
Single-payer healthcare would save $450B and 68k lives a year: study - bjourne
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)33019-3/fulltext
======
onemoresoop
I'm paying nearly 20k (parents+child) on insurance I don't have time to use
(and luckily no serious need) and once my son went to see his pediatrician and
our 'private' insurance company (that i'm not going to name) sent us bill of
$500, for a check-up. We disputed the charge with the insurance and they
agreed to wave the payment next month. Next month comes and guess what? The
same letter comes in mail. We disputed it again and again the month after when
the bill was sent to us the third time. This is been happening for 6 months
and don't take it seriously anymore, I don't have time to waste. I realize
that a lot of money goes to waste on a system that is not working even if
you're paying a lot. It is utterly broken. Downright revolting. And on top of
it I get a better deal if I use no insurance at all for prescriptions. Then
what am I paying for? Emergencies? I am paying nearly 20k a year for possible
emergencies? It's become so complicated that nothing can be reasoned about it,
this is a monster that has to be killed with fire then drowned in deep waters.

~~~
beat
This is where I think political leaders (Democrat or Republican) could do
really well. It's not just making sure people are covered. It's the
existential dread of dealing with opaque, unpredictable, and incomprehensible
bureaucracy that can make life-and-death decisions or drop financially
crippling bills in your lap, _even if you have good insurance_. The American
health care system isn't just bad for the poor. It's bad for everyone. We just
can't deal with it, because we are exposed directly to unnecessary complexity.

But the fact that the people with money and good insurance are suffering from
the system as well as the poor seems to be lost on Democrats, and the
Republicans are just paralyzed by the whole idea of fixing health care. It's a
massive political failure for both parties.

~~~
codegeek
"isn't just bad for the poor. It's bad for everyone"

Thank you for saying that. I am amazed at how so many people don't see and
understand this. It is not just about Cost which is insane alright. It is
about the BS we have to go through after a visit to a doctor or hospital. I am
scared about the type of bills and claim fights I have to do if I visit a doc.
Not because I cannot afford it necessarily. But because I have to spend may be
like 5 hours calling doctor's offices, insurance admins, billing departments
and what not.

~~~
beat
I went through a billing/process dispute with a provider last year after a
change in their process led to a 30x increase in out-of-pocket costs for
necessary treatment. It ended with them flatly lying to me that the changes
were for my "safety". When I first dealt with all the new process, I asked my
doctor why they were doing it, and he said "I think they just want to charge
more money".

------
mgraczyk
In the study, nearly all the computed savings comes from two sources.

1\. Decrease in pharmaceutical costs as a result of better bargaining power.

2\. Decrease in administrative overhead, calculated by extrapolating the
overhead in medicare to the entire US healthcare economy.

I don't have an informed opinion on either of these estimates, but my
intuition is that #1 seems reasonable while #2 seems unlikely. The
justifications they give include lower executive salaries and decreased fraud.
From what I have been told by healthcare professionals, medicare has less
incentive to negotiate cost, less incentive to investigate fraud, and
therefore lower administrative cost.

~~~
bduerst
I worked in the EMR software industry and have certifications that involve
hospital & lab billing, among others. I've been on site with healthcare
providers, and there are entire buildings full of people whose job it is just
to code and scrub claims, and cover disputes/negotiations with private
insurance providers.

Consumers do not see it because it's typically off-site from the main hospital
care facilities, but believe me, the administrative savings potential is real.

~~~
mochomocha
I once worked at a US biotech startup getting paid by insurers where we would
build ML models just to reverse-engineer the inconsistencies of CPT coding &
claim reimbursement by insurers & hospitals so we could get paid. Basically
trying to automate "learn that Karen at insurer X processing claims wiht code
Y from hospital Z usually decides to reimburse $XX". This whole idea of "free
market is more efficient for healthcare" has to die. All the incentives are
backwards. For example: insurers don't want efficient claim processing because
that means less revenues for them.

~~~
BurningFrog
> * This whole idea of "free market is more efficient for healthcare" has to
> die*

The current US healthcare system has very little to do with "free markets"!

~~~
joe_the_user
_" The current US healthcare system has very little to do with 'free
markets'!"_

Sure, the US health care system is certainly not governed by wide open
competition, transparent pricing or similar things. But it certainly _has
something to do_ with the "free markets".

The system is basically "what you get when you realize you have to insure and
regulate but you never, ever do it in a centralized rational way, 'cause that
would be socialism - plus you never, ever separate an 'entrepreneur' from a
real or potential stream profits". Which indeed, builds the worst of all
possible systems, sending risks to the consumer and profits to the
investor/rent-seekers.

And from here, we could go forward to actual socialized, state-run medicine as
functions adequately in most industrialized economies or back to a "wild west"
system, where costs are lower, treatment is often OK and the heroin runs in
large rivers as due the fatal scams(as was the US' 19th century health care
reality).

~~~
maxerickson
Medicine changed so much after ~1880 (or maybe ~1900) that there's little to
learn from the prior era.

------
legitster
The _net_ savings would be $450B, but the total cost would still be in the 10s
of trillions of dollars (Edit: 30-50 over 10 years), bigger than all of our
federal spending combined. It's one thing to have as an objective, and another
as a plan for getting there. The proposal they cite would make federal
healthcare expenditures 69%(!!!) of the GDP (Edit: total federal
expenditures). It's simply not realistic to convert our entire economy into a
government and healthcare first system within only 4 years.

