
Build Your Own ‘Medicare for All’ Plan. Beware: There Are Tough Choices - smacktoward
https://www.nytimes.com/interactive/2019/02/21/upshot/up-medicareforall.html
======
iandanforth
The fact that the provided charts have no comparison to existing universal
coverage systems (e.g. Canada, Europe) is frustrating. American news
organizations treat the topic as if it were _new_ and as if the care of
American bodies is radically different from the care of the hundreds of
millions of human bodies already being looked after by existing social welfare
plans.

~~~
citilife
You really really don't want to compare with the rest of the worlds universal
coverage systems to the U.S.. Many places have way more significant wait times
for treatment...

Canada: [https://torontosun.com/2017/02/16/canada-has-worst-
erreferra...](https://torontosun.com/2017/02/16/canada-has-worst-erreferral-
wait-times-in-11-developed-countries-
report/wcm/2f7966f0-0daa-4589-aba7-68e54e0a056e)

Ireland: [https://www.irishtimes.com/news/health/new-record-of-more-
th...](https://www.irishtimes.com/news/health/new-record-of-more-
than-718-000-patients-on-waiting-lists-1.3628584)

There's more, but lets get real. The U.S. system has it's problems, but at
least I can get treatment. That's why it's a difficult subject and why we
should be cautious on how to proceed. Perhaps run trials per state or
something as well.

~~~
taoistextremist
So, according to your article, 29% of Canadians had to wait 4 or more hours,
whereas 24% of Americans did, so I'm not seeing much comparative improvements
and I'd hypothesize that long ER wait times are not to do with which
healthcare model you have, it has to do with misuse of ER. Meanwhile, France,
Germany and the Netherlands all had outstanding numbers, and as far as I know
they all have universal coverage.

~~~
CountSessine
_So, according to your article, 29% of Canadians had to wait 4 or more hours,
whereas 24% of Americans did_

What? Where does it say that in the report? The figure is 24% of Americans and
_56%_ of Canadians!

 _Patients who waited 4 weeks or longer to see a specialist, after they were
advised or decided to see one in the last 2 years: Country results from
highest to lowest_

 _Canada, 56% (below average); Norway, 52%; New Zealand, 44%; Sweden, 42%;
United Kingdom, 37%; Commonwealth Fund average, 36%; France, 36%; Australia,
35%; Germany, 25%; United States, 24%; Netherlands, 23%; Switzerland, 22%_

Also, here's a quick guide to health insurance systems around the world. As a
Canadian, I would urge all Americans to be extremely suspicious of the
National Health Insurance model that Canada has. Wait lists are very real. The
Bismarck model seem like a better fit for US culture and needs (still
universal access).

[http://www.pnhp.org/single_payer_resources/health_care_syste...](http://www.pnhp.org/single_payer_resources/health_care_systems_four_basic_models.php)

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stult
It's a little misleading that they marked experts as opposing ideas when that
opposition was merely based on political feasibility.

~~~
chiefalchemist
I agree. We hire and pay politicians to represent us and get done what needs
to get done. They work for us, and their political careers are not my / our
concern. If they don't have to will to be leaders then we simply need to hire
someone else.

I'm tired of "political feasibility" being a euphemism for negligence,
incompetence and lack of creativity.

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lucian1900
I don't see any tough choices. Saying yes to all of them merely brings the US
in line with most of the developed world.

~~~
alistairSH
The only question I hesitated to answer "Yes" was the cost-sharing/co-pay
question. In principle, I'm not opposed to some co-pay or deductible. But, the
devil is in the details.

~~~
snuxoll
Even other developed nations often have some form of cost-sharing, I think
having some small charge helps offset administrative costs and prevents people
from going to the doctor for every cold.

What we have right now with deductibles and co-insurance is ludicrous though,
that shit needs to go.

~~~
kenhwang
Taiwan had to introduce cost-sharing for pharmaceuticals because of abuse of
the system. I truly because cost-sharing is necessary to keep total costs
reasonable and unnecessary visits down.

Plus, it offers a minor incentive to actually be healthy. Health should be a
personal responsibility just as much as a government responsibility. I don't
support subsidizing unhealthy habits.

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Glyptodon
I don't know that I want Medicare for all (not sure what it means, and at
least where I am it's considered a real question whether doctors accept
medicare patients), but I would love to see the end of employer financed
health care (which I feel traps people in jobs), some form of minimal
universal coverage, and many other reforms.

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Someone1234
There's a lack of nuance the answers provided.

For example one asks:

> Do you support replacing individually purchased private coverage, like
> Affordable Care Act plans or Medicare Advantage?

What's odd even on the face of it is that Medicare Advantage works VERY
differently than traditional private insurance (one being supplemental and the
other being primary coverage).

Many countries have a mixed system. A basic level of healthcare with
supplemental plans built on top to provide improved benefits, reduced OOP
costs, and so on.

> Do you support ending employer-based private coverage?

Again, lacks nuance.

Some plans outright ban employer involvement, whereas others allow employers
to make pre-tax contributions to something akin to a HSA (which can be used on
premiums torwards a plan of the employee's choosing).

> Do you support eliminating cost sharing — meaning co-payments, coinsurance,
> deductibles — for everyone?

All or nothing. We cannot talk about eliminating cost in some services/areas.

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legohead
I was hoping for something like choosing where to get the funds from. Defense
budget, taxes, etc.

At least tell me the estimated cost for the choices available...

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jawns
The fifth choice presented in this Upshot piece is whether there should be
some form of cost sharing in a universal health care system.

The argument against cost sharing is that it penalizes the poor, who are
likely to put off treatment if they can't afford it.

The argument in favor of cost sharing is that it helps prevent people from
taking advantage of the system.

I wonder if it might be possible to strike a balance using graduated (rather
than fixed) cost sharing based on income.

So, let's say the cost sharing for a monthly prescription is normally $30.

But someone with an AGI below $50K might pay $20, and someone with an AGI
below $30K might pay $10, and someone with an AGI below $10K might pay $5.

You would always have to pay _something_ (because, as NYU's Glied points out,
"the biggest effects are moving from zero to something"). But that something
would be proportionate to your means.

