I CAN’T TAKE IT ANY more: I need to rant about health care.
There’s absolutely no reason to continue the current health-care payment system, none, not one. Where’s the rationale for having private insurance, Obamacare, Medicare, Medicaid, TRICARE and the Children’s Health Insurance Program (CHIP)? Each was developed to deal with the same issue—paying for health care.
Some form of Medicare for all, or M4A as it’s sometimes known, is the only system that makes sense. Before I hear it one more time, I am not talking about socialized medicine or a care system like the U.K.’s National Health Service.
Instead, I’m talking about a universal payment system funded through employer and worker taxes, premiums and out-of-pocket cost sharing—all calibrated relative to the individual’s ability to pay. There’s no such thing as free health care, so let’s not even use the “f” word.
The popular arguments against a universal billing plan are largely false and misleading. Wait times, third-party involvement between patients and providers, denied care and health-care rationing are already part of our current systems in some form or another. Even for people with insurance, thousands of dollars in deductibles and coinsurance can be devastating to their budget.
And please don’t talk about instilling competition in providing health care—that’s nonsense. The system is nothing but incentives to provide more care—often unnecessarily—either for profit or to protect the medical provider from lawsuits. If you invest in a multi-million-dollar piece of equipment, the only way to make it pay is to use it. It’s well documented that a great deal of health care is unnecessary. If you think more care is always better care, think again.
For Americans who insist on private insurance, maintaining a form of Medicare Advantage is possible. Sixty-five million Americans are enrolled in Medicare. As of January 2023, another 93 million people were enrolled in Medicaid and CHIP, about 17 million more in Obamacare and 9.6 million in TRICARE, the health-care system for military personnel and their families.
Altogether, then, about 184 million Americans use some form of government-run health insurance system, often operated in coordination with private insurers and with care provided by the private sector. Yet, according to some, Medicare for all is not acceptable. That’s laughable.
I know all the arguments against M4A. I know there are consequences and I know the projected cost savings are imaginary. I know many health-care providers won’t be paid at their current rates, but they’ll have reduced administrative hassles as well. During the transition, there may be shortages.
Still, everyone will have health-care coverage, and there will be a fairer distribution of costs and tremendous opportunity for better coordination of care no matter where you are in the U.S. Isn’t it absurd that, in this era of technology, you can’t walk into any doctor’s office or health-care facility and have them instantly access all your medical records before they start tests or provide care? Don’t like that idea of health record coordination? Fine, you could opt out and end up having more tests.
Any transition will take years, resistance from self-interested parties will be tremendous and Twitter will be overwhelmed by raucous debates. But who has a better idea for how to achieve universal coverage that offers a fair distribution of costs and the opportunity for better coordination of health care for individuals?
Medicare Advantage is terrible. From the Lever magazine:
The $20 Billion Scam At The Heart Of Medicare AdvantageMay 26, 2023
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Matthew Cunningham-Cook
&
Andrew Perez
As Medicare privatization continues, insurers are milking massive profits from systematic overbilling and kneecapping modest Biden proposals to stop the scheme.
Richard, thank you for a VERY thought provoking article. I will be pondering your thoughts for quite a while.
One question up front: Would a “universal payment system” require a “universal pricing system?” To me, the biggest benefit of health insurance are the discounts insurance companies negotiate with providers. (Real example: getting a $10,000 service reduced to $300.) However, in this day and age, I worry about a centralized entity (federal government?) having that kind of absolute power.
Related question: In order to have costs “calibrated relative to the individual’s ability to pay,” are you thinking wealthier people will pay inflated prices, or are you thinking of a welfare-type program funded with tax revenue?
Another question that just hit me: What are your thoughts on a universal “base level” of health care that everyone receives (at a reasonable cost), but services beyond the base are each person’s responsibility, and for which they may protect themselves by purchasing private insurance?
What you describe is part of the problem. Each payer has different payment levels so what is the real and fair price? Are private insurers pay more because Medicare and Medicaid pay less. A M4A would have to find common ground somewhere between current allowable fees perhaps adjusted for cost of living geographically. Medicare sets allowable fees today so it’s not new. To me it’s critical part of managing costs.
I suggest wealthy people (to be defined) pay higher premiums and deductibles and higher maximum out of pocket costs. Taxes would be a percent of total pay with a minimum for those who do nit have a salary.
