Post New

First, during the 2024 campaign Trump repeatedly promised to bring consumer prices way down beginning on “day one.” We’re now 11 months in, prices are still rising, and voters who believed him feel, with reason, that they were lied to. Last night Trump insisted that prices are, in fact, coming way down. Again, “Who you gonna believe, me or your lying eyes?” is a self-destructive political strategy.

Second, Trump would be in much better political shape right now if he had basically continued Biden’s policies, with only a few cosmetic changes. When he took office inflation was on a declining trajectory. Consumer sentiment was relatively favorable at the start of 2025. Americans were still angry about high prices, but the inflation surge of 2021-3 had happened on Biden’s watch and was receding into the past. My guess is that many voters would have accepted Trump’s claims that high prices were Democrats’ fault and given him the benefit of the doubt about the economy’s future if he had simply done nothing drastic and left policies mostly as they were.

Instead, he brought chaos: Massive and massively unpopular tariffs, DOGE disruptions, masked ICE agents grabbing people off the street, saber-rattling and war crimes in the Caribbean. Many swing voters, I believe, supported Trump out of nostalgia for the relative calm that prevailed before Covid struck. They didn’t think they were voting for nonstop political PTSD.

And there’s more to come. Health insurance costs are about to spike, because Republicans refuse to extend Biden-era subsidies. Inflation may pick up in the next few months as retailers, who have so far absorbed much of the cost of Trump’s tariffs, begin passing them on to consumers.

So the “affordability tour” is off to a disastrous start. And it won’t get better, because while Trump insists that the problem is you, it’s actually him. And he isn’t going to change. —Nobel-Prize-winning economist Paul Krugman

We’re now 11 months in, prices are still rising, and voters who believed him feel, with reason, that they were lied to.

====================


I just bought a dozen XL eggs at Kroger for $2.50. Gas here north of Houston is $2.33. My friend lives down in Houston and he reports gas is $2.13 in his neighborhood. Ammo is still too expensive.

I just bought a dozen XL eggs at Kroger for $2.50. Gas here north of Houston is $2.33. My friend lives down in Houston and he reports gas is $2.13 in his neighborhood. Ammo is still too expensive.

Exactly. Prices aren't rising the way that liberals claim they are...

...unless of course you live in a blue state, where insanely high taxes on energy (thanks to the Climate Change Cultists) drive gas prices through the roof. We pay almost double what you do here in Seattle.

And what the CCC'ers don't understand is that gasoline costs are literally an input to every. single. thing. that gets shipped around to and inside of a state. Which means that when gas prices go up...so do a lot of other things.

For the LINKSLINKSLINKS people who never provide links of their own:
https://gasprices.aaa.com/todays-state-averages/

Washington's average is $4.06; in Seattle it's more like $4.60+.

Interestingly, with the fed cutting rates that will actually drive to move prices up eventually (as it will spur more economic activity, which tends to be an inflation driver).

Telling people that they’re ignorant about how costs (food, healthcare, housing, transportation, etc) continue to increase is a wonderful strategy for Republicans.

Estimates of Americans living paycheck to paycheck vary from 25% to 67%. Just keep telling those people that they’ve been hoodwinked into believing that costs are raising faster than their income.

Brilliant move. Keep up the good work Republicans. It’s a winner!

So the “affordability tour” is off to a disastrous start.

Couple things: I am remembering the shambling “tours” of the last time he was in office. “Infrastructure week” was a running joke, it happened so many times without ever happening at all. I have been impressed at how effective the administration has been this go round on any variety of things (none to my liking, of course), but I think this “affordability tour” will be the first that goes up in flames, and publicly so.

And that’s because it’s the first measurable yardstick that people can actually see and compare, as opposed to “woke in schools” or “immigrants in your backyard” or whatever the other cause-du-jour has been to this point. People shop. They go to the grocery store every week and they know that prices haven’t gone down; indeed they know they’re going up.

All the “Democratic hoax” or “Joe Biden’s fault” rhetoric in the world isn’t going to play. This isn’t a “feelings” issue, this is cold hard cash, and it’s verifiable. (And just wait if ACA premiums balloon, while that won’t affect *everyone* as grocery prices do, it’s millions upon millions.)

So yeah, this is where Donnie’s lies are exposed for all to see, and all the blubbering and mouth-foaming in the world isn’t going to change that. ‘Bout time.

Sadly even when his supporters admit that the emperor has no clothes, some of them will still say he's the best dressed POTUS ever because they are in a cult. They will follow him to the end. Think about Jim Jones and Jonestown. For them the only choice is what flavor of "Kook"-aid they want to drink.

I just bought a dozen XL eggs at Kroger for $2.50. Gas here north of Houston is $2.33.

Congrats. Everyone else must be simply wrong or stupid, then. You should let more folks know that. Tell them Trump agrees with you.

Well, Trump is going to be president until January 20, 2028.

It's not about "following him to the bitter end" or whatever catchphrase you just used.

He's the President, and will be for another 3+ years.

Deal with it.

Speak for yourself, Mr. Fungus, maybe you are stupid?

My family's ACA health insurance is going up by 79% (for the same income level*) so that's nice.

Healthcare was my family's biggest expense in 2025. It won't lose the top spot in 2026.


(* I can mitigate *some* of the increased cost by staying under 400% FPL. That means taking on less work. 2026 could be the year I finally pull the plug.)

Think about Jim Jones and Jonestown.

And think about Joe Biden, worst President ever.
Democrats and the left blindly followed senile Joe.

one can see evidence here (and moreso xhitter,fakebook, etc...) that the gop distraction-from-affordability tour may work.

MAGA does not understand the cantillon efect, nor inflation. they will gladly repeat that 1 month the price of something went down due to a sporadic shift in supply and demand. and if its greasy fastfood promotion, that makes them go frothy!
but yet, trump was gonna make them rich, just like the first time! somehow they are not posting pics of all their new cars and vacation homes.

given the level of comprehension of the gop voter, i would say a massacre in the midterms has less to do with affordability and more to do with them unable to reinforce their core identity with trump (and they historically lose interest when he himself is not on the ticket).

LurkerMom: And think about Joe Biden, worst President ever. Democrats and the left blindly followed senile Joe.

Historians rank Biden 14th among presidents, rating him 62.66 on a scale of 100 for overall greatness.

Historians rank Dozy Don dead last, rating him 10.92, worse than James Buchanan, the second-worst rated president at 16.71.

Even republican historians rank Dozy Don worse than Biden: Trump ranked 41st and 43rd by Republicans and conservatives, respectively. Meanwhile, Biden was ranked 30th by both.

Maybe you're in a cult.


https://www.upi.com/Top_News/US/2024/02/19/preside...

If everyone reading (nay, all Americans) starts with the axiom that 100% of this presidency is about self-enrichment and revenge, it will make life a lot more manageable.

Stop replying to her, really. That's what she wants. Let the cultists bask in their spiral.

(* I can mitigate *some* of the increased cost by staying under 400% FPL. That means taking on less work. 2026 could be the year I finally pull the plug.)

I assume from your posts that you're an independent contractor but don't operate under your own LLC so you need to get insurance on the open market, is that correct?

As an aside on the ACA:

The math doesn't work out from either party. The GOP seems to be offering $1k-ish into your HSA, which pays for...about 1 month of Obamacare insurance. The democrats want to extend the existing subsidies for 3 years and take this as an acceptable solution.

How much are the subsidies, really? That's the missing piece of informaiton.

Also not being pointed out:

If COVID hadn't happened there would be not subsidies to extend. And everyone would be paying these exorbitant costs.

So how is the ACA in any way a success?

Historians rank Biden 14th among presidents, rating him 62.66 on a scale of 100 for overall greatness.

LOL at your left wing stupidity

“AI Overview
The American Political Science Association (APSA) and the broader political science field lean left, with studies showing a significant majority of professors and scholars identifying as liberal or left-leaning compared to the general public, though faculty lean more centrist than undergraduates, creating an ideological gap between professors and students, and a strong Democratic bias in donations and self-placement, reflecting a trend of increased leftward drift in academia over decades.”

Maybe you're in a cult.

Better than the democrats wandering around in the wilderness without a Leader, no direction, no plans, flat broke, no money, in debt, infighting, and more. All the dems and the left have in unison is to criticize and badmouth President Trump and in need for help for your/their Trump Derangement Syndrome.

commonone, Get help before your head explodes and you end up
in a mental institution.

Historians rank Biden 14th among presidents

14th at what? Watching Matlock reruns while drooling on himself? He's #1 going away in that category.

Oh..and an added note for you commonone,

“AI Overview
Yes, studies and data consistently show that political scientists and presidential historians lean left, with a significant majority identifying as liberal or Democratic, especially in fields like history, leading to biases where they often rank presidents who align with progressive values higher, notes The Daily Economy and Inside Higher Ed. This ideological skew, evident in professor demographics and presidential rankings, suggests political leanings influence scholarly evaluations, creating a perception of partisan bias in historical assessments, according to sources like F1000Research and JoeUSCinski.com.”

Stop it with your left wing nonsense commonone and face the reality
you suffer with TDS and reality.

What can't go on, won't go on.

The crisis point is being reached and "something will be done" (what, I don't know) before the 2026 mid terms.

The Democrats only need a few Republicans to come on board with a plan in the House, and maybe 10 or 12 in the Senate.

So the Democrats really need to focus on this, like they promised (but haven't).

Stop with the "norms" and "guardrails" and "democracy" and "pack the Supreme Court" and "transgender" and "Trump" this and that.

Stop with the encouraging riots against ICE. Who cares about Venezuela fishing boats? Stop with absolutely all of that Heather Cox Richardson/Jeff Tiedrich etc. nonsense. That's just campaign crap. Heather Cox Richardson and Jeff Tiedrich and all the rest are not responsible for actually getting anything done.

You drown yourselves out on anything important that you might actually be able to do anything about.

You guys got 1 job and 1 job only--build a bipartisan coalition to fix health care/health insurance.

It won't be easy so stop putzing around. You guys claim to be way smarter than MAGA morons--now is the time to prove it.

Don't worry about Trump. Trump will sign off on anything that looks popular to the American public.

(Let the ranting insults, abdication of responsibility, and fecklessness begin!)

It will also make life a lot more delusional.

Dope1,

ACA was designed to fail but was budgeted/structured in such a way that the 10 year projection of costs would pass muster with the CBO. The plan was designed so costs would explode after about 10 years but by then ACA would be so interwoven into the health care and health insurance system that the transition to a single-payer plan would be more or less inevitable.

That seems to be what is happening right now, since we are just past 10 years since ACA started in 2014.

The plan is chock full of crazy counterproductive incentives. AdrianC gives a great example--he is hugely incentivized to lower his business productivity to remain within the 400% FPL "cliff" so as to be able to receive subsidies.

There are others but this one is obvious.

"We punish you for being too productive."

That isn't good for anyone. Multiply by millions of people and you get what you get.

OMG historians!!!

Unless it's Harri Selden IDGAF.

Yeah I always perceived Biden as more of a Millard Fillmore type, a machine politician type hack who was basically just filling up space, and for whom the office of the President didn't somehow magically endow him with statesman like superpowers.

I guess maybe if Biden had just nuked a few hundred thousand non-white skinned people on his way up the door, then at least he'd have an opportunity in the future to be "reassessed" by "historians" and be declared one of the "great men of history."

LurkerMom: Yes, studies and data consistently show that political scientists and presidential historians lean left, with a significant majority identifying as liberal or Democratic, especially in fields like history...

That's why I included this data in my response: Even republican historians rank Dozy Don worse than Biden: Trump ranked 41st and 43rd by Republicans and conservatives, respectively. Meanwhile, Biden was ranked 30th by both.

Even republican and conservative historians recognize Dozy Don is a clusterfcuk for America and place Biden in the middle of the pack.

