>"Quit fucking around" and institute a national, single-payer plan that covers everyone, like every other modern industrialized country.
Except we're not starting from a blank slate. So short of heavy-handed, dictatorial decisions how would you propose to get to a single-payer plan that covers everyone? You'll have to work with the existing hospital infrastructure, insurance companies, and citizens who don't want a single-payer system. They all get a say, too. People who act like its a straightforward solution don't really understand the problem. But to avoid sounding overly cynical, I'll throw out a couple of recommendations.
1) Expand the VA system to cover all vets, regardless of whether it's a service-connected health issue or not, without insurance. This is politically possibly the easiest step because its hard for a politician to stand up and say they aren't an advocate for better care for the troops. However, the VA is entwined with medical schools and you'd have ensure you expand the funding proportionately to avoid pissing off that constituency.
2) Gradually ratchet down the age for medicare, over decades.
(I'd also argue you'd have to get money out of politics first for any really change to have a chance)
Oh no the vultures in the system will go hungry whatever shall we do
> citizens who don't want a single-payer system
Buy premium insurance above and beyond the public option, same as every other modern industrialized country. If you don't like the offering for free, the market can cover whatever gap exists.
Ignoring that a “stroke of the pen” is a dictatorial solution almost by definition…
Considering Medicare/Medicaid are currently approaching $1T annually to serve less than 20% of the population how dues your stroke of the pen plan pay for the increase when everyone is enrolled?
Hospitals are forced to accept Medicare, but in many cases this is at a loss, subsidized by private charges elsewhere. So you’ll need to find out how to shore up that cost, too.
These types of naive solutions assume everyone else is very very stupid or very very corrupt (or else why didn’t such a simple solution get implemented already?)
Medicare covers the most expensive part of the population.
The US spends 2-3x what the rest of the OECD spends per-capita, with about the same outcomes. Our system is the least cost efficient system in the entire developed world. It’s hard to see how Medicare-for-all could manage to do worse.
I agree with the population part. But more nuance is that a huge part is the last few weeks of life because of cultural aspects regarding protecting life by all means necessary.
However, they’re a saying in healthcare that you can optimize for quality, access, or cost but you only get two.
The US system is largely focused on optimizing for quality and access (although I admit the latter isn’t necessarily done well and generally relies on reactive care). So to open up access further, you’d probably need to address the other two levers, and I’m not seeing anyone discuss that. There’s also the disproportionate amount of R&D done by the US which effectively subsidizes the rest of the world to help keep their costs down. All that to say, none of the simple solutions bandied about really talk about those effects, let alone how to manage them.
> Considering Medicare/Medicaid are currently approaching $1T annually to serve less than 20% of the population how dues your stroke of the pen plan pay for the increase when everyone is enrolled?
Most countries manage on ~12% or less of GDP, the US takes ~17% of GDP to pay for healthcare [0]. For example, the UK manages to cover everyone for about 12% of GDP. If the US adopted a plan as ubiquitous as the UK, in the same manner as the UK, it'd be cheaper than the current system. Expense seems to be correlated more with the presence of insurance than with the ubiquity of healthcare.
This is the frustrating part of these conversations because people act like you can just swap one country for another like they are interchangeable. They aren’t.
For example, other countries get to keep drug costs low because the companies that make them get huge profits in the US. If the US charges the same, the profits and R&D also dry up unless you set up another system.
Also, the US tends to rely on extreme measures more often very late in life. I’ve heard (but can’t confirm) this drives a huge proportion of costs. This is rooted in cultural ideas of the sanctity of life. You can’t just pull the rug out unless you’re prepared for backlash about “death panels” and such.
There’s a lot of nuance and the “just do what other countries do” misses it completely.
That's simply misinformation. The US government funds some of the basic research that produces candidate molecules. But the vast majority of the cost in drug development comes in phase 3 human clinical trials. Almost all of that is paid for by pharmaceutical companies, and many trials fail.
> Seven of the 10 largest drugmakers by revenue in 2020 spent more money on selling and marketing existing drugs than on research and development for new drugs, according to an analysis published Oct. 27 by America's Health Insurance Plans.