These calculations also ignore any affects of changed consumer preferences if
you eliminate copays and deductibles, something no other universal healthcare
system has done.

This is one of those calculations that is entirely accurate, but also entirely
misleading.

~~~
nbp160130
The "10s of trillions of dollars" estimates you see are for 10 years of
projected spending, not for one year.

~~~
legitster
Thanks. Good correction.

------
markroseman
That also doesn't factor in the indirect benefits to the economy, like all the
people who can't start a new business (etc.), being stuck in jobs they don't
want because if they left they'd lose their benefits.

~~~
bduerst
Or the boon from not having one of the highest infant mortality rates in the
developed world.

~~~
burkaman
The US also has the highest rate of maternal mortality in the developed world.

[https://www.propublica.org/article/lost-mothers-maternal-
hea...](https://www.propublica.org/article/lost-mothers-maternal-health-died-
childbirth-pregnancy)

~~~
sjg007
Yeah that's because a lot of US obgyns don't follow standard checklist
protocols. They don't even study it properly. I think the UK has the best one
and I know California uses it. Is it a question of treating the birth as a
medical event or as something else? I've read about doctors who have given
birth at a hospital and died and the death was preventable.

Other possible factors could be a lack of prenatal care or (and this is
separate) births outside of a hospital / medical setting.

------
dcolkitt
> Employer contributions to health insurance currently average $10446 per
> employee and cover 71% of a household’s premium. These employer premiums are
> equivalent to a 12.29% tax on payroll exceeding the first $2 million...
> Therefore, any payroll tax less than 12.29%, our upper bound in the SHIFT
> interface, would result in savings for employers.

This excerpt makes it glaringly obvious that no economists were consulted when
writing this paper. Checking the list of authors confirms this. While they may
be experts in public health, they're making one of the most elementary errors
in Econ 101. That is they're assuming that a private expenditure (employer
provided healthcare insurance) can be transformed into a public tax with no
loss of efficiency.

Deadweight loss[1] is the very first consideration in tax policy analysis. The
reason it exists is very simple. Private actors have an incentive to minimize
taxes in a way they do not with private expenditures. If you cut your
company's health insurance plan, your employees will be unhappy and you'll
either lose workers or have to raise compensation in other forms. If you
restructure your company to avoid payroll taxes, your employees still enjoy
the same access to single-payer healthcare.

Many M4A advocates try to hand-wave away this problem. It's the equivalent of
declaring "Then a miracle occurs". In this case the authors assume that the
current employer-paid premiums are equivalent to replacing with a uniform
payroll tax matching this aggregate. While 12.29% is the _average_ across the
entire economy, there's still wide variance between employers. Approximately
half of employers are currently paying less than this. A significant
proportion are paying substantially less than this.

If the current system was replaced with a uniform payroll tax, the cost of
labor for employers falling into this category will rise. In response that
means those employers will lower their demand for labor, which results in
either both economy-wide reductions in employment, wages and ultimately
investment and GDP. Those results will mean that not only will the
hypothetical new payroll tax not raise the revenue the authors are projecting,
but current pre-existing taxes, like income and capital gains, will also see
revenue shortfalls relative to baseline.

[1]
[https://en.wikipedia.org/wiki/Deadweight_loss#Tax](https://en.wikipedia.org/wiki/Deadweight_loss#Tax)

~~~
Denvercoder9
Why won't the rising cost of labor for the employers that currently pay less
be offset by the falling cost of labor for the employers that currently pay
more?

~~~
dcolkitt
To a certain extent that would have an effect. However there are strong
asymmetries between the two countervailing forces.

First labor isn't perfectly fungible between sectors and firms. Moving workers
will result in significant productivity lowering frictions. The clearest
example of this is that the group most likely to have low insurance outlays
relative to wages are high income workers. When the denominator's larger, the
fraction's smaller

For example a worker making $500,000 a year, even with a platinum plan $25,000
a year plan is only outlaying the equivalent of a 5% payroll tax. They'd get
hit very hard under single-player payroll tax. In contrast a worker making
$25,000 with a $6000 employer-insurance is paying 20%. Unfortunately the
typical $500k/year high skilled job can't easily be replaced with twenty
$25k/year workers.

Second, you have to consider not just the reshuffling of demand between
employers. You all also have to consider the tradeoffs potential workers make
between paid labor and leisure. Universal single-payer will cause some workers
to drop out of the labor force, scale back their hours worked, or take less
stressful but lower productivity jobs. When everyone has access to the same
healthcare regardless, the incentives between those options becomes less
differentiated. People retiring early or spending more time as homemakers
could be a good thing or a bad thing. But without a doubt it lowers economic
output, and therefore the tax base.

Finally raising payroll taxes creates incentives for workers to reclassify in
a way that shields their income. One form is outright evasion. More jobs will
pay cash under the table, more "employee leasing" schemes, or just simply not
declaring income. The higher taxes are the more incentive there is to take the
risk. But there's also many perfectly legal ways to dodge payroll taxes. Cash
compensation can be shifted to exempt benefits like life insurance, employee
discounts, and meals. Employee compensation can be reclassified as director
fees. American Workers can relocated to foreign offices, where they're exempt
from payroll taxes. Self-employed people can re-incorporate as an S-corp.

This just scratches the surface. Once you double the effective payroll tax,
expect a lot more effort and money invested in strategies to evade it. This
not only means the proposed payroll tax rate captures less revenue than
projected. It also means the pre-existing payroll tax now collects less
revenue.

------
threeseed
Pretty disingenuous study.

If you move to a Medicare for All policy it would shift employer health care
costs to the government. Which they would never be able to financially support
especially with the challenges of an ageing population and excessive debt. And
so when they say it saves $450b it's not taxpayers. It's mostly employers.

There is a reason that countries that started with M4A e.g. Australia, UK have
all transitioned to a public-private mix because it's simply not sustainable
otherwise.

