Medicare for all is not entirely efficient

There is increasing interest in expanding Medicare health insurance coverage in the U.S., but it is not clear whether the current program is the right foundation on which to build. Traditional Medicare covers a uniform set of benefits for all income groups and provides more generous access to providers and new treatments than public programs in other developed countries. We develop an economic framework to assess the efficiency and equity tradeoffs involved with reforming this generous, uniform structure.We argue that three major shifts make a uniform design less efficient today than when Medicare began in 1965. First, rising income inequality makes it more difficult to design a single plan that serves the needs of both higher- and lower-income people. Second, the dramatic expansion of expensive medical technology means that a generous program increasingly crowds out other public programs valued by the poor and middle class. Finally, as medical spending rises, the tax-financing of the system creates mounting economic costs and increasingly untenable policy constraints. These forces motivate reforms that shift towards a more basic public benefit that individuals can “top-up” with private spending.If combined with an increase in other progressive transfers, such a reform could improve efficiency and reduce public spending while benefiting low income populations.

That is from a new NBER working paper by Mark Shepard, Katherine Baicker, and Jonathan S. Skinner.

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I have been saying this for ages... Medicare in Australia is nothing like Medicare in the US. If you are going to extend US Medicare to all it needs to be cut back a lot. An guess what.. the Boomers are not going to let you do that. When they work this out Warren will lose faster than you can say "gold plated health care for Boomers".

If Karen Boomer wants her knee replaced NOW instead of endure the “communist wait line” for 6 months, she can go to a private doctor that doesn’t take any Medicare funds.

That makes for a hell of campaign slogan.

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Just like Canada! Except the wait is more like 2-3 years. You might get an appointment in 6 months if you are lucky.

I am not really opposed to Medicare for all. But what they are actually proposing is to destroy Medicare and give us Medicaid for all. Medicare requires that you pay into it for 45 years of your working life. THEN you must pay into it every month while you are eligible after age 65. THEN you must pay a 20% co-pay. This is not what they are proposing. As usual the politicians are lying to you.

I'm glad you brought up Canada, because their own guidelines for knee replacement recommend a 6 month wait time. The long term average for completing the procedure before the 6 month mark is 82%. The population glut of Boomers has temporarily bumped the average down to 69%. The more urgent cases are almost certainly prioritized, and again, if you really want your knee replaced now, there are other options.

https://www.cbc.ca/news/health/hip-knee-replacement-wait-times-1.4615531

People always tell me that more urgent cases are "prioritized", but what does that mean? We know that diminished mobility prior to total knee arthoplasty, for instance, has a 3-year all cause mortality rate of doubles going from patients who can walk >1 km and patients who cannot, it doubles again for people who can only walk indoors, and then doubles again for people who cannot walk. We know that delay makes it more likely for people to flip down to more pathologic states. We know that knees that merit replacement tend to result in increasing functional immobility over time.

So when you "prioritize" how exactly is that handled? How many patients will be bumped up in "priority" because their functional ability drops and their risk of death doubles?

Patients don't sit in a bin harmlessly. The whole point of doing the surgery is that waiting is more harmful than not. Truth is that knee health is on a continuum and waiting has small absolute risk of mortality.

So what exactly are the numbers? How many people will die to longer waiting times that would not have if they received their knee replacement in a more timely fashion?

I mean the cost savings may say that those (few) lives just are not worth saving, but let's be honest about it.

I found wait list prioritization guidelines for Western Canada in particular. Visit the link below and scroll down to the first image (Table 1). Those criteria seem like a pretty effective way for doctors to triage patients for hip and knee replacement, and you'd have to be really cynical to assume all patients will game the system, all doctors will play along, and everyone will be rated as maximum priority. Again, contextualize this with the fact that most people, regardless of priority, get their knee replacement within 6 months. Moreover, also consider that Americans wait until the last second for a knee replacement anyway, and many don't get a replacement at all, because it just costs too darn much.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211637/#__sec11title

The guidelines were developed in January 2000, interestingly with significant inspiration from the New Zealand system. Government run healthcare is a known quantity, and we can pick and choose the best examples of each subsystem around the world to craft Medicare for All. "Americans are fat," "Americans are greedy," etc...are poor excuses not to fix one of the most broken aspects of our society. We can do much better, and we only have ONE chance to change the system so we better change it a lot. The healthcare industry, citing how different Americans are, will cynically back milder public healthcare reform, knowing that it will take another 20 years to realize that the reform is not enough and that more changes are needed.

I am familiar with Canadian guidelines, they are not what I inquired about. How often do patients move from being able to walk 5 blocks to 1 while waiting? Wait is the increase in absolute risk for mortality and morbidity when they do?

