Everything I read about healthcare recently just reinforces the notion that we need public health care. Let's just model our system after say, Canada's, and call it done.
I don't even need public healthcare. I just want something that does away with the current employer-sponsored system. We should make it easier, not harder, for people to move between jobs, take gaps to start companies or get new training, etc. We shouldn't be discouraging younger workers from getting preventative care so they can stay healthy and keep contributing to the economy.
David Goldhill wrote an excellent piece in The Atlantic a few years ago on this topic. The fix is quite simple, but nearly impossible to implement: Stop using insurance for health care, and buy actual insurance (you know, for catastrophes).
How often do you use your car insurance? Fire insurance? That's because insurance is designed to never be used, by most people. Health insurance has been unfortunately recast into comprehensive health care, with disastrous results. But the system is very entrenched now.
That's the core concept behind a Health Savings Account and has been excellent in my case.
If you think of it as a 401k - put money when you're young before you need it - I think it is viable for many people under in their 20's and early/mid 30's.
But HSA's were eviscerated until Health Care "Reform" so it probably doesn't matter now anyway..
I'm sure that you're aware of this (and is why you used the word "many"), but the fundamental problem with this is the assumption that you're saving when young for what you need when old. There are those of us who aren't particularly healthy through no fault of our own.
While I'm sure no system under the sun could be made universally fair, it seems particularly unfair to saddle people with vastly different costs based on purely external factors. With nearly every other expenditure I can think of, a person has a choice whether to pay it or not, or at the very least whether to pay more or pay less. If I wind up in the hospital, there are a certain number of things that need to be paid for no matter what. My employer gives me an option for a regular PPO and an HSA-based PPO. The latter would have cost me several thousand more a year.
And all of this notwithstanding, this methodology of health care payment doesn't appear to me to work for people who actually have no or very little money. I'm fortunate enough to not be one of those people at the present, so I couldn't say for sure how an HSA-based health care system would be any better or worse for them than our current system.
Of all the things I'm thankful for, being thankful that it's not my job to try to figure this stuff out is near the top of my list.
I don't get the negotiated rate business. With a large enough pool (eg universal coverage) the costs level out. The divide and conquer scam played by US insurers is just a way to segment the market to maximize their profits.
Seconded. I'm starting a new job Monday, a large part of being able to switch was having my wife start a job that also provided insurance. I could have bridged the gap with a spare $1500 a month, but having an alternative in place certainly helps.
No it doesn't. It doesn't scrap employer-provided care, but it takes significant steps towards alternatives.
The major reason employer-provided care is dominant is that employer care is guaranteed-issue and automatically deducted. Employees of large companies are not screened or given physicals before insurance is extended.
Under PPACA, all health insurance is guaranteed issue. And while enrollment isn't automatic, it's enforced; you're fined if you don't get insurance.
The new plan does make it easier to move between jobs, take gaps etc.: pre-existing conditions no longer matter when getting insurance, and the employer tax break for providing insurance is now extended to individual health insurance as well (which used to only happen if medical expenses exceeded X% of your income).
Give me a break. Republicans are anti-public health care because public care sets in motion a process that moves care decisions into federal bureaucracies, which is absolutely a problem that Canada and the UK have.
Also, health care is ineluctably two things: a vital necessity and a commercial service. With a single payer, the commercial service objective is warped: patients and doctors are motivated to make care decisions that are inefficient or even harmful, and customer service or premium care for people who want it is eliminated.
Finally, from a philosophical perspective, single-payer implies that the government sets rates for care. Health care is not a natural resource; we don't sell land rights to extract health care to people who drill for it. Doctors spend years and years driving themselves into debt to become care providers, and drug companies sink billions into research for pharmaceuticals. The market for health services is fucking gigantic. It is legitimately daunting to consider replacing that market with a command economy!
I am pro-public-option. But don't pretend that Republicans, conservatives, libertarians, and people who understand health care economics are crazy or corrupted for opposing single-payer.
There is a big difference between single-payer and a nationalized healthcare system. In the latter, doctors are government employees. The UK and Canada work that way, and choose to spend very little money on healthcare. But most peer nations have single-payer non-nationalized healthcare systems and choose to spend more than Canada and the UK, but much much less than the US.
With a single payer, the commercial service objective is warped: patients and doctors are motivated to make care decisions that are inefficient or even harmful, and customer service or premium care for people who want it is eliminated.
See, this is not true at all. Consider the French system. Basic care is provided by a government plan, but doctors don't work for the state and everyone can supplement with private coverage if they want to pay extra.
Not all doctors in the UK are government employees working in the NHS - there is a private health care system here as well. Nobody makes you go or work for the NHS - but you do have to pay for it - I have private health insurance from my employer (I would never pay for it myself although I could afford it) and I'm quite happy to pay for the NHS.
NB My son was born in an NHS hospital, when he has had an accident it's the dedicated NHS childrens hospital he gets taken to, when my wife got seriously injured climbing it was an NHS hospital that treated her - all of which were awesome. The NHS is far from perfect but I like knowing that everyone in this country can get a decent standard of healthcare free at the point of delivery "In Place of Fear":
The entire private health care budget in the UK is £5Bn. The second largest purchaser of private care in the UK is... wait for it... the NHS. The NHS budget is over £100Bn. The government has overwhelming control over the health care market of the UK.
But as a consumer of health care in the UK I'm struggling to see what the problem is - the NHS is cost effective and generally available and if you want a slightly nicer room and to jump the NHS waiting queues (which do happen) then you can go private and get any kind of treatment pretty much when you want it.
I'm not saying there is a problem with it, I'm just saying that the existence of a PH market in the UK is not a strong counter to the Republican concern about a government takeover of the market for health services.
Indeed, and that is perhaps one of the two coherent claims made by republicans against a decent public options (single payer or otherwise).
Coherent Claim 1: The existence of a public option harms the viability and structure of a private option
Coherent Claim 2: A healthy, careful individual should not be forced to subsidize an individual who does not take care of their own health - but is forced to by a public option.
Both claims are a matter of opinion; It is my opinion that it is no different than police, school or war. (1: The existence of police harms private security; the existence of public schools harms private schools; the existence of the US army harms private mercenaries. 2: I should not be forced to pay for protecting someone who does not make an effort to protect themselves; I shouldn't be forced to subsidize teaching to anyone; I shouldn't pay for a war I didn't ask for).
I'm not sure why health care, which is sometimes (literally) a matter of life and death, and about which one has much less control than anything else, would not get a public option when schools do. And I have yet to find a republican who was coherent about why, if public healthcare is a problem, should we not also abolish police departments and public schools. But I guess one might exist.
The bigger problem with the republican standpoint, is that the coherent arguments aren't even made all that often; instead they tend to spread FUD with arguments that are easy to refute if you just care to look at examples - see, e.g. : http://news.ycombinator.com/item?id=4888507
Those two "coherent claims" are so broad that they capture most of the the individual specific arguments made against public health insurance; a conservative could reply that there are only a few "coherent claims" for public insurance too.
And, obviously, Republicans aren't big fans of public schools either. In fact, unlike private health care, which is out-executed by Medicare, public education is generally outperformed dollar-for-dollar by private education. (Note: I am strong, strong supporter of public education and oppose vouchers).
Your support of public monopoly education is interesting to me, as your comments on this thread make you sound like a thoughtful, well-informed person. Presumably there are some aspects of public monopoly education you would like to change. Do you support seniority-based pay scales, strong unions, and teacher tenure?
There's a few education economists that have noted that if we could fire the worst 7% of teachers in the US and replace them with merely average teachers, then the US would have the best schools in the world (Eric Hanushek out of Stanford is one). This is a vital and cheap policy for us to carry out, but it is well-known that you can't get fired from government jobs. I can't imaging school systems being the first to change.
Do you think it is politically possible to reform the worst parts of the public monopoly school systems with its current structure? School boards in population-dense areas are often staffed exclusively with union representatives. What model of the world convinces you that these school bureaucracies will do what is right for the students?
I find the arguments for student educational choice to be compelling. In a place like Washington DC, I think it will be much more effective to simply pay for the students to attend good schools than to reform schools that have been horrible (and overfunded!) for decades.
> two "coherent claims" are so broad that they capture most of the the individual specific arguments
That's not been my experience (I linked to a discussion from a month ago, but you can find the same points reiterated in this discussion by others). Those "other points" are not remotely covered by these two claims, and are touted far more often.
> a conservative could reply that there are only a few "coherent claims" for public insurance too.
