I want to get universal coverage of the American population. I want to get that coverage in a way that frees up significant resources for other things. I want to expend my energy and efforts on plausible pathways to achieving those goals. I don’t see single payer as an end in and of itself. I see it as a means to an end. I also see it as a lower probability means to and end than other methods that involve building kludges on top of kludges to get 1% there, .75% here, slightly better actuarial value there. My preferred methodology is far less sexy, far less exciting but in my estimate, far more likely to achieve my desired end state than advocating slipshod and sloppy single payer panacea solutions.
I am skeptical of single payer plans because the American healthcare and American health finance systems are complex. Single payer is an easy/simple solution to a very complex problem. My training and experience makes me reluctant to embrace simple solutions to complex problems.
I also have not seen single payer advocates do enough of their homework to answer some of the tough questions with anything more than breezy handwaves and assertions that the aggregate will be better off so the clusters of people who are worse off won’t fight too hard because this policy makes society as a whole better off.
Others have repeatedly asked me if I have a conflict of interest in that single payer would put me out of a job.
Yes, single payer if it was implemented tomorrow morning would put me out of a job within six to eighteen months depending on how long the data conversions take. My bet would be closer to eighteen months than six months.
However, I am not worried. I have not been looking for a new position but in the past nine months, I have been headhunted, interviewed and sounded out on four separate positions, three laterals and one promotion. None of these opportunities were in the health insurance industry.
And that is with me not actively looking for a new position. I’m not worried about my employment prospects for if Mayhew Insurance was shut down, I would be in a similar paying position within two months.
I think asking if I have a conflict of interest as a grounds for my skepticism for single payer is a reasonable question. I don’t think my employment prospects drive my skepticism to the current iteration of single payer plans.
Walker
I do not understand how we would ever get single payer in this country without having an actual public health care system. This isn’t just about disrupting the insurance industry.
My wife comes was raised in two countries with public health care: Poland and New Zealand. Her mother worked in the public health care system in both countries.
She would smoother me in my sleep if I were to vote for a public health care system in this country.
Seebach
I think facts don’t actually matter here. Sanders gives people an outlet for their anger and Clinton refuses to.
That’s going to decide a lot.
Applejinx
Can’t ask fairer than that. Thank you, Richard :)
I can only be envious of any person who’s all like ‘I have about four lateral moves ready, all of which make me easily twice minimum wage, therefore the system kind of sort of works’. I envy that quite a lot as I struggle like a crazy person to get UP to what would be minimum wage.
Truly, the insurance industry is indeed seeing boom times. Guess that’s the new ‘STEM’.
C.V. Danes
And yet most of the rest of the industrialized world has managed to pull it off.
I suggest the complexity is in getting from here to there without asking big Pharma to give up their yachts.
OzarkHillbilly
Richard, you say that like someone who knows what they are talking about.
magurakurin
No reasonable people here are questioning your motives for posting your opinions here. It is a little bit sad that you felt the need to have to clarify this. This primary is getting weirder and weirder.
I appreciate your insight and perspective on this issue greatly. Thank you for many informative posts and I look forward to reading many more in the future.
Starfish
You have mentioned before that the current state of health care is difficult for the people making just above the amount that they need to make to get subsided care. Reflecting on this, I think it is difficult for those people and getting more difficult. Deductibles are all due now. They are not spread out over all your pay checks over the course of the year so people who can’t afford health insurance + co-pay + deductible are still not getting health care. Would subsidized clinics that operated on a sliding scale work better?
magurakurin
@Seebach:
The rhetoric is obviously very, very different as are the intentions, but if this is true, I fail to see how Sanders is really all that much different from Trump then.
Emma
@C.V. Danes: Have you ever really looked at “single payer” in other countries? Some are tightly-regulated private insurance, some are kludges of public and private, some are run by the federal level government, some are decentralized. We need to shoot for “universal coverage.” That’s the prize.
Gin & Tonic
@Applejinx:
I corrected or attempted to amplify one of your references downstairs, where you link to an article saying property-casualty insurance employment is growing. That has nothing to do with health (care) insurance. Property-casualty and health-life are effectively two different and unrelated industries. There are some companies that play in both fields, but an awful lot, probably a majority, do not.
schrodinger's cat
@magurakurin: He is not that different, he is the left wing manifestation of the same phenomenon. He says what his base wants to hear, it doesn’t matter how grounded in reality it is.
magurakurin
@C.V. Danes: Well, I can tell you from personal experience, that Japan, most definitely does not have single payer health care. It has employer based with a public option for those who don’t have that. And the public option has a premium equal to about 10% of your salary and a straight up 30% copay. Germany doesn’t have single payer and neither does France. Both have multi-payer systems. The list is long of the various solutions to achieve universal health care.
Frank Wilhoit
Part (? much) of the complexity of the problem is due to the conflicting incentives among the stakeholders. The primary reason to move to single payer (in my view!) is to reduce those conflicting incentives so as to increase quality of care. Also, the word “single” in “single payer” is not just in opposition to a horizontal multiple but also to a vertical multiple. The foremost economic inefficiency in the current system is the excessive number of skim points, each with its skimmers. Congress would enact single payer tomorrow if it were framed in terms of a “public-private partnership” or some such dishonest formula, with the effect that the skimmers could still skim; but this would lead only to more skimming, lower quality of care, etc.
(Look for John Kasich to propose some such idea, btw, as he is all about the skimming.)
slag
This is unfortunate. Some of the best solutions to complex problems are simple ones. It’s actually a really interesting design challenge to see how simple of a solution you can find to a tough problem. Some great examples over the years that have saved many many lives:
1. The plimsoll line
2. The mosquito net
3. Even CPR training.
Not saying that any single payer plan is one of those things but just that you shouldn’t always be looking for complex solutions to complex problems.
MomSense
Well I hope you enjoy your corporate controlled future, Richard (someone actually tweeted this at me the other day).
Richard Mayhew
@C.V. Danes: NO NO NO
Single payer is not a universal system in the rest of the world. The rest of the industrialized world has universal or near universal coverage. Single payer is a minority method of achieving that universal coverage.
