Comments by "Xyz Same" (@xyzsame4081) on "Pramila Jayapal's Strong Argument Against The Public Option" video.

Public option is plan B of the insurers now - and their propaganda works, with the candidates AND the voters. For the underinformed audience it sounds plausible that MfA with "choice" is even better. The folks with the allegedly good company /union plans can let the others test the water and jump in later. That plan can be taken away, the company can fire you, change the plan at a whim, can go bankrupt. They are not that good either, still deductibles, still attempting to deny paying for treatments. And of course even companies like GM or Boeing pay way too much for these plans. The money could go to staff either as higher wages or other benefits, not to the for-profit insurers. Wendell Potter was the senior PR man for Cigna, then he turned whistle blower. One case was the straw that broke the camel's back in late 2007. A teenager had coverage under a Mercedes family plan (the car manufacturer). The plan covered transplants, she needed a liver transplant, they had found a good match, doctors ready to go ahead. The insurer refused to pay. Public pressure got them to revise that a few days later (it was 450,000 for the surgery alone - plus the medication later). Meanwhile the organs of Nataline had started to shut down, she became unfit for the surgery, and died a few hours after Cigna gave the green light (the doctors had declined 2 livers that would have been a good match in that time). That family had a "Cadillac" plan. The insurance companies know change is inevitable, with Public option their market share will be reduced but they get to keep the most lucrative segment. It is ideal for Divide and Conquer. they CAN make seemingly good offers to the young and healthy. 90 % of costs are caused by 10 % of the insured. They already have the Art of the Purge perfectioned. so the young and healthy will get better offers than now - so they are lost as allies for the epic battle. Since Medicare would be stuck with the high cost patients some defunding and maybe some complicated rules forced on Medicare would go a long way to undermine Medicare. And then badmouth it and defund it some more. The Republicans relentlessy go after SS and badmouth that too - the only reason it still exists is because it is UNIVERSAL, and not means tested either. I think under GWB the agencies were forbidden to negotiate drug prices (only VA can - they brought prices down by 40 %) - that provision is still in the books.
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Netherlands to a degree. and the U.K. - may they be voted out in December !
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It is possible to set up a single payer system in one province - the pools do not have to be that large * as long as there is no cherry picking. Mixing for profit insurers with the public offer is much more problematic. * per ten or hundred thousand residents a certain number of doctors and hospitals is needed. that can be scaled up and down. Same for training of medical staff. I guess the doctors did not have time to consider if they wanted to migrate to other provinces where they could get better rates. The other provinces follwed suite. Or maybe income was less important for doctors then. Most medical issues are generic - the conjoined twins are rare - and if patients with rare conditions need special treatments outside the country / system / province it does not make a dent. It is more cost efficient to buy the special treatments from the outside if the system is not large enough to warrant the special units. so the system needs hospitals for general care (broken bones, giving birth, heart attacks, diabetes,... ) They have to get medical equipment from outside the province or country (more or less a free market) and they need the medical drugs (standardized internationally comparable products, so even small players can compare prices and get good offers). Iceland has 360,000 people they blow the U.S. out of the water with spending and life expectancy, and you bet they also pay much less for drugs. If big pharma wanted to take advantage of them the Icelanders can have a friendly chat with the agencies in the other Nordic countries (or a large player like U.K. France, ...) For profit insurers have an interest to guard their information advantage if they think they negotiated well, but that does not apply to national non-profit public agencies ...... Just checked out their costs: the median age is 36,5 so that is relatively young for Europe, may be even younger than the U.S. , they are the 9th most expensive country in the world, their spending per person is very reasonable for that (wages matter) with USD 5,000 in 2016. And of course their life expectancy is higher 82,4 verus 78,7 years for the U.S. most wealthy countries in Europe are in the range of spending of USD 5,000 - 5,600 per person per year (in 2016 - 2017) Their age advantage likely compensates for the higher wages they have to pay (higher costs of living). And they have one medical school (in Reykjavik with approx. 43 graduates per year). Even smaller pools can well controll their costs. Shows also with the large versus other small countries in Europe
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Wendell Potter (fmr senior executive of Cigna turned whistle blower) in an interview in 2019: they now purge companies. When they do not think the company is profitable enough or they make a loss they drive up the premiums or they increase dedductibles or the family members are not included anymore. If they want to get rid of a company they will achieve that. And in a comment to that video (it was Chris Hedges in On Contact or on The Real News) a person wrote: yes, or the company figures that out in time and fires the staff member when they (or a family member) gets sick and would need costly treatments. That way the company contract is not spoilt for everyone. For the same reason companies that do offer plans are hesistant to emloy poeple with preexisting conditions or when they are older. (Walmart does not care, they weasel out of offering aplan by using 28 hour contracts only to the lower charges). Insurers do not play that game with GM of Boeing of course - but with small to medium sized companies they can do that.
