Earlier this week, Seanly raised an interesting point in comments in a post about multi-million dollar drug costs:
JFC, I avoid saying this Every. Single. Time that we get one of theses posts, but at some point we have to admit that the entire industry is just broken as hell. Wouldn’t it just be 10000 times easier to have a single-payer system? It’s such a big market and there are some many sick people that the greedy bastards who want to get rich will still find a way.
I appreciate the hard work & dedication David puts into these posts, but the unspoken answer always seems to be that we need to shitcan the current system & try again.
I get this, our system, on a good day is an ungodly complex mess that is more kludge than design with massive equity problems inherent in it. On a bad day,it is simply a mess designed by Kafka on a benzo bender. And yet, it is what we have and there is some value in that.
The rest is purely my opinion.
I’m an inherently cautious person when thinking about big changes. A colleague of mine recently noted over coffee that I spend almost all of my time thinking about either what is or what nearly could be instead of what “should” be. They are right. My thought process and experience is really good at looking at a rule set within a given paradigm, find the edge cases and then finding ways to break the system within the paradigm. I am not a good dreamer of big dreams. I never have been. The first woman who I was in a significant and meaningful relationship with made an extraordinary comment about me that is still true twenty years later after that night drinking a pitcher of cheap beer at the Forbes Avenue Primantis — “You’re an evolutionary, not a revolutionary….” as I had mentioned that people like me, my friends and my family would be crushed afterthoughts in the pursuit of glory. And she is still right about that aspect of me.
Shitcanning the system is a major paradigm leap. That, to me, is inherently scary, especially as I know how the current system works and the mechanical infrastructure that undergirds current functionality. It may be a failure of my imaginiation, it may be a nod to my inherent caution, or it may be my fascination with complexity, but that is where I come from when I read those types of statements. We have a system that has some functionality today and it is tweakable in very significant ways and there is also other sets of systems that could be designed to be less of an ungodly mess but are not currently deployed.
Deployment would be several years to a decade long project of transitions with known and unknown challenges. One of the big ones is that the push to single payer usually has two objectives: universality of coverage and reducing total national health expenditures. One of the big known challenges is the guaranteed push back by invested stakeholders who are far more trusted and respected by the public than health economists and politicians. We are seeing this in the surprise billing sausage making process right now:
The folks against surprise billing reforms are the PE firms that own EmCare and TeamHealth. Their bonds are taking a bath as legislators ponder regs.
Their lobbying + ads = WHY WE NEED patient protections. Even ACEP reps PE- their former Pres was Exec VP at EmCare pic.twitter.com/5uyGKlVAwK
— Zack Cooper (@zackcooperYale) August 30, 2019
Surprise billing fixes have broad general, public support, can act as a fairly significant pay-for and actually makes healthcare markets work better as the current system makes a hash of common contract law.
No need for rate setting. I’m surprised that @AEI doesn’t see this as a simple market failure that common law principles can solve. Let’s not overthink this. There’s a reason certain law doctrines last for centuries, and there’s a (bad) reason most health policies increase costs.
— Barak Richman (@BarakRichman) February 14, 2019
And yet, the emergency room staffing firms are likely to be successful in fighting off most of the attempts to pull money out of their owners’ pockets. Universality potentially may only be bought by stuffing the clinical chokepoint holders’ mouths with gold.
This is an obvious example of the difficulty of change and knocking the entire structure down in order to rebuild anew. To rebuild anew, requires almost everyone involved to be on the same page as to what things should look like and that, to me, is an extraordinarily difficult challenge while reworking within the current paradigm has a much smaller set of needed agreement partners and far larger sets of groups that can be rationally ignorant or indifferent at any given time as none of their core interests would be touched.
I get nervous when thinking about complete rebuilds. That is a core aspect of my personality and outlook.
Butch
We became insured under an ACA policy after I lost my job last year. To call it “garbage” doesn’t do it justice. All we’re really doing is buying an extremely expensive premium, and I’ve already discovered that the company has all kinds of sneaky ways around essential health services and expenditure caps. I want to see the whole private industry system burned to the ground.