Single payer is a very specific means to an end of providing universal coverage.
In my value system, the end of universal coverage is far more important than any particular means.
Matt McIrvin
@C.V. Danes: Most other countries have some form of universal coverage. Not all of those are single payer.
terraformer
Thanks, Richard. Based on your knowledge and expertise in this area, what are the kludges that you think can get us there? What are the reasonable approaches, what order should they be implemented, and what kind of timeline do you think makes sense?
OzarkHillbilly
OT but, Whoa.…
WarMunchkin
I don’t think your motives are in question.
What I don’t understand is – if single payer is just a house of cards bereft of any numerical consistency, it’s completely reasonable to say that other aspects of liberalism are based on numerically dubious claims.
Liberals have been arguing for single payer for decades now. And those liberals include Paul Krugman and Ezra Klein and Nancy Pelosi. And nobody realized that their policy was mathematical gibberish? Not one person who wasn’t a conservative?
@magurakurin: That just strikes me as a high-horse opinion. Sanders’ critique of American democratic institutions isn’t new, and it follows decades of people saying the same thing, including President Eisenhower, Mario Cuomo, 2004 John Edwards and… Barack Obama.
Jeffro
OT but certainly deserves its own thread at some point: Politico’s article about how all of the remaining GOP campaigns are preparing for a brokered convention:
http://www.politico.com/story/2016/02/brokered-republican-convention-cleveland-219306#ixzz40LHIXalF
The shenanigans that are gonna go on this those delegates…it’s going to be a train wreck…
A brokered convention, coupled with the Scalia thing (which I believe will include a direct appeal from Obama to ‘moderate’/Establishment Republicans, that they support their Senators against Tea Party pressure/primary challengers) is going to crack the GOP for good this summer.
Llelldorin
@Applejinx:
Richard Mayhew, guessing from his posts, sounds like an actuary or a quantitative analyst. That’s not the new STEM, that’s the old one… it’s the “M”.
schrodinger's cat
@MomSense: Bernie Sanders supporters love to generalize. That’s what I found out yesterday.
Revrick
I’ve said it before and I’ll say it again. The biggest insurmountable in moving from what we have to single-payer is people. If 1500 people hitting the roof in Indiana, because Carrier is moving their plant to Mexico is any indication, what kind of fury will we see when the thousands and millions figure out that Bernie’s plan means the destruction of their livelihoods?
Shaking our fists at evil CEO’s and big Pharma and insurance companies provides cheap gratification. But there is a vast army of middle-class people who would have their lives upended in this process and I dare say none would take it lying down. And they will vote their anger.
Bernie will cause a revolution alright, a revolution that kills the Democratic party and hands power over to the Republicans for the next 50 years.
MomSense
@schrodinger’s cat:
This has been an interesting ride so far.
Genghis
I appreciate Richard’s detailed discussions from the trenches of the world of US healthcare, specifically the insurance side. My wife does insurance so some of the terminology is all too familiar. In any case, my criticism isn’t intended to be personal.
Why precisely is most of the civilized world able to provide better and cheaper health care than the US? Could it be…. less of a focus on profit$?
My conservative business owner friends from New Zealand are quite proud of their nation’s health care system. Then again, Kiwis are generally very proud of competing above their weight class – and America no longer seems to have the *can do* attitude of the past. My French friends also seem to like having a top rated health system. They also enjoy food that is less about profit and more about nutrition and enjoyment. Even English friends living in the US say their experience UK health system was superior.
I have doctor friends who moaned about “Obummercare”, how their pay was going to evaporate, blah blah. Instead of dropping, they’ve seen $ignificant increa$e$. (They still bitch and moan about Obama during surgeries.) If it were up to me, there would be a national project to double, triple or quadruple the number of doctors in this country. Send deserving kids to medical school in exchange for 2 or 3 years of service.
Do we really need the list of ways the U$ health system is messed up?
When our corporate health care system puts the focus on health, let me know. Until then, get used to hearing about calls for single payer. Maybe we could drop that fancy new stealth fighter bomber submarine project.
schrodinger's cat
@MomSense: Also their broad brush opinions trump the lived experience of people. I got a taste of what black people find so annoying about some of Bernie Sanders keyboard warriors.
Richard Mayhew
@OzarkHillbilly: I at least try to fake it.
@slag: Agreed, not every simple solution to a complex problem is wrong… but those simple solutions need to be tested and validated before being proffered as a very good solution to a complex problem
(the other one I would add is clean water is a simple solution to many problems… the complexity is getting the water clean)
Betty Cracker
@Frank Wilhoit: I think you’ve hit the nail on the head. Richard is almost certainly correct about the political impossibility of moving to a single payer system in the USA in any of our lifetimes. But from a value-delivery point of view, a patchwork system like ours is self-evidently inefficient. What value in terms of population health do redundant sets of claims processors and systems, provider relations representatives, customer service call centers, marketing teams, claims reviewers, underwriters, legal teams, actuaries, executive officers, etc., etc. add?
MomSense
@Richard Mayhew:
It seems to me from recent debates on this topic that many people are not aware that single payer is not the system used in all countries that have universal coverage. There was a book that came out in 2009 I think that discussed many of the different ways other countries have used to achieve universal coverage.
I also want to say that we have to be really careful about single payer because of how determined the opposition (Republicans) is to undermine our current Medicare system. To be successful, single payer really does require that the value of health care as a right be something that is shared by the whole nation. It really isn’t here. I also look at what the conservatives in the UK have been doing to the NHS and think that single payer would make us terribly vulnerable to the Republican death cult.
Forgotten in this debate is that the PPACA is the largest transfer of wealth to the middle and lower classes we have ever accomplished in this country. That it uses the private insurance companies to carry it out is very clever.
Amir Khalid
@slag:
Implementing single-payer healthcare is not as simple as painting a line on a ship’s hull, draping a net over your bed, or taking a CPR class. That much has been plain all along from Richard’s writings here.
Richard Mayhew
@Llelldorin: Yep, I’m a quant who can actually speak to people, so I don’t do as much data diving as I would sometimes like because I am often the interface between the quants who mumble at their shoes and end users who can’t find the right coins to pay for their coffee at Starbucks in the lobby.
