Universal Healthcare?

[Meadbh]

The biggest obstacle that I see to universal healthcare in the US is the multi-billion dollar insurance industry and the seemingly inherent American fear of their government.

+1

 

[pb4uski]

The biggest obstacle that I see to universal healthcare in the US is .... the seemingly inherent American fear of their government.

+1 I think that between medicare, medicaid and the VA systems troubles that many are very skeptical that the government could pull it off without it being an unmitigated disaster, especially in this partisan age. And of course, the botched roll-out of healthcare,gov didn't help either.

 

[ERhoosier]

Although I think that it would help if people have some "skin in the game".....

I think the bigger problem is that health care is so expensive because doctors, hospitals and drug companies in the US can charge what the market will bear and that tends to be much higher than the rest of the world because there is little or no negotiations for many health care products and services. I take one pill daily to keep my cancer in remission and it costs about $460 per pill (close to $13,000 every 28 days).... /QUOTE]

Agree 100% that people ("consumers") should have some "skin in the game", at least with US public attitudes that "more is always better". IMHO This is critical to folks not abusing the HC system as well as using market forces (consumers) to encourage some serious cost containment. Clearly US "consuming" vast HC resources ($$$) has not paid off in better health (on ave) than other developed nations which spend far less.

Also agree that Big Pharma (& most medical device makers) have largely been able to set their own prices. Often Big Pharma keeps raising prices even after the drugs' R&D costs have been recouped &/or partially funded by others (e.g. philanthropy, gov't). As one former Big Pharma exec put it recently, “Everyone is engaging in extreme prices because they can get away with it.”.
Why Prescription Drug Prices Keep Rising Higher - Businessweek
Not surprising that drug costs in US are much higher for same meds than in other countries, a fact even the US gov't has admitted for many years.
Cost of Prescription Drugs

OTOH- Most US docs & hospitals have long been subject to price negotiations. And most US docs are now HC system employees anyway, so not negotiating their own fees like in traditional fee-for-service private practice.
http://www.nytimes.com/2010/03/26/health/policy/26docs.html?pagewanted=all&_r=0

Interesting to look at recent industry net profit margins (public financial data, publicly traded firms):

Big Pharma 20.8%
Medical instruments/suppliers 12.8%
Other Pharma (mostly generics) 11%
Hospital Systems 3.8%
Health Plans (HI carriers) 3.2%
Industry Browser - Yahoo! Finance - Full Industry List

 

[unno2002]

[FONT=&quot]Imagine car insurance if your employer provided it to you via a group policy. Imagine car insurance if the government paid for it. Health insurance should be no different.[/FONT]
[FONT=&quot] [/FONT]

 

[haha]

I would like to see health insurance divorced from employment - it was a bad idea to begin with (and was the unintended consequence of a different government intervention).

Many aspects of ACA are heading in the right direction in my opinion. I think everyone should be required to have health insurance so people can't freeload off the system. I think that health insurance should be subsidized if someone's income is low and it is unaffordable and ACA does that. I like mandating that a limited number of maintenance services are included in coverage "free" so people don't have an incentive to ignore health issues.

Where I would diverge with proponents of universal health care is that I think health insurance should remain in the private sector and not be subsumed by the government like in Canada and the UK.

The bottom line is that health insurance and health care is expensive and each person needs to be personally responsible for their healthcare which means that health care for people with health issues will end up paying more than those who rate healthy.

Considering the very ample dole given from taxpayers to far from impoverished people to allow them to buy these allegedly private insurances, I question whether this isn't just a mechanism to transfer money from those unfortunate enough to still be taxpayers, to all kinds of medical crony monopolies.

Ha

 

[Meadbh]

[FONT=&quot] Imagine car insurance if the government paid for it. [/FONT]
[FONT=&quot] [/FONT]

Actually I experienced this in Manitoba. It was pretty good! Rates were very competitive and when someone T-boned my car on an icy street, I was properly compensated pretty quickly.

Manitoba Public Insurance

 

[6miths]

And bear in mind that the government doesn't pay for it. Citizens pay for it. The government just cuts out all the middle men with their fingers in the pie and is able to negotiate costs with caregivers, drug companies, hospitals, etc. One can go online in Ontario (and I am guessing most Canadian provinces) and find out exactly what a doctor is paid for a consultation, visit or procedure and with only a little bit more effort (looking up a phone number and calling the hospital) you can find out how much a stay will be with reasonable accuracy.

