With recent events in the American healthcare industry, let’s hope this can be a rallying call to end privatization of healthcare. Profiteering by holding patients and their families hostage with overly complex payout schemes, “deny, delay, defend” policies aimed at squeezing max profits, and complicating the relationship between patient care, doctors, and hospitals/clinics is beyond unethical. It’s inhumane.
I agree with the problems. I'm a bit uninformed, but in theory ending privatization isn't the only option, right? Hasn't there been problems with corruption in centralized healthcare as well? It seems like regulation could be an option (though I know that it has its own trade-offs as well).
Also, healthcare isn't the only industry suffering this pain though obviously a very important one.
Also, there's a question of how much of this is a cultural problem. How has this sort of thing been addressed in the past? Is the same solution even possible now with the power imbalance created with the current state of capitalism and technology?
regulation is what caused this nonsense. there's no reason for our medical care to be inaccessible for most people in the US. it's sort of like kidnapping or enslaving the entire population who isn't rich.
> there's no reason for our medical care to be inaccessible for most people in the US.
A limited number of physicians, especially general practices? High cost therapies and treatments? Capital-intensive diagnostic devices? Lack of access outside of cities?
There are certainly a lot of things that could be done better, but this isn't 1950 -- some available medical technology is incredibly expensive.
Simply unshackling Medicare/aid and allowing it more freedom to negotiate costs would go a long way towards reducing US health care expenditures.
There's a big difference between training, staffing, and funding free health care when we're talking about a doctor's bag and penicillin vs MRIs and monoclonal antibodies.
> every single other country has free healthcare, lower costs, and better outcomes than USA.
Aside from those first two being mutually exclusive, no, they don't all.
There are a large variety of funding methods, ultimate out of pocket costs, and outcomes throughout the world.
The US is certainly an outlier based on {total spent of healthcare}:{health outcomes}, but it's generally in the middle of the pack in terms of GDP-adjusted out-of-pocket costs. (Mostly as a consequence of private insurance + Medicare/aid)
It's easiest if you sort by decreasing coverage, then look at all the 100% coverage countries, which tend to be developed.
To summarize though, aside from single payer, mandatory public-private hybrid and private are also used.
And you should look into the numbers before making absolute statements.
The facts, in contrast to how you stated it:
- The US spends more per capita on healthcare than many (all?) other countries
- Of that, an average amount is out of pocket (relative to developed country peers)
- The US has some poor metrics, particularly in maternal mortality and lifestyle diseases, but is average on others (relative to developed country peers)
- Because of EMTALA [0], all Americans within range of a hospital (that accepts Medicaid) have access to emergency care, whether or not they're insured. The primary problem with access is the scarcity of rural doctors, especially generalists (an AMA/federal-government problem because of limits put in place in the 80s)
Yes. In the UK the state gets to make the life/death decisions, even if you want to fight for your life they can decide you’re a lost cause and too expensive. There’s no perfect solution here, as one is nihilistic & utilitarian and the other is expensive and rife with greed
Not to be a doomer, but we have very short attention span. News will move on roughly within 2 weeks once we have something more “fun” to discuss. Most of the NA capital understands this, so no change will be experienced. There are very rare exceptions, but if I was a betting guy, i’d bet against.
>Not to be a doomer, but we have very short attention span.
Yea, fixing this would require decades long effort that is extremely difficult without catalyst. Most of European Health Care came about after periods of extreme difficulty like WWI, Great Depression or WWII. Closest US ever came was Great Depression and unlike Europe, US didn't experience massive hardship after WWII.
Pretty much, yeah. Also, since the system technically works, and produces decent results compared to other countries' results... it's a hard sell to rile up super majority of the population for some change.
I'm not saying it's better! I'm saying it's not that far worse off that it would start an introspective for people to question the current state of affairs. Most people get a decent amount of care, despite all the negative side effects (debt, premiums, uncovered areas due to lack of private hospitals and etc.).
A healthcare CEO was just murdered and the killer is considered a hero. Many are even referring to the dead CEO as a serial killer because of all the preventable deaths he profited from. You're not paying attention if you think people aren't already introspective about healthcare in this country.
The killing could have happened to nearly any CEO and the response would be similar. The issue is of wealth inequality, not strictly healthcare, though it certainly exacerbated the response in this particular case. See the social media response to titan submersible deaths.
People say a lot of things, but given there's no action, it's just... words. It's weird for me to say this, as I consider myself a general optimist. But when it comes to navigating layered political structures that involves trillions of dollars, it's hard to believe that anything of significance will be done.
The assassination itself is one hell of an action, though.
Also, police has already said that they are concerned about the lack of cooperation from the public at large when it comes to success of the manhunt. The people who usually jump onto that kind of stuff are explicitly disengaging.
You can argue that this all does nothing wrt navigating the politics that would actually lead to change. But I think that, at the minimum, it creates some incentive for the people who work with those structures on a day to day basis to do so. If CEOs of healthcare companies are now a socially approved assassination target, apparently, what does it say about healthcare lobbyists?
cause and effect may be getting conflated. is the media driving people's attention spans, or are people naturally careless?
i'd prefer to think people care about themselves and others, and are otherwise distracted by trivialities to take their mind off of things, sometimes (hopefully less than 49% of the time) to excess
Yeah, you might be totally right! But in this specific topic, it really doesn't matter. That's much bigger topic of discussion. My point was, most likely people will move on and forget about it once a new hot topic comes up. Everything that could've been said online, has already been said. Markets and people have decided multiple times within US policy making that the way it is structured right now is what people want. It would change a huge outrage to start changing the infrastructure around it.
Unfortunately, i must agree with you. To believe the average person will care or mobilize in a month is naive. We have the attention spans of a toddler and worse we are susceptible to tribal groups which makes change impossible.
um, that's kind of....the diametric opposite of what a majority, somewhat historic in the context that no Republican president has won the popular vote in 20 years, of Americans just voted for.
Look forward to alarming levels of healthcare privatization in the next four years unfortunately with players like Dr Oz (who is explicitly looking to make Medicare Advantage more the default) and Jay Bhattacharya in leading key healthcare roles
> A key part of that strategy is to expand the private Medicare Advantage program and push more and more Medicare recipients into it, leading to a death spiral of traditional public Medicare. The details are spelled out in the Project 2025 blueprint.
> um, that's kind of....the diametric opposite of what an overwhelming majority of Americans just voted for.
Not really. ACA, Medicare, Medicaid, and VA's health insurance programs are all extremely popular among voters.
There are lots of issues on the ballot, and approximately no one was voting for Trump's nonexistent "concept of a plan" for healthcare. Feel free to post evidence of "an overwhelming majority" of people voting for Trump's healthcare plan to back up your initial claim, if you'd like.
By the way, the popular vote had less than a 1.5% margin. There was no "overwhelming majority" in any sense.
This was the 49th largest "overwhelming majority" victory ever by popular vote and the 44th largest victory by Electoral College vote. That is to say: an extremely tight race by any measure.
Opinion polls arent the same as elections and the people voted in favor of expansion of Medicare Advantage whether that's their preference or not.
Considering no Republican president has won the popular vote in 20 years, the relatively small majority popular vote margin is nonetheless quite dramatic in the context of recent history.
Huh? Here's what you said prior to your edit (though your edit isn't actually responsive to my counterargument anyway):
> um, that's kind of....the diametric opposite of what an overwhelming majority of Americans just voted for.
