My current assumption is that private healthcare/insurance is to blame, because countries without that or with less generally have better outcomes at less cost. Looking for evidence to the contrary
> countries without that or with less generally have better outcomes at less cost.
This isn't necessarily a great metric, because almost all countries have better outcomes and all countries have lower per capita cost, whether their systems are public, private, or mixed. The US spends more public funds on healthcare than countries with universal socialized health care systems. The fact that we're also personally bankrupted after spending the same tax proportion on healthcare is just a bonus.
It's not specifically private healthcare or insurance that's the problem, it's the specific corruption of the people who own the healthcare industry and their legislators.
Wow, I had to check your facts here, and I can’t believe it. The US federal healthcare spending is very close to the UK healthcare spending, but we cover WAY less for individuals.
The US federal govt spends >8% of GDP on healthcare, with the current system of all of our insurance and payments and everything that we have to pay in addition, totaling nearly 20% of GDP: https://www.crfb.org/papers/american-health-care-health-spen...
That has to be related to the fact that American drugs are sold to a lesser price abroad than at home, right?
In Quebec, cancer treatment is free. Given that even late-stage cancer patients live much longer nowadays, and those treatments are probably expensive as heck, I wonder how we can afford it.
Across the board price controls seem to be a common to the various European health care systems. It is my understanding that upper limits are set for the cost of medicine.
There is quite a bit of variety across Europe - U.K. is 100% government run, France is a public/private mix, Germany is similar to Obamacare in some ways, others are single payer, apparently some are private, also. But I've read that they all have cost controls.
Wikipedia said 8% of health care in England is private, mostly specialist, often through employer provided plans meant to augment NHS. The other 92% of health care is directly supplied by NHS [0]. So they appear to be a mix of public and private, like many other systems.
I know I'm a broken record on this but people who say this are simply wrong.
1) There is not one NHS for the UK. Health is devolved and there are totally separate systems for NI, Scotland, Wales, and England.
2) Speaking only for England, it's not "run by the government". The NHS in England is run by NHS England and Improvement. The people who work for NHSE/I are not civil servants, they do not work for the government.
beyond Europe as well. Singapore which has exceptionally low healthcare spending (5.9% of GDP) heavily controls prices and purchases down to individual equipment in hospitals.
Singapore does not control prices (though it’s moving in that direction), it’s public hospitals are privately run, and it has a system of “forced savings” to make sure patients have enough money to cover out of pocket costs and buy health insurance. It’s ethos is “the patient has to pay something out of pocket, even if it’s just $2”. It’s also more than happy to tell poor patients “if you don’t have enough money, there is nothing we can do”.
It is more similar to the US system than a system like the UK or Canada.
>Singapore does not control prices (though it’s moving in that direction), it’s public hospitals are privately run,
Singapore controls prices through collective bargaining at the national level and unlike the US practically every purchase in its hospitals has to go through registration with the HSA (the country's relevant regulatory agency). You essentially cannot purchase any major equipment without running it by the national government. That's one of the reasons why the country has a very transparent pricing system.
It's not only savings accounts but also a very tight control over costs and acquisitions that keeps the price low, that's completely missing in the American system which just keeps growing.
Singapore doesn’t control all prices - drugs can be freely priced, but as I stated it’s changing right now.
And getting HSA approval doesn’t have anything to do with price - that regulatory. Even the FDA has to approve anything used in the US.
It is true you can’t purchase at the hospital level without some agreement on price, but the hospitals often do their own tenders, which are confidential prices. It’s not done at the national level for everything.
And yes, prices are tightening but companies are already deciding to just not market in Singapore if prices get too low.
Check out Germany, I think it was AZ that decided to just not launch a drug there at all because the price was too low.
Aren’t all 3 major hospital groups government owned? These are not private hospitals, they may charge you fees, but ultimately they’re government owned.
Actually are correct, they are government owned corporations. There is SingHealth and the NUHS system. But they are corporations, with boards of directors, which is entirely intentional since the government wants "private" competition between providers to drive efficiency.
That 90% number is plain not true. Please cite any source for that.
The costs for obese folk are on average 90%-100% higher than for non-obese folk, but that's not 90% of total spending. (See e.g. https://pubmed.ncbi.nlm.nih.gov/33470881/)
Obesity, like smoking, is one of those morbidities that lower lifetime healthcare costs significantly, as most costs are incurred in old age, as you saisd. Obesity, smoking, etc can kill before reaching an age where people start incurring high costs.
There is a lovely tale from Czech Republic in 2001 where Philip Morris was distributing analysis showing the economic benefits of smoking to their shared healthcare pool.
This is a topic that’s always going to have wildly different numbers. Who cares? It doesn’t change what we all know to be true. Nothing has been undermined whatsoever
My state has a "stupid motorist" law that requires people who negligently put their vehicles in danger and then use state resources to get bailed out, to pay for the rescue themselves. Perhaps we could create a "stupid eater law" for medicare/medicaid, forcing obese people etc to pay for their own private health insurance or healthcare which would free up money for others to buy more healthcare privately (via lower tax burden). My families healthcare would definitely be more affordable if I weren't burdened paying for the negligent actions of others.
Should we apply the same sort of "stupid X law" to people who drink alcohol or drive motorcycles or play rugby? This is one of the moral hazards of a socialized medical system. When the rest of society is paying for your medical care it becomes tempting to save money be dictating exactly how you're allowed to live your life.