Anyone can see how bad symptoms are, the question is how much does the average patient change while waiting? I can assure that some patients will get worse. How much additional mortality does that wait bring? The guidelines are silent.

The only element of the guidelines about progression appears to just be surgeon's gestalt. It would be nice to know what that translates into for post facto morbidity and mortality before assuring everyone that living with a waitlist and less capacity is better than having shorter waits and more capacity.

Physician's gestalt is used for so many things, independent of payment model. I think I've made my case, but I'll summarize:
1. The "wait time" gestalt is structured and prioritizes care for patients who most urgently need it.
2. Even low priority patients get care in a reasonable amount of time
3. Low priority patients or those that believe they have been misclassified can get faster care elsewhere, and
4. Without Medicare for All, many people delay or entirely forego treatment because of the cost, resulting in lost productivity, lost quality of life, fewer years of life, and a societal Dead Weight Loss.

Good discussion.

1. You have an odd definition of "structured" the formal guidelines are entirely unstructured citing no laboratory, radiological, or empiric testing for progression likelihood.
2. Likewise, "reasonable" is one of those words that would require some actual outcomes data to back it up. How many preventable deaths would be too much to still be reasonable? There will definitely be a few (if only from the elevated PE risk during the wait period), so when does the body count become unreasonable?
3. Actually no. Canada bans duplicative insurance. If you want to get "faster care elsewhere" your only "choice" is out of pocket. We have talked a lot about knees, but there are many of other procedures where I am willing to pay an extra five grand a year to more quickly get treated; such insurance is banned in Canada and in many other single payer systems. Where such options are heavily used, e.g. India, the mortality difference becomes large and the public option is often clearly inferior.
4. With "Medicare for All" Canada has a higher rate of individuals than the US who do not take drugs due to financial reasons. As a physician, I would drastically prefer my patients to take the medications than to get the surgery. As far as people delaying or foregoing treatment entirely, I would like to see your data. It would need to be an exceedingly higher number than my personal experience suggests is likely to burn more DALYs than additional months of waiting for everyone.

To whit, you assumed that single payer would be better. When asked about the real costs of delays, you have assumed they are not worthy of attention. If you have anything other than yet another restatement of you basic assumption, please let me know. As is, my physician's gestalt is that these sorts of delays are too deadly to be worth a mere $4,000 per annum.

Certainly I would be much more willing to trade away Canada's more expensive housing and "cheaper" healthcare for the American setup of cheaper homes and more "expensive" healthcare.

I went to my 6 months doctors visit and the doctor wanted a CT scan of my lungs. I went to the imaging department and they set me up wioth an appointment in two days. I could have had it the same day if I was willing to wait an hour or so. As we drove away we got a call from imaging to come back in 20 minutes and they would schedule it so I wouldn't have to wait. We have relatives in Canada who tell us they cannot get a CT scan. Not that the appointments are 6 months out but that the hospitals don't have CT machines and they would have to travel to Toronto to get one. THAT is what "free" health care gets you.

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Me too. Statutory insurance is nowhere like Medicare.

Lobbyist pharma, doctors, boomers, the usual unholy alliances ... .

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All forms of high US med costs are driven by high consumption. Medicare may have generous consumption, but so must other US (private) programs to explain what is seen. No form of medical reform will do much for the US's costs if consumption patterns remain as they do.

Actually, the better phrasing is all forms of high US med costs are driven by perverse incentives, and the resulting profits. Including how patients sue doctors, often in an attempt to cover medical bills - which just happens to profit lawyers, who then try to find more patients as customers. The result of this suing cycle is doctors then try to cover themselves by generally ensuring that many conceivable contingencies are looked at, which malpractice insurance generally requires before providing coverage.

The U.S. health care system is generally crazier than most non-Americans can even begin to imagine. Imagine if every NHS doctor had this sort of expense - 'The AMA report shows that obstetricians can expect to pay around $150,000 in annual premiums for malpractice insurance. If your speciality requires fewer actual procedures, you can likely get by in the neighborhood of $30,000 to $50,000. Some low-risk specialties in low-risk areas of the country will pay less than $10,000 a year for coverage.' https://www.leveragerx.com/blog/medical-malpractice-insurance-cost/

This is true, but the the primary driver of US costs are:
1. Everything is more expensive here. Most physicians are smart enough that they could manage to be lawyers, low level finance people, or computer programmers or something similar. Physician wages, hence, have to reflect this opportunity cost and the top end for finance, computer science, and law compensation all resides in the US. And it continues down the scale. US nurses have many other job options, all of which tend to pay more than their counterparts in the rest of the world (e.g. education, accounting, civil service).
2. An unhealthier baseline. We smoked more up until not too long ago and are only beginning to equalize the lagged health effects. We are far more obese and have more metabolic syndrome. We are more sedentary. We use more dangerous drugs. We prefer more deadly forms of attempting suicide.
3. A low tolerance for morbidity. The average hospital stay in the US is below OECD average by around a third. This is due to American docs using tests and more expensive treatments to get patients out more quickly. Similarly, we are far less tolerant of waiting and risking complications instead of getting quick treatment.