Betty Cracker
@Butch: When a critical mass of people experience something like what you’re going through, the risk assessment may finally shift to “burn it to the fucking ground.” I have no idea when we’ll arrive at that tipping point, but I suspect you’re getting more company in your disgust with the status quo every damned day.
Baud
Burn it to the ground almost never works to our advantage. YMMV.
Jackie
Since you brought it up always call your insurance company about radiology (and probably er but I’ve not needed that). Two different insurance companies have agreed to pay the in network amount for me when I complained that the hospital was in network and I couldn’t select my radiologist.
These were major carriers and a big contract employer so ymmv but worth a call.
Ohio Mom
All I know is that the entire health coverage system is deeply corrupt, although we are so inured to it, we don’t think of it in those terms.
The system is set up so that people and entities can take their cuts, skim off the top, hold lives in ransom. Sometimes some sick person finds a work-around for their specific circumstances and we cheer them on, even as we recognize that it’s not fair things work that way.
I am not sure if it is more like living in a banana republic or an Eastern Block totalitarian country. The things we claim to value as a democracy, such as equal treatment and transparency, are nowhere to be seen.
What the solution is, I have no idea. As bad as it is, I lean toward incremental change because bad actors can be very adept at stepping in and taking over. I think of all the excitement when the USSR fell, and what happened, a handful of creeps took over and bent everything their way.
Ohio Mom
@Jackie: This is what I mean about work arounds. It’s like being told, When you cross into that little Central American town, be sure to have some twenties to keep any cop or thug who comes your way off your back.
Eolirin
@Baud: I can think of one example of it working out, with Britain’s NHS, but that involved a sizable chunk of the country literally getting burned to the ground.
I think people underestimate how severe things have to get before change like this, where there are powerful entrenched interests, can happen. Incrementalism isn’t just about being practical, it’s literally the best you can do outside of a severe shock that takes out most of the existing stakeholders. If things merely get bad, the existential threat to those stakeholders causes them to make concessions and the improvements pull people just below the threshold of being bothered enough to get out the pitchforks and torches. And if you try to tear the whole system down while there are still powers, there’s no way they’re not going to have a significant role in rebuilding it, even if only through obstruction, the outcome of which will be blamed on the people trying to make positive changes.
John Cooper
Overwhelming and unworkable complexity is a sign of a paradigm at its end. Over and over again, a better solution overturns the paradigm (think of innovations from Apple, Amazon, Google). Or the pain of the paradigm swells until all concerned shift their attention and energies to a managed transition away from the old paradigm to a new paradigm. But to do that, we must define the new paradigm to wide agreement, then focus on the managed transition. Spending time propping up an old paradigm might feel good, especially to those who built their careers at being good with its complexities, but it produces diminishing returns. At some point, we all must shift to the managed transition – even if it does take 10 years and is painful, it is moving in the right direction. Old, bad paradigms suck the oxygen out of the room and prevent us from moving ahead.
Baud
@Eolirin:
By an external force. Reformers can’t burn something to the ground in the hopes that they will then be looked to to rebuild a better system. Nothing is impossible but that is highly improbable.
Butch
@Betty Cracker: I can’t be the only one who throws things at the TV when the Democratic candidates start yapping about people who “love” their private insurance. I would like to meet one of these mythical beings.
Betty Cracker
@Eolirin:
This is true — that sequence of events has been happening for pretty much all our lives. We’re a potful of frogs.
@Butch: Right there with you. I have one of those fabled employer-based plans, and it is expensive as fuck, and it sucks big green gators. I suspect but cannot prove that polling that suggests people love their “plans” actually reflects their affection for access to their healthcare providers. Big difference.
daveNYC
They’re out there, just that I suspect a lot of them love their insurance relative to not having any. There’s just not that many people with super awesome health insurance.
Eolirin
@Baud: Yes, it can’t be by the reformers. To be willing to even try suggests that you’re not interested enough in the consequences of your actions to be successful at navigating the complexity of building a new system.
You’d need a group of technocratic sociopaths that weren’t interested in enriching themselves.