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they have to accept the application under ACA. But then they can drive the insured person crazy with refusals to pay (when it is covered) with steeply rising premiums and deductibles every year - until the insured hopefully quit. Check out Wendell Potter fmr. senior executive turned whistle blower - I paraphrase: "Now they purge companies, they drive up the premiums if they want to get rid of a company or they worsen the condition for everyone". That can also result in employees being fired if they (of a family member if family is included in the plan) cause high spending. That way the employer avoids that the premiums go up for the whole company. That is also a reason to not employ people over 50 (if the company offers a plan). The insurers do not play that game with GM or Boeing of course - but there are many samller or medium sized companies.
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90 % of costs are caused by 10 % of the insured. The U.S. insurers excell in the Art of the Purge.
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The mandate is the necessary condition for a cost-efficient and good system for everyone. - that is how the countries do it (for the most part) that have half the spending of the U.S. - wealthy countries with better outcomes too. - the mandate must be affordable (for staff and employer) in order to avoid resistance and the rest of the funding comes from general tax revenue. (which is a recruiting advantage for start ups that are not yet profitable). The mandate also constitutes a right - to full coverage. I do not think people will resist the mandate with that framing.
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All insurers are administrative middle men - not more and not less, they do not provide CARE but if sufficiently funded they can pay the rates so the insured can get good care. If the private insurers have a space in the market the public coverage is not comprehensive and not sufficiently funded - can be a developing country that cannot afford it or a government is doing favors for insurance industry, doctors and rich unwilling tax payers. In medicine there is no "nice to have" as with consumer goods. It is either necessary and gives the chance to better outcomes - or not. Even a person with a gold plated plan would not want unnecessary treatments. Public non-profit agencies are middle men, too. (The NHS takes it to the next level of efficiency, they are insurer and provider combined - it shows in the spending of the U.K. - most of it is done via the NHS. That top efficiency is likely the reason the NHS is still hanging on despite being defunded over 10 years - and the Tories started that from a lean but sufficient budget. (42 % of the U.S. spending, most wealthy nations have 50 - 54 %). Public non-profit insurance agencies work quietly in the background, but would be responsive to public opinion - it helps that the whole country is required to pay into it and all but the really rich use the system - that gives a lot of leverage to the insured. Such agencies have little overhead (2 to max 5 % internationally), no profit incentive, are expected to stay within the budget, but can ask for better funding - they just have to take it to the court of public opinion and make their case. Required to serve the insured and the common good. If the founders were reasonable they are a self-governed public agency - so separate from the sitting government and relatively independent. Insurance companies answer to the shareholders and their management, the most important goal is to make a profit. ACA was supposed to limit the overhead of U.S. insurance companies to 20 %. Give the public non-profit a sufficient but not extravagant budget and they will beat the heck out of any insurance company (all other conditions being equal). That applies everywhere but especially in the U.S. The single payer agency is dominant on the market they can well negotiate with big pharma, they can counteract the power of hospitals and doctors (which are much more important than the glorified for-profit paper shufflers). In the U.S. the number of graduates from Medical School is kept down, the more important to have one powerful negotiating partner on the other side. I heard the phrase "insurers in a bidding contest for the limited resource doctors". But in other countries private insurers also pay higher rates for doctors and hospitals. That is an extra cost of private insurance. the admin is streamlined. collecting contributions, negotiating contracts, paying bills. Software, prevention - but essentially that is it. For profits have marketing, sales, profit, processing the applications and healthcare questions. In the U.S. departments with doctors, lawyers, beancounters - it is a lot of work to deny paying for treatments. Call centers, someone has to be on the other end of the line when doctors, nurses patients fight about what will be paid for. It is usual that pre-approval is required for everything. Single payer agencies don't ask for that, they would not even have the staff to cope with that. They set a framework with the contract (what is on principle available for every patient - and what are the rates) and then the doctors decide together with the patients what is necessary.
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Healthcare is a terrible fit for the "free market" - but it is very standardized. It is a service that is needed by all income and age groups and gets a lot of attention. People are stressed out when they need it, so they will pay attention if the admin and delivery of care functions well and if they felt treated well. If not and the flaws are systemic the citizens will straighten the system out (and the affluent will lead the charge, they are a valuable ally when it comes to quality of the services - another reason to net let them opt out). When funding is sufficient, only inept management can be the reason for insufficient quality. For management there are blueprints in healthcare, that can be solved - and it has been solved. The uniformity of the service (as much as it needed and not more, humans have the same medical needs and body), the standardization in medicine and admin around medicine - all that means that public agencies can to a good job. Creativity is not necessary, nor are marketing or entrepreneurial skills needed - on the contrary, it would be counterproductive or even create toxic incentives. It is a clockwork. The profit incentive does nothing to provide better healthcare or lower costs. it is even a factor that leads to higher costs, dysfunction, and predatory behavior (or mild gaming of the system if regulations work to a degree - think Switzerland, Australia, Netherlands or Germany). Since for-profit adds nothing (except toxic incentives especially in the U.S. ) the countries that make private for-profit healthcare insurers obsolete fare best. The way to do that: enough funding and comprehensive coverage with the mandate for everyone. And no duplicative coverage allowed. No one pays double - the private insurers can only offer what the public agency does not cover (better room, expensive dental, accupuncture, travel insurance ...) Doctors can of course refuse to have the Medicare contract. (Hospitals realistically not: they would not have enough patients to stay open). If the services are essential medicine and would be covered by Medicare - then the patients cannot settle that with any other insurance. It is out of pocket only. Which is a deterrent for patients and the doctors For any person that cannot cope with costs of 1 million USD the insurer is the de facto gate keeper for getting healthcare. Rich people can of course always pay out of pocket. There is no reason to let the private insurers have that powerful role that enables them to extract profit (an incentive that does not bring better results for healthcare) - while the insured have no choice: they cannot abstain from having healthcare / treatments. They do not have the most important choice: to not buy at all.
