[koolba]

I’d take it a step further and mandate a single price for everybody. Let insurance cover whatever the actual is going to be for paying in cash and not some voodoo accounting that generates a cash price backwards from the maximum negotiated rates.

Insurance should be to cover unforeseen events. Baking in the cost of trivial things like a “fee flu shot” just acts as a way to obscure the true costs.

[arcticbull]

Let's take it one step further and everyone pays for health insurance out of their taxes according to their means, and the state handles all the billing, negotiation and pricing on their end - and the individual never has to care who's paying and how much. Socialized medicine already covers 40% of Americans between Medicare, Medicaid and the VA. Time to get it to 100%.

The Canada Health Act is a great model. The Feds mandate that the Provinces figure out how to provide everyone a minimum standard of care, and each Province administers a public health insurance program that covers everyone. This would map perfectly to the states.

[mc32]

I'm not sure I would want to go there. "People of means" already pay greater taxes which support government programs. If you think they are not paying enough, raise their taxes, but avoid double taxation.

In other words, I don't think just because I would pay $1000 for a broken arm means I would agree that Bezos should pay $100,000,000 for the same. It would make no sense. It would make sense to close his tax loopholes. Sure.

[arcticbull]

Sorry for the unintentionally charged and hence confusing language there. I just meant via progressive taxation. Something like the Ontario Health Premium [1] which ranges from $0 per year if your taxable income is $20,000 or less, to $900 per year if your taxable income is more than $200,600.

I agree and also do not want what you outlined! :)

I strongly suspect that a socialized medical program in the US would not actually cost individuals any more than they're paying now - it's just that the cost they're paying is hidden behind employer paid premiums. That's just a private tax.

[1] https://www.ontario.ca/page/health-premium

[b9a2cab5]

> I strongly suspect that a socialized medical program in the US would not actually cost individuals any more than they're paying now

The definition of progressive taxation means this is not the case for anyone making more than 100-150k, given current tax brackets.

Medicare already is 1/3 of the federal budget and I can assure you someone making low 6 figures definitely pays more in tax than 3x $900.

[arcticbull]

> Medicare already is 1/3 of the federal budget and I can assure you someone making low 6 figures definitely pays more in tax than 3x $900.

Well the first step is redirecting all the premiums paid by employers on behalf of employees into the federal pot. That should net ~$5500 per taxpayer or an additional ~$1.8T per year. That will sort out the bulk of it with no additional cost visible to individuals.

[b9a2cab5]

That is not the plan put forth by Medicare for All advocates. There is a strong undertone of income redistribution in progressive proposals for single payer.

I would also expect that if the government was taking that money my health benefits would be at least as good as they are now. And I don't think that will be the case. When I was a kid there was a period where I was on California MediCal and I distinctly remember getting glasses with _super_ thick lenses because all MediCal would pay for was the cheapest frames and lenses.

[jollybean]

A few years ago, in Canada, we were paying $4500 per person - and everyone was covered.

The US was paying $5K public per person and $5K private per person.

Meaning - the US is already paying more per capita in public healthcare spending, than Canada, and for that price in Canada - everyone is covered.

This kind of means, the US could literally give all of its citizens 'Canadian Quality Universal Coverage' and literally save a few dollars in public spending, and wipe out the need for private spending.

So 'cost' and 'profit' are different things.

The US HC system is a giant elephant of inefficiency.

This is not a small thing:

'Healthcare' is a 'Pillar of American Decline'. I don't mean that America is falling apart, but rather, it's having less influence in the world.

50 years ago, you went to the Hospital because you were hurt. Now - it's all about aging people who are elderly who see the doctor 20x a year and it's why costs have skyrocketed. It's also when people are the least productive and less likely to be working with good insurance.

HC is a disaster that makes the US a 'much less attractive place to live' for one's entire life, unless one is rich - whereas that was not the case before.

It really needs to be sorted out.

