I guess I could agree with that
Why was there NO QUESTION about universal health care such as Medicare for all with private insurers picking up co-pays, as Medicare has now. The Brits and Canucks and Europeans have similar systems, yet pay FAR LESS per capita and ENJOY better care, more years of useful abilities, and longer life-span expectancy. Those economists know all this and yet were not asked about these specifics???
2
Was single-payer health care even listed as an option for the economists to discuss?
2
Why not combine all of the Federal health programs, Medicare, Medicaid, V.A health, Indian health service, FEHBP, Public Health Service, Black Lung , and any other federal health program into one program and save on the administration costs that each one incurs by itself, this would save money and the people would not possibly have any tax increase to pay for the health program
2
I wonder why we never hear anyone mention the possibility of taxing revenues above $138,000 for FICA.
Our representatives in Congress established a program to offer workers a modest retirement and people in certain protected classes health insurance?
Why should people with higher incomes be less liable than people with lower incomes for funding these public services?
3
I would bet the annual health care costs of an 83-year-old man that something over 80 percent of those economists favor some form of single-payer financing of health care.
In September Margot Katz Sanger asked whether healthcare is a fixer upper or a rebuild. Economists default to rebuild which is simply the wrong choice. Better analogy is Tower of Babel. Just because the medical industrial complex is the largest component of our economy, the tapeworm will soon overwhelm and kill its host. Adding stories to the Tower of Babel claim to fix it will only delay the inevitable collapse and the longer we delay the more difficult and painful it will be. Time to get real and do what is necessary. Call it what you will Medicare for all, government run health care, socialized medicine it is the only way to fix our mess.
4
Interesting data, but this would be more interesting if we understood why they thought this way.
4
I see comments that the underlying problem is greed, or that universal health care is a panacea. That is a simplification of a very complex issue. The vast American health care system has evolved to where it is over the last 50-100 years. Changing on aspect of the system is going to effect the entire system, and my provide many negative incentives. In the early 90s, I worked in a medical system controlled by HMOs. Costs were lower, but there was a strong incentive for providers to provide less care. We all try to do the right thing, but cognitive biases seem to affect even the most well intentioned providers when their salary is at stake.
Any change in the system is going to cause changes throughout the system, some of which will undoubtedly be negative. If change is implemented, it needs to be monitored carefully, and there will likely need to be constant reassessment and recalibration. In this partisan political environment, is that really possible? The ACA was really minimal change from the basic US healthcare system, but the attitude of some is, if it doesn’t work perfectly initially, get rid of it. At a fundamental level, I think universal healthcare is a good idea, but I suspect the only way to get there from here is incrementally, and carefully.
1
@Richard And start with the children!!! Free health care for ALL children. It should be a no-brainer, and the lack of it makes us a third-world country. Shame on us!
7
I am surprised that pricing was not part of the article. The fee for service model where providers can charge pretty much whatever they want and with little price transparency makes for expensive health care in this country.
3
Again, why is it that just about every "developed" country (i.e. OECD) in the world has universal health coverage, but the USA "can't afford it". Bottom line: our health care system has an infection- it's called greed.
9
@MTDougC
You can’t afford it because it is less expensive and produces better outcomes.
Errrr...ummmmm, Ok I haven’t a clue why you don’t have universal healthcare except for “American exceptionalism”.
1
It is a basic human right to be able to have access to health care. Sometimes it isn't all about the money but the quality of life we are able to live. Obama Care gave so many people the opportunity to health care that have never had the chance before. Also the taxing on unhealthy habits is a great idea because the hope is to possibly deter people from making those unhealthy habits such as smoking. But, the soft drink tax seems to be taking it a bit too far. Yes, soft drink are not healthy but at that point you might as well tax every item of junk food. If other countries can have free/ affordable heath care so should the U.S.
2
I don’t really care what health economists think, although I’m glad they don't support taking away health care from those who have it.
The most important question we can ask, as a society, is whether or not health care is a right. Should everyone be entitled to decent health care from cradle (or womb) to grave?
The obvious answer is Yes. Every other advanced country has answered this question in the affirmative. And they’ve enacted policies, not all the same, to make sure all of their citizens (and visitors) receive it.
As long as the United States remains an outlier, we will keep asking health economists, and others, who deserves health care - and who doesn’t.
3
The most pertinent policy question was notably excluded, namely: whether economist agree/disagree that a single-payer system would be preferable.
Also, having the extended survey results would have been helpful.
2
I agree with a among tax and an obesity tax
These are choices
2
@Mary M Obesity is multifactorial and cannot be attributed merely to "choice," as you so blithely do. Moreover, such a tax would disproportionately harm the poor. (I have no idea what "a among" tax is.)
3
One aspect of Obamacare is great - that more people than before are able to access medicaid. 2 aspects of Obamacare ar negative. First, that out taxes are being paid, not so support people's health care, but to subsidize health INSURERS, to support an industry which increases it's profits through denying health care. Second, The people who earn a bit too much for the subsidies are no longer able to access the insurance policies they had prior to Obamacare, & are now paying more for health insurance, if they can afford it at all, & frequently find accessing actual health care much more of a challenge than previously. These problems would be resolved with a single payer system, which dispensed with the need for individual health insurance. It would also be cheaper.
6
I'm not an economist, but I prepare taxes (as a volunteer) for low income and middle class people and I'm doing an impromptu study here "on the ground."
Last year:
Working-poor people almost all had insurance except the completely ignorant, absolutely destitute, and those who were unable to navigate the process (which was WAY more than a few). We did a LOT of exemptions, gave out a TON of brochures for Virginia's newly expanded Medicaid.
This year:
I am seeing a gargantuan rise in the number of people who are getting their care from the "free clinic." They don't have insurance. They didn't bother to buy it. MANY of those people had it last year. They simply CHOSE not to buy it this year. No penalty.
Last year, they would have.
---
Raising Medicare eligibility takes Medicare away from EXACTLY the people who need it most.
The working poor.
People who work with their hands and their bodies wear those bodies out faster. The NEED Medicare at a YOUNGER age: 56 (or 45) not 65. This is why Medicare for All is so DESPERATELY needed. They have bad backs and trick knees.
Economist is a glowing-white collar job. Their bodies are NOT worn out and their middle class privilege shows.
Don't raise the age. Instead, LOWER the age, raise the Medicare taxes for the top 30% of incomes--or all incomes, for crissakes.
The nonsense about "Medicare for All will cost $35 Trillion" elides that fact what we have NOW costs $10T MORE!
We will SAVE TEN TRILLION DOLLARS.
3
The best way an economist can help US healthcare is by showing how they manage an economy. US Healthcare is probably as large as the 4th or 5th largest economy of the world and good economists can point out some basic deficiencies in healthcare. Imagine an economist working without access to data such as employment figures or census information. Yet that's true of healthcare. Most of healthcare data is considered "secret" - such as pricing of hospital services or drug costs. While we hear of the famous saying "If you can't measure it, you can't manage it," quantitative measures in healthcare - metrics for "health of a population" or for "changes in health of a population" - are missing. You don't have to be in charge of healthcare to make these contributions. You can be on the sidelines - even writing opinion columns for the Times - and contribute. Get to work - if you are serious!
2
My grandmother has dialysis twice a week now and is blind due to kidney failure. Her husband my grandfather has been hiding his newly diagnosed Crones disease. My father wants me to go Michigan for a couple weeks with him to help get them sorted with nurses food etc and just to be around while they run errands since grandpa can't drive right now while my dad and his sister who is a ER nurse get organized. My family is all GOP but they know they need Medicare. These are successful people with insurance, some savings but it won't last with what is coming. I'm self employed but there is no real health leave for kids or parents in this country. It is a joke and our elders DON'T want to ask for help because they are terrified of all the unforeseen bills and anguish that getting severe medical help requires. My other grandfather died in a nursing home he built and was paid rent by as a investor and contractor on the project to the tune of 89k a year. Which he paid for 5 years before dying.
Now ask me how on earth can I even prepare for that? It is really horrible. It really is. To think that we have no respect for ourselves to allow this disaster and diseased healthcare system to abuse us because we fear the price of help. Perhaps it's good if die young it's a insult to grow old here you can afford it and all your kids want is to file piles of forms and beg for help with care so they can keep working till it's their time to hide their health conditions from their kids
4
This is all fine and dandy, but as an aging bread winner I understand that if I become seriously ill, I will need to choose to die as quickly as possible to cut costs and possibly save my family from homelessness. The extraordinary costs associated with senior care is another prong to this.
I do live in a 'right to die' state, but I understand perfectly well that doesn't cover illnesses that are costly to treat but not imminently fatal.
I'll just have to die illegally, but die I will. I love my family, and I refuse to let health care for me eat up what little I can help contribute to the whole. I will literally die first.
That's where we are folks. Some people wouldn't choose my path, thinking that life at all costs is sacred. They'll bleed their families dry and die anyway, usually after years of living a very tortured and limited existence.
I can't help but wonder what it would be like to live in a country where I wouldn't need to chose suicide over ruining my family. I wish I lived in one of those countries.
9
@JW
Really sorry to hear that.
The only thing aI can you help with is what it feels like to have universal healthcare.
It’s the feeling of true freedom.
Freedom to change jobs or be self employed with never thinking about healthcare issues.
Freedom to go to the doctor, the ER or call an ambulance based upon need rather than financial considerations.
This is one of the many times that Socialism provides true freedom, as opposed to dog eat dog policies.
2
I can't believe that in 2020 an article that doesn't even ask about National Health Insurance could present itself as "asking economists what they think about the health system."
16
Raising the eligibility age for Medicare is a path favored by comfortable keyboard warriors that don't sweat for their bread. According to the CDC, the average life expectancy for African-americans born in 1970 is 64.1 years.
https://www.cdc.gov/nchs/data/hus/2017/015.pdf
In other words, more african americans die before becoming eligible for Medicare than live to collect it. This is also a problem for people that work low-wage jobs or even physically demanding skilled trades. It is not easy installing HVAC sheet-metal when you are 60 years old. Lower the medicare age and pay for it by taxing all wages and passive income.
17
Doctors make twice what they do in all other countries, urban hospitals which are crystal cathedrals of technology, while rural hospitals close. Healthcare gobbling up 17% GDP, also twice that of other developed countries, all with better health outcomes. Big Pharma rent taking. Medical debt as the leading cause of bankruptcy. None of this is by accident.
Just like guns (the US is the only developed country with nearly-unlimited access), the US is the only developed country without universal healthcare, so the well off and the uninsured live in separate worlds, and the uninsured get sicker, and die earlier.