In word: people.

Americans are unique in some many other ways in the world, why exactly should expect them to regress to the mean in healthcare?

'Everything is more expensive here.'

And those profiting from the American health care system don't want it any other way. And the amount they spend on shills and lobbyists is a drop in the bucket, but ensures that the profit margins are never reduced.

'Physician wages, hence, have to reflect this opportunity cost and the top end for finance, computer science, and law compensation'

Dean Baker has nothing but scorn for this sort or argument, based on the reality that allowing American doctors to face competition from doctors in the rest of the world would lead to quite a reduction in what American doctors could charge for their services. Oddly, this sort of free trade agreement is never discussed when talking about the benefits of opening up markets to international competition.

'US nurses have many other job options'

And they are welcome to take them, assuming the U.S. allowed market mechanisms to function by opening up the nursing market to international competition.

Total profit margins for healthcare amount to a couple years of price increases, tops.

Physicians already face international competition. Almost one third of the profession was foreign born. As far as nurses, about a fifth are already international and about quarter of all healthcare workers are foreign in origin. Frankly, I suspect the gains are quite limited. You can already apply, directly after medical school, for US residencies as a foreign medical student graduate (no need for double residencies). Yet less 10% of eligible foreign medical student graduates even bother. Likewise, we have minimal restrictions on practicing in different US states, yet we have deltas well over $100,000 per annum that persist. If $100,000 is not enough to temp physicians to move from Delaware to Wyoming, I am not sure why $200,000 is going to magically pull in scads from even India.

Frankly if this were all so easy, any of the Caribbean islands, which already host US accredited medical schools, should be able to make massive bank by setting up health tourism using much cheaper, but equivalent doctors. Yet none of them have done so. Is that not just a bit strange?

But I understand, magically you expect people to leave the families and status to come work for a smaller delta than current IMGs are turning their noses up at now.

'Total profit margins for healthcare amount' to an incredible amount.

As noted here - 'Of the $1.05 trillion revenue for the global pharmaceutical market, nearly half of it -- roughly $515 billion -- comes from the U.S. and Canada. However, the two countries make up only around 7% of the total world population.'

Along with this - 'This is the 2015 profit margin that Forbes estimated for the healthcare technology industry, making it by far the most profitable industry of all, with major and generic pharmaceutical companies leading the way. The company really setting the pace is Gilead Sciences (NASDAQ:GILD), which has a profit margin of nearly 53% over the last 12 months.' https://www.fool.com/investing/2016/07/31/12-big-pharma-stats-that-will-blow-you-away.aspx One can reasonably assume that nothing much has changed in the last several years since this article appeared in 2016.

'Almost one third of the profession was foreign born.'

Which sounds less impressive when compared to the total percentage of American citizens that are foreign born, which is more than 13%.

'magically you expect people to leave the families and status to come'

I am not advocating anything, but I doubt you read Dean Baker, who has some interesting thoughts - 'As I always point out, we can easily compensate developing countries for the loss of the doctors and other professionals they train. We can provide enough money to train two or three doctors for every one that comes here and still be way ahead.

I realize that many people don't like this idea, but this seems more a matter of religion that anything based in the world. As it is, we already get many doctors and other professionals from developing countries and their home countries get zero by way of compensation. I am proposing a route that might double or triple the flow from the developing world, but provide compensation. In almost all cases I suspect that developing countries would come out way ahead in this story.'

And here is Baker explaining reality - 'First, it is important to note a point where there is no dispute, we don't have free trade in doctors (or dentists or other highly paid professionals). This is a simple fact.

It matters because when people talk about manufacturing workers losing jobs and pay because of international competition, and thereby putting downward pressure on the pay of the 70 percent of the workforce who don't have a college degree, this is not due to "globalization," it is due to a policy of selective protectionism. There is no shortage of smart and ambitious people in India, China, Mexico etc. who would be happy to train to our standards, learn English, and work as doctors for a fraction of the pay of our doctors. The reason this doesn't happen is because we have rules that don't allow it.

