Munger Says We Will Have Single Payer

[Guest Schwab711]

A free market solution cannot exist without being able to deny those who don't pay service and allowing those who day the ability to differentiate between products. But we, as a country, don't have the political will to tell people they cannot receive treatment NOR will the government enact a forced pricing scheme on private institutions.

 

I don't like the term free market in this context so I will use a different term. Normal market. You can have a pretty good "normal market" solution to this problem. And that is what Singapore has done. Its extremely effective in providing high degrees of health care availability, good outcomes, no lineups and very low costs. Singapore is a multi-payer system and its the single most effective healthcare system in the world.

 

By "normal market" I mean a system where the vast majority of consumers are paying for thing directly out of their own pockets with money they earned and for their own direct consumption (not to resell to someone else).  I would say that housing, stock market, education, car repair, healthcare are mostly abnormal markets since in these cases the consumers are mostly not paying using their own money directly for their direct consumption. Instead they are using loans, insurance.

 

Normal markets work well. In most normal markets prices typically decline, quality improves, pricing is rational and there are no large scale societal problems. Clothing, food, consumer goods are examples.

 

Healthcare is not a normal market since everyone uses insurance. But Singapore found a way to turn it into one. Their system is not a "free" market. But it provides all the true advantages that free markets have. Brad Delong has a solution that essentially accomplishes the same thing and is described here:

http://delong.typepad.com/sdj/2007/06/dealing_with_th.html

 

Basically the solution is as follows:

1) Compulsory HSA's and everything paid out of the HSAs up to a certain limit which is dependent on income

2) 100% insured coverage if you exceed the HSA limit

 

This is generally the solution I would advocate for, but just don't see the political will for it. Someone, somewhere, is going to stand up and say that some people still won't be able to afford it and that even the $30-40/month for a high deductible plan would be too much to pay, let along them being on the hook for a $2-3k deductible.

 

We don't have the political will to refuse those people service,s o still don't think this would work - though it would certainly be better than what we have now.

 

I think it's a bit of a flywheel right now. Costs are out of control so too many folks take advantage of EMTALA for services and then go bankrupt (or hospitals/other HC services don't bother trying to collect). That effectively spreads costs around to everyone. The point of ACA was to avoid having emergency room bills be shared by everyone and instead just give health insurance so that the charges would be lower. We also guaranteed coverage of pre-existing conditions at the same time so I think the country ended up conflating causes. Most research papers I've read point to pre-existing condition, the 80% expense ratio mandate for health insurers, and the lack of Medicaid expansion by many states as the primary contributing factors of rising health insurance and healthcare costs since 2008.

 

The biggest problems with EMTALA overuse are in non-Medicaid expansion states (as we'd expect). With Medicaid expansion, there's generally a pretty small percentage of people expected to pay the full premium on a HDHP, yet still making meaningfully below median income. No solution will help everyone. If low-income folks paid $50/month on a $5k deductible, I think we'd see a major improvement. Spontaneous $5,000 bills of any type will cause problems for many people but we'd certainly reduce the usage of EMTALA (and thus lower the cost of HC treatment overall). I don't know if most people here have been in this situation but most low-income folks would love to pay for affordable healthcare. Not being sure if you can get/afford healthcare treatment is extremely stressful.

 

I think if we can lower EMTALA usage (by increasing Medicaid programs in states), HC cost pressure would ease some and more people would be eligible for HSA accounts. More HSA accounts means more people would be putting money towards their medical bills, which reduces the nominal amount of healthcare costs shared among everyone. If HC costs decrease then cash compensation as a percentage of total compensation increases and the relative HC costs decrease by more than the nominal costs. As I said, the US is trapped in a negative flywheel. It can switch to a positive flywheel with small policy changes and a small shift in attitude/political will.