~~~
three_seagrass
That's why the Medicare for all will still be funded, in part, through a
business tax. The difference being you've removed the for-profit middlemen, so
the healthcare costs are less for businesses than the privatized hybrid
version we have now.

~~~
fjp
The important issue with Warren's "plan" is that it's essentially a $8,000 per
year per employee head tax, so it's a regressive tax. An afterthought in the
expense of hiring a very highly-paid employee, but a not-insignificant expense
of hiring a lower-paid employee.

Not to mention that her plan exempts contractors and business under 50
employees, so it incentivizes businesses to to lean on contract labor or
reorganize themselves into smaller sub-companies - a small paperwork expense
in the scheme of things.

The business tax should be universal to stamp out avoidance and scaled to all
payroll spend so it's at least not regressive, even if it's not a progressive
tax.

~~~
threeseed
The problem with a new business tax is that it doesn't come for free.

Increasing businesses taxes reduces international competitiveness which can
reduce taxation collected in other areas. Also politically it's an incredibly
hard thing to implement.

And remember you have to do this at the same time as you're implementing
Medicare for All. Making it a pretty radical transition by any measure.

~~~
fjp
Oh I agree it's a radical change from what we have now (Although the resulting
system is one many countries have already succeeded with). I was merely
pointing out how if the program - and the tax to support it - is not truly
universal, you have created incentives for businesses to weasel out of it.

The exemptions are billed as being "pro-small-business" but that's a BS
talking point. Universal medicare for all would take away all that healthcare-
plan-administration overhead that small businesses already have to deal with
and pay for. Plus the extraneous benefits of having employees and customers
who aren't pressured to avoid basic health care and preventative care and then
go bankrupt when they need a larger procedure.

But I think only a radical change can have any real effect. You have to get
the denying-care-for-profit insurance bloodsuckers out of the system
completely; any concessions to them should be viewed with extreme suspicion.

------
cmollis
It’s a complete scam run by insurance companies who operate with ostensibly a
government mandate (although with seemingly zero oversight). I work for myself
and and have historically been paying about 20k per year in premiums for my
family with a family deductible which I’ve never gotten remotely close to
hitting. I have an hsa which I use to pay for out of pocket expenses pre tax
and there is a tax deduction for health care premiums. This year I decided to
test the system.. and didn’t purchase health care for myself. It turns out
that many of the services and drugs we all pay through the nose for are so
much cheaper If you ‘self pay’. I spoke to admins at both my doctor and the
affiliated hospital and they all have programs to help alleiviate payment
hardship if you don’t have insurance (translation: you’ll just have to pay the
actual cost of the procedure. Not the bullshit one that the insurance company
tells you that you saved a bunch on by overpaying for their insurance).
Ridiculous. Inevitably someone will figure out that it’s the insurance
companies ripping everyone off and do something that removes their
intermediation state-sponsored fleece-job. Ultimately you’re actually paying
for catastrophic insurance, oh and Medicaid and long term elderly Medicare,
but the rip off of your standard, healthy consumer is a travesty. Maybe
someone should be reviewing the actuarial models (or whatever they are) to
determine an apporopiate cost for someone who’s ‘heathy’. Me? I’ll just
continue to pay like I’m poor... and save some cash.

~~~
codegeek
I wish i could upvote you 1000 times. Why is it so hard for many people to
understand all of this ?

~~~
TheAlpacalypse
Because it takes advantage of risk. OP's gamble pays off if he never has an
emergency, but if he ever pays more than 20k on doctors visits he's fucked.

Granted, that doesn't often happen. But it's a risk that most people can't
afford.

~~~
shoo
> but if he ever pays more than 20k on doctors visits he's fucked.

I agree with the general point that there's more risk, but it doesn't
logically follow that if you pay more than 20k in a given year you are ruined,
compared to if you'd taken the insurance policy. Suppose you were paying 20k /
year minimum for "insurance", needed some healthcare, and ended up paying 25k
= 20k for the cost of the "insurance" and another 5k out of pocket that wasn't
covered. Does that mean you're ruined even if you do take insurance?

To make a better argument we'd need to understand how much wealth & income &
expenses someone has, and if they're able to set aside spare cash (perhaps in
an investment account) that's saved in the good years by not paying for
insurance, that can be used to cover or partially cover expenses in the years
where healthcare expenses are high.

------
macinjosh
I am sure, on paper, it is a brilliant plan. Unfortunately, reality and human
behavior almost never follow the plan.