Yarrow
@Butch: You have to read the claims that people “love” their employer-based insurance as a way of acknowledging that people are afraid that something else would be worse. And it usually is, at least at the moment. No one loves their insurance but a whole lot of people are terrified that getting rid of it would mean they couldn’t go to the doctors they have, they’d be denied coverage even more often, medications wouldn’t be covered, etc. I see the candidates saying those kinds of things to acknowledge that fear without saying “you’re afraid the alternative will be worse” out loud.
unknown known
@Baud:
That’s the basic premise behind “disaster capitalism”, although used by the forces of bad, not good.
Sister Machine Gun of Quiet Harmony
@Baud:
And yet, when you listen to Wilmer’s people that is exactly what they think they can do. Talk of revolution always makes me nervous. It rarely works out well.
unknown known
@Butch: Oh, there are plenty of people who love their private insurance. They just tend to be rich enough (or have jobs with gold-plated plans) such that the system treats them pretty well in return for relatively little personally-felt pain. They also tend to be at least moderately healthy.
A private system works just great, so long as you have limited exposure to it, and plenty of money to keep feeding into it.
I used to teach a class on markets and society, and I had a list of about 5 kinds of market failure that can turn markets from helpful to unhelpful (off the top of my head, power and information asymmetries, externalities, consumer’s psychological limits, and flat-out market failures, such as sewage lines where it just doesn’t make sense to build competing sets of pipes under every road)… And the kicker was that medicine ticked every single box. There are huge and obvious power and information asymmetries between doctors, insurers, and patients, there are all kinds of externalities (the insurance company doesn’t die from your cancer, you do), patients just are not capable of following the complexities of the plans they are forced to choose and deal with, there are things that the market just will not provide on its own (i.e., new antibiotics). Basically every single one. That means it’s just inherently going to work poorly as a market. You can get around a lot of it with enough careful, sustained, and vigorous regulation, but we don’t always get that, and powerful forces work hard at capturing those to subvert them.
Eolirin
@Betty Cracker: I dunno. Things can gradually get better that way too. Those concessions can diminish the power of a lobby enough to make the next advance a little bit easier, and then a little bit easier after that.
If we look to the ACA, it makes it harder for insurance to lobby, but it didn’t do much about the provider end, and weakening insurance company power strengthened providers. A lot of these issues that we’re now looking at, surprise out of network costs, drug price gouging, etc, are provider rents not insurance ones. It’ll be easier to make additional changes to insurance regulations than it’ll be to make changes that reduce the profits of providers. Singlepayer will get even more push back from doctors groups and pharma than it’ll get from insurers. Look at how hard of a fight there is to change rules to increase the use of nurse practitioners to address the shortage of doctors.
We have to start chipping away at that power, and it’ll be a gradual process at best.
Roger Moore
@Baud:
This. I would add that they shouldn’t be trusted to design the replacement if they cheered on the other guys when they destroyed the original.
Brachiator
I can certainly understand the frustration. But I was listening to a podcast recently about the Canadian Health Care system and was surprised to learn that it was not a national system. Each province and territory is responsible, and there is another system for people in the armed forces. In addition, a majority of people have supplementary insurance, often through employers.
Also, Canada built their program slowly, beginning in 1947, and the government had to battle physicians groups and other opponents.
Other countries faced various challenges as they adopted their versions of universal health care, and not all of them were based on a national single payer model.
We don’t have to fight for 50 years to get a better health care system, but we have the advantage of being able to review the best of other universal health care systems in coming up with something that best serves everyone.
Roger Moore
@Butch:
I’m actually very happy with my private insurance with Kaiser Southern California. I have predictable, low out-of-pocket costs, minimal paperwork, and I know I’ll never get caught in a payment dispute between my insurance company and medical provider. Honestly, my experience as Kaiser has played a big role in convincing me that the best solution to medical care is a system that’s akin to the British NHS; not just single payer, but single payer/provider.
Betty Cracker
@Eolirin: It may be easier to achieve incremental change when a politically significant portion of the country isn’t represented by sociopaths. Republicans reacted to timid, corporate-friendly healthcare reform by raising racist astroturf armies to screech about socialism. Reminds me of the way gun nuts foam at the mouth and lay in arsenals every time someone mentions background checks. Sometimes you can chip away at the sort of intransigence that racks up enormous body counts, but sometimes the dam bursts.
