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Pharma CEO Worries Americans Will Embrace Single-Payer Plan (theintercept.com)
99 points by rbanffy 9 months ago | hide | past | web | favorite | 134 comments

Throw-away because I like to keep my financial details personal.

I'm self employed and have been for about 15 years. We purchase health insurance from the state exchange. Prior to this, I'd purchased it as an individual directly from the insurers, or used the plan my wife had through her employer. Those options are no longer available to us, so we use the state exchange.

My family's health insurance rates increased 17% last year. This year, my state has approved an increase of 27% for the provider I use and a 31% increase for one of the other providers in the state.

To insure our family of four, we'll pay around $25,000 for insurance before a dollar is spent on deductibles, co-pays or other associated costs. We're generally all healthy. Have no pre-existing conditions to speak-of. We earn more than the level where you qualify for any subsidy.

This is unsustainable.

> This is unsustainable.

It's not just unsustainable, it's absurd! $25,000 USD is most of, if not the entirety, of the TOTAL income taxes many people pay in other OECD nations. How are these other nations providing all of the functions of government, including universal health care, for what Americans are paying just for insurance? This shouldn't be a partisan issue - even the most conservative of Americans should be outraged that we are being ripped off.

https://data.oecd.org/healthres/health-spending.htm - the US spends $9,800/year per capita, clearly an outlier, and yet we still can't cover everyone in a reasonable way?!

I took my child in for a regular 15 minute doctors appointment recently and the cost of seeing the provider (no tests) was $350. Does it really cost $1,400/hour to operate a medical clinic? Google tells me that the average GP salary in the US is $189,000 ($90/hour), average salary for a nurse is $67,000 ($32/hour), and average for a receptionist is $27,000 ($12/hour). Add another nurse for administering shots/drawing blood and the total payroll per hour is about $166/hour. Where is the other $1,234/hour going?

I'm sure there are reasonable explanations for some of it (cost of the building, cost of medical equipment in the clinic, professional insurance, and maintenance on the fish tank) but the ridiculous cost of everything is the elephant in the room that no amount of "cracking down on fraud" or "incentivizing healthy behaviors" will solve.

As an immigrant to the US, it's maddening. It just doesn't have to be this way, there is half a century of evidence showing that alternative systems are cheaper and more effective. I also look at that $9,800/year per capita and wonder what our economy looks like if everyone had an extra $2-4,000/year in their pocket. Or if we eliminated the burden of health care from businesses and individuals trying to start a business.

Not to take away from any of your points, but just a minor correction that in many OECD nations (Europe specifically), it's payroll taxes that pay for the healthcare, not income taxes. The former can be double what the latter are.

To some degree, hospitals perform a kind of internal socialism: a poor, homeless person can't be turned away from the emergency room, but they also can't pay for its actual cost. To balance their books, hospitals then have to overcharge people with good insurance.

This is similar to private universities charging rich students the full sticker price, while giving poorer students scholarships and financial aid.

Hospitals put the costs of uncompensated care at 5-6% of total expenses:


(that's charity care and non payments but not any unfunded expenses due to Medicaid and Medicare)

"*The above uncompensated care figures represent the estimated cost of bad debt and charity care to the hospital."

Cost is the key word there and is bolded in the link. The billed amount they would have lost would be much higher. Most hospitals collect about only 25% of patient payments owed to them. When they write it down, they use the cost to the hospital not the amount billed.

I don't see what is important about that.

What is interesting about the amount they attempt to bill?

For example, if we're talking about a $5 bandaid (in terms of cost), the hospital will list the price at $20 on the chargemaster. They'll charge an in-network payer $15 and an out of network payer $20. An uninsured patient would probably get charged $10.

In any case, if the patient gets charged $10 and doesn't pay, the hospital only writes off $5 as uncompensated care because that's the requirement for government reimbursement. But really they lost $10 on gross patient revenue. It scales up much higher as you can imagine. The point is that the financial cost of uncompensated care is much higher than the dollar amount and why so many hospitals are in financial danger today.

Why are "cost" and "financial cost" different things?

The stated "cost" of say, taking an x-ray, should be the fully loaded cost, the facility space, the equipment depreciation, any consumables, the time, etc.

Because the margin is so huge in healthcare products and services, especially at hospitals. Hospitals rely on astronomical margins on certain payer classes to subsidize uncompensated care costs.

The point is that providers are far more invested in maintaining the huge margins rather than minimizing the cost.

Problem is the payer mix has been shifting from insurance companies to patients via high deductible health plans over the past decade so it's starting to wreck their margins, even though the cost doesn't change.

This is nonsense. Public health systems in Australia and Europe also has to take care of everybody.

> I took my child in for a regular 15 minute doctors appointment recently and the cost of seeing the provider (no tests) was $350.

A 30 minute visit with my primary care doctor is ~$160.

I now realize my local hospital is fairly reasonably priced.

Also don't forget to factor in the small army in the billing department that has to deal with the insurance company. And the third party payment provider that runs the online web portal that you pay through.

Interestingly enough, in Washington State all hospital finances are a matter of public record[1]. I am somewhat amused that health insurance for employees make up ~5.7% of the hospital's total expenses.

Charity care was only .87% of overall expenses.


> It's not just unsustainable, it's absurd! $25,000 USD is most of, if not the entirety, of the TOTAL income taxes many people pay in other OECD nations.

In most European countries (probably in all of them, but I do have motivation to check) the cost of the health care is paid based on the solidarity principle. This means that the amount that goes for the state level insurer is proportional to the income amount (private insurances for the extra coverage usually work on the fixed amount basis).

