So, admittedly not knowing how that all works - what’s the method to the madness they use there and how does their system differ from ours?
[NA] Health Insurance. US vs. Elsewhere
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Chip Sylverne
Final Approach
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Quit with the negative waves, man.
Texas passed limitation on medical liability claims as well as a brief statute of limitations on filing suit several years ago. Has made not a whit of difference on slowing the rise in cost. Malpractice as a driver is a canard.
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3G
Most people who think they can, can’t.
Much if what you’ve been writing circulates around a broader topic known as public goods and services when ideologies and/or philosophies are stripped from them. Your example of Tricare has nothing to do with public goods or services. Tricare is a health benefits plan exclusive to those eligible for it as defined in public law, which can be changed by Congress at any time. In fact, not even all military members are eligible for Tricare coverage, much less coverage for their dependents.
This is coming from a dude with multiple advanced degrees in political science and also is a retired .mil working in the private sector with the option to choose between employer sponsored plans, FEHB, and Tricare.
EdFred
Taxi to Parking
It's not the only contributor.
If you spend some time on it, you will find that it's extremely difficult to make the case that size matters. Unless you are a country like Qatar, which is insanely wealthy on a per capita basis due to gas wealth and very few people, it doesn't much matter how big the country is. But if you want to try and make the case, I'm reading...
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Llewtrah
First - I shouldn’t bring a knife to a gunfight
The first to admit I’m not a poli sci guy. I would say, despite the difficulty defining “socialism”, that the US military meets most reasonable definitions that I’ve seen, most particularly “the government controls the means of production”, even if it is providing a public good.
I would also say, almost without regard for a “true” definition, that (the socialist military’s healthcare system) TRICARE, in its implementation and operation, sure seems to be virtually identical to what most people - including those in the systems - call “socialized medicine”. Even in those countries they, too, have the option of choosing between the state system and private (in the cases in Europe I worked with).
Some comparison as requested in the first post:
- In Canada, all non specialized stuff is covered by taxes. Governments spent about 23% of taxes on healthcare. Dentist, optometrist etc is not included. There are benefit plans out there, that cost about 2k CAD/year to get that covered. Source: www150.statcan.gc.ca/n1/daily-quotidien/201127/dq201127a-eng.htm
- In Europe (let's say Belgium for example), a lot of the healthcare is covered, but it isn't free. You pay the full amount (which is always much cheaper than in the US or even Canada for specialized stuff), and you get roughly 95% back from the government. Long hospital stays etc are not covered. Extra private insurance costs a few hundred dollars / year. About 10 of the GDP is spent on health care, 45% GDP are the taxes, so that's roughly 20%.
Having experienced both the Canadian and European system, I would say the European system is superior. Less abuse, less inflated costs. I have not experienced the US system, but must say that what I hear about it, does not seem too appealing.
- In Canada, all non specialized stuff is covered by taxes. Governments spent about 23% of taxes on healthcare. Dentist, optometrist etc is not included. There are benefit plans out there, that cost about 2k CAD/year to get that covered. Source: www150.statcan.gc.ca/n1/daily-quotidien/201127/dq201127a-eng.htm
- In Europe (let's say Belgium for example), a lot of the healthcare is covered, but it isn't free. You pay the full amount (which is always much cheaper than in the US or even Canada for specialized stuff), and you get roughly 95% back from the government. Long hospital stays etc are not covered. Extra private insurance costs a few hundred dollars / year. About 10 of the GDP is spent on health care, 45% GDP are the taxes, so that's roughly 20%.
Having experienced both the Canadian and European system, I would say the European system is superior. Less abuse, less inflated costs. I have not experienced the US system, but must say that what I hear about it, does not seem too appealing.
Sluggo63
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Sluggo63
I've lived for a few years over in Germany, but I had private insurance (it was required by the Germans as part of my work visa). Talking to my German friends and also healthcare providers, the German system is very good for 90% of your needs. Good doctors and relatively short wait times. The private insurance was phenomenal. There was a clinic that took private insurance and pretty much every specialty was under one roof. My wife saw a doctor there and the doctor ordered a scan. In the US, it probably goes like this:
I'm a dual European/American citizen and am seriously thinking about retiring over there. Among the many reasons why, healthcare is up there. (@hindsight2020 if you want to PM me, it's not as drastic as a process as you might think). Even with the great public healthcare there, even if you wanted to get private insurance, you'd be paying pennies compared what it costs in the US. And I'm TRICARE eligible as well.