I assume from your posts that you're an independent contractor but don't operate under your own LLC so you need to get insurance on the open market, is that correct?

I am an independent contractor, do operate under my own LLC, and need to get insurance on the open market.

As far as I know having an LLC does not get me into any group coverage, but I'm all ears.

ACA was designed to fail but was budgeted/structured in such a way that the 10 year projection of costs would pass muster with the CBO. The plan was designed so costs would explode after about 10 years but by then ACA would be so interwoven into the health care and health insurance system that the transition to a single-payer plan would be more or less inevitable.

That seems to be what is happening right now, since we are just past 10 years since ACA started in 2014.

Yup. The democrats have always wanted government control of healthcare, and now they're going to use this to push for single payer even though they know we'd have to massively increase taxes and spending for it.

But they don't care. If this is something they can win elections on, they don't care about how much damage they do.

I am an independent contractor, do operate under my own LLC, and need to get insurance on the open market.

As far as I know having an LLC does not get me into any group coverage, but I'm all ears.

Thanks for the answer. I had thought there was some way for business owners to incorporate themselves and get access to small business health care collectives:

https://smallbusiness.uhc.com/?cid=utm_source=EI_A...

Healthcare.gov says
https://www.healthcare.gov/small-businesses/#:~:te...

The Small Business Health Care Tax Credit
You may qualify for the Small Business Health Care Tax Credit that could be worth up to 50% of the costs you pay for your employees' premiums (35% for non-profit employers).
You may qualify for savings
Enrolling in a Small Business Health Options Program (SHOP) plan is generally the only way for a small business or non-profit to claim the Small Business Health Care Tax Credit. To qualify for the tax credit, all of the following must apply:
You have fewer than 25 full-time equivalent (FTE) employees
Your average employee salary is about $65,000 per year or less
You pay at least 50% of your full-time employees' premium costs
You offer SHOP coverage to all of your full-time employees. (You don't have to offer it to dependents or employees working fewer than 30 hours per week to qualify for the tax credit.)

Are you in this bucket? (If you don't mind answering)

Yup. The democrats have always wanted government control of healthcare, and now they're going to use this to push for single payer even though they know we'd have to massively increase taxes and spending for it.

My only concern is that the system work for the people who pay for it. Show me a system that does that, rather than benefit the CEOs and the Pols they buy.

Steve

If everyone reading (nay, all Americans) starts with the axiom that 100% of this presidency is about self-enrichment and revenge, it will make life a lot more manageable.

I'd argue that you've already got nearly 100% agreement with that.

The problem is you statement isn't specific enough. Whose self-enrichment and revenge?

In an oversimplification of the math, half the country thinks that it's their own self-enrichment and revenge, and the other half thinks its about Trump's self-enrichment and revenge.

--Peter

That's why I included this data in my response: Even republican historians rank Dozy Don worse than Biden: Trump ranked 41st and 43rd by Republicans and conservatives, respectively. Meanwhile, Biden was ranked 30th by both.

The article you are quoting from is dated “U.S. NEWS FEB. 19, 2024 / 10:53 AM”, a year before Biden completed his term as president.

President Trump began his second term in the White House on January 20, 2025, not even serving a full year yet.

Let’s remember the democratic party kicked Joe Biden to the curb and Kamala was a sorry second choice.
So your left wing old news doesn’t amount to a hill of beans.

single payer even though they know we'd have to massively increase taxes and spending for it.

The increased taxes and spending are only half the story. The other half of the story is that all the money spent on health insurance premiums would stop.

As a rough cut, these would offset each other, so there would be no net increase in costs or spending, it would simply get shuffled around. The money spent on health insurance would instead become a tax, and the insurance co spending on health care services would become government spending on health services.

In reality, there should be some overall savings, as insurance co profits come out of premiums. And there might be some minor savings elsewhere in administrative costs.

--Peter

With tens of millions of Americans about to get hammered by doubled insurance premiums....

That's tens of millions of pissed-off Americans who may have reached the stage of enlightenment that views single payer in a more positive light.

It doesn't take comprehensive studies on health care costs to sway the public.

It merely takes what it takes, and that point is fast approaching.

As a rough cut, these would offset each other, so there would be no net increase in costs or spending, it would simply get shuffled around. The money spent on health insurance would instead become a tax, and the insurance co spending on health care services would become government spending on health services.

In reality, there should be some overall savings, as insurance co profits come out of premiums. And there might be some minor savings elsewhere in administrative costs.


Right now, most Americans are ensured by their employers. When the employers stop paying the premiums, they're not going to suddenly increase the salaries of their workers by x% to offset the savings. They'll just dump the benefits.

Let's look at some numbers. California floated Assembly Bill 1400 (California Guaranteed Health Care for All Act) in 2022. It carried a price tag of $400 billion.
https://legalclarity.org/californias-single-payer-...

California had ~39 million people in it in 2022. That works out to $10,256 per person.

Later estimates on another form of the legislation pegged the cost at more like $500 billion:
https://trackbill.com/s3/bills/CA/2023/AB/2200/ana...

The analysis estimated that with no changes, total health care spending would be $517 billion in
2022. The following are example scenarios and associated total spending estimates:
1) No cost sharing, direct payments to providers, and no LTSS expansion: $501 billion ($16
billion savings over status quo).
2) Income-related cost sharing, no LTSS expansion: $482 billion ($35 billion savings compared
to status quo).
3) Income-related cost sharing, LTSS expansion: $508 billion ($9 billion savings compared to
status quo).
4) Including an intermediary increases estimated spending for the above scenarios by $4 billion
to $5 billion.

At $500 billion and with CA's population of 39.4M, that's $12,690 per person and a national commitment of $4.3 trillion.

Single payer health plans by themselves won't work with health care service priced as it is today; more reforms would be needed.

It merely takes what it takes, and that point is fast approaching.

Sure. Your party is counting on Obamacare crashing the current system and bringing it down. That was by design as many of us pointed out years ago.

The problem is...the democrats have zero clue what to replace it with.

gop math :
[reservoir of stupidity] >> [capability for independent attribution] = greater american greatness

It doesn't take comprehensive studies on health care costs to sway the public.

It merely takes what it takes, and that point is fast approaching.

And what's the counter? ACA was designed by the Dems to blow up at this point. They've had what? Some 15 to 20 years to fix Obamacare, and can only talk about concepts of a plan? The Republicans have no plan, just a blame game. So here we are. The Republicans need to kick their representatives butts and get them working on manageable health care.

AI Overview

Are you letting AI do your thinking for you LM? :)

President Trump began his second term in the White House on January 20, 2025, not even serving a full year yet.

Yes, we all agree that he is making significant progress on the way to becoming the worst of the worst Presidents that have ever been. We grant you that.

"The Republicans need to kick their representatives butts and get them working on manageable health care."

But they never do. I listen to GOP candidates during election runup, for years, they
just spout what amounts to gibberish.
"I'm the Family Values Cadidate": Who is the anti-family values candidate ??

"I'm tough on Crime Candidate": As they ley White Collar Criminals and Jan 6th
rampagers scoot off consequence free.

" National Debt is unsustainable": As they run up more national debt than
Dems, time after time after time.

GOP has had how long to come up with a healthcare plan ??
They have raged about ACA for over a decade, but still no alternative coming
from them. Latest is $1,000 into an HSA ?? B.F.D. that is, it's actually
insulting to any person with a brain.

All the GOP will do leading up to the '26 midterms is culture war stuff. They
have literally nothing. And with Trump, the best thing the Country can hope for
is that he does nothing, his actual economics policies are the biggest disaster
bearing down on Americans. But hey, MAGA is a catchy slogan, that supersedes
anything like actual constructive policies.

I consider myself middle of the road, I voted for a couple of Republicans in last
election. But any MAGA candidate is a no go, I want to see MAGA fade away into the
trash bin, before they take the whole Country with it.

No, the Democrats need to kick butt, not the Republicans.

Obamacare broke health care or certainly greatly accelerated the crisis that has been reached.

You broke it--you fix it.

“I had thought there was some way for business owners to incorporate themselves and get access to small business health care collectives”

Only if the business has full time employees who are not the owner and spouse. I got out of that a long time ago. Use other independents when I need help, which isn’t often.

https://www.healthcare.gov/small-businesses/learn-...

“Health coverage for self-employed

Generally, your business won't qualify for group coverage if you:
Run your own business and have no employees
Are self-employed with no employees
Work as a freelancer or consultant
Instead, you can buy Marketplace health coverage for individuals and families. Learn more about self-employment coverage.”

"The Republicans need to kick their representatives butts and get them working on manageable health care."

But they never do. I listen to GOP candidates during election runup, for years, they
just spout what amounts to gibberish.
"I'm the Family Values Cadidate": Who is the anti-family values candidate ??

"I'm tough on Crime Candidate": As they ley White Collar Criminals and Jan 6th
rampagers scoot off consequence free.

" National Debt is unsustainable": As they run up more national debt than
Dems, time after time after time.

“If you can convince the lowest white man he's better than the best colored man, he won't notice you're picking his pocket. Hell, give him somebody to look down on, and he'll empty his pockets for you.”
― Lyndon B. Johnson

The truth is we're gullible, dumb as hell, critical, very intelligent, and easily manipulated. We vote stupidly sometimes and we vote well too. Look at the LBJ quote and apply it to Trump.

Take health care, even if you go to Medicare for all, you get a three tier system. The top 5% can easily pay for any health care they need.

So we have this extreme focus on immigrants and illegals and we're letting the enhanced subsidies expire.

Take health care, even if you go to Medicare for all, you get a three tier system. The top 5% can easily pay for any health care they need.

How three tiers? I see "Medicare for all", because an MRI for Musk would cost the same as an MRI for me. If the top 5% don't want to rub elbows with we Proles, then they can have their private doctors and private hospitals, which will be reimbursed by Medicare at the same rate as the public facilities are, and the extra hand-holding and amenities, are billed to supplemental insurance the top 5%, or more probably, the company they retired from, pays for.

Steve

How three tiers? I see "Medicare for all",


If you look around the world where it exists, you'll find at least a two tier system in countries, that's why. You may disagree as to how many tiers there are, but there's at least two tiers. From the net:

"While Canada's system is officially single-payer for medically necessary care, critics often describe it as a de facto four-tiered system, encompassing: 1) Publicly funded basic care (family doctors, hospitals), 2) Private insurance for uncovered services (dental, vision), 3) Private for-profit care (limited private clinics), and 4) A tier for those with no access to family doctors or resources."

Ask the net sifter how many tiers that countries health system really has and you may get a different answer depending no how you ask it, but it's there, and we should recognize it. I've talked about it. The French have a hybrid system. Are you on Medicare? It actually doesn't pay for a small part, so people get Medigap and Medicare Advantage. But some people rely on medicare for everything.

We've talked about the Canadians coming across the border for clinical treatment, etc. It's there, you've read it here.

We've talked about the Canadians coming across the border for clinical treatment, etc. It's there, you've read it here.

The opponents of "big gummit health care" love to burble about "all the Canadians coming to the US for treatment". Seems a lot of that is non-critical care, for people who just don't feel like waiting their turn. You may recall when Tim had a real problem, with a duff gall bladder. He was in the hospital without delay, the nasty bladder yanked in the middle of the night, and turned loose, to his delight. A former coworker of mine used the Ontario system. He questioned the sanity of anyone who would prefer the US system. Tim did say the public system in Germany was not too good, and people would opt for the private system, if they had the means.

How many "tiers" does the US system have? Medicare. privatized Medicare, VA Medical. Federal Medicaid. 50 state Medicaid systems, plus all the private insurance companies (the net sifter says over 900) I keep wondering how much of the $5T spent on health care in the US each year is burned up by redundant administrative overhead?

