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I’m all for single payer in the US but this diagram is a bit misleading.
- There’s still a program receiving government funding (e.g. Medicare).
- There’s still admin and billing (for the government program).
What I assume you’re really gutting are profits and shareholders for insurance companies. (Good, because healthcare in my opinion should not be a profit driven business in any respect.)
What I fear, however, is who is in power at any given time might change the care you receive if such a system isn’t setup with safeguards and ironclad mandates.
For instance, Republicans would absolutely attempt, through legislation, executive order, and the courts, to implement an effective federal ban on abortion or healthcare for trans and LGBTQ groups by changing how/if a single payer system would cover these services.
I would also be worried about the public availability of coverage data such that lists of frequent providers for these services are easily obtained and become a tool for harassment by religious zealots.
Or, imagine an anti-vaxxer put in charge of the program during the next pandemic.
How do other countries deal with these issues? Or, have politics become so broken in the US that this is a somewhat uniquely American problem?
Canada deals with some of those problems by having a separation of state and medicine similar to our separation of state and church.
For example, I think we are the only country in the world with no abortion law. It’s a medical procedure, so it’s left to the medical community to develop standards of care and standards of practice.
It’s not perfect, but it’s worked out quite well since the 1980s. There were some major cases that led to our abortion laws being struck down by the courts and no government has yet had the courage to introduce new legislation of any kind.
That sounds really nice. We should try separating the state from medicine in America. Heck while we’re at it we could separate the state from religion
Considering one entire half of our political establishment is trying to do away with the separation of church and state altogether, I don’t think we’re gonna have a lot of success with that in the near future, unfortunately.
It is a bit simplified but it is much more streamlined than the insurance system outlined.
The UK model is single payer. The government pays the money into a national body like NHS England (or NHS Scotland etc) and it distributes money. The internals of the system itself are complicated (there are commissioning groups, acute hospitals, mental health services, dental services, public health services etc) and have overhead as with any organisation.
But there are not multiple government health organisations or paying systems - there is a single national tarrif for what each part of gealthcare costs and that money is distributed down to the providers like hospitals and GPs/family doctors. 2/3 of the cost of Healthcare is staff wages; it’s people intense.
No insurers, no billing agencies or debt collectors. Essentially there are not 3rd party businesses creaming off money for doing little more than handle the money. More of the money goes directly to healthcare rather than intermediaries. The infrastructure and administration within the system such as commissioning groups etc have fixed costs - none of it is run for profit.
In terms of government control - that is a concern but US politicians already heavily interfere in the system. Abortion is a good example of that. What you don’t get is Healthcare businesses of various types interfering in government.
The real issue for a single provider system is the staff - wages are kept down as its a national system. That causes strife if wages of pushed down too much. So you do get unions exerting pressure on government. I see that as a good thing but your mileage may vary.
Also if there is under investment then that can severely hamper the system - we have that problem in the UK - demand is going up as the population ages, but the politicians won’t make the hard choices of taxing the elderly to support expanding the Healthcare system.
I would earn far more in my specialty in the US. However even so I much prefer the UK system. I don’t want us to go down the route of the very broken US system. However there are public system with insurance models that do seem to work well - Australia and Canada have good reputations both in terms of cost, efficiency and pay for staff etc.
Essentially Universal Healthcare should be the aim, and it doesn’t necessarily have to be a single payer system to work. But single payer systems can work.
Also if there is under investment then that can severely hamper the system - we have that problem in the UK - demand is going up as the population ages, but the politicians won’t make the hard choices of taxing the elderly to support expanding the Healthcare system.
Politicians are drunk on the growing private ‘optional’ sector, letting unequal access creep in through the door they got their muddy feet in. This absolutely has to stop.
We see it here, as some regions take their levy and starve the public system in the hopes of forcing people shell out for the only option in this ‘optional’ alternative.
The NHS is a model of how to do it except any part that even speaks - or offers a business license - to any clinic offering any services which overlap at all with public space. This insidious taint needs to result in jail time for cruelty.
Admin and billing would still exist, but it would be savagely curtailed. We now have to account for every insurance agreement between insurance companies and healthcare systems. These can vary on a hospital by hospital basis causing the incredibly complex system of pricing that are currently used. A single payer system would vastly decrease the need for this administrative overhead. Of course this would result in lost jobs, and an honest assessment of M4A would acknowledge this. Bernie Sanders 2016 M4A bill had funding for the workers having to transition jobs during this change if I remember correctly.
Of course this would result in lost jobs, and an honest assessment of M4A would acknowledge this.