Obesity is a serious public health problem but we won't fix it by calling people stupid or charging them extra.
Yes I think that makes sense, to an extent. Maybe not specifically those because they are too hard to measure. But it would be a great way to have people put skin in the game. As a taxpayer paying for others’ healthcare I’d love if they were incentivized to live healthier lives to reduce costs
There are people genetically predisposed to gain weight or have heart disease. Cancer can be Russian roulette, as is your immune system picking up random autoimmune disorders. Accidents happen.
There are too many stakeholders with too many backgrounds and conditions for anything like your proposed system to work. Everyone would be angry.
> There are people genetically predisposed to gain weight
And this genetic mutation somehow happened in the last 50-100 years or so? Obese people have always existed. Obese poor people are fairly new. The root cause is diet, not genetics.
>Should we apply the same sort of "stupid X law" to people who drink alcohol or drive motorcycles or play rugby?
Yes, precisely. Keep chopping down at these factors until all that's practically left is private healthcare -- that's a feature not a bug. It's enough that I have to pay the bill to scrape the blood off the street when a motorcycle is crashed, not interested in paying someone elses motorcycle related health premiums on top of that (I've gotten enough motorcycle injuries while carrying my own private healthcare :) )
>This is one of the moral hazards of a socialized medical system.
As you say with public healthcare the effect (you say temptation) is to socialize your health related losses while privatizing the gains you reap.
I'm not sure how the heck you jumped from "drive motorcycles" to "drive cars".
Driving cars would be minor and apply to almost everyone, so it would mostly cancel out and be negligible. Really it would be a slight discount for taking transit, and that seems... fine to me.
And those other ones aren't even notable risk factors.
Not people who live in dense cities with good subway systems and a walkable infrastructure. Driving is one of the most dangerous things humans do. The argument that all health care should be private– the perspective this comment addressed– would not make such a consolation simply because it's common.
> Not people who live in dense cities with good subway systems and a walkable infrastructure.
Yeah, so almost everyone.
> Driving is one of the most dangerous things humans do. The argument that all health care should be private– the perspective this comment addressed– would not make such a consolation simply because it's common.
Car deaths are about 1% of deaths. Heart disease and cancer are each around 15x as likely.
Even if it's high on the danger scale, I don't think it would be a very big factor in health care costs.
The US is a big place but most people live in cities. Few car accidents are fatal.
CDC: Motor vehicle crashes are a leading cause of death in the U.S.1, with over 100 people dying every day. 2 More than 2.5 million drivers and passengers were treated in emergency departments as the result of being injured in motor vehicle traffic crashes in 2015.1 The economic impact is also notable: for crashes that occurred in 2017, the cost of medical care and productivity losses associated with occupant injuries and deaths from motor vehicle traffic crashes exceeded $75 Billion."
American Society of Civil Engineers infrastructure report card says only 45% of the US population has no access to public transit.
> Motor vehicle crashes are a leading cause of death in the U.S.1, with over 100 people dying every day.
Motor vehicle crashes are slightly outside the top ten causes of death. Those 100+ deaths are coming out of about 9300 total deaths.
> The economic impact is also notable: for crashes that occurred in 2017, the cost of medical care and productivity losses associated with occupant injuries and deaths from motor vehicle traffic crashes exceeded $75 Billion.
Productivity losses are outside the scope of medical costs, but even if we include those dollars that's $75B out of $4100B in health care spending.
So I stand by my statement that it's a pretty small impact.
> American Society of Civil Engineers infrastructure report card says only 45% of the US population has no access to public transit.
And most of the other 55% still need cars.
You said "good subway systems and a walkable infrastructure" and that's what I responded to. We can go ahead and remove the word "subway", but the fraction of people with access to good public transit systems is pretty small.
> Perhaps we could create a "stupid eater law" for medicare/medicaid, forcing obese people etc to pay for their own private health insurance
That might be a good idea after we make sure that every single person has equal access to healthy foods and equal ability to afford healthier options. Maybe we could also ban companies from adding HFCS to everything, ban advertising of any unhealthy foods, fine people for not wearing masks or vaccinating their babies, and police what people are allowed to have in their refrigerators so we can punish anyone who has too many unhealthy foods in their home!
Or... maybe we can let doctors and scientists figure out what the best ways to combat the obesity problem are and try to find ways to help people instead of punishing them while in the meantime making sure everyone has access to the care that they need. If we had universal healthcare the costs for your family would the same as everyone else no matter if you or the next person drinks, or smokes, or likes rock climbing, or plays sports, or drives more than x number of miles in a year, or has more than x number of sexual partners, or doesn't exercise at least x number of hours a day and nobody would have to go around spying on everybody to make sure they aren't doing anything that might raise someone else's costs "or else".
>yea because they have healthy population, its not because of some smart govt policy
yes it is, because the health population itself is supported by strong intervention. Singapore banned the advertisements of sugary drinks years ago, Singapore strictly regulates the number of vehicle licenses in the country encouraging public transport and walking, it forces citizens to allocate money for healthcare to private savings funds which incentives reducing your own healthcare costs, and so on.
The reason American's are obese isn't a miracle or because Americans are stupider, it's because Americans refuse to take collective action when it comes to the health of the nation.
