The 2020 Presidential Election Primary Thread

[All-American]

https://www.theatlantic.com/internat...-on-it/259153/

Developed nations with universal health care are indicated in green, all the rest are 'developing' nations:

That settles it. We can’t do universal health care because we are not north enough.

[Northwestcoug]

I don't care how many political parties Canada has. Canada is as polarized as the US for the reasons I stated. A greater proportion of its population lives in urban areas which is probably why it's remained more leftist in its government. You must know that Justin Trudeau is reviled in many quarters in Canada. Ironically, some woke hate him because of his hypocrisy supporting the oil pipeline, etc.

That article is solid. Andrew Sullivan tweeted it.

LOL. Well played.

My wife's family is almost all from Alberta, so Trudeau is a name that shall not be spoken of forevermore. So I know of that. But still, you can be hardcore socialist or centrist democrat (when compared to the states) or somewhere in between, and find a party that more closely aligns with your beliefs more easily there.

[Omaha 680]

If you are referring to a two tier system where the wealthy pay more for superior care as compared to what the average person receives then that is, by definition, not "universal health care."

That is the exact system that exists in the US, which leads to scenarios that Cardiac has described.

That being said, I do have supplemental health insurance through my employer. My supplemental insurance can be used to pay for physiotherapy or mental health care. In other words, if I need to see a psychiatrist, or I need physio I don't have to ask for a referral from my family doctor. I can pay for such services up front through my insurance plan.

Eye and dental care are not universally covered, so my supplemental insurance also pays for visits to an eye doctor or dentist.

No, I was referring to Bernie's plan which outlaws supplemental insurance for any service "covered" under medicare for all.

[cowboy]

What kind of world do you think we live in? Of course if there's no insurance, the bill usually gets written off. But not until after the health care provider tries to collect as much as possible, ultimately resorting to collection agencies or even suits.

This is only true if the patient makes no attempt to negotiate their bill. As I said, it may be area-specific, and most of the hospitals I'm familiar with are county-owned, but ability to pay is a function of income. If people don't have the cash flow, their bill is written down to a payment they can afford. Usually, hospitals will carry a bill out for up to 10 years or more if it's a big-ticket item, though there are some exceptions. For anything over $50k a catastrophic coverage policy should keep people out of bankruptcy and be affordable.

[Northwestcoug]

I had a roommate from Canada that had surgery in US. It was paid for by the Canadian gov. They don’t want to trade healthcare situations even though it has its flaws.

This usually happens in cancer care, when a specialized center in the US has a treatment that Canada hasn't developed yet. I have heard this in CAR-T therapy, which is still pretty unusual but is gaining a foothold in some cancers. I'm sure there's some red tape involved, but yes, a province will cover health care costs like these when a patient can't get it in Canada.

There's a bonafide knock on socialized health care. A lot of innovation happens elsewhere, and while other countries usually adopt it they do play catch up. That's not to say that Canadian health care is substandard. I will bet my heavily tax-subsidized Canadian medial education is as good as any doc here received state-side. In my experience, cancer care, urgent care, surgery, and OB/GYN was just as good.

The other knock is non-urgent care. My FIL had to wait 5 months for cataract surgery and 10 months for a colonoscopy. But in my town, the wait to get into the biggest GI clinic is currently 5 months. So there's that.

When people ask my wife about Canadian health care, she gives a reasoned response. It goes something like this. Her cousin was diagnosed with acute leukemia in her 30's. She went through 2 rounds of induction chemo, almost died, but then finally got into remission enough to get a bone marrow transplant. This meant months in ICU and other high-level care. Then a couple of years of additional therapy, home aides, etc. Not once was she asked about her health insurance coverage, a deductible, or denied a therapist who was outside of her coverage. Of course it was a financial strain when she couldn't work for those years, but she never lost her house or filed for bankruptcy. On the other hand, in addition to the non-urgent care problems cited above, don't expect to get much of a choice in hospital meals or beautiful buildings. Funding for medical care is tight as it is, and there is little to no appetite to spend it on what is perceived as frivolous 'Cadillac care'.

