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What will the future of the US healthcare system look like?
The current system is a patchwork of primarily employer-sponsored healthcare (60% of non-elderly Americans), the ACA marketplace (offering government-approved plans through private insurance companies), Medicare for the elderly, and Medicaid for the poor, disabled, and children. About 8-9% of the population is uninsured. Prices are higher and health outcomes worse than comparable developed countries.
Obamacare attempted to reduce the uninsured population by, among other things, implementing Medicaid expansion to all adults under 138% of the federal poverty level and granting tax credits to help defray the cost of marketplace plans (for incomes up to 400% of the FPL). During COVID, these subsidies were increased and expanded to higher income levels, but Congress allowed them to expire this year, resulting in average premium increases of ~114% for about 22 million people, although an additional vote is scheduled this month.
In addition, low-income adults utilizing expanded Medicaid will be required to demonstrate 80 hours of work per month starting in 2027. Mike Johnson framed this as kicking out unemployed young men mooching off the system - even the old welfare queen trope has been de-DEIified. Georgia already implemented a similar work-requirements program as part of their Medicaid expansion in 2023, resulting in the bulk of the money going to administrative costs and only about 9k out of 250k low-income adults enrolled.
As a result of all of this, the uninsured population will likely increase this year, which may even cause premiums for people with health insurance to rise due to a death spiral effect - if more people are uninsured and can't pay their medical bills, the costs may be shifted to covered patients.
The above article takes the pessimistic view that the system is unlikely to improve significantly, because tying healthcare to employment is such a nice perk for employers (the system started during WW2 when companies offered health insurance as a replacement for wage increases due to federal wage freezes). European or Canadian style universal healthcare certainly seems less likely than ever.
The blackpill moment for me came about five or six Christmases ago.
I was came home to see mom, dad, and my siblings a few days before Christmas. At this time of year, every year, my dad finalizes his books. He has always run the household finances top to bottom, even though my mom had her own entrepreneurial career since I was little. This year, however, dad had extra time on his hands because, well, he'd been retired for the full year. Probably to keep busy, he was self-auditing the family's entire financial history since my oldest sibling was born (if you haven't figured it out by now, my dad was a finance nerd).
Coming into his office to greet him after, of course, hugging my mom first and learning about all the amazing Christmas cookie recipes she had shared with the other church ladies, I found my dad looking a bit sullen. Nothing catastrophic, but definitely something there. I perked up at once. Had he miscalculated their retirement forecast? Impossible, he'd been thinking about that daily for over a decade before he retired. What was it? Had mom started splurging on fur coats or trinkets for the grandkids?
I asked him what the matter was and his response was direct, "We should've never paid for heath insurance. We came out behind."
This was beyond stunning to hear. It was like finding out that I was adopted all these years later. Why? Because one of my siblings, in her teenage years, had had five major surgeries that required; A specialist-of-specialist surgeon to actually do each one, multi week hospital stays each time, weekly (later monthly) checkups locally, and prescriptions for all sorts of exotic medications. The whole saga actually played out over 4 years. Complications, poor recovery, etc. I was fairly young so I don't remember the worse of it, but this has always been cited as why my mother went prematurely grey.
I asked my father to explain. Pulling up the World's Greatest Excel Spreadsheet, he walked me through historical premiums, deductibles, out of pocket expenses. At the end, the =SUM() function told the tale; had mom and dad paid out of pocket instead for all that time, they would've saved money.
Two important caveats
Still in all, this was my helathcare blackpill moment. The normie narrative around healthcare is "yeah, it's too damn expensive, but if you really need it it's worth it." Well, like, no. My sister's bills probably put us into about the top 5% of expenditure for the years she was in the middle of everything. And yet, the numbers still didn't crunch.
Since then, I've learned that the top 1% of healthcare "users" (that is, people who are consuming care) represent about 50% of overall healthcare spending. It's a crazy power law. But that actually isn't the problem. As others have pointed out, it's all of the off book spending that gets done for defectors. This then gets passed up the chain to the middle and top. For every deadbeat who uses the ER as his or her primary care physician, many of them as "frequent fliers", that's thousands to tens of thousands of unpaid costs that have to get paid somewhere. And that somewhere is you, the dutiful policy holder. It is the ponzi schemes of ponzi schemes because the pyramid is upside down -- the people at the top aren't actually capturing a bunch of value and then playing slight of hand with those lower, it's that those at the very bottom are pushing all the cost up.
This is one of the moral dilemmas I actually think about most. If I, god forbid, ever need some sort of major procedure done, do I just defect and refuse to pay? They can't send me to jail. Maybe my credit score goes to shit forever, maybe I even go bankrupt. Eh, but then I'm just going to be a cash-only vagabond and live as free as I please.