 

[haha]

And bear in mind that the government doesn't pay for it. Citizens pay for it.

Well if it were in America, to be more accurate something around 45% of the citizens would pay for it, their own, and the other 55% ers share too. And since taxpayers tend to be more prudent in other areas of life, including health and hygiene, the 55%ers likely would make a bigger draw per capita from the system. Great system if you are a booze-hound slacker

Ha

 

[FIRE'd@51]

Although I think that it would help if people have some "skin in the game", if you've ever used health care for something like cancer, you really have little or no control over the cost of the care. It is usually extremely expensive. So for the most part I disagree with your assessment of putting a limit on coverage. Someone like me can go for 55 years with little or no health care usage but then all of a sudden get diagnosed with cancer. I should not be penalized for doing everything right for 55 years and then then having bad luck, get cancer.

+1000

ACA attempts to move in this direction and should help IF you can find a policy that includes your doctors in the network and perhaps more importantly, has the drugs you need on its formulary.

 

[razztazz]

Well if it were in America, to be more accurate something around 45% of the citizens would pay for it, their own, and the other 55% ers share too. And since taxpayers tend to be more prudent in other areas of life, including health and hygiene, the 55%ers likely would make a bigger draw per capita from the system. Great system if you are a booze-hound slackerHa

That's only because the system does an inadequate job of distributing the wealth. As long as the system is rigged to mal-distibute wealth into as few hands as possible yeah, you're gonna have that pucking froblem.

As far as dissolute behavior... Ok Kill 'em. There's more than one way to round people up and kill 'em. The Havers engage in all that behavior and then some but they do not suffer anywhere near the deleterious effects because they have the money to cover for it and they run far far less risk of losing everything so they don't look like slackers and boozers even though they are.

And then there's my case. I was quite healthy and indestructible.... until I let doctors try to treat me for diseases I didn't have. Cholesterol and an alleged subclinical infection that was not detectable by any test but he swore I had one. Them, complete denial of the unfortunate sequalae that progressively destroyed any remaining quality of life. Over several yrs spent hundreds of thousand on medical bills tax payers actually as I am retired military).

I finally stopped doing everything they said and my health started to improve. I still need a prescription for the rest of my life and surgery that I do not trust any doctor to do. Should I be penalized for pissing away resources? Should we do what the Doctor says? Do it then blame the victim? I am lucky" in that I did not have to worry about losing my job even tho I was left unable to work. And I had solid med insurance to pay the doctor for destroying my health and keep me from living in a dumpster.

And we all know I am not the only one.

 

[6miths]

It seems ironic to me that on early retirement sites and financial sites (like Bogleheads) that health care is such a taboo topic given that the only way things will ever change is via (or at least the strong support of) a grassroots movement of financially literate people who recognize the implications of an every man/woman for themselves approach. I can retire early because I have worked hard/saved diligently/invested wisely (been very lucky/blah/blah) but also (and more importantly) because I have no significant worry about my healthcare costs or those of DW, our children or our extended family. In the US the leading cause of bankruptcy is medical expenses and it seems that people stay in jobs because they can't afford not to from a health insurance perspective. The truth is that in the US, all but the top few percentile of the population is at risk of financial catastrophe due to medical problems and despite spending far more per capita on healthcare than any other country, the US indicators for healthcare are pretty poor (and perhaps poor is a bit of an understatement). At any rate, there are issues of which all are aware, hopefully one day solutions will be found and implemented to the benefit of all.

 

[brett]

I cannot imagine living in a country without universal health care.

For us it means the provision of quality health care regardless of employer benefits. After all, why on earth does something basic like the provision of health services be linked to an employer It is no different to us than the provision of police and fire service, or clean water from the tap.

For us, it means early retirement at 57/58 with absolutely no concern for the cost /availability of health insurance insurance policies until we reach 65.

For us it means that medical costs are not the largest reason for personal bankruptcies. Becoming ill without insurance is not a reason to loose all of the assets that we have accumulated over our working years.

We pay higher taxes and there are challenges to the system. We see some US politicians claim that our system is not good. The fact is there are some issues but the hard reality..backed by 20 plus years of annual polling shows that 80 plus percent of the population like it and demand it.

We could not imagine not having it.

 

[Willers]

Sent from my iPhone using Early Retirement Forum

 

[Bryan Barnfellow]

I have lived in Switzerland for about 5 years now and like the Swiss model.

