So, last, I looked at healthcare triage's series on various healthcare systems around the world. And we can talk all day about what system is theoretically the best, but at the end of the day, we need a system that works with the American system and its problems. Costs are spiralling out of control. This is due to some people being uninsured, price gauging, and massive inefficiencies within our system. People lack access to healthcare, mostly due to costs. Something as essential as healthcare should arguably not be so expensive or inaccessible to the average person. There are multiple models of healthcare, which ones are best?
Generally speaking, there are three major models for universal healthcare, as well as many other hybrid models that may exist:
Beverridge model- This is a model of universal healthcare in which the government runs healthcare directly. Think the NHS in the UK. Basically, government runs the hospitals, government employs the doctors, the whole system is government run. Healthcare is a centrally planned economy.
Single payer model- This is a model of universal healthcare in which the government acts as the single or primary insurer for healthcare. This is different than the government running the healthcare system directly. The hospitals, doctors, etc. operate in a market. But, the government is the "single payer" for healthcare. It covers the bills, negotiates with the parties, etc.
Insurance mandate system- Government mandates everyone buys insurance, often through a heavily regulated marketplace. Often times the government provides subsidies to ensure that healthcare is affordable, as well as maybe having a public option for the poor.
And of course, mixed systems exist. Very few systems are pure in every way. THe US, for example has attempted an insurance mandate system with the ACA, with medicaid for the poor. But then for the elderly there is medicare, which operates more like a government insurance program. Honestly, our system is all over the place, and this approach is why healthcare is so expensive. Again, we have for profit insurance companies gauging people some without care at all, heavy decentralization in the implementation of the ACA leading to many holes, many states not participating, many court challenges, and many sub par implementations of the idea. I mean, the ACA was a 1000 page bill, which is insane (I've read healthcare bills, most good ones aren't that long), no one read it or knew what was in it when it passed, and it's been sub par through and through. Many states refused to participate. In mine in order to get the mediicaid expansion you have to fill out a 22 page form asking dozens of intrusive questions, most of which aren't even related to that plan. It's a mess.
That said, insurance mandate system? It sounds nice on paper, but I don't like it. Quite frankly. I'm a fan of Andrew Yang's concept of "modern and effective governance", and having a simple system that works. I feel like the democrats went with the mandate system as they deemed it to be the least controversial, but it's also the least effective at solving our problems. Because an insurance mandate system is very piecemeal. It fits the democrat's approach to incrementalism, and caving to the GOP ideologically on the role of the market in our lives, but it's also extremely fractured. And at the end of the day, I feel like given our problems, an insurance mandate system will always have coverage gaps, always be unnecessarily bureaucratic, and still lead to excessively expensive care for many. As long as you spend hundreds a month for a service that still leaves you paying hundreds if not thousands at the point of service, healthcare is still going to be unaffordable for many.
In an ideal world, a beverridge system seems attractive. I remember when I did healthcare traige's series on healthcare systems, I actually preferred the UK's NHS system. It was simple, it was straightforward, it provides good care, and it was cheap. THe real question is, is there a path for us to get there in the US? I'm not sure. Given our government can't handle a mandate system well, and seems to screw up everything it touches that is complex, I'm not sure how I feel about the government just taking over and nationalizing the whole healthcare industry. It might be kind of messy.
I honestly think that the solution is either single payer healthcare, or perhaps some hybrid system that attempts to move us in that direction. US healthcare is expensive, and would cost $4.1 trillion to implement. I recently attempted to fund it, only for the numbers to...surprisingly work, though. Many costs actually came from existing sources. 1.6 trillion, roughly 40%, we're already putting out with medicare and medicaid. A payroll tax on employers would essentially replace their existing contributions, where one expense is merely replaced with another. While taxes would go up on americans, a 4% tax would essentially be replacing an 8% household expense between insurance, deductibles, etc. And people would pay in line with what they can. Bernie's 4% tax would only tax households making above $29000 a year, while mine would tax everyone, as I assume UBI exists in my ideal world and that would be exempt from the tax. I mean, think about it. If you have a household income of $60,000, which is fairly average these days, a 4% tax is $2400 a year. $200 a month. And that would replace insurance. And deductibles, and copays. Then you have stuff like tax breaks for health insurance going toward healthcare. And between all of those things, you generally got around $3 trillion covered. The other $1 trillion essentially comes from higher taxes on the right. Stuff like wealth taxes, and corporate taxes, and estate taxes. Much like with UBI, the cost of single payer healthcare is deceptive. It looks big on the balance sheet, but given it's replacing other expenses people paid, it often ends up just shifting the bulk of the expenses from payments in a private market to taxes, expanding access, and distributing the burden far more equally.
