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Notes -
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.
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.
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As I understand it, this is part of the problem: since you're 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.
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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.
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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…
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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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