> Single-payer essentially nationalizes more than fifteen percent of the US economy (by dollars). It would more or less make every doctor, nurse, and technician an employee of the US government. But much more importantly than that, it would remove broad market price discovery from allocation of medical services. Instead of prices rising or falling to match demand from actual consumers, things would cost what a system of bureaucracies would say they cost
Eh? Universal healthcare doesn't mean price regulation. The price signals are still there but you now have a very large public buyer able to negotiate prices with very big private suppliers. How is that not better than the current system where large numbers of citizens cannot afford adequate healthcare and big companies can extort whatever price they want out of those seeking access to life-saving drugs?
> They also have a valid concern that single-payer would distort and degrade the health care system.
Degrade how? Universal healthcare can still work with e.g. privately-run hospitals and clinics. You don't need the government to hire all the medical practitioners; just pay for the cost of treatment.
If there's a single federal buyer paying for 90+% of the market (look how much of the market for seniors Medicare covers), it's hard to see how the price signals continue to work the same way. The (slow, error-prone) political process is engaged in every buying decision.
Already you can see that changes in the way Medicare reimburses and measures outcomes have impacts on the way services are delivered today, and Medicare is just a fraction of the overall market for health care in the US.
The federal government doesn't hire all the practitioners. They just fix all the prices.
At any rate, there's a difference between disagreeing with an argument and pretending that it doesn't exist, as other comments on this thread did.
(I am in part assuming the mantel of the GOP argument against single-payer here; I prefer the Swiss system to the NHS, but unlike most Republicans I strongly believed that a national solution was needed for health insurance and financing.)
Public and private spending in most single-payer countries is far, far lower than what it is in the United States. The bloat is a product of market inefficiencies:
What you are suggesting is essentially that market failures have made private health care "too big to fail." Not a reasonable argument when public health is at stake.
First, be careful with the word "you". As I've been at pains to point out in both comments on this thread: this isn't my position.
Second, "lack of single-payer insurance" isn't why Americans overpay for health insurance. We have collusion between cartels of buyers and sellers (hospital chains and insurance companies) with secret price lists, funded by HR managers several hops away from the actual demand for services. It is probably enough to decouple insurance from employment. The Swiss, for instance, don't have a single-payer system, and they also pay far less than the US on health care.
(That latter argument, unlike the ones I've written about previously on this thread, actually does represent some of what I believe).
> If there's a single federal buyer paying for 90+% of the market (look how much of the market for seniors Medicare covers), it's hard to see how the price signals continue to work the same way.
I'm not sure I follow. Price signals are based on demand. The same demand is still there in the sense that customers still interact with private health providers. The only thing that changes is payment is now handled by a single government system. Uncle Sam guarantees you access and his guys sort out the payment with the private provider, later.
> The (slow, error-prone) political process is engaged in every buying decision.
I'm not sure I agree with your premise for a start (i.e. publicly ran organisations are necessarily slow and error prone) but setting that aside, why is bulk billing between government financiers and the private health providers not an option? The government knows how much demand they have for XYZ product or service so they can negotiate based on volume. Have I missed something?
> Price signals are based on demand. The same demand is still there in the sense that customers still interact with private health providers.
Price signals require both a supply side and a demand side. Government funded healthcare likely increases demand, since it reduces cost on an elastic good. However, it also reduces supply, since it reduces payment.
To put it another way... if we passed a law saying that all programmers could charge at most $30/hr [edit: which is a good wage compared to other non-degree requiring jobs] we would have increased programmer demand (since now more businesses can afford programmers) and would also have less total programmers since many would switch careers to meet their financial needs. Something similar would happen in the medical industry with a single large federal buyer.
> The government knows how much demand they have for XYZ product or service so they can negotiate based on volume. Have I missed something?
This is also missing the supply side. When you take money from one group and give it to another it is very very important to look at what happens to the group you've taken from in addition to the group you've given to.
The real value in healthcare hasn't been created yet. It's in the drugs of the future. Changing the incentive structure for health startups changes how many people found healthcare startups.
A system with basically a single buyer is a reverse monopoly (ie http://en.wikipedia.org/wiki/Monopsony). If you find you're building a product for essentially a single customer... you should probably found a different company. They're not going to voluntarily pay you anywhere near what you'd make in a real market.