- GP wants wife to see specialist
- Wife makes appointment for specialist, can't be seen for a few weeks.
- Specialist orders CT scan, wife calls imaging place, makes appointment there, another week or so.
- Wife gets scan, waits to have it read.
- Go back to specialist.
I'm a dual European/American citizen and am seriously thinking about retiring over there. Among the many reasons why, healthcare is up there. (@hindsight2020 if you want to PM me, it's not as drastic as a process as you might think). Even with the great public healthcare there, even if you wanted to get private insurance, you'd be paying pennies compared what it costs in the US. And I'm TRICARE eligible as well.
David Megginson
Pattern Altitude
Thanks -- that's a new definition for me, and I'm always interested in learning points of view I haven't heard before. And your example about firefighting is bang on -- I've frequently used that myself.First, thank you for your service. You are welcome to the benefit.
Those are not socialism, other than maybe the Fire Department. We've largely shifted to thinking of that as a function of government, like the police.
So your suggestion is that whether something is "socialism" depends not on whether the government funds it, but on whether the population considers it a function of government. That would suggest that universal healthcare in other rich countries doesn't count as socialism, because over the past 50 years or so we've come to think of healthcare as a function of government (like policing, highways, parks, or firefighting), but it would count as socialism in the U.S., because you haven't come to think of healthcare that way. Is that an accurate readback?
David Megginson
Pattern Altitude
As a Canadian, I agree -- I find the system in the UK or Germany simpler than the system in Canada.
What's unique about Canada's system is that we don't allow parallel private services. If a service is publicly funded, no one is allowed to offer a private alternative. I didn't realise how unusual that is until I learned more about healthcare systems in other countries.
The upside is that rich people are mostly stuck with same system as poorer people, so they have a stake in making it work (unlike, say, the UK, where the rich pay to jump the queue and the NHS languishes with cut after cut) -- I write "mostly" because rich Canadians can still fly to India, the UK, U.S., etc for specific non-emergency private procedures.
The downside is the same -- there's no way to jump the queue if you have to wait 6 months for an elective procedure like hip surgery.
I'm not sure why Canada is different in that regard, except for maybe an overdeveloped national sense of "fairness" and "not cutting in line."
David Megginson
Pattern Altitude
May I also praise everyone for how civil this discussion has been? Most of the posts have been respectful and constructive, even if we don't all agree. I wish more online forums were like that.
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3G
Healthcare systems (generically) are independent of political/governmental or economic systems. Healthcare systems can he designed/implemented in any of them.
Same with public goods and services. The gold standard is a military; it provides a common good that is most efficiently delivered by a government, regardless of why particular ideological bent is adopted by a .gov. Private Military Companies/Corps (PMCs) are generally not a public good/service, but may be contracted by a .gov to provide certain services as a public good.
While not particularly challenging to understand, socialism has ideological/politcal and fluidly sociological definitions where capitalism is purely an economic system.
Not at all.
One could be a cynic and say:
(in Marxist theory) a transitional social state between the overthrow of capitalism and the realization of Communism.
I use it in the more classical meaning, that the means of production is controlled by society as a whole. That "as a whole" is generally "via government".
As I said Fire Departments can easily be classified as socialist. They could be done another way. Not sure it could be done better nowadays as competing companies, but hey, it's possible.
I'm lost how the military or police could run as for profit businesses competing with other businesses. They are extensions of the government, not how they are funding, but how they operate, what they do. I would label neither socialism, but rather an innate part of government.
Healthcare could obviously be done in either mode as it is in multiple countries. Many countries do both, and in different ways. The UK has both socialist healthcare and private / capitalistic healthcare. So does the US; Medicare and Medicaid vs private healthcare.
