Petition to expand Medicare to be the Single Payer Healthcare System for the USA

[vertical_doug]

Do we have any forum members living in South Korea? In 2000, South Korea converted from a many insurer model to a single-payer model. We can see how they like living under the new system.

The empathy for other Matthew mentions above is really about social solidarity. Even if you don't need it now, people should realize how quickly their health can change. To not recognize this is extremely short sighted.

http://www.coopami.be/en/countries/c...otection03.pdf
Lessons from Korean on implementing Universal coverage.

Health Care Reform in South Korea: Success or Failure?
(above is link to NCBI article.

[jlyon]

As with most big Ideas I think the main fight will be about money.

Who will pay for a single payer system and in turn how much will be paid to Medical service providers.

Currently our tax rate on just Medicare is 1.65% of our wages plus that same amount from the employer. Everyone knows we are spending much more than this already.

If there is never a set price for each category of individual that fight will continue from everyone who could buy insurance on the open market for less than the necessary tax increase.

If you set one lifetime rate young people would balk at paying for old people. I you charged older people their true actuarial rates I bet 60% of them could not pay for more than a few years before becoming truly broke.

So is anyone working on a plan to make care cheap; not just more affordable?

Basic human needs are food clothing and shelter. Do we need Government plans to make sure everyone has those first? It seems most people have figured out how to acquire those items many times on the cheap for much lower quality than many of us would accept. So who gets to set the healthcare standards?

[vertical_doug]

Moving away from fee-for-service requires realigning the care delivery and payment incentives in the health care system. Transition from saying for "value over Volume" or "paying for performance" is often discussed in healthcare policy. Unnecessary or redundant treatments, defensive treatments (I dont want to get sued theory) etc etc.

If you recall, the republicans morphed this into the Obama death panels back in 2009.

My aunt (she is very sickly) look me in the eye and told me she will spend as much as possible to get one more second of life. We've discussed her medical bills and she has already spent multiples of what she earned in her lifetime and a good chunk of my lifetime earnings. She will happily consume all of mine, my childrens, yours and anyone elses.

How do you want to deal with these high volume users? At what point should the care change from extension of life to end of life comfort and care? (the death panels)

[Corso]

As with most big Ideas I think the main fight will be about money.

Who will pay for a single payer system and in turn how much will be paid to Medical service providers.

Exactly.

The Single payer becomes the Government. If they follow the Medicaid system, they choose how much to pay providers. My wife is in Elder Care. Facilities are closing because companies lose money on every Medicaid bed. Private pay is the way they stay in business. Unless the Gov gets into the elder care business, mom & dad will not have anywhere to go. Much like ACA in some states, if insurance co decide to leave, what’s the option?

Who will pay? I expect the wealthy and middle class, those under Gov assistance don’t pay taxes now, so they won’t be paying into the system. The wealthy will end up paying more I’m sure a sliding scale like tax rates will be involved. But the wealthy may choose Private facilities anyway, so they will pay into a system they may not use-balancing the scale (hopefully). The ones in the middle will, as always, bear the brunt of real life: pay and not have options they may need. Will Doctors be content when the Gov decides what they should be compensated?

Sort of related example: My kids went to a different town’s high school, it’s called “school of choice”- gives kids state-run options vs private school. The host school lost thousands on each kid, as the State (Gov) locked the $ rebate (from town to town) in like 1975 dollars. So for the host school, it cost $10,000 per year per Choice kid. Rebate is $4,500. Year after year, the number of choice kids gets smaller and smaller, as schools can’t keep taking a loss. Eventually the program will go away…

The Gov never appears to want to pay the going rate.

Anyone here from Canada? How’s it work up North?

I’ve read and heard negatives, but that could all be “fake news”. I trust folks here more.

[mbrtool]

I own a small (six employees) tool and die shop. We have Blue Cross Blue Shield PPO/HMO and we pay about $72K per year. Couldn't that money be switched over to a single payer?

Ray

[caleb]

There is no rational argument against single payer.

