Big ups to Marc the intern. I'd bet it's intimidating to write the first article for a website NOT written by it's founder and one of the best-known policy writers in the United States, about an issue as complicated and aggressive as universal healthcare. Good work, the article turned out great. It matches the style and tone of Slow Boring and has depth to it.
I'm a primary care doctor in Southern California in a small private practice. We accept most insurance plans (except straight Medical b/c it simply does not pay enough per visit to break even). We have a mix of straight Medicare/PPO and HMO. My husband works for Kaiser so I've been able to compare various systems and here are my thoughts and observations:
1) I am definitely in favor of a single payor system. Not only do I think it is ethically necessary for a society to care for its citizens, but I agree with Craig, who reflected that "everyone's health affects the people around them." Simply put, I think access to a decent, basic level of health care should be a right (like access to education), not a privilege.
2) There definitely needs to be a "tiered" system. Those who are rich or who can afford, should be able to purchase better access, fancier procedures, "concierge medicine," what have you. I know some people are fixed on fairness and equity, but in my opinion, efforts to enforce "equity" cause untold damage. Utopian visions are frightening.
3)Deciding what is covered will be difficult. There may be wait times for procedures. There will be articles in the papers about how someone had to wait 6 months for their knee surgery, while the rich guy in the next town got his in a week. But you know what? Covering basic primary care , vaccines, generic blood pressure/diabetic medications, etc, is HUGE (as I think the article points out). And I would like to see a cost analysis (if possible) about possible cost-savings if these issues are controlled and people don't end up at the emergency room when their illnesses are out of control .
4) One well-run system would hopefully cut down on costs. I am appalled by the amount of waste that I see simply in my practice. For example- if I have a patient with HMO, money goes to his provider (for ex: Blue Cross), then a portion goes to the IPA, and finally to pay for his care. Think about all of that administrative nonsense - the people at Blue Cross , then the reviewers at the IPA level, etc. And the duplication of tests is outrageous, partly because we don't all have access to one set of records, so the endocrinologist orders the same blood tests that the primary care doctor just did. Whatever else about Kaiser (and it has its flaws), it is generally an efficient, evidence-based, well-oiled machine. To my mind, it's a good model for how socialized medicine could be.
5) Last issue . This is the tough one and I don't have a solution. End of life care. It's very, very expensive. Are there rules that would be put in place if we/the taxpayer are paying for everyone's care? Are there age limits to dialysis? To intubation? What about the person who is brain dead? This is tough, a slippery slope. And what the Republicans use to scare the public: remember the death panels?
I'd just like to point out one thing that is *not* wrong with the present-day state of affairs, and which needs to be left unchanged at all costs by any reform: The richest country in the world (USA) is footing the bill for a whole lot of medical research (both new pharmaceuticals and new procedure development) which would not be happening without that money.
Something like a good new Alzheimer's, diabetes or Parkinson's drug would alleviate way more death and suffering worldwide over the long run than more equal care in the US would. Reducing pharma profits (as would surely result from Medicare For All's passage) could easily delay the development of such drugs by 5 or 10 years. That's a pretty price to pay for health care equity in terms of the global body count over those years.
I'm definitely not saying don't provide universal coverage. I'm saying either do it in a privately-provided way that doesn't wreck the incentive structure we have in place now, *or* introduce a new publicly-funded incentive structure for medical research, prove that it works, *then* switch to single-payer.
Progressives seem to operate in a framework where the soaring cost of healthcare in our current pseudo-market-based system is like gravity - a physical law that can only be overcome by pushing against it. But in reality do have control over that gravitational force, and I reject any proposal that doesn't deal directly with it. We have zero price transparency in the current system - the consumers of the service have no idea what the service costs and neither do the providers of the service! Healthcare providers have no incentive to bring value to the service. That's the first thing that has to change.
However... as a recently-diagnosed Type 1 Diabetic, I've joined a myriad of diabetes facebook groups that are global in nature. What I've learned is that in single-payer insurance programs, there are distinct decisions that country-based benefit managers make around which innovations the citizens of said country are able to enjoy... and not.