Is waste, fraud, and abuse taken into account at all in this study? What about
the inevitable changes to consumers' motivation, behavior, and decision making
around healthcare? It will change drastically as the cost of their care is
even further removed from them than it is now.

People who have a proclivity to go to the doctor too much will go even more
when its 'free'. Younger people who eschew doctors because it interferes with
their current lifestyle will feel even safer continuing bad health habits
because free care will be there for them later in life.

Why should I subsidize other people's bad decision making?

EDIT: All healthcare is really too broad of category for government funding.
Obvious things like cosmetic surgery and others are already excluded from
consideration because they are not necessary. But IMO even when medical care
is necessary I don't think it always falls into the category of something
society should pay for. How many ER visits, ambulance rides, and surgeries a
year can be attributed to purposeful recklessness by an individual? If someone
decides it is a good idea to stand on a motorcycle's seat on the freeway and
then crashes, why should the public pay for that? On the other hand people who
have medical issues that are no fault of their own do deserve care.

~~~
burkaman
Did you read it? Also, are you familiar with any modern nations where a
single-payer healthcare system has been tried? Perhaps we could use them to
predict the effects.

> Is waste, fraud, and abuse taken into account at all in this study?

From the paper: "In addition to savings on overheads, a comprehensive database
of health-care charges would facilitate detection of fraud, which extracts
$85·7 billion every year. Following the transition to a single-payer system in
Taiwan, an 8% reduction in overall national expenditure was attributed to the
reduction in fraud. By moving from a fragmented health-care payment system to
a unified system, irregularities in provider claims can be more easily
detected. For example, under the fragmented system excessive claims for
physician time can be spread across patients with several different insurance
providers. However, acknowledging that improvements have been made in fraud
detection since Taiwan's transition, we conservatively assume that the
improved fraud detection would garner savings amounting to half that observed
in Taiwan, corresponding to 4% of total health-care expenditure."

[https://www.thelancet.com/journals/lancet/article/PIIS0140-6...](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736\(19\)33019-3/fulltext#seccestitle50)

> People who have a proclivity to go to the doctor too much will go even more
> when its 'free'. Younger people who eschew doctors because it interferes
> with their current lifestyle will feel even safer continuing bad health
> habits because free care will be there for them later in life.

Is this a significant problem in countries with single-payer systems?

> Why should I subsidize other people's bad decision making?

You already are? That's how health insurance works. What this study is showing
is that you'll have to subsidize other people less, because the whole system
will be less expensive.

~~~
macinjosh
> You already are? That's how health insurance works.

I am not a defender of the insurance system. It blows. But single-payer is not
the only other choice.

I want a freer healthcare market where prices are known before consuming
services. Real market competition could actually occur to bring down prices.
For drugs, research and development for less profitable cases could be a very
worthy target of government funding. I don't have all the answers but neither
does single-payer.

~~~
burkaman
Healthcare is not and cannot ever be a free market. You cannot have price
transparency when a buyer may be unconscious at the time of "purchase". You
cannot have price competition when buyers are frequently forced to immediately
purchase a good or service if they don't want to die. Hospitals are chosen by
proximity, not price. These are the consequences of being mortal human beings.
If we were all immortal, and "healthcare" was nothing more than voluntary
cosmetic surgery, a free market might make sense.

~~~
macinjosh
> You cannot have price competition when buyers are frequently forced to
> immediately purchase a good or service if they don't want to die.

The number of instances where this dire case occurs is minimal compared to
every other instance. Sure, when its life and death its not practical. Perhaps
those sorts of situations is where single payer or insurance makes sense.

For humdrum things like physicals, wellness visits, cold and flu checks,
vaccinations, routine labs and imaging, etc. a free market could work very
well.

~~~
burkaman
Hospital care is the largest spending category by far:
[https://www.cms.gov/Research-Statistics-Data-and-
Systems/Sta...](https://www.cms.gov/Research-Statistics-Data-and-
Systems/Statistics-Trends-and-
Reports/NationalHealthExpendData/Downloads/highlights.pdf)

While the other things you list are technically not immediate life-or-death
decisions, they still are not voluntary purchases. The presence of any kind of
coercion distorts a free market.

Also, I don't want to live in a society where individuals must decide between
vaccinating their newborn children or paying their electricity bill that
month. Or between getting a flu shot and buying groceries for the week. The
externalities of these "individual" decisions are obvious, and a free market
has no answer.

Finally, let's imagine a system where emergency care is covered by a national
single payer, but "humdrum things" are available in a free market. Now the
poor can't afford basic physicals and flu shots, so we all end up paying more
into the single payer system to cover such people being hospitalized for
conditions that could have been prevented by regular medical checkups.

------
partiallypro
I don't know why the idea of a "public option" fell out of favor with
Democrats. It's a good stop along the way, and doesn't risk completely
destroying an industry overnight...and therefore has a much higher chance of
passing. Eventually employers would push people onto the public option plan,
but it wouldn't be overnight. Bernie's plan, imo has so much room for error,
it's not even worth considering without a stop along the way. It's also ironic
he wants to ban private insurance completely (I assume that even means
supplemental) when pretty much every single country he cites as a model
doesn't do that.

~~~
foolbiter
the end result of the public option is employer-based plans offloading their
least valuable (and most vulnerable) customers onto the public option, leading
to much higher costs for everyone. the abolition of private insurance is
necessary for the efficiency and bargaining power of a maximalist medicare-
for-all system.