Eolirin
@Betty Cracker: Yeah, we’re kinda screwed on that count. But I kind of take it as a given that nothing can improve as long as the GOP has any sort of political power. Removing that has to come first.
patrick II
Loss aversion is just a psychological fact and any change is difficult in a system that has over-rewarded a lucky few. They will fight overall efficiency aggressively if they have to take any loss.
Change is hard, especially in a system who’s inefficiency is so highly rewarded for a few.
Another Scott
My MIL retired from a US Government job and kept her BCBS coverage. She also had Medicare, and when the time came, Medicaid.
It worked very, very well.
We will burn the system down, but we’ll do it slowly and let the market do the work. How? Medicare/Medicaid buy-in via Obamacare. Incrementally lower the age when one can first buy-in. Incrementally raise subsidies on the Exchanges. Slowly, slowly, squeeze the profit margins for the private insurance companies and they’ll get out of the business.
Easy, peasy. ;-)
Cheers,
Scott.
Eolirin
@Betty Cracker: Also, I should note, that level of intransigence breaks the dynamic of releasing just enough pressure so that the general public aren’t out for your heads. It eventually leads to the removal of power from the intransigent party if they don’t have the means to oppress everyone else.
But the intransigence has to be past the point that stuff starts to seriously break. There needs to be serious and near universal condemnation and outrage. We’re getting close to that in Healthcare and guns, but we’re not quite there yet.
Eolirin
@Another Scott: Yeah, that would work to handle the insurance side, but the providers are the bigger issue. The rates providers can charge relative to the rest of the world aren’t sustainable even for as large an economy as the US. Changing demographics and expensive new treatments will wreck the system if there aren’t more cost controls. And as we see by the inability for Medicare to negotiate drug prices, government provided programs aren’t immune to the sort of regulatory capture that would prevent us from redressing that.
Right now private insurance has a greater impact on cost control than our regulatory system. They can actually say no. We need to change that before we kill them off.
Chris Johnson
You’re only encouraging them.
Why wouldn’t they prefer to be choked with gold AND not give people health care? I feel these are unwarranted assumptions on your part, with a history of unpleasant reality intruding. You cannot reform bandits by giving them all your money and then coming back later with more. You are misunderstanding the nature of the situation.
CathieFonz (used to be Cathie from Canada)
Medicare-for-all is the way to go — it doesn’t require burning anything down, just gradually back-expanding Medicare, first to 55 year olds, then to 45 year olds, etc etc, until finally you get to zero. Along the way, you will work out the problems as they come up.
In Canada, we brought in what is basically Medicare-for-all 50 years ago, and still it took 25 years of tinkering to get it approximately right, in a population that is significantly smaller than the US. We still don’t cover dental or drugs, though the Liberals want to bring that into effect someday.
Butch
@Roger Moore: Just lost an appeal because Blue Cross of Michigan denied coverage for preventive and wellness services, based on a single sentence on page 111 of the policy, along with a “tsk tsk” letter about the consumer’s responsibility to fully understand the policy. I live in the Upper Peninsula, and just found out that I’ll be required to see a specialist in Grand Rapids (nine hour drive) because the convenient one in Green Bay (90 minutes) is out of state and won’t be covered. I hate Blue Cross with a passion.
timmeh
” And yet, it is what we have and there is some value in that.”
invalid assertion
jan
If you think politics gets too involved in health insurance now, just imagine Mitch McConnell being in charge of a Senate, Paul Ryan in charge of a House, and Donald Trump appointing a Cabinet member to decide what is and isn’t covered. Sometimes those beancounters in private industry may see us as nothing but risk scores on a ledger, but I’d trust their medical decisions over those of people who think I’m not worthy of civil rights and that my medical needs can be solved with prayer.
Nancema
@Butch: Over the last 10 years I’ve had employer-sponsored insurance and a year of ACA coverage between jobs. Claims were paid with no surprises and I had no problem with preapprovals. During that time period I had a serious health issue that required multiple PET/CT scans, specialist visits and much lab work (my veins hate me!). During three of those years I blew through my out of pocket max by April. I’m fortunate, I was able to pay. All-in-all my personal experience was pretty good.
