I'd like to believe this, but the study makes a bunch of really hasty assumptions.
The authors derive the $1T number from $1.3T in total cost savings and $304B in incremental spend (incremental spend is due to insuring more people). The $1.3T in cost savings come from five big buckets: lower pharmaceutical prices, Medicare-level payments to providers, reduced administrative overhead, less fraudulent billing, and fewer avoidable emergency department visits and hospitalizations.
The buckets themselves don't necessarily survive much scrutiny.
Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
The line item of "fewer avoidable emergency department visits and hospitalizations" assumes greater insurance coverage leads to greater access to primary care. It's true that great primary care prevents hospitalizations, and can be a net cost saving under certain assumptions [1]. But, we're actually in a primary care shortage. Existing insurance payments for primary care are low enough that private practices are going out of business and fewer residents are going into family medicine. Cutting rates (the paragraph above) would make this worse.
For "less fraudulent billing," a lot of people in the industry believe that Medicare has a large amount of undetected fraud. That's unfortunately the flip-side of reduced administrative overhead. The authors assume an 8% savings here, but the 2003 paper they cite uses the word "fraud" only twice and doesn't give a number.
>> Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
You arent considering
1. Hospitals eating the cost of the uninsured, which this would solve
2. Hospital spending tons on administrative duties fighting with insurers on coverage, which this would reduce
A lot of the reason hospitals have to charge so much is that they take massive losses on uninsured people in emergency rooms. Medicare for all means they don't have to treat anyone for free.
They are not taking any losses; they just charge the regular price with a very tiny profit margin. US healthcare costs are heavily inflated. Insurance is a scam that lets the rich get richer. All insurance should be non-profit.
We all contribute to the pool at a time when we don't need it so we can use the money when we do, not to make CEOs or stockholders rich. That is how an insurance pool should work. Any excess money at the end of the year should be moved to the pool for the next year, not as a bonus on CEOs' 100m+ salary.
No, this absolutely does not explain the US's wildly off-base per-capita expenditure because uninsured people still go in the denominator of the per-capita figure! I'm sure the per-insured-capita figure is worse but that's not what we are comparing!
Americans are constantly trying to exclude uninsured people from their statistics (and, worse, from the care itself) but the comparable countries don't do this so it is utterly ridiculous to propose that the correct statistical comparison is one in which the US excludes the undesirables while other countries don't.
That claim is at odds with the working paper's methodology, which gets a good chunk of the $1T in savings it discussed by assuming very sharp cuts to practitioner compensation.
A lot of the rest of the reasons are carrying the deadweight of administering regulation, and dancing with the existing and prospective malpractice suits that randomly benefit the system sometimes, but always cost everybody, and warp the practice of medicine and patient healthcare experiences.
It also means that emergency rooms can be used just for emergencies and ongoing and preventative care can happen in clinics. Cheaper to operate and preventing preventable emergencies lowers the load.
Healthcare reform isn’t actually hard. Every advanced country has done it bar the United States.
In every case costs have gone down and outcomes have improved.
You always build on what you have because you can’t pause healthcare for very obvious reasons.
Hence a lot of different systems all with the same aim. Controlled costs and universal coverage.
The idea the US is somehow different and cannot make the change is the result of propaganda and a mistaken belief that the current Us system is the worlds best despite its costs.
Healthcare reform is easy and there is an ocean of prior art.
Yeah, and they all generally get there by paying practitioners much less than the US does (by integer multiples). Single-payer, which this working paper equates with "universal coverage", is in fact not the norm among universal systems; besides using Medicare to ration the supply of practitioners, the original sin of our system is employer-based coverage, not payer structure.
Health care is an absolutely massive industry (everywhere, not just in the United States), and slashing compensation in a massive industry by top-down fiat is in fact not an especially easy thing to do.
I think for the math to work you have to consider the bigger bulk of work that could be eliminated by universal healthcare: the payer industry. Insurers, PBMs, and all the smaller sectors that support them. The utility provided to society is fairly low — basically, just selective claims denial.
Any model that gets rid of these frees up a huge swath of capital and work from society, and can use that work elsewhere. Of course, that is easier said than done.
Truly. Aetna, United Healthcare, Anthem, etc are examples of industry that does not need to exist, and exist only to serve the status quo.
Each of those are companies worth billions of dollars that could be instead used to lower the individual cost of providing health insurance.
As you say, this would of course be unsavory in some respects as those companies employ a lot of people. It's not a very economically productive industry though, the main output seems to be consuming patients' and doctors' time, causing financial anguish, and causing stress among people as to whether or not if their condition will be covered.
You can search for more reports, because they do vary based on methodology. But the median hospital in the US makes between -1% (yes, negative, they lose money, because a huge percentage are non profits) and 4% depending on the source.
When the hospital charges you $37 for an aspirin, that singular pill might have a crazy profit margin in isolation. But your entire treatment could very well be losing the hospital money.
In my own anecdotal experience, the one hospital I know enough details about to comment on specifically, had something like 85% of patients costing the hospital more money than the hospital made. It was entirely funded by the relatively small number of people who had the “right” insurance and had the “right” procedures done.
On the occasions that I’ve watched a hospital go through the actual process of selling a small amount of inexpensive medication for a large amount of money, there is a ridiculous amount of ceremony involved. I can easily imagine that it costs that hospital 2 cents for the pill, $5 in amortized capital plus operating expense for the facility that stores that pill, plus $25 in labor and IT expenses to get that pill to the patient.
Audited financial statements of all kinds of hospitals, both non-profit and for-profit. Here’s data from Moodey’s a credit rating agency: https://www.chartis.com/insights/hospital-margins-trend-high... (“This month, Moody’s credit rating agency released its annual not-for-profit and public healthcare median financial report for 2024, showing that overall hospital performance continues to improve. The median operating margin increased from 0.5% in 2023 to 1.5% in 2024.”).
The $37 for an aspirin offsets huge costs elsewhere for (non-NP) nurses, receptionists, janitors, orderlies, etc., who can’t bill directly to medicare.
Insurance pays the higher of their negotiated rate or the billed charge. Medical facilities set their billed rates so high that they’re guaranteed to be higher than all negotiated rates, ensuring that they get paid.
When you see $37 aspirin on the line, nobody actually pays $37 for it. The billed amount is replaced with whatever insurance rate is allowed for that. If someone is cash paying they get a large discount.
The billed items also have to cover everything. It’s not directly $37 for the aspirin, or the $5 or whatever allowed coverage it ultimately gets billed it. That had to cover the facilities, the salaries of the pharmacy staff who reviewed the request and dispensed it, the staff who inventory and order the medications, and the cost of billing insurance.
The only part that nationalized health care would change are the allowable billed rate and maybe the administrative overhead of billing different insurances. Even nationalized health care systems have admin overhead though.
You can think of it like when you have to pay $11 for a single glass of wine from a bottle that the restaurant paid $10 for. You’re not just paying for the liquid, you are paying into a big bucket of charges that all need to add up to more than the cost of the supplies, staff, building, and everything that goes into running it. The margin on individual products doesn’t make the entire operation profitable.
It comes from the fact that lots of the charges they bill (both of the patient share billed to insured patients and of all costs billed to uninsured patients) end up written down or off because they are uncollectable.
The margin built into the prices bulled is not the actual margin the hospital ends up with.
Hospital billing practices are often terrible or even fraudulent, but stories about the $37 aspirin are generally misleading. Most hospital claims and bills are actually coded around day rates and DRGs, so even if the aspirin shows up as a line item it doesn't actually impact the patient's financial responsibility or the amount allowed by their health plan. (I'm not trying to defend such a confusing system, just explaining how it works.)
Medicare has been playing a shell game with reimbursements for decades. They cut the base rate for an office visit or hospital stay to below the cost of the actual service, but allow for separate charges for various things that make up the difference so that doctors don't just stop accepting Medicare in mass. That's why you get billed $37 dollars for aspirin, $15 for drug administration, $50 for IV placement, $10/bag for saline drips, $75 for vitals checks, etc. That way the hospital can make up the money lost from the actual visit charge, this also requires more administration overhead, to both keep track of all the additional charges, and to make changes as the rules change.
You understand that hospitals have more costs than just aspirin, right? Depreciation, amortization, utilities, rent, taxes, maintenance, salaries, etc...
Ever hear of loss leaders? Some parts of a typical hospital make money while others lose it hand over fist. The overall margin isn’t across the board, it’s after everything hopefully balances out.
ER’s for example are money pits, but society really needs them.
Hospitals, now that private equity is involved, do this weird cost shifting accounting BS with shell companies etc, as such their books aren’t straight forward and the 2-5% thing is likely greatly underestimated given the amount of understaffing PE has driven in that space and how much gouging there is from PBM etc.
Hand-waving numerous details, but - That $37 isn't the price in the hospital's gift shop. It's n=1 pricing, hand delivered to your bedside by a nurse with a whole hierarchy of higher-level medical & admin staff behind her, and documented out the wazoo. Aspirin could be free & unlimited at the hospital pharmacy's receiving dock, and it wouldn't affect the @bedside price.
Even if universal health coverage lost money it would be better than the current system that is based on a "causing cancer is better for the GDP than curing it" mentality.
The US has top-tier cancer survival-after-diagnosis outcomes. We spend too much to get there, and other countries in our cohort would "argue" that we get those numbers in part by diagnosing earlier and that our outcomes are broadly similar, but if you're going into these debates with "the US private health care system causes cancer deaths", that's a pretty rebuttable argument.
There is a ton of ideology baked into naive-level analysis of this stuff.
I am constantly told how much less Europeans pay for better health outcomes and all I can think about was the obesity crisis I grew up around in Texas.
Socializing healthcare isn’t going to get an huge portion of the population out of their cars and get them walking as a primary or secondary mode of transportation. Not when it’s 100° and the grocery store is five miles away.
Americans, in no small part, have worse health outcomes because we have dramatically worse lifestyles. I support German-style universal healthcare, but I’m not going to pretend it will suddenly give us German health outcomes.
>Socializing healthcare isn’t going to get an huge portion of the population out of their cars and get them walking as a primary or secondary mode of transportation
You would think so but once healthcare cost becomes a government policy issue people complain about its spending and they are forced to try and bring that cost down. One of the ways they did that in my country was to promote biking to work and build bike ways.
I'm curious where you got this figure, because it doesn't track with my own experience.
I used to work for a place that worked closely with hospital clients (and prospective clients) to resolve billing issues with a particular EMR system, and we regularly discovered that a given hospital was losing hundreds of thousands to millions of dollars weekly due to missing charges. The problem was, so much money was sloshing around that the hospitals were virtually always unaware of the missing charges, and many CIOs were more interested in saving face by shutting down further discussion than in walking through the collected data, how to fix the charging issues, and even claw back some of the lost charges (which you can generally do up to several months after the fact).
FWIW, your experience doesn't seem contradictory to the operating margin claims.
Your experience seems to be that hospitals are run very inefficiently, implying that if they were run efficiently that their operating margins would be much higher than 2-5%. That may be the case, but that still means the Yale paper's claims don't make sense (unless they also propose some mechanism by which to suddenly force all hospitals to start operating efficiently).
But I'm also skeptical of your claim that hospitals are leaving a huge amount of operating margin on the table. IME, very little can be explained by "everyone is stupid." Would I be surprised if a given hospital was run very inefficiently or if a given hospital had a particular poor CIO or administrator? Not in the slightest. Would I be surprised if ALL hospitals were run by idiots who were leaving 10% operating margin on the table? Yes, I would be.
I don't spend any healthcare money at the hospital. It's all all providers office, private clinic, etc.
It costs $300 for my primary care doctor to see me for about 7 minutes. An assistant takes my blood pressure, he asks me a few questions about my habits and diet, and then I come back next year.
If I actually need any services, I go to much more expensive specialist, or urgent care facility. A visit there is about $100 and then a couple bucks for whatever prescription they give me.
How does this work when many/most US hospitals operate as non-profits? Quick search shows the for-profits have operating margins nearly triple your figures. And the non-profits are beholden to the community to provide some level of "freebies" to maintain their status, right? IE, they're aren't really all operating on razor thin margins.
I don't think a price transparency reform would be hard. Other than in terms of political will. We did go part of the way there a few years ago, though it's not common knowledge yet.
Are you saying that most hospitals have 50% profit margins, of which 90% are paid to the chairman leaving only a thin margin? That seems difficult to believe.
They may have 4.2% margins knocked down to 4% by exec comp but I don't see that how that fact would change OPs point.
> Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
I mean, admin costs at hospitals are ~25%, around half of that is directly linked to billing. Administrative costs in the US (because of course you have the same costs on the other side in the insurance side) are around 30% of cost in general, which is pretty insane.
The lack of regulation around pricing transparency and generally the lack of one-price-per-code (which the government uses to its "advantage" to get lower medicaid/medicare rates for sure) is what has caused this stupid arms race on both sides.
Billing and insurance ("BIR") is reported at around 8.5% of revenue --- admin isn't just BIR, as you note. But replacing private insurance with Medicare doesn't drive BIR to zero; Medicare is also a claims-based system. Estimates are that you'd cut BIR by somewhere around 30-40% (of 8.5%).
Most of the savings in these kinds of reports simply comes from paying doctors less (or delivering fewer procedures, which is also a problem we have.)
Yes, these cost savings would be a deflationary event. Most layoffs will come from insurance companies and administration necessary to satisfy them in hospitals.
One reason hospitals have such low margins is many people simply can't pay. If you have a payment guarantee like a medicare for all system, this will increase the stability of hospitals. In fact likely bring back some hospitals in places that didn't make sense like rural areas, which have been struggling via hospital closures.
If you are worried a low cost system will reduce doctors and hospitals per capita you don't need to, as countries that have universal healthcare often have more per capita.
The US' healthcare model is not unique, and almost no countries have zero-cost-to-consumer healthcare systems (and none of them are free -- they're just paid by taxpayers instead of consumers). "Free" healthcare is the exception rather than some kind of international norm you incorrectly make it out to be.
The first step to reforming US healthcare is actually understanding it, and understanding some international designs. Lying about it doesn't help.
People wouldn't be externalities if healthcare costs money. Next thing you know you would have to pay attention to the environment or god forbid the food. It would eat away the budget for overthrowing countries and bombing children. Watch them elect a democrat to do the bombing next round and a new republican after that. It sounds like a joke but it isn't funny.
I don't see you complaining that the US military has a low operating margin, so maybe we can just agree that some things are just normal expenses for a population. Which therefore leads to step 2: nationalize every single hospital.
>cutting salaries for doctors/nurses/etc
Considering that over 50% of the money that goes into healthcare is just siphoned off by middlemen, no, just getting rid of these means that your health workers do not have a worse salary.
>But, we're actually in a primary care shortage.
Because people do not even go see their GP since there's a chance it leads to life ruining expenses.
> fewer residents are going into family medicine.
Because they're going where money is. Remove that from the equation, and all you have is a public service with public servants.
>a lot of people in the industry believe that Medicare has a large amount of undetected fraud.
Aside from the fact that "people in the industry" have a financial interest in making you believe Medicare is a net negative, there's a great thing that comes from making healthcare a public service: there's no longer any fraud. And those "fraudulent" expenses you used to have that were costing you millions anyways have just had their costs cut in half.
>Healthcare reform is hard.
It's the easiest thing in the world when you have the amount of money the US does. Healthcare reform isn't a financial or infrastructure problem, it's a political one. Cuba has a working healthcare system despite being under US embargo. Botswana has a working healthcare system. Rwanda has a working healthcare system. Azerbaijan, Sri Lanka, Turkey, Serbia, and the list goes on.
Once you grow the balls to nationalize everything, even a first year economy student could make a plan that works.
Every country with nationalized healthcare systems has lower wages for clinicians. So the notion that this wouldn't lower salaries is just ludicrous. That might be an acceptable trade-off but let's not pretend it doesn't exist.
In practice what we would see under a single-payer system is that many doctors would opt out and shift to a cash payment model. So the shortage of doctors would get even worse for patients who can't afford to pay out of pocket.
Yes, I consider big numbers like this to be red flags.
The GDP of the US is $32T. Saving $1T will essentially make 3% of the US economy vanish. You don't vanish 3% of an economy without wide ranging repercussion, it would be a crisis similar in scale to that of 2008.
With such numbers we are not "saving money", these are about rebuilding an entire economy, a painful process. So either the effect will be much smaller than that, or there will be riots.
This is broken window fallacy. The $1T not wasted on healthcare inefficiencies would be spent/invested on other things, creating jobs there. Yes, there would be churn because a good number of people involved in the bureaucracy of private health insurance would lose their job and possibly their career. But these things get smoothed out. Social supports (should) exist to dampen the effects of such churn and keep the economy agile.
We're quick to want to automate trucking, manufacturing, even knowledge jobs and say "ooh but the horse shoe maker became the tire installer" but the pointless middleman jobs making everyone's health worse seems to be the line in the sand for job automation.
You can't touch the legions of people who exist to make things more expensive.
Only the American mind can comprehend leading to the deaths of tens of thousands of your own people for the sake of 3% of your economy. As long as the line goes up.
If we're taking the $1T figure seriously, let's take the other figure seriously too. Let's slash it to be more conservative while we're at it and say it would only save 90k lives. Do you think 3% of your economy is worth sacrificing to prevent the equivalent of 30 9/11s? And that's before considering that other people here already explained how these 3% are offset by other gains - if not completely then still substantially.
The money doesn't vanish. It stays in the hands of people. People who would spend it on other things, feeding it into the wider economy instead of the pockets of a small number of corporations. There's zero reason to think this would result in anyone rioting except maybe insurance company CEOs.
I mean there's flavors of contributions to gdp. Spending money on make work for people digging holes still counts. I wouldn't mind 1 trilly being freed up for more effective use. I imagine we could get pretty good returns on it just paying it against the debt as a simple idea, effectively a tax cut.
You can quibble with the specific projected savings, or the projected lives saved. But it kinda doesn't matter? If we can have net savings of half what this paper said, or a quarter, and still have more lives saved, that would still be a strong argument to do it.
Somewhere there's a pareto-optimal frontier where one can't possibly save more lives without spending more, or spend less without more people having negative health outcomes ... and the question is whether universal health coverage would be a step towards that frontier (b/c we're all pretty sure we're far from the frontier today). And the fact that plenty of countries have both lower costs and better outcomes through such a system is highly suggestive that it is a more efficient policy regime.
Maybe the big quibble is whether the American penchant for creating corporate givewaways to powerful organizations that lobby politicians would create an especially toxic public-private-partnership monopoly in which the biggest existing private healthcare networks are granted regional monopolies and set crazy prices (or some other dystopian warping of an initially reasonable idea) so costs actually balloon. I do think that would be a risk and so we need to be careful about the specifics of how we implement this.
Of course it does, but only one country has to keep commissioning and ignoring studies to work out a group of 300million people can get better prices for everything if the incentive for the government is to decrease the price rather than increase it for their buddies
We've been down this road. ACA was predicated on studies like this, to no avail (it turns out that intense opposition chips away at it over time regardless of these studies).
I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
I'm not saying that this is what is happening now, but I am saying that calls for universal health coverage, no matter how correct and well supported, are going to probably face the same obstacles they did last time, so we need new coalitions and implementation proposals if we're going to give it a go again. It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to.
ACA has saved tons of lives. Due to the intense opposition, it was not structured in a way that could save money, but rather structured in the way that it could get through congress.
Additionally, as somebody who was around pre-ACA, I can not tell you how much better, in every single way, the post-ACA healthcare world is. Pre-existing conditions? Access to healthcare as an individual? These are life-changing possibilities, especially for entrepreneurs.
There's a very clear type of fallacy you are engaging in here that only works in politics: you're taking a vague general idea X, ignoring all particulars, and then lumping an idea Y together as if they identical and that any change in that general direction of Y could ever be different than what happened with X. There's no intellectual rigor or honesty in that sort of thinking, yet it somehow pops up throughout all of politics.
>Additionally, as somebody who was around pre-ACA, I can not tell you how much better, in every single way, the post-ACA healthcare world is. Pre-existing conditions? Access to healthcare as an individual? These are life-changing possibilities, especially for entrepreneurs.
The failures and politicization of the ACA have caused us to be a little too dismissive of its successes and popularity.
Protections for pre-existing conditions and allowing children to stay on family plans until 26 in particular have made an incredible difference in a lot of people's lives and are wildly popular. So much so that it would be close to political suicide to try to remove them as evidence by Republicans controlling all three branches of government including both chambers of Congress and there is no serious talk of repealing them.
