Will ObamaCare Make Early Retirement More Difficult?

[forummm]

I don't have any particular insight on cosmetic surgery costs. But I can see how something that's entirely optional would be cheaper. If it were too expensive, people wouldn't get it as much. It's a little different than having an actual health problem and needing to get that taken care of.*

*I'm ignoring the small portion of plastic surgeries that are deemed more medically necessary.

Yes, there is a difference in the type of demand, but plastic surgeons are not underpaid compared to other doctors.  They do quite well.  Of course their supply probably is more responsive to demand than other specialties as if plastic surgeons were underpaid, you'd see people stop specializing in it, but that doesn't change the fact that it's clear the private market will work, if you let it, even with some pretty ridiculous restrictions on supply. 

The amount of care that cannot be competitively shopped (basically your emergency care, maybe some non-emergency care in very low population density, remote areas) may need to be treated differently from day to day care where the price mechanism can be allowed to work, but it seems pretty clear that we are inflating the cost of healthcare through poorly thought out regulation and too great of a reliance on third party payments. 

Again, I'm just assuming you're correct that cosmetic surgeries are cheaper. If so, cosmetic surgeons can also have lower costs because they can do their surgeries in their offices. It's more comparable to outpatient surgery (which is also cheaper). Anytime you get a hospital involved, costs spike. And cosmetic surgeries may also be much less complicated than others (it's probably a lot harder to do a heart transplant or hip reconstruction than to suck out some fat or stick in some implants, and requires less staff support and cheaper devices and materials).

You say the private market will work. But it hasn't. We had largely unregulated private sector providers and private insurance markets for decades for the ~200 million people who didn't have public insurance and those private markets just got more and more expensive. And totally non price transparent. The ACA has started to regulate private insurance, so in the coming years you could start to see whether those changes are good or bad. But pre-2010, costs were going crazy. Yes, you needed to have a medical license (but those aren't hard to get). But with that in hand, you could largely practice medicine however you, your patient, your patient's private insurance company, and your medical malpractice insurer (also private) agreed was acceptable medical practice.

[forummm]

I'm totally fine with having hospitals be no frills.

As I would be, as it doesn't have a big impact on quality of care.  But the horse is out of the barn on that one.  We already have a hospital infrastructure built up that depends primarily on single occupancy rooms.  We can't save money by building new, but no frills hospitals or by blowing walls out. 

You could save money by having more outpatient surgery in cheaper venues. Hospitals could put 2 people in the rooms. Etc. 3rd party payers do obscure the cost of those more expensive options. But the private insurance market hasn't been great at helping move people to high quality but lower cost providers.

Or having waiting lists for non urgent procedures.

I suspect you would be very unhappy to find out what the government considers non-urgent.  Maybe you'd be fine with the definition of non-urgent for other people, but when it's you or your Great aunt emma or whoever laid up for weeks on end in pain waiting for hip surgery, it will suddenly seem completely unreasonable.

First off, the wait list argument is overblown. But let's pretend that it's a huge problem (even though people in those countries are generally happy with their health systems). I'd be totally fine taking the risk that I might be in pain for weeks at some point if it meant saving $250k or $500k in today's dollars over my lifetime. That's a bargain. That's about the amount that other countries save per person compared to spending what we spend.

If that saves money--fantastic! It would be a problem if health outcomes were worse as a result. But the fact is that these other countries spend less and have the same or better health outcomes as the US.

  This is generally not true.  Other countries have the same life expectancy as the U.S., but that's primarily driven by factors other than health care (taking out driving and gun fatalities does away with a substantial portion of the discrepancies).  A lot of the differences can also be controlled out by looking at lifestyle.  We have a much higher rate of "life style" diseases, like diabetes and heart disease, than other rich countries.  And controlling for demographics, which is a lot more difficult (or maybe not more difficult but it's a lot less clear what the justification is) makes a lot of the differences disappear.  For example, Japan has a significantly longer life expectancy than the U.S., but americans of Japanese descent have longer life expectancies than Japanese.  If you compare actual health outcomes, the U.S. does well.  But then you run into problems like, are we treating cancer better, or are we finding it earlier, which results in longer life expectancy after diagnosis?   

The reality is when you look at the numbers, we spend more and in many ways we get better care.  We don't get a ton of bang for our buck and it seems clear that a lot of healthcare costs are wasteful, but it's not easy to identify what was wasteful until after the fact.  The areas where we clearly spend more than other countries it's politically difficult to change (e.g., we politically apparently can't just pay our doctors and nurses less) or would come at a significant social cost (e.g., no longer pumping up the price for prescription drugs bought in the U.S. would make drugs cheaper for people in the U.S., but would significantly change the calculus on how much drug R&D can be justified).

You say it's not true. But then generally agree with me. Various rankings give the US being middle or bottom of the group of industrialized nations. I said we're about the same or worse than some that spend a lot less than we do. You can quibble with their methodology. But you seem to agree that our outcomes are at least pretty similar. And yet we pay double on average. Clearly not an efficient use of that extra money.

