With the impending U.S. elections, it seems to me that one of the most important decisions that will be decided will be what happens with U.S. healthcare. I'm honestly not the most informed when it comes to either candidates healthcare policy, but I thought it would be interesting to get a discussion going surrounding the issues at hand. Trump seems to want to completely remove Obamacare, and although I have not heard of any concrete plan (correct me if I'm wrong, this is intended to be non-partisan), he has said multiple times that he plans on keeping coverage for pre existing conditions. Biden seems to want to build on Obamacare, and would like to give people the option of electing a public option, as well as giving middle to lower income individuals tax credits in order to help subsidize their premiums, as well as capping premiums on the individual market place, and lastly pulling back current privileges and advantages that big pharma enjoys (note, Trump has also made it clear with executive orders and other statements that he is in the same camp when it comes to big pharma).
Some of you may have heard this, or at least seen it before, but
of Milton Friedman discussing healthcare and particularly the Q&A (American Medical Association) got me thinking; why is neither candidate focused on removing this licensing entity? Is it simply outside of the current Overton Window?
Milton articulates in the video above that the Q&A is basically the largest and most protected monopoly allowed to operate inside the U.S. (and this was years ago), because of the fact that it is the only entity capable of granting medical licenses, and only licensed doctors are allowed to practice in America. He then goes on to say that eventually, if this is not corrected, we will see the socialization of that industry as the people and prevailing sentiment will feel that this is their only recourse. Unfortunately a complete socialization of the industry would probably result in a better system for some and a worse system for others, whereas if this system was actually forced to operate in the free market, it is likely that healthcare outcomes to price ratios would improve for everyone.
The obvious fix seems to be that one would have the right to know where their GP went to school, and schools or previous work experience, (i.e. certain hospital systems could also act as gatekeepers), would then begin to determine the quality of the physician, and of course those physicians would make more money. However, just because someone attended a subpar medical school does not mean that they are necessarily going to be a subpar doctor. Basically becoming a physician would then be similar to law, in that there are a small group of schools which are far and away the most prestigious and would lend themselves to the best opportunities, but there are also other schools which are not bad, just not as good, and would in fact be where the majority of physicians graduate from. At the end of your schooling you would be required to pass an exam (note, there would never be a cap as to how many could take this exam), and if you passed then you are permitted to practice.
The point of this is that it seems that neither the left nor the right are tackling what seems to be one of the largest causes of our current dilemma, and are instead focused on the effects.
Thoughts?
My thoughts are: the only way to fix the healthcare system is to remove the health insurance companies from it. What purpose do they serve, other than to drive up costs and frustrate physicians? My plan would be to eliminate the health insurers and let people pay physicians out of their owns pockets, based on income level. All of this would be subject to a maximum out of pocket expense and at this point, the government would pay the rest.
Correct me if my thinking is wrong, I would say insurance companies do serve a purpose and that purpose is to diversify/manage the financial risks associated with random health events in the life of the everyday person and the costs associated with servicing those random health events on the healthcare providers (the doctors or hospitals in this context) as well as the financial burdens on the subject individual of course. Insurance companies, in my impression, in a sense serve as a hedge for the other parties in the event something unforeseeable and drastic happens.
I hear your solution on capping individual expenses and having the government subsidize the rest to cut out the insurance company, but what stops hospitals and doctors from inflating the itemized costs of treatments to drive their own personal economics if they know the US government can print the money? Similar to how some have argued that government-backed mortgages and student loans led to incentivized over-borrowing on the gov't dime and are among the primary reasons why the housing market imploded and why college tuition costs have skyrocketed. I think the argument to keep insurers and make healthcare a for-profit and competitive industry is so that these firms would be incentivized to keep costs lower to win the most business, like classic laissez faire capitalism economics or whatever.
I am not involved with healthcare at all, but this my 5 minute bird's eye view analysis of where the competing interests and incentives could be that make the situation as evidently controversial and hard to solve for as it is. Anyone, feel free to educate me where my assumptions/first intuition are wrong. I have no strong feelings at all regarding policy change because I am so uneducated on the dynamics so I would love to hear more.
