[NA] Health Insurance. US vs. Elsewhere

[David Megginson]

I get in line, it takes over an hour to get a number. From that point, it says there is a 45 minute wait, which is pretty accurate. Guess what gets reported as a waiting time? One example of many.

Could the problem just be that the DMV is understaffed and underfunded? Ontario's government red tape is nothing to write home about either, but my past few in-person visits to Service Ontario to renew a license were under 10 minutes.

Perhaps the DMV employees in the U.S. are just forced to try to do too much with too little.

It makes me think of those long lines you see at polling stations on TV during U.S. elections. The longest I've ever lined up to vote for a Canadian federal or provincial election in 40 years was 15 minutes, and typically I just walk straight up and get my ballot. It sounds a lot like U.S. public services are simply underfunded, and the public servants are stuck with the blame.

 

[Llewtrah381]

The best 'bang for the buck' we have in medicine would be to train more geriatricians and palliative care specialists. The 'problem' is often to get families to accept the reality of the situation and to move someone to geriatric or palliative care. The hospital/ER/ICU/SNF/rehab is a machine and once you feed someone in, the machine will do its thing. Of course it's not logical to do the tenth abdominal CT in as many weeks on a dying patient with abdominal pain. Scan #10 will have as little influence on the patients well-being as did #7 and #5. But once the private ambulance from the nursing home wheels the victim patient through the ER door, the machine will do it's thing. All of us who are involved in the farce care know its insane and futile, but until the family calls an end to it, it will continue.

A-frickin'-MEN! It has been very painful to watch families, with the best of intentions, not want to be the one to "pull the plug" and "give up hope" for a loved one whose course was inevitable. We're ALL going to die and hopefully we can all "die well" at the right time. Prolonging the pain, frustration, anxiety, etc. just doesn't make sense or a difference. Palliative care and hospice aren't "throwing in the towel" - they're allowing a natural and inevitable course to play out with dignity and compassion. (At the risk of triggering a lock,) That's why talk some years ago about "death panels" was so maddening - and inhumanely inaccurate, from a clinician's perspective.

ALL of us, regardless of age and health, should make it clear to our loved ones what we would and wouldn't like done if we're not able to voice our desires because of illness or injury. I encourage everyone to have a Living Will prepared. That's NOT a document that says "pull the plug": it's a document that says what you do and don't want done for you. If you want a full-court press, it's documented. If you want to let nature run its course without intervention except pain management, it's documented. But document it so your family can honor your wishes, whatever they are, and live in peace.

 

[weilke]

Healthcare billing is WAAY more complicated than a reasonable-length post here could describe. It's full of "you're kidding me!!" realities. Some quick ones: insurance often pays via a "percent of billed charges": they'll negotiate to pay, say, 50% of the hospital/provider's usual and customary rate. Sounds impressive! Then the hospital/provider sets the rate pretty high. Who wouldn't, in that situation?

'Percentage of charges' is a extremely rare insurance product, I dont remember the last time that I have seen one that paid us a straight percentage. The 'Usual and Customary' (U&C) is actually set by the insurance companies through a survey process. Once in a blue moon I have an out of network patient where we collect U&C and its quite a bit better than any of our contracted rates. Its the penalty an insurer has to pay for being dicks.

Now it is true that for the U&C rate setting, it does matter what providers in a particular area charge. So it is in everyones interest to set their charges above the highest insurance contract in an effort to keep that regional rate at a good level.

And self-pay? Believe it or not, they're expected to pay that "usual and customary" rate, with some relatively minor discounts offered for prompt pay, etc. The latter is driven by car insurance regs: insurers didn't want to pay one price for body work while someone else walking in and paying out of pocket pays a rate a fraction of that.

The lowest price you can charge is set by the government. The government doesn't want us to offer cash prices that are below the medicare allowable. Do away with that CMS regulation and providers would be free to offer services at a price they see fit.

