Who'd a thunk it? Obamacare not repealed

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The biggest problem with Medicare is that it is prohibited by law from actually negotiating things like drug prices. Of course its inefficient. It's designed that way to favor the providers.

[classical_Liberal]

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[classical_Liberal]

,,,

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YOU -- are correct, sir!

[BRUTE]

I too believed Medicare was a horror show--based on complaints about it from people I know in the medical industry--until people I knew got over 65 and began relying on it significant medical conditions. None of them have complaints. Some of them have very serious conditions (my mom and my aunt) and only typical low middle class financial resources (no actual financial wealth, only a fixed monthly income). Medicare isn't really intended to be free healthcare for the lowest income people. That's the purview of Medicaid. Medicare is a a medical plan and isn't intended to solve the social issue of elderly living alone (something I agree is a gap in out social safety net system). The only reason I mentioned it was that is an example of a taxpayer funded medical that by-in-large works pretty well. If we want it to pay every nickel of every service every person might desire, medically necessary or not, and include non-medical in-home care for the elderly, well, it's going to cost us a bit more than a 2.9% nick in our paychecks.

of course. humans who get way more health care than they paid for are happy for it. this does not mean "it works". the solution can't be "the government will simply pay all humans way more than they paid in". medicare is already way too expensive, and it's only going to get worse.

[IlliniDave]

of course. humans who get way more health care than they paid for are happy for it. this does not mean "it works". the solution can't be "the government will simply pay all humans way more than they paid in". medicare is already way too expensive, and it's only going to get worse.

In a sense this is what I've been saying all along. Since the political discussion right now is largely centered on paying for it, the situation is that the country has a bill. We can pay for it directly "out of pocket" (insurance premiums, copays, coinsurance, etc.) or indirectly through taxes. Medicare does both. Premiums are lower for people who participated in the system (by paying payroll taxes).

Yes, it is expensive, so paying it is expensive. We're collectively paying it right now whether we want to acknowledge it or not. The only other option is to refuse medical care to people short on money. I get that some people prefer the latter, it just happens that I'm not one of them.

The way insurance works is that most years, most participants put more into it than they get out. That's the cost of getting more out of the system than you put in on occasion when your turn comes. It's just like say homeowners insurance. You are agreeing to pay a chunk of other people's medical bills on an ongoing basis so they'll pay some of yours when your turn comes. It's a risk mitigation activity, not an investment. Some people have a hard time seeing that.

Out of 300+ million people and the collection medical coverage plans in the country it's easy enough to point to the exceptions on both tails of the distribution (people who because of chronic long-term conditions will get more out than they put in, and people who pay in for a lifetime but who are relatively healthy and die quick and cheap). But leaning on those cases to derail every attempt to make the best we can out of a difficult situation seems at best pointlessly disruptive. Yet that's what we do again and again. And those cases can be exceptionally stark during transition to a new system (the first people to go on SS and Medicare back in the 1930s made out like bandits). IMO the way to view these systems is in the steady state where you have a population that is participating for a lifetime, not a year-by-year survey of who gets more out of it than me.

[Lemon]

@IlliniDave

But the options are not as simple as 'Medicare for all' and 'no healthcare for the unfortunate'

Medicare now costs per capita more than healthcare in my country as a total of government expenditure and we cover everyone. The Medicare system expanded to all would be so, so expensive. With a single payer system you no longer have any sort of price control from the impact on an insurance company or the patient's own wallet (unless you use lots of copay in which case you just shrink but don't eliminate option 2.


So you have to put a cap in what you pay for. Here we use broadly speaking QUALYs. More than £40k and it won't be routinely funded (other than special cases, experimental, private, etc. ). Or you do the other form of rationing which is waiting. Or both.

There are other savings to be made. People get Atorvastatin not Lipitor, don't MRI everything etc. That would also help. Also with total single payer you can compress medical wages (much as I would prefer to earn on US scales!

The question as far as I can see is most Americans are not a huge fan of our 'death panels' (which is a hilarious hyperbolic misnomer but there we go.)
Not to mention as people have said how that could impact the drug pipeline given not everyone can wait around for generics and expect the drug companies to do anywhere near as much work...

[jennypenny]

Also with total single payer you can compress medical wages (much as I would prefer to earn on US scales!

That's another thing that concerns me. I want the medical profession to be one of the highest paying because I want it to attract the best and brightest as the saying goes. I worry about quality issues if medicine becomes a service industry. I wish it paid more than finance jobs and some tech jobs to draw more people to the field, particularly men (to avoid a velvet ghetto).

@CL--I'm not assuming that everyone goes into it for financial reasons so please don't take that as a presumption of your talents.


I agree a big fix is needed but it's more than one issue so it's going to require more than one solution. I think we need to ...