Around 500 per person in month is probably not on the very high side considering decent salary levels. The difference is that the health care of the minors is free. This splits the amount in half.

In Germany, this is less. Suppose you are insured through the public system (Krankenkasse) and you have a salary high enough to pay the maximum rate, you pay 365.40€/month (your employer pay about the same amount). If you are self employed, you pay 656.85€ (employer and employee part).

This covers you, your kids and your partner if he/she is not working. If your partner is working, he/she pays like you.

So, imagine you are a family of four, both self employed, the maximum you pay is 656.85€ x 12 x 2 = 15764€/year. This covers 100% of the kids medications, 70 to 100% of the adult medications, 100% of the visit to the doctor and stay in a hospital. You do not have to pay and get reimbursed, you just provide your insurance card and the doctor/hospital will automatically charge your insurance (Krankenkasse).

The system is working a bit differently if you opt-in for a private insurance.

Edit: I cannot reply to the question about the maximum, so, answering as an edit. Yes you have a maximum and the values I gave are at this maximum.

Slight offtopic. Did I understand right that there is a limit for 'Krankenkasse' monthly payment?

Where I live - there is no limit.

If your _payroll_ is ~1315eur, that means your _income_ is 1000eur, because you've paid (or employer did that for you):

- 15% income tax (~197eur),

- public health insurance 6% (~79eur),

- public retirement fund 3% (~40eur).

- employer pays 31.18% of the _payroll_ to public health insurance (~410eur).

Making the __whole employment price__ - 1726eur, of which 489eur goes to public health insurance. If your __income__ is 10 000eur - everything is tenfold.

I do not know nuances of self employment, but you pay less for the public health insurance. From 1726eur, you'd pay ~234eur for public health insurance and ~181eur income tax - leaving you with ~1311eur.

well, you probably also make a lot more than in your home country ;) So that seems to be the game we're all in...

> How are these other nations providing all of the functions of government, including universal health care, for what Americans are paying just for insurance?

by america subsidizing their defense spending

You're not wrong. I'm sure there are points to debate, but the US does provide a free military to the EU.


Very sorry to hear about the burden you and your family are bearing.

I hope we can devise an alternative to the current system, as $25,000 is more costly than just buying everything up front!

I did some research and found that an apendectomy is one of the most important things insurance can pay for, as it is sudden, life threatening, and generally not easily controlled by lifestyle choices.

The quoted cost of an apendectomy from a variety of different countries and hospitals?

"Between $3,000 and $150,000 USD"

It might as well be "blank check", if this price gouging is allowed in the US.

A single person can easily incur more than $30,000 of medical expenses, even at a hospital with reasonable prices.

So no, $25,000 isn't more expensive than buying everything up front for 4 people.

It's expensive, but the US spends something like $10,000 a year per capita on health care, so it isn't an outsized chunk.

Over 10 years ago, I had my gallbladder taken out. I spent two nights in the hospital (one in the ER, where they diagnosed it, and one more after they took it out).

I was uninsured at the time, and at the end was given a bill for $18,000.

Gallbladder removal is the simplest major surgery that can be done on a person; it's a simple organ to remove, and rarely presents any challenges.

I could easily see surpassing that dollar amount for anything more complicated.

For comparison, the total cost to do the surgery in a developing nation (where I spent several years in my early 20s) would have been $300-400, according to friends there.

In 2004, I had gallbladder removed. Total bill for surgery and overnight stay was around $11k. The insurance I had at the time covered things, and I got a bill for around ~$40. That was it. I had employer-provided insurance, but I'd been there less than a month(!).

With different insurance, different state, a few years later, my wife had to go to ER with pneumonia. 5 hours in total to draw some blood, xray, and a drip. Bill later - with blue cross insurance - was ~$3000.

Health "care" here is insanely priced and managed.

had mine out last year. 3 nights in hospital. the bill for just the room and what little food i was allowed to have after surgery was 40K billed to insurance. that didn't include all of the smaller charges submitted by the pharmacy, radiology, anesthesia, the surgeon, the GI doc who visited once...

Did a quick look-up of appendectomy pricing based on published CMS data from 2015. Results listed here:




Sometimes I think other nations should be a bit more pragmatic in generating revenue from the huge costs of healthcare in the US.

In the UK we can charge foreigners for use of our NHS. I believe that using this private service, is significantly cheaper than the equivalent in the states. Flight costs are trivial when looking at US healthcare costs. Of course this can only deal with non-urgent and (relatively) well off people.

My family has employer provided healthcare. But at this point if the premiums go up faster than we can afford I'm switching to an HSA. I can easily afford to fly my family to Cent/South America to have a checkup or surgery compared to the money I'm throwing into the wind with our HMO.

We're young, healthy, with no chronic issues. Just the type of people insurance companies would want to insure.

That's why a lot of people at the border go to a private dr in Mexico instead.

Sucks but I'm pretty sure they'll take every penny. People said college costs were out of control in 2000, stuff kept going up for a decade.

Again for comparison, Germany has free tuition even at university level. And it doesn’t cost the country a great deal. These sudden rises in tuition in the US Zaire a relatively recent phenomenon too.

To be fair, you do give up some things for that free tuition in Germany. You basically attend lecture and take the test at the end. It scales well, and some people do really well, but it might not be for everyone.

Free tuition for foreigners as well.

Pretty sure they are still going up

I graduated in 2009. Tuition has passed double what I paid, and today is approaching 3 times what I paid.

Would it be more cost effective to buy a catastrophic insurance policy and self-insure (pay cash) for routine services?

