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I believe its better in the cities but not necessarily the large ones as I don't think Baltimore and Orlando are among the largest cities.
When I lived in Stuart, FL I had an "issue" with a collapsed lung and the idiot surgeon gave me a 50/50 percent chance of making it. Day of operation he wasn't comfortable, so I took an ambulance ride to Orlando. Turned out my collapsed lung was due to stage 3 testicular cancer. ORMC was affiliated with MD Anderson in Houston, TX. That was 1999, this is me writing today. ORMC/MD Anderson was great.
Fast forward to a heart attack and kidney issues in 2013. My local hospital (Salisbury, MD) wasn't bad for my heart issues and my quad bypass the following year, but I live 3 hours away from Baltimore with Johns Hopkins and University of MD Medical Center. I had UMMC list me. They both are excellent hospitals which have excellent transplant teams, but UMMC also has a few satellite offices in the rural part of the state near me so I could list and be seen in one of those offices in a small, rural hospital. 7 years of dialysis and the first time I saw UMMC in Baltimore, other then a drive-by (not that kind......though it is Balt!) to make sure I knew where to go/park when the kidney call came, was when I actually had my transplant in 2020. That same week I needed a heart valve and the DR at UMMC was one of the DR's that started the (I forget what its called) procedure of placing a valve up through an artery in the groin by catheterization. State of the art procedure where I didn't need my chest cut open like my bypass required 6 years earlier.
I'm in northeast TN about an hour and a half east of Knoxville - Tri-Cities area. The area has a combined population of over 500k, but the hospital system was created five years ago from the merger of two former regional competitors.
I worked there for over six years. I know operations inside and out. Pay has been so low for so long that the most capable staff have left. There have been notable disputes between physician and business leadership, and big turnover among top specialists. Those specialists usually aren't replaced.
Quality metrics have consistently declined since the merger. 3-4 star rated hospitals by the Centers for Medicare and Medicaid have declined to mostly 1 or 2 stars.
I'm fairly young with no serious health issues, but I have severe sleep apnea. As an employee, seeing any non-system provider was considered out of network. I couldn't get any contact back from the sleep lab that the system PCP referred me to. I eventually had to go to an out-of-network provider, where I was promptly diagnosed and treated.
My ex had significant health issues. She was sent 4.5 hours away to Nashville for anything much more than a sniffle. She had to have several surgeries the local system wasn't equipped to handle. It's one thing if you're in a small town an hour outside of Nashville, but when you're having to take off at least a day for each trip, it's challenging.
One of my grandmothers had a stroke last year. She was sent to a hospital where I implemented software that the switchboard uses to alert on-call physicians. She laid in the ED on a gurney for about ten hours before being seen. I remember testing stroke call coverage at that hospital before I left. I did some calling around and found out that the rapid response stroke team at that hospital had been eliminated within those few months.
Other grandmother presented to the ED with chest pains a couple months ago. It was over fifteen hours before she was triaged. Again, not much in the way of real diagnosis or care.
ED waits over twelve or more hours have become very common.
My mom is 66 and has her own health issues. She's now going to some specialists in Knoxville. The healthcare situation here is so bad that it's a big reason in why they are looking elsewhere.
We do have some smaller physician groups that are in decent, but all acute care is monopolized by the idiotic hospital system.
The for-profit medical industry continues to close facilities in low population areas due to lack of paying customers and/or inability to get doctors to move to such regions.
<I know your post is from last September so I hope it is OK to still reply to it in this thread.>
<sigh.>
<I'm going to apologize in advance because my response is probably longer than necessary. I hope some will find it worthwhile.>
***
There are obvious costs and not-so-obvious opportunity costs of making the decision to live in a rural or remote location. It makes perfect sense not to locate scarce & expensive services in a location with few people. This is a good thing, as it would be a suboptimal allocation of scarce economic and healthcare services.
When individual citizens make a decision to live in a remote location, they take into account the availability (or lack thereof) af all manner of services including health care services. They see other factors that make such a location desirable which, on balance, tip the scales toward living there even though they know the health care available in the remote/rural location or small town is not the same quantity or quality as are available in major metropolitan areas with medical schools and teaching hospitals. And they are good with that.
They choose the benefits of rural/remote living understanding one cost is less-than-state-of-the-art healthcare. That is a rational decision they make. It is their decision to make.
Quote:
Originally Posted by Mike from back east
If we had a true public health service with a universal single payer system then we could afford to build and run hospitals in rural areas since the profit motive would be off the table.
Mike, you've decided to bring up the political/economic issue of "universal single payer." I would have thought that to be off-topic, but you're the moderator, so I will follow your lead that it is a fair discussion topic for this thread and forum.
Respectfully, I disagree with your position.
