When thinking about making bold policy moves to solve healthcare problems, I think, we need to approach the problem from 2 angles:
1. How to provide medical care to people without bankrupting either people or the country - removing rent seekers, especially monopolies, is probably the easiest way (comparatively) to decrease cost and use the money saved to fund care, ban high deductible health plans and slowly start moving to Medicare for all, starting with allowing people to buy Medicare on health exchanges.
2. Increase the health of the people so they consume lower downstream costs - we don't spend enough on basic infrastructure needs which manifests in higher healthcare costs e.g. housing. Public health programs take decades to show improvement or decline (e.g. the current rhetoric on removing fluoride in water will manifest in 1-2 decades down the road when people have higher dental costs). I wrote about the role of socioeconomic/environmental factors in my article "From Doctors to Social Workers" https://www.pcplens.com/p/doctors-to-social-workers
Also, when we consider Medicare for All, we often forget that employees already pay for their healthcare through paycheck deductions. Converting that into a tax, may actually increase employee take home pay.
There is nothing pragmatic about incremental solutions to catastrophic problems.
As to the financial ‘problem(s)’ with transitioning to single payer; nothing there that can’t be addressed by a modern monetary theory application to the issues.
The people must force the political will on the politicians. This can only happen when a majority of citizens recognize there is no politics but class politics. The answer will not come from Rs or Ds; both bought and paid for by monied interests.
It is interesting to witness you settling on rate-setting as the sine qua non of effective cost control. I've always believed that myself - -and that the quest for "accountable care" is mostly an elaborate workaround our political inability to set rates for all payers. That said, a few quibbles:
1) I'm surprised you kind of wave away antitrust as an important cost control tool. Good research, e.g. by Zach Cooper and Martin Gaynor, provides pretty powerful evidence that when hospital systems consolidate, rates go up, and when hospitals buy up physician practices, rates go up, and when private equity rolls up physician practices, rates go up. Lina Khan, should she survive into a new admin, has her sights trained on private equity in healthcare, and I'd love to see her go after it. I've seen claims that she has already put a chill to some extent on PE acquisition.
2) IIRC you have marveled (eloquently) about the bending of the healthcare cost curve since circa 2010. Here you pivot and almost cast that mere bending as an ultimate failure if we don't move on to more radical means of cost control. That's not to say you're wrong, but there's a glass half full/empty shift here. (I suspect we've bent the cost curve largely by making care unaffordable (with prohibitive OOP) or unobtainable via coverage denials.)
3) OOP is too high for too many in the ACA marketplace (individual market), but it's not primarily because insurers are *marketing* bronze plans (though $0 deductible bronze plans, available in some large markets, do fit that category). Risk adjustment in the ACA marketplace favors silver plans, and insurers compete fiercely to offer the cheapest and second-cheapest (benchmark) silver plan, especially now that almost half of all enrollees, and more than half in the federal exchange, qualify for free high-CSR silver coverage). Bronze plan selection has risen primarily because (I think):
a) Silver loading -- the pricing of CSR mostly into silver plans after Trump cut off direct payments for CSR made bronze plans free for millions of prospective enrollees, starting in 2018.
b) At incomes over 200% FPL, bronze plans are almost invariably a better financial bet than silver plans, which have very high OOP at income levels with weak CSR or no CSR.
c) Competition in the ACA marketplace has driven plan offerings toward narrow networks. It seems that increasing numbers of enrollees who qualify for high CSR/cheap silver are opting for bronze plans with broader networks, sacrificing OOP for provider access, as the insurers offering broader networks may have silver plans price well above benchmark.
d) Insurers in most states have resisted pricing gold plans below silver -- the predicted outcome of the CSR cutoff, because CSR makes silver plans on average higher-AV than gold plans. That leaves bronze as the most viable option for many with income over 200% FPL. The resistance, according to some, stems from the risk adjustment system punishing enrollment in metal levels other than silver.
All that said, it's undeniable that out of pocket costs are too high for at least half of marketplace enrollees. And even lower-income enrollees, who get silver plans with a 94% actuarial value, would probably mostly be better off in Medicaid, as even relatively modest OOP can be prohibitive at low incomes.
