In the US market, where union participation is also very low, it's weird to me that this is an important reason people stay in their jobs, may influence what kind of jobs you take (full time vs contracting?), but:
- job offers generally do not want to get into details on the health insurance offering. it's not a main "competition" point
- except when subject to some kind of union negotiated contract, the employer can change their insurance options from year to year as they try to save costs, but it's not regarded as a mass pay cut when they do
- there's no standard metric on "how much do our employees pay on healthcare" (i.e. employee premium contributions, deductibles, copays), "how much time do employees spend on the phone with the insurance company", and certainly no way to feed in your last year's records of health-care to see "on plan Y you would have paid C"
Though I think the private health insurance system is a dumb waste of overhead and paperwork and misaligned incentives, I do think that people would be more willing to switch jobs if they could know their plan was at least as good as the one they were leaving, both in money spent and in employee satisfaction. Opacity, in part owing to lack of commitment from employers, makes this harder.
Not to mention that tying your insurance to your job is a *huge* pain. If you switch jobs or get fired you need to deal with coverage gaps, considering individual coverage for the duration, and you may need to switch care providers depending on what your new coverage is.
You mean for the user. It is great for the insurance companies, though, since tying health insurance to employment indirectly keeps the average user age lower, thus making the overall scheme more profitable.
As a general rule, people use health benefits more as they age.
It's really tough on people with a particular health condition and it can turn into an additional expense if a critical provider is suddenly out-of-network. Employers have definitely given me side eye when I've asked for details on the health insurance plan.
United Healthcare is pretty big in the US, they are also famous for forcing people to spend a lot of time on the phone, waiting on hold or advocating for care. I expect this ends up taking time that the employee would otherwise have been working as well as negatively impacting morale.
Markets require information to operate efficiently, but it's not actually in the interest of the companies involved. Who wants to have to endlessly ruthlessly compete? They would much prefer monopolies or cartels - however governments regulate against those.
Hence the "Confusopoly".
The more complex and opaque the system is, the more opportunities for value extraction by those on the inside.
The main reason health insurance matters so much is it can't be bought. No amount of money can "upgrade" your employer plan to a good one if it sucks. If you have a nice PPO with a low deductible and low out of pocket max, that's a diamond in the rough. If you switch to an HMO, now you can't arbitrarily see specialists. Yes you could maybe cover the deductible cost or whatever, but your actual care will be impacted. And money can't fix that.
Most people don't care, including me. Until I got cancer, then I cared, because suddenly this was the stuff that could make the difference between me living and dying.
While I am incredibly privileged, it shouldn't be this way. Beyond the waste it's horribly anti-competitive for consumers. Consumers want better plans, and they have the money. They can't get them. That's a huge smell for "the market is fucked". And fucked it is, beyond belief.
My workplace has made health insurance a competitive point: zero employee premium, zero copays except for an ambulance call which does not result in an admission, zero Rx costs. Full family coverage.
The dental coverage was screwed up for the first 4 months of the year. An assumption was made that all dental plans were basically the same in terms of payments to dentists. This turned out not to be the case.
Everyone should have this, but until we do, it will be a reasonable negotiating point. Why should non-health-care employers be in the healthcare business?
I don't think think I've ever had a job offer where this wasn't a topic of conversation. its further down the flow signing bonus, salary + bonus/equity/incentive are obviously the big ones, but I've always seen vacation, 401k+match, summary health care, relo package, etc care before accepting an offer admittedly its never been a obstacle and probably only moves the total comp needle a couple of percent. honestly its always been the easiest place for me to pick up money with little push back (extra week vacation, 5 years seniority at start for full 401k vesting/match etc.)
Chiming in to say that health insurance and benefits are a huge part of what I look for in job listings, and all of my friends currently looking for new jobs too. It may feel less relevant when we were young, but approaching middle age and it becomes a huge driver of continuing in a shitty job and in accepting an offer.
And in the US a new worker can only join the healthcare plan during certain times of year! New workers often have to wait months with a health insurance gap before they can get on the new plan.
That's up to the new employer. Federal law only requires special enrollment within 90 days of hire. So technically there can be up to a 3 month gap.
In practice, that is very rare. Usually new coverage becomes effective on the hire date.
Workers changing jobs often just elect for COBRA or selecting a temporary subsidized ACA plan to bridge the gap though. Nobody is really forced to go without coverage.
I am not an expert but I am pretty sure changing a job is a "qualified life event" that allows an out-of-band change. I hate privatized insurance but I didn't think this thing in particular was a problem.
That is incorrect. When you start a new job you have a few weeks to enroll.
However, you sometimes have to wait for the plan to begin coverage. Something like "after 30 days of employment", or "on the first day of the first full month of employment". These are indeed idiotic limitations.
Worst case scenario, if you are changing job and something really bad happens during these 2 weeks where you don't have coverage you can retroactively enroll in COBRA.
>- there's no standard metric on "how much do our employees pay on healthcare" (i.e. employee premium contributions, deductibles, copays), "how much time do employees spend on the phone with the insurance company", and certainly no way to feed in your last year's records of health-care to see "on plan Y you would have paid C"
"how much companies/employees pay for healthcare" is a poor metric too, because it would depend on the demographics of the company. You'd expect a startup of 30-somethings would have lower premiums than a company of boomers, even for the same coverage.
I can only speak to my own experiences with salaried work. I'll also preface that I don't like healthcare being tied to employment.
All the job interviews that went to the point of discussing compensation, healthcare benefits were almost always included when negotiating what actual compensation would be. A difference of them covering several hundred dollars a month in premiums and them matching some % of HSA contributions is several thousand dollars a year in compensation differences. When multiple job offers are pretty close, that can make a difference.
Also, the few times employers have offered healthcare concierge as a benefit it was definitely mentioned in the overall compensation package.
It may just be a me thing, but when discussing a job offer I always ask for details about the health insurance. I want to see the premiums, what is covered, the networks, etc. All the details given to current employees when they go through open enrollment. And I can count on one hand the times where it was difficult to obtain from the recruiter or "HR lady".
That being said, nothing tells me the plans won't completely change in a few months of course. That's just the "game" and I also hate it.
Just give me the money directly and let me pick my plan from a marketplace that doesn't suck balls. If employers still want to give some incentives to be more competitive fine, but I shouldn't have to time my job switching to avoid coverage gaps.
> job offers generally do not want to get into details on the health insurance offering. it's not a main "competition" point
Health insurance has been a primary topic in every job offer I’ve had, my entire career.
If a company won’t discuss the insurance situation or provide details about the employee contribution, that’s a warning sign. This is a routine topic for negotiations and any company hiding this data is not a company you want to be working with.
Are there really employers who negotiate this? Every job I've ever had in tech had a single "medical benefit" package that everyone just got. You couldn't negotiate your particular health insurance premium or what portion the employer paid for. Everyone gets the same thing. The only choice I've ever seen was a menu of two options: PPO or high-deductible plan.
So it's good to know the details of the plan (so you know your doctor isn't going to suddenly be out-of-network) but there's not much you can do with this info besides "take the job or leave it."
I'm sure when it comes to executive compensation, everything is open to negotiation, but not for us worker bees.
This is less about private healthcare and more about how employer-provided healthcare is tax advantaged. Credits and tax breaks should go to the individual so they can choose and keep their insurance through different jobs.
Yes, the title gave me whiplash because I went in expecting an argument for socialized healthcare, then read a couple paragraphs and realized the article was actually presenting an argument against government meddling in the healthcare industry, then read further and realized it was actually using the problems created by government meddling in the healthcare industry to argue for more government meddling.
"the thing I miss most is the NHS. It’s been treated like a political football since I left and is apparently a shell of its former self — not because the idea is bad and can’t work but because conservative politicians, some of whom have received funding from private healthcare companies, have deliberately sabotaged it."
really it could not be because government is bad at managing massive programs and provides no incentive for high performance and efficiency....
Real truth is that health care just is massively expensive. Any efficiency gains that are also somewhat limited have been overshot by more "products".
Nurses and doctors can only handle so many patients. This has not increased that much compared to say farming or most other areas. And while there has been some gains. There is also lot more produces and costs of those.
Indeed. It's been argued that people intensive activities, like healthcare, thus become relatively more expensive as other, more automation friendly, industries become highly optinised.
ie the relative price of a new car versus a heart transplant is going to continually drop such that we spend more and more as a percentage of GDP on things like health ( and social ) care.
So it's not sure much that health care has become more expensive, as much as relatively more expensive.
The other strong effect is nobodies life is saved, death is simply delayed, and the older you get the more problems you have.
So as well as historically being relatively resistent to automation, success breeds more need.
US healthcare is very expensive because it's horribly inefficient. There's lots of insurers, lots of providers, and lots of treatments. The intersections of all of that are complex and requires huge amount of overhead to resolve.
Not to mention, the entire point of insurance is to provide that overhead. They want to deny coverage, obviously, so they're going to waste doctor's time on peer-to-peer and force their own customers to aggressively advocate for their own care. It's a huge waste of time for everyone involved, but the insurance company wants that waste of time, that's what they're optimizing for. They've gotten really good at both calling all the shots and wasting time.
Your doctor is more or less a vessel for the insurance company. The insurance company is your doctor: they decide how long visits are, what you can visit for, what medications you can take, which procedures you can get, when you can get those procedures, how much they will cost, and how you will have to pay. Your doctor gets a tiny bit of freedom. Maybe they can prescribe you a medicine out of, like, 3 predetermined choices. After, of course, you've completed all the testing. And after you've tried medicines A through C. And after you've been monitored for whatever time period the insurance decides.
One answer is it is more expensive compared to most of the rest of the first world countries because it was more expensive compared to them 50 years ago, and over that time the growth rates in health costs have been fairly similar for us and them.
The question then is why was it more expensive then? I've not seen much on that.
It is expensive in every developed country. USA just have made everyone involved to try to maximise their profits by shadiest possible practises.
Other places are less expensive. But it does not mean they are cheap. At least in as far as you think of general cost of living. The cost might not be directly visible, but it is there in some way.
The NHS is known for being pretty efficient when compared to other healthcare systems, especially the US. The problem is that there is no money and healthcare is getting more expensive.
There are incentives for high performance and efficiency. GPs are private partnerships contracted to treat patients. They can keep profits.
There's been attempts to do more private outsourcing (with the NHS still paying), but they tend to work out less efficient when you consider the whole system, because, for example they might only treat the easy cases and leave the hard ones to the normal hospitals.
While there are some centralized decisions ( we are paying only for one round of IVF, or this drug isn't good value for money ), most of it is delegated to front line doctors - by the simple mechanism of faced with a fixed time/budget they triage based on medical need.
Note that the UK system is actually a rather odd hybrid of public and private due to historic reasons. It's quite easy to queue jump the waiting for an initial consultant by going private, and then be referred back to the public system for treatment.
