
Economic Analysis of Medicare for All - cribbles
https://www.peri.umass.edu/publication/item/1127-economic-analysis-of-medicare-for-all
======
entee
One thing that sometimes gets lost in the "health care is inefficient"
discussion is that one person's inefficiency is another person's living. The
cost controls the paper appears to advocate for literally mean someone is
making less money, that someone will advocate strongly against it. I've spent
the past 3.5 years in healthcare, everyone is convinced they're not the
problem, that they're underpaid or overworked or whatever. I would love for
some sort of centralized system to push down costs, but I fear it's not
realistically every going to happen.

~~~
ArchTypical
> that they're underpaid or overworked or whatever

Having family in healthcare and being a lifelong patient due to a congenital
defect, a job in software (including management obv) is a breeze compared to
health care worker jobs across the board. They require more "schooling" (via
mind-numbing training), are underpaid, have much more serious consequences
from mistakes, have less oversight, work longer hours and under worse
conditions. It's disheartening.

~~~
agumonkey
People's work shouldn't be reduced, but drugs and devices should be to an
extent. Firefighters told the portable EKG costed thousands of dollars (5 or
10 don't recall). That thing had bad 2G connectivity so the graph coudn't be
sent to a cardiologist. The sensor/dsp part is worth money, the rest would
cost 100$ from any smartphone maker today with better performance and
portability.

I'm sure the price is rigged for margins. This shouldn't be a market, it
should be an open duty to make these cost efficient.

~~~
ams6110
The real cost is not so much in the hardware but in the certification
requirements. Medical devices need to be built to and work at a higher
standard than consumer electronics, for obvious reasons.

~~~
epicureanideal
But if the cost becomes so high that people simply go without the devices, is
that really a good tradeoff? Maybe a device with 1 in 10,000 failures is
better than no device at all, for some subset of illnesses?

Also, I suspect this is FUD by some entrenched medical devices companies who
know how to play the game of complying with standards. Anyone here ever gone
through compliance testing with software? I've seen systems pass that are
worse than what I would have just thought up in 30 minutes and coded up for
fun. It's just a warm fuzzy feeling.

~~~
candiodari
That's one thing. But there's other problems:

1) certification that takes 10 years (more like 3, but ...) means you, at the
very best, have 10 year old technology

2) Certified at a higher level. That can for various reasons be very different
from reliable at a different level. For instance, circumstances change or
knowledge advances.

For instance certification tends to take "proof" that something works. Yet the
most reliable robots are pretty bad hardware, with the ability for multiple
components to do the same job "most" of the time. Such a device, despite being
much more reliable, is disqualified a priori in nearly all certification
processes I've seen.

(needless to say, every time the things they take as proof tend to be ... less
than proof)

Plus we've all been in a company having this discussion. "For the price of
this one 'reliable' server we could have 20 normal ones, and they would be a
hell of a lot more reliable together. Hell, just give me 3 of the cheap ones
and I'll make it more reliable". And we all know what the boss's answer and
the resulting reliability was.

3) You assume no regulatory capture (or outright dishonesty on the part of
government employees and/or lawmakers)

------
pdq
Hypothetical economic studies and analyses are almost worthless. In normal
science, you need something to be testable, verifiable, and reproducible. I'm
quite sure none of these are possible.

Just as a counterpoint, the US public primary school education is state run
and funded, and has both poor outcomes and is the most expensive in the world
[1]. Just because something is run or controlled by the state does not mean it
will magically be either efficient or high quality.

[1] [https://www.theguardian.com/us-news/2018/sep/07/us-
education...](https://www.theguardian.com/us-news/2018/sep/07/us-education-
spending-finland-south-korea)

~~~
VikingCoder
Quick question:

What if America's education problem is that the children don't have parents
who can nurture them?

Because we have stagnant or decreasing real wages? Because the cost of
daycare, housing, health, and advanced education have all gone up? Because
we're making it harder to declare bankruptcy? Because we're criminalizing
activities, and ripping families apart?

Maybe it shouldn't be a surprise that our education is ranked poorly.

And _pointing to_ education, as though it's a system we can study in
isolation, and claim that it's a failure, therefore other state-run systems
must also be failures, isn't really being honest?

And maybe it's worthwhile to look at other countries with the economic
conditions we're proposing. Like single payer healthcare. Because we can look
at them.