You are mixing two unrelated concepts: (1)Universal Healthcare aka Single Payer aka "Medicare for All", and (2) Building/running hospitals in non-economically-feasible remote/rural/underpopulated areas.
FIRST: Single Payer
Our health care system is screwed up - both the delivery side AND the financing/insurance side. Everyone agrees. But Universal Healthcare is not the answer to the problem.
Universal Healthcare aka "Medicare For All" is an economic pipe dream. It makes no economic sense.
People who call for "Universal Healthcare" a.k.a. "Medicare for All" a.k.a. "Single Payer" usually haven't thought through the issues of health care economics, or, at least as often, lack the analytical ability to do so.
Single Payer doesn't solve the problem that medical care costs too darn much in this country.
Single Payer doesn't rip costs out of the system. It doesn't unscrew our screwed-up system.
Single Payer doesn't reduce the total expenditures on health care - it just changes who pays.
Pre-pandemic, TOTAL U.S. health care spending for 2019 reached $3.8 Trillion or $11,582 per person. As a share of the nation's Gross Domestic Product, health spending accounted for 17.7 percent.
For 2022, total healthcare spending in the United States reached $4.5 Trillion, or $13,493 per person for every man, woman and child in the nation.
So, on average, across the entire nation, we consumed about $13,493 per person of health care goods and services. A family of 4, on average, consumed about $51,656 in health care goods and services.
And, to be clear, that $13,493 per person is just for the health care expenditures - not for any insurance overhead or insurance company profit.
If we implemented Universal Healthcare, people could stop buying insurance from Aetna, Cigna, UNH etc. so their household costs go down and their employer's contribution to health insurance would zero out as well - but simultaneously, people's individual taxes must go up to pay for Single Payer. So - what would the extra taxes be per person to pay for that?
Well, each human being alive in the USA would need to pay about $13,493 to the Federal Government in extra taxes (insurance premium equivalents) so the Federal Government could turn around and dole out that same $13,493 to the various health care providers of hospitals, doctors, respiratory therapists, physical therapists, X-Ray technicians, RNs, NPs, PAs, nursing homes, CT/MRI imaging centers, pharmacies for prescription drugs, home health care, etc. In facilities such as hospitals and nursing homes, that money also goes to pay for plumbers, electricians, handymen, cafeteria food prep workers, janitors, landscaping maintenance people and armies of non-clinical clerks who sit in front of computer screens.
But wait. There's more.
The work of collecting the extra $13,493 in tax revenue and then doling it out to the various health care providers isn't free. It requires employees. Lots of employees. Lots of computer systems. Lots of buildings and infrastructure and consultants.
The easiest way to accomplish all that work would be to just nationalize all the health insurance companies out there - Aetna, Cigna, United Healthcare, Humana and and the scores of medium-sized and hundreds of smaller-sized insurance companies. On Friday, all those employees worked for Aetna, Cigna, United Healthcare, Humana etc... and on Monday they all work for the Federal Government, doing the exact same thing they did the previous Friday: collecting money from citizens, accounting for it, and doling it out to health care providers of hospitals, doctors, etc etc.
So in addition to the $13,493 each man, woman and child must pay to the Federal Government as an insurance premium-equivalent tax, each would need to add on to that money to pay for all those insurance company employees who will now be on the federal payroll. How much? 10% more? 20% more?
So - with "Single Payer" aka "Medicare for All", each person would have their taxes go up by at least $13,493 per person plus extra for administration (the work Aetna, Cigna et al currently perform) plus extra for government inefficiency. Those former employees of Aetna & Cigna that now work for the Federal Government will get raises & federal defined benefit pensions, don't forget.
So a family of 4 must have their taxes go up by $53,972 (to pay for health care delivery) plus extra for government overhead.
Each time a woman gives birth to a baby, she is handed her bundle of joy swaddled in a baby blanket PLUS a tax bill for an extra $13,493 to pay for the health care tax for that new life. If she has twins? Make that $26,986.
The primary reason Single Payer aka "Medicare For All" doesn't work -- and the reason our current system is screwed up -- is we don't really have a system of health insurance in the USA. Instead, we have a system of pre-paid all-you-can-eat health care, for the most part. Insurance is a transfer of risk for a fee, and that does not describe what we have in our country with Aetna, Cigna, United Healthcare, Humana, etc. We do not pay to transfer risk.
To illustrate this point, we all have cars and car insurance, which of course kicks in when we have an accident. But, we don't expect Allstate, State Farm or Geico to pay for oil changes, brake jobs, and A/C repair. But somehow, we think Aetna, Cigna, United Healthcare and Humana ought to pay for a knee replacement.
A pregnant woman and her doctor know well in advance that she is pregnant and will give birth about 38 weeks after conception - yet for some dumb reason we finance this the same way we finance the repair of an accidental unexpected fender-bender in the parking lot: by filling out insurance claim forms.