 

[PeterNSteinmetz]

I have sometimes wondered what healthcare insurance would look like in a truly free market today.

Perhaps one would actually start buying it for a child prior to conception, when there is the big random event of recombination still to occur. After that you can know a lot more these days about genetic risks, etc. Then, like term health insurance, the company is on the hook for certain benefits for specific events and limits, as long as the premiums are paid. Seems like it would put a lot of the economic incentives in the right place.

 

[weilke]

I have sometimes wondered what healthcare insurance would look like in a truly free market today.

Perhaps one would actually start buying it for a child prior to conception, when there is the big random event of recombination still to occur. After that you can know a lot more these days about genetic risks, etc. Then, like term health insurance, the company is on the hook for certain benefits for specific events and limits, as long as the premiums are paid. Seems like it would put a lot of the economic incentives in the right place.

I dont know. There is no 'free' insurance market in the US, they are all regulated at the state level to some extent. Most of that deals with things like required reserves, but other than that, much of it is just a requirement that the insurers filed their policy form and pay what they promised to pay.

 

[TCABM]

I'd take it a step further, and suggest that "capitalism" has changed meaning to fill a void for an opposite to socialism.

I don’t disagree with that nor with the statement around no pure models. The brilliance of Marx’s writings were to combine political, economic, and social theories into one or two tidy little words.

Based on what I’ve seen of your responses, it would be interesting and fun to have an in-depth discussion around some of the finer points across all the theories that commonly get missed. Alas, neither this thread nor POA is appropriate for that discussion though.

 

[Palmpilot]

Amazingly not locked yet. And so far as I can see, has nothing to do with aviation.

Except for politics and religion, with are specifically prohibited, the Rules of Conduct state that "Off Topic (OT) threads are not prohibited, but should be posted within reason." I guess this thread is considered reasonable so far.

 

[CaptainXap]

As someone who lived most of their life in the UK, and who is now living in the US, here's my perspective:

For most of my life, I never had to pay directly for any healthcare, and prescription drugs were very cheap. There is no charge for any treatment on the NHS, and a flat charge for prescriptions, which was less than 10GBP when I left. You get it for free if you're a child, or elderly, or low income, or unemployed etc. Even if you don't qualify for free prescriptions you can get a a card that will pay for unlimited prescriptions for a year for not much over 100GBP. Things get a bit more complicated with dental and eye treatment, but there are free NHS options for them as well.

This works fairly well so long as the NHS is being well-funded, but unfortunately that depends rather on which political party is in power. During the Blair/Brown years it was very well funded, and waiting lists for operations etc were short. However once the Conservatives got in power they put the whole country into austerity following the financial crisis, and have been mercilessly reducing funding and closing hospitals ever since. What this means practically now is that waiting lists are long - and due to things getting closed down there are areas of the country which just don't offer some specialist services. It's very difficult to get mental health services, and god help you if you are trans - a combination of funding cuts and a rabidly transphobic media mean that you may have to wait years to even be seen by a specialist.

You can still get private health insurance in the UK, at a bunch of different levels. The more expensive ones will get you treated in a private hospital with your own room, as opposed to the wards that you'll find in most NHS hospitals. There are also insurance plans that will get you private treatment if the waitlist for your treatment is over a certain level. A couple of companies I worked at gave their workers private health insurance, but I never really used it - I was so used to the NHS I didn't really understand what that extra insurance would give me.

Coming to the US, I found the insurance bewildering, and found it very difficult to get accurate information in order to make the right choice of plan. I found this again when changing job - trying to get a straight answer on whether my PCP was in-network was impossible - I got completely difference answers depending on whom I spoke to. The thing I like about my US health insurance is the ease of getting the treatment you want. At the NHS your GP was the gatekeeper to all NHS treatments so you'd have to persuade them that you needed it. Over here it's a lot more straightforward.