The Media Left, by highlighting Woke issues, instead of things like outrageous healthcare, has completely lost their minds. MSNBC was calling Elon Musk 'racist and misogynist' for his completely benign comments about this giant tax bill. Instead of looking at inequality issues through economic lenses, they're committed to throwing around gender and racial slander. The HC system is a soft, easy target because there are unlimited stories of people getting huge bills, unfair pricing. But you won't see to many stories, because "Sponsored by Phizer".

[erichocean]

> 50 years ago, you went to the Hospital because you were hurt. Now - it's all about aging people who are elderly who see the doctor 20x a year and it's why costs have skyrocketed. It's also when people are the least productive and less likely to be working with good insurance.

Literally 100% of the elderly in the US are already covered by the socialized medicine you seem to be advocating for. It's not optional.

[kwhitefoot]

> a socialized medical program in the US would not actually cost individuals any more than they're paying now

But think of all those insurance company employees who would be out of work!

[zaroth]

I think a great way to do this would be for the government to enter the market with a fixed enrollment and a lottery system.

They can run the program for 3 years for 100,000 people and transparently report all their findings and we can see how it went.

[mc32]

Ok. Yes, that makes sense.

[Karunamon]

Anyone who's had extensive dealings with the VA would be glad to share why they are not interested in single payer. Making that switch will not remove the incompetence, poor staffing lack of care, lack of accountability, and so forth.

Some sane standards need to be drafted and then enforced, hard and fast, before we start mandating how healthcare is paid for.

[arcticbull]

And anyone who has dealt with socialized medicine in the OECD will tell you the exact opposite :) Wholesale reform is needed, and that can certainly be part of the package. However, parceling it out is a great way to achieve absolutely nothing as evidenced by the current morass.

[xyzzyz]

Huh? I have experience with “socialized medicine” in Poland, and, in short, it’s shit.

[arcticbull]

Heh, maybe not the whole OECD but [1] America ranks near the bottom as-is.

[1] https://worldpopulationreview.com/country-rankings/best-heal...

[rascul]

Interesting to look at the population from your link. The United States appears to be doing the best (LPI 2020 ranked 18) out of all the countries with population over 100 million. After Japan (ranked 19) the next closest are China (54) and Indonesia (57). I'm not sure what relevance this might have, I just found it interesting. The CEO rankings show a much different picture.

[yes_really]

> and the individual never has to care who's paying and how much

But then nobody cares about how much the government is paying, and you end up with more and more taxes and inflation.

Taxes are increasing. Government debt and inflation are skyrocketing. Can't we put an end to it?

Also the government can't even build passenger rail without wasting absurd amounts of money and having "unexpected delays" in all projects. Why should we trust it to manage everyone's healthcare?

[lmm]

Because every comparable country that has a government-run healthcare system has somehow ends up with it being ~twice as efficient. I get that there's theory that says a private healthcare system should be better at keeping costs under control, but it's not borne out by the evidence.

[yes_really]

"~twice as efficient" is a stretch. They might cost half the price, but they are not necessarily twice as efficient.

Medical treatments and equipments in the US are the best in the world (discounting super small countries). Americans have the highest life expectancy in the world (discounting homicides and transit deaths). Americans can get treatments fast while people in Canada or the UK have to wait for months because the government is rationing treatments.

And we should consider other reasons that explain the costs besides "private system inefficiency": American companies carry the world on medical innovation (so other countries are benefitting from the Free-Rider Problem, and Americans are paying for it). American regulation requires doctors to spend several more years in training than at other countries (in other countries the medical school is usually merged with undergrad). And, finally, Americans just earn more than people in other countries. GDP per capita is 60k in the US, 40k in other developed countries.

[arcticbull]

> Medical treatments and equipments in the US are the best in the world (discounting super small countries).

