These problems have long been apparent and the solution has been available for decades. The problem is the method used to elect a chief executive. The electoral college must be ditched. The executive branch has the tools to breakup and to prevent monopolies, but it has become corrupted by the way that elections are financed. We have a Citizens United because of John Roberts. We have John Roberts because of Bush the younger, we had Bush the younger because of the electoral college. Only one Republican has won a majority of the popular vote since 1990 that being W in 2004, yet we have a SCOTUS with a 6 to 3 majority. Nearly all of the outrageous rulings from the Court have been authored by the Court's conservative wing since 2000. The Clayton Act and Sherman Act will never be enforced by republican administrations and we may never be able to elect any administration which has any interest in anti trust enforcement or consumer protection as long as corporations are allowed to use the electoral college and voter suppression to elect its administrations and its corporate subsidiary highest Court can be counted on to protect the plutocrats. We must remember that there is no constitutional right to operate a business as a corporation or to make a profit since the words capitalism and corporation are mentioned nowhere in the Constitution.
I work for a company that provides alternative solutions for self-funded employer health benefits. For those not in the industry: as bad as you think it is, it's way worse. The system, from top to bottom, is designed to extract cash from as many corners of the process as possible and outcomes are dumped at the feet of health professionals. The US has higher health care costs than the next two countries combined and is 17th in outcomes. We have to make large systemic changes but there are trillions of dollars committed to making sure that never happens.
Private Equity -- the real-life BORG in our midst. It should be flatly illegal for any of them to have any involvement whatsoever in any kind of human or animal-related healthcare.
10 years ago, there were a surprising number of people who were equally intrigued by both Sanders and Trump. That should have been taken as a sign that the 20th century understanding of Liberals vs Conservatives was breaking down. The two political parties were representative of constituencies that didn’t fully address many of our growing problems, not least of which was health care.
Neoliberalism has not lived up to Milton Friedman’s promises of shared prosperity, and Libertarianism has proven especially counterproductive in addressing issues of health and well being. The ‘system’ is decreasingly satisfactory. It isn’t just health care that is warped by the worst aspects of Capitalism, but it is certainly one of the most significant failing aspects of our economic and political system.
The question for me is what emerges from this growing dissatisfaction. Neither of our two political parties are rising to this challenge. One is trapped in indulgent blame and conspiracy narratives, while the other still believes that Managerialism can solve all problems.
Jonathan, what were the top 3 ways the ACA was supposed to control health care premiums and prices (the affordable part for anyone not getting Medicaid or a subsidy)? Will a Dem org ever suggest 1. reinstating the tax penalty for not having insurance or 2. removing the tax exemption for even very generous employer provided health insurance (thereby forcing more price sensitivity and bringing in revenue)?
The way to control healthcare costs is to get rid of private health insurance. Then, we can use a market mechanism to control cost. We can have representatives of the people negotiate directly with the suppliers and set payments for pharmaceutical, procedure, and medical equipment.
That puts the two main parties--the suppliers and the consumers--on an equal footing, and we can get rational pricing.
Plus, it eliminates the main driver of costs: the plethora of plans. That would radically cut the overhead for the system.
So is it a government agency that is setting prices and insuring everyone? Who assumes the risk when someone gets cancer? Is the government paying for the full range of cancer treatments? Who decides on deductibles, copays and premiums and how often someone can go to the doctor or a specialist? Do you support getting rid of the tax exemption for health insurance as a way to increase price sensitivity and pay for the potentially huge cost of government provided health care?
I thought the main driver of cost was the actual healthcare such as high hospital and pharmaceutical costs. I would think the plethora of plans would allow people to shop for cheaper premiums if they wanted to.
I suspect you know a lot more about health care than I do, so perhaps you can address some of those questions.
You're right that I should answer those questions. I'm working on that, but it is time-consuming.
My suggestion, which I call "Healthcare for All", has specific recommendations. It's not intended to be a turnkey solution. It's a guideline.
In it, the federal government would create regional organizations to provide healthcare coverage. Those organizations would assume risks, and they would have the mandate to pay for all essential healthcare.
Premiums would be related to family income. There would not be deductibles or co-pays.
The healthcare providers would determine how often someone got to see a doctor based on medical need.