Paymentwise, my employer and I pay around $24,000 a year for my family's insurance, and I have a $500 deductable, and all prescriptions seem to be between $10 and $40 depending on how exotic they are. So total costs for my family's care (most of which my employer pays) probably comes in between $26,000 and $30,000. I think it's notable that that's probably more than the entire amount of tax I paid for everything for most of when I was living in the UK.

I would say the big advantage the NHS has is its efficiency. It's the largest employer in the UK, and as it negotiates for basically the entire country with pharmaceutical companies, it tends to get very good prices on drugs*. I'm convinced that there are also enormous efficiency benefits from not having to chase down who is going to pay for every little thing, and also from not having to itemize every little thing. I was astonished by the amount of paperwork generated when my wife fractured her ankle. I think another point to make is that because doctor's appointments are free, the cost of an appointment does not put people off from getting something looked at early, rather than waiting until they have no choice.

* - one of the reasons the Conservatives are unhappy with the NHS and keep privatising as much of it as they can - it reduces the profits of the companies they hold stock and board positions on.

I think given the choice, I would probably go for a reasonably well-funded NHS-style system, although I would probably get a bit of a top-up insurance on top of that.

 

[NHWannabe]

Everyone still dies in the end. It is end of life stuff that takes medical costs exponential. Both of my parents were very healthy until the last 5 years of their lives. Both had numerous events in their last years that drove multi-day hospital stays, rehab, in-home nursing, etc.

For the most part yes end of life is highest cost but that continues to change as obesity increases and more and more chronic conditions need to be managed.
https://www.cdc.gov/chronicdisease/about/costs/index.htm

 

[David Megginson]

I think given the choice, I would probably go for a reasonably well-funded NHS-style system, although I would probably get a bit of a top-up insurance on top of that.

That might be a better path for the U.S. than a Canadian-style system. Provide a universal foundation that everyone can rely one, whether employed or unemployed, but that is very basic and might involve waits for things like hip surgery; then give Americans (or their employers) the option to buy private insurance on top of that that will give them shorter waits for elective surgery, access to private clinics, more bells and whistles, etc. (which would be a fraction of the cost of full health insurance, because it wouldn't have to cover expensive surgery, etc).

That still leaves a big role for the U.S. private insurers — who are too rich and politically powerful to go away without a scorched-earth battle — but takes away the fear of being bankrupted by unexpected medical bills when you lose your job, finish school, etc. Canada doesn't allow an alternative private healthcare system, but the UK and most other countries do, and it would be a better fit with the U.S. preference that you should be able to buy better care if you're better off financially. The downside is that if the rich and middle classes aren't using the basic system, governments will keep cutting it (as @CaptainXap mentions for the UK).

 

[Chip Sylverne]

This ^^^^^^

I went through this with several elderly relatives. The first was in a very nice assisted living place and he kept having issues where they would call the ambulance. He would end up spending 3 days in the hospital being prodded and poked. The head nurse came to me and asked why he kept going to the hospital, I told her because your people keep calling the ambulance for him. She said, well, if you're ok with it, I'll put a stop to that. We did, he was much happier, we ended up having to get him and aide so he could stay in the non-skilled environment. He lived another couple months relatively happy and at peace.

I still see friends doing surgeries on 85 year old very demented parents, it make me feel bad. Do your living wills people, get a health proxy whom you trust and talk over what you want done if you can't make the decisions yourself. I could save you lots of pain at the end.

Many people in their 50's, 60's even early 70's will profess and proclaim how they "don't want to be kept alive by artificial means and "I'll sign any living will, DNR etc. you put in front of me.." Now comes 85 or 90, and those same folks looking at the Great Maw of death, and suddenly they are willing to spend every last nickel of everybody else's money for that last 30 seconds of life, regardless of the quality thereof. It's rare the families that are going to intervene. Quite the opposite.

 

[NHWannabe]

I’m glad to hear some offices can answer the question.