I'm still surprised that we have this argument. I mean come on, don't you remember Walt? Would he have broke bad had he access to affordable health care?!?

[SeattleUte]

This is only true if the patient makes no attempt to negotiate their bill. As I said, it may be area-specific, and most of the hospitals I'm familiar with are county-owned, but ability to pay is a function of income. If people don't have the cash flow, their bill is written down to a payment they can afford. Usually, hospitals will carry a bill out for up to 10 years or more if it's a big-ticket item, though there are some exceptions. For anything over $50k a catastrophic coverage policy should keep people out of bankruptcy and be affordable.

Withyour first sentence you make my point.

[Eddie]

So - apparently Bernie was telling a crowd in Cali today that Medicare for all will save the US $300 billion annually.

I'm curious where he's getting those numbers from - because that sounds like some pretty crazy numbers. And as messed up as health care is right now - there just don't seem to be many things that government does for cheaper than private industry - not $300 billion cheaper.

[cowboy]

Withyour first sentence you make my point.

I guess I don't understand how that proves the ACA is worth keeping. All people need to do to avoid bankruptcy is walk in to the hospital and set up a payment plan. We obviously have much different experiences dealing with healthcare, and I'm as befuddled that you think the ACA is good legislation as you are that I don't.

Help me understand your position. Why is pooling across state lines a bad thing? From my perspective, it allows little players to compete against the big insurers, creating more competition. Also, why shouldn't health insurance be offered outside of exchanges? It seems like personal choice should be maximized, not restricted. Those are my biggest beefs, but I'll listen to your reasoning.

[ERCougar]

I love "I have a friend..." stories.
There is actually plenty of data on wait times, specialist availiabilty, etc. Here's a nice article breaking some of it down. Despite the title, I think it will surprise some liberals to hear that M4A is not the panacea it's being touted as--Public without private option does the worst in nearly every category, and the US is near the top at all of them.

https://askepticalhuman.com/politics/2018/10/1/debunking-republican-healthcare-myths-us-quality-amp-outcomes

EDIT: here's the right article (although that one is interesting too): https://askepticalhuman.com/politics...imes-rationing
Having worked for a year in a pretty well regarded socialized with private system, here are my observations to throw in:
The good:
-Most people will be better off under a socialized plan. The exceptions are the well-insured (not nearly as common as SU thinks, but also not a small portion of the population, and outside of strong unions, the wealthiest), and those on Medicaid. They'll be worse off.
-More rational decision making. When you centralize payment, protocols become more widespread (and are almost always more evidence-based). I'm pretty sure Cardiac has pointed the futility of stenting non-critical lesions. And yet, cardiologists keep doing them. See also, most knee scopes, MRIs, CTs, etc.
-Taking price out of decision making - Patients just aren't equipped with the knowledge to make a lot of these decisions (some, they are--I'll get to this), and to add the mental fog that emotional stress brings about to the equation is a recipe for disaster
-Fewer bad incentives - doctors are incentivized to do more than is really necessary (my field is a great exception here--we just want you out of the ER, for the most part). No one is really immune to incentives subconsciously.
-Less customer-service driven - Medicine is a terrible place to have "customer is king" ethics. What patients want is more often than not (that's not an exaggeration) either useless or actually counterproductive to good outcomes.