In most all state-based health systems, people are "stuck" with a certain technology that has been approved by the state for 3 years at a time, at a time when diabetes management technology is accelerating on an annual basis thanks to technology. This happens in America too, under Medicare. My dad is also diabetic, and his choices are so much more limited than mine. It makes me miserable to think about what he's missing out on because his insurance is state-based.
If state-based systems are unable or unwilling (or can't afford to) keep up with medical innovations, then how can I support such a system, when I enjoy the latest and greatest technology support under my private insurance plan? And how do we incentivize entrepreneurs and companies to push the envelop on medical innovations if there's a limited market for it?
If we go with state-based basics PLUS private add-ons, I can get behind that. But I've switched from being pro-single-payer to anti-single-only-payer, now that I see things from the inside.
I’m Scandinavian so I’m surely biased by my access to universal comprehensive healthcare, free university, parental leave, subsidized pre-K, basic income for the under-18 and whatnot, but the single most baffling thing about the US is the insistence that marginal consumption for the well-off is a more worthwhile policy goal than universal healthcare. Frankly, there is something deeply sociopathic going on here.
Matt and Marc: what about Medicaid for all? Basically Medicaid expansion to include everyone. Sounds much easier because all you have to do is spend money instead of altering the structure too much
I think you've missed the most important point about why some degree of government-sponsored healthcare is desirable, which is something I've realized in the course of the current pandemic: To a degree, everyone's health affects the people around them. At least when it comes to communicable diseases, your inability to get tested, vaccinated, or treated potentially affects everyone you come into contact with, and through them, lots more people. It is therefore to MY advantage for YOU to have access to healthcare. This is a valid rebuttal to the kind of people who say things like, "My taxes shouldn't pay for your healthcare."
Now, there's still room to debate how much, or what type, of healthcare falls into this category. Purely elective procedures, probably not. But even many types of care related to non-communicable health issues have benefits beyond the individual receiving the treatment. If treating you for some condition helps you to return to work sooner or avoid going on permanent disability, then that again benefits society in general.
So if you're going to open with a paean to precision and care, you should maybe think a little harder about a statement like:
> There are 28.9 million uninsured people. Nobody should be uninsured.
Because the problem is _not_ that N number of people lack, of all things, an insurance policy. I'm hard pressed to imagine a metric _less_ related to the problems at hand than "are a sufficient number of people handing over a monthly tithe to Anthem/Aetna?" If anything, the fact that we've decided that the economic model that we apply to hedging against the risk of auto theft or house fires is an appropriate one for handling the near-certainty that we will in our later years require medical care is the original sin of this debate.
I live in a country with universal healthcare and can confirm it's worth fighting for. Healthcare isn't even something I think about. Having a baby? Just show up. Don't even need your wallet, just your health card. I can't imagine having to fight for this basic necessity.
Thanks Marc! Would love to learn more about the history of how healthcare became so entangled with employment. To what degree is this so in other OECD countries? Did they go through an exercise of disentanglement to get their healthcare systems to the place they are currently?
Great article Marc, and I totally agree with you that our goal should be increasing coverage, period, and that we should apply political pressure to achieve any individual policy that would get us closer to that goal. I think a big pitfall is being overprescriptive on specific policy, and we all too often in this debate we somehow let perfect be the enemy of the good (see: you are literally killing people if you don't support immediate universal 100% government provided healthcare).
Honesty, pragmatism, and ambitious goals good politics make.
Matt or Marc - when the ACA was first being put together, wonky technocratic progressives had lots of ideas about how to bend the cost curve of health care in the US. I've heard Sarah Kliff say recently in podcast interviews that a lot of the things that were supposed to bend the cost curve didn't work the way people had hoped.
I'd love to read an in-depth update on the state of cost control - what worked, what didn't, how are costs looking now vs 2008, and what new ideas have been put forward since then.
Yes, this should be blindingly obvious to the entire political spectrum. There are only two valid opinions about US healthcare: "it should be universal and not tied to employment", or "I don't understand US healthcare". Adopting any of the other OECD models would improve outcomes, shrink government deficits, and increase corporate profitability.
