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Jayapal and Sanders Medicare for All Bills: One Is a Lot Better Than the Other (thedeductible.com)
21 points by howard941 3 months ago | hide | past | web | favorite | 37 comments

> S 1129 contains the clause that every true single-payer bill contains – a clause stating that on a certain date after the bill becomes law insurance companies may not sell policies that duplicate the coverage of the Medicare For All program.

I'm a single payer noob. Can someone explain to me why such a clause is necessary? If people are already paying for health care coverage from a federal system through taxes, why would they pay more to purchase a plan that duplicates that coverage from a private insurer? And if nobody is paying for that duplicate coverage, why is it necessary to outlaw it (rather than just letting insurance companies decide it doesn't make sense to sell it anymore)?

It makes me suspicious that they need to outlaw something that would appear to be unnecessary under the rest of the system they're creating. It makes me think the outlawed coverage might actually be useful for some reason, in which case it would be a bummer for it to be outlawed.

> Can someone explain to me why such a clause is necessary?

Because legally, such a plan offers you literally nothing and there is no rational reason why you should purchase it. To purchase it would be irrational and likely a result of someone trying to swindle you out of your money.

> why would they pay more to purchase a plan that duplicates that coverage from a private insurer?

A few reasons I can think of:

- They're continuing a plan they've had for years and would rather keep paying for it than accept change.

- Marketing tricks them into it despite it being a stupid idea (see timeshares for evidence this happens in reality).

- Because it comes as an add-on to a larger package with something that _does_ have value.

It seems like the crux of it more so is what the providers accept. If a major driving force is to improve administrative efficiency for providers (which it appears to be from reading this article), then it defeats the purpose if providers are still accepting payments from other insurers. But it seems like you could controller this at the provider rather than insurer level, that is by forcing providers to only take payments from the national plan. Then if any insurers were selling plans, they would be fraudulent because they couldn't actually pay for anything. But I can see that this is more or less equivalent to the law I was asking about, so I suppose I get it now.

It also prevents some of the anticipated benefits of the single-payer system.

- Providers don't realize the anticipated reductions in administrative overhead, since they may still need to retain the same complexity in billing but just with a radically different distribution of claims.

- Consumers may still end up having issues with providers accepting plans. Especially if you leave a loophole that allows providers to decline the single-payer option but accept the private versions that cover the same service.

- Consumer confusion can come into play related to covered services. One potential draw of the private version would be lax qualification standards for a specific coverage item. But if they decline coverage and the consumer tries to fallback on the single payer system, they may not have gotten the proper approvals or step therapy to have the procedure covered. The private company will have a marketing department to ensure negative consumer sentiment ends up falling on the lap of the single payer system.

- Economies of scale. The single payer system has market power specifically explicitly because of the fact that they own the whole consumer pool. If you allow it to remain fragmented, it lowers the single payer's negotiating power.

- Risk pool. The private company is more likely to skim off the healthiest consumers from the risk pool, and leaving the unhealthiest. This causes all kinds of issues from a political standpoint. The private companies can offer more attractive "perks" (like covering the same procedure, but streamlining the qualification process) because their risk pool is less likely to actually need that procedure. This would incentivize the top end of the market to purchase the plans (or offer as employee benefits, such as now), who would then feel negatively about the single-payer option because they're being forced to pay into that while not actively using it since it appears "worse" (even though it covers the same things).

At the end of the day, the clause isn't strictly necessary for a single payer system. But without that clause, you introduce quite a few failure modes and unnecessary friction points that can be completely avoided by simply disallowing duplicative private policies from being sold.

All of your points except the first one seem more relevant to the debate between single payer vs. multi payer. But I'm specifically asking, assuming single payer (ie. without a loophole that makes it multi payer), why is it necessary to proactively outlaw other plans rather than let them die?

I think your first point kind of gets at the crux of it though: you want providers to only have to support a single payer in order to reap the administrative efficiencies, so you either need to make a law that says that providers must only accept payments from the single national plan, or that insurers can't offer plans that pay separately. Those two options seem equivalent to me, but the first one (forcing providers to only accept payments from the national plan) seems more intuitive than the second to me.