I envision private insurance being available perhaps similar to Medicare Advantage, but a different structure of subsidies. Most programs in other countries allow private insurance or private pay in some manner.
Thank you for your thoughts. Hopefully, one day, we will have a system that works effectively and efficiently.
I wouldn’t lump Obamacare in with Medicare, Medicaid, TRICARE and CHIP.
It’s not a universal payment system, it simply provides subsidies for people to purchase expensive private insurance, with all the hassles that entails, along high deductibles ($10,000/year) for the least expensive plans, and high co-pays.
It was designed to preserve the private insurance industry, not replace it.
True, totally agree with the subsidies part but if we had a system similar to what the author is proposing, that then would obviate the need for ACA (Obama care). Not for nothing, Last I read, about 30 million people use Obama care.
You have a point, but as you say it’s subsidized and regulated as far as benefits and spending goes.
Word.
M4A may not be perfect, but it is the best option. As a humane society, we need to care for our fellow citizens. I am on Original Medicare with a supplemental plan. I am enormously grateful that I have access to a system that monitors charges and looks over my shoulders. I shudder when I look at what health care providers bill Medicare and thankful they do not get reimbursed preposterous charges.
Medicare Advantage rip off the government
Richard, you claim that instilling competition in providing health care is nonsense because the system only provides incentives for more care. Yet, the cost of health care continues to rise at a rate greater than the CPI.
Even with M4A, there is nothing to check the seemingly unbounded rise in the cost of health care. Isn’t this because people don’t pay for their care directly—third parties pay the bill? The result, as I understand it, is that there is no incentive to compare prices and no meaningful competition among health care providers that could lower those prices.
What if, instead of insurance, people were provided some sort of voucher to pay for health care—possibly backed with some type of catastrophic coverage. Say, analogous to an HSA, but provided by government. Maybe any money left over in this year’s voucher could be added to next year’s voucher.
If people paid for their care directly from the voucher, wouldn’t that encourage more comparison shopping and force health care providers to compete? In our capitalist system, it seems that such competition could help reduce the cost and increase the availability of care.
So you are suggesting people would shop around for the cheapest cardiologist to save a few bucks? Why are those services less expensive, you would ask? Don’t we all want the best when it comes to our health and hope we can afford it? Medicare seems to be a really good system from my and my wife’s experience, and certainly obtainable and affordable. When I was employed and had a family medical benefit, it was better than nothing but an awful lot of expenses came from my pocket, not the insurance company’s pocket. They seemed to spend a fortune researching me and my doc’s motives rather than just paying for negotiated charges they had a part in…all BS. Medicare has taken them to the woodshed, so to speak, and shown how private insurance tends to be abusive to many people. I thank God for my good health knowing some people have very unfortunate and very costly experiences, with or without medical coverages.
M4A seems to be a reasonable option for huge societies such as ours, ensuring everyone has skin in the game.
A lot of what you say is correct, but the idea that people will shop and become consumers of health care given the info needed is not realistic and it is being tried via high deductible plans. The more serious and expensive care needed the less a person will shop. Health care is not like buying and paying for any other service, but yes, the very existence of any coverage reduces the sensitivity to cost.
when I started working in 1961 the only coverage was for inpatient services and fixed amounts for X-rays and chemo, no coverage for outpatient services or Rx. As benefits continued to expand so did costs.
Keep in mind that NOBODY wants to spend their hard earned miney on healthcare. That’s why burying the cost in taxes is appealing to many people.
I’ll give you one good reason why not universal healthcare and that’s because of our current political system. And that it can be weaponized against those dependent on it if they’re not of the right “ilk.” My wife turned 65 September 2021 and we set up her monthly premium payments for Medicare through our mutual HSA account, the same as me because she was delaying Social Security until FRA (full retirement age.) Everything worked fine until the new year when for some reason the automatic deductions from Medicare stopped. Since we only get quarterly statements we didn’t know they had stopped and had no reason to verify monthly deductions because it had worked fine for me over several years. Needless to say Medicare canceled her benefits in March 2022 for non-payment. Contact with the SSA told her to go to our local office, pay the overdue premiums and a small fine and they would be reinstated; lie #1. She did as they said but several weeks later no return of coverage. I won’t bore you with the in-between stuff or the countless hours spent on the phone, letters written and visits to the SSA offices, nor the verbal abuse she was subjected to by agents on the phone. Such as screaming and cursing, abrupt hang-ups and telling her Medicare was for people that deserved it more than her. A long story shorter, she was only allowed her reinstatement after nearly a year through the work of our U.S. Senator’s office. Our U.S. Representative tried at first but finally told us there was nothing they could do which is why we contacted our Senator. Medicare also imposed a 10% lifetime penalty deducted from her Social Security as a fine. I wanted to fight that but my wife said “no” because she didn’t want to go through the hassle again. And that’s why not universal healthcare!