Recall, "Plan Steve" finances the single payer system with a tax, like a VAT, so that people are not dependent on the goodwill of an employer to have insurance they can afford. Too many people would like to work full time, but the employer restricts them to less than 40 hours/week, so they don't qualify for "full time" benefits, like medical. I have told the story before, about a guy at the pump seal company, after I left, who developed cancer. He had to keep working, no matter how sick he was, because, if he quit, he would lose his medical insurance and be bankrupted by the bills. Dave ended up working until a few days before he died. To me, making a guy that sick keep working is beyond sociopathic, bordering on sadistic.

The number of people employed part time for economic reasons was 5.5 million in November, an
increase of 909,000 from September. These individuals would have preferred full-time employment but
were working part time because their hours had been reduced or they were unable to find full-time jobs.
(See table A-8.)

https://www.bls.gov/news.release/pdf/empsit.pdf

Steve

The opponents of "big gummit health care" love to burble about "all the Canadians coming to the US for treatment". Seems a lot of that is non-critical care, for people who just don't feel like waiting their turn. You may recall when Tim had a real problem, with a duff gall bladder.

Listen, people can talk about some Canadians coming across the border without it being a big criticism of the system. Recognizing what does happen doesn't have to be derision. I'm not knocking it at all. Just in case you think I am knocking it. :) I think they do better than we do.

One of the bigger questions in the USA is how do we deliver good health care to people in rural areas? remote areas? We can send RNs,PAs around in medical vans on schedules, we can license Veterinarians to treat humans in areas, we can recognize the problem and make attempts - but the money is against us - what you call JCs.

But many JCs they want a system that allows them to extract the best profit. Profit, and how much they acquire, is what motivates them. I know you know this. We need the mercenary part out of the health system. We don't need Elmo crunching down on a system till something breaks, I mean for God's sake, it's people's health and we need people who can balance a system with Health being a major value.

We have to combat our own bigotry which works against us. Lotsa people are gonna think lazy niggers, lazy Indians, lazy latinos, thieving Somalians now, free money!, communism!, socialism!, the anti-Christ!, Jesus commands you!, and pollies in the pockets of JCs are going to use all that against it - AND it has worked well so far.

We need the mercenary part out of the health system.

Problem is, it is so ingrained, and the "JCs" have the money to buy the key people to keep it that way.

The rural hospitals could be the opening we need. As you said, the "JCs" want to close everything they aren't making a profit on. Then what? They close the profit making operations that make the least profit, to raise their average. That makes something else the least profitable, so they close that too. Wash, rinse, repeat, until the only hospitals left are a handful in Billionaire communities, where everyone has company paid, gold plated, coverage.

So the national health plan picks up everything the "JCs" abandon. Start with the rural hospitals and clinics. The hard thing is getting the tax approved, with a phased in approach to taking over the markets the "JCs" don't want, because relatively few will benefit, initially. People have gotten it into their heads that everything the government does is supposed to be free.

The really hard part will be making the insurance companies not want to cover Proles. Maybe cap ACA premiums at what the same coverage would cost from Medicare. BUT, offer the option of buying into Medicare. The the "JCs" don't want any part of covering Proles, so the Proles all flock to Medicare.

Or, give employers the option of buying medical for their employees from Medicare. If Medicare is lower cost, the "JCs" own greed will make Medicare their choice, no matter how many rounds of golf they play with the insurance company salesman.

There's a thought: merge VA Medical and Medicare, because the VA has hospital management experience. Take over the abandoned rural hospitals, and leverage the VA's expertise to run them. I have heard "experts" complain about the VA medical system, but the net sifter says VA medical is more cost efficient, while providing equal or better quality care. Who to believe?

Steve

The really hard part will be making the insurance companies not want to cover Proles.

That's not the hard part. It's easy to ban private insurance companies, if that's what you want to do. If not, you can easily drive them out of business by offering the public insurance at a premium that's lower than they can afford to match. That's why we still have (mostly) public schools in this country - because the schools have a near-zero marginal cost to enrollees, it's difficult for private competitors to take over.

The hard part is paying for it. In all the states that have made a serious run at a state-wide single-payer system, most notably Vermont, that's where they've foundered. They can't find a way to make the funding work.

That's not the hard part. It's easy to ban private insurance companies, if that's what you want to do.

The for-profit insurance companies have their place in "Plan Steve": providing coverage for the private facilities with extra hand-holding and amenities, for the people with really big stacks of money to pay for frills.

The hard part is paying for it.

That's why "Plan Steve" has a tax, like a VAT.

All this has been worked out in other countries, over the last 80 years. All we need to do is adopt the best practices.

I don't know why the UK national health program is such a train wreck, but I do note that country had several years of Tory rule, so that may explain the financial distress of the government.

Steve

That's why "Plan Steve" has a tax, like a VAT.

All this has been worked out in other countries, over the last 80 years. All we need to do is adopt the best practices.

We can't. Path dependence exists. Our entire healthcare system has been built around the current payment structure, and there's no way to get from our system to their system without a lot of people being made worse off than they are now. Which represents in insuperable obstacle to making the change.

Again, there's a reason why Vermont (and others) failed to make this change. It's not because of nefarious JC's or Powers that Be - there was massive political will to get this done in those states. It's because they couldn't make the dollars work.

It's because they couldn't make the dollars work.

Or, nefarious "JCs" who don't want it to work? :) I doubt that a state's attempt happened in a vacuum without "input" from interested parties elsewhere in the country that did not want the status quo upset.

Net sifter output on "is the French national health system solvent?"

France's national health system(PUMA) is solvent due to diverse funding (payroll/income taxes, VAT) and strong government financial management, but faces ongoing pressures from an aging population, rising chronic diseases (like obesity/alcoholism), and the high costs of care, leading to continuous reforms aimed at cost control and shifting focus towards prevention, though it remains highly regarded for quality and universal access.

Key Factors for Solvency & Challenges:

Diverse Funding: It's not just taxes; it's payroll contributions, national income tax, and specific levies on industries/products.

Strong Oversight: The government actively manages expenditure through targets and monitoring to ensure financial stability.

Supplemental Insurance: 95% of French citizens have private top-up insurance, reducing the burden on the public system for out-of-pocket costs.

Aging Population: A growing elderly population with more chronic conditions increases demand and costs.

Prevention Gap: Poor lifestyle habits (smoking, alcohol, inactivity) lead to higher chronic disease rates, stressing the system.

Hospital-Centric Model: A focus on cure over prevention, with fragmented primary care, adds to inefficiencies.

Overall Picture: While the system is robust and delivers high-quality care with excellent outcomes (like high life expectancy), it constantly balances its universal coverage mandate with the need to control rising costs, especially with demographic shifts. Reforms aim to improve efficiency, but financial sustainability remains a key focus for French policymakers

Steve

Or, nefarious "JCs" who don't want it to work? :) I doubt that a state's attempt happened in a vacuum without "input" from interested parties elsewhere in the country that did not want the status quo upset.

Perhaps, but that doesn't seem to be the main reason. The then-governor was hugely invested in it, and had gotten strong support from the legislature, and it was immensely popular. But they couldn't make the money work:

The financing model Shumlin rejected would have paid for a top-shelf benefits package, one on par with the plan enjoyed by Vermont state employees. Shumlin said the state could have reduced pressure on the financing plan by reducing the quality of the benefits package. But he said Vermonters by and large have high-quality plans in the current system.

Offering a lower-value plan, he said, would have resulted in too many residents paying more money for worse coverage in a publicly financed system.

Shumlin says he doesn’t regret promising his supporters a single-payer system that he’s now learned he won’t be able to deliver.

https://www.vermontpublic.org/vpr-news/2014-12-17/...

This is the main problem for single-payer health care financing. The money. It's very expensive to give everyone top-flight insurance. But in the current system, a large number of folks (a minority but a sizable minority) have very good health care plans for which they don't pay very high premiums. The "Cadillac" plans, mostly held by unionized workers both private and public. If you give everyone a Cadillac plan - or even a plan as good as a standard large group health plan - the system can't work without very large tax increases. If you don't give everyone a Cadillac plan, then a large number of people end up with worse coverage (and probably paying more money for it). A large enough number to be fatal.

Put another way, it's a variant of the Wobegone effect. Half the voters in your state have insurance that's better than average. If you set up a single-payer system that provides better than average coverage, you can't afford it. But if it doesn't provide better than average coverage, then half your voters will see their quality of coverage get worse under your new single-payer system. And in all likelihood, it's not "average" that's the political killer - whoever's got the top 20% quality health coverage in the state is probably where you need to be, because if you make 20% of your voters' health insurance worth, it will kill the proposal.

It's not the JC's. Or rather, it's not just the JC's. You can't make the switch without making a large number of ordinary voters worse off, because the money just can't work out. It's easy to blame the JC's, because of course there are some JC's who are against single-payer health care. But even in states where the political decision is made to blow off those JC's, you still can't square the circle and give people insurance that's above current average and find a way to pay for it.

If you give everyone a Cadillac plan - or even a plan as good as a standard large group health plan - the system can't work without very large tax increases.

Moving money from one pocket to another pocket: those with employer paid/partially paid insurance, would not be paying premiums for private baseline insurance, nor would their employer. If the French model was adopted the money paid by the employer would be paid to the national health plan, instead of to the private insurance company. Unionized Proles with better than average coverage, could pay for private insurance to make up the difference between their high tier coverage, and the government baseline coverage.

Keep in mind, estimates have put the cost/year of a US single payer system at $2.4-3T. Presently, USians are paying nearly $5T/year for health care. If all the money spent on health care now, was returned to the government, we could have a universal single payer system *and* the annual Federal deficit would vanish, due to the money saved.

This is not difficult. It is only made difficult by the special interests that want to keep the status quo.

Steve

Moving money from one pocket to another pocket: those with employer paid/partially paid insurance, would not be paying premiums for private baseline insurance, nor would their employer.

It's not moving money from one pocket to the other. You need more money. The money has to cover: i) all the people who were previously uninsured; ii) all the people who were previously underinsured; and iii) all the people who previously had plans that were less than the Cadillac plan. And a big segment of the workforce pays substantially less for their health care coverage than the majority - unionized and public sector plans are typically far more generous and have lower employee contributions than the typical plan.

The money doesn't work out for too many people.

The money doesn't work out for too many people.

$3T<$5T

Steve

$3T<$5T

Only if you reduce health care expenditures by $2 trillion, down to 60% of current levels. But that's what I was talking about in terms of path dependency. The amount of economic damage you would inflict on virtually everyone who is employed in the health care industry would be massive. There are far too many people who have structured their lives assuming that providing health care services would pay $X for you to be able to come in and decree that they will now be paid only 60% of $X.

You can put the pain on the taxpayers, or you can put the pain on every doctor and nurse and lab tech and orderly and clinician and medical administrative aide and....well you get the point. TANSTAAFL.

Vermont didn't want any of its voters to pay more money for worse insurance, and it couldn't make all their medical providers cut their price of services nearly in half. So it couldn't make the money work.

The same is true of the country at large. Not because of JC's. But because something like 12% of all U.S. workers are in the health care sector.

5% of the population uses 50% of health care services and dollars.

The top 1% of the population uses 21% of health care services and dollars.

The only way to "save health care" is to drastically ration the amounts of dollars and services being expended on the top 1% and 5% of users.

Fat shaming needs to come back into vogue, too.

As well as shaming of people who do dangerous things in general.

The amount of economic damage you would inflict on virtually everyone who is employed in the health care industry would be massive.

Hang on a sec...(cleaning out ears)...are you saying we *need* to provide employment for legions of redundant paper shufflers, who do nothing productive, at the expense of everyone else? /sarcasm I heard an argument like this some 60 years ago, when the railroad engineers union opposed the elimination of coal stokers, on diesel locomotives. The stokers were eliminated anyway, and, somehow, the national economy did not collapse. /more sarcasm

Some radical named Tom wrote about this a while back.

He has erected a multitude of New Offices, and sent hither swarms of Officers to harrass our people, and eat out their substance.

https://billofrightsinstitute.org/primary-sources/...