Though I have am MBA in healthcare policy, this isn't necessary to understand the problem: greed and corruption, enabled by a decades-long fight against public healthcare that is a right in all other developed countries (using "socialism" as a bogeyman).
https://pnhp.org/a-brief-history-universal-health-care-efforts-in-the-us/
13
@Fran Cisco as a physician I agree that physicians in america on the whole are overpaid, but even if you paid american physicians the same rates as foreign physicians, you would barely move the needle on savings to our health system. i believe there are 2 main and obvious causes of our inflated medical care. first and foremost, having multiple private insures has created MILLION of workers both for the insurers and for the providers that produce no societal healthcare benefit. Now, imagine 50% of those employees providing healthcare, providing services to people at no appreciable cost to the system. Secondly, we have created a culture over the past century that equates more care with better care, not surprising, when everyone in the system makes money on more care. Get a hold of these 2 issues, and you would see large reductions in healthcare costs. it would be nice to blame things on evil greed, but it would be better to actually improve the system
18
Those claims that smoking is an economic burden to society are based on fraud. They pretend that others paid costs paid by smokers, and that non-smokers' costs don't exist at all (e.g. SAMMEC). The bottom line: Smokers' lifetime health costs are lower than non-smokers'.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2225430/
Those supposed PhD economists who uncritically regurgitate the government hate propaganda against smoking must be completely lacking in competence and integrity.
3
@CarolT You are misrepresenting the findings of that article by claiming to cite a "bottom line." The only reason total lifetime medical costs for smokers are lower is because their lifetimes are shorter - that article puts it at 8 years shorter. Until age 56, again, according to the article you cite, annual medical costs for smokers are higher than for the non-smoking healthy group.
PhD economists, government officials, and others who advocate against smoking are not pushing propaganda. We are making a simple point - we would all be better off when smokers stop and add eight years to their lives.
Anyone who would claim an efficiency because one group dies 8 years younger than they would otherwise seems to be lacking in compassion.
8
I'm extremely wary of any American "Health Economist".
They are infected by the bias of working in a system mostly based on private insurance. The idea that we even need 200 experts on health economics shows just how overly complex our system is. And these economists have a vested interest in continuing this complexity and keeping their jobs.
If we had a single payer system, how many health economists would we need? 10? 20? I doubt the NHS, or Canadian Medicare, need such complex calculations to figure out how it's system works.
The only change worth making is to a single payer system.
11
I agree that the US needs universal coverage. For those screaming about waits for service, unless you go into an ER in the US, you won't treatment without a wait. Even then, unless you are bleeding, having a heart attack or something that must be handled immediately, there is still a wait. Anyone in the US that needs to see some type of specialist (oncologist, cardiologist, etc.) can't get an immediate appointment. So, US residents do wait for care, just as in other countries that have some type of national health coverage.
What I haven't heard anyone talk about in the healthcare debate, what happens to all those people working in the health insurance industry and the organizations that do business with them if we get some type of universal coverage? What is the impact on our economy if a few million people are out of work?
4
@Kay Just be sure to provide universal food, universal water, universal garbage, universal sewage, universal housing and universal clothing, as these are all more important to people's lives than healthcare. Socialism rejects that people are different and are best cared for by allowing them to keep their money for their own needs.
2
@Kay
That is a fair question, and there is no easy answer. Support while retraining would be a place to start.
1
@David So what you are saying is that if a middle income family of 4 suddenly had it's breadwinner(s) crippled by accident or catastrophic illness should have the bread winners die as quickly as possible, so that any life insurance could be used to feed and house the children and/or remaining spouse?
That seems to be what you are saying, because the number of medical bankruptcies in this country, even for people with 'insurance' indicates that when you look at a homeless person, you are only one chronic, hard to treat illness or serious accident away from being just that person. Could you be any more insulated from reality? I doubt it.
3
Why was this survey limited to American economists, who likely have limited real-world experience with other health systems? If we must hear from economists -- itself a dubious notion -- I would prefer to hear the views of Canadian economists, German, Japanese, etc.
12
I think it's odd that dental costs are so seldom discussed. At a recent visit my dentist strongly recommended "deep cleaning" which would take 3+ hours at $500 per hour. The dental insurance I've seen is so expensive and has such poor coverage it isn't worth buying. I could go on about my costs and friends costs and yet the astronomical costs regarding teeth never get written about
9
@DJAlexander We could try free markets and allow wider competition for services with published prices. All of America's greatness comes from its liberty and ability to trade freely for the things people want.
1
Healthcare is not a free market. After all. it's your money or your life. That should be clear to everyone.
Until the government has real control over pricing, Americans will continue to pay more than other OECD countries. Our pretend capitalist market produces extreme inequalities, which account for the poor outcome statistics. Wealthy Americans have the world's best care, hands down. Those lower on the economic rung get care that is more typical of a third-world country.
There are many mechanism for the government to exercise control over prices. Medicare for All is one mechanism, but so is a German style system which includes insurance companies.
13
@Boston Barry It's called rent taking; it is a form of corruption.
https://www.investopedia.com/terms/r/rentseeking.asp
1
Well, economists don’t run health policy. Politicians do, so tax breaks are doled out to favored industries and constituent groups regardless of how good the idea is.
People who have no cushy corporate plan are taxed to subsidize those who are lucky enough to have one. The elderly have Medicare, paid for by workers who we are told should not be permitted socialized medicine.
Feel The Bern!
7
Economists limit their answers to important policy matters by tailoring the questions they seek to answer. Austin Frakt does just that by reference to a survey of 200 economists which omits costs from the conversation. There is so much to consider here that I will limit myself to two basic questions: How can we curtail non-beneficial and actually harmful care (which may amount to something on the order of 25% of health spending), and which plans would reduce the overall growth in health care spending. One might note that health care economists remain pre-occupied with the Rand experiment, conducted over 40 years ago in a very different world, as the base from which they build their policy prescriptions.
2
However we do it America, we always make the people responsible for themselves and the corporations. The corporations must not be at risk. We must protect the corporations from any reality. Jobs as paper fillers and movers must be maintained. There needs to be millions employed in moving this paper about. And probably most important of all, the profits of the pharmaceutical companies must not be hindered by anyone. We can do this. Shareholders are depending on you. Punch down America, it's what your good at.
5
Not much said on cost controls which Medicare is much better than private insurance companies. Or the better health outcomes from Medicare. The battles between hospitals, physicians and health insurance companies about reimbursement that costs patients lots of money are not mentioned.
8
Given the major difficulties economists have had over the decades in forecasting economic activity just a few months away let alone years in the future its challenging to expect health economists ought play an expert role in designing the nation’s health systems. Lets remember that relatively few economists, experts on the economy, are ever hired by major money management or investing firms. Why should we expect better results with academic health economists designing the nation’s huge health system serving hundreds of millions of Americans. We’d likely have more success accessing those actually involved in our huge health system - hospitals, providers, physicians, drug firms, nursing facilities, etc. As well as evaluating what works or doesn’t work overseas. And if we’re really serious we’ll modify our health system over time taking advantage of what we learn.
3
@Peter I Berman The economists forecasting economic activity and the economists who study health care choices and funding methods are two entirely different groups of people, studying two entirely different subjects. Health economists probably haven't thought about macroeconomics since the one class they were forced to take in grad school.
The massive increase in insured people that accompanied the introduction of the ACA is due to mechanisms studied and introduced by health economists.
1
I am impressed (read: sorely disappointed, in case you fall into the sarchasm) by how you have completely sidestepped the question of whether insurance companies are necessary at all?! Or whether their shenanigans and high salaried CEOs are actually providing an economic good at all? The question of high cost of healthcare is three pronged - costs to providers (hospitals, doctors etc. are this prong) costs to pharma and device providers are the second prong; and finally the money paid to insurance companies, the third prong, who are *supposed* to be reducing the price paid by companies to the other two prongs. I have yet to meet someone who says they LOVE their insurance company or the money that is paid to the third prong by their employer and themselves - 99% of people only love their healthcare provider.
When you really conduct a proper study including the useleseness of insurance companies, remind me - until then, I take it you are in the pocket of the insurance companies?
15
@Indian Rediff Well, that's because insurance was designed to pay for unexpected problems. Now it's just pre-paid medical services, in which others are required to fund your services.
1
@David
Insurance works by having everyone pay into a pot, from which medical care is funded.
Pre-paid medical services works on exactly the same principle.
Only the very wealthy can pay out of pocket for their own medical care. In all other instances you have some form of people funding other people's care. The issue for the economists is what is the most efficient way to gather the money and then provide the health care.
The free market is a failure at this.
3
Many comments are about the expense of healthcare, especially Medicare. I would like to see an article about what happens to the money spent through Medicare. This pays for healthcare salaries, construction and remodeling of health facilities, and supports a huge supply chain. This is money turned over in the economy every day. If we spend less, how are these economic issues affected?
@Amy H Nobody knows how it will turn out because you cannot predict the future or how hundreds of millions of people will adapt. Central planning has always had worse results over time because individuals are not a common cog in a government monopoly's machine, hence the ideas of liberty and equal protection via limited government that is the American ideal until socialist/corporatist imperialism became the norm.
1
@David
All western countries have lower costs and better health outcomes than America.
It truly is a case of ‘American Exceptionalism”
There are two broad questions to be addressed when we debate providing affordable healthcare to all Americans: 1) how should healthcare broadly be organized to deliver efficient and effective care? And 2) how should delivery of healthcare be financed.
Regarding the first question, our current system of healthcare, being based on delivering maximum income to providers as opposed to maximum beneficial outcomes to patients, results in wasteful over-diagnosis and over-treatment. We need a healthcare system that focuses on health outcomes, which it clearly does not currently do - one need only look at how low the US ranks among developed countries on such key health measures as life expectancy and infant mortality.
Regarding the second question, optimal healthcare financing rests on a three legged stool: everybody is covered; pre-existing conditions do no affect coverage; those who can’t afford premiums receive financial assistance. The Affordable Care Act provided that. Medicare for All would provide that too. If one started from scratch to build a system, the latter would probably be best. But we are not starting from scratch.
The politically realistic approach today is ACA plus a public option (along with several other adjustments). To those who shame such an approach as being not bold enough: don’t sacrifice the good for the perfect. If a publicly run option outcompetes the private options, market forces will eventually drive us toward Medicare for All.
4
Shouldn't the first point of discussion be the purposes and principles the economists are aiming to achieve with their recommendations for health care economics? Otherwise you have a hodge-podge of recommendations aimed at this or that specific problem, often resulting in unintended results.
The principles underlying the economics in my opinion should be:
1. universal eligibility for all properly resident
2. evidence-based coverage for all medically necessary treatment
3. contribution to the system from all who are eligible
OK economists. NOW figure out how to do this.
3
I wish I could say I learned something or gained new insight from this article. Our health insurance system is massively dysfunctional. It is not sustainable. The ACA is a broken system in that it requires people verging on poverty to deal with massive deductibles. It may be able to be improved, but leaving drug companies and insurance companies free to make massive profits is unworkable. Healthcare is not cheap and rarely efficient. The US needs to switch to a universal health insurance system.
8
Clearly these economists have day jobs with employer-sponsored healthcare. Either that, or have incomes so lavish from consulting work that the actual cost of health care doesn't matter to them.
We're a family of 3, and we pay $24K per year in premiums for a plan on the exchange. We have a $6500 deductible, which we meet every year (it's the lowest deductible available for a family). We pay another $1200 for dental insurance, which doesn't cover much, so we pay often pay another $1K to $2K year in "co-insurance". We can't get vision care, and with a family of eyeglass and contact wearers, we spend maybe another $500 to $1000 (complicated enough issues that we can't just order glasses online). And apparently, no one covers root canals -- not our healthcare, not our dental insurance -- so there's another $1500 this month.
