Why Single Payer in the US?

[PainRack]

Dann it... I made a mistake in my post. Dementia care services are tertiary preventive care, not primary. Ditto to meals on wheels and respite care.

[Esquire]

Firstly, this exact thing. There's overwhelming [admittedly ecological, but still overwhelming] evidence in favor of single-payer health care systems as both an economic and a common-decency measure; Painrack, please provide any credible evidence whatsoever that this wouldn't be true in the US as well.

But that's not my contention. My contention is whether single payer will CUT costs because of preventive care, my answer is no. It gain health by paying for it.

Proof? CDMP arrested healthcare rise in.inflation along with consolidation during the Clinton administration, it didn't cut it. The NHS went through the exact same thing when it broadly implemented health screening and clinical based services for smoking cessation and chronic disease.

That's logically equivalent, by the transitive and multiplicative properties. Arrested rise in costs with [currency]inflation and an aging population is a net real-dollar savings.

More to the point, $355 are saved in lifetime treatment costs per HIV infection prevented, "medical costs are reduced by approximately $3.27 for every dollar spent on workplace wellness programs" (SGO), "tobacco screening is estimated to result in lifetime savings of $9,800 per person" (SGO), and "an investment of $10 per person per year in community-based programs tackling physical inactivity, poor nutrition, and smoking could yield more than $16 billion... annually... a remarkable return of $5.60 for every dollar spent, without considering the additional gains in worker productivity, reduced absenteeism at work and school, and enhanced quality of life" (CDC). Nobody said that all preventative interventions are net-savings generators; that would be stupid. All of them, though, are by definition net quality of life generators.

None of these are from clinical services, which will be the only factor that's changed in a single payer system. You DO know that these are being done by the ACA now, something that's NOT single payer???

For future reference, this is Section 1:

At present, most public health (PH) funding comes from one level of government or another. The government receives a massive portion of its funds from taxes on the citizenry. If the citizenry didn't have to subsidize health insurance companies with their respective profit margins, higher taxes could be extracted at a net savings per citizen. Every differential-dollar thus extracted could be funneled towards the cost-effective PH interventions identified earlier (plus others as indicated by research), at a further net savings to both government and taxpayer. We're dealing with a system here; one part's inefficiencies affect the others.

... So we use the savings from the ones that do to pay for the ones that don't. Why is this controversial?

Because your definition of preventive care is too fucking narrow. Dementia care services, meals on wheels, caregiver subsidies are also primary preventive care , they cost money. And you see way more money being spent on adjusting and preventing disability in primary and secondary care, be it through clinical services or other aspects of public health.

Tertiary preventive care or even secondary preventive care is something you left out entirely. For example, breast cancer screening doesn't save money, but it save lives. Preventive care.

... Remember the bit when I said "Nobody said that all preventative interventions are net-savings generators; that would be stupid. All of them, though, are by definition net quality of life generators?" This is exactly what I was talking about. Additionally, breast cancer screening actually is cost-effective for at-risk subpopulations; see [url=http://www.ncbi.nlm.nih.gov/pubmed/21419333]here[/u].

Yes, the difference is that I'm not reading them from a (deliberately?) pedantic viewpoint. If it's cheaper to treat problems at a subclinical level, then by definition doing so will cut down on system expenditures. I'm sure you're thinking 'but Esquire, not all funding has to come from the government now!' Well, so what? The source of all funding is ultimately the citizenry/taxpayers/consumers, and it's objectively less efficient to funnel that funding through multiple profit-generating corporations instead of doing it directly through a centralized administration. As K.A. Pital said, we know this from comparison with... let's see, literally every other appropriate comparison nation.

My argument is that these services don't need a single payer to emerge and has been done by non single payer healthcare societies....SUCH as the US. Where the US is lacking is in welfare provisions, again something a single switch to single payer will not resolve UNLESS you put in more money. Which the argument that single payer cut costs is counter productive.

See Section 1 above. All the money comes from the same place; administrative efficiencies will as a logical necessity reduce overall system cost; those savings will allow more funding for cost-effective prevention. It is, again, simply not true that the US has effectively implemented such programs. You can tell because we have higher incidence of preventable disease than nearly all comparable nations.