But this does illustrate my point about many of the issues here being driven by 3rd party payment rather than direct cash payment for most routine things. This does not allow a market and competition to develop and function. And the preference for employer provided health insurance is largely driven by the tax treatment as a pre-tax benefit as well as preferential treatment of HMOs.

What is the preferential treatment HMO's receive?

 

[PeterNSteinmetz]

What is the preferential treatment HMO's receive?

It looks like most of the preferences were put in place back in the 70s when the Federal government was giving out funds to establish them - https://www.cchfreedom.org/cchf.php/171

Also they are apparently exempt from lawsuits for denial of coverage - “In 1974, buyer monopolization was strengthened during the Nixon Administration after the Employee Retirement Income Security Act exempted employee health benefit plans offered by large employers (e.g., HMOs) from state regulations and lawsuits (e.g., brought by people denied coverage).”

From https://www.intellectualtakeout.org/blog/how-government-regulations-made-healthcare-so-expensive/

That a rather large market advantage.

I remember this time when HMOs were offered as this big new alternative to the regular insurance.

It is a very heavily regulated market.

 

[NHWannabe]

I think to some extent driven by the way it was 60 years ago when the Blues were set up. Back then there wasn’t a lot of expensive stuff that could be done for most people. So the insurance said “we will pay for everything to be done” and we could afford that on average as a society.

Nowadays there are a lot more expensive things which can be done at the end of life. And since the average person makes perhaps $2M over the course of their working life, clearly we cannot on average be paying $1M in end of life care.

There were no policies in the 60's that paid for everything even into the 70's and even early 80's traditional indemnity plans were the norm. Those plans had no first dollar coverage and you had to meet your deductible before any coinsurance payment from the insurer kicked in. Those plans forced people to make decisions like maybe little Johnny just needs to rest and take some aspirin for that fever and doesn't need to be seen by the doctor today. The advent of HMO's caused people to lose sight of how much an actual doctors appointment cost and the craziness started

 

[PeterNSteinmetz]

There were no policies in the 60's that paid for everything even into the 70's and even early 80's traditional indemnity plans were the norm. Those plans had no first dollar coverage and you had to meet your deductible before any coinsurance payment from the insurer kicked in. Those plans forced people to make decisions like maybe little Johnny just needs to rest and take some aspirin for that fever and doesn't need to be seen by the doctor today. The advent of HMO's caused people to lose sight of how much an actual doctors appointment cost and the craziness started

Right. I was referring to expenses on the other end, not the little things. In other words we spend everything necessary to keep you alive after you’ve met your deductible. The idea of no upper limit on expensive procedures.

 

[Chip Sylverne]

Sure, the NHS might be efficient, but our US hospitals have marble lobbies, waterfalls in the atrium, birthing suites, gourmet chefs and advertise on TV for your business.

 

[kyleb]

... Back then there wasn’t a lot of expensive stuff that could be done for most people...

And this is the problem and the opportunity. Eisenhower had high blood pressure and multiple heart attacks, but there was darned little anyone could do about his problems through the 40's, 50's, and 60's (he died in 1969), regardless of his relative stature in the world. Five years after his passing, he would have been a bypass candidate. Today, between stents, and improved med's and surgery techniques, his heart issues could have been substantially mitigated at a 6 or 7 figure cost.

But back in his day, his treatment costs were pretty low given that the treatment was to put him in a inexpensive rehab facility until either he died or recovered, then send him out the door with some nitroglycerin tablets.

 

[Lachlan]

Move!

Some are. In NYC, getting your driver's license renewed was a whole day affair . In ND and WV I can go by the DMV on the way to work and pick up some tags in 25min out the door.

In June my wife and I both went to the DMV to get our NY state driver licenses renewed and upgraded to RealID compliance. We were in and out in less than 15 minutes, both with new IDs. Granted, we live in the middle of nowhere, but the people working at the DMV were kind, professional, humorous, and pleasant. I guess you reap what you sow sometimes.

