Obamacare - practical discussion

Obamacare - practical discussion


Hospital consolidation allowing hospitals to charge monopoly rents can be solved with single-payer, antitrust enforcement, or ideally, both. In rural areas, however, there may not be enough demand to support multiple hospitals.

The inefficiencies created by numerous intermediaries can be solved with single-payer. Administrative expenses in the US are far higher than anywhere else.

Drug prices would be reduced under single-payer, provided Medicare was actually allowed to negotiate prices and establish a formulary. The WSJ article talks about Humira in particular. An NYT article about Humira from January, citing a 2015 source, says:

Similarly, the $600 EpiPens (which IIRC actually cost closer to $300 after average PBM rebates were applied, but that is still excessive) are cheaper elsewhere: about $68 at current exchange rates in the UK under the NHS.

These are only a few high-profile overpriced drugs. There are many more.

There is also the advantage that doctors can easily familiarize themselves with a single Medicare formulary and consider cost in their prescribing decisions. In many cases, there are multiple drugs that could be used to treat a condition, with similar side effect and safety profiles. PBMs currently establish formularies, guidelines, and may require step therapy for some drugs (which requires the patient to try lower-cost drugs first, unless there is some reason not to, and step up from there if they don’t work). This is a pain for doctors to deal with because there are numerous PBM formularies out there (even from the same PBM), and different PBMs have different negotiated deals, so the lowest-cost drug to one PBM may be the highest-cost drug to another. One formulary for everyone would be easily manageable; dozens of them depending on the patient’s insurer, plan, and PBM formulary is not. Not to mention that if/when the patient switches insurers, it may be necessary to go through the entire authorization process again and potentially try different drugs if the new PBM’s requirements are different.

Suggesting that doctors could simply go cash-only to solve this problem is naive. For one, cost-sharing discourages use even when the use is medically advisable, and we shouldn’t discourage the use of primary care – it’s way cheaper to resolve something via primary care than to risk it turning into a hospital situation later. Second, it’s not a solution for catastrophic risks – e.g. a cancer diagnosis, a major accident, or any other serious condition – as most people do not have the means to self-insure for such risks. (It’s also inefficient to do so.) You could then suggest a combination system of cash-only for cheap services like PCP visits and private insurance for higher-cost services like hospitals, but then you have the same administrative bloat on the hospital side while discouraging cheap primary care use. It’s the worst of both worlds.

In general, cost-sharing works when the insured has some ability to eliminate or mitigate damages. For example, your auto deductible encourages you not to leave your car somewhere unlocked with the keys in it. Healthcare is different – things are often just random (or we later find out that something thought to be safe actually wasn’t), and the patient already has “skin in the game” by virtue of, well, their health being involved.


Do you have any clue what the VA is like. Thats 100% govt run healthcare. It will be the exact same thing under single payer. Not initially but yes it will become so.
Do you plan on having death panels ? U cannot budget without them. So yes or no. We have death panels right now. The insurance company says ur not covered if u die so what. What exactly do you think will happen when the deep pockets of uncle sam are footing the bill.
Either u have death panels … which oh by the way isnt very popular with the voters … or you will have super run away costs.
You think drug makers are going to lower their costs ? Uh no. They will just lobby n support congress candidates who support doing away with death panels.
Grandma needs medication that MAY prolong her life on avg 7 months. But it costs 100,000$ a month. Now that uncle sam is picking up the bill … why not ?
Now lets get back to the VA. Do u know why the VA sucks ? Because they are fighting with govt to fund basic shit. Why ? Because tax dollars need to goto other places so the VA only gets so much. Not multiply that by the entire nation. Yes in the very short term thing will be better. But by year three we will be in here talking about how to fix this ballooning costs in our medical care. Except when that comes … it will be of staggering proportions.
Remember. Once u go single u can never go back.


I don’t have any personal experience with the VA, so I can’t comment there, but I will say that not everyone agrees with you on the quality of the VA. No question it is not perfect – no system is – but keep in mind that it is a large system and you’ll see disproportionately higher media coverage of the issues (especially given the money to be made if it were privatized).

In any case, the current M4A proposals operate like traditional Medicare with private providers.

I think the “death panel” framing is stupid to begin with, but props to you for realizing that private insurers currently operate them as well. And that’s the message that needs to be brought to the public: it’s something that is already done and there has to be some limit somewhere. (Although FWIW, the one person I know who brought up “death panels” had a completely different understanding of it – he thought there was literally a death panel under the ACA that would consider individual cases and decide whether to kill them, not just considering QALY or similar of treatments. Which I guess is what happens to people who get their news from Fox.)

Somehow this hasn’t been an issue in the rest of the world, which pays far less than we do.

Those 7 months will probably be miserable. Does Grandma want that?