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No paying double, the Sanders plan forbids duplicative coverage (and it is regulated like this in other single payer countries).
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people are forced to buy these upgrades. That is a sign that the coverage is not comprehensive and the funding is not sufficient - else Medicare could pay for all that is medically necessary. ALL insurers are adminstrative middle man. Medicare does what is necessary (collect contributions, negotiating, paying the bills) at modest costs - the private insurers are predators and have high costs. Medicare has less than 3 % overhead and negotiates better rates (they are not allowed to negotiate drug prices - but the private insurers have no interest in that either). The private insurers are supposed to remain below 20 % overhead (ACA) - well they found ways around that. So people need to buy upgrades which is bad enough. Who is the administrative middle, the gate keeper for the upgrades ? for some reason THAT was given to for-profit insurers (the expensive adminstrators) The right wingers doing favors for the profiteers. And of course the defunding of Medicare makes it necessary to reduce coverage.
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@Yaw F Even the public option would have been better than ACA. At least people would have care. I also think the industry got more skillful / predatory in the last 10 years). Now it is ACA that needs to be replaced by Medicare for All (Single payer). - Else it would be the public option being replaced by MfA. One course correction is O.K. - but TWO ?? (ACA / Public Option / MfA)
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Medicare is just being defunded. Since they have the most costly group a little defunding can go a long way to really cause them trouble. - your argument would have merit if the Republicans and Democrats would not be completely bought. The industry will become obsolete, and healthcare is a large pie. The insurers likely do not even "want" the group of 50 - 65 that much - BUT if that is the first step to them becoming obsolete (and no one will miss them) then they will fight like hell. And those who like the donations and the jobs for ex politicans will help them. That is why it is important to steamroll them right away.
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it will be Medicare (improved Warren said) but for all over 50 not 65. For the rest it will be with the opt out - if the insurance agency wants them and gives them a good offer. in the group 0 - 50 therea re also the most lucrative clients. young and healthy.
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What you describe IS the public option. Public option is now plan B for the profiteers. - The young and healthy get offers that seem to be reasonably priced the costly patients land with Medicare. 90 % of costs are caused by 10 % of the insured, they just need to do the purges right, and they are really good with that already. Divide and conquer - it undermines the solidarity and thus the political leverage that is typical for an important ! UNIVERSAL system. Even IF the private insurers would be honest: an opportunity to save costs with a streamlined admin and billing process is squandered, there will be ONE MfA coverage - and countless other packages from the private insurers. So the hospitals and doctors still have the adminstrative costs, the phone calls, the pre-approval. And not only during the transition time (as long as some are still with private insurance, the rollout of the Sanders plan is over 4 years). That inefficiency stays. In the younger age groups luckily most do not have higher risks or are already in need of costly treatments. Those few will land with Medicare, but chances are good they will cost the agency dearly (10 : 90 ratio ! see above). Politically it means that the majority among younger people will think they finally got reasonable offers. you bet media would be eager to muddy the water. So they will not fight when their support is needed for the better plan that is so successful for many other nations. The unfortunate souls among the younger are not enough to make a dent politically. Of course the patients that NEED Medicare because the private insurers will avoid covering them like the plague will be hit by the defunding - and you bet there would be cuts to the funding. Much harder to pull that off if the cuts damage coverage and services for everyone. There is a reason no wealthy nation has the public option (maybe a developing country has - would result in a 2 class system of course). It will be easy to defund Medicare - since they have so disproportiate costs it is easy to badmouth them and a little defunding goes a long way to get them into trouble. And like I said, the majority of the younger population will not pay attention if they get theirs. It takes only a few years to derail the project in the transition phase. It is harder to ruin a well established system like the NHS (the Tories: Hold my beer), but the transition phase will be difficult even without making it easy for Republicans (and some Democrats) and the predators from the industry to sabotage the reform
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I am sure it was a rightwing government. The 3,5 tax is not enough anyway, the affordable wage related contriubtion must be propped up with government funding coming from general tax revenue. 1 % less tax contribution is not much if you are low income - it was the gateway to relief the rich and profitable biz from their contribution via general tax revenue. Plus when the public agency is underfunded they have to cut coverage or the rates - or ask for co-pays. That CREATES a need to have private insurance for supplemental. Which is a blast for the insurance companies (think donors). The doctors get better rates (think constituents). The private insurers have no interest in te big stuff (surgery, expensive medication). They like to cover the harmless stuff, like dental, specialists, single room in hospital ..... harmless compared to dramatic interventions that can cost hundreds of thousands of dollar.