You're absolutely right that "just because something is run or controlled by
the state does not mean it will magically be either efficient or high
quality."

But people like you seem to _delight_ in using that as an argument against
government programs that have been shown to be effective, again and again, in
country after country.

So then I can say, "just because something is run or controlled by the state
does not mean it will be either inefficient or low quality."

And we've both said something completely meaningless, and now can we please
get back to looking at examples from other countries, and try to learn from
them?

~~~
beginningguava
US education is top notch based on international PISA scores if you break it
down by race and compare them to europe, latin america, africa, etc

[https://nces.ed.gov/surveys/pisa/pisa2015/pisa2015highlights...](https://nces.ed.gov/surveys/pisa/pisa2015/pisa2015highlights_3f.asp)

Singapore almost always takes 1st in international test scores and their long
time leader didn't pull punches

[https://imgur.com/a/a8nCQUO](https://imgur.com/a/a8nCQUO)

and it's not an income thing, the poorest whites and asians score as high as
black students from families making 200k+ a year

[https://i.imgur.com/PD9hz9b.jpg](https://i.imgur.com/PD9hz9b.jpg)

So in a way you're right, US government does run their education system very
well, it just seems to be a racial thing which can never be spoken about
politically so it's just ignored as the elephant in the room

~~~
VikingCoder
Since people were treated separately based on their race (slavery, no right to
vote, no civil rights, redlining, segregated schools), it's not a surprise you
can still measure the impacts of that decades later, based on race.

It takes a long time to undo damage like that.

------
pg_bot
A lot of issues with America's healthcare system boil down to what I call "the
interception problem". A quarterback who throws an interception directly to a
defender without a wide receiver in the vicinity is treated the same as
someone who hit a receivers hands and was tipped to a defender when you are
looking at the stat sheet. Your perception of the analysis changes drastically
if you actually observe the actions going on.

I'll take an example from the real world to illustrate my point. When you look
at the data, the United States clearly has the highest infant mortality rate
of developed countries. On its face it would seem that the United States is
clearly failing pregnant women, and that this is a terrible problem that needs
to be addressed. However, if you observe the differences between the data sets
and actually view how deliveries happen in real life you see a different
picture.

Not all pregnancies carry the same risk, and the US has a higher percentage of
high risk pregnancies than other countries. If you compare people in the same
cohorts the US fares a lot better. In layman's terms, we shouldn't treat an
infant death from a 25 year old mother who carried to term the same as one
from a 40 year old born a month premature. The US is also the most aggressive
country in the world when it comes to attempting to save prematurely born
children. We try and succeed at a higher rate than anywhere else in the world.
I have failed to meet a person who thinks trying to save a prematurely born
child is a bad thing. Yet it's those kind of actions that skew the stats.

We need more advanced medical statistics. I hope the sabermetrics revolution
makes its way into the medical field. If more people are interested, I could
probably expand my thoughts further with other examples that look bad on the
surface, but actually aren't as bad as you think.

------
DubiousPusher
It seems to me that industrialized countries the world round have different
ways of organizing the relationship between patients, payers and providers.
There's nearly 100% public models like the NHS in the UK and hybrid market
systems like those in Singapore and Switzerland.

But the one thing they all seem to do the same is how they keep costs down.
They give the payer, whether that's the government or separate insurers a
legal framework for setting prices.

I know correlation is not causation but until some country shows strong price
performance while implementing a different scheme it seems wise to defer to
the one that is ubiquitous.

~~~
ams6110
Price controls cause shortages. Simple economics.

~~~
jedharris
there is always a simple economic reply to every proposal —- neat, plausible,
and wrong

------
zjaffee
My biggest fear of a bill like this is even should we have the most
progressive anti corruption government implement this law originally, whats to
prevent this from becoming incredibly wasteful just like our military is. I.e.
we spend a trillion dollars over decades trying to develop some drug that
turns out to take us nowhere, while enriching pfizer shareholders this time
instead of lockheed martin ones.

