I’ve been working in the health tech space for awhile now and it’s sad how you’re not alone in noticing this. It’s the dirty secret of the entire industry, and there’s too many things disincentivizing any fixes.
The more I witness this the more I realize that having a single payer is necessary to actually break up enough of the monopoly to get some traction on this problem. Until then there are too many middle men and bureaucrats blocking this change.
> The more I witness this the more I realize that having a single payer is necessary to actually break up enough of the monopoly to get some traction on this problem. Until then there are too many middle men and bureaucrats blocking this change.
By "single payer" do you mean the European model of "socialized" healthcare? That may be necessary (I don't know) but it's clearly not enough.
I'm in France, and I hear the exact same complaints from physicians here [0], and the hospitals seem to be in terrible shape. People quitting or being on leave, hence understaffing, so more people quitting because of burnout, etc.
[0] Basically, the gist is that for some time, hospitals have been run "like an enterprise", seeking (cash) efficiency above all. There was absolutely no slack in the system, so when COVID hit, medical professionals ended up in a terrible situation. This situation has not subsided even after the epidemic became less of an issue.
I'd like to see a different take on single payer. First, allow anyone to buy into medicare for their insurance provider (at a market reasonable price for younger people, subsidized like it is now for seniors). This could act as a nation-wide insurer without any "funny business" such as getting charged thousands because an assistant that wasn't in-network showed up the day of your surgery.
Second, if an employee isn't covered by employer healthcare, the employer side of FICA should be increased to provide for employee coverage. That way if someone is working 40 hours a week, but for multiple part-time employers, they still get the same medical coverage as a full-time employee.
Third, when I go in for a procedure, I want all bills to go to the insurance provider, they pay everything. Then the insurance sends me a bill for my co-pay. Make that a law. That way I'm not stuck with getting dozens of separate bills up to years after a procedure, with no way of really knowing what should have been covered by insurance or not.
This is essentially what the “public option” in the original Obamacare proposal was — an opt-in publicly owned insurance company, which would compete with all the other insurers, but not have the overhead of their business models. Unfortunately, it was axed alone with much of the other important aspects of that bill.
The great irony is that the initial Obamacare proposal was a Republican policy — originally proposed in the mid-‘90s as an alternative to the proposal from the Clinton White House, and implemented in Massachusetts by Mitt Romney when he was the governor. The Republican congress and conservative media machine were so invested in seeing Obama fail that they instead branded it socialism and fought it tooth and nail. It would’ve been a fantastic opportunity for a resurgence in bipartisanship in government, and could potentially have averted the subsequent 14 years of animosity and bitter obstructionism. Ah well, so it goes.
> By "single payer" do you mean the European model of "socialized" healthcare?
Its socialized healthcare. You dont have to put in quotes. It was first advocated by socialists in the First Socialist International at the end of 19th century. It constitutes part of the social democratic program.
The reason I put it in quotes is that at least in France, healthcare is not completely free, and somewhat resembles the US model. Sure, everyone has to pay and gets "free" healthcare, but that's the basic level, barely above "none".
If you need dental work, glasses, etc, you better have either cash or a "mutuelle", which is usually tied to your employer (though you can purchase your own above that if you like). Lower-level jobs don't always have one (or it doesn't cover much).
However, procedure prices might be lower than in the US, though (I don't actually know) which is a big part of the issue with access to healthcare.
> in France, healthcare is not completely free, and somewhat resembles the US model
That's the result of the privatization that has been pushed by the Anglosaxon business lobbies to Europe and everywhere else since Reagan/Thatcher period. They forced privatization of whatever they could get away with. Its still a socialized system with some forced privatization being pushed through. France is not the only country - all US satellites have been pushed to do some degree of privatization.
Procedure cost is a huge factor: AFAICT, it's generally cheaper everywhere than the US, frequently dramatically cheaper, for the same procedure, for out-of-pocket (non-insurance) cost.
Here in Japan, everyone has insurance, either private through their company, or public through the government, and the insurance pays a flat 70% of the cost, and the patient pays the other 30%. But the procedure costs are generally not that high to begin with, so the 30% copay ends up being pretty cheap usually.
Single payer is certainly socialized public healthcare, but not all socialized public healthcare is single payer. I think Americans are predisposed to treat it as an either-or because Canada, which is used most often for comparisons by virtue of being the country with which relatively more Americans are familiar, is single payer. However, many European countries aren't, and there's no discernible pattern for countries with single payer being better than other forms of public healthcare.
I think pushing for single payer specifically is one of the biggest mistakes of the American left, because it's that much harder to sell in US due to more restrictions - and that's inherent in the model. If we took something like the German model instead, I think we'd be way ahead by now.
I could see a single payer system having the same problems. All it would take is a system with some incentive to save money, and a bureaucracy. I could easily see Congress designing a single payer system that had both of those.