You say we can't politically do some things. But those factors have been controlled significantly by the private market for decades--not the government. Who decides what a doctor can get paid for a service provided to a person with private health insurance? The doctor and the insurer. They have decided that prices should be higher. I don't hear a lot of argument that Medicaid and Medicare overpay providers in general. There are some specific services that Medicare overpays (like in chemo delivery), but in general for services I don't hear that claim.

[Jrr85]

Again, I'm just assuming you're correct that cosmetic surgeries are cheaper.

It's not that cosmetic surgeries are cheaper, it's that inflation in cosmetic surgery has been much lower than general healthcare, and it's been lower despite pay not trailing other sectors of healthcare.  That's the important thing to compare. 

If so, cosmetic surgeons can also have lower costs because they can do their surgeries in their offices. It's more comparable to outpatient surgery (which is also cheaper).

  To my knowledge, outpatient surgery in general has not experienced lower rates of inflation. 

Anytime you get a hospital involved, costs spike.

  I'm not sure that's true, but if it is, what does that tell you about how regulation impacts inflation?

And cosmetic surgeries may also be much less complicated than others (it's probably a lot harder to do a heart transplant or hip reconstruction than to suck out some fat or stick in some implants, and requires less staff support and cheaper devices and materials).

    So in the only sector that sort of gets to operate in a free market, they have found a way to economize and provide the same treatment for cheaper, but in other areas, they haven't?  You're proving my point. 

You say the private market will work. But it hasn't. We had largely unregulated private sector providers and private insurance markets for decades for the ~200 million people who didn't have public insurance and those private markets just got more and more expensive. And totally non price transparent. The ACA has started to regulate private insurance, so in the coming years you could start to see whether those changes are good or bad. But pre-2010, costs were going crazy. Yes, you needed to have a medical license (but those aren't hard to get). But with that in hand, you could largely practice medicine however you, your patient, your patient's private insurance company, and your medical malpractice insurer (also private) agreed was acceptable medical practice.

There's a lot wrong here to unpack.  First, I'm not sure what decades you think we had free market in healthcare, but it certainly wasn't the decades leading up to the enactment of the ACA. 

We didn't have anywhere close to 200M people uninsured.  It was less than a quarter of that, and that includes anybody that is uninsured over the course of a year, which is probably the right way to look at if you are looking at policies aimed at alleviating short term breaks in coverage; it's not the right number if you are looking to put in place insurance provided by and paid for by the government. 

The ACA hasn't "started to regulate private insurance".  Private health insurance has been heavily regulated for at least a couple of decades before that.

Getting a medical license is not hard to get in the sense that it is easy to go through roughly four years of post secondary education, get selected for a limited number of positions in medical schools, and then get selected for a limited number of residency positions, and then complete residency and, for some specialties, an additional residency in your specialization.  And it takes probably on average, what,  4 years longer to get licensed in the U.S. than other countries?  But sure, easy enough I guess, and then you enter a market where government makes payments for about half of all costs, and then heavily regulated insurance companies pay for another roughly 38% of costs (with a lot of those insurance policies being paid for with tax-free income).  But sure, other than that, totally free market.   

[Jrr85]

First off, the wait list argument is overblown. But let's pretend that it's a huge problem (even though people in those countries are generally happy with their health systems). I'd be totally fine taking the risk that I might be in pain for weeks at some point if it meant saving $250k or $500k in today's dollars over my lifetime. That's a bargain. That's about the amount that other countries save per person compared to spending what we spend.

If a government agency publishes reports describing how terrible their service is, I tend to believe them, so I will take the wait list problem at face value.  And I recognize that I was the one that said weeks on end, but it's not a matter of being in pain for weeks, it's a matter of being in pain for a year or longer.  And of course it's easy to say that when you're not in pain.  And if we're going to accept people being generally happy with their health systems as good enough, why did we need Obamacare, since people were generally happy with their health insurance and health care in the U.S.  That's why they told the lies about being able to keep your coverage if you liked it.  Most people self reported that they were happy with their coverage and didn't want it to be changed by new regulations. 

You say it's not true. But then generally agree with me. Various rankings give the US being middle or bottom of the group of industrialized nations. I said we're about the same or worse than some that spend a lot less than we do. You can quibble with their methodology. But you seem to agree that our outcomes are at least pretty similar. And yet we pay double on average. Clearly not an efficient use of that extra money.

  Who are you to say it's not an efficient use?  The people who are getting a little extra life, or a little better quality of life, tend to think it's worth it.  I wish they would be spending their own money rather than largely spending government money, but the fact that we spend a lot of government money (or even insurance company money) on end of life care is hardly a reason to nationalize healthcare.  Provide a basic safety net and then let people buy the health care beyond the basics that they want (or by insurance that does or does not cover expensive end of life care). 

You say we can't politically do some things. But those factors have been controlled significantly by the private market for decades--not the government. Who decides what a doctor can get paid for a service provided to a person with private health insurance? The doctor and the insurer. They have decided that prices should be higher.