So do insurance based ones. And if you aren't 100% insured, that limit depends on how rich you and your parents are, and the balancing is often between health and other things.
Seeing how the US GOP has intentionally sabotaged the USPS with fiscal responsibility burdens unlike any other agency, then declare it fiscally untenable and in need of privatization: yes, I completely believe it possible conservatives will sabotage the function of government in order to demonstrate to voters that government is ineffective.
You can deduct some of your medical expenses. I think it’s over 7.5% of your AGI.
But tax deduction or not isn’t what makes individual health insurance so expensive. When you have employer provided health insurance you’re in a completely different risk pool than people buying on the open market.
And that's the issue, we need regulation to break the quid pro quo system we have right now, and an innovative enterprise to design and sell a realistic risk pool for the public.
That might look like the government requiring freedom of choice in your employer healthcare plan -- eg: the employer has to allow you to port a defined contribution amount to any healthcare plan you prefer, including simply taking the money as salary (disincentivized by taxation though).
It might look like regulating mandatory profit caps on high priced insurance -- meaning if you overpay for your actual risk you get a refund, or maybe free months on the plan etc.
I don't want the government to be the insurance/solution, I want them to set standards that make the game fair and companies can play if they want.
I agree we need to do more. I do wonder if just providing a public option to compete against private insurance is the way to go though.
>profit caps
We have profit caps on health insurance. It has many downsides though. The first is that it removes incentives for health insurers to reduce healthcare costs. It actually incentives them to want higher healthcare costs because 15% of a bigger number is more money.
Second, it incentives things like spinning out your insurance division into separate company and then buying an urgent care clinic to run as a sibling company to the insurance company.
Then when the insurance company
spends their required 85% on healthcare costs, they just make sure a big chunk of that is spent on services from the sibling provider company.
United Healthcare does exactly this.
Of course functional regulators could stop this, but it’s hard and they don’t. Which is why I think offering a public instead of some of these direct regulations of private companies might work better.
I don't get why decoupling insurance from employment isn't a bigger part of the healthcare reform discourse. It's the most obvious, easiest, lowest hanging fruit for improving the US healthcare system, and almost uniquely politically acceptable to both Democratic and Republican voters. Decoupling also doesn't entail disrupting any of the established incumbents (pharma, AMA, insurance companies, etc.) who typically kill any reform. The policy is also arguably market-oriented, or at least is not a form of government intervention that would otherwise offend Republicans, yet benefits individuals over large companies so can appeal to Dems too.
The Republicans have utterly failed to offer *any* alternative at all to Obamacare after 16 years, which is insane for many reasons, but especially considering that they could have put decoupling insurance from employment at the heart of an alternative (even more than the ACA) market-oriented reform. Letting individuals choose their own insurance would put more pressure on insurance companies to actually deliver quality care because, unlike employers, individuals are highly sensitive to the quality of care they receive and are more likely to switch insurers if the insurer unreasonably denies claims or otherwise fails to deliver a decent product. On the other side, individuals are also more sensitive to costs so with greater control over their plan choices would be more able to pick plans that are structured to match their anticipated costs.
In other words, individual insurance would improve the functioning of the market, which should in theory appeal to Republicans. Instead, they only focus on making individuals pay more at the point of care, on the theory that cost-sharing discourages insured people from over-consuming healthcare. Yet they don't think about how the current system makes it impossible for individuals to be truly cost sensitive when selecting plans.
I would guess the Republicans haven't adopted the idea because they are not really in favor of free markets, they are in bed with big business, and employer-provided insurance tends to favor larger companies that can demand better terms from insurers, that can amortize the HR overhead over a larger number of employees, and that tend to benefit disproportionately from lower labor mobility compared to small business (people are more likely to be involuntarily locked into a big company job for security than at a small business, and it's harder for people who are worried about maintaining quality healthcare access to move to a startup, reducing the competition experienced by the bigger companies).
I think a lot of people want to decouple insurance from employment but the mechanics would be tricky.
Ideally all business would take what they pay for insurance and stick it in the employee's paycheck and then the employee would buy insurance with that money. Reality says, a lot less people end up having insurance if you do it that way. Maybe force companies who once offered insurance to fund an employee HSAs and change the HSA rules so it can be used to buy insurance. It would take some thoughtful design to actually pull off the transition while keeping people on insurance.
I’m likewise baffled. Healthcare spending is a major cost for all employers. Decoupling healthcare from employment would theoretically remove this cost immediately. Shouldn’t pro-business groups have long been lobbying for this?
The fact that they are not tells me there must be some other financial incentives at work that are unclear to me.
> The Republicans have utterly failed to offer any alternative at all to Obamacare after 16 years
That’s because before Obama picked it up, it was the Republican free market compromise plan in the face of a growing for socialized healthcare.
And now the Republican Party has been taken over by Trump. To the extent any political party has real principles they have given up theirs completely. Their principles are whatever Trump says they are this week.
So the question is “why hasn’t Trump pushed for separating healthcare from employment?” And the answer to that could be as simple as because he doesn’t think it’s exciting enough.
Good article in general but such a misleading headline and framing. The problem, as described in the article's body, is employer-provided health insurance, not private healthcare.
It is also frustrated that this was meant to be a temporary hack during WWII that never went away. People should just get $$ into their HSA from their employer and but whatever plan they want.
AFAIK it's even worse and want never really "meant" to be anything but it was a workaround of mandated salary caps to compete for workers. Pretty much every time someone tries to limit the market, unintended consequences result. We are still paying for this one.
private healthcare is getting more and more expensive due to private prices available to bulk insurers but not for private person
even if this is not completely deliberate, effect is that you are "serf of whomever pays your insurance" or go bankrupt the moment you have any kind of emergency
in europe some private healthcare providers are showing their colors from different perspective, they outright refuse or cancel private contracts when you are above certain age
> effect is that you are "serf of whomever pays your insurance"
That's why in normal countries public healthcare is a thing and it competes with the private healthcare sector, forcing it to offer relatively affordable premium services.
It’s not connected at all in the US since 2011. The only thing employer provided health insurance gets you is the ability to pay for it with pre-tax income (which is a significant saving). Otherwise, you can go to healthcare.gov and buy it without an employer.
We don’t describe shelter, food, entertainment as being employer provided, even though those are also acquired with money obtained from an employer.
The distinction in the US before 2011 is that couldn’t buy health insurance as an individual, hence it was a benefit dependent upon being employed. Post 2011, health insurance became attainable without an employer.
What are you basing that on? The ACA did not make individual insurance legal, it was already legal and widespread, it was not dependent on employment. The ACA made improvements, the ACA made individual insurance more accessible.
I’m basing that on reality. While health insurance for an individual was legal, it was basically inaccessible. Also, there were pre existing condition clauses and benefit maximums that made the insurance pretty worthless without a well funded employer willing to pay the costs.
ACA made it so anyone can get it, with standardized metal levels to make comparing plans possible, and out of pocket maximums and the inability to use health risks to deny insurance coverage to ensure one can actually buy and use it as long as premiums were paid. There were even generous tax credits to help pay the premiums.
Obviously, it is still very expensive, but the situation is far different than pre-2011. There would have been no “bank a few million at a tech company and be financially independent at 40” people without ACA.
You're just flat out wrong, it was not "basically inaccessible". Tens of millions of people had individual health insurance prior to the ACA, over 30 million in 2010, averaging 10% of all insured people from 2000 to 2010. The ACA, while very important and valuable legislation, only increased the number of individually insured people by around 25%.
But that was not the same "health insurance" that was sold post-ACA. The product itself was completely different, due to the pre existing condition clauses and benefit maximums. Paying $x premiums to only receive a maximum of $y of healthcare and only in certain cases is not what people refer to as the health insurance available in various European countries, which is ostensibly what the situation is compared to.
Even now, when I write health insurance, I mean "ACA complaint health insurance", because the limitations in other kinds of products labeled "health insurance" are useless to the point of not being worth discussing.
You can get healthcare outside of employers and it's incredibly expensive. The cost of private healthcare (either employer sponsored or not) is what is responsible for what the article is talking about, it's certainly not just employer provided plans. Are you saying that if employers didn't provide health insurance that it would help the situation somehow?
Yes. Employers get huge tax incentives for providing insurance, while individuals don't. This ensures that the only economical way to buy health insurance is through an employer, which means you are not free to change plans without changing employers (or change employers without changing plans).
The article says that lower mobility is caused by insurance being coupled to your employer. Yes, you can get health insurance on your own but there are a lot of issues with quitting and getting your own insurance or even moving to a different employer. If you get your own insurance you don't get the same tax breaks employers get. They also have not bargaining power with the insurance. Your new insurance, at your new employer might not have your current doctor covered. There is so much at stake with changing health insurance that it's quite frankly a little scary. Nobody wants to risk accidentally not having coverage for a few weeks because you filled in some form wrong. So it's easiest to just stay at your employer who carries most of the cost and you keep what you have already.
It's funny that he (accurately) quotes the Cato Institute as being opposed to employer-provided health insurance... and then implies that the sole alternative is the NHS. Um, I'm pretty sure that's not what the libertarian Cato Institute was suggesting!
With all respect: what exactly is the alternative you're imagining? The market emphatically did not provide accessible private health care to individuals, largely because of the wellness trap (no one buys insurance until they need it). It existed only as extremely expensive boutique products until the government put its regulatory thumb on the scale and passed the ACA.
Employer health care may have bad externalities, but it has the extremely important (but... maybe invisible to the median libertarian) property that it constitutes collective bargaining. You can force insurers to cover folks they wouldn't want to otherwise by bringing more customers (employees) to the table.
It's so weird that even now, with the ACA having been proved out over decades, that we have to have these weird free market arguments. It didn't work, guys. It's not a good that works well in an efficient market sense.
> It existed only as extremely expensive boutique products until the government put its regulatory thumb on the scale and passed the ACA.
100% untrue. There were affordable catastrophic coverage plans available, and many were made illegal by the ACA and the requirement to provide boutique services for "free" (i.e., forced to pay for even if you don't use).
Markets are made by the government, just cuz the government is involved doesn’t mean there’s not dichotomy of private and public healthcare. Countries like Switzerland or the Netherlands or Singapore have competitive private insurance markets as the primary form of healthcare.
Similarly, even in the United States car insurance, for example, is private even though it’s mandated and expected to be universal. There is no car wellness trap.
> You can force insurers to cover folks they wouldn't want to otherwise by bringing more customers (employees) to the table.
The word you're looking for is "convince," not "force." This whole discussion is replete with misuses of words like "free" and "force," and it's a little worrying.
There are just so many middle steps that are unnecessary, though I think the easiest policy lever is simply mandatory price transparencies, with zero exceptions.