The bad:
-inefficiency - I don't think this is as big a deal as conservatives think. It's not the DMV, and there is still competition between health districts to achieve better outcomes at lower costs. However, there is definitely a level of inefficiency that wasn't present in the US.
-rationing - You can't cut costs without rationing. Forget the elective MRI (and there are a lot of these)--my patients are not ready to not get the CT they are convinced they need when they want it. They're also not ready to wait for a life-threatening cholecystitis before you remove their gallbladder.
-non-sustainability - what Bernie is proposing would swing us from the most conservative of healthcare systems to the most liberal. Medicare for All would be more generous than anything healthcare system that I know of, and that in an already dubious sustainability future. I'm not sure how we think we can take what is likely the most fragile future government planned expenditure and radically expand it.
-fewer treatment/diagnostic options - I worked in a hospital about the size of Dixie Regional. We had one CT scanner. We had a functional cath lab once a week, and that was iffy. We had no MRI. We had limited ultrasound.
-staffing crisis - a quick google search will point out the burnout crisis and the current-and-expected-to[worsen doctor shortage. Whatever you think of physician pay, both of these problems worsen if you cut salaries, and Bernie's plan depends on this. Yes, I make more than I did in New Zealand, but if I were to somehow break it down into pay per work unit, it would be about equal. I'll bail and I know plenty of others who will as well.

[tooblue]

I love "I have a friend..." stories.
There is actually plenty of data on wait times, specialist availiabilty, etc. Here's a nice article breaking some of it down. Despite the title, I think it will surprise some liberals to hear that M4A is not the panacea it's being touted as--Public without private option does the worst in nearly every category, and the US is near the top at all of them.

https://askepticalhuman.com/politics/2018/10/1/debunking-republican-healthcare-myths-us-quality-amp-outcomes

Having worked for a year in a pretty well regarded socialized with private system, here are my observations to throw in:
The good:
-Most people will be better off under a socialized plan. The exceptions are the well-insured (not nearly as common as SU thinks, but also not a small portion of the population, and outside of strong unions, the wealthiest), and those on Medicaid. They'll be worse off.
-More rational decision making. When you centralize payment, protocols become more widespread (and are almost always more evidence-based). I'm pretty sure Cardiac has pointed the futility of stenting non-critical lesions. And yet, cardiologists keep doing them. See also, most knee scopes, MRIs, CTs, etc.
-Taking price out of decision making - Patients just aren't equipped with the knowledge to make a lot of these decisions (some, they are--I'll get to this), and to add the mental fog that emotional stress brings about to the equation is a recipe for disaster
-Fewer bad incentives - doctors are incentivized to do more than is really necessary (my field is a great exception here--we just want you out of the ER, for the most part). No one is really immune to incentives subconsciously.
-Less customer-service driven - Medicine is a terrible place to have "customer is king" ethics. What patients want is more often than not (that's not an exaggeration) either useless or actually counterproductive to good outcomes.

The bad:
-inefficiency - I don't think this is as big a deal as conservatives think. It's not the DMV, and there is still competition between health districts to achieve better outcomes at lower costs. However, there is definitely a level of inefficiency that wasn't present in the US.
-rationing - You can't cut costs without rationing. Forget the elective MRI (and there are a lot of these)--my patients are not ready to not get the CT they are convinced they need when they want it. They're also not ready to wait for a life-threatening cholecystitis before you remove their gallbladder.
-non-sustainability - what Bernie is proposing would swing us from the most conservative of healthcare systems to the most liberal. Medicare for All would be more generous than anything healthcare system that I know of, and that in an already dubious sustainability future. I'm not sure how we think we can take what is likely the most fragile future government planned expenditure and radically expand it.
-fewer treatment/diagnostic options - I worked in a hospital about the size of Dixie Regional. We had one CT scanner. We had a functional cath lab once a week, and that was iffy. We had no MRI. We had limited ultrasound.
-staffing crisis - a quick google search will point out the burnout crisis and the current-and-expected-to[worsen doctor shortage. Whatever you think of physician pay, both of these problems worsen if you cut salaries, and Bernie's plan depends on this. Yes, I make more than I did in New Zealand, but if I were to somehow break it down into pay per work unit, it would be about equal. I'll bail and I know plenty of others who will as well.

