I’m running out of chances to nudge you before publication, so let me say again, please preorder my book (out in less than a week!) if you haven’t already. As has been said many times, the term “health insurance” is actually a misnomer, and the reason why says a lot about why government has to play an active role in the distribution of healthcare.
The present govt in the UK has for a number of years been progressively privatising the National Health Service (& even if power changes hands at the next election that will continue). In order to justify this the govt has restricted resources to the NHS causing a worsening of services the hard-pressed staff try to give. Waiting times rise, treatments previously available are removed, staff shortages occur, hospitals become run down. If this is allowed to continue the govt, of whichever party, will argue that 'private is better' & one of this country's real achievements will, to all intents & purposes, be gone.
A properly funded NHS works very well & what it takes is the commitment of politicians to make that funding available. In addition, health services can & should look to prevent illness as much as possible. For the moment in Britain there are a number of testing programmes for different groups run by the NHS aimed at early diagnosis. I myself benefited from routine prostate cancer checks. Am I correct that in the US such testing is of course available but, if your insurance doesn't cover it you pay?
The NHS is enormously popular in the UK & people are fighting to protect it. But our corporate funded (yes here too) political parties are determined to damage it beyond repair.
Finally, one point I always like to make - a NHS (or US single payer) isn't 'free'. We pay through our taxes which, if levied fairly & progressively, the best solution. I don't want my or anybody else's illnesses to be exploited for profit. I don't want a private insurance-based service where the profit motive can influence decisions on the quality of care affordable. I hope the United States gets a govt asap that puts the health & welfare of ALL its citizens front & centre.
Capitalism is probably great for sneakers and widgets. How a person finances their medical bills is not a sneaker or widget. A true free market needs empowered and informed consumers. A patient is not easy to fully empower or inform. In the end Health Insurance Companies seem lot like government anyway with their premiums being analogous to taxes, their in-networks serving as borders. So can't we get some of that instinctual hatred for the bureaucracy of government the ideological right as pointed at the bureaucracy of the health insurance companies?
On a somewhat related note, if one was curious about the history of efforts to nationalize an industry that was balanced, both the good and bad, where would one start?
Having lived in and worked on six continents, the best system is in Switzerland. Hayek talks about Gemeinschaft and Gessellschaft in discussing the difference between household economics and market economics. In Switzerland, they combine the socialism with the free market to provide the best health care system. The ACA initially had a mandate to mirror that system.....everyone is required to have basic/catastrophic insurance at an affordable rate negotiated between government and private insurers. Those basic policies are the ante insurance companies pay to provide market-based supplemental insurance policies for those interested in different packages & services.
The worst are the single payer systems that are rationed to the point of being obsolete....hey you have insurance, but there are no doctors or hospitals to treat you. US healthcare is expensive because of the free riders, the link to employment (a direct result of the income tax implementation of the Progressive Era), a progressive tax system that underfunds health care....but mostly because the American Utopia Therapy Cult has medicalized ordinary life stress into a mental illness and our vapid culture's overindulgence in "spa" treatments like acupuncture, massage and other pseudo-therapies under the guise of health care.
Just wait until gender affirmation becomes a medical right and we can add the expense to the list too.....and of course the reversal surgery when 90% of these cases change their mind later.
Simply put, the American people want Scandinavian healthcare benefits without their taxes. Too bad politicians can't make a coherent argument for raising taxes that the American people will accept. I think both are to blame.
Related to that, Obamacare was spot on to make the healthy subsidize the sick (that's how insurance works, right?), but when that fell apart, we still are struggling.
1. Doctors will not take a pay cut. In the 1970s, doctors in California went on strike. (They ignored their Hippocratic Oaths; many are more businessmen than healers. Interestingly, during the short strike, the death rate went down, a very hard fact to discover, by the way.)
2. The same drugs cost less in Mexico and Canada. (Sick Americans are being forced to subsidize them.)
3. Despite our seeming obsession with health, exercise, and diet, Americans are the second-fattest people on Earth. (We were #1, but Mexico very recently surpassed us by .3%.) Obese people are unhealthy people; they have more medical problems and thus higher medical bills, a drag on the system, which we all pay for.