I would say that there's no compelling macroeconomic argument against single payer.

The strongest argument I see for continuing with our current system isn't really for medical care in the present, it's that by throwing mountains of cash at drugs, devices, and other research, we potentially accrue future benefits that we're not presently able to foresee - i.e. a cure for cancer, diabetes, alzheimer's, etcetera. Of course if those are the goals, we're doing a very inefficient job of pursuing them.

Even if we want to prioritize the sort of "moonshot" innovations, there's no reason research can't be decoupled nearly entirely from consumer healthcare through a system of government research funding.

The rational reason for maintaining the status quo, as I understand it, is entirely political. Imagine turning healthcare into something similar to a public utility in which providers had a mandate to provide a standard menu of options at the lowest possible cost. I have never heard of anyone, of any party or economic school, argue that such a move wouldn't be good for the economy as a whole over the long haul. Plenty of people have ideological aversions to it, but that's not the same as an economic analysis. The problem with a transition to single payer is that the average citizen would see some benefit, but there would be millions of individuals who would more or less have their livelihoods, life plans, and expectations for the future destroyed. Partly or entirely eliminate the private insurance industry. Impose a compensation structure for what remains similar to every other national health service. It all makes macroeconomic sense, but 10-15% of the population would directly and personally be impacted "bigly," and not in a good way.

When any election decided by more than 5% is a landslide, making a bipartisan group of 10-15% your mortal enemies isn't an option.

[caleb]

I own a small (six employees) tool and die shop. We have Blue Cross Blue Shield PPO/HMO and we pay about $72K per year. Couldn't that money be switched over to a single payer?

Ray

Yes, and it's a perfect example of the easy efficiencies to be achieved. Here's some rough back-of-the-napkin math:

According to the Centers for Medicare and Medicaid Services, average cost to insure a working-age person was $6632/year in 2012 with Medicaid (most recent numbers I could find quickly). Since the low income people currently served by Medicaid tend to be sicker than high income people, and given that your workers are almost certainly above the Medicaid cutoff, your employees would probably cost even less.

But let's just accept the worst-case 2012 cost of Medicaid, and round up to $7500 for inflation. Six workers at $7500 would cost $45,000 annually in total, a savings of $27,000, or 37.5%. Not coincidentally, that 37% savings is about the difference between what we currently pay for healthcare and what the rest of the developed world pays.

We can debate about the specific numbers, but I've never seen a scenario in which you as a business owner, your workers, or hopefully both aren't financially much better off buying into a government insurance plan instead of buying it on the private "market."

[Len J]

Exactly.

The Single payer becomes the Government. If they follow the Medicaid system, they choose how much to pay providers. My wife is in Elder Care. Facilities are closing because companies lose money on every Medicaid bed. Private pay is the way they stay in business. Unless the Gov gets into the elder care business, mom & dad will not have anywhere to go. Much like ACA in some states, if insurance co decide to leave, what’s the option?

Who will pay? I expect the wealthy and middle class, those under Gov assistance don’t pay taxes now, so they won’t be paying into the system. The wealthy will end up paying more I’m sure a sliding scale like tax rates will be involved. But the wealthy may choose Private facilities anyway, so they will pay into a system they may not use-balancing the scale (hopefully). The ones in the middle will, as always, bear the brunt of real life: pay and not have options they may need. Will Doctors be content when the Gov decides what they should be compensated?

Sort of related example: My kids went to a different town’s high school, it’s called “school of choice”- gives kids state-run options vs private school. The host school lost thousands on each kid, as the State (Gov) locked the $ rebate (from town to town) in like 1975 dollars. So for the host school, it cost $10,000 per year per Choice kid. Rebate is $4,500. Year after year, the number of choice kids gets smaller and smaller, as schools can’t keep taking a loss. Eventually the program will go away…

The Gov never appears to want to pay the going rate.

Anyone here from Canada? How’s it work up North?

I’ve read and heard negatives, but that could all be “fake news”. I trust folks here more.