Please substantiate your claim. There was no overwhelming majority, and even if there were, it does not at all mean that people voted for this particular policy. Again: you're free to provide evidence otherwise.
it's not at all the primary point i was making and the army of HN pedants to argue about a particular poorly chosen adjective to pretend somehow that the more important point I made is moot is as usual very tiresome, I edited the post to remove the offending adjective.
It doesn’t matter how popular those programs are. Rich Republicans are furious that their taxes are funding public health care and will stop at nothing to get “their” money back. And now they have full control of the government.
> um, that's kind of....the diametric opposite of what an overwhelming majority of Americans just voted for.
Point taken about the election outcome, but to quibble, it wasn't "an overwhelming majority of Americans". It was a bare majority of voters. Trump got 50% of the vote with 64% turnout, so it was under a third of the eligible voting population, and of course nobody under age 18.
overwhelming majority of Americans just voted for.
Trump won with a plurality of 64% of registered voters which works out to about 45% of the overall population. Put another way, less than a quarter of the population voted for this shit.
I'd much rather follow Germany's model of healthcare (which is privatized) than the UK or Italy's (which is nationalized), having experienced all three and the US's.
I'd wager that America is culturally closer to the UK and Italy than Germany (ironically enough), particularly with regard to our attitudes towards social welfare. A decade after ACA's full implementation, I'm thinking that we maybe can't be trusted with Germany's model. It's all-or-nothing, as far as the greater system goes; sprinkle some private coverage on top for the wealthy, if you must.
Before revolutionizing the system, why not start with capping insurer profits and pay it back to policyholders? That will put a limiter on the greed machine
As I understand it, the ACA caps profits by requiring that insurance companies spend 80% of their revenue on "medical care and quality improvement". Therefore, the only ways for insurance companies to make more money is if they get a lot more customers OR if the price of medical care skyrockets.
I suspect the reason why UHC has decided to deny so many claims is that this will allow them to marginally lower he price of their premiums relative to their competitors. This'll get them more money via method 1. The whole industry is working around the clock on method #2.
That's broadly correct. One of the most under-appreciated wins of the ACA was capping non-care premium costs (read: admin, et al).
From working on automation inside the system at insurers at the time, I can definitively say this spurred health insurers to streamline and lower operational cost overheads.
With regards to the denials, I think you're right too. People like to point at insurers and blame them, but it's easy to forget they're just the middleman.
There's "cost of care" on the other side of them. At the end of the day, premiums need to balance with costs... (somewhat, in aggregate)
There are probably some edge cases where there are opportunities to profit, mostly to do with privately-administered but publicly-funded areas of health insurance (read: FEP and Medicare Advantage), but generally it's trying to get premiums lower for competitive reasons.
Public system has strictly defined coverage and tightly regulated premiums that are explicitly decoupled from individual health conditions and tied to percentage of salary instead. But providers themselves are decentralized and one is free to choose any provider that complies with all the govt requirements. Private providers can and do exist.
In some cases - e.g. self-employment, or income above a certain threshold - one can opt out of the public system and go fully private. Switching back is then only possible if income drops below the threshold. In practice, 90% of the population is in the public system.
The vast majority of germans use statutory health care insurance, with only 10% using private insurance.
Many other aspects of healthcare follow a similar model, where parts are fully private, parts are non-government-but-quite-close-in-function (Ärztekammern and other things) and many to most are public in some sense.
> let’s hope this can be a rallying call to end privatization of healthcare
It would be pretty funny if it ends up being another Shinzo Abe moment where the predominant takeaway is "wait a sec, that murderer kind of had a point".
100%: Nationalize all healthcare providers and facilities. Forgive any outstanding student loans. Expropriate all property used in healthcare delivery. Make medical licensing contingent on public employment. Set up compulsory public housing accommodations at healthcare facilities for every person involved in healthcare delivery. Establish healthcare unions to negotiate working conditions and wages. Use evidence based scientific measurement of expected quality of life years to justify any treatment allowed on a first come first served basis. Anything less is anti-ethical and unhuman.
This reads like the poison pill (mis)characterization of the original version of ACA that killed it. Most of the ideas are good, but you've snuck in a few obvious non-starters.
It's clear that there needs to be some degree of nationalization, though. Middlemen are literally killing us (and now, in a shift that might actually induce a change, getting killed).
Like, "Expropriate all property used in healthcare delivery." wouldn't work for my old dentist who had an office in a retail mall. Or, what of a rural nurse who uses her personal vehicle (reimbursed) to make house calls. A car is property. Or the on-site medical office for a large factory? (True story: I feel off the bike on the way to work on day, doing some contract programming work for a large company. Not only did the medical office check me over, but I got a tetanus shot, both free since I was working there.)
Are acupuncturists part of healthcare delivery?
> Make medical licensing contingent on public employment.
The TV series "The Love Boat" taught me that a large oceangoing cruise ship has a doctor on board, and that seems to be true still. Will this doctor be a public employee? State or federal? Or perhaps a joint employee?
> compulsory public housing accommodations
That sounds like you want to force all health care people to live at their workplace. Plus, what does "involved in healthcare delivery" supposed to include: the janitorial staff? The IT support staff? The food services staff?
> Establish healthcare unions
I've learned that's entirely too underspecified. A company union isn't an effective at negotiating for workers, for example. Plus, repeal Taft-Hartley.
> to justify any treatment allowed on a first come first served basis
That too needs some examination. How does one measure 'quality of life years'? Do rich people have a higher quality of life than poor? Do blind people have a different quality of life than sighted? What about someone bedridden? In a coma?
How are error estimates incorporated? How do we justify a novel experimental treatment which has no use evidence?
Is cosmetic treatment included? How do we measure quality of life for a nose job? For Lasik surgery?
The goals are great, don't get me wrong, but the taskforce is going to need work out the details better than an HN comment, and you might use my feedback to tweak your wording.
No, it’s simple but people lack conviction or maybe coherence in pursuing their beliefs.
If an activity requires a healthcare license, only allow the government to pay for it. Some things are required for healthcare delivery and are not of value outside of those activities. Apply imminent domain law to expropriate those things to prevent fraud on the part of their owners.
The examples of extra-scientific or optional healthcare activities are likewise simple. Establish a lottery for such procedures using any resources not expended to improve existing quality of life years. Current private provision of healthcare resources bids up the fixed pool of providers and causes us all to pay more for life-continuing care.
Ancillary nonmedical services are red herring. Charge back the cost of those services against provider payments. Much of health IT exists as an elaborate method by healthcare providers to justify payments from payors and can be eliminated.
Just because you believe things simple doesn't make it so.
I noticed, for example, that you haven't actually answered my questions.
How do we measure quality of life years in any operationally useful way?
Which healthcare is optional?
Is acupuncture - which requires a healthcare license in some states - included? Why or why not?
How does one expropriate the health care services provided on a cruise ship, and how does it prevent fraud when there is a sole provider of power, water, etc. to said services which can charge whatever they want? Surely you need strict cost controls, but in that case you don't need to expropriate in the first place.
I don't follow what you suggest by the solution to the red herring, so here's a concrete example. I was near-sighted, and paid for new prescription glasses every few years. I decided to get Lasix surgery, which I don't regret, though now I need to get (much cheaper) reading glasses every few years.
Is Lasix for this case non-medical? Who is the provider which would be charged? For that matter, are prescription glasses part of health care, and if so, do people only get basic glasses (like US Army slang "Birth Control Glasses"), or are fancier glasses included, and who pays for the cost difference?
