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We have multiple insurance programs – based on age and income, there are differences among the states, who pays how much is a mess – many seniors pay more than younger Americans at the same income level.
Enrollment periods and rules differ by type of coverage. Out of pocket costs frequently ignore ability to pay. Employers try to mask costs via FSAs, HSAs and HRAs – if you can afford to contribute. Trying to deal with out-of-pocket costs jeopardizes the ability to save for retirement.
We allow drug companies to market directly to consumers driving demand and costs and perhaps creating health risks.
Allowable fees paid to providers for the same service vary greatly depending on the source of payment – Medicaid, Medicare, employer coverage, private pay – thus causing cost shifting and an unfair distribution of costs to patients.
Employers continue to shift costs to workers sometimes offsetting raises.
We make our disconnected approach so confusing few can figure it out.
Make an attempt at change and we hear the cry “socialized medicine” which is nonsense as we are talking about a payment system not health care delivery system.
I hear people from other countries talk about their much better “free” healthcare system. Of course, it is not free, but the very fact they feel that way tells us the perceived value of paying via taxes and not at the point of service. Everyone is in the same risk pool.
Why can’t America do better? I don’t expect to see significant change in my lifetime, but someday we may see the light.
Sorry, there is no valid argument against a universal USA health insurance system. We have tinkered with our system since the 1960s and I was involved in trying change after change to manage costs, nothing has worked. Nothing has assured universal coverage.
I once lobbied Congress against the Clinton health care plan, I was wrong. Will any universal system be perfect? Certainly not. Will there be tradeoffs? Absolutely!
But if our system works fine for people like me – aside from premiums over $2,000 a month for us – it doesn’t for tens of millions of others young and old and the cost shifting to the middle class is getting worse.
Our goals should be universal insurance coverage, uniform management of costs, fair distribution of costs and no variations based on where you live.
I would like to see serious tuition help for medical students as the debt where I live is preventing them from buying into practices. Our PCP is overloaded with patients. Also, raises in Medicare should be included in the Social Security COLA, rather than erasing the small increases we get. We are anxiously awaiting the promised 2025 cap on Part D of Medicare, as it runs us about $8K/year and we have good insurance!
to understand how convoluted and “weird” our healthcare system is in terms of who and how we pay listen to the podcast an arm and a leg. It’s surreal at times what people have to go through. One hint is clear there are profits being earned by big corporations that are not adding a penny to the quality of healthcare. I’m not sure what the answer is since to change anything you have to pass laws but these corporations make huge political contributions.
Keep in mind that in places where there are perceived
long waits for health care services as in Canada and the UK there is budgeting intended to manage costs, but which also limits available services in some cases. Medicare does not do that, but attempts to manage cost by limiting payable fees.
No matter what, the open access and generally readily availability of healthcare resources Americans want and expect will always be expensive.
For example the US has 38 MRIs per million population, Canada has 10. The UK 8.6 Only Japan has more than the US.
So easier access, more spending. Also, scanners are expensive so to pay for them they have to be used – who creates the demand?
No valid argument against universal health insurance, huh? I admire your confidence. You may find of interest a concept called “steel-manning,” where instead of exposing the weakest possible argument against your position, you deliberately discuss the opposing side’s strongest case.
My dad’s from a communist country that has universal health insurance and their health care is terrible. Have you ever wondered why the richest people from all over the world come to the US for care? They don’t go to Canada or UK. They come here because you can pay for the best care possible.
I, for one, love it when my doctors get rich. It means they’re providing a valuable service to many people who reward them for their skill with certificates of appreciation with presidents faces on them. This is the same reason I love it when my lawyer, accountant, plumber, and car mechanic get rich. If they profit it is because they delivered a good or service that the market found valuable.
Just in case you think I’m the Monopoly Guy, I grew up poor in this country. My mother died of cancer with no health insurance. That sucked, but that doesn’t change the fact that free enterprise is the answer, and “universalizing” (socialism) is not. Never has been. Once “universal” heath care comes to the US our system will be just as dreadful as all of the other countries that have it.
I can’t think of any reason a brilliant, skilled person would go into medicine to become a doctor just to be paid like a government employee. Instead our best and brightest will go into non-“Universalized” fields…until those are “universalized” too.
I completely agree.