Don't be pedantic. Any time an illness or injury becomes clinically-significant, it's an admission of failure for every system that bears on the specific condition. If you want to specifically define preventative care as necessarily taking place in a clinical setting, it may in the most narrow-minded of technical senses be different from public health, but that's a ridiculous and, as regards this discussion, utterly pointless line of argument.

How is this being pedantic? Again. The change to single payer only affects clinical services. Single payer will not increase welfare provisions on it own. It will not improve public health on its own.The sole difference is that it helps improve access by removing payment for services at point of use, I.e, clinical services.

No, it doesn't; see Section 1 above. Or at least the two problems are closely related - savings in clinical costs can be passed on to welfare/prevention/infrastructure/whatever-you-want programs, but only in a single-payer environment.

Moreover, public health is explicitly not being done well in the US as current; you can tell because our rates of nearly all preventable diseases are higher than all other comparable nations. In a single-payer environment, every dollar currently lining the pockets of insurance CEOs would be available for public health measures*, improving both cost efficiency* and, more importantly, population quality of life.

You keep saying that we pay for gains in health. Fine, but if we can** pay less for equivalent or larger gains in health, that's exactly the same as a savings; how do you think division works? 2 value-units for 1 cost-unit is better than 1 for 1.

*The cost-effective ones, obviously.

**And we can, see above.

And? How will that change when converting over to single payer, since the major factors are system wide rather than clinical services, the one thing that single payer will change? Or will single payer increase physical activity, reduce harmful behaviors such as unprotected sex or smoking?

On the areas where it does affect preventive care, such as medication compliance, hypertension,or diabetes management, the US pioneered and has widely implemented said clinical services, such that the rest of the world is copying them.
The U.S. Pioneered harm reduction and bench to bedside, zero central lines infection? USA. Even the bloody phone calls and telemedicine was first pioneered by them, not to mention recognising geriatric changes to increase medication compliance and QUALY.
Even the god dann ice cream label test comes from them.
https://uanews.arizona.edu/story/health ... ream-label


Primary preventive care through education and etc is much harder to contrast,because the NHS and US has varying budgetary constraints. The only real answer we get is that states /funds with more money to spend do better in said primary preventive care than those who aren't.

You're missing the point. We spend massively more than any other comparable nation in exchange for objectively worse health outcomes. Arguing against trying to fix such a clearly broken system is, quite literally, the clinical definition of insanity. Just because we do some very specific things well doesn't mean our health care system isn't a steaming pile of crap, relative to what other first-world nations have achieved for massively lower costs and massively higher equity and quality of outcomes.

[PainRack]

]
That's logically equivalent, by the transitive and multiplicative properties. Arrested rise in costs with [currency]inflation and an aging population is a net real-dollar savings.

First of all, healthcare inflation, not inflation. They two separate indexes. Healthcare inflation rises faster than inflation.

Secondly, the point of contention was preventive care will cut healthcare expenditure. Nope, it didn't. Not in the NHS, not in the US CDMP.

[


... Remember the bit when I said "Nobody said that all preventative interventions are net-savings generators; that would be stupid. All of them, though, are by definition net quality of life generators?" This is exactly what I was talking about. Additionally, breast cancer screening actually is cost-effective for at-risk subpopulations; see [url=http://www.ncbi.nlm.nih.gov/pubmed/21419333]here[/u].

And that's where I asked you to name them. Note: every single intervention you name is under primary preventive care, aka, public health. NOT preventive care. The bulk of preventive care under secondary and tertiary, apart from hypertension is not cost effective .

Also, I noted the dodge. The article states the same. Breast cancer screening does not cut costs, being cost savings only for high risk such as BRCA carriers. By your argument, that would mean the small, less than 1% savings from high risk population is going to offset costs for the other 99%?

See Section 1 above. All the money comes from the same place; administrative efficiencies will as a logical necessity reduce overall system cost; those savings will allow more funding for cost-effective prevention. It is, again, simply not true that the US has effectively implemented such programs. You can tell because we have higher incidence of preventable disease than nearly all comparable nations.