------
lwb
Is this Bernie's plan? I know there are subtle but important differences
between all the different varieties of "universal healthcare" that exist in
the world.

The Twitter account @BadEconTakes enumerated something about this in a recent
post:
[https://twitter.com/BadEconTakes/status/1228143455399858176/...](https://twitter.com/BadEconTakes/status/1228143455399858176/photo/1)

Excuse their obvious bias against it; I wonder what the difference in expected
savings (money + lives) might be between all these different variations on the
same theme.

~~~
secabeen
The fundamental challenge of any universal health care system is that to cut
our spending on health care to the level of other western industrialized
countries will take $1 Trillion of annual revenue out of the existing system.
There's going to be a lot of disruption and people who need new jobs when that
revenue goes to other things in our economy.

~~~
Loughla
Real question, not snarky:

Why is this sort of downsizing always wrong for white-collar workers when
blue-collar workers have been dealing with it for decades?

~~~
koolba
There’s a huge difference between downsizing caused by economic forces of the
private sector and downsizing caused by outright elimination of an industry by
elected officials.

~~~
ablekh
Healthcare (as some other sectors) is full of inefficiencies and removing or,
at least, reducing them cannot be seriously labeled as "elimination of an
industry". I don't see how job market restructuring in healthcare industry due
to proposed transition to the single payer model is different in its essence
from potential significant job market restructuring across various industry
sectors due to automation trend.

------
dboreham
As Churchill said...

“You can always count on the Americans to do the right thing. After they have
tried everything else.”

~~~
grayed-down
Would the right thing be single-payer or what would have to replace it once
the economy and the medical profession have been destroyed?

~~~
scottmcf
Alarmist nonsense.

~~~
grayed-down
We'll see. I've got enough money to survive single-payer, do you?

~~~
codegeek
I am rich enough but running out of money every year to pay for Insurance
Companies profits. So yea.

------
VHRanger
The study's methodology is awful as described here:

[https://www.reddit.com/r/neoliberal/comments/f4uk13/a_critiq...](https://www.reddit.com/r/neoliberal/comments/f4uk13/a_critique_of_the_lancets_medicare_for_all_study)

Not sure how it even got published

------
jkingsbery
> "Furthermore, we estimate that ensuring health-care access for all
> Americans"

From many anecdotes I've read about medicine in socialized countries, it's
unwise to assume that having insurance is the same as access. Many procedures
are made unavailable due to being considered cost effective by The Single
Payer, and the wait time for specialists can often be long.

Further, what counts as "costs" in US health industry is kind of funny -
health care providers have a book-price that is often inflated, so that
insurance companies can claim to their customers (mostly employers) what a
good job they do in reducing costs.

For the opposite perspective, some of these points are discussed in much more
detail in these two recent EconTalk episodes:

* [https://www.econtalk.org/marty-makary-on-the-price-we-pay/](https://www.econtalk.org/marty-makary-on-the-price-we-pay/)

* [https://www.econtalk.org/keith-smith-on-free-market-health-c...](https://www.econtalk.org/keith-smith-on-free-market-health-care/)

~~~
notatoad
>Many procedures are made unavailable due to being considered cost effective
by The Single Payer

whether the insurance is coming from a single payer or a private company,
access to health care does not mean unrestricted access to any medical
procedure you want. Private insurers also deny treatments that aren't
considered to be cost effective.

~~~
Loughla
That's what I've never understood about the arguments against single payer:

>You can't pick your own doctor

I already can't. If they're in network, I'm good, but if they're out of
network - like my doctor was - then I have to find a new one.

>You can't pick your treatments

My spouse was denied medication by an insurance company because it was too
new. So.

>You don't get to have all the healthcare you want

I already have to have pre-approval for anything up to and including emergency
surgery according to my annual medical contract. So that's out the window,
too.

And I have good insurance through a respectable company who may or may not
have a name that rhymes with smue-smoss smue-smield.

Not sure what other arguments there are.

~~~
dx87
I know it's an edge case, but there was that kid in the UK with an easily
fixable, but fatal, heart condition. Their health association refused to pay
for it because no doctors in the UK knew how to perform the surgery, and they
weren't willing to pay for them fly to the USA where there were specialists
who could do the surgery. After they started a GoFundMe to pay for the surgery
themselves, and there was a lot of press about it, the government finally
agreed to pay for it instead of letting the kid die. I've also read a lot of
stories from people in Canada and the UK saying that it's almost impossible to
get same day medical care, even from a general practicioner. Like, they'll
have to call as soon as they open, and hope they aren't already booked for the
day.

~~~
notatoad
>there was that kid in the UK with an easily fixable, but fatal, heart
condition

i'm curious what story you're referring to. The two that were in the news
recently were Charlie Gard and Alfie Evans, but neither of those were heart
conditions and neither were easily fixable. They were denied access to
treatments that most medical experts agreed would not be effective.

------
markroseman
People seem to think that if you move to single payer that the single payer
would behave like any of the existing payers, i.e. you call to fight for
approval for everything you do, argue about fees for each item, denying things
is routine, blah blah blah.