Prices for medical care (healthcare providers and facilities, pharmaceuticals, and medical equipment) would be set by negotiations between the suppliers and representatives of the people in each region. In general, providers would be represented by their professional organizations. The people in the region would be represented by a group of experts appointed by the states in those regions.
This provides a market-based mechanism for setting prices, which keeps costs reasonable. The size of the parties on each side would be comparable, which should lead to fair prices.
The main driver of cost in our system is the enormous number of plans, which is a function of private health insurance (payers). Each payer has many different plans, generally based on how much people are willing to pay, their geographic locations, and other factors.
This results in a lot of overhead. Each medical provider has to understand their patient’s plan to determine what it will pay for. Then, each payer has to figure out which plan is applicable to be able to decide how to best deny payment.
Healthcare for All gets rid of that overhead. The overhead in the system is enormous. Under ACA it is up to 15% for some cases and can be 20%. Healthcare for All should have an overhead of 5%, comparable to the UK’s NHS and the VA here.
Just as a rough estimate, out of a system that pays about $1.5 trillion just in the private sector, cutting overhead by 10% cuts about $150 billion a year from costs.
That should be more than enough to pay for healthcare for the people currently not covered and those under-covered in the U.S.
I’m sure one driver of costs is that hospitals, clinics, and pharmaceutical companies can charge high prices. But I don’t think that’s the main driver, although Healthcare for All would eliminate a lot of that through market-based pricing.
Mary Beth, I believe I’ve over-answered your questions. But I’m glad you asked these questions, because they are important. We need to figure out a solution, because the healthcare sector is now about 18% of the economy, and the costs are growing there faster than in the other sectors.
Plus, there are enormous numbers of problems. People die who shouldn’t and very few people are happy with what they get. I really think we can do better.
I did research this in depth some years ago. The situation hasn’t fundamentally changed, other than prices continue to climb. If someone has a better solution, then I’d like to see it implement. By proposing something, I’ve overcome one big obstacle: the objection that no one has a solution to the problem.
Thanks for taking the time to respond. I have done a lot of research in the area as well. As with so many of the country’s biggest problems, there are experts who have lots of ideas, but there seems to be no political will to create legislation that can get 60 votes in the Senate. In the meantime, our family pays about $40k every year for health care (small employer, laughable out of network deductible for services with few in network providers, etc.). Any solution to health care has to look at the cost, how we pay for it with $39 trillion in debt and ballooning interest payments, and MUST revise the favorable tax treatment for employer sponsored health care. Thanks for the conversation!
Healthcare is obviously a complicated issue. I think one of the biggest challenges we are going to face until this changes is a fundamental idea of focusing on cures instead of prevention. I think we have worse outcomes because many people engage with the system in worse condition. I'm not blaming them, we are inundated with messages about making our own choices and we have multiple industries from alcohol, to food, to gambling that depend on some level of overindulgence and addiction to thrive. We should levy high taxes on them and fund healthcare from that revenue.
MAHA claims it's about making people healthy but it's really a matter of health scams making into government. We know what the healthiest choices are - good diets that are very low in saturated fats and sugars, getting regular exercise, wearing sunscreen, not drinking and not smoking. The trouble is that we have conditioned the population to insist on virtually unlimited consumption of all or most of those things and MAHA says, go for it and wait for a magic cure when things go wrong.
To me, the most important policies we need to put into place are the ones that stop letting companies profit from misleading people and using tax revenue from addicts to go into general funds. The system is failing because we are overwhelming it.
Why not push for the return of mutual health insurance companies. The premium payers are the shareholders. Profits are returned in the form of rate adjustments. The system we have now is rewarding poor coverage, delays and denials. Whereas the point of health insurance is the same as all forms of insurance: spreading risk among a large group of people, but allocating costly benefits for those who need it, a much smaller group. The “insurance” part is that most won’t need the expensive procedures, but if you did, you were covered.
It's best to have one big mutual company. Universal healthcare eliminates the profits and a lot of other overhead.
That's why I favor a system where premiums are tied to family income and rates are set by negotiations between people and the suppliers.
It's the job of the government to protect people from dangers they can't protect themselves from. Health problems fall squarely in that category. The government needs to step in and do its job.