Bail out and do what exactly? Welders don't make the same kind of money doctors make, even those who practice within a universal health care system. And burnout in the health care industry is just as high in the US as elsewhere:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6367114/

Otherwise, you offer very valid insights.

[SeattleUte]

I guess I don't understand how that proves the ACA is worth keeping. All people need to do to avoid bankruptcy is walk in to the hospital and set up a payment plan. We obviously have much different experiences dealing with healthcare, and I'm as befuddled that you think the ACA is good legislation as you are that I don't.

Help me understand your position. Why is pooling across state lines a bad thing? From my perspective, it allows little players to compete against the big insurers, creating more competition. Also, why shouldn't health insurance be offered outside of exchanges? It seems like personal choice should be maximized, not restricted. Those are my biggest beefs, but I'll listen to your reasoning.

You may think it's just dandy for a heart attack or cancer patient with no insurance to get a 100k bill and have to beg the hospital for a discount or forgiveness of the loan, or, failing that, seek bankruptcy protection so he can feed his family. Or, for an inner city uninsured mother to have to take her kid with the flu to the emergency room and beg for treatment. I think it's callous if not cruel, and with this attitude you're defining yourself as possessing all the negative characteristics with which urbanites caricaturize cowboys from Wyoming.

This attitude is also why we have a big risk of electing a communist next election. Had Republicans supported the ACA--again, with private markets, state regulation, and choice--there would be no Communist campaign built on single payor that is the democratic front runner. Get real.

[Jeff Lebowski]

I love "I have a friend..." stories.
There is actually plenty of data on wait times, specialist availiabilty, etc. Here's a nice article breaking some of it down. Despite the title, I think it will surprise some liberals to hear that M4A is not the panacea it's being touted as--Public without private option does the worst in nearly every category, and the US is near the top at all of them.

https://askepticalhuman.com/politics/2018/10/1/debunking-republican-healthcare-myths-us-quality-amp-outcomes

Having worked for a year in a pretty well regarded socialized with private system, here are my observations to throw in:
The good:
-Most people will be better off under a socialized plan. The exceptions are the well-insured (not nearly as common as SU thinks, but also not a small portion of the population, and outside of strong unions, the wealthiest), and those on Medicaid. They'll be worse off.
-More rational decision making. When you centralize payment, protocols become more widespread (and are almost always more evidence-based). I'm pretty sure Cardiac has pointed the futility of stenting non-critical lesions. And yet, cardiologists keep doing them. See also, most knee scopes, MRIs, CTs, etc.
-Taking price out of decision making - Patients just aren't equipped with the knowledge to make a lot of these decisions (some, they are--I'll get to this), and to add the mental fog that emotional stress brings about to the equation is a recipe for disaster
-Fewer bad incentives - doctors are incentivized to do more than is really necessary (my field is a great exception here--we just want you out of the ER, for the most part). No one is really immune to incentives subconsciously.
-Less customer-service driven - Medicine is a terrible place to have "customer is king" ethics. What patients want is more often than not (that's not an exaggeration) either useless or actually counterproductive to good outcomes.

The bad:
-inefficiency - I don't think this is as big a deal as conservatives think. It's not the DMV, and there is still competition between health districts to achieve better outcomes at lower costs. However, there is definitely a level of inefficiency that wasn't present in the US.
-rationing - You can't cut costs without rationing. Forget the elective MRI (and there are a lot of these)--my patients are not ready to not get the CT they are convinced they need when they want it. They're also not ready to wait for a life-threatening cholecystitis before you remove their gallbladder.
-non-sustainability - what Bernie is proposing would swing us from the most conservative of healthcare systems to the most liberal. Medicare for All would be more generous than anything healthcare system that I know of, and that in an already dubious sustainability future. I'm not sure how we think we can take what is likely the most fragile future government planned expenditure and radically expand it.
-fewer treatment/diagnostic options - I worked in a hospital about the size of Dixie Regional. We had one CT scanner. We had a functional cath lab once a week, and that was iffy. We had no MRI. We had limited ultrasound.
-staffing crisis - a quick google search will point out the burnout crisis and the current-and-expected-to[worsen doctor shortage. Whatever you think of physician pay, both of these problems worsen if you cut salaries, and Bernie's plan depends on this. Yes, I make more than I did in New Zealand, but if I were to somehow break it down into pay per work unit, it would be about equal. I'll bail and I know plenty of others who will as well.