  They haven't "decided" costs should be higher.  Providers and insurers negotiate over reimbursement rates, and they negotiate in the context of what the providers can get from Medicaid and Medicare also.  Insurers essentially negotiate on behalf of insureds, but there is a limit to what they can do because the supply of doctors is constrained.  Their insureds want to actually be able to see a doctor, so they have to agree to reimbursement rates high enough that they get enough doctors in network that insureds feel they are getting good coverage.  And of course providers have to negotiate rates that are well above average cost of service, because Medicare pays below and Medicaid pays well below the average cost of service for most doctors and hospitals.

I don't hear a lot of argument that Medicaid and Medicare overpay providers in general. There are some specific services that Medicare overpays (like in chemo delivery), but in general for services I don't hear that claim.

  You don't hear that argument because Medicaid (grossly) and Medicare (somewhat) both underpay providers compared to average cost.  Hospitals do cost of service studies and Medicare is happy to be paying below average cost of service (but obviously above marginal), which means that private insurers must pay well above average cost of service.  But that's only a trick that can be pulled off if there are non-government payors.  If we did medicaid for all, reimbursement rates would have to come way up or it would be de facto rationing of care. 

[forummm]

Again, I'm just assuming you're correct that cosmetic surgeries are cheaper.

It's not that cosmetic surgeries are cheaper, it's that inflation in cosmetic surgery has been much lower than general healthcare, and it's been lower despite pay not trailing other sectors of healthcare.  That's the important thing to compare. 

OK. Again, I'm assuming this is correct because I have no idea. Can you provide any evidence of this?

If so, cosmetic surgeons can also have lower costs because they can do their surgeries in their offices. It's more comparable to outpatient surgery (which is also cheaper).

  To my knowledge, outpatient surgery in general has not experienced lower rates of inflation. 

Anytime you get a hospital involved, costs spike.

  I'm not sure that's true, but if it is, what does that tell you about how regulation impacts inflation?

Hospitals have a ton of overhead because of all the expensive equipment and the expensive building and losing money on people who don't have insurance, etc. Hospitals also buy up outpatient surgery centers because they can 1) charge the higher hospital rates, while 2) enjoying the lower cost of providing the services. So they jack up profits. Again, in a properly functioning market, the private insurers wouldn't put up with this and would only pay a lower rate. The real problem is that hospitals have monopoly or oligopoly in most markets. There isn't enough business to pay for more hospitals. And hospitals work to have a brand name. And they also try to form networks in each area so 4 of the 6 hospitals in the metro area might be owned by the same company. So this lets them essentially set prices. Insurers have to pay if they want the hospitals in their network. And insurance buyers (mostly employers) insist on having the hospitals in the networks of the plan they by. So lots of cost increase over time.

It's a failure of the free market. It's a lack of regulation and cost control.

And cosmetic surgeries may also be much less complicated than others (it's probably a lot harder to do a heart transplant or hip reconstruction than to suck out some fat or stick in some implants, and requires less staff support and cheaper devices and materials).

    So in the only sector that sort of gets to operate in a free market, they have found a way to economize and provide the same treatment for cheaper, but in other areas, they haven't?  You're proving my point. 

I don't know how that's related. It's just medically MUCH more difficult to do a heart transplant than to suck some fat out. The free market will charge you much more to build an entire house than to paint your house. Same thing.

You say the private market will work. But it hasn't. We had largely unregulated private sector providers and private insurance markets for decades for the ~200 million people who didn't have public insurance and those private markets just got more and more expensive. And totally non price transparent. The ACA has started to regulate private insurance, so in the coming years you could start to see whether those changes are good or bad. But pre-2010, costs were going crazy. Yes, you needed to have a medical license (but those aren't hard to get). But with that in hand, you could largely practice medicine however you, your patient, your patient's private insurance company, and your medical malpractice insurer (also private) agreed was acceptable medical practice.

There's a lot wrong here to unpack.  First, I'm not sure what decades you think we had free market in healthcare, but it certainly wasn't the decades leading up to the enactment of the ACA. 

We didn't have anywhere close to 200M people uninsured.  It was less than a quarter of that, and that includes anybody that is uninsured over the course of a year, which is probably the right way to look at if you are looking at policies aimed at alleviating short term breaks in coverage; it's not the right number if you are looking to put in place insurance provided by and paid for by the government. 

The ACA hasn't "started to regulate private insurance".  Private health insurance has been heavily regulated for at least a couple of decades before that.

Getting a medical license is not hard to get in the sense that it is easy to go through roughly four years of post secondary education, get selected for a limited number of positions in medical schools, and then get selected for a limited number of residency positions, and then complete residency and, for some specialties, an additional residency in your specialization.  And it takes probably on average, what,  4 years longer to get licensed in the U.S. than other countries?  But sure, easy enough I guess, and then you enter a market where government makes payments for about half of all costs, and then heavily regulated insurance companies pay for another roughly 38% of costs (with a lot of those insurance policies being paid for with tax-free income).  But sure, other than that, totally free market.

I didn't say there were 200M uninsured. I said there were 200M people without public insurance--i.e. they were privately insured or uninsured.

