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Build Your Own ‘Medicare for All’ Plan. Beware: There Are Tough Choices (nytimes.com)
40 points by smacktoward 31 days ago | hide | past | web | favorite | 71 comments

The fact that the provided charts have no comparison to existing universal coverage systems (e.g. Canada, Europe) is frustrating. American news organizations treat the topic as if it were new and as if the care of American bodies is radically different from the care of the hundreds of millions of human bodies already being looked after by existing social welfare plans.

One difference I’ve noted between Americans and Europeans (especially the British) is the attitude towards quality of care. Many more Americans expect the “best” care; it’s almost encoded in DNA, like a byproduct of their fiercely independent historical nature. By contrast, the British are more communal and expect the same care that the vast majority of their fellow citizens receive. It doesn’t seem to bother the British that a small % of wealthy people can purchase better care in a mirrored private insurance system. If the American health care system is restructured and the result is 70% universal medicare and 30% supplemental private insurance or fee for service (with better quality providers, expanded diagnostic services, and shorter wait times), is that a real leap forward or will there simply be a different set of political problems created?

There was an NPR interview with a director or journalist with the Kaiser Family Foundation in which she addressed this in a slightly different way that presented a variation on this theme to me.

She said when you go to a hospital or medical office in Europe they generally look like an American junior high school. When you go to a hospital in the US, they often look like a resort hotel, especially the new ones. Such amenities are unrelated (or even counter-indicative) to the quality of medical care provided. The average European receives better care on average.

This also resonates with one area of my own medical care experience here in America: dentistry. My current dentist operates out of a modest office in an old strip mall in an unglamorous part of town. No fancy monitors hovering over every dental chair. No efforts to upsell me on cosmetics or prescriptions every visit. Just solid reliable affordable dental care.

I recognized in retrospect an anxious subtle almost subliminal feeling I would get whenever I walked into most dental offices before finding my current dentist. All these fancy state-of-the-art amenities, the giant saltwater aquarium, who knows how much in loans to pay off for a newly graduated dentist: somebody's gotta pay for these niceties somehow.

I wouldn't be surprised to find out the majority of patients were, unfortunately, impressed and reassured by such superfluities.

I agree wholeheartedly. I've been in several Canadian hospitals, and the older ones tend to feel cramped and have old fixtures, chairs, etc. Like a school built in the 70s. However in all cases I - or my loved ones - received what I would consider excellent care.

This resembles the "crisis" in education, where Univesities are spending huge sums of money from rising tuition fees on fancy facilities and amenities even as full professors are replaced with adjuncts.

> is that a real leap forward or will there simply be a different set of political problems created?

The question you should be asking is, will fewer people die of preventable medical causes.

That’s a very commendable metric to use but there’s very little political support for it. If Medicare banned hip replacements for anyone older than 75 and reallocated those resources to preventative care, many more “years” of life would likely be saved. (Not to mention heroic end of life care in hospital ICUs which Americans seem to culturally celebrate.) But you would start to see backlash from families affected. My point is simply that you couldn’t import the NHS to America and expect it to function well; there are unique social, cultural, and political considerations that have to be factored into a reform of the system.

ICU heroics isn't anywhere near as revered as our media makes it out to be. If it were, hospice and death with dignity (in some states like my own) would not be offered.

Most dying people I've seen choose to live the best quality of life they can rather than attempt to extend their lifespan with procedures that likely will not help.


How'd you go from "will fewer people die of preventable medical causes" to "[i]f Medicare banned hip replacements for anyone older than 75"? To your specific example, immobility is a significant contributing factor for most age related conditions and a hip replacement is an expensive but efficient preventative treatment in old age, especially when it enables the patient to return to regular exercise. Hip replacements aren't like organ transplants where there are a limited number to go around that present an unavoidable moral dilemma. Such a ban would be political suicide for anyone who even proposes it since seniors vote much more reliably so I don't think anyone expects to ship the NHS bureaucracy here wholesale.

