Which of these claims is false?

The Democratic-controlled House just voted to abolish the “Cadillac tax” on employer-supplied health plans.

The Independent Payments Advisory Board no longer exists, having been abolished with support from both parties.

In the public option for Democratic-controlled Washington State, reimbursement rates were set at up to 160 percent of Medicare levels.

Single-payer health care will save America a great amount of money.


The Medicare reimbursement rate is lower than many private insurance rates

And that's why you won't get Medicare-for-all at Medicare rates.

An impressive share! I have just forwarded this onto a friend who had been doing a little research
on this. And he in fact ordered me breakfast due to the fact that
I discovered it for him... lol. So allow me to
reword this.... Thank YOU for the meal!! But yeah, thanx for spending some
time to talk about this issue here on your web page.

Because price controls can magically reduce prices and increase quantity supplied at the same time, right?

They are all false

Decreasing quantity shouldn’t have too much impact on health, so long as vaccines and antibiotics use remains high. Of course, the cheapest way to increase health is to raise taxes on alcohol.

we wonder how many public health doctors at john hopkins medical school actually believe that hiring a 26 year old to head! the baltimore county health dept was a good idea?

so far
there are no john hopkins public health doctors who are willing to say
that hiring a 26 year to direct the Baltimore health dept. is either a good
or bad idea

'Single-payer health care will save America a great amount of money.'

Really depends on the definition of single payer, doesn't it? Germany has 'single payer' in the sense that the Krankenkassen (health care funds is a much better term than health insurers) tell doctors and pharmacies what they will pay for medical services and drugs, and as the German health care system is run for profit on the part of the doctors, hospitals, pharmacies, drug companies, etc., those offering medical services are free to take it or leave it.

Oddly enough, considering the market power of the Krankenkassen, who have an interest in lower costs (as that translates to lower insurance rates, which the Krankenkassen compete on), the German for profit health care seems to be able to do just fine. And since the Krankenkassen (like much of German industry) have an interest in standardization as a way to reduce costs, a typical German doctor's or dentist's office does not employ anyone to handle billing in the American sense - they just take your card, put it in the reader, and basically the entire billing process is finished. Plus, members of any Krankenkassen can go to basically any doctor or dentist or pharmacy.

The amount of saved overhead is considerable, though considering that such wasteful overhead is a significant part of the 'profits' associated with American health care, one can be sure that there will be plenty of Americans defending the exceptional American system.

Basically, there is a lot wrong with the American system, and as any public choice economist will tell you, the political system will be gamed to ensure those profiting from waste and inefficiency continue to profit.

So when are you moving to Germany?

Shark Lasers, your response is the kind of ignorant comment that makes any rational political discussion impossible. Advanced countries study the best practices of other countries, but only in the US does one consistently get a stupid reaction like yours the moment one suggests that we might learn something.

How many bars of Wi-Fi do you get in your ivory tower?

There's quite a difference between studying "the best practices of other countries" and assuming wholesale they have the answers to implement here, especially considering that the notion that billing constitutes a significant portion of health care costs has been addressed below.

Well, 1992 actually.

Or did you think that was the sort of cutting criticism that makes this comment section so entertaining?

Inject this response into my veins

I'm not interested in what you find entertaining but I am curious as to why you care what is going on with America's health care system. Trust me, we have enough people with all the answers, we don't need more phoning them in remotely.

Well, as an American citizen, my answer would be the one you already dismissed by Rebes, which was 'Advanced countries study the best practices of other countries, but only in the US does one consistently get a stupid reaction like yours.'

And as noted below, I don't care how the American system changes, nor am I advocating anything in terms of changing it.

However, I am pointing out how exceptional it is.

The US has an exceptional health care system because it is an exceptional country. I don't necessarily mean that in the jingoistic sense but to say that what works in a European country with a homogeneous population a fraction of the size of the US, and an entirely different culture, will more likely than not fail to work here.

We're working on solving the inhomogeneity part. MAGA.

I had more in mind the different attitudes people have regarding medical care due to their religion or culture. But now that you mention it, it does not help that we advertise free emergency care to anyone who shows up (to say nothing of the proposals to provide free health care to illegal immigrants).

The US's healthcare system is the best, because the US is the best country in the world! So there!
USA! USA! We're Number One! We're Number one! The statistics are lies! We're all living to 100! I know this because this is AMERICA! If you don't think we're the best, you hate America! Go back where you came from clockwork_prior!

I don't know what part of "I don't necessarily mean that in the jingoistic sense" is difficult for you to understand but keep building those straw men if it keeps you from having to think too much. It is Friday after all.

"Really depends on the definition of single payer, doesn't it? "

Also depends on what is meant by "will save America a great amount of money".

Absolutely, but as the link below in response to Sure notes, America spends 10,000 dollars on health consumption expenditures per capita, U.S. dollars, PPP adjusted, 2017. The next most expensive country was Switzerland, at 8,000, and German was third at 5,700. If the U.S. could even simply reduce that 4.1% difference in U.S./German administration costs that Sure notes, that would still be an actually noticeable amount of 400 dollars per American in 2017. Yes, the numbers might not be so simplistic to compare in such a straightforward fashion, but only when discussing certain American industries (health or defense) is it so easy to dismiss 400 dollars a year per American that is being spent on something that other systems consider unnecessary as 'insignificant.'

It looks to me like they all spend way too much. The UK and Italy manage to spend less.
BTW in Utah per capita spending is about what it is in Germany.


Also depends on the meaning of "seems to do just fine."

Ahh, so 4.1% is "considerable". Which is, after all, the entire difference between German and American administration costs.

If you are talking about merely simple billing for primary care, sorry, but by the numbers that would not even result in a single percentage point of savings if zeroed out billing costs entirely.

The big driver for American costs are the hospitals. Always have been, always will be. Within the hospitals the big drivers are the fact that American hospitals are more staffed. For instance German nurses fought not to long ago to reduce general patient-to-nurse rations; from 12 down to 9. These new, lower staffing ratios are wildly illegal in most US states; Sherrod Brown had legislation going for 6:1 ... for uncomplicated, healthy post-partum mothers.

A full time biller is a fraction of the total costs of hiring another nurse. Direct costs of billing is frankly a rounding error when comparing the US and Germany.

'Ahh, so 4.1% is "considerable". Which is, after all, the entire difference between German and American administration costs.'