This is a hugely important fact for people to acknowledge. It is protectionism that allows doctors to get an average annual pay in excess of $250,000 a year, not anything inherent to the market and the process of globalization.' http://cepr.net/blogs/beat-the-press/more-of-free-trade-in-doctors-response-to-simon-lester

Oh please.

The latest GOA report puts drug company profits at 17.1% for the whole sector. S&P 500 at the same time was 13.1%. Knocking pharma profits down to national average would maybe save us 13 billion. Of course, that would occur with a likely long term loss of new life saving drugs.

As far as nothing changing, sure whatever. Gilead's operating profit last year was 17.7%. So if by "nothing much has changed", you really mean "has fallen by 2/3rds and almost completely reverted to mean", sure whatever.

Exactly how many professions have double the baseline rate of foreign born professionals?

"There is no shortage of smart and ambitious people in India, China, Mexico etc. who would be happy to train to our standards, learn English, and work as doctors for a fraction of the pay of our doctors. The reason this doesn't happen is because we have rules that don't allow it."

India graduates 50,000 new MDs every year, where, if memory serves, most all medical education is conducted in English. Around 1,200 of these fresh graduates apply as international medical graduates in the US. These are not physicians who need to double up residencies. These are not physicians who are older and less likely to move in general. These are the prime demographic for moving and less than 5% even bother applying.

Average physician salary in Milwaukee last year was $395,363. In Raleigh average was $266,180. Remind me again how this protectionism works? How are physicians in Wisconsin keeping the hordes of physicians from North Carolina from moving in on Wisconsin turf? How does a delta of $130,000 survive?

But let's have more fun. Charlotte, NC has average salaries of $368,205. How is protectionism keeping a delta of $102,000 alive within one state?

Face it, the internal market for docs does not clear on price. South Dakota, Alaska, and several other states offer wildly more money to physicians, yet physicians refuse to move a single domestic flight away. No issues with racism, religion, citizenship ... and we cannot get enough physicians to move even waiving around $100,000 annual pay differentials.

But somehow all of that will go up in smoke if we just let in everyone ... and somehow we will so more applicants when the differential is less.

Could more immigration reduce physician fees? Sure. Because most of the rest of the world does not expect physicians to burn 8 years of earnings on training, go over $200,000 in debt, and then work at hourly rates below minimum wage for another 3-9 years. But if we want those gains, we should just restructure medical education. Instead we want to open the flood gates where most of the physicians people talk about (Canadians, Brits, Israelies, Germans, etc.) are looking at smaller average deltas than we see in the states and the ones who are looking at huge ones (e.g. India, Taiwan, Pakistan) have some serious quality issues by their own admission.

Even if we are successful and bring down average physician compensation to OECD averages, we are only looking at a couple of percent in total healthcare spending tops.

Sorry, but no there is not some magical pot of gold in the middle of healthcare being held by magical beings. If it were simple to deliver American level care at third world prices, we would see someplace like Antigua or Grenada build out a world class hospital that does it.

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Loser pays might help.

Cap or eliminate pain and suffering awards, loss of consortium, loss of services, and any other "general damages." That's it. You can have a tort system or you can have a comp system but you can't have both.

But most states subsume general damages into the right to trial by jury so getting this changed is extremely difficult.

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Great comment. I don’t understand why Democrats continue to make universal healthcare their primary issue, and I say that as someone who votes for Democrats. It is their proverbial white whale, and yet they could do a whole lot more good for a whole lot less money in many different ways. Increasing taxes on alcohol and cigarettes would save more lives and actually improves the government’s fiscal position. Hell, you could end child poverty in the US for a fraction of a cost of most of the Medicare for all plans.

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These forces motivate reforms that shift towards a more basic public benefit that individuals can “top-up” with private spending.

Only Scrooge would offer Medicaid for all. Just soak Scrooge and we can have Medicare for all and everything else on our Christmas list.

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Medicare for all would not work in the USA. There isn't really any nation that has anything like that in the free world. Other nations are far more stingy than Medicare when it comes to prescription drugs(Canada comes to mind). Additionally, as imagined be Bernie Sanders and Elizebeth Warren M4A would be far more generous than most nations are with things like vision, dental, and skin care. If we could transform Medicare into a forced savings program for all citizens that would be better. Single payer might work for more narrow things like catastrophes and emergencies.

Citation needed. The status quo is a Kafkasque scam that swallows a fifth of the U.S. economy. No price transparency, insurance companies getting kickbacks for higher reimbursements from providers, hordes of overpaid specialists, etc...That is not capitalism, that is cronyism. Medicare for All is the best solution.