On one hand you’re not wrong, but on the other hand there’s something downright perverse about lamenting the loss of middleman leech jobs.
100% agree. However, I try to keep in mind that these are real people with real families doing real work in the ineficient system that we’ve allowed to exist.
Amazon always hiring. McDonald’s always hiring. Hell just about every service industry employer is hiring here.
Republicans would absolutely attempt, through legislation, executive order, and the courts, to implement an effective federal ban on abortion or healthcare for trans and LGBTQ groups by changing how/if a single payer system would cover these services.
I think they are already doing it now, even solely in states with strong emphasis on privatized healthcare. I think as long as politicians can make law, they can easily sabotage the healthcare system, single payer or not.
How do other countries deal with these issues? Or, have politics become so broken in the US that this is a somewhat uniquely American problem?
I think this is a uniquely American problem, because individual (or small groups of) politicians have enormous power over these kinds of things in our current system. I think the answer is to not allow politicians to directly decide what is and isn’t covered - you leave that up to whatever federal agency is responsible for enacting the single payer system.
What you said about safeguards is true, but removing politicians’ ability to directly control what care is provided would be the first and biggest safeguard I think.
Or, have politics become so broken in the US that this is a somewhat uniquely American problem?
That is a signifigant issue, yes, but the rightwing politicians in a lot of other countries are moving further from the center and are also trying to gut the public health system in favour of privatizing increasing parts of it (to the benefit of their political donors and the companies on whose boards they will sit after they exit politics)
Bingo.
Anyone who wants a single-payer system should be required to be in an HMO for 20 years first.
The fight to get care is crazy, because bureaucrats up the food chain looked at stats and said “you don’t need this care” (because it won’t lower our risk stats). You’re just a number - if the stats say this won’t reduce your risk of dying, or reduce the likelihood of needing further care, welp, too bad.
I’ve been in 2 HMOs over the last 35 years… Same experience in both.
The “problem” in medicine is primarily insurance companies, and secondarily business management approaches that are inappropriate for medicine.
Get those people out of medicine first, or the problems will never go away, regardless of who’s paying.
My fucking coworker got denied coverage to replace his heart monitor that his doctor requested because “he didn’t have a stroke yet.”
The fucking business school shitheads are making medical calls overriding doctors orders because money… Money money money. My coworkers life is meaningless, he’s just “lost profit” to them.
This whole system makes me equal parts disgusted and enraged.
But what about profits for all of the businesses? /S
Won’t somebody think of the shareholders!
The economy!
I think this is a bit too simplified. The “Government pays the bill” is not how it works at least in Germany. We have “Private health insurance” and “compulsory health insurance”. If you decide to leave the later, you do not pay into the system anymore, but have to get a private insurance (and you might not be able to get back into the compulsory insurance when you get older).
Anyway, the way the system works is that there are many insurance companies that you can choose from with different profiles that take care of the bureaucratic underbelly of managing the whole process. These company has thousands of workers to take care of these processes and guide/deny their customers services. My Insurance company alone has 15.000 employees.
If the “Government pays the bill”, then you might need something like 30.000 - 80.000 federal workers to take care of the bills/requests to guide the patients and prevent fraud. Will the government hire them? Is the plan like having a NHS like the UK?
My point is, the Government will not pay your bills. A subsidiary with a over decades grown structure will do that. I can already see how people gonna hate the new structure, as it will struggle for the first 10-20 years to define their processes and layout the services. On the other side will be people with deep pockets still using private insurance. These companies will use their money to attack everything this new government system will do and will rile up people against it to gain back the market.
I am absolutely pro-single payer system. I just hope no one is so naive to think it will be just like the graph shows it. It will be much more complex than that and people need to fight for it and endure some “finding phase” for the first two decade before one of their presidents will trash it again. I can already see fox news headlines about how people died because of the new system or how a grandma in ohio did not got the right care at the right time and therefore the whole thing is apparently a bad idea. It will be rough to say the least. I would not always tell people that the “Government” pays the bill, as many people in the us are sadly on the spectrum of cringe conspiracies and have a retention for everything the “Goberment” does. I think it is a bad idea to say the Government does everything, as it will be used against the system: People will claim their grandma died because of the Government (“death panels!!!”) and people will say the government be the one who denied their claim to getting a new hip with 90 years (“outrages!!!”) or some of the funds getting wasted for hard-to-communicate reasons (the swamp!!!) tainting more and more the public opinion of the governments work. You should better start using the subsidiary in your graph communication that will take the praise/blame for the development. Because the Government will not pay your bills.
Will americans have the voice to change the system? Will americans have the patience to overcome the problems? We can only hope so.