So when people say they want Single Payer, what they REALLY mean is they want SOMEONE ELSE TO PAY. They want some other person to pay for their health care. That doesn't unscrew our screwed up system. That doesn't make health care cost less. That doesn't fix the problem. That doesn't rip costs out of the system.
Fixing this screwed up system is another topic, of course.
SECOND - Regarding placement of new hospitals in remote/rural locations:
At the start of the pandemic, the costs to build a hospital were in the range of $1 Million per bed. Nowadays, with inflation, figure at least $1.2 Million per bed - and that is without an Emergency Room. Emergency Room construction costs at the start of the pandemic were in the $500/square foot range, and with inflation are now in the $600 per sf range.
Want a state-of-the-art facility with the most modern equipment? That's extra. Building the hospital is just the start, of course, as you have to staff it, and we're back to the "who pays" issue.
Establishing more hospitals in more remote locations adds costs to the system rather than extracting costs from the system. We are already well north of 17% of GDP going to health care; the LAST thing we need is to drive it ever higher with non-economic pseudo-investments in new plant and equipment where it doesn't belong.
Quote:
Originally Posted by Mike from back east
We don't run our police, fire, highways, airways, waterways and schools as for-profit operations, nor should we be doing that for health care.
Respectfully, I disagree with you. Again, you focus on "for-profit" as if that were a bad thing. It is not.
In economics, there is a distinction between a "public good" and a "private good."
Health care services are private goods, not public goods. Health care goods and services are products consumed by the individual patient, and that is fundamentally different from a public good.
Quote:
Originally Posted by Mike from back east
The constant urgency to make as much profit as possible means a further concentration of for-profit medical care in densely population regions.
You keep focusing on profit as if it were bad, and of course it is not.
But let's take your focus to heart and talk about the implications of reducing profits, because your view is profits are bad and perhaps even sinful
CRSP, the Center for Research in Security Prices at The University of Chicago, lists about 3,700 individual publicly traded stocks in the US Total Market Index. Most of these are very small companies, of course. But who owns the bulk of these companies? Who owns their shares? The largest owners are public sector union pension funds, public sector non-union pension funds, private sector union pension funds, university endowments, charitable trusts, private sector non-union pension funds, employees owning stock via their 401K plans & IRAs and Roth equivalents, public sector 403b plans, other forms of defined contribution plans, and of course individual households owning stocks in taxable accounts as they save for their kids' college education, their own golden years, save for a down payment on a new car or house, and a long-delayed trip to Disneyworld for the family.
All those retirees who receive defined benefit pensions: the pension plans rely upon the profits generated by companies in the pension plan such as Aetna, Cigna, United Healthcare, Humana etc to generate returns so the monthly pension check can be put in the mail. Pre-retirees building their nesteggs? They rely upon the profits generated to help their nesteggs grow.
Ask those retirees the simple question, "Are you willing to have your monthly pension payment reduced because Mike from back east on C-D says healthcare companies & health insurance companies shouldn't make a profit?" Ask the pre-retirees planing to retire @ 65, "Are you willing to work more years because Mike from back east on C-D says healthcare companies & health insurance companies shouldn't make a profit" and hence your nestegg won't grow large enough in time?
****
Look, we can all agree our system is screwed up. Your prescription of Single Payer does not unscrew our screwed up system. It does not rip costs out of the system. It does not solve the problem.
Last edited by moguldreamer; 04-16-2024 at 02:29 PM..
My view is that when people of all ages spread viral and bacterial contaminants like the common colds, various flu strains, STIs/STDs, HIV, covid, Pneumonia, TB, etc, which can afflict and kill other people, then it darned sure is a public good and is just one of many reasons why we have a Public Health Service at the Federal, State and Local levels. Beyond that, people injured by the actions of others (car wrecks, hit and run, crimes, floods, wildfires) should not be on the hook to finance their recoveries from causes beyond their control.
To me, healthcare most certainly is in the government's lane. The public sphere can begin with the EMTs who gather us up and take us to a Trauma Center, ER, Burn Center, etc, and it goes from there. We agree that Police and Fire/EMT forces who also respond to our urgent call for help are the public good, thus ER care and hospital stays are merely an extension of the public good that started with the call for help. The EMT path to medical care is the most obvious example, but simply showing up on our own for medical care belongs in the public good sphere.
I've seen stats that the insurance companies keep as much as 25% of their receipts for 'overhead' and profit but what I keep in mind is that Medicare only keeps 5% of its receipts for overhead.
For profit hospitals have forsaken rural areas, as reported in the media and by the posting before yours, and will continue to cut staff and reduce costs for the sake of their profits regardless of the negative impacts on the health of the people. That's just not right. We have to do better. Universal single payer is the only way I can see out of this mess.