Everyone thinks they can fix the problem by changing who makes the decisions and pays the bills when the reality is no one agrees on what should be paid for and how much should be paid? That is the 10,000 lb gorilla that no one wants to acknowledge IMO. There is this implicit assumption that single Payer will solve all the problems, It won't.

There are several legs of this table, all of which need to be addressed to find a workable solution:

- Agreement on what care is paid for and what isn't. The definition of "Basic care" varies as widely as there are people with opinions. There are a million examples of this and it's near impossible to get 100% agreement. And when it's your loved one who is impacted by the decision, it gets even harder. People hit emotional buttons when they talk about "death Panels", but, unless we are actually willing to pay for it and decide not to pay for something else, it's all conceptual. If a amputation is required, what type of prosthetic should we pay for? If a woman needs a mastectomy, do we also pay for reconstruction & what type of reconstruction? What type of "experimental" treatments are paid for? How are decisions made, especially at end of life, as to cost vs benefit? Many behave as if health care is an unlimited resource when in fact it is a very limited resource, unless we decide to fund it appropriately. This includes agreement on when health care is reduced. Something like 60% of all health dollars you consume in your life will be in the last 6 mos of life (on average).

- How much should that care cost & how do we determine it? How do you weigh drug prices vs research dollars spent in "dry well" research? Do we define profit levels for medical suppliers? Do we determine how much medical professionals should make? There is no doubt that the current system both incentives some of the wrong things and has redundant costs in the system, but what is the benefit of having research focused on open market opportunities, or attracting the "Best and the brightest" to health care & what do we lose if we let the pendulum swing too far in the other direction? How do we allocate dollars to treatment vs prevention? How do we manage resource allocation?

- How do you both fund the cost of errors and/or acknowledge that Medicine is as much an art as a science?

- Agreement on how long you wait for service. If we think poroviding all care at all times to all people, immediately isn't expensive, run the numbers.

- What is the most efficient vehicle to deliver this care and pay for it. Single Payer "Can" be an efficient vehicle and take costs out of the system. It "Can" also be used by special interests to influence decisions across a broader scope....especially in light of pressure to cut costs. Demographics plus overall poor average health in the US is pushing costs higher and higher. Projections going forward with no change are not optimistic about our ability to solve this problem. I actually heard an economist say that the only way this problem will be solved and not bankrupt the county is for a severe epidemic to reduce the aging population quickly. He was only partially tongue in cheek as the numbers support us heading for crisis. Gaining efficiency in the system has to be part of the solution.

But single payer alone isn't going to solve anything. ACA was envisioned as the first step in the process, enlarging the insured pools to the point where the Mandate would reduce the overall cost per insured, with a second major effort aimed at reducing the delivery costs. Because the mandate penalties were gutted to the point where the healthy didn't enroll (and bore the penalties), the opposite occurred and the cost/insured rose as more sick people came into the insurance pools. Until there is agreement that it is in everyone's best interest to have mandated coverage for all, with teeth, it won't matter if it's single payer or not. As long as people believe that the healthy should have the choice to opt out until they need it, costs will be prohibitive, multi-payer or not. Getting agreement on that is a herculean task, getting agreement on the other issues I raised may be an even bigger hill to climb. Hell, we don't even have conversations on that that don't evolve into emotional "Death Panel" discussions.

If we decide that as a society, we are going to provide all medical care to all people at all times in their lives and we are going to do it immediately, damn the cost, then we better be prepared to both be taxed at a much higher level and not do other things that we currently use our taxes for, Single payer or not. While the economic benefits of single payer would help, they are a drop in the bucket compared to the impact of the other decisions we need to make. IMO & IME.

Len

[caleb]

http://www.coopami.be/en/countries/c...otection03.pdf
Lessons from Korean on implementing Universal coverage.

Fantastic article. Looks like they have achieved very positive results while transitioning:



For comparison, overall life expectancy in the US in 2003 was 77.4, but the South Koreans accomplished similar results for 5.6% of GDP (2004). That's about a third of what the US pays.


