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Based on discussion here, and at TMF, albaby -in particular- thinks "Medicare for All" is not possible. Personally, I think it is, though some major changes would have to occur (none of them would be popular with everyone, but individually they would be popular with different parts of the population, IMO). However, Dems are starting to campaign on this. It would be really difficult to do this in the near-term, so they are -probably- setting themselves up for failure. And angry voters, whom will vote against them the next time.


Democrats are united in bashing GOP on Obamacare. Medicare for All could reopen a rift. - POLITICO https://share.google/QKaMuFoyLOlP4M8Xa

Bash away. But don't make promises you can't keep. Better to campaign on something like making it more affordable, perhaps a public option (I would definitely favor that one). Something achievable in a reasonable amount of time.

Medicare for All is definitely possible but it doesn't mean everyone can get all the healthcare they want at the level of service they want if they are relying on other people specifically the taxpayers to fund it.

Health care is a scarce and valuable resource subject to rationing. If not rationed by market forces it will be rationed by other means.

Often the other means are obscure mazes of bureaucratic decisions and delays or simply shortages caused by lack of adequate supply.

The perfect example is NYC w Mamdani and his free bus rides. He declared free bus rides by fiat. Bus fares just increased to $3.00. In principle there are free bus rides of you can find a free bus to ride on though.

The U.S. already has a system of free healthcare for the extremely poor called Medicaid.

At some point the solution is that the 5% of the population using 50% of health care dollars and 1% using 21% will have their spigot of health care dollars cut off.

The rest of us will also see cuts especially in the availability of subsidized care for procedures which are not for life threatening issues. Instead of getting that knee replacement in three months it may take three years. Or never. Don't like it, pay for it yourself.

Entire industries will have to change. If you know anything about personal injury claims then you know how much if the supposed medical care received by patients is of questionable medical necessity.

When people complain about rising health insurance premiums they are really complaining about having to pay for other people's medical costs due to risk pooling.

Personally I resent having to pay for other people's obesity drugs because apparently most American adults are now obese and can't stop stuffing food in their faces.

There's lots of other things that other people won't like paying for. That one is obvious because there is a behavioral solution that renders these drugs entirely unnecessary. STOP STUFFING YOUR FACES.

One of my extended family relatives a young woman who is about to have a baby apparently has gestational diabetes. Or so I was told.

Eff that she was obese before getting pregnant. The pregnancy may have pushed her into diabetic territory for some metabolic reason but she was very unhealthy to begin with. Don't blame that shit on the fetus

Based on discussion here, and at TMF, albaby -in particular- thinks "Medicare for All" is not possible.

The U.S. is exceptional in several bad ways, and this is one of them. Every other OECD country has universal government run healthcare. They all have lower costs and most of them have better outcomes. I don’t think any other proof is necessary that Medicare for All is possible.

The problem is there is no will to do it at the policy level. The health care parasites are too wealthy and can easily purchase enough lawmakers to prevent it.

Welcome to the oligarchy, er, I mean, end stage capitalism, uh that is, rule by the "job creators".

Every other OECD country has universal government run healthcare. They all have lower costs and most of them have better outcomes. I don’t think any other proof is necessary that Medicare for All is possible.

Yes, you need other proof.

All of those countries have universal government run healthcare. None of them has tried to convert from a private health care system that has grown to 18% of GDP into a universal government run health care system.

Path dependence is a real thing. Having allowed our health care sector to grow to the current size, with decades of decisions based upon having a private system, it is no longer possible to switch. You would inflict too much economic harm on too many people for it to be politically feasible. You can't switch over unless you either: i) adopt levels of coverage lower than the typical large group employer plan; or ii) slash provider compensation; or iii) have massive, broad based increases in the amount that most people pay for health care either in premiums or taxes. All of those are political non-starters. The idea of single-payer health care might be popular, but because of where we are, the path to get there requires doing some very unpopular things. Which is why Vermont and California and other sapphire-blue states with progressive leadership have failed to make it happen.

The U.S. already has a system of free healthcare for the extremely poor called Medicaid.