We'll have to agree to disagree on if healthcare is a private good or a public good but for me it comes down to words in the Constitution about Life, Liberty and the Pursuit of happiness and to "promote the general Welfare" of we the people.
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Last edited by Mike from back east; 04-17-2024 at 10:31 AM..
I wasn't talking about rural. Rural have hospitals that can easily handle the basics.
Just my own experience, there are excellent doctors, surgeons, and specialists here in Knoxville, and Knoxville isn't really a "big city". Pretty much all the worst in East TN gets sent to UT medical here.
You sort of answered your question there. UT Medical School.
I think anywhere you have a large Med school especially one that's known for research you're on solid ground. I'd rather be treated in Knoxville than Memphis for many things.
Raleigh-Durham isn't among the "biggest cities" but we have Duke and UNC right here.
<I know your post is from last September so I hope it is OK to still reply to it in this thread.>
<sigh.>
<I'm going to apologize in advance because my response is probably longer than necessary. I hope some will find it worthwhile.>
***
There are obvious costs and not-so-obvious opportunity costs of making the decision to live in a rural or remote location. It makes perfect sense not to locate scarce & expensive services in a location with few people. This is a good thing, as it would be a suboptimal allocation of scarce economic and healthcare services.
When individual citizens make a decision to live in a remote location, they take into account the availability (or lack thereof) af all manner of services including health care services. They see other factors that make such a location desirable which, on balance, tip the scales toward living there even though they know the health care available in the remote/rural location or small town is not the same quantity or quality as are available in major metropolitan areas with medical schools and teaching hospitals. And they are good with that.
They choose the benefits of rural/remote living understanding one cost is less-than-state-of-the-art healthcare. That is a rational decision they make. It is their decision to make.
Our health care system is screwed up - both the delivery side AND the financing/insurance side. Everyone agrees. But Universal Healthcare is not the answer to the problem.
****
Look, we can all agree our system is screwed up. Your prescription of Single Payer does not unscrew our screwed up system. It does not rip costs out of the system. It does not solve the problem.
The reality of the situation is that many people simply don't carefully evaluate their healthcare choices prior to relocating to a rural area.
Many people who moved from bigger cities in blue states to smaller ones in red states didn't seem to do their due diligence on this. Many moved for tax, political, or lifestyle reasons, assuming that quality healthcare will just "be there" for them in the new location.
My girlfriend has an aunt and uncle who are fairly well-to-do by regional standards. They moved from an affluent mountain community in NC to a gated lakefront community that is about half an hour from a small city of about 25,000. She was diagnosed with some form of cancer, and is being treated at Dana Farber in Boston. She flies to Boston periodically for treatment. Even routine care is about 1h15m in Knoxville, TN. While the care in the previous location in NC was not top-tier, it is leagues better than what they have in their immediate local area now.
I've probably talked to a dozen or so people originally from outside of my area over the last year or so who have mentioned that they didn't realize the healthcare was so poor here prior to moving. I moved my PCP and sleep medicine specialist from TN to NC, and couldn't be happier. The area I have my medical care in is more affluent than here, and tends to attract wealthier retirees. The standards that the population demands are higher. There are fewer of the lifestyle related chronic conditions there.
In an emergent situation, I'd be stuck with my lousy local option. If I was well/with it enough to drive/be taken to UT Medical Center, that's what I would do, but it's an hour and a half away.
At 37 with good medical insurance and generous sick leave, it's not a big deal for me to take some sick time to go to better doctors out of the area. If you're 80 and have difficulty getting around, you're sort of stuck with the bad care here.
The hospital system I worked for has seen various quality metrics consistently decline over the five or so years since the merger - meanwhile, the CEO's total comp has gone up threefold. It would be one thing if the hospitals consistently performed better as his comp grew, but they haven't.
The real bugaboo on costs are huge contingent and travel labor costs that run into tens of millions of dollars a quarter.
My view is that when people of all ages spread viral and bacterial contaminants like the common colds, various flu strains, STIs/STDs, HIV, covid, Pneumonia, TB, etc, which can afflict and kill other people, then it darned sure is a public good and is just one of many reasons why we have a Public Health Service at the Federal, State and Local levels.
We have Public Health Departments for all the reasons you describe above. For example, when President Trump launched "Operation Warp Speed" as a crash program to develop a Covid-19 vaccine for the benefit of the people, that was a matter of Public Health.
In contrast, the administration of a single dose of that Covid 19 vaccine to a single human being is not a Public Good (Term of Art) - it is a Private Good (also a Term of Art) (see https://en.wikipedia.org/wiki/Private_good). Why? If that single dose is administered to me, it is not available to be administered to you. Consumption by one person necessarily excludes its consumption by another person. The same is true regarding food: if I eat a specific banana, it is no longer available for you to eat.