It is not even close to the entire difference, as noted by the fact that a normal doctor's office in the U.S. will employ at least one person whose entire job is merely dealing with insurance companies (as for hospitals, well, an entire department). And of course, the health insurance companies in America are expected to earn a profit. A simple rate schedule, used by all, would eliminate market intransparency while basically eliminating the entire American exceptionalism involving that 'out of network' framework. (Though if you have a link concerning administration costs, please do share.)

'A full time biller is a fraction of the total costs of hiring another nurse.'

Probably not merely 4.1%, but who knows, maybe you can find a way to explain how a single nurse costs about as much as 25 billers, or how those billers are critical in providing the sort of health care that those living in countries that ration health care are unaware of.

'Direct costs of billing is frankly a rounding error when comparing the US and Germany.'

Interesting how you seem to have missed the real point completely - 'the Krankenkassen ... tell doctors and pharmacies what they will pay for medical services and drugs, and as the German health care system is run for profit on the part of the doctors, hospitals, pharmacies, drug companies, etc., those offering medical services are free to take it or leave it.' Particularly in light of how Germany's very expensive for profit system compares to the U.S.'s https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-average-wealthy-countries-spend-half-much-per-person-health-u-s-spends

Market power is a fine way to reduce health care costs, particularly in a for profit health care system. Reducing unnecessary overhead in billing through 'single payer' is just a bit of whip cream extra.

Median hourly cost for a medical biller is $15.81.

A certified MA is $14.94.

A registered nurse (RN) is $29.33.

A family physician is $97.11.

Assuming a very terrible billing setup of an MA, biller, a nurse, and an MD in one office leaves us with billing being only 10% of salary costs. Add in the overhead for the building, various insurance costs (e.g. malpractice, building), and of course the services a family med doc has to pay and yeah billing is very small percentage. In reality, a single biller is split among multiple MDs.

In a hospital, this is an even lower percentage.

Billing is far less than 4% of healthcare.

Regardless, per the OECD administration (which includes billing) is 4.1% of German healthcare costs. Administration is 8.2%of US healthcare costs. At best, adopting the German system will give us a 4.1% cheaper bill.

But of course that is a wild overestimate. The US has a much lower population density and needs more hospitals. The US provides more high intensity care for a variety of reasons (e.g. lower baseline health), which again bumps administration ratios.

Realistically, we are talking about an overhaul of whole system. It would take decades to recoup the costs during retraining alone (e.g. when one hospital in Boston changed billing systems it budgeted over a billion dollars in disruption costs, you want to do worse than that for thousands of hospitals).

'Realistically, we are talking about an overhaul of whole system.'

And realistically, there is far too much money at stake for the system to be overhauled.

'when one hospital in Boston changed billing systems it budgeted over a billion dollars in disruption costs'

So, the entire German electronic Gesundheitskarte/billing/data storage system seems to have cost as much as 14 billion euros (other estimates are lower according to the German language wiki article). Amazing how the German health care system could introduce a system to basically cover 80 million people with a system that seamlessly meshes doctors, pharmacies, the Krankenkassen, and patients for the cost, apparently, of 15 American hospitals changing their billing systems.

America is truly an exceptional place when it comes to health care. But of course it has nothing to do with any flaws in the American system, which is the undoubtedly the best in the world, as long as one properly adjusts the numbers to compensate for reality.

Those are direct costs. The indirect costs are what kill things. Ignoring the cost of the software, the formal retraining, etc. the big problem is that once you know a system, doing a new one bogs down a lot of time relearning.

To this day, there are physicians who refuse to use electronic medical records. The benefits are not great enough offset the need to take months of lower patient loads.

You are proposing far more than just changing software. Such changes inevitably run into problems when someone tries to do things the "old way" and the mistake propagates.

It is always massively cheaper to build a system up from scratch than to try to remake a system on the fly. Again, you can make many arguments about single payer, and I myself think billing could be made much better.

But billing is not where the major cost differences lie.

As always, those lie with hospitals and there mainly with non-physician employees. The most obvious cost bin are the nurses, how many of them should we fire?

'Those are direct costs.'

Well, no - but it is true that it was not difficult to train people. Before the electronic health card was introduced, they were already using networked systems to exchange information. The new card has multiple features, but one of them was to prevent fraud - people used to share cards as a way to not pay for health insurance.

'You are proposing far more than just changing software.'

I am not proposing anything, simply pointing out that in another for profit health care system, it is possible to reduce costs through the use of market power. Or to introduce a new electronic billing system without major costs.

'The most obvious cost bin are the nurses, how many of them should we fire?'

Interesting question - I would start with getting rid of that 4.1% unnecessary administrative overhead, which admittedly is only a paltry 400 dollars a year per American.

It's idiotic to simply assume that the additional administrative costs are simply unnecessary.

Particularly because so many of them are due to legal requirements that do not exist in Germany. For instance, US health providers have far greater legal requirements for medical translation services than those in Germany. Likewise HIPAA requires that the US use more secure (and more expensive) computer systems. And of course their is the entire affirmative action/non-discrimination compliance which is costlier than anything in Germany.

All of the stupidest and least useful administration line items are exactly the ones foisted upon us by government.

'US health providers have far greater legal requirements for medical translation services than those in Germany'

I'm guessing that the fact that Germany is in the EU has escaped you. Though I have no particulars about health care in whatever terms you mean by translation, something routine like driver license exams are provided in all the recognized languages used in the EU (plus several outside of the EU). I would assume that a normal Krankenkasse has paperwork in something like a dozen languages, but certainly could be mistaken. Or maybe I could ask a friend about his practice, in terms of normal medical routine. In his case, he said a few years ago that HIPAA was not anything noteworthy compared to his normal standards and was surprised it took so long for the U.S. to have such a basic policy, though again you are welcome to question his opinion.

'Likewise HIPAA requires that the US use more secure (and more expensive) computer systems.'

That is a joke, right? HIPAA is not something other than what is generally considered normal practice here - admittedly, with that American ability to overregulate and underregulate in equal measure, without actually improving much. Data security was an integral part of the planning and execution of the electronic Gesundsheitkarte a decade and a half ago (you are welcome to decide whether such discussion and execution was adequate, of course).

The American system is exceptional, but HIPAA is not a particular example of it, at least in comparison to Germany.

'And of course their is the entire affirmative action/non-discrimination compliance which is costlier than anything in Germany.'

