Single payer healthcare system discussion

One interesting detail is what India is doing for their healthcare- they're one of the most recent nations to provide a public option, which functions essentially as a cash system up to $1500 for a set period to help deal with their massive poverty 'caste' and to continue to elevate as a world power. To do this, they have been finding more and more ways to 'force' competitive prices- real capitalism at work- while at the same time providing public options for their needy by doing things like having nurses begin AND END the surgery while only billing specialists for the time and work only they can do. This is just one of the articles about it, and has such gems as this:

"This tightly coordinated web cuts costs by concentrating the most expensive equipment and expertise in the hub, rather than duplicating it in every village. It also creates specialists at the hubs who, while performing high volumes of focused procedures, develop the skills that will improve quality. By contrast, hospitals in the U.S. are spread out and uncoordinated, duplicating care in many places without high enough volume in any of them to provide the critical mass to make the procedures affordable. Similarly, an MRI machine might be used four to five times a day in the U.S. but 15 to 20 times a day in the Indian hospitals. As one CEO told us, “We have to make the equipment sweat!”

U.S. hospitals have been developing similar structures, but there are still too many hubs and not enough spokes. Moreover, when hospitals consolidate, the motive often is to increase market power vis-à-vis insurance companies, rather than to lower costs by creating a hub-and-spoke structure."

One of the links to this.

STM317 said:

In reply to The0retical :

I understand how insurance spreads cost around. I guess what I'm suggesting is that instead of simply sharing the cost after the fact, we should try to reduce or control those costs upfront.

I also get how a larger entity should be able to use scale to negotiate lower prices. Medicare is a decent example of this already, and they seem to do a decent job of it compared ot private insurers. But I think it's likely that hospitals, etc take less from Medicare because they know they can overcharge other places to make up the difference. So I kind of expect adopting a "medicare for all" type of model might result in prices higher than current Medicare prices, even with a much larger pool. I would hope they'd be lower than current private costs however.

Completely agree with your point about medical billing being a case of seeing what sticks. Believe it or not, the current Administration has already laid some groundwork for more clarity with regards to pricing and quality. I see no downsides here. This act alone could increase competition and allow consumers to make informed choices about their medical care (when they have a choice). And when an X-Ray is cheaper for elective stuff, then it should become cheaper for emergency situations too.

I know that in emergency cases, there is little or no choice about where you seek treatment or if you seek treatment. But there's a ton of medical stuff that takes place that does involve some choice from consumers. I'd guess that elective stuff makes up a larger percentage of most people's spending on healthcare. Things like dental appointments, knee replacements, cosmetic surgery, annual checkups, etc all let consumers pick where/when/if they want medical care and having clear pricing upfront should allow consumers direct control of their care. So it's not always like buying a Miata, but sometimes it is.

That has been tried several times. Most recently by a couple seeking to not only control their out of pocket costs but charges to the insurance company.

Turns out what you get is an estimate, not a true cost,  

You cannot get a “bid”  and the estimate is adjusted frequently. 

While their out of pocket costs were only a few hundred off.  Billing to their insurance company  was almost $7000 off. ( and not in a good way) 

I find it rather alarming that so many think that their health care is the responsibility of others.

Our health has a lot to do with the choices we make.  Chronic smoker's doctor tells him to quit, but he doesn't and runs up a mountain of medical bills.  You paying for that?  

What about the lethargic, the morbidly obese, the drug-addicted, the self-destructive?  These groups are getting larger, not smaller.   

Remember that at the root of it, it's not the government, or a "single payer" that pays these costs.  It's other people.  It's you and me.  Some just scraping by, some loaded, most somewhere in between, with their own needs, wants and dreams.

I agree there's no easy answer, but we're well-acquainted with the inefficient and corruption-ridden mess that is government.  Giving government the dominant role in this is not going to make it better.

Healthcare costs are where everything goes to hell in a handbasket.  Nearly 20 years ago I was in school for my BSN degree and the professor was telling us about a particular drug used to treat a particular for of hemophilia.  This particular drug cost $125,000 per month and she was holding it up as an example of how important insurance can be.