~~~
zeroonetwothree
The could be good in theory but it seems like a nightmare to implement. At the
time you pay you don't actually know your income for the year so how would it
work exactly? You guess and then get it adjusted at tax time (would everyone
then just put $0?)

~~~
nybble41
You could just use average income over the previous 3-5 years rather than the
current tax year income. The IRS already has that data on file.

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scarejunba
I support the idea but it looks a lot like we plan to keep current medical
prices while just funding it from the government. I think we should glut the
doctor economy by starting a hundred new medical schools and brain draining
the best doctors out of every other nation.

There is a supply limit imposed by the AMA. Kill it.

~~~
elektor
In 2014, the Institute of Medicine released a thorough analysis on graduate
medical education that argued there was no doctor shortage, and that we didn’t
really need to invest more in new physicians.

The system isn’t undermanned, it said: It’s inefficient. We rely too heavily
on physicians and not enough on midlevel practitioners, like physician
assistants and nurse practitioners, especially because evidence supports they
are just as effective in primary care settings. We don’t account for advances
in technology, like telehealth and new drugs and devices that lessen the
burden on physician visits to maintain health.

Source: [https://www.nytimes.com/2016/11/08/upshot/a-doctor-
shortage-...](https://www.nytimes.com/2016/11/08/upshot/a-doctor-shortage-
lets-take-a-closer-look.html)

~~~
klagermkii
> We don’t account for advances in technology, like telehealth and new drugs
> and devices that lessen the burden on physician visits to maintain health.

Can you give some examples of how other modern countries use telehealth and
similar technologies as the basis of their provision of affordable universal
healthcare? It has seemed like those countries were able to provide cost-
effective healthcare without hand-waving future tech by rather boosting the
supply in supply and demand.

~~~
vkou
> Can you give some examples of how other modern countries use telehealth and
> similar technologies as the basis of their provision of affordable universal
> healthcare?

In BC, Canada, there is the 24/7/365 BC Nurse's Hotline. (Healthlink BC)

It's a phone number, that you can call, to get medical advice.

"I have peanut allergies, and I am having an allergic reaction to peanut
butter. I've taken my emergency pills for it, and I have an epipen with me. My
symptoms are such and such. It's 3 am, and I'm at a provincial park's parking
lot, 20 km out of town. Should I inject myself? Should I wait it out? Should I
drive myself to the hospital? Should I call an ambulance?"

The practitioner at the other end will, given the information presented,
provide medical advice.

The American reaction to this situation would be to go straight to the ER,
regardless of whether or not they actually need it.

PS. In the exact situation I described, the person in question was told that
someone should drive them to the ER (It turned out that they would have died,
if they hadn't.) But, people call the BC nurse's hotline for all sorts of
reasons, many of which do not necessitate a trip to the hospital.

~~~
scarejunba
Also how it happens in the UK.

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chiefalchemist
Healthcare is only part of the issue / problem. Health, as in personal health,
also plays a very significant role in this system. That is, the healthier you
are, the less likely you are to need healthcare. I'm not sure why it's rarely
if ever mentioned. There is "news" on obesity and T2D, but rarely is that tied
to healthcare.

To that point, for me the question(s) is straightforward:

\- which other countries are the healthiest, \- and which have the best
healthcare outcomes?

I understand those might not be objective questions / answers but let's start
there. The idea that there are no baselines or reference points is absurd.

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jellicle
There aren't, really. If the USA implemented anything similar to what, say,
Canada does today, right now, it would be:

\- everyone can go to any doctor without any payments or paperwork, all of
that being done behind the scenes

\- you'd get a tax refund (it is literally cheaper than you pay in taxes right
now, you just don't get universal care for your taxes now)

\- your health insurance costs would be eliminated

~~~
dawnerd
It’s amazing many people in the states don’t get how having everyone
contribute via taxes would lower prices for everyone. Not to mention it’s kind
of ridiculous anyways to have a middle-man company taking a slice of payments
that could be used to treat someone else.

~~~
tick_tock_tick
It would for the vast majority of American's just not the ones using this
site. Most people here in already pay very little for medical as their
employer takes care of it.