If you have a single payer system, it doesn't have to work that way. Not even
close!

~~~
refurb
No, you wouldn’t have to fight for everything.

With a single payer, there would be a list - this is what we pay for, this is
what we don’t pay for.

------
riazrizvi
Currently that money is flowing from the pockets of everyone into the pockets
of investors, legislators and workers tied to the healthcare industry. What is
the correct amount of profit? Who is to say the healthcare industry was making
enough before they started hiking prices? Perhaps they saved their industry?
Other countries have cheaper healthcare costs, but maybe they have less
healthcare? Sure other countries might be living longer but perhaps that is
tied to diet/lifestyle. Maybe Americans are living less because they are
working harder, are being destroyed by a bountiful food industry that they
can't resist, maybe the healthcare industry is picking up the slack... The
solution offered here is a state-controlled market, which didn't work well for
the Soviet Union so is it good now, or is this just our last desperate attempt
to pick the lesser of two evils? But then is that the solution for out of
control internet charges? For out of control property prices?

The single issue we should be focusing on in America, across healthcare, tech,
government contracts, is _fair_ markets, not _free_ markets. _Free_ markets
are the flag which incumbent industry rallies behind because they can rig the
system when there are no rules. Similar to the Glass-Steagall Act which
enabled a fairer market for average investors competing against financial
institutions, the hospitals, pharmaceutical companies and insurance companies
need to be broken up, so that we can restore a _fair_ market for healthcare.
Politically it is our best strategy for an improved service. Since it will
raise industry allies, those with solutions that are being unfairly crushed by
an uncompetitive industry. Remember we are living in the Citizens United era,
corporations have very strong political power. Universal Healthcare is going
to cause the healthcare industry to stop infighting, they will circle their
wagons, and collude with better effect by engineering supply shortages,
confusing legislators using bribery and misinformation, and doubling down on
pricing loopholes...

~~~
bazooka_penguin
Is profit the problem here? Not a horde of unnecessary make-work jobs and
overpaid workers?

------
OrgNet
The worst thing for me is if you go, for example, to the emergency room, the
hospital charges you something like $200 and you think that is the end of it,
but about a month later, other bills start coming in: $300 for xray, $350 for
doctor X, etc... health insurance in the US sucks.

~~~
n9
ER visit as a foreigner in Switzerland. Saw a dr. Saw a neurologist. Had a
full bank of blood tests. Had an MRI of my head and neck. In and out in five
hours. I was billed $400.

------
LordFast
The problem has never been about what system works, that's always been clear.

The problem has been, and will continue to be about all the people that are
currently employed by the dysfunctional system. Managing that situation is the
meat of the challenge.

~~~
UnFleshedOne
It was never a problem when companies started outsourcing to developing
countries in droves...

~~~
LordFast
"Hey if you join me in this scheme to make more profit by squeezing other
people out of what they have today, I'll give you a cut of that profit. What
do you say? I promise you'll keep getting a cut until it makes sense to
squeeze you out as well."

Less obvious, and more eloquent, of course.

Better choices, better opportunities, and real innovative solutions to solve
real problems. Those are the rising tides that will raise our boats instead of
sinking them.

I concede though that it's easier when we're talking about 10 people and a
startup, rather than 330 million human beings across 3.8 million square miles.

I want to see more leaders focus on the real crux of the problem, taking into
account human nature while we're at it. I'm not holding my breath.

------
twodave
The biggest problem I have with health insurance is that it’s nearly
impossible for either the insurance or a provider to tell me how much
something other than a routine visit will cost me until after services have
already been rendered. Forget the high costs, I can’t even make an informed
decision half the time unless I just go by the uninsured rates.

------
api
The fact that it would save money may be part of the problem. The massive and
very redundant health insurance bureaucracy employs a lot of people.

In the realm of government contracting and large scale policy decisions like
this, efficiency is often politically inconvenient since it means jobs may be
lost.

------
newguy1234
What I don't get is how do 37 million Americans not have health insurance when
the ACA was suppose to fix that issue? All of the plans are adjusted based on
your income level and you get a tax credit if you are low income. If you are
very poor then you get free healthcare....

~~~
megiddo
If you have a reasonably middle-class income, the plans are prohibitively
expensive and unbelievably shitty.

I'm only anecdotal, but by comparison, prior the ACA, my insurance for a
family of 3 was $300/month with a $2500/year deductible. That $300/$5000 plan
was considered predatory and high deductible.

The first plan offered to me under the ACA was something like $700/month with
an $8000 deductible. Plans this year were ~$950/month with a ~$15,000
deductible. It's Cadillac pricing and one-star benefits.

Meanwhile, my "non-compliant, high deductible" plan from a private market is
$400/month with a $5000/deductible.

I opted out of ACA - it made sense to opt out even when I had to pay the
$2100/year penalty, because the premiums and the deductible were still less. I
qualify as "underinsured", but that couldn't be farther from the truth. My
plan can be irritating to use, but they have online self-service tools for
providing healthcare, and I have never been questioned about paying for
necessary treatments. I pay them, they pay the doc. Very simple.

For people who relied on private insurance and weren't destitute, the ACA has
been a shit-show from day one.

The only highlight to the ACA for me is the hundreds of thousands in billables
I've accrued helping institutions become "compliant" with the ACA.

~~~
newguy1234
Interesting I didn't know it had those issues

------
xmly
Universal Care = Medicare + Medicaid + ObamaCare + Employment sponsonered care
???

My opinion is that we should first optimize the existing system to lower the
medical cost first. Health insurance is just prepaid medical costs.

If the cost is lowered, no system would work.