Here's the graph I found especially interesting:




Although out of pocket costs have declined, their system has been and continues to be built on a model of high out of pocket costs. Does anyone know how the out of pocket costs are structured - if they're across the board or narrowly targeted? That goes to some of Len's real questions above about who/what/when/where/why/how, but could also inform policy discussions about what has to be covered by an insurance plan and at what rate, as well as what can be excluded without producing bad outcomes.

Anyway, good food for thought.

[jlyon]

From what I can tell the US has about 315 Beds per 10,000 people so 4 times Korea's number.
But our average hospital days per admission 4.5 days so we could have 12 times the capacity per capita at least as far as available Hospital beds.

I know where I live North of Dallas there have been over 20 new Hospital built in the last 20 years within 12 miles of my house. I just seems crazy that they can all make money.

[jclay]

Thank you all for the feedback; it's provided me with additional insight, personal and wrt target audience reactions.

I am surprised that the following core facts (these are facts) didn't generate more comments:

1) The vast majority of our total, lifetime health care contributions are made to insurance policies that cease to provide coverage during job interruptions and upon retirement (for those that get it via employment or who can't service premiums during employment interruptions).

2) While consuming the majority of our contributions our insurance based coverage is aligned with our years of lower HC cost (statistically we chew up more HC $ the older we get).

3) Private HC insurance contributions will total well into six figures; for me, and including employer contributions, a reasonable estimate for my shorter than average professional career is $175,000. That's a lot less than folks starting out within the last ten years will pay.

4) Single payer systems have substantially lower administrative costs than HC systems based on private insurance companies (it's well documented).

Regardless of anyone's ultimate stance on the HC route to take, I'd have thought that #1 through #3 would cause folks to stop in their tracks and ask some fundamental questions. Some of the other characteristics I mentioned in my posts wouldn't be expected (by me anyway) to generate whiplash, but I thought 1-3 would. I'm going to have to revisit how that's presented. If the personal economic argument, the enlightened self interest of each of us, doesn't get traction then I am flummoxed.

As an aside, and wrt South Korea's experience; I think Canada (or France and several others, but Canada should be adequate), with her historical/cultural similarity, would be a vastly more appropriate comparison. Based on the research/reading I've done, and the Canadians with whom I've spoken (and when I meet one I do ask), the benefits of single payer make it a total slam dunk, but that's just my closing editorial comment.

Thanks again for the feedback.

[jlyon]

Since we are talking about the entire system what I would like to see to start would be to have every Doctor and Hospital post standard pricing so we could compare how or where we would like to spend out money. I know there is unlimited variety of procedures but if X type of Doctors were listed at $200 per 6 minutes and hospital rooms at $400 a night and such they could be charted and compared. Some would be proud and some would be shamed when it is shown they are charging 10 times someone else.

I believe the proliferation of the formerly Dock in a box shops into now ER shops is to hope someone comes in not knowing how much they will be charged for the same service but is now considered by the provider only as an ER service. Preying on the uneducated and maybe those who don't care since they have insurance until they figure out insurance for ER trips carry as much higher deductible.

Even single payer will require deductibles and I believe we should have a system like private tax free savings accounts to cover them. Once we become more responsible we will really need the cost information of nearby providers to help make our decisions. The current system is just not transparent enough for anyone.

My parents still use a primary care doctor that does not take any insurance and each visit cost them about $60. The Doctor is now quite old so I am sure that will never catch on elsewhere.

As for the points above:

#1 Cobra law currently allows us to keep the exact same coverage for 18 months after loosing or moving jobs. But we have to pay for 102% of the ocst where as the employer used to cover maybe 60% of it for us. I think the only alternative would be to disconnect the insurance from the job market. Again this is very established and will be extremely hard to do. Retirement usually means you are on your own so if your are too young for Medicare it will be a huge cost.

#3 I think your numbers are way too low as of now good coverage is about $800 a month for an individual and I read somewhere recently that an average person will spend $375,000 of their own money on Healthcare after they retire.

