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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 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.
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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