There is belief among a lot of its supporters that universal healthcare would have a similar wave of support if enacted and that the opposition is mostly irrational political arguments rather than people's true feelings about an actual policy. This is why the "ACA" polls higher than "Obamacare" despite those being two terms for the same legislation.
I agree with you about the ACA (as an opponent of single-payer). Prior to the ACA, members of my immediate family were uninsurable on the individual market --- not insurable at a higher rate, not insurable with exclusions, but literally uninsurable: their only options were employer-provided group coverage or state catastrophic safety net coverage programs. The twist: neither has any chronic health conditions. The underwriting refusals were based on symptoms reported in previous engagements with the health care system.
Before I went indie, prior to ACA requirements I researched private insurance and found plans for around $3K. This year I’ll pay over $20K for a bronze plan for my family. 700% increase in less than a decade. Aetna left the marketplace input state and no pediatrician in a 10 mile radius takes the most cost effective ACA plan. The pediatricians we found are actually just GPs who have training in pediatric medicine, but we bring in the only minors they see. This is in a top-5 market based on population.
All of the providers have consolidated. I don’t know if ACA affected that or not, but wait times for checkups went from later this afternoon to sometime 6 months from now.
Part of my experience is going from corporate health insurance to marketplace, but in the past 5 years, ACA plans have consistently gotten worse and more expensive while service for those plans has gotten significantly worse in almost every way.
No system that saves money can pass in congress: that's the real problem that we cannot actually avoid. Forget pressure from large companies: So many of US costs come from very high salaries, and a lot of bureaucratic positions that don't exist elsewhere. Every dollar we pay goes to someone, and it's not just some random mogul here or there that will be OK anyway. Reform that really lowers prices means loss of jobs, which them will be blamed on the politicians who signed the bill into law.
ACA also greatly increased costs. As an entrepreneur at the time, insurance premiums increased 25% overnight for the same plan. Many people had similar experiences.
That the ACA forced a large number of people to pay a lot more for literally the same product is not a good outcome for those people. Too many people try to pretend this didn't happen.
I lost my individual healthcare plan, and I couldn’t afford the new ones. Remember when they said you could keep your plan? Yeah, that’s the one I lost.
Keep in mind, I made no value judgement on ACA at all, just suggested that we learn about its opposition and, as you rightly point out, the difficulty of passing such legislation that can last over time.
I agree that "To no avail" could be read as "was worthless" to an adversarial reader, but trust me when I say it was meant as "which didn't save it from being opposed and stripped over time". As in "the studies and facts don't move the politics"
It should be obvious the messaging is oppositional along party lines. Every chip away at ACA makes it a worse program, and is celebrated by half the electorate. This is a core problem with the legislation. A second iteration on top, or in place, would have to learn from this and work to make the program stickier.
Let’s be honest, it was DOA. Even Gruber admitted to it later. The whole thing was basically a scam.
Edit: I will never understand why people think ACA was so great. It was a bad policy because they couldn’t get it through whole. They passed it with all the compromises that made it DOA. You can’t fix something when you are still in denial about it being bad. ACA is not a transition to universal healthcare when you allowed massive consolidation in the space with some of the biggest companies in this country. Good luck deconstructing that mess.
Republicans finalized things to address medical costs and chiseling at hospital billing - regulations promulgated during Democrat regimes - so I would say there is bipartisan consensus for the actual arguments, if people listened to the actual arguments instead of seeing a no-vote as an opposite nonsensical ideology.
This has been one of the opposition points - don't just give a handout to insurance companies without addressing their billing practices
The original ACA did not have consensus for some of the proposals to address the billing practices such as existing and new state healthcare programs having collective bargaining. And yeah I think the original ACA was unworkable, compromise is taught as a good thing to children in this country, but it just means "the wrong answer".
The tweaks now, alongside the original democrat led ACA, alongside the parts that were stripped out I think could have better consensus
does need a rebranding though.
The only thing that will actually lower costs in our society is healthy people. And right now, everyone is unhealthy and not doing preventative measures due to expense.
The real problem with universal healthcare is that it immediately completely eradicates religious charity.
Any single mom who works as a stripper can go see a doctor who doesn't have the slightest inclination to judge- you're just a number in a government database.
Everyone's getting free shit no questions asked.
It was the Medicaid expansion that has been cited as saving lives [0]. An expansion that has almost nothing to do with the rest of the ACA.
> "There's a very clear type of fallacy you are engaging ... There's no intellectual rigor or honesty in that sort of thinking"
So you're claiming that the person who posted that is not only falling into a fallacy, but they are neither intellectually rigorous or honest? I think you're reading a lot into their comment which seemed pretty benign, but possibly contrary to your viewpoint?
These types of studies, and the goals they aim to support, always frustrate me as solving a surface-level problem rather than root cause.
The problem with US healthcare isn't who pays for it, its how damn expensive it is. As always there are multiple factors at play, my list would include corruption, lack of legal accountability/responsibility, and a population that is much less healthy than reasonable.
Go after any one of those and we'd make a lot more headway than trying to ram through a universal, government-run healthcare or insurance program. And yes, such a program could impact the above topics, but it doesn't have to and could make any of them worse.
The point of nationalisation is to address those underlying concerns. But it’s fair to say that in practice, nationalisation doesn’t always solve those problems.
The problem is you either need to regular or nationalise. And neither of those are particularly “American”.
I haven't finished reading the paper and have no opinions on it (other than that most successful universal systems aren't single-payer) but if we start from actual numbers the discussion will be better.
> The problem with US healthcare isn't who pays for it, its how damn expensive it is
Exactly! There's so much paperwork that a doctor sometimes need two assistants just for the paper work. There's so much cost for independent practice that increasingly more doctors end up joining big hospitals. Charges with and without insurance have a huge difference. Just to name a few.
I have a strong dislike for the industry as a whole. There's too many ridiculous situations I've been subject to, along with hearing of some from my friends.
My favorite was a friend who had to deliver her baby, alone, in a hallway, because they forgot about her. And the hospital billed her for it. LOL.
We never attempted to solve the issue of distorted price signals that occur when customers aren't the ones paying for something. We're still charging $600 for a bag of saline.
It's extremely challenging to go after high costs in the current system, because the doctors who charge them are popular and the insurance companies who pay them are hated. There was a 2024 story that stuck in my mind (https://www.npr.org/2024/12/05/nx-s1-5217617/blue-cross-blue...) when Anthem tried to negotiate down the rate of certain anesthesia procedures; the public was absolutely outraged, successfully demanding that Anthem must back down and accept whatever the doctors feel is the appropriate pricing model.
I agree that this proposal would not solve all of the problems; absent more changes you would still see the creep up of healthcare costs at too high a rate. But slashing $1 trillion off of a $5.3 trillion costs is a pretty big bite of the apple. Even if you go with the more conservative $663 number, that is still a great first step. And both of those numbers are after adding the costs of covering currency uncovered people. So we are collectively getting more for significantly less money.
It does this by eliminating a very inefficient layer of our current system (insurance companies), and by having there replacement for that (the government) negotiate on drug prices (how much savings there is the reason there are two estimates). Currently insurance companies almost have a negative incentive to push down drug prices (their profits are limited to a percentage of total spending, and most large companies are pushing against that limit).
Most of the cost control pressures in our current system come out of Medicare/Medicade, and this would widen that out to the whole system. That in turn would wedge open the door to pushing on the other drivers of the cost spirals: hospital administration, new expensive drugs that are not worth the additional costs, doctor salaries ballooning, and the broken system between malpractice insurance and dysfunctional enforcement against malpractice.
ACA is not Universal Health Coverage. So this would be different enough. And you don't need perpetual majority control, only sensible politicians for about a generation (like FDR/Truman/Eisenhower/JFK) to lock in a popular entitlement.
FDR and "sensible" is always funny to me. The sensible politician that imprisoned Japanese Americans, destroying the lives of 120,000 of our fellow citizens.
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
You mean like overturning Roe v. Wade? Can't ever happen, right?
George Bush Sr. made a deal with Democrats to raise taxes and cut spending. Ever since then the Republican strategy has been to oppose pretty much anything a Democratic President proposes. The ACA was a Republican healthcare idea and they didn’t support it because a Democrat proposed it.
There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think. If it gets implemented quickly enough then getting rid of it will be very difficult to do. People won’t give up free at the point of usage healthcare once they try it out.
> There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think.
It's worth keeping in mind that Eisonhower's cabinet argued against the idea of giving the polio vaccine away for free on the basis of it being a "backdoor to socialized medicine". We're over seven decades past the point where it makes sense to give a shit about what anyone says about "socialized medicine".
"If your solution requires addressing the slow-burn civil war, your solution is just a campaign slogan".
Essentially, all solutions require addressing the slow-burn civil war, which is today capable of of subsuming any issue. Not a single policy issue can realistically be addressed while the rabid 800lb gorilla is in the room. That gorilla is not Trump, that gorilla is Heritage, Fox News, Koch, et al.
> ACA was predicated on studies like this, to no avail
ACA was also predicated on broad participation. As with all insurance, the bigger the pool, the lower the premium. Insurance of any kind is primarily a risk arbitrage business and fundamentally relies on the presence of low risk consumers. ACA was designed with this in mind and made participation in the insurance pool mandatory(whether via the public marketplace, or via private).
Unfortunately for the ACA, the individual mandate was removed in 2017 via Trump's Tax Cuts and Jobs Act, which reduced the penalty to $0, while leaving intact the ban on denials based on preexisting conditions(on it's own a good thing). The elimination of the federal tax penalty caused health insurance premiums on the ACA individual marketplace to increase by an estimated 10% annually, as younger and healthier individuals dropped coverage and left behind a sicker, more expensive risk pool.
So, while it's fair to criticize the ACA, you simply can't expect a law to work if it's intentionally altered to engineer the worst case scenario specifically.
Here's the overall timeline
* March 23, 2010: President Barack Obama signs the ACA into law, establishing the individual mandate and its future financial penalties.
* June 28, 2012: The Supreme Court upholds the individual mandate's financial penalty, ruling it a valid exercise of Congress’s taxing power.
December 22, 2017: The TCJA sets the individual mandate penalty to $0. Lawmakers attached the repeal to a major federal tax overhaul package and used the budget reconciliation process that allowed the Senate to pass the measure with a simple majority vote, avoiding a filibuster.
January 1, 2019: The tax penalty officially drops to $0 nationwide, effectively eliminating the financial pressure to participate.
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
At this point it says more about the state of our democracy than it does about any proposed solution. Even policies widely supported by the American public these days are met with obstructionists who care less about the welfare of the country than they do about scoring and blocking political "points".
I mean, the original plan for what became ACA was single payer. They didn't have the votes from the moderate democrats though, which is why the "private plans on public exchanges" became a thing instead.
You're not wrong at at least for the forseeable future, single payer does seem untenable politically, but I'd argue that dismissing studies like this on the basis that it needs solved before debating it on its merits is circular, because the only plausible political objection to a policy like this is financial. If you reflexively claim that nothing without broad consensus appeal at a given point in time is worth discussing, you're essentially arguing in favor of freezing our public policy to whatever the current public opinion is today. I don't think you need to go very far back in history to see some pretty striking examples of why that would be undesirable.
They had 59 votes from Democrats for the public option, not single payer. Public option is to let people choose either a non-profit government insurance plan or private insurers. They needed 60 votes to break a Republican filibuster. Joe Lieberman (Ind-CT) said he would filibuster the public option but would vote for the ACA without it.
I would never have had healthcare as an adult without the ACA due to an illness as a child that was expensive enough that I’m sure some insurance exec was only able to get a 26 foot yacht instead of a 30 footer.
It was a great success for people in my boat(no pun intended)
My favorite part of the ACA is that the nickname, Obamacare, was created by Republicans, thinking it would fail and the nickname would make that failure stick to Obama better. Problem was, the ACA helped a lot of people, particularly people in red areas. So, then Republicans started complaining that Obama and the Democrats were being arrogant for putting Obama's name on the ACA.
There's been tons of short interviews showing MAGA people having no idea ACA and Obamacare were the same things. They cheered when Obamacare got repelled even though they were beneficiaries of it. MAGA propaganda is powerful
You mean obstacles from politicians who took money from the healthcare industry. That’s how we ended up with PPACA and they used it to justify massive cost increases and consolidations. They passed that junk to save face and now healthcare is far worse. But we “closed” the donut hole, right? Quite literally made everyone worse off and no one wants to talk about it. I still can’t believe they allowed payors such as UNH to buy up everything without ANY proper investigations during that period.
This is exactly the argument that gave us the Affordable Care Act. It was literally a republican plan from Massachusetts. It was supposed to be broadly acceptable and that's why it was implemented with a billion compromises.
But the Republicans called the Democrats commies anyway and refused to participate. And that has been their playbook ever since. That is what they are going to do, no matter what we propose.
So we may as well propose actual universal healthcare. But I agree with you that we need to create strong majorities to keep it in place until it reaches the kind of momentum it has in Canada or Sweden and opposition to it becomes a practical impossibility, like opposing social security.
Maybe someday we can have a system where losing health insurance isn't a motivation for not starting a company. Our current system is a complete disaster for entrepreneurial capitalism.
can someone tell me this. Right now level of care is rationed by type of insurance you can afford. eg: northwestern in chicago downtown is inaccesible to ppl below certain income level.
In universal everyone has access to every hospital ? Why would someone go to lower level hospital if they can go to northwestern. Now the acess to best hosptials is gated by a queue?
I am not saying this is right but ppl who already have access to northwestern its in their best selfish interst to oppose universal?
i am just countering the point that "ppl opposing it are merely brainwashed by foxnews or are stupid" . Its no different than ppl preventing outsider kids from going to your school.
You're right, it's not just that people opposing it are stupid or brainwashed: Some of them, to your point, are selfish and don't want others to have access to the nice things that they have.
Can you explain why those people DESERVE access to better care? Do they have more complex/rare diseases that require specialized treatment? Are there specialists who only work at that hospital? Those feel like warranted needs. But "I can pay more so I should have better things" is a ruinous worldview that, at its end, is just Might Makes Right.
> Now the acess to best hosptials is gated by a queue?
I mean, yes? Literally the same principle we all learned in kindergarten for how to make access to something fair. You didn't get to skip the line in lunch because your parents had a better job than someone else either.
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan
So you'll never vote GOP again. And you tacitly agree with Trump's repeated claim that conservatives will stay in the minority unless they _reform_ election rules -- https://www.theguardian.com/us-news/2020/mar/30/trump-republ.... Vote suppression and the "perpetual majority control of legislative, executive, and judicial branches," is Republican stated aim since the late 60s/early 70s when their party began its creep into permanent minority status
> It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to
What does this even mean? ACA was based on a GOP-governor-in-a-blue-state's successful implementation of HCR. Everyone loved it until Obama loved it, then the highly organized GOP minority hated it, fight it, wasted ~20 years claiming insanely to have a better solution they knew they never had nor will have
Back when Nancy's daughter Alexandra Pelosi used to make mini-doc shorts for the intolerable Bill Maher she made one about southern white Americans' opposition to ACA. She interviewed one fellow -- perpetually unemployed, alcohol/drug/legal problems etc -- who came well out of his chest against Democrats, socialism, The Gubmint and all the other typical lefty stuff that Fox News mentors him and so many others on. Then we find out he's on welfare. Then we find out he's on Medicare/medicaid. Pelosi's like "What?? Wait a minute ... I thought you didn't like this government stuff. Why're you all over it" and mans goes "WELL I DESERVE IT!!!"
Let's just call anti-UHC arguments what they are: wet bullshit from private healthcare industry stakeholders and the uninformed partisans who repeat Trumpist mantras
Universal Health Coverage has a lot of other benefits:
1. It detaches health insurance from the employment market. This means those minimum wage walmart jobs just became more feasible, or any low end job really, since their is no pressure to provide "benefits" anymore. This would seriously lubricate the labor market, because the friction to providing, taking, and changing a job is reduced.
2. It ends a bias for group plans. If you are poor or are a trades worker and need to buy insurance outside of a group plan, you are going to be in an expensive high risk pool.
3. Its a benefit we can fund socially with taxes that will immediately have a positive impact on lower income workers, as well as poorer regions of the country (e.g. red states).
The US is far too broken for such a thing to ever come to be. Politicians are bought and paid for, and the impact on the insurance companies and their profits make this impossible.
US legislators will never, ever, ever put the needs of the people above the needs of corporations, not as long as corporations can wield their massive wealth as "free speech" in the form of lobbying and political donations.
The US has gone through a lot of changes since it's inception, so there's no reason we can't change this. Preferably to a system where people have the freedom to pay out of pocket for whatever level of care they want when they can afford it, avoiding the "death panels" and extended wait times that exist just about everywhere that already has a universal health system.
When I was a kid, my parents would say “with that attitude, you’re right.”
We can and should expect a lot out of the people around us and especially the ones who choose civil service.
Our grandparents ended slavery, got votes for women, established a merit-based civil service, fought fascism, passed equal rights legislation, and created the most dynamic large economy in history.
We have problems, too, but we are not powerless to fix them.
It's literally everywhere. So much negativity. Sometimes I wonder how much is enemy action and how much is just depression or some other mental illness.
> We have problems, too, but we are not powerless to fix them.
Indeed. Even as some of the more mainstream methods to address our current problems become less effective, we should be open to other ways change can come about. Among your list, many of those achievements had their roots in various approaches that didn't involve legislators.
Nobody, including congress, gives a rat's ass about insurance companies and their profits. The truth is that someone has to approve or deny healthcare. Every universal system does it too, but by government policy instead of corporate decision. After the CEO of United Healthcare was gunned down in the streets for doing that thankless job do you think congress is saying to themselves "hey, maybe we should get into that business"?
Man I wish I could downvote a comment. This is what you’d see on Reddit.
“Thankless job” is a crazy way to describe United Healthcare.
No one cares about insurance companies and their profits?? This doesn’t even make sense, so many people rely on insurance and many stakeholders profit off the American insurance system.
In a more sane world the Republican Party would be in favor of universal health coverage. How many potential entrepreneurs stay working at BigCorp because they need the health benefits? How many small businesses are crushed by the cost of providing healthcare to their employees? It would be great for business to remove any involvement they have in personal healthcare.
But I suppose they are the party of big business, not the party of business in general.
The Republican party is not a Conservative party, its a Reactionist party of capital, so generally anything that threatens the interests of capital will be absolutely crushed.
As a reply to Helloworldboy (sibling comment marked as dead), the US is not even in the top 10 of best countries to live in terms of quality of life. It's not even close to the top in any QoL metrics: life expectancy, child mortality, education, poverty/wealth gaps, air pollution, food quality...
When they make campaign promises, they go to small towns and talk about "Main St" businesses. Not sure why anyone believes them at this point (for the reasons you mention), but it is what they campaign on.
I think republicans could get behind some measure of portable health plans between employers. What they could not get behind is universal, in the sense of "everyone living in USA" health care footed by the US Government. The objection would be about centralization of health care funding and about, you know, who would get the benefits.
… in Massachusetts. New England Republicans are not the bulk of the party, and that’s not all bad - remember, the phrase was “banned in Boston”, not “banned in Bakersfield”.
Bill Clinton was a once-a-century skilled politician, but if you translated his policies without his extreme personal charisma to today it’s unlikely he would make it through the Dem primaries.
> In a more sane world the Republican Party would be in favor of universal health coverage. How many potential entrepreneurs stay working at BigCorp because they need the health benefits?
BigCorp gives money to politicians and gets to depress worker wages because they can't leave — sounds perfectly sane to tie your insurance to your employer under capitalism.
The insurance companies had substantial input to the specific text of the ACA. I'm not sure how you can imply the ACA was not a BigCorp bill when BigCorp wrote it.
It's also well known from leaks that the first Obama administration selected his cabinet using recommendations from Citigroup.
Decoupling health insurance from your job and going single payer are separate things.
You can have one without the other.
You can have a very healthy system with private insurers (like in Switzerland) and you can have completely dysfunctional single payer system (like in Poland and I guess many other countries).
Main problems are elsewhere: doctors gatekeeping the market, lack of transparency when it comes to pricing, regulation making it impossible to compete for smaller players etc.
If they published the plan, it was a normal rational one without carveouts for their friends, and they started pushing specific legislation now to implement it, they'd crush the Democrats, and Trump could declare himself God-Emperor.
