Why Single Payer in the US?

[Flagg]

The US is able to scale up due to the overall wealth of the society, the question is whether the US is willing to pay the bill.

I don't have cites handy (it's early and I have to be off the work) but it's a common effect that when access is increase there is an initial UPTICK in costs when the new people, who have been without access, are added, because of the diagnosis and treatment of problems that have been deferred due to lack of access and/or funds.

And, purely anecdotally, even a healthy person like myself is going to have that effect when entering the system - when I regained access I had to catch up on both routine exams and vaccinations. When I got dental access again there were two fillings and a bad tooth to pull. Access to vision? New glasses, hadn't been updated in years. Yep, I cost a little money that first year back in the system. Probably won't need more than routine dental exams for a decade or more, likely won't need new glasses for a couple years, vaccines caught up until at least 2018 so I'm relatively cheap at this point. That's for a healthy person. Someone who has undiagnosed/untreated diabetes or something else will start costing a lot more than simply ignoring the person until they are hospitalized (at which point they cost a fuck-ton more) or die (which is comparatively cheap, financially, but corrosive socially).

The biggest issue I've seen from personal experience is that wait times have increased, but simple triage can handle it until there are more docs in the system. It just means wealthy Wilton has to wait when he gets the sniffles because poverty Preston has meningitis.

[PainRack]

The US does relatively well at certain very specific kinds of preventative care, in the places and subpopulations where it's available. The massive un- or under-insured underclass does not have access to these programs, and as a result must use emergency rooms (which are legally required to provide lifesaving care without compensation) to treat illness and injuries that could have been prevented or mitigated with regular medical services. An excellent CDMP is, in a way, an admission of failure; most chronic diseases are preventable. We are dead last at efficiency of care, which is to say 'health care dollars per health care value unit.

First of all, CDMP and public health aren't inversely correlated. You can have very good public health but lousy chronic disease management, which was the default in the 90s.

For public health, certain factors such as teen pregnancy, obesity, smoking and vaccinations, along with OSHA for workplace accidents, the U.S. Isn't dramatically lagging behind despite pioneering the obesity epidemic. Vaccination rates for example is still vastly superior to the UK.

Secondly, efficiency of care measures costs. It has nothing to do with whether the US has poor preventive care.

Thirdly, the V.A shows us exactly what happens when demand rises without investment in capacity. Backlog and disaster. The U.S. Has a free market that will expand to meet demand, indeed, we already seeing an explosion in services to exploit health IT but doctors,hospitals and etc are not that responsive without rapid immigration.
I extremely leery of claims like those made by Bernie Sanders regarding how preventive costs will reduce healthcare costs, because the VA and HMO show us two scenarios why it failed. VA due to uptick in demand from the gulf war, HMO and CDMP reduced healthcare inflation before it became a runaway rise during Bush.

This is ignoring how socio economics and poor compliance isn't just a matter of access. Again, the UK highlights this.

I believe the figure is something like a 500% efficiency improvement from preventative care over curative care, as established by numerous scientific studies. It's an objective fact that moving population health curves is a better plan than expensive treatment of preventable diseases.

just what do you mean by preventive care?

Because it appears to me you're conflating preventive care with public health.

The IOM defines public health as the fulfillment of society's interest in assuring the conditions under which people can be healthy.
Preventive care is healthcare services aimed at preventing or reducing disease or complications from disease

Preventive care does overlap, from screening, children health services and dental to teach brushing and checking development milestones and vaccinations, but it seems you tacking on changing health behavior, which is under the aegis of public health.

So, yes, preventive care when you give statins to prevent strokes and heart attacks, manage blood pressure, diabetes, reduce obesity so risks of diabetes is lower and etc.... Those figures of improvement you quote are from THESE measures, not say engineering cities and sidewalks to encourage 1 thousand steps daily .

Furthermore, you seem to be ignoring the full spectrum of preventive care. For example, for dementia, we know full well that dementia services reduce and delay rates of institutionalization, and with adequate home care services, many patients can be nursed in the community. Are such services available and able to be scaled up to meet the increased demand from patients? Yes? No?

