I'm a Brit and America, your health care system is torturing me • Hacker News Board

Re: I'm a Brit and America, your health care system is torturing me

#61

Post by sethev » Sat, Jan 05, 2019, 1:00 AM UTC

tptacek wrote: post #53

sethev wrote: post #48

Earlier quoted context omitted.

In Switzerland, the basic insurance plan is defined by the government and everybody is required to participate in at least that plan. Everybody has the same deductible and out of pocket maximum and premiums (as paid by individuals) are capped at 8% of income. If you don't sign up the penalties can actually be higher than premiums and if you persist in not getting insurance the government will sign you up and allow th…

How are you not describing the ACA system? The ACA makes health insurance compulsory (not as effectively as the Swiss system, to be sure), mandates a minimum health plan (quite effectively, and quite similarly to the LAMal), guarantees issuance, and prices through community rating, the same way the Swiss system does. US spending on health insurance is 6% of income, 8% if you include expenditures outside insurance. I'…

Sure, it's similar (no coincidence, as you point out). Most people in the US don't directly participate in the ACA marketplace. For all the talk about freedom of choice, i'd venture that the majority of Americans have no real choice in what insurance they'll get (apart from their freedom to switch jobs or pay a higher price on the exchange by forfeiting their employer's contribution).

We also have a significant population (~15%) on a public system that has an influence on prices that everyone pays but no authority to negotiate drug prices.

I don't think that any one of these differences is an explanation for the gap between ~11% of GDP and ~17% but there are enough of them that it's hard for me to decide public vs private is orthogonal.

Re: I'm a Brit and America, your health care system is torturing me

#62

Post by kasey_junk » Sat, Jan 05, 2019, 1:43 AM UTC

tptacek wrote: post #46

kasey_junk wrote: post #44

Earlier quoted context omitted.

The VA is the best example of single payer system in the US, it does not suffer from either of these problems (though for demographic reasons it suffers from a host of others). As for the private options do any of them have the weird employer provided health care indirection?

I think employer-provided insurance at scale is a uniquely American problem, and agree that it is problematic, but I don't see how it produces more overconsumption and less centralization than a purely individual market would. In fact, if you maintain a system of private providers (even with a public payer), I don't see a connection between funding and these structural problems at all.

Nearly 150 million people in the states get their medical funding chosen for them by an HR analyst III & their favorite consultant buddy. Then it gets paid for in a combination of literally hidden payments, pre-pay deductions & tax subsidies. The idea that there isn’t a connection between this and costs is incredible. That’s before talking about the impacts on small businesses, long term care & the like.

Re: I'm a Brit and America, your health care system is torturing me

#63

Post by tptacek » Sat, Jan 05, 2019, 1:52 AM UTC

kasey_junk wrote: post #62

tptacek wrote: post #46

Earlier quoted context omitted.

I think employer-provided insurance at scale is a uniquely American problem, and agree that it is problematic, but I don't see how it produces more overconsumption and less centralization than a purely individual market would. In fact, if you maintain a system of private providers (even with a public payer), I don't see a connection between funding and these structural problems at all.

Nearly 150 million people in the states get their medical funding chosen for them by an HR analyst III & their favorite consultant buddy. Then it gets paid for in a combination of literally hidden payments, pre-pay deductions & tax subsidies. The idea that there isn’t a connection between this and costs is incredible. That’s before talking about the impacts on small businesses, long term care & the like.

Lack of price transparency is a problem. But by what I (off the top of my head) understand to be an overwhelming margin, Americans who get their health insurance from their employers like that insurance; it's also hard to see how the HR rep at your company is influencing decisions about how many hospitals to build or how many MRIs to prescribe.

Re: I'm a Brit and America, your health care system is torturing me

#64

Post by tomc1985 » Sat, Jan 05, 2019, 3:39 AM UTC

virusduck wrote: post #16

tomc1985 wrote: post #2

The HMO system is misery. PPOs are better but costly :/

Are you in an area where Kaiser Permenente operates? It has been, on the whole, a great healthcare provider. The level of integration of their centers is great--I can walk downstairs for an MRI or Xray or lab test (no waiting for one doctor's office to phone in authorization/orders). Electronic records are fully and usefully integrated. Costs are relatively low, and there are several options of locations in my area--…

I had Kaiser years ago and while the quality of care was high I remember eight- to ten-week waits to see certain specialists for non-critical issues.

The HMO approach concerns me more as someone with special medical needs -- I would strongly prefer the flexibility to see a specialist that is experienced with my specific condition as I've had problems with doctors whose only experience with my condition is in a textbook

Re: I'm a Brit and America, your health care system is torturing me

#65

Post by pcwalton » Sat, Jan 05, 2019, 4:25 AM UTC

tptacek wrote: post #53

sethev wrote: post #48

Earlier quoted context omitted.