Let me start off by saying this, I think for-profit health care is a disgusting business. I’m a firm capitalist and believe in the open markets. But I can’t fathom how so many Americans die because of they are uninsured while hospitals, insurance companies, and big pharma get rich.
Now what’s my solution? I understand and agree with Friedman’s solution. However, the problem is how to deal with the credibility of physicians now that the AMA will not have a licensing monopoly under his solution. I have ease of mind knowing that there’s a central regulatory body making sure that physicians are certified.
As for actual health insurance policy, I’m in favor of income-based health care. So that means your monthly premium is based on your income and health record. For example, Joe is a healthy adult who makes $50,000 a year. He pays $56 a month because he has a healthy history & $56 is a fair amount for coverage that won’t kill his pockets. The remaining cost would be picked up by the government. If Joe made $50,000 but was not a healthy adult then his premium would be $82, not ridiculously much higher but slightly higher to cover the added risk. It’s still better than nothing. This would also incentivize Americans to live & eat healthier because there is an economic benefit while also not severely punishing those with conditions. Basically, reform health insurance to mirror affordable housing. Affordable housing programs dictate that an individual should not pay more than 30% of one’s income on rent. Maybe for health care it can be 10% or some number that is based on economic data.
I’m not saying this should be the only insurance option out there. Like I said I’m a firm believer in capitalism. So that means I’d also support private insurance but now since we have government offering very affordable health care to its citizens, the private industry can’t jack up rates because there is now an attractive alternative. If people want to complain about the overall cost, think about how much we waste on the military, space force, and foreign aid every year. Government can do this without raising taxes. Just find a more efficient way of leveraging your budget.
Medicare does everything private sector health insurance companies do but better and at lower cost.
That’s why Sanders and many Democrats want Medicare for all.
Spreading out the financial risk is not necessary if the government is the backstop. If there is transparency in pricing, hospitals and doctors would not be able to drive up the costs. They would compete in the market place for customers like most other industries. At the moment, there is no transparency because service providers do not disclose prices until after a service is performed.
Whatever the government pays, comes out of taxpayers' pockets.
Whatever form of insurance you're describing is already done by many private insurers (called Flexible Spending Account).
And whatever the government can do, private companies can do better (as a result of market forces, namely competition).
Hence it makes no sense for only the government to do it because they'll waste our tax revenue more than private companies will waste our premiums. QED
In an ideal world, there would be competition but at the moment, there is very little. How can there be competition when there is almost no disclosure of prices?
Everyone can just pay for themselves. The prices would drop significantly if the gov were to leave the market
I’m not disagreeing with you, but as I said in my post, I think this only solves a part of the issue. If the government leaves a market which is more or less already controlled by a monopolistic entity, then all they are doing is giving more power to said entity (just to be clear I’m talking about the AMA). It would seem to me that doing what you are suggesting as well as forcing a free market approach (I.e. removing the monopolistic entity) is a potential solution. I do however take issue with the idea of individuals that end up with cancer etc through no fault of their own and are forced to bankrupt themselves because of it. This is bad for society as a whole, and the whole idea of a collective state, or state at all, is to avoid these sorts of situations.
This is true. Fully deregulating the healthcare sector would give better results that what we have now (higher accessibility), but it's also not the most optimal (something that we can achieve).
Nope. This monopoly only exists because the government enables it through regulations that protect this said monopoly.
You have no idea how much hospitals charge. Only the top 1% would be able to afford.
Cancer would bankrupt even a multi-millionaire. Shit is not a joke. Nobody should die or go poor because of a health condition that is through no fault of their own.
How many Americans can afford six-figure treatment for premature babies, cancer or dozens of other conditions?
Read that famous essay by Kenneth Arrow on why markets don’t work for medical care. There aren’t two equally well-informed parties negotiating, each free to walk away and seek another party to bargain with.
If setting broken leg costs $500, you don’t ask doctor to stop work when he hits your $250 limit. Or you don’t wait until doctor has post-Christmas sale on setting broken leg. And doctors can’t treat your headache if you can’t afford tests if he suspects the pain you’re describing may be a brain tumor.
Medical bills are the top reason people file for personal bankruptcy.
that's why people should purchase health insurance.... easy solution.....
