8 ms·

Build Your Own ‘Medicare for All’ Plan. Beware: There Are Tough Choices

40 points by smacktoward 8y ago

lucian1900 8y ago
I don't see any tough choices. Saying yes to all of them merely brings the US in line with most of the developed world.
- alistairSH 8y ago
  The only question I hesitated to answer "Yes" was the cost-sharing/co-pay question. In principle, I'm not opposed to some co-pay or deductible. But, the devil is in the details.
  - snuxoll 8y ago
    Even other developed nations often have some form of cost-sharing, I think having some small charge helps offset administrative costs and prevents people from going to the doctor for every cold. What we have right now with deductibles and co-insurance is ludicrous though, that shit needs to go.
    - kenhwang 8y ago
      Taiwan had to introduce cost-sharing for pharmaceuticals because of abuse of the system. I truly because cost-sharing is necessary to keep total costs reasonable and unnecessary visits down. Plus, it offers a minor incentive to actually be healthy. Health should be a personal responsibility just as much as a government responsibility. I don't support subsidizing unhealthy habits.
- int_19h 8y ago
  Most of the developed world does allow for private coverage on top of whatever public system they provide. Similarly, many have some kind of premiums.
stult 8y ago
It's a little misleading that they marked experts as opposing ideas when that opposition was merely based on political feasibility.
- chiefalchemist 8y ago
  I agree. We hire and pay politicians to represent us and get done what needs to get done. They work for us, and their political careers are not my / our concern. If they don't have to will to be leaders then we simply need to hire someone else. I'm tired of "political feasibility" being a euphemism for negligence, incompetence and lack of creativity.
iandanforth 8y ago
The fact that the provided charts have no comparison to existing universal coverage systems (e.g. Canada, Europe) is frustrating. American news organizations treat the topic as if it were new and as if the care of American bodies is radically different from the care of the hundreds of millions of human bodies already being looked after by existing social welfare plans.
- citilife 8y ago
  You really really don't want to compare with the rest of the worlds universal coverage systems to the U.S.. Many places have way more significant wait times for treatment... Canada: https://torontosun.com/2017/02/16/canada-has-worst-erreferral-wait-times-in-11-developed-countries-report/wcm/2f7966f0-0daa-4589-aba7-68e54e0a056e https://torontosun.com/2017/02/16/canada-has-worst-erreferra... Ireland: https://www.irishtimes.com/news/health/new-record-of-more-than-718-000-patients-on-waiting-lists-1.3628584 https://www.irishtimes.com/news/health/new-record-of-more-th... There's more, but lets get real. The U.S. system has it's problems, but at least I can get treatment. That's why it's a difficult subject and why we should be cautious on how to proceed. Perhaps run trials per state or something as well.
  - bertil 8y ago
    > at least I can get treatment I’m assuming that you realise the singular first person in that statement is very much that: singular. > Let’s get real The New York Times sees “real” as under a Rawlsian veil: they imagine being any citizen. You seemingly disagree with that approach.
  - patmcc 8y ago
    >>Many places have way more significant wait times for treatment... Canadian here - yep, there are sometimes wait times, especially for specialists, especially if it's something that is unpleasant but not urgently life threatening. That sucks. I'd still take that over some percentage of the population just not having access to care, or having a huge number of medical bankruptcies. As for the ER - it even says in the article you link, that's largely people who could have gone to their primary care physician. Those are the people waiting. If you go in with a stroke, you're not waiting. I've (luckily) never been to the ER for a life-threatening situation, but I have for injuries where I needed urgent care, and got excellent treatment - and yes, once I had to wait for the guy ahead of me who had a stroke. I'm ok with that.
jawns 8y ago
The fifth choice presented in this Upshot piece is whether there should be some form of cost sharing in a universal health care system. The argument against cost sharing is that it penalizes the poor, who are likely to put off treatment if they can't afford it. The argument in favor of cost sharing is that it helps prevent people from taking advantage of the system. I wonder if it might be possible to strike a balance using graduated (rather than fixed) cost sharing based on income. So, let's say the cost sharing for a monthly prescription is normally $30. But someone with an AGI below $50K might pay $20, and someone with an AGI below $30K might pay $10, and someone with an AGI below $10K might pay $5. You would always have to pay something (because, as NYU's Glied points out, "the biggest effects are moving from zero to something"). But that something would be proportionate to your means.
- basch 8y ago
  >a monthly prescription Fund drug research through public-private hybrids and grants, instead of intellectual property monopolies for the first x years of the drug. You can then spread the cost of developing the drug over a generation or two, instead of making the first people to be treated foot the entire bill. The public will own the intellectual property, the government can decide what diseases to fund/fight, and private companies still have incentive to perform research. All the while, private research can still compete for other treatments, or rare diseases with funding.
- zeroonetwothree 8y ago
  The could be good in theory but it seems like a nightmare to implement. At the time you pay you don't actually know your income for the year so how would it work exactly? You guess and then get it adjusted at tax time (would everyone then just put $0?)
  - occamrazor 8y ago