In Switzerland, the basic insurance plan is defined by the government and everybody is required to participate in at least that plan. Everybody has the same deductible and out of pocket maximum and premiums (as paid by individuals) are capped at 8% of income. If you don't sign up the penalties can actually be higher than premiums and if you persist in not getting insurance the government will sign you up and allow th…

How are you not describing the ACA system? The ACA makes health insurance compulsory (not as effectively as the Swiss system, to be sure), mandates a minimum health plan (quite effectively, and quite similarly to the LAMal), guarantees issuance, and prices through community rating, the same way the Swiss system does. US spending on health insurance is 6% of income, 8% if you include expenditures outside insurance. I'…

I basically agree with you that we overfocus on the single-payer vs. private distinction. But I think there's more to it than that: when you get down to it, most Americans who want to reform the US health care system don't really care whether it's public or private. They care whether it's universal or not. The Swiss system is universal health care because the basic plan is capped at 8% of income at the federal level, with cash subsidies given to those with incomes lower than that.

By contrast, Medicaid in the United States is administered to the states, who have broad leeway in determining who is and who is not eligible for the system, especially after National Federation of Independent Business v. Sebelius. Income level alone does not necessarily qualify one for Medicaid. Medicaid is not considered universal health care, even with the ACA, and that makes a huge difference.

It's not so much that Americans don't want the Swiss system as that we're missing the crucial part of the Swiss system that makes people feel secure that they'll be insured.

Re: I'm a Brit and America, your health care system is torturing me

#66

Post by pcwalton » Sat, Jan 05, 2019, 4:36 AM UTC

tptacek wrote: post #39

bb88 wrote: post #36

Earlier quoted context omitted.

> (high on my list would be price transparency regulations) Why didn't the republicans do that over the past two years in the US? It seems like it would be great for the free market, and also encourage competition. Or do they believe in large company profit "protectionism"?

I don't know, except to say that national health policy has become a political football. I don't think there's an ideological reason for the decisions Congress has made; the system we have now was the Republican's proposed system in the 1990s (and was even a policy plank the the 1996 Republican Platform).

It's very easy to explain Republican opposition to the ACA. The 2016 election has made it clear that the GOP is motivated not by outcomes, not even by ideology (the current GOP, driven as it is by one person, has no coherent ideology), but by tribalism. Obama was and still is considered an enemy who cannot be allowed to score a victory at any cost, and so Republicans had to oppose the ACA.

I know that this take is likely to be viewed as extremely uncharitable to Republicans, but there really is no other logical way I can see to explain the party's anti-ACA plank.

(I think it's actually quite counterproductive to the conservative movement, because by abandoning ideology in favor of naked partisanship the GOP has guaranteed that Democrats will never give them a seat at the table when health care reform comes up again while Dems are in power. As a liberal, I couldn't care less, of course, but I can't help but note the irony...)

Re: I'm a Brit and America, your health care system is torturing me

#67

Post by tptacek » Sat, Jan 05, 2019, 5:03 AM UTC

pcwalton wrote: post #66

tptacek wrote: post #39

Earlier quoted context omitted.

I don't know, except to say that national health policy has become a political football. I don't think there's an ideological reason for the decisions Congress has made; the system we have now was the Republican's proposed system in the 1990s (and was even a policy plank the the 1996 Republican Platform).

It's very easy to explain Republican opposition to the ACA. The 2016 election has made it clear that the GOP is motivated not by outcomes, not even by ideology (the current GOP, driven as it is by one person, has no coherent ideology), but by tribalism. Obama was and still is considered an enemy who cannot be allowed to score a victory at any cost, and so Republicans had to oppose the ACA. I know that this take is li…

That's an argument I'm familiar with and sympathetic to, but not something I'd necessarily argue in mixed company, which is what I think of HN as. I don't understand the current coherent argument the GOP has regarding health care but I'm open to there being an ostensible argument and would only ask that Republicans recognize that whatever the new argument is, it's distinct from the original argument, which is that we should have a system that looks basically exactly like the ACA.

Re: I'm a Brit and America, your health care system is torturing me

#68

Post by tfehring » Sat, Jan 05, 2019, 7:20 AM UTC

pcwalton wrote: post #65

tptacek wrote: post #53

Earlier quoted context omitted.