In other words, we spend about $35,000 per year on healthcare expenses. We earn just a little above the cutoff for subsidies, so we don't qualify for any assistance. The result: We pay about 35% of pre-tax income in healthcare costs.
The candidates like Bloomberg and Buttigieg who talk about expanding subsidies so no one pays more than 8.5% of their income on healthcare premiums -- they are on to something! Ditto those who are talking about lowering "out of pocket expenses" and expanding plans to include vision and better dental.
The economic perk: Money for vacation, entertainment, eating out. We could keep the economy humming again.
8
@Rose I hear you. Our situation is about the same, with the major exception being that the university where one of us is employed covers about 75 percent of the premium. So with such a great "perk," why would we complain? Well, our deductible is $7500 and we meet it each year, plus co-pays. One test that Healthcare BlueBook says should be between $400-800 came out as $5000, and the insurance company graciously agreed to pay $3500 of it! So with "good" insurance I'm still paying 2 to 3 times MORE than out-of-pociet? Plus, our dental and vision situation is similar to yours.
It isn't "freedom" if you have to stay in a bad job to have fiscal access to healthcare, or you're a freelancer in the gig economy and basically have only catastrophic coverage. These are middle and even upper-middle-income scenarios, it must be incredibly difficult on people who are poor or on that "cusp" between subsidies.
The whole system is organized about profit, not people. This was illegal until Nixon. I'm tired of the oppression of big corporations dictating prices and paying lobbyists and politicians to do their bidding. I'm also tired of non-rich people supporting the "free market." Healthcare is not a free market situation, it's rigged against you and we can't fix it with your obtuse obstruction.
2
Great idea to ask economists what they think! Let's ask chimpanzees next!
Or maybe we could ask nurses. You know, the ones who are in the trenches of healthcare every day. Oh, wait. We already know what nurses think.
Single payer. Yeah, let's go with what the actual experts think.
28
Wonder where all those health economists work? Surely, not in our crappy health care system.
10
This analysis feels like asking a hundred accountants about cleaning up the tax code. Certainly, they may have some industry insight and ideas about how to patch things. It seems unlikely, however, that any of them would go so far as to recommend something like a flat income tax or standard consumption tax, because it would put a significant chunk of those hundred accountants out of business.
In other words, it seems Medicare for All would significantly reduce the need for health economists, and likely wouldn't be popular.
12
@Anthony You'll have to contact the UK's Health Economists' Study Group and the Canadian Health Economics Association and let them know their services haven't been required in those countries for decades.
2
Nothing on single-payer v. multiple-payers to get at universal care?
15
@NH That's almost a moot point, most developed countries have multiple levels of healthcare access from government providers to private practices. The US under Medicare-4-All would be no different, despite what some Democratic candidates might say.
1
@Jonathan
Not if you use the Canadian model, better outcomes, lower costs.
This is what happens when people are stuck in their boxes: they find a rationale for what is seen as the way to do things. Thomas Kuhn saw this and explained how insights had to battle until the opposition died off.
The insights here comes from Linda Gorman, Singapore, and Elinor Ostrom. Gorman is at the Wisconsin. Policy Research Center, and showed how escalating costs resulted from third party payers; continuing that system won't work to contain costs since the brake in cost in any market system is the customer. But her Center is funded by the Kochs and their libertarian agenda is not kind to those customers. Ostrom won the Nobel Prize for showing how empowering those with the understanding and the meaning that comes with community action resolves the tragedy of the commons that results form the abuses of the wealthy. In terms of health policy that means putting the patient back into control and what they need to exert that control is a well funded Health Savings Account. Based on Singapore's model, described by William Haseltine in "Affordable Excellence", these are funded by employer and employee, shared within a family, and we would add a community (church, workplace, etc.) and the government if needed. Singapore has, according to Bloomberg, the best system in the world, and it works because their life expectancy is fifth highest in the world, and implementing it here could save us about 2 TRILLION annually.
6
@America's Favorite Country Doctor except all research extant shows that HSAs and high-deductible plans lead to self-rationing. To get around that, you need the HSAs to be SO well-funded that consumers/ patients aren't afraid to spend it in fear of the next big hit.
2
We already have a healthcare system run by economists and that's the problem.
18
Let your 200 economists argue these 5 facts: Why is Single Payer the most cost efficient way to pay for healthcare?
1. Using Maximum Negotiating Power to negotiate Lower Prices from ALL the de-facto monopolies on the supply side of healthcare! Prices that are on par or at least in the same ballpark as in other developed countries.
2. Cutting out all the unnecessary middlemen and their expenses.
3. Minimum Administrative Overhead! One health insurance instead of myriads of “health plans” to deal with.
4. Maximum Efficiency of Large Numbers: Spreading the risks/costs over the Maximum amount of people = Everyone, over the Maximum amount of time = Lifetime! (this is basic insurance math!)
5. Preventive care for Everyone! Earlier treatment = Less expensive!
19
This clearly preserves the income of the "health professionals" which dooms it to total failure.
Wake up.
13
@William You need to incentivize the providers also or you will not have high quality treatment. It's that simple--like the drug companies, who need to be encouraged to innovate. No health professional will spend 12-15 years at study and another 10-15 eliminating that debt to work for average wages. As a dentist, I didn't make a nickel until I was 35 and I didn't pay off my debts until I was 42. I worked for 20 years in private practice and another 15 in public health. If you really want to see health care costs decrease, eliminate all insurance. Fees will plummet and patients will start taking care of their own health. We've built a house of cards with the current system.
3
@Doug Leen
If there is indeed a "house of cards" waiting to collapse, extravagantly compensated health professionals are one of the main causes. Doctors and dentists are protected by a guild system that requires far more education than is actually needed to do the work they do—once you know how to identify a cavity and drill a filling, all the biochemistry you learned flies out the window, never to be used or thought about again. The continuing education you get focuses on how to use imaging technology to manufacture problems that aren't there, magnifying naturally occurring and harmless imperfections to scare patients into agreeing to unnecessary procedures. We are sick to death of hearing from doctors and dentists who complain about long hours and inadequate pay—no one I know can afford to live in your neighborhood or send their kids to the schools you do. It's maddening to listen to this tired drum beat pleading for the need to 'incentivize' the system—the system is plenty incentivized, and excessively so judging from our health outcome rankings among developed countries.
5
Economists are always behind the times. Medicare went to an optional (what the economists now call) "voucher"-* program about 25 years ago (based on a plan by two far leftTeddy Kennedy staffers that used the correct terminology in their plan's second sentence: "We propose converting Medicare from a “service reimbursement” system to a “premium support” system.').
The leftists' idea manifested itself as Part C of Medicare two years later and is now by far the most popular choice of people fully signing up for Medicare for the first time, having grown from no beneficiaries (0% of total for all) to almost 25,000,000 beneficiaries (37% of total of all). Well over half of people fully signing up for Medicare for the first time today are choosing "vouchers." They get better health care, better financial protection and save on average about $25,000 over their first 10 years on Medicare vs what the two authors called in 1995 "real Medicare" (having to also buy expensive private supplements because 1965 LBJ Medicare is such bad.
And the Trust Funds on average have expended less per person over the 25 years than if the people on Part C had stayed with LBJ Medicare (although per year that difference has ranged from 9% negative to 6% positive to the Trust Funds; it has been all positive for the last 8-9 years as the number of people on Part C has doubled).
*-The only people that ever proposed an actual voucher system for Medicare were the Democrats led by Richard Gephardt in 1981
My guess is that all of these economists are tenured academics with good healthcare coverage provided by their colleges and universities. They also have decent and secure incomes sufficient to meet their needs and a retirement plan to help out in their old age. For those of us without tenured, well-paying jobs the picture is a bit different with regard to healthcare in the US. How rational is it that we spend more per capita than anyone else in the world and yet have such poor outcomes with respect to life expectancy and other measures of health? Tweaking Obamacare just isn't going to do it--we need to lose the insurance vultures and the pharmaceutical extortionists and prevent hospitals from dispensing the $100 aspirin. Single payer is the only way this is likely to happen.
16
I feel like a progressive tax on heavily processed foods in general and sugars in particular could probably cover a single payer system and then some.
9
@Alexander Total spending on food in the US in 2014 was $1.5 trillion (USDA-ERS, 2019). Healthcare expenditure in 2019 was projected to reach $3.9 trillion (CMS, 2017).
Even if you clear out the insurance companies profits ($23 billion in 2018; NAIC, 2018) in a single-payer system, we aren't going to be funding healthcare with a tax on food any time soon.
1
When I became disabled, I probably would have lost everything if I had not had health insurance and then, after two years, Medicare. Even with Medicare, there were years when about 40% of my Social Security disability income, my primary source of money, went to pay for medical care, prescriptions and supplemental insurance. Given this experience, I am not a fan of basing Medicare on income except for the wealthiest, though in fact, people with higher incomes but not high incomes already pay more for Part B than people with lower incomes.
However, pre-existing conditions should always be covered, "sin" or not. As noted here, most smokers start in their teens, when their brains and therefore their decision-making capacity are not fully developed. Medical for these conditions can well prevent worse health and more expensive treatment.
7
It is possible for most people to prevent the onset of most of societies chronic medical conditions such as diabetes, heart disease, cancer, obesity, sedentary lifestyles, etc but these “health economists” along with opinion makers don’t even consider the possibility of allocating any resources to the potential ly game-changing field of wellness and disease prevention.
5
We all carry genetic defects.
Unhealthy health habits should be paid for, in higher taxes, by the producers, transporters and consumers of the unhealthy product. Those taxes should cover the health, education and sanitation costs of the practice.
5
Like it or not, allocation of finite resources is necessary. There is not enough money to do everything. It is sad that this survey which extracts rational thought from experts will not have any impact on our increasingly irrational reality show Presidential administration. For example, there is already good data published in the New England Journal of Medicine showing that Medicaid work requirements don’t increase productivity but do decrease access to medical care for a large number of poor people.
1
Most of the proposed fixes to U.S. health are akin to rearranging deck chairs. And most of the proposed "fixes" are based on oversimplified economic assumptions. What I like about this article is that it rejects some popular libertarian fantasies (e.g. work requirements will fix Medicaid) and acknowledges that the broken market is the fundamental barrier to sustainable improvements.
1
I am an expat retired in my wife's country Germany here our healthcare provider is non profit our premiums are about the same as Medicare Advantage stateside, co-pays for meds are 5 Euros, office visits, specialist referrals, out patient treatments are nada zilch, last year I was hospitalized for two days, the cost for surgery, nursing care and my room however was 20 Euros. Workers pay a tax of 7.9% on earnings for coverage, there is no annual self payment, cap on treatment. Many will say what about the wait times? I did have to wait a week for my surgery, what about the wait time for the uninsured back home with a serious illness who get treated in the ER or a clinic?
Why are my fellow Americans not em masse on the streets with torches and pitchforks? None of my German neighbors would ever give up their system for ours!
27
@Robert Keller and if you want to reduce wait times or see the Herr Professor Doctor, you can opt for the private option. In either case, public or private, you will be covered if you lose or change your job.
Why don't Americans take to the streets? because they are ill informed and/or brainwashed to consider this to be socialism, the great evil.