Singapore's area is 283 square miles. Rhode Island is the smallest state, and it has an area of 1214 square miles. Four times larger, with people throughout needing care. That alone will add a fair amount of cost.
Granted, not the total amount spent, but city states do have some advantages on things like this.
I don't think that disproves a general trend that increased socialization in healthcare costs leads to better outcomes and less per-capita spending.
Also FWIW France and Switzerland both have universal healthcare, under different systems where France splits payments 3 ways and covers more with the govt[1], and Switzerland seems to have a system like the ACA in the US where it's compulsory, but they also set caps on the deductibles and maximum price.
It's not just Switzerland and France; the Netherlands also has a private-only health insurance system. It's also very difficult to draw decisive conclusions since, across countries, there are hundreds of confounding variables — it's not just public vs private, but it's also which regulations exist in each country, whether it's employer-sponsored vs individual, general willingness to pay, etc. You're correct that Switzerland has a system like the ACA in the US, but the biggest difference is that it's not common for the Swiss to get their private insurance from their employers; it's all on the individual market. The US is actually unique in that regard, and is probably the most significant difference — the vast majority of working age adults in the US get their insurance from their employers, and as a result the ACA's individual market has been in a dire state since the program's inception.
Also "socialization" is very different from "nationalization". The general trend you're talking about is more to do with the fact that having society subsidize healthcare for the poor can lead to better outcomes. As it relates to who actually does the insuring, underwriting, and payment (public vs private), one isn't necessarily better than the other; each has its trade-offs. It's just that the US (in particular) has chosen the worst of both worlds.
I work in this industry, and from where I sit, the closest thing we have to a clean A/B test that controls for all of those confounding variables is actually being run in the US right now, with Medicare. When you turn 65, you have the option to enroll either in "Original Medicare", which is what we usually think of when we talk about "single payer healthcare in America", or you can enroll in Medicare Advantage (aka Medicare "Part C"), where the premiums that would go to the CMS instead go to private insurers like Humana, United, Oscar Health, Aetna, Clover, etc. These plans replace Original Medicare.
- 48% of Medicare beneficiaries are on private Medicare Advantage plans instead of the public "Original Medicare". Because everyone is entitled to "Original Medicare", this is purely voluntary. This number has been growing so rapidly that the CBO projects that by 2023, the majority of beneficiaries with choose the private over the public option. The CBO further projects this proportion to increase to 61%(!!) by 2032. (https://www.kff.org/medicare/issue-brief/medicare-advantage-...)
- In Urban areas, Medicare Advantage costs less per capita to administer than Medicare — and that's not including the extra Medicare Part D insurance that you would have to buy if you're on the Original Medicare plan (https://www.commonwealthfund.org/publications/issue-briefs/2...)
So no, you cannot look the cost difference between the US and other countries and simply conclude that it's because of private insurance, because the actual data tells a different story. And "universal healthcare" is not the same as "public" healthcare. It might help to think about it this way: universal access to food can be achieved without nationalizing the food industry, or the food payment industry.
It's the mutuelle. The way healthcare works here, the essential medical stuff is reimbursed by the universal healthcare system (sécurité sociale), and the rest is out of pocket. The mutuelle covers the part that's normally for you to pay, which can be quite significant for dentistry and glasses. My employer currently gives me a mutuelle that's decent to start with, and I chose to pay a 15€/month premium for increased coverage.
For example I just got a 900€ dentist bill recently. By default the sécurité sociale would just reimburse 300€ of it, for the essential care as well as a standard deductible on dental crowns. With my current mutuelle there's only 3€ left for me to pay.
That's a mandatory complementary insurance, the base costs are covered by the national insurance. It's a confusing situation that's somewhat similar to the US in that it's wasteful, pointless and mostly serves some private interests, but on a much smaller scale.
> Medicare Advantage Plans are another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare. (emphasis added)
Those rules are, IIUC, substantively different than the ones that cover the non-medicare private insurance industry, and as a result I'm not sure what any of the (true) facts that you've quoted really mean in the context of the questions being asked here.
Also, from reading up about MA, it would seem that MA is operating on the "HMO" (health maintainance organization) model that started to be touted in the 1990s. AFAIK, the HMO model has not done much to contain consts in the broader US private health insurance world. It would be interesting to know if it is specifically the combination of the HMO model and Medicare rules that has allowed MA to apparently work better than OM.
I actually work in this industry and adjust claims myself from time to time, so I love talking about this stuff!
> that must follow rules set by Medicare. (emphasis added)
Yeah, I'm not sure that anyone seriously believes that insurance companies should operate in a 100% unregulated fashion. Even the US's food industry (which is predominately privatized) is regulated in some capacity. The argument is whether regulated private insurance can deliver good outcomes. That is very much the case, as evidenced by Switzerland, the Netherlands, and Medicare Advantage.
> Those rules are, IIUC, substantively different than the ones that cover the non-medicare private insurance industry, and as a result I'm not sure what any of the (true) facts that you've quoted really mean in the context of the questions being asked here.
