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

[Jonathan]

To a large extent we are already paying for treating 350 million plus Americans in a variety of ways. Any new plan just addresses how we finance that with some of the other issues in the margins. I usually lean libertarian but when I get over myself and the fantasy of exceptionalism, I really can't come up with any good reason why healthcare can't be higher as a national priority.

I use a lot of healthcare. In the last year I've used every premium I've ever paid, probably more if I think about it. I spend time with folks who use a lot of healthcare too, and many of them are poorly insured. With all the outreach and advocacy I've done I've never met another chronically ill person who felt specifically entitled to someone else's labor. I'm sure some people do and I'm sure many of them are desperate too, but the majority of the chronically ill people I've met would like a system that better addresses the needs for everyone. I don't disagree.

Ps my property taxes break out the millage for the uninsured healthcare cost for my county. We are paying already, we should bring the costs out in the open and be honest about our priorities and goals.

[vertical_doug]

To a large extent we are already paying for treating 350 million plus Americans in a variety of ways. Any new plan just addresses how we finance that with some of the other issues in the margins. I usually lean libertarian but when I get over myself and the fantasy of exceptionalism, I really can't come up with any good reason why healthcare can't be higher as a national priority.

I use a lot of healthcare. In the last year I've used every premium I've ever paid, probably more if I think about it. I spend time with folks who use a lot of healthcare too, and many of them are poorly insured. With all the outreach and advocacy I've done I've never met another chronically ill person who felt specifically entitled to someone else's labor. I'm sure some people do and I'm sure many of them are desperate too, but the majority of the chronically ill people I've met would like a system that better addresses the needs for everyone. I don't disagree.

Ps my property taxes break out the millage for the uninsured healthcare cost for my county. We are paying already, we should bring the costs out in the open and be honest about our priorities and goals.

The conversation always seems to become who is going to pay instead of an equal how do you pay and why does it cost so much.

Jonathon, depending on who you use for insurance, the settle rate for your medical bills is probably 50% (private), 35% (medicare) and maybe 20% (medicaid). When your hospital talks about charge-offs for the unpaid bills, are they using the headline rate? private insurance rate? medicare rate? It makes a big difference. If a hospital claims 5% charge-offs, if it is as medicare rate the charge off really is only 1,5% which is lower than charge-offs for credit cards and other loans. The same argument goes into the charity the hospital claims. Which rate are they booking?

I believe the system gets much simpler if you forced disclosed pricing. Why is a hospital justified in charging more if I pay, less if Blue Shield pays and even less if medicare pays for the same procedure. I am in favor of singe payer, but first I want focus on the cost side with regulation forcing disclosure. States regulate usury laws, they need to get on board with health care.

For private insurers, the difference between benefits and premiums is about 12%. That is at the 50% reimbursement level. If they went to the medicare model of reimbursement, the difference between premiums and benefits would be 37.5%, so you should expect a significant decline in premiums to keep the same level of profitability.

[Jonathan]

I use Aetna, it's a "Cadillac plan" plan. I'm fortunate, or not if you look at it another way. I met my max out of pocket in March. I watch what the reimbursement rates are on EOB statements because I'm curious and my immunoglobulin treatments are closer to 75% reimbursement. These are higher margin products.

I said above the chronically ill generally aren't out to pick anyone's pockets and I also believe that most tax payers would be willing to pay for better healthcare for all if they felt that is intact what they were paying for. That statement gives away how I lean politically, but I do belive there is much room for health expansion AND market based reform.

[fiveller]

I'm so sick of knee jerk attacks on our government, its programs and employees. There's lots of programs that work pretty damn well. I'm not even going to credit your rhetorical demand with a list.

Of course programs could work better. That's true of private industry too. That doesn't make the core concept - programs designed not for profit but for the benefit of the citizenry - wrong.

And the idea behind a single-payer system - of healthcare delivery decoupled from employment, available to all citizens as needed for prevention and treatment - is a hell of a lot better than the multi-headed beast of doctors, HMOs, hospitals, and insurance conglomerates we have now. Obamacare was a compromise to provide universal access within this disfunctional arrangement. It's made some things better but the baseline arrangement is, to put it politely, sub-optimal.