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It is the opt out for the few in Germany. Most people are not even allowed the choice between public coverage and private insurance: income minimum around 90,000 Euro per year OR certain professions only. Essentially folks with high income, or those who can be sure to have a steady and increasing income - civil servants, teachers - professions that usually do not lose their job. Self-employed architects, lawyers and entrepreneurs. That also protects the private insurers (which can be non-profits or for profit) from having to chase after the money. If the privately insured do not pay on time they might lose coverage and then they might land in the hospital with no coverage at all. since it is tax decuctible it makes sense for people with higher incomes - The admin stays complex with the many different packages. There are healthcare questions so someone has to process that and the private insurers can exclude risks (pre existing conditiions) I just checked that out - yes the private insurers still can CHERRY PICK. they can aks for additonal premiums for higher risks (the higher prices makes it more likely that a person will chose to have the public coverage). if the additional premium cannot cover the additional risk they can exclude that risk and if the preexisting condition is severe they can deny coverage. - in other words those who are in bad shape in young(er) years and likely to cause high costs are sure to land with the public pool. The exclusion of a more harmless condition will likely not deter to have private insurance but when it is about a big risk .... someone has to check what is covered when the patient gets treated, the billing needs more attention and the insurers must check before they pay the bill. The private packages provide an incentive to milk the good policies. In areas like Berlin it seems to be difficult to get appointments, especially for specialists when a person has only public coverage. There are more people with full private insurance or supplemental. High incomes or civil servants in the capital. The doctors get higher rates from private insurers, so they prefer to make do without the publicly insured if they can - and in certain areas they can. Sad day for low income people, or if they do not have a generous employer that contributes to supplemental insurance. Private insurers pay higher rates and have costs like marketing and maybe sales staff plus profit (if they are for-profit, I think in Germany there are still non-profits. But they cannot compete with the negotiating power of a public non-profit agency. Plus they add costs for the providers (hospitals, doctor practices) with the more compex billing. Germany has relatively high spending per person - to be sure with a high age of the population - second only to Japan *, but neighbour Austria is doing better and the age is not much different (spending per person USD 5,700 versus 5,500 in 2017 - in that range). Japan does really well, they are in the range of 4,800 USD per person, while having the oldest population. Must be the seafood and lifestyle.
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They take ONLY the lucrative clients - and offer packages that seem to be reasoably priced - 10 % of insured cause 90 % of spending. They just have to get the purges right (and they already know how to do that, they purge individuals and companies now. Driving up premiums or deductibles If you factor in the cherry picking and the 10 : 90 rule the plans for the young and healthy are still way too expensive. But it is not obvious for the public because the spending differs so much between age and risk groups. (I read an article: on average spending of plus USD 15,000 per person per year when over 60 and around 2,000 per year in the age group 20 - 25. - In that range - to give you an idea. On average the U.S. spending per person (all age groups) is 10,260. (2017). so the young and healthy will not be taken care of in a cost efficient manner. (but it undermines solidarity among the insured and the political leverage). a chance to cut costs is squandered: As long as there are so many insurance plans there are a lot of admin costs - not only for the private insurers but also on the side of the hospitals and doctors. pre-approval, checking if and to what extent the insurance will pay. Then fighting with them. then the complicated billing, the software necessary to match the insanity (I read a comment of a coder !) - bills will not always be paid if the insurance pays only a part or noting, so they lose money. MfA - wage deduction (so Medicare gets the money from the employer), treatment free at the point of delivery, the hospital can be sure to get paid and the billing is simple. It is also clear what is covered and what not (no calls to Medicare, no pre-approval).
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with healthcare it is: medically necessary (with some room to err on the side of caution) - Or not necessary = does not offer the chance for better outcomes. What is the basic versus the luxury version of a gall bladder surgery ? or of a life saving heart surgery ? If we accept that no one should be excluded from getting necessary care and that no one should receive treatments or tests only because the insurance can be deceived to pay for it - then there is only ONE kind of coverage, and it is ethical and reasonable. And cost-efficient. the "luxury" aspect would be the single room, better food, some treatments like accupuncture, ... which becomes trivial for the big stuff, then when the big costs manifest and when you need the coverage th most. (Intensive care station: you are on the drip, and they have several beds in one room. you can only enjoy those luxuries (single room, food) when you have a relatively harmless procedure. the system should have competent doctors with acceptable waiting times. with sufficient funding that is not an isssue. Buying yourself shorter waiting times should not be made possible with insurance. That motivates the affluent to help with their taxes so that everbody can have short waiting times. If people want the doctor that accepts only private clients - they have to pay out of pocket.