 

[PaulS]

Many people in their 50's, 60's even early 70's will profess and proclaim how they "don't want to be kept alive by artificial means and "I'll sign any living will, DNR etc. you put in front of me.." Now comes 85 or 90, and those same folks looking at the Great Maw of death, and suddenly they are willing to spend every last nickel of everybody else's money for that last 30 seconds of life, regardless of the quality thereof. It's rare the families that are going to intervene. Quite the opposite.

Not my experience Chip, but I'm sure there are people like that.

 

[wilkersk]

Man, and I complain about paying $25.25 a month for Tricare.

Wait'll you hit 65, you'll dream about those Tricare premiums. If you were conscientious about saving for retirement, and want to maintain a comfortable life style, you can count on paying quite a bit more in Medicare Part B premiums, just so you can keep Tricare. Or, at least that's the way I understand it as of now. I'm about 3 years out from claiming Social Security and Medicare, and between medical premiums and property taxes, my Navy retired pay will be spent before I get it. Its a good thing I saved for retirement, or Uncle Jimmy wouldn't have anything left to tax.

 

[wilkersk]

Many people in their 50's, 60's even early 70's will profess and proclaim how they "don't want to be kept alive by artificial means and "I'll sign any living will, DNR etc. you put in front of me.." Now comes 85 or 90, and those same folks looking at the Great Maw of death, and suddenly they are willing to spend every last nickel of everybody else's money for that last 30 seconds of life, regardless of the quality thereof. It's rare the families that are going to intervene. Quite the opposite.

After the great "financial crisis", I went back to school to work in healthcare. I worked for 15 years in the ER and OR of a level I trauma center. In my experience, it isn't the 85, 90 year olds wanting to spend that last nickle. Its their family members insisting that "Aunty Em surely would not the plug to be pulled."

Make sure you have a medical directive. And, educate your next-of-kin about your wishes!

 

[kyleb]

In my experience, it isn't the 85, 90 year olds wanting to spend that last nickle. Its their family members insisting that "Aunty Em surely would not the plug to be pulled."

As someone who's been the decider or a huge influencer in several of those situations, I can tell you that it is a bear of a decision, and you'll never know if you made the right one. Living wills and "no heroic measures" leave a huge grey area.

 

[Velocity173]

Wait'll you hit 65, you'll dream about those Tricare premiums. If you were conscientious about saving for retirement, and want to maintain a comfortable life style, you can count on paying quite a bit more in Medicare Part B premiums, just so you can keep Tricare. Or, at least that's the way I understand it as of now. I'm about 3 years out from claiming Social Security and Medicare, and between medical premiums and property taxes, my Navy retired pay will be spent before I get it. Its a good thing I saved for retirement, or Uncle Jimmy wouldn't have anything left to tax.

Saving for retirement? With two planes and my latest money pit (Delorean), I’ll be broke long before retirement.

 

[Everskyward]

The best 'bang for the buck' we have in medicine would be to train more geriatricians and palliative care specialists. The 'problem' is often to get families to accept the reality of the situation and to move someone to geriatric or palliative care. The hospital/ER/ICU/SNF/rehab is a machine and once you feed someone in, the machine will do its thing. Of course it's not logical to do the tenth abdominal CT in as many weeks on a dying patient with abdominal pain. Scan #10 will have as little influence on the patients well-being as did #7 and #5. But once the private ambulance from the nursing home wheels the victim patient through the ER door, the machine will do it's thing. All of us who are involved in the farce care know its insane and futile, but until the family calls an end to it, it will continue.

I was glad when the hospitalist came into my mom's room and gave me the "talk". She had aspiration pneumonia, was 97, with late onset Alzheimers. He asked me if I could see that there would be no good outcome. I agreed and consented to hospice care.

 

[EdFred]

I've left my medical deicisions up to someone I am NOT related to with various instructions which basically says pull the plug for everything and there's a specific reason I selected the person I did.