Would it be as bad? Hard to say. In one way it would be worse: There would be no alternative. You couldn't switch insurance providers to get something better.
And, in fact, just today I saw stuff about a lady in Canada who had to wait 7 hours (+/- a small amount, don't have it in front of me) for the ER, and wound up dying. People were saying "The system is broken." Well, isn't Canada single payer?
So maybe single payer isn't a magic solution. Maybe we should look at what's going wrong in Canada before we design such a system ourselves. (Single payer may still be the answer, but it's going to have to be a well-designed single payer system.)
>I could see a single payer system having the same problems.
You can look at the UK right now. The root problem has nothing to do with health insurance companies or who is paying. The problem is drastic increases in net benefit recipients relative to net payers/labor providers into the system.
I.e. declining proportions of healthy, working people willing to provide labor at a sufficiently low price, such that in order to keep providing the same level of service, more and more of the country’s resources have to go towards healthcare.
The other problem is also advancements in medicine that keep people alive longer and longer while utilizing ever more healthcare services.
To be fair, the current govt is preciding over a (self inflicted) economic collapse in all areas, not just the NHS.
And ultimately voters have no-one to blame but themselves. (or half of them anyway.) leaving the EU is epically dumb on a truly impressive scale.
So now looking at the NHS, complaining about under-funding and under-staffing, when those were completely predictable outcomes of Brexit isn't going to inform good health system forces.
Japan might be a better place to look if you want examples.
In truth the US has plenty of money in the pot to implement effecient health care. But for-profit companies will not go quietly into the night.
> So now looking at the NHS, complaining about under-funding and under-staffing, when those were completely predictable outcomes of Brexit isn't going to inform good health system forces.
I don't agree with this. I don't live in Britain, so I'm not fully aware of how Brexit has affected things over there.
I live in France. Didn't leave the EU, as a matter of fact it's one of the countries pushing the most for it. Same issues with the health system. A few months ago we were rationing paracetamol. Now we're back to not allowing sales of it online because of shortages.
I'm not saying Brexit helped, but I doubt it was the main cause, seeing how the same exact effect happened elsewhere, at the same time, while staying in the EU.
It would seem to me that, for whatever reason, many countries chose efficiency of the healthcare system above all else. Meaning closure of hospital beds, reduction of medical staff, etc.
This may be great for producing cheap Toyotas. No one cares if theirs is one week late because something unforeseen came up. It doesn't work as well for medical emergencies.
Its pretty easy to find shortages and flaws in any system.
And yes, national health is always tempting for budget cuts because its a huge number, and trimming it 5% gives real returns.
Shortages of drugs and equipment are often tied to supply-chain issues more than budget, and again that's a barrel of worms best left for another thread.
Clearly single-payer can work, but it does need the single-payer to, well, pay.
Brexit is a large factor because the UK was a net-importer of aid from Europe. And Europe was the biggest trading partner. Predictably leaving has decreased the economy such that tax revenues are down, which in turn means less to spend on social services.
Then we can talk about freedom of movement, and the number of Europeans who staffed the NHS and who no longer do so, and cannot be replaced by other Europeans.
So sure, the global economy is taking strain at the moment. Brexit is not the only cause. But its a pretty big sucking chest wound.
Sure, every situation has its shortcomings, possibly even big sucking chest wounds which don't help.
But my point was that if multiple systems, some of which seem different (US vs EU), all with different apparent wounds, appear to fail in the same way at the same time, maybe there's something that's common among them which is the actual cause. Perhaps it's just a coincidence. But which is more likely?
France absolutely has staff and funding shortages, on top of the supply chain issues for medicine [0].
For the US, there sure is the affordability issue, but I don't think that's anything new. However, OP's point is that there had already been staff shortages for a while before COVID, but now the proverbial camel's back has been broken:
> Ultra lean staffing prior to covid led to the sh*tshow during the pandemic and, now that everyone is quitting, things are now in total collapse. [...] There are 30 rooms in the ER, but 3 nurses overnight…
This is the exact situation in France. The hospitals are physically still there, but there's not enough staff.
I don't get why the underlying problem is not even being discussed here at all. Any attempt to fix the system will have to increase investment in both training and drug research.
This will be a large investment (if doubling the training budget produced double the graduates that would not be enough), and will NOT bear fruit until those people actually graduate, which is 6 years minimum, and mostly 10 years away. So for 10 years, it means paying through taxes while getting minimum to no improvements in return. Furthermore, such a large increase is not possible at short notice, even if the money is available, so it will take more than 10 years time.
For research one might take profit margins of large pharma as an indicator: a fully nationalized, but equally capable, pharma research system would cost some 15% less, assuming nationalizing introduces zero inefficiencies. BUT that money would have to come from taxpayers directly through the government budget.
