Without implying too much other than what can be directly inferred from this line
Private health care is sold as a luxury for the affluent
and usually only covers hospital treatment, not primary
care—that is, visits to a doctor.
I'd like to reiterate that this is where the American model of healthcare delivery is headed.
The Affordable Care Act just made this abundantly inevitable.
We will soon have a tiered system - if it already isn't here - where the wealthy shall be catered to by doctors and health professionals, who have completely removed themselves from the insurance model and thus only serve in a Direct-Pay model.
The best surgeons and experts will exclusively cater in a on-demand model, flying down to multiple locations a day to offer their premium services to wealthy clients. Concierge medicine is already here. [1]
Even with things like Telemedicine and Remote surgery, I don't see why the doctors will behave any differently in how they choose to split their precious hours.
In the UK, while there are some that provide only direct-pay services, most of the private healthcare is operated by, or contracted by, large private insurance companies, that offers quite cheap "add-on" insurance offered as perks by companies, or which you can buy separately.
Most of the private health-care offerings are also deeply incestuous with the NHS. Large part of the surgeons are NHS surgeons that offer additional services on their own time. Many of the surgeries happens in NHS facilities that make excess capacity available to help offset operating costs, and so on.
Additional private cover in the UK is well within reach for most people that are not that far below a median salary.
Private stuff in the UK is also reasonably common in employment contracts for anyone above middle manager level, since you effectively get the same treatment as the NHS for the reasons mentioned, but with a much shorter waiting period, so companies can get their employees back to work faster.
I guess it's some UK thing but I expected "middle manager" to be something pretty exclusive with not many people above. And this is where it loses relevancy to many people on HN.
Maybe you call shop clerks middle managers or something.
You would have to be somewhat out of touch to think we haven't had a tiered system in the US since long before the ACA. The fact that people can talk about "good insurance" and "bad insurance" where the deciding factor is how good of a job you have - and still keep a straight face - is pretty telling.
You would have to be somewhat out of touch to think we haven't had a tiered system in the US since long before the ACA.
Yeah, but that interferes with the narrative, that the ACA is responsible for everything bad that's happening in the US. It is appalling to me how much is blamed on the ACA.
If you really want to figure it out you have to go back to WWII when wage controls were implemented. Employers had little way to compete for talent so for some reason the IRS said that various benefits like health insurance weren't taxable. Now your insurance changes with your job, rather than by your decision.
Imagine how often car insurance companies would try and deny claims and generally be shitty if their customers were locked in and couldn't switch unless they changed jobs.
I think that's one of the biggest problems with healthcare right now. The employer is the "customer" not the employees, so fuck 'em!
That was part of the initial motivation for tying insurance to employment, but the main reason it's persisted is that it's a way of solving the adverse-selection problem. If you let individuals choose when to buy insurance, on average people buy it when they need it and risk going without when they don't. But if you insure a company's whole workforce at once, with individual employees not being able to opt out, you have a risk pool not specifically selected for high-risk patients.
This is also a reason group coverage typically has a minimum size for coverage, because small companies still have the adverse-selection problem— founders more worried about their health are more likely to buy their company group insurance than those who think their health is fine. But once a company reaches a certain size, those individual factors get less important since everything's averaged over a large mandatory-coverage pool.
That's an excellent point. Adverse selection is a real problem because some people can have a very good idea of what their bills will be. If it's cheaper to pay out of pocket they'll do so, but if they could save money by buying insurance they would do so.
Another part of that problem is that the price is all wrong. People who have very little risk of dying regularly buy health insurance in part because the premiums are so reasonable. $200 a year (or whatever it costs) is such a small amount of money for so, so many people that you're a fool not to buy it if you have dependents.
If you could pay the actual market rate at the doctor's office -- the rate the insurance companies get -- you could afford most medical problems out of pocket. I mean it's demonstrably true, the insurance companies don't pay out more than everyone pays in so by default we can all afford to pay for healthcare. What we can't all afford to do is pay $50k for big procedure X or $200k for cancer treatment Y. But those are major medical type issues which we can insure for not horrific amounts of money.
The adverse selection problem can be solved in large part by having affordable major medical that makes you an idiot not to take it. I can totally understand why single people in their 20s aren't keen on shelling out $450 a month for insurance. But $20-$50 a month? That's less than car insurance or a cell phone or cable. Save $400 a month on insurance and you could afford to get ACL surgery every couple of years!
But here's the thing: if you want to buy your own insurance you can't 1) because of the adverse selection issue and 2) because an already high price would get about 30% higher as you get taxed on that money.
> We will soon have a tiered system - if it already isn't here
That has indeed been the case in the U.S. for years. The three most common health-insurance structures, EPOs, PPOs, and HMOs, each have very specific lists of doctors who accept "in-network" coverage (they differ largely on the terms by which you can pay out of pocket to go "out of network"). How big those lists are and what kinds of doctors they include is pretty noticeably correlated with price: the cheapest insurances don't get you access to a wide range of top-quality "in-network" doctors. And there are a handful of boutique clinics and surgeons who don't take any packages at all. (There's an additional negative impact of this "networks" system in that companies seem to change networks semi-regularly as they renegotiate packages, and people change networks when they change jobs, which interrupts continuity of care.)
Where I live now (Denmark) the whole system is just run publicly, except for a handful of elective things (non-reconstructive plastic surgery, etc.), which are allowed to be done in private practice since they aren't properly considered part of the healthcare system. That removes the possibility of any tiering among "regular" care, and somewhat simplifies bureaucracy (plus, kids can keep the same doctor throughout their childhood, not having to switch every few years). I wouldn't actually mind a multi-tiered system, though, as long as the "free" tier can maintain sufficient quality. I particularly don't mind differences in amenities (if people are willing to pay a lot to go to boutique hospitals that have luxurious private suites, like some of the medical-tourism-oriented hospitals in Jordan offer, that's fine). Tiering does have potentially bad consequences for the quality of the free tier, but to me those consequences are what matter more than the tiering itself, i.e. if System A provides everyone level-7 quality healthcare, while System B provides everyone level-8 quality healthcare and those who pay extra level-9, I'd prefer System B despite its inequality, due to the higher absolute standard of its generally-available care.
In terms of your worry of doctors dropping out of the insurance system to make higher incomes, I think that is something to watch out for, although afaict the big monetary lure currently isn't to keep the same general profession but go out-of-network, but rather to leave "regular" healthcare entirely and go to super-premium boutique stuff like plastic surgery, IVF treatments, sports medicine, etc., which is where the real "superstar doctor" money is. Some of this may be because it's harder to become a superstar doctor in areas like cancer treatment without being at a top research hospital, and research hospitals tend to see themselves as having a public-service (rather than income-maximization) mission, which impacts their policy decisions. If necessary the government could also probably lean on those kinds of hospitals (places like M.D. Anderson, Johns Hopkins, etc.) by adding strings to NIH funding.
The Affordable Care Act just made this abundantly inevitable.
We will soon have a tiered system - if it already isn't here - where the wealthy shall be catered to by doctors and health professionals, who have completely removed themselves from the insurance model and thus only serve in a Direct-Pay model.
The best surgeons and experts will exclusively cater in a on-demand model, flying down to multiple locations a day to offer their premium services to wealthy clients. Concierge medicine is already here. [1]
Even with things like Telemedicine and Remote surgery, I don't see why the doctors will behave any differently in how they choose to split their precious hours.
[1]
http://en.wikipedia.org/wiki/Concierge_medicine
http://stanfordhospital.org/clinicsmedServices/clinics/prima...