Medicare for All is based on the premise that if there is only one payor for medical services - the US government - prices will be lower and the process will be more efficient. We have a great example how this works: the US military. Price transparency, cost savings, avoiding unnecessary equipment or procedures, reigning in large corporate suppliers - yep, it's all working really well ...

Why go farther to compare than current Medicare itself?
Their reimbursements are low. And their efficiency high. Medicare pays low but works fairly easily from a doctor's and a patient's standpoint. (I'm both a doctor and patient)

Why? Because currently private insurance subsidizes Medicare, which would fall away in the Medicare for All scenario. Here is an example:

The average cost of an ambulance trip in California is about $750. Medicare and Medi-Cal pay ambulance companies a fixed amount for each trip. Medicare pays about $450 per trip and Medi-Cal pays about $100 per trip. As a result, ambulance companies lose money transporting Medicare and Medi-Cal patients. Ambulance companies also lose money when they transport patients with no insurance. This is because these patients typically cannot pay for these trips. To make up for these losses, ambulance companies bill patients with commercial insurance more than the average cost of an ambulance trip. On average, commercial insurers pay $1,800 per trip, more than double the cost of a typical ambulance ride.

Is the $750 the overhead of doing business each run, meaning no profit? Or is that the average charge?

Don’t know. I didn’t analyze this. The example comes from the State itself, page 62:

https://vig.cdn.sos.ca.gov/2018/general/pdf/complete-vig.pdf

https://www.google.com/search?source=hp&ei=rRDfXZ36Cae7tgWZtZyYBA&q=The+average+cost+of+an+ambulance+trip+in+California&oq=The+average+cost+of+an+ambulance+trip+in+California&gs_l=psy-ab.12..33i299.2117.2117..3722...0.0..0.191.191.0j1......0....2j1..gws-wiz.WdAup4mrZC0&ved=0ahUKEwjdhNmhz4vmAhWnna0KHZkaB0MQ4dUDCAs

Could be the average negotiated price. It is common for HC entities to inflate prices simply to show all who will listen to their 'write offs' and 'losses'. The question will remain if the service can be sustained and reasonably profit from Medicare reimbursements.

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You get to pick your poison. Per the House of Commons Library, last year Britons who visited emergency services and were deemed sick enough to need inpatient admission spent more than four hours on gurney's waiting for transfer over 10% of the time. Now this happens here too, the hospital has only so many beds and so many people able to transfer patients between floors ... it just happens rarely when some statistical outlier completely overwhelms the system. In the UK over 10% of ED admits have had to wait 4 hours or more for 45 of the last 48 months.

This is pretty terrible. The physician has already said that an admit, with some degree of closer observation, sequestration from the general patient population, and the like is necessary, but they just cannot get patients into beds.

Nor is this unique. Cancer can often be a "time is life" scenario. The UK goal is to have patients see a specialist within two months. All but 4 trusts are unable to manage to clear this criminally (i.e. literally in the US) low bar. 35 NHS trusts cannot even get an urgent cancer referral through for 75% of their patients. In the US, for all new cancer patients (regardless of urgency), less that 15% are not seen by a specialist within 45 days. On a broad measure of cancer targets, 95% of NHS trusts have missed targets that would place them in the bottom ranked health systems in the US.

Nor is this just the UK. Sweden, for instance, refused to pay for a Gardasil vaccine for half a decade due to some price issues. During that time a large number of women contracted the virus and will get cancer in a few decades. This was after the vaccine was deemed to be safe and effective by the relevant authorities. And we see this elsewhere places like the NICE will note that new medications pass their own cost benefit calculations handily, and then spend months or years dickering for further cost savings because it is politically challenging to cut older, less efficient healthcare spending, and getting more funding needs the right political environment.

True nationalized care is invariably stingier and trades morbidity, and frankly mortality, for lower costs.

How do long waiting times for cancer treatment decrease costs?

And remember, there aren't enough sick people who vote to sway decisions. So you end up with perversities like free needles to drug addicts who are littering the streets and bothering people while at the same time changing the rules so that diabetics pay for their needles. Far fewer diabetics who vote than people who have to deal with addicts. How perverse? A phone call would get an addict a box of needles, the diabetic had to commute to a pharmacy, wait for service and pay for them.

You need to have a screw loose somewhere to think that the politicians in the Congress, Senate and White House will make the best decisions for your health care. And you will see the same efficiencies as the LA homeless housing. There will be beneficiaries for sure, but not the ill. Ill people don't vote and often are dead by the time the election comes around.