> Price signals require both a supply side and a demand side. Government funded healthcare likely increases demand, since it reduces cost on an elastic good. However, it also reduces supply, since it reduces payment.
I'm not arguing for the government to fix the cost of drugs or health services. I'm arguing for the government to guarantee access to a minimum set of healthcare products and services and then negotiate price with the providers based on uptake. From a consumer perspective, this is much better. Far better than buying said products and services directly from a monolithic private entity.
From a supplier perspective, this is less good and there may be some incentive to artificially limit supply. But that's why we have governments in the first place: to take over in cases where the market is unable or unwilling to function in a way that is beneficial to society as a whole. If private hospitals decide to limit the number of e.g. heart procedures per year then government needs to step in and either regulate or take other measures to ensure the delivery of essential services.
> If the government is guaranteeing it'll pay, why give them a price break?
Because you want to stay in business and there are other healthcare providers the government could use instead? Including those providers that are publicly funded?
In the case of expensive drugs, there are a myriad things the government could do including taxpayer subsidies, government health loans and placing limits on the length of the period a private company can exercise monopoly control over substances deemed necessary for universal health.
> Because you want to stay in business and there are other healthcare providers the government could use instead?
Okay, now suppose that you have a patent on a particular drug or device or procedure and as a result are the monopoly provider of it. Where does the government go to get the lower cost alternative? Where is the downward pressure on your prices?
Please refer to my points re subsides, loans and limits. These are not insurmountable problems. Many other countries have figured how to make universal health achievable. IMO it is time America did the same.
>>>> If the government is guaranteeing it'll pay, why give them a price break?
>>> Because you want to stay in business and there are other healthcare providers the government could use instead?
>> Okay, now suppose that you have a patent on a particular drug or device or procedure and as a result are the monopoly provider of it. Where does the government go to get the lower cost alternative? Where is the downward pressure on your prices?
> Please refer to my points re subsides, loans and limits. These are not insurmountable problems.
So first you say that market forces will still be in play because the government could always go elsewhere. Then when provided with an example of a situation where market forces cannot come into play, you suggest that legislation can fix it. That is EXACTLY what tptacek was the problem, the loss of MARKET incentives and information.
> I'm not sure I follow. Price signals are based on demand.
Normally demand goes down as price goes up because more and more entities get priced out of the market. With the government as the sole (or very nearly sole) buyer demand is constant because the government quite literally has a mandate to supply healthcare to the citizens. That means that suppliers have no incentive (short of avoiding legislative action aimed at them which they can cheaply and easily dodge through lobbying) to bring prices down. It's in their interests (read profit motive) to supply as much as they can at as high of a price as they can. This is the problem that people are talking about.
> 1. If the government is guaranteeing it'll pay, why give them a price break?
Why indeed? The threat of legislative action? See my comments above re: lobbying. Got a way around that? Most of the population of the US would be VERY interested to hear how you circumvent it. So far the only halfway viable strategy is what Lawrence Lessig is doing with mayday.us and that's a long way from making it a solved problem.
2. If the reason is passing laws saying you have to give them a price break (as you imply in paragraph 2), how is that not price fixing?
Again, see comments re: lobbying. Unless there is no possible way to circumvent the lobbying problem you're simply proposing that we replace one broken system which you dislike -- and rightly so, it's not that great -- with another broken system which you like. Sure you like it better but others do not. We're at the point of arguing about opinions.
"But other countries do it just fine!" you say. Okay sure, but which other countries with single payer systems have the kind of demographics that we do here in the US? Answer: none. They're all relatively small countries (relative to 310mm people) with rather homogeneous demographics (again at least compared to the US).
It MIGHT work OK and it MIGHT not be more broken than the system we have now but those aren't guarantees.
Way to miss my point. Well done guy. Fight that good fight for unfettered capitalism. Americans don't need no stinking commie health system, amirite?
Once again: universal health doesn't mean price regulation. Like any private insurer the government can negotiate for lower prices when multiple providers exist and subsidise the cost when they do not. I also see no problem with limiting monopoly control over life saving substances. That's why we have governments. To act in the best collective interest.
