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The US is 5-10x larger in population than the other single-payer-ish systems usually cited. (And, more culturally/politically/geographically varied.) Also, we

by gojomo 13y ago

The US is 5-10x larger in population than the other single-payer-ish systems usually cited. (And, more culturally/politically/geographically varied.) Also, we in the US tend to have bigger problems running giant federal bureaucracies, compared to these other smaller, more-unified nations. (How many government shutdowns have they had in the past 40 years?) Our existing single-payer-ish health bureacracies, like Medicare, suffer more fraud and cost-problems, and have a harder time enforcing steely-eyed rationing (aka "death panels") than elsewhere. These smaller systems also benefit as free-riders from positive externalities thrown off by the United States' eccentric overexpenditures - like drug and new-treatment beta-testing. (If we become more like them, their own medical indicators could get worse.) So the argument can't just be, "make it work like over there", when nothing here works quite like there, and our challenges of scale, culture, and politics are larger.

ceejayoz 13y ago
> The US is 5-10x larger in population than the other single-payer-ish systems usually cited. (And, more culturally/politically/geographically varied.) I see this argument all the time, and never an elaboration. I understand going from 1,000 to 1,000,000 people incurring growing pains, but I have a hard time understanding why people seem to think a system that works for 80,000,000 people in Germany wouldn't be scalable to 300,000,000.
- gojomo 13y ago
  Germany… …isn't quite single-payer, more like a "public option". …has far more labor-business-government cooperation than the US. …has the oldest tradition of social insurance, but still their current system was the result of gradual expansions over many years. …runs lots of government services better than the US. …is only half the area of Texas, but that area is as population-dense as Maryland (our 5th densest state). Why can't any 300 million people in Africa just adopt US-levels of public services by willpower and legal fiat? Why can't the US make our 50-million-member Medicare as efficient as the German system? These structural, historical, cultural, and political path-dependencies matter. "Make it work because I don't understand how it couldn't" isn't a good basis for the largest nationalization experiment ever.
  - deleted 13y ago
    [deleted]
dragonwriter 13y ago
> The US is 5-10x larger in population than the other single-payer-ish systems usually cited. Which doesn't explain the vastly higher per capita (and even per GDP) costs. > Also, we in the US tend to have bigger problems running giant federal bureaucracies That doesn't explain why the US costs (again, per capita or per GDP) are still higher than the total costs in many countries providing universal coverage even if you exclude the slightly-less-than-half of US spending that is public spending. > Our existing single-payer-ish health bureacracies, like Medicare Medicare isn't single-payer-ish, as for decades there has been policy to move from traditional single-payer-ish "Original Medicare" to (usually partially, with a personal premium as well) publicly subsidized private insurance "Medicare Advantage" plans. > These smaller systems also benefit as free-riders from positive externalities thrown off by the United States' eccentric overexpenditures - like drug and new-treatment beta-testing. Er, a lot of drugs and new treatments are tested and accepted overseas before they are in the US.
- gojomo 13y ago
  You're right: our costs are off-the-charts. There's something about our culture and politics that's making that happen, even in a system with centralized price-setting like Medicare. If you can't answer why Medicare seems to do worse than your favorite "single-payer-ish" models, you haven't explained how making the entire system into a single-payer system, a bureaucracy of unprecedented size, will improve things over a smaller bureaucracy that's failing at controlling costs. Some drugs and new treatments start elsewhere. A disproportionate number start in the US. Fancy new (and often unnecessary) treatments are one of the things driving our costs up.
  - timr 13y ago
    "There's something about our culture and politics that's making that happen, even in a system with centralized price-setting like Medicare" It's not a difficult puzzle: nobody in our system is incentivized to care about costs. The insured consumer never sees the cost, the physician is incentivized to be cost-blind when choosing treatment options, and the insurance companies pass the costs back to employers, who don't get any say in treatment. The only other people who know what health care costs are unemployed and/or poor, and well...screw them, right? You couldn't possibly choose a worse economic model for allocating health care. Medicare is much cheaper and more efficient than employer-based healthcare, but it can't overcome the structural expenses created by a system dominated by people who are almost totally cost-insensitive when it comes to their health.

by gojomo 13y ago

ceejayoz 13y ago

> The US is 5-10x larger in population than the other single-payer-ish systems usually cited. (And, more culturally/politically/geographically varied.) I see this argument all the time, and never an elaboration. I understand going from 1,000 to 1,000,000 people incurring growing pains, but I have a hard time understanding why people seem to think a system that works for 80,000,000 people in Germany wouldn't be scalable to 300,000,000.

gojomo 13y ago
Germany… …isn't quite single-payer, more like a "public option". …has far more labor-business-government cooperation than the US. …has the oldest tradition of social insurance, but still their current system was the result of gradual expansions over many years. …runs lots of government services better than the US. …is only half the area of Texas, but that area is as population-dense as Maryland (our 5th densest state). Why can't any 300 million people in Africa just adopt US-levels of public services by willpower and legal fiat? Why can't the US make our 50-million-member Medicare as efficient as the German system? These structural, historical, cultural, and political path-dependencies matter. "Make it work because I don't understand how it couldn't" isn't a good basis for the largest nationalization experiment ever.
- deleted 13y ago
  [deleted]

dragonwriter 13y ago

> The US is 5-10x larger in population than the other single-payer-ish systems usually cited. Which doesn't explain the vastly higher per capita (and even per GDP) costs. > Also, we in the US tend to have bigger problems running giant federal bureaucracies That doesn't explain why the US costs (again, per capita or per GDP) are still higher than the total costs in many countries providing universal coverage even if you exclude the slightly-less-than-half of US spending that is public spending. > Our existing single-payer-ish health bureacracies, like Medicare Medicare isn't single-payer-ish, as for decades there has been policy to move from traditional single-payer-ish "Original Medicare" to (usually partially, with a personal premium as well) publicly subsidized private insurance "Medicare Advantage" plans. > These smaller systems also benefit as free-riders from positive externalities thrown off by the United States' eccentric overexpenditures - like drug and new-treatment beta-testing. Er, a lot of drugs and new treatments are tested and accepted overseas before they are in the US.

gojomo 13y ago
You're right: our costs are off-the-charts. There's something about our culture and politics that's making that happen, even in a system with centralized price-setting like Medicare. If you can't answer why Medicare seems to do worse than your favorite "single-payer-ish" models, you haven't explained how making the entire system into a single-payer system, a bureaucracy of unprecedented size, will improve things over a smaller bureaucracy that's failing at controlling costs. Some drugs and new treatments start elsewhere. A disproportionate number start in the US. Fancy new (and often unnecessary) treatments are one of the things driving our costs up.
- timr 13y ago
  "There's something about our culture and politics that's making that happen, even in a system with centralized price-setting like Medicare" It's not a difficult puzzle: nobody in our system is incentivized to care about costs. The insured consumer never sees the cost, the physician is incentivized to be cost-blind when choosing treatment options, and the insurance companies pass the costs back to employers, who don't get any say in treatment. The only other people who know what health care costs are unemployed and/or poor, and well...screw them, right? You couldn't possibly choose a worse economic model for allocating health care. Medicare is much cheaper and more efficient than employer-based healthcare, but it can't overcome the structural expenses created by a system dominated by people who are almost totally cost-insensitive when it comes to their health.