That's true; perhaps it's just one claim - but it's a matter of fact, rather than opinion:
1. Every western country that implemented single payer spends significantly less for comparable or better results (normalized by just about every attribute you want)
(corollary) 2. Medical bankruptcies (that is, attributable directly to cost medical treatment, rather than, say, the inability to produce income due to sickness) are essentially nonexistent in any other part of the world, yet are the reason for more than 25% of US bankruptcies http://www.factcheck.org/2008/12/health-care-bill-bankruptci...
re: education - I'm with you on that. That's also something that the US can learn from other western countries - where generally, public education (at all levels, including preschool and academic levels) outperforms private education.
Sorry I was reacting (probably a bit emotionally) to the assertion by another poster that all doctors in the UK are government employees - which makes it all sound far too much like some kind of Soviet bloc nightmare.
Single payer implies that negotiations, budgeting, and coverage decisions are made by the government, who is the "single payer" the term refers to. That doctors ostensibly work for private companies doesn't ameliorate the Republican concern here.
But the existence of the French or Japanese or Dutch healthcare systems do. At some point, empty theorizing has to give way to observation of how these systems actually work in practice. In practice, all of these systems provide care that is much much cheaper than the US system with very high levels of public satisfaction.
Also, I think you're wrong in claiming that the Republican party rejects single payer for those reasons. The Republican party loves single-payer healthcare for old people. They expanded the single-payer program for old people massively and they make political hay out of any efforts to reduce its spending.
This comment does not respond to the issues I brought up in my comment at all. In fact, my comment ends with "I support single-payer". Did you think I was arguing that it was unworkable? My issue was with the mischaracterization of the Republican position.
The Dutch system, for what it's worth, strongly resembles the trajectory we are on with PPACA: guaranteed-issue private health insurance and Medicare.
Note, for what it's worth, the Dutch system does not work as well as that of our neighboring countries. Here people often have to wait a long time to have something done, whereas for example in Belgium you are helped much quicker (resulting in some Dutch people going to Belgium for healthcare).
Most Family doctors in the UK are self employed anf their surgeries have contracts with an local primary care trust. There are other models as well and big changes in the arrangements this year. The organisation of the NHS is complex (this is not a criticism).
There are lots of different systems of health care. Even though in most places the government pays the bill, the method of implementation varies widely.
> Republicans are anti-public health care because public care sets in motion a process that moves care decisions into federal bureaucracies, which is absolutely a problem that Canada and the UK have.
I thought that it was supposed to be state bureaucracies, rather than federal? Isn't that why states are supposed to set up their exchanges? (And the feds will only step in if they don't?)
Regardless, republicans say a lot about wanting a small government that gets out of the way, but their actions speak much, much louder than words, and they are not aligned with the "small government" mantra.
I don't think the size and investment costs of physicians and pharma are incomparable to natural resources. Oil companies have great investment costs, their market is huge. Rather I would say it's the complexity, dynamic nature and innovation of healthcare that make it unfit for a command economy.
Advanced technology is the single biggest problem in healthcare today. Expense is damn near the only natural limit on quality of service that can be provided. It's impossible to have a rational conversation over how much we should spend to keep someone alive in their last months.
> Republicans are anti-public health care because public care sets in motion a process that
> moves care decisions into federal bureaucracies...
Corporatists oppose "public care" because it's pro-labor. Insurers and pharma oppose anything that will lessen their profits.
I have no idea why any one else would oppose universal health care with a single payer using the capitation model. Probably something they heard on talk radio.
The problem is not so much big companies wanting to lock in employees as the political nightmare of ending a tax-break. Right now, people who get employer based health care get a tax break: their compensation used to pay for health insurance doesn't get taxed. The more money you make, the more valuable that tax break is. People with employer based health care tend to be richer than people without. Every year, the government foregoes $80 billion in tax revenue by refusing to tax employer provided health benefits, and most of that money goes to middle and upper-middle class workers.
Congress isn't going to threaten an $80 billion/year tax cut that is almost entirely consumed by middle and upper middle class professionals.
The reason Republicans are not for single payer healthcare is because it will require raising taxes to pay for, not because they want to immobilize labor.
I don't suggest you model it after Canada's system. It's good, but it could be better.
I moved to Canada from Australia, so I'll compare the two systems for you.
Canada: "healthcare for all" provides basic coverage of everything you need. Works pretty well. Even homeless / out of work people are fully covered. Things like dental and chiropractor are not covered, so you pay for those. Employers give "health care" which really just means they will pay a percentage of your costs for things like dental, chiropractors, prescriptions, etc.
The problem here is that if you want "better than basic" healthcare, it's tied to your employer, which has all the negative impacts of the US system of being stuck to your job. This sucks.
Australia: Same as Canada in that basic coverage covers emergencies and what-not for everyone. Again dental, chiropractors are not covered. BUT if you want "better than basic" care, it's your choice if you want to go out (with your own cash) and buy "private health care" which again will pay a percentage of your out-of-pocket costs for those extras (dental, etc.).
The massive, massive, massive advantage here is that your health is in not directly linked to your job. Your employer has no say or impact on your choice of healthcare provider, or if you even want to buy that extra coverage. As a single, healthy 30 year old, I've never seen the need to pay the extra, but in Canada I'm forced to because my employer says so.
I've been in Canada 7 years, and I actually think I'll go back to Australia, primarily for exactly that reason.
EDIT: OK, sure. In Canada you can also choose to buy your own "extra" health care from your own money. What I think is bad is how employers do it for you, without you having much say in the matter. In this way, Canadians feel their health is connected to their employer (a great example is when you interview for a job in Canada, people ask "what are the benefits like"? - In Australia, that is not a question.)
While most employers do offer an "extra frills" health plan as part of employment, private insurance at fairly good rates is available to everyone. I could call up Blue Cross this afternoon and get a private health plan equivalent to my employer's if I chose to.
EDIT: I still really like the Australian system and wouldn't be upset if we started incorporating some of the ideas it contains. I just wanted to point out that for at least this one case the Canadian situation isn't quite as bad as it would appear.
Right, but your employer is still deducting that amount from your paycheck, so you are losing out.
(At the Canadian company I work for, they estimate the 'benefits' overhead is around 26% of my salary - Yes, that is extremely high, because I can't choose the plan or coverage, the company dictates it for me. Married people with 10 kids pay the same amount I do... so you can see I'm getting a shit deal and would much rather just have my own money to spend)
Nothing is forcing them to offer it, but I'm expressing my opinion and saying something should force them not to, because my employer should have nothing to do with my health
Here in Canada, if you want "better than basic" health-care you can pay for it yourself. The net cost is under $1,000 a year for a typical individual who wants the deluxe treatment.
This is indeed a pretty sweet deal. In the US anything outside of teeth cleaning might result in personal bankruptcy, depending on employment situation.
Yup. In Canada, hard-core health care is quick, cheap and amazingly efficient. Any thing that can seriously screw with you is covered 100%. People with a cancer diagnosis get started on treatment within days. Pregnancies are smooth and straightforward, even more so if there are complications. Trauma is just the same as an American hospital.
The Canadian system slips a little when it comes to non life threatening issues that could be considered "quality of life" concerns. Knee and hip surgeries, elective procedures, chronic conditions, non serious specialist procedures (dependent on field)
There is a movement here to expand private health care into these areas. Personally, I support such a move but in Canada we have a group as pig headed about "no private health care" as you do about "no public health care" which makes things a little difficult.
net of teeth cleaning, it is included in the $0 basic packages (paid by taxes, so of course you pay for it if you pay taxes. But you get it even if you never worked and are unemployed and never paid taxes. Also, the taxes are independent of any "pre-existing condition" or anything like that).
Dental is not included in the $0 package. A dental package likely includes cleaning, for less than $1000 a year, yes.
Some provinces have emergency dental care for minors covered under their health plans, which is a nice thing, too. A root canal can be an expensive procedure.
Does anything legally tie your optional health insurance to your employment in Canada and legally prohibit Australian employers from providing private health insurance, or is that simply the way the two markets have developed?
> Does anything legally tie your optional health insurance to your employment in Canada
No. Supplementary insurance can be a perk of employment just like actual health insurance can be a perk of employment in the US, but you can get supplementary without it.
Canada's private health care insurance is very broad, and while you aren't necessarily incorrect about anything you are only giving part of the picture.
The "Employer sponsored" extended health coverage you are referring to is Group Insurance. It is a form of insurance that can be offered to all people aligned to an entity (employer, trust, association, etc) that removes the requirement for personal health questionnaires and medical assessments. The coverage you are offered by your employer as "mandatory" is guaranteed to you so long as you remain connected to the entity in question. There is a huge advantage to this and this is the reason it has become the de-facto standard for private insurance in Canada.
Of course the trade off is that the entity qualifying as a "group" needs to have an overwhelming percentage (often 100% if it is small) participating in the plan to mitigate the risk. Insurance breaks down if the only people buying it are high users.