I’m not alone. I hear complaints from friends & family about out-of-pockets and deductibles, but they’re terrified of losing the system they have because they’re familiar with it. They’re in the “happy to bitch about it” stage, not the “burn it all down” stage. There are many steps between those two.
Even though my personal experience has been good, I know the system is a cluster. It’s unsustainable. Nonprofit hospitals in this area are adding new buildings and upgrading their facilities to the point where they look like luxe resorts — and every time I walk in the door I think “Okay, so THIS is why an MRI costs $10,000 these days when, in another country, it’s less than $1,000. This is why the list price for my mom’s partial hip replacement was $140,000.” It’s ridiculous.
Starfish
I started following your posts less closely because you are focused on small reform when the system is failing in big ways.
Basically, we have a system that is broken and getting more broken. What Bruce is saying in comment one is really common.
You have pointed out some of the deficits of the current system:
1) High-deductible plans are causing people to cut healthcare expenses whether or not the healthcare is needed, and yet a lot of ACA plans are high-deductible.
2) The increasing expense of these plans is leading people who have to pay their own way to flee the system.
3) You are still analyzing drug costs in QALY as if people are going to be able to pay monthly prescription costs that are more than rent or their mortgage.
People were trying to create fear of bigger public systems by saying “Oh, people have to wait forever” as if they do not have to wait two months to get an appointment with a doctor right now. I hope people are not falling for this nonsense again.
Also, the states that did not do Medicaid expansion blamed Obama for the rising prices of drugs not looking at their stupid Republican governors for whom austerity is always the answer even when people are dying.
We did not get anything like “Oh, here is a specialized service that will be really high-touch with the diabetics to make sure they are staying on track and not getting gangrene.” We got, “Oh, here are the diabetes medicines with drug costs spiraling out of control.”
Burn all this down because when there is a table to discuss future policies, there are some people representing the doctors, some people representing the insurance companies, some people representing the drug companies, but there is no one representing the patients who are being treated badly by these unfathomably large bureaucratic structures that have all the incentives to extract as much money as possible. People are turning to quackery because they have lost trust in the system and do not have meaningful relationships with any of the people in it.
TenguPhule
@Baud:
Typically that was because we were the ones being set on fire by white folks.
I believe its a bit different when we’re the ones setting them on fire.
spc
@Baud: Yep, universal is the goal and there ways there that are far less disruptive than single payer – we are already halfway to true universal (German, Dutch systems for example – which are not single-payer).
Betty Cracker
@Eolirin: It’s anecdata, and therefore worth nothing, but just about everyone in my family of origin is a clinician of some type (mostly nurses, some doctors and allied health professionals), and they are slowly coming around to Team Burn It Down because they’re sick of these fucking insurance companies putting themselves between medical professionals and patients.
TenguPhule
@Eolirin:
You rang?
Searcher
I think in addition to the many other stated reasons for wanting to burn everything to the ground — vengeance, frustration, urgency — there’s also just a lot of fatigue induced by gradual reform.
Gradual reform means picking and choosing and fighting a hundred, a thousand uphill battles over the next twenty, thirty, fifty years. Each one is very winnable, and each one won will improve the lives of thousands or millions of people.
But each one has to be fought, and it’s just exhausting, so it sometimes seems like it would be easier just to burn it all down and start over.
But we can win with incremental reform, and we are winning. The last few years haven’t been great, but how little of the ACA has been unrolled is itself a victory, for the permanence of the change wrought.
Victor Matheson
My recent brush with different healthcare systems was enlightening. I spent a month in May with a group of my students, as well as my family in Bangalore, India during an unfortunate major outbreak of Dengue Fever (basically think of this as Malaria – mosquito borne, common, occasionally deadly.) We had 2 people hospitalized. The first was hospitalized in Bangalore. He spent 5 full days in the hospital. The bill for the entire stay including emergency room visit with diagnosis, all drugs, IVs, semi-private hospital room, doctor’s and nurse’s visits, and lab testing was $700 (less than normal 5 day stay at a Marriott. The second made it back to the US before being diagnosed. She was in the hospital for 4 days, 3 nights. Similar severity and treatment as the first patient and both hospitals appeared identical on the surface as least. Total bill – $16,000.