    Two possible solutions relatively easy to implement: 1. Use previous year income. 2. Everybody pays the maximum copay and then gets some money back with their taxes.
  - 8y ago
scarejunba 8y ago
I support the idea but it looks a lot like we plan to keep current medical prices while just funding it from the government. I think we should glut the doctor economy by starting a hundred new medical schools and brain draining the best doctors out of every other nation. There is a supply limit imposed by the AMA. Kill it.
- elektor 8y ago
  In 2014, the Institute of Medicine released a thorough analysis on graduate medical education that argued there was no doctor shortage, and that we didn’t really need to invest more in new physicians. The system isn’t undermanned, it said: It’s inefficient. We rely too heavily on physicians and not enough on midlevel practitioners, like physician assistants and nurse practitioners, especially because evidence supports they are just as effective in primary care settings. We don’t account for advances in technology, like telehealth and new drugs and devices that lessen the burden on physician visits to maintain health. Source: https://www.nytimes.com/2016/11/08/upshot/a-doctor-shortage-lets-take-a-closer-look.html https://www.nytimes.com/2016/11/08/upshot/a-doctor-shortage-...
  - klagermkii 8y ago
    > We don’t account for advances in technology, like telehealth and new drugs and devices that lessen the burden on physician visits to maintain health. Can you give some examples of how other modern countries use telehealth and similar technologies as the basis of their provision of affordable universal healthcare? It has seemed like those countries were able to provide cost-effective healthcare without hand-waving future tech by rather boosting the supply in supply and demand.
    - vkou 8y ago
      > Can you give some examples of how other modern countries use telehealth and similar technologies as the basis of their provision of affordable universal healthcare? In BC, Canada, there is the 24/7/365 BC Nurse's Hotline. (Healthlink BC) It's a phone number, that you can call, to get medical advice. "I have peanut allergies, and I am having an allergic reaction to peanut butter. I've taken my emergency pills for it, and I have an epipen with me. My symptoms are such and such. It's 3 am, and I'm at a provincial park's parking lot, 20 km out of town. Should I inject myself? Should I wait it out? Should I drive myself to the hospital? Should I call an ambulance?" The practitioner at the other end will, given the information presented, provide medical advice. The American reaction to this situation would be to go straight to the ER, regardless of whether or not they actually need it. PS. In the exact situation I described, the person in question was told that someone should drive them to the ER (It turned out that they would have died, if they hadn't.) But, people call the BC nurse's hotline for all sorts of reasons, many of which do not necessitate a trip to the hospital.
deleted 8y ago
[deleted]
legohead 8y ago
I was hoping for something like choosing where to get the funds from. Defense budget, taxes, etc. At least tell me the estimated cost for the choices available...
jellicle 8y ago
There aren't, really. If the USA implemented anything similar to what, say, Canada does today, right now, it would be: - everyone can go to any doctor without any payments or paperwork, all of that being done behind the scenes - you'd get a tax refund (it is literally cheaper than you pay in taxes right now, you just don't get universal care for your taxes now) - your health insurance costs would be eliminated
- dawnerd 8y ago
  It’s amazing many people in the states don’t get how having everyone contribute via taxes would lower prices for everyone. Not to mention it’s kind of ridiculous anyways to have a middle-man company taking a slice of payments that could be used to treat someone else.
  - tick_tock_tick 8y ago
    It would for the vast majority of American's just not the ones using this site. Most people here in already pay very little for medical as their employer takes care of it.
Glyptodon 8y ago
I don't know that I want Medicare for all (not sure what it means, and at least where I am it's considered a real question whether doctors accept medicare patients), but I would love to see the end of employer financed health care (which I feel traps people in jobs), some form of minimal universal coverage, and many other reforms.
chiefalchemist 8y ago
Healthcare is only part of the issue / problem. Health, as in personal health, also plays a very significant role in this system. That is, the healthier you are, the less likely you are to need healthcare. I'm not sure why it's rarely if ever mentioned. There is "news" on obesity and T2D, but rarely is that tied to healthcare. To that point, for me the question(s) is straightforward: - which other countries are the healthiest, - and which have the best healthcare outcomes? I understand those might not be objective questions / answers but let's start there. The idea that there are no baselines or reference points is absurd.
Someone1234 8y ago
There's a lack of nuance the answers provided. For example one asks: > Do you support replacing individually purchased private coverage, like Affordable Care Act plans or Medicare Advantage? What's odd even on the face of it is that Medicare Advantage works VERY differently than traditional private insurance (one being supplemental and the other being primary coverage). Many countries have a mixed system. A basic level of healthcare with supplemental plans built on top to provide improved benefits, reduced OOP costs, and so on. > Do you support ending employer-based private coverage? Again, lacks nuance. Some plans outright ban employer involvement, whereas others allow employers to make pre-tax contributions to something akin to a HSA (which can be used on premiums torwards a plan of the employee's choosing). > Do you support eliminating cost sharing — meaning co-payments, coinsurance, deductibles — for everyone? All or nothing. We cannot talk about eliminating cost in some services/areas.