In contrast, a true Public Good is a thing such as a sunset or rainbow: my consumption of that sunset or rainbow does not impact your ability to consume it (by consume in this context I mean look at and enjoy it). Ditto for generalized police protection & fire protection.
Clean air is another interesting example: it is a Public Good (my breathing the air does not preclude you from breathing it) AND for Public Health reasons, we have anti-air pollution statutes and regulations.
Unlike public goods such as clean air or national defense or fire department protection, private goods are less likely to have the free rider problem (also a term of art) in which a person benefits from a public good without contributing towards it.
Private Goods are things we should buy for ourselves out of our own paychecks, while Public Goods are things we should have our government purchase for us on our behalf. What we call health insurance is not insurance - it is not a transfer of risk; it is pre-paid health care.
So health care is by its nature a Private Good (term of art). A doctor may rely upon Public Health guidelines, but that doctor sees only one patient during a specific appointment and hence that appointment slot is a Private Good. Prescription medicine is prescribed for that single patient and hence is a Private Good. A preventative procedure such as a colonoscopy, prostate exam or mammogram is performed on a single patient at a time and is a Private Good, even though as a matter of Public Health (as you and I are using the term) the guideline may be for all people who meet a particular criterion to be screened via a colonoscopy, prostate exam or mammogram.
Quote:
Originally Posted by Mike from back east
I've seen stats that the insurance companies keep as much as 25% of their receipts for 'overhead' and profit but what I keep in mind is that Medicare only keeps 5% of its receipts for overhead.
I think it is appropriate to talk about the post-Affordable Care Act (ACA or Obamacare) era as being different from the pre-ACA era (both by statute and by regulations).
In the post-ACA era, there are Medical Loss Ratio (MLR) requirements: The ACA requires health insurance companies to spend at least 80% (for individual and small group plans) or 85% (for large group plans) of their premium dollars on medical care and quality improvement, rather than on administrative costs and profits. If they do not, they must rebate the excess to their customers. So, in the post ACA era, the profit motive has been neutered: if they discover a way to save money via an investment (for example), the returns on that investment are no longer captured by shareholders but instead are rebated because of the 80% or 85% MLR rule (which translates to 20% or 15% overhead & profit).
While Medicare keeps less for overhead and on the surface appears more economically efficient, in reality it is not an apples-to-apples comparison. Unlike Medicare, private insurance companies spend money on extensive (extensive compared to Medicare) claims review, approval authorizations (or denials), fraud detection and the like.
And let's not forget that most Medicare-eligible people (typically seniors) do not just have Medicare - they typically have a part D prescription drug plan and a Medicare supplement plan (e.g., a "G" plan). Traditional medicare foists costs onto the Part D and Medicare Supplement provider (e.g. "G" plan). Some seniors opt not to go Medicare with a supplement and instead purchase Medicare Advantage plans which are the things advertised non-stop on TV infomercials. Again, Medicare foists costs onto the Medicare Advantage provider.
My point is Medicare cannot do the all the work themselves for a mere 5% overhead. Comparing Medicare's 5% overhead with an ACA insurance provider's 20% or 15% is not apples to apples.
Quote:
Originally Posted by Mike from back east
For profit hospitals have forsaken rural areas,
I find it fascinating you decided to use an emotion laden term "forsaken" in an attempt to elicit a response from the reader.
By the way:
Would you also say that Sears Roebuck & Co has forsaken rural areas?
Would you say frozen yogurt shops have forsaken rural areas?
Would you say movie rental stores renting VHS tapes have forsaken the nation?
Would you say animal feed lots have forsakenurban areas?
Would you say tractor supply companies have forsakenurban areas?
Quote:
Originally Posted by Mike from back east
... and will continue to cut staff and reduce costs for the sake of their profits
We've gone over this. Corporate profits are used to pay the defined benefit pensions of retired public sector union employees. Do you have a particular interest in reducing the pension checks of retired public sector union employees?
Some counties have publicly funded hospitals. I know people who work in county hospitals largely funded via tax revenues as their clientele usually has limited financial resources to pay. Remote locations can, if they desire, tax their residents and use the proceeds to create a public hospital.
Quote:
Originally Posted by Mike from back east
... That's just not right. We have to do better.
As I mentioned in my prior post, I agree with you that our health care system is screwed up. I think most everyone would agree that our current health care system is screwed up.
Quote:
Originally Posted by Mike from back east
... Universal single payer is the only way I can see out of this mess.
A family of 4 must have their taxes (insurance premiums) go up by $53,972 (to pay for health care delivery) plus extra for government overhead under a Universal Single Payer paradigm. I don't think most families of 4 can swing that.