But it would be wrong and immoral. As much as it is a totally rigged game, I see the only hope for society to be to continue to at least observe the rules of the game. Defecting in a collective action problem shifts immediate personal cost to prolonged socialized cost. It's inherently anti-social.
You make the case like you have and if it doesn't (can't) get heard - you defect. The longer you play along the longer you incentivise the status quo. But I probably wouldn't have the balls to defect also.
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Usually reminders that everyone ignores when this comes up:
-Physician salaries are not a large portion of healthcare spending, cutting them in half wouldn't do much.
-U.S. doctors do make good money but most specialties are making way less than the numbers bandied about in this thread.
-Many of the problems with U.S. healthcare stem from salaries being too low (ex: issues with primary care, location preferences).
-N.P.s provide a massive decrease in quality of care over MDs, they also have....like no training.
Source
*More than 239. The occupation page gives per-specialty mean (not median) numbers ranging from 222 to 451.
Many specialties have average salaries in the 200s. Some make even less than that. Many average in the 300s. Those making over 500 are rare and are generally procedural specialties that are paying a cost to get paid that much (such as extra years of training).
All of this in the setting of years and years of training, shitty work life balance, and so on.
And that's not taking into account things like NYC - where nurse and physician take home is pretty comparable.
So like I said, exaggerated numbers downthread.
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Houston, Texas, piloted a ‘gold card’ system before the state made them stop because it was covering illegals, where preventative care and EMTALA treatments were covered by the government when given to people who weren’t going to pay any amount anyways. Eventually, healthcare systems will get this nationally as a bailout for themselves. The old will still be on Medicare, the health sharing orgs will keep growing, and the poor will just have shitty non-emergency care.
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Single payer, with the costs (paid by taxes) ballooning like they now do in the US, the waiting times ballooning like they do in Canada, and British-style dental care. Good news is we'll probably reduce old-people medical care with essentially-mandatory US MAID. And drug development will probably be cut back. The problem is that socialism is a one-way street; it's easy to get more but it tends to take an existential crisis to move it back. And there's always a constituency for more socialism -- anyone who wants more of what someone else has, or is perceived to have.
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I feel obligated to point out a loophole that people constantly fail to mention: you alternatively can demonstrate monthly income equal to 80 hours of work at the federal minimum wage of 7.25 $/h (580 $/mo, 6960 $/a). This allows many "unemployed young men mooching off the system" to still qualify on the strength of the dividends from their investments. See § 71119 of the text.
Purely out of curiosity - can you mix and match income sources here?
Eg: could a live at home guy make $3,000 from door dash, $3,000 from stock dividends on an inheritance, and $1,000 from interest in a savings account and qualify?
A quick reading seems to suggest he could.
I don't see why not.
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Surely these programs have net worth caps far too low to be able to generate $7k a year. I looked it up and some seem to have a primary home exemption, but securities I doubt are included.
Medicaid-subsidized nursing-home care has an asset limit of around 2 k$ (plus house of around 550 k$). Medicaid-subsidized health insurance has no asset limit at all.
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Single payer makes sense
Relative to GDP and median income, British doctors and nurses are paid like shit. This is objectively good for the taxpayer and user of healthcare services. The NHS is worse than the US system, but this is likely more because Britain is much poorer than America than that it spends a much lower proportion of GDP on healthcare (both are true). The fact that it works at all, most of the time, is kind of great. US annual healthcare spending per capita is 300%, in dollar terms, of UK annual healthcare spending. The British spend $5000 per year per capita, the Americans spend $15,000. There is no major difference in life expectancy. A few niche cancers have higher mortality in Britain, but for most people, most of the time, the outcome difference is marginal and reflects a comparatively lower economic baseline and therefore budget than it does some inherent problem with single payer.
In addition, British doctors can emigrate to places that pay more, whereas the US under a single payer system would probably still have the highest medicine pay of any major country, it just wouldn’t be so much higher because one central employer could negotiate centrally (not just for pay, of course, but also for things like drug costs where the Brits pay far less for the same drugs than Americans do). I’ve been to the ER here on a couple of occasions, in both it was no worse than the US equivalent. If an American doctor currently making $600k had their pay cut to $300k, there’s still pretty much no other Western country they could move to where they would be paid much more, even in Australia most doctors don’t make that (450k AUD) and Australia isn’t big enough to absorb that demand anyway.