4. To increase profits for people and institutions in medicine, expensive tests are run, partly to avoid malpractice suits: "We left no stone unturned, but she died anyway." (You, thus, can't really blame them for running CT scans and MRIs for a patient with a broken leg. What if he slightly hit his head or maybe damaged an organ?) When we're in the emergency room, we want everything available on the menu, or many of us do, anyway; fear is the ultimate motivator.
Unwinding, reorganizing, or eliminating any of these Gordian knots is, to be realistic, beyond anyone's, or any group's, ability, power, or patience.
In a Hail-Mary effort, we could place German health administrators in charge of our healthcare system. They could make it function like theirs, that is, they could make it function like theirs if all Americans would get on-board. Not gonna happen. Some problems cannot be solved. A defeatist attitude? I see this conclusion as undeniable and thus telling it like it must be told.
All Mother Nature expects of you is that you live long enough to reproduce and get your offspring to the point where they can stand on their own two feet. Afterwards, humans are, again according to cold Mother Nature, superfluous. However, we beg to differ and refuse to go gentle in that dark night: We want to live forever, a fact made manifest by many religions offering eternal life. Billions have signed up for such programs. Death is too scary for most of us; it's literally unthinkable for everyone (Some tough guys may try to bluff us with their nonchalance, but I doubt that they would remain calm if experiencing a life-threatening event; for example, remember the complete panic of the people atop the Twin Towers as they looked down at the raging, unavoidable fire below them, trapping them where they were. Many tried to save themselves by jumping off and flapping their arms, screaming at the top of their lungs as they dropped).
I’m always surprised to see people argue for an NHS-style single payer system when there’s evidence that multi-payer universal systems in which the government regulates pricing (such as Germany’s) work better for patients.
This lack of planning at a higher administrative levels results in numerous morbid symptoms. Rural hospitals are closing in favor of highly centralized complexes. Hospitals charge monopoly rents, despite being operated on non-profit bases. Hospitals also routinely defraud Medicare. Pharmaceutical companies use public research create super profitable non-essential medicines, whilst neglecting antibiotics. Essential medicines like insulin have price increases for no reason besides profit. We've been making it for decades!
A not-so-much discussed problem is the guild nature of medical doctors. The AMA has lobbied for reducing medical schools, capping federal funding, and cutting residency positions for the sake of protecting their compensation and status. This is why we have seen the enormous growth of NPs and PAs.
Kudos for bringing up EMTALA. I didn't realize it was so recent.
US healthcare actuary here. As far as I can tell, the biggest problem really is about health care itself rather than health insurance.
A large portion of private health insurance in the US is financed on a non-profit basis, and the costs are still quite high. Many of the largest insurers (the Blues) are mutual companies that return premiums to members in the event that their claims experience is better than expected. On top of that, most large employers do not really "buy" health insurance for their employees. They just piggyback on the negotiated prices and administrative systems of a major insurer and finance the claims themselves on a non-profit basis.
The obvious problem, and one that I have no idea how to "solve" is just that the care itself costs a ridiculously huge amount in the US compared to other countries. If providing care in the US cost the same as it does in Germany, nobody would care that much how we financed it. Germany spends something like 40% less per capita on healthcare than the US, adjusted for purchasing power. But that seems like it would involve doctors and nurses and such getting paid way less than they do now.
Maybe in a single payer setup the government could declare that all healthcare providers in the US get their revenue cut by 40% and just tell them to deal with it, but I would expect there to be some major disruptions if that happened. A more realistic scenario might be freezing reimbursements at current levels and waiting for inflation to cut out the 40%. Even so, we're definitely talking about a major restructuring of a major segment of the economy, not just moving some dollars around, in order to achieve anything like affordable care.
Germany doesn’t have single payer, The Netherlands, doesn’t have single payer. When people talk about single payer I assume they have no idea what they are taking about.
There is no reason to expect single payer to work better than a system of highly regulated non-profit insurers. Why do people keep bringing it up?
I think that two instances where the free market is naturally unbalanced is in medicine and criminal defense for the reasons you describe. I’ve long wondered if we would be able to provide some baseline healthcare akin to the public defenders/right to an attorney, leaving room for a private pay “more attention for your money” tier akin to privately funded defense attorneys. Never been able to figure that out.