I absolutely support medicare for all, even though as a healthy young software
engineer this will raise the cost of my healthcare a ton, I'm just nervous
that this will result in the largest negative iron triangle in the history of
our country.

~~~
nickysielicki
This is why the scope of government matters.

I do not understand why people have this idea that it's the job of the
government to do things like speculate on the economy via quantitative easing,
or save money overall on healthcare costs. The federal government ought to
have a few simple jobs --- the ones laid out in the constitution, and
everything else can be left up to the people and to the states.

I would rather live in a country where healthcare maybe costs more than it
otherwise could, and where the economy maybe recovers slower than it otherwise
would have, than to live in a country where the government takes lots of our
money trying to fulfill promises that it cannot keep.

Medicare is projected to be insolvent in 2026, and Social Security is
projected to be insolvent 8 years later. We're due for an economic downswing
in the next few years (if not the next few months). Our economy will not keep
up with the developing world powers; NATO is increasingly irrelevant and the
petrodollar is threatened.

What are we going to tell the people who depend on these dying programs? "I
know that you worked your whole life in a factory, and I know that you are too
old to work, and I know that you paid into this system your entire career, and
I know you aren't getting enough to get by. But we had the best intentions in
mind!"

America is rich because we won WWII, not because of American Exceptionalism.
The comfortable life that American culture was built on (while the rest of the
world needed half a century to recover) is going away quickly. The social
programs that we _already_ have in place have less than 6,000 days remaining
before they fall apart, and in these last hours, we're seriously talking about
adding on?

No thanks. I'm okay with living in a poor country. I'd prefer for my
government to not fail as a result, though.

~~~
maxxxxx
Medicare and social security won't be insolvent. They can go on for a long
time by doing some adjustments that account for life expectancy and other
factors. Unfortunately the people in DC are more interested in fighting each
other than running the country in a responsible manner.

------
rb808
Its such a fundamental change I doubt a study could accurately predict
changes. I can't read the PDF but I know debate often misses things like: * A
big boost for companies as unprofitable companies don't have to pay healthcare
of employees. (assuming paid with taxes) * Free medical care means things like
ambulance chasing lawyers are not required * Govt is more incentivized to look
after the health of citizens as it has to pay for diabetes treatment etc. *
People are more likely to retire early, or quit work and live cheaply.

------
travisoneill1
For an in depth look at the state of the current US system as compared to
other developed countries see this report:

[https://www.mckinsey.com/~/media/McKinsey/Industries/Healthc...](https://www.mckinsey.com/~/media/McKinsey/Industries/Healthcare%20Systems%20and%20Services/Our%20Insights/Accounting%20for%20the%20cost%20of%20US%20health%20care/MGI_Accounting_for_cost_of_US_health_care_full_report.ashx)