Are the insurance companies the ultimate welfare queens? Is that the best use of the money the rest of us earn by productive work?

Steve

Hang on a sec...(cleaning out ears)...are you saying we *need* to provide employment for legions of redundant paper shufflers, who do nothing productive, at the expense of everyone else?

No, because I'm not talking about redundant paper shufflers. I'm talking about the people who actually provide the medical services. Nurses and orderlies and lab techs and all the people who actually do the work in the health care field.

Insurance companies - or in this conversation "redundant paper shufflers" - serve the same purpose for advocates of a single-payer health care system as "waste, fraud, and abuse" does for conservatives who want to slash taxes. It's a magical - and mythical - pot of money that they posit so that they can argue for what they want without having to confront any trade-offs. For conservatives, the magic WFA money pot lets them argue that they can get huge amounts of tax cuts without having to reduce government services. Because if their tax cuts actually reduce government services, there would be a political backlash. So "waste, fraud, and abuse" let them have both the tax cuts and government programs.

For single-payer advocates, insurance companies (or paper shufflers or some other needless bureaucrats) fill the same role. They let advocates imagine that there's a way to dramatically cut health care spending without reducing the compensation to people or institutions they care about. All those hard-working nurses and orderlies and lab techs I mentioned, many of whom are union members in the SEIU holding solid middle-class jobs. If you reduce health care spending by 60%, then all those people have to get paid less. Or some of them have to get fired when you reimburse the hospitals or clinics they work at 60% less for all their treatments. There isn't a magic ball of money that's just being 'wasted' on things or people no one cares about that you can tap into. The money goes for people working in the health care sector to have solid well-paying and often middle-class jobs doing important work to help people.

That's what Vermont faced. There wasn't enough money to: i) give everyone a top-flight health care plan; ii) set taxes at a level that it was just taking money out of one pocket into another; and iii) not slash health care compensation to ordinary people working in the sector. You can't have all three. And the voters will never support abandoning any one of those three. Especially since they've been told over and over again that there's this magic ball of money (called "insurance skim" or whatever) that obviates the need for hard choices. Since there's no magic ball of money, and no support for the steps that have to be taken without the magic ball of money, there's no single-payer health care. And everyone gets to just blame "JC's," rather than face the real problem....

albaby1,

That's an interesting and informative take. IOW this is a really really complex issue and can't be solved by easy pat answers. It involves many different aspects and dimensions of our society and economy.

That's why I think currently the politician who is making the most sense about what to do between now and December 31 is John Fetterman.

Because there isn't really enough time to figure out a long term solution between now and year end, he advocates extending the current enhanced ACA benefits at least through the end of 2026, but even for two or three more years if there can be bi-partisan support for it.

This obviously makes the most sense, right now. This will at least maintain the status quo and give the players more time to actually work out a longer-term approach.

This is probably why Fetterman is a pariah in the Democrat party and probably won't run again.

He makes too much sense.

No, because I'm not talking about redundant paper shufflers. I'm talking about the people who actually provide the medical services. Nurses and orderlies and lab techs and all the people who actually do the work in the health care field.

According to the net sifter, it seems French nurses are paid slightly less than in the US, and French doctors are paid significantly less. France has slightly more doctors per capita than the US, but fewer nurses.

Yet, the French system provides better outcomes for it's citizens, at lower cost.

What should the objective be? Higher staffing? Higher pay for professionals? Higher standard of patient care, at lower cost?

Steve

What should the objective be? Higher staffing? Higher pay for professionals? Higher standard of patient care, at lower cost?

There is no right answer. All of those people are stakeholders in the health care system. We tend to be solicitous of the interests of workers, even when squeezing those workers would have benefits for taxpayers (which is why we have unions for public sector jobs).

But regardless of the "should" questions, there remains the "is" question. Health care costs are higher in this country because we pay people more to provide health care services to people than most other countries do. There is no way to change that without paying people less to provide health care services than we do today.

So if your plan for transitioning to single-payer depends on deep cuts to the amount of money we pay for health care spending, you have to account for the fact that there are tons and tons of people on the other side of that. Ordinary people, hard-working people, people like doctors and nurses and orderlies and whomever that are sympathetic in any political context. Roughly 12% of the workforce is in the healthcare sector, so slashing that sector by 60% is going to affect a lot of people. You'd have to do what virtually other single-payer country does - set a price list for services and squeeeeeeeeeeeze the providers as much as possible.

"Should" we do that? Don't know. Doesn't matter, in this context. This is an "is" question. We do pay a ton more for health care than other countries. So if we want the single-payer system that other countries have, we either have to: i) stop doing that; or ii) pay a shirt-ton more for health care than we do now. Both are political poison. Which is why we don't ever switch to single-payer systems, even in states that really really really want to.

And everyone gets to just blame "JC's," rather than face the real problem....

What is the real problem(s)?

Central California is facing a dire shortage of primary care physicians.
Many people blame a system that reimburses physicians/medical facilities in rural areas at a lower rate for medicare/medical services.

What if a POTUS were to declare the shortage of healthcare personnel a national emergency and fund medical schools, such that healthcare workers could afford to practice in rural regions with lower pay? The loans a young doctor/nurse shoulders is crippling.

What is the real problem(s)?

What is the real problem(s)?

The real problem is the triad I mentioned above. To be politically palatable, a conversion to single-payer has to:

1) Give nearly everyone access to above-average health care coverage (or else the people whose coverage gets worse will be pissed); and
2) Keep provider compensation more or less at current levels (or else the millions and millions of workers in the health care industry will be pissed); but
3) Not make people pay more for health care in taxes or premiums than they do already (or else they will be pissed that they're paying more).

That's the problem that has to be solved in order to make the switch. It's not a problem with the current system (of which there are many) or a problem with single-payer (of which there are still some). It's the barrier to making the transition. There actually isn't a way to deliver all three things. But because you have to break one of those three things, it's politically impossible to get it done.

It's more satisfying to blame some group of unpopular entities (insurance companies or 'big pharma' or whomever). But the reality is that if you want to reduce the amount we pay for health care, you have to reduce the amount we pay for health care - and we don't spend enough on "wasteful" things to do it just by cutting waste.

Roughly 12% of the workforce is in the healthcare sector,

from the net sifter: Workforce Share: Around 5.3% of the French workforce is in healthcare.

Less than half the staff, but they deliver better outcomes. It is anecdotal, but I have read of doctors in private practice, in the US, crying a river, about the amount of staff they need, to handle insurance company paperwork. There used to be a Brit ex-pat, living in France, on the Fool. He talked about how France had wrung administrative overhead out of the system. When the doc was done with him, the receptionist would swipe his national health card, type in the codes for what the doc did, and payment would be in the doc's bank account, before he was out the door.

Ordinary people, hard-working people, people like doctors and nurses and orderlies and whomever that are sympathetic in any political context.

That is what "JCs" say, when they want a government handout "bail the company out of the bad decisions we in management made, or all these Proles will be out of work". Is the US healthcare system supposed to, primarily, be a "make work" program?

I am epically stubborn, but, how has the rest of the "first world" delivered better outcomes, at lower cost, than the US?

Steve

What if a POTUS were to declare the shortage of healthcare personnel a national emergency and fund medical schools, such that healthcare workers could afford to practice in rural regions with lower pay? The loans a young doctor/nurse shoulders is crippling.

The current USian regime seems to be going in the opposite direction. Certain professions qualify for a much higher limit on student loans. Recently, the regime decreed nurses no longer qualify for that higher limit.

According to the net sifter, the typical newly graduated MD in the US has about a quarter million in student load debt.

From the net sifter: French M.D.s generally have significantly lower or even no education debt at graduation compared to their U.S. counterparts because medical school in France is heavily subsidized by the state, with low tuition fees; most debt incurred is often for living expenses or pre-med studies, not the medical degree itself, which is more akin to a €500-$2,000 annual fee rather than the $200,000+ average in the US

Would doctors and nurses be willing to take a pay cut, in exchange for having their student loans wiped out, or obtaining that education at little to no cost?

Steve

you have to reduce the amount we pay for health care - and we don't spend enough on "wasteful" things to do it just by cutting waste.

Wow. Somebody on the board has been saying exactly this for years!

I am epically stubborn, but, how has the rest of the "first world" delivered better outcomes, at lower cost, than the US?

They never let it build up.

This is an example of path dependence. It's very possible to limit your health care sector to half the size of that of the U.S. Many countries have done it. But once you let your health care sector build to the size of that of the U.S., it becomes nearly impossible to undo that. There are just too many stakeholders that would lose too much for you to get sufficient political cover to claw it back.

Would doctors and nurses be willing to take a pay cut, in exchange for having their student loans wiped out, or obtaining that education at little to no cost?

While I've enjoyed a week in Sun Valley at one of 4 homes belonging to a Bay Area heart surgeon, it was hard to not think about 'the nut' he has to meet to keep them all in perfect year-round condition.

A home in the Bay Area, a Palm Desert golf home, a Montana ski lodge, and the Sun Valley lodge.... and a 9 passenger airplane to shuttle his family and friends between them.

Attorney's fees are mind boggling as well. That guys like Trump can use the cost of litigation to beat/cheat/defeat people who cannot afford a protracted lawsuit is a real abuse of the only channel people have for seeking justice.

The USA has problems it cannot afford to resolve because the people with the money can afford to block solutions.

The USA has problems it cannot afford to resolve because the people with
the money can afford to block solutions.

We have been hoisted by our own Constitutional petard. A corrupt Supreme Court is most likely the final nail in the coffin.

Every morning, reading the news is equivalent to doom scrolling.

Associate POTUS Stephen Miller has banned people from 39 non-white nations, but not a single white nation.

Associate POTUS Hegseth is murdering civilians in boats and hijacking tankers.

And all the CiC can say is "I don't know him - her - anything about it - ask so and so - he/she is doing a great job."

"Net sifter."

O.K.

That's some fine critical analysis of an issue.

albaby1,

Do you know if these other countries have a similar tort system to the United States?

Are European health care professionals protected from liability for negligence, and if so, under what circumstances?

Same thing with injuries from car accidents and so forth.

I'm wondering if all the lefties who complain that our medical system costs are too high would even be a little bit interested in some version of "tort reform."

I am epically stubborn, but, how has the rest of the "first world" delivered better outcomes, at lower cost, than the US?

They never let it build up.

This is an example of path dependence. It's very possible to limit your health care sector to half the size of that of the U.S. Many countries have done it. But once you let your health care sector build to the size of that of the U.S., it becomes nearly impossible to undo that. There are just too many stakeholders that would lose too much for you to get sufficient political cover to claw it back.

And this is what I refer too when I say, "You can't get there from here." We need to go back to when I was 16, when my father, influenced by the AMA, was bashing socialized medicine, and start anew.

The USA has problems it cannot afford to resolve because the people with the money can afford to block solutions.

That may be true in a lot of cases. But the effort to transition to single-payer isn't one of them.

We don't move to single payer because there's no way to do it that won't negatively affect a whole lot of people. Not just people with money. Millions of millions of voters. You either negatively affect the medical providers, you negatively affect the taxpayers, or you negatively affect people with above-average insurance with above-average employer shares. All of those groups are massive numbers of people.

All the talk about what we "should" do doesn't change the "is" question. Because our health care sector has grown to 18% of GDP, switching to single payer can't be achieved without denting the rice bowl of millions of ordinary people.

So regardless of what the people with the money do (and there's lots of people with money who push for single-payer as well), that barrier to change will still be present. And sufficient to stop any conversion.

But we do spend a lot on arguably "wasteful" in the sense of "this should not be necessary in the first place" expenses.

Such as, the rampant and chronic obesity epidemic in America. And alcoholism. And a lot of other what are essentially behavioral or character issues being addressed from a purely medical model.