Under ACA medical plans deductibles are capped at "For 2017, your out-of-pocket maximum can be no more than $7,150 for an individual plan and $14,300 for a family plan before marketplace subsidies."[1]

[1] https://obamacarefacts.com/health-insurance/out-of-pocket-ma...

Not sure if only plans in the ACA system must meet this requirement or that private companies cannot even offer say a $50,000 deductible plan with a $3 mil cap.

Probably the option we'll explore when reviewing plans. Or go back to work for a company which provides coverage as part of the employment package.

It's worse than that. With the biologics on their way to market today, and with guidelines changing, we could be treating relatively common diseases with absurdly expensive drugs, and insurance companies will have no choice but to cover these therapies. That will in turn cause premiums to skyrocket.

At that cost would you not be better off saving it?

It might be.

But then you either get hit with a penalty for not buying insurance, or you get hit with a penalty and also a bill for $500,000 when you find out you've got some illness you didn't know about and hospital bills bankrupt you.

Just noticed your throwaway user ID. Clever. I'm guessing that you support single payer?

Seems to work reasonably well in other countries.

Something has to be done as status quo is not working. The idea that one could go bankrupt if they don't have health insurance or god forbid are hit with an illness such as Cancer is ridiculous.

Is single payer the answer ? Frankly I don't know. But as Americans, we live in fear when it comes to healthcare. If you have a job where your employer provides great coverage, then you are ok for the time being. But what if you lose that job ? What if you want to start your own business ? What if you want to be self employed ? What if...there are more like this.

Ok lets pay out of pocket then. Fine. If you have a family of 4 or more, be ready to shell out anywhere from $1500-$2000/Month (yes per month) to get a decent enough plan that doesn't have crazy deductibles and out of pocket limits. Can't afford this ? Oops sorry, you are on your own (some exceptions if you can prove you are extremely poor and get medicaid etc)

Fear. That is the issue I have. I don't want to be scared and I am not a dramatic person. But it is scary. Just the thought of getting sick and not having insurance.

Not to mention too many cooks. Don't believe me ? See below:

1. The Patient (so far so good)

2. The doctor/hospital (still good)

3. Insurance Company (things start to get worse. Too much power)

4. Doc's/Hospital Billing Company and their own process (now this is really idiotic). I once ran for a month to get billing errors corrected (not kidding).

Ideally, a system should only have the top 2 mentioned above. Single payer can certainly replace #3 with Govt. but that part is the tricky one. Part 4 should not even exist. But hey, medical billing/coding is an entire Business in the US.

Well, you could always adopt the European model and go free universal healthcare paid through taxes.

E.g. in Norway, people mostly pay around 30% in tax, and 8.2 percentage points out of those 30 go towards free universal healthcare.

The Norwegian state's annual healthcare expenditure per capita is below $8000, for one of the highest quality systems in the world.

Before something like this happens we need to address the costs. There are ridiculous situations where you can pay $X in cash but when using insurance the charge against the policy will be $X*4 or higher.

Or the fact that ~half of what your provider charges goes towards their own insurance they have to keep to cover lawsuits against them etc.

Also, not sure what the breakdown is outside of the US - here about 50% of the population (the "bottom 50%") effectively don't pay any taxes so the burden on the rest of the population can be significant if there's any movement towards using taxation to pay for universal healthcare.

Before, or while. If the health agency is the final player stuck with the bill, you can bet there will be a strong push and leverage) to contain costs.

CMS already applies downward pressure for many things; drugs are the one area where they can't because someone thought it was a good idea to pass a law forbidding them to negociate drug prices.

... because someone thought it was a good idea to pass a law forbidding them to negociate drug prices.

Good post. Just want to highlight that it's not so much that someone thought it was a good idea as someone lobbied so that they/their company would make more money.

> Before, or while. If the health agency is the final player stuck with the bill, you can bet there will be a strong push and leverage) to contain costs.

Not really - in fact, the current pricing situation is exacerbated by Medicare, not alleviated by it.

Medicare sets its reimbursement rates at whatever level it decides to pay (there isn't really any "negotiation" that happens), and providers are required, by law, to charge insurers and uninsured patients more than what Medicare pays. Unsurprisingly, this results in Medicare paying rates that are below COGS (and therefore literally unsustainable), and private insurers and uninsured patients make up for the difference.

The situation is so bad that Medicare has not one but two special programs to compensate providers who mostly or exclusively treat Medicare patients, because otherwise they would literally go out of business because they couldn't pay for their supplies, let alone rent and staff wages.

My experience is the opposite. Cash payer gets list price, insurance gets a much lower negotiated price. I always thought an 'insurance plan' with zero actual coverage but the negotiated prices could be ideal for self employed (with separate catastrophic policy)

That's effectively what a high deductible plan is. The ACA bronze plans are essentially high deductible catastrophic plans with some bundled services (but those services represent a small fraction of the plan cost).

The bills for simple services can still be pretty large.

Everyone already pays into Medicare, it isn't part of the income tax brackets. Not nearly enough to cover their own health care costs, but let's not conflate no federal income taxes with no taxes.

> Medicare is funded primarily from three sources: general revenues (45 percent), payroll taxes (36 percent), and beneficiary premiums (13 percent)


Not to mention those $35 bags of saline...

And the ironic thing is, the fear and anxiety caused by healthcare costs (along with the many other things that everyone middleclass and down is anxious over) makes us less healthy.

This is one reason that I am glad to have my own policy (although if the ACA gets repealed, there is no guarantee that I won't get kicked off of it eventually) since my company is too small to have a group plan. I have private health insurance (with a stipend from my employer) and private disability insurance as well. I pay significantly more than I would for a group plan, but I also have some peace of mind knowing that losing my job doesn't directly put that in jeopardy (assuming I can still make my payments that is).

