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Economic Analysis of Medicare for All (umass.edu)
78 points by cribbles 3 months ago | hide | past | web | favorite | 108 comments

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.

> 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.

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.

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.

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.

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)

Of course, but the interface and connectivity part of that EKG machine wasn't even up to 2005 cellphones standard. On that point, it's a scam.

So you would trust a random baseband chip to never ever in a thousand years lie to you about the success or failure of its operation or its internal status? Or to behave in an unexpected way that interferes with the core function of the device? E.g. by suddenly sending random junk to the main CPU?

How do you verify that the display controller is not acting up and not blanking out a region of the display that contains essential data?

If you cannot prove things like that for your medical device, you won't be allowed to sell it.

If only. I work in the same town as a big medical device manufacturer, and several co workers over the years had worked there and immediately nope-ed out on moral grounds. Stuff like panics on anything out of the order in a morphine pump that defaults to full on while resetting. Apparently those killed a few people.

Meeting the FDA guidelines is more about finding the cheapest way to technically meet the spec rather than trying to build something safe.

I do get that such a device panics on the smallest error. But then it is supposed to go into a safe mode. "Full on" does not seem safe to me. Full off and emitting an acoustic alarm until it is actively acknowledged would be the right thing to do. Whoever designed this thing to do what it did was frankly a morron.

But gaming the certification process is unfortunately also a thing. In the EU the certification is performed by private companies who are themselves certified by the government for this job. The kicker is that they are competing against each other on a free market. Potentially shopping around for the most lenient certification process could be a thing. I haven't witnessed it yet but it certainly is possible in that system. The thought alone scares me.

Oh yeah EU certifications are sadly super weak. Now to your original point, I think it's quite possible to have an open review system. Linux and the likes have shown great capabilities in finding and fixing issues fast. With a national effort to ensure paid engineers it's not science fiction.

You know this mindset is becoming the norm. Everything is about doing the minimum to be legal and avoid lawsuit.

I think primary care workers are generally underpaid and specialists are generally overpaid. That said there's a lot of variation in the data. If you look at some studies of why the US spends more than other countries on healthcare without better outcomes, the difference in prices between the US and other systems is a significant driver. Labor (particularly physicians), drugs and administration costs more here than elsewhere [1]. It's true doctors go through a lot of training, but I'm not terribly sympathetic to stories of a surgeon not being paid enough. Family practice, primary care I'd be more inclined, but even there we spend more than most countries it seems. [EDIT] I'm less sure on what the "blue collar" healthcare workforce (health aides, etc.) wages looks like, I would totally buy that many are underpaid.

Administrative costs are a terrible drag, and I say that knowing that currently I am personally paid by administrative costs. We could bring them more in line to the international norm, but we'd still be substantially more expensive because administrative costs are still not the bulk of total expense.

Drugs are an interesting story because the US effectively subsidizes international drug costs [2]. Also, drugs are a way to stop way more expensive interventions (better to take a $100K drug that cures Hepatitis C than get a liver transplant that will cost far more than that and won't give as good quality of life), so maybe in some ways we should spend more there if the treatments are worthwhile. That said there are disturbing pricing trends in the industry that are clearly exploitative.

In summary, what nationalized systems buy you is fewer administrative costs (good), price controls on medical services (maybe good, but necessarily docs get paid less down the line), price controls on drugs/devices (maybe good, but maybe trade-offs in developing treatments that are less expensive than other interventions). All of the parties involved will be fighting this "efficiency", some more justifiably than others. Who knew healthcare could be so hard?

[1] https://www.hsph.harvard.edu/news/press-releases/labor-pharm...

[2] https://www.vox.com/science-and-health/2016/11/30/12945756/p...

I'm pretty sure most people, even administrators in hospitals and insurance, are overworked. Health care in the US is the textbook definition of big business. The only people making easy, stupid money are shareholders.

> One thing that sometimes gets lost in the "health care is inefficient" discussion is that one person's inefficiency is another person's living.

You are not entitled to a living as bureaucratic waste. We should of course help retrain those who lose their jobs, just as we're doing for coal workers who are going to be out of a job within the next five years. I want my healthcare dollars going to healthcare providers (doctors, nurses, nurse practitioners, CNAs, drug research R&D, medical technology innovators), not private insurance companies, not administrators or third party billers, and most assuredly, not shareholders. I want the AMA to be handicapped from preventing us from dramatically increasing the number of doctors in the US (the American Medical Association operates as a cartel/cabal, attempting to limit supply to keep wages high); they also attempt to reduce the authority given to nurse practitioners [1].

