I want to highlight two really good comments from yesterday’s post on Medicare for All as a means or as an end in and of itself:
First from Barbara:
What people like about Medicare is its “thereness.” You have it no matter what. That’s what it’s like in other countries. You just show the card and questions about insurance cease. That is a combination of eligibility plus the government’s ability to impose rules that private payers cannot by themselves. These include limits on balance billing and a significant weighting against providers for performing noncovered services without notice to the beneficiary (called the ABN rules).
What people who are not covered by Medicare don’t see, often enough: fragmentation, unlimited cost sharing, incentives to overutilize care for people who are unlikely to question the need for procedures, the need to get supplemental coverage and a separate prescription drug plan, both at additional cost, what seems like incessant arbitraging of reimbursement rules by providers to extract money from the system regardless of benefit to patient, and, importantly, almost no push back by the payer (Medicare program) to rein in these tactics.
There is great value in knowing that something will be taken care of. I see that, I acknowledge that, I value that. But here it is a question of means or ends. In my mind, the end is the knowledge that something will be taken care of, the “thereness”. I love this phrasing and insight. It just is, and problems are addressed. Barbara also points out how oddly designed Medicare is for people who have to deal with it for living or a living. Medicare FFS at the Centers for Medicare and Medicaid Services (CMS) level is a minimally involved payer. Once a claim meets minimum standards, it is going through quickly without systemic management or analysis of a case.
Rob brings up the practical impact of cost savings:
in order for us to see the cost savings Medicare for All can bring (spending more like 12-14% of GDP on healthcare rather than 18-19% now), we’d have to use it like a hammer to cram down on providers. Doctors. Hospitals. Nursing homes & other outpatient facilities. Medical device manufacturers. Pharma. All of them. Those groups of people are not without political power. They’ll fight.
Systemic waste is someone’s mortgage payment.
The most important thing to remember in health policy is that doctors and nurses are the most trusted professions in America while hospitals are often the largest employers in a district. On the other hand, insurers and Congress routinely strive to stay above chlamydia in the popularity rankings.
Lee
This might have been covered in the other thread but this right here:
Is a real problem. My Father-In-Law is a victim of this and my wife is a veterinarian that is really involved with his care. He lives in assisted living and if he gets sent to the hospital for whatever reasons he will have a battery of things done some of which are completely unnecessary.
They will come after him for the remainder and she’ll write a letter that it was unnecessary so they will not be getting paid from him (he doesn’t have the money anyway).
WereBear
@Lee: This is a serious problem I hear about from health providers who do not do this, and are harsh on those who do. But they also acknowledge the pressure from the relatives; who, all too often, want “everything possible done.”
Even to a 90-year-old who is not completely there and the procedure is uncomfortable and can undermine their ability to operate at the level they are at right now. As long as they don’t have to face this person’s mortality, they don’t seem to grasp quality of life issues.
In my experience, at least, the one who understands that the most, and is the least listened to, is the patient themselves.
Thus, the Democrats trying to discuss End of Life issues and the Republicans blowing it up into Death Panels.
Percysowner
@WereBear: The family aspect is one part of this, but sometimes they don’t know their options either. Years ago my Mother-in-law had a stroke and ended up in a nursing home. She barely knew her family, often had no idea where she was or even who she was. She got constant UTIs and would be rushed to the hospital (and upgraded from Medicaid to Medicare) multiple times. Finally I said to my SIL, who had the POA, to put instructions that my MIL should not be taken to the hospital for emergencies unless my SIL approved it. It had never occurred to her that she could make those decisions and that if she didn’t the nursing home pretty much had to keep shipping my MIL to the hospital just so they could avoid the family not thinking they didn’t “do everything”. My SIL did put in that order and although she approved her Mom going to the hospital one more time, the time after that, she did not and my MIL died reasonably peacefully.
Families letting go is tricky to navigate, but many of them don’t know how to deny treatment that is only keeping someone breathing, not keeping them truly alive.
Sab
I am technologically impaired, so I cannot highlight your post comparing insurers to chlamydia to insurance companies in popularity ratings, but that is my world. Lol if it wasn’t so sad.
Baud
I don’t like doctors or hospitals.