I think you’ve actually just agreed with me and some others in this thread without realizing it. Your initial position is that healthcare and free markets do not work which I think is incorrect. But you actually dissect the problem eloquently, in saying that the reason for this is that each party involved in the transaction does not have equal leverage or understanding of the transaction. However, your conclusion cannot be readily implied with the support you provide since the support directly implies that the industry isn’t operating in a free market system, because if we were then consumers would in fact have leverage because they would have options. For example, if we follow my original post, and you break your leg, you could call around and get quotes (just like you can do for lawyers), and of course the guy that went to Harvard with a superb track record is going to cost you a lot, however your friend goes to a doctor that graduated from the university of South Dakota, he’s had good experiences with him, and he’s half the price, so you go there. Note, the above example is assuming everyone is paying for themselves which I am actually against. I think insurance companies actually serve a good purpose, which is to spread risk. The cost of premiums etc., are directly related to the cost of healthcare, which if there were legitimate options like in my example above, would be much lower across the board. As I said in my OP, all of this depends on the government not giving power to this licensing entity (I.e. deregulating) which artificially limits the supply of doctors, giving you less options, and costing you more.
Facts x 100
The biggest driver of healthcare costs in the US is actually government regulation set up to to benefit insurance companies, pharmaceutical companies, and the AMA.
All at the expense of competition and consumers.
The government should have two roles in healthcare: to provide a backstop for people who need help and to a provide a regulatory framework that protects consumers. The latter is the system we have in finance, as the SEC. FINRA and other regulatory authorities main role to promote market integrity and to protect investors.
Bump
TL; DR on my long post:
Healthcare is a trade-off btw Quality and Accessibility. There is a sweet-spot where you can have best of both (95% quality with 95% accessibility). The US sucks at it (99% quality with 50% accessibility). The US can achieve that sweet spot through - 1) Replacing dumb regulations that keep healthcare costs up with smart regulations (ends up in a mostly deregulated environment where companies and hospitals aren't given unfair advantages at the expense of patients), 2) Providing a public healthcare option for the underprivileged, and 3) curbing the power of AMA so they can't artificially limit the number of doctors, hospitals, and number of other medical professionals like technicians (all at the expense of the patients).
Another thing the US can do is innovate on hospital administration systems (software, business practices, etc...) to improve the state of the trade-off curve (improving the 95-95 sweet spot to become a 98-98 sweet spot).
I’m in basically total agreement with you. Throw big pharma on the list and I think the above would more or less fix everything. The interesting thing to me, is that both candidates seem to be highly focused on insurance, which in and of itself is not bad, since it only serves to spread risk around. Insurance is in fact just a product of our current system, and explains very little as to why the system is so bad for the average consumer. Do you think it is simply not politically viable to talk about deregulating healthcare, and in the same sentence talk about having a totally government sponsored option available to those making under $X?
I don't think Trump campaign actually cares. They just think throwing soundbites will work and insurance is a big one (probably why they don't actually have any real policy plans for the re-election). If you don't believe me, visit both campaign sites. Trump only lists things he did and tried to do, not things that he'll do (does he even have a plan other than tweeting away another 4 years?). Biden has a gigantic list of things he'll do (don't know how much he'll achieve or even try to achieve but at least you can hold him accountable).
As for the Biden campaign, it actually specifically targets drug prices (on the Biden campaign website). It's promising to do couple things - 1) Getting rid of regulation that bars Medicare from negotiating drug prices, 2) soft price ceilings or prince increase ceilings on drugs and other expensive medical products (there are enough mainstream economists who think that the drug market isn't self-stabilizing, so this might be a one of those "smart" regulation), 3) pulling back some regulations on importation of foreign drugs (I like this very much), 4) pulling back regulations on bio-similar drugs (same drugs produced by manufacturers other than the original patent holder, once a patent is outdated) to allow bio-similars to be as competitive as they should be in a free market (I REALLY LIKE THIS), and 5) getting rid of tax deductibles for drug ads, which AMA studies found increases drug prices (not sure how valid this study is and who's behind it so this one sounds a little fishy).
I think when people here "deregulations" they think corporations going amok and doing whatever the hell they want to do (in reality, it's rather more regulations that causes this behavior). So absolutely, they hate to hear any deregulation talks.
