Universal Medical Insurance

[lpetrich]

Vox explores health care systems around the world in Everybody Covered - Vox - "What the US can learn from other countries’ health systems."

... Vox reporters traveled the world last fall to see other health systems in action, talking with doctors, patients, and government officials to get the full and often complex picture. Everybody Covered takes a closer look at a single-payer plan in Taiwan, a private-public hybrid in Australia, supercharged Obamacare in the Netherlands, the vaunted National Health Service of Great Britain, and an innovative hospital budgeting scheme right here in Maryland. Our project was made possible by a grant from The Commonwealth Fund.

How Taiwan built “Medicare for all” and gave everyone health insurance - Vox

In the 1990s, Taiwan did what has long been considered impossible in the US: The island of 24 million people took a fractured and inequitable health care system and transformed it into something as close to Sen. Bernie Sanders’s vision of Medicare-for-all as anything in the world.

...
There’s clearly a need for lessons. Compared to the rest of the developed world, America spends more money on health care and produces worse outcomes. By one advanced metric — mortality for causes that should be avoidable with accessible, high-quality health care — the United States ranked last among the G7 countries in 2016. America’s infant mortality rate is almost double that of some of its peers. Nearly one in 10 Americans lack insurance. People go bankrupt over medical bills. Yet Americans still spend about twice as much money on health care per capita as the average comparable country.

No health care system is perfect. But most of America’s economic peers have figured out a way to deliver truly universal coverage and quality care. The United States has not.

It was inspired by Canada's single-payer system and the UK's National Health Service.

A lot of people didn't like it at first, and many people doubted that it would succeed, but it did. Some 25 years after it was established, its approval rating is 80%.

Part of its appeal is its simplicity. Everybody in Taiwan is insured through the National Health Insurance Administration (NHIA). They receive an ID card as proof of coverage, which also stores their medical records. The Taiwanese program runs with extraordinary efficiency: About 1 percent of its funding is spent on administration, according to a 2015 review by Cheng. (Compare that to the US, where researchers have estimated that private insurers spend around 12 percent of overhead, and hospitals spend around 25 percent on administrative work.) Experts say Taiwan’s advanced IT infrastructure deserves a good share of the credit.

Benefits are generous, and though it does have copays, they are small, about $12.

"Taiwanese patients use a lot of health care, and it puts a strain on providers"

Chien says he sometimes sees the same patient dozens of times every year in the emergency department where he works, often for problems that aren’t emergencies. The low costs mean patients have little incentive to avoid the ER.

“Everyone wants to live forever, but it’s impossible,” Chien says. “Some people abuse emergency, abuse health care.”

At the same time, because Taipei has a lot of traffic accidents, injured drivers and pedestrians come through his emergency department’s doors all the time. His attention is divided when it shouldn’t be.

"Sustaining a single-payer system requires hard choices for patients, providers, and taxpayers"

National health insurance achieved what the Taiwanese government hoped it would. Everybody can afford health care. People are living longer, healthier lives. But the ever-growing cost of providing health care to everybody makes it challenging for the program to remain financially sustainable.

...
But it helps that national health insurance has proven so popular. People want to make it work because single-payer has clearly improved Taiwanese lives.

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It may take more than that. Shou-Hsia Cheng, the NTU professor, predicted Taiwan would soon have to reevaluate its payments for end-of-life care. The country is currently debating how to expand long-term care for an aging population; it’s not covered by the national health plan.

I think that that is a serious issue - how much should we try to keep alive people who are very sick, when it may be a lot of effort with very little gained.

 

[Trausti]

This US tort system permits patients to sue doctors and hospitals for alleged medical error. The legal costs of defending and paying out on such claims - whether meritorious or to avoid the risk at trial - is substantial. Equally substantial is the professional insurance premiums that that some doctors have to pay (especially obstetricians and surgeons) and the costs of self-insurance and umbrella insurance for hospitals. If you impose Medicare for All, with its very low reimbursement costs, the likelihood is that the US medical system would collapse. Doctors and hospitals would no longer have the income to afford liability insurance. Be careful what you wish for.

 

[Jolly_Penguin]

Medical malpractice lawsuits exist in Canada as well. Canadian doctors have liability insurance.

 

[Trausti]

Medical malpractice lawsuits exist in Canada as well. Canadian doctors have liability insurance.

Medical malpractice litigation is quite different in the States.

 

[ZiprHead]

Medical malpractice lawsuits exist in Canada as well. Canadian doctors have liability insurance.

Medical malpractice litigation is quite different in the States.

Please, explain the difference.

 

[Trausti]

Medical malpractice lawsuits exist in Canada as well. Canadian doctors have liability insurance.

Medical malpractice litigation is quite different in the States.

Please, explain the difference.