And insurance wasn't that regulated. Feel free to provide evidence that it was crazy over regulated. Since it was regulated almost entirely at the state level, you had plenty of opportunity for limited regulation states to show how their limited government provided amazingly low costs. Weird how that didn't happen.

All you need to do to be a doctor is 1) go to the lowest ranked accredited medical school in the country (or anywhere in the world where education is considered equivalent), 2) graduate at the bottom of your class, 3) do a 12 month residency, and 4) don't commit a major professional violation. That's it. Here's AZ's requirements for example. https://www.azmd.gov/PhysicianCenter/1422.aspx

[goatmom]

All you need to do to be a doctor is 1) go to the lowest ranked accredited medical school in the country (or anywhere in the world where education is considered equivalent), 2) graduate at the bottom of your class, 3) do a 12 month residency, and 4) don't commit a major professional violation. That's it. Here's AZ's requirements for example. https://www.azmd.gov/PhysicianCenter/1422.aspx

Do you know how hard it is to get into any medical school in this country?  You need to be at the top of your class, do outstandingly well on the MCATs, have lots of extracurriculars, impress on the interviews and still have some luck.  You then need to get through four years of medical school.  There are no 12 month residencies.  You mean a 12 month internship.  Along the way you need to pass three very rigorous licensing exams.  And yes, at that point you can call yourself doctor but if you don't complete a residency ( usually at least another three years ) no hospital is going to credential you.  Where I live, you can't get credentialed unless you complete a residency and pass your specialty boards.  Maybe this was easy - but it was a 12 year ordeal of often 80 hour weeks for me from start to finish.

[Jrr85]

OK. Again, I'm assuming this is correct because I have no idea. Can you provide any evidence of this?

https://www.aei.org/publication/what-economic-lessons-about-health-care-can-we-learn-from-the-market-for-cosmetic-procedures/

Hospitals have a ton of overhead because of all the expensive equipment and the expensive building and losing money on people who don't have insurance, etc. Hospitals also buy up outpatient surgery centers because they can 1) charge the higher hospital rates, while 2) enjoying the lower cost of providing the services. So they jack up profits. Again, in a properly functioning market, the private insurers wouldn't put up with this and would only pay a lower rate. The real problem is that hospitals have monopoly or oligopoly in most markets. There isn't enough business to pay for more hospitals. And hospitals work to have a brand name. And they also try to form networks in each area so 4 of the 6 hospitals in the metro area might be owned by the same company. So this lets them essentially set prices. Insurers have to pay if they want the hospitals in their network. And insurance buyers (mostly employers) insist on having the hospitals in the networks of the plan they by. So lots of cost increase over time.

It's a failure of the free market. It's a lack of regulation and cost control.

  You are arguing against your points.  First, it's regulation that drives a lot of the consolidation in insurance markets.  There is a lot of economies of scale in insurance, but the hefty regulatory costs puts smaller insurance companies at an even bigger disadvantage.  Once there are only a few insurers in a market, then it gives them a huge advantage in negotiating rates.  To counteract this, medical providers have to join together to be able to negotiate.  Hospitals are a natural entity to act as an umbrella to consolidate a bunch of providers under.  In most places, you will see very few independent providers any more.  They can't get the reimbursement rates they need.  And this is ignoring the impact of states that have Certificate of Need regimes, where you essentially have to ask for permission to compete with existing providers, which also drives consolidation.   

I don't know how that's related. It's just medically MUCH more difficult to do a heart transplant than to suck some fat out. The free market will charge you much more to build an entire house than to paint your house. Same thing.

Again, it's the inflation rate that's relevant.  And it's not just surgeries where inflation has been high.  It's been high across the board, except for the one place where third party payments are not as prevalent and the pricing mechanism is allowed to work. 

I didn't say there were 200M uninsured. I said there were 200M people without public insurance--i.e. they were privately insured or uninsured.

Doesn't seem like a problem for people to get private insurance that they pay for. 

And insurance wasn't that regulated. Feel free to provide evidence that it was crazy over regulated. Since it was regulated almost entirely at the state level, you had plenty of opportunity for limited regulation states to show how their limited government provided amazingly low costs. Weird how that didn't happen.

  Lighter regulation didn't provide amazingly low costs (which is unrealistic to expect given the supply constraints on the market), but it did provide cheaper rates.  http://www.heritage.org/research/reports/2005/10/the-effect-of-state-regulations-on-health-insurance-premiums-a-preliminary-analysis#_ftn3  And again, this is relatively lighter rates.  I think there are probably a lot of lawyers and insurance company employees that would be a little perplexed by your statement that they weren't that regualted. 

But regardless, a lighter regulatory touch does tend to result in cheaper rates, because coverage mandates, guaranteed issue, community rating, etc. cost a lot of money, and that's typical of how more regulation manifests itself.  A somewhat lighter regulatory touch doesn't really equip insurers to restrict inflation, but at least they didn't unnecessarily add to it.  For health insurers to slow the growth in medical costs, they'd have to be able to go back to the HMO model used in the 90's, which people hated because they didn't like HMO's deciding that they wouldn't reimburse for certain procedures or treatments, which resulted in complaints to state and federal legislators, which resulted in threats of more regulation. 