Are breast implants ancillary nonmedical services? Some women find that having larger breasts improves the quality of their lives. Does that make it ancillary or not? What about for women who had a double mastectomy and are depressed about the loss of her breasts? What about gender affirming care for transwomen? What about that guy I saw on TV who got breast implants because he lost a bet?
There are similar issues for cosmetic dental treatment, where fixing a chipped tooth may depend on personal vanity and external perceptions - a model's career may be negatively affected by an ugly-looking tooth. Do we factor in the difference in potential earnings when figuring out quality of life years?
And on and on.
These are not simple problems, and there is no simple answer.
Your typing skills are excellent [0]. Quality of life years is an imperfect measure, but a measure that exists [1] and addresses the current provisioning regime, dubbed “profiteering” [2].
Life’s complications are certainly soluble through relatively simple algorithms. For example, what to do on a cruise ship? Start with “is the care under the jurisdiction of this healthcare regime?” If no, then it is not addressed and entirely up to the individual. If yes, then the person must make their way to the nearest government healthcare facility. I would expect a significant uptake in medical tourism in this form.
Examples like “birth control glasses”: just do the math. Minor likely benefit over a likely long time period for a medium cost. Same for any other example. Will people be unhappy because they value something at more than a standard deviation from the mean? Absolutely, same as people are unhappy now. Not very interesting.
> Aggregate health gains, measured by conventional QALYs, are one of many inputs to the processes of individual clinical decision-making, societal or programmatic audit, or resource allocation. The other considerations, including equity and fairness, need to be considered separately in the conventional QALY approach.
> The assessment of effectiveness is not and can never merely be a technical exercise. Whatever measure of effectiveness is chosen—even one that has the seeming appeal of being “objective,” such as a clinical endpoint—implies a value judgement about the importance of the various aspects of treatment outcomes.
> It is also important to remember that QALYs and their use to estimate incremental cost-effectiveness ratios inform, rather than dictate, decisions. Limitations of QALYs—or, indeed, any chosen alternative to them—can in principle be handled via careful deliberative processes or addressed by the consideration of other kinds of evidence and decision rules, as is typically the case in the HTA processes of many jurisdictions.
My gallop gave specific examples which require value judgements, and therefore cannot be made with "relatively simple algorithms".
"Same for any other example."
You don't seem to understand that no matter what system is used, it's fundamentally driven by political decisions of what is appropriate.
We know that politics means some healthcare systems will prohibit gender affirmation therapy. Can the person go elsewhere, where that is allowed, and pay for said therapy, or does the other system have to accept anyone who shows up, on a first-come-first-served basis?
Your proposal seems to say that there can be no healthcare outside the government system, so those who want chiropractic treatment, those who want acupuncture, etc. are forbidden by law from even using their own money. (I picked these two because while the science doesn't support their efficacy, often require licensed practitioners because doing it wrong can kill people.)
There are not simple solutions, and the longer you insist it's true the more cold shoulders you'll receive.
What’s always missing from these calls to action is: what are you replacing it with? There are a number of healthcare programs across the world and every country has a variety of different problems. There are no silver bullets.
If you want a great read about a few different countries, I recommend The Healing of America by T.R. Reid. It has some suggestions, but in general it is great at illustrating how treating the same illness in different countries can be varied in terms of treatment and cost.
This is true, but some of the problems show up in outcomes and some don’t. Sure, I’d rather not wait six weeks for an appointment. But if you can’t show me any sort of worse health outcomes related to those waits, then that seems like a reasonable tradeoff for single digit percentages of gdp.
As your source notes, the US tends to do average on point of care metrics (e.g. hospital outcomes, versus other similarly developed countries), but worse on lifelong metrics that would conceivably be impacted by income disparity (e.g. life expectancy, maternal mortality).
The metrics the US does poorly on seem like they're more of an access problem (than acute care being bad), which suggests broadening access to affordable healthcare would be the best redress -- i.e. universal healthcare.
The US health system seems like it would be better served by explicitly breaking it into a multi-tier one.
Basic tier: universal health care for basic access and procedurings, including proactive health measures
Everything else: private health insurance available (not attached to an employer)
>"What comes next" doesn't matter when most alternatives would be better.
It really does matter. I'm no fan of our current system either, but by and large people do receive quality healthcare on it. If you rip out that system, you need to replace it with something that's at least meets the same standard.
How would this work for the majority of people? Most people live paycheck-to-paycheck. Even those who make more than enough not to. It's a habit. If health care isn't baked in, will people pay for it? If not, how will they avoid bankruptcy?
Instead of US-style employer + individual paying insurance premium...
... you increase taxes and fund universal insurance directly from those revenues.
In the end, it should hypothetically balance out ($1 for healthcare == $1 for healthcare), except employment would no longer be a precondition for having access to affordable insurance.
> In other words, a number of government surveys just contradict LendingClub’s survey. Why does [politician] choose to believe a survey by a payday lender with a secret methodology, instead of multiple surveys by the U.S. government with transparent methodologies? I guess being ...
I wish people would stop linking Noah Smith substacks. He makes a strawman out of the LendingClub survey and then beats it with surveys that do not contradict the original survey. In fact, a lot of his writings are strawman beatdowns.
Living paycheck to paycheck has low bearing on savings. The LendingClub survey is self reported, and includes people whose finances fluctuate seasonally (they overall live paycheck to paycheck but wind up with random windfalls) and people who maintain a small pile of cash but are always counting on the next paycheck to avoid dipping into their savings. The report even mentions that a chunk of the paycheck to paycheck people are superprime credit consumers, but Noah refuses to stop and think about why that is the case.
I personally know people who very well off who are riding the razor’s edge so to speak- they have huge savings but 100% of income does straight to bills.
How about not tying choosing health insurance to employers. Let’s permit employers reimburse insurance for employees, but put the choice of insurance to employers into the marketplaces. I think it would improve state of things significantly by tying beneficiaries and customers into same person again.
Part of the issue there is group policy. Insurers by the nature of their business prefer blended groups vs individuals, especially when individuals have a choice among insurers.
Or to put it another way, any insurer offering a "better" policy (in terms of more coverage for less money) will attract the highest-consuming patients, individually.
If they sign up groups with less choice, they're more likely to get a balanced cohort of consumers / non-consumers, young / old, etc. etc.
US healthcare problem is cost disease starting around 50 years ago.
You just can't beat O(2) function with linear policies. You must make it cost less - but making it costing less means everyone in the healthcare is making less. So there will be massive resistance to any kind of change. You could achieve slightly more healthcare for money spent, but you can't meaningfully reduce costs.
No argument from me other than to say: you've just described every public-private partnership, ever.
The seemingly inevitable part-privatization we're now facing for Social Security and Medicare is nothing more than the wealthy looting the public purse.
> No argument from me other than to say: you've just described every public-private partnership, ever.
This is patently untrue. The entity that paid for my 2yr college was a public-private partnership. It was administered by the Dept of Labor. The private end was a mix of businesses and philanthropy that wanted to better align education and careers.
Funding was predicated on students completing degrees and a period of related employment. It was tremendously successful. It was also immediately axed when the 'Contract with America' took effect.
“Public-private partnership” normally refers to public money going to private enterprise. I’m not sure what private money going to quasi-public higher ed, publically administered(?) would qualify as.
I can't speak to the specifics of whatever program you went through. Whatever it is, I'm glad it worked out for you.
But my question is: why does college cost anything? Particularly more vocational courses, which 2 year Associate's degrees tend to be.
We have a model for this: the military. You pick a job, they train you to do that job and then you do that job. There is absolutely no reason why education can't be this accessible to everyone.