It is "universal" in the sense that it is compulsory for everyone in the country who is here for more than 3 months. However it is not a single payer plan and is not connected to employment, which makes it portable. Individuals pay for it and do so all of their lives. If you cannot pay the whole premium, your canton (=state) will assist you based on your income. But you own the policy/contract.

There are no pre-existing conditions exclusions and your premiums cannot go up due to your own medical experience -- they are tied to your age group.
My premiums have gone up 1 or 2% each year at most. One year they did not go up at all. It was a shock.

For the basic insurance plan, which is compulsory, the government (or a governament commission, not sure) determines what illnesses are covered and publishes a drug formulary; but it is very comprehensive. It's like the US Blue Cross/Blue Shield used to be. There is no hassle with getting health services (you can go to a general practitioner or directly to a specialist). You show your insurance card and they bill the insurer.

The basic plan is reasonably priced and includes medications and even spa treatments if these are prescribed by a doctor for physical ailments or stress/burnout. Also if you are physically unable to care for yourself or your home due to an illness, you can receive home help until you are better. Some alternative medicines are covered as is acupuncture, for example. So you get doctor visits, lab stuff, medications/equipment, and hospitalization.

What you do not get is a private room in a hospital (only semi-private) or the ability to go outside your canton for treatment. If you want that, you buy a supplemental policy, which about 20-30% of Swiss residents do. It allows for some other benefits as well. Most people are okay with the basic plan. You can never be dumped by your insurer and you can change once a year to another if you would like. The medical staff are well trained and often speak very good English. My wife had a small procedure at our local hospital and was kept in hospital for most of a week (!) to be sure she was okay, and then we had help with house stuff for two weeks following.

There are about 60 nonprofit companies which offer insurance plans, competing on some aspects of price and service.

So in summary, I like that it is not connected to my j*b, making it portable. It is compulsory, so the healthy youngsters are in the pool as well. It covers things like medications and is generally form-free and has the bonus of no hassles/gamesmanship. The companies pay the bills and we are almost never on the 'phone with them as we constantly were when we lived in the US.

One small worry. Switzerland is a true direct democracy. This means citizens can change laws based on majority vote. There is a nationwide referendum this month to switch out the current system with a single-payer government system supported by taxes. I cannot believe this will be better for us; but I don't have a vote here.

BB

 

[pb4uski]

That sounds like a sensible system to me other than the restriction to be treated in your own canton. Is there some provision for people who travel or do you need to buy a supplemental policy if you travel?

 

[MichaelB]

Well if it were in America, to be more accurate something around 45% of the citizens would pay for it, their own, and the other 55% ers share too. And since taxpayers tend to be more prudent in other areas of life, including health and hygiene, the 55%ers likely would make a bigger draw per capita from the system. Great system if you are a booze-hound slacker

Ha

The single largest tax benefit in the US is the tax credit for health care to employees. Over the next decade the biggest healthcare subsidy is not ACA or Medicaid. Even combined they will cost 1/3 less than the tax credit to people getting their health care from employers.

Medicare recipients also get a significant subsidy, but I haven't seen the numbers broken out anywhere.

 

[ShokWaveRider]

As an MD and consumer in the Canadian system - I think it's among the best in the world. As an MD in the American system (now years ago) - not so much!

But (Big But), if a new young family, unfortunately has a child with (God Forbid, and I am not religious) has a child that needs a lot of surgeries and car for a long time, does not have the rest of their financial life ruined because oif the costs of paying for their child's care.

This is a BIG one that would NEVER happen in a universal system.

 

[ShokWaveRider]

And bear in mind that the government doesn't pay for it. Citizens pay for it. The government just cuts out all the middle men with their fingers in the pie and is able to negotiate costs with caregivers, drug companies, hospitals, etc. One can go online in Ontario (and I am guessing most Canadian provinces) and find out exactly what a doctor is paid for a consultation, visit or procedure and with only a little bit more effort (looking up a phone number and calling the hospital) you can find out how much a stay will be with reasonable accuracy.

Massive +1

 

[pb4uski]

The single largest tax benefit in the US is the tax credit for health care to employees. Over the next decade the biggest healthcare subsidy is not ACA or Medicaid. Even combined they will cost 1/3 less than the tax credit to people getting their health care from employers. ....