Not really. They're fine. In line with OECD. And further, America has a number of blemishes such as among the highest maternal mortality and infant rate in the entire OECD. [1]

  ...the U.S. ranks 33 out of 36 Organization of Economic Cooperation and Development (OECD) nations. In 2018, while infant mortality reached an all-time low in the U.S., at 5.9 infant deaths per 1,000 live births, still more than 21,000 infants died. Compared to countries with a similar GDP, the U.S. infant mortality rate is much higher. France and the U.K., for example, have 3.8 deaths per 1,000 live births.

The only area the US really excels is in cancer 5-year survival rates - not because the mortality rate is lower, however, it's about the same as everywhere else. The US just biases towards earlier screenings that do not extend life or reduce mortality.

> Americans have the highest life expectancy in the world (discounting homicides and transit deaths).

Are you sure about that? It doesn't look like that on this chart. [2] Not to mention the US spends dramatically more to achieve that much lower life expectancy than anyone else does.

> Americans can get treatments fast while people in Canada or the UK have to wait for months because the government is rationing treatments.

This is a straight-up lie peddled by the US medical insurance industry. Here's an admission and an apology by a Cigna executive tasked with doing so. [3]

  "Our industry PR and lobbying group, AHIP, supplied my colleagues and me with cherry-picked data and anecdotes to make people think Canadians wait endlessly for their care. It's a lie. And I'll always regret the disservice I did to folks on both sides of the border."

They pulled the same thing when Canada instituted single-payer healthcare in 1962. [4]

> American companies carry the world on medical innovation.

Not really. There are as many European as there are American medical companies in the top R&D spenders worldwide. That's before we factor in government expenditures worldwide.

> And, finally, Americans just earn more than people in other countries. GDP per capita is 60k in the US, 40k in other developed countries.

Now imagine what they could do with an extra $5K per person per year - the difference between what the US and Canadian medical systems cost per capita.

[1] https://www.forbes.com/sites/joshuacohen/2021/08/01/us-mater...

[2] https://ourworldindata.org/grapher/life-expectancy-vs-health...

[3] https://www.npr.org/2020/06/27/884307565/after-pushing-lies-...

[4] https://canadiandimension.com/articles/view/the-birth-of-med...

[yes_really]

The infant mortality rate is based on extremely misleading statistics.

In the US, if a baby is born who can be saved but isn't, their death is reported in the neonatal mortality statistics. But in other countries it is more common for babies in these situations to be counted as miscarriages or stillbirths.

In the US, very low birth weight infants are considered to be alive (because, of course, they are), but in Canada, Germany, Australia, and other countries, a premature baby weighting less than 500g is considered to be already dead, even if it is breathing and has a heartbeat. So they don't have to add it to their infant mortality statistics when their healthcare system fails to save its life.

In fact, since the year 2000, of the 52 surviving babies who were born weighting less than 400g, 42 were born and saved in the US.

Sources:

- https://youtu.be/KEHM3EHUTew?list=PLWu1-TbpoIFJZga03X-Wzf1UH...

- https://www.healthsystemtracker.org/chart-collection/infant-...

- https://www.forbes.com/sites/physiciansfoundation/2016/04/12...

[Consultant32452]

When you are imagining single payer in the US, are you imagining it being designed and run by the people who created the current system?

[arcticbull]

People seem to be big fans of Medicare. Of those covered by Medicare 75% say the system is working well, only 22% say it is working poorly. [1]

[1] https://www.kff.org/medicaid/poll-finding/medicare-and-medic...

[Consultant32452]

Thank you for the thoughtful response to my question.

[arcticbull]

What's really interesting is that 60% of people in general (including those already on it) say Medicare is working well for seniors - but when you drill down only to the people actually covered, that number jumps up to 75%. Same source. Seems like a marketing issue?

[technofiend]

Unfortunately as one example Medicare Part D price negotiation has been blocked since 2003. When some drugs were moved to Part B, insurance companies were furious because it allowed price negotiation for those.