First of all, the non-Medicare private insurance industry is heavily regulated, often more so than Medicare Advantage private insurers. In fact, you raise an important point: it's important to consider which specific regulations are helping and which are hurting. Outside of Medicare Advantage, there are regulations that strictly control insurance company's profit margins, how much of premiums can be spent on collecting medical claims (see: the 80/20 rule and Medical Loss Ratio rules), the fact that every beneficiary must be treated exactly the same (ERISA, parts of ACA), a minimum amount of coverage required (the ACA added this), the employer mandate (ACA), etc.
To give you a sense for some of the unintended consequences that have been created by regulations on non-Medicare Advantage health insurance plans, due to Federal mandates and tax incentives, health insurance is predominately provided by employers rather than the individual market (unlike Switzerland, Germany, or the Netherlands). What we're seeing in healthcare costs is analogous to what you might see happen to airline ticket costs if we all got our air tickets through our employers: the vast majority of us would fly business class, while the unemployed would be simply unable to pay for business class fares out of pocket. A big reason for this is that employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals. If you take this behavior and combine it with the fact that health insurers' profit margins are capped by law, insurers pay more absolute dollars for treatments (which doctors happily accept), charge more to employers (who are generally less price conscious vs individuals), thus bring in more absolute revenue, and therefore more profit because a capped profit percentage of a higher revenue is higher than a capped percentage of lower revenue. It's somewhat counter-intuitive, but the policy combination of an employer mandate and insurance profit cap results in increased prices.
This cocktail of regulations does not exist for Medicare Advantage insurers — even though they are still regulated in different ways. That's a very important distinction. Currently, Medicare Advantage insurers are allowed to return 50 percent to 70 percent of any cost savings to beneficiaries in the form of reduced premiums or expanded benefits — whereas with employer-sponsored insurance, even if such cost savings existed, they would accrue to employers (unbeknownst to worker beneficiaries) — and that's assuming there are cost savings for employers; there aren't, due to the aforementioned regulatory concoction. A big part of why Medicare Advantage actually works really well is because it's effectively a basic income for health insurance, it's just that individuals are empowered to use those dollars to buy whichever healthcare plan meets their needs (including a public option), as opposed to being forced to choose among a small selection of plans curated by an employer.
> Also, from reading up about MA, it would seem that MA is operating on the "HMO" (health maintainance organization) model that started to be touted in the 1990s. AFAIK, the HMO model has not done much to contain consts in the broader US private health insurance world. It would be interesting to know if it is specifically the combination of the HMO model and Medicare rules that has allowed MA to apparently work better than OM.
Medicare Advantage plans can both be HMOs as well as PPOs (https://www.medicare.gov/types-of-medicare-health-plans/pref...), it's just that there happen to be many MA plans that are HMOs. HMOs can have very good outcomes with significant cost savings (think of the pre-2010 UK NHS as a public HMO), but can also have bad outcomes if managed poorly (think of the 2022 NHS or US's VA as poorly managed public HMOs). With Medicare Advantage, seniors have the option to choose.
The obvious regulation which almost every other country has is direct price controls on medicines, treatments etc. Not profit percentage controls. A dead simple “this is how much you’re allowed to charge”.
I don’t really understand why anybody would be against introducing this in the US.
It is not so obvious at all. Medicare Advantage does not have price controls, and it still costs less per capita than Original Medicare.
> A dead simple “this is how much you’re allowed to charge”.
This has its own set of unintended consequences, including physician rationing (it's a huge crisis of the NHS right now), and a reduction of investment in new medical research. There are many good reasons to be against introducing this in the US.
Switzerland does not have price controls on medicines, treatments, etc. and the reason why it is so often cited is because it enjoys a comparable level of healthcare innovation to the US while still ensuring universal access (through its ACA-like subsidies). It also costs a lot per capita (among the highest in the OECD), but it actually gets what it pays for (https://pubmed.ncbi.nlm.nih.gov/26766626/) (https://www.theweek.in/news/world/2022/05/07/7-reasons-why-s...)
In fact, of the countries that usually make up the global leaders in health/medical innovators, all but 1 (the UK) engage in price controls (https://immigrantinvest.com/insider/the-best-healthcare-coun...), and the UK's NHS is suffering from a rationing crisis, and (ironically) a cost crisis.
> In fact, of the countries that usually make up the global leaders in health/medical innovators, all but 1 (the UK) engage in price controls (https://immigrantinvest.com/insider/the-best-healthcare-coun...), and the UK's NHS is suffering from a rationing crisis, and (ironically) a cost crisis.
The UK's difficulty lie in their leadership and political issues and in the economic consequences of Brexit. I'm not sure it's the best example for your argument.
The NHS's difficulty lies in the simple fact that it is understaffed (https://www.express.co.uk/life-style/health/1633058/general-...) and the staff are underpaid (https://www.bbc.com/news/newsbeat-62290577) — leading to unprecedented wait times. This is because the "list prices" that the NHS pays for GP, nurses, and services are not subject to market forces, they are set by the government. The government is currently failing to address the supply loss with little political will to increase list prices (which propagate to the consumer through increased taxes). Brexit's influence is tenuous at best. Switzerland is also not part of the EU and doesn't face this problem. At best, Brexit exacerbated an already existing pricing problem.
Where you're correct is that the difficulty lies in leadership's inability to actually change the prices to attract the supply necessary to reflect the increase in demand — and that's because the Single Provider system is tied to politics rather than market forces. The NHS is a third rail of politics and real reform is extremely difficult given the political buy-in necessary. In contrast, the private sector can (and will) increase prices to overcome demand — we see this happening in Switzerland (https://pubmed.ncbi.nlm.nih.gov/26766626/).