There are an awful lot of people who are either the wealthy who are exploiting the working class or, way more likely, they think they someday will be:
> “John Steinbeck once said that socialism never took root in America because the poor see themselves not as an exploited proletariat but as temporarily embarrassed millionaires.
Why else would people fight so hard against Jeff Bezos paying slightly more in taxes? Jeff would use you as fertilizer or reactor shielding if it ticked up profits. You are not and will never be Jeff Bezos.
HN just skews to people who aspire to be the exploiters.
This is why I groan when people talk about, say, how the government needs to "incentivize" increased building volume in order to solve the housing crisis. If you accept the argument that there's a shortage of physical units (and not just a shortage of affordable units that haven't been converted to rentals, or just simply kept off the market)... the real estate market is never going to kneecap itself. No matter how much money we give them. The government needs to start building houses. Directly. Whatever loss is incurred will pale in comparison to the costs (social and otherwise) of another few decades of paying private corporations not to solve the problem.
We REALLY should have learned our lesson after what happened with the broadband rollout in the early 2000s.
I always believed a good president would declare a national emergency. Deploy the military, national guard, ect and begin a massive housing campaign. Imagine what can be built in 5 years time.
Traditional Medicare plus a type F supplement covers just about everything at 100%. Except hearing aids, glasses, and dental work. You can go to any doctor that accepts Medicare.
"Medicare Disadvantage" is an HMO scheme, with limited doctor lists and lots more limiting rules. Avoid.
The ACA lets people get healthcare insurance who are not otherwise eligible for it, for example: part-time workers, independent contractors, employees of companies with fewer than 50 employees, temporarily unemployeed (fired, laid off, switching careers or jobs), people who have lost coverage because their spouse lost coverage. That's a pretty broad swath of people!
Some people qualify for a tax subsidy that can be anywhere from $0 to the entire cost of a plan, depending on their income. A unique feature is that the subsidy is based on your expected income for the upcoming year, but if you make less than that (are laid off for example) or more (independent contract gets an unexpected contract), the subsidy is adjusted when you file your taxes.
Currently the ACA does not accept anyone who has a policy through work. IMO, every should have the option of getting ACA healthcare coverage. If their work coverage is better or cheaper, they can stick with that, but if their work coverage is worse or more expensive, employees should be allowed to get ACA coverage, with the employer paying part or all of the subsidy (what they would have paid to a private insurance company for the employee) instead of just the government.
Great article that does justice to the complexity and nuances of the system.
From the underlying report that's cited [0]:
>> We include uncorrected coding intensity and favorable selection in our analysis so that the MA
and FFS populations are comparable. Because benchmarks do not account for these adjustments,
it is also unlikely that plan bids assume the effects of uncorrected coding and favorable selection. With these adjustments, we project that benchmarks in 2024 are 132 percent of [traditional Medicare fee-for-service / FFS] spending (i.e., the amount that would have been spent on MA enrollees if they were in FFS).
>> Overall, plan bids — 14 percent of which are projected to be nonmedical expenses for administration and profit — in 2024 are an estimated 101 percent of FFS spending.
>> Thus, though MA plans have lower medical costs than FFS, these projected efficiencies are offset by plans’ projected administration costs and profits.
>> In total, we project that plans will offer the standard Medicare benefit at about the same cost as FFS in 2024, which implies that the majority of extra benefits for MA enrollees are not financed by plans offering the benefit at lower costs than FFS, but rather by the taxpayers and beneficiaries who fund the program. Overall, we estimate that coding and selection cause MA payments to be 22 percentage points above FFS spending in 2024. That difference translates into MA payments that are a projected $83 billion above FFS spending in 2024.</i>
Trump has promised to end social security and medicare. We can't believe anything he says, buy maybe ending medicare could somehow end private insurance and the indentured servitude of Americans? Currently most Americans have to be employed to have access to the worst system in the first world ...
This is about Medicare Advantage [0] specifically, and how it's apparently more costly than traditional Medicare, even after accounting for confounding factors.
Why? If medicare is ended and there's no more private insurance, MA also would cease to exist. You're just bad at comprehension and probably didn't read the article based on context.
What logical leap am I missing here? Ending Medicare would do absolutely nothing to change the fact that most Americans receive private insurance through their employer, it would just result in 67 million people losing their insurance.
because medicare is a giant bandaid on the problem that is private health care. so removing the bandaid may cause the evil system to collapse through revolt or otherwise.
public greenbacks (that got lincoln wacked), privately printed fedmoney with taxes as part of the scam, or sam altman types hitting the 'make more crypto' send key.
With recent events in the American healthcare industry, let’s hope this can be a rallying call to end privatization of healthcare. Profiteering by holding patients and their families hostage with overly complex payout schemes, “deny, delay, defend” policies aimed at squeezing max profits, and complicating the relationship between patient care, doctors, and hospitals/clinics is beyond unethical. It’s inhumane.
I agree with the problems. I'm a bit uninformed, but in theory ending privatization isn't the only option, right? Hasn't there been problems with corruption in centralized healthcare as well? It seems like regulation could be an option (though I know that it has its own trade-offs as well).
Also, healthcare isn't the only industry suffering this pain though obviously a very important one.
Also, there's a question of how much of this is a cultural problem. How has this sort of thing been addressed in the past? Is the same solution even possible now with the power imbalance created with the current state of capitalism and technology?
regulation is what caused this nonsense. there's no reason for our medical care to be inaccessible for most people in the US. it's sort of like kidnapping or enslaving the entire population who isn't rich.
> there's no reason for our medical care to be inaccessible for most people in the US.
A limited number of physicians, especially general practices? High cost therapies and treatments? Capital-intensive diagnostic devices? Lack of access outside of cities?
There are certainly a lot of things that could be done better, but this isn't 1950 -- some available medical technology is incredibly expensive.
Simply unshackling Medicare/aid and allowing it more freedom to negotiate costs would go a long way towards reducing US health care expenditures.
I.e. doing for more payments what the Inflation Reduction Act allowed Medicare to do for (a limited number of) drugs: https://www.cms.gov/files/document/fact-sheet-medicare-selec...
umm... what? do you think there was free healthcare in the 50s in the US?
every single other country has free healthcare, lower costs, and better outcomes than USA.
There's a big difference between training, staffing, and funding free health care when we're talking about a doctor's bag and penicillin vs MRIs and monoclonal antibodies.
> every single other country has free healthcare, lower costs, and better outcomes than USA.
Aside from those first two being mutually exclusive, no, they don't all.
There are a large variety of funding methods, ultimate out of pocket costs, and outcomes throughout the world.
You'd probably find this an interesting read: https://ourworldindata.org/financing-healthcare
The US is certainly an outlier based on {total spent of healthcare}:{health outcomes}, but it's generally in the middle of the pack in terms of GDP-adjusted out-of-pocket costs. (Mostly as a consequence of private insurance + Medicare/aid)
which first world countries don't have single payer health care?
usa has by far highest cost and worst outcomes. practically speaking, most americans don't have access to medical care.
All the countries listed here? https://en.m.wikipedia.org/wiki/Health_care_systems_by_count...
It's easiest if you sort by decreasing coverage, then look at all the 100% coverage countries, which tend to be developed.
To summarize though, aside from single payer, mandatory public-private hybrid and private are also used.
And you should look into the numbers before making absolute statements.
