What should the income tax rates be?
Here is the current fraction of income taxes paid
That is kind of the essence of it. I would rather everyone get the care that they need instead of the care that they want. If that means, I don’t have my choice of five different imaging centers that I could get a stat MRI at tomorrow, then so be it.
The US per capita spend on healthcare is the highest in the world. We can afford to finance any system we want, but we ended up with this one.
That’s a pipe dream. There may be inefficiencies, but it’s a rounding error compared to the straighforward treatment costs.
You want free market healthcare, you need to get rid of insurance and all third-party payers. Otherwise, half of the free market equation simply doesnt care about what their treatments cost.
Actually, those free market principles is exactly why we’re seeing the insurance increases we are seeing. When everyone is entitled to hundreds (or thousands) of dollars of “free” healthcare, premiums are going to cost hundreds (or thousands). Insurance, yes including health, is designed to cover one-off risks. More and more people are using it for regular ongoing treatments, thus total costs are going up - there simply arent enough healthy people insuring only for one-off risks to absorb everyone’s daily needs.
Or, no one has the balls to make EVERYONE pay some income taxes. As you said after this, the people complaining most about high taxes are those who pay no taxes.
Soaking the upper class more is the convenient option, and passes because the upper class is the minority. Maybe we should start allocating votes based on income taxes paid? One voter person plus an additional 1 vote for every $10k in income tax you paid the previous year?
And out biggest problem isnt that such things are available, it’s that we’re using third-party payers to cover the costs and make them “entitlements” for everyone rather than just for those who can afford them.
I don’t know, but it was 91% for the highest bracket after WWII. I suppose that might be too high, but not all the rich pay their fair share, as most of their wealth is in stock that they never sell and only borrow against at low interest.
I think it passes because of math, not because it’s a minority. Per the “fair share” chart onenote posted above, the bottom 90% of earners share just over half of all income earned. The top 10% get the other half. You tax the people who have the money, not the people who are scraping by.
But the other half of that equation is those same 10% get privileges not available to the other 90%, including respect from the 90%. Which has become a source of uproar in recent times. There was an unspoken quid pro quo when that 10% funded over half the nation’s costs. Now the wealthy are getting criticized at every turn simply for buying stuff the average American cannot buy, and threatened with jail time when any special perks or access is unveiled. They’re seen as the common folk’s piggy bank, instead of someone people respect and appreciate.
This isnt the same world where a 91% tax rate was accepted.
At least for Canada, that’s not the everyday experience of my relative who are Canadian citizens. For most healthcare, it’s mostly free and accessible same/next day. One of my relative needed a couple of MRI last year. One was done same day, the other the next day. Both totally free along with the doctor visits that prescribed them.
I have my reservations on such a system. I cannot imagine an efficient non-wasteful healthcare system where cost is completely isolated from patients so they never do a cost vs. benefit analysis. That just doesn’t seem possible to me. Whether paid out of pocket (and people taxed less) or free (with people paying through higher taxes), the costs for care have to be paid. Any system disconnecting costs from patients seems like it’s bound to be hugely wasteful.
But that’s not the picture of Medicare either. 20% copay can add up pretty quickly without supplement or advantage plans. So patients on Medicare still have some skin in the game.
I’m glad they’re having a good experience. Wait lists are definitely a thing there
and especially so for “elective” procedures like hip or knee replacements, which are common for the elderly and make meaningful improvements in quality of life. Waiting a year or more for those is definitely a loss, and I’ve heard the richer Canadians just pay out of pocket and come here for those.
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I don’t think I’m totally against such a system honestly. At least for truly elective procedures, those who can afford to pay for not waiting, shift the healthcare costs down for everyone else. Our current entitlement system promoting the “right” to such elective procedures regardless of cost vs. benefit doesn’t sound sustainable to me hence why costs are consistently rising faster than inflation (and faster than our ability to actually pay for them other than growing our debt).
Exactly. Just because some can afford such quality of life treatments does mean everyone is entitled to receive them under some type of social/insurance payer program. Eventually, if they cant afford the surgery, they arent going to be able to afford the premiums for insurance that covers the surgery.
If “everyone” gets $10,000 in “free” treatments, everyone’s insurance premiums will be [at least] $10,000. There’s simply no way around that fact.
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I thought this was relevant to our discussion. It’s seems to make some good points
However, what is not mentioned is how the difference in MRI prices is no different than the price difference between the hospital ER and the local Urgent Care. The insurance company is paying for where the consumer chooses to go for treatment.
And insurance companies get raked over the coals when they try to only allow coverage at the low-cost facilities.
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Just like for other services, there could be a reasonable range of prices for a similar service. Maybe more expensive at facilities having newer, more sensitive equipment, etc.. Also a facility downtown may have higher operating costs due to its location compared to a facility on the outskirts of town. But it still should not amount to this much.
For me, one issue is the POS plans setup that allow only a fixed $ copay from customers regardless of actual cost. That moots cost vs. benefit analysis. On a HDHP, until I reach my annual deductible, I’m getting quotes for everything since I’m paying 100% of it. In a given year, if I happen to hit my deductible (and pay only 10% of costs), I check cost much less carefully. If I were to hit my max out of pocket, I’d choose the best most convenient cadillac option regardless of cost. With a fixed copay for any service, it’s the same thought-process: any incremental benefit is free to the patient who then has no incentive to control costs. In this respect, standard Medicare is better since the 20% copay still incentivizes patient to watch costs a bit.
Doing away with fixed $ copays insurance to control costs better, the next hurdle becomes your ability to quickly compare prices between providers. That’s where the current broken system which is fragmented with 100s of plans across dozens of insurers, completely obfuscates how much providers will charge. Sometimes the cash price is better, sometimes your insurer has negotiated a lower price. Process is opaque, time-consuming, costly for patients, providers, and even insurers and as a result extremely wasteful for total healthcare spending and outcomes.
