[bergstromm466]

> The point is that this often isn't someone's primary job. They take a job at Walmart or driving a school bus, it doesn't pay very well, so they get off work and pick up some rides to supplement their income before going home.

> They don't need health insurance because they got it through their first job or their spouse, and imposing that cost on the second job only requires them to get paid less or have less flexibility etc. as the trade off the company has to make to justify paying the additional cost of mandatory benefits.

Interesting to follow your thinking and your strategies, thanks for open sourcing it. From a European perspective all this sounds absurd though. Having medicare for all and a social safety net is standard in all European countries and other Global North countries.

[bhupy]

> Having medicare for all and a social safety net is standard in all European countries and other Global North countries.

No disagreements that having a robust social safety net is a necessity, but just want to nit-pick a little here and point out that not all European/Global North countries have "Medicare for all" or single payer systems. Germany has a public-private mix, Netherlands has a purely private universal healthcare system, Switzerland has a purely private universal healthcare system, Australia has a public-private mix (44% choose private), Singapore has universal catastrophic coverage but everything else is driven by savings accounts and private insurance among the upper-middle class, etc etc — Belgium, South Korea (technically "single payer" but only covers 60% of costs, private insurance fills in the gaps), Japan, etc.

Even "Medicare" in the US, is a public-private mix: roughly 37% of Medicare beneficiaries are on a private health insurance plan (Medicare Advantage), and we expect that number to reach 50% by 2025.

[bergstromm466]

Yes. I appreciate the nuance you bring. I would reword where I wrote 'medicare' as: 'affordable healthcare', which in it's current form is (as you described) often a mix between private and public mechanisms/institutions.

[AnthonyMouse]

But that makes all the difference.

Affordable healthcare is what people really want. The current system of government incentives/mandates for employer-provided insurance in the US does that poorly and we're rightly criticized for it.

But there are a dozen plausible alternatives that are all better, and "Medicare for All" isn't even a particularly well thought-out one, because the existing Medicare system is premised on the continued existence of private insurance to do things like establish market prices. It's also the moral equivalent of having healthcare policy done at the level of the EU rather than the individual member states, which tends to invite more corruption and waste since both of those are compounded by scale and deep pockets.

Which is the real problem with the US system as it is. The employer-provided system is largely created and regulated at the level of the whole US, and as a result there are some specific businesses who are making out like bandits under the status quo, and affordable healthcare is inherently inconsistent with those companies continuing to make three point six trillion dollars a year. So they lobby hard against anything that would actually fix it, no matter whose solution you choose.

[sidlls]

The Medicare “mix” is from supplemental insurance—insurance in addition to Medicare. It’s also contentious and arises due to the same issues that cause us not to adopt Medicare for All: the private insurance companies’ purchasing of politicians.

[bhupy]

It's not. When you turn 65, you have the option to enroll either in "Original Medicare", which is what we usually think of when we talk about "single payer healthcare in America", or you can enroll in Medicare Advantage (aka Medicare "Part C"), where the premiums that would go to the CMS instead go to private insurers like Humana, United, Oscar Health, and Clover. These plans replace Original Medicare, also cover Part D prescription drug benefits, and often include supplemental benefits that Original Medicare doesn't already cover. The supplemental insurance you're talking about is "Medigap", and that's for people that choose "Original Medicare", but wish to fill in the gaps with private insurance. Today, Original Medicare only covers 80% of costs, and does not cover Part D drug costs. It does NOT apply to Medicare Advantage beneficiaries, which is what I'm talking about in my original comment.

36% of Medicare beneficiaries are on private Medicare Advantage plans instead of the public "Original Medicare". This number has been growing so rapidly, that we expect by 2025, more seniors to be on a private plan than the public one. There's also great variance by State. In Florida, Pennsylvania, Wisconsin, Michigan, Minnesota, Oregon, Alabama, Hawaii, and Connecticut — over 40% of beneficiaries are on Medicare Advantage[1].

For most beneficiaries, Medicare Advantage costs about 39% less than Original Medicare[2].

Medicare Advantage plans are, on average, of higher quality than the public "Original Medicare"[3].

In Urban areas, Medicare Advantage costs less per capita to administer than Medicare [4] — and that's not including the extra Medicare Part D insurance that you would have to buy if you're on the Original Medicare plan. From this same research, public "Original Medicare" is still cheaper in rural areas, but not by a whole lot.

Disclaimer: I write software for claims processing and payment systems. I love talking about this stuff, so happy to chat more about it.

[1] https://www.kff.org/medicare/issue-brief/a-dozen-facts-about...

[2] https://healthpayerintelligence.com/news/medicare-advantage-...

[3] https://healthpayerintelligence.com/news/medicare-advantage-...

[4] https://www.commonwealthfund.org/publications/issue-briefs/2...

[sizzle]

"Medicare Advantage plans are, on average, of higher quality than the public "Original Medicare"[3]."