For sure, the first point is pretty critical to ensure market viability of a single payer system. The potential reductions in administrative overhead absorbs some of the expected reductions in reimbursement amounts that'd come with a single payer system.

But even if you can make it work out from an economics standpoint, it can ultimately fail from a political standpoint if people feel like it's a failure. And there are a lot of entrenched interests that would benefit from a failed single payer experiment. My other points were geared towards that component. Letting the multi-payer environment die out organically leaves a grey area with potential consumer confusion and frustration during the transition period, and also leaves the infrastructure in place to easily roll back the single payer plan if you adequately exploit that frustration. Forcefully cutting over to a single payer system allows a clean break so both the consumer and provider side of the market has the opportunity to validate if the claims in the single vs. multi payer debate can be realized, without creating a giant attack surface for political and market shenanigans that could kill it before it really got going. It also raises the level of effort required to roll back the single payer system, since the infrastructure and and staffing to support it is reduced more rapidly than if taking a "let them die on their own" stance.

Where "better" here means "allows doctors to continue to earn much more money than they do in other countries for performing the same services".

I'm all for free healthcare, but this is a legitimate concern due to exorbitant education costs. Doctors often enter the field with high 6 figure or low 7 figure debts, with the expectation they'll make enough to pay it off quickly. I can't see a fair path to lower salaries without subsidizing outstanding debts.

First, let's not use the phrase "free healthcare" because it's never going to be free. It's more about how we as a society choose to pay the cost. Secondly, reducing the barriers to getting a good medical education could easily be part of the solution. I also think there is a clear downward spiral that occurs when doctors earn exorbitant income, then medical school becomes more in demand, then prices increase, then salaries have to compensate and so on.

Do any of these bills attempt to dig us out of that doctor debt / high salary hole?

How much should they be allowed to earn?

However much they can get someone to pay them! So long as they're aren't also using their cartel power to reduce the availability of medical care. Which they are.

How would they get anyone to pay anything if their services are being offered by the government as a basic human right? They lose all bargaining power if they can't refuse their services.

If the government offers too little money, the supply drops and you get quotas, waiting lists, and denied treatments.

Let’s not make this into another stupid polarized fight. Sanders is a pragmatic guy who I am pretty sure would entertain other thoughts if they really addressed the real problems unlike most republican proposals.

The crux is hospitals and doctors don’t want their pay cut, when it should be cut (Sanders’ bill does this). This is the result of the AMA attempting to keep wages high through quotas (as well as bloated hospital admins), and the resulting policy required to fix cost inflation.

Healthcare is a utility, not a profit center, of course we’re going to compress unnecessarily high wages (or cut unnecessary non-provider jobs ruthlessly).

Compressing "unnecessarily" high wages will inevitably cause less people to want to assume large amounts of debt for the necessary education and training to become doctors. The doctors that I know chose their career explicitly because of the salary and status that comes with being a doctor. Remove the incentive and you will diminish the supply. Diminishing the supply while also promising free care to all (increasing demand greatly) will result in very long wait times and diminished quality of care.

Those folks can depart the system and we’ll put an express lane visa in for doctors who want to immigrate to the US. Lots of highly educated healthcare professionals in the world who would want to immigrate to the US and aren’t anchored to unreasonably high wages.

Those doctors you mention picked the wrong career for fat cash and prestige. We can’t allow a broken system to continue because of previously made bad decisions.

Interesting solution - I don't know how the visa system works but if these doctors decided to switch careers after they got here in order to provide better for themselves/their family is there anything stopping them? It still seems like it's misaligning the incentive structure to produce the desired results.

At the base of the issue is that being a doctor is a difficult, stressful job that requires high intelligence and sometimes even high physical dexterity. While it's nice to think that people would choose to do it because it's moral to take care of people, I don't think it's fair to expect that these people wouldn't want to be appropriately financially rewarded for their gifted skillset.

Ah yes, the best of both worlds; socialized medicine provided at rock bottom prices through mass immigration undercutting the salaries of US citizens that are paying billions towards non-dischargable loans taken in good faith.

Sarcasm of course. In my opinion, these are two great ideas for getting Trump re-elected.

You can always count on America to do the right thing after having exhausted all other options.