Actually none of my family members have any decision making ability in any of my "should I become mentally incapacitated" decisions. Because decisions like that should NOT be based on emotion or left up to someone with an emotional investment. Emotional decisions are always wrong.

 

[Chip Sylverne]

Not my experience Chip, but I'm sure there are people like that.

I've been to visit my in-laws at their retirement community and heard the old gray hairs brag about how much their last procedure cost. Don't kid y'self, there are no atheists in foxholes.

 

[Llewtrah381]

Wait'll you hit 65, you'll dream about those Tricare premiums. If you were conscientious about saving for retirement, and want to maintain a comfortable life style, you can count on paying quite a bit more in Medicare Part B premiums, just so you can keep Tricare. Or, at least that's the way I understand it as of now. I'm about 3 years out from claiming Social Security and Medicare, and between medical premiums and property taxes, my Navy retired pay will be spent before I get it. Its a good thing I saved for retirement, or Uncle Jimmy wouldn't have anything left to tax.

I highly recommend you speak with a TRICARE health benefits advisor. You’d have to pay Part B to get the Medicare benefits you bought into regardless of whether or not you’re eligible for TRICARE for Life. My wife is on TfL and pays $445/qtr for Part B - and that’s it. NO other payment for healthcare enrollment. And, of course, that includes TRICARE pharmacy benefits. She has seen several specialists so far, admittedly for relatively minor issues, with zero copay.

Ask any of your non-TRICARE-eligible friends if they think that’s a good deal. And don’t forget: Medicare doesn’t cover you if you travel overseas - TfL does. Go learn more about your benefits - It’s a shockingly good deal that you earned through serving our country.

 

[weilke]

For the most part yes end of life is highest cost but that continues to change as obesity increases and more and more chronic conditions need to be managed.
https://www.cdc.gov/chronicdisease/about/costs/index.htm

That statement about '60% of healthcare expenses in the last 6 months of life' is somewhat correct when looking at some individual accounts, it doesn't apply to healthcare cost as a whole.
I am always fascinated by the disparity by the difference in healthcare utilization between different individuals. We have 30 year olds with dozens of ER visits and hospitalizations every year, and then we have 90 year olds whose last hospitalization was for their appendix in the 50s. Some of those high utilizers suffer from a defined chronic condition, others suffer the consequences of bad choices but for others it is an almost compulsive behavior pattern and there is never anything really wrong with them.

 

[Clip4]

I own a medical facility. ACA destroyed the field. Schedule B providers (non-hospitals) are being purchased by the hospital corporations as our reimbursements are down 10 fold (yes, a vascular sono in the 90's was 2 grand now reimburses about $129). Schedule A is protected (of course) and the insurance companies raise rates automatically on employers 10% a year to cover their increase in unnecessary layers of employees.



Not so fast, I own a medical facility and can tell you ... Tricare requires authorizations which quite often are NOT approved. See how things go when you need something expensive that the military doesn't have a specialist for, or they're too full to get to you (like the VA waiting lists).



This is true ... other than lower malpractice insurance rates there was no effect. It did nothing to the Schedule A charges. Schedule B providers (docs, clinics all non-hospital) should be out of business within 5 years as those contracted rates were utterly decimated. Most physicians are now hospital owned. All physicians here complain as they cannot make any statements regarding patient care to the media ... gotta go with the narrative ...

If a cost of a any medical procedure is reduced 93% and the procedure is still readily available to patients with the same quality, I hope ruin continues through the industry.

 

[Huckster79]

Health “insurance” is insane. It’s an industry that we’ve created that adds ZERO value to the healthcare process- none- just added expense. Part of being smart is knowing when someone else has a good idea… and there’s so many models that work better than our for less money per capita but we’re stubborn and dismiss them without really thinking it through. It’s insane that medical bills still are the leading cause of bankruptcy here -even for insured people and has been for a very very long time….