 

If we are going to deny services then we need to transition to mandatory insurance and HSA account funding (like Singapore). Looking at the US and other countries, full personal accountability doesn't seem to be feasible without mandatory participation. Singapore mandates 8% of monthly income go towards their version of HSA accounts. I think the US max healthcare spending on insurance is 10% or 15% of gross income. If we made it 15% with 8% HSA and 7% insurance, over time the costs would decline and the maximum would be less of an issue for most. I definitely agree with you that mandatory healthcare participation has been a major sticking point, politically, in the US. Without mandatory participation, it's pointless to try to emulate Singapore. At some point, employer-provided insurance will no longer make sense either.

 

If everyone must participate and someone still decides to not fund or refuses to pay for services then it's easier (politically/socially/legally) to deny them future treatment. The issue now is most folks realistically cannot afford medical treatment and it's bad for everyone (economically and socially) to deny such a large percentage of the population adequate healthcare.

 

Finally, on denying services, the issue is the most sensible people to deny services is not necessarily folks that cannot afford basic treatment but forcing folks with seriously debilitating illnesses/conditions to pay out-of-pocket (since they *generally* have a lower expected value to society purely through the perspective of contributing to broad funds). If the US was excessively utilitarian about healthcare, you could argue that we'd only provide healthcare for working individuals and abandon folks after retirement. That's probably a stupid idea for all sorts of reasons. I think attempting to deny healthcare treatment should be done with extreme care. Many folks provide excess value to society when we give them free healthcare. There are many ways to create value.

 

Either way, I think the issue around misusing EMTALA (and thus, the proposed issued of should we deny services and how) is a symptom of upstream issues and not a direct cause of high healthcare costs. Healthcare costs were problematic well before EMTALA of state versions of EMTALA that popped up a decade before the federal law. EMTALA was a band-aid.

 

As long as we can remove the political polarization from healthcare then the US should at least begin to move in the right direction. The political rhetoric has been way too high for a long time now.

[Guest Schwab711]

This is generally the solution I would advocate for, but just don't see the political will for it. Someone, somewhere, is going to stand up and say that some people still won't be able to afford it and that even the $30-40/month for a high deductible plan would be too much to pay, let along them being on the hook for a $2-3k deductible.

 

We don't have the political will to refuse those people service,s o still don't think this would work - though it would certainly be better than what we have now.

What you say is true. The US is a mess. You have all sorts of policies programs and ideas etc, etc. If single payer will go ahead I don't see it being a federal thing. Firstly, as I've said the whole system is already a huge, giant mess. Secondly, the US at this point is pretty much divided on everything. For something like this big to work the people working to make it happen have to want for it to work. If anything gets done federally what will happen is that someone will sabotage the whole thing from the beginning.

 

One way that I can see this happening is that say a state like California that is more united around the issue decides to go single payer. I'm not choosing California just because of politics. It's economy is about the size of Britain. They have a pretty good health care system in Britain. Single payer, equal access, no deductibles, it's got good outcomes, high approval ratings, and it's pretty cheap. Whatever dissatisfaction with the NHS exists comes from the fact that the NHS rations out care to keep costs low which creates wait times. But you want to spend some more money, the system get better in a hurry. 

 

Now if you were to implement an NHS like system in Cali and increase its budget by 30% to make it fantastic, you still come out 30% below what you're currently spending. Non medicare/medicaid costs would come in 50% below what they are right now. Those are BIG numbers. If a big state like California successfully implements something like this other states will follow suit. Then the current system falls like dominoes.

 

I completely agree on the domino theory. Massachusetts has been pretty close to universal coverage and will likely lead the US in single payer. They are already showing signs of decelerating healthcare costs and it's possible they see costs decline in the near future.

[DeepSouth]

 

health care in the US........

 

any thoughts on this?

 

I am worried because I am invested in the MCOs

\

 

If the government were to institute a universal coverage system it would most likely be outsourced to MCOs. MCOs run most Medicaid plans today and are taking share quickly and close to half share in Medicare. Government run fee for service plans are not the way forward.

[flesh]

How about a constitutional amendment fixing the cost of nationalized healthcare to a % of gdp plus regular inflation not medical inflation adjustments.

 

Even if the initial number is nauseatingly high, this would reduce my fears by a substantial majority.