When thinking about making bold policy moves to solve healthcare problems, I think, we need to approach the problem from 2 angles:
1. How to provide medical care to people without bankrupting either people or the country - removing rent seekers, especially monopolies, is probably the easiest way (comparatively) to decrease cost and use the money saved to fund care, ban high deductible health plans and slowly start moving to Medicare for all, starting with allowing people to buy Medicare on health exchanges.
2. Increase the health of the people so they consume lower downstream costs - we don't spend enough on basic infrastructure needs which manifests in higher healthcare costs e.g. housing. Public health programs take decades to show improvement or decline (e.g. the current rhetoric on removing fluoride in water will manifest in 1-2 decades down the road when people have higher dental costs). I wrote about the role of socioeconomic/environmental factors in my article "From Doctors to Social Workers" https://www.pcplens.com/p/doctors-to-social-workers
Also, when we consider Medicare for All, we often forget that employees already pay for their healthcare through paycheck deductions. Converting that into a tax, may actually increase employee take home pay.
There is nothing pragmatic about incremental solutions to catastrophic problems.
As to the financial ‘problem(s)’ with transitioning to single payer; nothing there that can’t be addressed by a modern monetary theory application to the issues.
The people must force the political will on the politicians. This can only happen when a majority of citizens recognize there is no politics but class politics. The answer will not come from Rs or Ds; both bought and paid for by monied interests.
The neoliberal corporate coup is complete.
It is interesting to witness you settling on rate-setting as the sine qua non of effective cost control. I've always believed that myself - -and that the quest for "accountable care" is mostly an elaborate workaround our political inability to set rates for all payers. That said, a few quibbles:
1) I'm surprised you kind of wave away antitrust as an important cost control tool. Good research, e.g. by Zach Cooper and Martin Gaynor, provides pretty powerful evidence that when hospital systems consolidate, rates go up, and when hospitals buy up physician practices, rates go up, and when private equity rolls up physician practices, rates go up. Lina Khan, should she survive into a new admin, has her sights trained on private equity in healthcare, and I'd love to see her go after it. I've seen claims that she has already put a chill to some extent on PE acquisition.
2) IIRC you have marveled (eloquently) about the bending of the healthcare cost curve since circa 2010. Here you pivot and almost cast that mere bending as an ultimate failure if we don't move on to more radical means of cost control. That's not to say you're wrong, but there's a glass half full/empty shift here. (I suspect we've bent the cost curve largely by making care unaffordable (with prohibitive OOP) or unobtainable via coverage denials.)
3) OOP is too high for too many in the ACA marketplace (individual market), but it's not primarily because insurers are *marketing* bronze plans (though $0 deductible bronze plans, available in some large markets, do fit that category). Risk adjustment in the ACA marketplace favors silver plans, and insurers compete fiercely to offer the cheapest and second-cheapest (benchmark) silver plan, especially now that almost half of all enrollees, and more than half in the federal exchange, qualify for free high-CSR silver coverage). Bronze plan selection has risen primarily because (I think):
a) Silver loading -- the pricing of CSR mostly into silver plans after Trump cut off direct payments for CSR made bronze plans free for millions of prospective enrollees, starting in 2018.
b) At incomes over 200% FPL, bronze plans are almost invariably a better financial bet than silver plans, which have very high OOP at income levels with weak CSR or no CSR.
c) Competition in the ACA marketplace has driven plan offerings toward narrow networks. It seems that increasing numbers of enrollees who qualify for high CSR/cheap silver are opting for bronze plans with broader networks, sacrificing OOP for provider access, as the insurers offering broader networks may have silver plans price well above benchmark.
d) Insurers in most states have resisted pricing gold plans below silver -- the predicted outcome of the CSR cutoff, because CSR makes silver plans on average higher-AV than gold plans. That leaves bronze as the most viable option for many with income over 200% FPL. The resistance, according to some, stems from the risk adjustment system punishing enrollment in metal levels other than silver.
All that said, it's undeniable that out of pocket costs are too high for at least half of marketplace enrollees. And even lower-income enrollees, who get silver plans with a 94% actuarial value, would probably mostly be better off in Medicaid, as even relatively modest OOP can be prohibitive at low incomes.