This is what scares me the most. After finishing his residency, my son said that if any of his kids wants to do the med school thing, he would talk them out of it. I think his position will soften over time, but there is a huge personal cost to going that route. And in spite of US salaries, there is still a critical shortage of primary care physicians. My son started with zero patients in a new clinic (internal medicine), and after 18 months he is almost full - 1-2 month wait for new appointments.

[SeattleUte]

I love "I have a friend..." stories.
There is actually plenty of data on wait times, specialist availiabilty, etc. Here's a nice article breaking some of it down. Despite the title, I think it will surprise some liberals to hear that M4A is not the panacea it's being touted as--Public without private option does the worst in nearly every category, and the US is near the top at all of them.

https://askepticalhuman.com/politics/2018/10/1/debunking-republican-healthcare-myths-us-quality-amp-outcomes

Having worked for a year in a pretty well regarded socialized with private system, here are my observations to throw in:
The good:
-Most people will be better off under a socialized plan. The exceptions are the well-insured (not nearly as common as SU thinks, but also not a small portion of the population, and outside of strong unions, the wealthiest), and those on Medicaid. They'll be worse off.
-More rational decision making. When you centralize payment, protocols become more widespread (and are almost always more evidence-based). I'm pretty sure Cardiac has pointed the futility of stenting non-critical lesions. And yet, cardiologists keep doing them. See also, most knee scopes, MRIs, CTs, etc.
-Taking price out of decision making - Patients just aren't equipped with the knowledge to make a lot of these decisions (some, they are--I'll get to this), and to add the mental fog that emotional stress brings about to the equation is a recipe for disaster
-Fewer bad incentives - doctors are incentivized to do more than is really necessary (my field is a great exception here--we just want you out of the ER, for the most part). No one is really immune to incentives subconsciously.
-Less customer-service driven - Medicine is a terrible place to have "customer is king" ethics. What patients want is more often than not (that's not an exaggeration) either useless or actually counterproductive to good outcomes.

The bad:
-inefficiency - I don't think this is as big a deal as conservatives think. It's not the DMV, and there is still competition between health districts to achieve better outcomes at lower costs. However, there is definitely a level of inefficiency that wasn't present in the US.
-rationing - You can't cut costs without rationing. Forget the elective MRI (and there are a lot of these)--my patients are not ready to not get the CT they are convinced they need when they want it. They're also not ready to wait for a life-threatening cholecystitis before you remove their gallbladder.
-non-sustainability - what Bernie is proposing would swing us from the most conservative of healthcare systems to the most liberal. Medicare for All would be more generous than anything healthcare system that I know of, and that in an already dubious sustainability future. I'm not sure how we think we can take what is likely the most fragile future government planned expenditure and radically expand it.
-fewer treatment/diagnostic options - I worked in a hospital about the size of Dixie Regional. We had one CT scanner. We had a functional cath lab once a week, and that was iffy. We had no MRI. We had limited ultrasound.
-staffing crisis - a quick google search will point out the burnout crisis and the current-and-expected-to[worsen doctor shortage. Whatever you think of physician pay, both of these problems worsen if you cut salaries, and Bernie's plan depends on this. Yes, I make more than I did in New Zealand, but if I were to somehow break it down into pay per work unit, it would be about equal. I'll bail and I know plenty of others who will as well.