That said, Private Insurance (i.e. not Group) is most certainly available and affordable in Canada. With private insurance however your rate is going to be based on your own individual heath assessment and life situation. That means that while your Extended Health rates might be lower, as a single 30 year old male your Life Insurance rates will be higher than a Female's, for instance.
Overall, for a majority of people Group Insurance has the benefit of spreading the fluctuating lifetime rates out so that they are predictable and more equitable. You aren't going to be 30 forever, after all.
People can and do waive their employer sponsored insurance all the time (with the exception of participation minimums). In addition, employers have started to introduce "flexible" group insurance that allows limited plan choices, based on fixed credits.
Not much beyond that is fixed in these group plans, so the variance in plans, costs, and overall benefit to the employee from one employer to the next can be huge. It is an effective enticement to have a good benefit plan, hence the interview question. There is also nothing at all forcing an employer to offer any extended coverage.
Personally, I think Canada is right on the money with regards to how we handle private health care services and insurance. Keep in mind that self management also presents a fair amount of improperly covered people. People are simply too ignorant of the situation. At least under an employer sponsored plan a trained professional is designing a plan that meets as many of the needs of the employer's workplace as they feel is required.
> It is an effective enticement to have a good benefit plan, hence the interview question.
A better enticement is to divorce health coverage and employment 100%. They should have absolutely nothing to do with each other.
Imagine if the employer in Canada dictated where I can live, or what goods I can buy... that's how it feels for me when the employer dictates(or in fact has anything what-so-ever to do with) my health care.
> Keep in mind that self management also presents a fair amount of improperly covered people.
Those people are covered by Canada's public health care, which is exactly what it is there for.
> At least under an employer sponsored plan a trained professional is designing a plan that meets as many of the needs of the employer's workplace as they feel is required.
You are still not even accepting the option of no extended plan at all.
The number of people in Australia that opt for extended private care is small, because the public option is sufficient.
>They should have absolutely nothing to do with each other.
Says the healthy young guy. :-) Many people receive extended benefits at a significant cost advantage through group insurance.
Also most employers pay a significant portion (if not all) of the premium of these benefits! You and I may see a health questionnaire as a simple form where you answer "no" to everything and sign it, but many, many people not much older than you aren't able to do that.
>Imagine if the employer in Canada dictated where I can live, or what goods I can buy...
Um, your employer does dictate where you can live, since most roles expect you to come to a structure of the employer's choosing, and what you can buy through your paycheck. Regardless, there is no dictation here at all. You are being offered benefits, often paid at least in part by the employer as a condition of employment. It's like being offered a cell phone or a car allowance.
>You are still not even accepting the option of no extended plan at all.
As I already stated, this option does exist and IS USED. In almost any company of significant size (i.e. above 10 employees or so) you can refuse all coverage. All you have to do is do so with a written form. You can do so for Health and Dental in ALL cases if you are expected to pay the premium and have coverage elsewhere, inclusive of personal coverage.
Why in god's name you would turn down what in many cases is free money is beyond me, but that is your prerogative. To suggest you are unable to do so in Canada is incorrect.
> It's like being offered a cell phone or a car allowance.
Which reduces your overall salary - you might not be aware of it, and it might not be said in those terms, but it's absolutely true. All "side benefits" or "perks" of employment are just a way for the employer to give you something other than money. Too bad if the last thing you want is a cell phone.
> Why in god's name you would turn down what in many cases is free money is beyond me, but that is your prerogative.
Because it's not free money! My salary is being docked for that expense, as the "benefits overhead" (my company told me to my face it's about 26%). I'm perfectly happy with the public coverage, and want the rest of my salary in my hand, thank you.
At this point though, you are evaluating employers, not health care systems.
It's pretty easy to find an employer in Canada that offers no benefit plan at all, just stay away from larger companies.
Most privately run businesses would be more than happy contracting you at a higher rate and not paying you any additional benefits, or their share of CPP or EI. They are a significant expense to the company. Go get yourself a GST number and have at 'er.
Seriously, if this is that much of an issue for you, you should talk to your boss. I can pretty much guarantee they'd be more than happy to work something out with you.
> you are evaluating employers, not health care systems.
No I'm not. One health care system outright makes that illegal, so it's the health care system defining this, not the employers.
On that note, have you ever lived&worked in a system other than Canada's?
I ask, because you think Canada is "right on the money" with their system... though it makes me think you've not seen how other systems do it.
Don't get me wrong, Canada's system is good, but if I were in a country about to radically overhaul health care, I would by no means adopt Canada's system as-is (or any other single country, for that matter)
> if this is that much of an issue for you
You miss the point here thinking this is about me... The overall effect on society is very interesting and speaks volumes about a given system. Without a doubt, because of this "group plan" idea, Canadians are tied much more strongly to their employer, and that results in employees being treated worse, and overall a "negative" impact on those around me.
I have Canadian friends, and although they would do anything to preserve their health care, they complain about how long it takes them to make appointments for specialists, tests, etc. I live in the Bay Area, and I have Kaiser HMO, and I love them. They seem vastly superior to Canadian health care in every respect. Even in cost, my friends in Toronto have to pay $100/month each as a Health Tax.
Case in point, I got an endoscopy scheduled in 9 days. My friend told me that the average wait time in Canada for an endoscopy is 9 months. I had an MRI scheduled within 1 day. My friend's wife, who was suffering from gallstones, waited 4 months for her MRI. I just made an appointment to see a GI specialist, and it took 1 day. My friend who is a pharmacist for Shoppers Drug Mart in Toronto told me she was amazed at how quick that was.
Kaiser is great unless/until they refuse to cover you because your medical history includes one of hundreds of disqualifying conditions, or they decide to renege on their coverage using contract fine print and creative (re)interpretation of your medical history.
In other words, Kaiser is great if a big company that employs you is making sure you're covered.
My point is that Kaiser vs. Health Canada isn't an apples/apples comparison.
Reminds me of the ONE truly profitable piece of legal advice I've ever received from a lawyer: Having an insurance policy really only guarantees you the right to sue your insurance company if they refuse to pay a claim. He said this as we walked outdoors in a large American city and then pointed out the tallest building on the skyline - an insurance company HQ. This wasn't health insurance but the point is the same.
> My friend told me that the average wait time in Canada for an endoscopy is 9 months
Wait times for specialist visits that are not life threatening are just as long in the US as in Canada.
There is a persistent myth in Canada among people who have never had to get in depth medical care in Canada and the US that the Canadian system makes you wait until you are dying but in the US you just wave some bills and you see the specialist that day.
(US) Mother-in-Law has to schedule months (4-6) in advance for colon cancer screening because they find polyps every time, not just because of age. Cost - IIRC ~$50 with insurance.
(Canada) Father complained about shortness of breath walking to work (Wednesday), saw his doctor (Thursday), was checked in to the hospital that day, had a angioplasty. (Saturday). Why? Was life threatening. Cost - $150.
I'll take Canadian health care over the US squeeze for money every time.
Geography is also a factor. In both US and Canada.
In the US jurisdiction is a factor, with local legislators enabling fruitcake care providers and pharmacists to impose their neolithic values onto their patients.
The only measure I care about is cost per capita and life expectancy.
Canada is cheaper and their people live longer. That's not an accident.
There are two different issues here: how to structure your healthcare system and how much of society's resources to devote to it. Canada (and even more so the UK) have a nationalized healthcare system AND they've decided to spend very little money on it. Both countries spend substantially less on healthcare than the US or other advanced economies with similar healthcare systems. As a result, they have long lines sometimes. But that's a separate decision.
I think bundling most healthcare under the idea of insurance is a big problem. Insurance works because there's profitability in calculated risk. Everyone doesn't get in a wreck every day, everyone's house doesn't burn down regularly.
Dissimilarly, everyone gets old, everyone gets sick, everyone is going to need healthcare.
Companies make money off life insurance, even though mortality rates tend to 100% over time. It's similar with health insurance. This works due to several factors:
1. Insurance companies can invest payments from young people to cover costs when those people are older.
2. Not everyone gets old and sick. Healthy people who die in car accidents contribute much more than they take out.
3. While many people get old and sick, medical costs vary significantly and aren't very predictable for a given individual.
4. People are risk-averse. They would rather pay $1,500 every year than have a 1% chance of losing $100,000 in any given year. This is true even though 0.01 * $100,000 = $1,000 expected loss per year.
poppycock. Not everybody is going to need the same amount of healthcare. You can insure against the risk that something dire is going to strike you.
Your argument may work for old-age care, where the cost of care for most people soars off the charts for last-ditch, cutting-edge efforts to stay alive. But there is no reason the insurance model can't work for most of the population.
I heard so much about death panels and blah blah blah but I absolutely want to sign a document that says that if keeping me alive is going to cost over x dollars, please pull the plug and save the money.