The facts, in contrast to how you stated it:
- The US spends more per capita on healthcare than many (all?) other countries
- Of that, an average amount is out of pocket (relative to developed country peers)
- The US has some poor metrics, particularly in maternal mortality and lifestyle diseases, but is average on others (relative to developed country peers)
- Because of EMTALA [0], all Americans within range of a hospital (that accepts Medicaid) have access to emergency care, whether or not they're insured. The primary problem with access is the scarcity of rural doctors, especially generalists (an AMA/federal-government problem because of limits put in place in the 80s)
[0] https://en.m.wikipedia.org/wiki/Emergency_Medical_Treatment_...
Also https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope.... This mistake made some 20 years ago is a festering problem today.
Yes. In the UK the state gets to make the life/death decisions, even if you want to fight for your life they can decide you’re a lost cause and too expensive. There’s no perfect solution here, as one is nihilistic & utilitarian and the other is expensive and rife with greed
Not to be a doomer, but we have very short attention span. News will move on roughly within 2 weeks once we have something more “fun” to discuss. Most of the NA capital understands this, so no change will be experienced. There are very rare exceptions, but if I was a betting guy, i’d bet against.
>Not to be a doomer, but we have very short attention span.
Yea, fixing this would require decades long effort that is extremely difficult without catalyst. Most of European Health Care came about after periods of extreme difficulty like WWI, Great Depression or WWII. Closest US ever came was Great Depression and unlike Europe, US didn't experience massive hardship after WWII.
Pretty much, yeah. Also, since the system technically works, and produces decent results compared to other countries' results... it's a hard sell to rile up super majority of the population for some change.
> and produces decent results compared to other countries' results
What metrics are you looking at?
I'm not saying it's better! I'm saying it's not that far worse off that it would start an introspective for people to question the current state of affairs. Most people get a decent amount of care, despite all the negative side effects (debt, premiums, uncovered areas due to lack of private hospitals and etc.).
A healthcare CEO was just murdered and the killer is considered a hero. Many are even referring to the dead CEO as a serial killer because of all the preventable deaths he profited from. You're not paying attention if you think people aren't already introspective about healthcare in this country.
The killing could have happened to nearly any CEO and the response would be similar. The issue is of wealth inequality, not strictly healthcare, though it certainly exacerbated the response in this particular case. See the social media response to titan submersible deaths.
People say a lot of things, but given there's no action, it's just... words. It's weird for me to say this, as I consider myself a general optimist. But when it comes to navigating layered political structures that involves trillions of dollars, it's hard to believe that anything of significance will be done.
The assassination itself is one hell of an action, though.
Also, police has already said that they are concerned about the lack of cooperation from the public at large when it comes to success of the manhunt. The people who usually jump onto that kind of stuff are explicitly disengaging.
You can argue that this all does nothing wrt navigating the politics that would actually lead to change. But I think that, at the minimum, it creates some incentive for the people who work with those structures on a day to day basis to do so. If CEOs of healthcare companies are now a socially approved assassination target, apparently, what does it say about healthcare lobbyists?
> we have very short attention span
> News will move on
it's not up to the news (the media and their owners) to tell us what is important...
Maybe yes, maybe no, but people will need something new to talk about, so media will move on.
cause and effect may be getting conflated. is the media driving people's attention spans, or are people naturally careless?
i'd prefer to think people care about themselves and others, and are otherwise distracted by trivialities to take their mind off of things, sometimes (hopefully less than 49% of the time) to excess
Yeah, you might be totally right! But in this specific topic, it really doesn't matter. That's much bigger topic of discussion. My point was, most likely people will move on and forget about it once a new hot topic comes up. Everything that could've been said online, has already been said. Markets and people have decided multiple times within US policy making that the way it is structured right now is what people want. It would change a huge outrage to start changing the infrastructure around it.
> a huge outrage to start changing the infrastructure around it
that's my "tuesday" :) (infra)
Oh, it's my today :( (infra)
がんばりましょう!
Unfortunately, i must agree with you. To believe the average person will care or mobilize in a month is naive. We have the attention spans of a toddler and worse we are susceptible to tribal groups which makes change impossible.
um, that's kind of....the diametric opposite of what a majority, somewhat historic in the context that no Republican president has won the popular vote in 20 years, of Americans just voted for.
Look forward to alarming levels of healthcare privatization in the next four years unfortunately with players like Dr Oz (who is explicitly looking to make Medicare Advantage more the default) and Jay Bhattacharya in leading key healthcare roles
https://prospect.org/health/2024-11-26-dr-oz-stealth-destruc...
> A key part of that strategy is to expand the private Medicare Advantage program and push more and more Medicare recipients into it, leading to a death spiral of traditional public Medicare. The details are spelled out in the Project 2025 blueprint.
> um, that's kind of....the diametric opposite of what an overwhelming majority of Americans just voted for.
Not really. ACA, Medicare, Medicaid, and VA's health insurance programs are all extremely popular among voters.
There are lots of issues on the ballot, and approximately no one was voting for Trump's nonexistent "concept of a plan" for healthcare. Feel free to post evidence of "an overwhelming majority" of people voting for Trump's healthcare plan to back up your initial claim, if you'd like.
By the way, the popular vote had less than a 1.5% margin. There was no "overwhelming majority" in any sense.
This was the 49th largest "overwhelming majority" victory ever by popular vote and the 44th largest victory by Electoral College vote. That is to say: an extremely tight race by any measure.
Opinion polls arent the same as elections and the people voted in favor of expansion of Medicare Advantage whether that's their preference or not.
Considering no Republican president has won the popular vote in 20 years, the relatively small majority popular vote margin is nonetheless quite dramatic in the context of recent history.
Huh? Here's what you said prior to your edit (though your edit isn't actually responsive to my counterargument anyway):
> um, that's kind of....the diametric opposite of what an overwhelming majority of Americans just voted for.
Please substantiate your claim. There was no overwhelming majority, and even if there were, it does not at all mean that people voted for this particular policy. Again: you're free to provide evidence otherwise.
it's not at all the primary point i was making and the army of HN pedants to argue about a particular poorly chosen adjective to pretend somehow that the more important point I made is moot is as usual very tiresome, I edited the post to remove the offending adjective.
Your primary point is there is strong public sentiment toward healthcare privatization.
There is no evidence of this claim.
If you have any, please provide it. You attempted to provide the election which is not valid evidence for several reasons.
There is no evidence of a mandate from the public in the direction you’re suggesting there is.
It doesn’t matter how popular those programs are. Rich Republicans are furious that their taxes are funding public health care and will stop at nothing to get “their” money back. And now they have full control of the government.
I don't disagree with this. I was taking issue with the characterization that the American people actually want this.
> um, that's kind of....the diametric opposite of what an overwhelming majority of Americans just voted for.
Point taken about the election outcome, but to quibble, it wasn't "an overwhelming majority of Americans". It was a bare majority of voters. Trump got 50% of the vote with 64% turnout, so it was under a third of the eligible voting population, and of course nobody under age 18.
Trump won with a plurality of 64% of registered voters which works out to about 45% of the overall population. Put another way, less than a quarter of the population voted for this shit.
I'd much rather follow Germany's model of healthcare (which is privatized) than the UK or Italy's (which is nationalized), having experienced all three and the US's.
I'd wager that America is culturally closer to the UK and Italy than Germany (ironically enough), particularly with regard to our attitudes towards social welfare. A decade after ACA's full implementation, I'm thinking that we maybe can't be trusted with Germany's model. It's all-or-nothing, as far as the greater system goes; sprinkle some private coverage on top for the wealthy, if you must.
Before revolutionizing the system, why not start with capping insurer profits and pay it back to policyholders? That will put a limiter on the greed machine
As I understand it, the ACA caps profits by requiring that insurance companies spend 80% of their revenue on "medical care and quality improvement". Therefore, the only ways for insurance companies to make more money is if they get a lot more customers OR if the price of medical care skyrockets.