There's a major PR effort behind American care exceptionalism, though by any statistic you care to measure, US citizens get very poor care compared to any other first-world nation.

If you exclude the middle and lower classes, Americans get better than average care.

Thing is, that is 90% of the population which isn't getting quality care.

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

Canada: https://torontosun.com/2017/02/16/canada-has-worst-erreferra...

Ireland: https://www.irishtimes.com/news/health/new-record-of-more-th...

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

>>Many places have way more significant wait times for treatment...

Canadian here - yep, there are sometimes wait times, especially for specialists, especially if it's something that is unpleasant but not urgently life threatening. That sucks. I'd still take that over some percentage of the population just not having access to care, or having a huge number of medical bankruptcies.

As for the ER - it even says in the article you link, that's largely people who could have gone to their primary care physician. Those are the people waiting. If you go in with a stroke, you're not waiting. I've (luckily) never been to the ER for a life-threatening situation, but I have for injuries where I needed urgent care, and got excellent treatment - and yes, once I had to wait for the guy ahead of me who had a stroke. I'm ok with that.

> That sucks. I'd still take that over some percentage of the population just not having access to care, or having a huge number of medical bankruptcies.

Yup. I'd rather wait 10 hours in ER for something non-life-threatening than get immediate care and spend the next 10 weeks fighting with insurance companies or filing for bankruptcy.

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

So, according to your article, 29% of Canadians had to wait 4 or more hours, whereas 24% of Americans did

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

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

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

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


Having used the ER twice in fifth grade in Canada, it seemed fine? Like, yes, sure you have to wait 12 hours to see a doctor if you're not bleeding out the chest. But also, I didn't have to face the prospect of paying $300 for a 15 minute consult, or going to jail to receive treatment.

If you have a cold, you find a PCP or a "health clinic" and make an appointment for same-day or later-that-week. And sure it's hard to find that PCP, but with my PCP in the US I have to book appointments three weeks in advance!

I'd argue "75%ile time waiting in the ER" is not a great metric. That neither tells you how easy it is you are to get preventative or routine treatment, nor how well your ER is able to handle a mass-shooting type catastrophe.

_Without insurance_ you can see a doctor in the U.S. for relatively cheap. I'm talking, $100 for a clinic visit. I've done it plenty of times for less.

The healthcare in the U.S. seems nuts because you are _billed_ for hundreds of dollars, but that's because they have to subsidize medicare patients AND insurance companies have negotiated rates based on percentages. So, they may only pay 40% of what is billed, but you are shown much more.

It's a scam everyone is involved in, which is why we need open pricing and open "how much insurance actually paid".

Without insurance, a 15-minute consult in Canada is, like, $40 CAD. That's like $20 USD. Factor of 5x or 10x savings.

Since most of the other OECD states are representative democracies of one sort or another, and since pretty much all of them have some form of universal health coverage, if the US system's an improvement over any of those in other OECD states, I expect there are strong, popular reform movements in at least some of them looking to move their system closer to that of the US. Right? Not to improve their systems in other ways, but specifically to move closer to that of the US. Since that'd be a clear improvement if they just "get real".

I’ve raised this exact question and never seen an honest response. Why aren’t politicians in other OECD countries trying to make their system more like ours? Why aren’t their citizens demanding it?

You can always buy private medical insurance to give you fast access to specialists for non-urgent care, or it can be provided through your work, in exactly the same way as the American system. The difference between America and somewhere like the UK is that in the UK expensive private medical insurance is optional, and there is a baseline of decent medical care available to everyone. And that baseline universal care is provided for the same amount of taxpayer spending (as a percentage of GDP) as the US spends on providing Medicare, Medicaid, and those partial programmes.

The US spends about 8% of GDP on private medical care, and another 8% on public care. Universal healthcare is about making the public, taxpayer-funded part of that expenditure more efficient, not about abolishing the private part of it.