I think you're really talking about the fact that employer provided health insurance is deductible by the employer but not taxable to the employee. I think the employer should get a deduction for the cost of providing employee health insurance. Further, I think that employer provided health insurance should be taxable to the employee just like if the employer provided an employee with a car or a country club membership or similar personal expense and then the employee could take a deduction if they qualify. IOW, the tax implication to the insured should be the same whether the health insurance is paid for by the employer or by the insured.

 

[donheff]

I strongly believe ever-increasing health care costs are due in large part because many users have little (or no) "skin in the game."

The skin-in-the-game theory may have some merit for controlling costs but it isn't the primary problem. Countries with UHC programs that involve no skin-in-the-game get better health outcomes than the US with far lower costs. I have not seen statistics comparing costs in UHC programs that include skin-in-the-game and those that don't. It would be interesting to see whether there is a strong correlation.

 

[ziggy29]

I think you're really talking about the fact that employer provided health insurance is deductible by the employer but not taxable to the employee. I think the employer should get a deduction for the cost of providing employee health insurance. Further, I think that employer provided health insurance should be taxable to the employee just like if the employer provided an employee with a car or a country club membership or similar personal expense and then the employee could take a deduction if they qualify. IOW, the tax implication to the insured should be the same whether the health insurance is paid for by the employer or by the insured.

I'm not dogmatic one way or another, but the tax rules for employers paying for health care need to be the same as if individuals purchase their own. There should not be a tax advantage to employer-provided insurance that individuals don't get. Whether that means taxing both, exempting both or taxing the employee for the value of employee benefits, I'm not going to dig my heels in there. But for the sake of basic fairness the rules have to be the same. I'll let the sausage-makers work out the details.

A system that provides skewed incentives to link health care coverage to employment status are significant factor in the brokenness of the US healthcare delivery system, or at least in terms of how to pay for it and our ability to pay for it.

 

[pb4uski]

I agree and was suggesting that the employee rules be conformed to be the same as those for people who pay for their own health insurance, but you're right that it could be conformed to be the other way - we agree that the important thing is that they be the same. If that was done, then it would become easier to divorce health insurance from employment.

 

[MichaelB]

I think you're really talking about the fact that employer provided health insurance is deductible by the employer but not taxable to the employee.

Yes. This tax credit is projected to cost around $3T over the next decade. The point raised by both you and Ziggy, that everyone should be subject to the same tax and deduction rules, makes lots of sense.

 

[samclem]

If that was done, then it would become easier to divorce health insurance from employment.

Ironically, while the ACA makes it easier in one way to get away from employer-sponsored plans (because the exchanges/infrastructure is in place to accept those with formerly-provided employer plan), it penalizes employers who go that route (through the[-] fine/taxes[/-] whatever). But I think employers will increasingly choose to dump their plans regardless of the fine, and the CBO thinks so, too

In their original
analysis of the impact of the legislation, CBO and JCT estimated that, on balance, the number of people obtaining coverage through their employer would be about 3 million lower in 2019 under the legislation than under prior law. As reflected in CBO’s latest baseline projections, the two agencies now anticipate that, because of the ACA, about 3 million to 5 million fewer people, on net, will obtain coverage through their employer each year from 2019 through 2022 than would have been the case under prior law.

 

[scrabbler1]

I have posted here before about the inequity in the tax treatment of HI premiums between those in employer group plans versus those in individuals plans. There are 3 different types of treatment.

(1) The tax-free portion paid by employers.

(2) The tax-deductible portion those in group plans can always deduct regardless of AGI, and it doesn't matter if the employee itemizes his deductions on Schedule A. It's like a 401k deduction, it comes right off the top of income. Individuals at best can deduct only the portion above 10% of AGI if he is even itemizing to begin with.

(3) After-tax dollars are used. Those would be the first 10% of AGI if the indivdual can itemize his deductions or the whole thing if the individual can't itemize.

Those in group plans pay for their HI premiums using (1) and (2). Individuals use at best (2) and (3) and often only (3), as was the case for me in my first few years of ER. What I propose is to have everyone in (2). To do that, the employer-paid part gets taxed as income while any remaining part of one's HI becomes fully tax-deductible the way 401k or IRA deductions are deductible; they come off the top of income and it doesn't matter if one itemizes deductions or not. This would also simplify one's taxes because fewer people would itemize once HI premiums are removed from Schedule A.