3 ms·

Hasn’t done what? Apologies, you’ll have to elaborate. Medicare fee schedules do put downward pressure on costs, which is why they’re under attack, but lack suf

Hasn’t done what? Apologies, you’ll have to elaborate. Medicare fee schedules do put downward pressure on costs, which is why they’re under attack, but lack sufficient power to push down prices because they are not universal and exclude drug costs. Japan has universal price controls (and cheaper healthcare) for precisely these reasons. As to your second question, fee for service is too perverse of an incentive. What you end up with is an arms race where healthcare providers try to extract as much value as possible through as many procedures as possible and healthcare providers, in turn, try to make money by denying as much as possible (as well as pushing sick people into the government plans). The result is poor quality, expensive care, as the two factions devote more and more resources to waging this battle and less and less on creating good quality and affordable care.

tptacek 7y ago
What does universality have to do with it? They already cover virtually everyone in the most expensive segments of the market. They're not controlling costs for those patients; Medicare overpays, hugely, both compared to other countries and in historical terms (costs have skyrocketed over the last 20 years). I think the burden of proof is on you for this argument. "Excluding drug costs" can't be the problem, because drugs --- no matter what their provenance --- are a small fraction of total health care costs. Your response to my second question doesn't respond to my point. I was specific. You've responded with abstractions. Can you be more specific about what you meant by evidence-based care, and Medicare's unique ability to provide it?
- claudeganon 7y ago
  What does being the sole payer for services give you, besides a monopoly on payments and all the leverage that comes with it? It should be self-evident, but the ability to negotiate far better prices from healthcare suppliers. Medicare for All’s (not Medicare’s) “unique ability” is this ability to say do these things or you won’t get paid or paid as much. It’s a big part of what single payer systems do around the world to drive down costs and what allows for consistent care to prevent the development of more expensive conditions. Medicare doesn’t have this advantage because it is not “universal” in any regard and doesn’t have this leverage. The cost pressure from the ever escalating supplier-insurance war further down the chain bleeds into it, as thaumaturgy outlined. Not the very least in the form of lingering injuries and chronic illnesses in its beneficiaries that could’ve been better managed through a universal system before they came onboard. Which is related to your point about drug costs - the inability of Medicare to collectively negotiate drug prices allows them to be as ridiculous as they are in the US, which of course leads to horrible outcomes for managing care. When people can’t afford medicine, ration it, etc, their conditions worsen and become more expensive to treat. Even if the medicines themselves are not a large, direct source of upward pressure on costs, their inaccessibility creates the circumstances (and need) for more expensive care. And this happens throughout the system as people self-ration various, necessary forms of care. TLDR; Because Medicare isn’t universal coverage and it and it’s beneficiaries don’t exist in a vacuum.
  - tptacek 7y ago
    Are we talking about the same Medicare? Because Medicare today absolutely does have the ability to say "do these things or you won't get paid".
    - claudeganon 7y ago
      Yes, and as I already mentioned, the existing leverage Medicare has in this regard already puts downward pressure on costs. But it’s insufficient relative to how costs are being driven up further down in the system and quite obviously an orders of magnitude smaller amount of leverage than a universal system and a monopoly on payments.
      - tptacek 7y ago
        Medicare is the near-exclusive provider of medical services to the most lucrative and demanding segment of the market. You're going to need to explain, with specifics, why they've had such a limited ability to hold down costs. Adding a bunch of 30 year olds who see a doctor once every 3 years isn't going to do that automatically.
        claudeganon 7y ago
        They can’t hold down costs because they’re just a competing payer in a large, dysfunctional system whose overall costs are determined by the sum total of this dysfunction and the general trajectory of healthcare outcomes it produces. I’m sure you’re quite aware of this, as well as the difference between having a monopoly on payments, continuity of care, and “adding a bunch of 30 year olds” to the system, but feel free to waste more time with these obfuscations. A defense of the status quo isn’t really helped by them.
        tptacek 7y ago
        No. Medicare does not in fact meaningfully compete with private insurance in the markets it serves. It is a universal entitlement for US senior citizens.

tptacek 7y ago

What does universality have to do with it? They already cover virtually everyone in the most expensive segments of the market. They're not controlling costs for those patients; Medicare overpays, hugely, both compared to other countries and in historical terms (costs have skyrocketed over the last 20 years). I think the burden of proof is on you for this argument. "Excluding drug costs" can't be the problem, because drugs --- no matter what their provenance --- are a small fraction of total health care costs. Your response to my second question doesn't respond to my point. I was specific. You've responded with abstractions. Can you be more specific about what you meant by evidence-based care, and Medicare's unique ability to provide it?

claudeganon 7y ago
What does being the sole payer for services give you, besides a monopoly on payments and all the leverage that comes with it? It should be self-evident, but the ability to negotiate far better prices from healthcare suppliers. Medicare for All’s (not Medicare’s) “unique ability” is this ability to say do these things or you won’t get paid or paid as much. It’s a big part of what single payer systems do around the world to drive down costs and what allows for consistent care to prevent the development of more expensive conditions. Medicare doesn’t have this advantage because it is not “universal” in any regard and doesn’t have this leverage. The cost pressure from the ever escalating supplier-insurance war further down the chain bleeds into it, as thaumaturgy outlined. Not the very least in the form of lingering injuries and chronic illnesses in its beneficiaries that could’ve been better managed through a universal system before they came onboard. Which is related to your point about drug costs - the inability of Medicare to collectively negotiate drug prices allows them to be as ridiculous as they are in the US, which of course leads to horrible outcomes for managing care. When people can’t afford medicine, ration it, etc, their conditions worsen and become more expensive to treat. Even if the medicines themselves are not a large, direct source of upward pressure on costs, their inaccessibility creates the circumstances (and need) for more expensive care. And this happens throughout the system as people self-ration various, necessary forms of care. TLDR; Because Medicare isn’t universal coverage and it and it’s beneficiaries don’t exist in a vacuum.
- tptacek 7y ago
  Are we talking about the same Medicare? Because Medicare today absolutely does have the ability to say "do these things or you won't get paid".
  - claudeganon 7y ago
    Yes, and as I already mentioned, the existing leverage Medicare has in this regard already puts downward pressure on costs. But it’s insufficient relative to how costs are being driven up further down in the system and quite obviously an orders of magnitude smaller amount of leverage than a universal system and a monopoly on payments.
    - tptacek 7y ago
      Medicare is the near-exclusive provider of medical services to the most lucrative and demanding segment of the market. You're going to need to explain, with specifics, why they've had such a limited ability to hold down costs. Adding a bunch of 30 year olds who see a doctor once every 3 years isn't going to do that automatically.
      - claudeganon 7y ago
        They can’t hold down costs because they’re just a competing payer in a large, dysfunctional system whose overall costs are determined by the sum total of this dysfunction and the general trajectory of healthcare outcomes it produces. I’m sure you’re quite aware of this, as well as the difference between having a monopoly on payments, continuity of care, and “adding a bunch of 30 year olds” to the system, but feel free to waste more time with these obfuscations. A defense of the status quo isn’t really helped by them.
        tptacek 7y ago
        No. Medicare does not in fact meaningfully compete with private insurance in the markets it serves. It is a universal entitlement for US senior citizens.