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[Cyroth]

On October 19, 2016, Jessica Pell fainted and hit her head on a nearby table, cutting her ear. She went to the emergency room at Hoboken University Medical Center, where she was given an ice pack. She received no other treatment. She never received any diagnosis. But a bill arrived in the mail for $5,751.

......... a cousin of mine once had a ruptured intestine after a very serious case of abdominal influenza. Including surgery and a week in the hospital for observation, what did she pay? Less then a quarter of that.

I'm thinking that the US medical system might be a tad insane.

[McTraveller]

That issue in that Vox article won't be solved by single-payer - unless part of the single-payer legislation is "this is the maximum a provider can charge for service X."  But that's no longer an insurance program, that's price controls and/or antitrust.

I do agree that there are issues with charging people for service after it's rendered, when the prices were not made available before the services are rendered.

It is also crazy that hospitals try to charge a generous month's salary for such a small service.  But as others mentioned - they do it because they can.

[Lord Shonus]

You are wrong. They charge that because they have to give massive discounts to the insurance companies, so they inflate their prices to the point where they can still make a profit after said discount.

Additionally, US healthcare providers are heavily bloated in management positions (in part to deal with the insurance companies), so the "break even" point is higher to begin with.

Single-payer would kill those problems dead.

[Kagus]

But that's no longer an insurance program, that's price controls and/or antitrust.

That's kind of the point; it's not an insurance program. It's a healthcare program.


I don't have medical insurance. What I pay are taxes, and those taxes go towards covering every necessary, licensed medical expense I incur, except for co-pay. And after I've spent enough money on co-pay during the calendar year (about $278), I no longer pay any co-pay either. If I accidentally pay more than my limit, the extra amount gets paid back into my account automatically.

Norway's a bit of an extreme example, but stuff like this exists. It's the US that's the odd one out.

[McTraveller]

Incidentally, Norway has 4.4 doctors per 1000 people - 70% more than the 2.6 of the US!  All else equal, our health care costs would be lower if we had 70% more doctors.  Why does Norway have so many more doctors than the US? We've already touched on that one...

And

You are wrong. They charge that because they have to give massive discounts to the insurance companies, so they inflate their prices to the point where they can still make a profit after said discount.

Additionally, US healthcare providers are heavily bloated in management positions (in part to deal with the insurance companies), so the "break even" point is higher to begin with.

Single-payer would kill those problems dead.

Ok - I see what you're saying now: if there is a single entity paying for health care, then a provider couldn't charge one payer high prices because another payer pays low prices.  The only alternative is that providers would just close up shop if they don't get the prices they want.  So what, aside from cultural aspects, prevents providers from closing up shop in these situations?  Is it that if you lower barriers to entry to be a health provider then you naturally get enough providers?

I think that's the fear in the US - that if you impose single payer, then we'll get "long wait times" because generally the discussion doesn't include reducing the barrier to entry to health care in the reform, we will not have enough providers.  And in the short term that is probably correct - I don't know how many existing providers are willing to take a pay cut (I'm talking about actual doctors and nurses here, not health conglomerate administrators).  You'd have to transition over a generation or so; if we reduce the price of becoming a doctor, then the new doctors could charge lower prices than current ones and still make the same absolute profit amount...

Over what period of time, and under what conditions, did all the European health programs come into being?

[Kagus]

Why does Norway have so many more doctors than the US?

Well, just to mention it, it does help that the student loan system in Norway

• Does not accrue interest while you are enrolled in an educational program
• Does not require payments while you are enrolled in an educational program
• Has 40% of the loan gifted as a stipend if you successfully complete and graduate your studies
• Has the debt frozen if you do not earn more than a certain amount annually
• Doesn't have completely obscene interest rates to begin with (between 2 and 3%)

[Trekkin]

You'd have to transition over a generation or so; if we reduce the price of becoming a doctor, then the new doctors could charge lower prices than current ones and still make the same absolute profit amount...