Because many people are more likely to need the expensive procedures as they age, the only way health insurance can really work is if everyone is covered. Younger, healthier people will someday need the coverage they are paying for -- but if they are allowed to 'opt out' because they are healthy, it won't be affordable for them once they DO need it.
I agree. Universal coverage is the only way it will work to the benefit of all Americans. Healthcare is, essentially, part of our infrastructure for a modern industrial society. Just like roads, water, transportation, public safety have been for centuries, healthcare, communications, economic safety nets and regulations are crucial for the general welfare mandated in the Preamble.
Targeting private equity and profit seeking behavior generally in areas of daily life and society that should never be operated as profit making endeavors in the first place is such an obvious and easy lay up, it’s no wonder that a political entity as incompetent and philosophically adrift as the Democrats can’t be bothered to even take the shot.
My former primary care physician shared several horror stories of denial of care. An end of the day appointment gave him time to tell these stories. This is a doctor who did not recommend unnecessary treatment or make referrals for studies that weren’t needed. He referred a patient for a stress test. It was denied. He added one word to the referral, “angina”. The patient had not reported angina, but that 1 word change got approval for the stress test. The man had blockages and required stents. He referred another patient for a CAT Scan of his abdomen, which was denied. It was denied on appeal. “What do I do now? “ Go to the ER with the same complaint and be admitted, and cost the insurance $30, 000 instead of a few hundred for the scan. He asked for an MRI. “The reply was that he had to have physical therapy first. “You don’t understand; he can barely walk.” Well, has to have physical therapy first, even after talking with the physician consultant for the insurance firm. He could have named more such abuses if I had a couple of hours. On the other side, my wife has very fragile skin. It tears more than cuts. One ER visit required over 100 stitches. She was referred to a wound care specialist. She texted him a picture of 1 such wound on a Sunday morning. His reply, We are on our way back from the farm. I’ll see you in my office at 2:00. -on a Sunday based on a texted photo.That’s medical care.
A quick read of the comments here suggests the public is ready for wholesale change. I think most people are disgusted, if not frightened, by the current situation.
One of the main reasons for government is to protect people from what they can't protect themselves from. Most medical conditions fall into that category. Many are far too expensive for an individual to deal with themselves. And insurance is helpless. I don't know what kind of health problem I might have later today, let alone next year. How am I supposed to choose coverage?
Yet, in the U.S., the government doesn't protect people from medical problems. It's totally the Republican philosophy: "You're on your own, sucker!"
The Democratic Party should put together a solid proposal for universal healthcare. I think polls show that's what about 80% of people want. And if you look at how healthcare is operating, there's no mystery why.
It would be interesting to see the statistics of all Americans. Many people (those employed by large employers, unions or government) are happy with their health insurance coverage and blissfully unaware of health care prices. Any dramatic changes will upset people who like their insurance and they (and the large employer, union and hospital lobbies) will resist change. I actually think affordable catastrophic care and more access to tax free money in HSAs have to be part of the plan.
I think you could easily find that stat. But here's one that's close to it that I happen to have on hand.
In 2019, Jimmy Kimmel showed poll results on a variety of issues to Nancy Pelosi and asked her why Democrats don’t back progressive policy when it is so popular. One example:
Medicare for All : 74%
[From Jimmy Kimmel Live on ABC, 30 May 2019]
And here is something that came up in focus groups where Sarah talked with Margie Omero...
“We've asked people [who say they are willing to endure short-term pain] what's the pain that you're willing to put up with and what's the gain that you think is going to come out on the other side of tariffs? And they'll say, well, I'm willing to pay, you know, whatever... some amount they think they're willing to pay. And the long-term gain is I want, you know, universal healthcare and to be respected abroad. I'm like, well, that's, you know, that's not what he's offering, right? So, like even what he thinks he's offering folks, what he thinks he's asking of people is actually not what they want.”
This is a terrific piece. Yup, we need to put patients ahead of shareholders. In fact, we need to remove shareholders from medical decisions. Period.
