5 ms·

For folks who don’t believe in universal medical coverage, this is part of the reason why it’s so inefficient for it not to exist. The uninsured person going t

For folks who don’t believe in universal medical coverage, this is part of the reason why it’s so inefficient for it not to exist. The uninsured person going to the hospital at 1AM that requires an MRI because slipped a disc in their back still ends up getting that MRI. When they fail to pay that bill, which would be 5%-10% of their annual earnings, we all still pay for it. We just decided to layer in debt collection, anxiety, and depression onto the patient in lieu of cash. As someone who still considers themselves a fiscal conservative, and also believes we need true universal coverage for all Americans, this seems like a no brainer to me at this point (and I say that as someone who would have not supported this in the 00s but has evolved significantly on this issue).

nugget 6y ago
My takeaway from all that research was the same. Almost everyone benefits from universal coverage but the system has to incentivize patients to shop around for the optimal balance of price, quality, and convenience. This can be accomplished with an annual deductible of a few thousand dollars perhaps capped at a % of income. Without this incentive, costs skyrocket. Price transparency is a pre-requisite without which consumers can't easily shop around, so this law is a giant leap forward in the right direction. That is the #1 most effective thing that Americans can do to reduce health care costs. #2 would be to change the standard American diet and eat healthier to reduce rates of obesity and diabetes. Almost every other proposed structural change or intervention we looked at was minimal by comparison.
- zaphod12 6y ago
  There was an attempt at this with prescription drugs. Encourage patients to take generics by forcing a larger amount of cost onto the patients in the form of higher copays. Pharma companies realized and started giving copay vouchers (still charge insurance more, but short circuit the patient incentive). When that loophole got tighter they formed charitable foundations to give the vouchers instead. I'm not disagreeing with your points, per se. It's just amazing what entrenched interests can manage.
- smachiz 6y ago
  Do you have any studies or sources to back this up? As I understand it, in most EU markets there's no price component, nor much of a choice component and costs haven't skyrocketed.
  - coredog64 6y ago
    I lived under the French system for years, and it’s entirely untrue that there is no cost or choice component. You pick the doctors and you pay them fully out of pocket. Your insurance company reimburses you at ~80% of reasonable and customary rates. If you wind up going for inpatient care it’s different, as is the situation for those in extreme poverty. Also, you can pay extra for 100% coverage if you want, but ISTR it was expensive and not really worth it for us. Now, when I left, the doctors and insurance companies were setting up an analog of the US system: If you saw certain doctors, they would not charge you at point of delivery and there was no co-insurance requirement. It was still new and inconvenient, so I don’t know how that’s worked out. I don’t have direct experience with the Swiss system, but from everything I’ve read, conversations, etc., it’s a slightly cheaper version of the US system. You buy leveled insurance, you have to pay some out of pocket, etc.
    - vinay427 6y ago
      > I don’t have direct experience with the Swiss system, but from everything I’ve read, conversations, etc., it’s a slightly cheaper version of the US system. You buy leveled insurance, you have to pay some out of pocket, etc. I moved from the US to Switzerland so maybe I can offer some anecdotes here. You're basically right in that it's a slightly cheaper version of the US system. However, some things that I didn't have to pay for in the US such as calling am ambulance without riding in it or seasonal flu shots do cost money here ($500+ for an ambulance to show up in the middle of a large city...), but I think these small lapses are overshadowed by expensive inpatient treatment being essentially completely covered minus some reasonable deductibles as well as outpatient treatment that is usually partially covered depending on the insurance plan. The positives compared to the US largely revolve around necessary and typically expensive treatment being far more likely to be covered under insurance with relatively low copays and deductibles. The downsides in common with the US are the administrative hassles of dealing with an insurance company and its own billing middlemen (e.g. a COVID test was improperly billed to me which needed to be sorted out), the large monthly premiums for most people (~$250 is typical except for those who qualify for subsidies), and the lack of clarity over what and how much of anything is covered even when the billing is done correctly. Do I call an ambulance? Do I go in to see a doctor? Will I end up with a massive charge? I'd prefer a single-payer or completely comprehensive system for this last point alone.
- grey-area 6y ago
  Almost everyone benefits from universal coverage but the system has to incentivize patients to shop around for the optimal balance of price, quality, and convenience. Universal coverage does not need to incentivise shopping around in a single payer system. Also, the majority of patients are not capable of evaluating quality of healthcare, nor should they be.
  - aksss 6y ago