I see several alternatives to Universal Single Payer. And, as I previously posted, Universal Single Payer does NOT unscrew the system.
I'll leave it to you as the moderator to decide of that is off-topic, or if you would like to start a thread here in great debates on fixing our healthcare delivery and healthcare funding systems. (I don't say insurance, because as I mentioned, we do not currently employ an insurance system for health care in the USA).
Quote:
Originally Posted by Mike from back east
... We'll have to agree to disagree on if healthcare is a private good or a public good
Those terms of art have specific meanings - just as a Joule is a unit of work defined as the amount of work done when a force of one newton displaces an object through a distance of one meter in the direction of the force.
We can't just decide they have different meanings.
Private Goods are things we should buy for ourselves, while Public Goods are things we should have our government purchase for us on our behalf.
Quote:
Originally Posted by Mike from back east
... but for me it comes down to words in the Constitution about Life, Liberty and the Pursuit of happiness and to "promote the general Welfare" of we the people.
Public Health as we've used it here certainly falls with the concept of promoting the General Welfare of the people. But Public Good is a term of art with a specific definition.
As an aside, when the constitution was written, "Pursuit of Happiness" had a specific meaning which is now archaic. Back then, "Pursuit" meant what we in the modern era might call "job" or "profession". At that time, the question "What is your pursuit?" might be answered "I am a cobbler" or "I am a Cooper" or "I am a smith" (meaning, in today's lingo, shoe maker or wooden barrel maker or metal worker). The idea was that we each get to decide how we personally will earn money thereby contributing to the economic well being of the nascent nation. The government couldn't come in and say, "you must be a bartender." The idea of a government telling a person what profession they must pursue (e.g., pursuit) seems strange to us today. Note that some hard line authoritarian nations today still do so.
Last edited by moguldreamer; 04-21-2024 at 01:49 PM..
US Healthcare is more expensive for a number of reasons.
As for Universal Healthcare there are numerous systems and so called single payer is just one system, and even single payer can mean a number of different things.
There can also be differences in terms of Universal Healthcare in relation to the input of different sectors such as the Private Sector, Public Sector, Voluntary Sector, Academic Sector etc, and different systems have a different level of contribution from each sector.
Also contributions in terms of Universal Healthcare can vary, and can include a mixture of taxes and private contributions, whilst what is covered can vary according to different systems and this includes so called Single Payer system.
One of the advantages of a more unified system is the ability to both negotiate and purchase products on mass, and this means pharma and medical companies are forced to reduce some prices if they want market access, whilst a system without middle men such as nsurance companies and other profit making organisations will also be cheaper to operate.
Health care is totally hit or miss. It depends on where you are, which insurance you have, and who is running things there. In Hawaii, if anything big or complicated happened to you they shipped you off to the mainland. In Tucson, which is a sizable city, I had horrible health care. But in Albuquerque I had some of the best I ever encountered. I'm in Little Rock now and have been to 3 different healthcare providers before finding one that was good.
I used to work in physical therapy in-patient rehap in Savannah. Sometimes the patient's insurer would only pay for 15 minutes of physical therapy a day. There really isn't much you can do within that time frame, so we spent more time w/ them w/o being paid for it, and we worked 1-2 hours late every day (w/ no extra pay) just to deal w/ the paper work.
So I don't think this is a big city/small city thing. We need to find good health care by making the rounds and seeing how each facility works this out. Generally speaking, we get better health care from non profits like St Vincent's, and that good quality care is not dependent on where we live.
Last edited by stephenMM; 04-22-2024 at 10:47 AM..
One of the advantages of a more unified system is the ability to both negotiate and purchase products on mass, and this means pharma and medical companies are forced to reduce some prices if they want market access...
FIRST, let's talk pharmaceuticals.
A "single buyer" system for which you advocate is called a Monopsonyhttps://en.wikipedia.org/wiki/Monopsony. (In contrast to a Monopoly, where there is only a single seller).
Under a Monopsony, there really is no negotiation as the buyer dictates the price - and sellers either sell or abandon the marketplace. Producers make economic decisions, and, if the expected costs of bringing a new drug to market exceed expected revenue, that drug is never researched or produced in the first place.
It only takes a couple of white boards and some not terribly advanced mathematics for any graduate student of Economics to prove that a Monopsony causes a misallocation of resources resulting in societal welfare being lower than it otherwise would be.
So what can be done?
Well, for one, we can reduce future expected costs of bringing new medications to market by eliminating harmful federal bureaucracy and bureaucrats who add little value to society and are just in the way. Everyone who can spell Rx knows that Federal Bureaucrats make the highly regulated process of filing for an IND and a subsequent NDA extremely lengthy and costly. But the economic damage the FDA inflicts on the country goes far beyond that.