> GlaxoSmithKline spent $15 billion on sales and marketing in 2020 compared with $7 billion on research and development. Bayer spent $18 billion on sales and marketing compared with $8 billion for research and development. Johnson & Johnson spent $22 billion on sales and marketing, compared with $12 billion on research and development.
I think this is missing the point. I don't think anyone is arguing that pharma spends a lot on marketing and that this cost is passed on to consumers. Rather, the point being made is that the US system disproportionately funds pharma R&D. Meaning, if the idea is to have parity with other countries, at least one of several options needs to happen: 1) other countries start funding more R&D, 2) other countries drug prices increase, 3) we accept that less R&D occurs, or 4) we find alternative sources for funding R&D.
Glib answers like "just do what other countries do" don't address any of that.
At least according to ChatGPT, over 40% fail. If true that’s surprising, since you don’t start a Phase 3 unless a lot of very smart people are convinced it’s going to work, and lab results (including human) back that up.
Singapore has an authoritarian police state which prevents many of the chronic substance abuse problems that drive a significant fraction of US healthcare spending. I don't think Americans would be willing to accept that trade-off. Singapore is also nearly 100% urban which makes care delivery much more efficient.
The US healthcare system is a mess and needs reform. But we can't just copy other countries. We don't want to lose the best parts of our system or stifle innovation in (expensive) new drugs and medical devices.
An interesting aspect of cancer survivability is the jump in cancer rates in the US right around age 65. The implication is people aren't being seen until they qualify for Medicare, pointing to preventative healthcare access problems.
Just to add to the nuance, you're comparing a country with 6MM people to one with 370MM people. What dynamics do you think that difference of scale has on the overall healthcare outcome?
I very much doubt there are either large economies or diseconomies of scale in healthcare. Certainly no indication of it in spend western Europe I can see.
The UK has IMO created diseconomies of scale by having a monolithic system.
Would it outweigh the diseconomies of scale seen in the NHS? It is pretty clear that the less centralised systems in other western European countries are more efficient, nor can I see any evidence that smaller western European countries face consistently higher costs than larger ones.
What are you seeing as the drivers of those diseconomies of scale? That might help me better answer the question.
Again, though, I think it’s an error to treat each country as if it’s interchangeable. In other words, we need to understand the systemic causes of those costs to understand the impact as it relates to other nations.
In the above example with Medicare, the cause is due to negotiating power through volume. So it’s pretty clear that scale matters there.
Come on--obviously OP meant a "stroke of the pen, held by duly elected representatives". Nothing dictatorial about that.
We currently can almost get enough of those representatives in office to do it (and a president to sign it), if it weren't for things like the electoral college, gerrymandering, and grossly unequal representation in the Senate, things that currently give disproportionate power to the "team" that happens to oppose single-payer.
I meant it as an executive order, which is really the only stroke of a pen that would work. Otherwise you’d have to build the political capital to get enough representatives to sign on, and that’s exactly the non-simple task I was alluding to. Those are the same reps who make the rules you’re complaining about, and the same ones who can’t agree on a budget when we don’t have a massive increase in Medicare entitlements. Maybe I’m too cynical, but pretending like there’s the political capital to do it just in the horizon feels like a pipe dream to me. I’m old enough to remember politicians talking about a single payer system in the 1990s and yet here we are.
I see. Except Medicare isn’t currently an option for most people employed. I think there are some benefits to employer sponsered healthcare, particularly with large employers who can negotiate lower prices. But I’m not sure it’s better on balance.
Except we're not starting from a blank slate. So short of heavy-handed, dictatorial decisions how would you propose to get to a single-payer plan that covers everyone? You'll have to work with the existing hospital infrastructure, insurance companies, and citizens who don't want a single-payer system. They all get a say, too. People who act like its a straightforward solution don't really understand the problem. But to avoid sounding overly cynical, I'll throw out a couple of recommendations.
1) Expand the VA system to cover all vets, regardless of whether it's a service-connected health issue or not, without insurance. This is politically possibly the easiest step because its hard for a politician to stand up and say they aren't an advocate for better care for the troops. However, the VA is entwined with medical schools and you'd have ensure you expand the funding proportionately to avoid pissing off that constituency.
2) Gradually ratchet down the age for medicare, over decades.
(I'd also argue you'd have to get money out of politics first for any really change to have a chance)