This is why single-payer is the only way to go. There has to be some panel of disinterested experts evaluating the cost/benefit of a given treatment for a given illness, backed up by the buying power of something really huge. Yes, that's "death panels" to you Tea Party members following along at home.
Of course that wouldn't prevent any doctor and patient from doing whatever they wanted, at their own expense.
Medicare is essentially single-payer for old people, yet it's identified in the article as part of the problem. Like other government programs, it's so much better at measuring inputs (amount spent and procedures performed) than outputs, that there's an institutional bias in favor of overspending and overlooking corruption. ("Oh, no, that's not 10% more fraud and inefficiency this year, it's reaching 10% more of the needy.")
There's only one other sector of the US economy that's "single-payer": military procurement. And that's not known for its spending efficiency, either.
So it's not simply "single-payer" that magically saves money, but the specifics of the incentive system that's set up, and the other precedents from American federal governance are not positive.
Thank you for acknowledging that the main mechanism that a federal medical buyer monopsony (aka nationalization/single-payer) could use for cost-control is, essentially, "death panels" who say no to many treatments currently performed.
But can the American political system embrace that step, or will it wind up with single-payer without cost-controls? We wind up with the kinds of giant federal programs that can make it through the political system, and get implemented by the bureaucracy... not the kinds of idealized programs existing only in advocates' minds.
Finally, in single-payer systems, getting "whatever you want" done "at your own expense" is often effectively prohibited. For example, when the official system has particular limits (like price controls, limited participating providers, or waiting lists) for a covered procedure, it has often been illegal, in US Medicare or Canada's programs [1], to purchase that same procedure out-of-pocket/out-of-system for a negotiated price. Once you've nationalized, there's even a certain logic to such prohibitions: the system is straining under budget caps, and you can't risk the wealthy siphoning off capacity/copayments that could help support the common base.
Your glib bias-accusation is unimpressive and unresponsive: Cato cites verifiable details about the particular point I was making, that single-payer systems often do "prevent any doctor and patient from doing whatever they wanted, at their own expense".
Similar to the claim that under ACA, no one would lose a plan they liked [1], the claim that single-payer will still allow full freedom to work outside the system is a pre-implementation falsehood used to build support. Hell, it's even in the name: "single-payer". You have to crack down on competing payers, or your price leverage slips away, and voters stuck in the single-payer system get angry that they're facing the political cost-benefit rationing that others aren't.
None of the other-country "single-payer"-ish systems cover even 1/4th the population size of the US. If single-payer can work so well for cost-control in the US political reality, why doesn't it work for Medicare, and the Defense Department?
>None of the other-country "single-payer"-ish systems cover even 1/4th the population size of the US.
That is 100% meaningless. Cost per patient is the only metric that matters. Its the same old right-wing canards that get pulled around here by the same ultra-conservative libertarains. I am so glad you are on the losing side of history.
Imagine if I said "Whoa whoa, you can't open a giant factory in the US! No one has ever made one so big!" and you said "But my cost per item and cost per worker works out." Its madness that this kind of thinking is artificially applied to healthcare, like its some special industry immune to all the rules and can never, ever be regulated or be made in single payer like the Europeans have been doing for decades.
A nationalized service industry does not benefit from the same economies of scale as a factory. Also, health care isn't primarily delivered as standardized mass-produced widgets.
If what you say about the ease of running an efficient nationwide federal program were true, Medicare and the DoD would be known for their cost-controls. Instead, they're known for the opposite.
Fine, it's impossible to run at a national level because there's some magic cutoff population point past which single-payer can't be done. Let's take your word for it.
Why can't the feds force each state to figure out a single-payer system? No state is bigger than the UK or Canada (ok, California has a few more people than Canada), and they have it figured out.
Look, if you like the private system for some reason, give that reason. Don't spout bullshit about "it's impossible to manage because the US is 4X larger than the UK".
Why can't the feds force each state to figure out a single-payer system?
Our constitution, politics, and culture don't let "the feds" easily dictate such things. The federal government can nudge with some mandates and grants (as with the ACA itself), but forced nationalization of industries is hard, especially so when most states (by count) would prefer otherwise. It's also especially hard, if those in favor of single-payer takeover only barely or temporarily have the legislative majorities necessary (again, as with the ACA itself).
That much larger and more diverse populations, economies, geographies, and institutions are harder to govern via a working consensus isn't "bullshit", it's a political and historical reality. (How many government shutdowns has the UK had recently?) You can stomp your feet over this, and perhaps wish that some more-powerful central government could just "force" everyone to enthusiastically implement your preferred policy... but that's not the US way.
Maybe you could get a single-payer constitutional amendment passed. That'd establish clear legal authority, and prove a broad consensus that would help with implementation. Why don't you try that?
I dislike national single-payer (and the baby-step of the ACA) because I don't think it can work well here. It'll have the cost-efficiency of the pentagon, the compassion of the INS, the simplicity of the tax code, and the innovative pace of the FDA.