Not a generation, I think; the process of becoming a doctor in the US is a balance between the mad corporate rush to cheapen expert wages shoving people into higher education and the professional organizations resisting it by controlling throughput on the output end, so there are plenty of people who would make fine doctors who got some way along the process and then either ran out of money or weren't given a slot. Those people are still willing to become doctors, so depending on how you did it you'd have your new cheap doctors in a few years instead of decades.

It's like the mythical STEM shortage, really: we lack for jobs with compensation that makes up for the opportunity cost of post-graduate education, but nobody wants to pay experts more so they act like there's a shortage of willing people instead in order to flood the job market. The problem is how to pay people with doctorates enough, not how to make people want to heal the sick and discover things.

So in a way, the glut of demand produced by single-payer would itself drive a rise in the number of doctors; we have so few doctors because so few people can afford medical care, not the other way around.

[Lord Shonus]

Incidentally, Norway has 4.4 doctors per 1000 people - 70% more than the 2.6 of the US!  All else equal, our health care costs would be lower if we had 70% more doctors.  Why does Norway have so many more doctors than the US? We've already touched on that one...

And

You are wrong. They charge that because they have to give massive discounts to the insurance companies, so they inflate their prices to the point where they can still make a profit after said discount.

Additionally, US healthcare providers are heavily bloated in management positions (in part to deal with the insurance companies), so the "break even" point is higher to begin with.

Single-payer would kill those problems dead.

Ok - I see what you're saying now: if there is a single entity paying for health care, then a provider couldn't charge one payer high prices because another payer pays low prices.  The only alternative is that providers would just close up shop if they don't get the prices they want.  So what, aside from cultural aspects, prevents providers from closing up shop in these situations?  Is it that if you lower barriers to entry to be a health provider then you naturally get enough providers?

I think that's the fear in the US - that if you impose single payer, then we'll get "long wait times" because generally the discussion doesn't include reducing the barrier to entry to health care in the reform, we will not have enough providers.  And in the short term that is probably correct - I don't know how many existing providers are willing to take a pay cut (I'm talking about actual doctors and nurses here, not health conglomerate administrators).  You'd have to transition over a generation or so; if we reduce the price of becoming a doctor, then the new doctors could charge lower prices than current ones and still make the same absolute profit amount...

Over what period of time, and under what conditions, did all the European health programs come into being?

You are still not understanding. Let us say that a given procedure costs the hospital $250 in supplies and labor. Add in overhead and a bit of profit, you get $500. That is all the provider wants. To get that $500, they have to set the price at $25,000 because the insurance companies demands an 80% discount. So when Jim-Bob (who doesn't have insurance) comes in needing the procedure, he gets the full $25,000. So he declares bankruptcy, meaning that the provider gets absolutely nothing. so they start adding in a substantial "eat the cost" padding to the set price to offset the Jim-Bobs, raising it to $1000. Now the list price for that procedure is $50,000. That is where the five or six figure hospital bills you see posted online come from.


Now, replace the insurance companies with one universal insurer. The provider negotiates with this insurer to get $500 for that procedure, they always get paid, and the price stays at $500 (plus inflation) because they were only jacking up the prices because they wanted to always get $500 per patient in the first place. More likely, the price would wind up less than $500, because the provider's overhead costs would go way down. No medical provider (except, possibly, for now-obsolete bureaucrats) would take a pay cut of any kind.



Our problem is not "OMG! The doctors are so greedy!". The problem is "The hospitals have to jack the prices up super high to make any money at all because the insurance system is shit."


Now, there IS the separate issue of "the supply of doctors is artificially throttled to keep wages high", but that's not the area most in need of reform.

[McTraveller]

So in a way, the glut of demand produced by single-payer would itself drive a rise in the number of doctors; we have so few doctors because so few people can afford medical care, not the other way around.

Ok I have tried several times to understand this - can you rephrase it?  How will single payer increase the total amount of money available to doctors to allow for more doctors?  Or does single-payer include medical education and certification reforms, so that the cost of becoming a doctor is reduced?