This comparison is flawed if it excludes those who have to wait indefinitely due to not having sufficient coverage. Put those in and wait times wouldn’t look so great in the US anymore.

US stats don't include the 25%+, more like 50% really, of the population who are financially excluded from medical care (even though some are "insured").

Anybody who does this: "I have a medical issue but I'm not going to seek treatment for it because I'll get a bill for $10K" should be viewed as having infinite wait times, and counted in the stats thusly. But they aren't.

"Oh, I've got this giant infected cut on my hand and I'm not going to go to the doctor because I'll end up broke" simply doesn't exist in Canada or Ireland, or any other first-world nation.

And hey poster, I guess you didn't get to the bottom of your linked article: "Almost three-quarters of Canadians rated their quality of care as very good or excellent, well above the international average of 65%, she said."

You're cherry picking, and the US is getting worse every year in that metric, while other countries have started tackling that.

But the main thing is this has nothing to do with the universality of healthcare, more about how it has been implemented in those two countries. Go look at the UK, France, Germany, Australia.

> at least I can get treatment

I’m assuming that you realise the singular first person in that statement is very much that: singular.

> Let’s get real

The New York Times sees “real” as under a Rawlsian veil: they imagine being any citizen. You seemingly disagree with that approach.

I just want to point out that different countries in Europe have different implementation of universal health care system. UK != France != Swiss != Germany ~= Netherlands...

The German system, which is also the oldest universal healthcare system, would be the best/easiest fit to transition the USA towards that.

They’re also stupid because they perpetuate this meaningless idea that things can’t be done because of “politics”. Quote: “But most also said plans that eliminate it now are politically infeasible.”

Three years ago Medicare for All was “politically infeasible”. Then it turned out when you presented a direct, clear policy that improved people’s lives and was clearly untainted by special interests, people started to sign up. And suddenly every democrat candidate who hopes to have a shot at least has to pretend to offer Medicare for All. (Pretend because obviously some are for “realistic” “politically feasible” plans that mostly maintain the status quo and keep lobbyists and the insurance industry happy.)

The article mentions that the idea of “Medicare for All” is currently popular in part because it’s not clear:

> But when people hear arguments against it, their support plummets. It turns out that most people don’t really know what Medicare for all means. Even asking three policy experts might yield three different answers.

There’s a bunch of conjecture there, it doesn’t say what these arguments against it are. It doesn’t allow someone to argue for it and test to see if they remain persuaded when the idea is also defended. And in saying “most people don’t know what Medicare for All means” I don’t see anything testing that by asking what people think it means.

I suspect most people think “medicare for all” means exactly what it says. Everyone gets Medicare, that thing that you currently only get when you’re over 65.

Do they? According to a poll from last month, 55% of Americans thought that if "Medicare-for-all" was put into place, they'd be able to keep their current health insurance (35% thought they would not, 10% didn't know). [1]

...That's despite the fact that earlier in the same poll, according to the methodology document, the questioner had asked their opinion about "having a national health plan, sometimes called Medicare-for-all, in which all Americans would get their insurance from a single government plan" and, separately, "creating a national government administered health plan similar to Medicare that would be open to anyone, but would allow people to keep the coverage they have if they prefer". Take from that what you will.

After noticing that weirdness, I looked for polls from other pollsters on the same subject. In an online poll from last October [3], when asked "When you hear candidates talking about 'Medicare for All', what do you think they are proposing?", 52% picked "A single, government-run health insurance program to cover all Americans", 21% picked "An optional government-run program that would compete with private insurance"... and 24% picked "Neither of these". That's roughly consistent with the other poll if you group "optional" and "neither" together, but I have no idea what people who picked "neither" think Medicare-for-all actually is.