All they'd have to do is cut a few friends (insurers) loose. They'd still even have the power of the contract to reward theoretically productive elements of the new health system in return for kickbacks, and there'd simply be more money sloshing around within government to take advantage of. They could continue to stomp the planet freely, because Americans don't care about anyone but themselves. The upper-middle class post-Obama "left" would evaporate. Give them free state college and they'd start calling Republicans the real left.
Another reminder that the US government spends more per-capita on health care than every country with universal health care, and then the population pays again.
One of the things usually cited to defend this waste of money is the massive excess army of people working in healthcare administration, half of whom are employed to file paperwork and the other half employed to throw it in the trash. Now that they're all soon to be replaced by AIs which will be able to simultaneously file and delete worthless paperwork at inhuman speeds, we can let go of that garbage excuse.
But in a more sane world the Republican Party would simply acknowledge slavery as being a real debt owed, and stop being racist, without changing anything else. Most black people are socially conservative Christians, and it would instantly become another God-Emperor situation. Democrats haven't won whites since Kennedy; they gave them entirely up for supporting basic civil rights for black people (an own-goal for the Republican Party, started as a single-issue antislavery party) and big business. Without guaranteed black support (the only other choice black people have to Democrats is not to vote, which is quickly increasing its share), the Democrats wouldn't be a viable party at any level. Republicans are not sane, they are short-termists like everyone else.
Picking out the Republicans is unfair, though. Democrats lobbied furiously and entirely dishonestly against single-payer healthcare in 2016 and 2020. They even tried to sell single-payer and its supporters as racist.
If you could say Universal Healthcare only for MAGA white people Republican Party will get behind it. Especially if there is some opportunity to commit large scale fraud.
>A single-payer universal health care system could cover every American, save more than 100,000 lives a year, and still cost $1 trillion less than the system it would replace, according to a new preprint study led by researchers at the Yale School of Public Health.
FWIW, the methodology that produced this particular result is known to have significant issues. The claimed effect disappears after correcting for them. It also isn't the first time that these authors have published similar studies with these issues. They are not a credible source.
Universal health coverage may save lives and money but this study doesn't provide actual evidence for it.
"known" by whom, and documented where? if you're going to just parachute in and say this paper by domain experts is dead wrong, at least link to what you believe shows this to be the case.
Not really. Private health insurance would still exist alongside for the more wealthy (including nearly everyone on HN) that doesn’t want to wait a year for their public system MRI. Same thing that plays out in other countries. The U.S. already has a form of this in so-called concierge / premium providers too. Lots of profit to be made.
Total profits for US health insurance companies in 2025 were $50 billion. The other $950 billion has got to come from cutting:
1. money to providers
2. overall healthcare consumption
3. bureaucratic redundancy and waste
1 is going to piss off medical providers. 2 is going to piss of the general public. 3 is going to piss off the 20 million healthcare industry workers who are not direct care providers. So pick your poison. This is why it will never pass.
Most of the problems of the US system aren't really a matter of who pays, but the fact that so much is paid for services, at every level. Any really significant savings, cutting bureaucracy and pressuring providers to make costs resemble those of other developed countries, are taking money out of someone's pocket. Many hundreds of thousands of them, if not millions. This makes any significant reform very difficult, as those people vote, and will know exactly who made them worse off, even if the country in general was made much better off.
Read The Logic of Collective Action by Mancur Olsen. It wasn't written thinking of healthcare. but anyone looking at the US healthcare system will see that what is going on is stacks upon stacks of collective action beating overall societal efficiency, over and over and over again, in such a way that it's basically in none of the decision makers best interest to actually increase overall efficiency.
It’s also geographically distributed. Substantially all congressional districts count a healthcare system as a top-5 employer. Those 70k/yr butts-in-seats admin jobs are occupied by voters, making them difficult to eliminate nationally. You’d have to go down to the state level at least to get anything done.
I think it’s because Americans been taught that were democracy, not a federal system, but that’s exactly where we expect to do these kinds of reforms. The federal government could reasonably set certain regulatory requirements. The states would need to make sure that any provider within it conforms to the federal levels, you know like auto manufacturing and exhaust emissions. Seems doable. Unfortunately we’re gonna have to wait for the boomers to die because they’re the ones that have gotten theirs and they’ve screw everyone else. Also, unfortunately, the millennials are gonna have to take it on the chin like we have for so much else and realize there is going to be some lost jobs.
What about quality of care tradeoffs? In Canada, for example, you are forced to use the government system, and if it doesn't deem you important enough, there is no private option.
Interesting. In every European country I know of, the private option is still available. Just vastly cheaper and more beneficial due to having to compete with a public option which covers basic necessities, surgery etc.
Yes, this is what I find a little odd about the US proposals. I've lived in UK and Spain and in both they have great free public healthcare for everyone, and if you (or your employer) want to layer private insurance on top you can. Wouldn't that be a much more appealing proposal to Americans?
Is this quality improvements including or ignoring the 30-ish percent rejection rate of the most popular healthcare system, including such gems as insulin and pre-authorizations refusing surgery for necrotic tissue when “maybe they could PT it, have you tried?”
PT? Luxury! My daughter had PT referred by her pediatrician, then the insurance didn't pay all of it and when I asked the insurance company for the EOBs they said they were not allowed to give them to me because it would violate my daughter's privacy.
This is frequently true in the USA as well. My provider's dermatology department is pretty backed up and couldn't make me an appointment for an excision until November. Fortunately it's not urgent.
> If you need to see a specialist, you regularly have to wait months, assuming you can even get a referral in the first place.
Two months can be a luxury. With my insurance in the US, it usually takes longer for me to see an in-network specialist. For my kid, it has often taken over 6 months.
Of course, none of these were urgent, so it was fine. If it really was urgent as deemed by a medical professional, I likely could get a quicker appointment.
But my friend, who has even worse insurance, developed a condition and was having trouble getting a diagnosis. He got referred to neurology, and none of the in-network specialists had an appointment for over 2 months. His condition made it hard to sleep every night (averaging about an hour of sleep a night). Due to the lack of sleep, he couldn't function at work. Took a leave of absence, got a plane ticket to go to a relative's country, got to see a neurologist the next day, got treatment that day and had his first good night of sleep in a long time.
Lost his job because of it, though. Unsure what his medical insurance situation is while living on welfare...
That's not at all unusual in the US. My dad saw a neurologist for chronic severe headaches. It was very common for us to go to an appointment, have the doctor request a follow up appointment in 3 months, then be told during checkout that the earliest available time was in 5-6 months.
The US is not much different.
We don't have a wealth of specialists available to see people right away.
I've flat out been rejected from a specialist because they had no availability at all.
I actually tried again and got to be seen, but an appointment is months out, always.
Hah, even with "platinum" healthcare in the US, urology referral, 4 months. "You should start PT immediately" after a car accident, "we can see you in 5 months".
"Oh, your septum is deviated ~90% on the right. Surgery? No, first you need to go on these nasal sprays for a few months so we can decide they didn't reshape the cartilage in your nose before your insurance will decide whether they want to "allow"[1] surgery."
[1] Insurers will always say, and have won in court, saying "We don't allow or deny anyone any care they need. We are just saying we won't pay for it."
There are private options for lots of things in Canada, depending on the province.
Without data on what proportion of people are denied and what the consequences are, this isn’t a good faith argument.
On the flip side, cases that would get care in Canada are denied in the USA by private insurance. Private options are far outside the means of most people.
Does American private insurance pay for everything? And if you say "but they can pay out of pocket", well Canadians can come to America and pay out of pocket too.
For a lot of people it very much doesn’t. And the cost is very prohibitive for people getting any care at all when insurance doesn’t cover it, so they end up not getting necessary care and then ending up on disability for life.
A healthy population *makes money for taxes and buying things*, too.
I don't know about Canada, but here in Spain you have both. You have public health guaranteed, but many people also have different levels of private coverages, usually to get quicker appointments.
As I understand Medicaid, it would just be open Medicaid for 100% of the US population regardless of the income, remove Medicare (they are now under Medicaid), leave the private sector as it is. Do you think Medicaid is too slow, too low quality, too terrible in general? Pay for private insurance, but you can still go to Medicare if needed.
First off, all Canadian provinces are different. Here in Quebec, there is a absolutely a private option. Not everyone likes that it exists, but most people seem to like having that option.
Canadians live better for longer on average (for cheaper healthcare overall). Any other metric is just a misguided attempt to justify the US status quo, which has nothing going for it unless you're rich.
I'm in Canada. The only time I ever needed a doctor in my life it was denied. I ended up having an issue that took ~5 years to resolve, which could have been prevented easily by any competent doctor in a 30 minute session.
I'm originally from Mexico. With what I have paid in tax here over the years I can afford to set up and operate my own small hospital over there, with new equipment, this is not an exaggeration.
"Free" healthcare, as with many other free things, turns out to be the most expensive kind of healthcare. Anyone who thinks otherwise doesn't really know what they're talking about or they're just stupid.
What could work, imo, and since we're all giving opinions here, is private healthcare with a ceiling on profits. Let players take 2x-5x, but not 50x which is what they do now, bring and enforce usury laws into healthcare.
The differences in life expectancy are due entirely attributable to vehicular accidents, homicide, and life style factors. It has nothing to do with medical care.
My dad, in the US on Medicare (one of the government funded systems), was denied a test. Because we have the option and had the money, he went and got the test himself on his own dime. That kicked off a series of events that led to a quadruple bypass, avoided an impending heart attack, and likely added many years to his life and his ability to remain and functioning member of society.
While I love the idea of never having to think about health care costs for a variety of reasons, I do like that some services are available to anyone with a wallet and not locked behind government controlled gates.
This is what is never mentioned. Quality of care, access to cutting edge treatments, timely access to care are never discussed when moving to universal healthcare. There are examples of private and public systems out there, which would be a much better model.
What about them? The Canadian healthcare system has better outcomes than the American healthcare system in several areas. Most simply, Canadians live longer.
I'm 29 and when I was a kid, getting a family doctor used to be an easy task and if you needed to see your doctor you could get in that day. Now all the doctors are so overworked, they're fleeing to America where they can get paid a reasonable wage for a reasonable amount of work. If you can even get a family doctor, if you want to book an appointment, they'll ask you which day you'd like 4 months from now.
My mom's been dealing with an issue with her lungs for the better part of the past year, and trying to get help through any of the intended methods just gets her put on a 2 year wait list. At this point her plan is to pay tens of thousands of dollars out of pocket to see a specialist in America.
The current generation of elderly Canadians now having lived a long life spent most of that life in an entirely different Canada. My generation is going to die on a waitlist.
My understanding is that a clinic or hospital can’t legally charge you for a procedure that’s universally available through the provincial healthcare system.
So you’re free to pay for anything else if you want.
If spending drops by $1t, it will come out of someone's paycheck. Yes, some are greedy folks who will be just fine making 20% less a year. But many will be nurses or hospitals or some combination of providers.
impose universal health coverage & the jockeying will commence to see who is in charge of it. medical & diet fundamentalists will rejoice at the opportunity to seize control & force everyone to take certain drugs, eat or not eat certain foods or types of foods, exercise a particular way, surrender their organs at a particular age, or whatever else their hearts desire for everyone else. there have been so many rabbit trails taken, so much malfeasance, so much misinterpreting of data, etc., which has been uncovered just in the last decade or two to give anyone the ability to harm or control entire populations in this way. the increase in suffering will be great, & the long-term effects devastating.
Standard single payer insurance is not identical to 'seize total control of ever living body in America'. I shouldn't have to point this out.
The attempts by the current republican admin to seize control of certain 'illegal' bodies has caused so so much harm, I'd agree there. But even operating at 10x the nominal level of the past and ICE still haven't been able to exert temporary control over a single American city that resisted them, much less everyone in America.
You should figure out specifically what you are scared of and deal with that, rather than catastrophizing about things that cannot physically happen on any near timeframe.
Universal healthcare works just fine in Europe without major issues like that. It's the American political system that is broken. Your de facto two-party political system lets idiots take total control way too easily, as we can see with current US administration.
My country has universal public healthcare, and nobody forces you, or even your children to get vaccinated, monitors what you eat, or any other form of control that you're worried of. Organ donations are voluntary too, you can opt-out easily. And if you think the system sucks, nothing prevents you from taking extra insurance and using whatever private healthcare provider you want.
It sounds like you have issues with people telling you what to do. Would you like a pamphlet on the virtues of Anarchy as a way of building community to survive in a terrifying world?
Because none of the things you said have ANYTHING to do with "universal healthcare" and everything to do with "bad actors worming their way into positions of authority to enrich themselves". Surly you can't believe that "let every induvial person figure it out themselves in an unbalanced capitalist system" is a better answer, right? This isn't just about "if too many people are in the system then MY healthcare quality goes down", right?
In what possible conceivable way is single-payer healthcare in any way related to any of that tripe? Seriously, what an atrocious post. You may begin by observing that countries in e.g. Europe with such systems are not totalitarian hellholes where "the gobmint" tells you how to eat with "devastating long-term effects".....
WTF are you talking about dude - we average white collar/blue collar people are so desperate for a unified healthcare system in this country not tied to our (constantly unstable) jobs
We are so desperate that someone murdered a Healthcare CEO - ie resorting to violence
We are so desperate that many is (myself included travel to cheaper countries for dental and other healthcare)
Its a simple calculus but one that is obtuse to conservatives and richer people
There aren't enough Physicians, they don't make much and they all seem to be working 12 hour days but being paid a salary that would equate to an 8 hour day.
Doctors see downsides of a universal coverage are mostly about loss of autonomy and increased demand because when care becomes free demand rises along with pressure to expand access without extra staff.
There are not enough physicians because we have limited the number of physicians. This was done, in part, by limiting the number of residency positions.
Yeah, having lived under universal care, the dark side of it was atrociously long waits to see a specialist and having a GP who is obviously overworked and barely spends any time seeing you.
That may be your experience, and I’m sorry to hear it, but that is not the universal experience.
I’m in the hospital right now. My two year old had her tonsils and adenoids out this morning.
Regular Dr visit lead to an X-ray on the same day, specialist appointment 3 weeks later, surgery 2 months later (would have been one month, but we pushed it back because timing and life).
Just talking about how my wife is coming off 18 months of maternity leave. Before that she quit and just didn’t work for 3 years because burn out. I’ve been self employed for 10 years earning about $20k a year.
This whole thing cost us exactly nothing. Would be the same if we’d never had jobs.
Mum got stage 4 cancer in another country where she lived. 2.5 years of radiation, chemo, X-rays, mri, and dozens and dozens of specialist appointments (which she got paid for transit and free accommodation in the capital city) not to mention the mountains of serious drugs.
Total cost $0.
Anyone that argues against this is either not very intelligent (easily manipulated by the propaganda) or does not want to help others (“freeloaders”), or is getting rich from the status quo.
US federal budget is 23% of GDP, while UK is 44% of GDP. You can't compare fractions of the fractions directly. (Total spend is something like 11% vs 18% GDP.)
We hate it and are more and more powerless to change it every day. The parties are entrenched and swing districts are becoming increasingly rare. Those competitive districts that remain are flooded with unlimited campaign funds from big business and plutocrats, thanks to Citizens United.
The mortality numbers in this paper appear to be extrapolated from an observational study of 9,000 cases from 1988-1994. That paper distinguished between "privately insured" and "not privately insured". This paper distinguishes "adequately insured", "underinsured", and "uninsured", and applies the original paper's hazard numbers to everybody but the "adequately insured", with a coefficient modifier for the "underinsured" that they came up with themselves.
Since when has a government projection of costs ever been in any way realistic? The estimates for the costs of Medicare when it was established were low by a factor of 10.
Last time I joined a discussion about US health care on HN (years ago), the picture looked bleak: secret chargemasters in every hospital, no realistic way for patients to compare options because the options are too complicated, and lots of people still falling through the cracks.
I can't help but think the picture looks very different now. There is growing awareness that chargemasters can not be secret. LLMs offer a way to overcome the complexity of choosing options, opening doors for real competition. I sincerely hope we can take advantage of this changed landscape to provide better care. Universal health care remains an interesting possible direction, but I now have hope that we can do a lot better within the existing laws.
I would like to know if anyone has a method or resource to cover rough calculations on things like:
1) how much cost comes from "friction" like middleman, administrative bloat, shitty digitalization/note sharing, all the time the nurses and doctors have to spend on paperwork... Etc.
2) how much drug development is subsidized by the US patient via higher domestic vs. foreign pricing. Or even how much of the cost total is drugs?
3) how much roughly every added year of life past some marker of "high quality of life" is spent just keeping people alive. And if there's any trends there, cost going up or down total and per person.
4) some basic accounting of where the spend is actually going. A lot of people in this thread are talking about hospital margins. There's much more to health care than that. Labs, hospice, mental health, labs/diagnostics, drugs, r&d, nursing facilities and many things I probably don't even know about.
Basically an equivalent of david mackays "without the hot air" but for health care.
Also if anyone has some good reading on ideas around kind of SEZs for drug/treatment development where people opt in to riskier care. Not quite the same thing but I know for example that lots of medical device development and proving is done in spain to gather evidence for the FDA since the FDA process for devices is legitimately insane.
Oh and if there has been any proposals or even adoption of better health record management, digitization. Especially access to your own health record. Im not a crypto guy but it seems like maybe it could be an application for it?
It boggles the mind when you hear people defend the US healthcare system in terms of efficiency (OK, granted, maybe people have long stopped doing that).
It has to be one of the most bureaucratic and paperwork overloaded systems of all time. It's hard to imagine somebody who've had an actual health crisis would think otherwise, unless they can afford people who can shield them from the BS.
Hard to believe, currently Medicare/Medicaid make up around 23% of the budget. If you opened that to all, there would have to be a huge tax increase to pay for it. I suppose if you are very poor then it would be good, but the middle class would be the ones having to foot the bill for this.
People talk about policies like they're something like can be picked up off the shelf at supermarket. If you could take the policies and Sweden copy-paste them to the US, then sure, we could save $1T and a hundred thousand lives. This would be a very difficult thing to replicate if you're a country without any existing healthcare system. It is impossible in a country with an extremely mature healthcare system, which accounts for nearly 20% of GDP.
No politician is going to want to deal with the fallout of massive layoffs or millions of people having their coverage changed (e.g. no free chiropractor appointments or GLP-1s for weight loss), especially since the Democrats suffered one of the worst Congressional losses in US history the year the ACA was passed. There are ways to make this transition less painful, but the only people interested in health policy are those who make money from healthcare, so you generally only see solutions that involve throwing money at the problem. We need regular people to develop an understanding of health policy or else we'll end up with a policy that merges the worst parts of a planned economy and capitalism even more than today.
The US already has a national health insurance network that pays the vast majority of all providers, and as far as I know it is widely popular and covers everyone legally present in the US for a portion of their life, Medicare. Old people experience just about every ailment young people do, we can just get rid of the age restriction on Medicare, it's already fully integrated with our medical system. No need to copy-paste from Sweden.
Medicare also isn't something that you can copy paste from covering only old people to everyone. For one, margins from Medicare patients are much lower and often negative for hospitals, and that money has to come from somewhere. Medicare doesn't cover a lot of drugs that people are already used to their private insurance covering like GLP1s for weight loss. Of course, a transition from point a to point B is possible, but there will inevitably be a lot of kinks and bugs to work out, which MFA proponents seem to be unaware of.
It looks like this does not even include the current disincentive for insurers to treat chronic issues effectively early on. Since people switch insurers so often the odds you will be their “customer” in 5 or 10 years is low, so investing if your long term health won’t generate a return for them.
That's a very weird framework and dichotomy you have there. Try untangling yourself out of it by considering some empirical facts, for example, hospitals acquired by private equity often have worse outcomes.
> private equity acquisition was associated with a 25.4% increase in hospital-acquired conditions, which was driven by falls and central line–associated bloodstream infections
> Medicare beneficiaries in the emergency departments of private equity hospitals experienced seven additional deaths per 10,000 visits after acquisition relative to hospitals that were not acquired by private equity, the team found. This rise represented a 13 percent increase from a baseline of 52 deaths per 10,000 visits
What's the point of "state of the art healthcare" if it's only for rich people? If Jeff Bezos and I get the exact same health issue - say, some form of cancer, we're going to have radically different treatments and mostly likely outcomes. His will be "state of the art", mine will (hopefully) be good, but definitely not be like his.
