs to keep costs lower than the private system. That doesn't require a good job of controlling costs.
throwaway010718 8y ago
On our current trajectory, "who pays" isn't the most pressing issue. Suppose Medicare for All does save 10% as the article claims, if the cost just keeps rising then it only buys a little more time before no entity can foot the bill. 100 million people in the US have diabetes or pre-diabetes according to the CDC.[1] Diabetes costs $14,000/yr(?) and people are getting it at an earlier age and living longer. Of all the threats to the US, this one is particularly insidious. There is also the concern that big pharma (along with big-sugar/corn) has too much influence over congress. The U.S. is the only country besides NZ to allow direct to consumer drug advertisement. That fact alone makes me lose faith in the government. Is it prudent to give more power and money to our government when they appear to be complicit and bereft of root cause solutions to address the rising cost ? Bloomberg, as NYC's mayor, seemed like the only politician who was willing to pass unpopular and extreme legislation by way of banning or limiting certain foods. [1] https://www.cdc.gov/media/releases/2017/p0718-diabetes-report.html https://www.cdc.gov/media/releases/2017/p0718-diabetes-repor...
- martinald 8y ago
  But the US current system has afiak by far the highest rate of healthcare cost inflation. Single payer systems tend to inflate at less cost than the US one, so it is a win win.
- lhl 8y ago
  As a tangent, I do think it's increasingly obvious that T2D (and metabolic syndrome) is a disease that's specific to the modern western diet and that lifestyle interventions are very effective at stopping or reversing T2D entirely. Here's a recent publication on a controlled study being done by Virta Health et al. Of especial interest will be Fig 3 showing just how effective carbohydrate restriction was vs "usual care": https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194375/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194375/ IDF has also recently published case studies on the effectiveness of intermittent fasting as T2D treatment for those that can't/won't carb restrict: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194375/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194375/ To expand on the costs a bit, the ADA has similar estimates, and in their 2018 report [1] estimates $16.75K/ppy costs (also cited by the CDC [2]), with direct+indirect costs estimated at $327B/yr, and that 1/7th of every health-care dollar is spent on diabetes-related costs. The Milken Institute [3] recently published a report on American Obesity [4] that gives even bigger numbers: "chronic diseases driven by the risk factor of obesity and overweight accounted for $480.7 billion in direct health care costs in the U.S., with an additional $1.24 trillion in indirect costs due to lost economic productivity." [1] http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html http://www.diabetes.org/advocacy/news-events/cost-of-diabete... [2] https://www.cdc.gov/diabetes/diabetesatwork/plan/costs.html https://www.cdc.gov/diabetes/diabetesatwork/plan/costs.html [3] https://en.wikipedia.org/wiki/Milken_Institute https://en.wikipedia.org/wiki/Milken_Institute [4] https://www.milkeninstitute.org/publications/view/944 https://www.milkeninstitute.org/publications/view/944
jganetsk 8y ago
There is no problem paying for Medicare for All. The US federal government does not face an affordability constraint in dollars. It can pay for anything it wants, the only real constraint is inflation. https://www.forbes.com/sites/francescoppola/2018/04/17/everything-youve-been-told-about-government-debt-is-wrong/ https://www.forbes.com/sites/francescoppola/2018/04/17/every... https://www.nytimes.com/2017/10/05/opinion/deficit-tax-cuts-trump.html https://www.nytimes.com/2017/10/05/opinion/deficit-tax-cuts-...
- ikeboy 8y ago
  MMT is largely nonsense, sorry. Inflation would be the immediate result of such a policy and would largely destroy the spending ability of such money printing. No such thing as a free lunch.
  - jganetsk 8y ago
    "MMT is largely nonsense, sorry." You have not rebutted any content in either of the articles I posted. "Inflation would be the immediate result" I said that inflation is a risk, as does every MMTer. The conversation we should be having is "how much inflation is really at risk here?" And inflation has been, in fact, quite elusive for a long time. A bit of inflation would be a good thing. "such a policy" What policy? MMT is not a policy, it's a description of the way the economic system already functions. It's an explanation of why the Federal Reserve can engage in $4 trillion of QE and not cause inflation to budge. It's an explanation of why the US federal government can run $1 trillion annual deficits and not cause interest rates to skyrocket. It's most definitely not nonsense. "No such thing as a free lunch" It's not free. The government is paying for it, and will later collect that money back in tax revenues. That's the way the government buys anything.
    - ikeboy 8y ago
      The first is just saying you can borrow as long as nominal growth exceeds the interest you need to pay. Sure, but that doesn't mean you can borrow an infinite amount, since as you borrow more interest will rise. "What policy" you're advocating for printing money to spend regardless of the cost, which means costs will certainly rise. If you want to have the "is the current inflation target optimal, or should we have a higher one" debate, don't pollute it by implying that spending doesn't matter. I agree the with the second article that the risk is inflation, not bankruptcy, but that doesn't mean it's not a real risk or that we should have larger deficits.
ikeboy 8y ago
Are we supposed to believe a report issued at the Sanders Institute Gathering represents an unbiased evaluation of Bernie Sanders' health plan?
Glench 8y ago
Defund the military.