This too is a joke, right? If a 4.1% difference in administrative costs is too insignificant to matter in such discussions, I would love to see a link about how such costs are even higher than 4.1%.

'All of the stupidest and least useful administration line items are exactly the ones foisted upon us by government.'

Well, maybe that is the reason the for profit German health care system does so much better in terms of costs - far less is foisted on it by the government. Instead, it is the Krankenkassen, using their market power, that work diligently to keep costs from growing too large, as they compete for members using their rates.

I am surprised you have yet to mention the Marburger Bund, to be honest. Or is the idea of a doctor union (more or less) that opposes the rate setting power of the health funds difficult to imagine?

A dozen languages. How quaint. All of the languages recognized by the EU.

How nice. We have our basic paperwork in over 100. But those are cheap one time expenses. Let me know when you are required by law to translate into things like Sinhala, Kmer, Hausa, or Chittagonian. We are required to have on-demand interpretation services for all possible languages. I have had to spend significant amounts of time getting real time translation services for languages so rare that naming the specific Austronesian dialect violates HIPAA because there are not enough native speakers in the US to meet de-identification rules.

If you walk into any ED in the US and say "I need translator" we are required to spend a good bit of money just to find you a translator, and one who has been certified for medical translation. Legally, your average language instructor is not deemed qualified.

And this is again the difference with HIPAA. The policy of protecting data is not all that expensive. Proving you have done so, that is expensive. You cannot just buy off the shelf solutions here. You are required to follow standard of care - i.e. whatever other people have done that has avoided them being fined or sued. Unless your IT providers are willing to assume liability, you cannot use their products. SAP, for instance, was unwilling to assume liability so they steadily lost market share in the US.

The real cost is not getting the tasks done, it is proving that you did them up to the level required by the courts.

Physicians' unions will certainly come in time, I just suspect that even within the 4.1% difference in administrative costs you will find things that do not transfer into a different legal context. Changing insurance regulation towards the German model does not reduce my translation burden down to double digits of languages. I am still going to have to contract out for on-call real time medical translation. I am still going to have pay an overpriced fee for a terrible EMR like EPIC, Centricity, or Allscripts.

At some point this stopped being about the organization system and about the fact that Germany has a different culture, body of laws, and regulatory mechanisms. Ignoring that wildly overestimates any potential cost savings.

Here is an interesting thought UT spending comes in at about German spending, GA and AZ are just a little higher. How are they doing it.
It looks like a sate regulation problem to me.
I wonder if the feds sent all the $ that they would have spent to the state on an age adjusted per capita basis and insisted that the states cover at least the old and the poor what would happen. The more the feds spend the less the states consider costs when implementing regulations. Medicare brings Fed $ into the states which state level politicians like to do.

I'm pretty sure the point Tyler is trying to make is the United States probably can't achieve - for example - German levels of health expenditure by copying German health care reimbursement policies. American political institutions seem to have a hard time controlling health care costs even when the government is paying, and there's no reason to expect that single payer would change that.

'German levels of health expenditure by copying German health care reimbursement policies'

Well, American doctors are adamant they will never work for the same pay as German doctors, that is for sure.

On the other hand, the market power of the Krankenkassen seems to be quite effective, as an economist would expect, when dealing with pharma companies, who are given a take it or leave it offer.

My ageing parents are living in Germany and are making extensive use of the German health care system. It seems to me that they regularly face quite a bit of pressure to order additional tests which are not covered by insurance and must be paid out of pocket. Physicians seem to quite aggressively sell these tests to get additional income beyond the Kassensaetze from insurance. I'm not sure how wide-spread this is but find it problematic in a vague "elder-abuse" sense.

Claims? I see one claim. So by default it is the false one, yes?

This basically means that both parties even at their most polarized understand that the middle class is sick and tired of their health care costs reaching Mars before Elon Musk.

The middle class is also tired of work and of getting sick, maybe we should pass legislation outlawing those problems alongside the infinite money laws.

This one: "small steps toward a much better world."

Fact Don't Matter.

Single-payer likely would save America a great deal of money because it would dictate the rate of reimbursement (i.e., the income) of providers, who could either accept the rate or pursue a different career. My comments about health care in America reveal that we spend too much on health care, much of it pointless or worse, harmful. It's true that America has some of the best skilled physicians in the world, but they are a small minority of the army of physicians who are overpaid and who underperform. We would be healthier if many physicians chose a different career!

Over 50% of physicians are now employed by hospitals. Do they have an incentive to cut hospital services or to promote hospital services? Physicians who are independent of hospitals are rapidly consolidating into very large group practices. Why? Because the larger the practice the higher the reimbursement rate they can negotiate with insurers. Yesterday I pointed out that the epidemic of kidney disease is in large part self-inflicted, as many of the medications prescribed for patients with other real or imagined medical conditions damage the kidneys.

No, this comment isn't meant to promote single-payer, as it likely would only exacerbate the problem we already have in America, which is an over-medically-diagnosed, over-medicated, and over-medically-treated population.

Perhaps this is splitting hairs but I'm not sure the problem is the quantity or quality of physicians. We would be healthier if McDonald's et al. didn't exist either but then Ronald isn't exactly force-feeding people hamburgers, is he?

For those who don't see the connection, this blog post and the one preceding it regarding the role of middling colleges and universities are making the same point: Americans are over-medically-diagnosed, over-medicated, and over-medically-treated (this blog post) and over-educated (the preceding blog post), in both cases without getting much in return for the enormous cost being paid. Less of both would be more.


Physician owned hospitals are vastly more cost effective than either for profit or non-profit hospitals. Their patients receive far less services. Further, physicians' charges are typically separate charges from the hospital charges. When I see a patient I make decisions about consulting various services within the hospital for them, I get paid exactly the same if I consult everyone and if I consult no one.

Do I have incentive to cut hospital services? Absolutely. Thanks to opioids, we have chronic bed shortages and certain services like cardiology and IR are in short supply. Here, at least, if you over refer to these services you get a little warning asking if you really want to do this, and then you get a pain-in-ass full review. If you are over consulting, then you end up getting a pay dock. Docs referring to me also have incentives not to do so, after all if I see a patient we can get snagged by HRRP. Be to liberal about sending patients to the urgent care/ED can ding you up to 3% gross (and remember margins for the average hospital are only around 7%).