The most successful health care systems in the world are hybrids, where universal coverage is buttressed by the availability of private insurance. They are not “dreadful” — they are vastly superior to the US, which has the best physicians, best hospitals, best new medical devices, and worst outcomes.
The universal measuring stick for the effectiveness of a nation’s health care is how they care for babies and new mothers. The US infant mortality rate is 49th in the world. It’s more than double that of Slovenia, Cyprus, Belarus and Montenegro. Our maternal mortality rate is 21 per 100,000 births which is 65th in the world. That’s obscene. Israel and Australia have a rate of 3 per 100,000. Germany and France are 5 and 8 respectively. We are killing our new mothers with neglect.
Fewer than half of US physicians are self-employed and that number is only 32% for those under the age of 45 (a 13 percentage point drop in the past 10 years).
It appears you have not read the research which has demonstrated repeatedly that US health care, compared to all other developed countries, costs twice as much per person for results that are on average worse. Yes, if you are very rich you can get excellent care, but that’s not true of most people.
it wouldn’t be quite so bad if all that excess spending went to the doctors, but in general it does not. It goes to administrators and middle men and insurance companies. Not to mention professions other countries don’t need, like medical coders.
i don’t know which country your father grew up in, but France is held by experts to have the best medical system in the world. But they understand the difference between Communism and Socialism.
Nope, no reason and if you have a better idea that meets the criteria of universal coverage, fair income based costs to individuals and open access to care with reasonable cost management I am open to hear it.
Keep in mind we have Medicare as an example. It’s not perfect as is, but it does the job very well for 20% of Americans today.
Medicare is not even close to socialism, There’s no government ownership of healthcare at all. People who falsely claim a Medicare for all type approach is socialized medicine are one of the reasons we can’t get anywhere with change and yet if they are lucky some day they will enjoy the benefits of Medicare.
I agree wholeheartedly with your post and am preparing to go on Medicare in the next few months. Dick, you’ve mentioned a couple times now that your and your wife’s monthly premiums are over $2,000. Could you provide the breakdown of this by person and by part/component? I plan to choose traditional Medicare with a Medigap plan G supplement plus a drug plan. I am looking at much lower costs and am thinking I need to budget for a bigger increase as we age.
There are 3 methods for pricing Medicare supplements as they are regulated by the states. At the end of this comment I will add a link which explains them. The practical effect is that those who are fortunate enough to live in one of the 8 states which uses Community pricing will see dramatically lower costs for Medicare supplements over their lifetimes.
https://www.medicarefaq.com/faqs/medicare-supplement-plans-medigap-pricing-methods/
Very interesting. Thank you. I’m in Illinois so it’s Attained-Age-Rated pricing for me. Seems the Issue-Age-Rated approach would discourage insurance company switching. A BCBS G plan for a non-tobacco male is $159 for a 65 yo and $274 for an 80 yo.
Our Medigap Plan G are $262 and $273. Both are higher than average and reflect our ages and location. You can get community rated plans though. We were forced out of employer supplement coverage three years ago. A more realistic premium would be around $225. The balance is our Part B and D coverage both of which are IRMAA based rates. It’s IRMAA income based premiums that drive the largest part of the total.
The cost of Medigap plans varies considerably: by age, by how the plan is priced, and also by location. I looked into plans in Florida for a friend recently, and the cost there was much higher than in central North Carolina. I am 77, and my Plan F, always more expensive than Plan G, costs me $193 a month.
Thank you
I am certainly no expert on universal care in other countries but I can comment on a couple things. I had an uncle in Canada with cancer who died during a several month wait to see a specialist. I know that I am only giving one example for Canada. I grew up in Germany so that is the only country I will comment on. Yes the care is good. Trade offs are higher taxes and depending on condition wait time can be long. In Europe there has long been an acceptance of the government taking care or subsidizing social services. One of the things I respect of this site is it does not get political so I may be on thin ice with the next part. I would assume our government would manage any universal care program. As dysfunctional as our government is I cannot imagine them creating as well as managing such a system.
I take it you have yet to experience Medicare? It’s doing pretty well.
we are on medicare and for us it does work well, I would respectfully disagree that it is doing well. My comment was geared more towards creating a new program
I have been trained as a SHIP counselor in my state for the past several years. It is a highly rewarding volunteer mission – perhaps similar to those here at HD who assist with tax returns. The training takes significant time with annual full-day mandated sessions; that process can deter some folks. I am grateful for veteran volunteers who have been counselors for a decade or more- they help everyone guide through nuanced situations that arise all the time. Medicare choices are indeed financial decisions which are daunting for so many.