This is certainly true to an extent, but it ignores some big problems with fee for service. The biggest one is that incentives between patients and providers are not aligned, which means more than 10% of healthcare provided in the US is wasteful stuff the provider knows is unnecessary but prescribes anyway because it makes them money. There are real opportunities to save money without making outcomes worse, in fact, if we stop doing useless stuff that leaves more time to treat people with real issues.
Malcolm Gladwell is a massive charlatan and hack. Seeing tech bros use him to discuss healthcare policy (Malcom Gladwell is neither a health professional, public health expert, nor has he worked in the healthcare industry in any real capacity, nor has he ever discussed the plight of workers in the US once during his entire career) feels on point for out of touch our industry is.
"They" never intended for it to work and never tried.
Do away with the finance ledger.
Accurately measure where the people are.
Ensure enough resources flow there.
Special interests with a social moat to protect can pound sand or be hung from ports as a warning.
I would like to be free from hallucinated social belief Jeff Bezos is meaningful to humanity when mfer just gonna die and be forgotten like everyone else.
The thing studies like this never take into account is the degree to which all of these administrative jobs are corporate welfare. The inefficiency means a lot of people get a regular paycheck for work that is ultimately nonproductive. If you kill off those jobs by eliminating waste there will be millions of people looking for a new job.
But the bigger problem is the current system is really profitable for the millionaire and billionaire owners of those companies. They're well connected in Congress. Attempting to change the system is extremely difficult when it means so many rich people might lose their gravy train. These people go to expensive campaign dinners. Even when the ACA came out and the first versions had universal healthcare provisions those were quickly and quietly eliminated.
Administration is ~25% of provider expense; billing and insurance is ~8.5% of provider expense. Administration is:
* Billing and claims management
* Compliance
* Customer service
* Operations
* IT
You can drive billing all the way down to zero and you're still going to be spending a lot of money on administration just like any large enterprise does. Those jobs aren't really "corporate welfare" and they exist in every system, although the single-payer systems get a bit of a break on them because they can and do trade responsiveness off for customer service (at likely little cost to outcomes, to be fair!)
That ~25% is compounded at every step of the way. 25% of your doctor's office. 25% of the insurance company. Plus don't forget the brokers, which are almost all overhead effectively. 25% of pharmacy. 25% of drug companies.
The people providing actual healthcare end up being a minority in the system.
If this were at all true, now read it like the big wig or law maker holding the on/off lever who’s eyes see “Universal Health Coversge Could reduce $1T in available/taxable income”.
Did you notice the gorilla walk by? They sure didn’t.
For the most part, any time one person in the economy saves money, another person loses money. So, what about all the insurance company, private equity, and hospital system profits that would be eroded by a system that better serves individual humans?
they're tryna convince the populace who don't like to read with useless studies.
get rid of medicare etc, then let it be handled on a city / state level. if some states wanna provide for public hospitals clinics - let them do so. even more if cities too wanna provide for public healthcare. then we can gladly reduce taxes too. the amount spent on medicare vs outcomes is already scam level.
trying to solve this at a national level won't work - too many middleman, too much politics and perverse incentives.
This doesnt need yet another study. Instead of narrating the problem we should figure out whats actually stopping it. And people saying the ACA was universal health coverage or even an attempt at it should stop intentionally derailing this discussion.
What UHC proponents never honestly admit is that these headline figures require incredibly optimistic assumptions and also much more rationing of care than our current model. We spend a lot on healthcare because we consume a lot of services. To save money, you have to buy fewer services. Yes, you can squeeze providers a little bit ("Medicare-level payments to providers" -- which they will absolutely hate, by the way), and you get another little bit by disposing of insurance provider profit margins ("reduced administrative overhead"). But the vast majority is coming from rationing, which people hate. And it would also cost massively increased taxes on the middle class, which voters also hate.
"Fewer avoidable emergency department visits and hospitalizations" -- sheer optimism. "Less fraudulent billing" -- no reason to believe this would be true. There could be even more fraudulent billing! Medicare fraud has been a big problem, and solutions are largely reactionary.
How on earth have administrative costs been soaring when there have been so many healthtech startups propped up in the past 10 years to bring down the cost of administration?
Also - given the rate of AI progress, shouldn't we see this cost go to zero essentially.
I've become so cynical that I think even if universal health coverage would be passed, since it almost certainly would be run by the executive branch, it would become just another political football to be fucked with every 4 to 8 years.
Just think, if we had universal health care in the US today, the MMR vaccine would not be covered by it!
It will never not be funny that whenever universal health coverage comes up, Americans will act as if it's some impossible task that wouldn't solve any problems when the rest of world seems to have sorted it out just fine.
There is already a healthcare program run by the US government and it's called Veteran Affairs. Veterans can't even access the care they need resulting in almost twice the risk of suicide.
I'll pass on mandated, outlaw-private-insurance government healthcare, thanks.
There are many studies from reputable sources (one being the CBO) that say it would result in almost no savings or potentially even higher costs, just like there are many studies like this one that say there will be massive savings with no reduction in quality of care.
I support universal health care, but each side just lobs whatever data supports their position at the other without any real thought. Most people in support of a universal health care system seem to be completely unaware that the vast majority of households are happy with their current coverage (whether they should be or not isn't relevant really) and are not looking for someone who claims to know better to "improve their medical care" through a entity (the US federal government) that is generally not known for improving almost any situation it interacts with.
I personally would like to see Medicare opened up to the public as an option. It's simple, doesn't require anything of anyone who doesn't want to participate, and should be a reasonable test for the claims of cost savings. If it's truly a better option, people will move to it. If not, then the conversion will not happen.
Barring some sort of catastrophic financial or medical event, there is a 0% chance that anyone can make a radical change to the status quo.
You think they’re getting so much money from out current system that cutting out insurance companies would result in a 50% reduction in their pay? Have you ever looked up the size of the health insurance sector here?
You're being dishonest if you claim otherwise. UK brain surgeons get paid less than a Walmart general manager in the United States, let alone a like for like comparison.
I'm honestly curious how we square this with the only experimental evidence we have on cost-sharing in the US, like the Oregon Medicaid Study and the RAND study which showed no impact on mortality or really any physical health outcomes at all.
Bro nothing is free, if the goverment pays for all of us, then it is our own money being used for that, we have the most liberal tax code in the world, we spend the most in healthcare.
That's basically my concern, too. If we had a "Medicare for all" system, would it end up like Social Security, a system that started out with great intentions, but has since ballooned into an expensive, bureaucratic nightmare?
let's imagine an impossible country where somehow Democrats pull this off in 2029 and the 2030s start with actual healthcare for all and not just "insurance"
DOGE 2.0 will destroy it overnight
because somehow funding is not exempt from executive manipulation
look at what they did to ACA (and everything else)
all it takes another apathetic Congress and poof it will be gone so billionaires can get a few million off their taxes
there's absolutely no way to harden it against that
The Jews are obviously to blame for the lack of universal health care.
The USA spends the equivalent of about $10 per citizen per year on Israel. Medicaid spends about $10,000 per recipient per year. But antisemite math has its own rules.
Look no further than the UK, with 24 month waiting lists, the shunning of experimental treatments (many high profile kill decision cases) and skyrocketing costs.
In the UK, a brain surgeon is paid less than the General Manager of a single Buc-ees Gas Station location in the United States. Absolutely diabolical.
> The first issue with this is that the gap between the uninsured and insured is not necessarily due to the lack of insurance. It could be due to factors associated with not having insurance, like living on the streets, being schizophrenic, being poor, and so on.
Made up perspective to justify his angle.
Not having healthcare access for a lot of people is 100% a policy choice. Waved off here by a list that really says why we should have universal healthcare; some people are mental and not aware they could have access without the stupid policy decision.
Just strings together sentences to ultimately make a reductive point about arithmetic and their own literacy.
Despite Yale's issues they're still a better source than random blogger with high school math literacy.
The point he is making is valid: these groups are not randomly selected and are not representative of one another. Hence, it is not that simple to extrapolate from one to the other.
Would free healthcare reduce deaths in uranium miners that are smokers? Probably some, but would it bring that to the same levels as non-smoking, non miners? Unlikely so. Hence it would be silly to pretend all the cancer deaths are due to lack of health care.
The smoking uranium miner example has a surprisingly realistic story, comes from real data; the dangers of radon in the basement were deduced from comparing cancer rates in smoking uranium miners with high radon in their basements, then they removed what they thought was the smoking and uranium contribution, then fitted to the general population.
He's actually a well-known and widely promoted political activist on X. His niche is using technocratic language and a whiff of 'analysis' to advance MAGA policies.
The truth is once systems like this are implemented they change the dynamics of the study and as such could hurting lives.
As a simple example, the biggest cost to the healthcare system in the US is dialysis. Many of those folks already have health issues, and by both dialysis and for all the issues that caused the need for dialysis in the first place is a massive strain. The direct cost of dialysis is $33B annually [1], but indirectly is probably at least another doubling.
Further, the way the government has imposted monopolies in the space already has caused costs to balloon. While making it "universal" could mean the government gets control, and can limit the explosion. It can also could result in weird incentives like Canada, where they're promoting MAID.
This is why it doesn't happen: politicians get bought.
"Jeffries co-sponsored Medicare for All legislation between 2013 and 2021, but in August 2026, he stated he shifted his stance and stated that he no longer supports or co-sponsors the proposal." https://en.wikipedia.org/wiki/Hakeem_Jeffries#Healthcare
Universal healthcare doesn’t happen in the US because a certain subset of the American population would rather have worse health outcomes than guarantee abortions, HIV prevention, and gender-affirming care.
Also, ~150M people with employer coverage plus seniors on Medicare fear disruption more than they value expansion.
You can easily drop those from a universal healthcare system - look at the NHS and gender affirming care across the pond. So it can't only be that part - I think it's wanting the undeserving to not have healthcare.
There's also a racist element (I know that's a politically incorrect word here, but such things happen). People don't want to fund services to the lazy ______s - fill in one or more of many groups toward whom hate is promoted.
When a similar bill was voted down years ago, someone I was with laughed and said, 'no way were we paying for healthcare for the Blacks'. It fits the divide and conquer strategy to divide poorer people with hate so that they don't unite and vote for all these things - why do you think leaders promote hate?
There are many reasons Jeffries might change positions; why do you say the reason was that he was bought? Is there evidence?
Many Democratic politicians are moving away from progressive positions, including Ocasio-Cortez. They seem to be following the old (and failed) Democratic Party tactic of moving to the center to get elected.
One of two major political parties, and the one that currently holds all 3 branches of federal government, has labelled it un-American and communist. And yet you point the finger at...a Democrat.
> the one that currently holds all 3 branches of federal government
The key word here is "currently". When did Democrats ever propose or pass single payer when they were in power?
Moreover, when the leaders of both parties are opposed to single payer, how in the world do you expect it to ever pass? Jeffries wants to be Speaker of the House after the midterms. If he's opposed to single payer, then there's no hope for it.
The majority of Democrats support single payer. That's why I'm pointing the finger at a Democratic leader. I don't expect Republicans to support single payer. What I expect is for Democrats and Republicans to have opposing views, not the same views.
Quite weird to see such a study from Yale, Yale is the heart of the capitalistic western empire, and it exists to serve the oligarchy and the capitalists. So then what gives ? perhaps the person working on this report is still an innocent person and has not yet seen the reality of his situation :)
The last time we got similar results in the data (but not the text) was a Koch-backed study that a bunch of economists reviewed and went “so you’re saying we’d save 2 Trillion over 10 years relative the alternative?”
Come to a country with universal healthcare (England) and realise that if you work then you're paying 5x the market price for the worst healthcare imaginable. MRI scan - we don't know, one month wait, maybe two. Operation - are you going to die tomorrow with out it? No, ok then that could be years.
You need to pay rock bottom wages to doctors to make it work, so guess what all the good doctors leave for private healthcare and you end up with the dregs from the third world.
I know that you tend to be balls deep in American Exceptionalism, but the truth is that reasonable countries with reasonable health care average 15-30 MRI machines per million inhabitants.
America is a wild outlier, and unless you have data to back that those machines are put to good use, I'd trust the rest of the world who decided the sweet spot is 15-30 mer million, not 60.
I think this one might not be true anymore. Canada has 432 machines as of ~2023 (340 in 2015) and MA is on the order of ~300 (can't find exact figures). It's still a lot lower per capita (10.8 per million vs 42 per million).
I wonder how many people would be on board for a program to make Medicare available for free for households making over $100,000 annually with 1-3 children.
We're talking about families that are provably not lazy or sucking up handouts: taxpaying citizens with beautiful, healthy children. The job creators and professionals driving America, securing their future and their children's future.
If the government were to focus on these first-class citizens, who knows what could be accomplished once the drag is taken off the system of the useless eaters and the welfare queens.
Why do you limit it to people with children? Why do you assume that the children are beautiful and healthy?
> Medicare available for free for households making over $100,000 annually
Sure, why not try it? It's still 50% of America getting coverage.
After a few years maybe they'll realize that not having to think about health care insurance is a good thing actually (tm) and start supporting it for lower brackets of the population too.
Many people feel that winners should be rewarded and losers should be punished.
Systems thinkers may try to push notions of connectedness in societies, and moralists may try to push notions of universal equality of human dignity, but in the end, both are overwhelmingly outnumbered by tribal thinkers, who wish to harm the outgroup at absolutely any cost.
First class citizens? Wow, that is both disgusting and sad. What do you do that you think is so important and irreplacable that sets you above the average person?
I'd like to believe this, but the study makes a bunch of really hasty assumptions.
The authors derive the $1T number from $1.3T in total cost savings and $304B in incremental spend (incremental spend is due to insuring more people). The $1.3T in cost savings come from five big buckets: lower pharmaceutical prices, Medicare-level payments to providers, reduced administrative overhead, less fraudulent billing, and fewer avoidable emergency department visits and hospitalizations.
The buckets themselves don't necessarily survive much scrutiny.
Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
The line item of "fewer avoidable emergency department visits and hospitalizations" assumes greater insurance coverage leads to greater access to primary care. It's true that great primary care prevents hospitalizations, and can be a net cost saving under certain assumptions [1]. But, we're actually in a primary care shortage. Existing insurance payments for primary care are low enough that private practices are going out of business and fewer residents are going into family medicine. Cutting rates (the paragraph above) would make this worse.
For "less fraudulent billing," a lot of people in the industry believe that Medicare has a large amount of undetected fraud. That's unfortunately the flip-side of reduced administrative overhead. The authors assume an 8% savings here, but the 2003 paper they cite uses the word "fraud" only twice and doesn't give a number.
Healthcare reform is hard.
[1] Reasonable breakdown on the economics of advanced primary care models: https://olearykm.medium.com/the-cost-equation-for-new-primar...
>> Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
You arent considering
1. Hospitals eating the cost of the uninsured, which this would solve
2. Hospital spending tons on administrative duties fighting with insurers on coverage, which this would reduce
A lot of the reason hospitals have to charge so much is that they take massive losses on uninsured people in emergency rooms. Medicare for all means they don't have to treat anyone for free.
They are not taking any losses; they just charge the regular price with a very tiny profit margin. US healthcare costs are heavily inflated. Insurance is a scam that lets the rich get richer. All insurance should be non-profit.
We all contribute to the pool at a time when we don't need it so we can use the money when we do, not to make CEOs or stockholders rich. That is how an insurance pool should work. Any excess money at the end of the year should be moved to the pool for the next year, not as a bonus on CEOs' 100m+ salary.
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No, this absolutely does not explain the US's wildly off-base per-capita expenditure because uninsured people still go in the denominator of the per-capita figure! I'm sure the per-insured-capita figure is worse but that's not what we are comparing!
Americans are constantly trying to exclude uninsured people from their statistics (and, worse, from the care itself) but the comparable countries don't do this so it is utterly ridiculous to propose that the correct statistical comparison is one in which the US excludes the undesirables while other countries don't.
https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
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That claim is at odds with the working paper's methodology, which gets a good chunk of the $1T in savings it discussed by assuming very sharp cuts to practitioner compensation.
A lot of the rest of the reasons are carrying the deadweight of administering regulation, and dancing with the existing and prospective malpractice suits that randomly benefit the system sometimes, but always cost everybody, and warp the practice of medicine and patient healthcare experiences.
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It also means that emergency rooms can be used just for emergencies and ongoing and preventative care can happen in clinics. Cheaper to operate and preventing preventable emergencies lowers the load.
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Healthcare reform isn’t actually hard. Every advanced country has done it bar the United States.
In every case costs have gone down and outcomes have improved.
You always build on what you have because you can’t pause healthcare for very obvious reasons.
Hence a lot of different systems all with the same aim. Controlled costs and universal coverage.
The idea the US is somehow different and cannot make the change is the result of propaganda and a mistaken belief that the current Us system is the worlds best despite its costs.
Healthcare reform is easy and there is an ocean of prior art.
Yeah, and they all generally get there by paying practitioners much less than the US does (by integer multiples). Single-payer, which this working paper equates with "universal coverage", is in fact not the norm among universal systems; besides using Medicare to ration the supply of practitioners, the original sin of our system is employer-based coverage, not payer structure.
Health care is an absolutely massive industry (everywhere, not just in the United States), and slashing compensation in a massive industry by top-down fiat is in fact not an especially easy thing to do.
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>In every case costs have gone down and outcomes have improved.
this isn't really true though, if you look at survival rates of many diseases.
I think for the math to work you have to consider the bigger bulk of work that could be eliminated by universal healthcare: the payer industry. Insurers, PBMs, and all the smaller sectors that support them. The utility provided to society is fairly low — basically, just selective claims denial.
Any model that gets rid of these frees up a huge swath of capital and work from society, and can use that work elsewhere. Of course, that is easier said than done.
Truly. Aetna, United Healthcare, Anthem, etc are examples of industry that does not need to exist, and exist only to serve the status quo.
Each of those are companies worth billions of dollars that could be instead used to lower the individual cost of providing health insurance.
As you say, this would of course be unsavory in some respects as those companies employ a lot of people. It's not a very economically productive industry though, the main output seems to be consuming patients' and doctors' time, causing financial anguish, and causing stress among people as to whether or not if their condition will be covered.
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> Hospitals have an operating margin of 2-5%
Very curious where this comes from and how accurate it is. For example the $37 a provider charges for an Aspirin seems like more than 2-5% margin.
You can search for more reports, because they do vary based on methodology. But the median hospital in the US makes between -1% (yes, negative, they lose money, because a huge percentage are non profits) and 4% depending on the source.
When the hospital charges you $37 for an aspirin, that singular pill might have a crazy profit margin in isolation. But your entire treatment could very well be losing the hospital money.
In my own anecdotal experience, the one hospital I know enough details about to comment on specifically, had something like 85% of patients costing the hospital more money than the hospital made. It was entirely funded by the relatively small number of people who had the “right” insurance and had the “right” procedures done.
Eg Kaufman: https://www.vizient.com/insights/reports/national-hospital-f...
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On the occasions that I’ve watched a hospital go through the actual process of selling a small amount of inexpensive medication for a large amount of money, there is a ridiculous amount of ceremony involved. I can easily imagine that it costs that hospital 2 cents for the pill, $5 in amortized capital plus operating expense for the facility that stores that pill, plus $25 in labor and IT expenses to get that pill to the patient.
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Audited financial statements of all kinds of hospitals, both non-profit and for-profit. Here’s data from Moodey’s a credit rating agency: https://www.chartis.com/insights/hospital-margins-trend-high... (“This month, Moody’s credit rating agency released its annual not-for-profit and public healthcare median financial report for 2024, showing that overall hospital performance continues to improve. The median operating margin increased from 0.5% in 2023 to 1.5% in 2024.”).
The $37 for an aspirin offsets huge costs elsewhere for (non-NP) nurses, receptionists, janitors, orderlies, etc., who can’t bill directly to medicare.
Insurance pays the higher of their negotiated rate or the billed charge. Medical facilities set their billed rates so high that they’re guaranteed to be higher than all negotiated rates, ensuring that they get paid.
When you see $37 aspirin on the line, nobody actually pays $37 for it. The billed amount is replaced with whatever insurance rate is allowed for that. If someone is cash paying they get a large discount.
The billed items also have to cover everything. It’s not directly $37 for the aspirin, or the $5 or whatever allowed coverage it ultimately gets billed it. That had to cover the facilities, the salaries of the pharmacy staff who reviewed the request and dispensed it, the staff who inventory and order the medications, and the cost of billing insurance.