Sab
@Lee: This is why I hope Sarah Palin is tortured for many years in her old age in some nursing home that wants to cash out on her illgotten gains from her political grifting years. My mother passed a couple of years ago and fortunately she was sharp as a tack and could refuse excessive end of life care. We lived in terror of hospitals consulting my dad, who has dementia, who used to be a competent medical professional but is now just a sweet old man who was desperate not to lose his wife of sixty years. This is what the “death panels” were about. To record your own end of life decisions, and to protect you from well-meaning relatives who don’t want to lose you but choose to torture you in your final weeks or months in the name of love.
Sab
@Sab: On the other hand, I had a medical emergency last year that we would have ignored without insurance, and I definitely would have died. Instead the insurance co shelled out fifty grand and I am good to go for a few more years. so I love my insurance co.
Jim
Pithy post. Good. I’ve been on Medicare going on ten years. AARP (UHC) supplement, Plan J (grandfathered). Happy.
I want other people to have the same kind of coverage. Just because I got mine, it doesn’t mean they shouldn’t have theirs.
Ohio Mom
@Baud: I like my doctors — I don’t keep ’em if I don’t like them — but I don’t know why anyone with a lick of sense would completely trust any of them.
It’s a long story not worth retelling but I just spent two or three months convincing doctors in my stable that I needed to be tested for RA. Which it turns out I have.
They never apologize, either.
I don’t know who these people are who trust doctors and nurses, unless they haven’t had any body parts go kablooey yet.
Ohio Mom
One thing I’ve long wondered about is if there are any socio-economic or other category of groups who are more likely to go for every type of treatment even when it is clearly futile. Or the opposite, groups who are more likely to go for palliative care early on.
Sab
My nephew is a baby doctor(resident) and he is appalled by the stuff the Ohio right-to-lifers have rammed through the legislature. Resuscitation that breaks numerous ribs when you are 95 with a cardiac event, etc. If you don’t have some sort of notarized end of life document the ER doctors have no choice.
Chet Murthy
@Ohio Mom: http://www.kare11.com/news/health/mayo-88-of-patients-get-new-or-refined-diagnosis-with-2nd-opinion/428519257
low-tech cyclist
About those cost savings:
1) Of doctors, hospitals, and Pharma, Pharma looks like the lowest-hanging fruit. But the deal there – as I think David has said more than a few times before – is that in order to save bucks there, Medicare has to be in a position to say NO, the way (IIRC) that the VA and Medicaid do. IOW, if several drugs do the same thing and are roughly as effective as each other, Medicare would refuse to pay for drugs that cost way more than the others.
The problem is that if you do that, seniors on Medicare are going to holler if you take away the drugs that seem to work best for them, whether they really do due to variations in individual body chemistry, or just seem to because that’s what they trust.
In order to save money there, politicians have to be willing to deal with the hollering (and reliably voting) seniors. That’s tough for a politician. And yes, that’s the (comparatively) low-hanging fruit.
2) Hospitals: my intuition says there has to be big money to be saved here, because over time, hospitals have turned into profit centers. Fifty years ago, the hospitals were all city or county hospitals, or Catholic or Methodist hospitals or whatever: government or nonprofit. Now, they’re mostly owned by big corporations (or the Catholic Church, which won’t do abortions or even give info about that option), and I’d love to read a good treatment of how we got from one to the other.
The money’s there, but like David says, they’re big employers, so they’ve got clout.
3) Doctors. One thing I’ve been wondering for awhile is, couldn’t you decrease what doctors could charge by substantially increasing the number of doctors, by opening more med schools? ISTM that every other time a college becomes a university, it opens a law school. But you rarely hear of new med schools opening up.
Obviously new med schools are considerably more expensive than new law schools, and since doctors can take their M.D. degree anywhere, individual states and localities don’t have much incentive to fund new med schools. You’d have to have matching funds from the Federal government, probably.
And obviously, it would take awhile for the influx of new doctors to start bringing down salaries, but it would eventually start bending the curve. It would seem to me to be a thing worth doing when the Dems are next in charge.
MomSense
The other thing we will have to address and invest in if we are going to bring the actual cost of health care down, is medical school. We are going to have to bring the cost of medical school down and expand access to medical school especially specialties.
Ohio Mom
@Chet Murthy: I am not surprised to see that large numbers of people who have schlepped to the Mayo Clinic need to be rediagnosed. You have to be pretty unhappy with how your treatment is going to make the trip there, and the wrong treatment for the wrong diagnosis is going to be ineffective and probably enraging.
For me it helps that, one, there is a reliable blood test for RA, and two, I was born to be a persistent pain in the ass to others.