Hmm, isn’t another alternative to single payer that we require the purchase of private health insurance, similar to what we do with auto? That would still accomplish the goal of the young subsidizing the old.
The Australian health care system addresses many of these issues while retaining private and public aspects:
Everyone pays a Medicare levy of 2% of their taxable income. Medicare and the public hospital system provide free or low-cost access for all Australians to most of the out-patient health health care services. Private health insurance gives patients choice outside the public system, particularly for hospital I.e. hospital services. For private health care both in and out of hospital, patients pay monthly fees in order to contribute towards the cost of their health care.
An additional tax is payable by those that do not take out private health insurance to incentivize participation so that private health care companies remain financially viable. All medications are highly subsidized by Medicare which, by buying in bulk, has the power to negotiate low prices.
The other ways that health insurance is not like car insurance is that:
1. If you repeatedly put the wrong fuel in the car (as I do), then behave recklessly while driving, causing yourself to be involved in repeated similar accidents, the insurer is allowed to either say "no thanks" or make the premium so high that you are essentially uninsurable. When comparing ourselves to e.g. Singapore, it helps to also compare lifestyles.
2. If the car becomes severely damaged enough, they scrap it and give you money for a new one. How do you scrap a person's body and give them a new one?
Any moral argument for universal healthcare will fail its first encounter with a republican. And since there are many republicans in congress and in the wild….
Obama tried this and barely got halfway with ACA. It’s like a religious thing for the right…much like…well…religion, so it’s just not going to get very far.
I’m surprised Medicare and Medicaid have lasted this long. I think the argument for kids is the most tenable. Maybe you might have some luck with some version of Medicare for under age 18. But btw 18 and 65….that’s going to be a tough road to hoe.
For five years I worked customer service for a major US health insurer. It is an administrative labyrinth that requires much time, patience and skill to navigate. I’m
Not a fan of big government, yet I know the government could hardly do it worse. Also, with so many options available, insured people do not know details of their coverage that they pay for. They only find out when the bills are actually processed.
Why Government Intervention in Healthcare is Necessary (and Inevitable)
The present govt in the UK has for a number of years been progressively privatising the National Health Service (& even if power changes hands at the next election that will continue). In order to justify this the govt has restricted resources to the NHS causing a worsening of services the hard-pressed staff try to give. Waiting times rise, treatments previously available are removed, staff shortages occur, hospitals become run down. If this is allowed to continue the govt, of whichever party, will argue that 'private is better' & one of this country's real achievements will, to all intents & purposes, be gone.
A properly funded NHS works very well & what it takes is the commitment of politicians to make that funding available. In addition, health services can & should look to prevent illness as much as possible. For the moment in Britain there are a number of testing programmes for different groups run by the NHS aimed at early diagnosis. I myself benefited from routine prostate cancer checks. Am I correct that in the US such testing is of course available but, if your insurance doesn't cover it you pay?
The NHS is enormously popular in the UK & people are fighting to protect it. But our corporate funded (yes here too) political parties are determined to damage it beyond repair.
Finally, one point I always like to make - a NHS (or US single payer) isn't 'free'. We pay through our taxes which, if levied fairly & progressively, the best solution. I don't want my or anybody else's illnesses to be exploited for profit. I don't want a private insurance-based service where the profit motive can influence decisions on the quality of care affordable. I hope the United States gets a govt asap that puts the health & welfare of ALL its citizens front & centre.
Good luck.
"didn’t take any rabid socialist sentiments"
LOL, no, you just advocate taking away the individual's right to make health care decisions for himself and give them to a government bureaucracy.
Capitalism is probably great for sneakers and widgets. How a person finances their medical bills is not a sneaker or widget. A true free market needs empowered and informed consumers. A patient is not easy to fully empower or inform. In the end Health Insurance Companies seem lot like government anyway with their premiums being analogous to taxes, their in-networks serving as borders. So can't we get some of that instinctual hatred for the bureaucracy of government the ideological right as pointed at the bureaucracy of the health insurance companies?
On a somewhat related note, if one was curious about the history of efforts to nationalize an industry that was balanced, both the good and bad, where would one start?