Another relevant question is how many people support single payer or a public option when the choices are explained more clearly. Going back to the first poll, in the earlier question I mentioned before, 56% supported single payer, while 74% supported a public option. However, a later question asked "Would you favor or oppose a national Medicare-for-all plan if you heard that it would..." with a series of hypotheticals. One of those, "Guarantee health insurance as a right for all Americans", had 71% in favor; but "Require most Americans to pay more in taxes" and "Eliminate private health insurance companies" each had 37% in favor. (I suspect the authors of the NYTimes article had this poll in mind when they wrote "when people hear arguments against it, their support plummets".) Once again, the methodology is confusing: the question literally asks if the respondent would support (or oppose) Medicare-for-all as a whole if the hypothetical were true, but some probably responded based on whether they liked the hypothetical itself. That might help explain how "Eliminate private health insurance companies" polled worse than "having a national health plan [..] in which all Americans would get their insurance from a single government plan" from earlier. Another part of the explanation is probably just ignorance and people not thinking about the issue very hard.

From the second poll, when asked which option they would favor most, single payer, public option, and "neither" were all roughly tied, at 34%, 33%, and 30% respectively. The first two add up to 67% preferring either single payer or a public option. This is close to the 74% who supported a public option in the other poll, which makes the results roughly consistent, assuming that respondents to this poll who preferred single payer would still prefer a public option to nothing.

Anyway... it's certainly true that single payer has substantial support, and that it seems a lot more politically feasible today than it did in 2016, in large part due to the efforts of Bernie Sanders and others. But it's likely all downhill from here. Medicare-for-all has become such a popular rallying cry on the left that it doesn't have much room to grow. And for any variant of Medicare-for-all (like anything else), once a concrete policy is on the table and its costs and downsides are available to criticize, support will fall; and once conservative figures leap on the opportunity to rally the base with that criticism, what bipartisan support currently exists will evaporate. That doesn't mean it can't maintain enough momentum to become a reality: it could. But it will help to have a higher starting point of popularity, and so evaluations of "political feasibility" do matter.

[1] https://www.kff.org/slideshow/public-opinion-on-single-payer...

[2] http://files.kff.org/attachment/Topline-KFF-Health-Tracking-...

[3] https://www.axios.com/medicare-for-all-poll-midterm-election...

The ignorance about how other countries do it extends to proponents of various public healthcare plans, as well. For example, I was surprised to find out that a lot of people have recently become convinced that "Medicare for All" (i.e. single payer) is how things are done in all developed countries other than US, and that public option is some kind of conspiracy to cheat them of having the same.

It's because there is no direct comparison.

No country on earth with single payer or other universal coverage has anywhere near the number of citizens nor geographic or social diversity as the US.

Now, that doesn't mean we can't learn from those countries, but our own smaller scale federal health care systems (medicare, VA, tricare) are already large enough to compare with and done so.

It's quite unfortunate, but the entire federal system has to change in order to lay the groundwork for a single payer system.

> No country on earth with single payer or other universal coverage has anywhere near the number of citizens nor geographic or social diversity as the US.

That's both not true (the PRC exists, and alone is sufficient to disprove that no country with universal coverage exceeds the US on any of the measures you listed) and not relevant, as none of those are significant per-capita or per-GDP healthcare cost drivers.

I'm sorry, just to be clear, you're making a serious contention that the PRC 1. Has universal healthcare (false) and 2. that it's something that is to be imitated?

> you're making a serious contention that the PRC 1. Has universal healthcare (false)

The PRC has universal healthcare coverage entitlement by national policy, financed and administered largely by local governments under national standards (with central subsidies to poorer regions), and has over 95% of the population covered through public-funded programs. [0]

> 2. that it's something that is to be imitated?

The claim was no country with certain features exists; being worthy of imitation was not one of the features.

I never advocated emulating the PRC either in general or in the specifics of their mechanism of addressing universal healthcare access; in fact, I specifically pointed out that, as well.as being false, the claim about countries sharing those features was irrelevant to the healthcare discussion (which implies that a country meeting the supposedly unmet description has no particular reason to have special status as a model for the US.)

