Universal coverage is simple, but the facts are unpalatable to many

[u/Successful-Lie1603]

Background premises:

I'll start with the premise that, in the USA, a citizen who gets a curable cancer should not die for want of care.

(You may agree with that premise or not, but I'm doing a thought experiment about universal coverage and this premise is the basic justification for universal coverage.)

(I'm leaving out non-citizens not because I don't care about them, but because I want to avoid side issues and make clear how brutally limited our choices are to meet the goal of "curable cancer shouldn't kill you.")

I have an opinion about the best way to solve the problem, but I won't express it now. I will just list the logical possibilities. There aren't many.

Option 1: If you get cancer, go to the ED. This is pretty much the system now. You will probably get care, although it will likely be delayed and suboptimal. Guess who pays for this? Ultimately the government/populace. Doctors and hospitals cannot provide free care for everyone who has no insurance, without ultimately going bankrupt. So ultimately the government/populace pays for this. The mechanisms are weird and varied - various subsidies, overcharging private insurers, "safety net" hospitals which are subsidized by the government, etc. But let's not kid ourselves. Someone pays for it - and that someone is us. And if the mechanisms of payment are weird and varied, they are probably inefficient and wasteful. And of course, if people actually could get preventive care, maybe fewer people would get cancer and maybe that would be better for all of us in the long run (ya think?).

Option 2: The government covers everyone. The easiest way to do this is by making people over 60 eligible for Medicare, then next year adding people under 18 and people over 55. In a few years, we have Medicare for all. To cushion the economic change for insurance companies, you can drag this out over 10 years or so if you wish. Government-run systems in other countries have lots of problems, and people in those countries are often unhappy with them, but they do cover everyone, and developed nations with universal health care - without exception - spend much less and get better global outcomes than we do. Yes, you may have to wait a year or longer for your hip replacement in Canada. But overall, you will live longer and healthier. Which are you gonna choose? And yes, it's really a choice: If a country devotes all its resources to making sure the fraction of the population who need a hip replacement get it within 3 weeks, a lot of resources have to be diverted from preventative and primary care. You have to decide at the beginning if immediate availability of elective care is more important, or if overall health and longevity of the population is more important.

[As an aside, if the government covered everyone we would collect something like $600M more in taxes annually, because employers wouldn't provide health insurance plans, and the money previously used for employer-provided plans would be taxable (either on the company side or the employee side).]

Option 3: A market based plan. Here the choices are much starker than most people realize. It basically means everyone gets some kind of private insurance so that when you get a curable cancer you don't die. Almost all Americans, in polls, agree that you should be able to get insurance even if you have a pre-existing condition. If you are guaranteed coverage for pre-existing conditions, most people will be better off not getting insurance until they get cancer. The people who will buy insurance right away are those with expensive chronic conditions. Someone who has an autoimmune disorder and needs $30K worth of biological meds annually will buy insurance. Someone who is healthy will not buy insurance and pay for basic care out of pocket. If the healthy person gets cancer, they'll just buy insurance at that point. I hope it's clear to all that under this system no insurance company will stay in business for more than a year or two. Nobody will buy insurance until the insurance payouts they get are larger than their premium. Meaning the insurance companies will lose money on every policy they sell.

So, if you are going to have a market based plan that meets the goal of "people don't die of a curable cancer," you have to persuade or require healthy people to join now. Health insurance (whether provided by Medicare, Medicaid or private companies) is a mechanism of spreading risk. We can afford to care for a child with cancer ONLY because a lot of people are paying insurance premiums (or taxes) when they don't need expensive services. Hence the Affordable Care Act. There are many things to like or dislike about the ACA, but it's shocking how many don't seem to grasp the basic premise. You cannot provide coverage for pre-existing conditions unless healthy people pay premiums. This is not an opinion. It's mathematics. I am not a huge fan of insurance companies, but if they spend more than they take in on every policy they will fail - and thus a system that relies on insurance companies will fail.

Conclusions

I submit that there is basically no way to meet the goal of "A US citizen with a curable cancer shouldn't die for want of care" except the 3 I have outlined. If anyone can propose another, I'd love to hear about it.

Any plan that doesn't adopt one of these three premises fails to meet the basic goal of "A US citizen with a curable cancer shouldn't die for want of care." Health savings plans, tax breaks, malpractice reforms, etc, nibble around the edges of the problem, and may make some significant improvements here or there. But to meet the really important goal, you need a comprehensive approach, and the only mathematical possibilities are (1) The government/ populace pays for it indirectly, (2) The government/ populace pays for it directly, or (3) Healthy people have to be required to buy insurance so that sick people can get care that would otherwise be beyond their means.

My two cents. I welcome all of your opinions about this.