I would not use Medicaid as a model, because it adds 50 state administrative overheads, on top of the Federal administrative overhead.

I would start with Medicare. Other countries have done the heavy lifting, to find out what works. Find the best practices, and adopt them to Medicare. If what the net sifter keeps coming up with is accurate, docs in the US would move to preferring Medicare patients, because of the lack of administrative overhead, and fast payment. Find out why the level of fraud in other countries is so low, compared to the US too. Then start phasing in Medicare availability to progressively younger cohorts. Paying for it would be the tricky part. If you charge premiums to the under 65s that enroll, if the premiums represent the cost structure, they should be lower than what people pay under the ACA now, because the administrative overhead and insurance company skim are not a factor. Employers would be offered the choice of offering Medicare as their employee health insurance benefit. Eventually, the private insurance companies would wither due to their administrative overhead and corruption, because no-one wants to deal with them. Once the majority of people are on Medicare, then shift to a tax supported model, and fold in Medicaid.

Steve

All of those are political non-starters.

I think you're not considering everything. Or maybe it's because the weeds can get very deep. I'll approach one thicket here...

I was traveling and encountered some Canadians. Their daughter is in med school in Canada. Costs ~$400 (Canadian) per semester. She is going to become a doctor without the massive debt most med students in the US incur. Therefore, she can have a smaller salary and still be living quite well. We didn't get into insurance, but I suspect the laws are different in Canada regarding malpractice insurance. Two relatively simple things, and you've reduced how much doctors need to be paid to be doctors.

We need a complete system overhaul, and it will need to be phased-in over a generation or so (unless we're going to pay-off current doctors' loans in exchange for lower compensation rates, which is an idea...).

I was traveling and encountered some Canadians. Their daughter is in med school in Canada. Costs ~$400 (Canadian) per semester. She is going to become a doctor without the massive debt most med students in the US incur. Therefore, she can have a smaller salary and still be living quite well.

But that doesn't save you any money.

Sure, you're no longer charging the med students for the cost of running a med school. But that just means that you have to ask taxpayers to cover the cost of running the med school.

The total cost to the overall system doesn't change. Whatever costs the national health insurance program would save by being able to pay doctors less for the portion of their salary that covers medical school (which is non-zero, but not especially large) just gets added back in by having to cover the cost of medical school directly.

As for medical malpractice, that's a relatively small amount of healthcare costs. It was about $55 billion (costs of both liability insurance and defensive medicine) back in 2010, or about 2% of national health care expenditures back then:

https://pmc.ncbi.nlm.nih.gov/articles/PMC3048809/

So maybe you can shave a percentage point of health care costs by reforming the legal system? Probably not, once you factor in everything - but whatever you can save won't be much more than a rounding error.

Sure, you're no longer charging the med students for the cost of running a med school. But that just means that you have to ask taxpayers to cover the cost of running the med school.

Yes. With a progressive tax system, that should be manageable. As I always say, it's not how much tax you pay, but what you get for your money.

Also, I suspect government could influence the costs (at least at public universities).

Over the lifetime of the doctor, you'll probably pay -as patients- a lot less than just the cost of the med school. Doctors won't need to pay off huge debts (with interest!), but that lower salary will carry on after they -in our present system- would have paid off those loans. Time value of money will kick in for the doctors.

Every other OECD country has universal government run healthcare. They all have lower costs and most of them have better outcomes. I don’t think any other proof is necessary that Medicare for All is possible.

Yes, you need other proof.

All of those countries have universal government run healthcare. None of them has tried to convert from a private health care system that has grown to 18% of GDP into a universal government run health care system.

I didn't choose my words carefully enough. It's not a government run healthcare system that we're talking about, with government owned hospitals and clinics and all doctors etc. on the government payroll. Medicare for All is a single payer system, and it's not only possible but it would significantly reduce the overall national cost of health care. The transition would not be easy, with deeply ingrained interests and highly corrupt lobbying by those interests. But that shouldn't change the goal. The implementation would probably be gradual - starting with a drop in the Medicare eligibility age to 60, and perhaps also covering all children up to age 5, and then maybe closing the uninsured gap by another 10 years every couple of years. It's difficult, but it's possible and beneficial.