As far as kidney disease. BS. Of renal failure, 30-40% is from diabetes. Around 20% is from hypertension. Both of these are well attested to diet and are seen in places with minimal medication use (provided that said place eats anything close to a Western Diet). 12% is congenital (e.g. autosomal dominant polycystic kidney disease) and 7% is autoimmune.

Further, when you look at rates over time the "unknown" or "iatrogenic" buckets have not been budging. Instead DMII and HTN have been rising at very nice clips.

If we give you a nephrotoxic drug, it is because we believe it will do more harm than good. If you are in any way showing signs of renal dysfunction we will get an automated reminder before any nephrotoxic drug can be prescribed. We still give them to you because your kidneys should have over 200% redundancy (for the young and healthy it is something like 600% redundancy).

Unless you are over 70 a full court press of gent, cyclosporine, and amphotericin B should not kill your kidneys, but we would never give you that cocktail unless we had no other options (now the other options tend to be more expensive). If your kidney's get shot, I would offer 5:1 odds that they lost over 70% of their function before you ever took a drug that was troublesome from us.

"Physician owned hospitals are vastly more cost effective than either for profit or non-profit hospitals." So, a physician owned hospital is neither for profit nor non-profit? Is it in purgatory? Is it a virtual hospital? Likely so since federal law has prohibited physician-owned hospitals for years (with limited exceptions), for very good reasons.

"Do I have incentive to cut hospital services? Absolutely." If you own the hospital, you have an incentive to self-refer; indeed, a physician who is an employee of a hospital has incentive to refer because she knows her compensation, and continued employment, will be affected. No, it's not direct, but understood; the hospital employed physician who refers patients outside hospital owned facilities will soon not be a hospital employed physician.

I work with physicians and admire them greatly (I don't represent hospitals), but I am aware of their innate ability to see the world in a mirror. For example, I have organized dozens of outpatient surgery centers, which surgeons who use them are allowed to own. But it's the exception for the owner-physicians to be satisfied with just an ownership interest in the surgery center. Greed is the root of all evil (and of violation of self-referral laws).

It's a pass through corporation or partnership.

The reason they are banned is because the AHA doesn't like the competition. They BS argument is that these hospitals skim the healthy patients and make the safety net hospitals less financially secure.

Reality is the vast majority of physicians are now employees. They get dinged if they over consult and we face penalties up to 50% of the entire hospital margin for doing so.

"...who could either accept the rate or pursue a different career. "

Unless you envision a version of single-payer that bans other forms of payment (self-pay and private insurance), providers would also have the option of simply not accepting single-payer patients (or putting low limits on the number they accept). As is the case with Medicaid now. Put a low enough limit on single-payer reimbursements, and you may end up with a situation where everybody has government insurance but where it is difficult to find doctors and hospitals that accept it (and impossible to get an appointment in any reasonable amount of time). Imagine this situation writ large for healthcare overall:


You're also assuming that America's millions of MDs, nurses, therapists, pharmacists, and other medical staff along with employees of drug companies, medical device companies, insurance companies, etc will simply roll-over (or be rolled-over) in setting up a single-payer system. That seems politically naive in the extreme.

'Unless you envision a version of single-payer that bans other forms of payment (self-pay and private insurance), providers would also have the option of simply not accepting single-payer patients (or putting low limits on the number they accept).'

German doctors are free not to accept the patients that are covered by the Krankenkassen. They will also not be in business, because the Krankenkassen are the source of the largest amount of revenue.

' America's millions of MDs, nurses, therapists, pharmacists, and other medical staff along with employees of drug companies, medical device companies, insurance companies, etc will simply roll-over (or be rolled-over) in setting up a single-payer system'

Well, one can be thoroughly sure that they will continue to act in a fashion that makes America so exceptional in this area.

This is probably the funniest thing I have read this week:

My comments about health care in America reveal that we spend too much on health care, much of it pointless or worse, harmful.

The authority of anonymous commentary is hilarious.

The US ranks 26th among OECD countries in life expectancy even though the U.S. ranks first in health care expenses per capita ($10,224 as of 2017), which is 28% higher than the next highest per capita country, Switzerland. Hilarious, indeed.

When we stop doing stupid things when we're young I.e. shooting each other driving drunk driving stupid smoking doing drugs binge drinking I'm sure the U.S. life expectancy will rise with a corresponding decrease in medical spending.

Yet every ethnicity has a higher life expectancy in the U.S. than in their country of ancestry, right?

Yeah it's almost like the other 70-odd per cent of things that determine life expectancy are swamping the effects of health care.

Standard offer:
Name for me a disease which has better Kaplan-Meier curves in another country with comorbidity matched controls.

You have thousands of diseases, using one of the best statistical tools for isolating the effects of healthcare interventions ... which disease is fought better in another health system?


Too bad we’re almost like adversaries in the current system (a lot of my work involves detecting “bad actions” on the part of physicians and facilities for a very large US insurer - not that you’re personally doing anything wrong, just that your member-adjusted billing patterns are almost certainly being run through FWA algorithms I’ve created).

I feel confident we could actually do a lot of good if we were working together. Or at least show where the good lies.

Single Payer was better at keeping cost trend 1-2% lower back in the 70s/80s. Other then that there is little reason to expect it would keep costs down today, and basically no reason to believe it could shove thrown massive cost decreases.

To save a lot of money you'd probably have to fire a lot of people and cut the pay of many more. Such action might be very wise but who is going to have the balls, and the nobility, to do it?

The single biggest difference in costs of which I am aware is nursing. Nursing is a highly organized, politically engaged swing demographic. Bumping our nursing ratios up to the levels seen in even the more generous single payer states would require firing large masses of nurses.

Further, once you decide to go this route, the nurses will go to the media and quote replicated, peer reviewed data showing that lower patient : nurse ratios save lives. They would be correct. Now you are going to be directly voting on killing people to save money.

I would submit that this is not a vote winner.

As far as cutting pay goes, good luck. Doctors already exit the profession early and they often have other good career options (if nothing else we have shown that we can work hard and intelligently). We already have large physician populations that refuse Medicaid (either outright or de facto), cut reimbursement rates too much and they will all just dump Medicare and Medicaid. We are already seeing a rise in cash practices, so I suspect that you would just more movement to that model.