The U.S. Is too complex and big for broad sweeps to be accurate, but I highly doubtful that simple measures to promote preventive care will dramatically reduce healthcare costs without a large financial investment.

[Esquire]

I'll admit it, I was in fact conflating preventative medicine with public health - that's the governing point, I think. That said: being good at managing preventable diseases is an admission that we can't prevent them as well as we ought to. Obviously increase in demand for care without a corresponding (or disproportionate, since we're worse at every national measure of health care quality than we should be) increase in funding for same will lead to shortfalls.

Basically, my thesis is that the current system objectively does not work, and needs to be changed if the US wants to achieve health outcomes comparable to other first-world nations. A great deal of that change will come from increased investment in/support for public health measures, which is to say preventing disease before it needs to be treated or managed in the first place.

[PainRack]

I'll admit it, I was in fact conflating preventative medicine with public health - that's the governing point, I think. That said: being good at managing preventable diseases is an admission that we can't prevent them as well as we ought to. Obviously increase in demand for care without a corresponding (or disproportionate, since we're worse at every national measure of health care quality than we should be) increase in funding for same will lead to shortfalls.

Basically, my thesis is that the current system objectively does not work, and needs to be changed if the US wants to achieve health outcomes comparable to other first-world nations. A great deal of that change will come from increased investment in/support for public health measures, which is to say preventing disease before it needs to be treated or managed in the first place.

Except that doesn't follow. Chronic disease has non modifiable factors such as age itself. Unless the science rapidly catches up and give us solutions for Alzheimer's and hypertension, you are going to have to embrace preventive care. Apart from obesity, much of the preventing disease bits have been plucked although the lack of UHC in the US and funding for children services has brought back problems.
And preventing/reducing obesity is not a simple solution.
Nor is it cheap, and while the UK has their low salt reduction program, the U.S. Has Michelle Obama pushing forward very successful anti obesity programs that has stabilized and reduced in some instances childhood obesity. Weight loss however now includes very EXPENSIVE solutions such as re engineering entire cities to increase walking, health promotion challenges, the ideas of contracts and cash incentives are being tried out worldwide and etc.

Lastly, again, the U.S. quality of care is superb, from both customer perspective and independent statistics. The US is pioneering harm reduction, the first to pioneer health infomatics, yes, lack of UHC is hindering implementation across the population but it's not worse off. More importantly,my intent was to question whether claims of preventive medicine will reduce healthcare costs. The need to scale up services and etc require financial investment . The ACA is using market forces to implement this by mandating IT records and then letting companies devise solutions to tie in with say Blue Button but nowhere is it promised that it will be cheap enough to promise single payer, WITHOUT investment.

The NHS went through such a similar trial after all.



Moving on, your assertion that improved public health will reduce disease is again questionable. Non modifiable factors such as age will defeat your assertion easily. Note that we haven't asked how will the retirement of boomers cause healthcare inflation and demand to spike just as resources and expertise are withdrawn due to retirement.
Heh. At least the US has one factor going for it. Immigration is keeping the US young, with a large labour force compared to every other 1st world nation out there.

You're too dismissive of the demographic advantages and strength of the US system. The problem will be in retaining those strengths when it scale up to improve access and that thing cost money. Money that sequestration and the reduced NIH funding denies.

Let's not forget that active aging is expensive. I only aware of the home alerts, Tele medicine and assisted living villages for US but in the Singapore context, we rebuilding large tracts of public housing to include lift elevators, redistributing commercial zones so that shopping to get good and necessities are easier, trying to improve unpaid caregivers needs and manipulating public housing subsidies to motivate caregivers to assist on top of public insurance such as leaderships, or funds such as Senior Mobility Fund. Combine that with other healthcare services such as our termed senior activity centres to promote active aging and.living in the community, dementia care centres and etc.
I know from accounts that various US states don't have the expected facilities to meet expected demand for ILTC care and etc. Do you know what healthcare services are available or should be implemented in your state for active aging? One good factor the US has is that the Americans Disability Act has made many buildings wheelchair accessible, although I don't know whether public transport is accessible as opposed to proliferating disabled parking.

[PainRack]

Bah, stupid autocorrect. I meant Eldershield, not leaderships.