You would inflict too much economic harm on too many people for it to be politically feasible.

I have come to accept that. In my imagineerings I always allow the movement to happen, no matter how politically unfavorable it is, and large amounts of people are hurt, some fall through the cracks and never recover. We cause a recession and everyone is angry.

Better to campaign on something like making it more affordable, perhaps a public option (I would definitely favor that one). Something achievable in a reasonable amount of time.

I'd be in favor of a cheap public option to avoid going bankrupt. Where, say... you have negotiated prices, and caps that mean it'll be tight, but you get to keep your house, don't have to liquidate your 401k, sell your rentals or your car, but it's tight.

Medicare for All is a single payer system, and it's not only possible but it would significantly reduce the overall national cost of health care. The transition would not be easy, with deeply ingrained interests and highly corrupt lobbying by those interests. But that shouldn't change the goal. The implementation would probably be gradual - starting with a drop in the Medicare eligibility age to 60, and perhaps also covering all children up to age 5, and then maybe closing the uninsured gap by another 10 years every couple of years. It's difficult, but it's possible and beneficial.

It's not possible, and it wouldn't significantly reduce the overall national cost of health care.

We pay a ton of money for health care because we pay a ton of money for health care. The administrative costs of private insurance are a very, very small amount of national health care expenditures - barely a few percentage points. So switching how we pay for health care doesn't create much savings. In the meantime, extending the coverage of the average health care policy to: i) all the uninsured; and ii) all the people who have below average health care policies will blow up our health care expenditures even more.

Nor is it possible to do what you're describing. You can't incrementally expand the Medicare eligible population, because your new actuarial pools will unspool even before they form. You have to offer them coverage with a premium of at least the average cost of coverage for a 60-64 year old. But then, all the people who are sick will join the Medicare program (because their expected costs for the coming year will be higher than the premium, so it's a good deal for them), but all the people who are healthy will stay out of the new pool (because their expected costs are lower than the premium, so they can do better elsewhere).

Single-payer systems avoid this adverse selection problem by forcing everyone into the pool at once. There's no option. Medicare solves the problem by forcing everyone to pay into it for all their working life, and then when they hit the eligibility age they are offered insurance with a premium that is less than 20% of the cost of coverage. It's an offer they can't refuse. But you can't do that with the new 60-64 year olds - no one's been paying into the system for their entire life to cover that extended pool, and without being offered that unmissable "80% off" discount you end up with your adverse selection issue.

You also end up with a problem on the provider side, because Medicare pays less than private insurance. So if you take X% of private patients and move them from the private insurance pool to the public pool, you're cutting the amount of money that flows to medical providers. Some won't make the switch over, which is problematic for patients; others will make the switch but it will blow a hole in hospital and clinic and other institutional budgets, which is problematic for everyone involved.

Unless you raise taxes. By a lot. If you raise taxes by a lot you can offer the 60-64 year old group the massive subsidies that will induce healthier patients to join (like the ACA extended subsidies) and keep reimbursement rates high enough to induce providers in without blowing up their budgets and cover the cost of the uninsured that now have access to health care. But, of course, raising taxes by a lot is unpopular.

There's no avoiding the economic pain. And since everyone knows where this is going (switching everyone to Medicare), everyone will react to the proposal knowing that it's a total switch even though it's phased. So it's a political impossibility.

Over the lifetime of the doctor, you'll probably pay -as patients- a lot less than just the cost of the med school.

No, you wouldn't. If all you're doing is making med school free, you'd expect to see doctor compensation fall by...about the cost of med school. And everyone would pay in extra taxes...about the cost of med school. The financing costs for government are lower than for med school loans, but not really enough to be material.