> I would love for some sort of centralized system to push down costs, but I fear it's not realistically every going to happen.

The majority of Americans say the government should be responsible for ensuring health care coverage for all Americans [2]. Universal healthcare will arrive in the US eventually, the question is when. The current model is unsustainable, and will reach a tipping point.

[1] https://www.modernhealthcare.com/article/20171214/NEWS/17121...

[2] http://www.pewresearch.org/fact-tank/2017/01/13/more-america...

Only a few generations ago, healthcare was not so ruinously expensive in the USA. We've never had taxpayer-funded universal care. So what caused the explosion in costs?

TL;DR Lack of cost controls and unnecessary administrative costs.

> In the U.S., they point out, drugs are more expensive. Doctors get paid more. Hospital services and diagnostic tests cost more. And a lot more money goes to planning, regulating and managing medical services at the administrative level.

So, we're all getting a lower quality of care for a lot more money, due to how the healthcare "market" is configured.





This fails to address the elephant-sized American in the room. Any analysis of increasing healthcare costs that doesn't quantify the fiscal impact of the average American's failure to care for themselves is just beating around the bush. The obesity rate alone has gone from 10% in the 60s to 40% today. These people need more care that is harder to provide, and to not expect healthcare costs to rise significantly from that is to expect healthcare workers to work for free.

Our system is a little sick, sure, but the bulk of the responsibility for the current situation lies squarely at our own feet as individuals. This problem will never be solved before America puts down the fork.

The elastic nature of health care costs and the disconnect between the people making the purchases and the people paying the bills.

If you have insurance, chances are that you are not asking your doctor how much something is going to cost. You are not likely to shop around or work to get the best deal. As a healthcare provider, where is the incentive to bring costs down.

Also, hospitals typically won't tell you how much something will cost, so you can't shop around even when you are willing to.

Also sometimes hospitals will lie about what they will charge -- happened to my daughter regarding her appendectomy. Should count as fraud.

You’re missing the point. The parent isn’t suggesting this situation is good, or that we shouldn’t eliminate bureaucratic waste. They’re saying that there are a ton of people highly incentivized to keep the system as it is, because it pays for their salary. Concentrated benefits, diffuse costs.

Like, the living of some drug middleman who is a leach on the system and only exists because of some lobbying or other screwed up structure?

More like the doctor who has dropped six-figures + a crazy amount of years in education and certification to work very long hours seeing a lot of patients, many of whom think you're a quack and trust an online forum over anything you say.

Oh and don't forget the high premiums for malpractice insurance, as you're working crazy hours without breaks, and if you make a mistake you're sued up the whazoo.

And that's just describing a PCP - never mind a surgeon, EHS driver, hell even the nurses (though the latter are most likely unionized.)

Cost controls also have a cost. The UK NHS has chronic staffing shortages, UK doctors are going abroad for better pay; currently the favourites are Australia, Canada and the Middle East. I have heard quite a few people say they actively discourage their children from being doctors.

Australia and Canada have universal healthcare.

Poor purchasing power / stagnant wages is a problem across all sectors (except finance?) in the UK, not just healthcare.

Doctors aren’t a huge cost issue. Their pay isn’t that outrageous or out of line. It’s the pharmacy costs and administrative costs (and I think also DME costs?) that are seriously out of whack in this country.

Oh I'm not claiming they're out of line - they deserve that pay. My point was that it's not all these evil salesmen / drug capitalists driving high-costs in medicine. Sometimes better quality care just costs more.

These people get paid very well in Australia.

People will stop making lame arguments pretending that socialized medicine is impossibly unworkable maybe about 30 years after it's been successfully implemented in the US.

Why do we constantly pretend that America is an island universe and ignore that the rest of the developed world has already done this?

And a lot of this is administrative overhead. Coming from a country outside of the US, I was also shocked by the price of medecine, every medecine magically seems to be 5-10x more expensive in the US.

The prices help pay for the huge cost involved in developing drugs. How many drugs were developed in France in the past 10 years compared to how many were developed in the US? You know the answer.

I know that's what's pushed, but how much of that is true? Federal grants pay for a lot of initial frubt work, and drug companies spend around twice as much on marketing as they do on R&D. And that's with all sorts of tax benefits behooving them to call as much as possible of their budget R&D.

