Economics

The BCRA Is An Improvement Over Obamacare. Here’s Why..

Dr. Jha writes on these pages in typically stirring fashion about his views on the recent health care kerfuffle and rightly so fingers what the real focus of our efforts should be: Cost.  He ends by slaying both sides because of their refusal to confront the hospital chargemonster – the fee schedule hospitals make that remarkably only really applies to the uninsured.

Unfortunately, the solution proposed ensures hospital fee schedules for the uninsured are no greater than Medicare reimbursements, which is far from perfect.  Consider that the Medicare reimbursement for a stent placed to an ischemic limb is in the range of $15,000.  While this makes for a less daunting bill for the uninsured, in reality for the vast majority of folks that are uninsured $15,000 is about as far away as $150,000.

But my major disagreement with the good Dr. Jha relates not to his attempt to slay the chargemaster, but his underappreciation for the attempts made in the GOP bill to control health care spending.  A conservative mantra about the why of health care costs focuses on the existence of deep pocketed third party payers that make costs opaque to patients.  Attempting to have patients understand what they’re being charged has been conservative dogma, and there are a number of studies that suggest patients with health saving accounts are more cost conscious when they interact with the health care system.  Dr. Jha glosses over this important point – This is the Republican attempt to bend the cost curve!  And at least to this physician who’s lived through the last eight years, a plan that has a considerably greater chance of success than any number of failed acronyms designed so far by enlightened theorists from the Acela corridor.

HSA chart

The policy experts are hard to convince about HSAs, and point to the above chart as evidence of the uselessness of HSAs.

Our major problem clearly relates to the small number of patients (5%!) that account for 50% of all healthcare spending.  Patients that spend within their deductibles, I am told, aren’t why health care is expensive.  But this argument seems to imply that that the low lying fruit lies in the sick 5%, rather than the relatively healthy 95%.  This is bass ackwards – looking for cost efficiency gains is certainly possible for the 42 year old man who walked into my office today, a full year after dying while shopping at a PETCO.  He had no medical history prior to falling flat on his face in aisle 3.  A nurse who happened to be nearby started CPR, a police officer responding to the 911 call happened to have an defibrillator which found a shockable rhythm and delivered a shock which allowed the patient to make it to a neurointensive care unit where he was cooled to limit injury to his brain.  On waking, multiple incessant bouts of a ventricular arrhythmia – an electrical storm – followed that required not one, but two emergent procedures performed after hours on separate days.  A team lead by electrophysiologists finally mapped the source of his electrical storm and extinguished it.  The intensity of care that was delivered in this case is matched only by the cost of all of this care.  This is care that won’t be seen in life expectancy or infant mortality comparisons that would give you the false impression that Cuba or Chile are more appealing countries to get sick in.

Critics of the current system will point out that even if overall life expectancy and mortality statistics are blunt instruments, a more granular look at mortality rates for conditions that should be preventable – so called amenable mortality – also do not give favorable reviews to American health care.  A recent Lancet analysis that accounts for amenable health care conditions still ranks the United States behind the usual cast of European countries but also finds itself tied with Estonia, and behind Qatar and Kuwait.

Those puzzling over a model that finds Andorra and Iceland(#1 & #2) as countries that are ostensibly the best at preventing disease, won’t be surprised to hear that I think the methodology used to generate this list borders on useless.  Simply assigning cause to mortality can be difficult.  Attempting to ascertain which deaths may have been preventable with societal intervention with some degree of certainty would seem to be a tall task.  But there is no amount of complexity that seems beyond the data scientists of the 21st century.  Take ischemic heart disease – a disease that accounts for 7 million deaths world wide.  The WHO takes the stance – largely based on correlative studies – that a large percentage of cardiovascular mortality is preventable.  The actual percent preventable is again more feelings based on correlation with some experts stating 50% of deaths may be prevented with increased attention to diet and exercise.  Never mind that we don’t know what a good diet is, and the evidence from randomized control trials of diet would suggest at most a modest effect of diet on cardiovascular events.

Diet-effect-CVdeath

Even if we were to agree about the strength of the link between diet and cardiovascular mortality, is it reasonable to think that cheesesteak-loving Philadelphia will be amenable to cheesesteak reduction strategies?

Perhaps even more importantly, the diseases that are amenable to reductions in mortality change over time.  Chronic Myelogenous Leukemia (CML) used to be a diagnosis associated with a 5 year survival of 31%.  The discovery of Gleevec – a daily pill – revolutionized the treatment of this disease. Five year survival now stands at 69%.  Andorra and Iceland, by dint of size and economic scale, contribute little to the development of the next generation of wonder drugs and therapies but do accrue all the benefits of such a system.