Those who join Medicare after years of robust corporate health coverage face a reckoning with the monthly costs. Others who struggled with individual coverage before and with the ACA are often thrilled with lower monthly premiums. Myriad issues: when to enroll or delay; how to enroll; how to decide which coverage works best for a specific individual; and – now more then ever- how to check coverage every fall as drug formularies and doctor/hospital networks change within current plans.
It is rewarding to help individuals demystify Medicare. There is so much more to do -across the country many folks with limited incomes are still unaware of programs to help pay for coverage. Reaching them is hard.
And that’s part of the problem – the need to demystify – that should not be the case.
if there was no Part C doctors participating would not be an issue.
Extremely confusing when one has to make choices for Medicare. Boomer Benefits was very helpful even though I chose a plan that they could not sell. They have a FB group too. What I did learn was that Medicare Advantage is a very local choice and not to listen to pundits that slam it as a whole when it depends on the providers in one’s location.
The providers can change, often with little warning. Once you pass on Medigap coverage you may be stuck with Medicare Advantage because the insurance companies can refuse to cover you.
I was fortunate to be able to live in Australia (Brisbane) for 3 years, from 2015-2018. As I was on a temporary worker visa, I wasn’t covered by their national single-payer system, and was required to purchase health insurance.
Friends and colleagues when they heard this were very worried for me, that I had to pay for my own health insurance there. The monthly cost, for excellent health insurance was around 230 AUD$. When I had worked as a consultant in the US, and was self-pay, I paid around 800 USD$, so was thrilled to pay so little.
I didn’t have any big health care needs while in Australia, but when I did need care or checkups I was able to see excellent practitioners in a very short time.
I agree whole-heartedly that the health care payment system here in the US is designed to funnel money to Health Insurance Company Excecutives.
This is an excellent site for those dealing with medical bills: https://armandalegshow.com/
One of the most perverse situations in our healthcare system is that those without insurance pay list price, whereas Insurance companies pay less.
Next time you receive a bill look at the billed price, then the allowed price paid by the insurance companies.
Those without insurance should pay the lowest allowed price for a service as obviously the hospital negotiated what they consider a reasonable reimbursement rate.
If people speak up they can often lower the fee in such cases.
Agree totally. A universal USA health insurance system would eliminate all the marketing money waste by drug companies and for-profit healthcare systems while making things so much simpler for the consumer. I’ve waited my whole life for this solution. Next year I’ll see firsthand how close Medicare is to being that solution.
Thanks to all who’ve shared their wisdom here on HD.com re: Medicare. I am finding and learning from all the previous good articles. Right now I’m trying to get my husband to make the time to switch from Advantage to Traditional as his first year wraps up in October. He didn’t really take advantage of seeing a lot of doctors during his Advantage year, though. Will get the Barry advice book, and maybe try to find one of those “SHIP” counselors here in NY, too.
The biggest advantage of obtaining a Plan G if you can afford it is cost certainty. There is only the Federal yearly deductible that everyone who joins now has to pay. You pay no deductible, and no copays, and as with any Medicare supplement plan, can go to any doctor that accepts Medicare.
In my county I pay $170 per month. The above points make this seem like a great value for less than $2400 per year which I would venture to guess most HD readers can easily afford.
At this point I am healthy and rarely go to the doctor other than annual checkups so not getting much value at present, but who knows when good health comes to an end, and the bills start to pile up.
Get ready for a confusing array of choices.
I recommend a book called Medicare for Dummies by Patricia Barry who is considered the national Medicare expert. The book is well organized and written in plain spoken language.
If you are healthy I would suggest an Advantage plan with the highest rating and the lowest cost, then before the year is up changing to traditional with a supplement. You can change to traditional within the first year with guaranteed issue.
That’s the problem. In a nod to insurance companies Part C was added. Any choices distort the system and add unnecessary confusion.
I second the book recommendation, and would also suggest seeing a SHIP counselor (may be called something else in your state). My recommendation would be Medicare A and B plus Medigap Plan G and a drug plan. Choose a community rated plan rather than age rated if available. I wrote a couple of articles on Medicare.
As a retired physician, I second your wise advice!