Do the people who want a total reformation of health care also want to agree to have their diet, exercise habits, weight, and so forth monitored and controlled if necessary to ensure they are as healthy as reasonably possible and hence consume less health care dollars?

Probably not.

"I want free health care because I'm a fat lard butt and instead of healthy diet and exercise, I want my Ozempic!!!" "Oh yeah I have type II Diabetes and society has to pay all the costs of that, too, because dammit it's a free country and I won't change my behavior."

Cue: "My 600 pound life."

There are just too many stakeholders that would lose too much for you to get sufficient political cover to claw it back.

So, you are saying a totally corrupt system, and bought politicians, have sent the US into a death spiral where working people are expendable meat who only matter to the degree that money can be extracted from them? That is about what I have been saying, for years.

So all the talk about "reform" is nothing but a diversion, because the system will only become more corrupt and extractive, to the Proles, over time?

Steve

50% of all health care dollars are consumed by 5% of the population.

The top 1% of health care dollar consumers consume 21% of health care dollars (according to a recent analysis by Kaiser Foundation).

This is at heart an economics problem. A basic economics problem.

Scarce resources are valuable and the scarcer they are, the more valuable they become.

The poorer our general level of health becomes, the scarcer this resource becomes, hence the more valuable/more expensive.

Lots of people don't seem to grasp that there is not an infinite supply of health care.

And therefore, it must be rationed. The question is what mix of private market/public market is optimal.

Not: "Everyone can have infinite unlimited health care for no or very low cost."

People continue to confuse "government funded" (i.e. funded by taxpayers) with "free."

People DO NOT want to pay for their own health care. ANY of it.

They have somehow come to believe, or been led to believe, that it should be "free." Or close to "free."

But they don't want to give up their Twinkies. They don't want to exercise. They don't want to stop taking drugs and stop drinking and stop indulging in inherently dangerous activities.

And they certainly don't want any limitation at all on medical care for MawMaw and PawPaw.

They whine because they have a high deductible plan. As if the purpose of insurance is not fundamentally to protect against catastrophic events which would bankrupt you, but rather, it should pay for your ordinary predictable medical care.

They want their auto insurance to cover car maintenance, which it doesn't.

Steve,

Well said.

The first phase of health care reform is to ban health insurance companies for paying for obesity drugs and stop reimbursement for any medical expenses associated with Type II diabetes, unless and until: The particular patient agrees to stringent behavioral monitoring of diet and exercise to get to a healthy weight and other statistics and sticks to that program.

That will save billions in one fell swoop.

OK what's your idea? You're next.

So, you are saying a totally corrupt system, and bought politicians, have sent the US into a death spiral where working people are expendable meat who only matter to the degree that money can be extracted from them?

No, I'm not saying that.

I'm saying that many millions of people have stable, decent-paying, often middle-class jobs working in the health care sector. They will be negatively affected (significantly so) if we were to make significant reductions in health care spending. So it is politically infeasible to slash health care spending down to the levels of European countries (ie. something close to half of current levels).

There are many millions of people that have health care insurance coverage that is better than average - either better than average coverage or higher than average employer contributions. Many millions will have both, concentrated heavily in unionized jobs and public sector employment. So it is politically infeasible to provide a single-payer system that has health care coverage that isn't better than average.

Since both of the foregoing are true, it is impossible to convert to a single-payer system - which has to cover the extra expenses of both giving coverage to the currently uninsured and under-insured and now raise all the people with below-average coverage up to above-average coverage - without significantly increasing how much we spend on health care. And it is politically infeasible to impose taxes to pay for that.

None of that has anything to do with a corrupt system or bought politicians. As a matter of public policy, we have encouraged medical sector employers to provide decent wages to their employees, encouraged the development of "eds and meds" as a redevelopment and employment solution, and encouraged employers to provide generous health care plans through tax deductibility of medical insurance payments. That's not due to corruption or bought politicians.

Plus, you have to add in a health dollop of Baumol's Cost Disease, which health care is going to greatly suffer from. The richer a country gets, the more expensive services that can't be made more labor-efficient will get. We pay more for health care in the US because we have have a much more efficient labor force than other countries, so the salaries paid to health care workers have to rise more than in other countries even though they can't/don't provide medical services more efficiently.

There's no villain. I mean, there are villains - there's villains in every sector of the economy. But there's no villain that's keeping us from switching. It's just millions of ordinary people who don't want to get hurt by what we would have to do to make the switch.

I'm saying that many millions of people have stable, decent-paying, often middle-class jobs working in the health care sector.

In 1990, Tandy Corp, parent of Radio Shack, had some 44,000 employees. Were those people so "entitled" to their jobs that they should be taxpayer subsidized?

In 1978, Ford Motor employed 256,614 in the US. By 2014, that number had dwindled to 90,000, US and Canada combined. Were those other 166,000 entitled to be paid, forever, even though the company had no use for them?

Tens of thousands of Proles are kicked to the curb by their employers, because continuing their employment is not economic. Why should people working in health care be different?

Steve

Why should people working in health care be different?

Again, this is not a "should" question. It might be eminently justifiable to tell millions of health care workers that they should earn less money so that consumers pay less for health care.

But you still face the "is" question - regardless of whether those workers "should" earn less money, the fact "is" that they don't want to have their compensation cut. And there are millions and millions of them. Nearly 12% of the workforce is in the health care sector. Which raises a nearly insurmountable obstacle to switching to any kind of single-payer health care system that squeezes medical provider compensation rates. Which they all do.

That's what blocks us from moving to single-payer. That obstacle isn't caused by JC's or corrupt political ne'er do wells. It's caused by the fact that now that the health care sector has grown to its current size, there's an awful lot of stakeholders in the health care sector - and the political process will be very sensitive to those stakeholders.

No, albaby1,

the fundamental problem isn't that health care workers are earning too much money.

Health care workers will earn whatever the market for their services will bear.

The problem is that a small subset of 5% of the population uses 50% of the health care dollars. And 1% use 21% of health care services.

The problem is that a small subset of 5% of the population uses 50% of the health care dollars. And 1% use 21% of health care services.

This needs to be viewed in conjunction with the following:

A significant portion of a person's total healthcare spending occurs in their final year of life, often cited as 10% to 30% of total spending, with some studies showing it's concentrated among a small percentage of people who die each year, accounting for a large chunk of Medicare costs (around 27-30%), while being around 10-12% of all healthcare spending for the entire population, heavily skewed towards inpatient and hospital care in the last months.
Key Statistics & Findings:
Overall Spending Share: Estimates vary, but often fall in the 10% to 30% range for total health spending, depending on the population studied (Medicare vs. all ages).
For Medicare: A small fraction (around 6%) of Medicare beneficiaries who die account for a disproportionately large share (27-30%) of total Medicare costs in their last year.
For the General Population: Less than 1% of the population (those dying) account for roughly 10-12% of total healthcare spending, notes the American Hospital Association.

A significant portion of a person's total healthcare spending occurs in their final year of life, often cited as 10% to 30% of total spending, with some studies showing it's concentrated among a small percentage of people who die each year, accounting for a large chunk of Medicare costs (around 27-30%), while being around 10-12% of all healthcare spending for the entire population, heavily skewed towards inpatient and hospital care in the last months.

That's right.
So what does the recent surge in euthanasia laws and practices in Canada and Europe indicate to you?

Nearly 12% of the workforce is in the health care sector.

Let's review.

per the net sifter. If you don't like these numbers, bring numbers from another credible source.

France has significantly more doctors per capita than the U.S., with roughly 3.3 doctors per 1,000 people compared to the U.S.'s approximately 2.6

The U.S. generally has a slightly higher or comparable number of nurses per capita than France, though figures vary by source and year, with some data showing the U.S. around 8.5-12.5 nurses per 1,000 people and France around 10.9-12.2 per 1,000, placing the U.S. slightly ahead or neck-and-neck depending on the specific dataset used from organizations like
KFF/Peterson Tracker or World Population Review

So the US and France have roughly equal concentrations of people who actually care for patients.

The US has a significantly larger share of its workforce in healthcare (around 16%) compared to France (about 9%)
, indicating a more labor-intensive system in the US, though France has more healthcare workers per capita in certain roles, reflecting different care models with higher utilization (visits, hospital days) but lower costs and better population health in France

By the sources the net sifter uses, the US healthcare industry occupies an additional 7% of the entire US workforce. As the concentration of doctors and nurses is roughly the same, what does this extra 7% of the entire workforce do? Are they "administration", aka "paper shufflers", that I started this discussion barking about? And why are these paper shufflers supposed to have guaranteed employment, when the rest of us are seen as expendable?

Steve

And why are these paper shufflers supposed to have guaranteed employment, when the rest of us are seen as expendable?

You keep asking about "why" and "supposed to." Again, those are the wrong questions. Regardless of whether it is good that we have a larger share of our workforce in health care (16%) than France (9%), the fact is that we do.

The U.S. workforce is about 160 million, so the delta between a France-proportioned health-care system and our current one is about 11 million people. So trying to change to a France-proportioned workforce would require culling about 11 million people. Which is not something that is politically feasible.

They're not guaranteed employment - but they are guaranteed to resist changes that threaten their livelihood. With no JC's needed.

So what does the recent surge in euthanasia laws and practices in Canada and Europe indicate to you?

It doesn’t indicate that either Canada or Europe is encouraging people to off themselves.

The push for such laws is often led by those with terminal diseases.

Among the terminally ill, this issue is often seen as a guarantor of freedom- freedom to either continue life, or end it on their.

If I ever face a terminal diagnosis (other than the one that everyone has by virtue of currently being alive) I will most likely NOT avail myself of the option. But I will be glad that it is there if circumstances (pain/cost) become unbearable… even if I never use it.

Freedom of choice. It really is a thing.

Perhaps a solution. At the moment, everyone over 65 is on a single payer system. Each year, lower the qualifying age by one year and immediately start covering under 5. Then increase the qualifying age by one year each year. Within 30 years everyone is eligible. By about 10 years, people will say we can do it for everyone and the US will join the developed world in healthcare coverage.

Aussi

Perhaps a solution. At the moment, everyone over 65 is on a single payer system. Each year, lower the qualifying age by one year and immediately start covering under 5. Then increase the qualifying age by one year each year. Within 30 years everyone is eligible. By about 10 years, people will say we can do it for everyone and the US will join the developed world in healthcare coverage.

The transition to a single payer system is easy to describe. It is easy to identify how we would do it.

The problem is, how do we pay for it?

Medicare is super popular because enrollees pay very small premiums relative to the actuarial value of the policy they get. IOW, the enrollees put in far fewer dollars than get paid out in claims. Enrollees pay about $200 billion in premiums, and receive more than a trillion in medical services.

But you can't do that if you expand the pool. If everyone's in the pool, then the total amount of premiums (whether collected as premiums or as taxes) have to balance the expenditures.

If I ever face a terminal diagnosis (other than the one that everyone has by virtue of currently being alive) I will most likely NOT avail myself of the option. But I will be glad that it is there if circumstances (pain/cost) become unbearable… even if I never use it.

I suppose that most of us, by the time we hit our 50s, 60s, 70s, have witnessed a few friends and/or relatives die from accidents and/or disease.

I've watched morphine given in maintenance doses to relatives for whom there was no hope, were wasting rapidly; bed-ridden, end stage. Suffocating on a ball of phlegm; not a pleasant thing to witness and a thing to which I would prefer to not be subjected.

My friend, on the other hand, suffering end stage cancer with no more than a week to go, asked for the "the pill" while he was still capable of making that choice. It was a dignified process. He just went to sleep. I salute his choice and would hope I have the courage to make the same decision.

A morbid topic, but in the wake of Raul Malo's rapid progression this month, I'm reminded it's an issue that ought to be addressed in one's advance directive.

Malo, who was battling stage 4 colon cancer and leptomeningeal disease, passed away on Dec. 8.

And just to keep it relevant to the US Policy theme.... Raul thought Trump was a malicious asshole who needs to go!

https://www.yahoo.com/entertainment/music/articles...

