[mekdoonggi]

You are extremely close to arriving at the solution, which is medicare for all. Cover everyone, then almost noone uses the insurance except when they need it, which is when they get old.

If the US had the equivalence of Canadian health insurance, the spending reduction would be so big, that as a working person, your health insurance bill would go to zero, out of pocket costs to zero, and everyone would have health insurance.

[Taikonerd]

> You are extremely close to arriving at the solution, which is medicare for all. Cover everyone, then almost noone uses the insurance except when they need it

Most Medicare recipients do get supplementary private insurance though? It's called "Medigap."

Medicare pays for 80% of patients' costs, but even the remaining 20% is a lot. (You get a $100,000 procedure -- you're on the hook for $20,000.) That's why people get Medigap coverage.

[mekdoonggi]

By "the insurance" I was referring to Medicare. I'm a working, healthy person and rarely use healthcare outside of preventative care. You could raise my Medicare taxes by hundreds monthly and still be less than what I pay for private insurance.

In a Medicare-for-all scenario, the individual price of a given procedure doesn't need to be so high, because the reimbursement is guaranteed. Right now, the "list" price of the procedure has to be high to subsidize the uninsured and Medicaid who lose money.

I'm sure there are single payer health insurance countries in which people still purchase insurance, which should inspire debate about the universal insurance cost-sharing.

Regardless, the only viable solution in the US is a single payer insurance model.

[SoftTalker]

Your private insurance isn't there (ideally) to pay for your preventative care, which you can easily pay for out of pocket. It's there to pay for the low-probability but very expensive scenarios, such as cancer, major accident/injury, etc. that would otherwise bankrupt you.

[mekdoonggi]

I understand how insurance is supposed to work. The problem is that private insurance captures all of the value I pay in during my working life, and doesn't have to pick up the tab when I inevitably get old and sick.

To use car insurance as an example, it would be like if we had a government program for cars over 150k miles. You have to pay for both private and government insurance. The private company collects more money than the government, but the government pays for all the expensive stuff because that's when cars break down. It's completely pointless.

If you want a medicare-for-all scheme where working people have a higher cost-share than children/retirees, fine, that's reasonable. Having private companies rake in profits from a system that has no business being a profit enterprise is insane.

[SoftTalker]

The value is that it is there. Most insurance isn't used, or ever pays back what you paid into it. That's the point; that's how it's a viable product. There's no way to insure old, sick people, that's why the government does it. It would be like selling automobile insurance only to drunk drivers, or selling homeowners insurance to people whose houses are already on fire.

[mekdoonggi]

There's a way to insure old, sick people (who were once young and healthy) and it's how every other developed nation does so at lower cost. How is it lower cost? the profits from the young and sick don't get shoveled to private corporations for performing the exact same function at higher cost.

[LorenPechtel]

Paying for the preventative is because it's been demonstrated that doing so reduces costs overall. The amount involved isn't all that much, it's not the driver of the costs.

[onlyrealcuzzo]

> You are extremely close to arriving at the solution, which is medicare for all. Cover everyone, then almost noone uses the insurance except when they need it, which is when they get old.

I strongly think that covering everyone in the existing system is not the best way to go.

The existing system is designed to cost as much as possible, and we have way too much demand for treatment (as is) and not enough supply. ER wait-times aren't 2-4 hours just because.

First, that needs to break.

Then, you can cover everyone.

We simply do not have enough doctors for how many old and unhealthy people we have. We should be thinking about how to keep people from going to the hospital that don't really need to be there. Do you really need to go to the ER because you stubbed your toe? If you didn't have insurance, you'd go to a low-cost clinic and get the same treatment for 1/10th the price.

We are slowly getting there already. Low cost clinics weren't widely available, but they are becoming more and more available as the cost of health care even WITH insurance is too high for most people.

The infrastructure for the bottom ~50% of people needs to exist to break free from a system that is not designed for them BEFORE they can move off it.

It's almost there.

Since One Medical became widely available, I basically have not gone to the hospital in 5+ years. Before, you kind of needed to go even for routine things (or at least I didn't know of a viable alternative). More and more places like this are springing up all over the US.

[b_t_s]

>ER wait-times aren't 2-4 hours just because.