For a start non-economic damages are capped at ~CA$300k. Most states have no caps, thus, you get multimillion dollar verdicts. Liability insurance is a different beast, as Canadian doctors are required to pay a fee to the Canadian Medical Protective Association. The provinces mostly reimburse doctors for the fee. The Association then defends the doctors against negligence claims. Not at all like in the States.

 

[KeepTalking]

Please, explain the difference.

For a start non-economic damages are capped at ~CA$300k. Most states have no caps, thus, you get multimillion dollar verdicts. Liability insurance is a different beast, as Canadian doctors are required to pay a fee to the Canadian Medical Protective Association. The provinces mostly reimburse doctors for the fee. The Association then defends the doctors against negligence claims. Not at all like in the States.

So, we change that at the same time. Either that, or we throw up our hands and say, "We can't change two things at one time, so it is better to do nothing." I know which plan sounds better to me.

 

[ZiprHead]

Please, explain the difference.

For a start non-economic damages are capped at ~CA$300k. Most states have no caps, thus, you get multimillion dollar verdicts. Liability insurance is a different beast, as Canadian doctors are required to pay a fee to the Canadian Medical Protective Association. The provinces mostly reimburse doctors for the fee. The Association then defends the doctors against negligence claims. Not at all like in the States.

We get multi million dollar verdicts because sometimes people will need millions throughout their lives to provide themselves the healthcare they need. That care is paid for in Canada by the state instead of the victim as in the US.

 

[Loren Pechtel]

Please, explain the difference.

For a start non-economic damages are capped at ~CA$300k. Most states have no caps, thus, you get multimillion dollar verdicts. Liability insurance is a different beast, as Canadian doctors are required to pay a fee to the Canadian Medical Protective Association. The provinces mostly reimburse doctors for the fee. The Association then defends the doctors against negligence claims. Not at all like in the States.

We get multi million dollar verdicts because sometimes people will need millions throughout their lives to provide themselves the healthcare they need. That care is paid for in Canada by the state instead of the victim as in the US.

The state covers their direct medical care, not the secondary costs. Even here the real financial threat is those secondary costs.

And note that non-economic damage caps can be a big problem with how our legal system works--lawyers usually get a percentage, a non-economic cap can easily end up leaving the patient with less than their costs. If there is to be a cap the costs should be separate from that.

 

[Jolly_Penguin]

I have been saying this for years: there should be an automatic review of that lawyer fees by a judge as part of every trial at the end of it when awarding damages. Too few clients even know that they have a right to an assessment and too many lawyers overcharge.

 

[SimpleDon]

This US tort system permits patients to sue doctors and hospitals for alleged medical error. The legal costs of defending and paying out on such claims - whether meritorious or to avoid the risk at trial - is substantial. Equally substantial is the professional insurance premiums that that some doctors have to pay (especially obstetricians and surgeons) and the costs of self-insurance and umbrella insurance for hospitals. If you impose Medicare for All, with its very low reimbursement costs, the likelihood is that the US medical system would collapse. Doctors and hospitals would no longer have the income to afford liability insurance. Be careful what you wish for.

Medicare was first proposed as a trade-off for the existing situation in 1964. The providers were having to treat a large number of seniors without any hope of being paid for the treatments. The same held true for them treating the poor. Medicare said that that they would pay them somewhat less than normal but you will get paid something rather than nothing and as partial compensation, we will pay quickly as billed, subject to a clawback in the case of fraud.

There is no question that reimbursement rates would have to go up under Medicare for all.

There will have to be some tort reform in MoA. The existing situation with runaway abuse of the tort system is intolerable fiscally for everyone involved, except for the attorneys, not just for medical malpractice.

There is no question that the most expensive health care in the world is provided by private for-profit insurance companies in the US for policies written for individuals. This is because they are enormously inefficient.

The maximum loss ratio of 0.8 allowed by the ACA means that for every dollar spent on a premium 20¢ goes to an insurance company and only 80¢ goes to pay for health care. Medicare operates on a greater than 0.97 loss ratio, more than 97¢ goes to pay for actual health care from every dollar.

But this is just the start of inefficiencies of the for-profit system.

 

[Worldtraveller]

There is no question that reimbursement rates would have to go up under Medicare for all.

Why?

I hate that even people who support progressive healthcare reform think this is a given. The cost of comparable services in every other country with universal healthcare of ANY kind is significantly lower than the US. Doctors in those countries aren't starving or suffering. Maybe, just maybe, along with the healthcare reform, we might need to do something about the ridiculously escalating educational costs so new docs don't come out of school oweing $200k, but that is something we need anyway.

 

[ZiprHead]

There is no question that reimbursement rates would have to go up under Medicare for all.

Why?