11
@Robert Keller
The cardiologist who successfully treated my pulmonary hypertension, which was first diagnosed by my PCP, is a medical school professor doing research on the disease. I only had to wait 17 days for a referral appointment. All costs, including tests and medications, covered by Taiwan's National Health Insurance, with usual US$17 copay per visit. No way I could afford to see such a doctor in the US.
9
Europe has evolved to the hybrid systems that make the most sense:
1. A payments system with full tax support that gives beneficiaries limited choices about where and from whom to obtain services, and strong incentives to adopt healthy habits.
2. A medical system that provides health care providers with adequate incentives to invest in medical skills and facilities, based in part on their ability to decline to provide unwarranted care and still get paid, plus a small private system that provides care people want but don't need.
5
It would be interesting to see nurses' responses to the survey compared to economists'. Personally, I would give more weight to the nurses.
6
@WmC “Weight”? The nurse POV would be slightly different I think as this is about *economics*. But I’d love to know what they think of this.
1
It should be evident to even the most dense analyst that the current system cannot be sustained. I can accept the idea that the ACA is viable in theory. But the GOP has ensured that it cannot survive in practice. I think that the ACA was the last hope for a healthcare marketplace. But that dream is ended. The GOP will not abide by anything other than Milton Friedman/Ayn Rand policies and will suffer nothing else demonizing all other solutions as socialist.
In a perfect world, there would be a rational approach to reform. However, like guns, we refuse to do anything in the face of calamity. Therefore, there is only on possible outcome: total system failure. The system will collapse under its own rot. Then we will have to start over. I do not root nor do I advocate for that outcome. But, it is the one I expect.
For you tea-partiers out there, you all complained about too big to fail. Well, you are going to get your wish. The next one will be too big to save. Before that one is over with you will be longing for the days of Obama's slow growth economy.
6
Economists won't dump ever increasing amounts of money into a lost cause, they understand sunk costs. The won't even bother treating lots of folks especially for things like cancer which have very low survival rates. Need a hip replacement @90 not worth the cost. These are the last folks the left wants running healthcare.
The health care dollar is not limitless. You can do hip replacements on everyone over 90 who is healthy enough to withstand the procedure, but maybe then you won’t have enough money to update an ICU to give optimal care to heart attack victims in their 50s. Allocation of funds for best use is always necessary. In an ideal world, society will have enough money for both.
1
I think the NYTimes should ask the same question of doctors/ nurses/ hospital administrators. There is nothing worse than seeing people come in with advanced disease because they couldn't afford care.
3
Gee. Remember all the Economists warning us about the coming Global Financial Crisis in 2007-8? I don't. They completely missed it. Even the Queen of England wondered how they could have been so clueless. Nonetheless we keep asking them for more advice on matters for which they have a terrible track record. Climatologists get ridiculed for being mostly right and economists get adored for being mostly wrong. This has got to change.
6
The problem with economists is they live in a glass bubble of 'the possible', and they don't really look at the human consequences. They treat it like a consumer product and push the notion the best thing is 'individual choice' a la Friedman (Milton), and it fundamentally blames the cost of medical care on people 'abusing it' because it is 'too cheap' and they are 'too separated ' from the cost consequences and that is ludicrous. Talk to anyone about their health insurance, and you will hear them worried that getting treatment will bankrupt them, that they are scared of going bankrupt (The GOP still claims bankruptcy is mostly credit card debt, it isn't, largest group is health care bills). Medications are no longer cheap, and people routinely look for the cheaper cost to them, the problem is you don't have choice. You have your employer insurance or whatever plan you can afford, then sit and worry. Most people don't go to the doctor unless they have to, and most do so with trepidation. And this idea of 'shopping around' for medical treatment is a joke. Yes, in plastic surgery this is true, but that is not life threatening (unless the doctor is a quack). But how can you shop around for things like cancer? Or heart disease? Some things like this exist, the express med kind of offices save money over routine office visits and ER's, for example and work fine. But who is going to go to the Earl Scheib heart disease clinic, advertising "any bypass, $10,000?
4
I would like to see the ACA strengthened and the age for Medicare dropped to 55.
8
@Brendan Varley < Medicare A should be available to all ages, paid for via a national health tax.
7
"Economists" are not a monolithic block of experts in agreement about everything. Rather, economics is a highly contested science. It is very much infected with political ideology - especially neoliberalism, ever since the downfall of Keynesianism in the 70s. Your polling might give different results if you eliminated all the neoclassicists from your list of economists. Try polling the MMTers / post-Keynesians (or even Marxists) instead of the orthodox neoliberals.
2
I get the feeling that no one wants to say Healthcare is a human right which should be given to all without exception, fear or favor. The real costs are not what is being charged by a long shot. These companies admit publicly they make billions. I can only imagine how much they are hiding in shells they purposely run badly or shift debt to, or the amounts of income they are just not declaring. Doesn't matter. We already know medical care should be costing half or less than what it does right now.
Taxing health care benefits before clawing back all the wealthy tax giveaways for the last 40 years intended to defund the government to force a cuts in benefits from programs we have all paid for out of our checks is a sick and cruel idea to do harm to the few luck enough to have insurance!
Western capitalism is not destructive self negating pursuit of money above all else. It is well regulated to keep itself stable and going long term to lift as many people as possible by being prudent, careful and conservative in how it operates. The nation and responsible obligations to it and its people come before profit of which there is plenty as I have mentioned. Good honest management is absolutely critical. Not as we have had since 1980 reckless and uncaring often corrupt pursuit of money seeking only to grab as much money as can be got right now without regard for how this might affect the economy this afternoon, let alone tomorrow.
@magicisnotreal None of Americans rights grant access to the time and labor of another individual except legal counsel. which required a very specific amendment.
@Steven RIghts are not just those enumerated in our Constitution. Our founders recognized rights that we should consider fundamental. And if you don’t accept that, then consider that we the people can decide what rights we want for our citizens — in a country which claims to be of, by, and for the People.
2
It would be interesting to know the political inclinations of these 'nearly 200 Ph.D. health economists'. One's political persuasion will likely influence one's political positions on health care matters.
5
Part of this exploding healthcare costs is the idea that healthcare is for profit, and the extensive end of life care.
These are in place of any practical solutions to the healthcare dilemma. Also, extensive measures to extend the care beyond what can be expected by a government funded program.
I’m not trying to be heartless, but at some point it is beyond what should be taxpayer funded. And yes, taxes should be levied equally, the wealthy not exempted.
5
Here is how health care would be run if people with common sense designed and IMPLEMENTED it.
1. Model it on the national defense, police and fire dept services. Paid for via taxes, available to all citizens. No questions asked when the system responds to emergencies, life threatening events such as heart attacks, cancer etc.
2. Other services such as annual exams, doctors' visits etc to be paid for via insurance premiums, analogous to the fire department that puts the fire out but does not install fire sprinklers , fire extinguishers etc. Fire sprinklers result is lower insurance premiums. Regular exams, no smoking, proven visits to fitness centers will result in lower health insurance premiums.
The free market on a global scale should play a role. If a dental crown or a non-emergency heart procedure can be done in Mexico (or in Canada or in China, or in India, or in Europe) at 1/4th the cost in Mexico then that is where it could/should be done.
Unless the free market, which lowers prices/costs because of competition, is allowed to play a role the costs will not come down.
Insurance companies can also play a role but at the back end where the individual does not have to deal with them. The government will deal with them and use economies of scale to keep premiums at a low level.
Wealthy individuals hire private security guards for protection but they are not excused from paying taxes that pay for national defense or police protection. Same with health care.
1
@Indian Diner
I was with you for the most part until you sent me to Mexico for a "dental crown or a non-emergency heart procedure ."
It's hard enough to get 1/2 day off for a crown or a day or 2 off for non-emergency procedures and if someone has to accompany the patient, then you're asking someone else to take time off as well.
4
@Indian Diner National Defense is an enumerated power of the federal government, police fire and schools are state issues, and states have always had the power to implement a cradle to grave social safety net. What they cannot do is pull money out of thin air to pay for it. they actually have to raise taxes.
1
@Lynn , where feasible, not all the time. There must be ways to increase competition at home here. Bring mexican dentists into the country.
1
Just as climate deniers claim the climatologists are wrong and are socialists in disguise, many of those commenting on the article claim that academic economists are misguided and capitalist flunkies. Do you really think that the economists have not studied other systems and systematically looked at behavior rather than just considering anecdotes out of context? This does not imply that I am justifying (or criticizing) the survey questions or the representativeness of the sample.
4
I wish they would have asked about Medicare for All and Medicare Buy-In...
15
@Scott Behson Currently medicare covers about 60 million folks, the taxes we pay for those 60 million are not enough to cover the costs, Add another 270 million folks to that and well taxes will have to go up 4 to 5x, and you the customer would still have to pay the premiums for Part B and Part D.
2
@Steven
"taxes we pay for those 60 million "
Except for the disabled those 60 million pay, retired or not, pay taxes as well.
4
@Lynn The taxes paid for Medicare do not cover the cost of Medicare and havent for years, and medicare only covers 1/5th the country. hence why people will need to pay 4 or 5 times the taxes they pay to close the gap for the total population.
I'm sorry, people, but too much of economics is not science and too many economists are selective about their data to support their politics. There is enough economic data around to support almost any idea, even those that any rational person would reject. For example, see Prof. Krugman's column today about Bloomberg still believing that liberal banking policies caused the 2008 crash. I would be interested in the ideas of individual economists who do truly evidenced-based work. But IMHO the mass opinion of the profession is worthless.
5
@NeilG So true considering the variables of the economy are never the same. Sure you can pick and choose individual variables, but the economy isn't just the unemployment rate, or GDP, or Government regulation, or Public Sentiment.
4
@NeilG Please open your mind. YOU are the one selectively choosing only data which supports your OPINIONS!
1
I wonder if they read the recent Lancet article out of Yale Public Health showing that Medicare for All would save $450 billion annually... oh and 68,000 lives too.
28
Did they discuss this with Swedish economists?
Or with economists in any country which provides full, free health care including dental, because in the long run, it's cheaper?
This is a 'deckchairs on the Titanic' type article.
Australia's health insurance, now dominated by foreign owners, and DESPITE punishing people who aren't insured, is on the verge of collapse.
Forty years of neo-fascist - oops - sorry - neo-liberal - economics will do that to a country.
11
When are you going to publish "The Health System We'd Have if Doctors Ran Things"?
Because we don't run things.
4
Tax the rich until they share in our experience of life. If they don’t like it and refuse to play there will be plenty of smart people
to replace them. All of a sudden we will find that not only will there be more money for health care but prices will suddenly come down.
4
Great article. It shows that professional economists understand the nuances more than right wing ideologue politicians. Free markets work great most of the time, but there are exceptions. Market failures are particularly bad with healthcare.
11
An optimized capitalist system allows for some socialization of gains (taxes) and some socialization of risks (depository insurance, municipal utilities, education, etc).