“The words ‘liberty and justice for all’ have faded into a distant past, “To some of us those words were deeply personal. My family came here because of those words. I was born here because of those words. I have had an extraordinary life because of those words. And now those words have lost their meaning. They are now abstract concepts used to inflict cruelty and suffering on the unsuspecting, the weak, the sick, the poor, the needy. We can add Purple Heart war veterans to that list as several have been deported already. This is America right now.

Some will tell me that I should leave the country or my favorite ‘shut up and sing (A statement so void of any sense that it is impossible to execute)’. “On the ‘leaving’ part … that may come true whether I want to leave or not.
The way the new law stands my mother could be stripped of her naturalized citizenship, then my sister and I would be illegal birthright citizens and away we go. As far as ‘shut up and sing’ well, clearly that’s not happening. You see the thing is this is my country too. Always has been. My country has been that beacon on the hill for so long and for so many.”
“As Lady Liberty’s flame dims with every atrocity committed in her name, we will not be afraid of the dark,” he wrote. “We will find the light again.”

The problem is, how do we pay for it?

Raise taxes on corporations, the stupid-wealthy, and obese pensions. There are sooo many people who were government/civil employees getting high 6 figure pensions....

Spiked pensions, overtime inflation of income, double dipping.. lots of them. They were supposed to serve us, not manipulate the pay structure to bleed us dry.

I don’t think we’ll ever be able to fix the current health care system until the current system blows up.

Seriously, I don’t. Too many entrenched interests in the status quo.

So nothing significant except for a bandaid or two to limp along until the whole thing falls apart.

Then comes the finger pointing, and then, well…

It’s amazing what folks can come up with together when they have no choice.

" Raise taxes on corporations, the stupid-wealthy, and obese pensions. There are sooo many people who were government/civil employees getting high 6 figure pensions...."

I do not have any stats, but I'm pretty sure there are a lot of people paying significant amounts of money for health care right now, either thru the ACA or
employer sponsored. If there was national health care, that money, or some large
portion of it, would not need to be spent. There is no free lunch, of course, so a
large portion or all of that money would need to go to pay for single-payer. So it is not like Americans are not already spending a ton of money on healthcare.

The vested interests will fight national health care tooth and nail, no doubt about it.
I do believe the "vested interests" are outnumbered by a lot. Come 2026, from everything I'm reading, there are a significant number of Americans who are going to get severely handcuffed by monthly HC premiums. And the HC plans are high deductible, shyte coverage.

If we stay on the current course, this is going to boil over. People of all
political persuasions are going to be hurting, just trying to keep up with mortgage
like HC premiums. Our crooked politicians are bribed by lobbyists for the "vested interests", but these same crooked pols need votes to get elected. And they want to stay in office in the worst possible way, at least long enough to make their fortune
from insider trading, ala MTG. It'll be interesting to see if the American voting
public wakes the Eff up, or if they stay hypnotized with culture war rhetoric.
2026 is going to be interesting.

"I don’t think we’ll ever be able to fix the current health care system until the current system blows up." - Pastor Bill

I think it would be difficult to get a much better healthcare system for the reasons you state, but I think a great first step to getting reasonable healthcare system would be to allow a public option people could pay for. Calculate the cost of adding individuals to Medicare, allow individuals (or employers) to pay for it just like they pay for a health insurance from an insurance company. Heck, they could probably even add a small percentage on top of the cost to help reduce the deficit. It would likely be one of the most popular options as it would be cheaper and better care.

So trying to change to a France-proportioned workforce would require culling about 11 million people. Which is not something that is politically feasible.

That's the wrong hill to die on. You stand there and say "these people need jobs, so they are given jobs in health care"

I stand on the next hill, and say to the other 80% that are not in health care, or the military, many of whom have been declared redundant and laid off, once, or twice, or more, "you folks are paying nearly twice as much for health care as you really need to, because you are paying for a health care system that is stuffed with people who do nothing for patient care, but only shuffle paper all day, for no benefit to the economy".

one more bit from the net sifter:

Involuntary layoffs in the U.S. vary significantly by year, averaging around 1.9 million monthly or
over 20 million annually in recent times (like 2025's pace) but can swing wildly, hitting record highs during crises (e.g., 13.5M in March 2020) and lows post-pandemic (e.g., 1.3M monthly in late 2021), with 2024 seeing about 1.1% of workers laid off, suggesting millions of people affected annually

Twenty million USians kicked to the curb as "redundant" per year, but health care paper shufflers are supposed to be protected?

Steve

That's the wrong hill to die on. You stand there and say "these people need jobs, so they are given jobs in health care"

No, I don't. I think you keep missing my point.

These are not arguments about why we should not switch to single-payer. They are explanations for why we don't.

We don't switch to a single-payer system because doing so would cause a very large number of Americans a lot of economic pain. That doesn't mean we wouldn't collectively be better off making the switch. It doesn't mean those Americans deserve to be spared from that economic pain. It's not an argument at all about what we should do.

It's just pointing out that the obstacle to the U.S. switching to single-payer isn't some nefarious cabal of conspiring Elites. It's just ordinary people. There's just too many ordinary people that would be hurt in the switch for it to be politically feasible.

This is not a defense of the status quo. Rather, I think that advocates for a single payer tend to be in denial about why they haven't been able to succeed in changing the system. They like to ascribe it to the actions of people they find reprehensible (insurance companies, drug manufacturers) because it is much more pleasant to imagine sticking it to those actors, rather than all the SEIU members that depend on well-paying hospital and healthcare jobs who are part of their coalition.

Calculate the cost of adding individuals to Medicare, allow individuals (or employers) to pay for it just like they pay for a health insurance from an insurance company.

But that's the hard part, and why we don't do this.

The cost of adding individuals to Medicare depends on what the expected medical costs of those individuals will be. But it's politically infeasible to charge different people higher premiums because they're going to cost more - that's the "pre-existing conditions" problem. But if you charge everyone the same premium (or the same within narrow differences of community rating), then when people have the choice of whether to go to Medicare or not, the system gets filled up with people whose medical costs are higher than the premium rather than folks whose medical costs are lower than the premium. That's the "adverse selection" problem.

That will be especially likely if employers are allowed to participate. Employers tend to have a much better sense of what the actuarial cost of their insurance coverage is than individuals. Every employer whose worker pool has a higher cost than the Medicare premium will dump them in Medicare, but all the employers whose pools have lower costs than the Medicare premium will keep them private.

Single-payer systems work because everyone (or a large, not self-selected slice of everyone) is automatically in the pool. You don't have an adverse selection problem.

In other words, albaby, the Left (including SEIU, teacher's unions, and so forth) are total hypocrites. They like the current system the way it is just fine, because they find it benefits them.

As does the Democrat party which gets so much of its voters and funds from these unions and Progressives who support them.

But in the end it will all boil down to 1) what form of rationing our society chooses to allocate health care and health care dollars and what mix of public/private we are left with after the dust clears; 2) whether or not as a whole society is willing to try to establish more rational economic and behavioral incentives.

For example, health care premiums provided by employers are generally tax deductible. That's an irrational economic incentive, a relic of wage & price controls from about the World War II era. Maybe gradually that could be changed over say a 10 or 20 year period so it won't be too much of a shock to the system.

Another irrationality of the current system, an obvious one, is that there is no means-testing for ACA subsidies.

So an early retiree with millions in investments can manage their AGI so as to be eligible for subsidies which in effect are paid for by other people with a lot less assets. It's great for them but it's inequitable and economically irrational.

There are probably numerous other examples.

In other words,

That’s where you jumped the shark.

It's just ordinary people. There's just too many ordinary people that would be hurt in the switch for it to be politically feasible.

The "many ordinary people" are only a fraction of the number of Proles who are declared redundant, and laid off, every year. The "many ordinary people" are dead weight that the rest of us are carrying, at considerable expense. Without "JC" propaganda filling the media, those "ordinary people" would be told to go out and get a real job, like everyone else.

I submit that it is the degree of featherbedding in US health care that is politically unacceptable.

laff break: the saga of the hospital with "administrative staff", but no doctors or nurses, due to budget cuts.

How To Run A Hospital | Yes Minister | BBC Comedy Greats

https://www.youtube.com/watch?v=JAk448volww

Steve

For example, health care premiums provided by employers are generally tax deductible.

What happens when the corporation pays no taxes, to deduct the health insurance premiums from? Then paying health insurance becomes just another "cost to be minimized", like the number of Proles on the payroll.

A few years ago, some 130 countries, including the US, agreed to a minimum 15% tax rate on corporations.

His nibs is trying to find a workaround, so that corporations can have another tax cut.

Much of Treasury’s recent mischief involves weakening the Corporate Alternative Minimum Tax (CAMT), which is supposed to ensure that the largest corporations pay federal income taxes equal to at least 15 percent of the profits they report to investors, regardless of what tax breaks they can use under the regular tax rules. But the Treasury has recently proposed regulations to limit the CAMT’s impacts on cryptocurrency companies, energy companies, and private equity firms, according to the Times.

https://itep.org/trump-goes-outside-the-law-to-giv...

Steve

Without "JC" propaganda filling the media, those "ordinary people" would be told to go out and get a real job, like everyone else.

Like I said, it's more comforting to believe that the impediments to switching to single-payer can be laid at the feet of nefarious actors like "JC's." Rather than the simple fact that it's politically unpopular to take steps that would result in ten million plus people losing their jobs.

Every Congressional district has a hospital in it, nearly every one has multiple hospitals in it, and while it's unlikely that the hospital(s) is the largest single employer in their district, in most districts the hospitals will be among the largest employers in their district. They also tend to have more union density than the economy at large, with specific sectors (like nursing) being heavily unionized. So going to a Congresscritter with a plan that requires their largest employers to lay off half their employees is not a recipe for success. Which, again, is why Vermont (and other states) couldn't do that.

And to clarify again - I am not saying this is the way things should be. I'm saying that this is one of the main reasons why we don't shift. You can't solve that problem by getting rid of "JC's" role in the process - whether directly or by 'propaganda' in the media. Congresscritters are going to be loath to slash health care reimbursement rates for fear of damaging the hospitals and other health care institutions in their district, and they're not going to be at all comforted by experts telling them that the hospitals will be just fine because they can lay off half their workers as redundant in the new system. Unlike the many millions who get fired from private companies, Congresscritters care a lot about whether the people that are fired get really unhappy about the people who orchestrated their firing.

that it's politically unpopular to take steps that would result in ten million plus people losing their jobs.

I've imagined it, and you can imagine it benignly, with everyone orderly moving to different jobs and magically the jobs move to them, etc. In reality it would be upheaval, strife, rafts of people falling through the cracks, and in the end pain and resentment of the new system. Tons of people saying it wasn't worth it.

I've imagined it, and you can imagine it benignly, with everyone orderly moving to different jobs and magically the jobs move to them, etc. In reality it would be upheaval, strife, rafts of people falling through the cracks, and in the end pain and resentment of the new system. Tons of people saying it wasn't worth it.

I don't think that's the reality either.

In reality, it would end up being just like the "doc fix" retreat on controlling Medicare costs. Remember that? In the late 1990's, Congress passed a law that would restrain the growth of health care spending by placing a limit on how much Medicare's payments could grow. There was a formula (the Sustainable Growth Rate or SGR) that was to be applied, and that would place an upper bound on reimbursement rates.

And then for a decade and a half, Congress would just not do it. Instead, there were a never-ending series of "doc fix" provisions that blocked the cuts. SGR never actually ended up limiting reimbursement rates for medical services in Medicare. Because, again, actually cutting reimbursement rates would have been very unpopular. They did that seventeen times, until they just capitulated and scrapped the whole SGR mechanism altogether.

https://www.medicareresources.org/faqs/what-is-the...

