No, because it's free, but 1/3 of Medicare recipients opt to receive their coverage through private insurers that typically add on additional coverage, an indicator that Medicare alone is not enough for a large segment of the population, or that they prefer a private insurer even with government subsidization.
Excellent. We are in agreement that the American government can and does provide a health insurance program that covers lots of people and has the property that people don’t seek to leave it.
Perhaps the idea that everyone be covered in such a system is not so far fetched.
Why would anyone refuse free money? Are you sure you understand the parent's point? They are taking the money but using private networks, which indicates they prefer private providers.
In the absence of Medicare/Medicaid there would not be universal coverage for the elderly. The elderly do not advocate dismantling this coverage. The coverage is a government program. We are in agreement that a U.S. government program can cover lots of people and maintain the property that those people don’t want to the program to be dismantled. It’s not, then, hard to imagine everyone being covered by such a program.
I did not support the ACA but I use the healthcare exchange because it is in my best interest to do so. I get free money from others to pay for my family's health insurance. In fact, I get a 100% subsidy. But the reason I get a 100% subsidy is because I am affluent enough to live comfortably on only a small portion of my income and funnel the rest into tax-advantaged accounts that reduce my AGI to a fraction of my actual income. It would thus not be in my interest to advocate the ending of the ACA. This is the same reason the elderly (who are the wealthiest cohort) do not wish to see Medicare/Medicaid dismantled. But is this what's best for society? Everyone gaming the system to benefit at the expense of everyone else?
I feel sorry for you that you think this way. There’s a reason Medicare came into being. It simply isn’t profitable to treat people near the end of their lives. One illness, calamity is enough to wipe out a lifetime of savings and leave one penniless. The absence of a government program for providing healthcare to the elderly would be horrific and immoral. Some things ought not be profit driven. You wish to make our already horrible system into something worse.
I’m glad your view does not prevail. I would hate to live in a country in which the majority shared this opinion.
How can it both be unprofitable to treat people near the end of their lives yet also wipe out a lifetime of savings? If end of life care transfers the life savings of the elderly to the providers, that sounds quite profitable. Why shouldn't the elderly pay for these services? They have most of the money! And the dying have the least use for it whereas the young (whom you would tax for these services) have plenty of life and obligations yet to pay for. How is taxing the poor to pay for the healthcare of the rich moral?
How can it both be unprofitable to treat people near the end of their lives yet also wipe out a lifetime of savings?
It's unprofitable for an insurance company to insure someone near death and still provide a decent level of services. It's why there used to be pre-existing condition exclusions and why health insurance companies like Aetna went out of their way to try to deny claims.
Also, if the expense of coverage is greater than the amount of money a person has then it won't be profitable to treat them whilst still bankrupting the person.
I doubt that people actually doing this are concerned with the morality of it, just the profitability. It’s not moral, but it’s easy, because they’re old and dying and desperate. I don’t think there’s more to it than the usual greed and expediency.
> We are in agreement that the American government can and does provide a health insurance program that covers lots of people and has the property that people don’t seek to leave it.
People literally are leaving it, to the fullest extent that they legally can.
It's not a small number, either. About 40% of Medicare patients aren't on the government-run system at all, and that number has consistently grown over the years.
They supplement it, I don't believe they are leaving it, unless they are wealthy and can afford to pay out of pocket because they want to use a doctor that is not participating in the medicare program. Do you have a cite?
> They supplement it, I don't believe they are leaving it, unless they are wealthy and can afford to pay out of pocket because they want to use a doctor that is not participating in the medicare program. Do you have a cite?
No, this is wrong. Private Medicare plans fully replace Original Medicare. If you are on a privately-managed Medicare plan, you receive none of your benefits from Original Medicare (the government-run program).
Unfortunately, you're still subject to some of the care delivery restrictions that Medicare sets, which means people moving from privately-managed plans (without Medicare) to Medicare Advantage (privately-managed Medicare plans) will typically experience a drop in coverage, because private insurers tend to be more forgiving with these limits.
> they want to use a doctor that is not participating in the medicare program
I'm not sure what you're referring to here. Though yes, one of the big advantages of Medicare Advantage is that it's dramatically easier to find in-network providers, even for Medicare Advantage plans that don't cost anything out-of-pocket above what Original Medicare does.
> No, this is wrong. Private Medicare plans fully replace Original Medicare.