Public program:


Apollo 11

Private program:



Chevy Cobalt - the one with the ignition that killed people

Large organizations, both public and private, suffer from many of the same ills in regards to bureaucracy, inefficiency, internal politics. For every government agency, there is an ATT (in their heyday), IBM (in their heyday, GM (prior to bankruptcy, in their heyday - are you seeing a pattern yet?), the Catholic Church in the Middle Ages, etc.

My bias: Grad school level Econ degree, ten years on Wall Street, more liberal than many.

Back to the conversation at hand.

[Will Neide]

I use Aetna, it's a "Cadillac plan" plan.

This is the next hot button issue. Everyone was against "Cadillac Plans" until they realized they had "Cadillac Plans." There will be sweeping changes to coverage if the "Cadillac Tax" isn't eliminated.

[Jonathan]

This is the next hot button issue. Everyone was against "Cadillac Plans" until they realized they had "Cadillac Plans." There will be sweeping changes to coverage if the "Cadillac Tax" isn't eliminated.

I pay quite a bit for this plan, more than my mortgage actually. Most employers don't offer these beasts anymore. This year I may have the opportunity to go to the exchange. I could probably save money. My treatments require a pretty rigorous review and periodic authorization so I'm disinclined to switch insurance companies and throw myself to the mercy of a new company.

[jclay]

I agree that it's stupid to tie health care to your job. It's a vestige to when people worked at the same place for their entire career and thought of their employer as some sort of benign entity. I get that a single payer system would be funded by taxes, but would there be caps? You say your net outlay would be a fraction of what it would have been had there been a single payer system been in place all these years, but would that be the case if you were a high income earner? As it is, medicare taxes are not capped, so people earning more simply pay more. If single payer worked the same way, it certainly would not be a win/win for everyone. If you think someone who earns double your pay should pay double the "price" for healthcare via taxes, that's a very different conversation that has very little to do with "efficiency" or other touted benefits of a single payer system.

Single Payer doesn’t require a particular contribution apportionment model. It can be whatever society decides. We could decide that the poorest among pay the same amount as the richest. I think that would be barbaric, astonishingly short sighted and ultimately detrimental to society since the jobs performed by low wage folks are necessary to the kind of society most of us care to live in. A society in which low wage folks have relatively decent lives (which would include health care) is also a more peaceful society; there is great value in that to the rest of us.



Based on what I’ve read, Western countries with national health care plans pay, on average, roughly 70% of what we pay on a per capita basis. The plans aren’t carbon copies of one another and don’t cover everything. I think dental is frequently not covered. But if you break a leg, get cancer, gash a foot or need some sort of operation to remain healthy, you get the service. As is the case here, 1) it may not always be tomorrow, 2) they aren’t perfect, 3) severity of the issue will (thankfully) have some bearing on rapidity of addressing the issue, but everybody is covered, nobody will go bankrupt over a health issue and world class care is delivered. I remember reading a NYT, or maybe it was a WSJ article with the headlines something like “Medical System Causing France To Go Broke”. What a crock. With the economic stressors (to Western countries) of the continuation of 40 years of industry flight to the Pacific Rim it’s a darn good thing they have a more efficient HC system than ours, else they’d be in deeper yogurt; as we are starting to find ourselves. The headlines should have read something like “France’s Efficient Healthcare System Attenuates The Financial Stress Of Industry Flight To Countries You Probably Wouldn’t Want To Live In”.

[Will Neide]

I pay quite a bit for this plan, more than my mortgage actually. Most employers don't offer these beasts anymore. This year I may have the opportunity to go to the exchange. I could probably save money. My treatments require a pretty rigorous review and periodic authorization so I'm disinclined to switch insurance companies and throw myself to the mercy of a new company.

Well it's a rolling timeline, so something that might not be "cadillac" this year, might be next year. And most people were/are surprised that what they have for insurance, or had for insurance since companies have already start revamping their plans, was considered "cadillac."

I hope your treatments and follow ups go smoothly. Your type of ailments are, IMO, when insurance is most needed.

[davids]

We accept the necessity of insuring ourselves, because it's been the norm for this country during our entire lifetimes. Layering private insurance into the healthcare recipe results in some very strange twists and turns which, unfortunately, most of us have run into. And we seem then as "normal" because in our experience, they are.