1) Healthcare costs are either paid for by “extra” taxes (UK model) or as part of the cost of goods and services (US employer provided coverage, excluding Medicare, Medicaid).
2) Populations are living longer and there are now more healthcare services available than we can probably afford as a society – e.g. joint replacements, cardiac operations, cancer treatments, all types of scans and tests, extensive end of life care, to name but a few as well as the cost of drugs for numerous conditions and diseases.
Individual patients want everything because it’s their life which is at risk while nobody wants to pay for it all.
There are a lot of people who fall outside any coverage you list in #1 40-50.million
An issue on which we are in complete agreement! 😎
Remember, this is not about health care it’s about paying for care. No different than current Medicare for all practical purposes. You can’t compare with the UK or even Canada.
However, to think any system can work without some limitations and over sight to care is not realistic.
And, there are some pretty long waits in the US now. I can attest from experience.
A couple of years back I was offered an appointment with a hematologist fourteen months out. My area is very well provided with hospitals and practitioners but a four month wait to see a specialist is normal. Often you’ll see a PA or NP instead.
Very often these days, but not necessarily a negative.
It’s interesting that wait times vary so much across the country. When my husband had a major medical issue last year, he was able to get into the Mayo clinic within a few days of his diagnosis. All of his follow up care happened in a very timely fashion. Perhaps it’s because we live in an area with more retirees than other parts of the country.
During our four recent years in NC (2019-2023) we encountered considerably longer wait times to see specialists than we did in NYC. My impression is that the longest wait times are in rural areas and places where population growth is outpacing the supply of specialists.
Not necessarily, after biopsy came back positive and she was referred to the oncologist the initial wait was over six weeks only because her gynecologist called again did she get an appointment in three days.
Two years ago I was in big trouble and tried to get urologist appointment but they were weeks away, time I did not have. It turned out when I called one office the person who answered knew me and got me in that day – to the surprise of the doctor.
I grew up in England with the National Health System. I was taken aback when I moved to the US and had to write a check to a doctor. The fact that the 2012 Olympic Games in London opened with a massive tribute to the NHS should tell people all they need to know about how Brits view “socialized medicine”. Although the recently defeated Conservative government did its best to destroy it.
The French system is generally held to be the best. I once visited a French doctor and he needed no back office staff at all. He charged me 30 euro ($33 today) for the consultation and my three drugs cost around 15 euro.
After hearing horror stories about Healthcare in Canada, a Canadian reminded me that they have the option to opt out and buy private insurance… but very few do that. That suggests to me that their system works pretty well.
Canadians do not have the opportunity to opt out and buy private insurance. We can pay out of pocket to a private clinic —- very rare — or we can travel to another country and pay there. A physician who accepts money directly cannot participate in the government-paid program, and I don’t know of a single doctor who follows this route.
Your last point is correct: the system works pretty well.
And before I get corrected about “government-paid”, I’m aware that it’s taxpayer-paid. I mean that the government handles the paperwork.
An interesting report about Canadian healthcare system wait times is here.
Here is a quote from the article: “In 2023, physicians report a median wait time of 27.7 weeks between a referral from a general practitioner and receipt of treatment. This represents the longest delay in the survey’s history and is 198% longer than the 9.3 weeks Canadian patients could expect to wait in 1993.”
Family, friends, and co-workers of mine have been able to receive treatment promptly in most cases. A well-off woman I know could not wait for a hip replacement and paid out-of-pocket to have the procedure done in Dallas. (I believe the wait time in Canada is a year.)
There are also regional considerations in a country as vast as Canada, where the population is concentrated heavily along the US border. A former next-door neighbor of mine, an ear surgeon, makes a one-week visit to northern Canada once per year. So if you miss his visit by a month, you would wait 11 months to see him. (I might add that the trip is made primarily at his expense, so credit where credit’s due.)
Canada had essentially the same healthcare system in 1993 that it does today which suggests that the increase in wait times may have more to do with an increasing shortage of specialists than it does with the nature of its healthcare system.
That can be an issue, but mostly when government makes budget allocations forcing such delays. Nevertheless you would be hard pressed to find a Canadian or anyone will to trade for our system. By the way there are considerable wait times in some areas and specialties in the US as well.
Also, I think a shortage of specialists in most countries is slowing things down.
Very likely and also people think they need to see a specialist first.