Having lived in and worked on six continents, the best system is in Switzerland. Hayek talks about Gemeinschaft and Gessellschaft in discussing the difference between household economics and market economics. In Switzerland, they combine the socialism with the free market to provide the best health care system. The ACA initially had a mandate to mirror that system.....everyone is required to have basic/catastrophic insurance at an affordable rate negotiated between government and private insurers. Those basic policies are the ante insurance companies pay to provide market-based supplemental insurance policies for those interested in different packages & services.
The worst are the single payer systems that are rationed to the point of being obsolete....hey you have insurance, but there are no doctors or hospitals to treat you. US healthcare is expensive because of the free riders, the link to employment (a direct result of the income tax implementation of the Progressive Era), a progressive tax system that underfunds health care....but mostly because the American Utopia Therapy Cult has medicalized ordinary life stress into a mental illness and our vapid culture's overindulgence in "spa" treatments like acupuncture, massage and other pseudo-therapies under the guise of health care.
Just wait until gender affirmation becomes a medical right and we can add the expense to the list too.....and of course the reversal surgery when 90% of these cases change their mind later.
Simply put, the American people want Scandinavian healthcare benefits without their taxes. Too bad politicians can't make a coherent argument for raising taxes that the American people will accept. I think both are to blame.
Related to that, Obamacare was spot on to make the healthy subsidize the sick (that's how insurance works, right?), but when that fell apart, we still are struggling.
A couple of givens:
1. Doctors will not take a pay cut. In the 1970s, doctors in California went on strike. (They ignored their Hippocratic Oaths; many are more businessmen than healers. Interestingly, during the short strike, the death rate went down, a very hard fact to discover, by the way.)
2. The same drugs cost less in Mexico and Canada. (Sick Americans are being forced to subsidize them.)
3. Despite our seeming obsession with health, exercise, and diet, Americans are the second-fattest people on Earth. (We were #1, but Mexico very recently surpassed us by .3%.) Obese people are unhealthy people; they have more medical problems and thus higher medical bills, a drag on the system, which we all pay for.
4. To increase profits for people and institutions in medicine, expensive tests are run, partly to avoid malpractice suits: "We left no stone unturned, but she died anyway." (You, thus, can't really blame them for running CT scans and MRIs for a patient with a broken leg. What if he slightly hit his head or maybe damaged an organ?) When we're in the emergency room, we want everything available on the menu, or many of us do, anyway; fear is the ultimate motivator.
Unwinding, reorganizing, or eliminating any of these Gordian knots is, to be realistic, beyond anyone's, or any group's, ability, power, or patience.
In a Hail-Mary effort, we could place German health administrators in charge of our healthcare system. They could make it function like theirs, that is, they could make it function like theirs if all Americans would get on-board. Not gonna happen. Some problems cannot be solved. A defeatist attitude? I see this conclusion as undeniable and thus telling it like it must be told.
All Mother Nature expects of you is that you live long enough to reproduce and get your offspring to the point where they can stand on their own two feet. Afterwards, humans are, again according to cold Mother Nature, superfluous. However, we beg to differ and refuse to go gentle in that dark night: We want to live forever, a fact made manifest by many religions offering eternal life. Billions have signed up for such programs. Death is too scary for most of us; it's literally unthinkable for everyone (Some tough guys may try to bluff us with their nonchalance, but I doubt that they would remain calm if experiencing a life-threatening event; for example, remember the complete panic of the people atop the Twin Towers as they looked down at the raging, unavoidable fire below them, trapping them where they were. Many tried to save themselves by jumping off and flapping their arms, screaming at the top of their lungs as they dropped).
I’m always surprised to see people argue for an NHS-style single payer system when there’s evidence that multi-payer universal systems in which the government regulates pricing (such as Germany’s) work better for patients.
This lack of planning at a higher administrative levels results in numerous morbid symptoms. Rural hospitals are closing in favor of highly centralized complexes. Hospitals charge monopoly rents, despite being operated on non-profit bases. Hospitals also routinely defraud Medicare. Pharmaceutical companies use public research create super profitable non-essential medicines, whilst neglecting antibiotics. Essential medicines like insulin have price increases for no reason besides profit. We've been making it for decades!