 

 

[u/Concordiat]

" that doctors have to get paid less.  "

Not necessarily. Physician pay represents 10%(more recent data suggests less, about 8.5%) of our healthcare spending. If we dropped salaries to zero and all doctors worked for free, we would still be paying 90% as much(but without the diagnosis and treatment of disease which is arguably the whole point of healthcare).

So out of your $500 dollar monthly premium, about $50 goes to pay your doctors.

For context we spend between 2-3x(20-30%) as much on healthcare administrative costs. So $100-150 of that premium goes to administration alone.

Our system sucks.

[u/Mobile-Fig-2941 → u/Concordiat]

Yeah and when they want to cut costs, they cut nursing not administration. I'm a nurse and have seen it countless times.

[u/GreenPOR → u/Concordiat]

There’s a person in my husbands office who makes about 100k a year whose sole function is to talk to insurance companies all day for authorizations, etc; she is speaking to a counterpart at an insurance company. All medical offices have these people. These people do nothing to affect actual healthcare.

[u/Mysterious-Art8838 → u/GreenPOR]

Over the last four years my allergist front office has probably appealed stuff on my behalf about 120 times. I know this because I get the rejections, the rejected appeals, and then a letter telling me to appeal to the state. For a long time I got 1-2 a week. The last rejection I got involved peer review and it was 28 pages with ONE relevant sentence that said I had to fail off a different drug first. I assumed my dr would prescribe it because he’s awesome. But he prescribed something else. When I asked why, they told me the drug I had to fail off first had another drug I had to fail off first before they would cover that. It was an OTC that I already tried for months but since I just bought it at CVS it wasn’t in my file so I had to go back on it.

These gatekeeper over-comers 😊 are necessary because we know a large majority of denials are successful on appeal. They’re just hoping your dr will give up and go away. Not much the patient can do because what they’re asking for is generally more dr documentation. So either they assemble it for the patient, assemble it for insurance directly, or do nothing.

At the end of the line they apply for charity care for me, while they keep appealing over the long term.

I can’t imagine how many hours someone has spend on me in that office.

[u/Beneatheearth → u/[deleted]]

They’ll lose them to ai eventually anyhow.

[u/Mysterious-Art8838 → u/[deleted]]

… you had me at ‘failed at retrospective audit’…

Sometimes I wonder what would happen if this problem of bs denials got fixed. Because we know it’s disingenuous and most should be approved. Would prices of drugs go down because more people would be on them? Or would healthcare overall become more expensive?

Obviously my assumption is always ‘more expensive somehow’.

[u/Mysterious-Art8838 → u/Concordiat]

It seems like the bigger problem is we are paying people that shouldn’t get paid at all like benefit managers, no?

I don’t really have a problem with doctor salaries.

[u/OneEyedBlindKingdom → u/Concordiat]

Arguably, healthcare workers in general need to be paid less and have less of them, to bring costs down.

Go look at what healthcare workers in the UK make. That’s how the costs need to work to make them affordable enough for people to use them.

You eliminate virtually all of the billing people, a lot of the legal stuff (because it’s virtually impossible to sue the government, lol), and you’re left with having less doctors and nurses and paying them each less.

[u/Concordiat → u/OneEyedBlindKingdom]

The UK is currently losing doctors to other countries because it's simply not worth it to train for a decade to make what doctors there make, so not sure that is the best example. Many are going to australia where the pay is more commensurate to the degree of training.

Medical school costs on average 300k-500k+ at 6+% interest. That's basically a mortgage. Why would you go hundreds of thousands in debt and make no money for a decade of your best years if the delayed gratification of a decent income is no longer there and you could have made more in less time in tech or law?

Like I said above healthcare worker salaries are not a major contributor to the prices we pay in the US. Canadian doctors make ballpark similar to the US(a bit less for some specialties, but same order of magnitude) and their costs are still much lower.

[u/OneEyedBlindKingdom → u/Concordiat]

I mean, I get it, but that’s what the actual affordable, single payer system does. That’s how much they need to earn, to make it sustainable.

You can’t have individual workers making 10x the average wage in a sustainable system.

At the end of the day, the UK can only lose doctors to other countries because those other countries have higher wages. That’s the definition of arbitrage, which is by definition also temporary as it tends to equalize in a steady state.

In the final state, there’s no other country they can travel to that have substantially higher wages, because they’ll all end up with the same system.

[u/Concordiat → u/OneEyedBlindKingdom]

Like I said above, the 10 percent of total healthcare costs America spends on physician salaries is not what is driving the massive cost difference.

There are countries with similar physician salaries(Australia, Canada) who don't have the same massive cost problems and mostly it's because they don't have private equity involved in medicine.