The x will probably change as I make more money. Right now, two million dollars is probably where I'd balk. (Pretty sad I know but I think the government could put that two million dollars to better use than to keeping me alive.)
I guess a death panel is inevitable. I am pretty sure I will change my mind and chicken out at the last minute and say "I want to live even if it costs ten million to keep me alive". Don't listen to the senile me! Let me die and use the money on what matters -- kids.
I don't have kids and don't plan on having any anytime soon.
No, insuring against an inevitability isn't silly because there are other factors to consider. Like when the inevitable occurs. Insurers are taking a risk that you put more in before that happens.
Lots of times insurance companies only end up making a profit from investing (that is, they pay out more in claims than they take in premiums but make up the difference by investing wisely).
Since the US acts as a safety valve for Canada (look at the number of Canadians getting treatment in the US) and the USA's version of public health care for a small subset of the population is a disaster (google: don't get sick after june), I would much rather we pick some solutions other than public health care.
I really wish the US had started with better Health Savings Accounts, Catastrophic Insurance[1], tort reform, and reforming how we pay doctors (Medicaid is having problems with new doctors not accepting it). Moving on from there would have been better.
[1 - edit] 100% paid for a cost over some figure like $50,000 - cannot remember url of proposal
"Since the US acts as a safety valve for Canada (look at the number of Canadians getting treatment in the US)..."
While I don't doubt that there ARE Canadians who travel to the United States for medical treatment, I'd be curious as to the percentage of the population.
Growing up in both countries, I can say with certainty I had less hesitations in the Canadian system. In America, I worry all the time about switching jobs and figuring out healthplans. In Canada, I always assumed that I'd be covered in some form.
The old joke in Grand Forks, ND was that "Friendly Manitoba" license plates outnumber ND license plates. It was a big enough issue that in 2009, Canadian health agencies were contracting with hospitals in border cities[1]. Plus, the US has a lower cancer mortality rate than Canada.
One driving factor is waiting lists in Canada are much longer than in the US (well, except at IHS). This drives Canadians to seek treatment in the US. There are several studies done on this.
The only real advantage to the Canadian system is that it isn't tied to your employer. In pretty much all other respects[2] it is not as good in either time taken or results.
"Ah, the age old "tort reform" line. Haven't heard that one in a while."
I would guess that your not following all of the issues. Tort reform is going to have to be on the table or we are going to lose more general practitioners (not terribly popular now) and OB/GYNs. Insurance costs are not just a patient issue.
"Your stats about Canadians is total BS."
Not really sure how to respond to this one. If you mean the waiting list times, then you are wrong. If you mean the cancer survival rates, that you are wrong. These are not exactly in dispute and are very much related.
We need to get rid of the unregulated, manifest "socialist" medical system that the United States has today and replace it with something that is a known quantity. A public system is one option (and one that I'm in favor of), but there could be other solutions too.
In general, the current system doesn't stop people who can't pay from receiving care. If we agree that allowing someone to die because they can't pay isn't acceptable then we need to have some kind of public system. Care is rationed by insurers and providers who make judgement calls that, largely, aren't subject to public scrutiny or regulation. (We have the "death panels" that those opposed to public healthcare railed against, but these "panels" are made up of insurers and providers working in a decentralizd, uncoordianted, and uncontrolled manner.)
What we have is a "shadow socialist" system where those parties who can afford to pay have to carry the slack for everybody who can't. Individuals and employers end up paying higher premiums to insurers. Healthcare providers increase the cost of procedures to cover the write-offs for the uninsured. Insurers negotiate relationships that limit consumer choice or access to procedures that providers aren't willing or able to discount.
It's like the entire mess is designed to be suboptimal for all parties involved. It's depressing that, as a country, we can't have reasonable discourse, agree to compromise, and come up with some kind of substantive strategy.
"Socialist" is a bad term for what we have. The insured do pay for the uninsured (mostly via taxes), but the uninsured don't get free rides: the system we have bankrupts them, often repeatedly, when they have health problems.
That's why I said "socialist" (in quotes) instead of socialist. It's not a true socialist system-- it's just a big ball of mud that's grown up over time rather than being something that is designed. Different interest groups have exerted influence over the years to shape that ball of mud in such a way that it benefits them, but it's still a ball of mud. It has the effect of spreading the cost to those who can pay (or who don't have the leverage to get discounts), much the same way that a socialist system would, but without the benefits of having a well thought-out socialist system that is subject to public scrutiny and regulation.
I don't know what part of my taxes go to paying for the uninsured. I have anecdotal experience of seeing rather large hospital bills for emergency written-off because the person receiving care didn't have adequate insurance. I would agree that someone with health problems is likely to end up with no assets or credit, bankrupt, and receiving some kind of public assistance.
You haven't even mentioned the fact that people without insurance are forced to use the most expensive services (and then go bankrupt and not pay) because that's the only kind they can get.
Easier said than done. If you recall, the relatively modest improvements in the Affordable Care Act were narrowly approved by Congress and then narrowly avoided being struck down by the Supreme Court.
Canada's system would be as constitutional as Medicare is. The Affordable Care Act introduced a novel (to U.S. case law) mechanism for getting everyone insured.
A good book to continue your reading is The Healing of America by T.R. Reid. The author traveled to eight countries, checking out treatment options for his bum shoulder and learning about their healthcare systems.
Canada was one and did have some advantages. He also went to the U.K. But the best systems were in France, Germany, and Japan. They all have private (but nonprofit) insurance, a mandate, and no exclusions for preexisting conditions.
But they also have good electronic medical records systems, a government-controlled price list, and no claim denials allowed for anything on the list. Many German doctors don't even hire office staff. They swipe your card, your medical records pop up on screen, and whatever they do they're guaranteed to get paid in a week, no questions asked.
(On the other hand, another good book is Best Care Anywhere, which advocates extending the V.A. model to everyone. A nice bit from that book is the VistA medical records system, which V.A. doctors and interns built and opensourced. It's been adopted by several national healthcare systems.)
Instead they outsourced to people who outsourced to people...
"Accenture; Computer Sciences Corporation, or CSC; Fujitsu and BT. They were known as local service providers, or LSPs. BT and Fujitsu picked a US software firm, IDX, to work with, while Accenture and CSC both picked a British software company called iSoft. iSoft who offered a software system called Lorenzo, a program that had "achieved significant acclaim from healthcare providers”.
"However, the program was not finished..."
"CSC had to continue on its own, while the other two providers, BT and Fujitsu, were having their own problems. They were trying to implement American software, which is not such an easy thing to do in a British hospital, because American hospitals rely on billing for each and every activity and do not, conversely, expect to have to handle waiting lists."
You do realize that this is a recipe for inordinate amounts of public debt that you and I will never have to pay but our children and grandchildren will. Much like Social Security, Cananda's unfunded liabilities are long term too great:
Really, we have two separate problems that unfortunately get lumped together. First, is how to provide healthcare for the working age population and children. Nearly all the evidence points to public healthcare being better for this problem. Insurance discourages people from getting preventative care and ultimately costs more in the long run. Second, is how to provide healthcare for the boomer generation. I don't think there is a solution to this problem, that we can stomach, that doesn't ultimately involve working age people paying out the nose either in insurance premiums or taxes.
>Second, is how to provide healthcare for the boomer generation.
There absolutely has to be a dollar cap on how much the government will spend on health care on an individual. Then, we must absolutely stick to it. If the limit is reached, then no more money for that person.
I'd support such a limit on baby boomers only since those idiots are the ones who got us into this mess but I can't think of a way to implement that without a big discrimination lawsuit.
The boomers are not the ones who got us into this mess. It was actually their parents. They paid for their parents and then expected their children (us) to likewise pay for them. In that time, the average life expectancy and cost to prolong life grew enormously.
I do not have hate for the baby boomers. What I have hate for is solutions which foist upon OTHER generations costs and expenses associated with THIS generation.
I see that public care is perfect in a perfect world. We are not living in such a dream. Policiticians are elected today. Tomorrow they retire. As such there is very little long term planning because the incentive structure is not there to promote long term thinking. Hence, the ability to actually have a limit or cap would never last. Just look at copyright to see the types of things that could happen.
They paid for their parents and then expected their children (us) to likewise pay for them.
The first generation essentially got something for nothing. That does not sound right to me. If we follow the logic that we've been following, those who didn't pay into the system should not be able to extract back from it.
Perhaps, we the current generation ought to bite the bullet and double tax so we can pay for our parents and ourselves so we don't saddle the next generation with (what some people call) a ticking time bomb.
It is sad that we don't have anyone in the government call out what seems to me the perfect solution: both decreased spending and increased taxes. I guess we just have ourselves to blame for electing people who tell us what we want to hear.