My wife & I are trying to by a long-term care policy for our dotage right now. It's clear the ins companies are flailing here, trying to create a good product while also making a profit, and I just hope that this year's "great new idea" will play out in our favor.

In a better world we wouldn't need this insurance layer. We'd have the medical profession with some administrative overhead, and we'd have patients.

[jclay]

Well it's a rolling timeline, so something that might not be "cadillac" this year, might be next year. And most people were/are surprised that what they have for insurance, or had for insurance since companies have already start revamping their plans, was considered "cadillac."

I hope your treatments and follow ups go smoothly. Your type of ailments are, IMO, when insurance is most needed.

An important distinction is that neither Jonathan nor the rest of us need "insurance"; we need health care. Other first world countries have largely figured that out.

[Len J]

I personally think that focusing on the mechanics of payment (single payer vs multi payer) as the solution is akin to trying to fix a non-working car by painting it. It totally trips over nickels to pick up pennies and it distracts us from the real root cause issues.

We, as a society, have never had a real thorough conversation about priorities.... we expect, and implicitly demand, all things at all times at the lowest cost to us personally. Unfortunately, life doesn't work that way.

First principles.... health care is a limited resource.... its limited by both capacity and what we as a society are willing to commit, as a % of GDP to that care. What exactly does health care for all mean? Does it mean all care, to all people, at all times and in all instances, no matter the probability of success? If we decide it does, then we have to decide if that is a higher or lower priority than other consumers of societal dollars.... in other words, what else are we going to not do if we dedicate dollars to health care. If we decide we aren't willing to do all things at all times, then, while it may be cheaper, someone has to decide what health care services are going to be provided, to whom and when........ and no one wants that responsibility. It's the third rail. Currently those decisions are made by a combination of insurance companies, employers and legislators, but in the end, they are not made systemically, nor are they made transparently. Something like 2/3's of all dollars in the health care system are consumed on the last 6 months of life...... think about that. I'm not suggesting that these dollars shouldn't be spent, rather, I'm suggesting that we entertain a real open, honest conversation about when they should or shouldn't, and instead of automatically doing all things possible to extend life, we make choices, and in making those choices we are honest about what resources (taxes) we are willing to commit to the results of those decisions.

I'm not denying that systemic improvements aren't needed and wouldn't save money..... but they pale in comparison to aligning choices with funding. But, as in most things, the devil is in the details, and the details are incredibly complex.

A few other thoughts.

Someone mentioned that no government program worked effectively, I'd vehemently disagree. Social security is one of the most efficient, most well run system in the world. Administration costs less than 3.5% of annual disbursements.... that's pretty amazing. What is wrong w SS is the same thing that's wrong w healthcare, a total misalignment of intention, reality and funding. SS was created as a safety net and established w a retirement age 65, when life expectancy was less than 70. So a normal person would work 45 years or so and have 5 years of retirement. it was also assumed that through a combination of life expectancy and continuing expected increases in birth rates, that there would always be a very high number of workers relative to retirees, whose low taxes would fund the benefits. Flash forward to today, we waited way to long to raise the retirement age as life expectancies increased, so instead of a work to retirement years relationship of 45/5 we now have 46/23...... we have to fund retirement for 4.5 times as long.... at the same time the birth rates slow and now there are fewer workers to pay for more retirees. But that was ignored because god damn it, I have a right to retire at 65. Ignore the reality, and each successive year it gets harder to fix. Demographics can't be ignored.

Europe is struggling under the burden of their committed social programs mainly because of demographics. They are rolling back programs because the taxable workforce can not be taxed at a high enough rate to pay for the ever increasing number of nonworkers (unemployed and retired). Austerity is another word for program cuts.

Very complex stuff.

Len

[Jonathan]

Len, you always have a pragmatic way of looking at things but even you miss some of the Forrest through the trees. We spend almost double as a % of GDP compared to most 1st world nations, at least the ones you wouldn't be scared to get sick in. So while its fundamentally true our resources are limited, the details as you point out are important. We don't get the healthcare we pay for.

As far as efficiency goes, I agree and I know few people who complain about Medicare. The people I know with Medicare and private insurance all think Medicare is easier to navigate.

"Single payer" strikes me as a buzzword and hides the massive change that would come from enacting a universal legislation like that.