40 points by smacktoward 8y ago

lucian1900 8y ago

I don't see any tough choices. Saying yes to all of them merely brings the US in line with most of the developed world.

alistairSH 8y ago
The only question I hesitated to answer "Yes" was the cost-sharing/co-pay question. In principle, I'm not opposed to some co-pay or deductible. But, the devil is in the details.
- snuxoll 8y ago
  Even other developed nations often have some form of cost-sharing, I think having some small charge helps offset administrative costs and prevents people from going to the doctor for every cold. What we have right now with deductibles and co-insurance is ludicrous though, that shit needs to go.
  - kenhwang 8y ago
    Taiwan had to introduce cost-sharing for pharmaceuticals because of abuse of the system. I truly because cost-sharing is necessary to keep total costs reasonable and unnecessary visits down. Plus, it offers a minor incentive to actually be healthy. Health should be a personal responsibility just as much as a government responsibility. I don't support subsidizing unhealthy habits.
int_19h 8y ago
Most of the developed world does allow for private coverage on top of whatever public system they provide. Similarly, many have some kind of premiums.

stult 8y ago

It's a little misleading that they marked experts as opposing ideas when that opposition was merely based on political feasibility.

chiefalchemist 8y ago
I agree. We hire and pay politicians to represent us and get done what needs to get done. They work for us, and their political careers are not my / our concern. If they don't have to will to be leaders then we simply need to hire someone else. I'm tired of "political feasibility" being a euphemism for negligence, incompetence and lack of creativity.

iandanforth 8y ago

The fact that the provided charts have no comparison to existing universal coverage systems (e.g. Canada, Europe) is frustrating. American news organizations treat the topic as if it were new and as if the care of American bodies is radically different from the care of the hundreds of millions of human bodies already being looked after by existing social welfare plans.