You would likely have to go the full nine-yards and ban private insurance. That is going to get you into all manner of trouble; for instance a number of religious groups have doctrines about sharing the hardships of their co-religionists. They have pseudo-insurance for this purpose. Obama thought tangling with these would likely get slapped down as unconstitutional. There is also the whole federalism deal and such a ban would be particularly hard to uphold as a federal law given that medicine, by law, does not have interstate markets. Certainly it would behoove some small state to allow private healthcare within its borders and suck up a bunch of docs who like being higher paid and patients who do not want to wait in the queue (e.g. West Virginia could create carte blanche for concierge care for the DC burbs or NY could do so in a vane hope of keeping docs in NYC as even Medicare rates are going to make NYC unlivable for most physicians).

Right. The awesome power of government monopoly negotiating might convince people to accept a yearly COL adjustment more in line with the CPI, but it's not going to fire lots of people or cut their wages 50%.

The numbers bear you out. The higher cost level in the US traces to a period in the 70s-80s when us cost growth was much higher. These days, health care cost growth in the US is in the middle of the pack as compared to European single-payer systems (excepting the anomalous UK). And no country anywhere under any system has achieved actual sustained *reductions* in health care costs.

In other words, our system is currently doing about as well as the Germans on costs, and prior's comments are as misleading and meaningless as ever.

'In other words, our system is currently doing about as well as the Germans on costs'

Well, as the link above in a reply to Sure notes, so well that Germany's spending was about 50% of America's on a per capita basis in 2017.

That gap opened up decades ago though, a little at a time. A few % a year over a couple of decades adds up to a lot.

To get to German levels of absolute cost today would require massive layoffs, massive paycuts, or both. The German system never did anything like that, so its not clear to me that single payer would cut costs 50%.

'so its not clear to me that single payer would cut costs 50%'

I cannot imagine how basically any American reform that would be acceptable to the various interest groups will reduce costs by a single cent - there is far too much money involved in the current American system for that system to change without massive resistance.

And I am not advocating for single payer, nor do I personally care about whatever happens to the American health care system. What is the case is that in the for profit German system, the Krankenkassen use their market power to set rates which doctors or pharma companies are free to ignore - if they would like to lose something like 90-95% of their current revenue (that number is pretty much impossible to determine - could be as high as something like 99%, when excluding government employees, who are not covered by the Krankenkassen, as they are covered by private insurers, not the public ones).

"That gap opened up decades ago though, a little at a time. A few % a year over a couple of decades adds up to a lot."

So if the States doesn't do something now, in a couple of decades we'll expect the gap to be 100%.

Current cost trends are about the same between the USA and the rest of the OECD. But since we start at a higher level its sort of a locked in baseline.

I don't see single payer cutting costs in an absolute manner, but it would restrain future medical inflation. If monopsony does not produce lower cost levels than non-monopsony than our basic understanding of things like supply and demand are very wrong.

Thanks - that is a straightforward explanation of how the 'single payer' Krankenkassen in Germany keep costs down, without needing to point to a concrete real world example.

Cost trend is above inflation, but it's also above inflation in the rest of the OECD with single payer. There isn't much of a difference in real cost trend these days. There was back in the 70s/80s. Back then it was a small enough % of the economy that people just ate it rather than deal with it.

We have multiple monopsony counties in the US with reference to Obamacare. They are the most expensive counties in the US.

We have a complete monopsony with with Tri-Care with a covered population between Sweden and Austria. Its costs are not close to those of either Sweden or Austria, and it covers a population that is generally younger with a separate system (the VA) siphoning off sicker patients.

Vermont and California have both tried to create monopsonies and found them to not be affordable.

The reason monopsony fails is that very quickly it runs to into oligopoly, monopoly or de facto monopoly. The leverage from size works on both sides of supply and demand. Preventing supply from bulking up in response is hard to do.

In any event, from 2009 - 2013, US rates of healthcare inflation were significantly below Germany, Switzerland, Sweden, and Australia. From 2003-2009 they were significantly below the United Kingdom, Canada, Denmark, Japan, Australia, The Netherlands, and New Zealand.

The truth is that the US has beaten the OECD average many years and is rarely that far above in the rest. The days when our healthcare inflation was consistently ahead of OECD average are long behind us.

Furthermore, when you look at long run health care inflation there is no correlation between system types. Full on Beaveridge appears to be a bit better, but I don't see letting that many people being a viable change. Otherwise full Canadian monopsony vs insurance mandates in places like Germany appear to be a coin flip as to who has higher health care inflation.

The numbers just aren't there any more and haven't been since the 90s ended.

Outlaw pain and suffering rewards, 8%. Don't pay for second opinions, where the costs are bid up. Get rid of the capacity that can provide almost any procedure of treatment within a week. As Sure says, get rid of half the nurses. Close down 2/3 of the medical diagnostic facilities. Stop training doctors and nurses.

Maybe someone could compare these fees. https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/msp/physicians/payment-schedules/msc-payment-schedule

Canada is facing about 6% cost increases per year.

The only way costs will be cheaper is a major recession and the inability to deficit spend.

>Outlaw pain and suffering rewards,

In practice, pain and suffering rewards compensate for legal fees. Put differently, they allow the victim to be made whole after transaction costs.

Now, if you can figure out how to reduce those transaction costs while still making the victim whole, by all means. But that isn't going to be trivial -- the factually easy cases already settle.

No they don't. They make lawyers rich off an unquantifiable and completely arbitrary award by A spending B's money on C. Worker's comp doesn't have them for the very reason that they are inherently uneconomic. No country that socializes medical care has anything like the US tort system.

What ever gave you the idea that a socialist system would ever consider making the victim whole a priority?

BC government auto insurance just limited pain and suffering payouts to $5600.

so it looks like since there was one $289,000,000 sketchy lawsuit in California there have been about 3000 more lawsuits filed

'and basically no reason to believe it could shove thrown massive cost decreases'

Well, based on how likely the American health system is likely to accept a significant amount of its 'profit' removed, you are absolutely right.

See Obamacare for an example of how the fat of the American health insurance industry will not be trimmed any time soon.

(One of the things that leaves Germans most incredulous about the American health care system is trying to explain the idea of 'out of network,' as the very concept makes no sense in Germany's for profit health care system. As is the idea that a typical doctor's office requires one or two full time employees whose entire job is to handle health insurance company billing.)

'Out of network' works in the USA because the population knows that there are areas in public/private life that they don't belong to. Society is divided based on income and many other measures and people tend to only associate with the areas they belong to.