Every American who has ever used (or been forced to use) an anaesthesiologist making $600k is a pay pig for the AMA cartel. You can take the top 10% of nurse practitioners by IQ and train them to do this in a year. Even nurses make like $150k now in a lot of places. And the entire insurance system is a middleman grift, with zero incentives (due to both the nature of the business, the pricing power of hospital systems and doctors, and bad legislation) to rein in costs. Everything just gets passed on with an extra cut until ultimately the taxpayer foots a big proportion of the bill. In the American system, the solution is always increasing prices because that is all that can happen.
Three intertwined factors explain American healthcare costs, none of which have anything to do with great care. Extremely high physician salaries, high drug prices, and the entire bureaucratic insurance apparatus.
The first issue is part of a problem you also see in other professions like accounting and law, although medicine is by far the most egregious case, which you could call something like “professional capture”. In this case, a profession dominated by moderately intelligent people (say 2 standard deviations above the average) runs circles around legislators, regulators, administrators and others around the median to its advantage. In a single payer system where say 90% of hospitals are owned by the government, the government decides how much doctors get paid. You can do some private work for the super rich on the side, but outside of specialties like plastic surgery that isn’t going to pay the bills. Otherwise, you take the pay the state gives you, or you go somewhere else (which, as discussed, wouldn’t be an option for all but a tiny minority of American doctors). Since medicine is so overpaid relative to most other PMC professions, halving doctor pay like this would bring down costs by perhaps 5% with no disadvantage (even at half pay the average doctor would still make more than the average accountant or lawyer).
The second problem is a reality of the insurance and network system. For experimental/research treatments, patients can whine and complain about experimental therapies not covered, which generates bad press for the insurers, which forces them to cover some horrific experimental procedure that costs $10m and prolongs little Timmy’s life by 2 additional horrific months. In the UK, when this topic comes up at the water cooler, most people will defend the NHS’ QALY system because they rightfully understand the direct relationship between their tax money and this kind of bullshit waste. In America, where the consumer is distanced from this spending, far more people will argue that insurers are “greedy” whenever they don’t spend “whatever it takes”. Instead of seeing themselves as the losers, they see Big Business as the loser, because the average person cannot grasp even the most banal plumbing of the economic system. For mainstream treatments, big pharma has leverage over providers and insurers who are often local, and so can’t drive down prices. If you don’t sell to the NHS, you aren’t going to sell your drug in England (outside, again, of perhaps a handful of tiny private hospitals in London). In America, you don’t face that stark choice; there is no pressure to negotiate, and of course even Biden’s lifting of the prohibition on Medicare (the only entity large enough) negotiating drug prices seems to be being heavily diluted.
The inherent reality of insurance as applied to healthcare doesn’t make sense. Most people’s houses never burn to the ground. Most mail is never lost. Most people don’t die before they retire. Most ships don’t sink. Insurance works in these cases to pool risk. If every ship sinks some of the time, if everyone’s house burns down a few times in their life, insurance is bad model for handling these inevitabilities - a communal (eg church, guild, industry, whatever) or state-based scheme is economically preferable. The insurance bureaucracy (which extends far beyond the insurers themselves) has already been covered elsewhere, but a combination of the model’s inherent weaknesses and terrible regulation is responsible for significant upward pressure on all healthcare costs. Margins don’t have to be high (and they aren’t) for this to be the case, the process just needs to be labor and other cost intensive (and it is). In fact, with margins strictly limited, profitability is driven only by higher total insurer revenue, again incentivizing higher prices without any incentives for productivity growth.
As I’ve argued here before, if you are a middle class or above taxpayer in America, you should be fighting for single payer. Why? Because the dregs, the scum, the homeless, the degenerates, the old and sick who never contributed much, the welfare queens and trailer trash and lifelong can-never-works already get free single payer at the point of use and forever. They already have this. Only you, the pay pig, has to pay, get into medical debt, deal with endless bureaucracy. The homeless guy who ODs again or has some horrific needle induced injury walks in, gets his free stay under whatever name he chooses, costs YOU your share of the $150,000 bill (after all, the doctors and nurses and drug companies still get paid all the same) and leaves. No consequence.
Since the American people are too taken by pathological empathy to do something about that (does this make healthcare the ultimate example of anarcho-tyranny?), you may as well at least get the same deal for yourself.
I think the average middle class person you're trying to get this message to is also aware that American single-payer is far more likely to look like Universal Medicaid rather than Medicare-for-all. And also that Medicaid is known for being, for lack of a better word, "cheaper" [1] [2] [3] [4] than Medicare. Few of the good doctors take Medicaid (more, but not all, take regular Medicare), or there's frequently a waiting list unless you have private insurance or pay cash (I've literally overheard a receptionist having this conversation while waiting for an appointment before). Even within Medicare, Part C private-insurer-run ("Advantage") plans are more popular than vanilla single-payer Medicare (A and B) these days.
