Comments by "Xyz Same" (@xyzsame4081) on "Washington Post"
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@roguewade6733 Spending per person (All no matter who pays, that includes government subsidies) in the range of USD 4,700 - 4900 (Japan, France, Canada, Australia. And Belgium - that is a SMALLER country) ..... 5,700 Germany (OECD 2017). Most wealthy countries are in the range of 5,000 - 5,500 !
Outlier: UK with only 4,250 (but completely underfunded)
and Switzerland which like the U.S. leaves insurance to the for-profit insurance companies. It shows: USD 8,000 per person per year. (at least the system is good, they pay staff well and everyone is covered, the Kantons give subsidies).
And then there is the U.S. with USD 10,240 per person per year
(per person includes always residents that did not need any treatments and in the U.S. people that do not have coverage or are get too little treatment too late).
Single payer countries also ! give a lot of government subsidies. But since they are much more cost efficient the governments pay LESS in subsidies per person - and the citizens and the companies pay much, much less. **
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2:29 The U.S. does spend DOUBLE compared to other rich countries - outlier Switzerland has a system that relies on private insurers like the U.S. - it shows in the expenditures per person of USD 8,000 as shown in 2:44 - the claim made in 2:48 is not correct - All other nations are between 4,700 and 5,700 USD * - versus 10,2040 of the U.S. - most wealthy nations are in that range (maybe up to 6,000)
all numbers for 2017 - Keiser Foundation
I know only the U.S., CH, Taiwan (costs not comparable, much younger population , lower standard of wages), maybe Singapore, that use mainly private insurers.
All other countries (not only those shown with the costs) have AT LEAST a very strong (if not dominant) public non-profit insurance agency. That agency has contracts with for-profit and non-profit providers and companies. The more non-profit (escpecially when it comes to large providers like hospitals) the more cost-efficient.
The Swiss insurance companies are at least better regulated than in the U.S., they cannot kick people off insurance, the premiums are the same for all people in the same age group (so no pre-existing conditions, I assume that means also no healthcare questions), denial of treatment would not fly.
Lower income people get a subsidy (that is regulated per Kanton). And at least one Kanton offers a public option for insurance. With all these provisions - Switzerland still has costs of USD 8,000 per person per year.
Difference: Everyone is covered, going broke over medical bills is unknown. the insurerers do not have a cherrypicked pool (in the U.S. plus 65 year old and people on disability are in the public system. 10 % of patients cause 90 % of costs, and old age is a major factor - so the private insurers already have a huge advantage because the most expensive group is covered by Medicare / Medicaid).
Australia has a 2 tier system: Basics and the expensive treatments (hopsitals) are under the public coverage, but specialists, dental etc. is covered by "private" insurannce. That can be considered a gift to the insurance industry and high inomce people (their general tax helps fund the public system, which can be somewhat defunded if it does not cover ALL that is relevant for modern medicine. The private insurance will be somewhat overpriced but very wealthy people will still do better. It makes the _healthcare_system more expensive for everyone.
And there is MORE CHANCE that doctors can only offer private serivces. They will have enough patients, since the law makers carved out a niche for private. It is also possible to somewhat defund the public system which will cause wait times with the doctors and spcecialist that do accept public insurance coverage. - so people that want acceptable wait time will be fored to buy overpriced insurance.
Plus there is the incentive to "milk" the contracts of patients with good insurance coverage (overtesting, keeping them longer in the hospital). In a system where all people get the same treatment that is not done - it would become too expensive and the public agency would stop treatments and tests that do not have value (in avoided costs, better diagnosis, preventive effect etc).
In countries where the public insurance is comprehensive and reasonably funded wait times (for specialists, for elecitve surgery, in the ER) are acceptable. This is about funding and having the units spread out over the country. There a private doctor has to offer real value (a capacity in the field, offers a spceciality like accupuncture, really good with children, makes concessions regarding open times, ....). Acceptable waiting times, or being one of the few specialists in town will not suffice.
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2:44 What countries spend the most money annually on health care per person in USD
US 10,224 and Switzerland USD 8,009 = 78,34 % of the U.S. expenditures (both with private insurers * )
56,03 % Germany 5,728
53,90 % Sweden 5,511
53,21 % Austria 5,440
52,86 % Netherlands 5,386
47,95 % France 4,902
47,20 % Canada 4,826
46,69 % Belgium 4,774
46,14 % Japan 4717
Source: 2017 Kaiser Family foundation analysis of Organisation for Economic Co-operation and Development data and 2017 U.s. National health Expenditure Data
I added the percentage to the graphic - how many percent comparged to the U.S. expenditures.