Let me give you a real-world example. Everyone in the USA is well aware of the medical condition called "erectile dysfunction" and the prescription medicine called Cialis. In the US, you cannot get Cialis without a prescription.
Eli Lilly, the patent holder of Cialis, wants this medicine to be available Over The Counter (OTC - that is, available without a prescription from a medical doctor). After all, men who need Cialis are well aware if they have a problem getting an erection. They don't need an expensive doctor appointment for a diagnosis. An OTC version would save everyone a lot of money - no need for a doctors' appointment or insurance overhead, you just pick up Cialis in any retailer in the aisle next to Tylenol.
For at least 15 years, Eli Lilly and Sanofi (a drug company to which Eli Lilly licensed the OTC rights should the FDA ever allow OTC Cialis) have been paying for teams of employees and outside consultants to petition the FDA to allow the drug to be sold OTC.
The FDA does not want it to be OTC because they want it under the jurisdiction of the segment of the FDA that regulates prescription medicine. How ridiculous is its regulatory purview? The FDA regulates, for example, the "blackness" and "opaqueness" of the ink used in the patient instruction insert and the "whiteness" of the paper it is printed upon - all 18 pages of it. And, of course, the font size, width of columns, width of the borders between columns, etc. Employees at the FDA are dinosaurs who jealously guard their fiefdom - especially those who are medical doctors themselves. Their default answer is "no." The excuse the FDA medical doctors who vote "no" use is that a patient might have a heart condition and only a medical doctor can make the determination if that man is healthy enough to have sex and "is a boner pill safe for this customer?"
In the real world, some customers use one of the boner pill services advertised on late night TV where the customer takes a 1-minute telephone call with a "doctor" who asks the patient if they have a heart condition, to which the patient says "no, I do not have a heart condition", and then this doctor writes the Rx for a boner pill. Clearly, no true medical screening has occurred; it is a pro forma and perfunctory 60 second telephone call that just adds costs to the system (and profits to the companies who employe these "doctors.")
All these added costs are due to Government Bureaucrats Gone Wild.
And to be clear, I am not advocating for the elimination of the FDA - all of us want all of our medicines to be safe, and the government absolutely has a role in that. If Covid taught us anything, it showed the public how much infighting exists between the FDA and the CDC and just how dysfunctional they truly were.
What else can be done?
Transfer Pricing needs to be fixed. Nowadays, most pharmaceutical companies do most of their research inside the USA (some also is done outside the USA, of course). When there is a promising set of molecules, the company writes patents covering them, and transfers ownership of those patents to its subsidiary in, say, Switzerland. At the time of the transfer, the value of the patent is quite low because the drugs it covers is still an unknown and years away from clinical trial let alone potential approval. Some of those drug candidates will be worthless, and the subsidiary scrapes them off the balance sheet. Some turn into super star drugs - and then the subsidiary in Switzerland "licenses" the patent back to the US entity in exchange for HUGE royalties. This has the effect of raising costs in the USA - and as surely as night follows day, those higher costs translate into higher prices for customers.
It is high time to end differential pricing of medicine across the world. We need a single price, period. As a matter of course (and sometimes a matter of law), foreign jurisdictions say "but we're a poor country, so we should pay less for medicine." Clearly, that is irrelevant. They should pay the same price for medicine as we do in the USA. The argument "they should receive a discount" is identically equal (≡) to "we in the USA should pay more just so they can pay less." Poppycock.
SECOND, let's switch from Pharma to Medical Services.
The cost of health care has over quintupled since 1970. Go back a bit farther to 1960: the average 1960 worker spent six to at most ten days’ worth of their yearly paycheck on health insurance. Compare that to today: the average modern worker spends over sixty five days’ worth of their annual paycheck on healthcare. US health care costs over four times as much as equivalent health care in other First World countries.
Just where in the hell is all that health care money going?
* Medical doctors typically have a nice income, but they are not getting rich (No 300 foot yachts or $80 million private jets.)
* Hospital administrators typically also have a nice income, but they are not getting rich (no yachts or private jets.)
* Nurses are not getting rich.
* Respiratory therapists are not getting rich.
* X-Ray techs are not getting rich.
* Physical therapists are not getting rich.
* Health insurance companies' profits are regulated under Obamacare so they are not getting rich, although senior executives make a lot of money -- but they don't own 300 foot mega-yachts or $80 million private jets or private islands either.
Soooo..... where the hell is all the money going?
We expect that improving technology and globalization of supply chains ought to cut costs. In 1983, the first mobile phone cost $4,000 – well over $12,000 in today’s dollars. It was also a gigantic piece of crap. Today you can get a much better phone for under $100. This is the right and proper way of the universe. It’s why we fund scientists & engineers & entrepreneurs, why startups go public, and why we pay technical innovators the big bucks.