Ultimately, I think the biggest part of the problem is that even once cooler heads prevail (we're pretty good at throwing out ideas here, at least), the American Healthcare ship is huge and can't be steered on a dime. We need not just a valid concept and details of a final system, but also how we get there from here. Simplify the complexity of medical billing and procedure payouts (IMO the easiest starting point)? What do we do with the 200k odd medical billing specialists (plus whomever at the health care networks and insurers negotiate prices annually), and who's going to be checking for fraud? Cut doctor salaries? Not going to be popular and the AMA has huge power, plus many really do have student loans for med school to pay for. Someone's (or many's) oxen will have to get gored, and most politicians don't seem willing to make the sorts of enemies-for-life we're talking about here.
Universal Medicaid does seem the most viable option, and it's not that different from what I hear is done in Germany, which I understand is a two-ish tier system, and it's much easier to get appointments with private insurance. That isn't to say that I like it, it just seems easiest. Gradually reducing the Medicare eligibility age at least sounds promising as well, but probably has pitfalls I'm not considering at the moment.
[4] Correlation does not imply causation, but I've also heard plenty of
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The reason the UK doesn't spend more on healthcare is because they can't and their government has real limits on the total amount of money they can spend. America doesn't have these limits and it's why American government doesn't handle the cost-disease in anything else, including the already existing medicare and medicaid single-payer systems. Military equipment in the US is single-payer and yet the military industrial complex is completely clownish in blowing obscene amounts of money on small numbers of out-of-date or otherwise poorly performing equipment. The US doesn't even bother seriously stopping vast, industrial scale fraud in these systems.
But somehow, universalizing single-payer to everyone is going to force lower salaries and other cost-cutting measures, much of which could be done right now under current law given just the basic buying power of the federal government by conditioning funds. All of these hypotheticals in the above post about what a single-payer system could do could essentially be done now, but not only are they not done but we're not even doing the first step of any number of things to lower costs or reduce salaries or anything else right now. It is just not believable that US government would magically make these hard-decisions which would have real costs to powerful, concentrated interest groups, under single-payer when they don't do anything like this right now.
The only inherent thing to a single payer system is it centralizes control for better or worse (and after the covid hysteria, this should be pretty terrifying to people) and theoretically this would make it easier for someone to engage in a shock-and-awe approach to jolt the system back to something reasonable.
The best argument for single-payer, given all the other government interventions in healthcare which have made it far worse for vast bulk of productive people, is that it would significantly reduce the required individual effort to not just be completely fleeced by healthcare and at least remove that burden from a large number of people which would no doubt make their lives better in at least that respect.
The downsides will be numerous: healthcare quality will just get worse, innovation will just get worse, amount of healthcare delivered will just get worse.
IMO, the bulk of the benefit and lower downsides would be solved with universal catastrophic health insurance above which the gov foots the entire bill.
I am very skeptical of this claim and it just looks like a "find the lie" statistical factoid which are rampant and regularly posted in political discourse. It started with "actually, they have better outcomes!" and then it became, "okay they have the same outcomes," and then it became, "okay they have worse outcomes in some things, but it's marginal."
If I had to guess what the lie is in this regularly presented "fact," I would bet if you controlled for different demographics, different baseline population differences, different baseline health metrics, healthy user bias generally, we would find good evidence the US delivers much better outcomes pretty much across the spectrum. When I've poked at this "fact," it becomes clear the data just doesn't exist currently to meaningfully control for these things outside very broad population adjustments and other proxies and they immediately make the US system look better.
This is a lazy musing though and I don't expect you or anyone to really defend this.
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Very strong comment. I work in healthcare, and your last paragraph is especially relevant and, at least anecdotally, accurate. Working with chronically mentally ill patients, I sometimes try and follow the paper trail to see how these services are getting paid for. Occasionally there is talk of Medicare or Medicaid when it comes to specific practices, but generally, no one bats an eye at giving a homeless man a full head CT. For the worst patients who need long term care, the eye-watering cost of a 6-month bed is rounded down to a zero because they simply cannot and could never pay. I respect individual doctors who want to do no harm, but systemically it's a baffling injustice that some folks go bankrupt trying to pay for things that are doled out like Halloween candy to the underclass under the pretense of the Hippocratic oath. I have some logistical concerns with single-payer, but it should be instituted for this reason alone: as you said, insurance doesn't work when more ships are sinking than should be.