citilife 8y ago
You really really don't want to compare with the rest of the worlds universal coverage systems to the U.S.. Many places have way more significant wait times for treatment... Canada: https://torontosun.com/2017/02/16/canada-has-worst-erreferral-wait-times-in-11-developed-countries-report/wcm/2f7966f0-0daa-4589-aba7-68e54e0a056e https://torontosun.com/2017/02/16/canada-has-worst-erreferra... Ireland: https://www.irishtimes.com/news/health/new-record-of-more-than-718-000-patients-on-waiting-lists-1.3628584 https://www.irishtimes.com/news/health/new-record-of-more-th... There's more, but lets get real. The U.S. system has it's problems, but at least I can get treatment. That's why it's a difficult subject and why we should be cautious on how to proceed. Perhaps run trials per state or something as well.
- bertil 8y ago
  > at least I can get treatment I’m assuming that you realise the singular first person in that statement is very much that: singular. > Let’s get real The New York Times sees “real” as under a Rawlsian veil: they imagine being any citizen. You seemingly disagree with that approach.
- patmcc 8y ago
  >>Many places have way more significant wait times for treatment... Canadian here - yep, there are sometimes wait times, especially for specialists, especially if it's something that is unpleasant but not urgently life threatening. That sucks. I'd still take that over some percentage of the population just not having access to care, or having a huge number of medical bankruptcies. As for the ER - it even says in the article you link, that's largely people who could have gone to their primary care physician. Those are the people waiting. If you go in with a stroke, you're not waiting. I've (luckily) never been to the ER for a life-threatening situation, but I have for injuries where I needed urgent care, and got excellent treatment - and yes, once I had to wait for the guy ahead of me who had a stroke. I'm ok with that.

jawns 8y ago

The fifth choice presented in this Upshot piece is whether there should be some form of cost sharing in a universal health care system. The argument against cost sharing is that it penalizes the poor, who are likely to put off treatment if they can't afford it. The argument in favor of cost sharing is that it helps prevent people from taking advantage of the system. I wonder if it might be possible to strike a balance using graduated (rather than fixed) cost sharing based on income. So, let's say the cost sharing for a monthly prescription is normally $30. But someone with an AGI below $50K might pay $20, and someone with an AGI below $30K might pay $10, and someone with an AGI below $10K might pay $5. You would always have to pay something (because, as NYU's Glied points out, "the biggest effects are moving from zero to something"). But that something would be proportionate to your means.

basch 8y ago
>a monthly prescription Fund drug research through public-private hybrids and grants, instead of intellectual property monopolies for the first x years of the drug. You can then spread the cost of developing the drug over a generation or two, instead of making the first people to be treated foot the entire bill. The public will own the intellectual property, the government can decide what diseases to fund/fight, and private companies still have incentive to perform research. All the while, private research can still compete for other treatments, or rare diseases with funding.
zeroonetwothree 8y ago
The could be good in theory but it seems like a nightmare to implement. At the time you pay you don't actually know your income for the year so how would it work exactly? You guess and then get it adjusted at tax time (would everyone then just put $0?)
- occamrazor 8y ago
  Two possible solutions relatively easy to implement: 1. Use previous year income. 2. Everybody pays the maximum copay and then gets some money back with their taxes.
- 8y ago

scarejunba 8y ago

I support the idea but it looks a lot like we plan to keep current medical prices while just funding it from the government. I think we should glut the doctor economy by starting a hundred new medical schools and brain draining the best doctors out of every other nation. There is a supply limit imposed by the AMA. Kill it.