Uh, no. "Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans." [0] So although the Advantage plans are privately managed, the premiums are subsidized. I don't think this counts as "leaving" Medicare.
> Uh, no. "Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans." [0] So although the Advantage plans are privately managed, the premiums are subsidized. I don't think this counts as "leaving" Medicare.
By that logic, there's no way to leave Medicare, because you can't stop paying taxes for it or "disable" your eligibility for it (and all of the restrictions that Medicare eligibility brings for people on private insurance).
People leave Medicare to the full extent allowed by law. Unless you want to claim that people using school vouchers for private schools is a demonstration of their satisfaction with the public school system in their area, you can't view their use of Medicare Advantage as a demonstration of their satisfaction with Original Medicare either.
> people using school vouchers for private schools is [not] a demonstration of their satisfaction with the public school system in their area
It certainly doesn't indicate dissatisfaction with the fact that the money for those vouchers comes out of tax receipts! The primary education system is a single-payer system, and the use of vouchers doesn't change that.
> It certainly doesn't indicate dissatisfaction with the fact that the money for those vouchers comes out of tax receipts!
You're basically arguing a tautology: Because there's no legal way to fully opt out of the system if they dislike it, people can't leave it (by your definition), and you're then saying that, because people don't fully leave the system, that means they don't dislike it.
40% of people choose not to use Medicare, to the extent that's legally possible. The program that they choose to use instead outperforms Medicare on every key performance indicator (medical outcomes, cost, patient satisfaction), while also underperforming the same private insurers on those same indicators. It takes some real contortions to look at that data and use it as evidence in favor of a single-payer system, or even evidence that patients like Medicare, but if you're fully committed to interpreting available data in a way that supports that end goal, I guess that's all we can really say.
In both cases — Medicare Advantage and vouchers — people are accepting a government subsidy in a form that allows them more choice than the default form. You're the one trying to make some kind of point based on that. I see it as evidence of nothing more than the fact that people like to have choices. I'm not arguing that it proves that they like the system as a whole; I'm just rejecting your claim that it somehow proves that they don't. I do tend to agree that a system that allows them those choices is better than one that doesn't.
> The program that they choose to use instead outperforms Medicare on every key performance indicator (medical outcomes, cost, patient satisfaction), while also underperforming the same private insurers on those same indicators.
Cost to whom? I don't see how Medicare Advantage can cost less to patients than Medicare; nor does it seem likely that the premiums for a private plan are less than the subsidized Medicare Advantage premiums. (Re the latter, I guess you didn't see my other reply to you: https://news.ycombinator.com/item?id=16979926)
> Cost to whom? I don't see how Medicare Advantage can cost less to patients than Medicare
How do you think Medicare works? Do you think that, once you're covered by Medicare, you just show up at a doctor or hospital, flash your government-issued Medicare card, and receive free treatment for any covered services, without having to pay anything out of pocket?
(For the record, that is not how it works. Medicare is not free for patients. Premiums are neither your only nor your largest expense.)
My mother is supplementing her medicare with insurance. GAP insurance is I think what she calls it. I mean I'm sure what you are describing exists, but it's not universal.
> My mother is supplementing her medicare with insurance. GAP insurance is I think what she calls it. I mean I'm sure what you are describing exists, but it's not universal.
I am talking about Medicare Advantage. Medigap is different.
What I am talking about isn't "universal", but it's what about 40% of Medicare patients use in 2018. It's not universal because people have to choose to opt into Medicare Advantage, but it's an option for everyone: everyone[0] who's eligible for Original Medicare is eligible for Medicare Advantage.
[0] well, there are a couple of small exceptions, but I'm 100% sure your mom doesn't fall into those categories, based on what you've already said
> No, because it's free, but 1/3 of Medicare recipients opt to receive their coverage through private insurers that typically add on additional coverage
They don't simply add on coverage; they replace it. Most people on Medicare Advantage don't opt for coverage above what Medicare itself can provide - they simply receive their benefits from a private entity instead of Medicare, because Medicare provides such a bad experience for patients.