Physicians can cry about it, they'll still be a well-paid and well respected profession even with a pay cut.
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Doctors get paid well but the administrative burden is also a large part of the discrepancy. Providers have to spend way too much time negotiating with insurance companies over payments and what will and won't be covered. There's an entire business around denying as many claims as they can get away with. Part of it is inherent in a multi payer system (Germany's public-private system has higher costs than the UK) but there are plenty of aspects to the 'managed care' system, like provider networks and utilization management, that are unique to the US.
Similarly, drug development is notoriously expensive and the costs have to be passed down to the consumer at some point - but the insurance companies are hardly innocent bystanders forced to pass them through. Pharmacy benefit managers are supposed to negotiate reasonable prices/rebates and formularies between drug manufacturers, pharmacies, and insurance companies - but the three largest companies (Optum, Caremark, Express Scripts) managing 80% of all prescriptions are owned by UnitedHealth, CVS, and Cigna, which defeats the whole 'independent negotiator' thing and just makes them rent seekers at consumer/government expense. It also makes it possible to skirt the medical loss ratio rule by shifting profits.
Insurance companies are legally obligated to pay out 80% of premiums. I'm sure there are plenty of cases where they deny claims for bullshit reasons, and this is perhaps even part of their business strategy, but the big picture is that they spend the vast majority of premiums on payment for care.
It's not clear to me what "shifting profits" has to do with this, because the regulation is about how much premium revenue is spent on healthcare rather than anything to do with profits.
Vertically integrated insurance companies can charge themselves more so it looks like patients get more bang for their buck. The PBM (owned by the health insurance company) charges the health insurance company a high price for a drug, increasing "payout" (numerator of the medical loss ratio) while simply shifting revenue internally. The same thing happens with insurance-owned clinics and pharmacies.
https://healthjournalism.org/blog/2025/12/reports-show-health-insurers-skirt-medical-loss-ratio-rules/
Retail pharmaceutical spending accounts for 10% of total health spending. It's not the reason for high costs.
What fraction of healthcare spending goes through insurance owned clinics?
It's at least the reason for high drug costs.
If you look at UnitedHealth's 10-k, Optum (the provider network) made $253b in revenue, but $151b of that was 'internal eliminations' transfers from UnitedHealthcare (the insurance arm) to Optum.
https://www.unitedhealthgroup.com/content/dam/UHG/PDF/investors/2024/UNH-Q4-2024-Form-10-K.pdf
I don't see "internal eliminations" in that document.
Gemini suggests that the document says UHC got $290B in premium revenue and Optum Rx earned $80B and Optum health earned $64B primarily from UHC. I don't think the other Optum divisions could be considered patient care upon a cursory check.
That is a significant chunk of UHC premium revenue, so I take your point there. However, the money staying in the family like this would make UHC more likely to pay out claims than if it were going to a truly external company, and yet the common complaint is that they don't pay out enough.
It's on page 30 as 'eliminations'.
UHC pays its own doctors more, and in general insurance companies will steer customers towards their own, more expensive facilities, but there's limited studies on how it affects care in general. You'd think that it should increase the number of procedures done at least, but that's not so clear.
https://www.hks.harvard.edu/faculty-research/policy-topics/health/study-finds-vertical-integration-medicine-leading-higher
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The $151B number is listed as "Eliminations" on page 28; the same number is broken out by segment as "Total revenues - affiliated customers" on page 66. (The missing $7B is Optum Insights, an IT vendor that seems to sell software to both UnitedHealthcare and the other Optums.)
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As I understand it, this is part of the problem: since your loss ratio is floored at 80%, you don't have a strong incentive to manage costs. There is actually a bit of the opposite one: the higher the costs, the higher the premiums, and the bigger is the base from which you derive profits.
That's certainly true. But that would incentivize insurance companies to pay out more claims.
Insurance companies are probably not sufficiently motivated to play hardball with providers on costs. At the same time, people are getting most of their premiums back even if they don't like how much care they get for those premiums.
People aren't getting most of their premiums back. The healthcare system is getting most of the premiums rather than the insurance system, and it's not showing up as profit, but rather being paid to support the health care bureaucracy.
ETA: And sometimes the same entity is on both sides of the transaction, as @yunyun333 points out.
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I hadn't thought about the issue this way, and suppose it's especially exacerbated by the current proliferation of expensive end-of-life interventionalist procedures in which a whole lot of people are going to live long enough to consume a bunch of anti-cancer drugs & treatment in their last few years compared to back in the day where there was likely more a palliative attitude towards 'deaths of old age'.