    Any system should incentivize shopping around unless it wants inflated cost. That or discourage frequent engagement (the US consumes comparatively massive amounts of healthcare product and service with inefficient outcomes). Our present system is _designed_ to prevent price comparison and shopping around via price opacity, network lock-in, state-level artificial supply barriers, etc. Universal coverage on par with Europe would mean we all start consuming less individually (which isn’t a big deal to outcomes but not part of our culture), or we need to have a far more competitive environment for suppliers. Either would be better than what we have today, whether insurance is public, private, or a mix of both.
    - grey-area 6y ago
      I honestly don’t think price comparison can work for general healthcare, plus it would lead to huge disparities of care quality as the US has now, which means in practice a very expensive safety net for which the government picks up the tab. Better just to go with single payer healthcare, not linked to employment or insurance, and dramatically reduce costs with similar outcomes. Everyone wins, and those with money can still buy private care or private insurance if they wish, truly shopping around, as they have the means, education and leisure time to do so.
eldavido 6y ago
Also a fiscal conservative, I completely agree single-payer would be much better than what we have now. What I think would be best though, is to eliminate medicare/medicaid, hand people cash, and get out of the way. The high-order problem with medicine isn't coverage or insurance. It's price. There are only two ways to get price under control: meaningful competition, or government price controls (e.g. single payer). Single payer would end up like public schools: one choice for everyone, probably OK quality, but not great. I think we could do so much more here if we just created a cash market and handed people money. It's what Singapore does. It would let doctors compete on -- even discover -- what actually matters to consumers -- wait times, when procedures take place, even how comfortable the office is. I would much rather have a market with choice and variety than one that straitjackets everyone into a one-size-fits-all system that might work for some but probably won't for others. I know people are going to worry about rare (expensive) conditions not being covered, and this is indeed a problem. I don't have an answer to this. One good thing about competition though, is that it drives innovation. Provider prices will absolutely be set based on what they know people can pay. If people can't pay as much, the only thing for them to do is drop prices. It's funny. In a community where people are so focused on innovation, and startups, and choice, I see a lot of support for a national single-payer scheme. I would much rather take the collective energies of this community and apply them to innovation in this market, with meaningful choice and competition. Medicine needs more of a startup mindset. And for those roasting me about how it's different/dangerous/risky: what we have today is KILLING us, economically.
- jimmaswell 6y ago
  Patients would still decide where to be treated based on those factors, the only difference is the insurance is standardized. Nobody in countries with socialized health insurance seems to complain about lack of choices or any of that, and rich people in those places can still get private insurance to get their nose job done right away from a private practice. For everyone else I get the impression it works just fine.
  - eldavido 6y ago
    I'm less convinced. The NHS, Britain's version of this, is constantly underfunded, and has long wait times for a variety of procedures. The Economist writes about this frequently. https://www.economist.com/britain/2018/06/28/the-three-myths-of-the-nhs https://www.economist.com/britain/2018/06/28/the-three-myths...
rtx 6y ago
Why add additional steps, government should open hospitals and provide healthcare directly.
- sib 6y ago
  Why? (Seriously - you seem to be assuming the answer here.) Would the same statement be true for food and shelter (also necessary for life)? Should the government be the provider for all food and shelter in order to avoid additional steps?
  - lotsofpulp 6y ago
    Because a person is capable of determining good produce from bad produce and make informed decisions when purchasing groceries. The same is not true for healthcare. Even when purchasing shelter, people are not sufficiently informed to be able to make a good decision, hence the existence of electrical, plumbing, and structural codes and inspections. With healthcare, people are extremely uninformed. The costs are extremely high. The government doesn’t necessarily need to vet the doctors’ diagnoses and prescribed remedies, but they could. So could insurance companies, which is what currently happens in the US.
    - aksss 6y ago
      This is a bit chicken-and-egg. People are uninformed about cost and quality of healthcare because the third-party payer system obscures detail (often intentionally). Spend some time uninsured and you become a very discerning consumer. Further, for every service that requires healthcare advocacy (often provided by family members, btw, not professionals even in existing system) there are probably >five that are commodity services (labs, prescriptions, diagnosis, imaging, etc.)
  - pvaldes 6y ago
    Maybe. That would have economical benefits also by lowering crimes related with lack of food or shelter (therefore releasing money to spend in other things and contributing to social peace). The plan would deserve a closer look. The difference between an apple being stolen by a homeless and an apple being given to a homeless, is that you don't need to pay for fixing the broken window.