Medicine in the US is expensive because it is a non-busted monopoly with regulatory capture, not because there isn't enough demand.

And because I previewed:

You are wrong. They charge that because they have to give massive discounts to the insurance companies, so they inflate their prices to the point where they can still make a profit after said discount.

No - that's not how insurance works in the US*.  Insurance companies don't "demand an 80% discount".  Insurance providers establish reasonable prices for procedures, and are only willing to pay that much - it's NOT a percentage off a list price.

*At least for the four insurance companies and handful of major regional health provider networks I have had experience with - not as a customer, but in the operational side.

[Lord Shonus]

So in a way, the glut of demand produced by single-payer would itself drive a rise in the number of doctors; we have so few doctors because so few people can afford medical care, not the other way around.

Ok I have tried several times to understand this - can you rephrase it?  How will single payer increase the total amount of money available to doctors to allow for more doctors?  Or does single-payer include medical education and certification reforms, so that the cost of becoming a doctor is reduced?

The money is there. That is not the problem. The problem is that the medical certification system operates on a "We will allow this many new doctors, and not a single one more." If this policy changed, we would have millions more doctors a year from now.


As for your other point, I have family that handle insurance negotiations for hospitals. That is EXACTLY how every insurance company works, according to them.

[Trekkin]

So in a way, the glut of demand produced by single-payer would itself drive a rise in the number of doctors; we have so few doctors because so few people can afford medical care, not the other way around.

Ok I have tried several times to understand this - can you rephrase it?  How will single payer increase the total amount of money available to doctors to allow for more doctors?  Or does single-payer include medical education and certification reforms, so that the cost of becoming a doctor is reduced?

The total number of doctors available isn't strictly governed by the total money available; if the current tax cut fallout has taught us anything, it's that if you increase profits you get higher salaries rather than more employment, and US doctors are already overpaid. However, while it's physicians that dictate how many residency slots are available and thus regulate the supply of new doctors, there's enough federal money subsidizing those institutions that a public outcry created by long wait times could allow legislative pressure to increase the doctor supply.

In other words, while only 1% of the population can actually afford medical care, nobody notices we have too few doctors because the demand is so low, so they can keep the throttle low and thus keep salaries high. If that were not the case, and we actually had a demand for medical care proportional to our population, the only thing keeping the supply down would be artificial limits imposed by what the conservative commentariat will call ivory-tower intellectuals sacrificing public health to line their own pockets and the liberals will call greedy 1%ers extorting the government and so on and so forth. They'll move if you threaten their subsidies, and that's something the government is very good at.

[smjjames]

We do notice though, in rural areas, there actually is a doctor shortage for rural areas but people tend to ignore it for the same reasons that rural areas tend to get 'flown over'.

So in a way, the glut of demand produced by single-payer would itself drive a rise in the number of doctors; we have so few doctors because so few people can afford medical care, not the other way around.

Ok I have tried several times to understand this - can you rephrase it?  How will single payer increase the total amount of money available to doctors to allow for more doctors?  Or does single-payer include medical education and certification reforms, so that the cost of becoming a doctor is reduced?

The money is there. That is not the problem. The problem is that the medical certification system operates on a "We will allow this many new doctors, and not a single one more." If this policy changed, we would have millions more doctors a year from now.

Except home (as in natively) training takes time, so, in order to do that, we have to... *drumroll* bring in immigrants (not a dig at you, just immigration hawks in general). Don't even have to resort to meritocracy based immigration, just create the demand and they'll come. Obviously there will be some quality control as far as medical training goes and I have no idea about regulations.

[McTraveller]

As for your other point, I have family that handle insurance negotiations for hospitals. That is EXACTLY how every insurance company works, according to them.