It seems like there has been much talk and effort put into insuring people and very little into driving costs down. I hope somehow technology and education can help introduce a much cheaper form of medical providers in the future because the current system of licensed Doctors and Nurses create quite a barrier for entry for more competition. The growth of Medical Tourism can only go so far and shows that many procedures can be done much cheaper if some corners are cut. Again it comes down to what quality is acceptable and at what price.

[Dallas Tex]

I think the only alternative would be to disconnect the insurance from the job market. Again this is very established and will be extremely hard to do.

How many folks are reluctant to start their own business because their entire family's health care is tied to a 40 hour/week job ? How many folks would 'retire' at 50 and free up their high paying position for the next guy?

How much would it even the playing field for our employers to compete with products from other countries where the business isn't forced to pay employee health care costs ?

I think its time for major disruption. De-couple health care from your job.

[bigbill]

My insurance through work is around $1050 a month, my share is $500. Five years ago my share was $275. If insurance was decoupled from employment, it wouldn't fix the costs and I'd need another $500 a month in pay to maintain my same level of insurance. But since I'd be an individual instead of part of a thousands of employees, I'd likely have a very high deductible. So yeah, what Glenn said, try it and let us know.

[Dallas Tex]

My insurance through work is around $1050 a month, my share is $500. Five years ago my share was $275. If insurance was decoupled from employment, it wouldn't fix the costs and I'd need another $500 a month in pay to maintain my same level of insurance. But since I'd be an individual instead of part of a thousands of employees, I'd likely have a very high deductible. So yeah, what Glenn said, try it and let us know.

Yeah, decoupling Health Insurance from your employer is only one variable. Your example above is assuming that one variable changes while all of the other variables remain exactly the same.

Any successful change or disruption in this area will need to be a wholesale change, not just one piece.

I don't believe that any sort of incremental, 'soft' changes will make any meaningful difference at all. It'll be painful, but bust out the clean sheet of paper & do what makes the most sense. If you think it'll be too disruptive to the economy or healthcare delivery, just imagine how much harder it will be in 10 years.

[jclay]

My insurance through work is around $1050 a month, my share is $500. Five years ago my share was $275. If insurance was decoupled from employment, it wouldn't fix the costs and I'd need another $500 a month in pay to maintain my same level of insurance. But since I'd be an individual instead of part of a thousands of employees, I'd likely have a very high deductible. So yeah, what Glenn said, try it and let us know.

Bill,

If that was the only change it obviously wouldn't be helpful, but we're all smart enough, educated enough and adequately reflective to figure out a number of different frameworks that would offer the obvious advantages of employment decoupling without the disadvantages. And since you allude to the purchasing power benefits, how about the PP of something north of 300 million?

If a Canadian diaper plant was kicking, pardon me, the pants off of the Waco diaper facility where I believe you're an engineer, and they offered you a look-see as to how they ran things I think you'd be on the next flight out. Any person or business in any analogous industrial situation would be insane to refuse the offer of learning how the competition did more and better, for less. So why then, with the loads of available information as to the superior cost/benefit ratio of the HC systems some notable and culturally similar countries, do we continue to refuse acknowledgement that they might be worth looking at....that just maybe they're on to something that we missed and can benefit from? It seems pretty dunderheaded to keep saying "no" to approaches that by every metric I've been able to unearth, are better than ours. But such is the strength of unquestioned political and economic ideology.

In the interest of accuracy:
1) Your feedback to my post 239 included attribution for things I did not say.
2) WRT combat vets, my point was not that they are trained in things geopolitical but rather that when, particularly with the benefit of four or five decades of additional historical perspective, they are willing to question the larger framework that resulted in actions which cost them dearly (the lives and blood of buddies, themselves and collaterals), that's a positive circumstance. That is a personal/emotional and culturally extremely expensive place to go.

[bigbill]

Bill,

If that was the only change it obviously wouldn't be helpful, but we're all smart enough, educated enough and adequately reflective to figure out a number of different frameworks that would offer the obvious advantages of employment decoupling without the disadvantages. And since you allude to the purchasing power benefits, how about the PP of something north of 300 million?