How are you not describing the ACA system? The ACA makes health insurance compulsory (not as effectively as the Swiss system, to be sure), mandates a minimum health plan (quite effectively, and quite similarly to the LAMal), guarantees issuance, and prices through community rating, the same way the Swiss system does. US spending on health insurance is 6% of income, 8% if you include expenditures outside insurance. I'…

I basically agree with you that we overfocus on the single-payer vs. private distinction. But I think there's more to it than that: when you get down to it, most Americans who want to reform the US health care system don't really care whether it's public or private. They care whether it's universal or not. The Swiss system is universal health care because the basic plan is capped at 8% of income at the federal level,…

Medicaid isn't the only option for premium-controlled health insurance in the US. As far as I'm aware, everyone in the US is able to purchase health insurance for at most 9.86% of their income in 2019, except:

- Those who earn less than 100% of the federal poverty level ($12k/year for an individual, $25k/year for a family of 4) in states that haven't expanded Medicaid (~2.2 million people [0])

- Those who earn more than 400% of the federal poverty level ($48k/year for an individual, $100k/year for a family of 4) but aren't offered health insurance through an employer (e.g., because they're self-employed or work for a small business) (~900 thousand people [1])

Both are legitimate and significant coverage gaps, but they only affect ~1.5% of non-elderly adults in the US. For comparison, the number of adults that qualify for free or subsidized coverage but chose not to enroll is about 4x larger as of 2016 [2].

[0] https://www.kff.org/medicaid/issue-brief/the-coverage-gap-un...

[1] https://www.commonwealthfund.org/publications/issue-briefs/2...

[2] https://www.kff.org/uninsured/issue-brief/estimates-of-eligi...

Re: I'm a Brit and America, your health care system is torturing me

#69

Post by kasey_junk » Sat, Jan 05, 2019, 1:35 PM UTC

tptacek wrote: post #63

kasey_junk wrote: post #62

Earlier quoted context omitted.

Nearly 150 million people in the states get their medical funding chosen for them by an HR analyst III & their favorite consultant buddy. Then it gets paid for in a combination of literally hidden payments, pre-pay deductions & tax subsidies. The idea that there isn’t a connection between this and costs is incredible. That’s before talking about the impacts on small businesses, long term care & the like.

Lack of price transparency is a problem. But by what I (off the top of my head) understand to be an overwhelming margin, Americans who get their health insurance from their employers like that insurance ; it's also hard to see how the HR rep at your company is influencing decisions about how many hospitals to build or how many MRIs to prescribe.

I'd probably report I liked my car insurance if it included a twice a year detailing and paid for my lyft rides from the bar. Especially if the real cost of it was hidden from me. That is to say, the consumer of health care being unable to accurately judge the quality and efficiency of the funding of that care is at the heart of the problems with the market based approach to health care funding.

The fact that one of the major players in the funding space have an intermediary as a customer instead of the health care recipient is a further distortion of the market.

Imagine if we got our car insurance the way we get our health insurance. What impact would that have on efficiency of that industry?

Re: I'm a Brit and America, your health care system is torturing me

#70

Post by tptacek » Sat, Jan 05, 2019, 6:24 PM UTC

kasey_junk wrote: post #69

tptacek wrote: post #63

Earlier quoted context omitted.

Lack of price transparency is a problem. But by what I (off the top of my head) understand to be an overwhelming margin, Americans who get their health insurance from their employers like that insurance ; it's also hard to see how the HR rep at your company is influencing decisions about how many hospitals to build or how many MRIs to prescribe.

I'd probably report I liked my car insurance if it included a twice a year detailing and paid for my lyft rides from the bar. Especially if the real cost of it was hidden from me. That is to say, the consumer of health care being unable to accurately judge the quality and efficiency of the funding of that care is at the heart of the problems with the market based approach to health care funding. The fact that one of…

Our health insurance system is inefficient, and some of that inefficiency does come from the way employer-provided private health insurance works. My point though is that the numbers suggest that there are larger structural factors that operate independently of that inefficiency.

It's possible that the pathologies of our system created those other structural flaws; like, if we had an NHS instead of private insurers, we wouldn't have built all these inefficient hospitals. But whatever the cause, we are where we are, and switching to single payer won't undo those problems.

Which sums up my concern about single-payer: it might be a good way to lock in a lot of structural problems for a long time. Meanwhile, if you just directly address the problems themselves --- stabilize the markets, enact strong price transparency rules, aggressively incentivize efficiency --- you might not need single-payer (an immense, disruptive change) in the first place.

Also, if we want cost outcomes approaching that of the NHS, we have to do more than simply enact single-payer. We also have to aggressively set rates, reduce compensation for doctors, fire a lot of nurses, and make people wait years for knee surgery.