Marketing is needed everywhere, pharma included. You dont spread awareness of a new drug just by filing an application to the FDA. And marketing expenses are high because potential returns are high and make or break a drug. Note that you dont have really new drugs every year so you need marketing anyway to convince prescribers why your version of the drug in the same class as your competitor is slightly better. In reality most drugs of the same class are pretty similar in efficacy and side effects, but thats a tangential topic.

This is pretty specious reasoning. The US is a leader in a lot of industries that aren't healthcare.

Ever heard of Sanofi ?

Yeah and you know that their main drug market is the US and they target that market when deciding which drugs to develop? Also, ever heard of the concept of multinationals, where companies are spread around the world and not in a single country? same for Sanofi.

That's crap, often 80% of the price of a drug is marketing and profit.

Thats only if you consider the drug itself without all the cost of running operations and research. The actual profit margin at the company level is far from 80 percent. I suggest you read annual reports to educate yourself.

I think you're mischaracterizing the costs a little. It's certainly true that Company level profit margin is not in the 80s, but operating income is certainly fairly high. The profits come from compensating the Company for the risk that they have taken, and not necessarily straight for costs. There's certainly room to argue that the pharmas are capturing a too-large slice of the pie, and I personally welcome the debate.

Since Sanofi based in France is one of the top 3 pharma companies, along with Roche based in neighbouring Switzerland, I'm guessing the answer will be quite a lot.

The answer is very little compared to the whole market. And Sanofi targets the US market to fund its drug development. If they were not active there they would be a super minor company.

Personally, I would’ve liked to be asked whether I consented to paying 10x the price that every other country pays, in order to subsidize drug development, cause I definitely don’t recall ever agreeing to that deal.

The problem is your other option is likely not having the drug at all.

No, this is a myth. We know this because the same drugs often times cost a fraction of the price in other countries.

The real reason drug prices are astronomical in the US is because the US government is legally prohibited from negotiating drug prices. So the pharmaceutical companies can literally set any price they want.

You don’t have this problem with certain government agencies that are exempt from this prohibition. For example the VA can often acquire the drugs for much cheaper.

Does not matter how much it costs in other countries. the reality is that pharma companies make their revenues in the US at the level of 70 or 80 percent. You can be sure the level of investment would be very different if prices in the US were much lower. In practice the US is subsidizing drug development for the rest of the world.

If we removed the profit paid to investors, isn't there additional money to be paid to people facilitating healthcare and to bring the costs down?

It looks like there was $47 Billion, (~9%) in profit in healthcare companies in the US in 2018. https://www.axios.com/health-care-industry-on-track-massive-...

This accounts for less than 10% of the difference between healthcare spending between the US and other OECD states. See this report for a much more detailed analysis:


The cost problem in healthcare is exactly that: many pigs at the trough, and everyone points at the other pig for being the problem.

Healthcare administrators! Drug companies! Device companies! Trial Lawyers! Insurance companies! Doctors (especially specialists)!

They're all the problem, and yes lots of them should make less money. I know cardiologists pulling down 500k+ and that is ridiculous. I can see highly skilled surgeons making that much, but pill pushers?

> I know cardiologists pulling down 500k+ and that is ridiculous. I can see highly skilled surgeons making that much, but pill pushers?

I don't know about you but I'm not willing to be a student until I'm in my mid 30s, working crazy hours, likely accumulating a significant amount of debt along the way, without some kind of a substantial payout on the other side.

Which is a good reason to not make doctors spend so many years in school. The Europeans don't and their doctors are just fine.

Also a good reason for state-funded higher education.

Cardiologists aren’t pill pushers. They are interventional radiologists of the heart. They do need lots of skill also.

I’ve always worried about the political consequences to the loss of insurance jobs.

I also view that job loss as a foregone conclusion due to insurance companies fighting even moderate changes tooth and nail. If even minor improvements to a nakedly broken system are going to get fought against with such ferocity, it’s not surprising that their opponents would try and move the Overton window in response.

This is the problem with a for-profit healthcare system. Meaningful reform is almost impossible because there's jobs on the line and therefore voters to contend with. More importantly, they are also probably highly educated and well paid voters. Doctors, software engineers, sales, etc.

How much white collar employment comes from healthcare inefficiencies? Probably a good percentage of the sector.

These workers will need to acknowledge they are part of the problem and willingly give up these positions (or their absurd payouts from them) and vote accordingly. Or not and continue being part of the problem, which I think is your concern.

US has a host of not-for-profit providers, they’re not drastically cheaper.

Mostly due to the existing for profit system. Not for profits still have to reside within the existing construct of American healthcare and hardly provide any real advantages when they negotiate with for profit entities.