 

Aside from that, if you zoom out and look at the next century, I believe significantly more lives will be lost to reduced innovation than gained by single payer. The thing is, no one will be talking about that lives that weren't saved due to reduced innovation. Greater than 50% of lives saved from innovation in the last century are not a result of infant and children's death's. Plus, that's backward looking.... forward looking, a better innovation system humming on all cylinders with the tech that will come in the next century with 10 billion people innovating vs less people in the past could produce untold wonders.

 

What might have happened can't be calculated and isn't news on 99% of folks radar's.

 

 

 

 

 

[Guest Schwab711]

 

health care in the US........

 

any thoughts on this?

 

I am worried because I am invested in the MCOs

\

 

If the government were to institute a universal coverage system it would most likely be outsourced to MCOs. MCOs run most Medicaid plans today and are taking share quickly and close to half share in Medicare. Government run fee for service plans are not the way forward.

 

Word. The term 'single payer' is probably misleading for the broad population.

 

Aside from that, if you zoom out and look at the next century, I believe significantly more lives will be lost to reduced innovation than gained by single payer.

 

We can show that this this is unlikely to be true. In 2017, approximately 10% of the population didn't have health insurance. It was ~20% prior to ACA. This statement assumes that the remaining 10% are not worth insuring because we could 'save the lives' of 11.1% of the 90% insured (10% of the population). The 90% insured is generally composed of working folks (private [employer] insurance), elderly (Medicare), and the disable/poor (Medicaid). Most likely, the 11.1% we would be saving would come from the Medicaid population since you can't prevent aging and the working class is generally much healthier than any other group (since there's some Bayes Theorem in the sense that if you are healthy, you are able to work).

 

Pre-ACA, we'd have 20% of the population uninsured and the majority of insured Americans would be on private insurance or Medicare. It would be impossible to find 25% of the 80% on private insurance/Medicare that have inadequate coverage to the degree that those additional Medicaid subsidies would be better spent 'saving' them as opposed to providing basic treatment/services to uninsured. Obviously incremental gains are largest when you have no care (uninsured) relative to at least some care (the presently insured).

 

I can understand arguments along the lines of 'moral hazard' and they probably have a lot of validity (it's a subjective topic so I'm not sure how we can be any more generous than 'probably'). However, to say that incremental care of insured persons could provide greater healthcare outcomes relative to the gap between no care and basic care doesn't make sense to me. Especially in the numbers you are talking about.

 

 

Greater than 50% of lives saved from innovation in the last century are not a result of infant and children's death's.

 

Where does this stat come from? What metric are you using (or quoting) to determine 'lives saved'? I've never seen any study that even hints at anything other than infant mortality as the primary reason for increasing longevity.

 

Again, a simple thought experiment will show why.

 

Say we have 10 people in the country and 20% infant mortality. There lifetimes last (in years):

1

1

60

60

65

65

70

70

75

75

 

This implies a longevity of 54.2 years.

 

Let's say we decrease infant mortality to 10% and one of those babies lives to 60. The longevity would increase to 60.1 years.

 

Now instead, let's leave infant mortality at 20% and increase the life of surviving individuals by 5 years (that's huge innovation!). The longevity would increase to just 58.2 years.

 

Having more people live a full life is the easiest way to increase national longevity. It's really not even close. The properties of an average/mean dictate this. If the argument is more based on 'standard of living' then there is a lot of subjectivity and it's hard to rigorously conclude anything.

 

 

If you invest in biotech you'll know that 'innovation' in healthcare really isn't as impressive as marketing would make you think. Most leading cancer drugs barely provide statistically significant improvements over placebos or the current standard of treatment. The best treatments extend life expectancy of someone with terminal illness by 10% or so on average. The intended patient populations for these drugs are measured in the thousands. Obviously individual experiences may make folks think it's a miracle drug but it just doesn't move the needle for a nation's health. If anything, these types of innovations are the cause of our escalating healthcare costs.

 

The biggest healthcare innovations over the last 200 years are probably washing our hands, vaccine/inoculations, and penicillin. Simple stuff with mass application goes a long way.