Canada is indeed undergoing a debate on how to fund and deliver health care, but what is not under debate is whether it should it be kept public. It is also worth noting that the current government slashed taxes upon taking power and is now trying to cover the deficit by reducing social services. In this way it is a classic right-wing "starve the beast" tactic, wherein you take in less money and then say "Hey we can't afford these things anymore so we have to cut them" even though you could have paid for them without the tax cuts.
Most of the things the article talks about amount to adding efficiency to the public system, something that no one would protest. Nowhere in the article does it talk about the public system collapsing and serious discussion over switching to a private system. As far as public debt goes, Canada's debt is not great, but it is certainly nowhere near most other Western nations, so the whole "public health care is a recipe for inordinate amounts of public debt" doesn't seem to be true either.
This actually may not be true. Not sure if you're familiar with Modern Monetary Theory, but I highly recommend checking out this video: http://www.c-spanvideo.org/program/309410-1
I wouldn't say that I'm a full blown MMT'er but over time the arguments make more and more sense, and I haven't been presented with many credible counter-arguments yet.
I far prefer the Singapore model to Canada's. Have you informed yourself of the variety of different public healthcare models out there? UK and Canada seem to have issues with very long wait times and bad options for private care for niche conditions (private care was illegal in Canada not too long ago)
Singapore has good health outcomes, low health expenditure, and a high quality of care. They use a forced-savings model with a public backstop, giving consumers market incentive to conserve healthcare and keep costs down (unlike the US all-you-can-eat model). It's very effective and not too far from our current system for political feasibility.
There are economists who have been studying the problems and benefits of various universal public healthcare for years. Are you aware of their arguments?
1) The government hasn't been able to run anything efficiently as long as I've been alive. It's not like we can just go back if UHC doesn't work out.
2) The more the government runs our lives (especially something like health care), the more they will be able to dictate our choices (what we eat, risky behavior, etc).
3) I haven't seen one person that supports public health care tell me the downsides. I know they exist and we need to know the risks (and talk about them openly) before making such a huge change to our current system.
Medicare has been run for decades at a pay-out efficiency significantly higher than private insurance companies. There's a model that's in place and works even when loaded down with high-risk individuals.
The government already "runs your life" by dictating speed limits, acceptable levels of toxins in your foods, safety standards for cars, etc. You're freaking out about things that don't matter.
You know what the downsides to public health care are? Fewer jobs in the insurance industry. You also won't be able to expedite your care by paying a premium, everyone gets roughly the same treatment. For 99% of the people out there, this is a non-issue.
1) Given that the health insurance companies in America make billions in profit every year, I'm confident the government can be more efficient than that.
2) This is a naive line of reasoning. The (socialist) FDA already stops you from buying food with lead in it. The (socialist) DMV forces you to wear a seat-belt and wear a motorbike helmet and the (socialist) Police stop you beating people up on the street whenever you want.
You are basically saying you don't want "big government" to tell you want you can't do, even though those rules and limitations would make your society better for everyone overall. Everyone's happiness would go up. This is very selfish and shortsighted.
3) It's very simple. Everyone is equal. A billionaire is treated the same as a homeless person. A strongly classed society (like America) does not like this idea, because Americans define success as "better than other people". Public healthcare would take away this distinction.
> You are basically saying you don't want "big government" to tell you want you can't do, even though those rules and limitations would make your society better for everyone overall.
You're demonstrating a very common misconception, which is that people who don't want the government to perform a function do not want that function to be performed, or that certain functions can only be performed by a government.
> It's very simple. Everyone is equal. A billionaire is treated the same as a homeless person. A strongly classed society (like America) does not like this idea, because Americans define success as "better than other people". Public healthcare would take away this distinction.
Is there a competition being held in this thread to see who can make the most ridiculous generalization? Seriously, at least put forth a bit of effort into making your argument seem remotely credible.
"1) Given that the health insurance companies in America make billions in profit every year, I'm confident the government can be more efficient than that."
Given this theory, explain Indian Health Service.
Point 1 is bad reasoning and demonstrated to be false. On point 2, rules are not inherently socialist (Capitalism actually requires a strong rule of law).
I know rules are not inherently socialist, what I was saying is you already live with a ton of them, and thinking that adding a few more will drastically decrease your "freedoms" is delusional at best.
Indian Health Service is the currently running, government health care for a small fraction of the population. If they cannot get that right, they cannot get it right for the rest.
Adding a few more rules is the dictionary definition of loosing freedom. Adding the wrong rules will.
"The government hasn't been able to run anything efficiently as long as I've been alive."
I'm not so sure private insurance companies and hospitals are all that "efficient" either, but define "efficient" first. Private insurance companies are motivated by making a profit, and the easiest way to do that is to take in money, but pay out as little as possible.
There's very little competition in insurance, as 'the market' is primarily larger employers, so insurance companies by and large cater towards the needs of their biggest customers.
We need to get rid of employer-provided health care benefits, and focus on getting people to buy it directly themselves. This will bring more market forces to bear, getting more companies to compete for our business, not the employers', and perhaps we can then talk about 'efficiency' and having that be something positive for end recipients of health care.
> We need to get rid of employer-provided health care benefits, and focus on getting people to buy it directly themselves.
This. People are given these ridiculously expansive health care plans and most of the premium is picked up by their company or is deducted before they ever notice it. If people have to buy it themselves, they're going to choose higher deductible plans to get lower premiums. With higher deductible plans, they will want to see what their money is paying for and demand price transparency (which is sorely lacking in the US health care market). Allow companies to operate without stifling state interference and this will be a whole new market, one that actually responds to the forces of supply and demand (as opposed to the clusterfuck we deal with now).
1. Oh please, this is just a truism expressing your general political views. Government does lots of things well. Every time there's a relevant accident, the NTSB is on the spot within 24 hours. The FAA does an amazing job. I could go on with many other examples; and where government is slow to respond, it's often because the rules require government to engage in a lengthy public consultation process or make it easy for third parties to litigate against the government (see: any case involving environmental review). It's not like waste, inefficiency, and so on are absent from the private sector.
2. The more your choices impact the lives of others (making yourself chronically ill and sucking up expensive medical resources, driving at 100mph in the rain), the more costs your bad choices impose on other people. Government is the agency we delegate some of our individual autonomy to in order to deal with such systemic problems. The alternative is everyone suing everyone else all the time.
3. I'll tell you the downsides: there are waiting lists for some procedures that are in high demand. There are about as many industrial disputes as before. Everybody blames the government for everything (like a tiny country hospital shutting down, nurses' pay, availability of some experimental treatment of unknown efficacy). A commonly-voiced fear is that if healthcare is cheap then everyone will crowd up doctor's waiting rooms all the time. This doesn't happen, because other than a tiny number of hypochondriacs nobody likes going to the doctor unnecessarily, for the same reason that most people don't engage in recreational dentistry.
The fact is that healthcare can't clear like a normal market for three reasons: a) there are genetic factors that you have no ability to control or predict that can make you sick unexpectedly; b) you typically don't have a choice about when you get sick so you can't defer your healthcare spending accordingly; c) most participants in the market are woefully under-informed because they don't have any kind of medical degree, and price theory demands market transparency for all participants in order for equilibrium to emerge and vendors to be price takers. What we have instead is a monstrously inefficient and unresponsive form of monopolistic competition, in which part of your healthcare costs go towards billboards and TV commercials for goods and services whose efficacy you are incapable of judging properly, massive layers of incomprehensible administration, and heads-I-win-tails-you-lose pricing that royally shafts the individual consumer in insurance and care markets.
It is especially amusing to see people suggest that the government can't competently administer health care given that Medicare customer satisfaction exceeds that of private health insurers. It's weird how easily people "forget" that the federal government is already an extremely accomplished health management administrator.
But I take issue with your argument about the health market not clearing. In fact, consumers have important options for how they finance the cost of care. One obvious one: they can pay higher premiums for a low-deductible policy that gives them less control over their outlays but eliminates risks, or they can opt for nosebleed deductibles offset by rolling health savings accounts.
I see your point, but I think it's very hard to gauge what the appropriate level of insurance is, because the risk factors are opaque and the likely cost of treatment unpredictable.
The other reason I'm strongly in favor of socialized healthcare is because of the insane administrative burdens it imposes on patients, whether or not they have insurance. Every medical decision a person makes about their own health in the US suddenly takes on administrative and financial dimensions that are quite poorly correlated with the clinical considerations.
Our government only insures the absolute worst customers (old people, poor people, veterans), and STILL does it cheaper than the vaunted private sector. It's absolutely mind blowing how bad a job the insurance system does.
Regarding (1): The question isn't whether gov can run it 'efficiently', but if gov can run it MORE efficiently than the current system.
Based on the US's position as highest per-capita spender on healthcare + the underwhelming quality of care that $$$ gets you, more gov intervention seems like a pretty valid thing to look into.