Same for education. It can be done either way. It was done privately in the US until the early 20th century. Then private schools were prohibited. Now we have a mix.
Maybe I don't understand the Canadian ATC, but I would say it is not capitalism. It is outsourced from the government. There are not multiple companies competing for your flightplan. You are not picking which company handles your radar services for your arrival. The government not only "owns" the airspace, but makes the rules on its usage. So, ATC is in some ways like the police. But, maybe it is socialism as we have decided to have society own that via the government. Not sure how it would run with competing businesses.
Socialism is where we have decided (or some special people decided for us) that we don't want competition. We want society / government to run it with little to no competition allowed.
Capitalism does not mean zero rules, a free for all. It means companies / individuals are competing against each other for your business. Government is there to set the guard rails. Other groups set the guard rails too. Unions for example. Or insurance companies, as we see they often limit us in aviation more than the FAA.
Wayne
Chip Sylverne
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Quit with the negative waves, man.
Where I went to school it was taught that socialism was public ownership of means of production, exchange and distributionor administration. That doesn't necessarily preclude competition, nor does it necessarily preclude private or contract management of publicly owned enterprise, assets or entities.
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Drake the Outlaw
I think it is the edge cases which separate the US. Lots of places, you just get old and die. Here, if you are of reasonable means, we endeavor to keep you alive forever. And that turns into a money pit.
As far as obesity goes, it isn't a result of the medical system - it is a lifestyle choice that insurance and medical care can't fix. Oh, and it drives mortality and high expenses, but the cause->effect is fat->expensive, not expensive->fat.
Ted
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iFlyNothing
I'm not sure why Canada is different in that regard, except for maybe an overdeveloped national sense of "fairness" and "not cutting in line."
David Megginson
Pattern Altitude
Police forces in their modern civilian form didn't exist before Robert Peel's London Metropolitan Police (nicknamed "Bobbies" after him) in the early 19th century. Before that, it was a haphazard mixture of private services you could pay to arrest someone, watchmen, volunteers, and the army itself (which you could call in when things got out of control). After Britain's Peterloo massacre (where cavalry charged down unarmed protesters), they realised they needed a full-time, professional, government-run, non-military body to enforce law and public order, so socialised policing was a conscious decision two centuries ago.
After the American Revolution, the U.S. was reluctant to have a professional standing army like European powers did; they relied mainly on state militias, who were just badly-armed, badly-trained, and badly-supplied farmers. During the opening years of the War of 1812, the militias' embarassing defeats against tiny, professional (and battle-hardened) numbers of British troops — and the deaths of many more militia due to lack of basics like food, blankets, and winter clothing — convinced the U.S. that it was necessary to fund a large, permanent, "socialised" army of full-time professional soldiers, and by the end of the war, Americans were doing much better against British troops. The U.S. navy, which had been professional from the start, did well against the Royal Navy, and that probably helped convince Congress to take on the huge spending commitment of a standing army as well.
None of this is natural — every one is a consequence of a decision at some point in history that the government could do something better than private individuals, and that it was worth taxing and spending more (a lot more, in the case of a standing navy and army) to make it happen.
NHWannabe
Line Up and Wait
If you work for a really large employer they likely self-insure so the premium you pay is based on historical claims experience of the company's demographic.
If your employer has a fully insured policy, insurance company takes the risk, then the insurer must spend 80 cents of every premium dollar on claims for small group policies and 85 cents of every premium dollar on claims for a large group policy. These are mandated by the Affordable Care Act.
https://www.healthcare.gov/health-care-law-protections/rate-review/
David Megginson
Pattern Altitude
The worst of both worlds is when you have a publicly-owned company competing against privately-owned ones, like happened during the post-WWII nationalisation craze in most rich countries, from the 1950s to the 1980s. It wasn't so bad in Canada as in Europe, but we still had Air Canada competing against private airlines, PetroCan competing against private gas stations, etc. Fortunately, those are all privatised now.
We might disagree where the ideal dividing line between public and private ownership is,. but we can all agree that public and private need to stay on their own sides of the line.
Chip Sylverne
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Quit with the negative waves, man.