Given that many more people want to go to medical school than are allowed, we are no where near running out of would-be doctors. Except that existing doctors constrain the pipeline.

People want to go because it is a lucrative career. Lowering the education requirements would result in lower quality of care.

Yep. There are a lot of people making good money off the current system. They see no need for change unless it makes them even more money.

> They see no need for change unless it makes them even more money.

I think even "they" would appreciate the efficiency of consistent single-payer system. Just imagine the incredible overhead of bureaucracy that would be achieved, no more need of departments set to deal with insurance problems and all. Surely they appreciate how this will all be streamlined and made efficient.

The unneeded departments are also quite powerful and want to survive. We call them “deep healthcare”....

>The crux is hospitals and doctors don’t want their pay cut

Whether hospitals and doctors are really charging fair prices aside can't cost reductions also be accomplished by cutting out middlemen? I think there's going to be far more pushback from those rent seekers than the service providers.

The mentioned 15-20% off the top for insurance, but the insurance/billing industry is two sided, wouldn't there also be a ton of administrative savings by having a fraction of the 'billing/coders'? They'd only have to deal w/ the U.S. government which isn't going to be as nitpicky and litigious over every little line item.

On the contrary. Medicare is extremely nitpicky on every claim line item.

An option I've thought of btw -- also is what about hospitals BEING the insurer? For instance, say they simply charged 6% of income for insurance. You'd signup through your local/favorite nearby hospital -- and pay your 6% of salary (nothing if you are in poverty), the hospital benefits because they have recurring monthly income that they can count on for budgets and things. When you travel your hospital pays other doctors and hospitals. Your hospital also pays your primary doctor, and other professionals as needed. This would basically cut out the insurer middleman, still leave it fairly privatized, but also lower the need for billers. Hospitals aren't going to gouge prices when they're the ones paying the bill right?

Government could also give grants/subsidies to help w/ the system as needed or tax relief. I think fair % might be 2% per 30k annual salary upto 10% of income.

Apart from your idea of signing up to a specific hospital this is how systems like the NHS work. They are funded from a specific tax in the UK and general taxation in some other countries. They either don't bill anyone for the care they provide and have no bureaucratic machinery for doing so, like the UK NHS or a here in Norway we pay a sort of co-pay for each doctor or hospital visit but it is capped at quite low levels, a couple of hundred dollars a year. And it is not related to the fine details of the treatment you have received so again there is very little bureaucracy.

Kaiser Permanente already acts as both a provider and payer in a single organization. The rest of the industry is gradually moving toward that model. But patients probably won't pay based on an income percentage.

Only because they can be, if hospitals and law-makers meet in the middle come up w/ across the industry iron-clad rates for services, or hell -- what if hospitals just get a flat average monthly lump sum -- no piecemeal at all, just based on # of patients that go through their door in a month?

Dr's get x% based on patients they saw + hours booked in the OR. Hospital administrators would have pay caps of 1 million per year. Hospitals that struggle could get grants and loans while the system corrects and adjusts to pay them more so they meet their budget constraints.

Yes capitation is already being tried in some areas as one approach to shifting the market from a fee-for-service model to value-based care. However provider organizations still struggle with it because most lack the data, tools, and expertise to properly price the risk.

Medicare administrators and lawmakers already do set iron-clad rates for service. The rates are relatively low, which is why there's a shortage of doctors willing to treat Medicare patients.

And being nitpicky on claims isn't so much a matter of pricing. Instead the insurers are trying to prevent waste, fraud, and abuse.

Of course. Current middlemen are around 9% of healthcare expenditures.

The essayist seems to agree with you, writing:

> I write this essay as both a long-time organizer, writer and speaker for a single-payer (the older name for “Medicare for all” system) and a strong supporter of Senator Sanders.

Yeah I'm a Sanders' supporter, and I got the vibe that he just has technical problems w/ Sander's implementation, of course I can see on HN a shitstorm of politics coming up, so he op could've been aiming his comment pre-emptively at Sanders-haters. At this point I'm in favor of anything that moves the need towards full coverage for everyone, of course being able to pay for it and having a stronger law will make it last and endure the test of time, so that's better.

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