If a person's health is considered to be an utility, meaning that it has similar value to society as water, electricity, and internet bandwidth, then it follows that this utility must be regulated by the government and socialized. By "value", I refer to the contribution to the overall capitalist framework. Without water, electricity, and internet, the society today cannot function properly and if the society cannot function, then the capitalist goals cannot be achieved and capitalism becomes highly inefficient and suboptimal (how does one create another Google if one cannot afford water or electricity?).
The same is true for health. If someone's health is suboptimal, then that person would be unable to contribute to a capitalist society to the maximum possible extent. If Steve Jobs had pancreatic cancer while starting up Apple in his garage without a job or health insurance, would Apple have been launched?
Therefore, from the capitalist's perspective, labor must work optimally and a well-run government-provided health insurance system (eg. Medicare) ensures that the laborer's health is optimal to the extent that she can contribute the full value and fruits of her labor to the capitalist system. Both the capitalist and the laborer benefit from this optimization of individual health.
4
@Richard I profoundly disagree with you: a person’health should not be considered an utility. Health, as education, must be kept out from the capitalist logic of profit and gains. It should be considered a universal right, no matter of your efficiency or integration in the labor system. If your view is coherently followed to the extreme consequences (which I’m sure you personally wouldn’t), then elderly people and mentally diseased people should be left to die unaided. I think that in contemporary society we need a little more altruism and a little more thinking beyond the logic of money and efficiency. And the first step for this is that everybody contributes to the well being of the others, which is, to the well being of society as a whole. Sorry for my English, probably I made some mistakes
17
@Emanuele you missed the key point of my thesis. The thesis is that a government-funded and government-regulated health care system is not only consistent with an efficient capitalist framework, it also promotes, enhances, and optimizes the capitalist system due to the population having the individual liberty to engage in the profit motive without having to worry about something as basic as their health (or water or electricity). The extreme consequences that you mentioned are prevented by the same societal laws and regulations that govern murder, assault, theft, and other moral and cultural artifacts outside of the purview of capitalism. The key point is that a capitalist should support universal government health care on basis of efficiency and returns alone.
7
@Richard I get your point, and we agree on the fact that any "healthy" society should fund and organize its health care system. Still, I disagree with you on the reasons why it should do so. It may seem of secondary importance, but in my view instead it's of utmost relevance: there should be no connection at all between the aid provided by the government to the citizens and the engagement of the latter in the "profit motive". Otherwise, the risk is caring for the people as long as they work for the system. The starting point of our beliefs is the same, and that's why I would totally support your view when it comes to immediate political actions; but the possible developments of the two societies we imagine can be very very different. Varro, a latin author who wrote about the best ways to administrate a farmhouse, used to say that slaves are very expensive because they must be kept healthy in order to maximize the product. Fortunately that's not the case in our society, but if people work for a system who wants them healthy so they can work well, then there's no big difference with slavery in ancient times (or not so ancient). The societal laws and regulations you talk about change in time, and if we keep considering profit and personal success the only values, who says they will stay in place for long? People who do not produce must be considered on the exact same level of "productive" people when it comes to health and other basic rights.
11
A certain political party tends to toss around the term "wasteful health spending" when people who need health care can actually get it.
That is more expensive than letting people ill people suffer unaided, I suppose. But only in the short run.
7
Health care in the US is not a market because there is nearly zero visibility of the quality of the product and no transparency in pricing. Without correcting those two defects there cannot be informed consumers. Without informed consumers health care is not a market, it's a roulette wheel or a slot machine, and the players have little choice about how much to bet and when.
17
@Richard Schumacher But even if pricing becomes transparent it won't help that much. Healthcare is different than other products. We all need it and we can't control many aspects of our health. Insurance don't want people with less than perfect health. Every developed country on the planet except the US has already figured that out.
17
Huh, who knew! I agree with these guys 100%
I would add a couple of line items. Make medical education free with the proviso that doctors serve the country for a period of time at fixed livable salaries. If they are not for that idea, then allow importation of doctors.
Then I would have some Government agency look at all the consolidation happening in the Healthcare industrial complex and break them up. Each market has to have a minimum number of organizations, companies such that they don't fix prices.
Bonus: No more surprise billings and all the costs are disclosed before treatment begins.
Bonus 2: No out of network provider works at a provider hospital. The responsibility to insure this lies with the hospital and/or insurance company, not the patient.
8
Without questions addressing Medicare for All, anything related to cost reduction in general, or their thoughts on things like price transparency or incentives this is an incomplete survey.
10
As to whether people with unhealthy habits should be charged higher insurance premiums, think of this.
I believe it's a given that the older a person gets the greater health care expenses they incur. Also, that people with unhealthy habits such as smoking, over-eating, or alcoholism die younger.
So, I'm not suggesting that people with unhealthy habits should get a discount on their premiums, but is it justified to charge them more?
5
The middle class is where the money is so it is the middle class which would bear the brunt of these attractive-to-the-masses free services which populist politicians promote to get elected. If the Defense Dept. would give up some of its largesse and the plutocrats would take a bigger hit and there was much more vetting of food stamps and Medicaid and Medicare and SSI, then we could afford to pay more for those who need it, not just those who want it. And make sure everybody has skin in the game.
2
You state that more vetting (re: reduction in costs and savings) in Medicare, SSI and Medicaid.
At present in CA. IHSS, funded thru Medicaid (in home support services), requires from the recipient a letter from their Primary Care Doctor regarding their disability and an in home review by a Medicaid Nurse Practitioner.
The Provider must undergo an FBI background check ($275) and fingerprint check ($100). Misdemeanors and Felonies mean total rejection, no exceptions! Hard to see any criminals working here.
As to savings, the average cost of a nursing home bed in the SF Bay Area averages about $12,000 a month. IHSS pays me $1500 a month to take care of my totally disabled wife. That seems like a great deal for the taxpayer and my wife gets to stay in her home with better care (I would argue).
Research Matters.
2
We clearly need more value from our expenditures, and we need systems to promote more clinical research on what works and what does not. No one ever thanks a doctor or nurse for ideas that will save money while treating an illness better. We can't afford costly pharma of marginal benefit.
We first saw problems with healthcare finance in the 1970's, and the private sector has been putting "bandaids" on the system since then. Only Medicare has instituted some important but still insufficient measures to cut costs. The PPACA (Obamacare) was the first attempt at comprehensive legislation to control cost, ironically attacked by the very people who will ultimately benefit from lower cost. The mandate to cover pre-existing conditions is a logical consequence of reality: Anyone coming to a hospital with exacerbation of that condition will be treated. Republican attacks on the individual mandate make no economic or actuarial sense, since everyone gets care in an urgent or emergency situation. Absent universal participation, we shift cost from those with coverage to support those without. Insurance 101: To be alive creates risk, and all risks can be assigned a dollar value, a premium. Therefore, everyone must pay something into the pool.
We may need to eliminate the cap on income for which Medicare premiums are paid, since people are living longer and using more advanced treatments. People with high incomes in retirement also pay more, which is appropriate.
3
The only rational way to see healthcare is as a human right from which little profit should be made. There are plenty of people who will do the work and invest for a fair wage. If investment becomes a problem we should have our government invest in it. We used to use our tax money to invest in research all the time. I just realized I have not heard a story about US investment in our own research since the Clinton Administration if not earlier than that. That used ot be a great source of new products and jobs in our real economy outside the paper changers on Wall Street.
6
Once you see policies and popularity of them in the context of inherent racism (thank you 1619 project), lots of abysmal outcomes make sense.
5
Uh - that is the health care system we have. You mean you didn't notice?
2
It would be nice to think that all health economists base their decisions on the same fundamentals of health policy science and thus would be nearly uniform in their recommendations. As a student of health policy, I've observed that economists do not base their decisions on facts alone, but they are driven by ideology to one degree or another, just like the rest of us.
An economist who believes that everyone should have health care when needed and that a system should be established to make it affordable for all would support the single payer model of Medicare for All. An economist who believes that individual responsibility should prevail would support high deductibles and health savings accounts. The facts show that these models are quite different in enabling accessibility and affordability of health care - one works for everyone and the other works better for the healthy and wealthy.
With my ideological preferences, I'll take the system that works for everyone.
13
This article - and presumably the survey - leaves a huge stone unturned: cost-effectiveness analysis and rationing! Almost surely this would be overwhelmingly supported by the economists in the survey. Almost all economists (and insurers and providers) believe that we have to start saying "no" to certain kinds of (unproductive, low value) health expenditures in order to contain costs. This is, of course, almost never spoken of in the US lest terms like "death panel" come out. But many other world health systems, in particular the UK's National Health System, actively use cost-effectiveness studies & rationale to make hard coverage choices. If this wasn't part of the survey, the authors missed the boat about something that is inevitable and which will truly make a difference. The only question is how long til we get to that? Someone has to have some political courage to lead with a no.
18
@Derek Insurance companies do this all the time. Deny treatment based on some rationale, some justified, some not. The bottom line is always the bottom line, however. Somehow it's more palatable politically that the "free hand of the market" denies you coverage for a needed medication rather than the government.
One is doing it to protect profits. Another one is doing it to use resources judiciously. Guess which one I would trust more?
14
@Derek - We've had rationing in this country for years. Only it's the insurance companies doing the rationing. Apparently huge numbers of Americans have no problem with that kind of rationing.
24
@Derek My sister commonly cites the factoid "50% of our health care expenditures are done 6-months prior to death." I point out that, in and of itself, there really isn't any wisdom there since you can't tell in the moment if the 70-year old with a MI will live 5 days or 5 more years.
But I get that pushing treatment the default (has to, or else you get sued). One method of overcoming some issues could be giving people a portion of their unused Medicair spending to their heirs.
If a 80-year old has only consumed $20K over their life, and suddenly gets a cancer diagnosis with a $300K treatment; offering their estate $80k would be the rational economic choice. Some people would still take treatment, and some would take the money to pass on to their heirs.
If healthcare is a human right, that really means one is entitled to health spending. Which means that the person should have a choice as to whether the money should be spent extending their lives by a few years or passing on to the kids for a down payment on a home.
Maybe that's just the University of Chicago economics classes in me talking.
4
We currently have a health care system run by MBAs who are solely dedicated to maximizing short-term gain for shareholders (and themselves). It indeed provides superb wealth care for the CEOs of medical corporations and for Wall Street investors.
It should thus be no surprise that our system far too often fails patients who need health care, and drives many of them into debt and bankruptcy. Those MBAs call providing health care to patients "medical loss": They consider every dollar paid for the care of patients as stolen from the pockets of shareholders. The MBAs have thus erected an increasingly complex, confusing, and continually-shifting obstacle course of deductibles, copays, coinsurance, networks, formularies, prior authorization, and outright stonewalling, meant to deter and reduce "medical loss."
The real question we need to ask before any discussion of health care is whether we want to continue our unique health care system run by MBAs, whose sole focus is on short-term profit for shareholders. After all, every other "developed" country has rejected that approach in favor of a government-regulated (or government-run) system focused on health care for patients rather than return on shareholder investment. Unfortunately, the investment those MBAs have wisely made in campaign donations continues to answer that question for us, in the strong affirmative.
That said, I rather doubt a system run by economists would better serve patients than one run by MBAs.
48
@Ted
How about if we have to keep paying so much we at least get statistics kept for each doctor and hospitals outcomes. That way we can at least choose doctors who have better results for the exorbitant extortionate prices we pay.