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No it would not just be the sick in the public plan, but the very sick and the high risks that make all the difference regarding spending would be in the public pool. (again 10 : 90 rule).
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the bills (even that of Booker / Harris) have budgets for the retraining. It will not come right away. The unnecessary work for billing or the people in the call centers will become less and less necessary, they are not all jobless on day one. Also: Federal Jobs guarantee !
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It was either Pelosi OR 2 guys to the right of Pelosi. Or Democrats split and the Republicans presenting their choice - which could have won, it do not put it beyond some blue dogs to vote for a Republican speaker to spite the progressive wing. - AOC voted for Pelosi as well. Now if some of the big names of the Black Caucus would have run for speaker ..... you need to have some clout and standing in the party and experience to be the speaker. The party establishment would of course have hated it if John Lewis had run for that position. I cannot see how they could smear him though. Neither AOC nor Jaypal were in a position to run themselves for speaker. So they had to make do with Pelosi. Funny enough: Trump said then he found it unfair that she was being criticized as speaker. She just has to ask I will get her the Republican votes. (Of course that was on THAT day in THAT hour - and I do not think he had consulted the Republican members of Congress on that).
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That is a very good example !
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JC4PM - don't mess that up U.K.
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Meanwhile she too gave in to the lobbyists - another public option.
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yes but at least they also get the unproblematic healthy 50 year olds as well. Plus: many people have untreated diabetes. That is a recipe for disaster - human suffering and costs later. So from a preventive point covering the group plus 55 helps. The under 18 year olds does not cause a lot of spending. There is also not difference between the affluent and the low-income poeple. It is good to have the affluent on board, they are vocal and a good ally to have. I do not think they have a buy-in. I think the 4 years are meant to not overwhelm the system and to sort out flaws. The AMA has kept the number of graduates down, so it remains to be seen if there are enough doctors. The age group of 50 needs more treatments - so the doctors cannot afford to ignore that group. They have an incentive to accept the Medicare contract.
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Tulsis plan is nonsense, she either did not do her homework or she too fell for the lobbyists. - if a single payer agency gets sufficient funding there is no need to have supplemental insurance. - Does she not plan to fund it as is necessary ??? They will be able to pay the rates and cover ALL that is medically necessary - if they got the money. Which will be of course less in the long run than now. After all the U.S. spends twice as much as it should cost. The odd expensive dental care or accupuncture session can be paid out of pocket that is cheaper than having supplemental insurance. Insurance for supplemental never covers the big stuff in hospitals, they are not interested in that. The single room in the hospital, the specialists, if the coverage is not comprehensive, often expensive dental care. Specialists are in many countries the group that tends to work less with the public agency (accepting their rates and the patients under that coverage). - if they manage to not have too many graduates they can profit from the scarcity. Of course the system can counteract that by offering services in public centers provided they find enough doctors to hire them. When the doctors that prefer to have "private only" practice get some competition they might need the patients and will acccept the public contract. So if in a country people need supplemental care or have to pay out of pocket, the public coverage is not comprehenisve (basic dental and eyecare etc. is also medicine and necessary, even if it is more planable and often less urgent). The budgets are not enough = the rich do not want to pay the taxes necessary for FULL funding. The mandatory wage related contributions must be affordable for staff and companies, so there must be extra funding. Plus governments doing favors for insurance companies and a part of doctors who get better rates with that set-up - because they can make do w/o the public contract. In short either developing / emerging countries that cannot afford the necessary funding or right governments doing favors and protect big biz and affluent citizens from paying taxes. Most systems were implemented or overhauled after WW2 - the economy often was just recovering - so for instance in the UK basic dental was excluded from coverage. Not ideal but understandable in the historic context. Dental, even basic is more expensive of course. And the dentists that have an advantage compared to their peers in other countries (where many must provide basic care at agency rates to have enough patients) would riot if that would be changed now.
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@vn0688 Let me help you out with some arguments - btw I live in a counry with a well functioning single payer system - not that I knew that term before I got sucked into the debate. One characteristic is that people take it for granted and do not think about it. So there is a lot of implicit knowledge how a good, cost efficient system must be set-up.
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@vn0688 Sanders makes a massive mistake by not attacking the public option (thus making it clear who is a copycat * and who is the original and has the most knowledge and backbone regarding healthcare). The public option has the potential to set up the reform for failure. That is why it is the (secret) plan B of the for-profit insurers now. * all the other Medicare for XX Maybe plans that the other candidates parade around - they all take a piggy ride on the brand Medicare For All (which is a specific bill after all). The lobbyists of the industry have been busy and successful, Warren was the last to adopt some variety of public option. "Giving choice" (= the choice to opt out = public coverage via Medicare as one way to have insurance, the other is full coverage by some insurance company) is easy to sell as just this little seemingly innocent tweak. Pete Buttigieg did one "better" he "trusts the voters and does not "force" them. (Only Donald Trump gets more money from the healthcare industry). If interested in the detailled arguments see the following comments.