I suspect the reason why UHC has decided to deny so many claims is that this will allow them to marginally lower he price of their premiums relative to their competitors. This'll get them more money via method 1. The whole industry is working around the clock on method #2.
Anyone more informed, feel free to correct me.
That's broadly correct. One of the most under-appreciated wins of the ACA was capping non-care premium costs (read: admin, et al).
From working on automation inside the system at insurers at the time, I can definitively say this spurred health insurers to streamline and lower operational cost overheads.
With regards to the denials, I think you're right too. People like to point at insurers and blame them, but it's easy to forget they're just the middleman.
There's "cost of care" on the other side of them. At the end of the day, premiums need to balance with costs... (somewhat, in aggregate)
There are probably some edge cases where there are opportunities to profit, mostly to do with privately-administered but publicly-funded areas of health insurance (read: FEP and Medicare Advantage), but generally it's trying to get premiums lower for competitive reasons.
Oh I wasn’t aware of this, thanks for describing the mechanics
I'm not familiar with Germany's model. Can you give a brief explanation?
Health insurance is mandatory.
Public system has strictly defined coverage and tightly regulated premiums that are explicitly decoupled from individual health conditions and tied to percentage of salary instead. But providers themselves are decentralized and one is free to choose any provider that complies with all the govt requirements. Private providers can and do exist.
In some cases - e.g. self-employment, or income above a certain threshold - one can opt out of the public system and go fully private. Switching back is then only possible if income drops below the threshold. In practice, 90% of the population is in the public system.
The vast majority of germans use statutory health care insurance, with only 10% using private insurance.
Many other aspects of healthcare follow a similar model, where parts are fully private, parts are non-government-but-quite-close-in-function (Ärztekammern and other things) and many to most are public in some sense.
> let’s hope this can be a rallying call to end privatization of healthcare
It would be pretty funny if it ends up being another Shinzo Abe moment where the predominant takeaway is "wait a sec, that murderer kind of had a point".
> end privatization of healthcare
100%: Nationalize all healthcare providers and facilities. Forgive any outstanding student loans. Expropriate all property used in healthcare delivery. Make medical licensing contingent on public employment. Set up compulsory public housing accommodations at healthcare facilities for every person involved in healthcare delivery. Establish healthcare unions to negotiate working conditions and wages. Use evidence based scientific measurement of expected quality of life years to justify any treatment allowed on a first come first served basis. Anything less is anti-ethical and unhuman.
This reads like the poison pill (mis)characterization of the original version of ACA that killed it. Most of the ideas are good, but you've snuck in a few obvious non-starters.
It's clear that there needs to be some degree of nationalization, though. Middlemen are literally killing us (and now, in a shift that might actually induce a change, getting killed).
Typists like you killed a person with lies like “Middlemen are literally killing us.”
Some things don't seem practical.
Like, "Expropriate all property used in healthcare delivery." wouldn't work for my old dentist who had an office in a retail mall. Or, what of a rural nurse who uses her personal vehicle (reimbursed) to make house calls. A car is property. Or the on-site medical office for a large factory? (True story: I feel off the bike on the way to work on day, doing some contract programming work for a large company. Not only did the medical office check me over, but I got a tetanus shot, both free since I was working there.)
Are acupuncturists part of healthcare delivery?
> Make medical licensing contingent on public employment.
The TV series "The Love Boat" taught me that a large oceangoing cruise ship has a doctor on board, and that seems to be true still. Will this doctor be a public employee? State or federal? Or perhaps a joint employee?
> compulsory public housing accommodations
That sounds like you want to force all health care people to live at their workplace. Plus, what does "involved in healthcare delivery" supposed to include: the janitorial staff? The IT support staff? The food services staff?
> Establish healthcare unions
I've learned that's entirely too underspecified. A company union isn't an effective at negotiating for workers, for example. Plus, repeal Taft-Hartley.
> to justify any treatment allowed on a first come first served basis
That too needs some examination. How does one measure 'quality of life years'? Do rich people have a higher quality of life than poor? Do blind people have a different quality of life than sighted? What about someone bedridden? In a coma?
How are error estimates incorporated? How do we justify a novel experimental treatment which has no use evidence?
Is cosmetic treatment included? How do we measure quality of life for a nose job? For Lasik surgery?
The goals are great, don't get me wrong, but the taskforce is going to need work out the details better than an HN comment, and you might use my feedback to tweak your wording.
No, it’s simple but people lack conviction or maybe coherence in pursuing their beliefs.
If an activity requires a healthcare license, only allow the government to pay for it. Some things are required for healthcare delivery and are not of value outside of those activities. Apply imminent domain law to expropriate those things to prevent fraud on the part of their owners.
The examples of extra-scientific or optional healthcare activities are likewise simple. Establish a lottery for such procedures using any resources not expended to improve existing quality of life years. Current private provision of healthcare resources bids up the fixed pool of providers and causes us all to pay more for life-continuing care.
Ancillary nonmedical services are red herring. Charge back the cost of those services against provider payments. Much of health IT exists as an elaborate method by healthcare providers to justify payments from payors and can be eliminated.
Just because you believe things simple doesn't make it so.
I noticed, for example, that you haven't actually answered my questions.
How do we measure quality of life years in any operationally useful way?
Which healthcare is optional?
Is acupuncture - which requires a healthcare license in some states - included? Why or why not?
How does one expropriate the health care services provided on a cruise ship, and how does it prevent fraud when there is a sole provider of power, water, etc. to said services which can charge whatever they want? Surely you need strict cost controls, but in that case you don't need to expropriate in the first place.
I don't follow what you suggest by the solution to the red herring, so here's a concrete example. I was near-sighted, and paid for new prescription glasses every few years. I decided to get Lasix surgery, which I don't regret, though now I need to get (much cheaper) reading glasses every few years.
Is Lasix for this case non-medical? Who is the provider which would be charged? For that matter, are prescription glasses part of health care, and if so, do people only get basic glasses (like US Army slang "Birth Control Glasses"), or are fancier glasses included, and who pays for the cost difference?
Are breast implants ancillary nonmedical services? Some women find that having larger breasts improves the quality of their lives. Does that make it ancillary or not? What about for women who had a double mastectomy and are depressed about the loss of her breasts? What about gender affirming care for transwomen? What about that guy I saw on TV who got breast implants because he lost a bet?
There are similar issues for cosmetic dental treatment, where fixing a chipped tooth may depend on personal vanity and external perceptions - a model's career may be negatively affected by an ugly-looking tooth. Do we factor in the difference in potential earnings when figuring out quality of life years?
And on and on.
These are not simple problems, and there is no simple answer.
Your typing skills are excellent [0]. Quality of life years is an imperfect measure, but a measure that exists [1] and addresses the current provisioning regime, dubbed “profiteering” [2].
Life’s complications are certainly soluble through relatively simple algorithms. For example, what to do on a cruise ship? Start with “is the care under the jurisdiction of this healthcare regime?” If no, then it is not addressed and entirely up to the individual. If yes, then the person must make their way to the nearest government healthcare facility. I would expect a significant uptake in medical tourism in this form.
Examples like “birth control glasses”: just do the math. Minor likely benefit over a likely long time period for a medium cost. Same for any other example. Will people be unhappy because they value something at more than a standard deviation from the mean? Absolutely, same as people are unhappy now. Not very interesting.