And? That was never under contention. The contention was whether preventive care will cut healthcare expenditure, as in total expenditure. Nope, it doesn't. Not unless you define preventive care so narrowly as to exclude the BULK of it, and the main impact of single payer WILL be by increasing access to clinical interventions, hence said non cost saving expenditure. NOT on reducing disease burden via INCIDENCE.

No, it doesn't; see Section 1 above. Or at least the two problems are closely related - savings in clinical costs can be passed on to welfare/prevention/infrastructure/whatever-you-want programs, but only in a single-payer environment.

Name a program that done so. Again, CDMP only arrested rise in healthcare inflation, it did not cut expenditure.

You're missing the point. We spend massively more than any other comparable nation in exchange for objectively worse health outcomes. Arguing against trying to fix such a clearly broken system is, quite literally, the clinical definition of insanity. Just because we do some very specific things well doesn't mean our health care system isn't a steaming pile of crap, relative to what other first-world nations have achieved for massively lower costs and massively higher equity and quality of outcomes.

And? For your premise to hold true, you need to show that the poorer outcomes are a result of poorer clinical care linked to access. Because that is what single payer fixes. It does not automatically follow that single payer will magically change everything when the only thing it changes is ACCESS.

Clean water, vaccinations and clean air are already done. Nutrition in the form of obesity and activity are the last two major obstacles in public health, and reforms aren't going to be cheap.

[PainRack]

Right now, I think we talking past each other.

To make it clear, I am not anti single payer. The promised increased access to care more than offsets the costs to me. However, I fully expect it to cost the average taxpayer more, because healthcare is not cheap.

Anybody who thinks inplementing single payer will cut expenditure because of preventive care is lying. Price and Labour bargaining yes, rationalizing care and seeking efficiencies such as the ACA excise tax on medical devices yes, but preventive care? The successful cost saving prevention are already being implemented, to further broaden it's impact would require more immediate funding.

And I hesitate to imagine the political impact such a view has.
http://www.vox.com/policy-and-politics/ ... revolution

We see it detailed out here, where Bernie supporters are unwilling to make the financial investment to bring about single payer to America, even under Sanders underestimated cost plan.

I feel this false belief that cost savings can be sought out from preventive care as opposed to squeezing out efficiencies is detrimental to the very possibility of implementing a viable system.

If you so adamant that cost savings are possible to offset the costs involved in increasing the amount of preventive and treatment care given, show me the numbers. Because right now, the academics are saying it's not there.

[Esquire]

Let's change tacks - what, in your opinion, explains the fact that the rest of the developed world has better health outcomes for a fraction of the expenditure of the US?

[PainRack]

Let's change tacks - what, in your opinion, explains the fact that the rest of the developed world has better health outcomes for a fraction of the expenditure of the US?

Increased access while having lesser drug and Labour costs.

For example, a comparison between Canada and US for angiography shows that despite the shorter length of stay in the US, costs are equivalent due to labor costs. The median salary for a nursing assistant in the US is equivalent to mine as a registered nurse in Singapore, even though the cost of living is equivalent to New York. Granted, that comparison isn't fair as subsidies and license on cars artificially push the cost of living up as HSBC used expats, who are exposed to cost rises but do not enjoy subsidised on housing n healthcare. Still, labor costs.

Ditto to drug prices.

My belief that switching to single payer will increase expenditure, even though it will be more efficient in the long term is based on extrapolation from history.

http://www.vox.com/2016/1/28/10858644/b ... ngle-payer
Like in Vermont, use of healthcare rises significantly under UHC. Unlike republictards, I don't think that's a bad thing. Failing to budget for it however is stupidity.

Like my local government belief that hospital admissions will rise linearly instead of scalar.

[PainRack]

Lastly, with regards to public health, perhaps this analogy might work better.

It's an investment. If I purchase 100 dollar of drinks or of mutual funds, I still not cutting my spending. But buying fund means I will have increased resources in the future, or at least minimize the impact of inflation.

