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Its not exactly a chicken and egg problem then, and the solution doesn't start with divorcing insurance from employment. Put that "Medicare for All" into play

Its not exactly a chicken and egg problem then, and the solution doesn't start with divorcing insurance from employment. Put that "Medicare for All" into play first.

js2 7y ago
MFA is a single-payer option but there are plenty of multi-payer healthcare systems in the world which achieve universal coverage and contain costs. Germany would be the prime example, but see also Switzerland and France.
- throwaway_law 7y ago
  I like single payer, but I haven't had the luxury of living under either system of universal care. I think in the US we have different issues than face Germany/Switzerland/France, and for the US to contain costs my opinion is we would have to rip private insurance out completely. Our main Government provided system (Medicare for the elderly) is a combination of government and private, and to put that system in perspective, Germany spent 375B (not sure if $ or Euro) in healthcare total in 2017, and US Medicare spent $609B in 2017. Germany covered an entire country (82M people) Medicare covered 15% of the US (44M people).
  - js2 7y ago
    I am a U.S. citizen. Yes, cost is a huge issue. We would not have to rip out private insurance, but we would probably have to regulate pricing, which is how it works in Germany. Folks should be welcome to buy supplemental insurance as they do with Medicare. There's basically four models[1] for providing health care, and the US has all of them: The Bismarck model like Germany with multiple payers, but they are non-profit and pricing is regulated. Doctors and hospitals are private, and there is still supplemental private insurance. Financing is a combination of employer and taxes, where the government takes over the employer portion if the person is unemployed. This is sorta what the U.S. has for those with employer subsidized health care except for the insurers being for-profit and unregulated pricing. The Beveridge model like in the U.K. financed through taxes and where the government provides care. This is so-called socialized medicine. In the U.S. we have this system for veterans in the form of the V.A. The national health insurance model, with private doctors and hospitals but the government is a single-payer. Canada. Medicare. And lastly, out-of-pocket. We use all of these in the U.S. and it's insane. We could in theory adopt a Bismarck system. Force the insurers to be non-profit. Make everyone work off Medicare pricing. Supposedly existing Medicare pricing is too low. Fine, let the doctors and hospitals negotiate that with Medicare. Allow supplemental insurance for those who want it. MFA polls badly when you ask Americans what if they had to give up their current insurance. But I think this is misleading. Of course it's going to poll poorly if you ask someone to give something up. That's basic loss aversion. Turn the question on its head and ask a bunch of 65+ year olds how they'd feel about giving up Medicare in return for their Medicare withholdings back to buy their own private insurance. Guessing that wouldn't poll too well. I don't think MFA is necessarily the best option. Americans value choice. But it seems to be the universal care option with the most political momentum right now. I'll take it. But I'd be happy with a Bismarck-type system too. 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3596027/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3596027/
    - throwaway_law 7y ago
      Sorry, I figured you were German. As long as people are covered it would be a good start (I won't bother engaging further on the single payer/private insurance/hybrid systems, not enough room and not the right forum)...it just scares me to hear the game plan to get there is political pressure after a critical mass of people are uninsured. I know that is not attributable to you, and you seem optimistic we get there anyway, I hope you are right. One last thing I will note, is there are all kinds of hidden costs through other insurance that hopefully would come down under a single payer (maybe even under a public/private hybrid like Medicare Part D) , take car insurance one reason premiums and deductibles are so high is because a lot of that goes towards personal injury claims (medical costs). The same can be said for odd things like homeowners insurance for example. A lot of these insurance policies people already pay for in some ways supplement health care coverage. >We use all of these in the U.S. and it's insane. Well said.
