
I watched my patients die of poverty for 40 years. It’s time for single-payer - paulpauper
https://www.washingtonpost.com/news/posteverything/wp/2017/09/12/i-watched-my-patients-die-of-poverty-for-40-years-its-time-for-single-payer/
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ZainRiz
The biggest problem is not the lack of single payer, it's the lack of price
transparency. You have no idea how much any medical service will cost until
you get the bill, so everyone is free to price gouge you.

An example of how bad the current system is:

When my wife was pregnant and needed an ultrasound, her regular doctor was
busy one month and recommended we go to the doctor upstairs. Our regular
doctor charged us $200 for the ultrasound, the one upstairs sent us a bill for
$1000!

This 5x price difference was in the exact same building, just a different
floor!

Hospitals benefit from keeping the prices obscure, to the detriment of the
rest of the country

~~~
bgorman
The problem is health care is nothing close to a free market.

In many parts of the country, it is illegal to open up a new hospital without
a government license. Existing hospitals often lobby to prevent competing
hospitals from opening up.

~~~
subhobroto
> The problem is health care is nothing close to a free market.

It's not a problem, it's a feature.

In free market health care, those who can't afford care, die.

We as a society have agreed that's not acceptable and hence the regulations,
EMTALA being one

~~~
randyrand
Grocery shopping and farming are very competitive and mostly free, yet we
still have food stamps don't let people starve to death.

Why not have a system closer to food stamps but for healthcare? i.e. the
government will cover costs for the poor up to some amount.

~~~
subhobroto
> Why not have a system closer to food stamps but for healthcare? i.e. the
> government will cover costs for the poor up to some amount.

We have exactly that. It's called Medicare + Medicaid. The govt fixes the
price for what doctors/hospitals can charge on these plans and that's why
doctors/hospitals absolutely _hate_ Medicare + Medicaid.

For Native Indians, we also have the Indian Health Services.

For veterans, we have the VA.

That said, _you_ nor _I_ would really enjoy being on a Medicare + Medicaid
system.

Having the govt. set rates, getting out of the way and leaving who and how
that price gets paid provides the ultimate flexibility and value.

~~~
randyrand
Food stamps are much simpler than Medicare. It's basically just cash and you
pay market rates for whatever you buy.

It seems we are on the same page.

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subhobroto
I see everyone getting excited about single-payer but it addresses the core
issue of access via pricing as a mere sideffect that a single-payer happens to
have serious leverage over pricing being, well, single-payer.

The core issue though is price of medical services.

When an ER visit to sew together 5 inches of a cut skin at 10AM can generate a
claim for $40000, something is really broken.

The single-payer can outright refuse to pay $40000 for such a thing while you
and I would have that debt hound us for the rest of our lives.

One solution that addresses the root issue is to clamp down on what is
reasonable to charge to sew together 5 inches of a cut skin at 10AM.

That is called an all-payer rate set system.

It does not matter _who_ pays - what matters is _what_ price something is
available at.

Doctor's regular, scheduled visit? $150.

You pay in cash? ? $150.

You pay in chickens with white feathers ? $150.

Your employer provides you with coverage and they cover the first $500 worth
of expenses? $150.

Your'e an uber driver and that doctor would appreciate a ride back and forth
for the next month? $150.

When the same doctor's visit can range in price from $10 - $1000 depending on
what crap your employer signed you up for, we have a terrible access issue.

The U.S. has one of the best health care in the world, but also one of the
higest financial distress including outright bankruptcy for medical bills.

Something's going to give soon as the system starts to come under strain due
to SARS-COV2 and it's not likely to be pretty.

~~~
oblongx
First step was making sure you can actually get quoted a price for that
service. I might choose to go across town if it saved me $40K.