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I haven’t had insurance since Obama created the bill. Half because I hate Obama. Other half because my premiums from memory went to stupids levels immediately. I have not see a doctor since Obama.
To a more relevant question article are popping up that biotech is dead in Boston. Biotech stock prices have mostly been bad for 5 years. Can someone explain to me why health care costs continue to sky rocket? If the money isn’t finding its way into inventing new tech then it seems to me price go up with no improvement in quality. If biotechs are not making money then who is making money? This just feels to me like either a jobs program or another Somalian scam but 100x bigger.
Pharmacy benefit managers (PBMs) are supposed to negotiate drug prices between manufacturers, pharmacies, and health plans, since they can essentially pool negotiating power. In practice, they're integrated with the health insurance companies, so they rent-seek and take what are basically bribes from the manufacturers (in the form of rebates) to make the drugs "cheaper" to consumers, while also forcing independent pharmacies to take smaller reimbursements or lose access to their network.
https://www.commonwealthfund.org/publications/explainer/2025/mar/what-pharmacy-benefit-managers-do-how-they-contribute-drug-spending
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Single payer will stop medical development and reduce care quality while not reducing costs at all.
When it's single payer it's not really negotiating any more. It's lobbying... and corruption. The common pattern with such monopolies is the union or association negotiates not with the government itself but the politicians. The politicians are happy to pay for favors for themselves with government money. Since there's a concentrated benefit (the union/association members, who are generally politically popular) and distributed cost (taxpayers), the union/association wins every time.
This won't occur with things like drug development because those companies are very unpopular; they can offer money but won't have enough to offer in terms of votes compared to the populist who says he's going to fix the prices of new drugs. And since the regulatory framework obviously isn't going away, drugs will be as expensive or more to develop. The US is now basically subsidizing the result of the world in drug development because of this. If the US goes to single payer, no one will be paying, so drug development will simply cease. The same will go for other expensive new treatments.
If I’m an American citizen (only) and want to become a diplomat or a military submarine captain or a central banker, I pretty much have to work for the government. Making it so that if you want to be a doctor, you (mostly) have to work for the government is no different.
The politicians in single payer systems often stand up against paying doctors more because they know that if they do they have to pay all public sector workers more, and that means their own fiscal priorities often become unaffordable. The incentives aren’t perfect but they’re better than the current system where responsibility is diffused.
There are ways around it. The big drug makers have forced the UK to pay more by threatening to move well-paid pharma jobs offshore for example. Governments fund tens of billions of dollars in medical research, private universities do too. I’m unconvinced there will some collapse in new drug development if single payer happens, the global system might just become more fair instead of the American taxpayer paying for a disproportionate share of medical innovation.
Yes, if you want to become a diplomat (in a non-shithole country, anyway) it's good to have contributed a lot to the party in power. Like I said, corruption. Not sure how that's responsive to my issue, which is that your "negotiation" will consist of politicians negotiating doctor's reps with other people's money.
They actually don't have to pay all public sector workers more. But if they did... eh, it's not their money.
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The AMA would probably fight against most versions of single payer, and pretty heavily. If the proposal was "single payer and doctors are now going to be subject to the standard federal pay schedule", I don't think anything could prepare you for the fury that would be unleashed to prevent it from passing. Mayyyybe they could accept "...and we'll make a new, separate, special pay schedule (which can be changed separately from the standard schedule) for doctors, who are special," but there's just absolutely no way that the US government will actually have the political will to bulk force doctors to take a 3-8x pay cut.
Thousands of physicians are already public servants. They work for the public health service, the veterans administration or they're members of the armed forces. Other agencies employ them too (e.g. State dept, Indian Health Service). They receive special rates and do pretty well for themselves. They certainly make less than if they ran a successful practice, but not everyone is interested in those sorts of headaches and risk. And there are other tangible (loan forgiveness) and intangible (training, travel, work-life balance) benefits to working for the government beside the pay.
note that public doctors work immensely less because they get paid less - if you work for the va it isnt uncommon to see 1/2 or 1/3 the patients.
that would likely spread across the whole economy
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That’s nothing new. The BMA (British Medical Association) was the most aggressive and chief lobbyist against the formation of the NHS in the 1940s. Doctors hate single payer because it drives down physician pay. That is precisely a reason to do it.
I mean teachers pay is politically radioactive in the US and doctors are roughly as sympathetic.