There is no CUT in spending for public health unless you divert money from elsewhere. But it's still a worthwhile investment, even though in this case, it doesn't mean it's revenue neutral. Although well... Let say that the US investment in bioterrorism paid off by prepping it for Ebola and other epidemics, helping the entire world, but at the costs of cutting public health monies in STD and even existing diseases like malaria....

[bilateralrope]

This article seems relevant:

U.S. Health Care Prices Are All Over the Map, New Study Finds

Why does a knee replacement cost $29,000 in Kansas but $40,000 in next-door Colorado?

Health care prices are all over the map in the U.S., a new study finds. It digs deeply into the crazy pattern of health costs across the U.S. and shows there is very little consistency.

The report from the Health Care Cost Institute (HCCI) finds prices for the same procedures vary by sometimes huge amounts — even within the same state.

Unlike other reports, this one looks at prices paid by people with private health insurance.

"Prices for medical services varied more than threefold in certain instances," the team wrote in the report, which was published in the journal Health Affairs.

Some of the differences make some sense. Prices overall in Alaska are high, and medical costs there are 2.6 times the national average. Medical costs in Florida are just 79 percent of the average.

"There is a big shortage of child psychologists in this country. If you are a single child psychologist somewhere in rural Pennsylvania, you are able to charge a high price because there are children lined up down the hallway," HCCI executive director David Newman told NBC News. In that case, high prices are a symptom of a shortage.

"In some towns, the hospitals have consolidated. In some towns the imaging has consolidated. In some towns there is an ambulatory imaging center; in other towns there is not," Newman added.

Consolidation means the hospitals have more clout in setting prices, said Cynthia Cox of the Kaiser Family Foundation, which studies healthcare.

"Where a hospital has a monopoly, then prices tend to be much higher than those areas where there are multiple hospitals," said Cox, who was not involved in the study.

But other differences are harder to explain.

The national average for a knee replacement is $33,098, the organization found. But this operation costs nearly $39,000 in Indiana and Minnesota, $40,000 in New Hampshire and Wisconsin and $43,000 in Oregon, while you can get one for just $24,000 in New Jersey. In Sacramento, California, a knee replacement costs $57,000, while the California average is just under $40,000.

An ultrasound for a pregnant woman costs an average of $268. But Alaskans pay $895 for the scans and they cost $201 in Arizona. Got cataracts? It'll cost you $8,000 to get one removed in Alaska, compared to $2,300 in Florida. The national average? $3,300.

"The average price in Cleveland ($522) was almost three times that in Canton ($183), even though these two Ohio (cities) are only 60 miles apart," the HCCI team wrote.

"Some of the variation in imaging prices is eight-fold around the Philadelphia area," Newman added.

The team used the organization's health cost website Guroo to research the report. "Aetna, Humana and United give us all of their paid claims data. It amounts to data on about 50 million Americans from 2007 forward," Newman said.

Other studies have also shown prices varying wildly across the country. One of the best-known databases is the Dartmouth Atlas, which uses Medicare data.

Even in that single-payer system, the government pays twice as much for treating a patient in Miami as in San Francisco. People in the more expensive areas don't get better care.

"It's not necessarily the case where if you pay more you get more," Cox said.

Most Americans - more than 60 percent or 190 million people -- are covered by private health insurance, usually through an employer. About 32 percent have government health insurance of some kind, such as Medicare or Medicaid.

Medical costs can be paid by private insurance companies, directly by employers, by government-funded systems such as Medicare or Medicaid, and directly by patients. Hospitals negotiate different rates with different payers. Doctors and clinics sometimes do, too.

One study found that some hospitals mark up charges by as much as 1,000 percent.

"The concern is these higher prices get passed on to the consumer in the form of high co-pays and premiums," said Cox. Her organization found that the average deductible for people with employer-provided health coverage increased from $303 in 2006 to $1,077 in 2015.

And this price variation helps explain why U.S. has higher healthcare costs than other countries, Cox added.

Americans now spend $9,523 per person a year on medical expenses — by far the most among developed countries.

The report leaves out nine states. There wasn't enough data for eight of them, and Arkansas has a law forbidding its data from being incorporated into a national database.

I wonder how badly the prices in Arkansas compare.