[Daleth]

We've been trying to make healthcare 'affordable' through 50+ years of government healthcare expansions, and look where we're at now. Why should we believe that more of the same will help?

Because practically every other country in the world has far more government involvement in healthcare and their costs are lower with overall better outcomes.

Bingo.

Can anyone point to another country that has as little, or even less, government involvement in healthcare costs as the US does, and also has lower costs? That is a rhetorical question...

[Daleth]

You can't just compare expenses and think you are doing a meaningful analysis.  Most fairly rich countries that spend less than the U.S. per capita on healthcare use a pretty simple trick to do it, and a trick that most voting americans would not be ok with.  They just stop spending more money on healthcare.  Once you've more or less nationalized healthcare, it's a lot easier to ration by just not approving procedures or just having a significant wait times.

This certainly sounds plausible, particularly with end of life related expenses (someone linked a picture showing how much more the USA spends on age 67+ care than other countries -- the bulk of the difference between US healthcare spending and other countries).

Is there any research into this sort of analysis? Comparison of average procedure wait times for the USA vs countries in Europe, how hospitals/doctors would respond in various scenarios?

That's not actually the "trick" to spending less on health care. I've lived in the US, France and the UK and have experienced all three systems. This story pretty much sums up the US/France difference: When I lived in France I hurt my shoulder rollerblading and went to a doctor. I got an appointment like two days later, none of this "we're scheduling 3 months out" BS that you get in the US. He examined me, asked a bunch of questions, tested my range of motion and said, "It looks like you've pulled a muscle. Here's a prescription for some pain killers and some muscle relaxants. Take them for two weeks and you should be fine." He charged me the equivalent of $20, of which 65% was reimbursed by my French insurance, so total out of pocket was SEVEN BUCKS plus the prescriptions (which cost less than $20 and were also reimbursed at 65%).

A few days later I flew to the US to visit my mom and made the immense mistake (given my mom's worried nature) of mentioning this. She packed me off to the nearest emergency room to make sure I hadn't broken a bone. I spent 6+ hours there, saw a bunch of techs and residents, caught a brief glimpse of a doctor, got an x-ray... and was told, "Looks like you pulled a muscle. Here's a prescription for painkillers and muscle relaxants. You should be fine in a week or two"--and they charged me almost TWO THOUSAND DOLLARS!!!!!!

Point is, I got the same care (plus an x-ray in the US) at a drastically lower cost. The money wasn't saved by denying me care, but by running the system way the hell more efficiently.

France is awesome. No wait times (the UK has been known to send patients to France to get procedures when the wait times in the UK became ridiculous). Great results, including at the scientific discovery level (first face transplant, discovery of the HIV virus, etc.). No excess paperwork; no paperwork at all in most cases, since everyone has the same primary insurance and that's what doctors deal with (you as the patient handle the extremely minimal paperwork to get the additional reimbursements from your secondary insurance), and the national primary insurance sets maximum charges for everything, which is what all doctors charge. This means that you know up front what the costs will be, because you know what the doctor charges and what your insurance reimbursement will be. Generally you just hand the doctor your card, she runs it like a credit card (automatically paying herself the 65% or whatever that insurance reimburses), and you pay her the difference.

In France the extreme simplicity of insurance and the lack of paperwork mean that when you go to a doctor's office, the only people there are the doctor(s) and the receptionist. Doctors don't need to hire ANYONE to deal with insurance, which obviously saves them a ton of money on both salaries/benefits and rent (no need to rent extra space for employees dealing with insurance). That translates to massive cost savings for patients, both for everyday doctor visits and for hospital stays, physical therapy, etc. And the same is true of other costs that doctors have to bear: French doctors don't have $250k in student loans to pay back; they have $0 in loans. And they don't have to spend $20k or $50k a year on malpractice insurance, because that's covered by a national fund that spreads the cost over everyone (all taxpayers contribute a tiny bit). And here's a blog post with more info on how they save money: http://dolanecon.blogspot.com/2011/03/what-can-us-learn-from-french-health.html

So they're saving money by (ahem) making it cost less. Not by denying people treatment.

[ender]

Point is, I got the same care (plus an x-ray in the US) at a drastically lower cost. The money wasn't saved by denying me care, but by running the system way the hell more efficiently.

Uh, so you can't really compare a doctor on a prescheduled visit resulting in a short appointment and "you're probably fine, take some pain killers" vs going to the ER (?) and then having many hours of appointments and x-rays and then be surprised the latter cost a lot.


I mean, I don't disagree that they might be more efficient. But acting as if a routinely scheduled appointment and an ER visit should cost a consumer same? That seems... shortsighted.

[goatmom]

I guess the problem is that you went to the ER for a pulled muscle in the first place.  Americans are too quick to use the ER for non-urgent care.  And due to fear of malpractice - the doctors order unnecessary x-rays.  Not only unnecessary but potentially harmful.  And costly.