A great example is a few months ago I went with my family who owns a house in Long Island NY to a public playground that was a few blocks away but in the town over. We were playing in the playground with our 2 year old and someone came over and told us that we had to sign in at the entrance. Once we entered our zip code that was just adjacent to the playground, but not in the same zip code, we were told that we did not belong there, that there is a playground in our zip code that we had to go to. You probably don't have that happen in Germany. We are used to that here in the USA so we are okay with providers telling us our preferred doctor is out of network.

Oh cut the nonsense.

Insurers have in/out of network because they have to negotiate with providers and the only way to get a lower reimbursement rate is to credibly provide steerage. The cost differential is meant to get people to go to lower cost providers.

To pretend that our healthcare system cares about such things as "lower cost" when the prices aren't even listed and is scientifically in some kind of quantum superposition until way after it is observed is a laughable proposition at best.

There is no "healthcare system". There are individual insurers negotiating with individual providers. Insurers have found that providers will accept lower reimbursement to be preferred in a two tier model. They have also found that while patients complain about the two tier model when push comes to shove and they are trying to sell their insurance to clients the clients tend to choose lower premiums over single tier networks when the price differential is big enough.

This sounds right to me. In/out of network is an attempt to get patients to choose providers who data indicate do a better job of reducing total cost of care.

So to summarize, the town over kicked you out of the playground because you didn't pay the taxes needed to build or maintain it, asking you instead to use the playground that your family does pay for.

It's not very clear 1) why this is unreasonable (other than a playground having a guestbook and presumably security personnel to monitor it, which is bougie as hell) or 2) how exactly it relates to insurers leveraging the size of their pool to negotiate lower rates with medical providers then offering you reduced costs to visit those providers.

The root problem is the same as that in many other facets of modern life: the average person expects a standard of care that is simply unsustainable to provide to everyone.

It's a hard truth, but that doesn't make it any less true.

It is easily sustainable to provide platinum level care to everyone. It is just massively expensive. I could treat everyone at the cutting edge with more healthcare than they actually want, I would just need around 40% of GDP to do it.

It's not 100% clear to me that this is a bad option. If the US government stopped spending so many percentage points of GDP on things like war, the American public could afford to buy more health care. And why shouldn't they? "If you haven't got your health, you haven't got anything."

Unfortunately I think the public has a cognitive disconnect on this. They fully realize that health care is among the best uses of their money, but they simultaneously don't want to spend their money on health care and want someone else to pay their bills for them.

Some might venture to guess that fear of mortality is the root of all this, but I'm no psychologist.

If an enemy kills you, you haven't got anything.

Defense is a public good. It is government's job to provide public goods.

Health care is a private good. Private goods are best provided by private markets with people paying for their own resource uses.

Europe free rides on American defense. It wouldn't be able to afford its social entitlements if it didn't.

"Europe free rides on American defense." True, and shocking.
"It wouldn't be able to afford its social entitlements if it didn't." Also true, but not by that much. Countries like Germany, France and UK spends
1.2%, 2.3%, 1.8% of their GDP for defense (according to wikipedia). If they were to go up to 3% (a quite reasonable spending), that would cost them on average 1.3% of the GDP, a small dent in their entitlement expenses which are about 50% of GDP.

American defence would be a very fine thing. Much of the money, however, seems to be spent on offence.

I am all on board with you on this: that the government should only be in the business of providing and maintaining truly, strictly, public goods. Education, to cite just one example, is not a public good--not even close. But while we're running up $22T in debt for at or near zero real interest, it's hard to argue for F-35's over a subsidized medical care package I can take from employer to employer, or self-employ, if I want.

Politically, socialized medical care is low-hanging fruit. Eventually somebody is going to pick it and hold power for the next two generations. It might as well be us.

@Willitts, I would actually go one step further than you and suggest that the European health care market is in part subsidized by the fact that there is much more money to be made in the American biotechnology marketplace. That is, if Eli Lilly couldn't sell Humalog at such a high price in the United States, it likely wouldn't be able to sell it for such a low price in Greece.

I'm not for socialized medicine. I think the movement to cash markets for health care is a good development, and I hope it continues.

I stick to my policy of not advising Americans what to do about health care: I limit my central advice to what not to do i.e. don't copy the NHS.

But let me make an observation. Many Americans who like opining on blogs seem to have a remarkable blind spot. Ho!, they say, look at the poor old Brits who are denied such-and-such a treatment of vast expense and doubtful effectiveness - how horrible socialised medicine is! They don't seem to realise that all healthcare options must routinely deny people treatment for otherwise treatment would cost more than a country's entire GDP. The British method - which doesn't in fact deny treatment but does deny treatment on the NHS - is explicit, evidence-based, and publicised. The equivalent behaviour in the US is, I assume, better disguised.

To be clear: all healthcare, however funded and organised, will involve rationing. To deny that is to deny reality. Stuff is not free. Even insisting that someone else pay for it doesn't make it free.

"Stuff is not free. Even insisting that someone else pay for it doesn't make it free." There's about 25 people running for President that want to disagree.

Quick question, which areas of the US have more cost effective care, the suburban counties with lots of insurers or the rural counties with single very few (or one) insurer?

I would submit that the places in the US closest to single-payer healthcare have the most expensive care. Particularly once you factor in cost-of-living adjustments for geography.

If setting up some form of monopoly (e.g. Beaveridge and the UK) or monopsony (single-payer and France) were going to save money, why exactly are the places the closest to these always more expensive?

And before anyone tries to tell me about "profits", remember that these are the hospitals most likely to be insolvent and the insurers most likely to exit the market.

Looking at current data, the places in the US furthest from single payer dynamics are the most efficient. Yet we expect to save money by making the whole country more like the places that are struggling the most?

+1 brilliant comment. It is almost as if economic theory has something to say about the cost of health care.

Law of Supply something or other.

>Particularly once you factor in cost-of-living adjustments for geography.

Why would you do that? This is an inquiry where absolute cost should rule the day.

Because we are talking about remuneration for employees largely. If I have to pay a family physician in Nebraska $206,000 per annum that goes a lot further than if I pay $198,000 in Delaware. Same for nurses. Medicine is unusual in that the the best paying jobs for equivalent providers are typically not in the expensive coastal metropoli, but in the great flyover expanses.

If we achieved the total compensation typical in the counties closest to single payer for the whole country ... costs would rise steeply. Healthcare monopsonies somehow typically end up creating monopolies which results in minimal cost savings.