The only part that nationalized health care would change are the allowable billed rate and maybe the administrative overhead of billing different insurances. Even nationalized health care systems have admin overhead though.
You can think of it like when you have to pay $11 for a single glass of wine from a bottle that the restaurant paid $10 for. You’re not just paying for the liquid, you are paying into a big bucket of charges that all need to add up to more than the cost of the supplies, staff, building, and everything that goes into running it. The margin on individual products doesn’t make the entire operation profitable.
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It comes from the fact that lots of the charges they bill (both of the patient share billed to insured patients and of all costs billed to uninsured patients) end up written down or off because they are uncollectable.
The margin built into the prices bulled is not the actual margin the hospital ends up with.
Hospital billing practices are often terrible or even fraudulent, but stories about the $37 aspirin are generally misleading. Most hospital claims and bills are actually coded around day rates and DRGs, so even if the aspirin shows up as a line item it doesn't actually impact the patient's financial responsibility or the amount allowed by their health plan. (I'm not trying to defend such a confusing system, just explaining how it works.)
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Medicare has been playing a shell game with reimbursements for decades. They cut the base rate for an office visit or hospital stay to below the cost of the actual service, but allow for separate charges for various things that make up the difference so that doctors don't just stop accepting Medicare in mass. That's why you get billed $37 dollars for aspirin, $15 for drug administration, $50 for IV placement, $10/bag for saline drips, $75 for vitals checks, etc. That way the hospital can make up the money lost from the actual visit charge, this also requires more administration overhead, to both keep track of all the additional charges, and to make changes as the rules change.
You understand that hospitals have more costs than just aspirin, right? Depreciation, amortization, utilities, rent, taxes, maintenance, salaries, etc...
Its all coming out of revenue.
This is because a whole swath of people are getting the aspirin for free (uninsured) so they need to gouge the payers for the aspirin.
Also, then, of course, we need to cover the United Healthcare guy's salary, which decreases margins.
Ever hear of loss leaders? Some parts of a typical hospital make money while others lose it hand over fist. The overall margin isn’t across the board, it’s after everything hopefully balances out.
ER’s for example are money pits, but society really needs them.
https://www.definitivehc.com/resources/healthcare-insights/h...
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Hospitals, now that private equity is involved, do this weird cost shifting accounting BS with shell companies etc, as such their books aren’t straight forward and the 2-5% thing is likely greatly underestimated given the amount of understaffing PE has driven in that space and how much gouging there is from PBM etc.
Hand-waving numerous details, but - That $37 isn't the price in the hospital's gift shop. It's n=1 pricing, hand delivered to your bedside by a nurse with a whole hierarchy of higher-level medical & admin staff behind her, and documented out the wazoo. Aspirin could be free & unlimited at the hospital pharmacy's receiving dock, and it wouldn't affect the @bedside price.
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Even if universal health coverage lost money it would be better than the current system that is based on a "causing cancer is better for the GDP than curing it" mentality.
The US has top-tier cancer survival-after-diagnosis outcomes. We spend too much to get there, and other countries in our cohort would "argue" that we get those numbers in part by diagnosing earlier and that our outcomes are broadly similar, but if you're going into these debates with "the US private health care system causes cancer deaths", that's a pretty rebuttable argument.
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There is a ton of ideology baked into naive-level analysis of this stuff.
I am constantly told how much less Europeans pay for better health outcomes and all I can think about was the obesity crisis I grew up around in Texas.
Socializing healthcare isn’t going to get an huge portion of the population out of their cars and get them walking as a primary or secondary mode of transportation. Not when it’s 100° and the grocery store is five miles away.
Americans, in no small part, have worse health outcomes because we have dramatically worse lifestyles. I support German-style universal healthcare, but I’m not going to pretend it will suddenly give us German health outcomes.
>Socializing healthcare isn’t going to get an huge portion of the population out of their cars and get them walking as a primary or secondary mode of transportation
You would think so but once healthcare cost becomes a government policy issue people complain about its spending and they are forced to try and bring that cost down. One of the ways they did that in my country was to promote biking to work and build bike ways.
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Europeans do pay much less (though: for roughly the same outcomes --- probably the same outcomes if you control for wild SES variance across the US).
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> Hospitals have an operating margin of 2-5%
I'm curious where you got this figure, because it doesn't track with my own experience.
I used to work for a place that worked closely with hospital clients (and prospective clients) to resolve billing issues with a particular EMR system, and we regularly discovered that a given hospital was losing hundreds of thousands to millions of dollars weekly due to missing charges. The problem was, so much money was sloshing around that the hospitals were virtually always unaware of the missing charges, and many CIOs were more interested in saving face by shutting down further discussion than in walking through the collected data, how to fix the charging issues, and even claw back some of the lost charges (which you can generally do up to several months after the fact).
Not the parent, but here's one source: https://www.vizient.com/insights/reports/national-hospital-f...
There are many others as well.
FWIW, your experience doesn't seem contradictory to the operating margin claims.
Your experience seems to be that hospitals are run very inefficiently, implying that if they were run efficiently that their operating margins would be much higher than 2-5%. That may be the case, but that still means the Yale paper's claims don't make sense (unless they also propose some mechanism by which to suddenly force all hospitals to start operating efficiently).
But I'm also skeptical of your claim that hospitals are leaving a huge amount of operating margin on the table. IME, very little can be explained by "everyone is stupid." Would I be surprised if a given hospital was run very inefficiently or if a given hospital had a particular poor CIO or administrator? Not in the slightest. Would I be surprised if ALL hospitals were run by idiots who were leaving 10% operating margin on the table? Yes, I would be.
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> Hospitals have an operating margin of 2-5%
I don't spend any healthcare money at the hospital. It's all all providers office, private clinic, etc.
It costs $300 for my primary care doctor to see me for about 7 minutes. An assistant takes my blood pressure, he asks me a few questions about my habits and diet, and then I come back next year.
If I actually need any services, I go to much more expensive specialist, or urgent care facility. A visit there is about $100 and then a couple bucks for whatever prescription they give me.
Hospitals have an operating margin of 2-5%
How does this work when many/most US hospitals operate as non-profits? Quick search shows the for-profits have operating margins nearly triple your figures. And the non-profits are beholden to the community to provide some level of "freebies" to maintain their status, right? IE, they're aren't really all operating on razor thin margins.
"Healthcare reform is hard."
People tackle hard things for nothing, never mind billions in savings.
Yes, but there's a difference between finding out whether P=NP and some of the brightest geniuses in the country actively opposing you.
I don't think a price transparency reform would be hard. Other than in terms of political will. We did go part of the way there a few years ago, though it's not common knowledge yet.
> Hospitals have an operating margin of 2-5%
There's no way a Chairman/CEO would ever reduce the operating margin by just giving themselves and their buddies a raise is there?
Are you saying that most hospitals have 50% profit margins, of which 90% are paid to the chairman leaving only a thin margin? That seems difficult to believe.
They may have 4.2% margins knocked down to 4% by exec comp but I don't see that how that fact would change OPs point.
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> Take "Medicare-level payments to providers". Hospitals have an operating margin of 2-5%. Medicare pays 50% less than private insurance. So doing this would require either layoffs, cutting salaries for doctors/nurses/etc, or both. This may well be the right decision for society as a whole--that's a big part of the debate here--but there's no free lunch.
I mean, admin costs at hospitals are ~25%, around half of that is directly linked to billing. Administrative costs in the US (because of course you have the same costs on the other side in the insurance side) are around 30% of cost in general, which is pretty insane.
The lack of regulation around pricing transparency and generally the lack of one-price-per-code (which the government uses to its "advantage" to get lower medicaid/medicare rates for sure) is what has caused this stupid arms race on both sides.
Billing and insurance ("BIR") is reported at around 8.5% of revenue --- admin isn't just BIR, as you note. But replacing private insurance with Medicare doesn't drive BIR to zero; Medicare is also a claims-based system. Estimates are that you'd cut BIR by somewhere around 30-40% (of 8.5%).
Most of the savings in these kinds of reports simply comes from paying doctors less (or delivering fewer procedures, which is also a problem we have.)
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Yes, these cost savings would be a deflationary event. Most layoffs will come from insurance companies and administration necessary to satisfy them in hospitals.
One reason hospitals have such low margins is many people simply can't pay. If you have a payment guarantee like a medicare for all system, this will increase the stability of hospitals. In fact likely bring back some hospitals in places that didn't make sense like rural areas, which have been struggling via hospital closures.
If you are worried a low cost system will reduce doctors and hospitals per capita you don't need to, as countries that have universal healthcare often have more per capita.
https://worldpopulationreview.com/country-rankings/doctors-p...
If universal healthcare just made access simpler with less paperwork it would be a major improvement.
The flipside to fraudulent billing is that people that need care are denied. The fraudulent billing was perpetrated by the insurer.
No, fraudulent billing is the natural predator of insurance companies. You have this backwards.
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As the article said - it has not been peer reviewed
Why is the United States the only country on Earth where free healthcare doesn't work?
The US' healthcare model is not unique, and almost no countries have zero-cost-to-consumer healthcare systems (and none of them are free -- they're just paid by taxpayers instead of consumers). "Free" healthcare is the exception rather than some kind of international norm you incorrectly make it out to be.
The first step to reforming US healthcare is actually understanding it, and understanding some international designs. Lying about it doesn't help.
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Good old American Exceptionalism.
People wouldn't be externalities if healthcare costs money. Next thing you know you would have to pay attention to the environment or god forbid the food. It would eat away the budget for overthrowing countries and bombing children. Watch them elect a democrat to do the bombing next round and a new republican after that. It sounds like a joke but it isn't funny.
What do you recommend?
>Hospitals have an operating margin of 2-5%.
I don't see you complaining that the US military has a low operating margin, so maybe we can just agree that some things are just normal expenses for a population. Which therefore leads to step 2: nationalize every single hospital.
>cutting salaries for doctors/nurses/etc
Considering that over 50% of the money that goes into healthcare is just siphoned off by middlemen, no, just getting rid of these means that your health workers do not have a worse salary.
>But, we're actually in a primary care shortage.
Because people do not even go see their GP since there's a chance it leads to life ruining expenses.
> fewer residents are going into family medicine.
Because they're going where money is. Remove that from the equation, and all you have is a public service with public servants.
>a lot of people in the industry believe that Medicare has a large amount of undetected fraud.
Aside from the fact that "people in the industry" have a financial interest in making you believe Medicare is a net negative, there's a great thing that comes from making healthcare a public service: there's no longer any fraud. And those "fraudulent" expenses you used to have that were costing you millions anyways have just had their costs cut in half.
>Healthcare reform is hard.
It's the easiest thing in the world when you have the amount of money the US does. Healthcare reform isn't a financial or infrastructure problem, it's a political one. Cuba has a working healthcare system despite being under US embargo. Botswana has a working healthcare system. Rwanda has a working healthcare system. Azerbaijan, Sri Lanka, Turkey, Serbia, and the list goes on.
Once you grow the balls to nationalize everything, even a first year economy student could make a plan that works.
Every country with nationalized healthcare systems has lower wages for clinicians. So the notion that this wouldn't lower salaries is just ludicrous. That might be an acceptable trade-off but let's not pretend it doesn't exist.
In practice what we would see under a single-payer system is that many doctors would opt out and shift to a cash payment model. So the shortage of doctors would get even worse for patients who can't afford to pay out of pocket.
Yes, I consider big numbers like this to be red flags.
The GDP of the US is $32T. Saving $1T will essentially make 3% of the US economy vanish. You don't vanish 3% of an economy without wide ranging repercussion, it would be a crisis similar in scale to that of 2008.
With such numbers we are not "saving money", these are about rebuilding an entire economy, a painful process. So either the effect will be much smaller than that, or there will be riots.
This is broken window fallacy. The $1T not wasted on healthcare inefficiencies would be spent/invested on other things, creating jobs there. Yes, there would be churn because a good number of people involved in the bureaucracy of private health insurance would lose their job and possibly their career. But these things get smoothed out. Social supports (should) exist to dampen the effects of such churn and keep the economy agile.
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We're quick to want to automate trucking, manufacturing, even knowledge jobs and say "ooh but the horse shoe maker became the tire installer" but the pointless middleman jobs making everyone's health worse seems to be the line in the sand for job automation.
You can't touch the legions of people who exist to make things more expensive.
Only the American mind can comprehend leading to the deaths of tens of thousands of your own people for the sake of 3% of your economy. As long as the line goes up.
If we're taking the $1T figure seriously, let's take the other figure seriously too. Let's slash it to be more conservative while we're at it and say it would only save 90k lives. Do you think 3% of your economy is worth sacrificing to prevent the equivalent of 30 9/11s? And that's before considering that other people here already explained how these 3% are offset by other gains - if not completely then still substantially.
> these are about rebuilding an entire economy, a painful process.
"Sorry kids, can't turn off the Orphan Grinder 9000, there's a whole supply chain behind it that would have to restructure."
The money doesn't vanish. It stays in the hands of people. People who would spend it on other things, feeding it into the wider economy instead of the pockets of a small number of corporations. There's zero reason to think this would result in anyone rioting except maybe insurance company CEOs.
The US spends more than 16% of GDP on health. The UK around 11%.
Shrinking US health expenditure by 3% of GDP while roughly maintaining health outcomes is eminently, obviously doable.
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Well it wouldn't "vanish". The $1T savings (if produced) that were once spent on healthcare would instead be spent on anything else.
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This seems a lot like the parable of the broken window but for inefficiency rather than destruction per se.
I mean there's flavors of contributions to gdp. Spending money on make work for people digging holes still counts. I wouldn't mind 1 trilly being freed up for more effective use. I imagine we could get pretty good returns on it just paying it against the debt as a simple idea, effectively a tax cut.
You can quibble with the specific projected savings, or the projected lives saved. But it kinda doesn't matter? If we can have net savings of half what this paper said, or a quarter, and still have more lives saved, that would still be a strong argument to do it.
Somewhere there's a pareto-optimal frontier where one can't possibly save more lives without spending more, or spend less without more people having negative health outcomes ... and the question is whether universal health coverage would be a step towards that frontier (b/c we're all pretty sure we're far from the frontier today). And the fact that plenty of countries have both lower costs and better outcomes through such a system is highly suggestive that it is a more efficient policy regime.
Maybe the big quibble is whether the American penchant for creating corporate givewaways to powerful organizations that lobby politicians would create an especially toxic public-private-partnership monopoly in which the biggest existing private healthcare networks are granted regional monopolies and set crazy prices (or some other dystopian warping of an initially reasonable idea) so costs actually balloon. I do think that would be a risk and so we need to be careful about the specifics of how we implement this.
Of course it does, but only one country has to keep commissioning and ignoring studies to work out a group of 300million people can get better prices for everything if the incentive for the government is to decrease the price rather than increase it for their buddies
We've been down this road. ACA was predicated on studies like this, to no avail (it turns out that intense opposition chips away at it over time regardless of these studies).
I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
I'm not saying that this is what is happening now, but I am saying that calls for universal health coverage, no matter how correct and well supported, are going to probably face the same obstacles they did last time, so we need new coalitions and implementation proposals if we're going to give it a go again. It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to.
ACA has saved tons of lives. Due to the intense opposition, it was not structured in a way that could save money, but rather structured in the way that it could get through congress.
Additionally, as somebody who was around pre-ACA, I can not tell you how much better, in every single way, the post-ACA healthcare world is. Pre-existing conditions? Access to healthcare as an individual? These are life-changing possibilities, especially for entrepreneurs.
There's a very clear type of fallacy you are engaging in here that only works in politics: you're taking a vague general idea X, ignoring all particulars, and then lumping an idea Y together as if they identical and that any change in that general direction of Y could ever be different than what happened with X. There's no intellectual rigor or honesty in that sort of thinking, yet it somehow pops up throughout all of politics.
>Additionally, as somebody who was around pre-ACA, I can not tell you how much better, in every single way, the post-ACA healthcare world is. Pre-existing conditions? Access to healthcare as an individual? These are life-changing possibilities, especially for entrepreneurs.
The failures and politicization of the ACA have caused us to be a little too dismissive of its successes and popularity.
Protections for pre-existing conditions and allowing children to stay on family plans until 26 in particular have made an incredible difference in a lot of people's lives and are wildly popular. So much so that it would be close to political suicide to try to remove them as evidence by Republicans controlling all three branches of government including both chambers of Congress and there is no serious talk of repealing them.
There is belief among a lot of its supporters that universal healthcare would have a similar wave of support if enacted and that the opposition is mostly irrational political arguments rather than people's true feelings about an actual policy. This is why the "ACA" polls higher than "Obamacare" despite those being two terms for the same legislation.
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I agree with you about the ACA (as an opponent of single-payer). Prior to the ACA, members of my immediate family were uninsurable on the individual market --- not insurable at a higher rate, not insurable with exclusions, but literally uninsurable: their only options were employer-provided group coverage or state catastrophic safety net coverage programs. The twist: neither has any chronic health conditions. The underwriting refusals were based on symptoms reported in previous engagements with the health care system.
> These are life-changing possibilities, especially for entrepreneurs.
I would quit my day job and completely focus on my side business if I didn't have to worry about healthcare.
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Before I went indie, prior to ACA requirements I researched private insurance and found plans for around $3K. This year I’ll pay over $20K for a bronze plan for my family. 700% increase in less than a decade. Aetna left the marketplace input state and no pediatrician in a 10 mile radius takes the most cost effective ACA plan. The pediatricians we found are actually just GPs who have training in pediatric medicine, but we bring in the only minors they see. This is in a top-5 market based on population.
All of the providers have consolidated. I don’t know if ACA affected that or not, but wait times for checkups went from later this afternoon to sometime 6 months from now.
Part of my experience is going from corporate health insurance to marketplace, but in the past 5 years, ACA plans have consistently gotten worse and more expensive while service for those plans has gotten significantly worse in almost every way.
Who is it better for?
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No system that saves money can pass in congress: that's the real problem that we cannot actually avoid. Forget pressure from large companies: So many of US costs come from very high salaries, and a lot of bureaucratic positions that don't exist elsewhere. Every dollar we pay goes to someone, and it's not just some random mogul here or there that will be OK anyway. Reform that really lowers prices means loss of jobs, which them will be blamed on the politicians who signed the bill into law.
Pre-ACA, I could afford family insurance. My family premiums went up ~$500 a month post-ACA, while the coverage worsened.
My afib ER trip three years ago cost me $7k out of pocket even though I left the hospital still in afib.
Today in my 50s, my deductible is now $8,500. My partner doesn't have insurance because she's not poor enough or rich enough.
We had an insurance rep come to my work last year who said after ACA they had some people whose premiums went up 900%.
So yeah, ACA is better in your world, but not in mine.
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ACA also greatly increased costs. As an entrepreneur at the time, insurance premiums increased 25% overnight for the same plan. Many people had similar experiences.
That the ACA forced a large number of people to pay a lot more for literally the same product is not a good outcome for those people. Too many people try to pretend this didn't happen.
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I lost my individual healthcare plan, and I couldn’t afford the new ones. Remember when they said you could keep your plan? Yeah, that’s the one I lost.
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Keep in mind, I made no value judgement on ACA at all, just suggested that we learn about its opposition and, as you rightly point out, the difficulty of passing such legislation that can last over time.
I agree that "To no avail" could be read as "was worthless" to an adversarial reader, but trust me when I say it was meant as "which didn't save it from being opposed and stripped over time". As in "the studies and facts don't move the politics"
It should be obvious the messaging is oppositional along party lines. Every chip away at ACA makes it a worse program, and is celebrated by half the electorate. This is a core problem with the legislation. A second iteration on top, or in place, would have to learn from this and work to make the program stickier.
Let’s be honest, it was DOA. Even Gruber admitted to it later. The whole thing was basically a scam.
Edit: I will never understand why people think ACA was so great. It was a bad policy because they couldn’t get it through whole. They passed it with all the compromises that made it DOA. You can’t fix something when you are still in denial about it being bad. ACA is not a transition to universal healthcare when you allowed massive consolidation in the space with some of the biggest companies in this country. Good luck deconstructing that mess.
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Republicans finalized things to address medical costs and chiseling at hospital billing - regulations promulgated during Democrat regimes - so I would say there is bipartisan consensus for the actual arguments, if people listened to the actual arguments instead of seeing a no-vote as an opposite nonsensical ideology.
This has been one of the opposition points - don't just give a handout to insurance companies without addressing their billing practices
The original ACA did not have consensus for some of the proposals to address the billing practices such as existing and new state healthcare programs having collective bargaining. And yeah I think the original ACA was unworkable, compromise is taught as a good thing to children in this country, but it just means "the wrong answer".