There are screwups in every system. I have plenty of horror stories from private insurance and HMOs. In addition, the situation you describe is quite unique in the scheme of things. My wife and I have been on Medicare for thirteen years and received hundreds of thousands in benefits without one issue.
I’ve always marveled at how we in the U. S. pay more per capita for health care than in other developed countries yet get worse outcomes. We have lower life expectancies, and down in the south, the maternal death rates are horrific–worse than some third world countries. It’s crazy to think we could do better for less, but I believe we can.
Much of what you say is not because of the health care system, but lifestyles and eating habits and being the most obese country in the world with two exceptions.
The fundamental problem is that most Americans want unlimited access to care, they want it quickly, they want freedom of choice, they don’t want anyone interfering between them and their doctor and they want minimal if any cost sharing and of course low premiums. Good luck.
But the problem with that logic is, in many parts of the US doctors book months/years out (at least doctors that accept the most common insurance providers). If we’re having months long Waits, we might as well pay less too! I think right now is among the worst possible outcomes: paying significantly more while getting about the same (or less) as other developed countries
Paying for health care in this country is broken, but Medicare only seems to work due to cost shifting from private insurance for individuals not on a government sponsored plan. Medicare for all looks more like a disappointing mirage. The problem has been that the more government pays toward medical services, the faster medical pricing escalates.
Medicare only works at current cost levels because it does indeed shift costs to the private payers, and Medicaid does even more so, but that is the point. We need a level playing field which means that we need a fairer set of allowable fees across the board which when lower for some providers can be offset to some extent by better administrative costs.
I agree. Unfortunately, I doubt we’ll see it in my lifetime.
you may be right if you are 90. but if you are younger than that, get out there and work to “see it”. VOTE
Interesting that when you see your doctor and they bill your insurance, e.g., $1000 and they settle for $100. What a wonderful conundrum our gov’t and insurance CEOs have created. IMO it’s only going to get worse; not better.
It’s actually employers and unions and workers who created this in the quest to manage their costs. Insurance companies responded and so did Congress by creating HRAs, HSAs, cafeteria plans all of which shift costs to workers based on the flawed theory they will care about costs more. Limited provider networks and in and out of network fees are also part of the problem.
I agree with you pretty much down the line, Richard, but it will never happen. There are too many entrenched interests, too many politicians who would storm against anything even vaguely “socialistic” and too many Americans who truly believe that health care in this country is for those who can afford it.
I was living in the Bay Area when Obamacare was proposed, and my local congressional representative held an outdoor town hall to explain it. I stood up and asked her why she and her colleagues were supporting an entirely new state-by-state system that would be a rollout nightmare, wouldn’t cover everybody and would encounter intense political resistance. I asked her why not just expand a successful existing system — Medicare — by 50%, which would cover every uninsured American and face less opposition.
She didn’t have an answer, because there wasn’t one.
Sure enough, the rollout was a train wreck in many states, the whole thing came within a John McCain thumb of being legislatively burned to the ground, and nearly 30 million Americans remain uninsured. I’m glad we have Obamacare (my wife and mother-in-law have ACA policies now), but we could have done so much better.
“ There are too many entrenched interests,”—but not as many as there are patients living under this mess we have. Patients=Voters. Get out the vote!!
I totally agree with the author on the compelling need to move to more equitable health care system, and one that works across the whole country and not just limited to the state you live in. Sadly I too am pessimistic that a universal health care system will ever come to fruition in the US. There are way too many vested interests that make a living off of it and not the least of all, our elected representatives have no incentive to change the current model since (a) they get a much better insurance than ordinary citizens, I suspect and (b) I suspect as well that they gain a whole lot of political contribution from these vested interests that they would loath to give up.
I don’t know if this will do any good but a link of this article should be sent to all members of the US Congress, FWIW.