0. https://en.wikipedia.org/wiki/Gish_gallop
1. https://pmc.ncbi.nlm.nih.gov/articles/PMC317370/
2. https://news.ycombinator.com/item?id=42359960
Despite what you believe, I really am trying to highlight why your advocacy will likely go nowhere.
I thank you for pointing out QALYs. I had not heard of it. I have read now a few journal articles, and none of them say that QALYs stand alone. For example, https://onlinelibrary.wiley.com/doi/10.1111/j.1524-4733.2009... says:
> Aggregate health gains, measured by conventional QALYs, are one of many inputs to the processes of individual clinical decision-making, societal or programmatic audit, or resource allocation. The other considerations, including equity and fairness, need to be considered separately in the conventional QALY approach.
Or https://www.valueinhealthjournal.com/article/S1098-3015(24)0... is more recent article, from earlier this year, titled "Quality-Adjusted Life Years, Quality-Adjusted Life-Year-Like Measures, or Neither? The Debate Continues"
> The assessment of effectiveness is not and can never merely be a technical exercise. Whatever measure of effectiveness is chosen—even one that has the seeming appeal of being “objective,” such as a clinical endpoint—implies a value judgement about the importance of the various aspects of treatment outcomes.
> It is also important to remember that QALYs and their use to estimate incremental cost-effectiveness ratios inform, rather than dictate, decisions. Limitations of QALYs—or, indeed, any chosen alternative to them—can in principle be handled via careful deliberative processes or addressed by the consideration of other kinds of evidence and decision rules, as is typically the case in the HTA processes of many jurisdictions.
My gallop gave specific examples which require value judgements, and therefore cannot be made with "relatively simple algorithms".
"Same for any other example."
You don't seem to understand that no matter what system is used, it's fundamentally driven by political decisions of what is appropriate.
We know that politics means some healthcare systems will prohibit gender affirmation therapy. Can the person go elsewhere, where that is allowed, and pay for said therapy, or does the other system have to accept anyone who shows up, on a first-come-first-served basis?
Your proposal seems to say that there can be no healthcare outside the government system, so those who want chiropractic treatment, those who want acupuncture, etc. are forbidden by law from even using their own money. (I picked these two because while the science doesn't support their efficacy, often require licensed practitioners because doing it wrong can kill people.)
There are not simple solutions, and the longer you insist it's true the more cold shoulders you'll receive.
To quote a great play: “what comes next”?
What’s always missing from these calls to action is: what are you replacing it with? There are a number of healthcare programs across the world and every country has a variety of different problems. There are no silver bullets.
If you want a great read about a few different countries, I recommend The Healing of America by T.R. Reid. It has some suggestions, but in general it is great at illustrating how treating the same illness in different countries can be varied in terms of treatment and cost.
This is true, but some of the problems show up in outcomes and some don’t. Sure, I’d rather not wait six weeks for an appointment. But if you can’t show me any sort of worse health outcomes related to those waits, then that seems like a reasonable tradeoff for single digit percentages of gdp.
We have one of the worst healthcare systems in the developed world. "What comes next" doesn't matter when most alternatives would be better.
Most people won't agree on what that next system is so there isn't enough momentum to change it.
Do you have a source for that — what makes our healthcare systems "one of the worst"?
Lower life expectancy, higher infant and mother mortality, large numbers of untreated diabetes and other treatable illnesses
For example: https://www.kff.org/health-policy-101-international-comparis...
But a basic google search returns hundreds of sources
All for the highest cost per person, in the world
To be fair, there's an extremely strong correlation between GDP and absolute health care spending, regardless of underlying funding money.
And the US is near the top of the GDP rankings.
GDP and health spending is correlated and forms a nice line (see diagram below), but US spending is nowhere near that line.
https://www.kff.org/health-policy-101-international-comparis...
As your source notes, the US tends to do average on point of care metrics (e.g. hospital outcomes, versus other similarly developed countries), but worse on lifelong metrics that would conceivably be impacted by income disparity (e.g. life expectancy, maternal mortality).
The metrics the US does poorly on seem like they're more of an access problem (than acute care being bad), which suggests broadening access to affordable healthcare would be the best redress -- i.e. universal healthcare.
The US health system seems like it would be better served by explicitly breaking it into a multi-tier one.
Basic tier: universal health care for basic access and procedurings, including proactive health measures
Everything else: private health insurance available (not attached to an employer)
cost and outcomes. In aggregate, Americans pay much more and get worse outcomes
Careful there - it’s quite likely the incoming administration will pick one of those few that isn’t better
>"What comes next" doesn't matter when most alternatives would be better.
It really does matter. I'm no fan of our current system either, but by and large people do receive quality healthcare on it. If you rip out that system, you need to replace it with something that's at least meets the same standard.
If it were me I would do baby steps. Make it so health insurance isn't tied to your employment first.
How would this work for the majority of people? Most people live paycheck-to-paycheck. Even those who make more than enough not to. It's a habit. If health care isn't baked in, will people pay for it? If not, how will they avoid bankruptcy?
Public funding. Plenty of countries do this.
Instead of US-style employer + individual paying insurance premium...
... you increase taxes and fund universal insurance directly from those revenues.
In the end, it should hypothetically balance out ($1 for healthcare == $1 for healthcare), except employment would no longer be a precondition for having access to affordable insurance.
> Most people live paycheck-to-paycheck
Not in any meaningful sense.
https://www.noahpinion.blog/p/paycheck-to-paycheck-and-five-...
> In other words, a number of government surveys just contradict LendingClub’s survey. Why does [politician] choose to believe a survey by a payday lender with a secret methodology, instead of multiple surveys by the U.S. government with transparent methodologies? I guess being ...
Wow 40 percent of Americans have THREE months instead of ONE month of expense money saved up. Truly thunderous debunking by Noah Smith.
I wish people would stop linking Noah Smith substacks. He makes a strawman out of the LendingClub survey and then beats it with surveys that do not contradict the original survey. In fact, a lot of his writings are strawman beatdowns.
Living paycheck to paycheck has low bearing on savings. The LendingClub survey is self reported, and includes people whose finances fluctuate seasonally (they overall live paycheck to paycheck but wind up with random windfalls) and people who maintain a small pile of cash but are always counting on the next paycheck to avoid dipping into their savings. The report even mentions that a chunk of the paycheck to paycheck people are superprime credit consumers, but Noah refuses to stop and think about why that is the case.
I personally know people who very well off who are riding the razor’s edge so to speak- they have huge savings but 100% of income does straight to bills.
How about not tying choosing health insurance to employers. Let’s permit employers reimburse insurance for employees, but put the choice of insurance to employers into the marketplaces. I think it would improve state of things significantly by tying beneficiaries and customers into same person again.
Part of the issue there is group policy. Insurers by the nature of their business prefer blended groups vs individuals, especially when individuals have a choice among insurers.
Or to put it another way, any insurer offering a "better" policy (in terms of more coverage for less money) will attract the highest-consuming patients, individually.
If they sign up groups with less choice, they're more likely to get a balanced cohort of consumers / non-consumers, young / old, etc. etc.
The NHS in the UK costs less per capita than CMS currently spends.
Fire many administrators and managers over there, put a lot of them in prison and tell them to start again.
Putting a lot of people in prison sounds expensive, but still cheaper than American health care.
Need to do something with all the savings over the current system.
US healthcare problem is cost disease starting around 50 years ago.
You just can't beat O(2) function with linear policies. You must make it cost less - but making it costing less means everyone in the healthcare is making less. So there will be massive resistance to any kind of change. You could achieve slightly more healthcare for money spent, but you can't meaningfully reduce costs.