I thought the difference between Medicare advantage type plans is that it is an HMO type of deal where you can't pick your own specialized treatment centers and have to jump through a lot of hoops for complex medical issues and drugs as opposed to original PPO resembling Medicare (80% costs) + medigap part F? (remaining 20%) + part D for drugs.

Also thanks for the thorough breakdown, I had to go through Medicare hell getting this information to manage my parents care on an advantage plan that denied their cancer treatment at our preferred cancer center so I switched them back to original + medigap and never looked back cause everything is covered now at the world-class top ranking cancer center in our neighboring city.

[bhupy]

> I thought the difference between Medicare advantage type plans is that it is an HMO type of deal where you can't pick your own specialized treatment centers and have to jump through a lot of hoops for complex medical issues and drugs as opposed to original PPO resembling Medicare (80% costs) + medigap part F? (remaining 20%) + part D for drugs.

Nope, Medicare Advantage plans are usually just PPO plans on a nationwide insurance marketplace that covers the Part A, Part B, and Part D benefits. By default, "Original Medicare" is just a government run version of that which only covers Parts A and B. That plan is also not "free", per se, as the beneficiaries still have to pay a monthly premium — it's just that the monthly premium covers Part B benefits, and Part A benefits are all covered by FICA taxes. I think(?) there are also some HMO MA plans. Seniors are now on average choosing Medicare Advantage instead of "Original Medicare" more often because they happen to like the varieties/options. If you don't care about those options, you're still entitled to Original Medicare just like you did with your parents.

The closest the tech community has probably gotten to Medicare Advantage, as a concept, is Chamath's recent SPAC taking Clover Health public. They're an up and coming MAdv payer, and appear to be growing pretty quickly. Oscar Health, another hip tech company, has a big Medicare Advantage business as well.

[zests]

Healthcare costs per capita are generally higher in the US than they are in Europe. I am curious whether or not you think we should focus on increasing spending to increase medicare coverage or if we should focus on decreasing healthcare costs for the country as a whole.

The right answer is probably "both" but you can't exactly vote for "both" political parties. Its a boring answer anyway :)

[xg15]

So, what proposals have republicans for decreasing healthcare costs? Remind people to get sick less?

[zests]

> Trump Administration Announces Historic Price Transparency Requirements to Increase Competition and Lower Healthcare Costs for All Americans

> President Trump Signs “Most Favored Nation Price” Executive Order on Drug Pricing

Here are two headlines I offer without comment that can be searched with your favorite search engine for more information.

[xg15]

I get this [1] when googling.

Fair enough. More transparency is certainly a worthwhile goal, however, this rests on the basic assumption that a consumer always has the opportunity to make a rational choice between different alternative products or services (drugs, medical procedures, etc).

From what I've read, I doubt this is the problem in practice. Are you going to compare prices during a medical emergency? If your doctor tells you that you need an X-ray, will you stop him and check the nearby hospitals whether their X-rays are cheaper? How useful is price transparency if your essential medication is only made by a single company that can do arbitrary price hikes? What do you do if the "market rate" for some essential operation is still more than you can afford?

[1] https://www.hhs.gov/about/news/2019/11/15/trump-administrati...

[bergstromm466]

> Here are two headlines I offer without comment that can be searched with your favorite search engine for more information.

Headlines are not arguments...

[zests]

I didn't realize we were arguing.

[bergstromm466]

A proposal can be an argument.

"Legal Definition of argument. 1: a reason or the reasoning given for or against a matter under discussion — compare evidence, proof. 2: the act or process of arguing, reasoning, or discussing especially: oral argument."

[bergstromm466]

> I am curious whether or not you think we should focus on increasing spending to increase medicare coverage or if we should focus on decreasing healthcare costs for the country as a whole.

Yes, both.

> focus on decreasing healthcare costs for the country as a whole

Most importantly, I believe that through the patent system 1) Pharmaceutical Corporations, together with 2), politicians - who are corrupted through lobbying and who thus make advantageous laws (for Corps) - are getting away with murder. Yash Tandon gives a great example of this below:

“During the 1980s and 1990s I worked in many countries in eastern and southern Africa, and then for four years at the South Centre—2005–09. I can say from my experience that the industrialised countries of the North have been trying systematically to block all efforts by the countries of the South to industrialise. Their mega-corporations have tried—and, alas, succeeded—in privatising knowledge, and using it to promote corporate profits over the lives of people."

[...]

“It is the seeds and pharmaceutical companies of the West that have pirated the knowledge of seeds and medicinal products from the South. But whereas in the South this knowledge was shared as a public asset, the Western companies, having learnt from the South, proceeded to claim it as their private property. They are guilty—morally guilty—for the avoidable deaths of millions of people in the South who cannot afford their ‘patented’ medicines against, for example, AIDS, malaria, tuberculosis and other killer diseases. It is a sordid story. But it is not all doom and gloom. Those who control the system (the global corporations and the international organisations that the West controls) do not get their own way entirely. Wars do not always end in the victory of the militarily or ‘intellectually’ powerful.”

- Yash Tandon, Trade Is War: The West's War Against the World