Mr. Quinn writes, “I am not talking about socialized medicine…” and then immediately contradicts himself: “I’m talking about a universal payment system … all calibrated relative to the individual’s ability to pay,” as if this isn’t the very definition of socialized medicine. And how would Mr. Quinn determine an individual’s ability to pay under this means-tested system? Household income? Net worth? He doesn’t say.
”Please don’t talk about instilling competition in providing health care—that’s nonsense,” he writes. (In other words, if you don’t agree with me, shut up.) He suggests that under the current system, patients receive unnecessary treatment “to protect the medical provider from lawsuits.” So is tort reform part of his solution? Should providers be immunized from medical malpractice claims to reduce costs? Mr. Quinn seems uninterested in such details.
“During the transition [to M4A] there may be shortages,” he writes without further elaboration. Will people die because of these shortages? How much human suffering is Mr. Quinn willing to accept as the price for his transition to M4A?
“For Americans who insist on private insurance, maintaining a form of Medicare Advantage is possible.” Really? How so? Mr. Quinn doesn’t say.
There are many places on the Internet where one can find thoughtful, well-researched analyses of our nation’s health insurance predicament. Mr. Quinn’s half-baked, emotionally incontinent screed (“I can’t take it anymore,” he wails) is not among them.
You tear his piece apart but do not address the problem nor have a solution. Do you like our “system” as it is? We don’t have to invent a new system, there are many around the world that we can duplicate. And socialism is what we need.
If this response is supposed to be an example of “thoughtful analysis”, it not only fails miserably but serves as a case study of why the health care debate in this country fails as well. The respondent’s dismissiveness and derision come unaccompanied by even a single original thought, let alone a preferred alternative to what Mr. Quinn has presented.
The United States has the most expensive, inefficient and inaccessible health care system of any advanced nation on the planet, and as long as reasoned debate over comprehensive change is obliterated by reflexive political sloganeering, it will remain that way.
So I take it you have a better idea?
So what, exactly, is wrong with “socialized” medicine? Pretty much the whole of Europe operates “socialized” medical systems, and you don’t see Europeans complaining about it (the Brits are beginning to get upset – but it’s about the cuts made by Conservative governments, not the NHS as a system). The French system is generally rated the best in the world. “Socialism” is not communism, and the word seems to be mostly used in the US as a way to stop discussion.
I asked a question. Down-voting it is not an answer. Instead, it suggests that the voter does not have an answer, and is just reacting to a word s/he has been conditioned to regard as “bad”.
The French system is a combination of public and private care, insurance can be purchase most doctors are self employed. There is out of pocket cost sharing. It’s not socialized medicine but closer to the M4A concept.
There is a good outline of the French system here: https://en.wikipedia.org/wiki/Health_care_in_France
“…the government has taken responsibility for the financial and operational management of health insurance (by setting premium levels related to income and determining the prices of goods and services refunded).”
It would appear you do not understand socialize medicine or perhaps our current system. I spent all
my working life designing and managing health benefits, negotiating physician contracts and serving on the boards of several health plans. I think i have a modest understanding. PS the problem is not ins companies ir their CEOs.
Medicare uses 98% of its funding for medical care and 2% for administration. Insurance companies fought tooth and nail against the ACA requirement that they spend 85% on medical care. It should be obvious where much of US health care spending is going, and it’s not on health care. I believe there are some European systems that manage to include insurance companies in their medical systems, but with very strict government oversight. I can’t imagine that happening in the US, given the amount of money the companies are free to spend on politicians.
I think that simplification and lower costs are possible. You would need several things to make this happen. First you would need a single nationwide agreement on what care would be provided, deductibles, co-pays etc. There are significant costs in the present system as providers and patients struggle to understand what is covered and for how much with myriad different plans and processes.
Second, you need to reduce the number of entities which pay for services, at least within geographic areas. Providers incur significant costs in trying to collect what they receive from payers, such as insurance companies, or government departments.
Third you need a role for private insurance to play because they are players in the game and won’t cooperate without a piece of the action.
Fourth, the plan would need to cover everyone within the geographic area(s) for coverage. No matter where people are, they need to know that they can get medical care when they are in the country.
Fifth, you need a national agreement on how the plan would be funded between employers, workers, retired persons, and government.