Wag
@low-tech cyclist:
As a primary care provider, I see merit in going after Pharma and hospitals, and taking a carefully thought out approach to going after providers. The biggest problem in American Medicine from a provider standpoint is related to our pay differential when it comes to procedures vs cognition. An ophthalmologist spends 15 minutes removing a cataract and gets paid thousands of dollar. I spend 45 minutes dealing with an elderly patient recently discharged from the hospital with diabetes, heart failure, emphysema and mild dementia, spend an additional half hour filling our home health paperwork, and coordinate care to try and keep her from being readmitted to the hospital, and I get $200. As long as we pay providers to do things to people instead of doing things for people, we will have outrageous heath care costs.
We don’t need more doctors, we need to realign the incentives for the current doctors that we have so that they pare providing value instead of procedures.
cintibud
@low-tech cyclist: You forgot to mention that the AMA and other professional medical groups like the doctor shortage just the way it is. They don’t want to see salaries go down
cintibud
@Wag: And also This! My sister is a primary care physician as well. I should amend my last post to indicated the issues with specialists.
Sab
@low-tech cyclist: There is a huge bottleneck for residents (thank you AlGore) ie students who get into and through medical school but don’t get accepted into a residency program because back when Al Gore was slimming the Fed govt one of his brilliant ideas was to cut back on residency slots. So you manage to beat the odds to get into med school, then you get through med school, but when you get through you cannot fond a slot because there are fewer residency slots than there are graduating med students. Yet we still have a doc shortage which is why we cannot have universal healthcare.m
Ohio Mom
@Sab: What I have heard is that the sort of resuscitation you see in TV shows doesn’t work all that well and when it is “successful,” can leave you with not just broken bones but also brain damage. Your heart may start beating again but your brain never again fires on enough cylinders.
Just further proof that Right-to-lifers are sadists using various medical issues as cover.
WereBear
Which also happened to me with my illness. I don’t understand it. If what we are doing isn’t working, maybe it isn’t what they think it is!
rikyrah
I learn a lot, reading these threads. Thanks for the info, both Mayhew and the comments.
Sab
@cintibud: unI think I am in moderation and I don’t know why.
Barbara
@Wag: This, in a nutshell, is one of the core issues bedeviling the Medicare program. Medicare “pioneered” this pay differential with the RBRVS and even though everyone knows it is wrong and gives providers all kinds of bad incentives, and is bad for patients because they are constantly being referred to specialists and every referral increases the chance that their care will be fragmented and even at cross purposes, it has proven incredibly difficult to change.
In the case of radiology procedures, Congress actually stepped in to legislatively rewrite what the pricing committee came up with, which gave outrageous rewards to those doing radiology procedures by grossly reducing the assumed percentage of use of equipment. So: if you buy an MRI machine the RBRVS would estimate that you would only use it 30% of the time or 12 hours per week, and it had a useful life of three years and a cost of X, so you have to charge at least Y. Congress legislatively increased the rate of utilization to 75% and then was going to go up to 90% but I am not sure that change was made. This is one payment policy and I could go on for several pages about it. People simply have no idea how complex the Medicare program is.
Now, RBRVS has been in place for so long it has actually affected the make up of the American physician populations, which skews heavily towards specialists.
mb
Bona fides: I worked for many years on the provider end of Medicare healthcare — all types of care: specialty, longterm, inpatient, outpatient, medical office, home health, hospice, you name it, I managed it and, in some cases, did start-up operations (a particularly interesting interaction with the system.)
I regularly read that one of the risks of expanding Mcare to everyone (I think of it as Medicare Part E) is that the providers will revolt. In my fairly extensive experience, if I could show my bosses that Medicare covered a given service, I would usually get approval to start providing said service within days. I found that Medicare generally paid our costs, at least, and provided a base of business that was easy to build on. I had no problem showing, what we called,”excess revenues” in my Medicare not-for-profit business lines. You have to be a careful manager but Mcare is no harder to work with than any other payer — and often easier, imo.
Barbara
@mb: It is an article of faith of many providers that Medicare does not pay their “costs.” I have never yet seen one actually prove it.
Ohio Mom
@Wag: This seems especially true from my perspective as a patient.
After so many years, my PCP knows me in a way that the specialists I see don’t. The specialists are mostly short-term trouble-shooters who don’t see the bigger picture, and they aren’t good judges of my perceptions and comments because they have no way of knowing if I am a sensible person or a nut.