[Broomstick]

One good factor the US has is that the Americans Disability Act has made many buildings wheelchair accessible, although I don't know whether public transport is accessible as opposed to proliferating disabled parking.

Public transport is getting more and more accessible, from braille and spoken cues for the blind and deaf to elevators in stations to wheelchair lifts becoming more common on buses. That trend started back in the late 1980's and has continued since. Still not perfect, but it helps.

[Esquire]

I'll admit it, I was in fact conflating preventative medicine with public health - that's the governing point, I think. That said: being good at managing preventable diseases is an admission that we can't prevent them as well as we ought to. Obviously increase in demand for care without a corresponding (or disproportionate, since we're worse at every national measure of health care quality than we should be) increase in funding for same will lead to shortfalls.

Basically, my thesis is that the current system objectively does not work, and needs to be changed if the US wants to achieve health outcomes comparable to other first-world nations. A great deal of that change will come from increased investment in/support for public health measures, which is to say preventing disease before it needs to be treated or managed in the first place.

Except that doesn't follow. Chronic disease has non modifiable factors such as age itself. Unless the science rapidly catches up and give us solutions for Alzheimer's and hypertension, you are going to have to embrace preventive care. Apart from obesity, much of the preventing disease bits have been plucked although the lack of UHC in the US and funding for children services has brought back problems.
And preventing/reducing obesity is not a simple solution.
Nor is it cheap, and while the UK has their low salt reduction program, the U.S. Has Michelle Obama pushing forward very successful anti obesity programs that has stabilized and reduced in some instances childhood obesity. Weight loss however now includes very EXPENSIVE solutions such as re engineering entire cities to increase walking, health promotion challenges, the ideas of contracts and cash incentives are being tried out worldwide and etc.

Lastly, again, the U.S. quality of care is superb, from both customer perspective and independent statistics. The US is pioneering harm reduction, the first to pioneer health infomatics, yes, lack of UHC is hindering implementation across the population but it's not worse off. More importantly,my intent was to question whether claims of preventive medicine will reduce healthcare costs. The need to scale up services and etc require financial investment . The ACA is using market forces to implement this by mandating IT records and then letting companies devise solutions to tie in with say Blue Button but nowhere is it promised that it will be cheap enough to promise single payer, WITHOUT investment.

The NHS went through such a similar trial after all.

US care quality is excellent... if you can afford it. The problem, again, is that the costs of providing care to the uninsured are passed on to those with insurance through both taxes and opaque hospital and insurance pricing metrics; we wind up paying a huge amount for objectively inefficient care. Your own citation supports this criticism.

Moving on, your assertion that improved public health will reduce disease is again questionable. Non modifiable factors such as age will defeat your assertion easily. Note that we haven't asked how will the retirement of boomers cause healthcare inflation and demand to spike just as resources and expertise are withdrawn due to retirement.
Heh. At least the US has one factor going for it. Immigration is keeping the US young, with a large labour force compared to every other 1st world nation out there.

What? There's overwhelming evidence that prevention programs reduce costs overall while improving outcomes; I can cite sources if you really want me to, but this is basic logic. Age is a risk factor for... well, everything, but nearly every other risk factor can be controlled with proper programs and support systems. Since the rate of aging will stay constant at roughly one second per second, reductions in other risk factors will by definition reduce preventable disease incidence.

You're too dismissive of the demographic advantages and strength of the US system. The problem will be in retaining those strengths when it scale up to improve access and that thing cost money. Money that sequestration and the reduced NIH funding denies.

What advantages would those be? Please recall that the US health care system excludes more than 10% of the total population while offering objectively worse outcomes than the systems of comparable nations.

[PainRack]

US care quality is excellent... if you can afford it. The problem, again, is that the costs of providing care to the uninsured are passed on to those with insurance through both taxes and opaque hospital and insurance pricing metrics; we wind up paying a huge amount for objectively inefficient care. Your own citation supports this criticism.

Yes, I know. So? My initial contention is that we should view arguments that increased access to healthcare will reduce costs because of preventive care with suspicion. That's not a given unless certain other factors are made. And we KNOW this because the NHS went through the exact same thing decades ago.