The cost of such innovation is not cheap.  The cost of care delivered to all out of hospital cardiac arrests in the hopes that one 38 year old will walk out are massive.   It is easy to see why we spend so much on so few.  But should we be looking for savings in those with the greatest potential for improvement?

I’d argue strongly that it is the remaining 50% of care provided to 95% of the population – statins for primary prevention using a calculator that overestimates risk and would expand the pool of statin takers inappropriately by millions, ER visits for chest pain that take a test first, ask questions later policy, and 90% of MRIs for back pain.  This is the type of care that desperately needs primary care physicians with time to parse and avoid this type of low yield, expensive utilization of health care resources.  And it is with this in mind that I get on my obligatory soapbox whenever anyone asks to suggest that the Direct Primary Care movement (which involves direct flat monthly payments between patients and physicians to cover the vast majority of outpatient care needs) is an important part of the solution.  I’ve written before about how Obamacare doesn’t work particularly well with the DPC movement because the generous essential health benefits and the individual mandate results in physicians having to convince patients to pay $50-$100/month on top of the $400/month they are already paying for that wonderful high deductible bronze plan.  The BCRA is a win for DPC because it takes away the individual mandate, allows skinnier catastrophic only plans and allows for HSA’s to be used for monthly subscription type payments to physicians.  For those without the income to fully fund HSAs. state subsidized HSAs with nominal $5-$20/month patient payments would prove to be a cost efficient way of delivering high value care to those who need it the most.

The biggest issue Democrats have with the GOP attempts to reform health care as it exists relates to federal subsidies.  Support from the federal government in the House version for buying health insurance was in the form of flat tax credit based on age.  This happened ostensibly because small government conservatives like Paul Ryan, and Rand Paul believe any federal subsidy to insurance companies or patients raises the cost of health care.  Market-based proponents of universal health care are supportive of expanded subsidies to provide a safety net and the Senate Bill is reflective of these concerns.  The Senate version of the health care bill (BCRA) simply builds on the ACA infrastructure to provide premium tax credits that are less generous but (like the ACA) are based on age, income, and cost of insurance plans in the local market.

At 100% of the FPL ($11,880) premium payments would be capped at 2% of income –  ~$23/month.  If a plan with a premium less than the median value of plans locally were chosen, the monthly cost would be even less.  Someone in their 20s at 350% of the FPL ($41,580/year) would pay no more than 6.4% of their income in premiums ($260/month), while someone in their 60s at 350% of their FPL would pay a maximum of 16.2% of their income in premiums ($655/month).

High risk individuals with pre-existing problems have always been a tough lift for the individual market, and the ACA dealt with this by not allowing insurance companies to risk adjust – a so called community rating.  This had the effect of raising insurance costs greatly and saddled young, healthy individuals in the pool with higher costs – a fact not lost on the healthy insured who saw entering the market as a bad deal, and stayed out of the marketplace – choosing instead to pay a fine for not having insurance.  This was the problem of adverse selection that the BCRA hopes to solve by creating high risk pools and allocating fairly large sums of money specifically to help states lower the out of pocket cost of care for these individuals. The hope is that these direct federal subsidies for high risk patients will protect and stabilize the larger individual market. (Alaska appears to have done this successfully, funding the plan through a tax on health insurance companies).  The BCRA would allocate $50 billion in the first 4 years and another $60 billion over the course of 8 years for this same purpose.  It is hard to decide if these are appropriate amounts, but scale and context is provided by the national high risk pool that existed under the Obama administration prior to the ACA coming online in 2014.  At its peak enrollment, ~100,000 patients were enrolled in this plan with an average premium of ~$32,000.  Even tripling the number of currently high risk uninsured patients to 300,000 would still mean that the proposed funding would be greater than what was allocated per patient in the national high risk pre-ACA pool.

The CBO thinks little of any of these machinations – the coverage numbers change little whether there was a flat tax credit or expanded tax credits as present in the senate bill.  It would seem that the only way to get a good CBO score would be to impose a strong individual mandate with heavy subsidies for insurance companies, which effectively doubles down on the ACA approach, and does nothing to actually lower the cost of healthcare.