Same way my auto body repairs are done. I have insurance on my car that isn't through my company. I can choose who the provider is. I'm not limited to the two plans my company offers from the same provider. There are dozens of companies who want my business.
The current situation is even worse than it might seem: Employers must provide the same plan options to all employees. A high-earner might prefer a more premium plan over a barbones, catastrophic coverage-only plan while a low-earner at the same company might prefer the extra cash in their pocket. Even if some of the cost of the premium plans is forwarded to the employee the cost to the employer is still higher and they must price that case into their calculation of the overall comp package. The market is more competitive, by definition for high-earners. So the employer will offer plans that cater to them. But this cost still impacts the comp package of the low earner.
For many years this dynamic has eaten up most raises to take home pay got low income earners. See: https://www.econtalk.org/mark-warshawsky-on-compensation-hea...
I'd love to decouple insurance form employment and I'd also love to do away with the private insurance system in the US. I've always had insurance and the experience has been as uniformly poor, regardless of provider, as it is continuous. Any positive interactions and outcomes have felt like happy accidents, not the system working.
Remove the private actors, the adversarial billing, the friction with providers. It, at its best, ranges from bad to outright awful.
(I'd also love to do away with tax prep — the government knows what is owed, so why make folks prepare their own count and hope it matches?)
> the experience has been […] uniformly poor […] Any positive interactions and outcomes have felt like happy accidents
Which is to say, not uniformly poor?
> I'd also love to do away with tax prep — the government knows what is owed
Sometimes! We would probably have to simplify the tax code first. Otherwise instead of spreading out the work of identifying income and tax credit eligibility amongst taxpayers and such upon them who are most proximal to this knowledge, we would have a centralized body need to know all of the things that you and I know about ourselves, such as how many kids we have, what kind of car we drive, whether we use solar power, whether we invest in crypto, whether we earned money from gifts or gambling or dividends or farming. Or we could just simplify the code, which I would like.
I think the article is looking at the wrong abstraction.
private healthcare - e.g if there's a lot of private clinics - people paid cash, then yeah healthcare costs would go down & most of the care was preventive not treatment. competition naturally will force prices down & since individuals payers won't be able to afford massive amounts, the market will adjust it's prices vs having one large payer (gvt) i.e public healthcare or many private large payers(current insurance industry).
right now - the issue isn't private healthcare - but the wrong incentives to bill insurance companies massive amounts of money. then insurance companies countering back - by having large bureaucratic processes to avoid paying those large bills. typical complex systems.
The current administration is hell-bent on changing that, both by nerfing Medicaid and making it much harder to qualify for. Medicaid is already mega-nerfed, you get de-facto lower quality healthcare on Medicaid.
My partner and I both just got new jobs after a long period of unemployment. Neither of our new employers offer subsidized health insurance. We both have chronic conditions for which we need regular access to medication. The financial cliff we will both go over going from Medicaid to paying for health insurance via Covered California, and likely paying higher prices for medication in addition to astronomically high (and increasing!) monthly premiums, is going to eat a huge percentage of our increased incomes.
I have no idea who is supposed to benefit from this system, other than the private health insurance companies.
It also kills many, many people, so, the profit motive needs to be permanently and forever abolished from healthcare. In the US doctors look at patients with dollar signs in their eyes and simply ask, "How much money can I squeeze out of this NPC?" leading to countless abuses, from unecessary and harmful procedures being forced on non-consenting patients (like infant genital mutilation) to denial of needed healthcare because it isn't profitable enough and has an opportunity cost.
I agree with you about Infant genital mutilation (circumcision) but disagree the issue is the doctors themselves. I think the shrinking pool of competition is the major issue. (Hospitals being privatized with VC money etc)
> but disagree the issue is the doctors themselves
Who's fault was the opioid epidemic in the US?
I know a lot of blame has been levelled at the pharma involved, and rightly so, however every single one of those patients that got hooked via prescriptions had them from their doctor.
Those doctors aren't suppose to be automatons, just blindly follow Pharma marketing materials, they are suppose to be highly paid experts who's overriding concern is a duty of care to the patient.
There are many reasons the opioid epidemic was an almost uniquely US experience, but the private incentives for doctors was one of them.
Purdue was telling everyone around the world the same thing - but apparently only US doctors were fooled.
Typically, all single payer medical cost schemes are based on government facilities and intervention. Many Americans have little faith in their government to do anything, much less handle there medical care costs. This is why the employer model still exists.
Americans are different - they see themselves as not Europe or Asians - and they are proud of that. The "rugged individual" is still an ideal many cling to as part of their identity.
One thing that's never been clear to me is how either system plans on scaling healthcare. You have X doctors who can see (just a guess) 30X patients. Unless the number of doctors increase, some patients are going to be left out. In the current system it's those without employment. I'm other countries there's a waitlist. How can we make sure there's enough staff to provide adequate healthcare for everyone?
The U.S. has waitlists too? The U.S. makes people wait based on how much money they have, socialized healthcare systems make people wait based on an assessment of need. The latter is obviously better, even though it is not perfect. You’ll find that most everyone living with socialized healthcare believes it to be adequate when compared to the U.S. system. Adequate does not mean without flaws, adequate doesn’t mean available on demand, adequate means has good outcomes. Very few countries with a similar economy have as poor healthcare outcomes as the U.S.
> You’ll find that most everyone living with socialized healthcare believes it to be adequate when compared to the U.S. system
This is not true for Canadians. Many have to travel to the US, India, or otherwise abroad to purchase the healthcare they desire which is not available to them in Canada.
In Canada you have to get sick enough for the system to triage you into the quotas. But maybe you want to stay healthy before things get too bad?
The conclusion you're drawing does not follow. Canadians can be frustrated with the Canadian healthcare system and also believe it to be adequate when compared to the U.S. healthcare system. Canadians who are surveyed about healthcare typically say: the system is broken and needs to be fixed AND the socialized nature of it must be protected. Canadians are unhappy with underfunding, Canadians want more funding, they do not want the U.S. system.
I have a very simple and easy solution: allow any person with any medical education from any country around the world to practice medicine in their field of study, and relieve them from any medical malpractice responsibility (apart from criminal). Let them prescribe medicine, no paperwork, no regulation.
Anybody can choose to which hospital they go, the “state-licensed” crazy expensive one or the “unlicensed” one for 50 dollars a visit.
As far as I understand, currently the pool of people in the US who are allowed to do medical work is artificially limited, and doctors’ salaries are inflated. Just look around the world, there’s a huge supply of doctors with no student debt who would be happy to work for 60k a year. Also tens of thousands of US citizens will just go get a cheap medical degree from other countries, come back, and open private practice.
> You have X doctors who can see (just a guess) 30X patients
FWIW, it's about 1500X plus or minus.
> How can we make sure there's enough staff to provide adequate healthcare for everyone?
The solution now seems to be headed towards using FNP's and similar in place of fully licensed MDs. Which for things like primary care makes good sense IMO.
Forced labour? Poland has doctors on 32 hour shifts. Worker comes on monday morning, leaves tuesday evening. The night is spend on ER, with a few naps between patients. Perfectly legal!
The whole thing is a racket. The amount of doctors is artificially constrained by the AMA. It's also why the US medical school system is so competitive compared to other countries. For example, in England one does not need an undergrad degree then medical school. One just goes straight into medical school at university. It's a 5-6 year long program compared to the US's 8 year program.
Of course, doctors do not earn nearly as much in England as the USA, thus good luck ever getting something like to change in the USA. In America, most people go to medical school for the prestige and the paycheck, and our system utterly reflects both.
I'm not sure which country you're from, but many EU countries do have private health insurance. The Netherlands, for example, has a system of subsidized private insurance, and a mandate that everyone buy a policy.
(If Americans are thinking, "huh, that sounds like Obamacare / the ACA marketplace!" then you're right.)
Painting in such broad strokes, the German system also sounds like the ACA, but it's really not: the high level description really erases key differences.
In Germany there is nothing like bronze/silver/gold plans. All statutory health insurance covers what is required to be covered by regulations, with just a few bonus services, at the regulated tariff plus just a few percentage points of variation. So the 90% of people in Germany who have statutory health insurance [1] have essentially the same coverage. The tariff is a percentage of income (up to a cap), not a flat fee.
[1] not everyone is required to have statutory health insurance, for example employees above an income threshold and self-employed people
The Dutch system and the U.S. system are not comparable. Health insurance in the U.S. is a “free market” that the government dabbles in with a little policy here and there. Health insurance in The Netherlands is controlled by the government, it is heavily regulated.
Healthcare is "free" across Europe, including in The Netherlands. The choice of The Netherlands' to structure their system as mandatory insurance doesn't change the nature of it, it is free at the point of service with the mandatory insurance costs paid for by the government when someone is unable to pay themselves.
The European/"Socialist" solutions are never obvious to Americans.
It is like parliamentarianism, campaign financing regulations, gun control, multiple political parties, etc. Americans call these things "Socialism" and then freak out about them and refuse to see any good on them.
... and "Chat Control" and Digital ID and forcing digital currency and persistent digital surveillance and conceding your national sovereignty to a council that can pass binding laws without your consent and ....
Let's not pretend either system is perfect, or that the _underlying principles_ that both systems hold are the absolute correct way to organize a society.
Americans have be primed with _decades_ of rugged individualism and the idea that collective action is inherently weaker/flawed (just don't think about Social Security). It might have been reasonably true 100 years ago that everyone could pay for their own health care, but we're now in a world where the average person is perpetually on medications that are expensive to produce, and will demand increasingly expensive medical interventions throughout their life (heart health, cancer care, etc.). Combine that with AI probably wiping out a ton of industries/jobs - something has to change. I'm not going to pretend to have a solution, but I think it is disingenuous to suggest any EU nation has it figured out either and is obviously correct.
While Americans have been primed, it's still relatively new. If any of the new deal proposals were proposed today, everyone would lose their mind.
The dirty secret: half of what makes living in America tolerable comes from new deal policies. Everyone knows it, nobody will say it.
A similar thing goes for the ACA. Republicans hate it, but at the end of the day Americans don't want to be dropped from their insurance plans for having cancer or some genetic defect. Literally nobody wants that, only out-of-touch political talking heads want that.
That's not to say any of these policies are perfect, they all have flaws. But if you ask the American people what they want but carefully never name policy names, it becomes obvious everyone is on the same page.
Just a minor clarification: The Money freaks out, calls these things "Socialism" and then dumps billions on red-baiting campaigns and political donations to defend the (highly profitable) status quo. Most citizens would just like some healthcare.
We could easily do this and it would actually be significantly cheaper.
But I can’t imagine it happening nationwide. Maybe cities can create their own public options, say a flat 3% income tax and you get health insurance.
So much progress isn’t made in the US due to the welfare queen myth. Heavily intertwined with racism, many imagine “lazy” people getting something they didn’t absolutely earn.