These problems have long been apparent and the solution has been available for decades. The problem is the method used to elect a chief executive. The electoral college must be ditched. The executive branch has the tools to breakup and to prevent monopolies, but it has become corrupted by the way that elections are financed. We have a Citizens United because of John Roberts. We have John Roberts because of Bush the younger, we had Bush the younger because of the electoral college. Only one Republican has won a majority of the popular vote since 1990 that being W in 2004, yet we have a SCOTUS with a 6 to 3 majority. Nearly all of the outrageous rulings from the Court have been authored by the Court's conservative wing since 2000. The Clayton Act and Sherman Act will never be enforced by republican administrations and we may never be able to elect any administration which has any interest in anti trust enforcement or consumer protection as long as corporations are allowed to use the electoral college and voter suppression to elect its administrations and its corporate subsidiary highest Court can be counted on to protect the plutocrats. We must remember that there is no constitutional right to operate a business as a corporation or to make a profit since the words capitalism and corporation are mentioned nowhere in the Constitution.
finally. hospitals need to be non profit, period.
" “To hold public trust, medicine must embrace the value of patients first. Private equity is all about maximizing shareholder value.”
Yes.
Healthcare should be a service, not a business.
Like the military is a service, like the Postal Service is a service, like education is a service.
Once it's all about profits, people are sacrificed as a result.
At least we’re finally talking about it in a coherent way.
I work for a company that provides alternative solutions for self-funded employer health benefits. For those not in the industry: as bad as you think it is, it's way worse. The system, from top to bottom, is designed to extract cash from as many corners of the process as possible and outcomes are dumped at the feet of health professionals. The US has higher health care costs than the next two countries combined and is 17th in outcomes. We have to make large systemic changes but there are trillions of dollars committed to making sure that never happens.
Don't forget what PE has done to fire depts!
Private Equity -- the real-life BORG in our midst. It should be flatly illegal for any of them to have any involvement whatsoever in any kind of human or animal-related healthcare.
10 years ago, there were a surprising number of people who were equally intrigued by both Sanders and Trump. That should have been taken as a sign that the 20th century understanding of Liberals vs Conservatives was breaking down. The two political parties were representative of constituencies that didn’t fully address many of our growing problems, not least of which was health care.
Neoliberalism has not lived up to Milton Friedman’s promises of shared prosperity, and Libertarianism has proven especially counterproductive in addressing issues of health and well being. The ‘system’ is decreasingly satisfactory. It isn’t just health care that is warped by the worst aspects of Capitalism, but it is certainly one of the most significant failing aspects of our economic and political system.
The question for me is what emerges from this growing dissatisfaction. Neither of our two political parties are rising to this challenge. One is trapped in indulgent blame and conspiracy narratives, while the other still believes that Managerialism can solve all problems.
Jonathan, what were the top 3 ways the ACA was supposed to control health care premiums and prices (the affordable part for anyone not getting Medicaid or a subsidy)? Will a Dem org ever suggest 1. reinstating the tax penalty for not having insurance or 2. removing the tax exemption for even very generous employer provided health insurance (thereby forcing more price sensitivity and bringing in revenue)?
The way to control healthcare costs is to get rid of private health insurance. Then, we can use a market mechanism to control cost. We can have representatives of the people negotiate directly with the suppliers and set payments for pharmaceutical, procedure, and medical equipment.
That puts the two main parties--the suppliers and the consumers--on an equal footing, and we can get rational pricing.
Plus, it eliminates the main driver of costs: the plethora of plans. That would radically cut the overhead for the system.
So is it a government agency that is setting prices and insuring everyone? Who assumes the risk when someone gets cancer? Is the government paying for the full range of cancer treatments? Who decides on deductibles, copays and premiums and how often someone can go to the doctor or a specialist? Do you support getting rid of the tax exemption for health insurance as a way to increase price sensitivity and pay for the potentially huge cost of government provided health care?
I thought the main driver of cost was the actual healthcare such as high hospital and pharmaceutical costs. I would think the plethora of plans would allow people to shop for cheaper premiums if they wanted to.
I suspect you know a lot more about health care than I do, so perhaps you can address some of those questions.
You're right that I should answer those questions. I'm working on that, but it is time-consuming.
My suggestion, which I call "Healthcare for All", has specific recommendations. It's not intended to be a turnkey solution. It's a guideline.
In it, the federal government would create regional organizations to provide healthcare coverage. Those organizations would assume risks, and they would have the mandate to pay for all essential healthcare.
Premiums would be related to family income. There would not be deductibles or co-pays.