The tweaks now, alongside the original democrat led ACA, alongside the parts that were stripped out I think could have better consensus
does need a rebranding though.
The only thing that will actually lower costs in our society is healthy people. And right now, everyone is unhealthy and not doing preventative measures due to expense.
The real problem with universal healthcare is that it immediately completely eradicates religious charity.
Any single mom who works as a stripper can go see a doctor who doesn't have the slightest inclination to judge- you're just a number in a government database. Everyone's getting free shit no questions asked.
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>ACA has saved tons of lives.
The ACA has killed a whole lot more lives than it has saved by causing healthcare costs to spiral up.
If you begin with something that is obviously incorrect and trivially debunkable, perhaps that's indication that you should review your priors.
> ACA has saved tons of lives
It was the Medicaid expansion that has been cited as saving lives [0]. An expansion that has almost nothing to do with the rest of the ACA.
> "There's a very clear type of fallacy you are engaging ... There's no intellectual rigor or honesty in that sort of thinking"
So you're claiming that the person who posted that is not only falling into a fallacy, but they are neither intellectually rigorous or honest? I think you're reading a lot into their comment which seemed pretty benign, but possibly contrary to your viewpoint?
[0] https://news.uchicago.edu/story/new-research-shows-medicaid-...
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These types of studies, and the goals they aim to support, always frustrate me as solving a surface-level problem rather than root cause.
The problem with US healthcare isn't who pays for it, its how damn expensive it is. As always there are multiple factors at play, my list would include corruption, lack of legal accountability/responsibility, and a population that is much less healthy than reasonable.
Go after any one of those and we'd make a lot more headway than trying to ram through a universal, government-run healthcare or insurance program. And yes, such a program could impact the above topics, but it doesn't have to and could make any of them worse.
> The problem with US healthcare isn't who pays for it, its how damn expensive it is
Saving $1,000,000,000,000/yr is directly addressing how damn expensive it is.
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The point of nationalisation is to address those underlying concerns. But it’s fair to say that in practice, nationalisation doesn’t always solve those problems.
The problem is you either need to regular or nationalise. And neither of those are particularly “American”.
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This paper is based on numbers from the CMS NHE. Here are those numbers summarized (up to 2023):
https://nationalhealthspending.org/
I haven't finished reading the paper and have no opinions on it (other than that most successful universal systems aren't single-payer) but if we start from actual numbers the discussion will be better.
> The problem with US healthcare isn't who pays for it, its how damn expensive it is
Exactly! There's so much paperwork that a doctor sometimes need two assistants just for the paper work. There's so much cost for independent practice that increasingly more doctors end up joining big hospitals. Charges with and without insurance have a huge difference. Just to name a few.
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"The problem with US healthcare isn't who pays for it, its how damn expensive it is."
And also how much is required. I bet a study investigating how much money and lives could be saved by reducing obesity would have 2x numbers
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Americans just consume a lot of healthcare services. Any substantial cost savings requires providing less healthcare service.
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I have a strong dislike for the industry as a whole. There's too many ridiculous situations I've been subject to, along with hearing of some from my friends.
My favorite was a friend who had to deliver her baby, alone, in a hallway, because they forgot about her. And the hospital billed her for it. LOL.
No, it’s not a question of who pays for it but who benefits.
You could have universal health with zero additional spending by the US government, but all that administrative overhead is someone’s income.
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We never attempted to solve the issue of distorted price signals that occur when customers aren't the ones paying for something. We're still charging $600 for a bag of saline.
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It's extremely challenging to go after high costs in the current system, because the doctors who charge them are popular and the insurance companies who pay them are hated. There was a 2024 story that stuck in my mind (https://www.npr.org/2024/12/05/nx-s1-5217617/blue-cross-blue...) when Anthem tried to negotiate down the rate of certain anesthesia procedures; the public was absolutely outraged, successfully demanding that Anthem must back down and accept whatever the doctors feel is the appropriate pricing model.
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I agree that this proposal would not solve all of the problems; absent more changes you would still see the creep up of healthcare costs at too high a rate. But slashing $1 trillion off of a $5.3 trillion costs is a pretty big bite of the apple. Even if you go with the more conservative $663 number, that is still a great first step. And both of those numbers are after adding the costs of covering currency uncovered people. So we are collectively getting more for significantly less money.
It does this by eliminating a very inefficient layer of our current system (insurance companies), and by having there replacement for that (the government) negotiate on drug prices (how much savings there is the reason there are two estimates). Currently insurance companies almost have a negative incentive to push down drug prices (their profits are limited to a percentage of total spending, and most large companies are pushing against that limit).
Most of the cost control pressures in our current system come out of Medicare/Medicade, and this would widen that out to the whole system. That in turn would wedge open the door to pushing on the other drivers of the cost spirals: hospital administration, new expensive drugs that are not worth the additional costs, doctor salaries ballooning, and the broken system between malpractice insurance and dysfunctional enforcement against malpractice.
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> if your solution requires perpetual majority control
I think once universal health coverage is established, it amounts to political suicide to try to take it away again.
Yep. Nobody has repealed Medicare, for example
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I don’t think “political suicide” exists anymore.
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ACA is not Universal Health Coverage. So this would be different enough. And you don't need perpetual majority control, only sensible politicians for about a generation (like FDR/Truman/Eisenhower/JFK) to lock in a popular entitlement.
FDR and "sensible" is always funny to me. The sensible politician that imprisoned Japanese Americans, destroying the lives of 120,000 of our fellow citizens.
Sensible politicians? In the US? In this era? For a _generation_???
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It was pretty close until republicans pulled back Medicaid.
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
You mean like overturning Roe v. Wade? Can't ever happen, right?
George Bush Sr. made a deal with Democrats to raise taxes and cut spending. Ever since then the Republican strategy has been to oppose pretty much anything a Democratic President proposes. The ACA was a Republican healthcare idea and they didn’t support it because a Democrat proposed it.
There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think. If it gets implemented quickly enough then getting rid of it will be very difficult to do. People won’t give up free at the point of usage healthcare once they try it out.
> There are only two realistic possibilities. Get a Republican to propose some sort of national healthcare or have Democrats fully embrace socialized medicine and not give a shit what Republicans say or think.
It's worth keeping in mind that Eisonhower's cabinet argued against the idea of giving the polio vaccine away for free on the basis of it being a "backdoor to socialized medicine". We're over seven decades past the point where it makes sense to give a shit about what anyone says about "socialized medicine".
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"If your solution requires addressing the slow-burn civil war, your solution is just a campaign slogan".
Essentially, all solutions require addressing the slow-burn civil war, which is today capable of of subsuming any issue. Not a single policy issue can realistically be addressed while the rabid 800lb gorilla is in the room. That gorilla is not Trump, that gorilla is Heritage, Fox News, Koch, et al.
> ACA was predicated on studies like this, to no avail
ACA was also predicated on broad participation. As with all insurance, the bigger the pool, the lower the premium. Insurance of any kind is primarily a risk arbitrage business and fundamentally relies on the presence of low risk consumers. ACA was designed with this in mind and made participation in the insurance pool mandatory(whether via the public marketplace, or via private).
Unfortunately for the ACA, the individual mandate was removed in 2017 via Trump's Tax Cuts and Jobs Act, which reduced the penalty to $0, while leaving intact the ban on denials based on preexisting conditions(on it's own a good thing). The elimination of the federal tax penalty caused health insurance premiums on the ACA individual marketplace to increase by an estimated 10% annually, as younger and healthier individuals dropped coverage and left behind a sicker, more expensive risk pool.
So, while it's fair to criticize the ACA, you simply can't expect a law to work if it's intentionally altered to engineer the worst case scenario specifically.
Here's the overall timeline
* March 23, 2010: President Barack Obama signs the ACA into law, establishing the individual mandate and its future financial penalties.
* June 28, 2012: The Supreme Court upholds the individual mandate's financial penalty, ruling it a valid exercise of Congress’s taxing power.
December 22, 2017: The TCJA sets the individual mandate penalty to $0. Lawmakers attached the repeal to a major federal tax overhaul package and used the budget reconciliation process that allowed the Senate to pass the measure with a simple majority vote, avoiding a filibuster.
January 1, 2019: The tax penalty officially drops to $0 nationwide, effectively eliminating the financial pressure to participate.
> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
At this point it says more about the state of our democracy than it does about any proposed solution. Even policies widely supported by the American public these days are met with obstructionists who care less about the welfare of the country than they do about scoring and blocking political "points".
It seems far more plausible to do this at state levels. NY teased it recently and then backed off.
> …if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
I suspect Social Security would have met that definition at one point in time. Perhaps even paid overtime, the 40-hour work-week, etc.
Sort of. They were not campaign slogans though. They were battle cries, by militant labor, insisting on what they deserved.
I mean, the original plan for what became ACA was single payer. They didn't have the votes from the moderate democrats though, which is why the "private plans on public exchanges" became a thing instead.
You're not wrong at at least for the forseeable future, single payer does seem untenable politically, but I'd argue that dismissing studies like this on the basis that it needs solved before debating it on its merits is circular, because the only plausible political objection to a policy like this is financial. If you reflexively claim that nothing without broad consensus appeal at a given point in time is worth discussing, you're essentially arguing in favor of freezing our public policy to whatever the current public opinion is today. I don't think you need to go very far back in history to see some pretty striking examples of why that would be undesirable.
They had 59 votes from Democrats for the public option, not single payer. Public option is to let people choose either a non-profit government insurance plan or private insurers. They needed 60 votes to break a Republican filibuster. Joe Lieberman (Ind-CT) said he would filibuster the public option but would vote for the ACA without it.
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I would never have had healthcare as an adult without the ACA due to an illness as a child that was expensive enough that I’m sure some insurance exec was only able to get a 26 foot yacht instead of a 30 footer.
It was a great success for people in my boat(no pun intended)
My favorite part of the ACA is that the nickname, Obamacare, was created by Republicans, thinking it would fail and the nickname would make that failure stick to Obama better. Problem was, the ACA helped a lot of people, particularly people in red areas. So, then Republicans started complaining that Obama and the Democrats were being arrogant for putting Obama's name on the ACA.
There's been tons of short interviews showing MAGA people having no idea ACA and Obamacare were the same things. They cheered when Obamacare got repelled even though they were beneficiaries of it. MAGA propaganda is powerful
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You mean obstacles from politicians who took money from the healthcare industry. That’s how we ended up with PPACA and they used it to justify massive cost increases and consolidations. They passed that junk to save face and now healthcare is far worse. But we “closed” the donut hole, right? Quite literally made everyone worse off and no one wants to talk about it. I still can’t believe they allowed payors such as UNH to buy up everything without ANY proper investigations during that period.
This is exactly the argument that gave us the Affordable Care Act. It was literally a republican plan from Massachusetts. It was supposed to be broadly acceptable and that's why it was implemented with a billion compromises.
But the Republicans called the Democrats commies anyway and refused to participate. And that has been their playbook ever since. That is what they are going to do, no matter what we propose.
So we may as well propose actual universal healthcare. But I agree with you that we need to create strong majorities to keep it in place until it reaches the kind of momentum it has in Canada or Sweden and opposition to it becomes a practical impossibility, like opposing social security.
Maybe someday we can have a system where losing health insurance isn't a motivation for not starting a company. Our current system is a complete disaster for entrepreneurial capitalism.
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> If your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan.
Describes everything the GOP offers as “solutions.” Theirs tend to strip rights while Democrats tend to provide rights.
We’re still waiting on the GOP’s “concepts of a plan” for healthcare promised on the last campaign trail.
can someone tell me this. Right now level of care is rationed by type of insurance you can afford. eg: northwestern in chicago downtown is inaccesible to ppl below certain income level.
In universal everyone has access to every hospital ? Why would someone go to lower level hospital if they can go to northwestern. Now the acess to best hosptials is gated by a queue?
I am not saying this is right but ppl who already have access to northwestern its in their best selfish interst to oppose universal?
i am just countering the point that "ppl opposing it are merely brainwashed by foxnews or are stupid" . Its no different than ppl preventing outsider kids from going to your school.
You're right, it's not just that people opposing it are stupid or brainwashed: Some of them, to your point, are selfish and don't want others to have access to the nice things that they have.
Can you explain why those people DESERVE access to better care? Do they have more complex/rare diseases that require specialized treatment? Are there specialists who only work at that hospital? Those feel like warranted needs. But "I can pay more so I should have better things" is a ruinous worldview that, at its end, is just Might Makes Right.
> Now the acess to best hosptials is gated by a queue?
I mean, yes? Literally the same principle we all learned in kindergarten for how to make access to something fair. You didn't get to skip the line in lunch because your parents had a better job than someone else either.
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> I'm of the opinion that, if your solution requires perpetual majority control of legislative, executive, and judicial branches, your solution is in fact a campaign slogan
So you'll never vote GOP again. And you tacitly agree with Trump's repeated claim that conservatives will stay in the minority unless they _reform_ election rules -- https://www.theguardian.com/us-news/2020/mar/30/trump-republ.... Vote suppression and the "perpetual majority control of legislative, executive, and judicial branches," is Republican stated aim since the late 60s/early 70s when their party began its creep into permanent minority status
> It has to be different enough that those who would oppose it right after the inevitable pendulum swing do not want to
What does this even mean? ACA was based on a GOP-governor-in-a-blue-state's successful implementation of HCR. Everyone loved it until Obama loved it, then the highly organized GOP minority hated it, fight it, wasted ~20 years claiming insanely to have a better solution they knew they never had nor will have
Back when Nancy's daughter Alexandra Pelosi used to make mini-doc shorts for the intolerable Bill Maher she made one about southern white Americans' opposition to ACA. She interviewed one fellow -- perpetually unemployed, alcohol/drug/legal problems etc -- who came well out of his chest against Democrats, socialism, The Gubmint and all the other typical lefty stuff that Fox News mentors him and so many others on. Then we find out he's on welfare. Then we find out he's on Medicare/medicaid. Pelosi's like "What?? Wait a minute ... I thought you didn't like this government stuff. Why're you all over it" and mans goes "WELL I DESERVE IT!!!"
Let's just call anti-UHC arguments what they are: wet bullshit from private healthcare industry stakeholders and the uninformed partisans who repeat Trumpist mantras
Universal Health Coverage has a lot of other benefits:
1. It detaches health insurance from the employment market. This means those minimum wage walmart jobs just became more feasible, or any low end job really, since their is no pressure to provide "benefits" anymore. This would seriously lubricate the labor market, because the friction to providing, taking, and changing a job is reduced.
2. It ends a bias for group plans. If you are poor or are a trades worker and need to buy insurance outside of a group plan, you are going to be in an expensive high risk pool.
3. Its a benefit we can fund socially with taxes that will immediately have a positive impact on lower income workers, as well as poorer regions of the country (e.g. red states).
The US is far too broken for such a thing to ever come to be. Politicians are bought and paid for, and the impact on the insurance companies and their profits make this impossible.
US legislators will never, ever, ever put the needs of the people above the needs of corporations, not as long as corporations can wield their massive wealth as "free speech" in the form of lobbying and political donations.
Sounds nice, though.
The US has gone through a lot of changes since it's inception, so there's no reason we can't change this. Preferably to a system where people have the freedom to pay out of pocket for whatever level of care they want when they can afford it, avoiding the "death panels" and extended wait times that exist just about everywhere that already has a universal health system.
Universal healthcare brings the cost of private healthcare down.
I would still get private insurance for VIP car but it would cost less than what i am paying now.
When I was a kid, my parents would say “with that attitude, you’re right.”
We can and should expect a lot out of the people around us and especially the ones who choose civil service.
Our grandparents ended slavery, got votes for women, established a merit-based civil service, fought fascism, passed equal rights legislation, and created the most dynamic large economy in history.
We have problems, too, but we are not powerless to fix them.
You notice this?
It's literally everywhere. So much negativity. Sometimes I wonder how much is enemy action and how much is just depression or some other mental illness.
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> We have problems, too, but we are not powerless to fix them.
Indeed. Even as some of the more mainstream methods to address our current problems become less effective, we should be open to other ways change can come about. Among your list, many of those achievements had their roots in various approaches that didn't involve legislators.
Sadly so much of that, people are actively trying to undo it.
Nobody, including congress, gives a rat's ass about insurance companies and their profits. The truth is that someone has to approve or deny healthcare. Every universal system does it too, but by government policy instead of corporate decision. After the CEO of United Healthcare was gunned down in the streets for doing that thankless job do you think congress is saying to themselves "hey, maybe we should get into that business"?
> thankless job
His annual compensation was over $10 million.
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> someone has to approve or deny healthcare. Every universal system does it too, but by government policy instead of corporate decision
That's another lie you've been told and believed.
With Universal Healthcare the government just provides the funding. Medical decisions are made by Doctors.
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Man I wish I could downvote a comment. This is what you’d see on Reddit.
“Thankless job” is a crazy way to describe United Healthcare.
No one cares about insurance companies and their profits?? This doesn’t even make sense, so many people rely on insurance and many stakeholders profit off the American insurance system.
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I'm earnestly curious what the alternatives to CU look like and what that would mean for for-profit companies like The New York Times?
In a more sane world the Republican Party would be in favor of universal health coverage. How many potential entrepreneurs stay working at BigCorp because they need the health benefits? How many small businesses are crushed by the cost of providing healthcare to their employees? It would be great for business to remove any involvement they have in personal healthcare.
But I suppose they are the party of big business, not the party of business in general.
The Republican party is not a Conservative party, its a Reactionist party of capital, so generally anything that threatens the interests of capital will be absolutely crushed.
As a reply to Helloworldboy (sibling comment marked as dead), the US is not even in the top 10 of best countries to live in terms of quality of life. It's not even close to the top in any QoL metrics: life expectancy, child mortality, education, poverty/wealth gaps, air pollution, food quality...
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In what world is the Republican Party pro entrepreneur/small business enough to make these rhetorical questions meaningful?
When they make campaign promises, they go to small towns and talk about "Main St" businesses. Not sure why anyone believes them at this point (for the reasons you mention), but it is what they campaign on.
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That wing of the Republican Party does not exist anymore, they are now centrist Democrats.
As a sibling comment points out, the world of… 1974
https://news.ycombinator.com/item?id=49333468
I think republicans could get behind some measure of portable health plans between employers. What they could not get behind is universal, in the sense of "everyone living in USA" health care footed by the US Government. The objection would be about centralization of health care funding and about, you know, who would get the benefits.
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They used to be, before Trump and the MAGA clowns destroyed the party. So prior to 2015 or so.
A more sane world, you say? How about the Nixon administration, where Nixon proposes a universal healthcare system to Congress?
https://kffhealthnews.org/news/nixon-proposal/
The original universal healthcare plans were promoted by the GOP until Hillary got involved and it became a political football.
… in Massachusetts. New England Republicans are not the bulk of the party, and that’s not all bad - remember, the phrase was “banned in Boston”, not “banned in Bakersfield”.
Bill Clinton was a once-a-century skilled politician, but if you translated his policies without his extreme personal charisma to today it’s unlikely he would make it through the Dem primaries.
Republicans are the party of pulling up the ladder behind you.
They don't give any shits about free market economics or struggling entrepreneurs. They care about protecting their own money.
And it isn't about big business; that's the Democratic Party. It is about hoarding wealth and gaining more.
> In a more sane world the Republican Party would be in favor of universal health coverage. How many potential entrepreneurs stay working at BigCorp because they need the health benefits?
Oh hi. That is me.
BigCorp gives money to politicians and gets to depress worker wages because they can't leave — sounds perfectly sane to tie your insurance to your employer under capitalism.
The party in the pocket of BigCorp, that party...?
The insurance companies had substantial input to the specific text of the ACA. I'm not sure how you can imply the ACA was not a BigCorp bill when BigCorp wrote it.
It's also well known from leaks that the first Obama administration selected his cabinet using recommendations from Citigroup.
The Parties and Capital have multiple tools for disciplining Labor, health insurance tied to your employment status is one of the more effective ones.
Decoupling health insurance from your job and going single payer are separate things. You can have one without the other. You can have a very healthy system with private insurers (like in Switzerland) and you can have completely dysfunctional single payer system (like in Poland and I guess many other countries).
Main problems are elsewhere: doctors gatekeeping the market, lack of transparency when it comes to pricing, regulation making it impossible to compete for smaller players etc.