That's a bit unfair. I wasn't making a personal attack; just posting a sardonic rebuttal to a poster who seems to me more interested in pushing a specific ideology than posting a considered response to what I have been saying.
> Way to miss my point. Well done guy. Fight that good fight for unfettered capitalism. Americans don't need no stinking commie health system, amirite?
This is what bugs me. You're arguing against what you THINK I'm arguing, not against what I'm ACTUALLY arguing.
I'm not saying that American healthcare is a paragon of efficiency and low cost. Nor am I arguing against "commie health system" but instead that the idea that having a SINGLE purchaser of medical care will quite likely result in less good information about prices and as a result less efficiency.
Right now in the US we have a problem where not enough price information is known: almost no doctors list prices anywhere that a person can find PRIOR to going to a doctor. How could that be remotely efficient?
Wanna buy some Microsoft stock? OK just call up a million people who may or may not tell you how much they want for their shares. Depressed yet? That's how terrible the price information is in the medical world. It's no wonder everything is so damn expensive.
Yes you can trot out the tired old trope about "but medical care isn't something you can't shop around for!" which is true really only in trauma cases where minutes are the difference between life and death. Got a cold? You've got time. The flu? You can check around. Broken bone? Uncomfortable yes but realistically you could spend 15 minutes on doctor-yelp so long as it's not a blood-gushing compound fracture. Mess up a joint like say an ACL? They're not going to operate on you the same day anyhow so might as well spend an hour reading reviews. Having a kid? Guess what, there's a roughly 9 month lead time on that one. You could spend a week shopping around.
> Once again: universal health doesn't mean price regulation.
If the government is the only buyer of medical care and they "negotiate" for discounts and don't do business with people who "charge too much" then that's EFFECTIVELY regulation. It might not be in the technical sense; there might be no law saying "an ACL surgery costs $4200" but if the sole purchaser of ACL surgeries says it's not willing to pay more than $4200 that kinda-sorta sets the price.
You can argue 'til you're blue in the face on technicalities and whatnot but if it walks like a duck and quacks like a duck most people will agree that its a duck.
> I'm not saying that American healthcare is a paragon of efficiency and low cost.
Good. Because it isn't. American healthcare is a laughing stock in the developed world. Per capita, Americans spend more of their income on healthcare than countries with universal health. Ironically, health outcomes for Americans are actually worse.
You can shop around for elective procedures. If you are sick however, shopping around is a terrible and exploitative burden. You're sick. Your primary concern should be to get help and get better, not whether or not you can afford it.
> If the government is the only buyer of medical care and they "negotiate" for discounts and don't do business with people who "charge too much" then that's EFFECTIVELY regulation. It might not be in the technical sense; there might be no law saying "an ACL surgery costs $4200" but if the sole purchaser of ACL surgeries says it's not willing to pay more than $4200 that kinda-sorta sets the price.
This isn't what I'm saying at all.
Firstly, I'm not saying the government is the sole buyer of healthcare services because experiences the world over (UK, Australia etc) have shown there's plenty of room for private insurers.
Secondly, I'm not saying that prices are kinda-sorta fixed. What I am saying is that if the government decides apriori that ACL surgeries (whatever that is) are something that's important to universal health, and something everyone should have access to, they subsidise the cost. Period. Whatever it is.
If multiple providers exist, they opt for the cheaper option. If they're getting stiffed by all the private providers then the government has two options: (i) they can decide to offer ACL surgeries in public hospitals for a lower price; (ii) (in the case ACL surgeries depend on some very expensive bit of licensed kit controlled by a single supplier) they can set limits on the amount of time that supplier can wield exclusive control over this technology. Break the monopoly, lower the price. Recall that they've decided beforehand ACL surgery is something everyone should access to.
Eh? Universal healthcare doesn't mean price regulation. The price signals are still there but you now have a very large public buyer able to negotiate prices with very big private suppliers. How is that not better than the current system where large numbers of citizens cannot afford adequate healthcare and big companies can extort whatever price they want out of those seeking access to life-saving drugs?
> They also have a valid concern that single-payer would distort and degrade the health care system.
Degrade how? Universal healthcare can still work with e.g. privately-run hospitals and clinics. You don't need the government to hire all the medical practitioners; just pay for the cost of treatment.