> But I can’t imagine it happening nationwide. Maybe cities can create their own public options, say a flat 3% income tax and you get health insurance.
That “lazy people” getting something they didn’t absolutely earn is a core right wing narrative that has been very successfully propagandized for decades. People are still going to need work to pay for everything else. No one is going to stop working once the crushing weight of medical debt is lifted. It’s easy to debunk but I don’t see much effort going into this right now.
Wanna see less innovation in healthcare under a single payer? Come to Canada, you will be on a queue for an MRI for at least 8 months (if you even get one).
The cost reduction alone from everyone paying the same price (for the same service at the same facility of course) must be staggering. I agree - I don't see any need to ban any private insurance or providers and that's also aligned with a traditionally (lower case c) conservative free market view too.
While I agree that there’s probably a benefit of diversifying providers in most situations, I would take single provider over “I can’t afford care at all.”
Also, single provider countries like the UK still have private healthcare. A LOT of private healthcare. This idea that single provider/single payer will make most people’s care worse and remove everyone’s options has felt to me a lot like industry propaganda.
I don’t think it’s just healthcare, you have mortgages for inflated housing prices, expensive groceries and bills, and other expenses that make most people go to the route of boring stable job rather than innovative startup that might be out of business in a year and/or paying peanuts. Look at Canada for example, you can have a boring government job looking at excel sheets in the few hours you “actually” work in that week and still make $140k a year plus generous benefits, meanwhile you can grind your ass in a startup doing embedded firmware development and paid $70k a year with barely any benefits, hell, I have seen “senior robotic engineers” with a job descriptions enough to launch rockets and the pay is $60k!
Obviously people will go with the first option, innovation won’t feed their kids.
> ... my vote ... is for universal healthcare. The only real downside to it is that a bunch of companies that have entrenched their positions taking advantage of ordinary people will be denied a little profit.
Make that "many, many billions of dollars of profit". Then add on the probably-millions of jobs which the staggering inefficiencies of the current system support. (Everything from lobbyists for those companies, to the minions stamping "Denied" on health insurance claims, to the opposing medical billing staff who work for doctors & hospitals & such that need to get paid, to ...)
It'd be lovely if the leviathan could be slain, but don't hold your breath.
Nothing is free. We want both low cost and high quality healthcare.
This means we need to have ways in incentivize innovation (AI diagnostics, robotic procedures, drug discovery, deeper R&D).
Free Markets (with government controls against monopoly) are generally better than governments at delivering cost and quality improvements, but healthcare in most countries is somewhere between “100% not a market” and “70% not a market” (the US). In many cases, governments also actively create and enforce monopolies (eg AMA or local hospitals in the US).
There are a million other things but part of what is required for markets to work is skin in the game, which the UK, Canada, and the US all do bad jobs of in their own ways.
Some say medicine has no elasticity. I don’t think that is true for 90% of spend (for gunshot wounds, maybe, but most spending is on chronic diseases where multiple providers and approaches are available and people could price shop).
I would like to see more countries experiment with more free market healthcare. It’s remarkably effective for many pieces of healthcare.
Americans have been propagandized like crazy and don't really understand what can actually be done. "Single-payer" is treated as a synonym for "universal health care." "Private" is seen as mutually exclusive. People will say we should/shouldn't have something like Europe, then describe a system that only a handful of countries have.
Yeah, I find it discouraging that "single-payer" and "fully socialized" are treated like synonyms.
The "Bismarck model"[0] describes a family of healthcare models where people pay into a central healthcare fund, and that fund then pays medical providers -- which can be private businesses.
All doctor's offices in Canada are in fact private businesses. It's not actually a fully socialized system.
It's just there's a single payer. Those businesses bill the provincial government instead of you. Most of the dysfunctions in the Canadian system come down to provinces screw around with billing and payment and funding.
Take your dissatisfaction with the way the government manages payments to the voting booth instead of advocating dismantling what is on the whole a quite equitable system that has a history of actually producing very good health outcomes.
I actually have on the whole extremely pleasant experiences here in my corner of Ontario. And then I hear horror stories.
The system is underfunded and inconsistent. The province is to blame for that.
> Take your dissatisfaction with the way the government manages payments to the voting booth
And vote for who? I have yet to hear a compelling solution from any party. At most, politicians advocate for throwing more money at the problem.
> The system is underfunded
Hot take: the system will always be underfunded. The demand for healthcare is nearly infinite in practice. What stops people from going to the doctor for every sniffle is either cost (in a private system) or waiting times (in a public system). If you had infinite resources to offer services, there are some folks who would be going in for MRIs every year "just in case" and getting prescriptions for every flu they have.
Yup. Recently drove 6 hours (each way, twice) to get to a Canadian private clinic to get treatment. This saved approximately a year (or more) of waiting in the public system for a routine outpatient procedure that takes 30 minutes to perform. I was lucky this option was even available within driving distance though.
Canada's public healthcare system is massively overloaded and it seems to be getting worse.
I really didn't appreciate how much of a problem this is in my 20s and 30s (while I didn't need much healthcare) and it was easy to assume the bellyaching from older folks was overblown. Time makes fools of us all.
This is like the Canadian version of "no true Scotsman". When the province in question has 1/3 of the population of the country, what's the difference?
Its also described as a provincial problem but all of the provinces receive a substantial amount of funding, particularly for healthcare, via the federal government. People say "oh its the provinces fault, they just need to spend more", and then don't reflect on how much room there is for increased taxation, and particularly how much taxation the federal government currently applies. By far the most tax I pay as a Canadian is in the form of federal taxes. Of course, a bunch of this money does find its way back to the province, so the waters are a little muddy, but the federal government has been repeatedly downloading costs onto the provinces, while doing very little about its own spending. The Chretien government in particular did massive downloading of costs to the provincial governments, although their hand was forced by Canada's fiscal situation at the time. So simply saying, oh well the provinces need to step up, is an easy deflection from what is a pretty thorny problem. If the responsibility really is up to the provinces, then why does the federal government need all this money? If the feds are going to continue scooping up the lion's share of tax revenue then they need to continue helping to fund the various provincial responsibilities.
Yeah, so long as you can mooch off US healthcare innovation like COVID vaccines and weight loss drugs. There is a difference between going to doctor and getting effective treatment, as anyone who dealt with cancer in Soviet Union can testify.
I'm guessing you aren't aware how much of that innovation comes from academic research instead of direct private investment by pharma companies, or that there is a thriving pharmaceutical industry in places like Europe. Ironically your chosen examples are based on innovations pioneered by a German biotech (BioNTech) and a Danish pharmaceutical company (Novo Nordisk). What relevance the Soviet Union might have 34 years after it's collapse is something of a mystery.
> 1 in 4 American workers stay in their jobs because of the healthcare. It suppresses wages and working conditions - and prevents innovators from heading out on their own.
Yes. That is the point. This is how capitalism works. Just look at the story of Tetris as the pefect example of capitalism in action. Some Soviet programmers invented it in their spare time when they had access to computers, as enthusiasts. What did capitalism add? Licensing and sub-licensing agreements. Or, to put it another way, just building enclosures.
The idea that capitalism fosters innovation is a fairy tale. Companies reach a point where the only way to satisfy the market's need for growing profits is by cutting costs and raising prices. All of the inflation we've seen from the pandemic has been the "raising prices" part. AI exists for dynamic pricing. Dynamic pricing is nothing more than raising prices. Nobody is using dynamic prices to reduce prices. Why would they?
But the big part of AI is in labor displacement. This suppresses wages. Those who kept their jobs aren't asking for raises and aren't saying no to extra unpaid labor. Because they're in fear of losing their jobs. That's not a side effect. It's the goal.
US healthcare, if you can call it that, is part of this economic coercion. Being expensive to access out of employment is a feature not a bug. Everybody wins. Employers keep people who want to live. Healthcare company profits go up. You, as the individual? Nobody cares about you. Get back to work.
The end state for all this is something that looks like South Asian brick kilns where workers have debt they can never escape. Westerners are being loaded up with debt for a reason: to enrich various companies and to make sure we can't leave our jobs.
> Soviet programmers invented it in their spare time when they had access to computers, as enthusiasts. What did capitalism add?
Capitalism created the computers whose Soviet copies were Tetris' native platform, it made the languages Pajitnov used and the machines he ported it to. It incentivized people to bring Tetris to the rest of the world, and who knows, it might have spread on its own eventually, just for free, but maybe not.
> All of the inflation we've seen from the pandemic has been the "raising prices" part.
Superficially true, but vacuous. In anyway that matters this is flagrantly and amazingly false. But maybe you weren't aware of the $931 billion US dollars of stimulus paid to individuals, or you may not be familiar with the principle of supply and demand. More dollars in supply, the less the value of each dollar. Prices change to match the devalued currency.
> Being expensive to access out of employment is a feature not a bug.
I think this may qualify as a bug, to which you can credit the Revenue Act of 1954 for codifying the tax break given to companies who provide healthcare directly rather than pay that money as income to the employee. Classic example of a stale law. Now, vested interests may be keeping it in place, but I also see no significant awareness on the voter side of this issue nor the will to reform this discriminatory tax policy.
In the US market, where union participation is also very low, it's weird to me that this is an important reason people stay in their jobs, may influence what kind of jobs you take (full time vs contracting?), but:
- job offers generally do not want to get into details on the health insurance offering. it's not a main "competition" point
- except when subject to some kind of union negotiated contract, the employer can change their insurance options from year to year as they try to save costs, but it's not regarded as a mass pay cut when they do
- there's no standard metric on "how much do our employees pay on healthcare" (i.e. employee premium contributions, deductibles, copays), "how much time do employees spend on the phone with the insurance company", and certainly no way to feed in your last year's records of health-care to see "on plan Y you would have paid C"
Though I think the private health insurance system is a dumb waste of overhead and paperwork and misaligned incentives, I do think that people would be more willing to switch jobs if they could know their plan was at least as good as the one they were leaving, both in money spent and in employee satisfaction. Opacity, in part owing to lack of commitment from employers, makes this harder.
Not to mention that tying your insurance to your job is a *huge* pain. If you switch jobs or get fired you need to deal with coverage gaps, considering individual coverage for the duration, and you may need to switch care providers depending on what your new coverage is.
It is just a really awful system overall.
> It is just a really awful system overall.
You mean for the user. It is great for the insurance companies, though, since tying health insurance to employment indirectly keeps the average user age lower, thus making the overall scheme more profitable.
As a general rule, people use health benefits more as they age.
It's really tough on people with a particular health condition and it can turn into an additional expense if a critical provider is suddenly out-of-network. Employers have definitely given me side eye when I've asked for details on the health insurance plan.