29 points by howard941 8y ago

It's pretty simple, through taxes. Most of the tax we would pay would be akin to the premiums we pay for private insurance... remember that we already pay medicaid and medicare taxes now.

deleted 8y ago
[deleted]
martinald 8y ago
The US pays more as a percentage of GDP for Medicaid/Medicare/Veterans healthcare than the UK spends on the entire NHS (which covers 100% of people).
- qasdf 8y ago
  This is often overlooked in the health care debate. If the US paid European prices for health care, the government could give everyone free healthcare without raising taxes at all.
  - berbec 8y ago
    I think they could lower taxes. [1] 1: Citation needed

gammateam 8y ago

Would it be that hard of a stretch to convince people that a healthy population is more important and productive than how much you trust your neighbor’s work ethic and role in a darwinism nightmare?

awinder 8y ago

I don’t understand the reasoning / appeal of a new national sales tax for half of the new funding, as opposed to making this financed through payroll taxes exclusively. Maybe it’s to emphasize the 8% cost savings right off the bat to get private companies on board, but man, solving the escalating cost problem is a gift on its own. And we have already done the dance of trickle down, how about we directly deliver cost relief to the worker one time...

howard941 8y ago
I don't really wanna defend it but I'll try. If it's payroll taxes then it's only workers paying, but financed partially by sales tax broadens the base to include trust fund babies as well as retirees and public aid recipients.

bko 8y ago

> So we say by shifting everything to a single-payer system, with the government being the Medicare equivalent for everybody, we’re going to get about 9 percent savings for the whole system. Then we say, well, in Europe, on average they pay 50 percent less for drugs than we do. And we say, OK, well, we’ll take a more conservative number. We’ll say 40 percent less as opposed to 50 percent less. Cutting reimbursements for drugs by 40% is going to have impacts on everything from R&D to what drugs are available. Drug companies median profit margin varies widely but its about on average 12-14% [0]. I don't think you can just wave a magic wand and say now you get 40% less and you'll just deal with it. It's also naive to believe you can just export some reimbursement model from another country to the US and just plug and play. > That gives us 6 percent total savings in the system. Then we say Medicare rates for all providers, all doctors, hospitals, dentists. Everybody gets the Medicare rate. And that saves about 7 percent savings for the system cost. Same problem here. Paying doctors and hospitals 7% less will have an impact. Prices aren't just some arbitrary number you can change on a whim and have no effect. > And then finally we have high levels of inefficiency with so-called doctor-induced demand, where there’s too many procedures using high tech when you don’t need it, because they can charge more. This is just a change from bottom up (doctor) to top down (some medicare committee). I agree that there is a problem with over-treatment but I'm skeptical that a rule based system would be the ideal way to address this problem. > And there’s fraud. And so there’s a lot of estimates at very high levels of fraud and excessive costs. We took that service delivery savings as modest, maybe 1 to 2 percent. Add them all up, you get 19 percent savings. Traditionally government services are more susceptible to fraud as there is less of an incentive to address fraud. I'm not sure why a single federal agency would be more effective at rooting out fraud than smaller private insurers. Overall I'm skeptical of a top down approach primarily because they mainly address the problem by lowering prices by fiat rather than addressing the systematic issues of high costs. [0] https://yourbusiness.azcentral.com/average-profit-margin-pharmaceuticals-20671.html https://yourbusiness.azcentral.com/average-profit-margin-pha...

hnmonkey 8y ago
If you're the only customer for their businesses, yes you can waive a magic wand and say now you'll get 40% less and deal with it. Especially if you're the government and it's a law. It's like Walmart with their suppliers. If you're the biggest baddest around you can kinda do what you want. Certainly it will have impacts on R&D but are you suggesting that new drugs won't get created anymore? Don't drugs get created all throughout the EU?

reasonablemann 8y ago

I don't understand why there's so much resistance to having everybody save a huge amount of money while at the same time allowing everybody to be healthier. Boggles the mind.

hnmonkey 8y ago
It's not as lucrative for some people that way.
adamnemecek 8y ago
"It is difficult to get a man to understand something, when his salary depends upon his not understanding it!"
berbec 8y ago
Part of it is distrust of government. Part of it is status quo. Part of it is belief they will be worse off in the new system. Part of it is not wanting to have to supliment other's heath care. Those are the real underlying reasons, as far as I can tell.
- ams6110 8y ago
  For me, it's that I can't think of anything the government really does a good job at while also controlling costs.
  - hnmonkey 8y ago
    Really? For the most part, the government is pretty functional at all levels and while costs generally rise it seems like they do less so than compared to the privatized version. I'm sure there are many cases where they do a bad job and costs rise, but I'd imagine the things government has done well and that keep costs somewhat okay far outweighs it and I also imagine you never hear about 99% of the stuff where things are humming along.
  - charlesism 8y ago
    The good news is that government only needs to keep costs lower than the private system. That doesn't require a good job of controlling costs.