Richard Mayhew
@WarMunchkin: No, it is not a house of cards. It is a series of hard choices that can be made if we are actually honest about what those choices are. Sanders’ set of numbers show either his campaign is fundamentally dishonest or have not done enough work to actually arrive at where the trade-offs, pressure points and fault lines are.
MomSense
@Genghis:
Until the PPACA we had a system with few cost controls.
CONGRATULATIONS!
@Genghis: Number of doctors is one problem. What the current crop of doctors went into medicine for (to make money, not to heal the sick) is a far larger problem. And not one that can be fixed for decades.
When going through my latest list of in-network doctors, I was shocked but not surprised that over a third of them had MBAs in addition to the required MD. I don’t go to those doctors.
Linnaeus
@schrodinger’s cat:
I’d say there’s a significant difference between Sanders and Trump in terms of their campaign messages.
Richard Mayhew
@terraformer: Read my archives :)
Little salami slicing — expand CHIP to cover all kids, change the Legacy Medicaid match rate so the Feds pay a higher percentage of Legacy Medicaid instead of the states, offer to pay 100% of Medicaid Expansion for 3,5, 99 years, decreasing Medicare eligibility age by a year every year or 1:2 or 1:5 or 1:whatever
Create Medicare reimbursement rate high cost reinsurance pools for ESI
Expand Exchanges
Drop SHOP as that was an interesting experiment that is going nowhere
Tie CSR and APTC tax credits into bundled credits
Revrick
@Betty Cracker: From a mere numbers perspective you might say zero. BUT it puts bread on the table for a lot of families. I’ll pick people over efficiency any day of the week.
Revrick
@Richard Mayhew: If the goal is to elect new progressives to Congress, pissing off 6 million people seems like the wrong way to get there.
Botsplainer, Cryptofascist Tool of the Oppressor Class
@Applejinx:
Whenever you choose to smugly inveigh about the economic disruption of rapid single payer to people who work in the industry or of retirees nationwide who rely on Fortune 500 stock performance for the continued health of their pensions and 401Ks, remember this statement.
Then shut the fuck up.
cokane
healthcare is always going to be complex though, even in single payer countries, i’m not sure how that forms any substantive basis for being skeptical about it. If countries with substantially fewer resources than the US, such as Costa Rica and Chile can pull this off, with some better topline health stats than the US, than so can a country with the world’s top university system. The intellectual capacity is there.
FlipYrWhig
@CONGRATULATIONS!: I would like to see a plan for a widespread US public health corps or something of the kind. Non specialist primary care performed at community health clinics. Maybe the candidate most identified with community health centers could draw something up.
Richard Mayhew
@cokane: It is not an intellectual problem. There are 15 viable models to chase (we’re chasing the managed competition Swiss model right now).
It is a matter of politics and a matter of resource allocation.
FlipYrWhig
@cokane: We have a very well developed system of opinion manipulation here in the US as well, called the media.
Barbara
@C.V. Danes: I am a broken record on this point. Most other developed nations have universal access but many of these do not utilize “single payer” systems. Canada does, but Germany, England and France do not. In these countries, the closest parallel is probably to Medicare with significant numbers of people opting out to buy private insurance, and some opting to buy “better” coverage options that add on to what they receive in the way of basic benefits. Some countries (Switzerland and the Netherlands) utilize a system of private payers that operate similar to the ACA (though of course, also very differently because it’s not segmented by state and offers generally better coverage and leaves no one out). Medicare works in some ways and doesn’t work in many others. It also has “private payers” that are embedded into Medicare coverage. So does Medicaid.
Docg
Single payer health care systems are rare and not likely workable in the U.S. No system can provide “everything for everybody.” My major complaint is that corporatization of health care overspends wildly on management (hospital administrators, insurance company CEO’s, pharma execs, etc. making millions), lobbying to insure excessive pricing and profits, the standard short term financial assaults on consumers to pump stock prices up, all of the negatives of unfettered capitalism impacting the lives and well being of people.
I can (usually) just not do business with most companies or industries whose practices are objectional to me. This is not true of medicine. Limiting prices and profits, as well as service providers, in the model of a public utility, seems most likely to be a useful avenue for reform efforts. Limiting the number of companies offering health insurance, pharmaceuticals, etc. also fit with a public utility model. The current trends of increasing cost, decreasing coverage, less business participation in providing insurance will lead to collapse of the current system. If the x axis is cost (going up) and the y axis is provision of services (going down), at some point the intersect will make participation in the system pointless. Why wait for collapse?
slag
@Amir Khalid: Thank you, yoda. What you’re not seeing in those well-designed solutions to complex problems is the huge amount of design effort that went into them. They seem simple now that we have them, but it took a lot of work to get to those simple solutions. That’s the point.
Simplicity is not, itself, a bad standard to shoot for. But it often takes a lot of effort to achieve it. The same could well be true for a better designed healthcare system. Don’t distrust simplicity as a standard. Though you may as well distrust it as a method for achieving the standard.
Betty Cracker
@Revrick: Okay, but keep in mind that the hideously expensive and inefficient system that puts food on middle-class families’ tables also leaves millions of people uninsured and screws those it does cover to fund yachts for its top executives. As I said, I think Richard is right that we won’t get to single payer in our lifetimes. There are too many stakeholders involved who profit from / depend on the current system, and any serious alternative has to address what happens to them and the political fallout of pursuing such a change. But likewise, naysayers should acknowledge the inefficiencies and injustices of the system they’re asking us to perpetuate.
Genghis
@MomSense:
I’d add too few doctors. Of course adding doctors would be cost control of a sort.
I’d add a skewed focus on treatment as opposed to prevention and cure. Cures aren’t really profitable are they? Treatments can really make your stockholders happy, produce big bonuses.
Let’s also add big agricorp’s impact on our food. Compared to Europe, our food sucks and this is certainly having an impact on our national health picture. (For any of you that have had to give up wheat products, try baking with European flour. You won’t believe the difference.)