~~~
ogre_codes
No, this is talking about single payer healthcare which would mean the current
insurance industry would be out the door. No Obamacare, just one government
agency paying for healthcare.

Employment sponsored healthcare will likely still exist in some form, perhaps
to ensure speedier access to some care.

~~~
jandrese
Probably no employer sponsored healthcare for the most part. That money would
go towards the Medicare coverage. There might be some supplemental plans for
people who want to skip lines but most people will just use Medicare.

~~~
xmly
Is that what Canada has right now?

For US, the real problem is still health cost is too high. The market
regulation seems doe not work, at least for this decade.

~~~
n9
From what I see about half the cost is the admin overhead and another huge
chunk is providers billing very high rates because they end up paying a lot
less to the insurance companies. If you want to optimize the lowest fruit is
the admin overhead, which means just go single payer.

~~~
xmly
For admin overhead, my understanding is that each insurance firm has its own
standard and processing protocols, which brings a huge burden to providers.

The simple solution is having a simple and shared standard enforced by law.

------
winstonewert
What I wish is that everyone would be given a choice. Either opt completely
out of all government regulations/taxes/programs related to healthcare or opt
into a universal healthcare program. Think that you'd better off without
government involvement in your healthcare? Put your body/wallet where your
mouth is. Think you'd better off with a universal healthcare system, put your
body/wallet where your mouth is.

But no, we'll just keep the crappy status quo which nobody thinks is a good
idea.

------
naveen99
Why don’t they just move the Minimum age for Medicare down from 65 gradually,
and see what happens... change the speed of lowering the age depending on how
the market responds And How the public likes it.

------
ve55
I dislike how often I see justifications for the sources of inadequacies of
current systems supposedly shown by comparing different countries to the US.

An example of this in the paper is when they state that the US has more
expensive healthcare, but yet worse metrics such as life expectancy. As the
differences in healthcare systems between the US and these other comparison
countries are obvious, they want to clearly imply causation here. But, when
comparing one country to another country, you are changing so many variables
at once that it doesn't allow you to conclude the source or causality of these
differences. They may still be partially right, but it is nowhere near proven.

While the US does have more expensive health care, it also has higher real
incomes, which seem to correlate strongly with this (see the first two images
on [https://randomcriticalanalysis.com/why-conventional-
wisdom-o...](https://randomcriticalanalysis.com/why-conventional-wisdom-on-
health-care-is-wrong-a-primer/)). While the US does have a worse life
expectancy than many 'comparable' countries, it also has significantly worse
problems of obesity and drug overdoses, which when controlled for eliminate a
large amount of the discrepancy.

Some parts of the paper are definitely reasonable and generally agreed-upon,
but it's quite clear they had a specific goal and political call-to-action set
in their minds when writing it.

~~~
zanny
> has significantly worse problems of obesity and drug overdoses

Which can easily be caused by a destructive and broken healthcare system
leaving the ill unable to seek treatment and thus left to fend for themselves.

Even for those with insurance the costs - in time, in bureaucracy, in often
money when your insurance provider refuses to cover - are unreasonable to
consider seeing a doctor in a thousandfold situations that Europeans never
even second guess. Because they don't need a waist deep paper trail to go to
their physician, because they won't get a dozen different bill collectors
harassing them in every legally gray way possible, because they don't need to
break out the checkbook on the way out to pay the minimum barrier to entry
extortion at the end.

~~~
ve55
The reason I disagree with this is because our healthcare system is largely
built upon treating someone after they have an apparent issue, instead of
preventing the issue.

It seems very difficult for a healthcare system to stop someone from becoming
obese to begin with, or stop someone from abusing drugs that is intent on it
and not seeing anyone intentionally, or stop problems like depression by their
root cause instead of attempting to fix all of these things afterwards.

I'd be surprised if you really think a healthcare system by itself could be
powerful enough to stop obesity.

~~~
narag
Actually it happens. You go to the doctor with some side effect, like
headaches or high blood pressure and they nudge you to go to the dietist. Of
course you can refuse, but there are a lot of kind and caring professionals
and you know it won't cost you money, so it works sometimes.

~~~
ve55
Right, but the keyword there is 'nudge'.

If you are already having headaches and high blood pressure due to your diet,
your diet should have been modified long ago. Similarly when people have
cardiovascular issues and atherosclerosis, the time to change things was
likely decades ago, not after they've already damaged their body so much.
Sometimes these 'nudges' help patients, but getting someone to significantly
alter their life is very hard.

~~~
narag
Still there are much less obesity over here.

------
thecleaner
The answer is simple, vote for a candidate that campaigns on universal
healthcare. That candidate may not be the politically purest one.

~~~
usaar333
Isn't every Democrat supportive of universal healthcare? (Which at the minimum
is just ACA + technical fixes on it)

There are differences through whether it should be single-payer or not.

~~~
codegeek
ACA is not universal healthcare. It only made things worse overall except the
fact that people cannot get denied due to pre-existing conditions. Obama
should have pushed for a public option with ACA at the time. In 2020, fuck
that. We want to go straight to Universal healthcare, single payer. No middle
ground. Only 1 democrat supports that so I am voting for him.

