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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.
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 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.
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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.
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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.
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.
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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