1) Can this just stop until someone presents a direct (and accurate) comparison? You make it sound like it will be a fourth branch of Government. There are several Government Agencies that don't hemorrhage money and actually accomplish what they set out to do. Look at Medicaid - people were saying essentially the same exact things about it and now people probably couldn't imagine not having the program.
2) Please explain.
3) Probably because a wider availability to care and an overall increase in average quality of life is a good, if not great thing for a society.
> 2) The more the government runs our lives (especially something like health care), the more they will be able to dictate our choices (what we eat, risky behavior, etc).
I know I will be pushing for change towards less and not more freedom. It makes no sense that you have to pay for my reckless high-risk behavior such as jumping out of a second floor window "for shits and giggles".
Another thing in particular that I want to call out attention to is food. If I retarded enough to eat nothing but McDonalds every day for a year, why should you just not let me die? Why should you pay for my surgery? If you are going to pay for it, over time you will gravitate towards a "high-risk fee" on activities that are just plain dumb.
Let's increase taxes on cigarettes, alcohol, (and implement new ones on ecstacy, marijuana, and all drugs... I don't know how that's possible without legalization but there is no way I am paying for someone rehab for something that has not been taxed)
The idea is that nobody should have to pay for someone else's high risk activities. Over time, the high risk activities will become expensive enough. Money will be a driving force that will drive people towards a better lifestyle. Think about it. Money will be a force for good for once.
Just take McDonalds. People say McD is a cheaper to healthier food. If a McD meal is a dollar and causes a health maintenance fee of twenty dollars, what do we do? We tack that twenty dollars to the cost of the meal. Bam! The McDonalds meal is now $21. That $2.49 price tag on the celery at Aldi's is suddenly not so expensive by comparison.
Yes, there are downsides but if enough people are annoyed you will get real reform. Please don't do anything stupid like the last time when conservatives tried to "starve the beast"[1]. We have solid evidence that starve the beast does not work.
So certain people point guns at everybody else to extract money and pay for health care. It suddenly diminishes motivation to stay healthy and we need even more guns pointing to some other people so some third category of people would feel that motivation has been justly restored and everybody is moving towards brighter future.
And please don't even start with an argument that "you can go away if you don't like it". It is you, not me, have to prove that some people have a right to point a gun at us while we cannot do the same towards them. Either that, or there is no difference between initiation of force and self-defense, but then it does not prove why somebody has an exclusive right to use guns.
To those who are going to downvote me: are you able to come with a valid argument why it is me, not people with guns should prove a position before taking action?
1) How efficient is Medicare now? Private healthcare will always be an option. The existing private system would still be very good, and very competitive.
2) You can say the same for private industry.
3) The downsides are taxes. Expand the existing government payer system with minimal logistic cost. Remove the tax burden from employees (or employers passing it on to same) and watch the economy flourish. The biggest risk is to private insurance, which will never fully recover. Some may opt for the nonprofit model.
1) Private health insurers haven't been able to run anything efficiently as long as I've been alive. My premiums go up by double digit percentages every year because "costs" keep increasing, but at the same time, insurers' profits go up by double digit percentages every year. It seems like this is simply a money transfer to health care executives.
2) The more private companies run our lives (especially something like healthcare), the more they will be able to dictate our choices (what we eat, risky behavior etc). Oh wait... corporations already do dictate what we eat, what sort of medicine we use, where we work, how we communicate, how we move around, what we wear...The only difference between corporate control and government control is that we actually have some say in how the government controls us because at the end of the day we control the government.
3) I haven't seen on person that supports privated health care tell me the downside. I know they exist and we need to know the risks and talk about them openly before we stick with such a horrible system.
But anyways, the downsides to public health care: cafeteria health care (i.e., standardized treatments) which is good for most patients but not for the few who have nonstandard variations of ailments; higher taxes; less personalized care as a consequence of standardized treatments; potentially reduced choice of health care provider(s) (but if the entire system is UHC this may not be the case); potentially longer waits for medical treatment that cannot be handled in a day (i.e., anything that cannot be handled outpatient or by nurses or nurse practitioners).
And the downsides to private health care: all of the above, plus: risk of claim denial for valid claims (though admittedly less of a risk now as a consequence of numerous state and federal laws cracking down on claim denials); double-digit increases in premiums every year despite no corresponding increase in costs (this is actually happening, and has been happening, every year for the past decade); reduced choice of health care providers (which is actually the case now, i.e., in-network vs. out-of-network); ruinous medical bills; unnecessary tests and treatments; private health information being shared with "business partners"; inadequate medical facilities as a result of lack of capital investment due to premiums being redirected to marketing or executive retention.
It turns out the downsides of a private health care system outweigh the downsides of a public health care system, since you have all of the same downsides but the additional downsides that come with a profit-seeking business. And as history has amptly demonstrated, cost-cutting is not one of the benefits of a private health care system (costs are cut in a way that benefits the insurer's profits, but in ways which are detrimental to the insured).
> My premiums go up by double digit percentages every year because "costs" keep increasing, but at the same time, insurers' profits go up by double digit percentages every year.
The raw profit values in dollars? If the costs go up 20%, the premiums go up 20%, and the profits go up 20% all together I'm not going to cry foul. The problem is the fact that costs are going up because of bad management.
> at the end of the day we control the government
You also control which insurance company you use. You have even more power; think about how hard it is to switch countries.
> downsides of a private health care system outweigh the downsides of a public health care system
I agree there, at least when it comes to basic care.
>government control is that we actually have some say in how the government controls us because at the end of the day we control the government.
That was a joke right?
As it is there is a shortage of nurses and doctors. Partly because it costs a lot of money and effort to enter that profession. How many people will be motivated to go that direction if they'll be slaves to government decree? It will take some time, but the effect of government controlled healthcare will be a race to the bottom.
Also, the profit motive is what keeps costs down and service levels high. The less regulated an industry is, the better the service and products are available to consumers who now have choice.
> As it is there is a shortage of nurses and doctors. Partly because it costs a lot of money and effort to enter that profession.
In the not-so-distant-past (less than 10 years ago!) mostly because the AMA tightly controls the influx of new people to the field, in an attempt to make sure that the salaries remain high: http://skeptics.stackexchange.com/questions/4561/does-the-am...
(Although now they are trying, so far unsuccessfully, to reverse it)
> How many people will be motivated to go that direction if they'll be slaves to government decree?
Instead of philosophizing in the void, why don't you look at other countries where, gasp, that is the case? Look at Canada, France, the UK, Israel, Hungary, and any other single payer country. Medical schools still have a 1:10 acceptance ratio, and are usually the hardest or 2nd hardest to get into. There is no "race to the bottom" in countries that had this system for over 50 years.
> Also, the profit motive is what keeps costs down and service levels high.
And yet, the US system is the most expensive system for what it gives (compared to single payer), and what it gives isn't better when you measure e.g. life expectancy. I would say you never actually looked at data if you can say that with a straight face.
> The less regulated an industry is, the better the service and products are available to consumers who now have choice.
I agree about that, but the US healthcare industry is extremely regulated in all the wrong ways. For example, they are exempt from any claim of anticompetitive or antitrust. How do you think that affects choice?
>And yet, the US system is the most expensive system for what it gives...
I was making a generalized comment. As you said, the US healthcare industry is extremely regulated, which is what I believe is the root of the problem we face.
People who want a the government to control health care are pointing at a system with a ton of government interference and saying "Look that isn't working well, we must need more government."
>How do you think that affects choice?
Poorly. But they're exempt because they're also force to take all comers. It's a water fall of faulty logic and regulation.
I'm not defending the current system. I'm advocating a free market system, which isn't anything like what we have right now.
> People who want a the government to control health care
No one wants the government to control healthcare. Many people want the government to run healthcare, and accept that as a result it will be government controlled . You might consider this a distinction without difference, but it paints supporters of public health care in a light they do not deserve. An analogy:
You seem to want my health care to be controlled by people whose own profit is their motive -- in fact, by corporations who are required by law to maximize shareholder profit at the expense of my health.
> "Look that isn't working well, we must need more government."
Most are saying "look, that isn't working well. But e.g. NHS in England is working extremely well. Let's copy that". And after looking at the NHS, it turns out that you need more (and especially, a very different kind) of government involvement.
Can you point to a working example of a system that you believe in? Because if you can't, I think the NHS and government involvement carry a LOT more weight as arguments.
You say that as if socialised medicine is somehow novel and untested? Look at most of the Commonwealth countries, there are no shortage of students applying to study medicine and they still get paid well. Take your blinkers off - or leave them on to be honest, I'm super happy with my socialist healthcare (which I supplement with cheap private cover for faster elective procedures).
> Net consumers are typically very happy in socialist environments, no shock there.
99.9% are net consumers when it comes to healthcare. So you're saying we shouldn't do something that makes everyone happy?