2
@magicisnotreal - Most doctors aren't taking new patients, so even if you find one with a good rating, you're likely not going to be able to get an appointment.
6
"Various ideas to cut costs in Medicare and Medicaid have been proposed in recent years. Health economists generally oppose those changes."
Am I correct in assuming that these are the same economists who opposed the creation of medicare back in the '60s? The idea of medicare-for-all doesn't seem to have been considered by the group...
6
@Jerry You would be incorrect in that assumption.
Health economists (I'm one) overwhelmingly support Medicare and Medicaid - and are mostly mystified that so many states refused to expand Medicaid under the ACA when they were offered the deal of the century (no cost for the expanded-in enrollees for the first few years and states would never pay more than 10% of the cost for those enrollees ever - compared to the 23% - 50% that states pay for other Medicaid enrollees).
16
@David Bradford
I believe you misunderstand me. I am referring to the number of people of all sorts, health economists among them, who in the 1960s were opposed to the idea of Medicare and in this article, Frakt doesn't consider the Medicare-For-All as a possibility. In the '60s LBJ had the ability to push Medicare through congress; today we have no LBJ but hopefully you and many others will speak up and help push.
1
Let's start by saving money and preventing mental illness
1. Prevent head injury. Emergency room costs, hospital costs, occupational therapy, physical therapy, and nursing home costs.
All saved whenever a Traumatic Brain Injury is prevented.
Yes, I know, football and hockey and soccer all make lots of money and please a lot of advertisers. But Medicaid usually ends up paying for medical and custodial care of the brain damaged person. So let's prevent TBI, whatever it takes.
2. Pay for Family Planning and Birth Control for EVERY woman in the U.S. who wants it. Save money: prenatal care, obstetrical care, neonatal care. Care of premature babies can run up to $500,000. Plus, unplanned and (especially) unwanted babies cause chaos in their families: sleep deprivation alone is horribly stressful. Chaos and stress often result in neglect and abuse.
An abused child needs help which costs money: Child Protective Services, Foster Care, Pediatric psychiatry, and even juvenile justice expenses. Plus we have not yet figured out how to restore an abused child to complete mental health and function. All this leads to drug abuse and adult dysfunction.
Save all this, raise happy, functional self-sufficient children.
Save families from the angst of an unwanted pregnancy.
Then we'll think about reforming our health care system that makes investors happy and every one else scared to death.
13
The tax idea needs to include the fact that most heath plans cost over a thousand dollars a month, are complicated, unknown extra charges, limits, and high deductable's. Assume a family taxes went up but they had a guaranteed health plan, no surprises, no deductable's and drugs included. They would probably pay less in extra taxes then now for incomplete private plans.
Interesting , the Congress gets almost all their healthcare from tax payers paying for them. If private so great then let them pay the same as the rest,
Remember. 65% of our present health care costs are paid by governments. (Medicare, medicaid, Veterans, state and local, etc,)
24
Apparently, education and certificates don't bring wisdom. First, the issue must be broken up into healthcare and separately insurance. Health risk is a universal threat, it is unpredictable in small groups but highly predictable when measured over large populations. Insurance is simply a mechanism to financially protect uncertainty and an administrative service to spread the risk, collect premiums, pay claims. In a 327mil insured population annual predicted cost of risk is accurately predictable and therefore the risk insurance element of insurance is unnecessary. Every U.S. enterprise with over 500 members has reduced or eliminated use of insurance, it's frictional cost of profit and excessive administrative costs and to eliminate outside interference. Insurers and healthcare providers have created virtual monopolies by region. Demand for practitioners greatly exceeds demand. The idea that healthcare is capitalism is false. A universal offering will reduce inefficiencies while also increasing societal productivity, mobility, and overall health. Universal healthcare is a proven methodology having existed in countries for over 100 years. Initial support in the U.S. was by then Republican Teddy R and an early adopter was financial CEO and Mass Governor Republican Romney. Healthcare will reduce cost due to crime, economic uncertainty and even active shooters. Nations with mature programs have better quality, lower cost and happier populations. What's not to like?
9
They are health economists but they really don't seem to understand why our health care costs are too high. The primary driver is the commercial insurance plans pay between 2 and 4 times what Medicare pays for the same services. If we converted the entire system to a "single payment" system where everybody pays the same thing, let's say as a baseline or hospital costs plus 3% for profit, our entire system would cost more like what the other OECD counties pay.
As for Pharma, the economist are right. Profits do not drive innovation since so much of that innovation is for small marginal improvements in outcomes. It is more rational to have the national research organizations like the NIH fund research that focuses on the health problems that drive costs the most.
Finally, creating incentives to improve people's health is a fine idea in theory but (1) it is rife with significant ethical problems and (2) find me an actuary who would adjust premiums for it, and I'll by you a nice dinner. It is very difficult to estimate the impact. However, it does not mean you don't try.
9
Our healthcare system is too complicated, too focused on the bottom line....and it costs the end user, the patient, too much.
Fact is, it's not a problem that can be solved by economists....how about some solutions from doctors (not their Association/s), Nurses (not their Associations either), and patients. And then with a plan, the economists can advise. Single payer as an option seems to make a lot of sense.
How much does the insurance industry and their collaborators spend on lobbying each year?
19
I'm still waiting for US economists to weigh in on a single-payer system and how other countries have accomplished this well.
I'm a Canadian living in California with good health insurance through my employer. I recently had two unexpected ER hospital visits: one in Canada while visiting family over the Christmas holidays, and one in California in the new year.
The bill for the Canadian ER visit was $1,289 CDN ($974 US) and included X-rays, examination of X-rays by a radiologist, and then an examination by an ER physician (broken toe, not much more to be done). My portion of this bill was about $250, the rest paid by my US insurer for out-of-country coverage.
The bill for the California visit cost $5,540. I had accidentally sliced off a portion of the pad on my middle finger which would not stop bleeding. Treatment for this included first a topical application of Novacane to freeze the open wound, and then several applications of medical-grade glue (pretty much Crazy Glue) on to the wound. Bandaged up and was on my way. And I received a bill of $554 to pay (towards my 2020 deductible).
I cannot, in any way, understand how these two hospital costs are so vastly different - and my only explanation is that the US system is based on profit.
77
Well to some degree you're mixing apples and oranges because you're talking about an annual deductible. If this had happened later in the year there would have been no deductible and your cost would have been zero. So we would have to know over the year what's your average payment was.
3
@JerseyGirl You're definitely right - but the amount of my payment was quite secondary. The remarkable thing I was drawing attention to was the difference between the overall hospital bill: $974 US (including x-rays, a radiologist's review, and ER physician) vs $5540 (for ER physician). Just can't explain that easily!
19
@JerseyGirl - The cost would NOT have been zero, even later in the year. You're forgetting the ubiquitous co-pay. Very few insurance plans have a zero co-pay, and generally ONLY if offered by a high end employer.
11
An important factor to consider in relating pharmacy profits to research is whether the profit motive results in research that produces the drugs that are most needed. The various reports that I've read in recent years indicate that the profit motive is not very effective in producing the medications we actually need. In addition to this, the idea that a life-saving drug should have a high price not so much because of its research costs but because it saves lives is just another way of saying that only the lives of wealthy people are valuable. It would seem that government funding of research and clinical trials is a better way to focus on the types of drugs that are actually needed as well as keeping the costs of the end product down.
14
So these economists favor twiddling around the edges of health care finance, rather than adopting one of the systems in use everywhere else in the industrialized world. We already know what works: choose among single-provider, single-payer, or heavily regulated, nonprofit insurance companies with mandatory enrollment. The trouble is, the USA will never bring health care costs under control without slaughtering a few sacred cows.
21
I think we already have a health car system run by economists. Interesting, Austin, if you were to ask 200 Medicaid patients instead. They'd have very different ideas on what keeps people healthy, and how the system should work. And over time, I bet far less expensive.
8
Interesting that no economist addressed those who must pay for private insurance. Their assumption was that Obamacare is available to those who don't have employer based insurance. However, there are cut offs based upon income and once that is reached, Obamacare does not offer reasonable, affordable plans. Private insurance is VERY expensive. So if you are a successful pizzeria owner, self-employed plumber or making a go with a tech start-up, you must pay through the nose. America prides itself on entrepreneurship, self sufficiency, and independence. However, the surge in increased premiums by the insurance industry in reaction to Obamacare made health insurance virtually unaffordable.
My husband & I are both healthcare providers in private practice. (We are not high paid surgeons). After Obamacare, our premiums skyrocketed to $24,000 for the two of us with a $5000 deductible. I would say that most of our patients had better plans covering more than either of us could access. Not very good for patients when their providers must limit their own appointments and visits. (I, for one, refused to pay $2000 for an MRI breast screening when the standard in the past had always been mammogram/ultrasound). Medicaid was expanded under Obamacare but so too were private premiums. How fair is it that middle class taxpayers fund the poor but middle class self starters, small business owners and private practitioners pay the price in their own healthcare needs?
20
@Deb
I suggest you stick to medicine and not get into economics. You are blaming Obamacare for the cost of private insurance, but what you leave out is that insurance of any kind is expensive, that the cost of insurance has been going up across the board long before obamacare came into existence. Premiums were going up because healthcare has become a lot more expensive, but more importantly, the model for health insurance changed. Once upon a time, with insurance the companies broke even on premiums vs pay out, and they made money investing the 'float'. When market volatility led to losses, the companies took the advice of McKimsey and other companies, and started raising rates to make money on the premiums themselves, at a rate of 15% or even higher. As medical costs went up, premiums soared even more. As far as Obamacare goes, my employer, not exactly a radical company, said that of the increase in health premiums since Obamacare came i nto law, that a very small percent of the increase was bc of Obamacare. To give you an idea, my employer health care plan for a family is like 25,000 (paid for by them and myself), with deductibles up there as well and co pays....and that is a large plan, 5,000 member company. Private insurance is always more expensive, because it is not part of a pool. The real problem is that we have a system with a ton of individuals and pools out there, not to mention a system based on providers making more the more they do, even if uneccessary.
10
@Deb
Hmmm... My own experience is different than yours.
I've been an independent contractor for many years. As a consequence, I did not have access to any sort of decreased "group" policy rates for health care insurance, so it was expensive. My deductibles are about the same size as yours. And my income is large enough that I never expected to receive subsidies under the Affordable Care Act.
I paid close attention to what happened to my premiums when the Affordable Care Act took effect. The immediate impact was that my premiums decreased. As I recall, it was about a 20-30% drop.
I do notice there has been some increase in premiums over several years since then. Perhaps this corresponds to your reference to "after Obamacare"? However, my premiums are still lower than they were before the Affordable Care Act.
33
@Deb -- I used Obamacare for four years or so when it first became available until I change from contract work to life as an employee. In Chicago I always had multiple plans to choose from, and when I picked a plan I was able to choose plans I could afford (without subsidy, by the way).
Medical insurance costs had been increasing faster before Obamacare than after it went into effect. That and the trimming of benefits in employer plans - the days of being able to choose provider and go whenever you want were being nibbled away by PPOs and other restrictions - yet still costs were increasing in the private insurance plans.