> The system offers a high degree of choice and direct access to all levels of care with virtually no waiting times
So where we may agree to disagree is that the NHS's woes are in fact a very strong example of the greater argument, on net.
> The NHS's difficulty lies in the simple fact that it is understaffed and underpaid — leading to unprecedented wait times. This is because the "list prices" that the NHS pays for GP, nurses, and services are not subject to market forces, they are set by the government. The government is currently failing to address the supply loss with little political will to increase list prices.
And the US's problem is that the list prices it pays for GPs, nurses, and services are subject to market forces and thus are too high. The government is currently failing to address the service provision loss with little political will to decrease list prices (even though they would propagate through to consumers as decreased costs).
It seems to me that there's no getting around the need for good governance here. And that lack of it is no excuse for not governing at all.
> And the US's problem is that the list prices it pays for GPs, nurses, and services are subject to market forces and thus are too high. The government is currently failing to address the service provision loss with little political will to decrease list prices (even though they would propagate through to consumers as decreased costs).
Yeah that's completely untrue; the list prices that insurers pay for GPs are heavily inflated by the market distortions introduced by the Federal government. I don't know if you read any of what I've written up-thread, but I'll paste the relevant parts here for your benefit:
"First of all, the non-Medicare private insurance industry is heavily regulated, often more so than Medicare Advantage private insurers. In fact, you raise an important point: it's important to consider which specific regulations are helping and which are hurting. Outside of Medicare Advantage, there are regulations that strictly control insurance company's profit margins, how much of premiums can be spent on collecting medical claims (see: the 80/20 rule and Medical Loss Ratio rules), the fact that every beneficiary must be treated exactly the same (ERISA, parts of ACA), a minimum amount of coverage required (the ACA added this), the employer mandate (ACA), etc.
To give you a sense for some of the unintended consequences that have been created by regulations on non-Medicare Advantage health insurance plans, due to Federal mandates and tax incentives, health insurance is predominately provided by employers rather than the individual market (unlike Switzerland, Germany, or the Netherlands). What we're seeing in healthcare costs is analogous to what you might see happen to airline ticket costs if we all got our air tickets through our employers: the vast majority of us would fly business class, while the unemployed would be simply unable to pay for business class fares out of pocket. A big reason for this is that employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals. If you take this behavior and combine it with the fact that health insurers' profit margins are capped by law, insurers pay more absolute dollars for treatments (which doctors happily accept), charge more to employers (who are generally less price conscious vs individuals), thus bring in more absolute revenue, and therefore more profit because a capped profit percentage of a higher revenue is higher than a capped percentage of lower revenue. It's somewhat counter-intuitive, but the policy combination of an employer mandate and insurance profit cap results in increased prices."
Put simply, the US healthcare industry is not subject to traditional market forces.
> The government is currently failing to address the service provision loss with little political will to decrease list prices (even though they would propagate through to consumers as decreased costs).
It's quite clear that the reason the government is not doing this is because it would further exacerbate the staffing shortage and lead to even higher wait times. That's not a political problem, that's a hard economics problem.
> It seems to me that there's no getting around the need for good governance here. And that lack of it is no excuse for not governing at all.
There is a key governance difference between making the decision to lift distortionary regulations once & up-front so as to unblock efficient resources allocation vs actively having to continuously adjust resource allocation. With the former, you just have to trust that the "good governance" happens once, whereas with the latter, you have to trust that "good governance" happens forever (politics notwithstanding). The Swiss chose the former, whereas the UK struggles with the latter. Domestically in the US, Medicare Advantage is a proven model — and the governance prescription here is to have the entire private insurance industry look more like Medicare Advantage.
> big reason for this is that employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals.
I'm going to call you on this point, because what you're hinting at, whether you realize it or not, is that employers need to step up their medical care spend management game, which if implemented, looks damn near dystopian. As someone that works in insuretech, the number of times I've raised concerns about revealing too much about the shape of medical spend to employers is scary to quantify, because once you start going down that road, it isn't that far to "huh, 20% of our workforce is 80% of spend" hrrrm...
We do not want to be going down the road where employers are singled out as the appropriate optimizers there.
That's not what I'm suggesting at all. The point I'm making is that employers are not capable of being optimizers because they will generally be willing to spend more on medical care than individuals, and it's because they think about money very differently from individuals. Employers are generally able to swallow a premium increase of $15,000 -> $20,000 per employee per year (it just gets rolled up into total compensation). It's usually a drop in the bucket for employers, but to an individual that's actually a lot of money. It's the same reason why corporations typically cover business class (or economy plus) air travel without blinking an eye, whereas many individuals spring for basic economy depending on their willingness to pay. Showing employers the shape of their medical care spend doesn't change that equation all that much for the same reason that enterprises today are willing to spend more on SaaS licenses than individuals (or even small businesses) regardless of how precisely their QuickBooks or NetSuite instance shows them the shape of their SaaS spend. I work in insuretech too, sometimes even work directly with employer HR teams, and see this behavior all the time. We agree that employers should not be the optimizers here. It's not that they need to step up their spend management game, it's that the way they play that game will always be different from the way individuals play that game, and that's a big part of why per capita $'s spent are even able to be so inflated in the first place.