Depends on the cancer. With something like pancreatic you could look at perhaps halving the total costs. The cheapest option is always the patient dying.

For breast cancer, every 60 day of delay prior to treatment odds ratio of mortality increases by something around 25% relative risk increase.

On the flip side, using delays allows you to more optimally use your infrastructure. Patients seen quickly means there will be days when your shiny cancer center has below average censuses. Filling every single day, you might be able to get by with lower nursing ratios, fewer capital projects (e.g. proton accelerators), and dedicated oncology beds (a lot of these admissions are for treatment side effects). Making people wait allows for a higher utilization rate so you can more efficiently schedule.

Getting actual dollar amounts out is pretty hard. Cancer screening is very different between countries so the US finds a lot more cancer; that odds ratio above is only valid in the US, we should expect it to be higher (perhaps significantly) in the UK where their screening process is cheaper and average diagnoses is at a bit later stage/grade. Likewise, nursing ratios are drastically different between countries. Being able to save one FTE nurse in the US might be something like a 20% drop in nursing costs, in the UK that might only be something like 16%.

There have been a few minor scandals in the US with Medicaid. Medicaid patients take longer to get cancer treatment and their outcomes are worse for it even after controlling for standard confounders. Some Medicaids are notoriously bad at reimbursing for cancer treatment (e.g. New Hampshire) and we see an impact on survival rates.

Frankly, it has been my experience that the people who actually control healthcare policy and spending to be the directors of large "non-profits". Be those hospital systems or more traditional social charities, the bulk of fat I can see that is truly trimmable is massively protected by a bunch of highly remunerated people who also have regular dealings with the political powers. This appears to carry over into other healthcare systems elsewhere in the world.

Most of things people blame "doctors" for, are much more properly laid at the doorstep of specific non-profits: the AHA, the ACGME, the LCME, the Joint Commission ... creating a bunch of powerful, but not too obscenely rich, people whose empires depend on their being problems for which they gatekeep seems to be bad policy.

But then again, I am forbidden from actually running and owning a hospital with a consortia of actual physicians, we are required, by law, to turn the reigns of to exactly the sorts of administrators who manage to cut sweatheart deals.

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"True nationalized care is invariably stingier and trades morbidity, and frankly mortality, for lower costs".

And yet people in those socialised medical systems tend to outlive Americans. And, without exception, every American argument I've seen that purports to explain this discrepancy in fact merely tries to explain it away.

They also tended to outlive Americans before socialized healthcare.

In 1935, Brits lived to an average age of 62.0, Canadians to 62.4, Danes to 62.7, and the US was at a whopping 60.9.

Could be wrong, but my guess is that whatever was going on in 1935 might have kept going on after 1948, 1961, and 1962 respectively. But I suppose you have some explanation as to why difference seen in 1935 are due to policies implemented over 20 years later.

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" And, without exception, every American argument I've seen that purports to explain this discrepancy in fact merely tries to explain it away."

Is "we're fatter" explaining it away?

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That has more to do with public health and individual preventative care. The evidence from the " Oregon study" revealed greater access doesn't seem to translate to better outcomes. Asian Americans have life expectancies of about 86.5-87. Asian nations with single payer systems like Japan, S. Korea, and Taiwan have life expectancies of 84, 83, and 80 respectively. Air pollution, smoking, and suicide are bigger problems for most Asian nations than healthcare access. Hundreds of thousands of American deaths every year are linked to car crashes, homicides, suicides, tobacco, obesity, and opioids. Imagine cutting down on those by even 1/3.

Better mental health outcomes.

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The status quo is terrible, but it's also very ossified. We really can't just start over and try a big sudden change. That would probably be met by a strong negative political backlash. I foresee this only getting worse before it gets better. If we could expand Medicaid or try to implement a public option for catastrophes that would be good. On the supply side trying to confront hospital consolidation, excessive patenting, and the lack of interstate insurance competition.

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What else is not efficient? The status quo. Wealth and consumption inequality. Gift exchange. At least some of these are not exogenous to the model, as neutral as the authors might innocuously pretend to be.

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“Medicare for all is not entirely efficient”
Not entirely? That must be the understatement of the year.

M4A does not exist. Medicare as it is today is quite efficient. Again speaking as a doc and as a patient.

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I've dealt with contractors, car rental agencies, and hotels that try to hide their fees until the last minute using vague language or billing codes but in healthcare the whole industry is like that. Insurance companies, hospitals, pharmacy benefits, etc. They are all shady head to toe. I'm no fan of Trump but let's see if his attempt to rein in the hospitals will work.

https://www.nytimes.com/2019/11/15/health/list-hospital-prices-trump.html

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'Traditional Medicare covers a uniform set of benefits for all income groups and provides more generous access to providers and new treatments than public programs in other developed countries'

This is utterly laughable compared to Germany. Admittedly, the German health care system is primarily private and for profit, so possibly it is not properly considered 'public.'