[EnjoyIt]

You can't just compare expenses and think you are doing a meaningful analysis.  Most fairly rich countries that spend less than the U.S. per capita on healthcare use a pretty simple trick to do it, and a trick that most voting americans would not be ok with.  They just stop spending more money on healthcare.  Once you've more or less nationalized healthcare, it's a lot easier to ration by just not approving procedures or just having a significant wait times.

This certainly sounds plausible, particularly with end of life related expenses (someone linked a picture showing how much more the USA spends on age 67+ care than other countries -- the bulk of the difference between US healthcare spending and other countries).

Is there any research into this sort of analysis? Comparison of average procedure wait times for the USA vs countries in Europe, how hospitals/doctors would respond in various scenarios?

That's not actually the "trick" to spending less on health care. I've lived in the US, France and the UK and have experienced all three systems. This story pretty much sums up the US/France difference: When I lived in France I hurt my shoulder rollerblading and went to a doctor. I got an appointment like two days later, none of this "we're scheduling 3 months out" BS that you get in the US. He examined me, asked a bunch of questions, tested my range of motion and said, "It looks like you've pulled a muscle. Here's a prescription for some pain killers and some muscle relaxants. Take them for two weeks and you should be fine." He charged me the equivalent of $20, of which 65% was reimbursed by my French insurance, so total out of pocket was SEVEN BUCKS plus the prescriptions (which cost less than $20 and were also reimbursed at 65%).

A few days later I flew to the US to visit my mom and made the immense mistake (given my mom's worried nature) of mentioning this. She packed me off to the nearest emergency room to make sure I hadn't broken a bone. I spent 6+ hours there, saw a bunch of techs and residents, caught a brief glimpse of a doctor, got an x-ray... and was told, "Looks like you pulled a muscle. Here's a prescription for painkillers and muscle relaxants. You should be fine in a week or two"--and they charged me almost TWO THOUSAND DOLLARS!!!!!!

Point is, I got the same care (plus an x-ray in the US) at a drastically lower cost. The money wasn't saved by denying me care, but by running the system way the hell more efficiently.

France is awesome. No wait times (the UK has been known to send patients to France to get procedures when the wait times in the UK became ridiculous). Great results, including at the scientific discovery level (first face transplant, discovery of the HIV virus, etc.). No excess paperwork; no paperwork at all in most cases, since everyone has the same primary insurance and that's what doctors deal with (you as the patient handle the extremely minimal paperwork to get the additional reimbursements from your secondary insurance), and the national primary insurance sets maximum charges for everything, which is what all doctors charge. This means that you know up front what the costs will be, because you know what the doctor charges and what your insurance reimbursement will be. Generally you just hand the doctor your card, she runs it like a credit card (automatically paying herself the 65% or whatever that insurance reimburses), and you pay her the difference.

In France the extreme simplicity of insurance and the lack of paperwork mean that when you go to a doctor's office, the only people there are the doctor(s) and the receptionist. Doctors don't need to hire ANYONE to deal with insurance, which obviously saves them a ton of money on both salaries/benefits and rent (no need to rent extra space for employees dealing with insurance). That translates to massive cost savings for patients, both for everyday doctor visits and for hospital stays, physical therapy, etc. And the same is true of other costs that doctors have to bear: French doctors don't have $250k in student loans to pay back; they have $0 in loans. And they don't have to spend $20k or $50k a year on malpractice insurance, because that's covered by a national fund that spreads the cost over everyone (all taxpayers contribute a tiny bit). And here's a blog post with more info on how they save money: http://dolanecon.blogspot.com/2011/03/what-can-us-learn-from-french-health.html

So they're saving money by (ahem) making it cost less. Not by denying people treatment.

About 25 years ago my parents took me to see the doctor for a cold.  Office consisted of  just the doctor and the receptionist.  We knew before hand the cost of the visit.  Everything was very quick and personable.  Prior to leaving my parents wrote a check.  I can't remember how much it was, for some reason $45 is in my mind but I just can't remember.  I got my prescription and we went home.  Later that week my parents submitted the bill to the insurance company which covered everything but $5.  This seams very similar to what you described above but when there was less regulations in the US.

BTW, You could have visited your doctor instead of the ER and paid a fraction of the cost, but your mother chose poorly to go to an Emergency facility without having an emergency concern.

Forummm,
If getting an MD was easy many many more people would have one. On behalf of all doctors I want to tell you off, but I doubt you would care.

The rest,
Our medical system is fucked up.  Although it is true that some socialized healthcare models in other countries have significant benefits, it is also true that the segments of our healthcare industry that are not reimbursed by insurance actually decrease in cost.  Plastic surgery was one example.  Another example is vision correction. Lasik surgery used to cost thousands and now can be attained for a few hundred.  Basic dental care has not gone up outside of inflation as well.  None of those things have insurance intertwined and the cost of service is completely transparent.