And nobody is looking for 15% reduction in drugs costs. That just won't move the needle enough. So in reality the government would have to increase the drug research budget to make drugs cheap.
Failing to do this will mean medicine becomes less accessible to people, regardless of whether we switch to a single payer system or not.
So let's get real here: we will fail to do this, and it will get worse.
The problem in the UK is that conservatives and neo-liberals have been actively dismantling the service over the last 20 years.
At a time when there were already staffing difficulties conservatives dis-incentivised people from becoming nurses by removing training bursaries.
Parts of the system have already been stealthily privatised with the associated drop in quality and additional costs. In many cases employees of the NHS are simultaneously being paid private rates using public money through schemes like "right to choose".
At a time when staff nurses are being told they don't deserve higher pay, private agencies are being paid >3 times the staff rate in order to fill gaps in staffing caused by lack of pay and overwork. The result is artificially inflated staffing costs and an incentive for the remaining staff to move over to the agency for what is often double what they'd be earning.
The correct course of action is to bring costs back into line by expunging the parasitic private healthcare system. Every agency position eliminated pays for 2 staff nurses with a healthy pay rise. The improvement to staffing ratios would further improve the nature of the job.
Let poorer countries pay to train nurses and doctors, and then wealthier countries take the best because they can pay more for them due to economic dominance.
We do it in New Zealand by importing a lot of doctors (Chinese and Indian seem common), and nurses . The reason we need to import doctors is because we export a lot of doctors and nurses to wealthier countries such as the USA.
In New Zealand, we get people from poorer countries because we can pay more, and we also get people from first world countries because people want to move here for the lifestyle or for their children.
I've read that a single-payer system is very unlikely in the USA, due to political forces. The tremendous inefficiency of the American medical system increases costs, but also provides more jobs, and those job-holders vote.
In the USA its all about the money. Those "political forces" are not a grassroots movement, people in the street demanding insurance-based healthcare.
No, it's well organizes, very well paid, lobbying on behalf of a profit-based health system. A system that generates lots of profits for nice big companies.
And make no mistake, they're not going to roll over.
And sure, doctors are depressed because they're finally coming to realise that medical care (in the US) is not about "helping sick people" (despite their good intentions.)
Doctors and nurses set out with the noblest goals, then find themselves inside a system where the one true goal is to separate people from their money. They rile against "adminustrators" while at the same time failing to note that those administrators are the _reason_ for yhd business, and actual doctoring is just medical janitoring.
> are not a grassroots movement, people in the street demanding insurance-based healthcare.
> No, it's well organizes, very well paid, lobbying on behalf of a profit-based health system. A system that generates lots of profits for nice big companies.
I am not a lobbyist or an owner of an insurance company. I am a "person on the street". I do not want single payer.
I despise the current system, but arguments like this do a lot of damage to the reform cause.
Aside from the incredible arrogance of assuming that GP is just so much stupider and more manipulable than you, it's also factually wrong in enough cases that it instantly discredits you. For example, many people who are upper-middle-class and above are better off in the current system.
When there is a fixed amount of X available, a fair division of X across Y people gives everyone X / Y.
When you need more than X / Y, you are screwed (ask anyone in england who's needed cataract surgery on their second eye and was told that QoL improvement was not there, like it was for the first, so GTFO)
Since I can afford to buy a lot more than X / Y of healthcare for me and my family, should it be needed, the outcome for that limited and, to be honest, complete set of people whose well-being i care about is better in the current system.
I completely agree that the current system is excellent for those who can afford it, and queuing-based-on-worth certainly appeals to those with worth.
In the US this worth translates into money, which translates into lobbying. You are not marching in the streets because you don't need to. Your money speaks for you.
I say this not to patronise you, since you clearly understand this is the case. I say it merely to point out that this system works for the few, not the many. And yes it works well for the few.
Regarding your cateract example, if the queue is need based, and you have two patients, then one with 2 cateracts is ahead of someone with 1. That's another system, a system I agree which would be most distressing to someone with 1 careact and lots of spare cash.
I get that any system other than the current one will make you worse off. Equally I hope you see that any system at all will be a massive step forward for huge numbers of people.
Sure, I get it. I prefer systems that favor me. The seething masses aren't "real" to me. I don't know them like I know me and the people I care about. I care about my medical needs now, not some hypothetical "other person". Like you, I can pay for my medical, and I appreciate that I can.
But I also wonder if this is the best way. It works for me, but maybe there's something better for us all.
I will also add that many problems in the US and other countries stem from the perversion of incentives and benefits of the few over the many. What I mean is that keeping this broken system in place as it greatly benefits the insurance companies, of which there are a few. It’s so valuable that they have the money and resources to buy the politicians, pay for the media campaigns and lobby the propaganda outlets to mitigate any power the populace has to address the issue. This allows industries to control pretty much all policy in the US. It’s a sad state of affairs.