What? There's overwhelming evidence that prevention programs reduce costs overall while improving outcomes; I can cite sources if you really want me to, but this is basic logic.

For fuck sake, what is this a rebuttal to?
If it's the earlier post, I already told you. Is the US going to spend the investment to improve the capacity to meet increased demand, and said capacity isn't extremely responsive. Without said investment, costs don't drop overall.

Age is a risk factor for... well, everything, but nearly every other risk factor can be controlled with proper programs and support systems. Since the rate of aging will stay constant at roughly one second per second, reductions in other risk factors will by definition reduce preventable disease incidence.

. Except we aren't talking about INCIDENCE but DEMAND. I sure you going to be able to eliminate sex, genetic and etc while you at it too, but the fact remains that we expect to see a huge spike in demand for healthcare services as the baby.boomers retire, hence, why claims that preventive care will drop current healthcare costs, as oppose to slow healthcare inflation is questionable. And that this arrest in inflation itself requires an investment in capacity now.

You ignoring the salient points in favour of preaching from the soapbox. Stop. Read. Comprehend. Then reply.

We will see a rise in demand for healthcare for chronic disease simply because of old age. It's simply absurd to think otherwise. Nothing you do in the next ten years can change this simple fact.

What advantages would those be? Please recall that the US health care system excludes more than 10% of the total population while offering objectively worse outcomes than the systems of comparable nations.

Simply put? Density of healthcare services and the fact that America, as opposed to every other 1st world country is not an aging population. There's still expected cutbacks due to withdrawal of expertise and labour but the US is unique in that it isn't expected to serve an ever growing aging population with a shrinking labour force and tax base.

Pray tell. Have you read anything about the silver tsunami?

[Esquire]

Right, look. The US population is aging, true. As a result, we can expect disease incidence to increase, since, again, age is a risk factor for basically everything. The goal is to keep that growth at or below expected increase due to population aging.

Additionally, it's not like those not covered by the existing system don't get sick or injured; they do and they overwhelmingly wind up using emergency rooms for (what should be) routine medical care. Those costs are absorbed by the system through hospital charges to insurers, premiums charged to consumers, and taxes paid by same. All of this is in addition to the obviously-evil result that many people die of preventable illnesses for essentially no good reason.

The basic problem is that the US currently spends something like 2.5 times more per capita than the UK (as a proxy for other first-world nations) for, and I can't stress this enough, objectively worse outcomes. The present health care system does not work. While the various alternatives have their own individual downsides and tradeoffs, they're all better than the existing state of affairs.

And obviously no improvement is possible without proper investment, what kind of an idiot do you think I am? The question here is 'should the US adopt a single-payer health care system, like every other first-world nation,' and the answer is yes.

[PainRack]

So Esquire, then why claim that the US is poor in terms of preventive care? The data indicates otherwise. And public health isn't just a healthcare or single payer solution. At this point, you just preaching.on the soapbox as opposed to trying to elaborate because the topic was about costs and investment in capacity.


For...interests sake, I toss in these tidbits about US public health. The US used the social-ecological model
http://www.ecu.edu/cs-dhs/healthaccess/ ... -model.gif
Interventions aimed at one level affects those levels below it as well and successful solutions to complex health problems require coordinated interventions at multiple levels.

There are multiple behaviours that we want adopted. From vaccinations such as flu and pneumonia, shingles, clinical preventive services such as screening for hypertension and effective interventions for reducing complications from disease such as anticoagulant to reduce strikes and heart attacks, diabetes management. Lastly, we want seniors to remain active in mind and body for quality of life and regarding the impact of dementia, depression and mental health including suicide.

The last concept is the spectrum of health and "right siding" care. There will be degeneration related to aging, however, it's possible to enhance health and provide services so that both healthful, active aging takes places and that elders aren't institutionalised, or at most, are staying in assisted living care centres such as the shared apartment model.

Note that I talking about the elderly because most of the low lying fruits have been plucked. As the CDC listed in 1999, the great success in public health was good and water safety, motor vehicle safety, vaccination, safer workplaces, control of infectious diseases, healthier babies and mothers,family planning, fluoridation of drinking water and smoking.