If they published the plan, it was a normal rational one without carveouts for their friends, and they started pushing specific legislation now to implement it, they'd crush the Democrats, and Trump could declare himself God-Emperor.
All they'd have to do is cut a few friends (insurers) loose. They'd still even have the power of the contract to reward theoretically productive elements of the new health system in return for kickbacks, and there'd simply be more money sloshing around within government to take advantage of. They could continue to stomp the planet freely, because Americans don't care about anyone but themselves. The upper-middle class post-Obama "left" would evaporate. Give them free state college and they'd start calling Republicans the real left.
Another reminder that the US government spends more per-capita on health care than every country with universal health care, and then the population pays again.
One of the things usually cited to defend this waste of money is the massive excess army of people working in healthcare administration, half of whom are employed to file paperwork and the other half employed to throw it in the trash. Now that they're all soon to be replaced by AIs which will be able to simultaneously file and delete worthless paperwork at inhuman speeds, we can let go of that garbage excuse.
But in a more sane world the Republican Party would simply acknowledge slavery as being a real debt owed, and stop being racist, without changing anything else. Most black people are socially conservative Christians, and it would instantly become another God-Emperor situation. Democrats haven't won whites since Kennedy; they gave them entirely up for supporting basic civil rights for black people (an own-goal for the Republican Party, started as a single-issue antislavery party) and big business. Without guaranteed black support (the only other choice black people have to Democrats is not to vote, which is quickly increasing its share), the Democrats wouldn't be a viable party at any level. Republicans are not sane, they are short-termists like everyone else.
Picking out the Republicans is unfair, though. Democrats lobbied furiously and entirely dishonestly against single-payer healthcare in 2016 and 2020. They even tried to sell single-payer and its supporters as racist.
If you could say Universal Healthcare only for MAGA white people Republican Party will get behind it. Especially if there is some opportunity to commit large scale fraud.
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>A single-payer universal health care system could cover every American, save more than 100,000 lives a year, and still cost $1 trillion less than the system it would replace, according to a new preprint study led by researchers at the Yale School of Public Health.
FWIW, the methodology that produced this particular result is known to have significant issues. The claimed effect disappears after correcting for them. It also isn't the first time that these authors have published similar studies with these issues. They are not a credible source.
Universal health coverage may save lives and money but this study doesn't provide actual evidence for it.
"known" by whom, and documented where? if you're going to just parachute in and say this paper by domain experts is dead wrong, at least link to what you believe shows this to be the case.
> result is known to have significant issues.
So well known you neglected to state or cite them? I'd invite you to do so now.
Please cite and explain what those significant issues are. As it is your post is a "trust me bro", and is not contributing to the conversation.
$1 trillion less profit.
$1 trillion more efficient in allocation of resources, freeing up money for consumer spending on everything.
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$1 trillion less middle-men.
Not profit, just income
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Not really. Private health insurance would still exist alongside for the more wealthy (including nearly everyone on HN) that doesn’t want to wait a year for their public system MRI. Same thing that plays out in other countries. The U.S. already has a form of this in so-called concierge / premium providers too. Lots of profit to be made.
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Total profits for US health insurance companies in 2025 were $50 billion. The other $950 billion has got to come from cutting:
1. money to providers
2. overall healthcare consumption
3. bureaucratic redundancy and waste
1 is going to piss off medical providers. 2 is going to piss of the general public. 3 is going to piss off the 20 million healthcare industry workers who are not direct care providers. So pick your poison. This is why it will never pass.
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That would be a massive hit to our GDP.
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and what about the third yacht? who could afford the third yacht then? huh?
Most of the problems of the US system aren't really a matter of who pays, but the fact that so much is paid for services, at every level. Any really significant savings, cutting bureaucracy and pressuring providers to make costs resemble those of other developed countries, are taking money out of someone's pocket. Many hundreds of thousands of them, if not millions. This makes any significant reform very difficult, as those people vote, and will know exactly who made them worse off, even if the country in general was made much better off.
Read The Logic of Collective Action by Mancur Olsen. It wasn't written thinking of healthcare. but anyone looking at the US healthcare system will see that what is going on is stacks upon stacks of collective action beating overall societal efficiency, over and over and over again, in such a way that it's basically in none of the decision makers best interest to actually increase overall efficiency.
It’s also geographically distributed. Substantially all congressional districts count a healthcare system as a top-5 employer. Those 70k/yr butts-in-seats admin jobs are occupied by voters, making them difficult to eliminate nationally. You’d have to go down to the state level at least to get anything done.
I think it’s because Americans been taught that were democracy, not a federal system, but that’s exactly where we expect to do these kinds of reforms. The federal government could reasonably set certain regulatory requirements. The states would need to make sure that any provider within it conforms to the federal levels, you know like auto manufacturing and exhaust emissions. Seems doable. Unfortunately we’re gonna have to wait for the boomers to die because they’re the ones that have gotten theirs and they’ve screw everyone else. Also, unfortunately, the millennials are gonna have to take it on the chin like we have for so much else and realize there is going to be some lost jobs.
What about quality of care tradeoffs? In Canada, for example, you are forced to use the government system, and if it doesn't deem you important enough, there is no private option.
Interesting. In every European country I know of, the private option is still available. Just vastly cheaper and more beneficial due to having to compete with a public option which covers basic necessities, surgery etc.
Canadians can (and do) just cross the border and use private US health care. The vast majority of them live near the US border.
Yes, this is what I find a little odd about the US proposals. I've lived in UK and Spain and in both they have great free public healthcare for everyone, and if you (or your employer) want to layer private insurance on top you can. Wouldn't that be a much more appealing proposal to Americans?
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Is this quality improvements including or ignoring the 30-ish percent rejection rate of the most popular healthcare system, including such gems as insulin and pre-authorizations refusing surgery for necrotic tissue when “maybe they could PT it, have you tried?”
PT? Luxury! My daughter had PT referred by her pediatrician, then the insurance didn't pay all of it and when I asked the insurance company for the EOBs they said they were not allowed to give them to me because it would violate my daughter's privacy.
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Same here in the UK. If you need to see a specialist, you regularly have to wait months, assuming you can even get a referral in the first place.
This is frequently true in the USA as well. My provider's dermatology department is pretty backed up and couldn't make me an appointment for an excision until November. Fortunately it's not urgent.
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> If you need to see a specialist, you regularly have to wait months, assuming you can even get a referral in the first place.
Two months can be a luxury. With my insurance in the US, it usually takes longer for me to see an in-network specialist. For my kid, it has often taken over 6 months.
Of course, none of these were urgent, so it was fine. If it really was urgent as deemed by a medical professional, I likely could get a quicker appointment.
But my friend, who has even worse insurance, developed a condition and was having trouble getting a diagnosis. He got referred to neurology, and none of the in-network specialists had an appointment for over 2 months. His condition made it hard to sleep every night (averaging about an hour of sleep a night). Due to the lack of sleep, he couldn't function at work. Took a leave of absence, got a plane ticket to go to a relative's country, got to see a neurologist the next day, got treatment that day and had his first good night of sleep in a long time.
Lost his job because of it, though. Unsure what his medical insurance situation is while living on welfare...
My mother needed to see a Alzheimers specialist. I called around large metro area....wait times were 6 months minimum.
That's not at all unusual in the US. My dad saw a neurologist for chronic severe headaches. It was very common for us to go to an appointment, have the doctor request a follow up appointment in 3 months, then be told during checkout that the earliest available time was in 5-6 months.
That is absolutely the case for many private healthcare providers as well. It depends on where you are and what care you need
The US is not much different. We don't have a wealth of specialists available to see people right away.
I've flat out been rejected from a specialist because they had no availability at all. I actually tried again and got to be seen, but an appointment is months out, always.
Hah, even with "platinum" healthcare in the US, urology referral, 4 months. "You should start PT immediately" after a car accident, "we can see you in 5 months".
"Oh, your septum is deviated ~90% on the right. Surgery? No, first you need to go on these nasal sprays for a few months so we can decide they didn't reshape the cartilage in your nose before your insurance will decide whether they want to "allow"[1] surgery."
[1] Insurers will always say, and have won in court, saying "We don't allow or deny anyone any care they need. We are just saying we won't pay for it."
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There are private options for lots of things in Canada, depending on the province.
Without data on what proportion of people are denied and what the consequences are, this isn’t a good faith argument.
On the flip side, cases that would get care in Canada are denied in the USA by private insurance. Private options are far outside the means of most people.
Yes, roughly 30% of health care in Canada, from dental care to cosmetic surgery, is privately funded.
Does American private insurance pay for everything? And if you say "but they can pay out of pocket", well Canadians can come to America and pay out of pocket too.
No.
For a lot of people it very much doesn’t. And the cost is very prohibitive for people getting any care at all when insurance doesn’t cover it, so they end up not getting necessary care and then ending up on disability for life.
A healthy population *makes money for taxes and buying things*, too.
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The private option is medical tourism to Buffalo or whatever.
I don't know about Canada, but here in Spain you have both. You have public health guaranteed, but many people also have different levels of private coverages, usually to get quicker appointments.
As I understand Medicaid, it would just be open Medicaid for 100% of the US population regardless of the income, remove Medicare (they are now under Medicaid), leave the private sector as it is. Do you think Medicaid is too slow, too low quality, too terrible in general? Pay for private insurance, but you can still go to Medicare if needed.
The number of ridiculous claims in this thread...
First off, all Canadian provinces are different. Here in Quebec, there is a absolutely a private option. Not everyone likes that it exists, but most people seem to like having that option.
Canadians live better for longer on average (for cheaper healthcare overall). Any other metric is just a misguided attempt to justify the US status quo, which has nothing going for it unless you're rich.
I'm in Canada. The only time I ever needed a doctor in my life it was denied. I ended up having an issue that took ~5 years to resolve, which could have been prevented easily by any competent doctor in a 30 minute session.
I'm originally from Mexico. With what I have paid in tax here over the years I can afford to set up and operate my own small hospital over there, with new equipment, this is not an exaggeration.
"Free" healthcare, as with many other free things, turns out to be the most expensive kind of healthcare. Anyone who thinks otherwise doesn't really know what they're talking about or they're just stupid.
What could work, imo, and since we're all giving opinions here, is private healthcare with a ceiling on profits. Let players take 2x-5x, but not 50x which is what they do now, bring and enforce usury laws into healthcare.
I think the tradeoff is that in the US, on average one gets to spend about $4000 more per year and live about 3 years less when compared to Canada.
https://commons.wikimedia.org/wiki/File:Life_expectancy_vs_h...
The differences in life expectancy are due entirely attributable to vehicular accidents, homicide, and life style factors. It has nothing to do with medical care.
My dad, in the US on Medicare (one of the government funded systems), was denied a test. Because we have the option and had the money, he went and got the test himself on his own dime. That kicked off a series of events that led to a quadruple bypass, avoided an impending heart attack, and likely added many years to his life and his ability to remain and functioning member of society.
While I love the idea of never having to think about health care costs for a variety of reasons, I do like that some services are available to anyone with a wallet and not locked behind government controlled gates.
The availability of universal healthcare does not preclude the availability of privately paid healthcare as well.
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There's problems with every system, but as a Canadian, it doesn't sound like you know anything about our health care.
This is what is never mentioned. Quality of care, access to cutting edge treatments, timely access to care are never discussed when moving to universal healthcare. There are examples of private and public systems out there, which would be a much better model.
What about them? The Canadian healthcare system has better outcomes than the American healthcare system in several areas. Most simply, Canadians live longer.
I'm 29 and when I was a kid, getting a family doctor used to be an easy task and if you needed to see your doctor you could get in that day. Now all the doctors are so overworked, they're fleeing to America where they can get paid a reasonable wage for a reasonable amount of work. If you can even get a family doctor, if you want to book an appointment, they'll ask you which day you'd like 4 months from now.
My mom's been dealing with an issue with her lungs for the better part of the past year, and trying to get help through any of the intended methods just gets her put on a 2 year wait list. At this point her plan is to pay tens of thousands of dollars out of pocket to see a specialist in America.
The current generation of elderly Canadians now having lived a long life spent most of that life in an entirely different Canada. My generation is going to die on a waitlist.
6 month median wait time for treatment, as in the case now in Canada, is not something I'd trade the American system for.
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Can you reconcile this with skyrocketing Canada to US medical tourism?
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So the government provided healthcare covers everything then? If not, you cannot legally get it by paying for it by yourself? Curious.
My understanding is that a clinic or hospital can’t legally charge you for a procedure that’s universally available through the provincial healthcare system.
So you’re free to pay for anything else if you want.
They have also started recommending patients just kill themselves too
There have been studies like this for decades, going back to at least the Clinton administration.
And nothing will come of it. Too many entrenched interests, regulatory capture, and lobbying + political donations.
If spending drops by $1t, it will come out of someone's paycheck. Yes, some are greedy folks who will be just fine making 20% less a year. But many will be nurses or hospitals or some combination of providers.
That you actually believe that is so sad. No, the money would come out of the pockets of insurance CEOs.
impose universal health coverage & the jockeying will commence to see who is in charge of it. medical & diet fundamentalists will rejoice at the opportunity to seize control & force everyone to take certain drugs, eat or not eat certain foods or types of foods, exercise a particular way, surrender their organs at a particular age, or whatever else their hearts desire for everyone else. there have been so many rabbit trails taken, so much malfeasance, so much misinterpreting of data, etc., which has been uncovered just in the last decade or two to give anyone the ability to harm or control entire populations in this way. the increase in suffering will be great, & the long-term effects devastating.
Standard single payer insurance is not identical to 'seize total control of ever living body in America'. I shouldn't have to point this out.
The attempts by the current republican admin to seize control of certain 'illegal' bodies has caused so so much harm, I'd agree there. But even operating at 10x the nominal level of the past and ICE still haven't been able to exert temporary control over a single American city that resisted them, much less everyone in America.
You should figure out specifically what you are scared of and deal with that, rather than catastrophizing about things that cannot physically happen on any near timeframe.
Source on... any of that?
Fox News and 2010s Info Wars
Universal healthcare works just fine in Europe without major issues like that. It's the American political system that is broken. Your de facto two-party political system lets idiots take total control way too easily, as we can see with current US administration.
My country has universal public healthcare, and nobody forces you, or even your children to get vaccinated, monitors what you eat, or any other form of control that you're worried of. Organ donations are voluntary too, you can opt-out easily. And if you think the system sucks, nothing prevents you from taking extra insurance and using whatever private healthcare provider you want.
It sounds like you have issues with people telling you what to do. Would you like a pamphlet on the virtues of Anarchy as a way of building community to survive in a terrifying world?
Because none of the things you said have ANYTHING to do with "universal healthcare" and everything to do with "bad actors worming their way into positions of authority to enrich themselves". Surly you can't believe that "let every induvial person figure it out themselves in an unbalanced capitalist system" is a better answer, right? This isn't just about "if too many people are in the system then MY healthcare quality goes down", right?
In what possible conceivable way is single-payer healthcare in any way related to any of that tripe? Seriously, what an atrocious post. You may begin by observing that countries in e.g. Europe with such systems are not totalitarian hellholes where "the gobmint" tells you how to eat with "devastating long-term effects".....
WTF are you talking about dude - we average white collar/blue collar people are so desperate for a unified healthcare system in this country not tied to our (constantly unstable) jobs
We are so desperate that someone murdered a Healthcare CEO - ie resorting to violence
We are so desperate that many is (myself included travel to cheaper countries for dental and other healthcare)
Its a simple calculus but one that is obtuse to conservatives and richer people
There aren't enough Physicians, they don't make much and they all seem to be working 12 hour days but being paid a salary that would equate to an 8 hour day.
Doctors see downsides of a universal coverage are mostly about loss of autonomy and increased demand because when care becomes free demand rises along with pressure to expand access without extra staff.
> could save $1T and 114k ...
There are not enough physicians because we have limited the number of physicians. This was done, in part, by limiting the number of residency positions.
[1] https://petrieflom.law.harvard.edu/2022/03/15/ama-scope-of-p...
Yeah, having lived under universal care, the dark side of it was atrociously long waits to see a specialist and having a GP who is obviously overworked and barely spends any time seeing you.
If you want to be seen immediately (even when triage determines it not necessary) you can just supplement with private insurance
That may be your experience, and I’m sorry to hear it, but that is not the universal experience.
I’m in the hospital right now. My two year old had her tonsils and adenoids out this morning. Regular Dr visit lead to an X-ray on the same day, specialist appointment 3 weeks later, surgery 2 months later (would have been one month, but we pushed it back because timing and life).
Just talking about how my wife is coming off 18 months of maternity leave. Before that she quit and just didn’t work for 3 years because burn out. I’ve been self employed for 10 years earning about $20k a year.
This whole thing cost us exactly nothing. Would be the same if we’d never had jobs.
Mum got stage 4 cancer in another country where she lived. 2.5 years of radiation, chemo, X-rays, mri, and dozens and dozens of specialist appointments (which she got paid for transit and free accommodation in the capital city) not to mention the mountains of serious drugs.
Total cost $0.
Anyone that argues against this is either not very intelligent (easily manipulated by the propaganda) or does not want to help others (“freeloaders”), or is getting rich from the status quo.
And yet that's exactly my experience in the US healthcare system.
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As I understand it - ~30% of US federal spending is on health care.
In the UK it's about 20%.
Yet apparently the UK is mostly nationalised under the NHS, while in the US there is huge additional spending on private insurance.
Can somebody from the US explain to me how that's the case and why American's still put up with it?
US federal budget is 23% of GDP, while UK is 44% of GDP. You can't compare fractions of the fractions directly. (Total spend is something like 11% vs 18% GDP.)
Sure it's difficult to compare - but from your figures - the 11% is UK and the 18% is US ( total spend )?
With the UK spend roughly 80:20 government:private and the US spend about 50:50.
So as percentage of GDP government spend is about the same percentage of GDP but the much bigger private spend in the US what makes the difference.
We hate it and are more and more powerless to change it every day. The parties are entrenched and swing districts are becoming increasingly rare. Those competitive districts that remain are flooded with unlimited campaign funds from big business and plutocrats, thanks to Citizens United.
The mortality numbers in this paper appear to be extrapolated from an observational study of 9,000 cases from 1988-1994. That paper distinguished between "privately insured" and "not privately insured". This paper distinguishes "adequately insured", "underinsured", and "uninsured", and applies the original paper's hazard numbers to everybody but the "adequately insured", with a coefficient modifier for the "underinsured" that they came up with themselves.
How much would it save if you account for the fact that half of congress would sabotage it in to oblivion?
And if not that.. healthcare then becomes monopolized.
Maybe extreme but what prevents that entity from becoming the decider regarding who lives and dies?
Since when has a government projection of costs ever been in any way realistic? The estimates for the costs of Medicare when it was established were low by a factor of 10.
Last time I joined a discussion about US health care on HN (years ago), the picture looked bleak: secret chargemasters in every hospital, no realistic way for patients to compare options because the options are too complicated, and lots of people still falling through the cracks.
I can't help but think the picture looks very different now. There is growing awareness that chargemasters can not be secret. LLMs offer a way to overcome the complexity of choosing options, opening doors for real competition. I sincerely hope we can take advantage of this changed landscape to provide better care. Universal health care remains an interesting possible direction, but I now have hope that we can do a lot better within the existing laws.
Link to the preprint https://www.medrxiv.org/content/10.64898/2026.07.22.26358689...
I would like to know if anyone has a method or resource to cover rough calculations on things like:
1) how much cost comes from "friction" like middleman, administrative bloat, shitty digitalization/note sharing, all the time the nurses and doctors have to spend on paperwork... Etc.
2) how much drug development is subsidized by the US patient via higher domestic vs. foreign pricing. Or even how much of the cost total is drugs?
3) how much roughly every added year of life past some marker of "high quality of life" is spent just keeping people alive. And if there's any trends there, cost going up or down total and per person.
4) some basic accounting of where the spend is actually going. A lot of people in this thread are talking about hospital margins. There's much more to health care than that. Labs, hospice, mental health, labs/diagnostics, drugs, r&d, nursing facilities and many things I probably don't even know about.
Basically an equivalent of david mackays "without the hot air" but for health care.
Also if anyone has some good reading on ideas around kind of SEZs for drug/treatment development where people opt in to riskier care. Not quite the same thing but I know for example that lots of medical device development and proving is done in spain to gather evidence for the FDA since the FDA process for devices is legitimately insane.