> a system I agree which would be most distressing to someone with 1 careact and lots of spare cash.
It wouldn’t be distressing to someone with lots of spare cash in the UK because they would just get the surgery done privately. There seems to be a common misconception that private healthcare is not available in the UK.
> ask anyone in england who's needed cataract surgery on their second eye and was told that QoL improvement was not there, like it was for the first, so GTFO
A bad example, given that private cataract surgery is quite affordable in the UK. You could quite easily pay that much in the US even if you had insurance.
New technology, new knowledge and training all increase X. It's relatively fixed at a given moment in time (where your point is very true), but society shouldn't be making a major structural decision one moment at a time.
That is far too simple, as if citizens voting made a difference. Today, single-payer systems are overwhelmingly popular in the US, but one has yet to be implemented. The political corruption (known as "campaign contributions" which is "free speech" in the US after the citizens united decision) ensures that it won't happen, despite it being overwhelmingly positive in polling year after year on both sides of the aisle.
It will also massively hurt global drug and medical research.
We are the leader in it partly because we pay these exhortation prices when the rest of the developed world simply won't play that kind of game.
I'm okay with biting that bullet, and taking a global reduction of health research by some double digit percent for awhile, but that's a serious unintended consequence of single payer.
I'm a Bernie voter who supports single payer, but it's not sunshine and roses everywhere, and crooked capitalism really does do some "not bad" things for us.
> It will also massively hurt global drug and medical research.
This may not be the case, since much research is subsidized by the government and educational funding providing labs that train the scientists the pharmaceutical companies utilize. Single-payer may result in lower costs and therefore more money for support of research and laboratories. Also, pharmaceutical companies would not need to spend vast amounts for marketing their drugs direct to consumers.
The government subsidizes much of the basic research needed to identify candidate drugs. However, private companies usually pay for the human trials necessary to bring new drugs to market. A stage-3 clinical trial can cost >$1B with no guarantee of success. It's a huge financial risk.
In theory we could nationalize the whole industry, and let government bureaucrats decide which clinical trials to fund. I'm skeptical whether that would produce better results. Government employees with no skin in the game have a poor record of picking winners.
> It will also massively hurt global drug and medical research.
I doubt it would. Private drug companies would still exist and charge the same money regardless of whether the insurance is paying for it or "the single payer system".
I don't know, many of the major drugs, like penicillin, insulin, thorazine, birth control etc were developed without those hurdles, and not in the USA. But US gave us Viagra)
We already have a ridiculously regulated, stifling environment. More stifling is not the answer, just look at the wait times and patients being denied basic care in Canada and the UK. We need to end the ridiculous grip the AMA has on the # of doctors; get rid of the hospital certificates of need, and encourage a new industry of medical professionals who specialize in certain areas without unneeded training in other areas.
Canada and the UK illustrate the downside of single provider, but the US has embraced all of the bad about single provider, but with multiple providers. Anyone can get into the game, but no one tries to make the product better. The patient is not the customer in either the US or Canada or the UK. They are the same in that respect and that is what matters.
The American Medical Association does not control the number of doctors. The primary bottleneck in producing new doctors is limited federal (Medicare) funding for residency programs. The AMA has been actively lobbying Congress to increase the number of doctors.
“… encourage a new industry of medical professionals who specialize in certain areas without unneeded training in other areas.”
Sounds stifling. What’s the problem with holistic training? Except some admin does not want to pay for it?
Extreme division of labor will just create backups for some specialists and time to twiddle thumbs for others.
The opposite across society seems necessary; people need to become more self reliant across contexts. Remove industrial manufacture pipelines so more raw materials are available to the general public and make more holistic and well rounded people.
I don't know. In my opinion there's nothing wrong with holistic training but I think there's also nothing wrong with different training paths. Better to let them all flourish and find their way in the system.
It all needs to happen in my opinion though: let the current provider models stay, but let in lots of other educational models, and empower people to take more care of themselves by giving them access to what they need. Everything is far too overregulated in medicine, or at least is regulated in the wrong way.
Even within the physician model it's broken and overregulated. Board certification is ridiculous and insane in some specialties.
I think medicine is just an amplified version of a lot of problems in the US, but it also has significant consequences for life and wellbeing.
Single payer is good but it doesn’t solve the problem of really sick old people running up the bill for everyone. I don’t even see what the way out is. Really old people that are subjectively classified as irrecoverable have to get private insurance on top of single payer maybe otherwise you get cut off. That subjective decision maker will get called a “death panel” though. Someone’s got to make some hard decisions somewhere.
The more I witness this the more I realize that having a single payer is necessary to actually break up enough of the monopoly to get some traction on this problem. Until then there are too many middle men and bureaucrats blocking this change.
Thanks for fighting the good fight so far.