Think of the utility space. There are both privately and publicly owned utilities, and, generally speaking, the publicly owned companies provide better service at lower cost to the consumer than the privately owned ones. Not really analogous to your airline example, but a valid illustration of how different industries can benefit from different structures.
And then came Enron...
It could be legitimately argued that deregulation of hospital ownership and the rise of private hospital networks is what first started health care costs spiraling.
NHWannabe
Line Up and Wait
The disgust with the current system is happening at a corporate level too. One of my current clients puts companies together into a medi-share style pool, then backs the entire pool with re-insurance. The idea is that if premiums are not consumed in the pool, an employer can roll their saved money into the next year. The savings seem to run at about 15% in general, just by removing the insurance carrier's profit/overhead. They call it "Captive Insurance" and it's pretty fascinating, but one heck of a complicated structure to meet regulatory burden.
One of the more amusing pieces about it that I like is when a company brings its claims history to join the pool, particularly sick employees can be exempted and sent on to blue cross or whomever, so the pools are for genuinely "surprise" expenses and ordinary age-related care, not chronic super-expensive things once they're known. They're skimming the cream off of the top. Clever folks.
My wife holds a UK passport. I'm eligible for NHS the second I set foot on UK soil with intent to emigrate. That's our backup plan if things here get much worse. I've made a LOT of my career decisions in the last 10 years around healthcare, and I hate the gravity it has on our lives.
So the pool is accepting the healthy patients and pushing the unhealthy to traditional insurance...otherwise known as adverse selection. ACA individual policies cost so much because those people are all high utilizers.
NHWannabe
Line Up and Wait
True but it was supposed to reduce our premiums...$2500 a year for the average family.
NHWannabe
Line Up and Wait
One of my former employees lives in Arnprior he has private insurance through our employer and he is able to jump the line because of his private insurance. His son hurt his knee playing football a few years ago and he was able to get rehab quicker because of the private payer. Like many countries with single payer it inadvertently creates a two-tiered system.
schmookeeg
En-Route
Yep. They found a way to poison the big carriers while taking the healthy population out. And everyone at the company still gets the "no denial for pre-existing conditions" game -- but the legacy carriers get a disproportionate share. Gonna get ugly if they become more popular.
Yeah, it doesn't work like that for someone under the public system. While ambulatory healthcare delivery is provided by the private sector, it is constrained by a system of budgets. Basically every PCP gets a budget of whatever cost he can incur that is based on whatever he spent in the last 3 years +/- a fudge factor. If he exceeds that budget, his personal income gets cut (regress). Compared with other european countries, availability of specialist services and advanced imaging is very good, but it may require prodding and selling your case to your PCP to get him to order a scan.
There are usually no wait times, if you need to see a PCP, you can see someone on short notice. But the visits are brief, because the government reimbursement for 'ziffer 1' which is a basic consultation is €4.66. So in order to pay for the overhead of running a primary care office, the provider has to see 10-15 patients per hour. So it tends to be very brief and focussed. You come with an ear ache, he is going to look at your ear, say 'yep, its inflamed, here is your script for amoxicilin, come back if its not better by next week' and he'll breeze out of the room. The documentation requirements are rudimentary, back when I trained, it was entirely appropriate to make a 1 line entry in the chart for such a visit. The upside of that is, that lets say you have high blood pressure and you notice your prressures are up, you can quickly see your PCP, he changes something and you move on. Where this gets difficult is if your medical problems are complex, often the PCPs will have to split a service into multiple visits. So today its your blood pressure, wednesday its your diabetes and next week we deal with that nagging headache....
I dont know how it is in other european countries, but private health insurance as a retiree in germany is excruciatingly expensive because it is price to cover the actual expenses at 2.3-3.5x the government rate. Private health insurance as a young person is basically a life insurance product. Your premiums are front-loaded and you build a financial reserve to subsidize the premiums in old age. If you moved to germany as a retiree (which you can as a citizen of any other EU country), you would not have that buffer and have to pay full fare.