Ultimately, it’s all about profits. In the US, almost any behavior can be justified by saying “We made a profit” or “We would have lost money”.
And sorry, during election cycles the statements of politicians are either vague and extremely nuanced (Hillary) or overly simple (Sanders). The details don’t exist to be criticized in the former and the flaws are more visible in the latter.
cokane
@Richard Mayhew: I agree that public polling (what I think you mean by “politics”) of the US gives rise to justified skepticism of single payer in the near term. But the complexity being a factor is not an argument I buy. HC is still complicated in the UK, as I’m sure you know.
But again, other countries, with fewer resources have done this. Successfully. In fact, I think this is a stronger point than the constantly harped on “Europe has done it!” or “Other industrialized countries have done it!” Fuck, middle and low income countries have done it, that’s saying something even more. So I’m not sure I buy the resource allocation argument either, because public systems are working in scarcer environments. Resource allocation is an issue under the current system and was pre-ACA too… These are constants in ANY HC system, not peculiars in single payer.
BlueNC
@Richard Mayhew: Awesome job description.
Barbara
@cokane: I agree with this, mostly, but I also think that people simply underestimate the role of diversity in making the U.S. very different from other nations in being able to get to “one size fits all” public policy solutions. There are some homegrown models that could be used to come up with a much more rational system, even if it included private payers in the mix, but trying to say that any one of them should be “the” solution usually generates more rather than less conflict.
? Martin
@C.V. Danes:
Sort of. Most of the industrialized world pulled it off when their pre-existing health care system was bombed into oblivion in the early 40s. Many things become possible when there is nothing to displace. There wasn’t exactly a massive public debate as to what kind of health care system to have in these countries – there was widespread suffering and no market infrastructure – there was no alternative except to create a single-payer system.
That does not describe the context of the US healthcare debate. Keep in mind that the US does possess 3 separate single-payer systems – the VA, Medicare, and Hawaii’s state health care setup. They are all structurally very different. Which system do we use, understanding that the choice is going to cost a lot of people their jobs.
Revrick
@Betty Cracker: Oh sure, I absolutely agree that our system leaves an awful lot of people out in the cold. But Nancy Pelosi has already made it quite clear that Bernie’s tax hikes to support a single-payer plan is DOA. She knows that tax hikes don’t play well, but left unspoken is the knowledge that the huge systemic disruption would be the death of the Democratic party.
It is far easier and better politically to train our guns on the bad actors (Republican governors and legislators) who are obstructing the expansion of Medicaid.
FlipYrWhig
@Docg: This chimes a bit with what I once called “VA for All.” I think it would be great to have a robust network of public providers doing credible work that is not all aimed at maximizing profit, similar to how public education is regarded. That has both upsides and downsides of course. IMHO the “single payer” debate is a lot of storm and fury about something that isn’t really the problem and whose solution isn’t politically viable anyway. So let’s get creative in another direction — and show that it can be paid for reasonably and readily.
Barbara
@Betty Cracker: It’s the disruption part of it that scares people. It’s easy to see the losers, as with climate change, and it’s much harder to see the winners. And because so much of the cost is now borne by employers, there is no guarantee it will be shared with employees rather than just pocketed. However unjust, there are many communities that see health care as guaranteed economic development. Look at any community that is facing the shut down of a hospital. They go bananas and it’s nearly impossible to talk rationally about the fact that the facility is underutilized and inefficient, and that the community generally has way more hospital beds per capita or anything else along those lines. This is different from rural hospitals closing because the governor won’t expand Medicaid. That’s undoing a whole generation of health care expansion to underserved communities.
C.V. Danes
@Emma: @magurakurin: My point is that we don’t have to invent the wheel on this. Pick one of the several systems that other countries are currently using that closest meets our needs and modify it as needed. Better yet, build on the ACA to make it better.
@Matt McIrvin: @Barbara: @Richard Mayhew: Sorry for the confusion. I agree that universal coverage is more important than single payer. My opinion is that it’s better to work on improving the ACA, for all it’s warts, than trying to pass something new.
Betty Cracker
@Revrick: Agreed. Considering the effort it took to get the ACA passed, I’m not for expending any more political capital on reforming healthcare except around the margins, i.e., expanding access, etc., as you suggested.
@Barbara: There’s a whole plot line around that on Downton Abbey! :) I kid! But yeah, you’re right.
schrodinger's cat
@Linnaeus: Agreed Sanders goals are noble but you know what the road to hell is paved with? Workers of the world unite was a good goal too.
WereBear
@Genghis: I utterly agree, and nurse practitioners could do a lot more of the front-line work, so that the five minutes the doctor spends with you would be better spent.
With the current emphasis on pharma a simple app could do what most doctors do now. And would do a better job warning me about the side-effects. My GP is great, but with other doctors, I’ve learned to look stuff up in the waiting room, then go back in right then and demand a different drug because “I can’t risk these side effects.”
They are supposed to tell me about them, aren’t they? Why don’t they?
Docg
@FlipYrWhig: Absolutely. And smart people like Mr. Mayhew could be reasonably and well compensated to make things work.
gene108
@C.V. Danes:
An analogy:
When I was a teenager, I was an out-of-shape “90 lb” weakling (more like 125 lbs, at 5’7″). When I went to college, I had access to the gym and started working out. By the time I got out of college, I was in pretty good shape. I could play basketball after work, for an hour, and then run 2-3 miles, because I had extra energy to burn off.
I’m now 41. Overweight, out of shape and have other health problems, such as chronic kidney disease.
Trying to turn my physical health around, like I did, when I was a teenager going into early adulthood is impossible. I need to find a new solution that fits my age and my health constraints.
Modern medicine, such as it is with an understanding of how the body’s systems works, how microbes work, with advanced medicines that can treat illnesses such as penicillin and aspirin, were not available until the early part of the 20th century. Other countries that adopted single-payer, in the 1940’s or 1950’s, were like me, when I was a teenager. The healthcare system was relatively “young”, and easier to move towards a national healthcare system or single-payer.
America’s healthcare system is like me right now; older, with built in problems that a younger person / system would not encounter 40 or 50 years ago.