>Is single payer the answer ? Frankly I don't know

I think so, it works for European countries, and Canada, which are comparable in wealth to the US. I don’t see why not.

Most European countries don't have single payer. They just have better regulation.

Care to give some examples?

Look at Germany and Switzerland. They are quite similar to Obamacare in a sense: Mandatory insurance, multiple insurances, private providers.

If there is no political will to resist there is a good chance the US medical industry would mess up single payer in the same way they messed up the current system .

All European countries have universal healthcare, but not necessarily single payer. Germany(https://en.wikipedia.org/wiki/Healthcare_in_Germany) has a multiplayer system that allows self-employed and high income people to have private insurance, though all others must take public insurance.

And this varies, but a lot of countries have some form of public + private option, though it's usually universal.

Germany has 200 private insurance companies. They cover the state mandated minimum. You can get better coverage over the base price if you want. Many Scandinavian countries have cohorts or risk pools that are not the whole country. You pay into those pools. You get care anywhere. Kinda like a coop system. True single payer like Medicare or the British system are actually rare.

Germany. There are several public insurance... companies? with only minor differences. There is also private health insurance that some well-off people choose. Private is cheaper only when you are young and healthy but you have to stay private forever, and it provides "better" (usually just more luxurious, not substantially better) service.

German public health insurances are often "Körperschaften des öffentlichen Rechts".

While this means that they're "entities under public law", they're typically running on their own, as a type of non-profit company, with board of directors, annual reports, ...

Probably the closest US organization type would be a non-profit under 501(c)4.

by well off you mean 11% of the population? https://de.wikipedia.org/wiki/Private_Krankenversicherung

You can choose to take private insurance if you make more than 60kEUR ;)

Typical features for non-single-payer and non-nationalized European healthcare systems include: insurance mandate, "public option", price lists/controls, insurers must be non-profit, insurance must not suck (see: many expensive plans in the US that are, nonetheless, terrible, even post-Obamacare). IIRC Switzerland and Germany's systems both have some or all of those features.

"comparable in wealth to the US"

What is your point?

Qatar - $127,523 GDP (PPP) per capita

Is my point.

They're not, however, comparable in obesity rates.

I'd be happy to see a single-payer healthcare system in the United States with strict denial of coverage for smoking-linked lung cancer, type 2 diabetes, and any other medical problems caused by the choices of the patient.

They aren't, but you're looking at this the wrong way around. You want all levels of government working together to create a healthy society - If your urban planners just defer health costs to private health insurance, what incentive do they have to create spaces that are healthy and productive? Are there measures schools can take to lower mental health incident rates, etc.

Health outcomes aren't determined solely by visits to doctors and the availability of pills.

What about sports-related injuries? Serious question.

Should a marathon runner in this scenario get treatment for knee damage or amateur / recreational boxer - for head trauma?

I didn't say no treatment, just no coverage. If you choose to engage in risky behaviors/activities, then you are more than welcome to buy supplemental insurance as one of the costs of your lifestyle. It would likely be fairly cheap for boxers and runners. Possibly even offset entirely by their associated healthy lifestyles, and therefore eligible for default coverage on a net cost basis.

If anyone has to pay full medical out of pocket, then all medical expenses should be tax deductible. Period.

True, but most Americans don't pay enough in taxes to cover even 1 single significant medical issue per year. A few doctors visits maybe, but any kind of major injury or illness and you will likely blow your taxes out of the water.

Most people in America do not have enough money in savings to pay for a single ER visit.

Which is why companies like our health care system. It keeps us beholden to them and wages suppressed.

> Something has to be done as status quo is not working [for everyone].


It's working for me in a way that only one other healthcare system would be able to help me (and even that healthcare system can only help me because the US healthcare system developed the medical advances I benefit from). If I moved abroad, I would have to keep a US health insurance plan and return to the US regularly to get the treatment I need here that isn't available in the rest of the World.

I'm still waiting for proponents of single-payer healthcare to take the effort to find out what works about the current system and who it works for. If they don't figure that out, they won't propose a solution that maintains the benefits of the current system.

The single-payer system being proposed will almost certainly reduce efforts to improve medicine that would improve my health issues in the future.

"find out what works about the current system and who it works for"

For the most part, the issue is not the quality but the underlying costs and power that insurance companies and drug companies have. So you personally may be getting a treatment that only US provides and I am happy for you but the discussion still remains about the fact that if you don't have insurance, you could end up getting a ridiculous bill for the simplest of procedures. You have no control over that. That is the issue. I hope you can understand that.

And let me reaffirm that the system primarily works for the profit making insurance companies and drug companies. Yes, the drug companies do R&D but what do Insurance companies do really ? Nothing except squeezing every bit of profit they can. The point is that we don't need insurance companies to cover EVERY little procedure because then they get too much power.

The insurance company have a contract that typically requires them to provide whatever treatments are available for a medical problem and are not experimental.

It's competition in the insurance space that creates such a large market for pharma and other medical companies to bring products to market.

If you had a monopsony (single-payer healthcare), where the only buyer is the US government, then the only treatments available are those it has approved via bureaucratic process. Nothing about single-payer healthcare prevents private options from existing per se, but so many people will go without private insurance, greatly reducing the market for medical innovations and shrinking the size of the R&D market.

Take a look at these graphs: https://www.quora.com/Which-country-develops-the-most-effect...

Single payer healthcare will dramatically shrink the US contribution to medical innovations.

