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Notes -
I strongly question the insurance-based model for healthcare expenses.
One of the things that makes insurance work is that most people never need to use it. Life insurance stops being a thing (in almost all cases) when people retire - and most people make it to retirement. Car and home insurance are things most people pay for every year and yet use maybe once in a lifetime. Many people go on vacation every year for almost their entire lives and yet never file a single travel insurance claim. One third of physicians have been sued according to malpractice claim firms, but this is across a 40-year career - perhaps one in every sixty or seventy years as a doctor will they be (on average) required to use their malpractice insurance, if that. Most ships never sink. Most buildings never burn down. Most planes never crash.
Health insurance is different.
Many Americans, especially in old age, file health insurance claims most or all years. This is not what the classic insurance model is designed for, especially given the cost of some healthcare, which is why the US has created so many ‘workarounds’ that twist the provision of insurance to ameliorate the fundamental fact that health insurance makes no sense. These include Medicare (for a certain vast class of people no insurer could afford to insure) and Medicaid (for another vast class of people no insurer could afford to insure, just for a different reason). It’s why employers have to contribute to health insurance as a stealth tax, because otherwise many people would not be able to afford it. What is the difference between a system in which the government taxes companies by forcing them to pay for employees’ healthcare and then directly pays for the unemployed’s healthcare, and a classic single payer system? Multiple providers which are never really competitive because of an opaque pricing structure.
As with college tuition, the state has created a monster with no cost control, because the government backstops the most expensive treatment for a growing percentage of the population with unlimited “free” money. In a way, the US already has nationalized healthcare, just like it nationalized college education, it’s merely been nationalized in an extremely inefficient way.
I live in a country with a mediocre public healthcare system, in which almost every doctor and nurse is directly employed by the government in a full time capacity. But the NHS isn’t bad because it’s the NHS. It’s comparatively much cheaper than almost any other first-world healthcare system in a country populated primary by Europeans (can’t compare to eg. Singapore or Japan where people are much healthier and the culture is different). The NHS sucks because everything is done for the cheapest price possible, there’s been no economic growth in 20 years, and British GDP / capita is half of that in the USA, because Britain is poor. Its mediocrity is for the most part a consequence of the British economy, which is poor for largely unrelated reasons.
But I increasingly think the model, or maybe at least the Australian or Swiss semi-public models, could be successfully exported to the US. The usual criticisms of universal healthcare are already rendered bullshit by the American system. Homeless psycho scumbags already get millions of dollars in free healthcare in the US subsidized by the middle class taxpayer that they never pay back, it just gets taken from them in a slightly different way. The NHS isn’t really more “socialist” than the US system at all, because working people are still paying for everyone else in the same way. Old people (by far the most expensive demographic) already get free single payer in America. In fact, the US system is arguably even more unfair, since it costs much more as a percentage of GDP than the British system, which given usage statistics means middle class Americans are relatively redistributing more of their wealth to the old and poor in healthcare costs than many Europeans are.
Insurance is a useful model when there is high variability in potential costs. This is certainly true of healthcare, where outcomes range from regular checkups to major surgery. In any given year, healthcare expenditure will not be normally distributed across the population, but instead heavily skewed to a small segment. (I suspect this would also be true even considering the variance in individual lifetime healthcare costs, though it would be difficult to gather this data).
So while it's true that people interact far more frequently with health insurance than other forms of insurance, this doesn't really address the core reason for having an insurance model, which is to protect against those high variance outcomes. Another way to think about this - if healthcare costs were stable and predictable, you wouldn't need government involvement at all (apart from welfare subsidies), as it could be treated like any other essential item you budget for such as food.
To my mind the issue is more a free market vs government regulation issue, and whether or not you have insurers is less relevant. After all, public systems like the NHS are still effectively an insurance model, just one run by the government. The Netherlands may be a useful case study to look at, as its system is entirely based on private insurance, but it is heavily regulated and seems to function fairly well.
I don't have nearly enough familiarity with the US healthcare system to know where it's going wrong, but at least from the anecdotes I hear a lot of it sounds like toothless regulators (or just plain lack of regulation). For example, not knowing what a treatment will actually cost in advance seems to be a common complaint and one that's frankly pretty incomprehensible to me from my experiences in Australia (with both public and private healthcare), as knowing the cost of a service before receiving it is a pretty basic aspect of consumer law. Any provider attempting that sort of thing here would get hefty fines from the regulator. This is a guess though, and it's likely lots of factors, and the US system could well be at a disadvantage just due to the size of the country and the complexity that introduces.
This is extremely true and makes me wonder if we could put a few more chronic conditions in Medicare like we do with dialysis and cut costs enough for everyone else that it could be closer to actual insurance (literally moving the sickest 1% of the population or so could cut premium by 40% - sickest 5%, more like 70%)
Honestly, I kinda wonder why Obamacare wasn't more like this - seems like it would've been an easier sell to put more people on Medicare than what the ACA actually was, and it would've left people alone as far as purchasing more expensive plans? You'd have to figure out how to compensate providers somewhat, but I'd imagine there are ways (bump up Medicare reimbursement rates a bit, slight increase in Medicare taxes, slight increase in corporate taxes to offset decrease in large group premiums from some employees care shifting to Medicare?)
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