nugget 6y ago

My takeaway from all that research was the same. Almost everyone benefits from universal coverage but the system has to incentivize patients to shop around for the optimal balance of price, quality, and convenience. This can be accomplished with an annual deductible of a few thousand dollars perhaps capped at a % of income. Without this incentive, costs skyrocket. Price transparency is a pre-requisite without which consumers can't easily shop around, so this law is a giant leap forward in the right direction. That is the #1 most effective thing that Americans can do to reduce health care costs. #2 would be to change the standard American diet and eat healthier to reduce rates of obesity and diabetes. Almost every other proposed structural change or intervention we looked at was minimal by comparison.

zaphod12 6y ago
There was an attempt at this with prescription drugs. Encourage patients to take generics by forcing a larger amount of cost onto the patients in the form of higher copays. Pharma companies realized and started giving copay vouchers (still charge insurance more, but short circuit the patient incentive). When that loophole got tighter they formed charitable foundations to give the vouchers instead. I'm not disagreeing with your points, per se. It's just amazing what entrenched interests can manage.
smachiz 6y ago
Do you have any studies or sources to back this up? As I understand it, in most EU markets there's no price component, nor much of a choice component and costs haven't skyrocketed.
- coredog64 6y ago
  I lived under the French system for years, and it’s entirely untrue that there is no cost or choice component. You pick the doctors and you pay them fully out of pocket. Your insurance company reimburses you at ~80% of reasonable and customary rates. If you wind up going for inpatient care it’s different, as is the situation for those in extreme poverty. Also, you can pay extra for 100% coverage if you want, but ISTR it was expensive and not really worth it for us. Now, when I left, the doctors and insurance companies were setting up an analog of the US system: If you saw certain doctors, they would not charge you at point of delivery and there was no co-insurance requirement. It was still new and inconvenient, so I don’t know how that’s worked out. I don’t have direct experience with the Swiss system, but from everything I’ve read, conversations, etc., it’s a slightly cheaper version of the US system. You buy leveled insurance, you have to pay some out of pocket, etc.
  - vinay427 6y ago
    > I don’t have direct experience with the Swiss system, but from everything I’ve read, conversations, etc., it’s a slightly cheaper version of the US system. You buy leveled insurance, you have to pay some out of pocket, etc. I moved from the US to Switzerland so maybe I can offer some anecdotes here. You're basically right in that it's a slightly cheaper version of the US system. However, some things that I didn't have to pay for in the US such as calling am ambulance without riding in it or seasonal flu shots do cost money here ($500+ for an ambulance to show up in the middle of a large city...), but I think these small lapses are overshadowed by expensive inpatient treatment being essentially completely covered minus some reasonable deductibles as well as outpatient treatment that is usually partially covered depending on the insurance plan. The positives compared to the US largely revolve around necessary and typically expensive treatment being far more likely to be covered under insurance with relatively low copays and deductibles. The downsides in common with the US are the administrative hassles of dealing with an insurance company and its own billing middlemen (e.g. a COVID test was improperly billed to me which needed to be sorted out), the large monthly premiums for most people (~$250 is typical except for those who qualify for subsidies), and the lack of clarity over what and how much of anything is covered even when the billing is done correctly. Do I call an ambulance? Do I go in to see a doctor? Will I end up with a massive charge? I'd prefer a single-payer or completely comprehensive system for this last point alone.
grey-area 6y ago
Almost everyone benefits from universal coverage but the system has to incentivize patients to shop around for the optimal balance of price, quality, and convenience. Universal coverage does not need to incentivise shopping around in a single payer system. Also, the majority of patients are not capable of evaluating quality of healthcare, nor should they be.
- aksss 6y ago
  Any system should incentivize shopping around unless it wants inflated cost. That or discourage frequent engagement (the US consumes comparatively massive amounts of healthcare product and service with inefficient outcomes). Our present system is _designed_ to prevent price comparison and shopping around via price opacity, network lock-in, state-level artificial supply barriers, etc. Universal coverage on par with Europe would mean we all start consuming less individually (which isn’t a big deal to outcomes but not part of our culture), or we need to have a far more competitive environment for suppliers. Either would be better than what we have today, whether insurance is public, private, or a mix of both.
  - grey-area 6y ago
    I honestly don’t think price comparison can work for general healthcare, plus it would lead to huge disparities of care quality as the US has now, which means in practice a very expensive safety net for which the government picks up the tab. Better just to go with single payer healthcare, not linked to employment or insurance, and dramatically reduce costs with similar outcomes. Everyone wins, and those with money can still buy private care or private insurance if they wish, truly shopping around, as they have the means, education and leisure time to do so.