In a way, the US healthcare system is socialized medicine that benefits the other 7.2 billion people on this planet at the expense of the 40 million uninsured people in the US. This is a trolley problem.

The WHO publishes a list of essential medicines. http://www.who.int/medicines/services/essmedicines_def/en/

96 new pharmaceuticals were developed since the list was first published in 1977. There are 306 today, so 31 percent of essential medicines have been developed in just the past 40 years. How many of those 96 were developed in the US? How many fewer would we have developed under single-payer healthcare?

It's possible that we still develop as many medicines under single payer healthcare, but simple economics suggest that's unlikely enough that we really want to be sure it won't decimate the R&D market for new drugs because that is what is at risk here, if we are wrong. Are you willing to take the gamble of depriving your future self and the other 7.5 billion people on the planet of the medical innovations we'll lose without the US system. Once you hand people single-payer healthcare, there is no way politically to go back.

This callow fuck-you-gots-mine attitude is appalling.

what medical treatments are available to you in the US that aren't available in other developed countries?

Other developed countries are often more conservative when it comes to covering experimental treatments.

Since many of these countries are in Europe and Europe in general has an attitude of "prove that it's harmless before you go to market" (over the American "you can always sue for punitive damages when things go wrong"), that's probably less a property of the health insurance system than of society as a whole.

My treatment for cataplexy/narcolepsy. Only available in the US and Canada. It's also available in Italy, but not approved for cataplexy/narcolepsy.

Without the US, it wouldn't exist as a treatment option in Canada.


Isn't it in everyone's best interest to revamp healthcare? Who exactly loses here? Rich people in the health industry? I don't get it.

I read somewhere that half a trillion a year[1] would be saved by single-payer. It's probably an exaggeration, but even if its an order of magnitude too high... sounds good to me.

[1] http://www.pnhp.org/sites/default/files/docs/2012/Dollars%20...

Absolutely, except for the wealthy private interests like pharmaceutical companies and insurance.

Polls show the majority of Americans have favoured a single-payer system now for decades. This was the case under Reagan even, and still is today.

This shows the degree to which the US is not in fact a true democracy, but more of an oligarchy. However things can change if there is enough public pressure. People just need to be organized.

Pharma companies don't necessarily lose out with single payer. Consider that the vast majority of drugs prescribed are generics, and most generics (aside from those making headlines) are available pretty cheaply (you can check GoodRx to see real prices). Of course, you might shave a good amount of profit from big pharma by negotiation (if there's a single payer or a few payers, they have a lot of power), but you don't want to stop R&D. How we shift that R&D burden and to whom, I have no idea.

Disclaimer: I work in big pharma research (nothing to do with pricing)

This is very true. Prices might go down under single payer, but more people are covered. Overall, prices may go down, but volume drives overall revenue up.

I have read that the US spends 18% of GDP vs. most other countries spending around 10%. That means the health industry is at risk of losing 8% of GDP which at 18 trillion GDP is around 1.5 trillion.

People say this money is being wasted but it's going somewhere and these people will fight for keeping it.

Pretty much everyone with money in a 401k or any major index fund would suffer catastrophic losses as these are widely invested in various healthcare and pharma stocks.

The downstream economic effects of an 8% contraction would be nuts.

People forget about these unintended consequences. We have to make these changes more slowly. Start by passing legislation to cap cost increases so the job losses and valuations fall more slowly.

We also need to revisit end of life care. I see so many commercials for drugs that offer 9 months of life vs 6 months of life for existing treatments and there is little to say the quality of life is maintained. We can't afford to spend $100Ks for elder people with some kind of aging related cancer to have 3 extra months in hospice care. People can buy with their own saving but we need to unburden the system.

Assuming that it were to happen all at once, yes. But instituting these types of changes would probably take the better part of a decade, or at least several years to phase in.

Based on my understanding, that contraction in the pharmaceutical industry would put money back in the hands of the middle to lower income brackets who are currently impacted most. And given that the velocity of that money is higher for them than it is for the upper classes, it would theoretically lead to higher consumer spending, and growth, for the economy.

I think the comparison to other developed countries suggests that the 8% is inefficiently allocated, and with a more efficient system that 8% spent elsewhere would have economic growth elsewhere.

I don't have the figures in front of me, but I think public health indicators (maternal mortality rates, for instance) suggest we aren't getting great ROI on the extra 8% we spend.

Umm, no I don't think so. I regularly check my IRA and 401k's portfolio and I can't recall ever seeing a lopsided investment in healthcare or pharma like you're saying. And index funds track indices. Is the S&P 500 really dominated to that extent by big pharma?

Second largest sector at 14.7%. Click sector breakdown in the top right.


There are a lot of middle men that would get absolutely crushed or go out of business if single payer were passed. Others would have to slash margins in order to meet whatever cost cutting is needed.

Yes, but the other 85% of the sectors would likely benefit a reduction in costs (i.e. insurance premiums for their employees) that would positively affect their bottom line.

The 8% contraction would be concentrated in a single sector. The money unspent on healthcare would go elsewhere.

Besides, the way DC works, there would be plenty of time for markets to adjust, short-sell, etc.

My take is that any kind of fair renegotiation removing the regulatory capture and the anti-competitive behavior allowed (and in some cases, required) by decades of lobbying would improve the situation. Single payer would work, free(er) market would work, but we're currently reaping the fruits of generations of entrenched political class for sale.

> Single payer would work, free(er) market would work, but we're currently reaping the fruits of generations of entrenched political class for sale.