[https://www.npr.org/sections/health-
shots/2019/06/24/7354323...](https://www.npr.org/sections/health-
shots/2019/06/24/735432387/trump-administration-pushes-to-make-health-care-
pricing-more-transparent)

~~~
subhobroto
> actually get quoted a price for that service. I might choose to go across
> town if it saved me $40K

I have been working as a software consultant for decades now and always have a
menu price ready.

Even with this menu pricing, my customers still need my help in figuring out
what they need from the menu.

If my customers already knew what they needed to solve their problems, I have
0 value to add as a consultant - at that point, they just need to either hire
staff/developers to execute on their requirements.

If I broke my hip today, how exactly would a menu of hip related items help me
compare costs?

How would I even begin to know which items from the menu apply to my situation
without having some idea what is involved in fixing a broken hip?

Do I need a MRI? XRay? Both? Which sections of the hip? We even have not
started on diagnosis.

Price transparency is only useful when one knows exactly what is needed.

You pretty much have to be a doctor to shop prices unless you're doing an
elective surgery where time is on your side and you can do some research as
you wait and shop.

I'm not sure anyone's doing price comparison when their wife's on the delivery
table and has just had some complications.

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elipsey
I find the comments that 'Single Payer' isn't intended to address pricing
problems sort of strange.

'Single Payer' means that providers have to negotiate the prices with _one_
payer, the state, instead of separately for each insurance company (or having
a go at every uninsured patient, for every procedure).

Of course a seller of high value products will want to negotiate the price
individually for every sale; the cost is smaller than consumer surplus would
be in such cases, right? That's why we have car salesman.

Without respect to whether it's a good idea, isn't forbidding price
discrimination the whole point of single payer, rather than a side effect?

~~~
InTheArena
And yet, even when the government is the payer, they have shown consistently
that they are unwilling to enforce pricing control. For example, even though
medicare billing rates for doctors where supposed to go down several times, in
each case, threats of strikes by doctors with very public "look how evil the
government is" posts by doctors have kept the rates inflated.

Cost control isn't linked to single payer. Nor is efficiency. If you don't
believe that, look at Germany. Not single payer, but incredibly efficient, and
great at COVID19.

On top of that, there are places where the government enables horrible
behaviour and payments. For example, they negotiated a shitty deal on CPAP
machines, and now everyone who does CPAP gets medicare rules, which is $300 a
month lease for a machine that is sold commercially for $650. When I pushed
back on my insurance company they said that this was medicare rules.

Good governance is good governance. We don't have it, and single payer won't
fix it any more then Obamacare and health rationing fixed it.

~~~
elipsey
I agree that the govt seems to suck at negotiating. What do you think we
should do now?

> health rationing

What are you talking about?

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vikramkr
Setting all economics and politcs aside, the most gut wrenching part of this
read for me was the image of a hospital whose patients never get organ
transplants, but give organ transplants. That goes beyond one person getting
treatment while another is denied. That's the denied person, in death, still
giving. I dont know if single payer is the best system, or if a hybrid system
or regulated private monopoly or some other weird approach is better. But this
system that we have today isn't working.

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schoolornot
Broke my arm and needed surgery. We know that's pricey.

Before the surgery, I saw an ortho for 5 minutes. In what world are we living
in where a 5 minute appointment should cost $475 and that excludes the few
hundred billed by the radiologist.

+$475 Office or outpatient visit for a new patient (up to 45 minutes) \-
$125.53 Insurance discount = $349.47 Covered amount Plan pays: $329.47 FOR A
FIVE MINUTE CONSULT

We need 100x more medical schools in this country. Every single state school
should be a medical school.

------
simonblack
US medical costs will only come down if the the middlemen (Medical Insurance
Companies)are prevented from having an influence.

The medical insurance companies have deep pockets and lots of lobbyists.

Never going to happen.

I LOL a lot when I hear that the US can't afford to have single-payer
healthcare, when lots of tiny countries _can, and do_ afford it.

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randyrand
There are many problems with health care, and single payer is just sweeping
them all under the rug.

Single payer won't magically make the number of doctors or hospitals or
surgeries increase. It is not a panacea by any stretch, and we shouldn't
pretend it is one.

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ggm
It's time for an NHS but since that demands taxation change (probably a
hypothecated tax) it won't happen.

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fallingfrog
I think the need for single payer is best stated in terms of _risk_. There are
many things that can and should be paid for by the end user, because they are
things that you buy when you have money and forego when you don’t.

Health care is not one of those things. People get sick and poor _at the same
time_. Especially if it’s a serious illness. It just makes no sense to sell it
that way.