eldavido 6y ago

Also a fiscal conservative, I completely agree single-payer would be much better than what we have now. What I think would be best though, is to eliminate medicare/medicaid, hand people cash, and get out of the way. The high-order problem with medicine isn't coverage or insurance. It's price. There are only two ways to get price under control: meaningful competition, or government price controls (e.g. single payer). Single payer would end up like public schools: one choice for everyone, probably OK quality, but not great. I think we could do so much more here if we just created a cash market and handed people money. It's what Singapore does. It would let doctors compete on -- even discover -- what actually matters to consumers -- wait times, when procedures take place, even how comfortable the office is. I would much rather have a market with choice and variety than one that straitjackets everyone into a one-size-fits-all system that might work for some but probably won't for others. I know people are going to worry about rare (expensive) conditions not being covered, and this is indeed a problem. I don't have an answer to this. One good thing about competition though, is that it drives innovation. Provider prices will absolutely be set based on what they know people can pay. If people can't pay as much, the only thing for them to do is drop prices. It's funny. In a community where people are so focused on innovation, and startups, and choice, I see a lot of support for a national single-payer scheme. I would much rather take the collective energies of this community and apply them to innovation in this market, with meaningful choice and competition. Medicine needs more of a startup mindset. And for those roasting me about how it's different/dangerous/risky: what we have today is KILLING us, economically.

jimmaswell 6y ago
Patients would still decide where to be treated based on those factors, the only difference is the insurance is standardized. Nobody in countries with socialized health insurance seems to complain about lack of choices or any of that, and rich people in those places can still get private insurance to get their nose job done right away from a private practice. For everyone else I get the impression it works just fine.
- eldavido 6y ago
  I'm less convinced. The NHS, Britain's version of this, is constantly underfunded, and has long wait times for a variety of procedures. The Economist writes about this frequently. https://www.economist.com/britain/2018/06/28/the-three-myths-of-the-nhs https://www.economist.com/britain/2018/06/28/the-three-myths...

rtx 6y ago

Why add additional steps, government should open hospitals and provide healthcare directly.

sib 6y ago
Why? (Seriously - you seem to be assuming the answer here.) Would the same statement be true for food and shelter (also necessary for life)? Should the government be the provider for all food and shelter in order to avoid additional steps?
- lotsofpulp 6y ago
  Because a person is capable of determining good produce from bad produce and make informed decisions when purchasing groceries. The same is not true for healthcare. Even when purchasing shelter, people are not sufficiently informed to be able to make a good decision, hence the existence of electrical, plumbing, and structural codes and inspections. With healthcare, people are extremely uninformed. The costs are extremely high. The government doesn’t necessarily need to vet the doctors’ diagnoses and prescribed remedies, but they could. So could insurance companies, which is what currently happens in the US.
  - aksss 6y ago
    This is a bit chicken-and-egg. People are uninformed about cost and quality of healthcare because the third-party payer system obscures detail (often intentionally). Spend some time uninsured and you become a very discerning consumer. Further, for every service that requires healthcare advocacy (often provided by family members, btw, not professionals even in existing system) there are probably >five that are commodity services (labs, prescriptions, diagnosis, imaging, etc.)
- pvaldes 6y ago
  Maybe. That would have economical benefits also by lowering crimes related with lack of food or shelter (therefore releasing money to spend in other things and contributing to social peace). The plan would deserve a closer look. The difference between an apple being stolen by a homeless and an apple being given to a homeless, is that you don't need to pay for fixing the broken window.