Now here is the good news: If you came to germany with 'EU rights', you are not precluded from entering the government health insurance system. You are only excluded if you were eligible at one point and executed an opt-out. There is also a intergovernmental contract between germany and the US where under some circumstances your medicare and SSI eligibility would transfer (you would probably have to work for a few years).
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Snorting his way across the USA
The elimination of the insurance companies from the equation, for the most part. I think the government subsidizes health care somewhat but not in the sense that it is a payroll tax.
Clip4
Touchdown! Greaser!
Maybe you are just one of the families it didn’t reduce premiums for. For lower income employees the ACA limited what employers could charge and set a minimum standard for employer health insurance.
It also allowed 11.3 million people who previously did have health insurance to purchase it. Many of these people had preexisting conditions that prevented them from getting health insurance or couldn’t afford insurance due to age. The ACA put limits on age related premiums.
Another 15 million more people qualified for Medicaid.
Also $2500 a year for a family health insurance is dirt cheap these days. I pay 1.5x more than that for just myself as part of my retirement insurance and you pay less than a retired couple on a good Medigap plan.
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David Megginson
Pattern Altitude
Sort-of. Physiotherapy is not covered by OHIP at all in most cases, so there's no public queue to jump. Ditto for dentistry (outside of a hospital emergency) and psychotherapy. That's a social injustice that many Ontarians are pushing to fix, but it's not an automatic consequence of single-payer — OHIP used to cover physio when referred by a physician, and many other single-payer jurisdictions do cover dentistry. It's just a specific policy choice that the Ontario government made.
More generally, though, you're right that there will always be a two-tier system outside of whatever basic health insurance covers, whether that's OHIP or the mandatory minimum private coverage in the US. The goal is to move that line as far as we can, but it will never disappear. In Ontario, the poor get the same access to (e.g.) cardiac, cancer, or pre/post-natal care as the middle class and rich, but they don't get the same access to physiotherapy, psychotherapy, dentistry, etc etc.
Most Canadian full-time jobs come with supplemental Blue Cross (or similar) to cover these extras, but they're small policies, and usually capped at a few thousand/year in payouts.
Before my partner had a full-time job, I never bothered to buy one of these, because they're not really insurance in my opinion — insurance is to protect from charges that would be catastrophic, like a big hospital bill, not an alternative way to pay for an $80 physiotherapy session. But there are people for whom that $80 charge would be a big hit, and that's why I think OHIP should reinstate physio (and other) coverage.
David Megginson
Pattern Altitude
See my earlier post. Most rich governments subsidise healthcare to the tune of 6–8% of GDP per year according to the World Bank. The U.S. is already at the top end of that range (8.5% of GDP), but is the only rich country that doesn't manage to provide universal basic health coverage with it.
NHWannabe
Line Up and Wait
The "minimum" standard added all kinds of mandates which just like in Aviation add to overall costs. I wasn't promised a premium of $2500 I was promised a reduction of $2500. The costs to get the people in the individual market who didn't have coverage was astronomical and didn't change the cost it just shifted the cost from the individual to the taxpayer but only got those people crappy policies that were only slightly better than the catastrophic policies they already had at lower rates. It would have been cheaper to just wrote those people checks.
Clip4
Touchdown! Greaser!
That is an argument I hear all the time. The reality is when a person has a major health care event with crap or no insurance I get to pay for their health care when they can’t pay and go bankrupt. The cost is higher taxes and higher health care costs or both. Have a catastrophic event in September and you are quickly priced out of the insurance market and most are on their way to bankruptcy.
The mandate is gone and you can buy your catastrophic plan without penalty today, but with most things, you are getting what you pay for. The catastrophic plans work well if you need a few months insurance and are not the best option for most people. Because of the high deductible — so high that most healthy individuals will never reach it — these plans won’t cover all the regular health care costs that most people have.
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Neither does the crappy O-care plan that my employer switched me to after the new law passed. 2500/person , 12k oop for the family. This up from a $500 family deductible before the government improved things.
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Snorting his way across the USA
You touch on a couple of important points.