------
sedor0115
The only thing America can really do to get healthcare costs under control is
actually really obvious: put down the fork.

~~~
shard972
What about the herion addicts that the healthcare system created? I don't
think less food is going to solve their problems.

------
acslater00
The math here is based on the idea that MFA would reduce the per-person
expenditures by 19% (19.2% actually)

(1) 5.9% by unilaterally reducing drug prices by 40% (2) 2.8% by unilaterally
reducing medical service prices by 20% (3) 1.5% through the claim that MFA
would have fewer "excess services" (4) 9.0% from allegedly increased
efficiency due to only having to deal with one payer

Is this at all plausible?

Achieving (1) and (2) would be - um - difficult, to say the least! In real
life, prices would be set by a political process. Our actual history of
attempts to unilaterally reduce medical reimbursement reates is not promising!
[see
[https://en.wikipedia.org/wiki/Medicare_Sustainable_Growth_Ra...](https://en.wikipedia.org/wiki/Medicare_Sustainable_Growth_Rate)
or the debate over Medicare drug price negotiation].

(1) & (2) con't: Imposing a single-payer system and then having that payer set
prices is effectively the same as imposing a national price control regime,
which we in theory could do without MFA. We have not done this, despite the
fact that it would save everyone an enormous amount of money. Why not? Because
it would be insanely controversial and take a ton of money out of some
people's pockets, especially doctors and nurses. Will this be easier under
MFA?

(3) The idea that MFA would be structurally less likely to provide "excess"
health services seems pretty optimistic indeed. Our military, for example, is
not really known for being budget conscious and aggressively efficiency
minded. Nor are our state and local level agencies, e.g. the MTA here in NY.
Spending policies are set by a political process, and political processes are
prone to over- rather than under- spending in every case I can think of.

(4) The 9%(!) savings from "billing efficiencies" is based on an assumption
that billing expenses in medical offices will be reduced by 2/3 when there is
only a single payer. Why would this be? Billing expenses scale with the number
of bills, not the number of vendors. Will MFA lead to fewer procedures on net?
Will it eliminate the concept of prior authorizations, which represent the
bulk of these "excess" BIR expenses? Will providers and patients not have
coverage disputes? Will MFA have dramatically superior automation than private
payers? Note that Germany has a multi-payer system and has Canada-like
administrative costs
[[https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2013....](https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2013.1327)].
There are hidden variables here.

Here's the thing:

The most superficial argument in favor of MFA is to look at a country like
Canada and say "Canada spends X / pp on healthcare and they have a single
payer system, therefore if the US adopts a single payer system, our costs will
drop to X!". That's not real analysis, and it ignores all the cost drivers
that have nothing to do with the payer. This paper is a drill-down to
component costs, but ultimately is no less superficial. MFA billing will be
65% more efficient because Australia billing is 65% more efficient than the
US. Prescription drugs will be 40% cheaper because Canada pays 40% less than
the US. And so on.

If you could realize any of these cost savings in MFA, you could realize them
now. But you probably can't - not easily, anyway, and after burning all your
political capital on a $1T/year tax hike it will only be harder. The cost-
savings will be compromised to get the medical industry on board, just like it
was during the Obamacare debate. And now you can toss this whole analysis in
the garbage.

This is wish-casting dressed up in 200 pages of rigorous-looking analysis,
designed to get people to read the abstract, then look at the page count, and
then treat it as credible.

MFA is not going to save the system money. Take it to the bank.

------
time-domain0
Let's say an American has to have a very expensive treatment for stage IV
cancer that exceeds their insurance's lifetime limit and they can't work. They
can say goodbye to their health insurance, goodbye to their savings and hello
to bill collectors will force them into bankruptcy where they have to justify
keeping a home, a vehicle and the clothes on their back. Dying and having to
pay late fees that a person can't pay. It's criminal.

It really sucks when that person is married with children. It's often better
for the spouse to divorce them and take all the assets well ahead of declaring
bankruptcy so they can't be liquidated and lose everything.

This is what corporate hospitals, for-profit insurance companies and big
pharma has reduced care to: make as much money as possible while screwing over
patients, and killing them with substandard care compared to the rest of
established economies. Unregulated capitalism is a cannibal.

------
educationdata
How can they assume this will not change how everything else works?

Yes. You can say statistically we did the comparison by holding everything
else the same, but it only means "statistically". It definitely does not mean
in reality you can hold everything else the same. There is no way when the
policy changes, the system still works as before. This kind of study is
totally delusional.

A policy works in other countries does not guarantee it will work in the U.S.
For one thing, U.S. doctors make much more money than other countries. There
are also other many differences. How can you assume you can simply move a
policy successfully from other countries without making other important
changes?

~~~
AnimalMuppet
Second order effects... the bane of well-meaning policies.

On the other hand, how else are you going to do it? Do you know what the
second-order effects are going to be? How sure are you? Can you prove it to
someone who doesn't hold the same intellectual framework or political leaning
that you do?

------
ribble
| Medicare for All could reduce total health care spending in the U.S. by
nearly 10 percent, to $2.93 trillion, while creating stable access to good
care for all U.S. residents.

how? by taxing a few earners to pay for everyone else not earning. is that
fair? in that light, a ten percent reduction in cost is meaningless.

~~~
marricks
Uhh, you’re aware hospitals don’t turn people away who are injured and often
end up with a lot owed to them they just can’t recover right?

Also if everyone has healthcare they’ll get treated earlier before a condition
blows up and... they get stuck at the ER getting a bill they’ll never be able
to repay.

Our US healthcare system just sucks compared to other countries UNLESS you are
well off.

I wouldn’t short change arguments saying covering everyone is actually less
expensive.

~~~
sedor0115
Look up 5-year cancer survival rates by country. That metric at least attempts
to measure the performance of the healthcare system. The studies that say our
healthcare system "sucks" are looking at overall health of each country's
population, not the performance of their systems.

To condemn the healthcare system based on the overall health of a nation that
spends all day watching TV and shoving cheeseburgers in its face is absurdly
disingenuous.

~~~
marricks
I’d say the system sucks when a valid reason to exclude someone form an organ
transplant is “don’t have 10k in savings to cover rejection meds”.

Without Medicare for all it’s a pay to win system where the cost of life
saving treatments are literally beyond what most people could ever reasonably
make.