My PCP wasn’t available when I started my little journey to get dxed with RA, but I am pretty confident her reaction would have been, “Yes, let’s test you because I know you have proven to have good instincts about these kinds of things.”
And don’t get me started on the cataract surgery. The opthamologist doesn’t just make a ton of money on one 15 minute surgery, mine does no more than ten every Thursday, every week. I’m disgusted even before I start the arithmetic.
The Moar You Know
@low-tech cyclist: The AMA is way ahead of you. They’ve been fighting any increase in the number of medical schools for decades.
Thoroughly Pizzled
Fight the space aliens! Reinstate the draft! Nationalize the doctors! V.A. healthcare for all!
It’s foolproof.
Woodrowfan
@Ohio Mom: some are sadists. Some are just simpletons who have no clue how complicated some issues are. “Oh. Just do CPR like I see on the TV.”
Ohio Mom
@Woodrowfan: You are talking about the foot soldiers, the ones who show up on Saturdays at Planned Prenthood, and the others who faithfully respond to the direct mail solicitations with a check. I don’t doubt that they tend to be very misinformed.
The leadership? They know. They need to know all the facts so they can twist them enough to keep their base riled up and sending in the cash.
WereBear
This, so much.
I gather that was the idea behind the original HMOs, but it didn’t work because they could not keep the people they were keeping healthy… and the usual not wanting to pay for things.
Gosh, if we paid for prevention, a lot of chronic illness, and their staggering cost, could be cut way back. Look at what public health has done.
Barbara
@WereBear: You assume that necessary prevention is medical in nature. Most of the time it is not.
Rob in CT
@low-tech cyclist:
Re: your #1 – right, exactly. The ads practically write themselves. Actually using the power of single-payer to cram down costs involves playing hardball that will be politically fraught. It won’t happen automatically. There will have to be moments of “no, we’re not going to pay for that” and the drama that goes with it.
rikyrah
If we were to lower the Medicare age to 50, wouldn’t the expansion of the Medicare pool enlargen it enough so that it can force price controls?
Barbara
@rikyrah: Medicare forces price controls on everything it covers under the fee for service program. There is no fee for service program for prescription drugs, that is how drug makers escaped price controls.
Revrick
David, systemic waste isn’t just the microeconomic effect of someone’s mortgage payment. It’s also the macroeconomic effect of a near Great Depression hit to the whole economy. A six percent reduction in GDP spending on health care doesn’t magically get shifted to other parts of the economy.
That whack to the doctor’s mortgage payment, also becomes both a whack to the banking sector, but also a whack to a bank employees job which becomes a whack to the gal running a taco truck. Shrinking the health care sector of the economy quickly creates a vicious downward cycle for the whole economy.
Another Scott
@low-tech cyclist: On #2, there are huge efficiencies to be found in hospitals, but I don’t know who is going to do the work to make it happen.
Just a few things from our personal experience dealing with J’s parents:
1) They were on a wide variety of medications at home and when they got admitted to their nursing homes. Whenever they changed locations – home to nursing home, nursing home to hospital, they got new prescriptions and stocks for all of their drugs. Lots of medicine was wasted, and they refuse to take back opened packages (for good reasons, but maybe that’s a reason to go to single-dose packaging for everything that isn’t cheap).
2) Hospitals go through a mountain of sterile, disposable supplies, but often they are still filled with various dangerous bacteria that causes lots of other complications. A better system needs to be found, because too often it’s not working the way it is. If that means hiring someone to be in each patient’s room, and each operating room, to do nothing but sterilize gloves and equipment between touchings, then that needs to be done. It would be much cheaper in the long run (and maybe in the short-run too).
There are ways to cut hospital costs, but there’s too much inertia, too much “we have to cut our head count”, too much “this is the way we’ve always done things”, too much “I know how to wash my hands, don’t tell me what to do”, etc…
Cheers,
Scott.
WereBear
@Barbara: I don’t understand what you mean.
JustRuss
@Revrick:
Sure, but that’s true of making any major systemic change “quickly”, which is why you make these kind of changes in phases. Are you arguing that we should just leave the health care system as is forever?
ronrab
I’m sure this has been said already, but surely one of the biggest attractions of the solution ‘Medicaid for All’ is people LIKE it as a solution. Even my father, a diehard Republican and Trump supporter, wants an expanded Medicaid. This is an important consideration in an environment where, as we’ve seen, every attempt to change our health care system is wildly unpopular.