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Nightmaresville, no doubt about it.

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"These forces motivate reforms that shift towards a more basic public benefit that individuals can “top-up” with private spending.If combined with an increase in other progressive transfers, such a reform could improve efficiency and reduce public spending while benefiting low income populations"

That sounds fine. Just tell people that's what M4A means. The meaning of the term is still fluid.

Except that no one says that there aren't private savings anymore when you have 50% marginal tax rates at wages that don't qualify you for a mortgage.

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Might the US may be converging with Canada on "basic health care for all, feel free to supplement" from the other direction? Strikes me as obvious, commonsensical, but something about 2019 tells me this "two tier" approach is offensive nowadays, so the only choices are the current mess and a version of the UK "basic health care for all, feel free to get on a plane to supplement". Too bad.

The US already has this. Any American can get Medicaid and I have my social workers sign people up everyday. The trouble comes that Medicaid has means testing so that people face the choice to earn/own less to get this basic healthcare for all.

Many people have chosen, implicitly or explicitly, to spend more money on things like housing and transportation than healthcare.

Ultimately "universal healthcare" is not actually about everyone receiving healthcare, is about people not having to give up other things to do so.

Which is always a bit interesting to me. After all, US healthcare is expensive even relative to our incomes ... but our housing is cheap. Americans homes tend to run around twice our annual income while socialized medicine countries run much higher clustered around quadruple annual income.

What I suspect is actually happening is that people accept that somethings get more expensive because they directly see improved quality: homes get bigger (or have better insulation and a hot tub), iphones have longer lasting batteries, cars last twice as many miles, etc. "Healthcare" looks the same from the outside. You go to the doc, she orders tests, tells you everything is fine/you need a pill/you need more tests. The fact that the test has twice the AUC of the old one does not register with the consumer. The fact that the pill reduces associated mortality by 66% (say from 3/1000 to 1/1000) is likewise not evident. And the fact that it is only the unlucky individual who actually develops significant morbidity from some specific pathology means that you are unlikely to have too many close personal referrants for outcomes of whichever pathology starts hitting you. Basically, until you hit Medicare age healthcare is black box, and people expect it to be the same black box for decades even though healthcare has had more quality improvement than most industries.

Worse we get compared to grandpa's outcomes ... even though grandpa walked six miles a day, did not drink, and never caught an STI.

People see massive increases in costs for stuff where all the improvements are under the hood and tend not show their real impact for a few decades. They hear that medicine is cheaper elsewhere and conveniently ignore that so is housing, education, and most other labor intensive goods and hope that somebody will finally keep medicine from rising in price.

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'the UK "basic health care for all, feel free to get on a plane to supplement"'

You really don't have a clue what you are talking about.

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Physician allotment of time per patient under managerial healthcare orgs:
New patients have 11 in UK vs 32 in US
Routine visitors are allowed 10 UK minutes vs 18 US minutes. Note that 18 minutes allows about three patients an hour vs five or six in UK.
Patients getting a physical get to have 20 in the UK vs 30 in the US.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3621071/

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"today than when Medicare began in 1965. First, rising income inequality makes it more difficult to design a single plan that serves the needs of both higher- and lower-income people."

Are the authors idiots? There was a far higher gap between lower-income and higher income people in 1965 than there is today. A good chunk of the south east was essentially a 3rd world country at that point. Most of the rural population never saw a doctor and were never inside a hospital for their entire lives. Many didn't even have indoor plumbing.

The difference between a family living on $10K per year and a millionaire is vastly greater than the difference between a family living on $60K per year and a billionaire.

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How many MR readers have RIP Health Care? Very efficient…check the results. Two thirds of congressional districts represented by republicans have shorter life expectancy than Communist Cuba.

"The role of Cuban economic and political oppression in coercing ‘good’ health outcomes merits further study."

"Coercing or pressuring patients into having abortions artificially improve infant mortality by preventing marginally riskier births from occurring help doctors meet their centrally fixed targets. At 72.8 abortions per 100 births, Cuba has one of the highest abortion rates in the world."

Source: https://academic.oup.com/heapol/article/33/6/755/5035051

Does communist Cuba believe a 70% abortion rate cures cancer, heart disease, Alzheimer’s, diabetes, suicide, traffic fatalities, etc.?