I think it's difficult for most people to understand the nuances of deregulation. So they think "having a public option" means "more regulation". But the two are completely separate. You can have a highly deregulated healthcare market where a government offers a public option. You can also have a healthcare market with 0 public option whatsoever, but heavily regulated.
Such nuanced topics are difficult to discuss as a politician. Only a small number of talented orators can do that (like Obama level good orator).
My favorite topic. I'm glad you brought this up. It's one of the things I'd like to research if I end up doing a PhD so I read and think a lot about this topic.
I'll touch on 1. healthcare structure, 2. licensure, and 3. further improvements.
1. Healthcare Structure:
Healthcare, like every single services and products out there, is subject to 1 fundamental trade-off: Accessibility vs. Quality.
On one end, you have countries with nationalized healthcare like the UK and Canada. Everyone gets healthcare, but people have to wait for months before getting a surgery. On the other end, you have the US. If you can pay for it, then you get the best healthcare with minimal waiting period. The UK and Canada have full accessibility at the expense of quality. The US has optimal quality at the expense of accessibility.
Then we have to ask - Is the US hitting the sweet spot between the two? Unfortunately, the answer is a clear NO. I'm making up numbers here but the system we have in the US is something that achieves "99% quality with 50% accessibility" and the system in the UK and Canada achieves "50% quality with 99% accessibility". The reality is that you can achieve "95% quality with 95% accessibility", which is clearly a much more desired outcome.
Then, how do we go about hitting that sweet spot? The answer is three-fold - a) roll back dumb regulations and replace with smart regulations, b) design a public option, and c) limit the power of AMA. I'll discuss point c) on the licensure section.
a) Roll back dumb regulations & Replace with Smart Regulations:
The essence of replacing dumb regulations with smart ones is to decrease the costs of healthcare, which have been artificially driven up by these dumb regulations.
Let's start with deregulation - Should we completely deregulate? There are lots of good arguments for completely deregulating the healthcare sector. Essentially, the arguments all say that it'll actually make it a lot cheaper while not sacrificing too much on the quality. This sounds very attractive for the US because most of the regulations are set up to benefit specific companies and hospitals at the expense of patients (one of the most misunderstood fact about regulation). BUT, the catch is that this will achieve something like "90% quality with 75% accessibility". Much better than what we have now, but still not hitting that sweet spot.
So then, what regulations should we roll back on? The broad answer is, all regulations that benefit specific interest groups who are not patients themselves, but rather companies, hospitals, and doctors. Why? Because such regulations come at the expense of the patients. People really need to read into some of the regulations and how ridiculous they are. For example, did you know that 36 states require people to get approved by ALL or MAJORITY of hospitals within a set mile radius if you want to open up a new hospital? (No wonder why there aren't enough hospitals!). Did you know that the FDA has some ridiculous standards on the quality of drugs that prevent so many of foreign drugs that work just fine from being imported and prevent so many new pharmaceutical start-ups from coming with cheaper alternatives? (Again, 99% quality with 50% accessibility vs. 95% quality with 95% accessibility). The above two are just examples but the point is that most healthcare regulations are rigged, they are set up to benefit incumbent drug manufacturers, hospitals, doctors, medical equipment manufacturers, and other businesses at the EXPENSE of patients.
Finally, what are "smart" regulations?. The notion of "smart" regulation is simple - regulate only when necessary. This notion leads to mostly deregulated market with handful of regulations that sets up a fair playing field for everyone and stabilizes markets. In the context of healthcare, such "smart" regulation would be things like - require doctors to share patient information with other doctors and medical professionals in the team treating the patient, require drugs to be effective but not ridiculously so, require price transparency, etc... Anything else that doesn't belong to "smart" regulations, should be repealed or their stringency significantly lowered. Doing so would decrease healthcare costs A LOT.
b) Design a public option.
This is a simple point. Once you decrease medical costs through replacing dumb regulations with smart ones, what more can you do? My guess is that only doing away with dumb regulations would achieve "95% quality with 85% accessibility", good enough but still not hitting the "95-95" sweet spot. So you simply increase the accessibility by providing a public option that people at the fringes of society can afford.