 

[Sluggo63]

I read this article years ago when it came out, and I thought it was a good comparison of various healthcare systems around the world (Britain, Canada, Singapore, Germany, Switzerland, France, Australia and the US). They use an NCAA bracket system to whittle down the various systems until they come up with the winner.

Spoiler

Switzerland

And they give you an option to "play" by picking your winner based on the pros and cons of each.

https://www.nytimes.com/interactive/2017/09/18/upshot/best-health-care-system-country-bracket.html

 

[Bell206]

If a cost reimbursement of a any medical procedure is reduced 93% and the procedure is still readily available to patients with the same quality, I hope ruin continues through the industry.

FTFY: I guess you missed the part that the 93% reduction was in the reimbursement to the provider not the cost of the procedure. It was an effective way to put smaller providers out of business or forced them to join a hospital group. The ACA simply is the foundation to a single payer system that digitizes all medical records, expands the eligibility for free insurance, and provides a small group of income earners hugely subsidized premium/deductible costs. All at the cost to everyone not covered under the ACA to the tune of 500% to 2500+% in premium increases since 2014. Mine alone went up over 400% in 3 years and required me to completely re-due my retirement financials. There was a reason ACA was passed sight unseen with multiple 11th hour deals being made. Not to mention medical privacy was thrown out the door in the name of ACA.

 

[wsuffa]

FTFY: I guess you missed the part that the 93% reduction was in the reimbursement to the provider not the cost of the procedure. It was an effective way to put smaller providers out of business or forced them to join a hospital group. The ACA simply is the foundation to a single payer system that digitizes all medical records, expands the eligibility for free insurance, and provides a small group of income earners hugely subsidized premium/deductible costs. All at the cost to everyone not covered under the ACA to the tune of 500% to 2500+% in premium increases since 2014. Mine alone went up over 400% in 3 years and required me to completely re-due my retirement financials. There was a reason ACA was passed sight unseen with multiple 11th hour deals being made. Not to mention medical privacy was thrown out the door in the name of ACA.

The whisper in DC at the time was that the ACA was designed to fail so it could/would be replaced by government single payer.

 

[David Megginson]

The whisper in DC at the time was that the ACA was designed to fail so it could/would be replaced by government single payer.

If it had been designed to fail (which I doubt — see, as always, Hanlon's Razor), to goal would more likely have been to kill the idea of universal healthcare altogether, especially considering how many senators and congressional reps the health-insurance industry has in its pocket from both parties.

 

[wsuffa]

If it had been designed to fail (which I doubt — see, as always, Hanlon's Razor), to goal would more likely have been to kill the idea of universal healthcare altogether, especially considering how many senators and congressional reps the health-insurance industry has in its pocket from both parties.

Ever heard of the frog in the pot of water being slowly brought to boil?

 

[David Megginson]

I read this article years ago when it came out, and I thought it was a good comparison of various healthcare systems around the world (Britain, Canada, Singapore, Germany, Switzerland, France, Australia and the US). They use an NCAA bracket system to whittle down the various systems until they come up with the winner.

Spoiler

Switzerland

And they give you an option to "play" by picking your winner based on the pros and cons of each.

https://www.nytimes.com/interactive/2017/09/18/upshot/best-health-care-system-country-bracket.html

The "best" healthcare system is the one that pays your bill when you have a major medical expense, just like during the Second World War, the "best" airplane, tank, ship, etc was the one that was nearby when you needed it.

 

[David Megginson]

Ever heard of the frog in the pot of water being slowly brought to boil?

I've worked as a consultant for too many government departments in Canada and the U.S. to believe they're capable of pulling off a conspiracy (of any kind) — they can barely agree on what kind of sandwiches to order for a lunch meeting.

For a lot of Americans, the failures of the ACA (where it didn't work) left a bad feeling about universal healthcare, so in that case, the hypothetical conspiracy would be to kill off the desire for any kind of universal healthcare by introducing a highly-flawed one.