Single payer or similar universal coverage systems would be the safe (dare I say conservative?) bet, since we have tons of examples of systems like that working well in countries similar to ours while saving lots of money per-capita over our system. Looks like an easy win.

Messing with our regulations and hoping the market fixes things might work, but it's more of a gamble.

There are also examples of free market healthcare working very well, see Singapore.

Singapore has multiple providers, like Germany, but it's not a Free Market (TM) by any means.

There's a lot of people that see the government do an awful job in so many areas (over budget, over time, etc), and worry that the same would happen with healthcare; _"Have you seen how poorly the government handles 'abc'? I don't want them in charge of my health, too"_

I'm somewhat of the mind that the government couldn't possibly do it worse than it's being done now. However, looking at the constant issues with VA healthcare, I'm not sure of my opinion either.

Rich people gain from research, new drugs, new equipment and new procedures. If the system spends more on poor people and common illnesses, it'll spend less on the things that benefit rich people.

Billionaires from around the globe fly to the Mayo Clinic in the USA. Why seek medical care in the USA? It spends more on the things that are good for the rich.

> Who exactly loses here? Rich people in the health industry? I don't get it.

You forget lawmakers reaping various lobbyist benefits, which is one reason why not much changes. Two sides bicker for a while to satisfy their constituencies, then compromise by doing nothing.

Is this not a false equivalency though? I'm not saying either side is perfect, but wouldn't you say one side has done more to try to solve the problem? Can you point out a plan brought to the table by the republican party that hasn't been a total objective disaster that the democrats were unreasonably recalcitrant about? The ACA is/was a good faith attempt to fix some of the issues with our healthcare system. There was tons of negotiation even if the process wasn't perfect, but at least they tried to do something. The republicans only seem to care when they are railing against something else, they haven't (to my knowledge) brought anything useful to the table at a national level within my memory. I'm not trying to be partisan, and I accept that single payer is a huge leap from where we are politically, but the way the ACA has been demonized indicates that one side plays politics with healthcare more than the other.

ACA was shoehorned through without bi-partisan support. It's currently unsustainable from a cost perspective and was widely predicted to be upon passage. Having good intentions does not excuse you from the consequences of your actions. For something as fundamental to our country as healthcare, having a wide buy-in and costs that won't collapse under its own weight is crucial for cost and legislative sustainability.

Those sound like talking points to me and I'm aware that my comments probably sound the same since I didn't present sources for my claims.

As far as not having bipartisan support, the republicans did get concessions but really didn't seem to want to contribute and haven't really tried to do anything on their own while they were in charge (unless you can point to a reasonable proposal that was shot down by the left). On top of that, claims that the recent proposals were as secretive or anti-bipartisan as the ACA don't seem to hold up [0].

I can't present a truly objective truth that I think will convince you, but there are a few misleading things about the ACA that make it seem more unstable than it really is. Overall I think one basic failing is that the penalty for being uninsured is too low, causing to few healthy people to enter the market that essentially subsidize the unhealthy (which is pretty much how all insurance works at some level). Insurance companies were essentially promised tons of new customers who could offset the fact that they now have to offer plans that actually have coverage (and therefore cost them more). Because of this, they are largely still making money but less money than they were and want. This means they don't have much incentive to make the ACA work and might actively work to destroy it to continue making record profits in an unsustainable way [1]. Not only that, but some of the premium increases come from uncertainty around whether the ACA will continue [2], or whether the government will continue to make subsidy payments that were promised [3].

I don't expect any of this to convince you but hopefully it makes my arguments seem less opinionated. I think about it the same way I think about software, I cannot imagine having to design and build such a system with the adversarial system we have knowing that you have to do it in a couple years and the other party is going to work against you and then try to dismantle the system after you are gone. Expecting to not have to have to make changes over time to fix unforeseen problems seems totally unreasonable to me.

[0] http://www.snopes.com/aca-versus-ahca/ [1] http://www.latimes.com/business/hiltzik/la-fi-hiltzik-aetna-... [2] https://www.nbcnews.com/health/health-care/obamacare-uncerta... [3] https://www.usnews.com/news/us/articles/2017-07-29/trump-thr...

Please stop trying to frame everything in a partisan lens ("talking points"). It does not good for anyone.

I agree with you that the penalty for being uninsured is too low if you want to build a sustainable system. However, had a more realistic penalty been put in place from the start, there is no way that it would have passed in its existing form. I'm also very much against younger people having to subsidize something that for the most part they get little to no value from.

As far as insurance companies go, the law was by and large a handout to them by providing them a captive audience that did not exist before and an excuse to raise premiums on everyone else. If you create a law that binds consumers to companies and do not provide adequate protections to consumers in the process, this is what you get. Just like the fees, had these protections been in place from the start, there is no way that the law would have passed as it.

My whole beef with it is that there were enough glaring flaws in the law and not enough buy-in from everyone that there was real sustainability and repeal risk. If you pass laws that are knowingly flawed that affect this many people, you are being dishonest and I don't think you deserve points for good intentions in light of that.

What do you propose as an alternative other than "do it all right the first time magically"? Do you think honestly in a system like ours you can get all the buy in you need and get something passed the first time? I think its easy to criticize from the sidelines but a lot harder to actually do something. I still think it was a real effort to actually fix problems and it did fix some of those problems, it has some economic issues but I think everyone is trying to make a political career out of jumping on it rather than doing the mature thing and trying to make it work (which they didn't do in the first place).

I lose here. I don't work in pharma, but I benefit from a drug developed in the US that is only available and approved for my condition in the US and one other country.

Not only will I lose here, but the future you will lose here as will the future everyone on the planet. Healthcare needs don't just exist in the present.