Patients can now schedule their appointments online and view lab test results with a smartphone; doctors can send prescriptions through secure computer networks, pharmacies can keep track of medication histories on computer systems that interface with the Cloud, nurses get automatic reminders when they’re giving two drugs with a potential interaction, insurance companies accept digital payments, etc etc etc. --
-- and all of this costs ten times as much as it did in the days of IBM punch cards and staff who did calculations by hand with a manual crank adding machine.
It’s actually even worse than this. A lot of medical services have simultaneously decreased in quality while increasing in cost.
Think back to the 1950s (if you're old enough; if not, ask your parents or grandparents). Back in the 1950s, for women who give birth in the hospital, the standard length of stay was 8 to 14 days. It has declined to less than 2 days by today. Physicians say this decline isn’t because modern women are healthier; it’s because hospitals kick the new mothers out as soon as possible in order to control costs. Historic records of hospital care generally describe leisurely convalescence periods and making sure a new mother felt absolutely well and capable of caring for her newborn infant before letting them go home; this seems bizarre to anyone who has participated in a modern hospital, where the mantra is to kick people out as soon as they’re “stable” i.e. not in acute crisis. We only half-joke about drive-by childbirth.
I don’t know why more people don’t just come out and scream at our elected representatives: “LOOK, REALLY OUR MAIN PROBLEM IS THAT ALL THE MOST IMPORTANT THINGS COST TEN TIMES AS MUCH AS THEY USED TO FOR NO REASON, PLUS THEY SEEM TO BE GOING DOWN IN QUALITY, AND NOBODY KNOWS WHY, AND WE’RE MOSTLY JUST DESPERATELY FLAILING AROUND LOOKING FOR SOLUTIONS HERE.”
State that clearly, and a lot of the current political debates regarding health care & health insurance take on a different light.
(It isn't just healthcare that costs way too much; it is also education, roads & bridges, subways & other public infrastructure. They cost 10 times as much, 10 times more than they used to and 10 times more than in other countries.)
So where the hell is all that money going???
The money is not going to wages (employees are not getting rich).
The money is not going to profits (companies are not getting rich).
So where the hell is all that money going???
The answer: The number of people it takes to produce health care goods and services is skyrocketing. Labor productivity -- quality adjusted output per number of people involved in the entire input process delivering health care -- declined by a factor of 10 -- in contrast to every other industry where productivity goes up by a factor of 10.
Analytically, it has to be declining long-term productivity: if the money is not going to profits or to to each employee in the form of higher wages, then it must be going to an increase in the total number of employees. Think of the typical US hospital or clinic or doctor's office, and count the number of employees who are not involved in actual patient care but rather just push paper around or interact solely with computer screens.
In other words, all that money is going to administrative bloat. It is going into the paychecks of countless non-clinical administrative employees.
There are over 2.5 employees handling insurance claims for every doctor. And that's just at the medical practices & hospitals; the insurance companies have armies of people working on the claims as well. There are armies of people employed by hospitals and health care companies in IT, finance, legal, facilities management, compliance, billing, customer service, new patient intake, HR, accounting, payroll, advancement, etc etc etc - all of whom get a paycheck and none of whom actually provide medical care.
At the end of the day, government single payer just doesn't solve the problem of bloat because all those armies of administrative non-clinical people would still be on the payroll.
There are some areas of healthcare that are improving in quality AND declining in cost. The for-profit field of LASIK eye surgery is a great example. Except in rare cases, health insurance does not cover Lasik. So Ophthalmologists who specialize in LASIK just don't have that administrative bloat -- they don't have armies of clerks skilled in how to code insurance forms so as to maximize the payment from the insurer. The end result is the quality of LASIK has improved dramatically while the price of LASIK has plummeted. Ditto for many cosmetic surgical procedures such as breast implants, breast reduction, butt lifts & implants, chin lifts & tummy tucks. Quality has gone up while costs have gone down.
It is in the other section of medical care -- the section where insurance companies and the government are involved -- that's where the bloat occurs.
That's why I don't think single payer is the answer.
1. It is clear that Single Payer does not rip costs out of the system.
2. It is clear that Single payer doesn't entail separating the armies of non-clinical employees from the payroll.
The way to drop the nation's expenditures on health care is to - wait for it - consume less health care, which in turn means the health care system must right-size by laying off employees (both clinical and administrative).
Sadly, expenses in the health care field walk on two legs and are breadwinners for their families. Sadly, but necessarily, people currently employed in the health care industry need to lose their jobs so that the rest of us pay less for medical insurance.
Regarding the YouTube videos above, because this is a written word forum, I make it a policy not to watch videos. If you are so inclined, please write a couple paragraph summary for those of us who might be interested.
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