If it’s so terrible, I’m sure the public will demand and get change. There would be a lot of money to be made by the current insurance grifters, after all.


Some grandmas will want that. Some healthcare proxys will want that for grandma. But u skipped over the part where we … yes we … tax payers foot that bill. Im not likely to pay 700k tax in my lifetime. Where is that money going to come from ? Everybody.
I see u are being quite political with your answer about the VA. I find it complete bs u dont have an opinion on it. Almost as if u understand if you admit it then you will verify and legitize my position.
Since i believe u are being insincere about what you really know/understand and deep down what u know will happen but hope it wont happen because u think it just has to be better because “feelings”. This is the last time i will respond to u.
Do you think drug makers will allow lower drug prices here ? The only reason the rest of the world gets it so cheap IS BECAUSE WE SUBSIDIZE THEM. The profits needed to invent and profit off drugs is almost wholly born by the usa. Why can we no longer buy individual scripts drugs from canada ? Because canada realized that if they didnt stop it … the drug companies would raise the prices up there too.
Ill leave u with this. What says about budgets for universal healthcare coming from taxes n the fight yearly on who gets what of that pie us very true.


I apologize if I offended you; that was not my intention.

I believe I addressed that in my second quote-response. It seems likely this hypothetical treatment wouldn’t meet any reasonable QALY standard, and thus shouldn’t be funded. Do you think a private insurer would approve it?

How is the VA relevant to M4A? It’s more comparable to the NHS than to the M4A proposals.

This is a common claim, but I’ve never seen any actual evidence for it by a neutral (i.e. not a pharma lobbying group) source. Do you have any? Other countries are still paying prices far above the cost of production for brand-name drugs, which is what you’d expect given the need to recoup R&D. (Using Humira as mentioned above, how much of that $1,362 the UK is quoted as paying do you think is direct cost of production and how much is compensation for R&D, risk, etc.?)

US law prohibits this; I cannot find anything saying Canadian law does. Do you have a source?


I view the VA and NHS as good examples of single payer, government run healthcare - maybe it worked well for a while, but pretty soon the poor incentives and lack of accountability lead to poor quality care, high costs, long wait times, and an unmanageable bureaucratic mess. Who would want that?

Specifically regarding your RAND VA care study, do note this caveat:

The study did not examine issues related to accessing care in the VA health system, such as whether enrollees gain access to care in a timely manner.

VA wait lists are still an issue even after the attempted reforms in the wake of their 2014 scandal.

I’m not that sure how a Medicare for All scheme would be different. If the government is setting the price they’re willing to pay, you’re going to have either high costs to get relatively good care, or controlled costs and relatively poor care when the better doctors go private and stop taking government patients just like how more doctors these days are refusing Medicare. Right now the large US private insurance market is subsidizing smaller pool of Medicare patients by allowing doctors to charge higher rates to the typical private patient and lower costs, often at break even or a small loss, to Medicare and Medicaid patients. If almost everyone, except the very rich with post-M4A insurance or paying cash OOP, was going through a Medicare type coverage system, the typical doctor would no longer be able to stay in business with current economics since the pool of private higher paying patients to subsidize the government group would be much much smaller. So either the government pays full price to keep the current level of care (hence no cost savings) or they keep paying 80% of U&C and then lots of doctors either take a big pay cut or leave the system (hence worse care, either sooner as doctors leave or later as many fewer top potential doctors chose a medical career).

So maybe for a decade or so, you can screw the current crop of doctors by cutting their pay a lot and hoping most will suck it up since retraining and changing careers in your middle age is difficult, but starting then it will be clear to good students considering medical school that they should take a different path. The older doctors will retire sooner, and after the next crop or two of fewer and lower quality medical students become doctors, your average care will be worse and there will be fewer doctors so wait times will get longer. It’s hard to imagine that incentives don’t matter and that cutting a doctors pay substantially won’t result in fewer or worse quality doctors - that’s just supply and demand.


This point isn’t talked about enough.


To be clear, my intent in linking to that study wasn’t to endorse its conclusion, but just to say there were alternate views out there. I need to do more research into the current state of the VA, ideally finding some credible (i.e. not from lobbying groups trying to privatize it) perspectives that come to a different conclusion than RAND. That, and the lack of personal experience with it, is why I didn’t take any position regarding its quality. I have no doubt there are problems in places, just like with our private system; the question is whether, overall, the system is performing well relative to other options.