My hand went up "umm, who pays that $125,000?"  (at the time I was two years in to a 30 year mortgage for just that amount)

Her "their health insurance".

Me "but most health insurance caps you out at a million dollars, maybe 2 million, for your life"  **Now this may have changed in the past 20 years but my point was valid at the time.

Her  "Then they go on medicaid and the government pays for it."

Me  "Here is the problem, neither the insurance company nor the government 'pay' for anything.  They both take money in (premiums and taxes) and redistribute it according to who clamors for it the loudest.  But without regulating what a manufacturer can charge for a critical, life saving item the system will continue to sink under it's own greed."

Her "......"

Guess how well I did in that class  But my point is that a LOT of people have to pay in every single month to keep that one kid alive with an incurable, painful, and ultimately fatal disease.

Corollary to that story.  A buddy of mine went to Cambodia a couple of years ago.  Contracted Dengue Fever and had to be hospitalized.  Three days in a fully modern hospital, bloodwork, antibiotics, IV's, the whole nine yards.  At check out when he was done his bill?  $330.  He paid in cash.

How much would that same diagnosis and stay cost in Kansas City?  $100 grand?  More?  Costs are just out of control. 

1988RedT2 said:

I find it rather alarming that so many think that their health care is the responsibility of others.

Our health has a lot to do with the choices we make.  Chronic smoker's doctor tells him to quit, but he doesn't and runs up a mountain of medical bills.  You paying for that?  

What about the lethargic, the morbidly obese, the drug-addicted, the self-destructive?  These groups are getting larger, not smaller.   

Remember that at the root of it, it's not the government, or a "single payer" that pays these costs.  It's other people.  It's you and me.  Some just scraping by, some loaded, most somewhere in between, with their own needs, wants and dreams.

I agree there's no easy answer, but we're well-acquainted with the inefficient and corruption-ridden mess that is government.  Giving government the dominant role in this is not going to make it better.

That's not true, no one is saying that someone else should pay for their health.  They are saying that health care is a basic human right and that it should be paid for by the government.  Now, to pay for it the government has to raise taxes from a number of resources which you can argue that we are paying for.  But the government also pays for roads in Alaska I'll never use.  It pays for the coast guard to pull people out of the sea, which I hope I'll never need.  It pays for health care for life for members of congress etc.  Just because I don't get personal benefit for a specific thing that the government funds doesn't mean I shouldn't pay my fair share of it for the common good.

Adrian_Thompson said:That's not true, no one is saying that someone else should pay for their health.  They are saying that health care is a basic human right and that it should be paid for by the government. 

I'm sorry, but I find that those two sentences of yours are directly contradictory. 

I think that this is one of those times that we are going to have to agree to disagree.

I'm out.  Let's see if my self-discipline is sufficient to keep me from posting in this thread again!

I prefer a lack of knowledge of the health care system. I don't understand why our premiums for our workers has gone up 5-25% for 10+ years in a row. The rise in cost isn't sustainable for any business. I also don't understand how I can never get anyone to answer what my bill is for or what the cost is going to be? My aunt is very persistent about identifying pricing, she has wasted hours of her life trying to find these answers because of being in a high deductible plan. There are good ways to save money, but I get the feeling everyone is out to take as much money from you or the insurance companies because our lack of understanding the costs associated with treatment.  

How do you operate if nobody knows what things cost and nobody ever calls me back with that answer. The other thing I don't understand, since I pay no matter what, is getting refund checks because my insurance actually covered the tests that were from over 2 years ago.  

1988RedT2 said:

I agree there's no easy answer, but we're well-acquainted with the inefficient and corruption-ridden mess that is government.  Giving government the dominant role in this is not going to make it better.

I still don't understand why people think that corporations are not inefficient and corrupt.  They are.  Very much so.  There is SO MUCH WASTE in corporations, it's not even funny.    When there is money to be made, people have always found ways to get it, be it right or wrong.

The thing about the government system is that it's a lot easier to force it to be transparent so that we can make sure the waste and corruption is at a minimum.  Which we can't do for corporations.