The healthcare providers would determine how often someone got to see a doctor based on medical need.
Prices for medical care (healthcare providers and facilities, pharmaceuticals, and medical equipment) would be set by negotiations between the suppliers and representatives of the people in each region. In general, providers would be represented by their professional organizations. The people in the region would be represented by a group of experts appointed by the states in those regions.
This provides a market-based mechanism for setting prices, which keeps costs reasonable. The size of the parties on each side would be comparable, which should lead to fair prices.
The main driver of cost in our system is the enormous number of plans, which is a function of private health insurance (payers). Each payer has many different plans, generally based on how much people are willing to pay, their geographic locations, and other factors.
This results in a lot of overhead. Each medical provider has to understand their patient’s plan to determine what it will pay for. Then, each payer has to figure out which plan is applicable to be able to decide how to best deny payment.
Healthcare for All gets rid of that overhead. The overhead in the system is enormous. Under ACA it is up to 15% for some cases and can be 20%. Healthcare for All should have an overhead of 5%, comparable to the UK’s NHS and the VA here.
Just as a rough estimate, out of a system that pays about $1.5 trillion just in the private sector, cutting overhead by 10% cuts about $150 billion a year from costs.
That should be more than enough to pay for healthcare for the people currently not covered and those under-covered in the U.S.
I’m sure one driver of costs is that hospitals, clinics, and pharmaceutical companies can charge high prices. But I don’t think that’s the main driver, although Healthcare for All would eliminate a lot of that through market-based pricing.
Mary Beth, I believe I’ve over-answered your questions. But I’m glad you asked these questions, because they are important. We need to figure out a solution, because the healthcare sector is now about 18% of the economy, and the costs are growing there faster than in the other sectors.
Plus, there are enormous numbers of problems. People die who shouldn’t and very few people are happy with what they get. I really think we can do better.
I did research this in depth some years ago. The situation hasn’t fundamentally changed, other than prices continue to climb. If someone has a better solution, then I’d like to see it implement. By proposing something, I’ve overcome one big obstacle: the objection that no one has a solution to the problem.
Thanks for taking the time to respond. I have done a lot of research in the area as well. As with so many of the country’s biggest problems, there are experts who have lots of ideas, but there seems to be no political will to create legislation that can get 60 votes in the Senate. In the meantime, our family pays about $40k every year for health care (small employer, laughable out of network deductible for services with few in network providers, etc.). Any solution to health care has to look at the cost, how we pay for it with $39 trillion in debt and ballooning interest payments, and MUST revise the favorable tax treatment for employer sponsored health care. Thanks for the conversation!
Healthcare is obviously a complicated issue. I think one of the biggest challenges we are going to face until this changes is a fundamental idea of focusing on cures instead of prevention. I think we have worse outcomes because many people engage with the system in worse condition. I'm not blaming them, we are inundated with messages about making our own choices and we have multiple industries from alcohol, to food, to gambling that depend on some level of overindulgence and addiction to thrive. We should levy high taxes on them and fund healthcare from that revenue.
MAHA claims it's about making people healthy but it's really a matter of health scams making into government. We know what the healthiest choices are - good diets that are very low in saturated fats and sugars, getting regular exercise, wearing sunscreen, not drinking and not smoking. The trouble is that we have conditioned the population to insist on virtually unlimited consumption of all or most of those things and MAHA says, go for it and wait for a magic cure when things go wrong.
To me, the most important policies we need to put into place are the ones that stop letting companies profit from misleading people and using tax revenue from addicts to go into general funds. The system is failing because we are overwhelming it.
Why not push for the return of mutual health insurance companies. The premium payers are the shareholders. Profits are returned in the form of rate adjustments. The system we have now is rewarding poor coverage, delays and denials. Whereas the point of health insurance is the same as all forms of insurance: spreading risk among a large group of people, but allocating costly benefits for those who need it, a much smaller group. The “insurance” part is that most won’t need the expensive procedures, but if you did, you were covered.
It's best to have one big mutual company. Universal healthcare eliminates the profits and a lot of other overhead.
That's why I favor a system where premiums are tied to family income and rates are set by negotiations between people and the suppliers.