Ted Doolittle
Actually, in important ways, even the most ambitious reform proposals involving Medicare expansion (e.g., Sanders/Jayapal) are not that radical. That’s because even traditional Medicare at its core is a public-private partnership, including, importantly, all the major health insurance carriers. Medicare just is not a fundamentally government-run program the way Social Security is.
Medicare expansion of any kind will mean using the same companies that currently run the commercial health insurance ecosystem.
Thus, a number of the Medicare-expansion based proposals really do meet the “evolutionary not revolutionary” approach. The people and entities that run and provide the current flawed commercial system are preserved and re-deployed in any plan based on Medicare expansion. And though I know that the die-hard Medicare for All-ers don’t like to hear this, even traditional Medicare is provided by for-profit companies, and even Sanders/Jayapal does not propose to change the 50-year old Medicare approach of using for-profit companies to deliver Medicare. If your goal is to take the “profit motive” and the private sector out of healthcare, then Medicare for All doesn’t get your there.
(And BTW, FWIW I support all the proposals that have 1) a way to get to true universal coverage; and 2) a serious approach to cost control. Sanders/Jayapal is one of several that do meet this criteria, though the Schakowsky/DeLauro plan has the edge because it has the most thoughtful and pragmatic weaning/transition glidepath.)
Marc
One thing I’ve noticed when talking to people, those who’s most serious medical need has been treatment of a broken bone or the like, almost always love their insurance and don’t want to change it. Those who have had one or more serious illnesses generally hate their insurance. It’s like having a car that you love, but really only bought only because you might have to take a long trip someday, only to have it fail catastrophically the first time you take it out on the highway. I find this dynamic particularly true of the one huge HMO that my and nearly all local employers have been steering people toward (the one that starts with K). It’s wonderful for routine checkups, having babies, broken bones fixed, etc., but god help you if you get something like cancer…
J R in WV
@Nancema:
They told you what the list price was?
I couldn’t learn what my shoulder replacement was going to cost until the day I checked in and paid my out-of-pocket share, which was actually reasonable.
One of the things I hate about the current health care system is that no one, no matter how willing, can tell you how much anything will cost, from an aspirin in the ER to planned ahead surgery.
Seanly
Gulp… didn’t expect one of my comments to get frontpaged…
I do know that getting rid of the system & coming up with something better may not be possible before human civilization collapses.
My goal with reform that we might accomplish before climate change ruins everything: see that people don’t need to literally put a jar out at the local gas station for a new kidney or cancer treatments. My wife & I are lucky that I have very good coverage (even if expensive with a high deductible) as part of my employment. But there are so many who don’t have what she & I have. It’s pretty standard in my industry so I don’t even have to ask about health coverage if I were to with a new company (though the size of the company may be a factor).
I also know that I don’t know enough to comparison shop or whatever stupidity Republican’s want to add to the system. I get paid to design bridges, not spend the day getting health care estimates.
I do hope that if we do institute some changes that we can correct, reduce, eliminate, whatever some of the kluge-i-ness.
WaywardBoyz
@Roger Moore: I am also with Kaiser in Southern California, and I am also very happy with the coverage. And I don’t fall into the “happy because I never need to use it” category, either. I was hospitalized for five days last year for pneumonia – out of pocket cost was $0. I’ve also been getting HIV meds through Kaiser for nearly 20 years at $15 per month per prescription. Doctor visits $15, although they recently started offering telephone visits for routine things like reviewing test results (they do lots of testing at Kaiser). Those are presently free. In addition to the treatments already mentioned, I was successfully treated for tumors in my stomach with chemo. All covered, all affordable, with excellent staff. It can be done. Kaiser does it by keeping everything in-house -providers are on staff, they own the hospitals, own the equipment and run the labs for testing, and they’re about to open their own medical school. It’s essentially a private single-payer system. And it works.
Matt
“Sure the vampires keep devouring us, but if we want to rebuild anew we need them to agree on what the village should look like.” The people who are raking in cash by hurting others aren’t going to go quietly.
This is right up there with “we can’t abolish slavery because it would harm slaveowners’ property interests”.