[Cigarbutt]

If you invest in biotech you'll know that 'innovation' in healthcare really isn't as impressive as marketing would make you think. Most leading cancer drugs barely provide statistically significant improvements over placebos or the current standard of treatment. The best treatments extend life expectancy of someone with terminal illness by 10% or so on average. The intended patient populations for these drugs are measured in the thousands. Obviously individual experiences may make folks think it's a miracle drug but it just doesn't move the needle for a nation's health. If anything, these types of innovations are the cause of our escalating healthcare costs.

 

The biggest healthcare innovations over the last 200 years are probably washing our hands, vaccine/inoculations, and penicillin. Simple stuff with mass application goes a long way.

 

1+ from my perspective also.

From the what is provided point of view, perhaps we're in a diminishing return temporary plateau but, apart from some breakthroughs, progress at that level has been slow for quite some time.

 

The quality/cost curve has been unfavorable and whatever the reason (too little or too much government, distorted private incentives or a combination of both), innovation should not be limited to what is provided but also to how it is provided.

[Guest longinvestor]

https://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy

 

There are about 30 nations who have longer life expectancy stats than the US. One interesting stat is the Health Adjusted Life Expectancy (HALE) (Healthy Years  + Disability Years), which for the US is 69. Full LE is 79. That delta of 10 is in the same ballpark as the 30 higher ranking nations.

 

The purported healthcare innovation is akin to throwing money at the problem.

[Cigarbutt]

https://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy

 

There are about 30 nations who have longer life expectancy stats than the US. One interesting stat is the Health Adjusted Life Expectancy (HALE) (Healthy Years  + Disability Years), which for the US is 69. Full LE is 79. That delta of 10 is in the same ballpark as the 30 higher ranking nations.

 

The purported healthcare innovation is akin to throwing money at the problem.

 

Complementary info:

https://www.ncbi.nlm.nih.gov/books/NBK62584/

 

The first two paragraphs summarize well.

Basically, at the individual or "mutual level", it boils down to an NPV decision to see if potential useful life lost is worth the investment.

The Constitution mentioned that all are created equal and can have a free and happy life (duration not mentioned).

Life expectancy, when the document was written, was estimated in the mid 30's but recently, after incredible progress, in the aggregate, has been dropping for two years in a row.

Multi-dimensional problem but America's best days lie ahead (ref: Warren Buffett).

 

[KJP]

https://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy

 

There are about 30 nations who have longer life expectancy stats than the US. One interesting stat is the Health Adjusted Life Expectancy (HALE) (Healthy Years  + Disability Years), which for the US is 69. Full LE is 79. That delta of 10 is in the same ballpark as the 30 higher ranking nations.

 

The purported healthcare innovation is akin to throwing money at the problem.

 

Complementary info:

https://www.ncbi.nlm.nih.gov/books/NBK62584/

 

The first two paragraphs summarize well.

Basically, at the individual or "mutual level", it boils down to an NPV decision to see if potential useful life lost is worth the investment.

The Constitution mentioned that all are created equal and can have a free and happy life (duration not mentioned).

Life expectancy, when the document was written, was estimated in the mid 30's but recently, after incredible progress, in the aggregate, has been dropping for two years in a row.

Multi-dimensional problem but America's best days lie ahead (ref: Warren Buffett).

 

"In the aggregate" there's been a dip recently, but under the hood there's a more disturbing longer-term picture for some:

 

https://www.vox.com/science-and-health/2018/1/9/16860994/life-expectancy-us-income-inequality

 

Of course, there's more than just less access to healthcare driving the growing disparity in outcomes.

[frommi]

"In the aggregate" there's been a dip recently, but under the hood there's a more disturbing longer-term picture for some:

 

https://www.vox.com/science-and-health/2018/1/9/16860994/life-expectancy-us-income-inequality

 

Of course, there's more than just less access to healthcare driving the growing disparity in outcomes.

 

Based on what i know longevity has nothing to do with healthcare costs, its much more a factor of what you eat, drink, smoke and how much you use your body. No drug in the world will deliver what not smoking and drinking, eating healthy and running/weightlifting 2-3 times a week does for you. And the richer you are the more you know and care about that, its not even about the money directly.