The problem with going all socialist healthcare tomorrow is that most doctors and hospitals would go out of business.  The profit margin for most institutions is 1-3%  Cutting reimbursement for everything would cripple the system.  Physicians with $250k-$400k loans would go bankrupt.  Hospitals would be forced to lay off hundred's of thousands of people and many would likely be forced to close their doors.

I have laid out a sound plan for fixing the problem before and it all needs to start with transparency of cost and the ability to compete in a free market.  You want to have a social component to healthcare and that is fine.  We need a safety net for those who can not afford medical are. This is especially true in emergency situations.  In the process of cutting costs we need to eliminate malpractice while having a system in place to either remediate poor performers or remove them from practicing medicine.  Next, we need to stop irrational procedures on the brain dead, bedridden patients with no quality of life, and we need to work on decreasing the cost of medical education.  Lastly, we need to decrease documentation requirements allowing providers and nurses to be more efficient again which decreases the need to hire ancillary staff to do tedious paperwork that has no benefit to the patient.

Today I find myself spending well over half my day in front of a computer documenting instead of providing patient care.  Nurses who used to manage 15-20 patients years ago now can barely manage 4 or 5 at a time.  While at the same time hospitals hire teams of office people involved in regulatory paperwork, compliance and collections.  Just minimizing the above would cut costs well over 25%.  But unfortunately our government is a massive behemoth that would rather spread the wealth of healthcare amongst all those employees.  After all, all those regulations provide jobs.  Useless bullshit jobs that provide no medical benefit to the patient.

To those that have no experience in the medical field, just picture a world where the tax code was simple and could be figured out on a napkin by anyone.  The cost of doing taxes would plummet as well as the cost of making sure everyone is doing their taxes appropriately would plummet.  Unfortunately in the process many IRS employees and accountants would also be out of work.  We are in an intertwined mess. What government official wants to be known for firing 90,000 of the 95,000 IRS employees1 and bankrupting 1,000,000 of the 1,200,000 accountants in the US2?





1http://www.fool.com/investing/general/2014/02/08/10-incredible-facts-you-probably-didnt-know-about.aspx
2https://www.statista.com/topics/2121/accounting-industry-in-the-us/

[Daleth]

Point is, I got the same care (plus an x-ray in the US) at a drastically lower cost. The money wasn't saved by denying me care, but by running the system way the hell more efficiently.

Uh, so you can't really compare a doctor on a prescheduled visit resulting in a short appointment and "you're probably fine, take some pain killers" vs going to the ER (?) and then having many hours of appointments and x-rays and then be surprised the latter cost a lot.


I mean, I don't disagree that they might be more efficient. But acting as if a routinely scheduled appointment and an ER visit should cost a consumer same? That seems... shortsighted.

It depends on what happens during the ER visit, doesn't it. I didn't have "many hours of appointments"--I had many hours of sitting there, punctuated by an aide coming in to take my blood pressure, a resident popping in to ask what happened, an X-ray and finally a doctor spending approximately two minutes telling me the same thing the French doctor had told me. And one of the problems with the US in any case is that if something like that happens, you can't get an immediate appointment with your doctor--you can't even get one in the next week or two, usually--and if you don't already have a doctor, nobody will see you. That's why people end up having to go to the ER. Also, this was back in the 90s when urgent care centers didn't exist. Now they exist in some places, but very far from all.

[RangerOne]

The ER is not an economical option in the US unless you are well insured. Simply being seen usually runs a couple grand which comes straight out of your pocket if you have a deductible. The ER should really be reserved for immense pain or something that is life threatening. If you have extreme pain the ER will have you brought back with priority second only to people who are bleeding to death. Keep in mind we also have urgent care facilities which should be used for sudden issues that aren't life threatening or suspected of being life threatening.

Generally I find that under a PPO plan I can see a general practitioner about minor issues the same day or next day. I have never been told to wait longer than a day. Maybe if you are recommended to a specialist things may take longer.

With a deductible under Blue Cross Blue Shield a simple office visit costs ~$200 to see the doctor. Then maybe an extra $100 if you need a lab test, ~$200 for an x-ray. Pretty sure MRI's are much more expensive but haven't paid for one yet.

All I am saying is that PPO insured people in the US get near same day or next day service for all basic health issues. Paying for it is more complicated because you have to fully understand your own insurance provider. Most of us have deductibles these days of at least $1000 a year so you are likely to see full price on at least a few doctors visits.

[monstermonster]

I've been HMO and PPO'd insured and I've never had trouble getting a primary care appointment - or even a rheumatologist appointment- within a day or two. Perhaps I'm just lucky? It's not as though my city is a bustling metropolis, I assume it must vary wildly by region.

I also live four blocks from Zoomcare if I wanted to walk over.

I think the problem with this particular story is you went to the ER for a pulled muscle, not the differences in healthcare systems.

[forummm]

Forummm,
If getting an MD was easy many many more people would have one. On behalf of all doctors I want to tell you off, but I doubt you would care.

Did I say it was easy? No. I said that getting a license to practice medicine wasn't that big of a barrier to entry. Definitely not to the extent that it's the reason medical costs are so high in the US. You can be a pretty bad doctor and still have a license.