I don't quite understand the connection between single-payer and your implication that the drug you need wouldn't exist.

Healthcare is a racket. It takes advantage of our fear of death and suffering. It suggests it has solutions if you are willing to exchange your life savings for a few more weeks in $100k/ day ICUs.

I lean libertarian, but I have given up on the current system. I'd like to see all of the insurance companies and health care bureaucracy burned. This is an idea worth voting for Bernie.

I doubt that any real change is on the horizon as long as people keep confusing affordable health insurance with affordable health care. Obamacare was never the solution to the actual problem, which is unnatural pricing that is extracted under duress.

"The CEO has been under fire for taking the unprecedented step of transferring the patent of one of Allergan’s blockbuster drugs, the eye medication Restasis, to a sovereign Native American tribe as part of a bid to maintain monopoly control of the drug and its revenue."

"The Restasis patent was approved 15 years ago and was set to expire in 2014, but the Allergan deal is part of an attempt to renew the patent and extend the company’s control of the drug through 2024."

no shit people are fed up

I like Sanders as much as anyone else, but can anyone who supports it explain how Single Payer is obviously better than expanding the current system to provide universal healthcare? It seems to me that single payer would require a radical overhaul(more than 100 million people leaving their employer given insurance) and huge tax increases that requires a level of political consensus among the public and Democrat majority in both houses not seen since The New Deal.

That's not even to mention the fact that more vulnerable Blue seats are up for grabs than Red in 2018. I just don't see the current roster of the GOP supporting anything the Democrats put forward, especially something as radical as medicare-for-all.

I don't know if single-payer is the way to go, but I don't think that short-term disruption is a valid argument against almost anything, if there is evidence of mid-to-long-term benefit.

Separation of healthcare benefits from employment seems to have significant improvement in mobility for employees, overall. I think we (US citizens) need to have a serious, substantive discussion about how we get there. Actually doing that has been made incredibly difficult because of the way any government involvement in healthcare has been portrayed in the political arena for nearly 100 years.

... yet all of these concerns have been addressed by every other nation doing single-payer...

Your own research might be the best way to go - that way you can get the answer to your exact question.

People: We Americans think we are special - really we are just isolated and not exposed to other ideas directly.

There is a world of difference between reading about an idea, visiting a country's hotels, and really talking to the locals.

I see discussion time and time again:

* Healthcare * High-Speed Rail * Renewable Energy * Cities built for walking/biking instead of driving

All the above are solved problems for a generation in other parts of the world.

At some point, we owe it to ourselves to find out directly from the locals how things work.

What you list were solved by two things: the US providing the EU a military during the cold war and the fact that most of Europe was centered around dense cities since the Middle Ages.

You can't make high speed rail with stops in the US because our cities are spaced just far enough with low enough density to make the start stop process worthless. Walking cities are only possible if we force people into dense cities. As a country that does like freedom, you're going to start a civil war trying to relocate people through emanate domain into small apartments.

We need to learn what works for us. We have a different land useage pattern than Europe. We have a different approach the neighbors than The EU. Learn from them, but don't mindlessly copy.

>That's not even to mention the fact that more vulnerable Blue seats are up for grabs than Red in 2018. I just don't see the current roster of the GOP supporting anything the Democrats put forward, especially something as radical as medicare-for-all.

The GOP is going to oppose anything the democrats put forward, so it makes political sense for the democrats to aim for the most "left" solution possible so in case of compromise they can still get a lot. They learned from their mistake with Obamacare.

>I like Sanders as much as anyone else, but can anyone who supports it explain how Single Payer is obviously better than expanding the current system to provide universal healthcare?

It's cheaper. Taxes will go up, but bills will go down by more (for most people.) The political difficulties are actually part of the point, it allows the Sanders wing to set a litmus test for more traditional corporate dems. The Hillary-wing of the party is fighting a war on two fronts, single-payer and economic issues are what progressives are flanking them with.

Other countries usually control prices either through... well, price controls, or by establishing a monopsony on basic healthcare (single-payer). If we're not willing to create price controls (doubt it) then that leaves single payer.

Single-payer is the most startup-friendly system available.

It moves variable health care costs entirely out of your HR and payroll systems. You can get more experienced employees when they aren't afraid to risk their family's health care on a job move. By reducing risk exposure there, the risk of salary vs equity becomes more attractive.

For most industries, definitely. It may make it much harder for startups in the medical space (if it becomes more difficult to get that single payer to pay them).

You don't even need single payer. Most European countries don't have single payer either. what they have is more rules on pricing.

Price controls might see more resistance in the US than setting up a government (near) monopsony and letting that reduce prices (single-payer). The idea that price controls can ever, ever be a good idea is heresy to a lot of people here, to the point that they hold it as nigh-axiomatic that they always fail, and (clearly) no amount of real-world examples will convince them to add any nuance to their economic ideas.

I am afraid the US would mess up single payer if that attitude doesn't change.

Until I can see the VA work successfully or Doctors being excited about TriCare, I don't think we should entertain this idea. Further, right now all parts of the government are being weaponized by Democrats and Republicans. The last thing I want is my healthcare being used a political leverage, even more than it has been since Obamacare was passed.

I went to a walk in clinic a few months ago to get antibiotics for a severe sinus infection and I have insurance. I had to pay a $50 copay. While I was waiting another customer walked up who did not have insurance and was charged $99. A few weeks later I was billed an additional $97 because my insurance refused some items.

The clinic is allowed to charge some customers more than others, that seems unreasonable. The root issue though is that health care is a for profit business.