 

[jmp8822]

"In the aggregate" there's been a dip recently, but under the hood there's a more disturbing longer-term picture for some:

 

https://www.vox.com/science-and-health/2018/1/9/16860994/life-expectancy-us-income-inequality

 

Of course, there's more than just less access to healthcare driving the growing disparity in outcomes.

 

Based on what i know longevity has nothing to do with healthcare costs, its much more a factor of what you eat, drink, smoke and how much you use your body. No drug in the world will deliver what not smoking and drinking, eating healthy and running/weightlifting 2-3 times a week does for you. And the richer you are the more you know and care about that, its not even about the money directly.

 

+1

 

Also, to be rich you need self-discipline.  To eat healthy you need self-discipline.  To limit smoking/drinking you need self-discipline.  Poor people would be extremely unlikely to start eating kale and flax seeds if you gave them an extra $5,000 per year.  Junk food and poverty are a mindset, not an income.

[sleepydragon]

Speaking of flax seed, I gave my chicken that stuff. Lol

According to my wife, flax seed has long chain omega 3 which is very hard for human to digest. But chicken can digest it and turn them into short chain omega 3 in their eggs which is better for human

[KJP]

"In the aggregate" there's been a dip recently, but under the hood there's a more disturbing longer-term picture for some:

 

https://www.vox.com/science-and-health/2018/1/9/16860994/life-expectancy-us-income-inequality

 

Of course, there's more than just less access to healthcare driving the growing disparity in outcomes.

 

Based on what i know longevity has nothing to do with healthcare costs, its much more a factor of what you eat, drink, smoke and how much you use your body. No drug in the world will deliver what not smoking and drinking, eating healthy and running/weightlifting 2-3 times a week does for you. And the richer you are the more you know and care about that, its not even about the money directly.

 

It's quite difficult to tease out the effects of lack of health care access on mortality versus other factors, but to my knowledge the existing data suggests there is a relationship.  See, e.g.,  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775760/   

If you are aware of contrary studies that suggest no link in the US between access to healthcare and mortality, I'd be interested in seeing it.  More anecdotally, do you really believe that poverty has nothing to do with, for example, having hookworm, or that having hookworm has no impact on overall outcomes:  https://www.theguardian.com/us-news/2017/sep/05/hookworm-lowndes-county-alabama-water-waste-treatment-poverty

 

You also didn't mention a few other factors associated with poverty that likely increase mortality:  (i) more environmental pollution; (ii) more dangerous jobs; and (iii) more overall stress.

 

Regarding the "self-discipline" argument, I think it's easy (and perhaps comforting) to say that the poor die sooner because they are lazy, impulsive and stupid.  I personally doubt that account and the policies based upon (or justified by) it.

[jmp8822]

"In the aggregate" there's been a dip recently, but under the hood there's a more disturbing longer-term picture for some:

 

https://www.vox.com/science-and-health/2018/1/9/16860994/life-expectancy-us-income-inequality

 

Of course, there's more than just less access to healthcare driving the growing disparity in outcomes.

 

Based on what i know longevity has nothing to do with healthcare costs, its much more a factor of what you eat, drink, smoke and how much you use your body. No drug in the world will deliver what not smoking and drinking, eating healthy and running/weightlifting 2-3 times a week does for you. And the richer you are the more you know and care about that, its not even about the money directly.

 

It's quite difficult to tease out the effects of lack of health care access on mortality versus other factors, but to my knowledge the existing data suggests there is a relationship.  See, e.g.,  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775760/   

If you are aware of contrary studies that suggest no link in the US between access to healthcare and mortality, I'd be interested in seeing it.  More anecdotally, do you really believe that poverty has nothing to do with, for example, having hookworm, or that having hookworm has no impact on overall outcomes:  https://www.theguardian.com/us-news/2017/sep/05/hookworm-lowndes-county-alabama-water-waste-treatment-poverty

 

You also didn't mention a few other factors associated with poverty that likely increase mortality:  (i) more environmental pollution; (ii) more dangerous jobs; and (iii) more overall stress.