~~~
usaar333
Why is ACA not universal? (Ignoring technical problems it had that prevented
that from actually happening). It guaranteed affordability, coverage, and
prevented you from opting out.

------
jahaja
> Furthermore, we estimate that ensuring health-care access for all Americans
> would save more than 68 000 lives and 1·73 million life-years every year
> compared with the status quo.

That this has been allowed to go on in a land of plenty is an utter disgrace
that I can only hope will not go down well in the pages of history.

------
Olscore
Fundamentally, it is disgusting we are forced by government to buy insurance
products (e.g., car, health) provided by for-profit companies; however, I do
not support universal healthcare either. The government has zero ability to
control its expenditure, because the electorate vote themselves benefits.

The long-term financial incentives to maintain a functioning society are all
broken because of the misaligned short-term (vote for me, get free stuff) and
long-term incentives (debt reduction, financial management, business planning
and other investments.) Voters are simply looting the treasury at this point.
It is a shame. I cannot believe anyone actually buys into the notion that
government will fix problems, or somehow do a better job than what already
exists.

The candidates are just handing you money from your own pockets, and skimming
off the top.

It's so damn dumb.

~~~
SketchySeaBeast
> The government has zero ability to control its expenditure, because the
> electorate vote themselves benefits.

Could you give me some examples of this? Living in a nation with universal
healthcare, I've never seen this.

~~~
Olscore
What else would you call students voting for loan forgiveness? Point blank the
candidate is effectively saying, "we will give you $xx,xxx" in the form of
loan forgiveness. It is the same for healthcare. This is a literal voting for
benefits; and, this creates perverse incentives for the electorate to vote for
whomever will "pay them" the most for their vote. Candidates are simply buying
votes by offering free stuff with taxpayer monies. It is completely broken at
this point with one candidate trying to out-give the next.

~~~
turbinerneiter
Except that here in Europe (Germany and Austria) in each election, saving
money on social programs by cutting cost overhead as well as services is a big
topic and parties arguing for those cuts regularly get around half of the
votes.

The one candidate tries to buy votes by offering free stuff pairs by taxpayer
money, the other one tries to buy votes by promising to stop giving out free
and lowering taxes.

------
fmakunbound
Well there you have it, I guess. Thinking in the small, I wonder how it would
have affected that Rabies shot treatment I had to get that ended up costing me
$25,000 and the fucking thing wasn't even infected.

------
refurb
_The US Department of Veterans Affairs (VA) has the capacity to negotiate
prices that align with the therapeutic value of pharmaceutical drugs and could
be a potential model for the federal single-payer health-care system. This
bargaining power results in pharmaceutical prices that are 40% lower in the VA
system than those under Medicare_

This is a terrible proxy.

The VA doesn't really _negotiate_ , the discounts are mandatory to do business
with the VA, which is an incredibly small slice of the entire US healthcare
system.

When they do negotiate, it's because they promise to exclude other drugs. As a
result, there are many drugs you can't get at the VA.

~~~
briandear
And, if the VA is an example of single-payer, then we're doomed. The VA is
awful. That's the single best argument against single-payer.

------
oxide
I appreciate that they took the time and expense to create a proper study
looking at the numbers.

------
spaginal
If you think healthcare is expensive now, just wait until it's "free".

------
gridlockd
Single payer creates an unnecessary monopoly. One of the best health care
systems (Switzerland) is both private and not single payer - but purchase is
compulsory.

Obamacare and especially Trumpcare simply can not work when people delay
purchasing insurance until it's too late. You can't have your cake and eat it
too.

Furthermore, insurance plans should not be tied to employment/employers. It's
a bad incentive structure.

------
ghostpepper
Can anyone post the article? The site doesn't load without cookies enabled

------
jays
It’s hard not to appreciate the cost savings, saved lives, and benefits
employees and employers would see from universal healthcare.

Has anyone seen any studies on the potential impact it would have on insurance
and medical administration industries? i.e. lost revenue, jobs, etc.?

~~~
mullingitover
> Has anyone seen any studies on the potential impact it would have on
> insurance and medical administration industries? i.e. lost revenue, jobs,
> etc.?

I wonder about this in the same way I wonder about a world where we have
professional window breakers, and what effects it would have on the window
repair industry if we stopped having people go around breaking windows.

~~~
ThrowawayR2
Unfortunately, they can protest, lobby, and, shall we say, make unfortunate
voting choices even after being unemployed, so it might be wise to rethink
that opinion. Any changes that are made need to be gradual enough to allow
them to transition to other careers or political instability will follow.

------
protomyth
I just want an explanation of how this would work out better for the general
population of the US than Indian Health Service has worked out for the tribes?
I just don't trust any of these studies when the refuse or are ignorant of
what the government is currently doing and how problematic the governments
approach is.

------
grayed-down
My neighbor, a colorectal surgeon and very into what he does, has remarked on
several occasions that if single payer ever happens, he and most of the other
surgeons he knows will likely walk away from the profession very shortly
thereafter. There would be no financial or professional motivation to continue
practicing.

~~~
markroseman
Because all the doctors in countries that have single payer are so horribly
done by...?

~~~
refurb
20-30% decrease in reimbursement will tick doctors off big time.