Yes, I still would like to see a more detailed analysis done of an M4A transition from the provider perspective. I know the 40% number makes for a good headline, but I don’t think it tells the whole story. Under M4A:

  • Medicaid patients, which are currently subsidized by other payers, are transitioned into Medicare and their reimbursements are increased accordingly.
  • Uncompensated care (to uninsured patients and insured patients who don’t pay the deductible/copay/coinsurance, which isn’t always collected upfront) is eliminated.
  • Administrative costs can be significantly reduced due to the simplicity of the system. Not only does this result in staff bloat, some of this administrative overhead falls on doctors themselves rather than staff. That’s wasted time they could be spending on compensated patient care instead.
  • In some cases, as the WSJ article mentioned, provider consolidation and lack of competition is allowing providers to increase prices beyond what they would be in a competitive market and beyond any kind of reasonable calculation based on cost of doing business + fair compensation for risk assumed. A single-payer system fixes that.

Given that, it’s clear that an M4A that matches private reimbursement rates would amount to a windfall for providers and is unnecessary. So the question is, are the current reimbursement levels appropriate, all things considered, or is some increase warranted (but less than matching private insurers)? That’s what I’d like to see an analysis of.

On administrative costs, when Sanders announced his M4A bill, there was a claim going around about US vs. Canada overhead:

If those numbers are correct, that’s incredible. The problem is, I can’t find any source for this, just Friedman’s claim. Plus, Canada uses global budgeting, so a direct comparison may not be completely appropriate. I’d like to see an authoritative source on this.

(Anecdotally, the one medical biller I know loves dealing with Medicare and hates private insurers, because Medicare just pays what they’re supposed to while private insurers often have to be chased to pay. It’d be good to hear other data from that side.)


If you are a specialist and only getting $20 for a routine follow-up visit, you are going to cram as many patients into an hour as possible, and have a nurse practitioner do as much as legally possible. So, 12 months (if you can get an appt that soon) after a procedure, you go into the doc and get seen by him for all of 3 minutes and 45 seconds. He will hopefully have spent at least 15 seconds on your chart prior to walking in the exam room. :smile:


Unless I have something wrong (which is quite possible, as I won’t pretend to fully understand medical billing), the Medicare national rate for a 99213 office visit (which seems common based on EOBs I have) is about $74 with a possible locality adjustment (slight decrease in my area, but ~$10+ higher in high-cost localities like SF or NYC). BCBS’s allowed rate was about $80. Office visits do not appear to be where Medicare achieves significant cost reductions compared to private insurers.

If you have some private insurance EOBs available that list fee codes, you can use Medicare’s fee tool to see what Medicare would pay for the same service(s).


Why? I see this repeat a lot in recent years but why? If that’s the case, do you also support getting rid of FDA ? Get rid of law that mandate hospital has to treat someone?


I did not mean to imply that I was speaking of Medicare. I was speaking of govt run healthcare in other countries (not third world). The two that I am familiar with pay significantly more to specialists for new patients, and practically squat for routine follow-ups. Thus, many doctors either keep space in their calendars for new patients or readily make room for new patients, and squeeze as many follow-ups into an hour as possible.


Eh, they presented a PEER REVIEWED study. You got nuthin’ but regurgitated RightWing propaganda.

That’s NOT an “impasse”.


Give that man a cupie doll.


First, a repost of my predictions from June:

Back to the junk policies that aren’t worth the paper they’re written on, where if presented with anything more than minor medical bills, they can rescind the policy and stick you with massive medical bills. Back to annual and lifetime caps, and discrimination for pre-existing conditions.

Brace for a return to skyrocketing healthcare inflation, massive increases in medical bankruptcies, home foreclosures, and rising Poverty.

Now, reality bites:

Buyer Beware of Association Health Plans

These multi-state plans will also offer fewer consumer safeguards. In fact, they will not have to include protections for people with pre-existing conditions, nor will they be required to cover things like maternity care because they will not be subject to certain rules established by the Affordable Care Act (ACA).

If those facts aren’t enough to raise alarms about AHPs, consider this: If someone covered by an association plan gets sick and needs expensive treatments, that individual could be dropped from the plan - or the entire plan could be voided.

Encouraging people to leave the small-group market, however, will only harm small businesses by raising their premiums.

The Hill

(John Arensmeyer is the founder and CEO of Small Business Majority, which has a nationwide network of 58,000 small firms)


As I previously posted, when contrasting U.S. healthcare to the rest of the industrialized world, they win hands down. Not. Even. Close.


While true that our graph looks bad compared to everyone else, I wonder how much of that is due to the horrible eating habits of most Americans.


When I go to Walmart there are 450 pound people that use a scooter because they are not able to walk through the store with their own strength. Average American Woman weights 165 pounds now. I don’t think other countries have anywhere near the problem that we have.


Indeed, most other countries in the world have much healthier living habits as far as eating and exercise. They eat much less fast food. I don’t think healthcare is the issue here but more likely the habits of taking care of themselves.


Actually, we hashed this out previously @ FW. I’ll not go down the list, but the French eat way more butters and cheeses and heavy sauces than we do (which our experts claim is extremely unhealthy), and drink way more wine, but they are much healthier than we are and live longer.