What I'm suggesting is that the proven private sector model is one where employers are simply not involved, not a part of the equation. Private insurance purchased on the individual market. That's exactly how it works in Switzerland, the Netherlands, and also how it works in Medicare Advantage (seniors directly buy their insurance plans using dollars they theoretically set aside over the course of their lifetime through Medicare FICA taxes).
The most practical way to get there, in America, would be to either enact Medicare Advantage For All, or to tweak the employer mandate to only include ICHRAs rather than group health insurance. ICHRAs are employer-sponsored funds (in lieu of employer sponsored insurance) that the employee-beneficiary uses to buy health insurance on the individual market.
Most countries don't have price controls, they have purchasing controls for their Healthcare systems. There is a huge difference.
For example, if someone makes a pill that cost $1 million to live one more day, they can sell it, but most national health services won't buy it.
In the US, the national health services and insurance companies are mandated to buy it, and a byzantine system of price controls ensure we only pay 900k.
A big problem with this approach is that if the price limit makes certain medicines unprofitable to invent and produce, they will not be invented and/or produced.
This is of course already happening since, most of the world has price controls. The US market is probably financing most of the world's medical research, and if we stop paying so much, it may shrink a lot.
As a Canadian I have only know completely socialized healthcare.
One of our largest problems right now is that our system is failing and can’t keep up.
The solutions being rolled out by the provinces to fix the huge backlog of people waiting for care is to privatize more of the service delivery (while keeping single payer).
> France and Switzerland both have universal healthcare
You said private healthcare/insurance were to blame. Switzerland has private health insurance.
Universal healthcare is a separate goal post. For what it’s worth, I’m unclear its comprehensive iteration is compatible with America’s immigration model. (It absolutely is for life-saving measures.)
What aspect of America's immigration model do you think intersects with this?
> You said private healthcare/insurance were to blame. Switzerland has private health insurance.
Private business in all western countries operates within the regulations and laws that cover them. The health insurance industry in Switzerland operates under a very different set of regulations and laws than the same industry in the USA. If you want to blame the OP for not being more explicit - "private healthcare/insurance and the regulatory framework are to blame" - then fine, but ... this is actually the crux of the issue.
I'm not sure it is. Universal healthcare is orthogonal to private health insurance. That's the lesson of Switzerland's example. I don't believe this is commonly known or accepted in American politics. Instead, any attempt at reform is pitched and vilified as an attempt to end private health insurance and healthcare.
It may not be commonly known in the USA. However, I'm a european immigrant of 33 years, and it's well known to me.
However, "private health insurance" is not, in and of itself, really "a thing". Only "private health insurance plus a regulatory structure for it". It is in this department that the US falls over so badly, while, for example, Switzerland gets it (mostly) right.
Switzerland has very strictly and non-deniable obligatory minimum (very broad in coverage) insurance, with regulated yearly price adjustments and on top of that, publicly funded hospitals and clinics (mostly unprofitable but of high quality and offering treatments that would not be profitable for private hospitals) that issue their bills to the health insurances. And, to put the icing on the cake, there are treatments and operations (e.g. congenital defects and invalidity-related) that are directly billed to the public social insurance (funded by salary deductions) to help health insurances reduce their risk.
Switzerland's compulsory private health insurance is nothing comparable to other countries' private insurance. There is "additional private insurance" in Switzerland (covering alternative medicine treatments, access to single bed rooms in hospitals, etc.) which do operate as private insurances elsewhere.
> there are treatments and operations (e.g. congenital defects and invalidity-related) that are directly billed to the public social insurance (funded by salary deductions) to help health insurances reduce their risk.
> Switzerland's compulsory private health insurance is nothing comparable to other countries' private insurance. There is "additional private insurance" in Switzerland (covering alternative medicine treatments, access to single bed rooms in hospitals, etc.) which do operate as private insurances elsewhere.
You're mistaken, Switzerland has no centralized social insurance — it is fully privatized (for real medicine as well as alternative medicine), and is decentralized among its Cantons. It's just that the private Swiss insurers tend to be non-profits (same holds true for the US, e.g. Blue Cross, Kaiser, etc) and the for-profit insurers' profits are heavily capped/regulated (same holds true for the US).
Social insurance is covered by AHV/SVA/IV (funded by salary deductions and cover congenital defects, invalidity, some rehabilitation therapies and other non profitable coverage) and of course healthcare is not fully privatized as you say: private insurances are private, offering highly regulated compulsory insurance and can offer less regulated additional insurance. Some hospitals/clinics/health and elderly centers (cantonal) are kept with public debt & public donations even if deficitary because private clinics would be unprofitable otherwise.
I don't know if you legitimately do not know that.
I did not talk about federal/cantonal to avoid writing a thesis in a comment. I never said it was centralized.
You're conflating Switzerland's social pension with the Swiss health insurance system. Swiss pensions do not subsidize the cost of healthcare delivery, and are not used to cover health costs at the point of service (for real or alternative medicine). The payment of healthcare at the point of service is facilitated by a fully privatized industry of insurers.
Salary deductions pay for subsidies to lower income beneficiaries to purchase the same private health insurance (KV) as everyone else. This is more or less identical to the US's ACA, and in fact the ACA was modeled after the Swiss healthcare system.