2. Licensure:
Friedman had a good point about licenses - most license requirements are schemes of small interest groups to benefit at the expense of consumers and other workers in the similar field. In the context of medical doctors, this is no different. If you read Friedman's Capitalism and Freedom, he explains it quite well. Essentially, his point is that 1) medical licenses artificially limit the number of doctors to be too low (again, 99% quality with 50% accessibility) and 2) lots of tasks that require a medical license actually don't need to be performed by a doctor.
I'll elaborate on 2) first. Friedman envisioned a medical team consisting of medical doctors, nurses, and various technicians working together to offer affordable and high quality healthcare. I don't know about now, but at least during Friedman's time, only medical doctors were allowed to operate medical equipment like imaging machines (fMRI, MRI, PET, ultrasound, etc...). This was just ridiculous because you can easily train technicians to operate these machines. And many countries have a system like that where healthcare costs are kept low. Same goes for giving a shot, performing simple medical operations, etc... Most tasks don't require an expensive MD with 4 years of medical school training + 4 years of residency. They might only require technicians who studied enough biology and has 2 years of vocational training.
Now as for 1). The government enables AMA to pretty much controls how many people can go to medical school each year. This is nothing but a cheap scheme to keep doctor's wages slightly higher than what it would be (ie. Think about 100 people making 180K instead of 150 people making 150K). Friedman saw right through this and hence criticized the medical system. If you think about it, it's ridiculously difficult to get into medical school - you need a near perfect GPA, a near perfect MCAT score, and a litany of research experience. But seriously, you don't really need all that if all you end up doing is treat people with flu and other common diseases as most doctors end up doing.
AMA likes to artificially keep supply of doctors low, driving healthcare costs up.
3. Further Improvements
The trade-off curve between accessibility and quality is not a fixed one. In fact, it improves over time as technological improvements continue (meaning that sweet spot of "95% accessibility and 95% quality" might change to 98-98 in the next 20 years). In fact, many technological improvements have been made throughout the world that the US just hasn't adopted.
A quick case study: South Korea.
Sometime in the late 60s or early 70s, Korea adopted an universal healthcare system in a form of requiring everyone to pay for a basic insurance. In a developed economy, this would have been disastrous but Korea back then was a 3rd world country so there wasn't much sacrifice in quality of healthcare. Issue was that, at the sake of accessibility, Korea sacrificed potential for the quality by possibly capping the quality below what they can actually achieve.
Fortunately, Korean policymakers & regulators weren't as dumb and corrupt as their American counterparts. So they ended up imposing mostly "smart" regulations, not coming up with ridiculous limitations on number of hospitals, number of doctors, and who can provide certain healthcare services and what not. Korean government respected a medical team structure consisting of doctors, nurses, and variety of technicians to keep the quality up while keeping the costs down.
Another thing they did well was not to interfere much with the way doctors and hospitals conducted their business. In order to stay competitive and make higher wages, doctors and hospitals became so efficient in their administrative capabilities that they ended up being able to see a lot more patients without sacrificing quality, way higher than the rest of the world.
Now practically all hospitals from small to big are all digitized, with optimized administration. There are lots of hospital administration software products, professionals, and business practices that keeps waiting periods low while the Koreans were able to achieve very good quality healthcare through other technological innovation.
Summary is that the Koreans were able to achieve an amazing healthcare system that achieves "near 100% accessibility with 90% quality" through innovations that improved their quality vs accessibility trade-off curve.
What should the US take away from Korea? Many things - 1) self-disciplinary nature of the regulators, 2) an understanding of what regulations are smart and what are dumb, and 3) adaptation of better healthcare administrative practices (digitization and what not).
Hadn’t really heard of the critiques regarding over regulation on the industry before. Do you have any good sources that they layman can go to in order to see like a bigger list of these regulations and their impacts? Limiting the number of hospitals by requiring existing hospitals to approve is nuts. It’s hard to imagine any reason for that being the case other than anti-competitive forces
Unfortunately, I don't know such a source. I had to do lots of Google searches just to name those 2 examples. It's probably not in the interest of AMA and companies for such a holistic list to exist that people can easily access. I wouldn't be surprised if there are any laws or regulations that prevent such a list from existing.