I was a self-starter and it worked for me. I'd go with the approach of fixing some of the gaps in it that leave a hole in subsidies that some are hit with.
I'd also put in a public option for areas where insurers are not offering much - the rural areas and places where the state is hostile to the entire system (GOP states for the most part or entirely). Rural people without employer coverage shouldn't be penalized because for-profit insurers don't see a profit in that market - we should pick up the slack with public plans as an alternative.
6
“Charging a higher premium for a smoker is punishing someone with a disease, so why this disease?”
The answer is simple, addiction is covered under the FMLA and the ADA, however the protections afforded by both are limited by the fact that an addicted individual cannot use their continued addictive behavior to receive the protections afforded by the FMLA or the ADA.
The employment protective provisions of the FMLA and the ADA only apply for an addicted individual who participates in professional mental health and substance abuse programs to treat their addiction.
2
@Jim - I'm not sure we really want to go this punitive route. The biggest health problem in the US today is obesity. Do we really want to charge people more of they weigh more than the recommended weight for their height?
2
It boggles the mind that these are the only changes these health economists would make to our overburdened and lopsided healthcare system.
To zero in on a "sin tax" is disturbing and distracting. While I do agree that smoking affects your health more than sugary sodas, what about alcohol and other drugs? Where do we draw the line? Will we eventually include butter or high fructose in this madness?
Rein in Big Pharma. Get rid of PBM's and especially Express Scripts, whose sole purpose is to deny medications to all their consumers, or slow down the receipt of their medications while draining their bank accounts.
Get the abhorrent amount of money and greed out of our healthcare and see how our populace gets healthier and happier. It's our duty to look after our people. Do it responsibly and with transparency.
15
@Pamela L. Economics is the science of possible. Not moral, not desirable but possible given our human failings. You can not order the price and regulate whatever you want. If you do that too much - you will lose something - There are 3 pillars in health care - affordability, quality and universality. You can only have two of these at a time. If you want high quality universal coverage - it will be expensive. If you want to control costs - either quality or universality will have to give. If you want affordable, universal coverage - quality will have to give.
3
@sk Thank you for your response, and I understand what you're saying. I think quality and affordability are already suffering under our current system. Since we're in the business of change, why not trash our broken model and start over?
If we go for universality, affordability will no longer matter and we can concentrate on quality.
Nothing will ever be perfect. Look at Canada and Britain for examples. You can't satisfy everyone, but you can try to make it work for most of us, and that isn't happening now.
Anything is possible.
8
@sk ..."Not moral"...that's been the excuse for irresponsible policies across our economic system.
I'm not buying it. We live in a country that is supposed to provide or aspire to "Life, Liberty and the pursuit of Happiness " ...the healthcare industry isn't the only one that fails civic responsibility.
One of my favorite lines from a president, paraphrased, we do things because they are hard. Well, we used to, sometimes.
2
I'm glad these economists are looking out for private capitalistic interests in our healthcare system, even if it means the less fortunate have to jump through another million ACA and Medicaid hoops in order to get that tumor looked at.
These economists put the gold in Rube Goldberg!
8
American Society of Health Economists
No offense, but really, isn't already known that We have all have money coming out our whazoo even when one hasn't had any money for quite some time, and the the problem lays in who gets to do the squeezing?
4
There are 3 pillars in health care - affordability, quality and universality. You can only have two of these at a time. If you want high quality universal coverage - it will be expensive. If you want to control costs - either quality or universality will have to give. If you want affordable, universal coverage - quality will have to give.
6
@sk
All other advanced countries in the world manage to achieve all three goals. In the US, we pay double what other countries pay for healthcare, and our results are worse by most measures.
28
@James Ward - But all those advanced countries are not full of obese people. Obesity leads to diabetes, hypertension, arthritis and cancer. Diabetes and hypertension are foundation of heart attacks, strokes, kidney failure etc. You reduce the obesity rate in the US to less than 10%, you will reduce health care costs by 50% and doctors will be unemployed. What works elsewhere in the world, will not work in the US - thanks to supersized people.
2
@James Ward Not true. The U.S. has more drug problems, violence and out of wedlock births than many other countries which contribute to the mortality rates. It is not necessarily the quality of care. They don't tell you that in the newspapers. Furthermore, I have family in Israel and they have 5 different tiers of care as well as private care. Everyone is covered by the bottom basic care and everything else is then paid for out of pocket. Hospitals have wards--not the nice 1-2 beds per room as in the U.S. Doctors in England also run private practices because basic care isn't always adequate nor are the hospital personnel who are imported from third world countries.
American medical schools are the MOST difficult to be admitted to, with statistics more difficult than entrance to Harvard. Any foreign doctor who applies for American citizenship must redo a hospital residency no matter how experienced because standard abroad don't compare to here. And taxes in ALL those countries are through the roof. It doesn't pay for itself. It is not as simple as you think.
1
There is one more issue about health care costs that is not talked about at all. We can not talk about health care costs without talking obesity. I think there is some correlation between rise of obesity and health care costs at different points in time. In 60s - obesity was much lower in the US and so were health care costs. This data should also be looked at while comparing health systems of different nations. France and Japan have much lower obesity and lower health care costs. This correlation makes sense because obesity correlates with arthritis, diabetes, hypertension and cancer. Diabetes and hypertension are underlying reasons for cardiovascular disease.
4
It is surprising that health economists' views on health care are so close to the mainstream. Often, economists' assumptions and world view lead them to some unusual directions, usually market-oriented, and sometimes appearing cold-blooded. They offer an implicit "You might not like what we have to say, but we're right" message, and welcome the occasional times in the political cycle when their ideas are considered. But while contrarianism has its uses, it doesn't help with interdisciplinary problem-solving, which involves consideration of many fields and perspectives.
One possibility is that the survey is disproportionately represented by liberal economists. Another, actually welcome, is if the profession has become tired of being generally ignored and is moving in the direction of incorporating ethics, and/or a more realistic "We're not going to get everything we want, but let's go for as close as we can get" orientation. This movement, if that's what it is, could be helpful in other areas, as the field has a lot to offer, but has been hampered by too much loyalty or rigidity to their basic and limiting assumptions about human nature and society.
If so, I welcome their contributions to helping with the solving of the massive issues we're seeing (and are to come). I hope others become more willing to consider what they have to say.
Two suggestions: as others have noted, some key questions did not get asked. And I wonder what they learned from their individual mandate error.
2
@Matt Polsky
It often depends who is paying economists, and why. It's not as much that people take money to say the opposite of what they think but that those with the right views are hired, and who corporate news knows to ignore, because they might say the truth.
1
I would like to ask this group of economists, and others who have solutions for improving health care, how they value personal autonomy and freedom of choice.
I have no doubts that we could make changes to increase efficiency and lower costs. But many of those changes would at least marginally reduce individual and societal liberties. Compassionate authoritarianism might make is easier to improve some aspects of life, but would certainly degrade others.
1
@Bob Krantz There are two large providers where I live, Mercy and Cox. My insurance has one preferred provider--Mercy. While it's true I could, technically, choose to see the other provider, the cost would be prohibitive. So do I really have personal autonomy and freedom of choice?
75
@A. Boyd
Of course you have choices. You can find a different employer. You can move to a different town or city. You can buy health insurance from a different provider. You can forego insurance and save money for future costs (and technically break the law).
And yes, these choices might impose hardships on you. But demanding improvements in the system you have now will impose hardships on others. Do you think you have that right?
1
@Bob Krantz
What liberties? With M4A you just go to the doctor. If you want the freedom to be ripped off by some insurance company promising that you'll receive every experimental drug or treatment M4A won't cover, I'm sure you'll have the right to purchase that coverage for yourself because this is America, land of the free to make a buck.
My husband's 'liberties' were infringed when he had to purchase health insurance for his employees whether he liked it or not, and let me tell you, he really didn't care for it.
1
I’m not in the least surprised that there’s been little adverse selection with zero mandate penalties. The theory has always said more about the naïve cynicism of economists than anything in the real world.
And even if there were adverse selection, it’s not obvious this would be a bad thing in health insurance. See the book “Loss Coverage: Why Insurance Works Better with Some Adverse Selection.”
1
Should I have confidence in a study where a selection is "Don't know"? It doesn't seem like the survey is worded very well, and the percentage of those selecting "Don't know" is relatively high for a poll with only three option. Thoughts?
8
@Bridget Knowing what you know and what you don't know is actually very important. Dunning-Kruger effect is important, and the more and more focused in a single field one may become, it actually becomes more likely that you aren't skilled in adjacent subjects.
Economists spends years researching impacts of subsidies on willingness to see a physician; that person may have little to say about the capital structure of a pharma company. The ability to say "I don't know" shows self awareness.
2
This appears to have been a survey that avoided asking the most important question: should individuals and families prepare for the risk of health care costs by buying insurance (individually or through their employer) from private insurance companies.
That is: is it economically rational to provide the financing for health care through private insurance contracts, or (as is the case in most of the world), through a universal public insurance system?
A proportion of Americans do get public insurance through Medicare, the VA, and Medicaid. The majority get private insurance paid for by their employer. And a good proportion get neither, and have to buy insurance on the private market (mostly via Obamacare, now, which is an insurance _regulation_ system).
This patchwork, and the relatively large role of private insurers, sets the US apart and is one explanation for the exorbitant cost of health care here (along with the hobbling of the public systems by forbidding them to negotiate some costs).
29
@Pquincy14 - Actually, only barely over half of Americans get their insurance through an employer. Many working Americans have no access to insurance their their employer, whether it's because the employer doesn 't offer it at all, or because it's too expansive for poorly paid employees to afford, or because the employer deliberately limits employees' hours to the number just below what it would take to be eligible for the employer insurance plan.
4
The strongest individual mandate in the ACA survives: the limited enrollment period. You cannot wait until you are sick and then enroll.
If you don't enroll between Nov. 1 and Dec 15, you are out of luck. No one know if they are going to have a significant medical problem the following year, so they sign up to avoid a potential disaster.
The ACA is working well with the mandate fine set to zero, because the limited enrollment period was always the real individual mandate.
4
Wait! What? This group of "healthcare economists" conclude that if they "were in charge of the health system, not a lot would change, with some notable exceptions."
So having a quarter of all Americans not get needed medicines because of lack of money, having more than 30 million Americans without health insurance, operating a system twice as expensive as any healthcare system in the world, none of that points to a dire need to revamp the entire system? Our per capita drug costs are double those of any other developed country on the planet, yet less than half of those economists believe that the current level of profits of Big Pharma isn't too high?
Perhaps The Upshot would be well advised to report on the recent study by The Lancet, which concludes that "Medicare for All will save Americans $450 billion and prevent 68,000 unnecessary deaths each and every year."
https://www.commondreams.org/news/2020/02/15/sanders-applauds-new-medicare-all-study-will-save-americans-450-billion-and-prevent
Just demonstrates why the media cannot understand why Bernie Sanders is leading the race for president.
100
Instead of these guys asking a million questions, just look at almost any peer country, they have figured it out.
There are plenty of models to choose from.
Our neighbor Canada has one of the world's most popular followed by many countries around the world.