The one big difference between the US's ACA and the Swiss healthcare system is that the ACA also included an employer mandate and stimulated a regime in which the majority of working-age adults receive their private health insurance from their employers as opposed to the individual market, which is not how the Swiss KV works.
I guess that you don't know that, for example, if you get operated of a congenital defect in Switzerland, the bill goes to the SVA instead of to your private insurance (and so on for specific cases)
I am not conflating anything, you have a superficial understanding that makes you think it is privatized. If you dig into the spending public & private and the actual details you would see that Switzerland is not privatized as people generally think.
I'm referring to the majority of working age adults.
Even the US uses Medicare for certain congenital diseases as well (as well as end-stage renal disease).
The Swiss private KV system accounts for the vast majority of health expenditure, even more so than the US where half of health expenditure is nationalized in Medicare and Medicaid.
But another way in which Switzerland maintains its healthcare system with public money is through the -often deficitary- cantonal hospitals/clinics/health care centers (also helped at the municipal level)
As a heads up, ‘deficitary’ doesn’t mean ‘deficit running’ in English. It is closer to the word ‘deficient’ which I don’t think is your intended meaning. Thanks for the insightful comments.
Thanks for the comment! I was meaning the former (under debt).
The intention of my comments was to make clear that in that regard, Switzerland is not an efficient free market private insurance paradise. There are lots of nuances to it, and the private insurance system in fact brings in inefficiencies, namely, a very complex and costly cost itemization and enormous amounts of paperwork and stress for doctors, customers, employers, and the insurances (for example, if there is an accident in a public place involving a car, there are at least one or two days worth of people's times just filling in forms)
I'm not sure that your argument makes the case you think it does. The majority of Swiss health expenditure is in the private sector (which differentiates it from many other healthcare systems). Subsidies and municipal market participants do not change that fact. In every industry in the world, the government may play a participatory role within a greater market. We see this in the US in the food industry as well (food stamps, food banks, etc) — but that still doesn't change that it is essentially privatized. If the US adopted, like-for-like, Switzerland's healthcare system, the US's public spending towards healthcare would decrease, not increase.
Fortunately, life-threatening, chronic, bankruptcy-inducing, rare-and-disabling conditions represent a relatively small portion of the total healthcare spending (removing the most widespread chronic conditions). Those are also the least profitable things to insure (require a constant and sustained spending to maintain the knowledge/capability and fund research even if underutilized) if we want to ensure that any human can get reasonable access to those treatments regardless of their wealth. For this reason, countries like Switzerland or Germany maintain a "healthy" public (with lots of adjectives) healthcare system alongside.
This is where you might be out of your element, it seems. Life-threatening / chronic / bankruptcy-inducing conditions do not represent a "relatively small" — at least in the US, 90% of health expenditure is on chronic health conditions (https://www.cdc.gov/chronicdisease/about/costs/index.htm) — this includes heart disease, stroke, cancer, and diabetes. I work in the industry and this comports with what I see on the ground as well.
In Switzerland (and also the Netherlands), the vast majority of this is covered by private health insurance, not via any sort of public health insurance. That's what sets Switzerland and the Netherlands apart from other peer developed countries, and they have results to show for it.
Regarding rare conditions, we agree — even the US has a public healthcare system alongside which covers rare conditions (e.g. end stage renal disease). US's Medicare Advantage system of private individual health insurance for senior citizens (with Original Medicare as a public option) is also a proven model with results to show for it. The CBO expects that by 2032, 61% of health insurance expenditure for senior citizens will be by the private sector (https://www.kff.org/medicare/issue-brief/medicare-advantage-...).
OK - sorry then! That makes total sense too; I was simply reading too much into the payments discussion happening. Thanks for being polite and for your contributions.
But that’s the same as the US. If you are born with a disability you can get social security insurance (SSI) payments that can also qualify for public (Medicaid) insurance.
Blue Cross is sort of a franchise system with different regional/state franchises. All of them were originally nonprofit but many have changed over the years to be for-profit (notably BCBS of California, for example). My local franchise, BCBS of North Carolina is still not for profit: Blue Cross NC is a fully taxed, not-for-profit North Carolina company with major operations centers in Durham, Fayetteville and Winston-Salem.https://www.bluecrossnc.com/about-us
Ah good catch I was moving the goalposts there - I think in my head public and universal and basically interchangeable - if everyone has it is it a public good regardless of if it's provided by a collection of "private" companies
In an analysis we published in 2011, the ratio of social service spending to medical care spending was significantly associated with better health outcomes across 34 OECD (Organization for Economic Cooperation and Development) countries between 2000 and 2005.
and
When comparing state-to-state spending between 2000 and 2009, those states with higher ratios of social service spending to health care spending had better outcomes on average.
Life expectancy is a terrible measure for quality of healthcare. It ignore so many other factors. The only way it could be a suitable measure if you assumed every human in every country was the same except for the healthcare they receive. It's pretty clear they aren't - lifestyle, smoking rates, alcohol and drug abuse, accidents, suicides, genetics.
You’re far better to look at things like “survival after cancer diagnosis” where the US has some of the world’s best outcomes.
OK, so if we assume that, then is public health worse in Europe because smoking rates are higher than the US? How about higher alcohol consumption?