[Esquire]

The short answer is 'extremely poorly;' Arkansas is very low on essentially all health care measures.

Painrack, thanks for the illumination and I apologize if I've been unnecessarily confrontational in this thread - we seem to be disagreeing mostly over definitions*, rather than more fundamental matters. I spend a lot of time arguing with people who think universal health care is somehow ethically a bad thing, and I jumped to conclusions - you're a nurse, I'm sure you've had similar experiences.

*I was including public health measures as a large part of an idealized UHC-environment preventative interventions plan and projecting forwards to after that ideal system normalizes itself to something resembling the first-world efficiency standard. You're absolutely correct that any cost savings possible from plans that can plausibly be implemented in the US won't be realized for a long time, if at all.

[Esquire]

Biostem - specifically, Arkansas is ranked 48th overall for overall health quality compared with other US states.

[PainRack]

The short answer is 'extremely poorly;' Arkansas is very low on essentially all health care measures.

Painrack, thanks for the illumination and I apologize if I've been unnecessarily confrontational in this thread - we seem to be disagreeing mostly over definitions*, rather than more fundamental matters. I spend a lot of time arguing with people who think universal health care is somehow ethically a bad thing, and I jumped to conclusions - you're a nurse, I'm sure you've had similar experiences.

*I was including public health measures as a large part of an idealized UHC-environment preventative interventions plan and projecting forwards to after that ideal system normalizes itself to something resembling the first-world efficiency standard. You're absolutely correct that any cost savings possible from plans that can plausibly be implemented in the US won't be realized for a long time, if at all.

There's nothing much to apologize for. It's more of...different perspective.

I do get annoyed at the accusations that the quality of care is subpar in the US, as comparing it to other systems show otherwise. I don't believe however that this quality is a result of its cost and free markets, but rather, the legacy of a hundred years of investment, be it from the March for dimes and War on Cancer, it's progressive nature on female education in healthcare to the efforts of the New Deal and Great Society, the EPA clearing up of lead and brown smog for example.

It's a mystery to me why the quality doesn't translate to cost savings, every other system is trying to squeeze better outcome or efficiency, yet, the US efforts at achieving shorter LOS for example is negated out entirely by its economics.

The real problem with the US system is lack of access, especially on the financial part. Yes, the US rural and etc suffer from the same catchment problem found in Australia but the Aussies do compensate for this via their NHS.



Another bugbear I had was just over preventive care. Public health is primary preventive. Yes, neonatal care, folic acid supplementation...these are cheap effective care measures.
https://en.m.wikipedia.org/wiki/Preventive_healthcare
However, the increasing bulk of preventive care is in secondary or tertiary health and THAT gets....interesting.
Cancer screening for the general population doesn't save money. But we know dann well we should do it, because of its major benefits. Tertiary /rehab services don't get much glamour or support, because they don't save money, a... Travesty.
It gets worse once you go into hospice and the palliative movement and the bugbear of trying to find money and political support....

That ignores the...cost... I don't know the US political context, but the local efforts to promote physical activity and reduce obesity is.... Expensive, including giving each citizen money to go exercise and we still not hitting our outcomes, even though we having progress to our goals.


http://www.healthhub.sg/ and ActiveSg, along with AIC and silverpages....hell, the government ropes in the military and mandatory conscription as well.....It's Why the RT and IPT services are now orientated towards teaching and promoting health as opposed to punishing you for failing the fitness test. So, even under the sheer.... Total control the Singaporean government can exert, we can't improve on this aspect of public health. I'm quite sure that no current political process in the US can hope to do anything similar, although Michelle Obama anti obesity campaign........ Just how the hell did she convince the food companies to take out a trillion calories?!?!?!?!

[Broomstick]

She's charismatic?

I don't know, either, but even if her programs only enjoyed minor success I'm glad she made the attempt.

[PainRack]

She's charismatic?

I don't know, either, but even if her programs only enjoyed minor success I'm glad she made the attempt.

Arresting the rise in obesity amongst children?, That's huge

http://blogs.scientificamerican.com/obs ... tion-wide/

Having said that, it might also have levelled off due to maximum gains... I mean, at some point, the population should stop shifting right:)