"cost controls the paper appears to advocate for literally mean someone is making less money"

Reference Table S1.

Cost controls would account for ~14.5% of the total savings.

Hardly seems onerous. Medicare's medical loss ratio is approx 4% (?), whereas ACA caps private insurers at 15%. So clearly there's plenty of fat to be trimmed.

TL;DR: Single payer is cheaper, people live longer. Transition will be painful.

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...

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?

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


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


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


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

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.

Something about this seems right to me. I'd be interested to see if there are any studies correlating these issues.

Children from financially unstable families do worse in school. Hungry children do worse in school.

If you want studies, here's discussion of one I just saw the other day:


Just as the state taking control of something doesn’t magically fix it, it doesn’t magically break it. The article you sourced even posits that the systemic problems could be fixed by increasing funding to improve teacher salaries and make the job competitive with industry jobs, not by privatization. These are apples and oranges comparisons, and there are countless examples of both state-run efficiency and inefficiency to support any position. If you’re asking for scientific rigor to back up economic policy opinions, perhaps that should apply to both sides of the argument.

Hypothetical economic studies may not be "normal science". But if we're talking about a massive new government program that is going to cost X gazillion dollars, I'd kind of like to know what X is before deciding that we should support it. I'd especially like to know whether X is greater than the actual benefits.

And who am I going to trust to decide that? Not a politician. Not someone who strongly favors one side or the other, either. And not just somebody at a bar, nor even a media personality. I want someone who actually knows some economics, and actually is attempting to be impartial. In fact, I want several independent ones of that.

America seems to have a huge problem with everything it does being incredibly costly. It's definitely true in the public sector and universities and also in large areas of the private sector.

American healthcare being more expensive than anywhere else fits the pattern. It also apparently costs more to build a rail line or any other work of infrastructure here than anywhere else in the world.

I'm not sure why this is, but health care is not exceptional.

America has high costs anywhere that government is involved. Healthcare, infrastructure, etc...The pure private sector is quite efficient here.

How about internet access or cell phones? Is that the government's fault too?

In a word, yes. Those industries already have a high barrier to entry which stifles competition and can lead to high prices. However the governments response to that has not been to try to innovate or subsidize new competitors to lower barriers. Their response has been to establish rules that make it harder or even impossible for new competitors to enter the market.

Yes, those are excellent examples. Telecoms are heavily, heavily regulated.

As a scientist: WHAT? You're saying that science is useless without experimentalists? (my side) Theorists do a lot of great work and I don't think any experimentalist would say they are useless. Sure, there is the playful banter of who's more important, but when it comes down to it we all know everyone is an important part of the system and that we need both.

Theorists set the groundwork. They come up with a lot of vague notions and then move to work with experimentalists to figure out how they can test these notions. How to "prove" it.

But saying they are "worthless"? That's just hogwash. Even if wrong, they aren't worthless. (Hint: most of the time they are wrong) And yes, economics isn't as rigid as something like physics. But it is pretty complicated stuff and they don't have as much of a history and basic principles. They may not be a hard science (or some might say not even a science), but calling an analysis worthless is just bad. And saying that in "normal science" (it's just science) things need to be testable to be useful is also just wrong. I'd call string theorists mathematicians, but what they do isn't worthless.

If this is really the way people think science is done, we've got a big problem.

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.

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.

Price controls cause shortages. Simple economics.

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

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.

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.

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.

Maybe US citizens should demand better government instead of wasting time on the never-ending partisan warfare. There are plenty of countries with regulated healthcare markets that work very well for their citizens and are cheaper than the US system.

> Maybe US citizens should demand better government instead of wasting time on the never-ending partisan warfare.

Never ending partisan warfare is what you get when people demand better government but disagree deeply on what is necessary for better government.

I don't believe that people disagree along the lines drawn by parties. Most political fights are artificial constructs to keep the people busy while the the people in DC and their donors stay in power.

> I don't believe that people disagree along the lines drawn by parties.

There is plenty of evidence that they do, and also that (by comparing to other democracies and over time) this is directly a product of the party system—an electoral systen supporting small number of signficant parties results in a small number of significant viewpoints, mostly divided on the same lines that divide the parties.

> Most political fights are artificial constructs to keep the people busy while the the people in DC and their donors stay in power.

Even to the extent that is arguably true, that a fight is an artificial construct or a distraction does not mean that the people at whom it is directed don't deeply buy into and incorporate into their identity the side of the fight they have been propagandized into.

In fact, it wouldn't work if they didn't.