United Healthcare is pretty big in the US, they are also famous for forcing people to spend a lot of time on the phone, waiting on hold or advocating for care. I expect this ends up taking time that the employee would otherwise have been working as well as negatively impacting morale.
Markets require information to operate efficiently, but it's not actually in the interest of the companies involved. Who wants to have to endlessly ruthlessly compete? They would much prefer monopolies or cartels - however governments regulate against those.
Hence the "Confusopoly".
The more complex and opaque the system is, the more opportunities for value extraction by those on the inside.
The main reason health insurance matters so much is it can't be bought. No amount of money can "upgrade" your employer plan to a good one if it sucks. If you have a nice PPO with a low deductible and low out of pocket max, that's a diamond in the rough. If you switch to an HMO, now you can't arbitrarily see specialists. Yes you could maybe cover the deductible cost or whatever, but your actual care will be impacted. And money can't fix that.
Most people don't care, including me. Until I got cancer, then I cared, because suddenly this was the stuff that could make the difference between me living and dying.
While I am incredibly privileged, it shouldn't be this way. Beyond the waste it's horribly anti-competitive for consumers. Consumers want better plans, and they have the money. They can't get them. That's a huge smell for "the market is fucked". And fucked it is, beyond belief.
My workplace has made health insurance a competitive point: zero employee premium, zero copays except for an ambulance call which does not result in an admission, zero Rx costs. Full family coverage.
The dental coverage was screwed up for the first 4 months of the year. An assumption was made that all dental plans were basically the same in terms of payments to dentists. This turned out not to be the case.
Everyone should have this, but until we do, it will be a reasonable negotiating point. Why should non-health-care employers be in the healthcare business?
I don't think think I've ever had a job offer where this wasn't a topic of conversation. its further down the flow signing bonus, salary + bonus/equity/incentive are obviously the big ones, but I've always seen vacation, 401k+match, summary health care, relo package, etc care before accepting an offer admittedly its never been a obstacle and probably only moves the total comp needle a couple of percent. honestly its always been the easiest place for me to pick up money with little push back (extra week vacation, 5 years seniority at start for full 401k vesting/match etc.)
> Though I think the private health insurance system is a dumb waste of overhead and paperwork and misaligned incentives
There are countries where private health insurance works great. The problem in US is how it is regulated.
Chiming in to say that health insurance and benefits are a huge part of what I look for in job listings, and all of my friends currently looking for new jobs too. It may feel less relevant when we were young, but approaching middle age and it becomes a huge driver of continuing in a shitty job and in accepting an offer.
And in the US a new worker can only join the healthcare plan during certain times of year! New workers often have to wait months with a health insurance gap before they can get on the new plan.
That's not true. If you're new there's a special enrollment period right after you start.
That's up to the new employer. Federal law only requires special enrollment within 90 days of hire. So technically there can be up to a 3 month gap.
In practice, that is very rare. Usually new coverage becomes effective on the hire date.
Workers changing jobs often just elect for COBRA or selecting a temporary subsidized ACA plan to bridge the gap though. Nobody is really forced to go without coverage.
I am not an expert but I am pretty sure changing a job is a "qualified life event" that allows an out-of-band change. I hate privatized insurance but I didn't think this thing in particular was a problem.
That is incorrect. When you start a new job you have a few weeks to enroll.
However, you sometimes have to wait for the plan to begin coverage. Something like "after 30 days of employment", or "on the first day of the first full month of employment". These are indeed idiotic limitations.
Worst case scenario, if you are changing job and something really bad happens during these 2 weeks where you don't have coverage you can retroactively enroll in COBRA.
>- there's no standard metric on "how much do our employees pay on healthcare" (i.e. employee premium contributions, deductibles, copays), "how much time do employees spend on the phone with the insurance company", and certainly no way to feed in your last year's records of health-care to see "on plan Y you would have paid C"
"how much companies/employees pay for healthcare" is a poor metric too, because it would depend on the demographics of the company. You'd expect a startup of 30-somethings would have lower premiums than a company of boomers, even for the same coverage.
I can only speak to my own experiences with salaried work. I'll also preface that I don't like healthcare being tied to employment.
All the job interviews that went to the point of discussing compensation, healthcare benefits were almost always included when negotiating what actual compensation would be. A difference of them covering several hundred dollars a month in premiums and them matching some % of HSA contributions is several thousand dollars a year in compensation differences. When multiple job offers are pretty close, that can make a difference.
Also, the few times employers have offered healthcare concierge as a benefit it was definitely mentioned in the overall compensation package.
At the high end in tech it’s just assumed it’s all good plus you can make choices on what plan of several offered.
But for many normal jobs it’s very normal to use health care coverage as a negotiation or decision point.
It may just be a me thing, but when discussing a job offer I always ask for details about the health insurance. I want to see the premiums, what is covered, the networks, etc. All the details given to current employees when they go through open enrollment. And I can count on one hand the times where it was difficult to obtain from the recruiter or "HR lady".
That being said, nothing tells me the plans won't completely change in a few months of course. That's just the "game" and I also hate it.
Just give me the money directly and let me pick my plan from a marketplace that doesn't suck balls. If employers still want to give some incentives to be more competitive fine, but I shouldn't have to time my job switching to avoid coverage gaps.
> job offers generally do not want to get into details on the health insurance offering. it's not a main "competition" point
Health insurance has been a primary topic in every job offer I’ve had, my entire career.
If a company won’t discuss the insurance situation or provide details about the employee contribution, that’s a warning sign. This is a routine topic for negotiations and any company hiding this data is not a company you want to be working with.
Are there really employers who negotiate this? Every job I've ever had in tech had a single "medical benefit" package that everyone just got. You couldn't negotiate your particular health insurance premium or what portion the employer paid for. Everyone gets the same thing. The only choice I've ever seen was a menu of two options: PPO or high-deductible plan.
So it's good to know the details of the plan (so you know your doctor isn't going to suddenly be out-of-network) but there's not much you can do with this info besides "take the job or leave it."
I'm sure when it comes to executive compensation, everything is open to negotiation, but not for us worker bees.
They don't negotiate the terms of your health insurance.
It's presented as part of the negotiation for total compensation.
You have to know the benefits to be able to understand the total compensation, which is what you're negotiating.
This is less about private healthcare and more about how employer-provided healthcare is tax advantaged. Credits and tax breaks should go to the individual so they can choose and keep their insurance through different jobs.
Yes, the title gave me whiplash because I went in expecting an argument for socialized healthcare, then read a couple paragraphs and realized the article was actually presenting an argument against government meddling in the healthcare industry, then read further and realized it was actually using the problems created by government meddling in the healthcare industry to argue for more government meddling.
"the thing I miss most is the NHS. It’s been treated like a political football since I left and is apparently a shell of its former self — not because the idea is bad and can’t work but because conservative politicians, some of whom have received funding from private healthcare companies, have deliberately sabotaged it."
really it could not be because government is bad at managing massive programs and provides no incentive for high performance and efficiency....
Real truth is that health care just is massively expensive. Any efficiency gains that are also somewhat limited have been overshot by more "products".
Nurses and doctors can only handle so many patients. This has not increased that much compared to say farming or most other areas. And while there has been some gains. There is also lot more produces and costs of those.
Indeed. It's been argued that people intensive activities, like healthcare, thus become relatively more expensive as other, more automation friendly, industries become highly optinised.
ie the relative price of a new car versus a heart transplant is going to continually drop such that we spend more and more as a percentage of GDP on things like health ( and social ) care.
So it's not sure much that health care has become more expensive, as much as relatively more expensive.
The other strong effect is nobodies life is saved, death is simply delayed, and the older you get the more problems you have.
So as well as historically being relatively resistent to automation, success breeds more need.
Why is healthcare so uniquely expensive in the USA, but nowhere else?
US healthcare is very expensive because it's horribly inefficient. There's lots of insurers, lots of providers, and lots of treatments. The intersections of all of that are complex and requires huge amount of overhead to resolve.
Not to mention, the entire point of insurance is to provide that overhead. They want to deny coverage, obviously, so they're going to waste doctor's time on peer-to-peer and force their own customers to aggressively advocate for their own care. It's a huge waste of time for everyone involved, but the insurance company wants that waste of time, that's what they're optimizing for. They've gotten really good at both calling all the shots and wasting time.
Your doctor is more or less a vessel for the insurance company. The insurance company is your doctor: they decide how long visits are, what you can visit for, what medications you can take, which procedures you can get, when you can get those procedures, how much they will cost, and how you will have to pay. Your doctor gets a tiny bit of freedom. Maybe they can prescribe you a medicine out of, like, 3 predetermined choices. After, of course, you've completed all the testing. And after you've tried medicines A through C. And after you've been monitored for whatever time period the insurance decides.
Yes, that's all very expensive.
One answer is it is more expensive compared to most of the rest of the first world countries because it was more expensive compared to them 50 years ago, and over that time the growth rates in health costs have been fairly similar for us and them.
The question then is why was it more expensive then? I've not seen much on that.
It is expensive in every developed country. USA just have made everyone involved to try to maximise their profits by shadiest possible practises.
Other places are less expensive. But it does not mean they are cheap. At least in as far as you think of general cost of living. The cost might not be directly visible, but it is there in some way.
The NHS is known for being pretty efficient when compared to other healthcare systems, especially the US. The problem is that there is no money and healthcare is getting more expensive.
There are incentives for high performance and efficiency. GPs are private partnerships contracted to treat patients. They can keep profits.
There's been attempts to do more private outsourcing (with the NHS still paying), but they tend to work out less efficient when you consider the whole system, because, for example they might only treat the easy cases and leave the hard ones to the normal hospitals.
Socialized programs require strict definitions and firm hands on drawing lines of inclusions and limits to balance the budget.
Yes and no.
While there are some centralized decisions ( we are paying only for one round of IVF, or this drug isn't good value for money ), most of it is delegated to front line doctors - by the simple mechanism of faced with a fixed time/budget they triage based on medical need.
Note that the UK system is actually a rather odd hybrid of public and private due to historic reasons. It's quite easy to queue jump the waiting for an initial consultant by going private, and then be referred back to the public system for treatment.
So do insurance based ones. And if you aren't 100% insured, that limit depends on how rich you and your parents are, and the balancing is often between health and other things.
Seeing how the US GOP has intentionally sabotaged the USPS with fiscal responsibility burdens unlike any other agency, then declare it fiscally untenable and in need of privatization: yes, I completely believe it possible conservatives will sabotage the function of government in order to demonstrate to voters that government is ineffective.
You can deduct some of your medical expenses. I think it’s over 7.5% of your AGI.
But tax deduction or not isn’t what makes individual health insurance so expensive. When you have employer provided health insurance you’re in a completely different risk pool than people buying on the open market.
> completely different risk pool
And that's the issue, we need regulation to break the quid pro quo system we have right now, and an innovative enterprise to design and sell a realistic risk pool for the public.