 

[weilke]

The "best" healthcare system is the one that pays your bill when you have a major medical expense, just like during the Second World War, the "best" airplane, tank, ship, etc was the one that was nearby when you needed it.

Which is what the US system does for most consumers. 'Griping about health insurance' is our national pastime.

 

[wsuffa]

I've worked as a consultant for too many government departments in Canada and the U.S. to believe they're capable of pulling off a conspiracy (of any kind) — they can barely agree on what kind of sandwiches to order for a lunch meeting.

For a lot of Americans, the failures of the ACA (where it didn't work) left a bad feeling about universal healthcare, so in that case, the hypothetical conspiracy would be to kill off the desire for any kind of universal healthcare by introducing a highly-flawed one.

This really isn't about "a lot of Americans" - the division between "we want it" and "we don't" isn't that great. It's about politics and money.

Let's work it through more critical, shall we?

Who benefits?
The big health-care systems that can reduce overhead and squeeze pay to people as they get bigger?
The government contractors and insurance companies that will handle/manage the payment systems for a fee (like is done with CMS now)?
The insurance companies that can offload the less profitable patients and sell supplemental insurance?
The politicians that can claim that they "now covered everyone" or "brought the big evil corporations to heel"?
Pharma that depends on FDA/NIH to approve treatments?
Those with the ability to lobby and politicize things?

How about the losers?
The patients, who will be shunted to NPs and get far less doctor time?
The patients who will be handed script after script instead of getting a full and good diagnosis?
Pharma that has seen the likes of Martin Skreli and jacked up med prices?
The local doctor that's already squeezed by reimbursements (Medicare being particularly low)?
What about the docs that won't take medicare now as the reimbursement is too low?
Patients, who will see longer wait times?
Docs and local pharmacies that will be squeezed on price and availability of drugs as production is further crimped?
Folks who might benefit from new technologies?

Rule 1: government doesn't have the capability to handle payments itself. That will be outsourced.
Rule 2: this will not be "universal health care" as in "everyone can see anyone" - it will be government single payer, where a Fed entity will provide payment, but not service.
Rule 3: the deck chairs will be rearranged, but corporations and politicians will still benefit. The little guy won't.

I've worked for/with/in plenty of government agencies myself. There are plenty of ways to "beat the rules", and the rules rarely benefit the little guy. (and to be clear, 'deregulation' of stuff also causes similar disruptions, for example the deregulation of airlines)

This is why I say the entire system needs to be burned to the ground and built up anew. I am realistic enough to know that it's not going to happen.

I'll point to the Covid vaccine right now. A lot of folks are not getting vaccinated (partly a trust issue), and there are doses going to waste. Yet the FDA and NIH are not generally authorizing a third booster shot that manufacturers say are needed (Pfizer being the leading group) and other countries are already being dispensed (noted that they have approved it - only Friday - for a limited group of people). There's evidence that the original shots lose potency over time, and Delta (among others) is much more virulent. The FDA is chartered to provide treatments that are "safe and effective" - the vaccines have proved safe. So in a pandemic, why not lean more to the "safe" side even if the "effective" side is shown to be the case although not as deeply as the "safe side". It's not for money - the Feds have already bought the vaccines (and are sending it to other countries). There must be some other reason for the reluctance. But it's government and politics so we may never know.

 

[steingar]

I have sometimes wondered what healthcare insurance would look like in a truly free market today.

It simply can't. The only way it could is if hospitals were able to turn away those unable to pay. Don't have insurance, get into a big car crash? "That'll be ten thousand up front"(I'm assuming medical care costs decline in such a market). "Can't pay? Please go suffer out in the street or in your residence".

In that case we'd really see what the market would bear. That is the case in a number of so-called "****hole countries", and routine medical care is quite affordable. Care for something like cancer is less so, and of course lots of procedures that are routine here aren't found there.