ER wait times are long because ERs are the only place in the country where we effectively have medicare for all, albeit in a particularly perverse and dysfunctional form. Everyone gets treated at the ER even if they're broke & uninsured as long as they're willing to wait long enough. Now imagine if those folks could go to any primary care doc or even use One Medical, CVS walk-in clinic etc. That would go a long way toward fixing our overloaded ERs. We've legislated quazi-medicare for all but only in the most inappropriate part of the system.

[mekdoonggi]

Agreed. We all collectively understand that we can't allow people to die in the streets because of their lack of health insurance. We already have universal healthcare, we just have the worlds dumbest way to pay for it.

[teeray]

> Do you really need to go to the ER because you stubbed your toe?

Where else are some people supposed to go? Maybe that toe is starting to change colors… is it broken? Do I need to have it set? Is that possible for toes?

People have valid medical questions and don’t want to wait weeks to see their primary care. They might not live near an urgent care. The urgent care may have terrible hours, or they made the mistake of mentioning chest pain for their heartburn incident and now they are forced to the ER.

It’s a chicken and egg problem. Faster medical answers will lead to reduced ER wait times. Reducing ER wait times lead to faster medical answers.

[throwaway173738]

Who would you choose not to cover? The sick?

I hate to break it to you but insurance is meant to be a tax on the entire risk pool. What changed after the ACA is we couldn’t kick anyone out of the risk pool for getting sick.

[onlyrealcuzzo]

> Who would you choose not to cover? The sick?

You didn't read the post.

The sick are mostly the old (if you're looking at total spending), and they are already covered by Medicare.

The sick young are a minority, and are often times covered by Medicaid.

If the state covers the tail end and assuming they aren't covered already by Medicaid, there just isn't that much spending remaining.

They can get private insurance to cover the under $10k per year - but there's not really a product that covers that effectively - so unless a new insurance evolves, it still wouldn't make much sense.

The sick, young, non-medicaid tail is VERY small compared to the rest of the tail the state already covers. Just add it in. A 1% global tariff could easily cover it. You've still got 9-14% left to spend on more bombs, tax breaks for the rich, paying people to get underwater basket weaving degrees, whatever.

[LorenPechtel]

The premium charged for the sick, young is high enough that your math doesn't make sense. ACA plans have to pay out 80%. Since I'm paying $11k/yr for my ACA plan they are clearly paying out at least an average of $9k in claims for the average member of my cohort. (And the reality is worse as they are limited in the ratio between young and not so young, this effectively makes the young subsidize us not so young.)

[throwaway173738]

I’m not understanding how this is better than just putting everyone in one risk pool and having the young and healthy subsidize the old and sick? You’re basically saying if you’re healthy don’t carry any insurance and just rely on the government and taxes for catastrophic coverage. And then as soon as you get sick you’re supposed to apply for this coverage that only applies when you’re sick? The biggest problem with Medicaid is that you have to prove you can’t get the means to pay for healthcare which is essentially impossible without paying for healthcare.

So now you have this huge apparatus for intake and for rejecting people who are not sick enough or old enough but who can’t conventionally afford care. And you have to pay for that apparatus. Why would that be any better for the young people, other than seemingly using their taxes to make cruel decisions about a portion of the old and sick instead of simply providing care?

And what’s worse is a lot of those sick people wouldn’t have gotten that sick if they could pay for preventative care. So now in your system you have this huge group of people who have through lack of means let their illnesses and maladies get so severe that they can’t afford to treat. The whole point of preventative care is to keep people healthy so they don’t become a cost burden to the insurer. That’s why we pay more relative to what it costs. And it’s a hedge for us. We might find ourselves among the desperate ill some day without the means to pay for treatment.

[rickydroll]

Breaking the existing system will be extremely difficult. I have decade-long relationships with all of my doctors. The thought of a health plan that forces me to change all my doctor relationships is anger-provoking and exhausting. New doctors don't know me, they don't know my history, and haven't seen the medical shit show you've been through and why your treatment is the way it is. Then they think they can change your treatment to something that has already failed because "I didn't give it a long enough trial" or "That's a rare side effect," it won't happen to you.

I highly recommend you read the book "We've Got You Covered." It's an economist's view of health systems and how we can rearrange government spending to provide coverage for everybody and prevent medical bankruptcies.