It's the job of the government to protect people from dangers they can't protect themselves from. Health problems fall squarely in that category. The government needs to step in and do its job.
Because many people are more likely to need the expensive procedures as they age, the only way health insurance can really work is if everyone is covered. Younger, healthier people will someday need the coverage they are paying for -- but if they are allowed to 'opt out' because they are healthy, it won't be affordable for them once they DO need it.
I agree. Universal coverage is the only way it will work to the benefit of all Americans. Healthcare is, essentially, part of our infrastructure for a modern industrial society. Just like roads, water, transportation, public safety have been for centuries, healthcare, communications, economic safety nets and regulations are crucial for the general welfare mandated in the Preamble.
Targeting private equity and profit seeking behavior generally in areas of daily life and society that should never be operated as profit making endeavors in the first place is such an obvious and easy lay up, it’s no wonder that a political entity as incompetent and philosophically adrift as the Democrats can’t be bothered to even take the shot.
My former primary care physician shared several horror stories of denial of care. An end of the day appointment gave him time to tell these stories. This is a doctor who did not recommend unnecessary treatment or make referrals for studies that weren’t needed. He referred a patient for a stress test. It was denied. He added one word to the referral, “angina”. The patient had not reported angina, but that 1 word change got approval for the stress test. The man had blockages and required stents. He referred another patient for a CAT Scan of his abdomen, which was denied. It was denied on appeal. “What do I do now? “ Go to the ER with the same complaint and be admitted, and cost the insurance $30, 000 instead of a few hundred for the scan. He asked for an MRI. “The reply was that he had to have physical therapy first. “You don’t understand; he can barely walk.” Well, has to have physical therapy first, even after talking with the physician consultant for the insurance firm. He could have named more such abuses if I had a couple of hours. On the other side, my wife has very fragile skin. It tears more than cuts. One ER visit required over 100 stitches. She was referred to a wound care specialist. She texted him a picture of 1 such wound on a Sunday morning. His reply, We are on our way back from the farm. I’ll see you in my office at 2:00. -on a Sunday based on a texted photo.That’s medical care.
Please write more about healthcare.
A friend of mine lives in a trailer park just purchased by private equity. When his current lease runs out his rent will double.
Mark - unbridled capitalism is an invigorating force, eh? 🤔 Creates great opportunities to keep us on our toes 😡
A quick read of the comments here suggests the public is ready for wholesale change. I think most people are disgusted, if not frightened, by the current situation.
One of the main reasons for government is to protect people from what they can't protect themselves from. Most medical conditions fall into that category. Many are far too expensive for an individual to deal with themselves. And insurance is helpless. I don't know what kind of health problem I might have later today, let alone next year. How am I supposed to choose coverage?
Yet, in the U.S., the government doesn't protect people from medical problems. It's totally the Republican philosophy: "You're on your own, sucker!"
The Democratic Party should put together a solid proposal for universal healthcare. I think polls show that's what about 80% of people want. And if you look at how healthcare is operating, there's no mystery why.
It would be interesting to see the statistics of all Americans. Many people (those employed by large employers, unions or government) are happy with their health insurance coverage and blissfully unaware of health care prices. Any dramatic changes will upset people who like their insurance and they (and the large employer, union and hospital lobbies) will resist change. I actually think affordable catastrophic care and more access to tax free money in HSAs have to be part of the plan.
I think you could easily find that stat. But here's one that's close to it that I happen to have on hand.
In 2019, Jimmy Kimmel showed poll results on a variety of issues to Nancy Pelosi and asked her why Democrats don’t back progressive policy when it is so popular. One example:
Medicare for All : 74%
[From Jimmy Kimmel Live on ABC, 30 May 2019]
And here is something that came up in focus groups where Sarah talked with Margie Omero...
“We've asked people [who say they are willing to endure short-term pain] what's the pain that you're willing to put up with and what's the gain that you think is going to come out on the other side of tariffs? And they'll say, well, I'm willing to pay, you know, whatever... some amount they think they're willing to pay. And the long-term gain is I want, you know, universal healthcare and to be respected abroad. I'm like, well, that's, you know, that's not what he's offering, right? So, like even what he thinks he's offering folks, what he thinks he's asking of people is actually not what they want.”
https://www.youtube.com/watch?v=vd2zENto8pc