Oh and if there has been any proposals or even adoption of better health record management, digitization. Especially access to your own health record. Im not a crypto guy but it seems like maybe it could be an application for it?
It boggles the mind when you hear people defend the US healthcare system in terms of efficiency (OK, granted, maybe people have long stopped doing that).
It has to be one of the most bureaucratic and paperwork overloaded systems of all time. It's hard to imagine somebody who've had an actual health crisis would think otherwise, unless they can afford people who can shield them from the BS.
Hard to believe, currently Medicare/Medicaid make up around 23% of the budget. If you opened that to all, there would have to be a huge tax increase to pay for it. I suppose if you are very poor then it would be good, but the middle class would be the ones having to foot the bill for this.
People talk about policies like they're something like can be picked up off the shelf at supermarket. If you could take the policies and Sweden copy-paste them to the US, then sure, we could save $1T and a hundred thousand lives. This would be a very difficult thing to replicate if you're a country without any existing healthcare system. It is impossible in a country with an extremely mature healthcare system, which accounts for nearly 20% of GDP.
No politician is going to want to deal with the fallout of massive layoffs or millions of people having their coverage changed (e.g. no free chiropractor appointments or GLP-1s for weight loss), especially since the Democrats suffered one of the worst Congressional losses in US history the year the ACA was passed. There are ways to make this transition less painful, but the only people interested in health policy are those who make money from healthcare, so you generally only see solutions that involve throwing money at the problem. We need regular people to develop an understanding of health policy or else we'll end up with a policy that merges the worst parts of a planned economy and capitalism even more than today.
The US already has a national health insurance network that pays the vast majority of all providers, and as far as I know it is widely popular and covers everyone legally present in the US for a portion of their life, Medicare. Old people experience just about every ailment young people do, we can just get rid of the age restriction on Medicare, it's already fully integrated with our medical system. No need to copy-paste from Sweden.
Medicare also isn't something that you can copy paste from covering only old people to everyone. For one, margins from Medicare patients are much lower and often negative for hospitals, and that money has to come from somewhere. Medicare doesn't cover a lot of drugs that people are already used to their private insurance covering like GLP1s for weight loss. Of course, a transition from point a to point B is possible, but there will inevitably be a lot of kinks and bugs to work out, which MFA proponents seem to be unaware of.
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_could_
Universal health coverage will asymptotically reach infinity costs (same as private health insurance).
This is the harsh reality. No system (private or public) can save all of the lives.
We are debating who will make the decision of who gets to get a chance to live longer.
It looks like this does not even include the current disincentive for insurers to treat chronic issues effectively early on. Since people switch insurers so often the odds you will be their “customer” in 5 or 10 years is low, so investing if your long term health won’t generate a return for them.
"You can have state of art Healthcare, or you can have Universal healthcare, you can't have both." -- Malcolm Gladwell
The way that universal health coverage saves money is by rationing care. You do not save lives when you ration care.
That's a very weird framework and dichotomy you have there. Try untangling yourself out of it by considering some empirical facts, for example, hospitals acquired by private equity often have worse outcomes.
> private equity acquisition was associated with a 25.4% increase in hospital-acquired conditions, which was driven by falls and central line–associated bloodstream infections
https://pmc.ncbi.nlm.nih.gov/articles/PMC10751598/
> Medicare beneficiaries in the emergency departments of private equity hospitals experienced seven additional deaths per 10,000 visits after acquisition relative to hospitals that were not acquired by private equity, the team found. This rise represented a 13 percent increase from a baseline of 52 deaths per 10,000 visits
https://hms.harvard.edu/news/deaths-rose-emergency-rooms-aft...
What's the point of "state of the art healthcare" if it's only for rich people? If Jeff Bezos and I get the exact same health issue - say, some form of cancer, we're going to have radically different treatments and mostly likely outcomes. His will be "state of the art", mine will (hopefully) be good, but definitely not be like his.
This is certainly true to an extent, but it ignores some big problems with fee for service. The biggest one is that incentives between patients and providers are not aligned, which means more than 10% of healthcare provided in the US is wasteful stuff the provider knows is unnecessary but prescribes anyway because it makes them money. There are real opportunities to save money without making outcomes worse, in fact, if we stop doing useless stuff that leaves more time to treat people with real issues.
Malcolm Gladwell is a massive charlatan and hack. Seeing tech bros use him to discuss healthcare policy (Malcom Gladwell is neither a health professional, public health expert, nor has he worked in the healthcare industry in any real capacity, nor has he ever discussed the plight of workers in the US once during his entire career) feels on point for out of touch our industry is.
Contrarian take, even with free healthcare, UNH is happy - https://s-1.vercel.app/posts/unh-value-trap-or-chronically-u...
A perfect Communist economy could save even more money, eliminate most ads, duplication, and poverty. But they never figured out how to make it work.
I'm not opposed to a peaceful transition, but we'll need a big surplus and more idealism to make it happen.
"They" never intended for it to work and never tried.
Do away with the finance ledger.
Accurately measure where the people are.
Ensure enough resources flow there.
Special interests with a social moat to protect can pound sand or be hung from ports as a warning.
I would like to be free from hallucinated social belief Jeff Bezos is meaningful to humanity when mfer just gonna die and be forgotten like everyone else.
For the study, "which has not yet been peer reviewed"
Won’t happen the big players make too much money the way things are, and that is more important than people’s lives or for our country
Very interesting reading the comments here from USAnians. You are really hurting, and your system is objectively very bad.
Inappropriate application of capitalism. A market failure of epic proportions.
Do something about it! You live in a democracy, act like it!!
The thing studies like this never take into account is the degree to which all of these administrative jobs are corporate welfare. The inefficiency means a lot of people get a regular paycheck for work that is ultimately nonproductive. If you kill off those jobs by eliminating waste there will be millions of people looking for a new job.
But the bigger problem is the current system is really profitable for the millionaire and billionaire owners of those companies. They're well connected in Congress. Attempting to change the system is extremely difficult when it means so many rich people might lose their gravy train. These people go to expensive campaign dinners. Even when the ACA came out and the first versions had universal healthcare provisions those were quickly and quietly eliminated.
Administration is ~25% of provider expense; billing and insurance is ~8.5% of provider expense. Administration is:
* Billing and claims management
* Compliance
* Customer service
* Operations
* IT
You can drive billing all the way down to zero and you're still going to be spending a lot of money on administration just like any large enterprise does. Those jobs aren't really "corporate welfare" and they exist in every system, although the single-payer systems get a bit of a break on them because they can and do trade responsiveness off for customer service (at likely little cost to outcomes, to be fair!)
That ~25% is compounded at every step of the way. 25% of your doctor's office. 25% of the insurance company. Plus don't forget the brokers, which are almost all overhead effectively. 25% of pharmacy. 25% of drug companies.
The people providing actual healthcare end up being a minority in the system.
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What about all the new unemployed lawyers and bureaucrats that feed on the broken American system?
If this were at all true, now read it like the big wig or law maker holding the on/off lever who’s eyes see “Universal Health Coversge Could reduce $1T in available/taxable income”.
Did you notice the gorilla walk by? They sure didn’t.
Should The Government Stop Dumping Money Into A Giant Hole? - https://m.youtube.com/watch?v=JnX-D4kkPOQ
For the most part, any time one person in the economy saves money, another person loses money. So, what about all the insurance company, private equity, and hospital system profits that would be eroded by a system that better serves individual humans?
/sarc
they're tryna convince the populace who don't like to read with useless studies.
get rid of medicare etc, then let it be handled on a city / state level. if some states wanna provide for public hospitals clinics - let them do so. even more if cities too wanna provide for public healthcare. then we can gladly reduce taxes too. the amount spent on medicare vs outcomes is already scam level.
trying to solve this at a national level won't work - too many middleman, too much politics and perverse incentives.
This doesnt need yet another study. Instead of narrating the problem we should figure out whats actually stopping it. And people saying the ACA was universal health coverage or even an attempt at it should stop intentionally derailing this discussion.
Democracy is the biggest obstacle to universal healthcare in the US.
A lot of people do not want it, and you've thus far failed to make them want it.
Cool system.
How many employees trapped in a job for health benefits for their families would universal health coverage free up?
Quantify the impact on productivity
What UHC proponents never honestly admit is that these headline figures require incredibly optimistic assumptions and also much more rationing of care than our current model. We spend a lot on healthcare because we consume a lot of services. To save money, you have to buy fewer services. Yes, you can squeeze providers a little bit ("Medicare-level payments to providers" -- which they will absolutely hate, by the way), and you get another little bit by disposing of insurance provider profit margins ("reduced administrative overhead"). But the vast majority is coming from rationing, which people hate. And it would also cost massively increased taxes on the middle class, which voters also hate.
"Fewer avoidable emergency department visits and hospitalizations" -- sheer optimism. "Less fraudulent billing" -- no reason to believe this would be true. There could be even more fraudulent billing! Medicare fraud has been a big problem, and solutions are largely reactionary.
How on earth have administrative costs been soaring when there have been so many healthtech startups propped up in the past 10 years to bring down the cost of administration?
Also - given the rate of AI progress, shouldn't we see this cost go to zero essentially.
I've become so cynical that I think even if universal health coverage would be passed, since it almost certainly would be run by the executive branch, it would become just another political football to be fucked with every 4 to 8 years.
Just think, if we had universal health care in the US today, the MMR vaccine would not be covered by it!
"You millennials and your obsession with public healthcare. Back in my day we just died."
It will never not be funny that whenever universal health coverage comes up, Americans will act as if it's some impossible task that wouldn't solve any problems when the rest of world seems to have sorted it out just fine.
There is already a healthcare program run by the US government and it's called Veteran Affairs. Veterans can't even access the care they need resulting in almost twice the risk of suicide.
I'll pass on mandated, outlaw-private-insurance government healthcare, thanks.
Who said anything about outlawing private insurance?
The UK has a single payer healthcare system but folks may purchase (or obtain through work) private insurance.
Baumol's cost disease is the simple answer. until healthcare stops improving outcomes and or we reduce labor cost will go up
There are many studies from reputable sources (one being the CBO) that say it would result in almost no savings or potentially even higher costs, just like there are many studies like this one that say there will be massive savings with no reduction in quality of care.
I support universal health care, but each side just lobs whatever data supports their position at the other without any real thought. Most people in support of a universal health care system seem to be completely unaware that the vast majority of households are happy with their current coverage (whether they should be or not isn't relevant really) and are not looking for someone who claims to know better to "improve their medical care" through a entity (the US federal government) that is generally not known for improving almost any situation it interacts with.
I personally would like to see Medicare opened up to the public as an option. It's simple, doesn't require anything of anyone who doesn't want to participate, and should be a reasonable test for the claims of cost savings. If it's truly a better option, people will move to it. If not, then the conversion will not happen.
Barring some sort of catastrophic financial or medical event, there is a 0% chance that anyone can make a radical change to the status quo.
Ok but it doesn't save the donor class anything, so it won't happen.
Who's gonna tell the doctors and nurses that they get a 50% pay cut?
You think they’re getting so much money from out current system that cutting out insurance companies would result in a 50% reduction in their pay? Have you ever looked up the size of the health insurance sector here?
That's literally the premise of the report. The savings comes from getting Medicare's current rate sheet for every patient in the entire market.
You're being dishonest if you claim otherwise. UK brain surgeons get paid less than a Walmart general manager in the United States, let alone a like for like comparison.
Do they need to get a 50% paycut? Dealing with insurance companies takes a ton of time and resources.
I'm honestly curious how we square this with the only experimental evidence we have on cost-sharing in the US, like the Oregon Medicaid Study and the RAND study which showed no impact on mortality or really any physical health outcomes at all.
UHC proponents are just excessively optimistic about impact on health outcomes.
No, they are excessively optimistic about the financial outcomes. Healthcare should not bankrupt people.
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Bro nothing is free, if the goverment pays for all of us, then it is our own money being used for that, we have the most liberal tax code in the world, we spend the most in healthcare.
I don't want it. I don't want to pay for it either. anything the fed government does is utter crap.
That's basically my concern, too. If we had a "Medicare for all" system, would it end up like Social Security, a system that started out with great intentions, but has since ballooned into an expensive, bureaucratic nightmare?
precisely.
.....yeah
let's imagine an impossible country where somehow Democrats pull this off in 2029 and the 2030s start with actual healthcare for all and not just "insurance"
DOGE 2.0 will destroy it overnight
because somehow funding is not exempt from executive manipulation
look at what they did to ACA (and everything else)
all it takes another apathetic Congress and poof it will be gone so billionaires can get a few million off their taxes
there's absolutely no way to harden it against that
But how can we support israel? /s
The Jews are obviously to blame for the lack of universal health care.
The USA spends the equivalent of about $10 per citizen per year on Israel. Medicaid spends about $10,000 per recipient per year. But antisemite math has its own rules.
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The government provides your police force and fire department. Why not?
Look no further than the UK, with 24 month waiting lists, the shunning of experimental treatments (many high profile kill decision cases) and skyrocketing costs.
In the UK, a brain surgeon is paid less than the General Manager of a single Buc-ees Gas Station location in the United States. Absolutely diabolical.
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Right? What, are you all commies?
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You should probably be aware that Cremieux (Jordan Lasker) is a race scientist prior to repeating his claims. https://en.wikipedia.org/wiki/Jordan_Lasker
I did not know who that person was, but you seem to be saying none of his opinions could possibly be right?
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> The first issue with this is that the gap between the uninsured and insured is not necessarily due to the lack of insurance. It could be due to factors associated with not having insurance, like living on the streets, being schizophrenic, being poor, and so on.
Made up perspective to justify his angle.
Not having healthcare access for a lot of people is 100% a policy choice. Waved off here by a list that really says why we should have universal healthcare; some people are mental and not aware they could have access without the stupid policy decision.
Just strings together sentences to ultimately make a reductive point about arithmetic and their own literacy.
Despite Yale's issues they're still a better source than random blogger with high school math literacy.
The point he is making is valid: these groups are not randomly selected and are not representative of one another. Hence, it is not that simple to extrapolate from one to the other.
Would free healthcare reduce deaths in uranium miners that are smokers? Probably some, but would it bring that to the same levels as non-smoking, non miners? Unlikely so. Hence it would be silly to pretend all the cancer deaths are due to lack of health care.
The smoking uranium miner example has a surprisingly realistic story, comes from real data; the dangers of radon in the basement were deduced from comparing cancer rates in smoking uranium miners with high radon in their basements, then they removed what they thought was the smoking and uranium contribution, then fitted to the general population.
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> random blogger with high school math literacy
He's actually a well-known and widely promoted political activist on X. His niche is using technocratic language and a whiff of 'analysis' to advance MAGA policies.
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Ah yes, the claim free money would save lives!
The truth is once systems like this are implemented they change the dynamics of the study and as such could hurting lives.
As a simple example, the biggest cost to the healthcare system in the US is dialysis. Many of those folks already have health issues, and by both dialysis and for all the issues that caused the need for dialysis in the first place is a massive strain. The direct cost of dialysis is $33B annually [1], but indirectly is probably at least another doubling.
Further, the way the government has imposted monopolies in the space already has caused costs to balloon. While making it "universal" could mean the government gets control, and can limit the explosion. It can also could result in weird incentives like Canada, where they're promoting MAID.
[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC8729831/
This is why it doesn't happen: politicians get bought.
"Jeffries co-sponsored Medicare for All legislation between 2013 and 2021, but in August 2026, he stated he shifted his stance and stated that he no longer supports or co-sponsors the proposal." https://en.wikipedia.org/wiki/Hakeem_Jeffries#Healthcare
Universal healthcare doesn’t happen in the US because a certain subset of the American population would rather have worse health outcomes than guarantee abortions, HIV prevention, and gender-affirming care.
Also, ~150M people with employer coverage plus seniors on Medicare fear disruption more than they value expansion.
You can easily drop those from a universal healthcare system - look at the NHS and gender affirming care across the pond. So it can't only be that part - I think it's wanting the undeserving to not have healthcare.
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There's also a racist element (I know that's a politically incorrect word here, but such things happen). People don't want to fund services to the lazy ______s - fill in one or more of many groups toward whom hate is promoted.
When a similar bill was voted down years ago, someone I was with laughed and said, 'no way were we paying for healthcare for the Blacks'. It fits the divide and conquer strategy to divide poorer people with hate so that they don't unite and vote for all these things - why do you think leaders promote hate?
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This could equally be explained by wanting to be perceived as more moderate/centrist. Which would make sense for someone in a leadership position.
> This could equally be explained by wanting to be perceived as more moderate/centrist.
I don't think anyone perceives a flip-flopper as anything except unprincipled. There's nothing "moderate" about corruption.
There are many reasons Jeffries might change positions; why do you say the reason was that he was bought? Is there evidence?
Many Democratic politicians are moving away from progressive positions, including Ocasio-Cortez. They seem to be following the old (and failed) Democratic Party tactic of moving to the center to get elected.
> why do you say the reason was that he was bought? Is there evidence?
Look at his health PAC contributions over time:
https://www.opensecrets.org/profiles/hakeem-jeffries/us_cong...
One of two major political parties, and the one that currently holds all 3 branches of federal government, has labelled it un-American and communist. And yet you point the finger at...a Democrat.
> the one that currently holds all 3 branches of federal government
The key word here is "currently". When did Democrats ever propose or pass single payer when they were in power?
Moreover, when the leaders of both parties are opposed to single payer, how in the world do you expect it to ever pass? Jeffries wants to be Speaker of the House after the midterms. If he's opposed to single payer, then there's no hope for it.
The majority of Democrats support single payer. That's why I'm pointing the finger at a Democratic leader. I don't expect Republicans to support single payer. What I expect is for Democrats and Republicans to have opposing views, not the same views.
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Quite weird to see such a study from Yale, Yale is the heart of the capitalistic western empire, and it exists to serve the oligarchy and the capitalists. So then what gives ? perhaps the person working on this report is still an innocent person and has not yet seen the reality of his situation :)
The last time we got similar results in the data (but not the text) was a Koch-backed study that a bunch of economists reviewed and went “so you’re saying we’d save 2 Trillion over 10 years relative the alternative?”
https://pnhp.org/news/the-mercatus-analysis-of-bernie-sander...
or that trillion in health care isnt going into the oligarchs pockets, and could be..
Yeah, but how much would it cost in profits?
That's the only thing that matters in Amerika.
Come to a country with universal healthcare (England) and realise that if you work then you're paying 5x the market price for the worst healthcare imaginable. MRI scan - we don't know, one month wait, maybe two. Operation - are you going to die tomorrow with out it? No, ok then that could be years.
You need to pay rock bottom wages to doctors to make it work, so guess what all the good doctors leave for private healthcare and you end up with the dregs from the third world.
One of my favorite health care facts: there are more MRI machines in the state of Massachusetts than there are in the entire country of Canada.
I know that you tend to be balls deep in American Exceptionalism, but the truth is that reasonable countries with reasonable health care average 15-30 MRI machines per million inhabitants.
America is a wild outlier, and unless you have data to back that those machines are put to good use, I'd trust the rest of the world who decided the sweet spot is 15-30 mer million, not 60.
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I think this one might not be true anymore. Canada has 432 machines as of ~2023 (340 in 2015) and MA is on the order of ~300 (can't find exact figures). It's still a lot lower per capita (10.8 per million vs 42 per million).
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I wonder how many people would be on board for a program to make Medicare available for free for households making over $100,000 annually with 1-3 children.
We're talking about families that are provably not lazy or sucking up handouts: taxpaying citizens with beautiful, healthy children. The job creators and professionals driving America, securing their future and their children's future.
If the government were to focus on these first-class citizens, who knows what could be accomplished once the drag is taken off the system of the useless eaters and the welfare queens.
Why do you limit it to people with children? Why do you assume that the children are beautiful and healthy?
> Medicare available for free for households making over $100,000 annually
Sure, why not try it? It's still 50% of America getting coverage.
After a few years maybe they'll realize that not having to think about health care insurance is a good thing actually (tm) and start supporting it for lower brackets of the population too.
That's a very funny way of looking at the world.
Many people feel that winners should be rewarded and losers should be punished.
Systems thinkers may try to push notions of connectedness in societies, and moralists may try to push notions of universal equality of human dignity, but in the end, both are overwhelmingly outnumbered by tribal thinkers, who wish to harm the outgroup at absolutely any cost.
First class citizens? Wow, that is both disgusting and sad. What do you do that you think is so important and irreplacable that sets you above the average person?