Whether this is the best solution is irrelevant to most voters, and probably to most legislators. It’d be the easiest to propose and hardest to demonize. (Not that it would stop conservatives from demonizing it anyway, but that will happen with any solution.)
amygdala
@The Moar You Know:
The AAMC has been warning of a physician shortage for a number of years. New medical schools have opened. UC Riverside and UT Austin are two that come to mind, and there are others as well, open or in the planning stages. More, perhaps, to the point, is that existing med schools have been adding seats for at least the last five years or so. Some of these additional positions in programs designed to encourage students to pursue primary care.
It’s probably not a given that more docs will translate into lower salaries. Health care isn’t a consumer good. The person who tells patients they need something is often the doctor. Insurance companies put the brakes on that with the authorization process, but I remember learning in med school about a study (pre-HMO days, it’s important to note that when a new general surgeon moved into a remote community, there was a fairly rapid increase in the number of appendectomies performed.
Educational debt for physicians needs to be dealt with, perhaps through loan repayment programs favoring the work force we need–primary care pretty much everywhere, medical researchers (assuming the research budget doesn’t get totally gutted), surgeons and psychiatrists in rural communities, etc.
It’s not just debt that steers students away from primary care. The assembly line pace and dreadful bureaucratic burden get tedious pretty quickly and it’s not shift work, the way Emergency Medicine, Anesthesia, and Hospitalist Medicine can be. There are similar problems in so-called cognitive specialties, such as Infectious Disease (ID) and my own field, Neurology. ID fellowship programs haven’t been filing their slots in recent years, which is exactly what you don’t want when we’re running out of antibiotics. The American Academy of Neurology is starting to address burnout, based on recent surveys suggesting rates are scarily high among its members. Burned out doctors are bad for patients.
Finally, nowadays, it’s less an issue of med school seats than residency slots that influences the size of the physician work force. With increasing numbers of med school slots, if residency positions don’t increase soon, it could get like law, where there are graduates without the ability to get the only job that will allow them to pay off the amount of debt they’ve accrued. I suspect what’ll happen first is that international medical grads will stay home, or go to the UK, rather than the US. But really what we need are more residency programs, to accommodate them, and US grads.
Kelly
I’ve always had health insurance. Good insurance usually thru my job. Until 2009 or so I thought I understood health insurance. Now it’s like I’ve been thinking I know a pond but all I really saw was the ducks swimming on top. David Anderson has shown me all the stuff going on beneath the surface and in other ponds in other environments and what ties them together. David Anderson the David Attenborough of health insurance.
WereBear
I could not agree more. Democrats have this tendency to be too wonky for public understanding. Let’s get everyone together about something, shall we?
amygdala
@Another Scott: Regarding the piles of discharge medicines, The Joint Commission, which accredits hospitals, demands things like this. Doesn’t matter if you haven’t changed a damn thing; if you don’t confuse the hell out of someone with scrips for the same meds, you get dinged.
That’s actually more of an issue than is broadly appreciated. They should be on the hook in part for the opioid epidemic. Pain as the 5th vital sign? Please. But they were part of that movement, which Big Pharma exploited. Again, heaven help the attending whose patient had a pain score of 5 in a nurse’s note. You’re negligent and get a demerit. And then, a few years later, when opioid addiction rates are skyrocketing, we wonder why. There’s no check on regulatory agencies demanding interventions for which there is no evidence base. They should be part of the solution, not such a big part of the problem.
amygdala
David, I have a question about fraud in the US health care system, especially Medicare and Medicaid. I figure the chaos of myriad private insurers puts a bit of a check on that. I’ve tried to find out if there are similar problems in HealthCanada, NHS, etc., to no avail. The few friends and acquaintances I have who work in those systems sort of shrug and say, “interesting question” when I ask them about it. In general, they don’t think it’s a huge problem, but aren’t really sure.
Is fraud a big problem in those systems? If not, why not? Do they have better safeguards in place? Is profit so ingrained in the US system that it’s inevitable here without more regulation? Health care fraudsters are a blight and we need to do better dealing with them.
ruckus
@amygdala:
I have noticed at the VA that the first thing you are always asked is what is your pain level. I now always ask them back, “Do you mean this moment or in the last 24 hrs. My pain is transitory and not specific and that makes it a lot tougher to deal with. The RNs just stare at me but the docs seem to understand.
ruckus
@amygdala:
I’d bet it’s less, just because there aren’t as many entry points nor as many transfer/transaction points in those systems. They are smaller (overall) and prices are fixed as well.