"Medicine is unusual in that the the best paying jobs for equivalent providers are typically not in the expensive coastal metropoli, but in the great flyover expanses."
+1 bingo

Rates set at UP TO 160 percent.

Sort of like me saying:

"You can lose up to 200 pounds a week on this diet".

What's ironic is that Tyler is repeating this, when there was an earlier discussion which pointed to the HealthAffairs article which explained this better than the NYT article. Up to is a ceiling, not a floor.

Like saying: "We can remove up to 99% of the fecal matter from your cereal."

Washington state has not yet begun to negotiate rates. By the way, in some markets there are no or few competitors--rural areas, areas where large systems have merged--meaning perhaps market failure, so it is not unlikely you would have caps or other forms of price regulation tied to a third parties rate determination, such as Medicare rates.

Here is the HealthAffairs article:
"The new policy requires that the total amount these state-contracted standard plans pay providers for all health care services (excluding pharmacy benefits) cannot exceed 160 percent of the total amount Medicare would have paid for the same services. Rates for certain rural hospitals are capped at 101 percent of allowable costs under existing Federal programs (including Medicare), while payment for primary care service payments must be at least 135 percent of Medicare. To address prescription drug costs, the state Authority may impose additional requirements on these public option plans, including increasing utilization of generics and application of evidence-based formularies.

With regard to the overall cap on what the plan may spend on providers, the requirement may be lifted under three potential scenarios: (1) doing so, by 2023 or later, would not increase premiums ; (2) the carrier is unable to form a provider network using these reduced reimbursement amounts; or (3) the carrier can achieve actuarially sound premiums that are 10 percent less than the previous plan year through other means. Keep your eye on number 2.

Pivotally, the legislation does not require providers to participate in the public option plan. It also prohibits carriers who offer such a plan from requiring providers to accept the public option plan rates as a condition of participation in other plans offered by that carrier."


By the way, the article also says the cap is 160% of Medicare and what you refer to says private plans pay 174% of Medicare, so the difference is small, and, unlike the post, which made it appear that hospitals and docs had captured the regulator and were overpaying, you now have a different story.

So, which is false. If you do not read carefully, you could say: which of the three items in the post is a deceptive statement.

Your argument is incoherent and contradictory.

First you say this:

"Rates set at UP TO 160 percent. Sort of like me saying: "You can lose up to 200 pounds a week on this diet". Up to is a ceiling, not a floor."

This implies 160% is just a cap but the average treatment will be lower than 160%

Yet in the very next post you write this:

"By the way, the article also says the cap is 160% of Medicare and what you refer to says private plans pay 174% of Medicare, so the difference is small"

Which implies that the rates will be close to 160% and so the difference is small.

Nowhere do you address the critical complaint which is that the payments couldn't be set to be identical to Medicare because the providers wouldn't be profitable at that point.

Dear Rat,

1. If you are buying something on the market, and the market sellers don't have to participate, and your offer price is close to what private payers are paying, you can't claim injury when there is an even lower price, the Medicare price.

2. Private pay entities, such as managed careHMOs, or managed care Blue plans, get discounts below, and unmanaged plans do not get discounts may pay above.

Those address the points. By the way, Tyler's claim was that Washington was overpaying and there was regulatory capture, not that it was underpaying. Second, as to underpaying, its hard to argue that when payment is within the range--it is underpaying as well. Third, no payment rates have been set yet, so you are in fact, A Rat in Putin's Maze, a confused one at that. Also, read the HealthAffairs article to help solve your confusion problem.

You aren't addressing the contradiction in your own statements.

Fundamentally, Medicare for All would pay too little to keep our existing medical system. The Washington cap of 160% over Medicare rates is a strong indication that the state of Washington realizes this is true.

Do you agree that the current Medicare reimbursement rates are too low to cover the costs of the existing US system?

There is no contradiction. I am not talking about Medicare for All (notice you are changing the subject, Rat), I am talking about Washington state's program. You know that, you obfuscated. If you don't know the word, look it up.

As for Washington's program, let's look at that: 160% cap; 175% average both based on a Medicare base. Docs and hospitals not required to participate.

Go back to your high school econ class, which seems to be the limit of your knowledge, and remember that equation P x Q = Total Revenue. So, let's say, one doctor doesn't participate, and other doctor does. The one who does participate sees his (or hers) total revenue increase, even though rates are lower. The doctor who decides not to participate can still get private pay and private insurance rates.

By the way, this methodology is no different than Blues saying that they will pay 80% of the usual and customary rates charged by doctors in a given area.

As for Medicare for all, try another red herring.

Bill, I tried to have a good faith discussion with you, but you just resorted to personal insults. I shouldn't have bothered to engage with your argument.

I don't believe I have engaged in personal insults but I apologize if you think I did by referring to the name you chose for yourself.

If you choose to use the word Rat as a name, you should expect to be referred by it. If you choose to change the subject, you should expect to be called out. I also addressed the point that reimbursement could be adequate when you consider total revenue and alternatives available, and, I would add, your failure to establish that Medicare rates are inadequate. I have also pointed out that the Blues 80% UCR rate.

I have addressed all these issues, notwithstanding your claim that I am incoherent, and contradictory, and notwithstanding your other comments referenced above.

I have no apology for responding to your argument with facts and reason or for pointing out the flaws in your argument.

The implication in this progression is that we are hostage to industry lobbies and so any change from status quo must be worse.

I will admit that pessimism about incremental change in this environment is warranted.

But the long ball, a working single payer health care system, can't happen incrementally. It can only happen if some large majority of Americans get pissed off enough to tear things up and start with a clean sheet of paper.

My vote for a revolutionary solution would be federal government vouchers for HMOs only. Then consumers shop for HMOs .. in the same way you want them to shop for charter schools.

No more employer healthcare. Smaller vouchers for big earners. You can upgrade your HMO if you want. You can have a private doctor, or PPO outside the system.

You can burn yourself voucher in the street if you want to.

But by definition everyone has access to a basic HMO.

"The implication in this progression is that we are hostage to industry lobbies and so any change from status quo must be worse."

We're not hostage. As Sure points out above, if we just fire 1/3rd of the nurses, we'd match European rates and drastically lower our costs.

I don't know why you bother me about those claims, definitely not related to my plan, but "as of 2017, California is still the only state to have a safe patient ratio law" where are all these other requirements coming from?