• offer some form of basic medicaid to anyone who wants it or needs it

• even out the healthcare industry so it's not a hodgepodge of for-profit (pharma) and non-profit (hospitals) providers

• spread the burden of the assigned risk pool so that poorer states aren't overly burdened

• provide intervention, including therapy and rehab, for lifestyle issues as well as mental health and addiction problems for long-term savings and improved quality of life

• provide financial incentives to states that include such intervention as a matter of course and who also engage in other methods of keeping populations healthier (like bike paths, reduced polution, better water quality, etc)

• lower the cost of medical school

• decouple health insurance from employment since trends indicate that far fewer people will be in the workforce for the foreseeable future

• convince people that medical insurance is like car or home insurance and that it's a good thing if they never 'get their money's worth' so to speak

Can one piece of legislation accomplish all that? Doubtful.

[IlliniDave]

@IlliniDave

But the options are not as simple as 'Medicare for all' and 'no healthcare for the unfortunate'

Medicare now costs per capita more than healthcare in my country as a total of government expenditure and we cover everyone. The Medicare system expanded to all would be so, so expensive. With a single payer system you no longer have any sort of price control from the impact on an insurance company or the patient's own wallet (unless you use lots of copay in which case you just shrink but don't eliminate option 2.

Gah, I never said anything about medicare for all, I'm only discussing it as a data point that the US can handle a taxpayer funded system (above it was implied that we are incapable of doing that in this country). As far as people without money, either someone else pays for the cost of their care or they go untreated. There's no other choice that I can see.

Okay, hyperbole/straw men aside, the fact that the cost of healthcare in the US is spiraling out of control is a valid concern, but has a large degree of independence from the philosophy/mechanism of how we best/most efficiently go about doing the best we can to ensure universal access. We tried the "free market solution". It failed. We tried ACA/Obamacare. It failed. Now we're talking about this new bill. It doesn't seem destined to be a smashing success because it seems to marry some of the worst of the faux free market solution and the worst of Obamacare (but contains some good ideas too).

As it stands now taxpayers directly pay, I believe, ~50% of the country's medical costs through Medicaid, Medicare, and the VA. Add in ACA and I think it's up to two-thirds. So even a completely taxpayer-funded system isn't that big of a jump (even though it wouldn't be my personal choice--I've brought up what I think might work numerous times earlier in the thread).

The bigger issue long-term is that for the sake of costs the entire system needs streamlining, which probably includes removal of a lot of the corporate profits, duplication of effort, streamlined regulation, etc. (Kicking the can to the fifty states and telling them to come up with their own solution doesn't seem a step in that direction and might make it impossible.) There are times when taxpayer-funded care should prudently be curbed (your death panels). Of course that doesn't stop anyone with money from pursuing treatment that has vanishingly low expectation for improved outcome. Another area is to get the culture more proactive about its health. All good things worthy of their own threads, but that have nothing to do with the current bill aimed at the repeal of Obamacare/ACA.

[black_son_of_gray]

On some levels of the 'cost of healthcare' problem, there is (aptly named) 'cost disease': https://en.wikipedia.org/wiki/Baumol's_cost_disease

Which isn't to say that the US doesn't have a lot of room for making things cheaper... but realistically, a perfect solution would only reduce costs to about half, no? A major improvement, but still a significant expense for a household going forward - and likely to increase in the future as a fraction of expenses regardless

[classical_Liberal]

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[Riggerjack]

I go away for the weekend, and all kinds of gibberish goes unchecked...

I'll also note that road building and maintenance in the US is run very much like one of those socialist single-payer systems, except of course we don't call it that. All US public roads are paid for by taxes. Everybody can drive on them. While some people drive a lot on the roads and some never drive, very few are motivated to go out and drive as much as possible just because the roads are free (<- paid for by others). By far the most will just use the roads when they need them and for what they need them for. Also, you can use the "public option" state roads to get wherever you want and that works for most traffic. In some select cases, if you want to go faster, there are private toll roads where you can pay extra for the speed and luxury.

I've mentioned this before here, but 99.xx% of roads in America are privately built. The xx% changes, depending if you measure by lane-mile, or just by number of roads, but it has always been 99+% private. Maintenance is public. The cost of road construction is all private. Not sure how this model is supposed to support single payer systems.

[Riggerjack]

I go away for the weekend, and all kinds of gibberish goes unchecked...

I'll also note that road building and maintenance in the US is run very much like one of those socialist single-payer systems, except of course we don't call it that. All US public roads are paid for by taxes. Everybody can drive on them. While some people drive a lot on the roads and some never drive, very few are motivated to go out and drive as much as possible just because the roads are free (<- paid for by others). By far the most will just use the roads when they need them and for what they need them for. Also, you can use the "public option" state roads to get wherever you want and that works for most traffic. In some select cases, if you want to go faster, there are private toll roads where you can pay extra for the speed and luxury.