That might look like the government requiring freedom of choice in your employer healthcare plan -- eg: the employer has to allow you to port a defined contribution amount to any healthcare plan you prefer, including simply taking the money as salary (disincentivized by taxation though).
It might look like regulating mandatory profit caps on high priced insurance -- meaning if you overpay for your actual risk you get a refund, or maybe free months on the plan etc.
I don't want the government to be the insurance/solution, I want them to set standards that make the game fair and companies can play if they want.
I agree we need to do more. I do wonder if just providing a public option to compete against private insurance is the way to go though.
>profit caps
We have profit caps on health insurance. It has many downsides though. The first is that it removes incentives for health insurers to reduce healthcare costs. It actually incentives them to want higher healthcare costs because 15% of a bigger number is more money.
Second, it incentives things like spinning out your insurance division into separate company and then buying an urgent care clinic to run as a sibling company to the insurance company.
Then when the insurance company spends their required 85% on healthcare costs, they just make sure a big chunk of that is spent on services from the sibling provider company.
United Healthcare does exactly this.
Of course functional regulators could stop this, but it’s hard and they don’t. Which is why I think offering a public instead of some of these direct regulations of private companies might work better.
I don't get why decoupling insurance from employment isn't a bigger part of the healthcare reform discourse. It's the most obvious, easiest, lowest hanging fruit for improving the US healthcare system, and almost uniquely politically acceptable to both Democratic and Republican voters. Decoupling also doesn't entail disrupting any of the established incumbents (pharma, AMA, insurance companies, etc.) who typically kill any reform. The policy is also arguably market-oriented, or at least is not a form of government intervention that would otherwise offend Republicans, yet benefits individuals over large companies so can appeal to Dems too.
The Republicans have utterly failed to offer *any* alternative at all to Obamacare after 16 years, which is insane for many reasons, but especially considering that they could have put decoupling insurance from employment at the heart of an alternative (even more than the ACA) market-oriented reform. Letting individuals choose their own insurance would put more pressure on insurance companies to actually deliver quality care because, unlike employers, individuals are highly sensitive to the quality of care they receive and are more likely to switch insurers if the insurer unreasonably denies claims or otherwise fails to deliver a decent product. On the other side, individuals are also more sensitive to costs so with greater control over their plan choices would be more able to pick plans that are structured to match their anticipated costs.
In other words, individual insurance would improve the functioning of the market, which should in theory appeal to Republicans. Instead, they only focus on making individuals pay more at the point of care, on the theory that cost-sharing discourages insured people from over-consuming healthcare. Yet they don't think about how the current system makes it impossible for individuals to be truly cost sensitive when selecting plans.
I would guess the Republicans haven't adopted the idea because they are not really in favor of free markets, they are in bed with big business, and employer-provided insurance tends to favor larger companies that can demand better terms from insurers, that can amortize the HR overhead over a larger number of employees, and that tend to benefit disproportionately from lower labor mobility compared to small business (people are more likely to be involuntarily locked into a big company job for security than at a small business, and it's harder for people who are worried about maintaining quality healthcare access to move to a startup, reducing the competition experienced by the bigger companies).
I think a lot of people want to decouple insurance from employment but the mechanics would be tricky.
Ideally all business would take what they pay for insurance and stick it in the employee's paycheck and then the employee would buy insurance with that money. Reality says, a lot less people end up having insurance if you do it that way. Maybe force companies who once offered insurance to fund an employee HSAs and change the HSA rules so it can be used to buy insurance. It would take some thoughtful design to actually pull off the transition while keeping people on insurance.
I’m likewise baffled. Healthcare spending is a major cost for all employers. Decoupling healthcare from employment would theoretically remove this cost immediately. Shouldn’t pro-business groups have long been lobbying for this?
The fact that they are not tells me there must be some other financial incentives at work that are unclear to me.
> The Republicans have utterly failed to offer any alternative at all to Obamacare after 16 years
That’s because before Obama picked it up, it was the Republican free market compromise plan in the face of a growing for socialized healthcare.
And now the Republican Party has been taken over by Trump. To the extent any political party has real principles they have given up theirs completely. Their principles are whatever Trump says they are this week.
So the question is “why hasn’t Trump pushed for separating healthcare from employment?” And the answer to that could be as simple as because he doesn’t think it’s exciting enough.
Good article in general but such a misleading headline and framing. The problem, as described in the article's body, is employer-provided health insurance, not private healthcare.
It is also frustrated that this was meant to be a temporary hack during WWII that never went away. People should just get $$ into their HSA from their employer and but whatever plan they want.
AFAIK it's even worse and want never really "meant" to be anything but it was a workaround of mandated salary caps to compete for workers. Pretty much every time someone tries to limit the market, unintended consequences result. We are still paying for this one.
it's connected via vicious cycle
private healthcare is getting more and more expensive due to private prices available to bulk insurers but not for private person
even if this is not completely deliberate, effect is that you are "serf of whomever pays your insurance" or go bankrupt the moment you have any kind of emergency
in europe some private healthcare providers are showing their colors from different perspective, they outright refuse or cancel private contracts when you are above certain age
> effect is that you are "serf of whomever pays your insurance"
That's why in normal countries public healthcare is a thing and it competes with the private healthcare sector, forcing it to offer relatively affordable premium services.
It’s not connected at all in the US since 2011. The only thing employer provided health insurance gets you is the ability to pay for it with pre-tax income (which is a significant saving). Otherwise, you can go to healthcare.gov and buy it without an employer.
> Otherwise, you can go to healthcare.gov and buy it without an employer.
using what money? Most people get their money from their employer.
We don’t describe shelter, food, entertainment as being employer provided, even though those are also acquired with money obtained from an employer.
The distinction in the US before 2011 is that couldn’t buy health insurance as an individual, hence it was a benefit dependent upon being employed. Post 2011, health insurance became attainable without an employer.
What are you basing that on? The ACA did not make individual insurance legal, it was already legal and widespread, it was not dependent on employment. The ACA made improvements, the ACA made individual insurance more accessible.
I’m basing that on reality. While health insurance for an individual was legal, it was basically inaccessible. Also, there were pre existing condition clauses and benefit maximums that made the insurance pretty worthless without a well funded employer willing to pay the costs.
ACA made it so anyone can get it, with standardized metal levels to make comparing plans possible, and out of pocket maximums and the inability to use health risks to deny insurance coverage to ensure one can actually buy and use it as long as premiums were paid. There were even generous tax credits to help pay the premiums.
Obviously, it is still very expensive, but the situation is far different than pre-2011. There would have been no “bank a few million at a tech company and be financially independent at 40” people without ACA.
You're just flat out wrong, it was not "basically inaccessible". Tens of millions of people had individual health insurance prior to the ACA, over 30 million in 2010, averaging 10% of all insured people from 2000 to 2010. The ACA, while very important and valuable legislation, only increased the number of individually insured people by around 25%.
https://www.census.gov/data/tables/time-series/demo/health-i...
But that was not the same "health insurance" that was sold post-ACA. The product itself was completely different, due to the pre existing condition clauses and benefit maximums. Paying $x premiums to only receive a maximum of $y of healthcare and only in certain cases is not what people refer to as the health insurance available in various European countries, which is ostensibly what the situation is compared to.
Even now, when I write health insurance, I mean "ACA complaint health insurance", because the limitations in other kinds of products labeled "health insurance" are useless to the point of not being worth discussing.
You can get healthcare outside of employers and it's incredibly expensive. The cost of private healthcare (either employer sponsored or not) is what is responsible for what the article is talking about, it's certainly not just employer provided plans. Are you saying that if employers didn't provide health insurance that it would help the situation somehow?
Yes. Employers get huge tax incentives for providing insurance, while individuals don't. This ensures that the only economical way to buy health insurance is through an employer, which means you are not free to change plans without changing employers (or change employers without changing plans).
The article says that lower mobility is caused by insurance being coupled to your employer. Yes, you can get health insurance on your own but there are a lot of issues with quitting and getting your own insurance or even moving to a different employer. If you get your own insurance you don't get the same tax breaks employers get. They also have not bargaining power with the insurance. Your new insurance, at your new employer might not have your current doctor covered. There is so much at stake with changing health insurance that it's quite frankly a little scary. Nobody wants to risk accidentally not having coverage for a few weeks because you filled in some form wrong. So it's easiest to just stay at your employer who carries most of the cost and you keep what you have already.
Yeah, the article sort of conflates the two.
It's funny that he (accurately) quotes the Cato Institute as being opposed to employer-provided health insurance... and then implies that the sole alternative is the NHS. Um, I'm pretty sure that's not what the libertarian Cato Institute was suggesting!
With all respect: what exactly is the alternative you're imagining? The market emphatically did not provide accessible private health care to individuals, largely because of the wellness trap (no one buys insurance until they need it). It existed only as extremely expensive boutique products until the government put its regulatory thumb on the scale and passed the ACA.
Employer health care may have bad externalities, but it has the extremely important (but... maybe invisible to the median libertarian) property that it constitutes collective bargaining. You can force insurers to cover folks they wouldn't want to otherwise by bringing more customers (employees) to the table.
It's so weird that even now, with the ACA having been proved out over decades, that we have to have these weird free market arguments. It didn't work, guys. It's not a good that works well in an efficient market sense.
> It existed only as extremely expensive boutique products until the government put its regulatory thumb on the scale and passed the ACA.
100% untrue. There were affordable catastrophic coverage plans available, and many were made illegal by the ACA and the requirement to provide boutique services for "free" (i.e., forced to pay for even if you don't use).
Markets are made by the government, just cuz the government is involved doesn’t mean there’s not dichotomy of private and public healthcare. Countries like Switzerland or the Netherlands or Singapore have competitive private insurance markets as the primary form of healthcare. Similarly, even in the United States car insurance, for example, is private even though it’s mandated and expected to be universal. There is no car wellness trap.
> You can force insurers to cover folks they wouldn't want to otherwise by bringing more customers (employees) to the table.
The word you're looking for is "convince," not "force." This whole discussion is replete with misuses of words like "free" and "force," and it's a little worrying.
My point was there are lots of models available, not just 2. My post above wasn't endorsing one in particular.
I would say that the ACA is on the free market-ish side of the design space: individuals purchasing (subsidized) insurance from private companies.
There are just so many middle steps that are unnecessary, though I think the easiest policy lever is simply mandatory price transparencies, with zero exceptions.
So how would private healthcare happen without employer provided insurance?
Same way my auto body repairs are done. I have insurance on my car that isn't through my company. I can choose who the provider is. I'm not limited to the two plans my company offers from the same provider. There are dozens of companies who want my business.
Except your company covers a lot of the cost for your health insurance.
They can just give you that money instead.
