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

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

#51

Post by deogeo »

rayiner wrote: post #10

I favor nationalized health insurance, but I worry American idealism would screw up implementation. The British are aggressive about rationing care. They aim to pay around 20-30,000 pounds per quality adjusted life year: https://www.bbc.com/news/health-28983924 There was an article on HN the other day that talked about how much debt a woman had incurred for her husband’s cancer treatment after she hit her insurer’s l…

1.) Insurance companies don't have infinite money - they ration as well. See point 8.4 in https://slatestarcodex.com/2017/02/22/repost-the-non-liberta...

2.) If you want private healthcare in the UK, you can still get it: https://en.wikipedia.org/wiki/Private_medicine_in_the_United... Public healthcare doesn't mean private healthcare is illegal - why would you think that?

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

#52

Post by feistypharit »

tptacek wrote: post #27
kasey_junk wrote: post #26

Earlier quoted context omitted.

But aren't those structural problems directly caused by the way we fund the system?

No, I don't think that's even partially true. Medicare also overpays for care and responds to the same structural wackiness the rest of us deal with. Medicare has lower administration costs, but those costs are still higher than administration elsewhere in the world, and administration is not actually where most of our dollars go.

If Medicare overpays, then the entire system is really broken. The reason you see fewer and fewer private doctors hanging a shingle for a private practice is because you can't break even. Those that do, don't accept medicare, many don't even accept insurance anymore. They can't take medicare because they'd operate at a loss. They don't take insurance because they're a pain to work with and don't like to pay.

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

#53

Post by tptacek »

sethev wrote: post #48
tptacek wrote: post #31

Earlier quoted context omitted.

Correlation isn't causation. Switzerland's health spending is in line with that of Canada, France, and Germany, has roughly the same (better in some cases) life expectancy outcome, and is an entirely private system. Life expectancy is also a poor way to compare health care systems, because major factors decreasing life expectancy have nothing to do with quality or access to care --- for instance, one of the most sign…

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'm not arguing the US system is better or even close to as good as the Swiss system. We have a lot of problems, and overpay flagrantly. I'm saying the Swiss have a system that closely resembles ours (unsurprisingly, since ours is patterned on theirs) and theirs appears to work. That tells me our problems are orthogonal to the issue of private versus public insurance.

I think the weak penalties for not carrying insurance are a serious problem with our system, but you are going to have a difficult argument to make if you want to attribute the hundreds of billions of dollars we overspend in health care to just that factor, or even significantly to that factor.

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

#54

Post by tptacek »

deogeo wrote: post #49
tptacek wrote: post #31

Earlier quoted context omitted.

Correlation isn't causation. Switzerland's health spending is in line with that of Canada, France, and Germany, has roughly the same (better in some cases) life expectancy outcome, and is an entirely private system. Life expectancy is also a poor way to compare health care systems, because major factors decreasing life expectancy have nothing to do with quality or access to care --- for instance, one of the most sign…

You asked how the chart 'addresses' the question, not how it unambiguously proves single-payer will save US healthcare - if that's your standard, I'm afraid I, nor anyone else, can meet it. And it has life expectancy, infant mortality, and preventable deaths - I guess they're all poor comparisons? Finally, the Swiss system is private only by the standard that insurance companies are privately owned. If you look at ho…

The part of this comment that bears rebutting, I rebutted in your sibling comment. :)

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

#55

Post by dragonwriter »

kasey_junk wrote: post #26
tptacek wrote: post #24

Earlier quoted context omitted.

The ACA reduced the rate of growth in health insurance premiums, but health insurance premiums continue to grow and have been for decades --- spiraling health care costs were a part of the Republican Party platform... in 1980. Guaranteed issue, community-rated health insurance is a necessity for a private health care system, and the ACA brought those badly-needed features here. But the big problem with US health care…

But aren't those structural problems directly caused by the way we fund the system?

> But aren't those structural problems directly caused by the way we fund the system?

Yes. Almost entirely.

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

#56

Post by tptacek »

dragonwriter wrote: post #55
kasey_junk wrote: post #26

Earlier quoted context omitted.