The 0.1% providers should be made happy. Apparently, despite the claims laid by many Americans who argue this, almost every other western country has managed to make those providers happy enough to not all quite en masse and leave everyone without access to healthcare.
> My premiums go up by double digit percentages every year because "costs" keep increasing
Because of government regulation.
> The more private companies run our lives (especially something like healthcare), the more they will be able to dictate our choices (what we eat, risky behavior etc).
Not violently, under the threat of fees or imprisonment.
> The only difference between corporate control and government control is that we actually have some say in how the government controls us because at the end of the day we control the government.
That's not true. The principal difference is that government uses violence to maintain control, while companies almost universally do not (except when they do so by lobbying government). Businesses go out of business all the time, which is a prime example of society exercising control over unpopular businesses, but unpopular governments very rarely cease to exist. I'm not sure how you can justify the claim that society has more control over government, with its vast military and police system and its nationwide campaign of mandatory taxation, than over businesses, which (with very few counterexamples, most of which involve employing government violence) only make money through voluntary transactions where both parties believe they are benefiting.
When you list the downsides of public and private health care, you leave out the primary distinction, which is that with private health care each person gets to choose which (if any) provider and plan to pay for, while with public health care there is no (or less) individual choice.
Now, I won't deny that a "perfect public health care system" sounds ideal, but the problem is that the definition of "perfect" varies from individual to individual. This is not a particularly profound or original idea: any dictatorial control is great for the people who enjoy the choices the dictatorship makes. You can easily apply this to some industry that is mostly privatized, like automobiles. If the perfect vehicle for Bob is a 4 door sedan with great gas mileage because Bob commutes and drives his family around a lot, then a "perfect" system for Bob would probably be one where 4 door sedans were the only automobile produced, and every household paid a set fee and was issued one of these sedans. Bob's costs would almost certainly go down, both from the economy of scale from only manufacturing a single type of car, and from the distributed fees. But that system is really bad for Joe, a farmer who really needs a large pickup truck and will probably have to buy one himself while his government-issued sedan goes to waste. Joe could argue (and I would agree) that even though switching to a privatized automobile industry might cause higher prices for a lot of people (like Bob), the individual choice is the important factor.
"Private health insurers haven't been able to run anything efficiently as long as I've been alive. My premiums go up by double digit percentages every year because "costs" keep increasing, but at the same time, insurers' profits go up by double digit percentages every year. It seems like this is simply a money transfer to health care executives."
If they could compete across state lines, this would be different. You also seem to leave out the government regulations in place, which many times hurts the consumer rather than helps (see: Obama care).
"The more private companies run our lives (especially something like healthcare), the more they will be able to dictate our choices (what we eat, risky behavior etc). Oh wait... corporations already do dictate what we eat, what sort of medicine we use, where we work, how we communicate, how we move around, what we wear...The only difference between corporate control and government control is that we actually have some say in how the government controls us because at the end of the day we control the government."
So you are saying because all of the people here on HN and in the US that want MJ legalized, it's magically legalized? That's not how the government works.
What about the TSA and all of the control they have over us? We have a say..right?..right??
"The only difference between corporate control and government control is that we actually have some say in how the government controls us because at the end of the day we control the government."
The government can send you to prison for not doing what your are told. A corporation can do no such thing. If you don't agree with what a corporation is doing..you can just stop giving them money. Is there an opt-out with taxes? or following the law?
"And the downsides to private health care: all of the above"
With private health care, you have no choice. Yes, there may be private care, but it's so expensive..only the truly wealth can afford it (see: the UK). I still want a choice.
The system has been screwed up to the point where it certainly appears as if we need it, as if that is the most just solution to the problems. However, that appearance is a mirage.
Unfortunately, we are so far down the path of doing things the wrong way that stating the proper solution only leads to misunderstanding. Think of a complex software system that has hack piled upon hack, and where the only programmers left are those who've been the ones piling on the hacks. These are not the people who can understand that what they've been doing is wrong.
Our system is the final consequence of people who, among other things, want safety guaranteed by the government. Unfortunately, there are no guarantees in life, so they are chasing a fantasy, and fantasies can become hideously expensive, as this one has. It is tragic that they do not comprehend what they are doing to themselves, but it is even more tragic that what they are doing isn't only to themselves, but to those of us who understand as well.
I'm likely going to regret getting into this conversation.
> Our system is the final consequence of people who want safety guaranteed by the government.
That's quite a statement and I expect you intended unjustifiable hyperbole. Yet, for a moment, let's jump down the rabbit hole of political philosophy debate.
There are no guarantees in life (aside from death) and on this we agree. Accepting this fact does not require us to be a slave to it; however. As a parent, for example, I could tell my children, life isn't fair, go out and buy your own dinner, but I chose not to. I chose to create a household that in intentionally does not simulate the harsh realities of nature.
Likewise, I decide to live in a community in which we reject the idea that we are all barbarian animals, fighting for scarce resources in a dog-eat-dog world. Instead, we chose to compromise, pool resources and worth together to create the living environment to which we aspire.
This model extends naturally to government. Indeed it is the source from which government springs. Government is the cooperation of the community to reject the harsh world in which we live and try to create a better one. We often fall short. Yet in some ways, we achieve some victory over cruel nature. We establish security from enemies with our armies. We build and protect common goods such as roads and parks.
Now at some point, we quickly start to diverge in what everyone in the community wants. Some of us believe its in our benefit to fund the education of all of our next generation. And some of us believe that it would be in the benefit of the community that all would have equal access to some form of medical care. We believe that we are a rich enough, prosperous enough community, that we can afford to ensure even the poorest among us need not worry whether or not they can afford medical care. We do not believe the government is required to coddle us. We do not believe the government will solve all our problems or eliminate all disease. Instead, we want to live in a society which cares enough for one another that we fund health care for all members.
That's the philosophical difference. Not some delusional guarantee of safety or a misplaced sense of entitlement. It's an aspiration of a better world and a rejection of idea that we are enslaved into the brutal nature in which we find ourselves.
Likewise, I decide to live in a community in which we reject the idea that we are all barbarian animals, fighting for scarce resources in a dog-eat-dog world.
Your world is one where you point a gun to my head (using the government of course) and tell me what kind of medical care I can trade with some guy you don't even know. So don't talk to me about "barbarian animals", OK? Your only means of doing what you think is "ideal" is to resort to cowardly force -- cowardly because you just pull the voting lever and somebody else does your dirty work.
Don't wonder why "resources are scarce" when your reply to someone who creates an unapproved alternative is to beat them up with the government.
Instead, we agree on a mechanism by which to make decisions and reach compromise. As everyone has different opinions and agendas, compromise is required. Not everyone, no one perhaps, will get their full agenda realized. Via those mechanisms (voting, representation, legislating, enforcement), we establish the rules of the society.
If you don't like the rules of the society, you can choose to engage the mechanisms in an effort to change the rules. Or you can choose to leave and find a society more appropriate for you. Or you can choose to incite rebellion and expect appropriate resistance if the majority of the population do not support you.
What you don't get to choose is to enjoy the benefits of the society and ignore the rules, requirements and responsibilities of the society. You can be a sore loser, take your toys and go away, but you can't be a freeloader by enjoying the benefits but not taking on the burden of responsibility.
Now, that's an idealized version of civilization, I understand. The rules are often broken, twisted, manipulated. These are the injustices we must resist and fight to overturn. Yet I argue that the imperfect nature of civilization is not an excuse to reject it, but rather a call, or even a responsibility, to participate.
There's no concise way to answer why your underlying political philosophy is wrong, unfortunately. One thing that should be a clue though is that the majority agrees with you. That's always a bad sign.
As it happens I did write a book on this topic, I don't know what the etiquette is here for posting links, just search "for individual rights" in books, you'll see it. If I could provide a more concise argument, I would, but that's the best I can do, sorry.
Ah, see now we're getting into what are "natural rights" which is much more tricky, yes.
The facts of the matter are that we find ourselves born into some particular land and some particular society. We have no choice about these things, we didn't ask to be born. But yet by being born at a particular time and place causes rights and responsibilities to be thrust upon us. Agreements for us have been made my ancestors, neighbors and invaders without our consent.
My assessment is that despite this scenario not being idea, it is in fact the world we live in and history has its claims upon us without our choice or consent. Life just isn't fair. The choices for us are then not the choice of what our ideal world would be like, what our ideal contracts and agreements would be, but a choice of how to deal with the world as it is. In that case, we find ourselves bound by agreements and in a system not of our own choosing. Again, we are faced with the same decisions I outlined previously: work within the system, leave the system, fight the system. The choice of staying within the system but not abiding by its rules is effectively the same as fighting it, i.e.- expect resistance (the metaphorical gun you mentioned).