Maybe it's a regional thing?  I am friends with a VP of an insurance company, and have worked providing analytics software to insurance companies.  The insurance companies I've worked with/know about are stuck between population health mandates and the providers - and the people I know are all trying to really help people while dealing with the madness that is unreasonable expectations from the population (we don't want to pay anything) and the providers (sorry we are trying to rent seek as hard as we can!) - I would not wish the responsibility of being an insurance provider on my worst enemies.

[Iduno]

What is single-payer healthcare, then? What is gun control? What was the Green New Deal?

Yes, those are all successes we definitely have.

Language from the article suggests that current dhs management is a ljttle more concerned with public image this time. Hopefully that makes a lawful evil difference.

Is that still the one who was running an identity theft ring (by unlawfully arresting people he knew were in the country illegally, and copying their identification information) while running DHS?

I'd argue that limiting immigration isn't as much of a vital thing as people seem to assume.

Then how else are employers going to keep workers' incomes down if you can't threaten people with permanent exile if they don't please their corporate masters? Isn't that why they offer few enough visas that the major corporations in good bribes standing can buy up all of them, preventing actual legal immigration without wage slavery?[/s]

That's weird, why does it start noticeably increasing during the years great hero of the people Ronald Reagan was in charge?

[Reelya]

As for your other point, I have family that handle insurance negotiations for hospitals. That is EXACTLY how every insurance company works, according to them.

Maybe it's a regional thing?  I am friends with a VP of an insurance company, and have worked providing analytics software to insurance companies.  The insurance companies I've worked with/know about are stuck between population health mandates and the providers - and the people I know are all trying to really help people while dealing with the madness that is unreasonable expectations from the population (we don't want to pay anything) and the providers (sorry we are trying to rent seek as hard as we can!) - I would not wish the responsibility of being an insurance provider on my worst enemies.

This here seems to be the point where everyone is talking past each other. The key part of a national health service isn't just the insurance / payer side of things. That's half the equation. The other half is that those places have publicly owned hospitals. for example, UK's NHS isn't actually an "insurance scheme" the way Americans would understand it, it's a network of publicly funded medical facilities, which guarantee equitable access to medical care for all citizens.

So both the providers and the payer are public. if you have public money but private providers, you just get profit-gouging: the industry reshapes itself to work out how to extract the maximum limit of public money, while providing the least actual service. That's why you get medicines that "cost" $200 on American Medicare, but only $15 if you buy them at a pharmacy. When people question the "costs" they get told by the providers not to worry about it: after all, it's the "governments" money, not "your money", right ?

The provides have worked out pricing schemes to guarantee they extract that exact limit of medicare benefits each person is entitled to, regardless of how much treatment they actually need. That's the equation they've optimized: extract the exact maximum amount of benefit money possible. If you double the medicare allowances, they just basically double all prices, since the amount of treatment people needed didn't really change, but they still want to optimize to extract the maximum amount of money. That's why it's a broken system.

Public money + private providers = corruption. That's the reason America's system is so costly. First, you need well-run state hospitals. If you have state hospitals, then at least any profits are going to get spent on infrastructure.

So you're right single payer alone won't fix the problem, because it's private hospitals with no regulation on prices combined with a "feeding frenzy" to get the most share of the public money that's mainly responsible.

In fact, this identical structural problem plagues a ton of things in the USA. Since you have so many private colleges, and you have publicly funded student loans, there's a similar distortion and massive cost blowout in the student loan sphere, because private colleges set their fees based on how much student loan money they can extract from each student: that is their entire business model: extracting the maximum amount of government money per student, not providing a decent education.

The take-home lesson here is that you can't just have governments throwing money into a private sector and expect the amount of service to magically increase: the private service providers just ramp up prices to match the influx of cash until equilibrium is reached again. You need the government to build actual state-owned infrastructure with that money, and compete with the private sector. That's how social democratic societies actually make things better: state-owned enterprises compete against private-owned enterprises thus keeping costs low. It's normal supply/demand economics.

Pumping taxpayers money into the private sector isn't "socialism" at all, it's actually crony-capitalism:

https://en.wikipedia.org/wiki/Crony_capitalism