This is from 2016, so nothing has changed AFAIK. https://www.healthaffairs.org/do/10.1377/forefront.20160919....

Despite this election season’s divisiveness, both major parties’ presidential candidates have embraced the idea of authorizing Medicare Part D to negotiate directly with drug companies to set prescription drug prices. The Medicare Modernization Act of 2003 (MMA), which established Medicare Part D, included a ban on such negotiation.

Apparently both sides of the aisle pander to voters with the idea they'll help with healthcare costs and then don't once safely elected to office.

[refurb]

Your summary doesn’t make much sense.

Part D plans are administered by private insurance, who do negotiate prices.

Part B drugs aren’t negotiated even today. Government has a formula for what they will pay, but there is no negotiation.

[spaetzleesser]

Totally agree. Charge the same price for everybody no matter how they are paying.

[refurb]

Why mandate a single price? Don’t we want prices to be competitive? As a young doctor I may want to bill at a 10% discount?

[HarryHirsch]

Medicine is very much standardized, so you want to bill the same per procedure, but for complicated cases you want to allow upcharges.

[refurb]

So a fresh out of residency eye surgeon should get paid the same as a 20 year old doctor who has done 1,000s of the procedures?

[HarryHirsch]

The patient should pay the same, no matter who does it. Compensation of healthcare staff is an internal matter and frankly not relevant to the patient.

That's how it works in Germany.

[nradov]

So should every healthcare provider organization throughout the country be required to charge the same price for a given procedure? Many US doctors still run solo practices, so there is no real difference between the company and the "staff". It seems reasonable that doctors with more experience and better skills should charge higher fees.

[HarryHirsch]

It seems reasonable that doctors with more experience and better skills should charge higher fees.

That's entirely your opinion. A more experienced doctor shouldn't have problems finding cases that require advanced expertise.

[daniel-cussen]

I don't understand, are you being sarcastic? Which is preferable?

[refurb]

The preference would be a higher quality, by virtue of more experience, gets paid more.

Why would I be sarcastic?

[daniel-cussen]

To read your sarcasm I'd have to know whether you have in fact gotten surgery by a more experienced doctor. It just depends on so many things. First, you can't be a surgeon for that long, you start losing your "pulso" like stillness of hand at around 50. Then there's the vibe the old doctor and the young doctor give you.

You must use your judgment to interpret it, but let me tell you a trope: the old doctor, sure, he's done this thousands of times, so it's no big deal for him. But he might be complacent, and plus he's been a surgeon for decades, these guys get worshipped by the rest of the hospital, it typically gets to their head. He might have long ago lost sight of needing to help people who lost sight, if he's not a virtuous guy he'll hustle you, 100%. And if he fucks up? 1 divided by 2000 is what percentage error rate, .05%? Assuming it's never happened before.

Whereas the young doctor is probably hungry for his first paycheck after a decade of getting into debt and memorizing stuff, his big chance to stop getting hazed, this won't be his first time really, he'll want to do an amazing job. He has no track record so if he screws up, it won't be automatic to get a second chance, it's high stakes, and he'll have that error hanging over him. He might be nervous though, so you have to keep that in mind. But much better hands, and he'll actually perform the surgery according to the original definition of "perfection" : he'll carry it out all the way through. Won't skip steps to save himself a couple of minutes at the expense of weeks of pain. He doesn't yet know what parts of the surgery he can get away with not doing, he just does the whole thing.

On the other hand, if the old doctor is humble and the young doctor is arrogant, it could be the other way around. You need to judge the vibe.

[HarryHirsch]

So the choice would be between glaucoma surgery according to the standard of care - or glaucoma surgery according to the standard of care.

Now we are getting somewhere! What if all this "choice" did nothing to improve patient outcomes or public health but entirely served to get more money out of your pocket?

[JumpCrisscross]

What would be the difficult-to-foresee challenges this, for practitioners and consumers, would raise?