[0] https://international.commonwealthfund.org/countries/china/

I'm familiar with the "claim" they stake, however the actual system has effectively nothing resembling a functional national system like the "OECD First World" systems that the US is being compared to.

That's saying nothing of its outcomes or service level by the way. Simply in reference to its structure.

It's not even in the same ballpark.

> No country on earth with single payer or other universal coverage has anywhere near the number of citizens nor geographic or social diversity as the US.

This argument is so bizarre. Larger population sounds like better economies of scale to me. And social diversity? I mean we're talking about Homo Sapiens here. A kidney is a kidney is a kidney, no matter your cultural background.

Unfortunately those factors are relevant, as cultural and lifestyle and wealth differences make big differences in health outcomes.

Healthcare also hasn't shown that it can scale or that margins increase with more centralized services, while maintaining service levels. Said another way: doctors (the bottleneck for service) are expensive to grow, take a long time to make, in high demand, and work serially (no parallel service provided).

It's a structural problem, not just a policy one.

I think this diversity can be benefitial for insurance right? Isnt that the whole idea behind the idea of diversification?

"No country on earth with single payer or other universal coverage has anywhere near the number of citizens nor geographic or social diversity as the US"

Why is this relevant?

The UK for example has a population of 60+ million (v US's 300+ million), if that figure doubled or halved, I don't think that would fundamentally change how the NHS operates. Just like it doesn't fundamentally change how it operates in central London or the Scottish highlands.

Note that the AND operator in my statement isn't an OR operator

Semantics aside, you haven’t established that those are primary drivers of cost or effectiveness. France and UK have 10x the population of Norway and are considerably more diverse. Can you prove where this impacts their respective costs?

I'm not making any specific claims about either of those aspects, simply that you can't compare two populations that are incredibly different in this manner.

You haven’t shown any supporting evidence of why you can’t compare them. Universal healthcare has shown to scale from Norway, Sweden, Denmark size to Spain, Italy, Canada, Australia size to UK, France, Germany size. What is the evidence it can’t scale to US size?

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

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

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

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

Most of the developed world does allow for private coverage on top of whatever public system they provide. Similarly, many have some kind of premiums.

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

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

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

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

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

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

There's a lack of nuance the answers provided.

For example one asks:

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

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

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

> Do you support ending employer-based private coverage?

Again, lacks nuance.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Two possible solutions relatively easy to implement:

1. Use previous year income.

2. Everybody pays the maximum copay and then gets some money back with their taxes.

>a monthly prescription

Fund drug research through public-private hybrids and grants, instead of intellectual property monopolies for the first x years of the drug. You can then spread the cost of developing the drug over a generation or two, instead of making the first people to be treated foot the entire bill. The public will own the intellectual property, the government can decide what diseases to fund/fight, and private companies still have incentive to perform research. All the while, private research can still compete for other treatments, or rare diseases with funding.

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

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

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

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

Source: https://www.nytimes.com/2016/11/08/upshot/a-doctor-shortage-...

> The system isn’t undermanned, it said: It’s inefficient. We rely too heavily on physicians and not enough on midlevel practitioners, like physician assistants and nurse practitioners, especially because evidence supports they are just as effective in primary care settings.

I’ve been preaching this for ages, there’s a place for MD/DO’s but when you go in for a set of sutures, an annual physical, all sorts of basic procedures there’s simply no reason for anything but a PA or NPP to be involved.

Let mid level providers do their jobs without needing a physician to sign off on everything (many states have figured this out already) and encourage growth in these roles instead of saying “we don’t have enough doctors!”

I'm 100% on board. If you see how dentists run their practices you'll see the advantage of not being directly under the AMA. Not saying the ADA is a bunch of heroes but they're not the active enemy of America that the AMA is.

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

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

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

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

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

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

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

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

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

Also how it happens in the UK.

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

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

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

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

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

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

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

- your health insurance costs would be eliminated

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

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

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