If a Canadian diaper plant was kicking, pardon me, the pants off of the Waco diaper facility where I believe you're an engineer, and they offered you a look-see as to how they ran things I think you'd be on the next flight out. Any person or business in any analogous industrial situation would be insane to refuse the offer of learning how the competition did more and better, for less. So why then, with the loads of available information as to the superior cost/benefit ratio of the HC systems some notable and culturally similar countries, do we continue to refuse acknowledgement that they might be worth looking at....that just maybe they're on to something that we missed and can benefit from? It seems pretty dunderheaded to keep saying "no" to approaches that by every metric I've been able to unearth, are better than ours. But such is the strength of unquestioned political and economic ideology.

In the interest of accuracy:
1) Your feedback to my post 239 included attribution for things I did not say.
2) WRT combat vets, my point was not that they are trained in things geopolitical but rather that when, particularly with the benefit of four or five decades of additional historical perspective, they are willing to question the larger framework that resulted in actions which cost them dearly (the lives and blood of buddies, themselves and collaterals), that's a positive circumstance. That is a personal/emotional and culturally extremely expensive place to go.

I realize you are writing an article and have been trolling this for a while to try out your talking points. What Canada does is not any secret, it's easily analyzed. What If America Had Canada's Healthcare System? - The Atlantic There are positives and negatives. The Canadians accept the negatives like longer waiting times for specialists. It would take generations for Americans to accept that system. If I need a specialist, I can see one within a week, not weeks or months later. It is the healthcare system we have. We could copy some of Canada's cost savings measures to address the root cause of our issues, cost.

As far as the combat Veterans, they always questioned the motives and tactics, they were doing that in the Revolutionary War, this isn't some kind of clairvoyant moment we've suddenly reached. I don't really understand your inclusion of Veterans in your conversation anyway unless it's to support a cut in the defense budget to pay for single payer, and your argument is weak is that was your intention.

This entire thread at times reminded me of discussions with my son when he was a toddler and I had to explain why he couldn't have ice cream for dinner.

[vertical_doug]

Because of the vast amount of money flowing into politics, the biggest problem you have with any change is regulatory capture by special interest groups.

[jclay]

I realize you are writing an article and have been trolling this for a while to try out your talking points. What Canada does is not any secret, it's easily analyzed. What If America Had Canada's Healthcare System? - The Atlantic There are positives and negatives. The Canadians accept the negatives like longer waiting times for specialists. It would take generations for Americans to accept that system. If I need a specialist, I can see one within a week, not weeks or months later. It is the healthcare system we have. We could copy some of Canada's cost savings measures to address the root cause of our issues, cost.

As far as the combat Veterans, they always questioned the motives and tactics, they were doing that in the Revolutionary War, this isn't some kind of clairvoyant moment we've suddenly reached. I don't really understand your inclusion of Veterans in your conversation anyway unless it's to support a cut in the defense budget to pay for single payer, and your argument is weak is that was your intention.

This entire thread at times reminded me of discussions with my son when he was a toddler and I had to explain why he couldn't have ice cream for dinner.

Ridicule stage. Must be making progress.

[christian]

How many folks are reluctant to start their own business because their entire family's health care is tied to a 40 hour/week job ? How many folks would 'retire' at 50 and free up their high paying position for the next guy?

How much would it even the playing field for our employers to compete with products from other countries where the business isn't forced to pay employee health care costs ?

I think its time for major disruption. De-couple health care from your job.

This is, to me, the biggest mystery of why Republicans don't support single-payer -- it would provide an explosion of opportunity for people who now stick it out in jobs with health insurance benefits. I spent 2005-2009 running my own business. The _only_ reason I was able to do that was that I could get healthcare from my wife's employer (I was racing cars professionally, so buying insurance in the individual market wasn't a great option) . My wife runs her own consulting business now. Guess what, she's on my employer's insurance. Allowing people to individually opt in to Medicare and giving them the employer contribution for insurance as a subsidy would be a good start...