And it doesn't look like those proposed federal bills have gone anywhere since introduction.

So what does this have to do with me?

More related to what I'm talking about


Or as Sure does not point out, if we cut American doctors' salaries in half to meet German levels, we would save a bundle of money too.

At some point, someone should point out that Vermont and California both tried to implement Single Payer, and then quickly abandoned the idea because it was so obviously and laughably preposterous.

But by all means, keep talking about implementing it for a nation of 330 million people (with no borders). You all sound very knowledgeable.

Didn’t Tennessee try TennCare?

Yes and it failed. However, it was closer to Obamacare than to Medicare for All. It was an expansion of Medicaid.

The cost went up by a factor of 3x from 1994 to 2005. At that point it was drastically curtailed.


Single Payer: Because the Veterans Administration does such a fine job of treating people.

Amusingly enough, the VA was held up as an example during the Obamacare debates. Of course, that was before we found out how the VA achieved its numbers.

America has the highest per capita healthcare costs in the world. However, I am sure that our ingenuity and culture can find a way to make that even higher.

Let's hope so. I'd love to live to be 200.

Evidenctly US healthcare is not yet broken enough to fix.

But you say, other countries did it. Other countries established universal health insurance when healthcare was a much smaller part of the economy.

Certain other countries established that when we were covering most their defense budgets.

Bismarck would be interested to hear that when the public German health care system was set up, America was covering most of the Kaiser's defense budget.

Come now; American exceptionalism.

The forerunner of the NHS, a system called "the panel", was started between the two wars.

But you say, other countries did it. Other countries established universal health insurance when healthcare was a much smaller part of the economy.

Here's the kicker... in none of those countries did spending on health care go down, nor did they get improved results per unit of money spend after switching to single-payer. There's no reason to expect health care spending to improve in the U.S. if there was a switch to single-payer because it's literally never happened before anywhere else.

People naively think that the US can switch to single-payer and magically spend less because other countries who have single-payer spend less, but they fail to realize the US is much wealthier and spends more on all sorts of things, not just health care. The US government already spends more on health care than most comparable first world countries. There's no way that converting to single-payer lowers spending toward the spending levels of most other countries without severely curtailing (rationing) health care usage while limiting the supply even further than the government already limits it.

'There's no reason to expect health care spending to improve in the U.S. if there was a switch to single-payer because it's literally never happened before anywhere else.'

Yet in the system used in Germany, which has a for profit health care system, the Krankenkassen use their market power to keep costs lower than in the U.S.

If major purchasers of medical services follow a single rate schedule, and simply say take it or leave to those selling medical services and pharmaceuticals, the market is an effective way to reduce costs, as an economist would expect. Even if the doctors go on strike (which they did in Germany in 2006, actually).

America's infrastructure costs are more expensive than Europe by a wider margin than healthcare costs.

The U.S. public sector is an extreme outlier in cost efficiency. There is no compelling reason to believe that a larger role for the U.S. government would lower healthcare costs.

Like derek pointed out upthread, the money for public medical care is in the tort system. Otherwise public health advocates need to identify which Departments they're willing to axe and how they plan to limit immigration to net tax payors.

I like sassy Tyler!

These are great dots to connect that have flown under the radar while Trump is trying his darnedest to prove his critics right about his racism.

I have no idea if single-payer would save money.

But most people only support it because they have not actually thought through what it means. Most people just think it means "free medical care". They don't realize that it means "make private insurance illegal". Since the majority of the population is pretty comfortable with their generous employer-provided private insurance, any politician that tried to do that would be toast. Ergo, why the "cadillac tax" was repealed.
This is probably why California and Vermont gave up on the idea - someone realized that doing it effectively meant forcing the majority of voters in the state off of their nice, cushy, employer based plans and decided they didn't want to touch that with a 10 foot pole.

'it means "make private insurance illegal". '

Why must it mean that? You don't imagine that private health insurance is banned in countries such as Britain, do you?

It’s always interesting to see people’s reactions when they find out Medicare has monthly premiums and 20% co-pays, and that it doesn’t cover non-hospital drug costs.

For those that actually care about the truth and want the answers instead of arguing over misinformation and stale talking points in the comments:
True: https://ctmirror.org/2019/07/17/courtney-wins-house-repeal-of-cadillac-health-plan-tax
True: [from Tyler's link, linking the Wikipedia citation] http://legislink.org/us/pl-115-123
True: https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2019/05/14/washington-state-tries-a-public-option-health-plan also see Tyler's link
Debatable, but see below. Public option and single-payer Health care proponents insist its true, opponents insist it's false.

The statements chosen imply there is reason to doubt money will be saved via government intervention in America given the Democrats can't seem to control costs or raise the taxes as they claim they will. That it saves money in Europe doesn't imply it saves money in America nor does it guard against corruption, legislative failure, missed promises or unexpected side effects

There's also no evidence switching has saved money in Europe, either. To argue that, you'd need an example country in Europe which switched from a competitive health care market to single-payer and then spent less on health care as a result. That example doesn't exist. Instead, switching has resulted in higher costs in Europe.

'Instead, switching has resulted in higher costs in Europe.'

Depends. Germany still has a for profit health care system, one which spends more money than the true single payer system in the UK, which spends less. Admittedly, by many measures, that saved money comes from a system that does not compare all that favorably to the German system on many (though not all) measures.

However, not a single health care system spends more in Europe, which would seem to suggest that all of them use systems which spend less money, regardless of form.

I am reminded of Megan McArdle's argument. Things that work in Europe don't work in the US because the Federal government is less competent and more corrupt than comparable European governments. (I'm not sure that she considered Italy and Greece comparable. Nor the Vatican City.)

CMS says that 2018's $31.62 BILLION in Medicare "improper payments" is an *improvement* over improper payments for the prior year.

CMS manages only a part of the U.S. healthcare industry, and it "manages" to pay out over $31 BILLION that should not be spent, and calls it "good."
Why should anyone believe that the USG managing the entire U.S. healthcare industry would be any more prudent than today's CMS?
How do "single payer" healthcare systems perform in the corruption/erroneous payments segment of the cost side of the industry, and if better, then how do they accomplish that?

The point made about Germany is valid. However Germany is a STATE. The USA is the UNITED STATES. So, let any of the states of America implement that program. But most importantly, get the federal government OUT of it.

Comments for this post are closed