In reply to alfadriver :

There is waste in the corporate world, without doubt.  But in a free market the companies that waste too much die or get taken over.  But government has a monopoly on anything it manages, so there goes any semblance of natural selection.  Instead of having some environmental pressure toward efficiency, there is now NO pressure promoting efficiency.

I have been personally, directly involved in government projects that wasted more money following the required cost-saving protocols than the project itself actually would have cost to just straight up build.

alfadriver said:

1988RedT2 said:

I agree there's no easy answer, but we're well-acquainted with the inefficient and corruption-ridden mess that is government.  Giving government the dominant role in this is not going to make it better.

I still don't understand why people think that corporations are not inefficient and corrupt.  They are.  Very much so.  There is SO MUCH WASTE in corporations, it's not even funny.    When there is money to be made, people have always found ways to get it, be it right or wrong.

The thing about the government system is that it's a lot easier to force it to be transparent so that we can make sure the waste and corruption is at a minimum.  Which we can't do for corporations.

Probably personal experience.

My experience working for defense contractors:  On the surface things seem unbelievably inefficient.  When you look into details, its way worse.  I had a job as a mechanical engineer that was specifically to charge hours to the govt. along with 4 of my peers.  I did nothing all day, every day.  Not because I avoided work... because there was nothing to do. There was no engineering work on the contract to be done, but the govt. specified they wanted 5 engineers to support, so that's what they got.  When I brought this up to management, they looked at me like "WTF is your problem?  You are getting a paycheck for doing nothing, you should be happy".  Never once did I see any attempt to improve the efficiency of anything.

My experience in the private industry:  There is constant pressure from management to improve output, response time, etc.  Consultants are brought in to run workshops and help implement lean strategies.  This stuff works and companies do become significantly more efficient.  I won't say there is no waste... right now I work for largecorp. and there are some hilariously inefficient tasks we do, but in general its several orders of magnitue better than the govt/govt contract side

All that said, I am not against govt. programs.  I do wish there was some incentive govt. wide to improve efficiency across all programs.  It doesn't seem to be a concern whatsoever :(

In reply to Duke :

Not to mention the failure rate of private business.  

If it is trying to meet a national audience and fails, it may still survive as a niche business. Or they declare bankruptcy and start over.  

Federal programs have no such luxury.  The post office has to deliver mail where it isn’t profitable to do so.  They have to sell stamps and accept packages in the most out of the way places in the country.   Fed Ex or UPS can simply close a shop.   But every little town and burg gets their zip code and post office.  

The post office is one tiny non political item. There are countless more.  The government isn’t about efficiency, it’s about service.  Diverse goals indeed.  Dont measure one by the standards of another.  

Duke said:

In reply to alfadriver :

There is waste in the corporate world, without doubt.  But in a free market the companies that waste too much die or get taken over.  But government has a monopoly on anything it manages, so there goes any semblance of natural selection.  Instead of having some environmental pressure toward efficiency, there is now NO pressure promoting efficiency.

I have been personally, directly involved in government projects that wasted more money following the required cost-saving protocols than the project itself actually would have cost to just straight up build.

 

Remember, those cost savings protocols were demanded by the public, like us.  WE can prevent waste that is there to prevent waste.  WE are government.  Like it or not, it is a collection of us.  Assuming that we all take our responsibility....  

And I really don't agree about the idea the companies are efficient or die.  For some, especially the small one, probably.  But for companies the size of insurance companies- no.  It's their goal to take as much money of ours as they can and give it to their owners before paying out the care takers.  And to think they wont maximize that amount of money in any way they can is to be in denial of reality.  Large corporations can last decades with massive waste.  

alfadriver said:

1988RedT2 said:

I agree there's no easy answer, but we're well-acquainted with the inefficient and corruption-ridden mess that is government.  Giving government the dominant role in this is not going to make it better.

I still don't understand why people think that corporations are not inefficient and corrupt.  They are.  Very much so.  There is SO MUCH WASTE in corporations, it's not even funny.    When there is money to be made, people have always found ways to get it, be it right or wrong.