The current situation is even worse than it might seem: Employers must provide the same plan options to all employees. A high-earner might prefer a more premium plan over a barbones, catastrophic coverage-only plan while a low-earner at the same company might prefer the extra cash in their pocket. Even if some of the cost of the premium plans is forwarded to the employee the cost to the employer is still higher and they must price that case into their calculation of the overall comp package. The market is more competitive, by definition for high-earners. So the employer will offer plans that cater to them. But this cost still impacts the comp package of the low earner. For many years this dynamic has eaten up most raises to take home pay got low income earners. See: https://www.econtalk.org/mark-warshawsky-on-compensation-hea...
Same way you buy anything else without your employer getting in the way?
I'd love to decouple insurance form employment and I'd also love to do away with the private insurance system in the US. I've always had insurance and the experience has been as uniformly poor, regardless of provider, as it is continuous. Any positive interactions and outcomes have felt like happy accidents, not the system working.
Remove the private actors, the adversarial billing, the friction with providers. It, at its best, ranges from bad to outright awful.
(I'd also love to do away with tax prep — the government knows what is owed, so why make folks prepare their own count and hope it matches?)
> the experience has been […] uniformly poor […] Any positive interactions and outcomes have felt like happy accidents
Which is to say, not uniformly poor?
> I'd also love to do away with tax prep — the government knows what is owed
Sometimes! We would probably have to simplify the tax code first. Otherwise instead of spreading out the work of identifying income and tax credit eligibility amongst taxpayers and such upon them who are most proximal to this knowledge, we would have a centralized body need to know all of the things that you and I know about ourselves, such as how many kids we have, what kind of car we drive, whether we use solar power, whether we invest in crypto, whether we earned money from gifts or gambling or dividends or farming. Or we could just simplify the code, which I would like.
Perhaps mountains of frustration punctuated by relief that soon vanishes?
I’d cap income at $5 million a year and strip the tax code down to something devoid of exceptions, but I’m in no position to do that.
...What do you mean "cap"?
I think the article is looking at the wrong abstraction.
private healthcare - e.g if there's a lot of private clinics - people paid cash, then yeah healthcare costs would go down & most of the care was preventive not treatment. competition naturally will force prices down & since individuals payers won't be able to afford massive amounts, the market will adjust it's prices vs having one large payer (gvt) i.e public healthcare or many private large payers(current insurance industry).
right now - the issue isn't private healthcare - but the wrong incentives to bill insurance companies massive amounts of money. then insurance companies countering back - by having large bureaucratic processes to avoid paying those large bills. typical complex systems.
I see a bunch of comments with this same theme but to me it’s splitting hairs.
The term “private healthcare” is mostly referring to the fact that there is no such thing as non-private healthcare for the majority of Americans.
> is no such thing as non-private healthcare for the majority of Americans
We're up to about a third now.
The current administration is hell-bent on changing that, both by nerfing Medicaid and making it much harder to qualify for. Medicaid is already mega-nerfed, you get de-facto lower quality healthcare on Medicaid.
My partner and I both just got new jobs after a long period of unemployment. Neither of our new employers offer subsidized health insurance. We both have chronic conditions for which we need regular access to medication. The financial cliff we will both go over going from Medicaid to paying for health insurance via Covered California, and likely paying higher prices for medication in addition to astronomically high (and increasing!) monthly premiums, is going to eat a huge percentage of our increased incomes.
I have no idea who is supposed to benefit from this system, other than the private health insurance companies.
It also kills many, many people, so, the profit motive needs to be permanently and forever abolished from healthcare. In the US doctors look at patients with dollar signs in their eyes and simply ask, "How much money can I squeeze out of this NPC?" leading to countless abuses, from unecessary and harmful procedures being forced on non-consenting patients (like infant genital mutilation) to denial of needed healthcare because it isn't profitable enough and has an opportunity cost.
I agree with you about Infant genital mutilation (circumcision) but disagree the issue is the doctors themselves. I think the shrinking pool of competition is the major issue. (Hospitals being privatized with VC money etc)
> but disagree the issue is the doctors themselves
Who's fault was the opioid epidemic in the US?
I know a lot of blame has been levelled at the pharma involved, and rightly so, however every single one of those patients that got hooked via prescriptions had them from their doctor.
Those doctors aren't suppose to be automatons, just blindly follow Pharma marketing materials, they are suppose to be highly paid experts who's overriding concern is a duty of care to the patient.
There are many reasons the opioid epidemic was an almost uniquely US experience, but the private incentives for doctors was one of them.
Purdue was telling everyone around the world the same thing - but apparently only US doctors were fooled.
Typically, all single payer medical cost schemes are based on government facilities and intervention. Many Americans have little faith in their government to do anything, much less handle there medical care costs. This is why the employer model still exists.
Americans are different - they see themselves as not Europe or Asians - and they are proud of that. The "rugged individual" is still an ideal many cling to as part of their identity.
One thing that's never been clear to me is how either system plans on scaling healthcare. You have X doctors who can see (just a guess) 30X patients. Unless the number of doctors increase, some patients are going to be left out. In the current system it's those without employment. I'm other countries there's a waitlist. How can we make sure there's enough staff to provide adequate healthcare for everyone?
The U.S. has waitlists too? The U.S. makes people wait based on how much money they have, socialized healthcare systems make people wait based on an assessment of need. The latter is obviously better, even though it is not perfect. You’ll find that most everyone living with socialized healthcare believes it to be adequate when compared to the U.S. system. Adequate does not mean without flaws, adequate doesn’t mean available on demand, adequate means has good outcomes. Very few countries with a similar economy have as poor healthcare outcomes as the U.S.
> You’ll find that most everyone living with socialized healthcare believes it to be adequate when compared to the U.S. system
This is not true for Canadians. Many have to travel to the US, India, or otherwise abroad to purchase the healthcare they desire which is not available to them in Canada.
In Canada you have to get sick enough for the system to triage you into the quotas. But maybe you want to stay healthy before things get too bad?
The conclusion you're drawing does not follow. Canadians can be frustrated with the Canadian healthcare system and also believe it to be adequate when compared to the U.S. healthcare system. Canadians who are surveyed about healthcare typically say: the system is broken and needs to be fixed AND the socialized nature of it must be protected. Canadians are unhappy with underfunding, Canadians want more funding, they do not want the U.S. system.
I have a very simple and easy solution: allow any person with any medical education from any country around the world to practice medicine in their field of study, and relieve them from any medical malpractice responsibility (apart from criminal). Let them prescribe medicine, no paperwork, no regulation.
Anybody can choose to which hospital they go, the “state-licensed” crazy expensive one or the “unlicensed” one for 50 dollars a visit.
As far as I understand, currently the pool of people in the US who are allowed to do medical work is artificially limited, and doctors’ salaries are inflated. Just look around the world, there’s a huge supply of doctors with no student debt who would be happy to work for 60k a year. Also tens of thousands of US citizens will just go get a cheap medical degree from other countries, come back, and open private practice.
> You have X doctors who can see (just a guess) 30X patients
FWIW, it's about 1500X plus or minus.
> How can we make sure there's enough staff to provide adequate healthcare for everyone?
The solution now seems to be headed towards using FNP's and similar in place of fully licensed MDs. Which for things like primary care makes good sense IMO.
Forced labour? Poland has doctors on 32 hour shifts. Worker comes on monday morning, leaves tuesday evening. The night is spend on ER, with a few naps between patients. Perfectly legal!
The whole thing is a racket. The amount of doctors is artificially constrained by the AMA. It's also why the US medical school system is so competitive compared to other countries. For example, in England one does not need an undergrad degree then medical school. One just goes straight into medical school at university. It's a 5-6 year long program compared to the US's 8 year program.
Of course, doctors do not earn nearly as much in England as the USA, thus good luck ever getting something like to change in the USA. In America, most people go to medical school for the prestige and the paycheck, and our system utterly reflects both.
Why is this news? As a European this seems totally obvious.
I'm not sure which country you're from, but many EU countries do have private health insurance. The Netherlands, for example, has a system of subsidized private insurance, and a mandate that everyone buy a policy.
(If Americans are thinking, "huh, that sounds like Obamacare / the ACA marketplace!" then you're right.)
Painting in such broad strokes, the German system also sounds like the ACA, but it's really not: the high level description really erases key differences.
In Germany there is nothing like bronze/silver/gold plans. All statutory health insurance covers what is required to be covered by regulations, with just a few bonus services, at the regulated tariff plus just a few percentage points of variation. So the 90% of people in Germany who have statutory health insurance [1] have essentially the same coverage. The tariff is a percentage of income (up to a cap), not a flat fee.
[1] not everyone is required to have statutory health insurance, for example employees above an income threshold and self-employed people
The Dutch system and the U.S. system are not comparable. Health insurance in the U.S. is a “free market” that the government dabbles in with a little policy here and there. Health insurance in The Netherlands is controlled by the government, it is heavily regulated.
Still it is worth highlighting on this forum since many Americans believe that healthcare is "free" across Europe.
Healthcare is "free" across Europe, including in The Netherlands. The choice of The Netherlands' to structure their system as mandatory insurance doesn't change the nature of it, it is free at the point of service with the mandatory insurance costs paid for by the government when someone is unable to pay themselves.
The European/"Socialist" solutions are never obvious to Americans.
It is like parliamentarianism, campaign financing regulations, gun control, multiple political parties, etc. Americans call these things "Socialism" and then freak out about them and refuse to see any good on them.
Are the Americans in the room with us right now?
... and "Chat Control" and Digital ID and forcing digital currency and persistent digital surveillance and conceding your national sovereignty to a council that can pass binding laws without your consent and ....
Let's not pretend either system is perfect, or that the _underlying principles_ that both systems hold are the absolute correct way to organize a society.
Americans have be primed with _decades_ of rugged individualism and the idea that collective action is inherently weaker/flawed (just don't think about Social Security). It might have been reasonably true 100 years ago that everyone could pay for their own health care, but we're now in a world where the average person is perpetually on medications that are expensive to produce, and will demand increasingly expensive medical interventions throughout their life (heart health, cancer care, etc.). Combine that with AI probably wiping out a ton of industries/jobs - something has to change. I'm not going to pretend to have a solution, but I think it is disingenuous to suggest any EU nation has it figured out either and is obviously correct.
While Americans have been primed, it's still relatively new. If any of the new deal proposals were proposed today, everyone would lose their mind.
The dirty secret: half of what makes living in America tolerable comes from new deal policies. Everyone knows it, nobody will say it.
A similar thing goes for the ACA. Republicans hate it, but at the end of the day Americans don't want to be dropped from their insurance plans for having cancer or some genetic defect. Literally nobody wants that, only out-of-touch political talking heads want that.
That's not to say any of these policies are perfect, they all have flaws. But if you ask the American people what they want but carefully never name policy names, it becomes obvious everyone is on the same page.