I've mentioned this before here, but 99.xx% of roads in America are privately built. The xx% changes, depending if you measure by lane-mile, or just by number of roads, but it has always been 99+% private. Maintenance is public. The cost of road construction is all private. Not sure how this model is supposed to support single payer systems.

Sorry, but this kind of nonsensical fearmongering rhetoric just shows a total, foundational ignorance as to what single payer, or insurance itself, even is. Like conservatives who don't understand how marginal tax rates work claiming people won't want to earn more money if it puts them in a higher bracket. No. It doesn't work like that. At all. Not even a little bit. It's insurance, guy. Think about this carefully. Is your current surgeon an employee of the insurance companies he accepts? Right, I didn't think so. Why would that change under single payer? Right, it wouldn't. Providers paid under single payer care would be no more employees of the government insurer than they are currently employees of Aetna... or Medicare.

"there are cultural differences between the US and other western nations that will likely be exacerbated by a single payer system."

Right, it's those damn cultural differences. If you meant what you claim you meant by this, you may want to consider your words more carefully in the future, as "cultural differences" in this context is typically a cliche right-wing dog whistle used to suggest public services can't work in America because of blacks and single moms sucking up the resources, thus the need for more racial purity and Eurocentric Christian hegemony.

Um, yeah. Those who disagree with you are all hatred filled racists. Got it. BTW this is how we got trump. As big a buffoon as he is, he doesn't sound like you. Even Trump being a loud, confused douchebag is preferred over more of this prattle.

I worked for the VA 25 years ago. The problems are a combination of the client base (heavily psychiatric care-oriented, homeless, drug abuse, old folks home), legislative (the further a medical center is from Washington, D.C., the more likely things go right), the ties to research & teaching medical schools (medical researchers aren't caregivers), and extra veterans preference rule for hiring (less qualified candidates have priority in hiring).

Now, I highly doubt the public version of a single-payer healthcare system would look like the VA because we're unlikely to have those same requirements.

I too worked for the VA. So let's define terms. The pool being treated is young, in excellent shape (disabled new vets), or military retirees. In order to have VA benefits you need to be disabled in active duty, or retire after 20+ years of military service. So no matter how bad off they are right now, everyone who is served was in good shape. If a leg must be amputated, it helps if the patient is otherwise in excellent shape.

But VA hospital care is a horror show. How would a single payer be different? Keep treatment away from DC? Cut research? Ban vets? Seriously, what is so exceptional about vets that somehow we could use the same system on the general public, yet come out with better results?

So, proponents of single payer, please explain to me how your solution isn't to sentence us to VA hospitals. No, just saying we can do what other countries have done isn't enough. They didn't start where we are. We started with a free market system, and started our current system in reaction to the New Deal. Regulation created this mess. Please explain how removing the last of the market forces will make this better.

The biggest problem with Medicare is that it is prohibited by law from actually negotiating things like drug prices. Of course its inefficient. It's designed that way to favor the providers.

If you believe this, then you are fortunate that the white house is currently occupied by the self proclaimed world's greatest negotiator. He could totally fix everything. Or, if you think that's wrong, feel free to explain why your ideal guy could do better, and how you would keep the negotiator position full of people who would do the job in a way you approve of. Or maybe you meant this as a general statement about how much regulation has erroded standards already?

[ThisDinosaur]

I've mentioned this before here, but 99.xx% of roads in America are privately built.

Interesting. I know my HOA dues cover the roadways inside the neighborhood, and the interstate is federally funded. What about major roads, though? I always assumed those were built by contractors paid by city and state taxes.

So no matter how bad off they are right now, everyone who is served was in good shape. If a leg must be amputated, it helps if the patient is otherwise in excellent shape.

Anecdotal, but a guy I know who worked in a VA said that a vet would likely walk out of the hospital from a condition that was considered nonsurvivable in the community hospital. His theory was that anyone who survived a war was of superior protoplasm than the general population.

[enigmaT120]

Is your current surgeon an employee of the insurance companies he accepts? Right, I didn't think so.

I don't know if my doctor is a surgeon (I don't get surgeries) but I think he is an employee of Kaiser Permanante.

[Riggerjack]

Interesting. I know my HOA dues cover the roadways inside the neighborhood, and the interstate is federally funded. What about major roads, though? I always assumed those were built by contractors paid by city and state taxes.