1. Military/police.
What company do you want controlling your police? I could see outsourcing police. Police are outsourced. They are called private security. But military? Do you want a private company defending your nation? We have private companies defending private companies, and defending nations that are not our own. They are called "security contractors." I have zero issue with Blackwater or their successors fighting the Taliban (that has never been their role, by the way.) But duking it out with China or North Korea? Mmm no. Not happening, and point 2. plays in to this.
2. Utilities
There is a concept here that says that really, super expensive capital projects intended to provide lifeline services to citizens of a country or a state, should be owned, or at least controlled by the government. Makes sense. Roads. Waterworks. Sewer works. Gas. Electricity. But some of these things are privatized, right? You can't sink a billion dollars in invested infrastructure if you have to operate in a competitive environment. Well you can, but not for vital services. There are private, investor owned utilities. They get, a guaranteed seven percent rate of return on invested capital in exchange for being allowed to operate in a non-competitive environment. It's not a bad arrangement. They are motivated to earn that profit and operate efficiently, as to where the public utilities, are only on the ball to the goodness of their heart, and their boards of directors.
Where do I stand on healthcare?
Either socialize it, or not. We take the in-between stance and nobody wins. Government utility? Fine. Private operation? Works for third world countries and many first world. But our system breeds corruption, greed and waste, where it is not necessary.
PeterNSteinmetz
Ejection Handle Pulled
Amazingly not locked yet. And so far as I can see, has nothing to do with aviation.
But in any case, I have looked into this a bit in the past. So far as I can tell it becomes extremely difficult if not impossible to really know what people are paying for healthcare in countries that run these expenses through government programs. There are just so many ways for an expense to be counted or not counted as part of healthcare expenses.
PeterNSteinmetz
Ejection Handle Pulled
And really those are not an “insurable” risk in the classic sense.
What is sold as healthcare “insurance” in this country is really a combination of true insurance for a risk combined with a pre-paid set of purchases and a buyer’s discount club.
A variety of reasons for that historically. Largely due to the premiums being pre-tax benefits which encourages bundling things to lower the tax burden, regulations explicitly encouraging healthcare maintenance organizations, and regulation of drugs.
I have never met a doctor that actually knew the true cost of most recommended treatments. They are billed at a very high rate and then negotiated down by the insurers to often 50% or less of the list price. It is a very distorted marketplace.
PeterNSteinmetz
Ejection Handle Pulled
This is a nice attempt to make costs more transparent. However the ranges are so broad as to be almost meaningless for practical work. Consider the example they give for knee replacement - $21k - $51k a factor of 250%.
And if you then try to use this information and ask what the provider will charge for something, you will almost always be met with blank stares.
There are a few hospitals where they actually do cash only business now. Interestingly the costs for procedures there are about 50% of what insurers are paying elsewhere. So that is probably not a bad estimate of what our third party payment system presently costs us.
schmookeeg
En-Route
Not every thread (particularly in Hangar Talk) needs an aviation tie-in, it just needs to remain civil and uncontentious (or possibly just unreported and unnoticed)
Clip4
Touchdown! Greaser!
When there are a high percentage of no pays it is difficult to calculate true cost. The system has 4 prices, a true cash price negotiated with the provider, an private insurance price negotiated with the private insurance companies with a the Medicare / Medicaid price mandated by the govt., and the dumb ass price for those who earn too much for Medicaid and without insurance or cash. Each has its own default calculation built in or a cost transfer between the groups for the dead beats.
Chip Sylverne
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Quit with the negative waves, man.
My wife just recently had a mammogram done. Being the smart shopper (tightwad) she is, she asked what she'd have to pay. The answer?
"5%".
"5% of what, like, in dollars?"
"Oh, I have no Idea. But you only have to pay 5%."
WTF.
Having said that, we are self-employed and have a Kaiser Permanente O'care plan from our state exchange. All in all, compared to the individual market plans available before the ACA, it's far more stable both in coverage and price.
"5%".
"5% of what, like, in dollars?"
"Oh, I have no Idea. But you only have to pay 5%."
WTF.
Having said that, we are self-employed and have a Kaiser Permanente O'care plan from our state exchange. All in all, compared to the individual market plans available before the ACA, it's far more stable both in coverage and price.
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