ice queen is not a nice queen
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This seems overly optimistic to me, and I think itâs reasonable to be uncertain about the outcomes of any particular universal healthcare plan. Most of the conversations on this site seem to be based on the idea that the rest of the developed world has some common healthcare system that the US has chosen not to adopt. But thatâs not true - even though the rest of the developed world has adopted universal health care as a principle, countries have taken many different routes to get there. And all of those different routes involve tradeoffs.
This recent article has a pretty good discussion of healthcare in Taiwan, Australia, and the Netherlands:
To me, there are 2 factors that are crucial to how M4A will affect long-term care for the population:
- Reimbursement rates
- Utilization rates
On the reimbursement side, every other country with some form of UHC that Iâve read about exerts substantially more price pressure on providers than the US. Iâm not sure exactly how much Sandersâs plan cuts down on provider payments, but different sources claim reductions of 25-40%. (Many of those sources have an obvious bias, so I donât want to hang my hat on any one in particular.) This (presumably unbiased, but who knows) CBO analysis is interesting because it shows rates for a variety of medical procedures and is very consistent with medicare-level pricing being 25-40% lower than private insurer pricing:
You could argue that the net effect on providers wouldnât be that bad because whatâs being eliminated is admistrative costs and private insurer profits, so that provider net income wouldnât change. But I think thatâs inconsistent with the well-documented fact that physicians in the US earn significantly more than elsewhere. (https://www.medscape.com/slideshow/2019-international-compensation-report-6011814#1)
In any event, if Sandersâs plan just assumes that provider payments will be cut by 25-40% without any accompanying drop in supply, I think thatâs an enormously optimistic assumption. (Obviously Sanders believes that people respond to monetary incentives in selecting their occupations - thatâs why he supports raising minimum teacher salaries to $60,000.)
In terms of utilization rates, it seems obvious to me that if weâre substantially increasing access to care, thereâs going to be greater usage of that care. At least I hope thatâs what would happen - otherwise, whatâs the point? So a big question is how that increased access will affect the already-insured population. Here, the evidence so far seems pretty good, at least based on the ACAâs Medicaid expansion. For example:
and
But I think thereâs some uncertainty about how outcomes based on Medicaid expansion would translate to the M4A setting.
TL;DR:
Much of the support for M4A is based on the belief that it will lower costs and improve access for everyone, while vaguely referencing other countries as if those other countries have some common system that Sanders is simply trying to emulate. There are real tradeoffs involved and itâs very likely that those tradeoffs will negatively affect some part of the population in a move to M4A. Itâs silly to act like thatâs impossible or like those people are stupid for being opposed.
(I am covered by good insurance, Iâm not sure if Iâd be negatively affected by M4A, and I support a model thatâs similar to public education - provide guaranteed minimum coverage to everyone and allow purchase of private insurance.)
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I would hope that weâre all ok with lowering doctorâs salaries and health systemsâ profits as a trade off for providing universal zero cost healthcare for every American.
Like. Public defenders make a lot less than private firm lawyers do. Somehow theyâre still incredibly competitive jobs with no shortage of applicants or students going to law school.
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All the âBernie canât pass that stuff so you should vote for (Pete/Klob/Mike)â takes are absolute garbage and almost all made in bad faith.
These assholes that gave us Al Gore, John Kerry, tried to give us Hillary and failed, then actually gave us Hillary, all of whom lost, think they have standing to talk about electability? Fuck off.
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Thereâs also the underlying assumption there that Moscow Mitch is ready to vote for Medicare for All WHO WANT IT, but would turn up his nose at true m4a. Itâs ridiculous. If you can pass one, you can pass the other.
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Yeah itâs also like, what, you think Mitch McConnell is going to say, âOkay, you guys nominated Pete and he won, here are your votes on the public option!â
Fuck, no, heâs going to say, âThatâs a socialist takeover of the healthcare system and Iâm the grim reaper. NO!â
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Putting aside the fact that doctors arenât ok with that, my point was that a decline in salaries would likely decrease the supply of doctors, negatively affecting healthcare access for every American. Reasonable people can argue about how large that effect might be or how long it would take to show up, but I donât think you can argue the directional effect it would have.
Like. Public defenders make a lot less than private firm lawyers do. Somehow theyâre still incredibly competitive jobs with no shortage of applicants or students going to law school.
This seems like an insane take and very much in line with my argument - there are huge shortages of public defenders, resulting in terrible representation.
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Lol, yeah the public defender take is terrible. If the argument is that weâre all going to get public defender level quality of health care when we switch to M4A then we are all in big trouble.
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Public defenders have high caseloads because the localities refuse to provide adequate funding to hire enough of them. Itâs not because nobody is applying for those jobs.
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Also important to note that the reason why thereâs a Doctors shortage is that there are a shortage of medical school slots nationwide. Itâs not like there are a shortage of people who want to be doctors. The pipeline is intentionally insufficient to keep the supply and demand hugely out of whack and prices super high.
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@hobbes9324 should chime in, but I think there are a lot of reasons people donât want to be doctors anymore, but salary isnât one of them. M4A could lower salaries slightly and possibly still make the profession more attractive.
(Regardless, I agree with you on the public school model)
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The #1 reason doctors hate their jobs is the truly unbelievable amount of time they spend filling out bullshit forms to appease insurance companies. Like literally hours a day every day. Itâs insane.
Close behind is student loan debt, which is absolutely outrageous and can easily exceed $500,000.
The whole system, when viewed rationally, is a dystopian nightmare.
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You could dramatically improve the overall life quality of doctors while bringing down the total money we spend on them. Making medical school dramatically cheaper would be a major step in that direction. (one of the other reasons being a doctor sucks is that they work way way way too many hours)
Honestly free medical school (and a nice fat rebate check to everyone who graduated in the last 15 years) would be expensive af to implement but would cut the overall costs considerably.
Right, and at the end of these questions you realize that the m4a detractors sincerely believe that most healthcare providers in the US are much worse than the healthcare providers they use. And theyâre okay with that fact! And thatâs super fucking disgusting.
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Like if you believe utilization will rise significantly, like enough that it effects your access to care, then you either believe that a lot of people will spend tons of time at the doctor when they donât need to, or you believe that there are lots of people out there who arenât going to the doctor when they should. Either of those is bad.
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I totally believe the second, and I agree that itâs bad - thatâs why I think universal health care is good and necessary! I just think many of those arguing in favor of Sandersâs plan act as if there arenât important tradeoffs weâre going to have to face, where some people end up worse off.
We know that the wealthy are going to be worse off, and the poor better off. That is kind of the point.
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Thatâs fine, but then it shouldnât be surprising when those wealthy people (including the culinary union members with current coverage) are lukewarm about M4A.** My initial comment was based on arguments Iâve seen here and elsewhere that suggest people are idiots if they donât believe that they themselves will be better off. Like the one I originally responded to:
**What I mean here is wealthy in terms of current level of health coverage, not absolute level of wealth. The Culinary Union members are not likely to be wealthy, but they do have good insurance coverage. So itâs not surprising that their union is skeptica about M4A, since they very plausibly would be worse off.
Lol?
And to be clear, under Bernieâs plan literally everyone will have better health coverage than they currently have. Iâm not aware of any plans with zero deductible, zero copay, zero out of pocket, and no restrictions on what doctors you can see.
Some people will pay more than they currently do for that coverage, and my wife and I might be lumped into that simply because weâll probably see a tax increase and I pay very little for our excellent union health benefits. The culinary union members are likely not those people, but in any case itâs not going to give them worse coverage.
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