Sure, having the government pay for med school gives the government some more leverage to put the screws to med school to make them be more cost efficient. But that just takes us back to our original problem, just on a smaller scale. Imposing significant costs on a small group of people (all the people who work at medical schools, from the teaching doctors down to the orderlies) gets those people very upset. Conferring a small, often invisible benefit on a large number of people doesn't get those people especially happy. The emotions are asymmetric. People hate losses much more than they enjoy gains. So the political coalition that's likely to adopt this type of proposal (ie. Democrats) is pretty unlikely to use it as a chance to put the screws to medical school faculty, much less the often-unionized staff members at teaching hospitals and whatnot.

We pay a ton of money for health care because we pay a ton of money for health care.

Let's pose a hypothetical

Assume that the sales pitch of the health care industry is, literally,"your money or your life". Given that sales pitch, would a "JC", of either a hospital company, or an insurance company, tell you it is his fiduciary duty to probe for an upper limit of how much a person will pay to keep himself alive, to "maximize shareholder value"?

Let's further assume that, to maximize the number of people patronizing private insurance companies and commercial hospitals, the government run option is intentionally made as awkward, frustrating, and unremunerative as possible, so that all the interested parties want to avoid it.

What happens under those assumptions? The sheep follow the lead that "big gummit death panels" need to be avoided, at any cost, while the for-profit interests let their costs balloon, because they know they can pass the cost on, with a markup for profit, to patients and premium payers?

I would love to seem someone with deep knowledge of the operations of the French system, as an example, to inform this discussion with why French doctors report better job satisfaction. How do they avoid the administrative overhead and bureaucracy that adds to costs and aggravation in the US system? Why the French system suffers dramatically lower losses to fraud. Why the French system provides better outcomes than the US system, at dramatically lower cost?

If we simply accepted "it is what it is", for everything, we would still be a British colony.

Steve

B-b-b-but nefster:

"Insurance administrative costs
in the U.S. are a significant portion of total healthcare spending, typically ranging from 15% to 30%, with some estimates putting total administrative burden even higher, at one-quarter to one-third of all healthcare dollars, primarily due to complex billing, coding, and insurance processes. While public programs like Medicare have low overhead (2-5%), private insurance and hospital systems face much higher administrative loads, significantly driving up overall U.S. healthcare costs compared to other countries."

Maybe I'm asking the question wrong.

"Insurance administrative costs
in the U.S. are a significant portion of total healthcare spending, typically ranging from 15% to 30%, with some estimates putting total administrative burden even higher, at one-quarter to one-third of all healthcare dollars, primarily due to complex billing, coding, and insurance processes. While public programs like Medicare have low overhead (2-5%), private insurance and hospital systems face much higher administrative loads, significantly driving up overall U.S. healthcare costs compared to other countries."

Maybe I'm asking the question wrong.

You are, I think.

The federal government publishes a host of data about National Health Expenditures at the link at the bottom of this post, and Table 4 breaks down cost by program and expense. We see that the net cost of private insurance - basically the administrative load of all private health insurance - is about $150 billion. That's about 11% of total private health insurance costs...but it's only 3% of total national health care spending. When you look at the possible delta between the private load and the Medicare load (going from 11% to 3%), you're only at about 2.4%.

Again, a rounding error.

The reason for the discrepancy between those figures and the ones you cite above is that these are the costs on the insurance side, while the higher 15-30% estimates are based on some estimate of measuring provider administrative costs. But it's not kosher to add those back into the equation for private insurance and not for Medicare for all. Why? Because Medicare also has lots of administrative costs and recordkeeping requirements. In fact, since more medical care is already being provided through Medicare and Medicaid ($1.9 billion vs. $1.5 billion in private insurance), if the U.S. system has massive amounts of administrative load on providers it's a pretty good indication that the public systems are also putting providers through the wringer. Switching to Medicare doesn't make administrative load go away. You still have to keep medical records, still have to code and bill and follow up with recalcitrant payors, handle records requests from patients and deal with all of the hassles that come from providing medicine in the American system.

Which means there's not going to be much savings with a switch to single payer. Virtually none on the insurer side, and very little on the provider side. Which, again, is why state efforts to do this have all come to naught.


https://www.cms.gov/files/zip/nhe-tables.zip

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