"Even to the extent that is arguably true, that a fight is an artificial construct or a distraction does not mean that the people at whom it is directed don't deeply buy into and incorporate into their identity the side of the fight they have been propagandized into.


Most people don't bother understanding an issue or building a real opinion but just follow the part line Just watch the deficit discussion. When Obama was in power, a lot of people thought deficits are bad. Immediately after Trump came in the same people started worrying about deficits. The propaganda put out by the parties is finely tuned and very effective but that doesn't mean that the effects are lasting.

That is the line of thinking explored in Robin Hanson’s article, “Cut Medicine in Half.”


Combined with research on how wealth, family status, social status, access to sex partners, etc. etc. correlate with health outcomes even after controlling for access to doctors, hospital care, etc., it raises a lot of questions.

It seems most of the money we spend on medicine as a society is just a form of signalling. We “care” if we give X dollars worth of medical service, regardless of whether that led to a positive outcome or if the outcome could have been obtained more effectively through less “showy” ways or unglamorous things that don’t involve medical procedures or treatment.

It goes along with the idea of “betting is a tax on bullshit.” If we paid medical entities based on successful outcomes, including at the population level, then it might incentivize creative, cost-effective solutions instead of providers shoveling more ineffective treatment and demanding high pay just based on administering it.

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.

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


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

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

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... 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....]. 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.

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.

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?

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?

| 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.

In the documentary "Requiem for an American Dream", Noam Chomsky mentions the elite class tirelessly lobbying over decades for funding cuts programs to social security because they don't benefit the rich. The attitude that you expressed is similar.

What is legal is not always fair, and what is fair is not always legal.

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.

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.

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.

Earnings aren’t due to merit, so sure, why not?


> in that light, a ten percent reduction in cost is meaningless.

If you have the time, could you please clarify what you mean by 'meaningless'?

High earners were on average raised by high earning parents. Is being born rich fair? Which stages of the game should be fair?

(C'mon downvotes!) I thought the idea of paying your "fair share" was in relation to the services provided by the taxes paid. I can take an extreme example that I've tried to steel man to hold up this point: Bill Gates.

Does Bill Gates the man use more taxpayer provided military/healthcare/infrastructure.. than anyone else? Of those things that he does use more of, if he taxed by the volume of those services used (example: water/sewer) and therefore paying his fair share?

What difference does it make if her was born to rich parents? How does that make it right to make him pay more money?

I am asking respectfully and I sincerely hope that you do not take this as an attack.

edit: spelling

What is 'fair' is always debatable, but ... let me tell you one way I look at it.

I see democratic governments as an extension of society; and their most important service is a reasonably stable, safe society (with a few exceptions, there's no rioting; I can walk around the streets without fear of getting killed; I don't even worry about whether I lock my hour or car doors).

Given a live a nice upper/middle class life, I value this a lot, and am willing to pay high taxes for it; if I'm a poor teenager in the ghetto, I'm not getting as much from this; Bill Gates is getting much more than I am from this; it makes sense he pays a lot more than me, and that I pay a lot more than the teen from the ghetto.

Imagine society goes to heck ; do you think Bill (or me :) would keep his money ? his nice life ? his life ? :) If that happens, most people would be worse off than now, but Bill would be much worse off, whereas the teen from the ghetto may only be slightly worse off (and some people might even be better off). It seems 'fair' Bill pays more; it actually seems to me it is smart for Bill to pay more to keep our nice society (which is one reason he, and many other billionaires advocate for higher taxes).

This answer assumes that your nice neighborhood is somehow provided by the government with the tax dollars you give them. The government, especially the federal one, provides extremely little to upper/middle class neighborhoods. The real beneficiaries of government are the poor and the very rich.

Your neighborhood is only nice because of the people who live there :)

The wealthy want to believe it was their hard work and not luck that made them successful. (It’s both of course.)

Consider where their wealth comes from: it comes from skimming off some of the income earned by employees or by investment - which again, skims off earnings from productive enterprises.

Neither of those incomes come from their own actual work.

>How does that make it right to make him pay more money?

Because he can. And yes, he does use more Government services.

He was asking for a moral argument. "Because he can" is not an argument at all.

Can you expand on what you mean by "in that light, a ten percent reduction in cost is meaningless."?

that "ten percent less" of a payment is no longer being paid by particular patients, it's being paid by everyone.

that's like saying, "chris wasn't sick, but don't worry, though 50% of his salary is now gone so everyone has healthcare, he's paying 10% less."

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