The thing about the government system is that it's a lot easier to force it to be transparent so that we can make sure the waste and corruption is at a minimum.  Which we can't do for corporations.

Well said;  what you neglected to add is that with 330 million “customers” to satisfy with diverse goals, needs, and agenda’s  nobody will recognize how efficient the government is.  

A Company/ corporation  has one boss with one goal. Make Money!  

Well if you can step back and big picture things, Medicare  operates with a 2% administration cost . Insurance companies work on 35% or more.  Yes medicare has flaws and less than perfection but some of that is due to differing goals by their  political bosses.  Plus the varied support/ antagonism each group brings.  

Our Military suffers from the same issues, yet it is far and away the best in the world.  ( most expensive absolutely,  because we spend more than the next 7 militaries combined) 

STM317 said:

In reply to The0retical :

I understand how insurance spreads cost around. I guess what I'm suggesting is that instead of simply sharing the cost after the fact, we should try to reduce or control those costs upfront.

I also get how a larger entity should be able to use scale to negotiate lower prices. Medicare is a decent example of this already, and they seem to do a decent job of it compared ot private insurers. But I think it's likely that hospitals, etc take less from Medicare because they know they can overcharge other places to make up the difference. So I kind of expect adopting a "medicare for all" type of model might result in prices higher than current Medicare prices, even with a much larger pool. I would hope they'd be lower than current private costs however.

Completely agree with your point about medical billing being a case of seeing what sticks. Believe it or not, the current Administration has already laid some groundwork for more clarity with regards to pricing and quality. I see no downsides here. This act alone could increase competition and allow consumers to make informed choices about their medical care (when they have a choice). And when an X-Ray is cheaper for elective stuff, then it should become cheaper for emergency situations too.

I know that in emergency cases, there is little or no choice about where you seek treatment or if you seek treatment. But there's a ton of medical stuff that takes place that does involve some choice from consumers. I'd guess that elective stuff makes up a larger percentage of most people's spending on healthcare. Things like dental appointments, knee replacements, cosmetic surgery, annual checkups, etc all let consumers pick where/when/if they want medical care and having clear pricing upfront should allow consumers direct control of their care. So it's not always like buying a Miata, but sometimes it is.

Oh I absolutely agree. The current administration, despite whatever else I say about them, did a very good thing in making providers disclose their pricing. The providers of course attempted of obfuscate the matrixes with medical coding and short hand but that's pretty easy to overcome.

You and I appear to agree things need to be further be regulated, and the items which need attention, but it comes down to the how. I'm a bit further left, I wasn't always this way if you look at my early post history, mainly because my takeaway from the aftermath of the ACA regulations is extremely cynical.

I really question just motive on the part of the 3rd party inserting themselves between the doctor and I. Considering the motive is profit, not general well being of the populace, it makes me even more skeptical. That isn't to say the government would do a bang up ultra efficient job in that role (I was a defense contractor in a previous life after all so I've seen how sausage is made) but watching just the last 20 years makes me pretty willing to embrace almost any other legitimate alternative system. Especially when those systems have proven to be effective in other countries to our north, Europe, and Scandinavia (which is my preferred choice for a model.)

Brett_Murphy said:

There is some disagreement about the best way to move forward, but most of the people who have commented in the thread seem to agree that there are areas of the current US healthcare system that could be improved greatly.

I'm loosing interest in this thread because we are still talking about the issues and not directly about how a single payer does anything for those issues. 

However I strongly agree with your statement and it should be repeated. 

Also, just because there are massive problems doesn't mean we have to re-engineer the entire caboodle. In fact, I believe if we start taking ownership of the issues and making small changes today, soon we would have made a very large impact. One sweeping generic solution rarely (never?) solves issues with mega-complicated-systems like this. 

I would love to see statistics showing that Medicare has 2% overhead and exactly what is included and excluded from that calculation. 

In reply to Duke :

Looking for a quick reference. It's something Bernie Sanders said based on this CBO report.