      - shkkmo 7y ago
        > it just scares me to hear the game plan to get there is political pressure after a critical mass of people are uninsured And who are you attributing this to? This seems like either a strawman or a misunderstaning to me.
        throwaway_law 7y ago
        Well in response to my questions about why people want to divorce insurance from employment before universal care becomes a law/right/option, one commented answered: >>Having a critical mass of uninsured people is the foundation we need to resolve the healthcare crisis in America.
  - zaroth 7y ago
    $375B for 82M people (~$4,500 per person) for Germany. Versus $609B for 44M people (~$13,800 per person) for Medicare. FYI, USA currently spends about $10,800 per person on healthcare, roughly $3.5 trillion. IMO, the discussion should revolve purely around pricing and efficiency. Negotiating power alone isn’t going to drive $1.5 trillion in costs out of the system. I would like to see basic pricing reforms demonstrate that year-over-year price can be held constant. That would be a nice start.
    - js2 7y ago
      > Negotiating power alone isn’t going to drive $1.5 trillion in costs out of the system Of course it could. It works in Germany! And France! And Switzerland! Why not here? Look, I don't know how this can possibly work with our current system. It cannot be solved by the market alone. There's no transparency in the current system. Insurers can just keep passing price increases along. And many Americans want "the best" and "right now" and that ends up increasing costs for all of us. People will argue that the American system is so expensive because: reasons. e.g. we subsidize the rest of the world. Or we are overweight. Or we don't get enough exercise. Or we want the best of everything. Or health insurance profits and CEO salaries. Or fraud. We also keep saying: America is exceptional. None of what other countries do will work here. So what do you propose? At the end of the day, doctors, hospitals, and the payer or payers need to negotiate reasonable pricing for decent care. And that cost needs to be spread equally across all Americans. I'd favor doing it with cost-sharing from paychecks like we do now for Medicare, with the government picking up the bill for the unemployed, and with tax credits to offset income differences. I like the system than France has, where you have a co-pay, but it gets reimbursed. This makes the consumer at least aware that there is cost to using the system. Then allow supplemental insurance for people who want better. And Americans will somehow need to realize that not every medical problem has to be solved right away. And that you don't need the most expensive treatment option for every issue. We cannot continue to ration health care by ability to pay. It's immoral.
      - zaroth 7y ago
        My point centers around two things; 1) We cannot provide the same services with the same mechanisms, processes, and infrastructure at 50% of the current price. The margin simply isn’t that high. Everything from the design of the hospital, to the regulations around the equipment provisioned in each room, to the processes followed by staff throughout a given patient visit need to change, along with the specific tools and techniques used to perform procedures, before we even get into how and what procedures are chosen to treat or manage a given symptom or disease, whether acute or chronic. 2) Even with all of the above, a system that optimizes for price will absolutely have to make trade-offs in other areas to achieve that. Understanding where, when, and how those trade-offs are made and if they are being made fairly and uniformly based on malady, procedure, patient population, etc. is not a minor detail. These are massive structural, policy, and economic changes which will impact a double-digit percentage of GDP. Why should anyone have any faith that this will be done in any semblance of a sane, reasonable, compassionate, let alone fair, efficient, or effective manner? If the government has shown it’s entirely incapable of passing effective legislation to manage the cost of healthcare, why should government be granted an order of magnitude greater role in the provisioning of care?