EDIT: Because some people missing the point: I would add a shape between the Government and the Doctors on the right. Could you draw a chart about the UK or German Healthcare-System without once mentioning the NHS or Krankenkassen? They are a n essential part of the system to work and employ thousands of workers. I think the chart oversimplified this aspect.
U.K. here. “Government pays the bill” is exactly how it works over here. You can just walk into a hospital, be treated and walk out without paying anything or holding any particular insurance. It’s not a GREAT service by any stretch, but it’s free at point of use. We have a booming private insurance sector too - I pay a separate private insurance because although I’m absolutely pro NHS, I wouldn’t bet my life on it.
In Australia, private health insurance is better for non life threatening stuff.
Emergencies is where the public health system shines. They have a lot more practice with trauma and ED stuff than private.
I have private too.
This is very similar situarion in Brazil
i always say to americans: medicare keeps you alive and able to be productive, private insurance keeps you comfortable
… but medicare also drastically reduces private premiums
Ah yeah, that is a good way of putting it.
I very much appreciate your last sentence.
Medicare is a sad shell of its former self, good luck seeing a GP or a specialist for free these days. Want a specialist to check out your breasts? That’ll be $400 for the first visit and $210 out of pocket for all your follow ups, $800 (out of pocket) just for a biopsy if you need it. (Rough numbers from a friend). And consider that most women develop some kind of breast growths in their life time.
Sure it’s not US levels of price gouging, but heck. Medicare is being lost and we’re not fighting for it.
I won’t be satisfied until private health is dead. Fuck private health.
i wouldn’t say until private health is dead: there’s always a certain level of comfort or pseudo-science choice that i don’t think should be socialised… for example, my private health covers “alternative therapies” which should certainly not be covered by social healthcare, but people should be given the option to spend their money on that if they want to
same thing with private rooms, better hospital meals, etc: these things should be optional extras that you can pay more for
with that said, dental, optical, psychology, physio, and nutrition are all things that my private health covers that medicare should cover or should cover more
Oh yeah, that’s true (the alternative therapies), and for extras that aren’t at all better medical care
yup:
public is for keeping as many people as healthy as possible as efficiently as possible: it’s about optimisation
private is for things that you want but don’t need that would make the care of others less efficient without additional money, and where you can pay for that extra why not allow people to insure for it?
My point was that a chart where your doctor sends the government the bill would be misleading. National Health Service in England, NHS Scotland, NHS Wales and Health and Social Care in Northern Ireland pay the bill (and are basically the government) and are the names people are using to either blame or praise the work of these systems. In a country as divided over the government work as the US is, I think it is a bad idea to say “Government pays the bills” as it neglects all the work and effort (and funding problems) that the subsidiary has to do. Government is just allocating the funds for the NHS to pay out to the doctors.
Ahh good shout. I see your point and it’s well made.
This is why an argument for simplicity doesn’t really fly. Agree the US could really use a better government based health system (and yes, there is a sort of option now, but it’s a mess) but saying it’s simpler on a systems level isn’t really true. Most countries indeed have both systems to one degree or another going on at the same time.
from a CONSUMER perspective it’s FAR simpler
from a system perspective it’s far more complex
… but you literally never have to worry about that
living in australia i’ve thought about health care less than i’ve thought about my own health care in the US and i’ve been there a grand total of 6 weeks in my whole life
need a hospital? just go… need a doctor? just go… need medication? just get it… don’t think; just do it… the doctors are there to triage; you should not have to without any medical training
and ON TOP OF THAT: just do it whenever you need and don’t worry…
we
still
pay
less
Because this doesn’t describe what Germany has. There aren’t any insurance companies in the graphic. In Germany we don’t pay taxes for our healthcare, we pay contributions. So why would this be oversimplified because Germany?
I did not compare it to Germany. I used Germany only as a step into my post. It is over-simplified as it is not how it will be in the US. Can you draw a chart for the UK Health System without once mentioning the NHS or describe the German Health System without mentioning once the Krankenkassen? Between the government and the Doctors will be at least one institution that most possibly will be named “American Health Service” or something like that. Drawing a line from the Doctors to the Government makes it sound like people gonna send their bills to the White house. The reality is that the Government will only allocate the Funds for a certain subsidiary unit that will handle that worksload. The NHS in the UK employed 1.2 Million people. Leaving out that aspect is critical in a chart like that. In my view, the graph is too simplified. If you feel it is telling all you need to know, good for you. Apparently rough outlines like that are all you need. I would at least insert one shape between the Doctors and the Government as there will be hundrets of thousand of workers who will do the actual work. Government will only decide on the funding.