 

Regarding the "self-discipline" argument, I think it's easy (and perhaps comforting) to say that the poor die sooner because they are lazy, impulsive and stupid.  I personally doubt that account and the policies based upon (or justified by) it.

 

Here is what I know about my Midwest city: I grocery shop in the rich part of town every Wednesday and almost everyone is buying healthy food. I then grocery shop in the poor part of town every Sunday and almost everyone is buying junk food.  And the junk food is not cheaper - if anything, it is more expensive. I'm talking brand name everything junk food.  Why are those poorer people buying junk food that will kill them sooner? I'll let you solve that.  But, it is an undeniable, extremely strong correlation and if your answer is 'policies' good luck with that.

[KJP]

 

Why are those poorer people buying junk food that will kill them sooner? I'll let you solve that. 

 

This is an area of significant current research.  Here, for example, are recent thoughts from someone researching this question:  http://www.latimes.com/opinion/op-ed/la-oe-singh-food-deserts-nutritional-disparities-20180207-story.html

 

Lazy and stupid don't appear to be the reasons.  Instead, the reasons appear to be deeper and, in my view, profoundly sad.  At the end of the day, I think the poor are essentially the same as everyone else -- same hopes, same dreams, same love for their children, same fallibilities -- they just have a lot less money.  If I was working two minimum wage jobs while taking care of a few kids, and the only respite I could find was a bit of nicotine, maybe I'd smoke too.

 

 

[jmp8822]

 

Why are those poorer people buying junk food that will kill them sooner? I'll let you solve that. 

 

This is an area of significant current research.  Here, for example, are recent thoughts from someone researching this question:  http://www.latimes.com/opinion/op-ed/la-oe-singh-food-deserts-nutritional-disparities-20180207-story.html

 

Lazy and stupid don't appear to be the reasons.  Instead, the reasons appear to be deeper and, in my view, profoundly sad.  At the end of the day, I think the poor are essentially the same as everyone else -- same hopes, same dreams, same love for their children, same fallibilities -- they just have a lot less money.  If I was working two minimum wage jobs while taking care of a few kids, and the only respite I could find was a bit of nicotine, maybe I'd smoke too.

 

The store I shop at in the poor part of town has plenty of healthy, fresh food. Yet, many $200 grocery bills of Gatorade, Ruffles, Krispy Kremes, and Totino's. Perhaps the 'food deserts' are part of a brand new concept called supply and demand. Maybe if you opened a well-stocked farmer's market in poor parts of town it would simply not get enough customers. Seriously, that author seriously believes there isn't one entrepreneur willing to make a fortune opening a healthy store in a poor part of town? BS meter going off.  Victim mentality runs deep.

[KJP]

 

Why are those poorer people buying junk food that will kill them sooner? I'll let you solve that. 

 

This is an area of significant current research.  Here, for example, are recent thoughts from someone researching this question:  http://www.latimes.com/opinion/op-ed/la-oe-singh-food-deserts-nutritional-disparities-20180207-story.html

 

Lazy and stupid don't appear to be the reasons.  Instead, the reasons appear to be deeper and, in my view, profoundly sad.  At the end of the day, I think the poor are essentially the same as everyone else -- same hopes, same dreams, same love for their children, same fallibilities -- they just have a lot less money.  If I was working two minimum wage jobs while taking care of a few kids, and the only respite I could find was a bit of nicotine, maybe I'd smoke too.

 

The store I shop at in the poor part of town has plenty of healthy, fresh food. Yet, many $200 grocery bills of Gatorade, Ruffles, Krispy Kremes, and Totino's. Perhaps the 'food deserts' are part of a brand new concept called supply and demand. Maybe if you opened a well-stocked farmer's market in poor parts of town it would simply not get enough customers. Seriously, that author seriously believes there isn't one entrepreneur willing to make a fortune opening a healthy store in a poor part of town? BS meter going off.  Victim mentality runs deep.