Doing a little reading via Poltifact it's not necessarily a 1:1 correlation vs private healthcare as the things which comprise the pool of money in administrative costs are a bit different.

The main takeaway is that social security handles enrollment, payment, and tracking for Medicare.

Private insurance lumps in marketing, customer service, billing, claims review, quality assurance, information technology and profits while Medicare lumps in salaries and expenses, patient outreach, and fraud and abuse control by the Health and Human Services, Justice Department and FBI.

There isn't much clarity on the subject because of that.

I took the time to read through all of the posts. I found many of the links interesting. As we all have our unique lives. Nothing is going to be perfect for everyone. 

The debate of private vs government is interesting to me. I have worked on both sides and comparing government to private is not as simple as many seem to portray it. They have very different requirements and advantages when they try to do something in the same field. 

On a recent project I had to handle a contractor that was almost hysterical at our contract requirements. There were a collection of small issues with a building. The small issues would be irrelevant for a corporate entity as they could make more profit from using the building earlier than the cost saved from making the contractor complete work. For the government, we never make profit, so a collection of small issues is pure addition of tax dollars. 

Plus if a corporte entity wants to figure out a new field of work we can chose not too later. No reason just stop. And count it as a loss or bankruptcy and start over. No questions as to why. Maybe a lawsuit here or there but investors can lose. So risk taking is encouraged. A corporation could just stop performing as a health care provider. If the Federal Government  requires an agency to do a new field of work, it is deemed necessary for the benefit of the USA so we proceed with risk avoidance having a larger importance. Thus we may require 5 engineers on standby just in case. We move slower to ensure successful execution.  If the direction we take won't work for the mission we change course but that mistep gets lots of questions as to why we went the wrong way. Tax payers always get some say. I think this happens more than many think. My work has been adjusted by public individuals as often as by lobby groups. 

A government health payment system can take a long time to setup but that doesn't mean it doesn't perform it's task swiftly. But a lot of people are maybe hurt during the long development.

Anyhow. I think the single payer idea in general has some very good variations that I would be very happy to see put in place. It can work as a private or Government or both. It just takes getting started. 

alfadriver said:

Duke said:

In reply to alfadriver :

There is waste in the corporate world, without doubt.  But in a free market the companies that waste too much die or get taken over.  But government has a monopoly on anything it manages, so there goes any semblance of natural selection.  Instead of having some environmental pressure toward efficiency, there is now NO pressure promoting efficiency.

I have been personally, directly involved in government projects that wasted more money following the required cost-saving protocols than the project itself actually would have cost to just straight up build.

 

Remember, those cost savings protocols were demanded by the public, like us. 

Yes.  Demanding protocols is the wrong way to go about doing this.  Some private companies do this and fail terrible.  Some take other approaches and have success.  

IMO one of the issues is that you can't wait for something to be a giant system before implementing efficiency.  If you do, efficiency needs to be driven from the very top, not one department/branch/etc. at a time.

There are some good points in this thread.

Some disjointed thoughts:

I don't think the wording "Healthcare is a fundamental right" will work in America, nor is it helpful (even if you totally believe it).

A better statement might be: "America is rich enough at this point in history and we will increasingly take care of the health of our citizens."

The path (IMO) would be to say Health care is now a public utility (someone's idea from above^^) and move in that direction.

The justification would be there is  no trade secret or anything special in administering health care, so it should be as standardized as possible. (i.e we know in general what people will need over their lifetimes).

...

On the flip side:

I believe NHS works in other countries because they are in general small and/or very homogeneous compared to the US.

We have more people in California than Canada has. 

We have more than three times more drug addicts than Denmark has people.

We have almost 100 million obese people. 100 million diabetics/pre-diabetics.

When you start treating *all* drug addicts and diabetic people (and everything else)...even very efficiently...you see that it will quickly bankrupt us (IMO).

alfadriver said:

And I really don't agree about the idea the companies are efficient or die.  For some, especially the small one, probably.  But for companies the size of insurance companies- no.  It's their goal to take as much money of ours as they can and give it to their owners before paying out the care takers.  And to think they wont maximize that amount of money in any way they can is to be in denial of reality.  Large corporations can last decades with massive waste.  