The current debate about the GOP bill, which looks and smells a lot like the ACA, misses the point  as it is designed to do by those having the debate.  The goal of those on either side is to win at all costs – and in this case the party under siege, the Democrats, have weaponized the debate in order to provoke moral outrage.  It is virtually impossible to discuss Medicaid reform at this point because anyone supporting alternative paths that don’t involve greater federal subsidies for insurance companies is guilty of manslaughter.

The debate we should be having should focus on how to make the Medicaid program financially sustainable, expand access, and improve the quality of healthcare.  The only way to achieve this is to decrease the cost of health care – a goal that won’t be achieved by simply making hospitals charge medicare rates to the uninsured.  The Senate Bill attempts to create a robust individual market that safeguards patients from catastrophic medical bills, expands individual choice and personal responsibility with HSAs, and expands subsidies for those that need it.  There will be losers in an alternative path, and it should come as little surprise that organized medicine, the American Hospital Association and health insurance plans,are vehemently opposed to any plans that would threaten their stranglehold on the nation’s wallet.  I think we can do better, and current reform efforts that put patients in charge of their healthcare dollars with additional help for those that need it seems a reasonable step forward.

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48 replies »

  1. “And then he died”

    That is your fantasy. It turns out he didn’t die, but your ideology has to kill tens of millions of people if they don’t carry insurance. It is all BS. and because of this type of BS some patients actually don’t get the care they need because the BS has forced the system to be raped and plundered.

  2. In other words, he managed and obtained care like so many others. Being primarily an Internist I treated a lot of patients with no insurance or high deductible insurance. I told them the usual medical path and then we stripped that path down to the necessities. We didn’t run for an MRI and an orthopedic consult after a strain of the back.

    Why didn’t he carry insurance?
    Why didn’t he carry insurance before he got sick?
    Why didn’t he have high deductible insurance?
    If he had employees why didn’t he get a group policy?

  3. I didn’t even restrict my comment to just people on Medicaid. I have always spent most of my time in urban areas so there is no lack of doctors nearby.

    All one has to do is interview each patient that ends up in an ER and they will provide loads of good reasons that have nothing to do with access.

  4. Yes and no. I believe in a safety net, but that need not be the Medicaid we presently have.

    I picture a safety net as a true safety net that people leave as soon as they are able and move into the system that everyone else is in. I believe in subsidies to help those in need remain in the same pools as the rest of the population. I don’t believe in subsidies that are used to buy votes. I also believe in personal responsibility.

  5. Peter, I provided a simple example to keep things simple. Patients have all sorts of extenuating circumstances and co morbid diseases. Each patient reacts differently.

    I believe in listening to the patient. They have the ability to add to their own treatments. When determining the best course of treatment one has to determine the best course for a particular patient. Hadler said something similar, but my statement was that I was the captain of the boat and you were the admiral. I can only provide you with my knowledge and skill, the choice of action is yours.

    A simple break of the finger isn’t very eventful until or unless that finger is connected to a concert pianist or something similar. There is not just one way of managing a specific disease.

  6. Anish, I noted that when I was still in practice if the patient were cash pay or bought their own insurance on a free market I felt I could have saved a huge amount.

    Most patients don’t need a consult to remove a skin tag until they are so insured that it costs them nothing to get a consult. Most patients don’t need today’s gold standard medications to treat hypertension and heart disease. They could use last years gold standard at a much lower cost. Most people don’t need the latest in scanning equipment. In fact many don’t need any. Office visits don’t end up with the patient hospitalized as frequently and non fractured care can avoid hospitalizations in the first place. Then we come to all these services (VN, PT, DME) that provide benefit to a few and to many not enough benefit because we are treating code numbers rather than patients.

    A number of years back it became fashionable to prescribe diabetic shoes. I don’t know how many requests I got from podiatrists to document the need for a diabetic shoe when the need didn’t exist. I lost a good number of patients refusing to line pockets. We have got to reinstate the intellectual integrity of the physician and move away from treating code numbers.

  7. The top 5% are the scapegoat for why we can’t have a working market for the 95%… Yes most care now is overpriced – so what would the point of using real dollars be? I’m suggesting much of what’s done now – even below deductible is too expensive. I just saw an uninsured patient whose blood pressure was very high. I ordered labs with an online company for $30, started meds from wmt at $4/month, and asked him for a nominal fee for the visit. If I had sent him to the local hospital lab – those labs would have been hundreds of dollars because of the lovely chargemaster.

    With a teensy bit of help, I could provide even more comprehensive care to him. Regardless, for him… not necessarily the population – this is treatment that could avoid a heart attack or stroke that comes along with very high blood pressures.