[Len J]

Len, you always have a pragmatic way of looking at things but even you miss some of the Forrest through the trees. We spend almost double as a % of GDP compared to most 1st world nations, at least the ones you wouldn't be scared to get sick in. So while its fundamentally true our resources are limited, the details as you point out are important. We don't get the healthcare we pay for.

As far as efficiency goes, I agree and I know few people who complain about Medicare. The people I know with Medicare and private insurance all think Medicare is easier to navigate.

"Single payer" strikes me as a buzzword and hides the massive change that would come from enacting a universal legislation like that.

I don't deny we are spending more, but I disagree on the reason. You would attribute the majority of the difference to the multipayor system, I disagree.... I think the majority of the difference lies in the things we choose to pay for and when we pay for them.

I think the problem is 2/3rd or more related to the expectation that all things get done always, and less than 1/3rd is related to the payment infrastructure.

Len

[Will Neide]

Hypothetical.....

Jimmy carter was diagnosed with brain cancer. He's 90. How much in resources should be allocated to prolong his life? It's a pretty disturbing question, an uncomfortable one, but someone at some point would have to make such decisions.

[Jonathan]

Le

I don't deny we are spending more, but I disagree on the reason. You would attribute the majority of the difference to the multipayor system, I disagree.... I think the majority of the difference lies in the things we choose to pay for and when we pay for them.

I think the problem is 2/3rd or more related to the expectation that all things get done always, and less than 1/3rd is related to the payment infrastructure.

Len

I don't think I said that at all. I think you just set me up. I've been careful not to beat one drum or another. I'm involved in healthcare, I see it at a deep level. People like me expose the seams. I'm in Chicago today and tomorrow presenting to a Pharma co. I'm sensitive because without market forces a cure or treatment for someone like me could be rationed to the back burner but I still have to wonder....
22% of gdp for one of the most productive nations on earth is an incredibly huge number that's doesn't give us better coverage or outcomes. If Brittain, Canada France, Switzerland all doubled healthcare spending.....

[ericpmoss]

There's not one problem, so there won't be just one fix.

Billing is impossible to follow.
We are drowning in false choices and expected to make the best choice when we are at our weakest.
Heroic measures for what should be palliative care cases don't help anyone.
Over-medication and mis-medication in nursing homes is insane.
Home care is effectively banned in many states, with the "help" of nursing home association lobbying.
People with poor/no insurance wait until it's an emergency.
We have piss-poor nutrition education -- the people in this group are *not* representative, sadly.
There is a ridiculous amount of pollution people just don't know about, and industrial food isn't helping.
Stress is on the rise, sleep is on the decline.
Competing profit motives are, IMO, ridiculous measures of value, yet every newscast is about what's good for insurers or hospitals or pharma.

Other than that, it's all good. You should see my stock portfolio -- it's all based on pain and suffering, and it went up 60% in the last few years. It's so good that it's now enough to pay for 1/10th of what a serious illness or injury would cost me.

Hey, should this be in the Grumps thread?

[jclay]

When I decided to start building bicycle frames I figured I'd get best results by examinating the work and methods of successful framebuilders. Novel idea, eh? You can get mired down in healthcare FUD minutiae if you like but I'd suggest looking at how countries who deliver cradle to grave HC services to their entire populations do so; and then design a system around that information. Single payer is a common, important funding mechanism, not a buzzword. Approximately 40% of our population receives HC services via single payer (Tricare, Medicare, etc) and even with the other problems of our system they manage to be more cost efficient than private pay based funding.

One thing is certain; the Balkanized system we have has defects you could drive oil tankers through and it depreciates all of our lives. I was watching an episode of All Creatures Great And Small, based on a pretty old series of books, and the controversial subject of the then proposed National Healthcare Service came up. The same sorts of FUD subjects came up that I'm hearing in this discussion and in general. It won't work and it will destroy our HC system and, and, and. And 50 odd years later the UK, battered by all manner of industrial and economic challenges still manages to provide their population, all of it, with healthcare that's more cost effective than ours and which doesn't have coverage gaps. I think there is a not so subtle lesson in there.

[sine]

edit

Approximately 40% of our population receives HC services via single payer (Tricare, Medicare, etc) and even with the other problems of our system they manage to be more cost efficient than private pay based funding.