What Have the Romans Ever Done for Us?
My wife works in a hospital setting and has for the past 15-20 years. Not sure about the rest of the health Care system but hospitals have experienced massive administrative bloat over that time and I imagine all those highly paid administrators are a major driver of hospital care costs. What happens is the providers get squeezed (asked to do ever more) to find revenue to pay admin salaries.
Not sure if any of that is associated with the fragmented insurance market but it’s a problem. The same problem exists at colleges and universities and is a driver of tuition increases
amygdala
@ruckus: Heh… good for you. That’s a perfect response and illustrates the problem with initiatives like pain as the 5th vital sign. It’s not defined consistently, much less in a way that captures something important. And that’s because of The Joint Commission, not the VA.
Fraud in the US system isn’t always price gouging but sometimes billing for volumes of work that are patently absurd. You have to wonder how stupid some people are. If you’re billing for hundreds of patients being seen every day, that’s the kind of thing a computer can pick up, followed (I hope) by federal agents at the office door waving a subpoena.
Juice Box
@Sab: I don’t know where you got that idea. Almost all North American graduates get placed and an additional 25-30% of residency positions go to foreign graduates. Even with that many new doctors filling residency positions, there are still unfilled primary care positions open every year. Yes, it is hard to get a dermatology or ophthalmology position, but just about everybody gets placed and the ones who don’t probably should not be doctors.
Juice Box
@The Moar You Know: California opened two medical schools in this millenium, but the last one was 1970ish, just before prop. 13. They are much more expensive to build and run than law schools. Apparently, academic lawyers make more money than academic physicians, if LGM is to be believed.
The AMA is a small, noisy, but mostly powerless group.
Dr. Ronnie James, D.O.
@Juice Box: [ahem] The AMA mostly represents MDs. DOs are also physicians, with the exact same rights and privileges, but go to different schools, and have a separate set of residencies we can apply to (although this will be merged with the system for MDs by 2020). DO schools have been rapidly increasing in number and average class size for decades, to the point where 1 in 4 physicians will be a DO soon. We are represented by the AOA.
As other have mentioned, despite the increasing # of new physicians, the residency bottleneck is still a problem.
An earlier commenter mentioned that Al Gore limited the number of residency slots when he was vice president; one of the interesting things Kathleen Sibelius did was allocate a huge chunk of the discretionary portion of the prevention and public health fund created by the ACA to fund new residency slots, particularly for primary care doctors.
Kylroy
Having worked in insurance for both the start of Part D and the start of the ACA, I know that new programs can cause massive shocks even when their overall changes aren’t that great. So when people talk about lowering the Medicare eligibility age, I worry about the system getting crashed as millions of brand new entrants overwhelm an existing and popular medical program.
But I wonder – what if we dropped the the age of Medicare eligibility by a year, every year, until it covers the entire poulation? I realize this is a *very* slow solution, but it would make changes to the enrolled population gradual enough that stakeholders have time to adjust, and it eventually gets us that coveted single-payer system.
ruckus
@Kylroy:
A good point. I’d bet you could go a bit faster, say 2-3 yrs lower the age per calendar year and be OK, but Medicare as a system still has significant issues and would have to be changed to be the only healthcare provider unless your goal is just symbolic.
sempronia
@amygdala: Thanks for your comments. Too often the entire blame for dysfunction in our health care system is placed on the greedy, negligent doctors, and the thread devolves into doctor-bashing.
About ten years ago, the American College of Surgeons held its first panel on physician burnout at the annual meeting. People were shocked that it was jam-packed, standing-room only, in a large conference hall in Moscone Center. Just another indication of the realities of practice.
Revrick
@JustRuss: The more complex a system is, the more fragile it becomes, and the two most complex systems in our economy are the banking/financial sector and our health care system.
I don’t advocate keeping the system the same forever. The system is in constant evolution, for one thing. But I don’t buy either/or solutions. Many developed countries have health care systems that are based on both public and private funding.
The problem I see with Medicare for All is that its most vociferous supporters have absolutely no patience whatsoever for a gradual transition. But even if their impatience could be overcome, the question remains, how long would the transition have to be? You end up with the situation where it’s claimed I’m only a little bit pregnant.