  8. That’s what the state innovtion funds is for – $50billion over 4 years, $60 billion over 8 years, and now additional $70billion proposed – language in bill is that dollars are to reduce costs – here’s text –

    “Reduce out-of-pocket costs, such as copayments, coinsurance and deductibles, of individuals enrolled in plans offered in the individual market.”

  9. “He bought what he could afford from his personal savings. He chose to pay for some care and skip other. He was self-employed.”

    And then he died – The Republican Plan.

  10. I don’t remember any mention of the government putting money into HSAs in the AHCA or BRCA. Is that in there?

  11. He bought what he could afford from his personal savings. He chose to pay for some care and skip other. He was self-employed.

  12. Probably because there is no doc near them that will accept Medicaid. Again, not the patient’s fault.

  13. If sick people were kept from getting health access then blame the states who set the rules on eligibility.

    But don’t you want to restrict expansion of Medicaid? Doesn’t that dent treatment access?

  14. Collaboration should be about best care for the patient, not how much money is in the HSA.

  15. Assume in the hypothetical that you did not tell the doc about the hematologist diagnosis – how come. And if you only have 3 months to live why did you go to the brain tumor doc.

    But it’s interesting that you describe the example with the patient making the decision to not have the tumor operated on – where else would you want the decision?

  16. Peter, I have worked in ER’s and have seen poor people using the ER for things that belong to be treated in a doctor’s office.

  17. Apparently when Medicaid was expanded in some states, meaning a lot of healthy people got Medicaid ,other rules were tightened for budget reasons causing sick people to lose coverage.

  18. How about:

    Patient: I realize I might have a brain tumor, but my hematologist already told me that I am not going to survive more than 3 months. Do you really think we should pursue this finding that likely won’t turn up anything, but will waste part of my remaining time on this earth? Should I spend the money on a work-up or should I spend it on quality time with my children?

  19. I’ve treated those people you talk about, Peter. What Paul says makes excellent sense. Adding a bit of the free marketplace into healthcare can improve the delivery of healthcare.

    The best example I have seen involved my diabetics. Those diabetics that were uninsured were more likely to be cautious about how they managed their diabetes than those that were insured. They wanted to save on office visits, testing and the cost of their own supplies.

    All patients should question their doctors. Those questions frequently provide information that is just as important as the information provided by the patient when providing the doctor with a history. Intelligent questions also help to prevent errors.

  20. Just go read Hadler….although hangnails is not one of the categories of over use/medicalization he addresses.

  21. Peter, it is called collaboration and exploration with one’s doctor, not distrust. From what you said in your last post, I suspect we aren’t far apart in how we operate.

  22. Very impressive statement Paul. But what does it mean in real life when your doc says you need an MRI and you say no, that’s not the correct diagnosis.

    Why would you go to a doctor if you’re not going to take their advice?

    BTW, I avoid docs like the plague, usually use a PA at walk-in clinic, but when I go it’s because I’ve can’t solve the problem myself. I would not go unless I trusted the advice I was going to get. Poor people usually have less capacity to question their doctor, especially on medical grounds. How far does your medical degree take you Paul?

  23. Peter,
    Suggest you read any of Nortin Hadler’s books that address the optimal doctor patient relationship as well as extensive discussion of where there is rampant wasteful and harmful and costly over medicalization.

    Here are two quotes among dozens from Hadler: “the 21st century can support a new doctor-patient relationship, one where the patient is captain of the ship and the doctor is the navigator.” and “the doctor-patient relationship includes an understanding of the limitations of certainty regarding challenges in diagnosis and therapy.”

  24. Doctor: Paul, I think you have a brain tumor, to confirm I think it’s best to get you in for an MRI.

    Paul: No doc, I don’t trust you, I don’t think I have a brain tumor, so I’m going to save my HSA money.

    Really Paul?

  25. re poor getting superfluous tx? Yes.
    re do I question my doctor? Absolutely.

  26. “in that patients keep the money from declining the superfluous mri, and putting pressure on hospitals to disclose pricing.”

    Do you think poor people are getting “superfluous” treatments”, especially those on Medicaid? So you want poor people (and everyone else) to practice medicine by questioning their doctor’s advice and treatment?

    Is that what you do Paul.

  27. Peter, I wasn’t debating the overall system, just explaining that HSA benefits are the same, rich or poor. You may still oppose them as part of a solution, I understand that. I think they are a key to reducing waste, in that patients keep the money from declining the superfluous mri, and putting pressure on hospitals to disclose pricing.