Trying to do what others did, when they were younger is not a viable solution.
There is a way to get to universal affordable coverage, but it won’t be as easy as what was doable decades ago.
Single-payer is not the only way to universal affordable heatlhcare coverage. It may not even be the easiest way to get there now.
Emma
@cokane: I don’t know much about Chile but I do know that Costa Rica has private insurance on top of national insurance.
Eric S.
@Richard Mayhew:
OT but I fully understand that. I still write quite a bit of computer code but I often find I have to translate what fellow programmers tell our end users. Even some that are otherwise conversant and sociable in the real world fall into using tech-ese when it comes to work.
ETA: I’m not perfect at avoiding the tech-ese but I usually catch myself using it. I think.
Revrick
@Barbara: The disruption doesn’t merely scare them. It would enrage them. It would be like randomly burning down a house in your neighborhood, then doing it again in another neighborhood, then repeating it 1000 times in your Congressional district (that’s the 440,000 health insurance industry employees divided by the 435 CD’s). I think everybody would consider you to be an existential threat who needs to be stopped at all costs.
Starfish
@Richard Mayhew: Why do mathematicians do that? It drives me nuts.
cokane
@Barbara: A good point. I’d ideally like to see every US state have the ambition of Vermont, laboratories of democracy and all that. Sadly, a lot of states won’t at least not for decades.
I’d like to add that there many other diverse countries in the Americas. Colombia has a public % spending on HC on par with Euro countries dubbed as “single payer”. Despite a way way higher homicide rate, way poorer infrastructure and exposure to infectious tropical diseases, and obviously way higher poverty rates, their life expectancy is only ~5 years less than the US.
Ksmiami
@CONGRATULATIONS!: Unfortunately, unlike the American Bar Association, the AMA has lobbied for years against increasing the availability of med school spots to artificially inflate salaries. In most civilized countries, Doctors do well, but certainly do not come close to the amount of wealth they accumulate in the USA.
? Martin
@cokane:
Which actually works against us. Consider that the US is nearly 25% of global GDP. For all of the candidates bluster, a country with 4% of the worlds population produces 25% of its wealth. The problem with being rich and successful is that too often you don’t know all of the drivers for that success. Would a shift to single payer knock us off of that success? I don’t think so, nor do many on the left, but a lot of people on the right fully believe that it would, and we have no evidence to suggest otherwise. The very reason why we are more economically powerful than those other nations may have something to do with a free market healthcare system.
Most nations ‘chose’ a single payer system because they had little choice. This kind of large scale social and economic architecting is incredibly rare. You’re talking about an experiment on the same scale as the EU or China’s one-child policy.
Now, the advantage the US has in trying to do this is to use the states as laboratories. Hawaii is already there. Let’s try another state.
cokane
@Emma: So do a number of Euro countries that we label as single payer. There’s almost no country where HC spending is 100% public. For example, UK it’s 83%, France 77%, Norway 86%. In CR is 75%
azlib
I agree with Richard that the goal should be universal coverage. The financial solution to put such a system in place is an implementation detail.
Brachiator
@WarMunchkin:
But there is often an intellectual slight of hand at play here. I have heard people claim, “we should have single payer,” like all other industrialized nations have. This claim is manifestly untrue.
I remember some years ago watching a Bill Moyers program about health care. Every guest on the show, and Moyers himself, simply assumed as an article of faith that single payer was obviously the best solution, and the show went on to detail opposition to single payer.
But no one ever defined single payer or explained exactly why it was superior to any other plan. No one ever discussed how single payer was funded or administered. It was one of the most spectacular examples of “preaching to the converted” that I had ever seen.
Botsplainer, Cryptofascist Tool of the Oppressor Class
@Revrick:
That’s nearly a half million just employed by the insurers. Now add in the insurance clerks working at various doctors offices, hospitals, health clinics, etc., etc. That’s another half million.
And now let’s talk about the fact that every pension, annuity, 401K, 403B and mutual fund is heavily reliant on investments in the S&P 500 – and realize that nearly 30% of the S&P 500 consists of health insurance stocks.
Brachiator
@Genghis:
This is absurd. If this were true, we would still be “treating, but not curing” smallpox, polio, measles and a host of illnesses.
And of course, there is the quackery of alternative medicine that often promises outright cures, but which nonetheless is very profitable and never fails to find new suckers, uh, I mean, customers.
Frank Wilhoit
@Revrick: The skimmers are the existential threat.
Just One More Canuck
@magurakurin: I notice you say “no reasonable people here would question your motives”. You crack me up
gene108
@Betty Cracker:
Same goes for pretty much most of the economy.
Retail, in general, such as grocery stores, Macy’s, Amazon.com, E-Bay, Target, etc., only provide one service: they get goods produced by producers into the hands of consumers.
They provide many jobs.
The executives get big yachts.
But many people struggle to get enough food, clothing, etc.
I’m not sure how to make everything equitable.
Revrick
@Botsplainer, Cryptofascist Tool of the Oppressor Class: Exactly! When we’re talking $300-$600 billion in theoretical savings, we’re not just clobbering health insurance profits, yachts for CEO’s and putting the squeeze on Big Pharma. We’re also talking about those working on the provider side, plus the providers themselves — doctors, nurses, lab techs, hospitals and nursing homes will all get squeezed. And yeah, retirement funds too.
Blowing up the system in the name of some greater good is an exceedingly bad idea.
Doug R
Maybe cousin Peter can get you a job in the next star wars movie?
Barbara
@cokane: It’s interesting that Vermont did not want to emulate Massachusetts, and I can sort of understand why. Vermont is not nearly as prosperous, but it also has many fewer payers (basically, the Blues and maybe one or two others at the margins), Medicare and Medicaid. It could have adopted the Maryland approach, which really stabilized hospital care and rates in Maryland, but it did not give universal access. Anyway, I think Vermont could have gotten to a universal access system without running it through a single payer vehicle. It had way above coverage rates already, even pre-ACA. It’s costs are also below average per capita. Perhaps, in the end, it decided it wasn’t getting enough “more” to offset the additional structural costs that would be imposed. That’s probably not as true in some bigger states with historically lower rates of coverage.