Its not exactly a chicken and egg problem then, and the solution doesn't start with divorcing insurance from employment. Put that "Medicare for All" into play first.

js2 7y ago

MFA is a single-payer option but there are plenty of multi-payer healthcare systems in the world which achieve universal coverage and contain costs. Germany would be the prime example, but see also Switzerland and France.

throwaway_law 7y ago
I like single payer, but I haven't had the luxury of living under either system of universal care. I think in the US we have different issues than face Germany/Switzerland/France, and for the US to contain costs my opinion is we would have to rip private insurance out completely. Our main Government provided system (Medicare for the elderly) is a combination of government and private, and to put that system in perspective, Germany spent 375B (not sure if $ or Euro) in healthcare total in 2017, and US Medicare spent $609B in 2017. Germany covered an entire country (82M people) Medicare covered 15% of the US (44M people).
- js2 7y ago
  I am a U.S. citizen. Yes, cost is a huge issue. We would not have to rip out private insurance, but we would probably have to regulate pricing, which is how it works in Germany. Folks should be welcome to buy supplemental insurance as they do with Medicare. There's basically four models[1] for providing health care, and the US has all of them: The Bismarck model like Germany with multiple payers, but they are non-profit and pricing is regulated. Doctors and hospitals are private, and there is still supplemental private insurance. Financing is a combination of employer and taxes, where the government takes over the employer portion if the person is unemployed. This is sorta what the U.S. has for those with employer subsidized health care except for the insurers being for-profit and unregulated pricing. The Beveridge model like in the U.K. financed through taxes and where the government provides care. This is so-called socialized medicine. In the U.S. we have this system for veterans in the form of the V.A. The national health insurance model, with private doctors and hospitals but the government is a single-payer. Canada. Medicare. And lastly, out-of-pocket. We use all of these in the U.S. and it's insane. We could in theory adopt a Bismarck system. Force the insurers to be non-profit. Make everyone work off Medicare pricing. Supposedly existing Medicare pricing is too low. Fine, let the doctors and hospitals negotiate that with Medicare. Allow supplemental insurance for those who want it. MFA polls badly when you ask Americans what if they had to give up their current insurance. But I think this is misleading. Of course it's going to poll poorly if you ask someone to give something up. That's basic loss aversion. Turn the question on its head and ask a bunch of 65+ year olds how they'd feel about giving up Medicare in return for their Medicare withholdings back to buy their own private insurance. Guessing that wouldn't poll too well. I don't think MFA is necessarily the best option. Americans value choice. But it seems to be the universal care option with the most political momentum right now. I'll take it. But I'd be happy with a Bismarck-type system too. 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3596027/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3596027/
  - throwaway_law 7y ago
    Sorry, I figured you were German. As long as people are covered it would be a good start (I won't bother engaging further on the single payer/private insurance/hybrid systems, not enough room and not the right forum)...it just scares me to hear the game plan to get there is political pressure after a critical mass of people are uninsured. I know that is not attributable to you, and you seem optimistic we get there anyway, I hope you are right. One last thing I will note, is there are all kinds of hidden costs through other insurance that hopefully would come down under a single payer (maybe even under a public/private hybrid like Medicare Part D) , take car insurance one reason premiums and deductibles are so high is because a lot of that goes towards personal injury claims (medical costs). The same can be said for odd things like homeowners insurance for example. A lot of these insurance policies people already pay for in some ways supplement health care coverage. >We use all of these in the U.S. and it's insane. Well said.
    - shkkmo 7y ago
      > it just scares me to hear the game plan to get there is political pressure after a critical mass of people are uninsured And who are you attributing this to? This seems like either a strawman or a misunderstaning to me.
      - throwaway_law 7y ago
        Well in response to my questions about why people want to divorce insurance from employment before universal care becomes a law/right/option, one commented answered: >>Having a critical mass of uninsured people is the foundation we need to resolve the healthcare crisis in America.
- zaroth 7y ago
  $375B for 82M people (~$4,500 per person) for Germany. Versus $609B for 44M people (~$13,800 per person) for Medicare. FYI, USA currently spends about $10,800 per person on healthcare, roughly $3.5 trillion. IMO, the discussion should revolve purely around pricing and efficiency. Negotiating power alone isn’t going to drive $1.5 trillion in costs out of the system. I would like to see basic pricing reforms demonstrate that year-over-year price can be held constant. That would be a nice start.
  - js2 7y ago
    > Negotiating power alone isn’t going to drive $1.5 trillion in costs out of the system Of course it could. It works in Germany! And France! And Switzerland! Why not here? Look, I don't know how this can possibly work with our current system. It cannot be solved by the market alone. There's no transparency in the current system. Insurers can just keep passing price increases along. And many Americans want "the best" and "right now" and that ends up increasing costs for all of us. People will argue that the American system is so expensive because: reasons. e.g. we subsidize the rest of the world. Or we are overweight. Or we don't get enough exercise. Or we want the best of everything. Or health insurance profits and CEO salaries. Or fraud. We also keep saying: America is exceptional. None of what other countries do will work here. So what do you propose? At the end of the day, doctors, hospitals, and the payer or payers need to negotiate reasonable pricing for decent care. And that cost needs to be spread equally across all Americans. I'd favor doing it with cost-sharing from paychecks like we do now for Medicare, with the government picking up the bill for the unemployed, and with tax credits to offset income differences. I like the system than France has, where you have a co-pay, but it gets reimbursed. This makes the consumer at least aware that there is cost to using the system. Then allow supplemental insurance for people who want better. And Americans will somehow need to realize that not every medical problem has to be solved right away. And that you don't need the most expensive treatment option for every issue. We cannot continue to ration health care by ability to pay. It's immoral.
    - zaroth 7y ago
      My point centers around two things; 1) We cannot provide the same services with the same mechanisms, processes, and infrastructure at 50% of the current price. The margin simply isn’t that high. Everything from the design of the hospital, to the regulations around the equipment provisioned in each room, to the processes followed by staff throughout a given patient visit need to change, along with the specific tools and techniques used to perform procedures, before we even get into how and what procedures are chosen to treat or manage a given symptom or disease, whether acute or chronic. 2) Even with all of the above, a system that optimizes for price will absolutely have to make trade-offs in other areas to achieve that. Understanding where, when, and how those trade-offs are made and if they are being made fairly and uniformly based on malady, procedure, patient population, etc. is not a minor detail. These are massive structural, policy, and economic changes which will impact a double-digit percentage of GDP. Why should anyone have any faith that this will be done in any semblance of a sane, reasonable, compassionate, let alone fair, efficient, or effective manner? If the government has shown it’s entirely incapable of passing effective legislation to manage the cost of healthcare, why should government be granted an order of magnitude greater role in the provisioning of care?