  28. Paul, this is the perversion attitude of our health care system.

    The benefits for the taxpayer are not equal. Republicans look to cut millions of “poor” from access to health care while funding “rich” peoples health care and all the time claiming the system is unsustainable.

    Here’s “equality”, institute Medicare for all and fund this through the tax system. Everyone has the same stake in making sure the system stays sustainable.

  29. Peter,
    For a rich business man who has his HSA funded by his business he pays no taxes….and the $ in the HSA are his.
    For a poor person who has his HSA funded, the poor person pays no taxes….and the $ in the HSA are his.
    The benefits are equal.

  30. What did your brother in law do for healthcare while waiting to get into a high risk pool?

  31. Anish, I’ve read that in big cities like NYC, many low income people can’t afford to take time off work for an appointment and / or don’t have transportation to get to the office. Then, if they need to be referred to a specialist or hospital outpatient center, they can’t take time off on another day for that appointment either. So, they just go to the ER which they perceive as a one stop shop and they think rightly or wrongly the care is higher quality as well. Since the hospital accepts Medicaid and there is no copay or deductible, it’s the path of least resistance for way too many patients.

  32. You do realize that many people were not able to get into those high risk pools? Brother in law died waiting to get into one.

  33. Devil is in the details. How much is the state, or some government entity, putting into the HSAs? W/o a significant contribution they are just really high deductible plans. Also, we are seeing premiums for HSAs climb rapidly. People are learning to game them. Mark Pauly, probably the dean of conservative health care economists always seemed to feel HSAs weren’t likely to make a significant dent in costs.

    I would prefer to see a trial of the dpc model at the state(s) level first.

    Finally, I think you misinterpret the curve theory. I don’t think anyone I read has ever suggested that the low hanging fruit exists with the sick 5%. What is argued is that those people will go through their deductible, plus a lot more, so they just aren’t sensitive to deductibles. What you really should do is find the curve marked out in real dollars spent, rather than total heath care dollars as a percentage. Then look at deductibles. If you follow that curve down, you will find that a lot of people outside of the sick 5% still have pretty high deductibles, so they also aren’t going to have the incentive to cost shop. From memory, don’t have time to look up, a surprisingly small percentage of our health care budget is spent by people that you would reasonably expect to be price sensitive.

    Then of course there is the entire issue of transparency not changing spending habits that much. However, if doc works, then maybe we won’t need to rely upon trying to change the spending habits of patients.

    Steve

  34. 95% account for 50% of spending. At the moment we’re talking about the 40million strong individual market – No one’s forcing everyone to pay a dpc physician.. If you want a relationship with a physician for whatever reason, its a good option – no labs, no copays. Would work especially well and better for what is a tough medicaid population to take care of right now.

    Peter – From the above post – “For those without the income to fully fund HSAs. state subsidized HSAs with nominal $5-$20/month patient payments would prove to be a cost efficient way of delivering high value care to those who need it the most.” I think it would be a cheaper option for the state to directly pay PCPs 50-100 / month than what happens right now.

  35. Is it really out of hospital care of poor people that is bankrupting the system? Are they the ones over using the system, so we want to bribe them to stay away from the doctor?

    HSAs work (for rich people) because they offer tax savings. The poor don’t pay taxes.

  36. Since the healthiest 50% of the population accounts for only 3% of healthcare costs in any given year, if everyone spent $50-$100 per month for DPC, we could easily wind up spending more money than we save since millions of the folks now paying for DPC used no healthcare at all before or, at most, very little previously.

    DPC could be a great value and a very sensible investment for the complex patient. For the healthy, probably not so much.

  37. Peter – As i’ve suggested in article – A better use of federal dollars wld be to fund HSA’s for low income folks – that would be used to pay pCP’s a subscription rate. My strong bet is that this would result in better care for patients, fewer specialist and ER visits – thus saving the system lots of dollars.

  38. “Direct primary care would change the equation, make primary care attractive again for multiple reasons.”

    I support primary care based system – make them the gatekeepers. But how do you, “make primary care attractive again”? More money? If so where do you get the additional funds?

  39. Despite the median/average salaries reported – In philadelphia at the local AMC – starting pCP salary was $109k a few years ago. Aligning value with reimbursement is a great goal- the current metric raj won’t get us there. Direct primary care would change the equation, make primary care attractive again for multiple reasons.