Under single-payer, the medical industry basically turns into the defense contracting sector - but about eight times the size, both in dollars and employees. That's not a recipe for stringent Congressional cost-cutting and fiscal restraint.

Because, again, actually cutting reimbursement rates would have been very unpopular. They did that seventeen times, until they just capitulated and scrapped the whole SGR mechanism altogether.

No. Don't remember that, thanks for posting it. So in reality we;d never do it and doc fix our way until we gave up? Sounds like us. But how come we're going to let the enhanced subsidies lapse? That should be too painful too.

But how come we're going to let the enhanced subsidies lapse? That should be too painful too.

It is painful. That's why you've had Republicans cross the aisle in both the Senate and the House to keep them from lapsing, and why Johnson probably won't be able to keep it bottled up in the House (the discharge petition has already garnered enough signatures). Thune has a little more control in the Senate, so they might succeed in putting a lid on it - but it will be touch and go. I wouldn't be shocked if once it passes the House, Thune can't keep it from getting through the Senate. And even if he does, the impact very well could lead to a repeat of that time when Dan Rostenkowski got pwned in a parking lot over Medicare changes back in the 1980's:

https://www.npr.org/sections/health-shots/2009/08/...

The Medicare changes were repealed the following year.

... it's politically unpopular to take steps that would result in ten million plus people losing their jobs.


Seems we have reached an impasse. You hold that 7% of the workforce has the political juice to make their jobs inviolate, even though they contribute nothing to patient care. I hold that, if the 80% of the workforce who are paying for those unproductive jobs knew how their health care dollars are being wasted, the fact that they outnumber the paper shufflers more than 10 to 1 would make the elimination of that "administrative overhead" a political imperative.

I have enjoyed this discussion. Nice to know I can still hold my own in a debate.

Steve

You hold that 7% of the workforce has the political juice to make their jobs inviolate, even though they contribute nothing to patient care. I hold that, if the 80% of the workforce who are paying for those unproductive jobs knew how their health care dollars are being wasted, the fact that they outnumber the paper shufflers more than 10 to 1 would make the elimination of that "administrative overhead" a political imperative.

I laud you for your optimism. I just think it runs against the entire history of U.S. politics. The "doc fix" is instructive - when faced with imposing a significant cost on a small group of organized people, but which would have yielded a benefit to all U.S. taxpayers, Congress capitulated to the smaller group that was facing the big hit. Every single time. Seventeen times in a row. Same thing with the "Cadillac tax" and the individual mandate in the ACA. Provisions that would have reduced the health care costs for the masses, at the expense of imposing additional costs on a much smaller group of people....but tossed out the window on a bipartisan basis.

But I'm sure this time would be different.

Another meaningless cryptic "dunk" by Baloney.

Steve,

Tax deductions don't decrease "TAXES," they decrease "INCOME."

Albaby1,

It's not just that imposing non-market based arbitrary cuts on medical expenses would be "unpopular."

It would create shortages of health care.

It's not merely a political issue, it's an economics issue.

Zohran Mamdani promised free bus service to NYC.

How is that going?

Sure it's "free" but the number of "free" buses are zero, so no, you don't have to pay a dime for a ride on a bus that will never pick you up.

It's the same thing with health care and anything else.

Sure you can have all the "free health care" you want, it's "free" because you'll never get an appointment.

The "doc fix" is instructive - when faced with imposing a significant cost on a small group of organized people, but which would have yielded a benefit to all U.S. taxpayers,

I'm hazy on how that "doc fix" was supposed to work. If it was an arbitrary cut in reimbursement rate, without addressing the "administrative overhead", all it would do would be to shortchange the people who actually care for patients, while the paper shufflers are unscathed. In other words, it was set up to fail. Same thing with the tax on high end plans, and the personal mandate. Nothing touches the administrative overhead.

Steve

I'm hazy on how that "doc fix" was supposed to work. If it was an arbitrary cut in reimbursement rate, without addressing the "administrative overhead", all it would do would be to shortchange the people who actually care for patients, while the paper shufflers are unscathed. In other words, it was set up to fail. Same thing with the tax on high end plans, and the personal mandate. Nothing touches the administrative overhead.

It was supposed to work the way most single-payer systems keep health care costs under control. The government sets a price for medical services, and medical providers have to meet that price. So in the late 1990's, in order to keep Medicare costs from increasing too much, Congress wrote into the law a provision that said Medicare reimbursement rates couldn't increase by more than X% in a given year. "X%" was the result of a complicated formula, but that's not especially relevant here (and I would be lying if I denied that I was hazy on how the SGR actually was calculated myself).

It would have saved taxpayers a ton of money, but it would have reduced the rate of increase in medical provider reimbursement. So once the SGR caps started to kick in a few years after adoption, Congress would just suspend them. Every single time.

Congress is reluctant to impose heavy economic costs on a discrete group of people in order to finance diffuse and smaller benefits to a very large group of people. Mostly because economically hurting people leads them to call their Congressbeings and complain. No one calls their Congresscritter to complain that a diffuse future benefit that they didn't know about didn't end up materializing. It's a pretty easy choice for an elected official, which is why the status quo is so durable (in lots of scenarios).

Congress is reluctant to impose heavy economic costs on a discrete group of people in order to finance diffuse and smaller benefits to a very large group of people. Mostly because economically hurting people leads them to call their Congressbeings and complain. No one calls their Congresscritter to complain that a diffuse future benefit that they didn't know about didn't end up materializing. It's a pretty easy choice for an elected official, which is why the status quo is so durable (in lots of scenarios).

Well, sure, but another factor to consider is that price ceilings rarely work and instead lead to shortages of whatever good you're placing a cap on.

If the feds were to ever cap Medicare fees to high degrees you'll simply see more doctors and service providers...drop out of the program as they won't earn enough to cover *their* costs. As a result access to care for the people who need it most will get worse.

We don't have a free market in healthcare. If we did, profit motives and more agile practices would be brought to bear to wring inefficiencies out of the system much faster.

Well, sure, but another factor to consider is that price ceilings rarely work and instead lead to shortages of whatever good you're placing a cap on.

If the feds were to ever cap Medicare fees to high degrees you'll simply see more doctors and service providers...drop out of the program as they won't earn enough to cover *their* costs. As a result access to care for the people who need it most will get worse.

Well, the main counterexample to that would be....nearly every national health care system everywhere in the developed world. Virtually every Western developed country has a single-payer health system to cover all (or very nearly all) medical services, and they all have price lists for services. Results vary somewhat from country to country, but nearly all of them have a pretty well-functioning health care sector that keeps the population generally healthy without acute shortages. Some have made poor decisions in implementing their single-payer systems, of course - but we wouldn't look at the broad spectrum of results that include many countries without significant problems in providing medical care and conclude that having a price list inherently results in shortages.

With single-payer, the idea is that just like all the enrollees, all of the providers will have to get into the same pool as well. You won't have a situation where it's viable for too many doctors to drop out of the program, because all of their customers will be in the program.

But my point is that it's exceptionally unlikely that Congress would actually set the reimbursement rates in this new program low enough to either achieve much cost savings, or dissatisfy the medical providers. For the same reason why no one's writing articles about how mean and harsh Congress is to their defense contractors when setting budgets or issuing contracts for military services, you're not going to see too much in the way of sharpened pencils going after health care costs - especially once people stop paying actual premiums for health care and just have their annual year-end tax bill. Just like the "doc fix"....

Well, the main counterexample to that would be....nearly every national health care system everywhere in the developed world. Virtually every Western developed country has a single-payer health system to cover all (or very nearly all) medical services, and they all have price lists for services. Results vary somewhat from country to country, but nearly all of them have a pretty well-functioning health care sector that keeps the population generally healthy without acute shortages.

Because the compensation structure in Europe is vastly different than what we have here. You've spent the entire thread arguing against upending that.

With single-payer, the idea is that just like all the enrollees, all of the providers will have to get into the same pool as well. You won't have a situation where it's viable for too many doctors to drop out of the program, because all of their customers will be in the program.

We're not talking about Single payer. We're talking about Medicare. You're conflating the two.
Medicare /= single payer in today's system. If you impose price controls on Medicare providers, you'll have fewer of them.

You won't ever get every single provider in the United States "into the same pool". There will concierge doctors who operate outside of any single payer system...unless you're willing to outlaw that and essentially force medical providers to work for the government. That's not going to fly on any number of grounds.

Because the compensation structure in Europe is vastly different than what we have here. You've spent the entire thread arguing against upending that.

No, I haven't. Why doesn't anyone get that? I'm not arguing for or against changing to a single payer system. I'm pointing out that the obstacles to making such a switch are not merely what The Powers That Be want, but also (and I think primarily) just basic political reluctance to inflict significant economic damage on large numbers of ordinary voters. I'm diagnosing, not advocating.

You won't ever get every single provider in the United States "into the same pool". There will concierge doctors who operate outside of any single payer system...unless you're willing to outlaw that and essentially force medical providers to work for the government. That's not going to fly on any number of grounds.

You don't have every single provider in Europe in the single-payer pool, either. There are always private doctors. Just not very many of them.

If you had a single-payer system that was funded through taxes, almost every doctor would be in it. Because almost every patient would be in it. You can't really compete with "free" - or to be more accurate, "zero marginal cost." If everyone has to pay taxes to fund the single payer system, and everyone can get medical care with no additional charge (or just a co-pay) in the single payer system, then no one's going to have private insurance any more. So almost every patient is going to be choosing between "free to me" and "paying market rate" for medical services. "Free to me" will win almost every time, so nearly all the doctors will be in the "free to me" pool.

I'm not arguing for or against changing to a single payer system. I'm pointing out that the obstacles to making such a switch are not merely what The Powers That Be want, but also (and I think primarily) just basic political reluctance to inflict significant economic damage on large numbers of ordinary voters. I'm diagnosing, not advocating.

I didn't say you were advocating one way or the other for single payer.

There are always private doctors. Just not very many of them.

If you had a single-payer system that was funded through taxes, almost every doctor would be in it.

Depends on what the reimbursement rates are, doesn't it? If the rates are too low...doctors won't work for less than they make now.
And patients who can pay outside the system who don't want government care will head for that option.

"Free to me" will win almost every time, so nearly all the doctors will be in the "free to me" pool.

Again, it depends.

If the feds were to ever cap Medicare fees to high degrees you'll simply see more doctors and service providers...drop out of the program as they won't earn enough to cover *their* costs. As a result access to care for the people who need it most will get worse.

Correct. If you hurt the people who actually help patients, they will be motivated to quit. If you attack the administrative overhead, which I have been talking about, you cut costs without impacting patients or care providers.

I have, repeatedly, seen people complain about the increasing amounts of education funding that get sidetracked into administrative overhead, vs education. Why do I never hear the same complaints about the administrative overhead in health care?

I have not worked in a doctor's office. How are Medicare claims handled? The same inefficient way that private insurance is handled. Is everything about filing paper forms and waiting weeks/months for payment?

Steve

The Medicare changes were repealed the following year.

I'm amazed that you can remember all of this from the past. I have no memory of that.

I have not worked in a doctor's office. How are Medicare claims handled? The same inefficient way that private insurance is handled. Is everything about filing paper forms and waiting weeks/months for payment?

I have not worked in a doctor's office either, but both my wife and my brother accepted Medicare patients at various times in their careers. Both of them detested everything about the payment process, and both reported it to be vastly more time consuming, frustrating, and inefficient than dealing with private insurance. Both left Medicare entirely, and solely because it just wasn't worth the time and brain damage to get paid.

Seems to me that the main difference is that patients are shielded from being exposed to any of that frustration in Medicare, while they get dumped into the soup with the provider in private insurance.

I'm pointing out that the obstacles to making such a switch are not merely what The Powers That Be want, but also (and I think primarily) just basic political reluctance to inflict significant economic damage on large numbers of ordinary voters. I'm diagnosing, not advocating.