I hate that even people who support progressive healthcare reform think this is a given. The cost of comparable services in every other country with universal healthcare of ANY kind is significantly lower than the US. Doctors in those countries aren't starving or suffering. Maybe, just maybe, along with the healthcare reform, we might need to do something about the ridiculously escalating educational costs so new docs don't come out of school oweing $200k, but that is something we need anyway.

At the hospital I worked at, new doctors fresh out of training started at $180K/yr and had their student loans paid off. More experienced physicians got a good bit more.

 

[James Brown]

On another board I frequent, this is a common argument by an educated, well-spoken liberal. In short, way too many people are handsomely compensated by the current system for them to quietly accept M4A. And if that segment of the population (8% to 9% of working Americans, according to his figures), who are well-organized, and fully lobbied-up don't get on board, then it will always be a non-starter. It's not just doctors--it's nurses and specialists and hospital admins. Nearly everyone in the US medical industry out-earns their foreign counterparts.

Yes, it's inefficient on a macro scale. But tell a hospital lab tech that she'll have to take a 25% pay cut so that no one goes without health care, and a lot of decent folks like her will decide that maybe the current system isn't all that bad.

The attack ads write themselves. "No, you won't be able to keep your doctor because he'll refuse to see you."

 

[lpetrich]

Australia built a hybrid public-private health system. Here’s how it works. - Vox

It is a combination of "Medicare for All" single-payer and private insurance. The private insurance costs more, but it has a higher quality of care.

Every decision has trade-offs. Australia is still figuring out what role private health insurance should serve alongside its universal public system. Over the past 45 years, it’s been a pendulum swinging back and forth: Conservative governments try to strengthen the private sector, pushing for the public system to act as more of a safety net, while the liberal governments focus on investing in and strengthening the public system.

And a reckoning is coming. Experts warn that the private insurance industry is heading toward a death spiral, with premiums rising steadily and healthier people dropping private coverage and relying instead on the public system. The crisis is forcing Australia to ask fundamental questions about how the country distributes its health care resources, and whether to continue to prop up the private market or invest more in public providers and public coverage.

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The thread running through these dilemmas is the choice Australians made a few decades ago: to build a hybrid health care system. Can a country find a balance between universal coverage for all and private choice for some who can afford it?

Eloise Shepherd stresses that Aussies are “fiercely proud” of their universal public insurance program. Medicare continues to enjoy robust approval from the public. But support for private insurance also remains strong (if not as strong as for Medicare).

Australia is trying to keep both systems running. But as the problems start to pile up, it may be forced to choose one day.

I think that a US "Medicare for All" system is likely to resemble Australia's system, at least initially, because the medical-insurance industry may be hard to dislodge.

 

[Jolly_Penguin]

The attack ads write themselves. "No, you won't be able to keep your doctor because he'll refuse to see you."

If you do it as it is in Canada, he won't have a choice. This is why you don't make a two tiered system with both private and public health care.

 

[Tom Sawyer]

The attack ads write themselves. "No, you won't be able to keep your doctor because he'll refuse to see you."

If you do it as it is in Canada, he won't have a choice. This is why you don't make a two tiered system with both private and public health care.

Ya, the solution isn't actually complex and you don't actually have to create something from scratch without knowing what it will end up being like.

 

[James Brown]

The attack ads write themselves. "No, you won't be able to keep your doctor because he'll refuse to see you."

If you do it as it is in Canada, he won't have a choice. This is why you don't make a two tiered system with both private and public health care.

And therein lies the problem, no? What doctor would support legislation that will take away her choice of how much to earn?

Would a car mechanic who makes forty bucks an hour support being paid only twenty bucks an hour on the idea that car repairs are too expensive for the average American?

 

[Jolly_Penguin]

The attack ads write themselves. "No, you won't be able to keep your doctor because he'll refuse to see you."

If you do it as it is in Canada, he won't have a choice. This is why you don't make a two tiered system with both private and public health care.

And therein lies the problem, no? What doctor would support legislation that will take away her choice of how much to earn?

They earn quite a lot under the Canadian system. Its the insurance companies that lose out on a ton of money.

If you want to make a loss of money/jobs argument, the best one would be for the people who work for insurance companies. Some of your insurance companies will adapt and others will go out of business entirely.

 

[ZiprHead]

Health care spending decreases under single-payer systems: Study

It's been a persistent question on the campaign trail and during debates, whenever presidential hopefuls Sen. Elizabeth Warren, D-Mass., and Sen. Bernie Sanders, I-Vt., tout their respective Medicare for all plans: How much is this going to cost?

The Warren campaign priced her plan at an eye-popping $52 trillion over the next decade. Sanders' approach would cost $34 trillion over the same period, according to the Urban Institute, a public policy think tank.

While those steep price tags may spook some voters, new research, which analyzed nearly two dozen national and state-level single-payer health care proposals made over the last 30 years, suggests that single-payer plans are projected to save the country money over time, many in their first year after being implemented.