  40. Any aspect of financial reform in medicine has to realistically include not just the hospital “chargemonsters” but all aspects of the healthcare value chain. One can not seriously argue that there are not ample profits when hospitals are buying the newest and technology to put in their freshly constructed buildings, insurance companies are sponsoring sporting teams, and surgeons are driving McLaren sports cars.

    The time is long overdue to sort this out by following the dollar and finding where it goes.

  41. “I can see circumstances where what the payers pay is woefully inadequate”

    Has anyone in the health care industry claimed they’ve been paid too much? Trouble is rich reimbursements leads to a rich life – hence it’s hard to readjust to less money.

  42. Anish, I always try to read everything you post because I usually learn something, you’re a very smart guy and I’m especially interested in anything you have to say about cardiology related issues, I’ll look forward to the post on hospital costs.

  43. I don’t agree with surprise balance billing – I think hospitals and physicians need to be upfront about what things cost. I can see circumstances where what the payers pay is woefully inadequate – and as long as the providers are upfront about cost prior to the patient receiving the care or procedure – i’m not opposed.

  44. Bobby – You are all too right about the whining from the current winners of the health care system. I think that there will be winners and losers (perhaps more losers?) in a more market based set up. Its not lost on me for instance that specialists will likely get hurt if DPC does proliferate. I just tend to think the winners are more likely the one’s who should be winning – as opposed to those best able to game metrics or capture patients via narrow networks, etc..

    Barry – Tx for the comments. Your ?s reflect the debate we should be having as opposed to the heated apocalyptic ones that are standard fare.

    On inadequate dollars for ‘high-risk’ folks – there is no one size fits all solution. This plan addresses the 40 million folks not in some type of group plan, not medicare eligible. So the question is if there is enough money allocated for those in the individual market that are too high risk. As I noted – the national high risk pool had ~100k folks at its peak – avg premium $32k/pt. Even if you triple that number to 300k – the $15billion allocated for the first year for that # equals $50k/year. On top of this there is another $60billion over 8 years to help defray costs for those that need it. If someone thinks we need more money than that – fine. Keep the cap gains/investment income tax and use it to directly subsidize high risk folks.

    I was working on a post about the cost of health care and what we actually spend it on – you’ll be surprised, b4 I got derailed by Dr. Jha’s fun post. I used to think litigation was a big issue with regards to cost, until it seemingly became unimportant when folks started getting penalized for admissions/testing. Hopefully I can flesh this out some more if you can bear to read some future posts of mine

  45. Anish, I try to make it clear to doctors who treat me that I care about costs even when insurers or taxpayers are paying the bill. I know most people don’t do that but they should. Health insurance is expensive because healthcare is expensive. It’s as simple as that.

    I wonder to what extent medical practice patterns are developed by the specialty societies with the reality of our litigious society in mind. Defensive medicine baked into the system reflects the reality of litigation risk in this country that is probably not present to nearly the same degree in most other developed countries in Western Europe, Canada, Japan and Australia.

    Emergency room doctors are treating mostly patients they don’t know, never met, and may have no idea of what their medical histories are especially if the patient can’t communicate and no family member is present who can do it for him. It’s quite probable that the natural bias will be to order all the tests the doctor thinks are necessary, especially for complaints like chest pain to rule out a heart attack.

    The biggest problem with the ACA and the republican replacement bill is that it doesn’t come close to adequately dealing with the high risk patients, especially those with already known expensive to treat medical conditions. I’ve heard insurance experts suggest that if the 150 million lives currently covered by an employer plan had to go into the underwritten insurance market to buy a policy, as many as 30% would be declined outright or be subject to a rate-up of 25%-100% above the standard rate for their age. It’s probably that 10%-15% would be declined outright and would need high risk pool coverage. It could easily cost $15,000-$20,000 per covered life to cover these high risk individuals. That’s serious money that no politician appears willing to step up and vote to raise taxes enough to make these policies work for the people who need them at a cost they can afford. I don’t see that attitude changing anytime soon unfortunately.

    Finally, there is lots of futile or marginally useful care delivered at the end of life in the U.S.. Experts in other countries claim that we just don’t know when to stop treatment. Most people still don’t have a living will or advance directive. Maybe there is more that we could do to change that such as making it part of the process of signing up for Medicare and Medicaid. Litigiousness and end of life care attitudes are cultural realities in this country that may easily make our healthcare costs 20%-30% higher than they would be if we were significantly less litigious and more sensible and realistic about end of life care choices. A Medicare for all single payer system would do absolutely nothing about either of those issues.

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