Big ups to Marc the intern. I'd bet it's intimidating to write the first article for a website NOT written by it's founder and one of the best-known policy writers in the United States, about an issue as complicated and aggressive as universal healthcare. Good work, the article turned out great. It matches the style and tone of Slow Boring and has depth to it.
Nice to see Intern Marc flexing his writing skills! Great stuff.
I'm a primary care doctor in Southern California in a small private practice. We accept most insurance plans (except straight Medical b/c it simply does not pay enough per visit to break even). We have a mix of straight Medicare/PPO and HMO. My husband works for Kaiser so I've been able to compare various systems and here are my thoughts and observations:
1) I am definitely in favor of a single payor system. Not only do I think it is ethically necessary for a society to care for its citizens, but I agree with Craig, who reflected that "everyone's health affects the people around them." Simply put, I think access to a decent, basic level of health care should be a right (like access to education), not a privilege.
2) There definitely needs to be a "tiered" system. Those who are rich or who can afford, should be able to purchase better access, fancier procedures, "concierge medicine," what have you. I know some people are fixed on fairness and equity, but in my opinion, efforts to enforce "equity" cause untold damage. Utopian visions are frightening.
3)Deciding what is covered will be difficult. There may be wait times for procedures. There will be articles in the papers about how someone had to wait 6 months for their knee surgery, while the rich guy in the next town got his in a week. But you know what? Covering basic primary care , vaccines, generic blood pressure/diabetic medications, etc, is HUGE (as I think the article points out). And I would like to see a cost analysis (if possible) about possible cost-savings if these issues are controlled and people don't end up at the emergency room when their illnesses are out of control .
4) One well-run system would hopefully cut down on costs. I am appalled by the amount of waste that I see simply in my practice. For example- if I have a patient with HMO, money goes to his provider (for ex: Blue Cross), then a portion goes to the IPA, and finally to pay for his care. Think about all of that administrative nonsense - the people at Blue Cross , then the reviewers at the IPA level, etc. And the duplication of tests is outrageous, partly because we don't all have access to one set of records, so the endocrinologist orders the same blood tests that the primary care doctor just did. Whatever else about Kaiser (and it has its flaws), it is generally an efficient, evidence-based, well-oiled machine. To my mind, it's a good model for how socialized medicine could be.
5) Last issue . This is the tough one and I don't have a solution. End of life care. It's very, very expensive. Are there rules that would be put in place if we/the taxpayer are paying for everyone's care? Are there age limits to dialysis? To intubation? What about the person who is brain dead? This is tough, a slippery slope. And what the Republicans use to scare the public: remember the death panels?
I'd just like to point out one thing that is *not* wrong with the present-day state of affairs, and which needs to be left unchanged at all costs by any reform: The richest country in the world (USA) is footing the bill for a whole lot of medical research (both new pharmaceuticals and new procedure development) which would not be happening without that money.
Something like a good new Alzheimer's, diabetes or Parkinson's drug would alleviate way more death and suffering worldwide over the long run than more equal care in the US would. Reducing pharma profits (as would surely result from Medicare For All's passage) could easily delay the development of such drugs by 5 or 10 years. That's a pretty price to pay for health care equity in terms of the global body count over those years.
I'm definitely not saying don't provide universal coverage. I'm saying either do it in a privately-provided way that doesn't wreck the incentive structure we have in place now, *or* introduce a new publicly-funded incentive structure for medical research, prove that it works, *then* switch to single-payer.
You know what would be exciting? Be honest about how much taxes would go up to pay for this and don’t lie and claim we’re only going to tax the 1%.
Progressives seem to operate in a framework where the soaring cost of healthcare in our current pseudo-market-based system is like gravity - a physical law that can only be overcome by pushing against it. But in reality do have control over that gravitational force, and I reject any proposal that doesn't deal directly with it. We have zero price transparency in the current system - the consumers of the service have no idea what the service costs and neither do the providers of the service! Healthcare providers have no incentive to bring value to the service. That's the first thing that has to change.
Fair points.
However... as a recently-diagnosed Type 1 Diabetic, I've joined a myriad of diabetes facebook groups that are global in nature. What I've learned is that in single-payer insurance programs, there are distinct decisions that country-based benefit managers make around which innovations the citizens of said country are able to enjoy... and not.