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@vn0688 Single payer if set up well (Sanders plan Medicare For All) will lead to massive cost reductions. Not right away but over time (resp. the services will be improved, the backlog will be dealt with. All will be covered and the rising costs for an ageing population will be contained). Set up well = the public mandate = mandatory payroll taxes that give full coverage, no payments for patients later. No hassle for the companies, they pay the percentage and are done. It is also a recruiting advantage for start ups and smaller or not very profitable companies. Small companies have no leverage when negotiating with private insurers, but even GM or Boeing pay too much for the plans (and they all have now core staff and then different "tiers" of contractors. The last strike at GM was about giving the contractors better conditions). I currently live in a country with such a well set up single payer system (Austria) - and Sanders seems to be the only one who "gets" the necessary and indispensable conditions for such a cost-efficient system (in Austria 54 % of U.S. spending per person, most wealthy nations are in the range from 50 - 54 %). The payroll tax is mandatory, no "opting out" must of course be affordable for employees and companies. That is not enough funding for the non-profit public insurance agency (Medicare is an example for such an agency), the rest comes from general tax revenue. Which means that companies that do not (yet) make a lot of profit have an advantage. Their staff will have the same coverage as employees of a highly profitable multinational. No opting out ! from the payroll tax - that would be the public option. It means that some choose * to have full coverage by private insurance and others have full Medicare coverage (or the single payer agency that they are assigned to in their country). * In reality the insurance companies make that choice in the way they make the offers, the patients they do not want get a prohibitively high offer. btw no nation does public option on a large scale - neighbour country Germany has the "public option with the opt-out of the privilged". They allow the "choice" for affluent citizens (and certain professions that can be expected to have a good, safe and rising income, for instance self employed archtects, lawyers, ....) to have full coverage by private insurers. That results in cherrypicking of course. And some (minor) distortions and inefficiencies. That is more a historic relic (when the system was founded in 1884 a two-class society was taken for granted, after WW2 right governments doing favors for private insurance companies, doctors and affluent citizens. Private insurers playing more of a role in the system does not make the system better, more cost-efficient or fairer. In Germany only 10 % of the population have full private coverage - so they enjoy the benchmark and the protection of the 90 % (what must be covered, inflation rate in medical services). When the population takes good healthcare for granted the private insurers cannot play games with the privately insured when it comes to coverage (never mind many lawyers are among the privately insured).
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@vn0688 Public option means also the possibility to opt out - it allows the private insurance companies to cherrypick. Sure the "market" for the private insurers would be smaller - but they get to keep all the LUCRATIVE clients (young and healthy). A point that is often overlooked: public option / opting out undermines solidarity among the population. That means less political leverage for sufficient funding. and less corrective forces if the agency does not put the budgets to good use. Nothing like having the affluent citizens use the same system as the low(er) income people to make sure the system is cost-efficient AND good quality. With the Sanders plan a person can go to a doctor that does not have a contract with Medicare and pay out of pocket (but no insurance coverage, duplicative coverage is outlawed). If almost all providers (doctors, hospitals) accept the public contract and services are good (and that is a question of reasonable funding) patients will almost always use the services free at the point of delivery. The mandate (another very important pillar of the reform) makes them pay in form of payroll taxes, the very wealthy additionally contribute with general (wealth or higher income) taxes - they can as well use what they pay for. The rich will have their out of pocket private doctors of course - but in well run single payer systems the affluent and regular citizens meet in the ER or use the same hospitals where they get the same treatments (whatever the doctor thinks is best - in a single payer system the doctors have choice in the interest of their patients). The public non-profit insurance agency can keep it simple (no marketing, sales staff, profits - which even ethically acting for-profit insurers have). The agency has the task to collect the contributions, negotiate rates and pay the bills, plus thinking about preventive care, software solutions - all public non-profit agencies on the planet have figured that out - the private insurers simply cannot compete.
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@vn0688 If for-profit insurers play more than a very limited a role in a country it is because governments were doing them favors (always with higher costs). That is true for full coverage or supplemental. If there is a "need" for ANY private insurance the public system is not properly funded. (Also true for the Medicare upgrades). - Could be a developing country with minimal basic coverage and the affluent buy the upgrades. (Thailand has a universal system, but I assume there are differences and not all patients are "created equal"). If a service / treatment / drug is covered by Medicare For All the private insurers are not allowed to offer coverage for it (under the Sanders proposal). Private insurance is not outlawed - it is made obsolete. With a coverage that is good and comprehensive.. No duplicative coverage. So only out of pocket paymments for doctors that do not have a contract with the agency (which is a deterrent for patients and also for doctors - they have to chase payments or always ask for upfront payment).