If the goal is to get as much money as possible to the shareholders, then how are they capable of such significant waste? There's at least significant motivation to reduce waste to meet that goal of maximizing profit.

Adrian_Thompson said:

People keep saying 'if the US system is so bad, why do people come here for it'  Simple, the health system here is great if you can afford it.  The people who come here from overseas are either paying out of pocket or being covered by some kind of charity organization.  They are getting the best service, but it's service that simply isn't accessible to tens of millions of people.  This is what needs to get fixed.

Yep, nobody on any kind of budget chooses to pay for health care in the US on their own free will. Those are people who either have an inexhaustible mountain of cash to burn, are in need of some bleeding-edge procedure they can't get anywhere else, or have no other practical/safe options due to travel circumstances. From my experience in the Caribbean, central and south American countries are a popular option when the budget isn't infinite, especially Brazil. Even the stupendously rich will often go there if it's something that isn't terribly urgent, and save medevac'ing to the US for emergencies.

In reply to jamscal :

California's population is 39.5 MM. Canada's is 37.06 MM.

The GDP of California alone is 3.07 trillion dollars vs Canada's 1.6 trillion.

The US GDP is 19.39 trillion with 327 MM people.

The US has roughly 9x the population but 12x the GDP.

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The population of Denmark is 5.7 MM, I'm failing to find numbers for their NIH equivalent, but taking your number at face value that would mean 17.1 MM substance addicted individuals in the US or 1 in 19.21 people in the US have a substance abuse problem. That's about right given the NIH's 2014 numbers for those over the age of 18.

I suggest you read up on for Portugal mechanisms which can be adopted to combat substance abuse issues without huge expenditures of capital. They've managed to recover very well from a massive opioid epidemic with an overhaul of the criminal justice system.

---

Obesity can be solved pretty cheaply as well but it's often seen in lower income households. Removing barriers to accessing primary care has been shown, or at least appears, to reduce obesity rates.

----

Again it isn't a question of money but political will to regulate 17.9% of the US economy which is making a number of people, and thus prime donor targets, very rich. There's problems, no doubt, but the seemingly large numbers don't tell the whole tale.

My phone hates text editors or I have very large gorilla hands. I apologize for the tone and grammatical errors.

The0retical said:

In reply to jamscal :

California's population is 39.5 MM. Canada's is 37.06 MM.

The GDP of California alone is 3.07 trillion dollars vs Canada's 1.6 trillion.

The US GDP is 19.39 trillion with 327 MM people.

The US has roughly 9x the population but 12x the GDP.

-------

The population of Denmark is 5.7 MM, I'm failing to find numbers for their NIH equivalent, but taking your number at face value that would mean 17.1 MM substance addicted individuals in the US or 1 in 19.21 people in the US have a substance abuse problem. That's about right given the NIH's 2014 numbers for those over the age of 18.

I suggest you read up on for Portugal mechanisms which can be adopted to combat substance abuse issues without huge expenditures of capital. They've managed to recover very well from a massive opioid epidemic with an overhaul of the criminal justice system.

---

Obesity can be solved pretty cheaply as well but it's often seen in lower income households. Removing barriers to accessing primary care has been shown, or at least appears, to reduce obesity rates.

----

Again it isn't a question of money but political will to regulate 17.9% of the US economy which is making a number of people, and thus prime donor targets, very rich. There's problems, no doubt, but the seemingly large numbers don't tell the whole tale.

My phone hates text editors or I have very large gorilla hands. I apologize for the tone and grammatical errors.

Your numbers tell an interesting story. May I show my ignorance and could you correct me where I’m wrong and if I have something right let me know that too please?  

I’ve assumed that much of obesity  was due to a diet high in processed foods and lacking sufficient fresh fruits and vegetables.  The so called nutrition   deserts in dense lower income neighborhoods. 

Now you’re telling me that the prime issue is lack of. Access to affordable medical care?