Barbara
@gene108: You have a better safety net and a more progressive system of taxation. It’s not a mystery.
FlipYrWhig
@gene108: Profit is inefficiency by another name. Both are based on surplus. I don’t hear anyone saying that the computer business is so parasitic and extortionate that we need to have a public computer company. Or cars, or phones. Or oil! And people love to hate those industries too.
I mean, I’m a public employee. I know that not everything has to be profit-generating. But we put up with a lot of profit-generating in our lives in America. I’m not sure why the solution to the dastardly acts of health insurers isn’t to keep slapping them with regulations and taxes to make them serve the public interest, as opposed to trying to eliminate them by fiat.
Betty Cracker
@FlipYrWhig: I think it’s because healthcare access isn’t (or shouldn’t be) a commodity like cars, computers, etc.
Revrick
@Frank Wilhoit: I never saw them as an existential threat when I was rushed by ambulance for a fall in a state park nor the times I went to the ER for pneumonia or for a vagovasal reaction or for pleurisy.
FlipYrWhig
@Betty Cracker: Good point. Personally I’d rather hear Bernie Sanders-style arguments about health insurance and health care as the reason why single payer is best, rather than relying on Wall Street as the all-purpose villain.
WarMunchkin
@MomSense: What’s the name of this book? I’m interested in reading this now – I’m realizing through this campaign that I’m woefully unprepared to defend liberal policy solutions in the real world. If they’re wrong, they’re wrong, but I need to know why.
In the same comment, you’ve also discussed something else – the vulnerability of government-run programs to government interference. The Hyde Rule in particular comes to mind. Is the health care market the only place you have this concern?
Lastly, do you have a non-paywalled source on this:
gene108
@Betty Cracker:
What about clothes and food?
Plenty of for-profit stuff going on in those industries.
gene108
@Barbara:
Then why single out health insurance as the for-profit business that gets the ax because it violates the public trust?
You can pump more money to poorer people, so they can afford healthcare without needing a radical overhaul of the healthcare system and fund it by a big tax increase on the rich.
Betty Cracker
@gene108: So? I don’t object to Piggly-Wiggly or Forever 21 making a profit, and they have plenty of competitors to whom I can take my business to if I find their products ill-suited to filling my belly or covering my nakedness. If I’ve said something that led you to believe I’m a communist, I’ll take this opportunity to clarify: I’m not a communist.
The Other Bob
@magurakurin:
This x2 from me.
JohnB
@schrodinger’s cat: The difference:
Trump says what the base wants to hear.
The base wants to hear what Sanders says.
Yastreblyansky
All universal health care systems except the UK’s NHS have developed by the kludge method you suggest, and a lot of them are truly great. People use the term “single-payer” without a clear sense of what it means, which makes the debate just impossible to carry forward. It’s really regrettable. You do wonderful work, though. Keep trying!
Yastreblyansky
@FlipYrWhig: It’s 530,000 jobs, too.
gene108
@Betty Cracker:
Never said you were a communist or meant to imply you were a communist.
I just have a hard time figuring out why health insurance providers are the one for-profit gatekeeper of essential services that a sector of liberals want to see eradicated from existence above all the other for-profit entities that distribute essential goods and services.
FlipYrWhig
@gene108: I think the answer is that health insurance companies make money by denying claims. It’d be like grocery stores making money by NOT selling you food.
But that’s why the ACA was designed to make it harder for insurance companies to make money by denials and as a tradeoff permitted them to make a reasonable profit actually insuring, I.e., pooling risk and paying out when needed.
But, yeah, in general the same rhetoric about corporations and obscene profits could be used against most any industry, which is why it tends to ring false to me when used in some cases and not others.
Genghis
@Brachiator:
Absurd? Smallpox, measles, polio etc. were *cured* (made preventable) decades ago, no need to do anything about them these days but administer vaccine. I don’t recall Jonas Salk becoming wealthy for his work in this regard. While it’s possible that a bird flu or ebola epidemic would result in a similar approach, most diseases today are treated differently.
That’s the point of seeking cures for cancer, aids, diabetes, etc. There would be no need for treatment of a disease once a cure / prevention was found. But – this would not be profitable. Ask Martin Shkreli: http://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html?_r=0
While his example is egregious, this is what is to be expected in a health care system heavily influenced by hedge fund operators. Anyone confused about what Shkreli would do if he had the cure to a modern day polio? If the polio vaccine had been patented, it would have been worth $7 billion dollars – back then. Today?
Btw, there is no cure for polio – it can only be prevented, or treated.
MomSense
@WarMunchkin:
I’m always concerned about social security, education funding, head start, SNAP, etc.
I think Brookings did a big study on all the taxes and fees that are used to provide subsidies and Medicaid funding. The Economist and other publications did articles.
I can’t remember the name of the book off hand, but I think WHO provides some basic information about the various ways in which developed nations provide universal health care. Richard probably knows the book.
Bobby Thomson
@Applejinx: Christ, you’re an asshole. Richard has opportunities because he’s an educated professional and an intelligent policy analyst, not because the insurance industry made him a household name.
LeftWingCracker
@Richard Mayhew: Would single payer NOT lead to better cost controls through a centralized negotiation for costs? Yes, I anticipate providers would scream bloody murder initially, but it sees to me that the Government is the only entity large enough to go toe-to-toe with Big Pharma and doctors.
I do appreciate your thoughts.
NCSteve
@C.V. Danes: That’s because most of the industrialized world started when doctors only had a handful of drugs in their bags and hospitals were where you went to get bones set and die of pneumonia.
lowercae steve
As Kruthulu says, I’d chose single payer if I were starting from scratch. But we don’t have a clear path to a single-payer system right now. We do have a tortuous path to a Swiss universal coverage system though and that will be a huge improvement over our current system in both coverage and cost. So we should move toward it even if a swiss-style system is not the lowest cost option in a vacuum. Because it is actually achievable without a political miracle and without destroying an entire sector of the economy that maybe shouldn’t exist ideally but does and needs to be taken into account.
lowercae steve
@LeftWingCracker:
Monopsony power (assuming the government is allowed to negotiate costs..not like Medicare prescription drug coverage) is great and cutting costs, yeah. That is why a lot of people like Krugman would choose single payer if starting from scratch.