* the only two countries where insurance is left to private for profit insurance companies. Switzerland has high cost of living, they pay good wages overall and have also the reputation of paying medical staff well (even considering the higher wages in general) They have everyone covered, and the system has a very good reputation.
Even expensive Switzerland beats the crap out of the U.S. when it comes to healthcare.
The Swiss have the referendum system and they at least have some degree of control over the private insurers. That said - single payer is the way to go.
It should be noted that it means: all that is spent in the country divided by number of people - now that means that the U.S. includes people that do not even have insurance and do not get healthcare or only insufficient care.
Many wealthy countries of Europe are missing or Australia. But the picture is not that different from the World Bank 2014 data I know - Germany is at the higher end of the average - you can expect almost all wealthy !! nations to be in that range.
It would be interesting where the U.K. is - they deliver most of the care in the country via the NHS which has been massively defunded over the last 10 years.
in 2014 (data World Bank) they had only slightly higher expenditures than Japan.
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@padseven Well, I live in a country where affordable healthcare for everyone IS considered a right. And that makes it possible to deliver it with little hassle and red tape, low admincosts and in a COST-EFFICIENT manner.
The idea of a bankrupcy because of medical bills would be a foreign and exotic idea. people that do not know what is going on in the U.S. could not imagine such a thing.
Btw: the advantage of everyone getting the same coverage (even affluent people MUST pay into the system so of course they make use of the coverage they are getting) ?
The large numbers of users who get standardized services take care of cost-efficiency, the wealthy make sure there is good quality. They will not put up with crap. And it is not like a party that caters to the wealthy and corporations (to the right or center right) can specialize in going after the system. THEIR voters like the system as well as the voters of all other parties.
After WW2 the existing systems were expanded, other nations started them if they did not already have something in place.
The "right" of the profiteers to make profits in healthcare is of little concern. To make profit of a service where consumers neither have the expertise to evaluate the complicated service and the costs (even doctors consult other specialists when they get sick) nor do consumers have the possibilty to "avoid buying when it is too expensive for them".
healthcare is NOT a service like other products. The "free market" does not work when one group is so much weaker than the profiteers. They CAN be exploited so they will be exploited in the effort to maximize profits.
you can either have people dying on the doorsteps of hospitals, or going broke or have the overpriced dysfunctional mess of the U.S. Where the government already has to give insane amounts of subsidies, much more per person than in the cost-efficient single payer countries.
Or have single payer systems where everyone has the RIGHT to full coverage at very low costs and the strong shoulder are required to shoulder more of the burden.
Those U.S. subsidies prop up the profiteers and dysfunction. Not only does it cost double of what it should cost (literally ! 41 - 56 % of per capita spending - U.K. .... Germany, and most WEALTHY nations are in between, USD 5,000 - 5,500 per person) - the U.S. does not even get the good outcomes for the high price !
All the single payer / universal coverage systems avoid having POWERFUL for-profit players. So they cannot exert undue influence and start gaming the systems (doctor practices, pharmacists). The only exception is Big Pharma which is a large powerful for-profit player.
Luckily their products are very standardized and internationally comparable. They may have monopolies on crucial drugs (as long as the patents last), but they want to sell the whole range - so that gives the national public non-profit insurance agencies enough leverage in the price negotiations.
(And I assume the national agencies do exchange information, if only behind closed doors. They have no profit motive - so why not help each other out !)
All single payer nations have profitable insurance companies. And they never got their hands on healthcare - or only on a very limited portion (supplemental).
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It costs LESS per person - the way the funding works is different. (I also know the systems of Germany and Austria from experience). Right now the U.S citizens (and partially also their employers) pay very high premiums into a completely overpriced private system with uncertain coverage (or unexpected costs when treatment is needed).
I have World Bank Data from a few years ago. USD 9,200 per capita in the U.S., Germany 65 % and U.K. 41 % of that.
(most wealthy countries have per capita expenditures of USD 5,000 - 6,000 in that report - Germany USD 5,600, Austria 5,400. Both countries have GOOD services, the private insurance scene is not important (there are historic reasons why they even have them).
Affluent people use the public services as well, especially when it comes to the big stuff. And why would they pay extra ? the Public services are good - they are not the countries with the lowest costs (but population is older on average than in the U.S.) but the services are definitely good. The hassle and also the financial worries of paying for insurance or later for treatment are completely unknown in countries with single payer systems.
Going broke over medical bills would be a weird concept. you would have to explain it to citizens of Europe or Australia or Japan who do not know the U.S. system how that is even possible.
U.K. has even (most of) the doctors practices public, the high public non-profit share of providers may help them with their record setting low expenditures per person. (They have been defunded for 10 years - but with only 50 % of the U.S. expenditures per person the NHS would run like a charm).