We can do better than create and maintain a system that intrinsically requires coercion of peaceful people, and in fact this underling violence has a plethora of unintended consequences. We can do better. We must strive toward the ideal.
No one is pointing a gun to your head. Okay someone is "pointing a gun to your head" in the same sense they are "pointing a gun to your head" to prevent you from murdering someone.
But unless you are posting from North Korea you live in a country with the world's longest undefended border (aka the Canadian border). You can leave at any time and renounce your citizenship and literally no one will stop you.
Seriously, "pointing a gun at my head" is child talk for "making me follow the rules that I have implicitly agreed to obey by living in society", and you can at any time stop agreeing with those rules by leaving the society. Living in the society, enjoying its benefits and then crying about having to follow the rules is childish and hypocritical. If you don't like it, leave.
No one will try to stop you from leaving at gunpoint.
No it doesn't make right. But, excepting various inalienable rights, majority makes right in a representative democracy. And the majority have said that they derive greater utility out of having these rules and regulations than not having them. By staying in the society you are agreeing to abide by them, and to deal with the punishments for breaking them. You are not forced to stay in society though, so you can reject this deal at any time.
You claim there is a gun to your head, but this is the weirdest robbery I've ever heard of, where you can opt out at any time you choose. Any and all guns that may be metaphorically pointed at you are ones you have agreed to have pointed at you. Our system for determining what guns point where boils down to where the majority would like them to point, subject to the constraints of a constitution.
I normally hate the love it or leave it argument as well, but if you are going to insist on using this childish metaphor, then I have no alternative but to point out that you can end this apparently life or death matter at any time of your choosing. Literally any time.
You're begging the question, which is: is it legitimately "your land" to tell me to leave in the first place? (The answer by the way is "no.")
If the property legitimately belonged to you, then I'd have no problem with "my house, my rules, love them or leave them", but nothing but ownership gives you that kind of prerogative. You are making a pure might makes right argument, it's completely amoral. (Incidentally, do some research about what this megalomanical kind of "ownership" leads to, e.g. "Trail of Tears.")
That depends on our definition of property rights and sovereignty. You may "own" the land, but you are not sovereign on that land. The larger society, which claimed and defended the land prior to your ownership claims, has sovereignty over it and thus you while within those borders. If you do not wish to abide by the laws of the society, then you cannot claim land within that society's borders without emancipating the land. For better or worse, such rebellions are difficult to pull off.
Your conception is, to pick a metaphor, straight out of "The Matrix." Check your assumptions, you'll find that one of them is wrong, or arbitrary (which is really the same thing).
I've been hearing a lot of anecdotal evidence lately that the costs of private health insurance are stopping people, especially those with kids, from making the leap into their own start ups. Is anyone else getting that same impression?
In my own experience on the topic I've become increasingly frustrated with the U.S. system of employer provided health care. Either give us a public option with universal coverage, or a true private system with the benefits of market efficiencies and a standard tax policy. This muddled middle ground seems to give us the worst of both, and the only people who benefit are large employers who have one more thing to prevent employees from jumping ship.
Start-up with kids and no spouse providing health insurance is basically a no go. My friend had a baby last year, and they had a few month health insurance gap between graduating school and their starting their jobs. In the meantime, the baby fell off the changing table, and they faced the choice of either hoping he was fine, or going to the emergency room and paying thousands of dollars just to check for a concussion.
Another piece of anecdotal evidence, but my previous dentist was also married to a dentist and they worked at two different practices. Every time I went to him, he complained about how expensive medical insurance was for his family and their 2 kids. Eventually he quit practicing and joined an insurance company for the medical benefits.
I support my wife and 4 kids and the way I've had to deal with insurance is by getting a High-deductible Health Plan which pays 100% after the deductible is met. Then by having a HDHP I qualify for a Health Savings Account (HSA) which I can put a certain amount into each year pre-tax. The money I put into the HSA grows with decent interest if I don't use it. I get a Visa debit card which I use whenever I go to the doctor, dentist, etc. It still costs a lot of money each month, but so far so good.
You can get COBRA so it's not that you won't have insurance but rather that you will pay for it yourself. And have 18 months to find a longer term option if you can. It's what I did although I am single without kids so my rate was significantly lower.
Of course that is exactly what your employer paid on your behalf before. So you're basically complaining that other people will now no longer be subsidizing your medical costs. A private system won't help you much. A public one will but merely because people who pay taxes will now be subsidizing you.
This is exactly why a public system would help. Because the amount you pay for healthcare is scaled to your ability (via progressive taxes). Buying a private plan is not.
To see why this matters, imagine embarking on your "conquer the world" startup. You've saved up enough money for 12 months of runway. In a public system you are making 0 dollars and thus won't be taxed. However you will still have full health care. In a private system you will need to pair a fairly substantial amount (but probably not too much more than the amount of taxes that would go to healthcare in a public system) to receive coverage. You now have the following consquences: a) less runway or, b) more time saving up to get an equivalent amount of runway or, c) not having coverage and praying nothing goes wrong d) you just don't pursue your idea because it would be too hard.
Then, in a public system, when your startup succeeds and you make 10 million, you are taxed progressively on that money so as to fund the next hungry young graduate with a dream and a compiler.
I think it is pretty clear that the public system allows for more risk-taking. It is also important to note from your own example that private insurance is pretty expensive unless you are young, single, and without kids. This eliminates a huge swath of the population, all of whom might have different and awesome ideas. We bemoan the lack of gender and racial diversity in the computer field, but I think that the lack of age, lifestyle diversity in start-ups is just as important an issue.
Although one big problem with COBRA is that if you go work for a start up and it fails you're ineligible, there's no one left for you to buy insurance from. That happened to me a few years ago and if the timing had been slightly different it would have left us uninsured during the birth of my son. Another point is that the difference between your employer "subsidising" your health coverage and you paying for it yourself is that under the current system you get a tax break for your employer paying for your insurance that you don't get if you pay it yourself. So not only do companies pay less in general for insurance, the tax benefits represent a huge jump in out of pocket expenses for people looking to leave their employer and strike it out on their own.
God damn health care is like a boondoggle of epic proportions. Finding healthcare should be as easy as looking up a favorite restaurant and reading the reviews.
I would recommend Kaiser coverage to anyone thinking about switching from one of those plans with big increases. Their doctors don't get extra money for performing extra procedures as is the case in a lot of plans, so there is more incentive to just do what's necessary.
Would that mean that they would send the patients back home unless they can provably identify some issue? (This has happened to me a few times (with the issue re-discovered at a later point), though I have never been with Kaiser.)
Some of the Kaiser doctors are more evidence-based than others. But none of them take home more money if, for example, they operate on your rather than not. That is still true in many plans, even high-end ones, though they're not going to tell you about it.
I'd like a single insurance policy to cover me for everything, driving my car, riding my motorbike, health care, critical illness, theft/damage of my possessions or property etc. I'd be happy for lots of data to be collected to refine the policy and tailor the price specifically. Put a black box in my vehicles, collect data about my activity / exercise with a fitbit type device, access my medical record. If it means I have the convenience of just one policy to renew, and I'm paying an insurance premium based on me, my lifestyle, and my driving style - not the average Joe's, I'd be more than happy.
I got the green light to work on my startup full time. BUT, i have to figure out health care for my wife and infant before I can quit my job.
We've been spoiled with a tremendous insurance for so long. Can anyone offer any advice or give helpful anecdotes about their experiences (good or bad) going solo with a family?
This is going to really depend on your state and your needs.
Many states add some rules to the providers, often to your benefit.
If you have any pre-existing conditions, having continuos coverage is really important in many states, as it prevents companies from denying coverage for those conditions... in many states even if you change providers, as long as you have some coverage.
In New York, where I am, after a lot of research, I ended up joining a chamber of commerce with my company and enrolling my company (me) in a group HMO plan.
This cost me 1535 a month last year, and will cost 1680 a month this year. This covers basically everything, most prescriptions, numerous tests and treatments my family has needed because of pre-existing conditions. (I pay $300 a year to be in the chamber, as well.)
Note: If my company had an employee and I wasn't a sole proprietor, these rates would be 10-15% less.
If I didn't know we would hit the deductible, I would have been on a high deductible plan. If you hit the 10k deductible on the plans I looked at, it costs the same as the plan we are on, you just may end up paying the whole thing up-front.
So, in short, New York, family comprehensive co-pay plan, 20k a year.
(Do COBRA as long as you can, first, if you can. COBRA will almost always be cheaper because your former employer will be a group and have better rates.)
In my case (BCBS, Massachusetts), putting my wife and I in a group plan for our business was significantly cheaper than paying for a "personal" plan for my family.
What's the best place to start if you have a startup and don't know what you should pick? Should you just get in touch with an accountant who knows about this area and get their advice, or?