What would be a good decentralizing alternative to this current forced-march towards unprecedented-scale nationalization? Leave more details to the states. Use national action mainly to undo existing distortions, like medical cartels/protectionism and the tax-preference for non-portable employer coverage. And, provide direct payment assistance to the neediest/sickest, rather than new regulations on the shape and cost of policies for everyone.
I live in a single payer country. I can absolutely go to a private hospital and do what I want at my own expense (assuming it's passed the equivalent of FDA).
My wife has limited private health insurance. I can buy private health insurance.
I lived in a single payer country. I still remember how depressing it was at the end of each month looking at my paycheck. The amount of overhead and false incentives such a nationalized or semi-nationalized health care system generates truly paralyzes - not just the economy at large. You can get pretty decent prices for medical treatments in the US, but you always have to ask and price shop. Certain things seem more expensive then elsewhere. It's interesting to note how the great quality and extreme competition of dental care providers in former Eastern European countries have driven price down. Many people living in the neighboring socialized welfare funded health care systems take a bus/plane and get their teeth fixed in the "capitalist" alternative in the former communist countries. Oh the irony.
Except having a single-payer system doesn't mean you'll have a panel of disinterested experts evaluating the cost/benefit of a given treatment. This isn't speculation, either. I've experienced the results of a "panel" going against the consensus of experts. It's the reason we left Quebec to come to the US, as at the time (2011) Quebec's policy for children with Autism was horrific. It hasn't changed.
Basically, they didn't believe that early intervention was a priority. You can search for Autism problems in Quebec, specifically Montreal, and read lots of stories regarding that.
As for moving to the US, two reasons. 1) Wait times in other provinces were much longer than we wanted to wait. Even going the private route in Quebec would have mean a year and a half (that was on top of the year we had already been waiting). In the PA, we got more help for my son's Autism in the first 2 weeks than we had the entire time up in Quebec. 2) I'm American, and because of that, my sons are also American.
Note, I don't pretend that this means the US health care system as a whole is better, or that Canadian health care is worse. However, my experience with a child with Autism in Quebec is not unusual, and my recommendation to parents with Autistic children in Quebec is to leave.
Thanks for your reply, that's very informative. I'm Canadian (BC) and like to keep an eye on the health care system as my parents are aging and I'm looking to have kids soon.
Glad to hear you found treatment for your son, and best wishes for the future.
I don't think single payer, per se, would do anything to help with this. The parts of the US healthcare system that are single payer, Medicaid and Medicare, suffer from this just as much as the rest of our system.
Having a government run healthcare system like Great Britain's would solve the problem, but it could do that with or without single payer. In fact, Singapore has had quite a bit of success combining a semi-government run hospital system with private payment for healthcare.
Yes, that's "death panels" to you Tea Party members following along at home.
Well, now that you've put it that way, the idea of a government-led panel -- rather than the family -- deciding that Grandma is too old to bother treating sounds so much better.
Very disingenuous. It's a matter of a government-led panel allocating government funds. If the family wants to keep treating Grandma indefinitely, that is absolutely their right ... if they do it on their own dollar.
The "death panel" bit is just the question of how long the government would have continued to pay benefits.
We're not always talking about vegetables on life support here. There's a lot more to care of the elderly. My 93 year old grandfather recently got a hip replacement and he's doing great. Would he have received that hip under the ACA? Recall that a woman asked Obama a similar question and he said maybe she should just take a pill.
Who paid for that hip? If he did, or you did, or any other private party did; then it would work exactly the same! The question here (death panels) is only about what the government would have paid for. Since the government has finite money, it must decide what it will and will not pay for. There is not enough money to pay for everything. Decisions must be made.
We could have a situation where it's possible that you were paying for a plan that would pay for your hip, but the government decides to dissolve that plan and force you to buy a new plan that's not allowed to pay for your hip.
I'm not sure why you'd prefer an insurer with much stronger financial incentives not to treat Grandma to be the one making the final decision on funding...
That's not even in the problem - if the doctor disagrees with the prescribed treatment plan, they have enough leeway to prescribe some other solution, that they believe to be better.
The advantage of single-payer, is that he will not have a profit motive to do so. And monopoly bargaining power on the side of the public.
The advantage of single-payer, is that he will not have a profit motive to do so
According to the article (Physicians in general aren’t allowed to refer their patients for treatment in facilities that they also own), that's also generally true in the existing system except for some exceptions. In particular the one cited in the article.
I don't think single payer is the right answer especially for the USA. The US has a much stronger bent towards freedom, independence and self determination. I think some sort of hybrid, a la France, is more appropriate.
Not being able to quit your corporate job because you desperately need the health insurance is a really interesting kind of freedom, independence and self determination.
Calculated risk assessment isn't the same thing as lack of freedom. I have cystic fibrosis, so I've been making those decisions for a long time. (100% freelancer here)
The first rule of politics is that unintended consequences abound.
That isn't to say that a single-payer is better or worse, but we should be methodical and careful when considering wholesale replacement of the incentive structures.
Of course that wouldn't prevent any doctor and patient from doing whatever they wanted, at their own expense.