As for the fact the incumbent hospitals have to approve a creation of new hospital, look up Certificate of Need laws (CON). (FYI, I was actually wrong when I said it was federal, it's actually in enough states that it might as well as be federal).
Sources like this do offer some detail. But take it with a grain of salt since it's coming form an associations of hospitals. They do have valid points on telehealth though.
https://www.aha.org/system/files/2018-02/regulatory-overload-report.pdf
I’m less informed than some of the above comments, there’s a lot of good points made. I remember a quote from somewhere, possibly in some book I’ve read, that said, “Americans would rather pay a higher price for everything, if for no other reason to know than not a penny of that was to help their neighbor.” It’s pretty blatant in healthcare. Americans will moan “socialism” and “communism” for universal healthcare- yet they support the police, a completely (in theory) socialist entity. You don’t get shot and then they stop the investigation because you don’t have “getting shot” under your police insurance policy.
I’m less informed than some of the above comments, there’s a lot of good points made. I remember a quote from somewhere, possibly in some book I’ve read, that said, “Americans would rather pay a higher price for everything, if for no other reason to know than not a penny of that was to help their neighbor.” It’s pretty blatant in healthcare. Americans will moan “socialism” and “communism” for universal healthcare- yet they support the police, a completely (in theory) socialist entity. You don’t get shot and then they stop the investigation because you don’t have “getting shot” under your police insurance policy.
My biggest concern is that the more the government becomes involved in healthcare the less doctors will get paid. Doctors she’ll out a ton of money to go to school, and need to get paid after. If they don’t doctor no longer becomes a good job. The quality of people becoming doctors goes down. We already see that with how much work PAs and nurses do. Why even become a doctor?
For all of you who think the government could do better. I work in a sector of the government that is considered extremely good at what we do. We still suck. Trust me, the government sucks at everything.
My biggest concern is that the more the government becomes involved in healthcare the less doctors will get paid. Doctors she’ll out a ton of money to go to school, and need to get paid after. If they don’t doctor no longer becomes a good job. The quality of people becoming doctors goes down. We already see that with how much work PAs and nurses do. Why even become a doctor?
For all of you who think the government could do better. I work in a sector of the government that is considered extremely good at what we do. We still suck. Trust me, the government sucks at everything.
If you go back to my original post I think the answer to this is quite clear. If more medical schools were allowed then there would in fact be medical schools that were more affordable (perhaps of a lower quality) producing cheaper doctors. The candidates that are smart enough and can get into Harvard et al. will still have to pay a lot, but they will also make more because people are willing to pay for quality. This is how law works, and why it is a better system.
I think that is a great idea. The idea of a nationwide exam is smart as well. This could even lead to different certifications (think CFA, CPA, CFP) for doctors that make people more marketable and increase compensation. The left desperately wants more involvement in healthcare because a huge pitch of theirs is “more free stuff” (I’d rather pay as few taxes as I can to an incompetent organization- government)
The issue for the right is that while deregulation leads to increased innovation, drug companies have no reason to lower prices. Insurance will pay it and pass it off to all of their members.
The answer is to deregulate the insurance industry and all for more discriminatory practices. I.e. we want people with a BMI under 30, who can run x number of miles. Offer great rates, etc. then have an insurance agency for fat people. Higher premiums. People do what you incentivize. You have to incentivize being healthy
I think that is a great idea. The idea of a nationwide exam is smart as well. This could even lead to different certifications (think CFA, CPA, CFP) for doctors that make people more marketable and increase compensation. The left desperately wants more involvement in healthcare because a huge pitch of theirs is “more free stuff” (I’d rather pay as few taxes as I can to an incompetent organization- government)
The issue for the right is that while deregulation leads to increased innovation, drug companies have no reason to lower prices. Insurance will pay it and pass it off to all of their members.
The answer is to deregulate the insurance industry and all for more discriminatory practices. I.e. we want people with a BMI under 30, who can run x number of miles. Offer great rates, etc. then have an insurance agency for fat people. Higher premiums. People do what you incentivize. You have to incentivize being healthy
Dude, doctors not getting paid is based on contracts they have with the insurance companies. Practicing medicine today is not nearly as lucrative as it once was.
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