My point is not that enough people are insured. It's that everyone needs to be insured even if they can't afford it, or receive a subsidy to the extent they can't afford it. That is the ACA's model, without doing any violence to the good elements of the current system. The problem is that the left and right wings have both been working to undermine it. Unlike any other proposal, Romneycare actually can work.

[Northwestcoug]

I love "I have a friend..." stories.
There is actually plenty of data on wait times, specialist availiabilty, etc. Here's a nice article breaking some of it down. Despite the title, I think it will surprise some liberals to hear that M4A is not the panacea it's being touted as--Public without private option does the worst in nearly every category, and the US is near the top at all of them.

https://askepticalhuman.com/politics/2018/10/1/debunking-republican-healthcare-myths-us-quality-amp-outcomes

Having worked for a year in a pretty well regarded socialized with private system, here are my observations to throw in:
The good:
-Most people will be better off under a socialized plan. The exceptions are the well-insured (not nearly as common as SU thinks, but also not a small portion of the population, and outside of strong unions, the wealthiest), and those on Medicaid. They'll be worse off.
-More rational decision making. When you centralize payment, protocols become more widespread (and are almost always more evidence-based). I'm pretty sure Cardiac has pointed the futility of stenting non-critical lesions. And yet, cardiologists keep doing them. See also, most knee scopes, MRIs, CTs, etc.
-Taking price out of decision making - Patients just aren't equipped with the knowledge to make a lot of these decisions (some, they are--I'll get to this), and to add the mental fog that emotional stress brings about to the equation is a recipe for disaster
-Fewer bad incentives - doctors are incentivized to do more than is really necessary (my field is a great exception here--we just want you out of the ER, for the most part). No one is really immune to incentives subconsciously.
-Less customer-service driven - Medicine is a terrible place to have "customer is king" ethics. What patients want is more often than not (that's not an exaggeration) either useless or actually counterproductive to good outcomes.

The bad:
-inefficiency - I don't think this is as big a deal as conservatives think. It's not the DMV, and there is still competition between health districts to achieve better outcomes at lower costs. However, there is definitely a level of inefficiency that wasn't present in the US.
-rationing - You can't cut costs without rationing. Forget the elective MRI (and there are a lot of these)--my patients are not ready to not get the CT they are convinced they need when they want it. They're also not ready to wait for a life-threatening cholecystitis before you remove their gallbladder.
-non-sustainability - what Bernie is proposing would swing us from the most conservative of healthcare systems to the most liberal. Medicare for All would be more generous than anything healthcare system that I know of, and that in an already dubious sustainability future. I'm not sure how we think we can take what is likely the most fragile future government planned expenditure and radically expand it.
-fewer treatment/diagnostic options - I worked in a hospital about the size of Dixie Regional. We had one CT scanner. We had a functional cath lab once a week, and that was iffy. We had no MRI. We had limited ultrasound.
-staffing crisis - a quick google search will point out the burnout crisis and the current-and-expected-to[worsen doctor shortage. Whatever you think of physician pay, both of these problems worsen if you cut salaries, and Bernie's plan depends on this. Yes, I make more than I did in New Zealand, but if I were to somehow break it down into pay per work unit, it would be about equal. I'll bail and I know plenty of others who will as well.

That's a good breakdown. No one in America should look at the rest of the developed world and expect there won't be many downsides to socialized medicine. I don't think the US is ready for it. But if health insurance plans across the board continue to get worse, I expect within a generation there will be enough political pressure to move that way.

[imanihonjin]

That's a good breakdown. No one in America should look at the rest of the developed world and expect there won't be many downsides to socialized medicine. I don't think the US is ready for it. But if health insurance plans across the board continue to get worse, I expect within a generation there will be enough political pressure to move that way.

It is going to get worse before it gets better. Our current system is the worst of all worlds. We demand the best available care immediately and have no idea what we are actually going to be paying for that care at the time we consume it. It can be months before we actually know what we are going to pay for the care we consume.