Counterpoint: there are opportunities for harvesting efficiencies by eliminating middlemen (read: private insurers and price negotiators)
The US system is convoluted enough that I wouldn't be surprised if they're bringing negative value simply by existing.
Especially since with computerization, there's no need to have an entire company to track and route paper.
Medicare Advantage is a siphon from Medicare funds to corporate shareholders under the guise of for profit efficiency.
No argument from me other than to say: you've just described every public-private partnership, ever.
The seemingly inevitable part-privatization we're now facing for Social Security and Medicare is nothing more than the wealthy looting the public purse.
> No argument from me other than to say: you've just described every public-private partnership, ever.
This is patently untrue. The entity that paid for my 2yr college was a public-private partnership. It was administered by the Dept of Labor. The private end was a mix of businesses and philanthropy that wanted to better align education and careers.
Funding was predicated on students completing degrees and a period of related employment. It was tremendously successful. It was also immediately axed when the 'Contract with America' took effect.
“Public-private partnership” normally refers to public money going to private enterprise. I’m not sure what private money going to quasi-public higher ed, publically administered(?) would qualify as.
I can't speak to the specifics of whatever program you went through. Whatever it is, I'm glad it worked out for you.
But my question is: why does college cost anything? Particularly more vocational courses, which 2 year Associate's degrees tend to be.
We have a model for this: the military. You pick a job, they train you to do that job and then you do that job. There is absolutely no reason why education can't be this accessible to everyone.
It's a description of a toxic partnership. Not all partnerships are toxic.
I don't know why you're being downvoted.
Public private partnerships at the Federal level have historically just been elaborate grafts to enrich the already wealthy at everyone's expense.
Ever read The Shock Doctrine?
All PPP have levels of grift. The only ones that don't have overwhelming bureaucracy oversight that makes them really, really inefficient and costly.
In almost all cases, it's better for the state to build themselves, then lease/rent to private companies, or operate themselves in some cases.
Basically free market is shit at central planning, and the state is shit at offering diversity and finding out preferences.
We know why.
There are an awful lot of people who are either the wealthy who are exploiting the working class or, way more likely, they think they someday will be:
> “John Steinbeck once said that socialism never took root in America because the poor see themselves not as an exploited proletariat but as temporarily embarrassed millionaires.
Why else would people fight so hard against Jeff Bezos paying slightly more in taxes? Jeff would use you as fertilizer or reactor shielding if it ticked up profits. You are not and will never be Jeff Bezos.
HN just skews to people who aspire to be the exploiters.
This is why I groan when people talk about, say, how the government needs to "incentivize" increased building volume in order to solve the housing crisis. If you accept the argument that there's a shortage of physical units (and not just a shortage of affordable units that haven't been converted to rentals, or just simply kept off the market)... the real estate market is never going to kneecap itself. No matter how much money we give them. The government needs to start building houses. Directly. Whatever loss is incurred will pale in comparison to the costs (social and otherwise) of another few decades of paying private corporations not to solve the problem.
We REALLY should have learned our lesson after what happened with the broadband rollout in the early 2000s.
I always believed a good president would declare a national emergency. Deploy the military, national guard, ect and begin a massive housing campaign. Imagine what can be built in 5 years time.
You'll never guess which corporate entity got caught siphoning too much federal money via Medicare Advantage fraud...
https://www.nytimes.com/2017/02/16/business/dealbook/unitedh...
Also, here's a longer read about the same topic. The fraud wasn't limited to a single insurer, but some have been more blatant than others.
https://www.newyorker.com/magazine/2019/02/04/the-personal-t...
I am shocked, shocked!
Traditional Medicare plus a type F supplement covers just about everything at 100%. Except hearing aids, glasses, and dental work. You can go to any doctor that accepts Medicare.
"Medicare Disadvantage" is an HMO scheme, with limited doctor lists and lots more limiting rules. Avoid.
The ACA lets people get healthcare insurance who are not otherwise eligible for it, for example: part-time workers, independent contractors, employees of companies with fewer than 50 employees, temporarily unemployeed (fired, laid off, switching careers or jobs), people who have lost coverage because their spouse lost coverage. That's a pretty broad swath of people!
Some people qualify for a tax subsidy that can be anywhere from $0 to the entire cost of a plan, depending on their income. A unique feature is that the subsidy is based on your expected income for the upcoming year, but if you make less than that (are laid off for example) or more (independent contract gets an unexpected contract), the subsidy is adjusted when you file your taxes.
Currently the ACA does not accept anyone who has a policy through work. IMO, every should have the option of getting ACA healthcare coverage. If their work coverage is better or cheaper, they can stick with that, but if their work coverage is worse or more expensive, employees should be allowed to get ACA coverage, with the employer paying part or all of the subsidy (what they would have paid to a private insurance company for the employee) instead of just the government.
Great article that does justice to the complexity and nuances of the system.
From the underlying report that's cited [0]:
>> We include uncorrected coding intensity and favorable selection in our analysis so that the MA and FFS populations are comparable. Because benchmarks do not account for these adjustments, it is also unlikely that plan bids assume the effects of uncorrected coding and favorable selection. With these adjustments, we project that benchmarks in 2024 are 132 percent of [traditional Medicare fee-for-service / FFS] spending (i.e., the amount that would have been spent on MA enrollees if they were in FFS).
>> Overall, plan bids — 14 percent of which are projected to be nonmedical expenses for administration and profit — in 2024 are an estimated 101 percent of FFS spending.
>> Thus, though MA plans have lower medical costs than FFS, these projected efficiencies are offset by plans’ projected administration costs and profits.
>> In total, we project that plans will offer the standard Medicare benefit at about the same cost as FFS in 2024, which implies that the majority of extra benefits for MA enrollees are not financed by plans offering the benefit at lower costs than FFS, but rather by the taxpayers and beneficiaries who fund the program. Overall, we estimate that coding and selection cause MA payments to be 22 percentage points above FFS spending in 2024. That difference translates into MA payments that are a projected $83 billion above FFS spending in 2024.</i>
[0] p373 https://www.medpac.gov/wp-content/uploads/2024/03/Mar24_Ch12...
Trump has promised to end social security and medicare. We can't believe anything he says, buy maybe ending medicare could somehow end private insurance and the indentured servitude of Americans? Currently most Americans have to be employed to have access to the worst system in the first world ...
This is about Medicare Advantage [0] specifically, and how it's apparently more costly than traditional Medicare, even after accounting for confounding factors.
[0] https://en.m.wikipedia.org/wiki/Medicare_Advantage
i don't understand why you would reply to me with a definition of MA. it's laid out plainly in thousands of words in the article.
Because Medicare and Medicare Advantage are two different systems, only one of which is hybrid-private?
So you might want to be more specific in what you're talking about in your original comment, re: Medicare.
Why? If medicare is ended and there's no more private insurance, MA also would cease to exist. You're just bad at comprehension and probably didn't read the article based on context.
What logical leap am I missing here? Ending Medicare would do absolutely nothing to change the fact that most Americans receive private insurance through their employer, it would just result in 67 million people losing their insurance.
because medicare is a giant bandaid on the problem that is private health care. so removing the bandaid may cause the evil system to collapse through revolt or otherwise.
TLDR: Medicare Advantage's payment rules "overpay insurance companies," according to the article, "on the taxpayer’s dime."
public greenbacks (that got lincoln wacked), privately printed fedmoney with taxes as part of the scam, or sam altman types hitting the 'make more crypto' send key.