Using life expectancy to judge the quality of a healthcare system or quality of public health efforts is like judging car quality by how nice the body work is. It's a component, but a relatively minor one in overall quality.
You're arguing in circles and not making a lot of sense.
First I argued that life expectancy isn't a good measure because of lifestyle, then you say "public health should address those", then I argued Europe does worse than the US on several public health metrics like smoking rates and alcohol consumption, then you go back to life expectancy.
I have no idea the point your making because you're failing to actually provide counterfactuals.
Private healthcare in France is supplementary to public healthcare and mostly abides by regulations dictating what can be reimbursed by the social security system, there's quite a bit of price control. It only gets wild in niche products (say very fancy dental implants).
"90% of the nation's $4.1 trillion in annual health care expenditures go to people with chronic and mental health conditions"
Obesity is $173 billion, diabetes $327 billion.
We could certainly do much better, but blaming health care cost on metabolic diseases is disingenuous. Diabetes cost is roughly the same percentage of total expenditure as it is in other industrialized nations. (I didn't check obesity)
It stands to reason that really, the problem is the size of the pie, not the size of the slice.
> We could certainly do much better, but blaming health care cost on metabolic diseases is disingenuous.
How so? Only recommendation for all these chronic conditions is 'diet and exercise' is it not ?
Obesity isn't the only one. I am not obese , not even close, but I have hyperlipidemia. I am managing it with 'diet and exercise' after initially being put on statins. Same with hypertension, heart disease ect. All of these are metabolic diseases. Sure, I'll give you 'mental health conditions' may not be a lifestyle disease ( Even those are being now linked to diet ) .
No, "diet and exercise" is not the only recommendation. I don't even know what point you're trying to make there - if that were the only recommendation, health care costs would be fairly low.
And it's not just mental health issues (~25% of all chronic health issues), it's also respiratory issues (~10%).
Then add to that the fact that many metabolic diseases have long lists of causes that amount to "not really sure". Atherosclerosis? Can be caused by physical activity. Hypertension? Being older than 65 is a cause.
What the Rand paper does say is "90% of all health care cost is incurred by people with at least one chronic condition". Not metabolic diseases. What it also doesn't say is that the entire 90% are attributable to chronic diseases. (It's sort of akin to claiming that 10% of all healthcare costs are incurred by people named John, Robert, or James. True, but certainly not causal)
Again, I'm not saying that chronic diseases aren't contributing a huge cost burden. I am saying that they're far from the only cause of the cost burden, and that blaming it on metabolic diseases is highly misleading even if you just focus on chronic diseases.
> No, "diet and exercise" is not the only recommendation.
What else is there though? I consulted many physicians for my hyperlipidemia and all of them suggested 'diet and exercise' as the only solution. It is the only thing that worked for me.
yes 'not all' high cholesterol can be managed by lifestyle modifications( eg: your genetics might predispose you to high cholesterol.
Do you know how much of healthcare spend goes to to the exceptions you are talking about. I certainly couldn't find any data about this, not sure why.
> Hypertension? Being older than 65 is a cause.
Yes we don't know the cause but we do know the fix even if you are over 65.
If "diet and exercise" were the only thing physicians did to treat these diseases, have you tried to think about the internal consistency of your "and at the same time, this is 90% of healthcare costs" argument?
Have you, even for a moment, considered your own statement that your doctor prescribed you statins? Did this not lead you, for a brief nanosecond, to ponder that "maybe other people get treatment beyond diet and exercise too"?
Also, did it occur to you your nows on argument 3? "It's obesity". "It's metabolic diseases". "Actually, I'd like to argue there's no treatment outside of diet and exercise".
Imagine thinking statins are used to 'treat' hyperlipidemia. Statins block the production of cholestrol, they don't treat the disease which is causing your body to produce high cholesterol.
Maybe you need to ponder about the difference between treatment and management, or ask your doctor about it next time. All this was clearly explained to me by doctor when I was started on statins and that only way to treat the disease itself is through lifestyle modifications. Unfortunately, There is a whole swath of idiots on internet who think they know better than doctors and experts.
Thank you for bringing this up. The medical community's intense obsession with people's size and shape over their health causes a lot of misleading conclusions and misguided efforts.
If you walk into the doctor's office underweight and concerned about an issue you're having, the doctor doesn't put you on a strict fettuccine Alfredo and hamburger diet before treating you.
If you're overweight and concerned about an issue, you're far more likely to be told to lose weight and ignored.
Whether or not you're overweight, when you come in they'll take your vitals and run some standard tests until they find something they can treat and medicate for the rest of your life.
You'll be tested for thyroid dysfunction, for diabetes, for hypertension, for all sorts of stuff that won't be on your radar until a blood test turns up "abnormal" results once. Then you'll get pills, all the pills you care to eat and remember, there is no road map for getting off those pills, you'll just get larger doses and more frequent as your problems worsen (because you're not addressing root causes, just being medicated for "treatable" issues which correspond to existing pharmaceuticals.)
The link you posted says that the 90% is to treat all "chronic and mental health conditions," which is a much larger grouping than just obesity/metabolic disease.
Most countries have private healthcare (meaning private providers). Many others have a mix of for profit and non profit insurance companies. There’s not a whole lot of difference between Obamacare and say the system in say the Netherlands, Switzerland, or Japan. Those are also “individual mandate” systems.