This isn't even getting into how single payer could reduce costs over time. A lot of costs come from insanely inefficient and bureaucratic healthcare administration, which needs an army of bureaucrats to deal with our overly complicated insurance system. And of course, monopsony power granted by the "single buyer" being the US government would drive down the costs of many drugs and procedures.
Honestly, single payer seems, of the three, the best plan to get universal coverage. Expensive on paper, yes, but far less expensive in practice. It would shift a lot of costs from the private sector to the public, reduce costs for many, and distribute the burden a lot more fairly, with the rich effectively paying the difference.
That isn't to say single payer can't have concerns. If a single payer system is underfunded, it can lead to the outcomes conservatives scream it could, like rationing or long wait times. But honestly, we have wait times and rationing now, it's called poor people not being able to afford care. US healthcare is great if you're affluent, but not if you're not.
Also, given the controversy surrounding abortion, we have to worry about whether republicans would sabotage it to not provide procedures they deem controversial for religious reasons (on the other hand if healthcare is federally administered perhaps federal law would override state law on the issue at hand, which could work to preserve access, it can go both ways).
Honestly, my biggest aversion to single payer is cost. I support single payer, and I support UBI, and if I had to choose, I'd choose UBI and go with a compromise option on healthcare.
So let's go back and look at my compromise option.
Effectively, I support, as a compromise, if single payer proves too difficult, a public option. A public option is essentially a government insurance plan that exists within a private market. These plans can take a lot of forms. With some you might need to purchase a healthcare plan from the government, like you would a private plan. I'm not a fan of this approach. My approach would be akin to medicare extra for all. Medicare extra would effectively be a healthcare plan that anyone without a private insurance plan would automatically be enrolled in. Rather than relying on an opt in model, which leads to paperwork, bureaucracy, and barriers to entry (remember the 32 page form for the medicare expansion?), medicare extra would just enroll you automatically. Your bill would be determined by your income. If you're poor, you just get free care. For people who are wealthier, costs scale from 2-8% based on income. I think the original medicare extra plan scales from 1.5x the poverty rate to 4x the poverty rate, but I know that a congressional bill based on this plan was a bit more generous, scaling from 2-6x the poverty rate. So if you have a family of 3, and make say, $46000 a year (2x the poverty rate), you'd pay 2% of your income on healthcare. That's $920 a year, or $76 a month. You would still have copays and deductibles, but they would be low. I think a $1250 deductible for the year (given a $5000 maximum for the 8% people). If you make $138,000 a year (6x the poverty line), you would pay $11,040 a year for insurance, or $920 a month. That might seem unfair as it would be higher than they might pay normally, but that's how it would scale. Again, the poor pay less, the wealthy pay more. And of course wealthy people could opt out and buy a private plan if it's cheaper.
So how would this be subsidized? Well, the costs are less, like $250-500 billion depending on implementation, and taxing the rich would work. It would also be expected that employers would contribute to the costs. So again, the same costs are going out, they're just going out in a different way. Again, the relatively poor get free care basically, but you pay more and more as you gain in income and wealth. This plan isn't quite as elegant as single payer is for me. I mean, youre stuck with insurance, and premiums, and all of the trappings like copays and deductibles, but you dont really feel the pain associated with such things unless you're wealthy. I mean, again, this is a compromise. It would do the job, and keep costs down on the government side of things, but it would also externalize a lot of costs to the free market. While medicare extra would ultimately set us up for single payer in the long term, as it's expected that over time most people would go with the government model over private models, it doesn't quite get us there, and as such might do a poorer job at reducing costs. Still, again, this is what happens when you compromise.
So what model is best? Well, if we deem it affordable, single payer seems best. But I could get behind a robust public option like medicare extra if I had to. Both honestly have pros and cons, although I'd ultimately give it to single payer for being the best. The only issue is cost to the government, and whether we can do it AND still be able to properly fund a UBI.
Even a public option model would effectively solve the biggest issues with healthcare though.
I honestly don't think that a beverridge system would be good for the same reason i oppose large scale changes like socialism. While ambitious there's a lot that can go wrong, and while other countries have implemented it effectively, I question if we can really get there from where we are now. That might be a bridge too far, and I'd prefer to try single payer over that.
I also don't like the idea of an insurance mandate system. if anything most problems with healthcare come from our reliance on the insurance model. And while other countries may have made it work, I don't really think it's the ideal model for the US. It was attempted with the ACA, it sucked, it was full of holes, it's overly complicated, screw it, let's try something else.
And yeah, that's why I tend to prefer single payer as my ideal aspiration, but would settle for a public option. Both are solid approaches to producing universal coverage and more equitably distributing both access to healthcare and the burden of paying for it across society, while producing minimal drawbacks (assuming correct implementation of course).
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