The problem is that we are not starting from scratch. A swiss-system might not be as good as a single-payer system but we could reach it more quickly and with less disruption and through incremental changes to what the ACA already set up. Not that these wouldn’t be difficult fights but they are not on the same level as trying to fundamentally reorganize the entire healthcare industry in the US.
Alex.S
@LeftWingCracker: After single-payer is implemented, then the government can probably win the fight against doctors and other health care groups.
Before it is implemented, doctors will be screaming about how they’ll be forced to reduce services by 15-30%* because of how much their pay is being reduced for the services they can provide.
From what I’ve read on research, there’s a strong belief that a single-payer system will “bend the curve” but it won’t reduce current costs. The Sanders’ plan argument is that all of the savings will come from eliminating administrative costs — no billing department in the hospital and no insurance industry.
There is no indication of any form of cost control in the plan, including on the user in the form of deductibles or copays.
* We don’t know what the reimbursements rates will be. Estimates I’ve seen have included lower than Medicare’s.
lowercae steve
@Alex.S:
Hmm, I think you are right. I should have said controlling costs not cutting costs. A lot of our high cost of healthcare is baked in from years of not having a good system in place. Of course if you get the yearly rise in costs below gdp growth (or even below general inflation!) the problem solves itself over time anyway.
Richard Mayhew
@LeftWingCracker: yes but how to get 218-51-1-4?
FlipYrWhig
@Richard Mayhew: POLITICAL REVOLUTION, that’s how! Get a lot more liberals elected and/or push the non-liberals into voting like liberals out of fear and self-preservation, both of which seem to be implicit, neither of which seems to have taken into account what happens if the non-liberals say, fuck you, I’m voting against you and if you don’t like it you can try to vote me out next time.
Keith G
@WarMunchkin:
To be fair, Ezra Klein’s opinion is much more nuanced, as this column from 2014 shows. What he typed reads a lot like what Richard has given us above.
LeftWingCracker
@Richard Mayhew: I think that’s what Sanders is attempting, knowing that it won’t happen next year or even three years, but the conversation will be moved in that direction. I know it will be difficult. Thank you for responding!
Docg
@Revrick: Jesus H. Christ! This has already happened to millions of workers, jobs outsourced overseas or eliminated by technology. Others being “Ubered” into working poverty. You should not be shocked when it happens to your happy ass, no matter what you do. This is primarily the reason that Sanders call to revolution is resonating so well. A lot of those that have been useful to the 1% will have their turn in the barrel.
chopper
@Emma:
many, many people confuse universal coverage with single-payer. the latter is a form of the former but is not a necessary precondition for it.
many of the ‘other industrialized nations’ people argue have a single-payer system do not, but rather have a system that is either more similar to ours than a SP or at least is in between. establishing a full-on SP system depends on a great number of variables. many of them are unfortunately not in our country’s favor right now.
The Raven
f@FlipYrWhig: Any for-profit insurance system can raise its profits by overtesting and overtreating, and that is exactly what the US system does. It isn’t enough to regulate the health insurance companies while they are still in control of the system; to make the system sustainable, they have to be converted into highly-regulated for-profit service providers in a system that is overall non-profit and that they are fighting tooth and nail. Can you see any way of doing this without creating a single payer system?
The ACA allows health insurance firms between 15-20% gross profit (MLR.) Medicare, which is non-profit, gets by on 2% administrative costs. It’s not clear to me that the health insurance companies add any value; certainly not 13-18% of their revenues. Now, I can see 6% profit as a reasonable amount. But 13-18%, guaranteed by federal mandate? Why? And yet there is no reason to expect that amount will be reduced, and every reason to expect that a Congress and President heavily influenced by the financial services industry, which includes health insurance, to raise that amount. Hillary Clinton, personally, has profited from her connections with the financial services industry, and they make up a substantial part of her social circle. Her daughter, even, has married a hedge fund manager and former Goldman Sachs banker.
Finally, let’s talk about inequity. The ACA system puts the biggest direct costs on the poorest, oldest, and sickest participants in the exchanges. Many of these people feel that the insurance industry is profiting at their expense, and they are largely correct. What do you propose to do to rectify that inequity?
bin Lurkin'
The main reason people are interested in single payer is they have been dealing with insurance companies already. The last time I had private health insurance (I’m on Medicare now) it took me over a year to straighten out the billing for a Tetanus booster given as part of a regular checkup. Yeah, I could have paid it out of pocket, that’s what the insurance company wanted me to give up and do but I wasn’t going for that, eventually they paid but they made it as difficult and complicated as possible, about fourteen months worth of battling the bureaucracy.
That’s what people are tired of, documents that are indecipherable unless you are a lawyer with considerable medical knowledge as well, claims process that automatically reject your claim on the first pass hoping that you will give up and on and on and on with the bullshit.
The insurance in other nations with non-single payer isn’t really comparable to US insurance companies, their insurance companies haven’t been allowed to rampage like Godzilla through Tokyo and people have some reason to trust them, Americans have zero reason to trust medical insurance companies and millions of reasons not to.
Also, shopping for food or clothing is not like medical care in that you buy food ahead of need while medical care often the need comes first. You don’t pick your hospital by cost breakdown or reputation for excellence when you are in the ambulance with a compound fracture from a fall, you go where the ambulance takes you if you are even conscious in the first place. (this is a situation I have personally experienced).
FlipYrWhig
@bin Lurkin’:
Why is it, then, that every time people have it put before them that they could change their insurance to a government plan they explode with rage and/or whimper with dejection? Yes, health insurance sucks and is terribly confusing. My wife and I have 4 advanced degrees between us and we have no idea why we get weird paperwork that says it’s not a bill, then later a bill, then later a corrected bill, and so forth. It seems idiotic. But people with insurance appear to dread what would happen if they changed over to something else. Lest we forget, when people on the individual market were forced to switch _to a better plan_ it became the “lie of the year.” I don’t know how you fix that.
bin Lurkin'
@FlipYrWhig: They don’t, I can’t think of anyone I know in my age group who isn’t on Medicare.