One Medical looks interesting, but I wonder how they keep the price that low. Is it subsidized? Are they putting constraints on physicians and what they can do in the same way BetterHelp messes with the therapists? Are they servicing only the young and healthy?

Their senior care plans tell an interesting story. They only work with Medicare Advantage plans, specifically those known for up-coding, excessive pre-authorization requirements, and high rates of care denials. Medicare Advantage is an interesting failure in the marketplace in that it costs the government significantly more than classic Medicare and provides worse-quality care.

For the rest of us, we can skip the ER by going to an urgent care. But around here, urgent care offices are owned by private equity, have deceptive billing and are part of the reason why medical care costs so much.

[onlyrealcuzzo]

> I have decade-long relationships with all of my doctors. The thought of a health plan that forces me to change all my doctor relationships is anger-provoking and exhausting.

You are clearly not in the bottom 50% of health care spenders. You would be in the group that would keep private insurance and be happy.

> One Medical looks interesting, but I wonder how they keep the price that low. Is it subsidized?

No.

> Are they putting constraints on physicians and what they can do in the same way BetterHelp messes with the therapists?

The vast majority of their "doctors" are Physician's Assistants. You can see whoever you want for whatever you want (that they provide).

> Are they servicing only the young and healthy?

Mainly. It's a clinic. You can't go there for Open Heart Surgery and cancer treatments. They'll just (cheaply) refer you to a specialist (who will be expensive and require insurance).

What you can do is avoid huge wait times and get good enough treatment for ~90% of what the mostly healthy group of ~50% of the population needs for fair up-front prices - which previously did not exist.

[rickydroll]

That's a mighty big assumption you're making. I've had private insurance for years, and I've always been unhappy with it because of treatment delays, Treatment denials, pre-approvals, and unrealistic copay limitations.

Many of my health needs are not expensive, but my body's reaction to treatments is. Frequently, cheap drugs are all side effects and no benefit. Also, private insurance has bizarre coverage gaps. For example, ambulance costs. When I had a heart attack, I drove myself for 45 minutes to the nearest hospital with a cath lab rather than take an ambulance and end up with God knows how many thousands of dollars in uncovered ambulance fees. Then there are things like cardiac rehab, which go a long way toward restoring cardiac health. 12 weeks, three times a week at $50 copays, was an expense I wasn't counting on. When I qualified for Medicare, the quality of care improved significantly. Usually, wait times for service are much lower than with private insurance.

I also resent private insurance because my premium dollars go toward enriching stockholders rather than providing care for all policyholders.

[onlyrealcuzzo]

Okay - so you could keep your private insurance and not be happy, or move to Medicare and also not be happy.

I think you want a third solution - but that seems highly unlikely to be available in the mid term - and it doesn't look like anything is changing in the short term.

Who knows, my crystal ball doesn't work any better than anyone else's.

[UncleOxidant]

> We simply do not have enough doctors

We're going to need to make more doctors. To do that we'll need to identify kids in high school that would be good candidates and offer full-ride scholarships where needed. And we need to improve science education at the high school level to help with all of this.

[onlyrealcuzzo]

> To do that we'll need to identify kids in high school that would be good candidates and offer full-ride scholarships where needed. And we need to improve science education at the high school level to help with all of this.

We could import them.

We have tons of options. But the medical industry likes a shortage, because they like high wages, so I won't hold my breath.

They pick the rules. The rules favor them.

That's going to remain true for the foreseeable future, and on the list of problems, that's at the absolute bottom of things to fix that would actually move the needle.

The cost you spend on DIRECT HEALTHCARE is only ~20-30% of all spending. The rest is administration, drugs, insurance overhead, profits, ACTUAL insurance costs, cost overruns due to insurance making everything as expensive as possible to scrape 15% off the top, fraud, legal fees, etc.

The biggest benefit to moving to a centralized insurer is that fraud is centralized.

If you're a Republican and skeptical of government, you might assume the government will let massive fraud slip through to insiders, and you don't like that.

If you're a Democrat, and think the government can generally be good, you think the government can catch a lot of the fraud and cut total costs by 10% to get to fraud levels that are similar to other advanced countries (with similar systems).