throwaway010718 8y ago

On our current trajectory, "who pays" isn't the most pressing issue. Suppose Medicare for All does save 10% as the article claims, if the cost just keeps rising then it only buys a little more time before no entity can foot the bill. 100 million people in the US have diabetes or pre-diabetes according to the CDC.[1] Diabetes costs $14,000/yr(?) and people are getting it at an earlier age and living longer. Of all the threats to the US, this one is particularly insidious. There is also the concern that big pharma (along with big-sugar/corn) has too much influence over congress. The U.S. is the only country besides NZ to allow direct to consumer drug advertisement. That fact alone makes me lose faith in the government. Is it prudent to give more power and money to our government when they appear to be complicit and bereft of root cause solutions to address the rising cost ? Bloomberg, as NYC's mayor, seemed like the only politician who was willing to pass unpopular and extreme legislation by way of banning or limiting certain foods. [1] https://www.cdc.gov/media/releases/2017/p0718-diabetes-report.html https://www.cdc.gov/media/releases/2017/p0718-diabetes-repor...

martinald 8y ago
But the US current system has afiak by far the highest rate of healthcare cost inflation. Single payer systems tend to inflate at less cost than the US one, so it is a win win.
lhl 8y ago
As a tangent, I do think it's increasingly obvious that T2D (and metabolic syndrome) is a disease that's specific to the modern western diet and that lifestyle interventions are very effective at stopping or reversing T2D entirely. Here's a recent publication on a controlled study being done by Virta Health et al. Of especial interest will be Fig 3 showing just how effective carbohydrate restriction was vs "usual care": https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194375/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194375/ IDF has also recently published case studies on the effectiveness of intermittent fasting as T2D treatment for those that can't/won't carb restrict: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194375/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194375/ To expand on the costs a bit, the ADA has similar estimates, and in their 2018 report [1] estimates $16.75K/ppy costs (also cited by the CDC [2]), with direct+indirect costs estimated at $327B/yr, and that 1/7th of every health-care dollar is spent on diabetes-related costs. The Milken Institute [3] recently published a report on American Obesity [4] that gives even bigger numbers: "chronic diseases driven by the risk factor of obesity and overweight accounted for $480.7 billion in direct health care costs in the U.S., with an additional $1.24 trillion in indirect costs due to lost economic productivity." [1] http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html http://www.diabetes.org/advocacy/news-events/cost-of-diabete... [2] https://www.cdc.gov/diabetes/diabetesatwork/plan/costs.html https://www.cdc.gov/diabetes/diabetesatwork/plan/costs.html [3] https://en.wikipedia.org/wiki/Milken_Institute https://en.wikipedia.org/wiki/Milken_Institute [4] https://www.milkeninstitute.org/publications/view/944 https://www.milkeninstitute.org/publications/view/944

jganetsk 8y ago

There is no problem paying for Medicare for All. The US federal government does not face an affordability constraint in dollars. It can pay for anything it wants, the only real constraint is inflation. https://www.forbes.com/sites/francescoppola/2018/04/17/everything-youve-been-told-about-government-debt-is-wrong/ https://www.forbes.com/sites/francescoppola/2018/04/17/every... https://www.nytimes.com/2017/10/05/opinion/deficit-tax-cuts-trump.html https://www.nytimes.com/2017/10/05/opinion/deficit-tax-cuts-...

ikeboy 8y ago
MMT is largely nonsense, sorry. Inflation would be the immediate result of such a policy and would largely destroy the spending ability of such money printing. No such thing as a free lunch.
- jganetsk 8y ago
  "MMT is largely nonsense, sorry." You have not rebutted any content in either of the articles I posted. "Inflation would be the immediate result" I said that inflation is a risk, as does every MMTer. The conversation we should be having is "how much inflation is really at risk here?" And inflation has been, in fact, quite elusive for a long time. A bit of inflation would be a good thing. "such a policy" What policy? MMT is not a policy, it's a description of the way the economic system already functions. It's an explanation of why the Federal Reserve can engage in $4 trillion of QE and not cause inflation to budge. It's an explanation of why the US federal government can run $1 trillion annual deficits and not cause interest rates to skyrocket. It's most definitely not nonsense. "No such thing as a free lunch" It's not free. The government is paying for it, and will later collect that money back in tax revenues. That's the way the government buys anything.
  - ikeboy 8y ago
    The first is just saying you can borrow as long as nominal growth exceeds the interest you need to pay. Sure, but that doesn't mean you can borrow an infinite amount, since as you borrow more interest will rise. "What policy" you're advocating for printing money to spend regardless of the cost, which means costs will certainly rise. If you want to have the "is the current inflation target optimal, or should we have a higher one" debate, don't pollute it by implying that spending doesn't matter. I agree the with the second article that the risk is inflation, not bankruptcy, but that doesn't mean it's not a real risk or that we should have larger deficits.

ikeboy 8y ago

Are we supposed to believe a report issued at the Sanders Institute Gathering represents an unbiased evaluation of Bernie Sanders' health plan?

Glench 8y ago

Defund the military.