While I understand that profits are what drives drug companies to assume the risk of new drug development, people should not be forced to decide between going to the doctor or dentist to get important medical help or paying the rent. Many high cost procedures could be eliminated if they were caught earlier with affordable preventative care. Health care costs are further driven up by the hospital having to initially eat the cost of treating uninsured people.

Prior to obamacare both of my parents were uninsured due to being self employed and pre-existing medical conditions. In a span of a week my father had a heart attack and my mother shattered her arm (requiring surgery). Total cost was over $80,000. They of course could not pay that and defaulted.

Once Obamacare was introduced they both signed up and had insurance.

Long story short if you provide affordable options for people they will generally take it. Basic human decency states that the cost of medical care should never be prohibitive enough to stop people from seeking the care they need.

If Europe can make it work I see no reason the US cannot.

Want to hear something completely mind-blowing? I'm working on an issue regarding prescription drug benefit scoring. Whenever you fill a prescription, the pharmacy is required to share that information with certain entities, such as your insurance company. However, those entities then share it with data brokers.[0] Ever been turned down for health, or life insurance? Seen a premium spike? It could be because the prescription data brokers have rated you (based on your prescriptions) as a health risk. You cannot opt out of this. The only way to opt out is to never fill a prescription.

Whenever you apply for any type of health or life insurance, these brokers (think credit score for health) report a score based on the medications you take, have been prescribed but not filled, and those you've filled. You have no idea what's in the report, but you can request your report if you've been denied.

[0] https://www.consumerreports.org/drugs/prescriptions-not-secr...

There is a sweet spot for businesses who have massive regulatory protection the way pharma does, and who want to maximize rent extraction from society as much as possible.

For big pharma, this peaked in the past few years. The Mylan lawsuit and the outrage about Martin Shkreli are flare-ups that signal that public outrage is on the horizon.

In terms of social benefit, the trade-offs are not optimal at all. We are overly risk-averse to the point where FDA bureaucrats needlessly hold up drug approval, yet once a drug is granted approval we are very slow to sound the alarm if it turns out that additional data shows unanticipated risks. For example, the risks of Vioxx (as with many other NSAIDS) were well known to physicians long before the drug was taken off the market.

There is no such thing as a single wise entity that can appropriately vet all drugs for maximal societal value. Different people have different levels of risk-aversion. Our system exists to maximize the winner-take-all aspect of intellectual property protection for pharma, not to maximize the benefits of innovation to society or maximally incentivize innovation.

Certainly, someone who is 80 might be more willing to try a new drug with unknown 20 year side-effects than the parents of a 10 year old. The single regulator model is deeply flawed and creates massive harm on both ends of this risk spectrum.

But there is no need for big pharma to worry. We have broad bipartisan support of massive, long-term sponsorship of big pharma companies. Unlike Martin Shkreli, these companies play a longer-term game and for the most part avoid embarrassing fiascos such as the one that impacted Mylan.

But yet, in spite of this, they are insulated from competition by regulators and manage to extract sweeter and sweeter deals. Note the way Mylan gradually ramped up the cost of epi-pens following ACA? Mylan was just trying to get its share of the pie. Other firms, like health insurance firms, got their piece of the pie "de-contenting" bronze plans and removing high deductible options from ACA. The government got its share by being able to claim credit for passing a landmark law, etc. Like tigers tearing chunks of flesh from a fallen gazelle, the powerful interests manage to get what they came for, which is why the ACA passed in the first place, they all knew/expected the benefits to occur. The only group who got a bad deal were Americans relying on the ACA who were not poor enough to get a heavily subsidized plan... these people just had a massively regressive additional tax.

I simply cannot understand why the following question is never asked, addressed or even acknowledged to be a valid question:

"What health plan are all senators and government officials on? If congress cares about healthcare "for all Americans" - then put every American on the same health plan they have, or force them to only be allowed to use ObamaCare or whatever plan it is that they offer the people."


People ask it all the time.

At the moment, Congress and staff get subsidies to buy plans from the DC exchange.

All the time: https://www.google.com/search?q=congress+dc+exchange

I mean, I want a prominent, on air "news" personality to ask specifically this of any senator kvetching about healthcare live in front of millions.

It's like on NPR today they were talking about the tax reform, and the senator was asked if there was one single thing that he would want to see come from the tax bill. He said "many" she said again "name one" he said well there are dozens" and she said "yeah but name one change you want to see that will help middle class" and he deflected again and said "we will see what happens and if the American people want a simple tax system, then we will see about giving that to them" --- they are all lying sacks of shit.

What would the question reveal? They are on the same system as everyone else.

"Yes Woof, I buy my plan from the DC exchange and get services both in DC and from an excellent hospital in my district." KAPOW!


TL,DR: CEO of company screwing Americans, says one thing for PR purposes and then continues behavior for the dollars, euros, pounds.

Move along nothing to see here.

> I think we’ve got to do things to bring that trust back

The cynic in me wants to say "like not making indecent amount of profits on the back of miserable people".

There is nothing wrong with turning a profit, which is healthy. But when profit maximization is the prime directive, well... you know what happens.

As other commenters have pointed out, single-payer works well enough in Europe (there are issues, but I doubt they are directly inputable to the single-payer policy). Of course, that's rather hard to understand for the fringe of the population that can't distinguish between socialism and communism, solidarity and reckless selflessness.

Enough IS enough. When common arthritis drugs cost more than a year's salary, there is a problem. Normal people can't afford that. [0]

[0] https://www.everydayhealth.com/news/real-monthly-cost-arthri...

So what fraction of GDP goes to health costs in US vs other countries?

And are Americans healthier as a result?

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