[throwforfeds]

Or, like, not haze kids in their 20s for residency and make them take hundreds of thousands of dollars in debt. Whereas in Europe and other countries, residents work something like 50 hours per week and graduate with zero debt.

I've watched friends go through it here in the US and I have zero interest in working 24 hour shifts and sleeping in break rooms, working 80+ hour weeks for years. There just is no need other than hazing and keeping artificial scarcity of doctors for inflated wages. There are plenty of brilliant, scientifically minded, hard working people that care about others that probably could be great doctors, but the US training system is just hostile towards most people.

[46493168]

The United States will never have universal healthcare because a subset of the population would rather pay more for worse health outcomes than participate in a system the provides abortions, HRT, or PreP, or any healthcare at all to Black people.

See, for example, “Dying of Whiteness: How the Politics of Racial Resentment Is Killing America’s Heartland” by Jonathan Metzl

[onlyrealcuzzo]

> The United States will never have universal healthcare because a subset of the population would rather pay more for worse health outcomes than participate in a system the provides abortions, HRT, or PreP, or any healthcare at all to Black people.

This subset does exist, but is smaller than the percentage of people who think the system is broken - and the solution is not to just open up the floodgates and make it even more broken and even more expensive.

You FIRST have to fix the system before you open up the floodgates.

I am on your side that I think it would actually cost LESS to move all high-cost patients off of the ER and onto Medicaid.

But that's not a big enough problem to actually move the needle. In the rosiest scenario, you might save 2% per year. That's still like $20-40B, so nothing to scoff at - but in realistic scenarios, I'm doubtful it would save >$10B.

Even if they had Medicaid, they're so conditioned on going to the ER for everything, a lot of them might still go there instead of somewhere cheaper. For one, they might be convinced they get better care there (and maybe they would).

There's way bigger fish to fry.

[46493168]

>You FIRST have to fix the system before you open up the floodgates.

I don't see any reason to fix the system on a nationwide level. Let the individual states figure it out. There's things that the top 5 US states for healthcare have in common, and there's things that the bottom 5 US states have in common [0]. They know how to talk to each other if they want to know more.

[0]https://www.commonwealthfund.org/publications/scorecard/2025...

[onlyrealcuzzo]

> I don't see any reason to fix the system on a nationwide level. Let the individual states figure it out.

It's a problem because the nation already ineffectively covers the tail.

The state shall not fix what is not a problem for the state.

[jkestner]

But they’re a subset. It can happen.

The more critical, and yet smaller, subset is the people making bank from the current system. Get their money out of politics and watch resistance crumble.

[46493168]

Yes, precisely. The smaller subset that make bank from the current system directly benefit from us poors (aka non-billionaires) from blaming the person lower on the ladder.

[Projectiboga]

Medicare's admin cost is around 5%, private insurance is around 33% of claim dollars. There are around 27-28% uninsured. The money is already there who pays needs to be moved to the Billionaire and Multimillionaire class to reduce the annual costs for those who work for a living.

[onlyrealcuzzo]

> private insurance is around 33% of claim dollars.

The Medical Loss Ratio (MLR) requirement established by the Affordable Care Act (ACA) is 20%.

Typically it's closer to 15%.

As these are private companies, some percentage of that is obviously profit.

It doesn't cost that much more to run private insurance than Medicare.

The problem is the incentive of insurance to drive up cost to get a larger fixed cut, and the lack of a public option (which would require private insurance to actually be worth it).

[rexroad]

Those figures are in the right range, and the full picture is larger. The CMS NHE 2023 data puts total US healthcare administration at roughly $1.1-1.7T annually (depending on methodology), building on Woolhandler and Himmelstein's 2020 Annals paper ($812B in 2017 dollars). The per-capita comparison against 10 OECD peers: US $4,983 vs. a peer average of $884. That 5.6x gap is the number Issue #5 of this series will examine in detail, covering three separate computation methodologies and why the estimates range so widely. All source code will be in the repo: https://github.com/rexrodeo/american-healthcare-conundrum

The policy lever that addresses this is billing standardization, not just insurer reform. Countries like Germany and Switzerland run much lower admin under private insurance through standardized claims formats and all-payer rate setting.