What percentage of doctors in the USA accept Tricare and Medicare. My understanding is that nationally, fewer and fewer doctors accept Tricare.

[roseyscot]

Taxes.

The line on my pay stub that currently is labeled "Cigna Health Insurance" would be relabeled something like "National Health System" and the amount contributed would be smaller. Had we moved to a national single payer system back when Nixon suggested we needed something different than our current system (I'm being generous in calling it that) my working life contributions would have been roughly 65 to 70% of what they have been, I wouldn't lose the benefit of those contributions when I separate from service with my employer and Medicare, which would have been rolled into the same system wouldn't be under funded. That's how it's worked out for the other Western countries that have adopted national health systems.

Scale that across our entire population and pretty soon you're talking about real money, a better quality of life, improved ability of our industries to compete globally and workers that aren't tied to a particular job simply because of the "benefits".

Technically its a slam dunk.

I agree that it's stupid to tie health care to your job. It's a vestige to when people worked at the same place for their entire career and thought of their employer as some sort of benign entity. I get that a single payer system would be funded by taxes, but would there be caps? You say your net outlay would be a fraction of what it would have been had there been a single payer system been in place all these years, but would that be the case if you were a high income earner? As it is, medicare taxes are not capped, so people earning more simply pay more. If single payer worked the same way, it certainly would not be a win/win for everyone. If you think someone who earns double your pay should pay double the "price" for healthcare via taxes, that's a very different conversation that has very little to do with "efficiency" or other touted benefits of a single payer system.

When I decided to start building bicycle frames I figured I'd get best results by examinating the work and methods of successful framebuilders. Novel idea, eh? You can get mired down in healthcare FUD minutiae if you like but I'd suggest looking at how countries who deliver cradle to grave HC services to their entire populations do so; and then design a system around that information. Single payer is a common, important funding mechanism, not a buzzword. Approximately 40% of our population receives HC services via single payer (Tricare, Medicare, etc) and even with the other problems of our system they manage to be more cost efficient than private pay based funding.

One thing is certain; the Balkanized system we have has defects you could drive oil tankers through and it depreciates all of our lives. I was watching an episode of All Creatures Great And Small, based on a pretty old series of books, and the controversial subject of the then proposed National Healthcare Service came up. The same sorts of FUD subjects came up that I'm hearing in this discussion and in general. It won't work and it will destroy our HC system and, and, and. And 50 odd years later the UK, battered by all manner of industrial and economic challenges still manages to provide their population, all of it, with healthcare that's more cost effective than ours and which doesn't have coverage gaps. I think there is a not so subtle lesson in there.

edit



What percentage of doctors in the USA accept Tricare and Medicare. My understanding is that nationally, fewer and fewer doctors accept Tricare.

Medicare, Tricare, etc are more cost efficient because they pay rates that are below the cost of providing the services they are paying for. Can I go to Ford and pay them 15% less than what it cost them to make the car? Ford might be able to swallow that on a handful of sales, but if everyone got to pay less that amount, Ford would stop making cars.

If doctors, hospitals, etc are not able to cover their costs because of the low reimbursement rates (or not able to make a profit in line with the level of schooling and work they endure), why the heck would they want to continue doing what they do?

A shift to a single payor system would take a while to level out, during which the people who would suffer most are the people whose salaries are paid by that single payor.

[davids]

Medicare, Tricare, etc are more cost efficient because they pay rates that are below the cost of providing the services they are paying for. Can I go to Ford and pay them 15% less than what it cost them to make the car? Ford might be able to swallow that on a handful of sales, but if everyone got to pay less that amount, Ford would stop making cars.

If doctors, hospitals, etc are not able to cover their costs because of the low reimbursement rates (or not able to make a profit in line with the level of schooling and work they endure), why the heck would they want to continue doing what they do?

A shift to a single payor system would take a while to level out, during which the people who would suffer most are the people whose salaries are paid by that single payor.

Let's say this is true. Raise my Medicare taxes by 15%, and I can drop my health insurance coverage?

Let me run the numbers.

Increasing my family's FICA taxes by 15% comes to about a $425 annual increase. My family's health insurance currently costs $4,125 annually.

OK. Sold.