The key thing is not to do anything or the opposite a narrow dogmatic version of it upending everything ASAP.
Also it must be a mix of private and gov't. If you do the former only you get the de facto criminal system we have today and if you do the latter only, you go in the direction of total welfare like they have in England.
11
@Paul
Proponents of single payer insurance under whatever name seem to have unlimited faith that, given our divided society and politics, our general desire to get something for nothing and the enormous complexity of unraveling the system we have now, we won't mess it up. It's no longer sufficient to say that if Canada and Denmark can do it then we can do it. We need to say HOW we are going to do it and how to mitigate the impact of those who will be hurt in the process.
2
@PWR thank you for your reply.
Agree on a system like Canada, half private, half public. It is the gold standard.
If done right over time, costs will go down by 50% and life parameters will improve, like infants mortality, life exp. etc. etc. and it will be universal without up to 50 million Americans under insured or no insurance.
It's not rocket science. it's like telling the alcoholic the answer is simple, just stop drinking.
America is addicted to a de facto criminal, disfunction system. That is the problem.
2
@PWR - Ah, yes - American exceptionalism. It means everyone can do it EXCEPT Americans.
3
What about the high cost of healthcare? According to another NYT columnist and expert on healthcare costs, the biggest issue is the lack of standardized pricing for medical services. Apparently, the public vs private healthcare insurance debate is not as important as establishing a set of regulations, such as covering preconditions and standardized pricing. As usual we have become distracted.
5
"Sin tax."
A term designed to make one feel guilty. Shameful to use it.
This is really a case of shared responsibility, and the oft unmentioned yet always attached aspect called consequence. What is one's responsibility to all the *others* in the population (group, neighborhood, society, etc.)?
Consider this: one of your neighbors works for a (legal, legit) bomb manufacturer. He/she works from home. Are you cool that he/she is manufacturing bombs in your neighborhood? Are you find with that shared responsibility and consequence, more over, with the obvious decision *he/she* made to place that burden on you and the neighborhood?
Now imagine law saying you have to accept that person's choice, and consequences.
Now transfer that line of reasoning to healthcare. Are you fine paying premiums and other associated costs based on a system that has to take care of the alcoholic, the smoker, the IV drug user?
Not advocating tossing "sinners" out of the system, but I am advocating a sense of personal responsibility: get clean, stop the bad habit, etc., or pick up additional coverage that handles those who are expensive risks.
And FYI, I am an ex-drunk, sober 26 years this April. I had no "disease", have no "genetic defect". I had a choice, and until I was 30, I made bad choices. (And I was a cook so had no healthcare, btw. Ironic, that.)
Making the right choice is notoriously hard. Being forced to pay for other's bad choices, though, is wrong and unacceptable.
3
@DKM - Obesity is hugely expensive when it comes to health care costs. Are you sure you want to go there, since about 50% of Americans are obese?
1
@MegWright
If we don't go there, the problem will force itself into the conversation, if that is not what's happening now (once we get past the emotive responses). The choices by then will be limited to answers of which none will be satisfactory.
1
It seems that the “professional economists” opinions reflected a “capitalist” world view/preference, rather than any analyses of disease economic data.
So, one would expect the results to be similar to those of other “capitalists”, no?
And maybe different from people with a more social/humanitarian bent?
4
@Stephen Rinsler
You would prefer compassionate authoritarians?
1
Didn't ask about a single payer system?
3
@todji They also didn't ask about Tort Reform. If you just transfer the existing funding to the government for administration, we would still expect the same levels of lawsuits and the same level of defensive medicine (order lots of unnecessary tests to avoid telling a jury that you didn't screen for a 1 in a million diagnosis).
Arguably, the private system lowers the amount of money paid out in damages (profit motive provides incentive to fight claims). Would the Federal Government be willing to endure the same bad publicity?
Before single payer, lets enact tort reform. Since Single Payer would take away American's right to sue for a bad outcome, may as well make the change now.
1
@James - Check out the number of torts filed in countries with universal health care. They're a fraction of the suits filed in the US. That's in part because in those countries people think of their insurance system as THEIR insurance, and don't want to harm the system. It's also in part because in the US, a severe injury caused by medical malpractice might make someone uninsurable, yet the patient is still going to need very expensive medical care for life. In countries with universal coverage, people KNOW all their health care needs will be met, no matter what the cause of the illness is.
4
@James,
tort reform is a drop in the multi-oceans of health care costs. perspective please.
1
Work requirements mean bureaucracy and hassle. My handicapped brother needed a form from his employer for his subsidized housing. In theory, it was simple, one form to be filled out. In practice, the bookkeeper whose responsibility it was handed to had no incentive to put in the 15 minutes to research and fill out the form. So, it died in his inbox. The only way to get it filled out was for my sister to take a hour or two off work --- once a month--- to shove it under someone's nose and stand there until it was signed. It worked because my sister has flexible hours, because she's an expert at polite insistence. Because she had the control to never lose her temper over the thought of my brother being homeless because some jerk can't be bothered or over the stupidity of a bureaucracy that dreams up its own form rather than asking for paystubs or some existing documentation.
43
@SAO
And no one is taking into account the obvious, for some people such as myself: Can't get FT work until I can remedy my health problems (which include poor sleep, poor concentration, and occasional afternoon fatigue so intense that I drop off) -- but I can't afford to pay for a doc visit, tests, and meds until I have a job.
I've thought about creating a GoFundMe, but
-- I'd be publicizing health problems even as I'm trying to be a good candidate for work despite being 58, and
-- most don't raise enough to address the problem.
American stinks. These policies are not only cruel, they're counterproductive -- a nation in which people are well, and can change jobs w-o fearing the loss of insurance, is a more productive nation.
2
Personal habits play a huge part in our overall health. Problem is most Americans don't equate what they do with how they feel. Case in point, overheard conversation at the Y, "my doctor said I need to lose 20 pounds, I said that's not why I came here."
I agree the healthy should be awarded with some kind of perks, lower premium costs is one. Here in America all this seems impossible. Perhaps as part of the health care budget public service advertisement on TV promoting health. Why not, we have literally hundreds of ads for drugs.
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The challenge in US health care is that it exists in it's present form as neither a true, free enterprise based, competitive undertaking nor as a fully government provided, regulated, taxpayer funded program. It has evolved into a blend of both with some of the worst attributes of each. Pricing is opaque, barriers to entry are high, creative approaches are too rare, overall outcomes are below those of other developed countries and ever escalating costs are passed on via high insurance rates and government programs. Mixed incentives result in abuse and waste. Hospitals must treat anyone who shows up at the ER, regardless of insurance coverage or ability to pay. That sounds compassionate, but results in many people forgoing health insurance. The economists surveyed can't agree on the best way to provide better services at lower costs for more patients by doctors who are reasonably paid to work reasonable schedules and reign in pharmaceutical companies that currently have near monopolistic pricing power. Those who maintain a healthy lifestyle pay the same for health insurance as those who do not which makes little sense. Imagine if auto insurance were handled in this way? Intentionally high risk drivers with multiple traffic infractions would pay the same as those with few or no violations. People who wreck their cars could show up at the repair shop and the shop would be required by law to fix their car regardless of insurance or ability to pay. Kinda crazy.
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@Kevin Curtis
This would be an argument against a system where people with preexisting conditions pay the same premiums as those who are at least initially health when insured.
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It would be interesting to stratify by the economists' age as a proxy for likelihood they are anticipating their own participation in Medicare, given that they oppose increasing the age of eligibility, vouchers, and income-based benefits.
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Simplified Universal Coverage for Health Care
Maintain or expand the Obamacare patient protections and scope of coverages.
Open Medicaid enrollment to everyone, rich and poor, young and old. Disband Medicare.
Pay everyone a monthly stipend equal to their state of residence’s average Medicaid expenditure for non-institutionalized enrollees. Use the Social Security payment system to make deposits to healthcare-restricted accounts. (This makes Medicaid expansion revenue neutral to the States.)
Permit use of the monthly stipend to enroll in Medicaid, to purchase commercial insurance which meets the Obamacare standards, or to pay directly for health care services.
Treat the monthly stipend as regular income for federal income tax purposes for taxpayers with adjusted gross incomes above . Exclude those stipends from taxation by state and local taxing authorities.
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@David C. Murray
I'm unclear about one thing in your proposal. Who pays the monthly stipend and where does that money come from?
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It is surprising that economists were not asked about government price setting for drugs, procedures, hospital care and tests. This is a large factor in much lower health care costs in other countries. Many US economists are conservative and favor market-based mechanisms. But, there is little evidence that markets work for health care in the U.S. because requirements for markets to work are rarely met in US health care (e.g. choice of provider, informed consumers). A health care system that does use market-based principles to reduce costs (Singapore) has a government that plays a large role in health care policy to limit provider pricing power for key services. Big offenders contributing to high US health care costs are hospitals (non-profit & for-profit), patent drug companies, procedural medical specialists, and insurance companies with inefficient administative systems and who are unable or unwilling to lower prices charged by hospitals, procedural specialists and patent drug companies. The Catch 22 is that until monopolistic pricing power of hospitals, procedural specialists, and patent drug companies is fixed, it will be difficult to achieve universal coverage, but without universal coverage and large insurance pools administered for the public interest, it will be difficult to control costs. Insurance systems serve the providers, not the consumers, that is the problem.
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There is something to be said for government health care.I recently spent some time in hospital and was treated great.I had a gall bladder removal, CT scan and an endoscopy.I also had five days of observation. Total cost to me was $45 and that was for the ambulance that took me to the ER.The only problem was the wait times but small price to pay for the wonderful care.
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If that were true, administrators would cost 75% of the budget. Next question . . .
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I was surprised at the opposition to raising the age for Medicare. If the goal of investing in medical research is to increase longevity, how do we pay for that if people don't work longer?
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@Les Americans are not living longer. In places such as West Virginia death rates have gone up. It's only the well off that are living longer.
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Interesting that the economists were not asked the most interesting question: Is Medicare for All more efficient and economical than the current system of private insurers?
If market based principles were used to compare medicare for all with the current system of private insurance, the cost of delivering healthcare would dramatically decline. The largest reduction would come from reduced administrative costs.
And what if doctors were paid a salary, say $350,000 per year and did not have the economic incentive to include added measures, e.g. unnecessary tests, to increase their incomes? What if doctors' education costs were borne by the country so they didn't have to worry about paying back expensive school loans?
As Joseph Stieglitz said, "There is no invisible hand". Letting the private insurance companies determine the pricing of health care delivery is like letting the foxes count the chickens. We can wisely choose what is in the best interest of our people's health care with expert input from healthcare economists instead of attempting to rely on the principle of maximizing profits vs. the people's right to healthcare. Which is really in the best interest of the country?
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@Lee The British and most European health systems give services similar to those you advocate. The trouble with America seems to be a fear of taxes to pay or such services. None of them seem to realize that the taxes will be lower than insurance premiums which they will no longer have to pay and will cover everyone.
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@irdac - The trouble with America is the fear of The Other - the fear that "I" might have to pay for something that, on the surface, appears to benefit "Them", even if there is overall benefit to our society.
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@Lee,
I think Smith also said his invisible hand didn’t apply to disease.
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