Getting an MD and completing residency is usually very hard. And they also like to torture you with not getting enough regular sleep. But many other things in life are hard too. Many PhDs are just as hard to get as an MD IMO. The difficulties are sometimes different (maybe less sleep deprivation and more dissertation stress) but are still there. And there is no objective independent measure that you can rely on to satisfy and be assured your PhD--it's up to the arbitrary and capricious opinions of a handful of faculty members. And beyond that, you won't be able to get a job if your work wasn't high quality--as judged by the arbitrary and capricious opinions of a group of faculty members who may not have particular expertise in your area.

[stoaX]

I've been HMO and PPO'd insured and I've never had trouble getting a primary care appointment - or even a rheumatologist appointment- within a day or two. Perhaps I'm just lucky? It's not as though my city is a bustling metropolis, I assume it must vary wildly by region.

This mirrors my experience - I guess we're both just lucky. 

And perhaps it does vary by region, but I have never had a wait in the places I have lived as an adult - Connecticut, Utah, Northern California and Southern California.

[moof]

I guess the problem is that you went to the ER for a pulled muscle in the first place.  Americans are too quick to use the ER for non-urgent care.  And due to fear of malpractice - the doctors order unnecessary x-rays.  Not only unnecessary but potentially harmful.  And costly.

Not entirely fair, our system funnels people there.  I'll take my wife's recent experience:

1)  Call the doc due to bad wrist pain and a weak left hand grip.  Things are booked up for at least a week, and the symptoms are concerning enough they tell her to go to Urgent Care ASAP, freaking her out.  I wish she had talked to me about things at this point, but she was kind of panicking and just did what they said.

2)  Urgent Care is staffed by nitwits who can do stitches and hand out antibiotics, but suck at diagnosing anything else, so they tell her to go to the Emergency Room.

3)  Emergency room looks at her funny and can't understand how she ended up in their lap, even after calling the doc at Urgent Care.  Nothing life threatening is found, as they suck at anything that is not a broken bone, bleeding, or airway issue.  So they send her home.

So a full day is wasted until it dawns on both of us at once as we are grumpily heading to bed that the way she has been putting on her stupid FitBit one handed presses right on the painful spot , and that likely just irritating the tendons resulting in tendonitis.  A week of rest and no FitBit and she is A-OK.

Our system is poor on preventative care, and funnels people to the emergency room way too readily.

[Northwestie]

Oh no,  don't blame this one on the system.  I declare operator error.  Why was it necessary to go in right away?  Was it keeping her awake at night, was it above a 5 on the pain scale, was the sensation spreading, was there any reason not to just wait a day or two to see if it cleared up?

[EnjoyIt]

Oh no,  don't blame this one on the system.  I declare operator error.  Why was it necessary to go in right away?  Was it keeping her awake at night, was it above a 5 on the pain scale, was the sensation spreading, was there any reason not to just wait a day or two to see if it cleared up?

Although your statement is accurate, so is the comment that the system is geared towards shoving people into the ER. Many private practices are booked up and the person answering the phone will often say "just go to the ER."  I see it all the time.

[Gin1984]

Oh no,  don't blame this one on the system.  I declare operator error.  Why was it necessary to go in right away?  Was it keeping her awake at night, was it above a 5 on the pain scale, was the sensation spreading, was there any reason not to just wait a day or two to see if it cleared up?

Oh come now, you can't declare user error when the AVERAGE basic science knowledge for the American citizen is about grade 6 and the system solution is for the patients to obey the MDs.  They followed the MDs medical advice.

[goatmom]

I love the Urgent Care by my house.  They are fast, clean, and serve coffee and tea.  The docs are great.  We also have an urgent peds place that is open until midnight.

What happened to our old time family doctor?  When you called with an urgent matter - you were told to come by the office.  Now most practices are part of these mega-practices and the docs can't jut tell patients to show up or that they will stop by the patient's house on the way home.  Also, our lawsuit happy culture makes doctors always worrying about CYA.  They need to tell you to go to the ER if you are concerned.  That is what the malpractice carrier tells you to do.

It really is sad. 

I have seen people in the ER with yeast infections, diaper rash, stubbed toe, or a pregnancy test.  Really?  Are we really that dumb?

[Mississippi Mudstache]

Oh no,  don't blame this one on the system.  I declare operator error.  Why was it necessary to go in right away?  Was it keeping her awake at night, was it above a 5 on the pain scale, was the sensation spreading, was there any reason not to just wait a day or two to see if it cleared up?

Although your statement is accurate, so is the comment that the system is geared towards shoving people into the ER. Many private practices are booked up and the person answering the phone will often say "just go to the ER."  I see it all the time.

It's pretty much impossible to see a general practitioner where I live. None of them are accepting new patients. My wife has been waiting to see an ENT for swollen lymph nodes for over a month. Her appointment is next Friday. She's been to urgent care twice in that period, but they're just useless prescription factories who can't handle anything more complex than strep throat or a sprained ankle. "Here, have an antibiotic". It's pathetic.