Once you had an agreement on what was to be covered and how it would be paid for, you could move to a new process where the country could be divided into geographic regions and then insurance companies could compete for the privilege of providing the standard coverage to EVERYONE within that geographic area for say 3-5 year terms. The winners could then operate as the Center for Medicare Service operates as a single point for administration of the plan within the region.
You would need the IRS or some similar organization to collect the dollars to fund the coverage and pay the insurance companies.
Within each geographic area, there would be the efficiency of having a single payer and a single administrator. With a single coverage plan choices could be made about what coverage people are willing to pay for.
I think the chance of any of this happening is very remote.
We don’t need more or different coverage, wjat we need to do is cut costs.
In the current system, the government pays $1 trillion and private parties pay $3 trillion. If we took that $3 trillion and divided it into the total US payroll of $9.7 trillion, we would discover that a new tax of 30% of payroll would be required – at the current level of medical spending. However, once medical care was more available, system usage would probably rise substantially.
The truth is, if we don’t do something to reverse rising costs, we will end up spending 100% of GDP on medical care, and have nothing left for food, housing, and clothing.
Suggest reading Elisabeth Rosenthal’s “An American Sickness”. You will realize that rising costs are due to treating medical care as a profit center and not a service. There is a reason health care costs in the US are double those in other OECD countries, and it is not because the health outcomes are twice as good.
I have recommended this book to anyone who wants to truly understand what is wrong with the American healthcare system (or lack thereof). She also comes up with a number of solutions, of which there is practically zero political will to do so. It’s an excellent read, and somewhat depressing.
Books, articles, interviews, comment forums. There’s certainly no shortage of opinions on healthcare – how to fix it, whether it should be fixed. So many pontificate at length. I believe all it will ever be is talk. I’d be shocked to see any progress in the next 30 yrs.
The U.S. is far too broken to tackle any serious priority. As long as voters continue obsessing over which words are now insulting; which companies deserve to be cancelled for an unpopular opinion; which music, books or artwork must be banned; who can get birth control or say the word “gay”, healthcare will stay on the backburner.
To the poster who said “voting” fixes it. Nope. That requires citizens to care and have the critical thinking skills to avoid brainwashing by fake news or deceptive candidates. Voting does FAR more damage than good otherwise.
Many factors including obesity and most important American exceptions fir everything and anything immediately
Mr Quinn, read your comments before hitting ‘send’–too many typos make it unintelligible.
Not likely, but in any case where would you cut costs?
Pay doctors and hospitals less? Limit the number of facilities? Stricter monitoring of medical necessity and provided care? Fixed drug prices – which by the way despite the rhetoric are about 10% of total spending? Strict national or regional budgets?
What part of the health care delivery system do Americans want to change to lower costs?
They want to stop paying hospital and insurance company CEOs millions of dollars in salaries for doing nothing but finding ways to charge more. They want to stop having their doctors pay office staff just to deal with abstruse codes (apparently you can get a degree in medical coding!) and paperwork for insurance companies. They want to stop seeing every hospital buying the latest and and most expensive equipment when only a few pieces are needed. I could go on.
That simply is not correct. CEO pay is insignificant in premium costs. Medicare uses the same coding, but questions less care and has been criticized by the CBO and GAO for not checking more. Yup, we could do with less equipment, but explain that to people who don’t want to wait or travel farther for their care.
Your coding reply is backwards. Medicare (CMS) establishes DRG/RBRVS codes and reimbursement, and then private insurance piggybacks on that.
Agree on CEO reimbursement and drug spending. The real money is spent on doctors and hospitals (who are paid considerably more than their overseas counterparts). I guess I missed Bernie & Co. wailing about that.
CEO pay is part of the 15% of insurance company income not spent on care – and that’s for the ACA where the percentage is mandated. Likely even higher in the unregulated marketplace.
If you take CEO pay and divide it by the number of policies, you will see it is insignificant. Keep in mind that much of the admin cost is required by state and federal regulations. Also, state and federal benefit mandates add to the cost. In addition, Medicare law admin costs contribute to the high rates of undetected fraud. Finally, most large employers are self funded and the administrator often an insurance company has no incentive to deny claims or any risk for claims and still costs are high and continue to increase.
How do they manage to get a better quality of care and outcomes with fewer hassles to the patient in socialized systems? Take the extreme profit motive away. Fixing people is not the same as fixing cars.