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@vn0688 Almost all other candidates that are still in the debates have a fake Medicare for xx proposal that is a variety of public option. That is no coincidence: it is plan B of the insurers now. They know some change will come, and that is their best bet to keep a significant and the MOST LUCRATIVE share of the "market". The public option (that allows some to opt out) offers them the best chances to undermine any meaningful reform. (and it is easy to deceive the public, giving more "choice" seems innocent, a little tweak of Medicare for all). 90 % of spending in healthcare is caused by 10 % of the insured. The insurance companies in other countries have healthcare more as a fringe issue (supplemental for the most part, especially if for some historic reason things like basic dental are not covered. Typically the private insurance covers the services of specialists, the insurance companies are not interested in the expensive stuff like surgery in hospitals). These insurance companies do not have the hordes of beancounters. It would not warrant the costs. Also: if they are fringe players the chance to maintain ! regulation is much better. Not so in the U.S.: the for-profit insurance companies are predators, they have the Art Of The Purge perfectioned. And the lobbyists and professional gaslighers are already at work ! (Warren was the last to backtrack from genuine single payer with her weird plan for the rollout. ) With a public option the young and healthy would get offers that seem to be reasonably priced (but are anything but - considering the cherrypicked pool). All the patients with higher risks or costs will land with Medicare. Which is stuck with much higher spending. Currently the Medicare agency already has the most costly group over 65 years, so the private insurers in the U.S. already have a cherrypicked pool. Likewise Medicare is not allowed to negotiate drug prices - but private insurers could (they have no interest though). They had the opportunity to shine with the advantage that was handed to them - and look hat they made of it. Less efficient use of the funding by for profit insurers is systemic (even if they are honest). They always need higher budgets and on top there are incentives to game the system and they bring higher complexity into the admin - also for hospitals and doctors. As for wrong incentives because of profit: The range is from some tolerable distortions (Germany, ….) to considerably higher costs but at least good services (Switzerland) to predatory and ruthless behavior in the U.S. If the opt out is possible the for-profit INSURERS WILL CHERRYPICK and the public agency has to deal with the most costly partients. It will be easy to badmouth it and to defund it (even though Medicare puts the budgets to much better use, less than 3 % overhead versus 20 %, much simpler admin and better negotiated rates).
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@vn0688 ALL healthcare insurers (non-profit agencies or for-profit companies) are ADMINSTRATIVE MIDDLEMEN (no need to glorify private insurance). They do not deliver the services. If given enough budgets they can pay to get the insured good treatments - and the non-profits will ALWAYS pull it off with the lower costs. For that service (healthcare) the public non-profits without exception beat the heck out of the private for-profit actors - everywhere on the globe. The single payer agency has almost an monopoly and allows for a very streamlined admin and clarity (as opposed to countless insurance packages, no clarity for the doctors who has what coverage and with or without co-payments). It covers ALL that is necessary from a medical point of view, so no deductibles, ideally basic dental is covered as well, etc. Monopolies screw consumers if they are for profit, but as a non-profit they act for the benefit of the insured (which are the much weaker market participants in healthcare). That may seem "unfair" to doctors who more or less have to accept the contract even if they would prefer to work with private insurers which pay them higher rates. - but the patients also do not have a choice - so there goes the "fairness" argument With consumer products the citizens have the most important of all choices: to not buy at all - they do not have that power with healthcare. U.S. doctors (at least a part of them especially specialists) have a higher income than doctors in most other wealthy nations. Sure first they have to pay back the high costs of medical school. - which is free in most other nations. But even so - over lifetime they make much more money. (Of course U.S. doctors with their own practice have to finance the staff for the insane red tape and billing, and spend 3 weeks per year on the phone with insurance companies). On the other hand the doctors in other weatlhy countries are still doing fine. They deal with much less red tape and they hardly ever have to contact the agency to get clearance for a procedure - that is very rare. It will be a political / societal decision if U.S. doctors (at least some of them, typically specialists with their own practice) continue to get those higher incomes (financed with the revenue they get from Medicare). In that case Medicare will need higher budgets so they can pay the higher rates. And the spending per person will not get to the level of other wealthy nations - but at least it will not be as ridiculously overpriced as now. The American Medical Association has of course made sure that only a restricted number of doctors graduate and there are many hurdles to accept the certification of doctors from other countries. So they kept the "prices" high and competition down. (AMA was also fiercly opposed to Medicare in the 1960s, they almost prevented it) The almost monopoly of a non-profit public healthcare insurance ageny means: very streamlined admin, simple billing because there is only ONE insurer and one kind of coverage ("Single Payer"). They always achieve lower rates for doctors and hospitals compared to the many private insurers. But the doctors and hospitals save on administrative staff as well. Which is one of the downsides of public option: Medicare remains one of the many insurers and there are countless plans. Even if the U.S. insurance companies would not be predators - public option squanders the cost savings potential of a very streamlined admin. Most of the doctors (if they are not capacities in their field or offer a speciality like accupuncture) must accept the contract of a single payer agency (= a public non-profit insurance agency) Else they would not have enough patients. No duplicative coverage: if Medicare covers something then the private insurers are not allowed to offer insurance for it. That restricts the private insurers to the fringes where they belong (for healthcare !)