Even family doctors are employed with the NHS - in most countries they are small companies and have a contract with the non-profit public insurance company. The revenue pays for the costs of the practice and the few staff members - and the profit is the wage of the doctor so to speak. They make a good living - but in single payer systems the ONLY powerful and large for-profit player is Big Pharma. They have very standardized products, prices - or rather the discounts on list prices - are internationally comparable.
That gives the public non-profit agencies some leverage to get a well negotiated price list for their insured. (the price list is relatively simple to negotiate. The complexity is regarding what patient will get what drugs - and that complex decision that cannot be monitored by regulators is outside the sphere of "profit".
The profit motive is completely irrelevant, the doctors ARE FREE to decide according to medical necessity. So whenever complexity is involved - when not even well intended regulators could protect the consumers from being taken advantage of - the profit motive is taken out of the equation and does not play a role in the system.
Especially if the treatment would be costly (when you need insurance the most) the U.S. for-profit players have a huge incentive to NOT pay (or demand unexpected co-pays or do deny coverage for that treatment and wait if you will sue them).
I read a story that someone was denied cancer treatment (well the payment for it) because they forgot to mention in the application the acne treatments as teenager.
This was not just a mean employee doing overtime to screw an insurance client. That is a SYSTEM: when a person needs costly treatments the insurance company has a lot of employees dedicated to the task to go with a fine comb over the contracts to trick them out of coverage - and for that they need systems, procedures and software ! in place - and departments of office staff (and lawyers !).
Likewise the hospitals and doctors need a lot of staff to handle the very complicted billing. And hospitals have to chase the money for unpaid bills. They are legally not allowed to deny help (although they do that as well) - but often the patients that receive emergeny treatment just can't afford to pay out of pocket, not even with a payment plan. (And the ER does nothing for preventive care or chronic diseases).
It is not only cruel - it is also counterproductive for the whole society (if you want a healthy workforce and people able to take care of themselves, family, in old age ...)
Plus it is costly and inefficient from an administrative point (only for the profiteers it pays off - the bureaucraZy is part of the cost of doing business for them, the just add the costs to the calculation).
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@roguewade6733 A twist on ECONOMY OF SCALE (usually it means large volumes = lower prices. Not quite with healthcare). - One doctor practice does not serve 3 million patients, one hospital does not serve 10 millions (except when one department is extremely specialized, but then they attract international patients).
For GENERAL CARE and easy access you need to have the specialists and GPs and smaller hospitals spread out all over the country. (Driving distance is crucial in emergencies, and it is a quality factor for patients how long they have to drive to get there, with or without public transportation. Or even to visit patients in the hospitals).
A country that has remote areas like Canada, or Norway, Japan (the smaller rural islands) or Australia has disadvantages, either they need to run smaller clinics with less efficiency (in the remote areas) AND / OR they have the costs of more air lifts.
All countries need a system to bring the severe or specialized cases to the cities where the larger hospitals with more equipment are, that is especially true for the unplannable emergencies.
Where I live - Austria - the "country hospitals" provide general care and / or first aid to stablize a patient in an emergency (which may be airlifted later, or stay there, or be airlifted directly to a larger hospital. That decision is made by the doctor that arrives first at the scene. And every mode of tranport is free (ambulance, ambulance with an emergency doctor on board, helicopter transport. Of the patient is in better shape and gets a taxi transport or a refund for using public transportation).
But often these generic hospitals have one department with a plannable procedure, like eye surgery, hip replacements, surgery for varicose veins.
Almost all hospitals are non-profits and many are the fiscal responsibility of the town, city, state (with subsidies, a town of 8,000 cannot afford a hospital, the rates the insurance agency pays are not that high, all hospitals get extra subsidies from all levels of government. But the tax revenue is redistributed from the federal government to ALL states, so the states with less industry do not have a disadvantage).
Those patients with the planned surgeries / treatments are not in a bad shape so a longer tranport does not matter that much (it is a cultural norm that family will bring a patient - but if that is not possible, ambulance tranportation is for free and it is no hassle to get that).
These are not the surgeries that make the headlines, but it makes a difference in the life of patients. And they can be quite expensive (varicose veins surgery used to last long, of course they may have improved on that).
A lot of the treatments and surgical procedures are repetitive and somewhat generic / humble.
Adjusting a person with diabetes correctly is not rocket science, it is quite generic and often needed - but not having that in place will result in high preventable costs (when the inevitable complications manifest), lower life expectancy and much reduced quality of life. Also unnecessary suffering - if those humble basics are neglected.
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"...the idea [of supporters of single payer is] when the government - not competing companies - run the system, government can do a better job ..." - so WaPo staff has not yet realized that there is NO COMPETITION happening in the U.S. - Which is not surprising: a free market can only exist when the all actors in the game have about the same power. That is not at all the case with healthcare, not even close.