What happens is what always happens in America, the right and particularly the far right is just noisier than hell, even in liberal districts Congresscritters get more and angrier calls from conservatives than liberals.
If I hear someone loudly and ignorantly talking about politics in a public place it’s always a conservative. I stopped going to one convenience store that is closest to my house because I made a comment to the clerk (or owner, not sure) one day about something in the paper that was laying on the counter and she went off on a spittle punctuated wingnut rant.. Fine, I’ll take my liberal business elsewhere, that little rant has cost that store a few thousand dollars in my business over the last several years and it doesn’t look like the type of place that could stand to lose the traffic.
The billing stuff I’m fairly sure is just to keep us confused and off balance, I’ve seen fresh, never before seen bills from providers I’ve never even heard of trickle in for over a year after a family member had a surgical procedure that involved a single night hospital stay.
A nurse in the extended family used to deal with the insurance end of medical practice and is an expert on it, she loathes the insurance companies with the kind of fierce passion that would leave them smoking holes in the ground if she had her way.
The Raven
@FlipYrWhig: “Why is it, then, that every time people have it put before them that they could change their insurance to a government plan they explode with rage and/or whimper with dejection?”
Propaganda has taken the natural fear of change and the reasonable concern with abuses of government power and turned it into panic.
In detail:
1. This would involve raising taxes. Little effort has been made to explain that the tax rises would be offset by reductions in insurance premiums. Nor may we reasonably expect employers to make up their gains from having their employee health insurance costs vastly reduced by raising salaries, unless this is written into law.
2. Some of the public would prefer that no money be spent on the “undeserving.”
3. People are concerned that governmental health care policies will be corrupt and dangerous, perhaps even deadly. This is not a concern that can be lightly dismissed, but having watched the already corrupt for-profit system endanger and in some cases kill I think it is a matter of the lesser evil.
Only the Sanders campaign has made the effort to make this case. The Clinton campaign, so far a reliable supporter of the financial services industry, has actually undermined this case.
So there you have it.
What are you going to do about it?
Brachiator
@bin Lurkin’:
“People” are not interested in single payer. So called progressives push it as a panacea that will solve all problems.
mclaren
This, ladies and gentlemen, is the smoking gun. Mayhew finally comes right out and admits that he’s been lying to you all along.
Notice what Richard Mayhew does NOT say: “I want to get universal coverage of the American population with strong cost controls.”
You know why Mayhew doesn’t say he wan’t cost controls on American health care?
Because cost controls would hurt his income.
Cost controls would crush Mayhew’s income and probably drive him out of a job. What’s the point in hiring some asshole for a 6-figure salary when the mandated cost of medical procedures is so low that the insurance company would wind up saving, at best, 0.0000001%?
No, Mayhew loves the idea of universal coverage — at today’s ludicrous American health care prices. More $87,000 hip replacement surgeries? Great! Mayhew loves the idea. More cash for him and his corrupt buddies, the greedy corrupt doctors and the greedy corrupt hospitals and the greedy corrupt big pharma companies and the greedy corrupt medical devicemakers and the greedy corrupt imaging clinics.
More $1850 MRI scans? Wonderful! Mayhew loves that too.
But if you suggest universal health coverage with strict cost controls, so that those hip replacement surgeries plummet down to $7800 — the cost of a hip replacement surgery in Spain — then Mayhew will gyrate and convulse into pretzel-knots of creative accounting and sophistry to explain why American can never ever ever ever ever reduce health care costs to the level of the average European country. Or Japan. Or Singapore.
Cost controls.
Cost controls are the key.
American health care costs are insane, they’re wildly out of control, and they keep getting worse. Now, in the current health care system, a doctor who’s not in-network can walk by an operating room, tie 6 stitches, and bill the patient for $117,000. Mayhew loves that. That’s why Richard Mayhew has never utter a word about ‘drive-by doctoring.’
Source: “After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know,” The New York Times, 20 September 2014.
mclaren
@Brachiator:
You need to improve your lying skills. Go back to Karl Rove and ask for some additional pointers on telling lies that pass muster without being immediately debunked.
“Majority still supports single-payer option, poll finds,” The Hill magazine online, 15 January 2015.
Richard Mayhew
@mclaren: Troll, please read the second sentence:
“I want to get universal coverage of the American population. I want to get that coverage in a way that frees up significant resources for other things.”
That sure as hell reads as cost containment and efficiency as a priority.
The Raven
@mclaren: People are interested in single payer until they discover that it will raise their taxes, then they get cold feet.
Meantime, having just sweated through some more Exchange paperwork, I am of the general opinion that the ACA is doing an excellent job of proving to the public that the government cannot run a health care system.
fuckwit
I think Richard is right and Bernie is right.
Bernie is moving the Overton window. He’s doing what I (and Krugthlu!) wanted him to do in 2009. He’s rallying for a single-payer plan.
Will we get one? No fucking way. Not in this generation. For all the reasons Richard and others mention. But we should be aiming there.
A man’s reach should exceed his grasp, or what’s a Heaven for?
You don’t put forward a “reasonable compromise” plan as your first offer. That’s not how negotiation works, unless you’re negotiating against yourself.
It’ll take a generation to wind down the current system and switch to something UK or France like, without massive unemployment and upheaval. Bernie almost certainly knows that. But, he’s setting the sights higher.
Obama accomplished a miracle. It is, however, and by his own admission, only a first step.
I think in 20 years we’ll have single payer. I’m with Bernie: the time to start working on it is now. The door has been cracked open by Obamacare. We’re a lot better off now than where we were in 2009. But we’re not done either.
No One You Know
@Genghis: Couldn’t agree more. I work in non-profit health insurance, and see similar dynamics, although more concern for underserved populations.
The shortfall in federal dollars promised by the ACA has created some real problems. Moda went under state regulatory authority, and others are pulling out of “poorer” markets or restructuring. I’m not as up on this as I’d like to be, but there’s a lot of pain going around.