elektor 8y ago
In 2014, the Institute of Medicine released a thorough analysis on graduate medical education that argued there was no doctor shortage, and that we didn’t really need to invest more in new physicians. The system isn’t undermanned, it said: It’s inefficient. We rely too heavily on physicians and not enough on midlevel practitioners, like physician assistants and nurse practitioners, especially because evidence supports they are just as effective in primary care settings. We don’t account for advances in technology, like telehealth and new drugs and devices that lessen the burden on physician visits to maintain health. Source: https://www.nytimes.com/2016/11/08/upshot/a-doctor-shortage-lets-take-a-closer-look.html https://www.nytimes.com/2016/11/08/upshot/a-doctor-shortage-...
- klagermkii 8y ago
  > We don’t account for advances in technology, like telehealth and new drugs and devices that lessen the burden on physician visits to maintain health. Can you give some examples of how other modern countries use telehealth and similar technologies as the basis of their provision of affordable universal healthcare? It has seemed like those countries were able to provide cost-effective healthcare without hand-waving future tech by rather boosting the supply in supply and demand.
  - vkou 8y ago
    > Can you give some examples of how other modern countries use telehealth and similar technologies as the basis of their provision of affordable universal healthcare? In BC, Canada, there is the 24/7/365 BC Nurse's Hotline. (Healthlink BC) It's a phone number, that you can call, to get medical advice. "I have peanut allergies, and I am having an allergic reaction to peanut butter. I've taken my emergency pills for it, and I have an epipen with me. My symptoms are such and such. It's 3 am, and I'm at a provincial park's parking lot, 20 km out of town. Should I inject myself? Should I wait it out? Should I drive myself to the hospital? Should I call an ambulance?" The practitioner at the other end will, given the information presented, provide medical advice. The American reaction to this situation would be to go straight to the ER, regardless of whether or not they actually need it. PS. In the exact situation I described, the person in question was told that someone should drive them to the ER (It turned out that they would have died, if they hadn't.) But, people call the BC nurse's hotline for all sorts of reasons, many of which do not necessitate a trip to the hospital.

deleted 8y ago

[deleted]

legohead 8y ago

I was hoping for something like choosing where to get the funds from. Defense budget, taxes, etc. At least tell me the estimated cost for the choices available...

jellicle 8y ago

There aren't, really. If the USA implemented anything similar to what, say, Canada does today, right now, it would be: - everyone can go to any doctor without any payments or paperwork, all of that being done behind the scenes - you'd get a tax refund (it is literally cheaper than you pay in taxes right now, you just don't get universal care for your taxes now) - your health insurance costs would be eliminated

dawnerd 8y ago
It’s amazing many people in the states don’t get how having everyone contribute via taxes would lower prices for everyone. Not to mention it’s kind of ridiculous anyways to have a middle-man company taking a slice of payments that could be used to treat someone else.
- tick_tock_tick 8y ago
  It would for the vast majority of American's just not the ones using this site. Most people here in already pay very little for medical as their employer takes care of it.

Glyptodon 8y ago

I don't know that I want Medicare for all (not sure what it means, and at least where I am it's considered a real question whether doctors accept medicare patients), but I would love to see the end of employer financed health care (which I feel traps people in jobs), some form of minimal universal coverage, and many other reforms.

chiefalchemist 8y ago

Healthcare is only part of the issue / problem. Health, as in personal health, also plays a very significant role in this system. That is, the healthier you are, the less likely you are to need healthcare. I'm not sure why it's rarely if ever mentioned. There is "news" on obesity and T2D, but rarely is that tied to healthcare. To that point, for me the question(s) is straightforward: - which other countries are the healthiest, - and which have the best healthcare outcomes? I understand those might not be objective questions / answers but let's start there. The idea that there are no baselines or reference points is absurd.

Someone1234 8y ago

There's a lack of nuance the answers provided. For example one asks: > Do you support replacing individually purchased private coverage, like Affordable Care Act plans or Medicare Advantage? What's odd even on the face of it is that Medicare Advantage works VERY differently than traditional private insurance (one being supplemental and the other being primary coverage). Many countries have a mixed system. A basic level of healthcare with supplemental plans built on top to provide improved benefits, reduced OOP costs, and so on. > Do you support ending employer-based private coverage? Again, lacks nuance. Some plans outright ban employer involvement, whereas others allow employers to make pre-tax contributions to something akin to a HSA (which can be used on premiums torwards a plan of the employee's choosing). > Do you support eliminating cost sharing — meaning co-payments, coinsurance, deductibles — for everyone? All or nothing. We cannot talk about eliminating cost in some services/areas.