Nor is it possible that even well meaning regulators could protect them.
The for profit players will always be ahead 3 steps of patients and regulators.
Most nations figured that out in the late 1940s, it took Canada and Australia a little longer ....
If- IF - the profit motive plays are role when providing goods and services, there must be a free market and customers must have a choice - including the CHOICE NOT TO BUY at all. Else the desire of for-profit companies to make the highest possible profit will inevitably lead to exploitation of the consumers.
What makes free market impossible with healthcare (insurance and delivery of services) ?
The complexity of the system and the service, the impossibility to delay treatmentor to prepare for what you will need in the future (Will you need cancer treatment ? Which one ? hip replacement ? Emergency surgery because of an accident ? Asthma ? Diabetes ? ) - it will be leveraged against the consumers.
With healthcare not buying at all is not an option.
You can do that with most other goods and services. Or work around even if it is inconvenient. Live with family if you cannot afford rent, have a simple phone, no smartphone, delay repairing the car, ride a bike, lend a car from a family member or take the bus. It will not cost your life.
Treatment and administration (billing !) are very complex, it is often about life and death. And to make matters worse those costs can be the highest expenditures a regular person will ever have. Higher than buying a home.
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Hungry Hippo the "multi" payer part is not relevant. I live in Austria and I claim they have single payer. Now the reality is that they have several public non-profit insurance agencies. But they all have the typical traits of single payer: the mandate to participate, the employers or workers do not get to chose what their insurer is, they are assigned to it (either per state, plus certain profession.
And duplicative coverage is outlawed (the private insurers cannot offer coverage if the public agency covers it. So you can go to a private doctor, but you likely have to pay out of pocket).
The overwhelming part of the population is covered by one of the state agencies - and their rates are determined by law (and not much different for railway, civil servants, etc.). If you have more than 500 USD wage epr month you pay 3,8 % of the wage, the yearly cap is 2,400 USD (that means a wage of 60k). The employers must match that. So it does not matter which agency is responsible for you and your family.
There are historic reasons why they had 9 for each state and then also some for certain professions, like farmers, smaller entrepreneurs, railway, .... ).
The agencies cooperate regarding drug price negotiations, likely software development. It does not matter for patients where they go to the doctor. Most will remain in their state (else the agencies handle that among themselves. among states and provinces or even the agencies of other nations. EU citizens will be treated like natives in other countries when they need the services in another country. As tourists or on business trips).
The rates in the capital Vienna for doctor practices are higher than in other states (what the agency pays doctors for their services). (slightly and the other agencies know of those rates).
So for all intents and purposes: it is single payer even though the middleman is more than one administrative entity. The same applies for the other countries (it is different in Germany, but that does not help them with costs. They were on the frontier in 1884 starting an universal system and it has some quirks).
Even the centralized NHS of he U.K. has "sub divisions". The Scottish part fares better because they get additional local funding (oil revenue) while the English part has been hit by 10 years of defunding.
There is something to be said for having adminstrative sub units, and it hardly adds administrative costs (but allows for some bench marking).
Those "multi payer" agencies (single payer really !) are usually in charge of one province or state, that seems to work well in different countries as long as the federal government evens out the funding and as long as they closely COOPERATE.
Part of the funding comes from wage related contributions, and the economic power house states do better than states that are rural and have little industry.
But the cooperation between the public agencies is so close that it amounts to single payer, they certainly do not compete with each other. They share information, they work together, they even help each other out with cross transfer of money.
Vienna got a budget problem a few years ago, the federal gov. did not want to stand in for their minus, so the other agencies - if they had good surplus were asked to chime in. Now they are self-governed entities (for instance the goverment cannot determine or fire their directors) - but the wage related contributions are affordable to be acceptable for the voters - so a lot of money comes from general tax revenue.
So the "rich" agencies (in states with a lot of industry) have to play nice with the government too ;) - The agency of Vienna paid higher rates for doctors with their own practice, to a degree that can be justified (higher costs for a practice compared to rural areas or smaller cities) - but they were told by the other agencies that they had to overhaul their rates and clean up their act.
So some benchmarking going on.
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Switzerland after WW2 continued to use private for-profit insurance companies. (unlike almost all other nations, most went the single payer route). They pay much more today, the typical rich single payer nation spend 5,000 - 5,500 USD per person per year. Switzerland 8,000, the U.S. 10,240
OECD 2017 data.
At least the Swiss system is excellent, everyone has coverage (low income people get subsidies from the Kantons) and they pay medical staff well..
And then there is the U.S. with USD 10,240. And not even everybody covered. Hassle, bankrupcies, 40,000 additional deaths - and worse outcomes than most rich nations.
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