As I said, we seem to be at an impasse. In the Shinyland of today, how do the clerks, that populate the administrative overhead, have agency to guarantee their employment, as they are outnumbered more than 10 to 1, by the people paying high prices, because of the administrative costs? Proles, in general, have no agency in Shinyland today. Everything is run for the benefit of the "JCs". You reject the impact of "JC" money in the system, out of hand.

Another bit from the net sifter: Notice that, while the money skews a bit in one direction, plenty goes to the other side if the aisle. Recall, during the "shutdown", I was asking if Schumer's stand was for the benefit of the patients, or for the benefit of the insurance companies that might lose customers.

The health insurance industry donates tens of millions annually to U.S. politicians, with figures varying by election cycle, but recent data shows about$10-12 million from Insurance PACs to candidates in the 2023-2024 cycle alone, plus substantial lobbying spending, indicating significant influence through campaign contributions and lobbying, often favoring Republicans.

$10M divided 536 ways isn't that much. But concentrate that money in the hands of a few key people: House and Senate committee chairs, and the POTUS, and it starts to get traction.

Steve

In the Shinyland of today, how do the clerks, that populate the administrative overhead, have agency to guarantee their employment, as they are outnumbered more than 10 to 1, by the people paying high prices, because of the administrative costs?

The same way that New York train conductors have agency to guarantee their employment, when they are outnumbered by far more than 10 to 1, by the people paying higher prices for transit:

https://www.nytimes.com/2025/11/13/nyregion/subway...

It's pretty simple. When a policy action will impose a very large burden/b> on a small discrete number of people, all of those people will be outraged and driven to action. Getting fired from your job, or the risk of getting fired from your job, is a really serious outcome. You will know that it happened, and you will probably know that it's likely to happen, and you will invest a lot of energy into political effort to avoid having that happen to you. That translates into a sizable number of voters who are outraged and energized and will organize to defeat and/or inflict punishment on any elected official who did this to them.

But on the other side of that, when a policy action will confer a small or moderate benefit on a very large number of people....none of that happens. Very few of them know this is even going on, or even a thing, unless or until it happens. The benefit to them will be much, much smaller than the cost to the other people - so they won't really be motivated to do anything to support elected officials who make it happen, if ever they even make a connection between the policy and the benefit (which they won't). And humans are deeply loss-avoidant - our psychology is such that we tend to highly emphasize losses relative to how much we emphasize gains.

The TL;DR - hurting a small number of people to benefit a large number of people often results in bad political outcomes, and politicians know this. Which is why those train conductors get a bill that protects their jobs, why longshoremen get political support to fight automation at ports, and why the "doc fix" got passed every single time.

I have not worked in a doctor's office either, but both my wife and my brother accepted Medicare patients at various times in their careers. Both of them detested everything about the payment process, and both reported it to be vastly more time consuming, frustrating, and inefficient than dealing with private insurance. Both left Medicare entirely, and solely because it just wasn't worth the time and brain damage to get paid.

Thanks for that input.

Seems to me that the main difference is that patients are shielded from being exposed to any of that frustration in Medicare, while they get dumped into the soup with the provider in private insurance.

Time for a story. When I first went on Medicare, I mosied in to the doc for my first visit, my "welcome to Medicare" visit. A few months later, a bill came from the doc. Medicare had rejected the claim. I had to do the legwork myself to find the doc had used the wrong billing code. So, the doc resubmitted the claim. A few months later, I received another bill from the doc. He had used the wrong code again. I eventually found a single page on the net, that explained the coding for Medicare wellness visits, printed it out, and hand carried it to the doc's office. The girl at the desk said she had never seen anything before that laid out when to use each code. There are three codes: "welcome to Medicare", "first annual visit", and "subsequent annual visits". If you don't use the right code, the claim is rejected.

This all brings us back to the possibility that Medicare is set up to fail.

How about Medicare being made as easy to use, for the doc, as the French system: swipe a person's national health card, type a few codes into the terminal, instead of having a room full of paper shufflers, and receive payment in a few moments, instead of weeks?

More from the net sifter. As offered before, feel free to provide data from any other credible source, if you don't like what the sifter says.

French physicians generally report higher satisfaction with their system's balance of professional freedom and universal coverage compared to US physicians' satisfaction with Medicare and the broader US system. The French system provides more autonomy from insurance company interference and ensures virtually all patients have coverage, which reduces administrative burdens and ethical conflicts for doctors.

French Physician Satisfaction

Professional Autonomy: A high percentage of French doctors (49%) report having more freedom to practice medicine and make decisions without interference from government or insurance companies, compared to only 10% of US physicians.

Universal Coverage: French physicians rarely deal with uninsured patients, with 96% reporting their patients never or rarely lack health insurance, eliminating a major source of stress and disparity seen in the US.

Predictable Payment: Payments for similar services are standardized, which helps reduce administrative overhead and uncertainty. Their services are generally approved prospectively and rarely questioned after the fact.

Patient Access: Doctors in France see patients more frequently and can provide better follow-up care, which contributes to better national health outcomes and potentially higher professional satisfaction.

Income & Lifestyle: French doctors are often more satisfied with their income relative to the cost of living and education (less student debt) and report a better work-life balance compared to their US counterparts

US Physician Satisfaction (including with Medicare)

Administrative Burden: US physicians, including those working with Medicare, face significant administrative work and strict post-service payment reviews from various insurers, a major source of dissatisfaction.

Insurance Disparities: US physicians are more likely to care for uninsured or underinsured patients, leading to concerns about health disparities and access to care.

Cost Concerns: US doctors report having to focus more on the costs of medications and treatments due to patient co-pays and insurance structures, rather than solely on clinical guidelines.

Interference: Only a small percentage (10%) of US physicians feel they have high freedom to make medical decisions without interference from the government or insurance companies

In essence, French physicians express greater satisfaction due to a system that prioritizes universal access and professional autonomy, while US physicians face challenges related to administrative burdens and the complexities of a multi-payer system that impacts both patient care and professional freedom

Steve

How about Medicare being made as easy to use, for the doc, as the French system: swipe a person's national health card, type a few codes into the terminal, instead of having a room full of paper shufflers, and receive payment in a few moments, instead of weeks?

More from the net sifter. As offered before, feel free to provide data from any other credible source, if you don't like what the sifter says.

Again, not a should position. We're talking about what is.

Though I do feel the need to push back on your suggestion that all of these folks that aren't doctors or nurses are "paper shufflers." A quick trip over to the Bureau of Labor Statistics shows that nearly all folks who work in the health care field are providing patient services (click to the second page):

https://www.bls.gov/spotlight/2023/healthcare-occu...

The top four categories, which make up half of all such workers, are nurses, personal care assistants, nursing assistants, and physicians. Those are all folks that are providing patient care and services - we just have multiple different occupational classifications for the people who provide, say, 'nursing care.' So too with categories like "home health aide" and "licensed practical and licensed vocational nurses" and "medical assistants" and "nurse practitioners" The differences you think exist between our utilization and countries like France is almost certainly just an artifact of how we license and categorize our workers, and not that a huge number of our health care industry workers are "paper shufflers." These are people that are providing patient services, not just moving paper around.

There are two categories of workers in the top 25 that appear to be clerical: "medical records specialists" and "other healthcare support workers," but they're fewer than 400K in total, or only a few percentage points of all workers.

Not that this is great - it's probably not ideal that we have so much of our patient care provided by people who are "personal care assistants" or "nursing assistants" rather than actual nurses, either because it's cheaper to do that than to call them nurses or because it's cheaper to use people that aren't trained to be nurses for patient care. But it's not like half our health care system is made up of folks doing nothing but paperwork.

If you don't use the right code, the claim is rejected.

I've only had one claim, something regarding my CPAP, rejected. It was submitted again months later and paid. Dunno why. But lots of hospitals and clinics deal with Medicare every day and seem to weather that problem. Universities offer courses and Certificates in Medical Billing, like they do for quickbooks, etc. Now that there's AI, maybe it'll get easier.

There are two categories of workers in the top 25 that appear to be clerical: "medical records specialists" and "other healthcare support workers," but they're fewer than 400K in total, or only a few percentage points of all workers.

Thank you for posting some data. I do not see 43-6013 Medical Secretaries and Administrative Assistants in that chart. That classification accounts for 749,500 "jobs".

https://www.bls.gov/oes/2023/may/oes436013.htm

29-2072 Medical Records Specialists, on the chart, account for 185,690.

https://www.bls.gov/oes/2023/may/oes292072.htm

The chart you linked to totals 12.841M. The BLS' own data shows 17M employed in health care. I do not see 43-6013 Medical Secretaries and Administrative Assistants on that chart, which accounts for 3/4M. Where are the other 3M+ employees, and what do they do?

There seems to be overmanning somewhere in the US system. The data says per capita concentration of doctors and nurses is about the same in France as in the US. I see nurses picketing, complaining they are overworked and underpaid, regularly, so the US is probably not wildly overstaffed with nurses. Where is the overmanning, and why does it exist?

One thought occurs to me, wrt overmanning and waste. Defense contracts are usually written on a "cost plus" basis, so, the higher the cost, the higher the price. Profit, in dollars, increases with the fixed markup on the rising cost. Is health care working the same way? Overmanning costs are added to the actual cost of treatment, so the dollars of profit increase, while maintaining a "politically acceptable" profit margin?

More data to chew on, using the same site for both the US and France, expressed in staff/1000 population, 2021:

France: Healthcare assistants: 3.71 US: Healthcare assistants: NA

France: Other staff: 6.84 US: Other staff: 21.3

https://healthsystemsfacts.org/france/france-healt...

https://healthsystemsfacts.org/the-us-health-syste...

The US has three time as many "other staff", per 1000 The difference, about 14.36, works out to nearly 5M additional "other staff" in the US system, vs if the US had the same proportion as France. Wonder why the US number for "healthcare assistants" is "n/a"?

Steve

You can't make the switch without making a large number of ordinary voters worse off...

There has to be a sweet spot where not enough voters are worse off to scuttle it, and enough voters get better that they show up to support it.

As long as unions keep their contracts, they won't be affected and won't oppose. So that group should probably be ignored for this discussion.

There has to be a sweet spot where not enough voters are worse off to scuttle it, and enough voters get better that they show up to support it.

There doesn't have to be any such thing. And there's a good chance that there isn't one, given how this is a policy that has resisted adoption for so many decades.

Again, you have three policy impacts that you have to balance. You have to set the level of coverage, figure out what you're going to do with provider compensation, and determine how you're going to pay for it. It's not possible to set those three things in a way that doesn't make an awful lot of voters unhappy. Set the level of coverage lower than "above average," and half your voters end up seeing their coverage get worse [I know, it's not a normal distribution, should use the mean, but we're just chatting here]. Slash provider reimbursement rates, and a huge chunk of voters lose their jobs or get pay cuts. Do neither, and the amount of money you have to raise through taxes becomes politically unpalatable.

Is there a sweet spot in there? I kind of doubt it. The problem - not unique to this issue - is that humans generally get vastly more unhappy when they suffer a loss of what they have than they get happy when they get a gain of something they don't have. Something as massive and consequential as switching the health care system affects so many people both positively and negatively that you can't really avoid creating large pockets of people who will come out losing in the switch. And those people will be vastly animated against your project, much more than the people who will gain will support it. Our political system is geared towards weighing intensity of position, not just breadth of support or opposition for a proposal. So even if you're making more voters better off, it still becomes a political impossibility.

Slash provider reimbursement rates, and a huge chunk of voters lose their jobs or get pay cuts.

This is the one that would bother me the most. People who've had good dependable jobs are out of work and if we do this rapidly, there's a whole bunch of them out of work at the same time. Then, if you do Medicare For All, or similar, the Gov hires a bit more, but the insurance companies also let go. You can sponsor helping them find work, helping the states with unemployment insurance, it's liable to spark a recession too. The great single payer recession, and everyone predicted it.

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