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@vn0688 Healthcare is unusual - the mechanisms of "free market" do not apply. At. All ! (same with natural monopolies btw). - Single payer nations removed the profit motive from situations that are complex and where the patients have a massive information disadvantage, even doctors consult other specialists if they need treatment. Complexity always helps the for profit players to sneak in profits, to take advantage of the customers, and to game the system - at least a little bit. And it even allows for predatory behavior: Regulators cannot help to contain that, they would have to monitor EVERY medical situation resp. decisicion, which would be very costly and intrusive. If the doctors have no pressure (to withhold treatments or to apply without necessity) and the system is set up with proper funding they will do the right thing to the best of their professional knowledge. So doctors will tend the broken bone with the adequate care which might be simple if it is an uncomplicated break - and are free to ramp it up if there are complications. (And they never ask the public insurer for permission, the agency only sets the framework for the doctors to make the decisions and have the necessary tools). One of the most important reasons why healthcare is a terrible fit for the free market: In a free market all participants must have about the same power. - "Choice" is meaningless, the consumers cannot _choose to NOT have healthcare, _and the complexity is such that even doctors consult other experts if they need treatment. The consumers have a massive information disadvantage. Medicine is complex and billing and contracts can be MADE complex to put consumers at a disadvantage. With healthcare all humans have the same needs, and healthcare (the admin incl. "insurance" and the delivery of medical services) is very standardized. Product differentiation (be it in the insurance part which is ONLY admin ! or the delivery) does not make sense. With healthcare the profit motive does nothing to make better healthcare available for the patients - and therefore it makes no sense to make for-profit insurers the gatekeepers. Rich people can always pay out of pocket, but for the overwhelming majority the insurer (non-profit, or for-profit) will be the gatekeeper to getting medical services. Likewise non-profit hospitals will always beat for-profit hospitals. Certainly in 99,9 % of the cases regarding general care. There may be very ! rare exceptions, but I think many of the prestigious clinics (some of them in the U.S.) that are on the forefront of ground breaking surgery, cancer treatments, research, are private non-profits anyway. When it is basic research there is a very good chance they get public funding. For services that are a good fit for the free market (so not healthcare ! or natural monopolies) it makes sense to have very differentiated products. And profit is the reward for entrepreneurs to cater to those NICHES. There is the need for marketing and a sales staff etc. - but for THOSE products it is necessary so that the consumers "find" the product. These costs are necessary expenditures for the variety of offers. . Consumers have different needs, preferences and we accept that not all can afford the same. What would be the basic version of a life saving surgery versus a gold-plated one ? What is the basic version of adequate care for a uncomplicated broken bone versus a luxury version ? Even a rich person would not want to have unnecessary X-rays and surgery (never mind what their insurer could be deceived to pay based on their platinum plan). On the other hand there could be cases where a seemingly harmless break needs more medical intervention than usual. The incentive to sell more (typical for not necessary consumer products) would be toxic in healthcare. Marketing is not necessary. If people need surgery you do not have to convince them that they want it. Profit does not help to make healthcare better, the less for-profit there is in a system the better. Theoretical considerations and observation (70 years, more than 1 billion people, 3 continents, many nations) confirm that - the U.K. has the lowest spending per person for healthcare for any wealthy ! nation. 42 % of the U.S. spending per person, versus 50 - 54 % for most other wealthy nations (the range is 47 - 56 % and outlier Switzerland that has only private insurers with 78 %. 100 % = the base for the comparsion is U.S. spending per person of USD 10,260). Data Keiser Foundation 2017, also see World Bank. The U.K. does not have "single payer" they took it one step further with the National Health Service. Germany was on the frontier in 1884 (but as often the case the early adopters have some quirks grandfathered in and live with them if they are not too bad. The U.K. did good in 1948, they learned from the experiences of other nations. The NHS has been defunded for the last 10 years (and they had a lean but sufficient budget to begin with). Plus post-war (recovering) U.K. did not include basic dental, so needless to say that is expensive. If the NHS had sufficient funding (putting the UK still among the wealthy nations with the lowest spending per person) the NHS would run like a charm. But then there would not be any pretext why there should be a (partial) privatization. The Tories have been hostile towards the NHS since its foundation in 1948. They just had to become more sneaky about it because all voters love it. Most wealthy nations spend 8 - 11 % of GDP on healthcare (19 % in the U.S.) the Tories always found it offensive that such a market should be off limits for the "investor and landlord class".
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