In most all state-based health systems, people are "stuck" with a certain technology that has been approved by the state for 3 years at a time, at a time when diabetes management technology is accelerating on an annual basis thanks to technology. This happens in America too, under Medicare. My dad is also diabetic, and his choices are so much more limited than mine. It makes me miserable to think about what he's missing out on because his insurance is state-based.
If state-based systems are unable or unwilling (or can't afford to) keep up with medical innovations, then how can I support such a system, when I enjoy the latest and greatest technology support under my private insurance plan? And how do we incentivize entrepreneurs and companies to push the envelop on medical innovations if there's a limited market for it?
If we go with state-based basics PLUS private add-ons, I can get behind that. But I've switched from being pro-single-payer to anti-single-only-payer, now that I see things from the inside.
I’m Scandinavian so I’m surely biased by my access to universal comprehensive healthcare, free university, parental leave, subsidized pre-K, basic income for the under-18 and whatnot, but the single most baffling thing about the US is the insistence that marginal consumption for the well-off is a more worthwhile policy goal than universal healthcare. Frankly, there is something deeply sociopathic going on here.
Matt and Marc: what about Medicaid for all? Basically Medicaid expansion to include everyone. Sounds much easier because all you have to do is spend money instead of altering the structure too much
I think you've missed the most important point about why some degree of government-sponsored healthcare is desirable, which is something I've realized in the course of the current pandemic: To a degree, everyone's health affects the people around them. At least when it comes to communicable diseases, your inability to get tested, vaccinated, or treated potentially affects everyone you come into contact with, and through them, lots more people. It is therefore to MY advantage for YOU to have access to healthcare. This is a valid rebuttal to the kind of people who say things like, "My taxes shouldn't pay for your healthcare."
Now, there's still room to debate how much, or what type, of healthcare falls into this category. Purely elective procedures, probably not. But even many types of care related to non-communicable health issues have benefits beyond the individual receiving the treatment. If treating you for some condition helps you to return to work sooner or avoid going on permanent disability, then that again benefits society in general.
So if you're going to open with a paean to precision and care, you should maybe think a little harder about a statement like:
> There are 28.9 million uninsured people. Nobody should be uninsured.
Because the problem is _not_ that N number of people lack, of all things, an insurance policy. I'm hard pressed to imagine a metric _less_ related to the problems at hand than "are a sufficient number of people handing over a monthly tithe to Anthem/Aetna?" If anything, the fact that we've decided that the economic model that we apply to hedging against the risk of auto theft or house fires is an appropriate one for handling the near-certainty that we will in our later years require medical care is the original sin of this debate.
I live in a country with universal healthcare and can confirm it's worth fighting for. Healthcare isn't even something I think about. Having a baby? Just show up. Don't even need your wallet, just your health card. I can't imagine having to fight for this basic necessity.
Thanks Marc! Would love to learn more about the history of how healthcare became so entangled with employment. To what degree is this so in other OECD countries? Did they go through an exercise of disentanglement to get their healthcare systems to the place they are currently?
Great article Marc, and I totally agree with you that our goal should be increasing coverage, period, and that we should apply political pressure to achieve any individual policy that would get us closer to that goal. I think a big pitfall is being overprescriptive on specific policy, and we all too often in this debate we somehow let perfect be the enemy of the good (see: you are literally killing people if you don't support immediate universal 100% government provided healthcare).
Honesty, pragmatism, and ambitious goals good politics make.
Matt or Marc - when the ACA was first being put together, wonky technocratic progressives had lots of ideas about how to bend the cost curve of health care in the US. I've heard Sarah Kliff say recently in podcast interviews that a lot of the things that were supposed to bend the cost curve didn't work the way people had hoped.
I'd love to read an in-depth update on the state of cost control - what worked, what didn't, how are costs looking now vs 2008, and what new ideas have been put forward since then.
Yes, this should be blindingly obvious to the entire political spectrum. There are only two valid opinions about US healthcare: "it should be universal and not tied to employment", or "I don't understand US healthcare". Adopting any of the other OECD models would improve outcomes, shrink government deficits, and increase corporate profitability.