But aren't those structural problems directly caused by the way we fund the system?

> But aren't those structural problems directly caused by the way we fund the system? Yes. Almost entirely.

If that's true, and we stipulate that the two specific problems I called out are major contributes to the inefficiency of our system, you should easily be able to explain how switching to an alternate funding system would remediate them. Can you provide more detail?

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

#57

Post by dragonwriter »

tptacek wrote: post #27
kasey_junk wrote: post #26

Earlier quoted context omitted.

But aren't those structural problems directly caused by the way we fund the system?

No, I don't think that's even partially true. Medicare also overpays for care and responds to the same structural wackiness the rest of us deal with. Medicare has lower administration costs, but those costs are still higher than administration elsewhere in the world, and administration is not actually where most of our dollars go.

> Medicare also overpays for care and responds to the same structural wackiness the rest of us deal with.

Medicare isn't a closed system, and isn't the majority of funding, so it has to deal with the structural results of the rest of the system, which is majority private pay (and heck, Medicare itself is a partially-subsidized private-insurance voucher system with a public option for it's core services, which exclude prescription drug coverage, which is provided through an optional partially-subsidized private voucher with no public option.)

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

#58

Post by tptacek »

dragonwriter wrote: post #57
tptacek wrote: post #27

Earlier quoted context omitted.

No, I don't think that's even partially true. Medicare also overpays for care and responds to the same structural wackiness the rest of us deal with. Medicare has lower administration costs, but those costs are still higher than administration elsewhere in the world, and administration is not actually where most of our dollars go.

> Medicare also overpays for care and responds to the same structural wackiness the rest of us deal with. Medicare isn't a closed system, and isn't the majority of funding, so it has to deal with the structural results of the rest of the system, which is majority private pay (and heck, Medicare itself is a partially-subsidized private-insurance voucher system with a public option for it's core services, which exclude…

Help me understand what exactly, in broad strokes, a single-payer system adopted in the US in 2019 would do to correct those structural problems?

(I asked roughly the same question upthread a few minutes earlier, so if you answer there, I'll see that answer and consider it an answer to this question too. Thanks!)

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

#59

Post by dragonwriter »

tptacek wrote: post #43
dragonwriter wrote: post #41

Earlier quoted context omitted.

> Second, you can note that Medicare, our single-payer system, Medicare is not a single payer system, but a partial-subsidy voucher system for highly-regulated private insurance with (for the core inpatient and outpatient components) a fully-paid public option.

Fair enough. Consider my rebuttal so revised.

Let me expand on that: Medicare has recognized the problems you mentioned and has, fairly recently, begun directing efforts through payment system at the first broad class (inefficient interventions) through adoption of a variety of quality-incentive payment systems. But those aren't going to be as broadly effective, even for Medicare fee-for-service patients, as they could be if delivery systems and practice is shaped by conflicting incentives from different payers (who may be involved in covering some of the same claims, because coordination of benefits is a real thing, and even when they aren't for the same claims, will often over time be for treatment of the same patient.)

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

#60

Post by jschwartzi »

taurath wrote: post #14
jschwartzi wrote: post #4

Earlier quoted context omitted.

HMOs are great if you're healthy and plan to remain that way for a while. I have the same deductible and co-pays as a PPO but pay about $200 less per month. The level of care is adequate for my needs, and I actually go to the doctor now because the HMO is integrated with the provider network, so I can book appointments online. Since the HMO also owns the lab and other facilities at the clinic everything that they do…

HMOs fail most often on mental health from anecdotes of friends on them. They force you through only one provider who may be qualified or not, and you get a "permanent record" which can actually really hurt your care in the future. If Jill the ARNP says you were awful and maybe faking a sympton, and she has lunch with a bunch of other doctors in the cafeteria, you're gonna get treated like crap.

Yeah, I can see how that would be an issue. The HMO I'm on actually specifically covers private practitioners because their in-house practitioners are totally full for months. And it was pretty damn easy to get an appointment. I just had to call in and get a preapproval.
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