Just a minor clarification: The Money freaks out, calls these things "Socialism" and then dumps billions on red-baiting campaigns and political donations to defend the (highly profitable) status quo. Most citizens would just like some healthcare.
We could easily do this and it would actually be significantly cheaper.
But I can’t imagine it happening nationwide. Maybe cities can create their own public options, say a flat 3% income tax and you get health insurance.
So much progress isn’t made in the US due to the welfare queen myth. Heavily intertwined with racism, many imagine “lazy” people getting something they didn’t absolutely earn.
> But I can’t imagine it happening nationwide. Maybe cities can create their own public options, say a flat 3% income tax and you get health insurance.
It's interesting: 3 states (Vermont, Colorado, and Massachusetts) did recently try to make state-level single-payer systems. https://www.thirdway.org/report/single-payer-health-care-a-t...
That “lazy people” getting something they didn’t absolutely earn is a core right wing narrative that has been very successfully propagandized for decades. People are still going to need work to pay for everything else. No one is going to stop working once the crushing weight of medical debt is lifted. It’s easy to debunk but I don’t see much effort going into this right now.
It also makes them more risk averse. Kind of the other side of the coin of not being innovative
Why do governments steer clear from performing clinical trials for new medicines?
Wanna see less innovation in healthcare under a single payer? Come to Canada, you will be on a queue for an MRI for at least 8 months (if you even get one).
Universal single-payer healthcare is one of the most pro-business and traditionally conservative with a lower case C thing you can imagine.
It’s pretty much a no-brainer cost reduction for everyone.
This doesn’t even mean you need to get rid of private insurance companies (see: Germany).
The cost reduction alone from everyone paying the same price (for the same service at the same facility of course) must be staggering. I agree - I don't see any need to ban any private insurance or providers and that's also aligned with a traditionally (lower case c) conservative free market view too.
Single payer maybe, but single provider? Never.
While I agree that there’s probably a benefit of diversifying providers in most situations, I would take single provider over “I can’t afford care at all.”
Also, single provider countries like the UK still have private healthcare. A LOT of private healthcare. This idea that single provider/single payer will make most people’s care worse and remove everyone’s options has felt to me a lot like industry propaganda.
Sigh, another US Healthcare article that states the obvious and won't change our reality. This topic is such an insta-depression trigger.
I don’t think it’s just healthcare, you have mortgages for inflated housing prices, expensive groceries and bills, and other expenses that make most people go to the route of boring stable job rather than innovative startup that might be out of business in a year and/or paying peanuts. Look at Canada for example, you can have a boring government job looking at excel sheets in the few hours you “actually” work in that week and still make $140k a year plus generous benefits, meanwhile you can grind your ass in a startup doing embedded firmware development and paid $70k a year with barely any benefits, hell, I have seen “senior robotic engineers” with a job descriptions enough to launch rockets and the pay is $60k!
Obviously people will go with the first option, innovation won’t feed their kids.
> ... my vote ... is for universal healthcare. The only real downside to it is that a bunch of companies that have entrenched their positions taking advantage of ordinary people will be denied a little profit.
Make that "many, many billions of dollars of profit". Then add on the probably-millions of jobs which the staggering inefficiencies of the current system support. (Everything from lobbyists for those companies, to the minions stamping "Denied" on health insurance claims, to the opposing medical billing staff who work for doctors & hospitals & such that need to get paid, to ...)
It'd be lovely if the leviathan could be slain, but don't hold your breath.
Private healthcare isn't the problem, lack of free healthcare is the problem.
I would much rather live in the UK where private healthcare is good and reasonably priced than Canada where in most places it's simply not available.
Nothing is free. We want both low cost and high quality healthcare.
This means we need to have ways in incentivize innovation (AI diagnostics, robotic procedures, drug discovery, deeper R&D).
Free Markets (with government controls against monopoly) are generally better than governments at delivering cost and quality improvements, but healthcare in most countries is somewhere between “100% not a market” and “70% not a market” (the US). In many cases, governments also actively create and enforce monopolies (eg AMA or local hospitals in the US).
There are a million other things but part of what is required for markets to work is skin in the game, which the UK, Canada, and the US all do bad jobs of in their own ways.
Some say medicine has no elasticity. I don’t think that is true for 90% of spend (for gunshot wounds, maybe, but most spending is on chronic diseases where multiple providers and approaches are available and people could price shop).
I would like to see more countries experiment with more free market healthcare. It’s remarkably effective for many pieces of healthcare.
Americans have been propagandized like crazy and don't really understand what can actually be done. "Single-payer" is treated as a synonym for "universal health care." "Private" is seen as mutually exclusive. People will say we should/shouldn't have something like Europe, then describe a system that only a handful of countries have.
Yeah, I find it discouraging that "single-payer" and "fully socialized" are treated like synonyms.
The "Bismarck model"[0] describes a family of healthcare models where people pay into a central healthcare fund, and that fund then pays medical providers -- which can be private businesses.
[0]: https://en.wikipedia.org/wiki/Bismarck_model
All doctor's offices in Canada are in fact private businesses. It's not actually a fully socialized system.
It's just there's a single payer. Those businesses bill the provincial government instead of you. Most of the dysfunctions in the Canadian system come down to provinces screw around with billing and payment and funding.
Take your dissatisfaction with the way the government manages payments to the voting booth instead of advocating dismantling what is on the whole a quite equitable system that has a history of actually producing very good health outcomes.
I actually have on the whole extremely pleasant experiences here in my corner of Ontario. And then I hear horror stories.
The system is underfunded and inconsistent. The province is to blame for that.
> a history of actually producing very good health outcomes
It may outperform the US, but it doesn't outperform normal countries.
> Take your dissatisfaction with the way the government manages payments to the voting booth
And vote for who? I have yet to hear a compelling solution from any party. At most, politicians advocate for throwing more money at the problem.
> The system is underfunded
Hot take: the system will always be underfunded. The demand for healthcare is nearly infinite in practice. What stops people from going to the doctor for every sniffle is either cost (in a private system) or waiting times (in a public system). If you had infinite resources to offer services, there are some folks who would be going in for MRIs every year "just in case" and getting prescriptions for every flu they have.
Yup. Recently drove 6 hours (each way, twice) to get to a Canadian private clinic to get treatment. This saved approximately a year (or more) of waiting in the public system for a routine outpatient procedure that takes 30 minutes to perform. I was lucky this option was even available within driving distance though.
Canada's public healthcare system is massively overloaded and it seems to be getting worse.
I really didn't appreciate how much of a problem this is in my 20s and 30s (while I didn't need much healthcare) and it was easy to assume the bellyaching from older folks was overblown. Time makes fools of us all.
You're describing a provincial issue, not a national one.
This is like the Canadian version of "no true Scotsman". When the province in question has 1/3 of the population of the country, what's the difference?
Its also described as a provincial problem but all of the provinces receive a substantial amount of funding, particularly for healthcare, via the federal government. People say "oh its the provinces fault, they just need to spend more", and then don't reflect on how much room there is for increased taxation, and particularly how much taxation the federal government currently applies. By far the most tax I pay as a Canadian is in the form of federal taxes. Of course, a bunch of this money does find its way back to the province, so the waters are a little muddy, but the federal government has been repeatedly downloading costs onto the provinces, while doing very little about its own spending. The Chretien government in particular did massive downloading of costs to the provincial governments, although their hand was forced by Canada's fiscal situation at the time. So simply saying, oh well the provinces need to step up, is an easy deflection from what is a pretty thorny problem. If the responsibility really is up to the provinces, then why does the federal government need all this money? If the feds are going to continue scooping up the lion's share of tax revenue then they need to continue helping to fund the various provincial responsibilities.
“Just get seen” lol from uk
1000%
no it doesn't
Yeah, so long as you can mooch off US healthcare innovation like COVID vaccines and weight loss drugs. There is a difference between going to doctor and getting effective treatment, as anyone who dealt with cancer in Soviet Union can testify.
I'm guessing you aren't aware how much of that innovation comes from academic research instead of direct private investment by pharma companies, or that there is a thriving pharmaceutical industry in places like Europe. Ironically your chosen examples are based on innovations pioneered by a German biotech (BioNTech) and a Danish pharmaceutical company (Novo Nordisk). What relevance the Soviet Union might have 34 years after it's collapse is something of a mystery.
> 1 in 4 American workers stay in their jobs because of the healthcare. It suppresses wages and working conditions - and prevents innovators from heading out on their own.
Yes. That is the point. This is how capitalism works. Just look at the story of Tetris as the pefect example of capitalism in action. Some Soviet programmers invented it in their spare time when they had access to computers, as enthusiasts. What did capitalism add? Licensing and sub-licensing agreements. Or, to put it another way, just building enclosures.
The idea that capitalism fosters innovation is a fairy tale. Companies reach a point where the only way to satisfy the market's need for growing profits is by cutting costs and raising prices. All of the inflation we've seen from the pandemic has been the "raising prices" part. AI exists for dynamic pricing. Dynamic pricing is nothing more than raising prices. Nobody is using dynamic prices to reduce prices. Why would they?
But the big part of AI is in labor displacement. This suppresses wages. Those who kept their jobs aren't asking for raises and aren't saying no to extra unpaid labor. Because they're in fear of losing their jobs. That's not a side effect. It's the goal.
US healthcare, if you can call it that, is part of this economic coercion. Being expensive to access out of employment is a feature not a bug. Everybody wins. Employers keep people who want to live. Healthcare company profits go up. You, as the individual? Nobody cares about you. Get back to work.
The end state for all this is something that looks like South Asian brick kilns where workers have debt they can never escape. Westerners are being loaded up with debt for a reason: to enrich various companies and to make sure we can't leave our jobs.
> Soviet programmers invented it in their spare time when they had access to computers, as enthusiasts. What did capitalism add?
Capitalism created the computers whose Soviet copies were Tetris' native platform, it made the languages Pajitnov used and the machines he ported it to. It incentivized people to bring Tetris to the rest of the world, and who knows, it might have spread on its own eventually, just for free, but maybe not.
> All of the inflation we've seen from the pandemic has been the "raising prices" part.
Superficially true, but vacuous. In anyway that matters this is flagrantly and amazingly false. But maybe you weren't aware of the $931 billion US dollars of stimulus paid to individuals, or you may not be familiar with the principle of supply and demand. More dollars in supply, the less the value of each dollar. Prices change to match the devalued currency.
> Being expensive to access out of employment is a feature not a bug.
I think this may qualify as a bug, to which you can credit the Revenue Act of 1954 for codifying the tax break given to companies who provide healthcare directly rather than pay that money as income to the employee. Classic example of a stale law. Now, vested interests may be keeping it in place, but I also see no significant awareness on the voter side of this issue nor the will to reform this discriminatory tax policy.