> We are in agreement that the American government can and does provide a health insurance program that covers lots of people and has the property that people don’t seek to leave it.
People literally are leaving it, to the fullest extent that they legally can.
It's not a small number, either. About 40% of Medicare patients aren't on the government-run system at all, and that number has consistently grown over the years.
They supplement it, I don't believe they are leaving it, unless they are wealthy and can afford to pay out of pocket because they want to use a doctor that is not participating in the medicare program. Do you have a cite?
> They supplement it, I don't believe they are leaving it, unless they are wealthy and can afford to pay out of pocket because they want to use a doctor that is not participating in the medicare program. Do you have a cite?
No, this is wrong. Private Medicare plans fully replace Original Medicare. If you are on a privately-managed Medicare plan, you receive none of your benefits from Original Medicare (the government-run program).
Unfortunately, you're still subject to some of the care delivery restrictions that Medicare sets, which means people moving from privately-managed plans (without Medicare) to Medicare Advantage (privately-managed Medicare plans) will typically experience a drop in coverage, because private insurers tend to be more forgiving with these limits.
> they want to use a doctor that is not participating in the medicare program
I'm not sure what you're referring to here. Though yes, one of the big advantages of Medicare Advantage is that it's dramatically easier to find in-network providers, even for Medicare Advantage plans that don't cost anything out-of-pocket above what Original Medicare does.
> No, this is wrong. Private Medicare plans fully replace Original Medicare.
Uh, no. "Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans." [0] So although the Advantage plans are privately managed, the premiums are subsidized. I don't think this counts as "leaving" Medicare.
> Uh, no. "Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans." [0] So although the Advantage plans are privately managed, the premiums are subsidized. I don't think this counts as "leaving" Medicare.
By that logic, there's no way to leave Medicare, because you can't stop paying taxes for it or "disable" your eligibility for it (and all of the restrictions that Medicare eligibility brings for people on private insurance).
People leave Medicare to the full extent allowed by law. Unless you want to claim that people using school vouchers for private schools is a demonstration of their satisfaction with the public school system in their area, you can't view their use of Medicare Advantage as a demonstration of their satisfaction with Original Medicare either.
> people using school vouchers for private schools is [not] a demonstration of their satisfaction with the public school system in their area
It certainly doesn't indicate dissatisfaction with the fact that the money for those vouchers comes out of tax receipts! The primary education system is a single-payer system, and the use of vouchers doesn't change that.
> It certainly doesn't indicate dissatisfaction with the fact that the money for those vouchers comes out of tax receipts!
You're basically arguing a tautology: Because there's no legal way to fully opt out of the system if they dislike it, people can't leave it (by your definition), and you're then saying that, because people don't fully leave the system, that means they don't dislike it.
40% of people choose not to use Medicare, to the extent that's legally possible. The program that they choose to use instead outperforms Medicare on every key performance indicator (medical outcomes, cost, patient satisfaction), while also underperforming the same private insurers on those same indicators. It takes some real contortions to look at that data and use it as evidence in favor of a single-payer system, or even evidence that patients like Medicare, but if you're fully committed to interpreting available data in a way that supports that end goal, I guess that's all we can really say.
In both cases — Medicare Advantage and vouchers — people are accepting a government subsidy in a form that allows them more choice than the default form. You're the one trying to make some kind of point based on that. I see it as evidence of nothing more than the fact that people like to have choices. I'm not arguing that it proves that they like the system as a whole; I'm just rejecting your claim that it somehow proves that they don't. I do tend to agree that a system that allows them those choices is better than one that doesn't.
> The program that they choose to use instead outperforms Medicare on every key performance indicator (medical outcomes, cost, patient satisfaction), while also underperforming the same private insurers on those same indicators.
Cost to whom? I don't see how Medicare Advantage can cost less to patients than Medicare; nor does it seem likely that the premiums for a private plan are less than the subsidized Medicare Advantage premiums. (Re the latter, I guess you didn't see my other reply to you: https://news.ycombinator.com/item?id=16979926)
> Cost to whom? I don't see how Medicare Advantage can cost less to patients than Medicare
How do you think Medicare works? Do you think that, once you're covered by Medicare, you just show up at a doctor or hospital, flash your government-issued Medicare card, and receive free treatment for any covered services, without having to pay anything out of pocket?
(For the record, that is not how it works. Medicare is not free for patients. Premiums are neither your only nor your largest expense.)
My mother is supplementing her medicare with insurance. GAP insurance is I think what she calls it. I mean I'm sure what you are describing exists, but it's not universal.
> My mother is supplementing her medicare with insurance. GAP insurance is I think what she calls it. I mean I'm sure what you are describing exists, but it's not universal.
I am talking about Medicare Advantage. Medigap is different.
What I am talking about isn't "universal", but it's what about 40% of Medicare patients use in 2018. It's not universal because people have to choose to opt into Medicare Advantage, but it's an option for everyone: everyone[0] who's eligible for Original Medicare is eligible for Medicare Advantage.
[0] well, there are a couple of small exceptions, but I'm 100% sure your mom doesn't fall into those categories, based on what you've already said
People literally are leaving it, to the fullest extent that they legally can.
It's not a small number, either. About 40% of Medicare patients aren't on the government-run system at all, and that number has consistently grown over the years.