A not-so-much discussed problem is the guild nature of medical doctors. The AMA has lobbied for reducing medical schools, capping federal funding, and cutting residency positions for the sake of protecting their compensation and status. This is why we have seen the enormous growth of NPs and PAs.
Kudos for bringing up EMTALA. I didn't realize it was so recent.
US healthcare actuary here. As far as I can tell, the biggest problem really is about health care itself rather than health insurance.
A large portion of private health insurance in the US is financed on a non-profit basis, and the costs are still quite high. Many of the largest insurers (the Blues) are mutual companies that return premiums to members in the event that their claims experience is better than expected. On top of that, most large employers do not really "buy" health insurance for their employees. They just piggyback on the negotiated prices and administrative systems of a major insurer and finance the claims themselves on a non-profit basis.
The obvious problem, and one that I have no idea how to "solve" is just that the care itself costs a ridiculously huge amount in the US compared to other countries. If providing care in the US cost the same as it does in Germany, nobody would care that much how we financed it. Germany spends something like 40% less per capita on healthcare than the US, adjusted for purchasing power. But that seems like it would involve doctors and nurses and such getting paid way less than they do now.
Maybe in a single payer setup the government could declare that all healthcare providers in the US get their revenue cut by 40% and just tell them to deal with it, but I would expect there to be some major disruptions if that happened. A more realistic scenario might be freezing reimbursements at current levels and waiting for inflation to cut out the 40%. Even so, we're definitely talking about a major restructuring of a major segment of the economy, not just moving some dollars around, in order to achieve anything like affordable care.
Seems like a genuinely difficult problem.
Germany doesn’t have single payer, The Netherlands, doesn’t have single payer. When people talk about single payer I assume they have no idea what they are taking about.
There is no reason to expect single payer to work better than a system of highly regulated non-profit insurers. Why do people keep bringing it up?
I think that two instances where the free market is naturally unbalanced is in medicine and criminal defense for the reasons you describe. I’ve long wondered if we would be able to provide some baseline healthcare akin to the public defenders/right to an attorney, leaving room for a private pay “more attention for your money” tier akin to privately funded defense attorneys. Never been able to figure that out.
Hmm, isn’t another alternative to single payer that we require the purchase of private health insurance, similar to what we do with auto? That would still accomplish the goal of the young subsidizing the old.
The Australian health care system addresses many of these issues while retaining private and public aspects:
Everyone pays a Medicare levy of 2% of their taxable income. Medicare and the public hospital system provide free or low-cost access for all Australians to most of the out-patient health health care services. Private health insurance gives patients choice outside the public system, particularly for hospital I.e. hospital services. For private health care both in and out of hospital, patients pay monthly fees in order to contribute towards the cost of their health care.
An additional tax is payable by those that do not take out private health insurance to incentivize participation so that private health care companies remain financially viable. All medications are highly subsidized by Medicare which, by buying in bulk, has the power to negotiate low prices.
The other ways that health insurance is not like car insurance is that:
1. If you repeatedly put the wrong fuel in the car (as I do), then behave recklessly while driving, causing yourself to be involved in repeated similar accidents, the insurer is allowed to either say "no thanks" or make the premium so high that you are essentially uninsurable. When comparing ourselves to e.g. Singapore, it helps to also compare lifestyles.
2. If the car becomes severely damaged enough, they scrap it and give you money for a new one. How do you scrap a person's body and give them a new one?
Any moral argument for universal healthcare will fail its first encounter with a republican. And since there are many republicans in congress and in the wild….
Obama tried this and barely got halfway with ACA. It’s like a religious thing for the right…much like…well…religion, so it’s just not going to get very far.
I’m surprised Medicare and Medicaid have lasted this long. I think the argument for kids is the most tenable. Maybe you might have some luck with some version of Medicare for under age 18. But btw 18 and 65….that’s going to be a tough road to hoe.
For five years I worked customer service for a major US health insurer. It is an administrative labyrinth that requires much time, patience and skill to navigate. I’m
Not a fan of big government, yet I know the government could hardly do it worse. Also, with so many options available, insured people do not know details of their coverage that they pay for. They only find out when the bills are actually processed.