I think that’s where a Medicare-like system could solve many of the issues. Insurers could differentiate their offerings along the % out of pocket copay vs premiums line. And providers would have to openly list their fixed price for each procedure. For patient, out of pocket cost would be as simple as looking up the provider full cost and multiplying by their insured % copay. Oh and no medicare supplement option where patient is again totally insulated from actual costs. Just an annual catastrophic out of pocket maximum.
For me the combination of keeping skin-in-the-game for patients and easy to compare costs between providers, has to be part of any improved healthcare landscape.
The problem is that you can’t make consumers care about the price of their health care unless you’re making them pay for the health care. And now you’re taking away their entitlement and only giving them their health care if they can afford it. “I can’t get an appt at the $10 copay place for 6 months, and I can’t afford the $250 copay place. It’s the same scan, so insurance should cover it when I need it, period”.
This is a mess of our own making.
Yet, I don’t see any other way but have patients feel the cost of healthcare enough to influence their decisions. Regardless of how we pay for it collectively through taxes + copays, if we don’t control costs, it’ll just be more wasteful spending. People hate on managed healthcare because they’re disconnected from the actual bills.
The only feasible solution requires pissing off virtually everyone, one way or another. There simply is no overlap between “what people expect” and “viable solution”.
What we need is to get back to when insurance was purchased to cover risk, not routine. It was the entire (valid, in my opinion) basis for excluding preexisting conditions - if you hadnt insured against the risk of developing diabetes, you shouldnt be able to get coverage for the routine costs of having diabetes.
Maybe health insurance should go the way of life insurance. You insure your health, and you get a fixed payout if you suffer a covered loss. Get the flu? Get a $XXX payout. Break your leg? Get a $XX,XXX payout. Get cancer? Get a $XXX,XXX payout. And it’s then up to you how you want to spend that money treating your condition. Do the minimum necessary using cheap clinics, and you might come out ahead in the wallet. Want all the bells and whistles to cover all basis, and you’ll need to contibute some money of your own as well.
One major flaw of that system was what happened when you changed insurance, say signed up with new insurance after losing your job. You could be refused by new insurer even though you were previously insured.
That doesn’t happen with Medicare since your insurer doesn’t change.
I think that was also the purpose behind the ACA penalties to make sure people have continuous insurance instead of signing up when they start having huge expenses. That’s also why the late enrollment penalties for Medicare are so stiff. An insurance system needs to be continuously on so that your claims are essentially prepaid by all the times you paid premiums without having claims. Kinda like homeowner insurance. It’d not be financially viable if you could wait to signup until the fire starts, hail starts hitting your roof, or your burglar alarm goes off.
I don’t know if that’d work but it would likely simplify things for providers. Not sure it’d be much simpler for patients to figure out costs. Your broken leg is not actually one bill. Depending on the actual bone broken and how, it’ll be a different set of medical procedures each with a code which may need to have a separate payout associated with it. Other issue is for patients to control costs, they’d often need to know what they have in advance and which provider will charge the least for whatever it is they have.
That’s why I think the Medicare system is not terrible in its setup. You have forced universal enrollment deterred by huge penalties. That removes the issue of pre-existing conditions and people skipping insurance until very sick (or older). You have 20% copay which gives some incentives to not go for unnecessary procedures and shop around for the ones you really need. I think the copays could be further improved though. Maybe tiered copays over some thresholds: keep the procedure under $X, 10% copay, from $X to 1.1 $X, 20% copay, above 1.1 $X 30% copay. IMO the main issue with this system currently are the premiums which are unsustainably too low for this cohort (elderly).
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Granted, I had very little experience with this. But every time I signed up for insurance, one question was whether I’d had coverage within the previous 60 days. Yes eliminated any followup on preexisting conditions since it was maintaining continuous coverage.
It may have been the insurer, or it may have been a state law thing. But preexisting exclusions wasnt a major flaw, it was a detail that could’ve easily been tweaked to support continuous coverage.
The major flaw was created when preexisting condition exclusions were banned, and people could wait to sign up for insurance after a risk had become reality.
Not necessary. Three categories, three payment amount options based on average costs for each category. Then you decide how thorough you want your treatment to be.
The problem will be that far too many people will feel that payment burning a hole in their pocket, and they’ll splurge on whatever random crap suits their fancy then complain about not being able to afford to complete their treatment.
My niece broke her leg last fall; I forget exactly, but essentially a hairline fracture. She was on crutches for 6 weeks. An ER visit (after walking on if for a week), 4 MRI scans, 6 office visits, and 2 days of weekly physical therapy later, she’s now back to walking fine, with PT still scheduled for another month. Tell me how much of that would’ve been necessary had insurance (medicaid) not beein covering 100% of the bills? That is why our healthcare costs so much. Getting the treatment is always going to be better than not getting it, necessary or not, and when you’re entitled to someone else paying for it “necessary” develops a much more liberal definition.
I went to the ER with a puncture wound (a stick between the toes). I was upfront that my HDHP wouldnt be covering it so I was only wanting what was necessary to ensure my foot didnt get infected. About 5 times during treatment, the doctor explained that what he was doing was good enough then noted 2-3 other things he’d also be doing if insurance was paying. “Cover your [his] ass” type things, “just in case”. Again, THAT is why insurance costs so much.
That’s what lump sum pre-determined payments would eliminate. If you want extra piece of mind, you pay extra for that piece of mind.
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I think we all agree that every health system national or otherwise need some form of gatekeeping care. Outside the US they do it with doctors and referrals, or death panels if you wish, and in the US, we end up doing it with money..