 

I think we read different articles.  The author is saying that "food deserts" are NOT the whole story.

[Cigarbutt]

The key variables are cost and coverage.

 

Invariably, this debate will put to the fore the clash between personal responsibility and social solidarity. The above comments just show how hard it would be to achieve a satisfactory consensus on coverage and "shared" costs.

 

At a certain point, limited or unaffordable access to healthcare in our increasingly unequal world may eventually prove to be detrimental.

 

Otto von Bismark is often recognized as the father of state socialism. However, he did not promote reforms out of idealism. He simply wanted to maintain the balance of power. Call it what you want but make it affordable.

https://www.smithsonianmag.com/history/bismarck-tried-end-socialisms-grip-offering-government-healthcare-180964064/

 

 

[KJP]

The key variables are cost and coverage.

 

Invariably, this debate will put to the fore the clash between personal responsibility and social solidarity. The above comments just show how hard it would be to achieve a satisfactory consensus on coverage and "shared" costs.

 

At a certain point, limited or unaffordable access to healthcare in our increasingly unequal world may eventually prove to be detrimental.

 

Otto von Bismark is often recognized as the father of state socialism. However, he did not promote reforms out of idealism. He simply wanted to maintain the balance of power. Call it what you want but make it affordable.

https://www.smithsonianmag.com/history/bismarck-tried-end-socialisms-grip-offering-government-healthcare-180964064/

 

Is it really true that the US must make these very hard choices?  Or is there something fundamentally dysfunctional about our healthcare system that, if addressed, would allow an essentially "free lunch" of more access, better outcomes and less cost?

 

Studies like this suggest there's something fundamentally wrong with what we're doing:  https://jamanetwork.com/journals/jama/article-abstract/2674671  [only a summary freely available]  How is it possible that we spend at least 550 bps more of GDP and get worse outcomes and less coverage?  Studies like this one are also why it baffles me that people think expanding coverage is "too expensive"?  It seems clear to me that it's whatever we're doing now that's "too expensive". 

 

Imagine all the things we could do if we could free up 5.5% (or more) of GDP ...

[rb]

Well you wouldn't really free up 5.5% of GDP. Mostly you'll just reallocate it. I think maybe at most you create 2% of GDP (finger in the air measurement). But that's still nothing to sneeze at.

[KJP]

How do you get to only 2%?  What is the reallocation you're talking about?  I'm not saying you're wrong; I'm just not sure what you are referring to.

 

And your 2% is with near universal coverage, correct?

[rb]

Yea. By the way just so I'm clear. What I'm saying is not that you can't lower HC costs by 5.5% of GDP. If think you can and probably even more than that.

 

What I'm saying is that if you lower HC costs by 5.5% of GDP you won't also get a 5.5% GDP pop on top of it. The GDP pop would most likely be around 2%.

[KJP]

I see.  I wasn't counting any additional pop.  Just the re-allocation alone would be quite useful.

[Jurgis]

https://www.propublica.org/article/in-montana-a-tough-negotiator-proved-employers-do-not-have-to-pay-so-much-for-health-care

[Spekulatius]

 

Why are those poorer people buying junk food that will kill them sooner? I'll let you solve that. 

 

This is an area of significant current research.  Here, for example, are recent thoughts from someone researching this question:  http://www.latimes.com/opinion/op-ed/la-oe-singh-food-deserts-nutritional-disparities-20180207-story.html

 

Lazy and stupid don't appear to be the reasons.  Instead, the reasons appear to be deeper and, in my view, profoundly sad.  At the end of the day, I think the poor are essentially the same as everyone else -- same hopes, same dreams, same love for their children, same fallibilities -- they just have a lot less money.  If I was working two minimum wage jobs while taking care of a few kids, and the only respite I could find was a bit of nicotine, maybe I'd smoke too.

 

A lot of the poorer people have very little time to prepare meals, because they work several jobs. I got aware of this because my wife worked and heard what the techs were doing at her facility. Most of them were working two jobs, some of them 3 jobs. There are other reasons and they were undoubtedly wasting money too, but they was one factor that was evident.