While you may have a good argument against a "single-manager" health care system, this doesn't seem like an argument against a single-payer system. In fairness, I guess a lot of existing universal-coverage systems, such as the UK's NHS, are also single-manager (someone will correct me if I'm mistaken), but the very existence of Medicare Advantage shows an alternative possibility. I think that, far from being an argument against single-payer, it shows how single-payer can be made to work even better, through premium subsidies (and, I would guess, reinsurance for catastrophic losses) to private insurance companies, for those who are willing and able to pay additional premiums for better care.
The NHS is what is called a Beveridge style system. I think that is what you mean by single managed. Similar systems are used in Spain, the Nordics, etc. They are often managed at local levels though and may include private hospitals and treatment that gets reimbursed by the payer at the same level as public ones. The VA is an example of this type of system although other nations have far more oversight and performance control than the VA does.
A competing setup is the Bismarck style of insurance company administered management, either for-profit or non-profit. Germany, the Nederland's, Switzerland, etc runs this sort of system. Always with a lot of legislation and safeguards to ensure that people do not fall outside the system. It is similar to the US employer-provided insurance setups.
Other systems are National Insurance, as used in Canada and Japan. Similar to Medicare. Canada is fairly unique in its hostility to private provision.
And then there is out of pocket, like rural Africa does it. That's basically like being uninsured and not qualifying for Medicaid.
Thing is, the US accumulated massive bureaucracy and costs by h\trying to run every system at the same time with little attempt at standardization and lots of billing and gatekeeping. Everyone else picked one system and stuck with it, letting private providers fill in the gaps. (Except Canada for the last)
> I guess a lot of existing universal-coverage systems, such as the UK's NHS, are also single-manager (someone will correct me if I'm mistaken), but the very existence of Medicare Advantage shows an alternative possibility. I think that, far from being an argument against single-payer, it shows how single-payer can be made to work even better, through premium subsidies (and, I would guess, reinsurance for catastrophic losses) to private insurance companies, for those who are willing and able to pay additional premiums for better care.
I don't think you understand how Medicare Advantage works. There's really nothing about it that suggests a single-payer system would work. The premiums are not subsidized. (Reimbursements are, but that's a separate matter.)
Medicare is the fullest extent to which people can legally opt out of Medicare, short of claiming religious exemptions (rare), working for a foreign government while in the US (rarer and legally questionable for citizens), or surrendering US citizenship altogether (drastic). Medicare Advantage outperforms Original Medicare on the top performance indicators (medical outcomes, cost, patient satisfaction), though underperforms the same exact private insurers on those same metrics, despite the latttermost also being saddled with the burden of subsidizing Original Medicare reimbursements.
If you still want to advocate for single-payer healthcare on philosophical grounds, okay. But from an empirical standpoint, Medicare is not the place to look for data to support that stance.
I already quoted from medicare.gov [0], but I'll repeat: Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans.
Private entities contract with Medicare to provide insurance that covers what Medicare covers (and perhaps more). Would said insurers cover everyone that Medicare covers in the absence of Medicare? The answer is no.
How many of these people on private Medicare plans pay for Medigap? Everyone who get kicked off a private plan can go back to the original Medicare. Your point is disingenuous. Medicare is the universal insurer of last resort for elderly. Their lives would be much worse without this last resort insurer.
> Medicare is the universal insurer of last resort for elderly. Their lives would be much worse without this last resort insurer
That's a far cry from "people don't seek to leave Medicare", which is literally the original claim. By and large, people do seek to leave it, to the extent that they can, both legally and financially.
Yes, for people who can't access anything better, having Medicare is better than literally nothing, but nobody's arguing that. That doesn't mean that Medicare provides a good model of what would best suit everyone else, and that's the relevant question when talking about a single-payer system.
If you want to talk about a single-payer system and use Medicare as an example in support of it, you have to address the fact that privately managed plans consistently outperform Medicare on the top three performance indicators, and that patients themselves prefer all the alternatives to Medicare except "no coverage at all".
> Do Medicare recipients seek to leave it? That’s a government run healthcare system.
Since you asked - yes, yes they do. Medicare patients can opt to receive their inpatient/outpatient benefits from a private insurer in lieu of traditional Medicare benefits, and an increasing number of people do so.
Privately managed Medicare plans, incidentally, outperform Medicare on the three key performance indicators: medical outcomes, cost, and patient satisfaction.
Do Medicare recipients seek to leave it? That’s a government run healthcare system.
Universal healthcare can be implemented poorly but it doesn’t have to be. It can be done right. There are lots of examples of this.