EDIT: Man you must be mad. Downvoting me one minute after I post this. Using your alt accounts to give yourself 3 upvotes one minute after you posted it? Crazy. But who cares.
I didn’t use any alt or downvote anyone. But why would I draw a chart of Germanys system without insurance companies? That wouldn’t be the German system.
And that’s my point. This isn’t showing the German system. So your initial assessment of this being oversimplified because it’s different in Germany doesn’t make any sense.
So unpopular opinion here: the diagram is a bit skewed in making a point. It’s not that private systems are inherently worse, or more expensive. I’ve lived in a country with single payer, and now I’m in a country with privatized healthcare. I’m paying much less here with a much better standard of care.
The problem as I see it in the US is that if one group in power (such as corps in the US) gets outsized power in the process, then the system will work for them instead of for the people. Even the current US healthcare system would work well if there were some common sense regulations in place.
That said, switching to single payer would also fix the current issue by removing the power of corps. I’m just saying that single payer is no silver bullet at all, and you can fuck that up as well.
This explains why they’ll never willingly do single payer - all the money waste that would no longer go into the pockets of all those fucking middlemen. “Won’t somebody think of the corporations!?”
That is a vast oversimplification of our current system. I wish I was kidding
Supplementary point: here in New Zealand we also have Single Buyer.
That means for all medicine there is one buyer, who is able to negotiate bulk pricing with international drug companies.
Isn’t that an intrinsic part of single payer healthcare?
Not necessarily, but in effect, yes – because the state itself buys so much medicine at the lowest price available, the price for private businesses also drops as if they were buying via the state
I read this as “single player”.
“But you can’t trust the government to be put in charge of what’s best for the general populace - instead, you should trust private companies who are legally obligated to maximise their shareholders’ profits to use their monopolistic position in a way that’s best for their victims, sorry, I mean regular people.”
the reality of a “single payer” system is not usually that the government pays for everything: public health will keep you alive, but if you want to be comfortable (eg private room, skip a queue: it’s not nice, but private surgeons still exist and use public services) then you can go private either through insurance or paying outright…
insurance usually also covers what we in australia call “extras” and that’s a whole category of private health (ie things not on medicare that everyone gets)… this is things like dental, massage, optical, etc
don’t get me wrong, this is STILL far superior to the shit show in the US, but it’s NOT simpler from a moving parts perspective - it’s MUCH more complex, just every day people neither have to worry about or pay for that complexity most of the time
Yeah, Australian system is currently trash, but only because we’ve let things slide back towards private health, not because a single payer system is not simple. It’s only complex because private health is encroaching and government funding is waning. If we actually had a single payer system it would be simpler (but we don’t actually).
So many low cost GPs and other health services are needing to charge more because the rebate is way too low.
Plus, in my opinion, some price gouging by some areas, by some (psychologists come to mind for recent crazy price inflation)
Get rid of private health, and we can just pay our insurance premiums to the government, and actually be guaranteed care, not this stupid tiered nonsense.
Dental, optical, and all these other “extras” should just be provided. We’re one of the richest countries per capita in the world, it’s embarrassing.
there are plenty of other extras though: agree optical, dental, better psych etc should be included
… but alternative medicine? nicer rooms? massage? these are things that people should have the option to pay for via insurance, and the public system certainly shouldn’t provide
public should efficiently keep everyone healthy; private should add some additional comfort choices to your life
How does the cost break down in terms of private insurance versus single payer+private insurance? Basically what I’m wondering is if I currently have private insurance and it covers me for most things, what would be the difference if we switched to single payer (which covers far fewer things) and then I was also required to supplement with private (to fill in the gaps for what used to be covered but now isn’t under single payer). I suspect single payer is great for people who don’t currently have private insurance, but far worse for people who do.
In Australia we get a rebate on tax if we hold private cover. The rebate is generally larger if you hold better cover up to a certain level of income where you can clearly afford both.
Hospital + extras for myself and wife was about 3k last year.
For things like regular scripts I’m on some stupid expensive drugs but because of PBS instead of 20,000 per month I pay $35 ish per script until hitting a safety net threshold and it drops to $5 per script.
After turning 31 if you don’t get private cover it costs more for each year you don’t get it when you eventually do. It’s to encourage people to get it if they can afford it. I’m not a fan but that’s how it works at the moment
skip a queue
If everyone skips a queue you will get another queue
private doctors charge more. one would assume more private health insurance means more doctors and surgeons to cover the extra
again, public health is about keeping people alive and reasonably healthy at low cost: it’s about efficiency; not comfort
you pay more for comfort, which means less efficiency but more availability