For a grip on this, you have to look at history. There were a few Federal and state sponsored turnpike's on the east coast, and federal interstates. But otherwise, roads are built by landowners, usually to comply with regulations to subdivide property for sale. For instance, you mentioned an HOA. HOAs are created as part of a subdivision. The developer bought the land, divided it, provisioned roads and utilities to each lot, then either sold lots to builders,or built himself. In WA, if the roads met county standards, the county would then take ownership, schedule maintenance, and establish Right of Way, bill utilities for it. We have a few regulations that work in conjunction to force this solution. The key being no more than 4 dwellings can be accessed by a noncompliant access road. If you want to build the 5th house onadriveway, you need to get a 60' wide access road past the first dwelling.

"Main roads" are not built as such. They started as roads that were then designated as arterials. Then they get widened. This is done by first.making the designation. Then, any time a homeowner tries to pull a permit for anything, they have to be in compliance. So, adding on the the garage, means giving the local government the front 15 feet of your front yard. Or adding a sidewalk along the front of your house. Whatever the city aspires to, and can sticks homeowner with the cost of. When enough lots have given up the 15' strip,eminent domain allows the government to take the last few pieces of property, widen the road,and the utilities will move as part of the hat process.

You can see this if you use Google earth, close enough to see property lines. The front property line is staggered where roads are expanding. If you look at many older neighborhoods, you can see how much closer the houses are to the main road. They didn't start like that, the road expanded into the front yards.

A side effect of my job, is every property division, road widening or regrading, from Seattle to Canada, used to cross my desk. Now it goes to my wife.

[bryan]

Why can't Vanguard give me my healthcare. ugh. (joke about Vanguard/BlackRock becoming more active players in the market)

That's another thing that concerns me. I want the medical profession to be one of the highest paying because I want it to attract the best and brightest as the saying goes. I worry about quality issues if medicine becomes a service industry. I wish it paid more than finance jobs and some tech jobs to draw more people to the field, particularly men (to avoid a velvet ghetto).

I think it is very possible to convince a crop of medical professionals to accept lower compensation. For many (most) medical professionals financial compensation is only one, relatively minor consideration when choosing this career pathway. However, it would require reduced costs associated with attaining degrees/certifications, but more importantly would require making the professions more tolerable on a day-to-day basis. Meaning less total hours worked, more reasonable schedules, and having lower quantity but higher quality patient interactions. The last would also likely help improve outcomes (reducing costs) through early detection and prevention. With the system as is, retention of the current crop requires higher and higher compensation simply to maintain baseline as burn out is rampant in virtually all medical fields.

Agreed with both of you. Maybe we can fix the problem by basically renaming nursing school to medical school and add a new school/credential for uber doctors? Someone get an economist onto this solution!

Part of the problem, unknown if it is mentioned elsewhere, seems to be the American Medical Association (AMA) trying to control the supply of doctors too much? I've heard people whining about it in the past...

i also believe that tort is a large factor in the decisions many providers make.

Maybe it's just the American in me, but I like the possibility of a person or group of persons suing over tort. Call me crazy, but the insurance companies already have good lawyers whereas a healthcare consumer does not. Who is the money behind tort reform? Of course there should be some large encumbrance of proof, like for suing police officers/departments/etc.


@Riggerjack, I think you will have to give some proof about the 99% roads thing.. after all the government usually owns/buys the land the major roads are built on? At least in the US.

[Riggerjack]

@Riggerjack, I think you will have to give some proof about the 99% roads thing.. after all the government usually owns/buys the land the major roads are built on? At least in the US.l

I can go as deep into this rabbit hole as you like, but a healthcare thread isn't the right place for it. I would be happy to talk about this in a separate thread.

[bryan]

I think it would educate some folks. I will read it. Just as a counter-example (maybe it fits into the 1%...) I saw an empty house lot for sale but it had no road attached. How to get the road? The city charges a tax when you buy such designated lots and they build the road..

[OTCW]

Subdivision roads are privately built. Developers get their money back when they sell the lots. Interstates are paid for with public moneys. Gas tax, wheel tax, vehicle registrations, property tax, ROW fees paid by utilities, telecoms, etc all pay for upkeep/widening of roads that are built to specs/standards. Private roads are usually not built to standard and things like condo fees and HOA fees pay for their upkeep.

I'm sure there are exceptions/gray areas/partenships, but I would say rds are well above 90% privately built. If going by miles I would say 99% is believable. If going by miles driven on, it would be lower by a bit. If going by cost, also lower. Any way you look at it though most roads are privately built.

<I'm a civil engineer. Roads are part of the world I work in. Not my specialty though/not claiming expertise, just more than general familiarity.>

Back to healthcare...as costs have skyrocketed (for lots of reasons), it is no wonder we spend all this effort on deciding who is going to pay for what. Get costs under control, and a shared solution gets a lot easier to construct IMO.