Mr. Kotlarz, did you read the source article from the London School of Hygiene & Tropical Medicine?

It is little wonder that the great majority of refugees that have come to the US, have done so to escape brutal oppression in communist countries.

Do we conclude that a 70% abortion rate and brutal oppression lead to life expectancy in Communist Cuba longer than 2/3 of congressional districts represented by republicans?

Mr. Korlatz, please give a citation for your claim.

Get a list of republican congressional districts and google life expectancy. I'm not aware of a link with both.

Understood now; an uncorroborated random assertion.

“An uncorroborated random assertion.” Sorry Buddy, you can’t make this stuff up.

Life expectancy in Mitch McConnell's Kentucky runs a year less than the former communist U.S.S.R. capital, Moscow.

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No but the government restrictions on automobile ownership (less than 6% of Cubans can own cars) and the government forcing people to use bicycles might have just a bit to do with cancer, heart disease, and traffic fatalities.

Then of course there is that whole thing where Cubans spent most of the 90s dirt poor and their calories dropped enough to halve obesity rates.

Suicides, yeah being too poor to take psychoactive recreational drugs tends to work that way. As does banning private firearm ownership.

Much of the backsliding in healthcare stats in the West are due to being wealthy enough to afford things that are bad for your health: drugs, gluttony, promiscuity, and cars to name a few. Having a totalitarian government ruin the economy and enforce less consumption of vices does tend to improve lifespan ... it is just odd that people rag on me when I even suggest something like doubling ethanol taxes and Cuba is somehow a viable model or option.

Do those with shorter life expectancy from drugs, gluttony and promiscuity tend to vote republican?

Depends on ethnicity. African Americans tend to go Democratic while Caucasians tend Republic. If you look at obesity rates and drug abuse rates, yeah there is a good bit of overlap with Republican voting.

This, of course, is in a bit of flux, particularly as the most recent two elections have seen a dramatic shift in suburban voting where the effects of drugs, gluttony, and promiscuity are muted so the correlation tipped less toward Republicans back in 2014.

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Is there anyone more vile than republicans? The communists in Cuba are far better.

Chuck, take the pledge to the flag...and to the republic for which it stands. A republic requires a middle class stronger than the aristocracy otherwise it's not a republic, it's an aristocracy.

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Would like to see a bold candidate run against Medicare and Tricare since we need to give our Boomers and Troops the healthcare they deserve not what they want.

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I think there should be three tiers of HC insurance for adults. Children should be handled separately.
1. A baseline very much like Medicaid, funded as Medicare is now, with a low flat rate tax. It would mainly cover those who are poor, disabled, elderly, or temporarily unemployed. But young healthy non-risk-seekers might also enroll.
Middle tier would be a voluntary enrollment program that would provide added / broader coverage but would be premium based instead of tax funded. The premium would be the same for every adult and would cover the incremental cost above Tier I. The premiums would be at least in part, tax deductible, making this attractive to working people.
Tier 3 a largely unregulated private insurance market that would compete with Tier 2 but would likely morph into a number of specialized offerings rather than broad coverage. The premiums would not be tax advantaged.

I would eliminate Medicare. It strikes me as economically idiotic to direct so much of our fiscal resources to nonworking people at the expense of working people.

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The main reason we have Medicare is because of the vastly higher HC risks and costs due to age. The great equalizer is that most of us will enjoy Medicare in time.

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"First, rising income inequality makes it more difficult to design a single plan that serves the needs of both higher- and lower-income people."

A feature, not a bug. The ruling class should be forced to eat its own dog food.

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This is true, but the the primary driver of US costs are:
1. Everything costs more here. Most doctors and physicians are smart enough that they could manage to be lawyers, low level finance people, or computer programmers or something similar. Physician wages, hence, have to reflect this opportunity cost and the top end for finance, computer science, and law compensation all resides in the US. And it continues down the scale. US nurses have many other job options, all of which tend to pay more than their counterparts in the rest of the world (e.g. education, accounting, civil service).
2. An unhealthier baseline. On average Americans smoked more tobacco up until not too long ago and are only beginning to equalize the lagged health effects. We are far more obese and have more metabolic syndrome. We are more sedentary. We use more dangerous drugs. We prefer more deadly forms of attempting suicide.
3. A low tolerance for morbidity. The average hospital stay in the US is below OECD average by around a third. This is due to American docs using tests and more expensive treatments to get patients out more quickly. Similarly, we are far less tolerant of waiting and risking complications instead of getting quick treatment.
In word: people.
Americans are unique in some many other ways in the world, why exactly should expect them to regress to the mean in healthcare?

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