No, it’s different. Public school teachers are paid relatively averagely given years in the workforce and levels of education; a few make $130k but that’s a small minority in the highest paying districts in the country. They are paid toward the bottom of the most common ‘public service professions’ pay scale (cops, nurses, local government workers), especially in red states. In blue states, particularly rich ones in big cities with very high private sector salaries where the ‘we support underpaid teachers’ sentiment is most common they are paid slightly better, but so are the NYPD and nurses who work in Manhattan.
Meanwhile, while Americans have a lot of respect for doctors, I’ve never heard the sentiment that they’re underpaid except from doctors. They might say underpaid ‘compared to’ dislikes groups like CEOs and bankers, but that is more about the latter than the former. “No, I believe my anaesthesiologist should make $900k a year instead of $600k - hell why not a million?” just isn’t really the kind of thing people are saying or thinking.
The perception that certain specialties are underpaid is pretty widespread in the social groups familiar with specialty pay breakdowns. Many Pediatricians and ID doctors make under 200k, and government agencies and other organizations have made costly decisions to encourage more people to become PCPs because the pay is noted to be too low.
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Top 5 comment all time.
You could also greatly simplify credentialling and training. Doctors don't feel like they have it great because the training hours are unnecessary and shit. Even the work hours can be pretty bad in US once qualified. Train more, work fewer hours, more open/simple credentialling.
Single payer has a very ugly aspect to it that you see when you are exposed to it a lot. There's a good book written by an Indian about it in England (forget the name). I've seen people come to ER and get a bed because their wife was in. Complain of some general stomach pain. Unable to elicit any signs. Probably the current system has this as well. It's just a very ugly thing when you make something free for common good and the underclass abuse it in ways that make you want to put them on the moon.
To speak to the work hours specifically - one reason behind it is because a huge amount of medical issues arise specifically on the switch between shifts. I’ve heard it discussed with regards to nurses - but it’s things like “shift changes at midnight, pills are due at 11:55pm, did the previous nurse give them or does the new nurse?” You’d assume it’s obvious, but if the previous nurse was dealing with a patient coding next door, then…
Yes, one of the justifications for 24 hour shifts for residents is that transitions in staff are more dangerous than your doctor being drunk from sleep deprivation.
On complicated cases this can get really important, losing track on how much blood we gave in the SICU on an open abdomen is not good and the EMR can't keep up well, but nurse Betty remembers....until she goes off shift.
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Sure, although as mentioned, the underclass already have this in the US since they don’t pay for anything. If anything, the extreme bed pressure on the NHS means they’re more likely to turn away someone with no medical issues who just wants a bed.
For normal hypochondriacs and elderly people with nothing better to do but some money, implementing an ER fee is still completely possible in a single payer system (it’s just that England doesn’t have one). It would not affect the true underclass but would affect a lot of abuse which is by people who have some money but just nothing better to do.
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It's true that almost all people in developed countries eventually get old and frail, but it's not like people want to have health insurance so that it keeps them from getting old and frail. I imagine most sensible people who want it do so because they want insurance that they don't die from curable diseases that aren't their own fault. Theoretically there should be room for insurance of this sort.
This got nuked when it became illegal to deny people for preexisting conditions. It's doubly fucked when something like half all all chronic conditions can be traced to poor lifestyle management; diet, exercise, and substance misuse/abuse both legal and otherwise.
To extend the "most ships don't sink, most mail doesn't get lost" metaphor; most people want to drive their cars forever without hitting anyone or being hit by anyone. People who drink too much, smoke, don't exercise, and eat pseudo-food might not desire to see the doctor in a philosophical sense, but they're loudly ignoring the reality that they will need to in short order. It's the equivalent of driving blindfolded with your feet and, after hitting a lightpost, proclaiming, "_of course I didn't want to do that!"
In the west, we're actually pretty good at solving the big problems of actual healthcare (not health insurance) through good old fashioned innovation and market incentives. Diabetes used to mean losing a foot, and insulin changed that. Antibiotics going back to penicillin mean that you can literally get your can now body cavity opened up in ways that, in yesteryear, would've been a slow and agonizing death by infection. I contend that the greatest medicinal invention ever was functional public sewage and waste disposal paired with ubiquitous flush toilets and showers.
We're very bad at dealing with repeated objectively horrible decision making at the individual level. This is the thread that ties together not only healthcare but also welfare, criminal punishment, and abortion (to name the a few off the top of my head). If a given person wants to keep making awful decision, a free society has to tolerate that to some extent. The alternative is tyranny. What a free society should not do, in my opinion, and cannot do perpetually, is actively subsidize these bad decisions and/or the consequences arising from them.
There's a mechanism that's good at that; call it the "invisible iron fist". But we do our best to prevent it from operating.
