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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

by 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.

by nugget 6y ago

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.