Exactly. But the cost of that prevention is passed on to people who make good decisions. That's the whole perversion of it. "Suicidal empathy" is one of the great bon mots of culture war discourse. It is possible to love-your-neighbor-to-(mutual)-death
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Yeah but the issue with the current healthcare meta is that a huge amount of spending is then absorbed fighting over the last hitpoints of people with cancer that can be delayed but not really cured along with other chronic old age issues. Sudden deaths from Strokes/Heart Attacks are down due to improved diets and better practice, meaning more and more people are dying in the midst of prolonged arm wrestles with chronic conditions at great expense.
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One option could be to have a ‘premium’ package on a critical care / serious illness model for working age people where they get access to priority care, better hospitals and treatment if, say, aged 18 to 65 and seriously ill, and then a standard package for people above and below that age paid for by the state.
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It's already cheaper to fly out to other countries for specific procedures in a lot of cases - I'm expecting this trend to continue. Cheap barebones plan at home for bad edge cases and trips over the border for anything else. But 'cheap' plans are also getting expensive. I'm on a $12k deductible plan that runs me $320/m. I'll probably go uninsured once it starts costing $400/m+ in 1-2 years. I can afford it, but it just seems ridiculous to pay this much for something that does nothing for me. I had to see a specialized professional recently - $300/visit, $50/m medication with goodrx coupon, $220 bloodwork (not covered by insurance because not generalized bloodwork). Had to see them for 9 months - almost $4k total. Not a single thing was covered by the insurance I'm paying $320/m for.
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Assuming that this person is correct and that ACA enrollment is increasingly becoming dominated by early retirees I would expect the enhanced subsidies to be reinstated fairly quickly A. because Bill and Shelly vote in midterm elections and B. because doing so is easier (and maybe cheaper) than expanding Medicare eligibility to 55+ or whatever.
I've already said that Mike Johnson's crusade against gamer NEETs on Medicaid is a smoke and mirrors show to distract from the fact that unless we undo the ACA's Medicaid expansion (which mostly covers the working poor), there isn't much we can tweak in terms of eligibility that will actually cut costs.
An unfortunate occurrence in the last few years is that the Great Recession through Covid era of stagnation in healthcare spending has ended and healthcare spending is again growing faster than the economy, such that we're rapidly heading for healthcare spending making up 20% of US GDP.
The above is why I assume that we're nowhere near a universal system. No country with such a system spends as much of their economy on healthcare as the US does. Germany is the closest and the US spends about 50% more of its GDP on healthcare than Germany. For reference, if we moved to a German level of healthcare spending we could nearly triple the defense budget (which is currently about 3.5% of GDP). For another fun comparison, what we spend on healthcare now is pretty similar to the entire revenue of the federal government. Put simply, I don’t think that the US has either the capacity to bring healthcare spending in line with other OECD countries (which would require mass firings and/or salary cuts that would hit a well-educated and engaged chunk of the electorate) or the ability to raise taxes enough to cover said spending, so I assume that the system will remain largely as-is.
Even if you’re cynical enough to regard health insurance companies as make-work programs for bureaucrats, they’re a necessary evil because they’re also the paypigs that keep the whole thing afloat. Privately insured patients are the only ones that medical providers actually make money treating (Off the top of my head, Medicare patients are close to break-even, Medicaid patients are a net-loss, and of course the uninsured are near-total write-offs.) and unlike House representatives are able to impose payroll taxes on corporations and the upper-middle class without getting kicked out of office in the next midterm.
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In my imo there's no way out unless more typical medical costs are shifted towards self pay (such as with HDHP/HSA and similar). Otherwise your "insurance" for a huge percentage of times is just paying out thousands of dollars for mundane everyday costs. It's effectively a horribly inefficient way to passthrough those costs, plus actual insurance.
The most important uses that medical insurance is actually needed for people who actually work is for accidents and heart attacks, as well as catastrophic chronic conditions as well. We should be able to buy this. And for the poors who can't afford everyday care, they can get some kind of subsidies or whatever.
The Obamacare plans in New Jersey are so bad that there's a lot of self-pay involved. The problem is you can't just self-pay it all (or self-pay and buy catastrophic coverage). You still have to pay the sky-high premiums for basically nothing.
But Democrats are dead-set against any rollback of universal, comprehensive, coverage with no real underwriting, and the Republicans don't care enough. And no one but evil libertarians wants to let anyone die because they can't afford treatment, even if that treatment is hundreds of thousands or millions of dollars. So the only solution available is the only solution that was ever available, which is more socialism. With the usual failing result, but that doesn't make it go away, it's a positive feedback loop.
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