While much of this is now threatened, such as the attack on Planned Parenthood and anti vax campaigns, they still remain mostly intact. The last two great challenges is regarding obesity and STD..... And these are not simple to achieve. Michelle Obama has taken out a trillion calories yes, obtained companies consent to stop marketing to children and etc, but all this has done is arrest the growth in.childhood obesity. Steps to reduce obesity further now include re engineering cities to increase walking and re engineering food deserts to address the zip code effect.
http://www.cdc.gov/obesity/downloads/PA_2011_WEB.pdf
Much of this however lies in socio economics as well. Which brings us to the lacklustre of SNAP and other welfare programs.


Well, back to preventive care I.e,medical. Although preventive care is usually cost effective with respect to population health,only a few preventive interventions are cost savings in terms of expenditure. (Cohen, Neumann, and Weinstein,2008.Does preventive care save money? Health economics and the presidential candidates. New England journal of medicine 358:661-63)
We can talk about the hypothesis of compressed mortality and etc, but to put it simply, we don't see much data that healthier individuals who live longer spend less money than people who died earlier.
Outside of stuff like vaccines , a lot of interventions don't cost less in the LONG term. Note: this does not mean you shouldn't do it, because many of the interventions mean healthier, more productive citizens who are less of a burden for longer periods of time, but the money spent to achieve said health isn't gained back as dollars saved, but rather as dollars earned.


To put it simply. Public health measures at societal levels have much more of an impact on health outcomes than letting everyone see a doctor. It was public attacks on smoking that drove down smoking rates, not clinical smoking cessation.

Hence, barring some sea change in technology and techniques, I question whether increased access to healthcare will cut costs. The easy bits have already been done.

Edit: or we can shut debate down and revert this to a me too thread that the US should go single payer because it's horribly unequal in access.

[PainRack]

One good factor the US has is that the Americans Disability Act has made many buildings wheelchair accessible, although I don't know whether public transport is accessible as opposed to proliferating disabled parking.

Public transport is getting more and more accessible, from braille and spoken cues for the blind and deaf to elevators in stations to wheelchair lifts becoming more common on buses. That trend started back in the late 1980's and has continued since. Still not perfect, but it helps.

Hmm. Anything new about helping caregivers then? You got to admit, the MacMillian nurses for the NHS or the Nordic system, where they even hire people to help with gardening is great.

[Esquire]

So Esquire, then why claim that the US is poor in terms of preventive care? The data indicates otherwise. And public health isn't just a healthcare or single payer solution. At this point, you just preaching.on the soapbox as opposed to trying to elaborate because the topic was about costs and investment in capacity.

I... didn't? My point is that, although the US is good at certain preventative programs, we're shooting ourselves in the foot by not applying them more broadly. This is evidenced by the fact that US incidence and prevalence of most chronic diseases are massively higher than other first-world nations. I apologize if that wasn't clear. And the topic, as per the title of the thread, was 'Why [should we adopt] Single Payer in the US?' I feel that increased equality of health care access and reduced overall costs are fairly good reasons.

While much of this is now threatened, such as the attack on Planned Parenthood and anti vax campaigns, they still remain mostly intact. The last two great challenges is regarding obesity and STD..... And these are not simple to achieve. Michelle Obama has taken out a trillion calories yes, obtained companies consent to stop marketing to children and etc, but all this has done is arrest the growth in.childhood obesity. Steps to reduce obesity further now include re engineering cities to increase walking and re engineering food deserts to address the zip code effect.
http://www.cdc.gov/obesity/downloads/PA_2011_WEB.pdf
Much of this however lies in socio economics as well. Which brings us to the lacklustre of SNAP and other welfare programs.

Yes, I'm well aware. This, in fact, is rather the point of switching to an [objectively more] efficient health care system; national-level savings could be used to support healthier cities.

Well, back to preventive care I.e,medical. Although preventive care is usually cost effective with respect to population health,only a few preventive interventions are cost savings in terms of expenditure. (Cohen, Neumann, and Weinstein,2008.Does preventive care save money? Health economics and the presidential candidates. New England journal of medicine 358:661-63)
We can talk about the hypothesis of compressed mortality and etc, but to put it simply, we don't see much data that healthier individuals who live longer spend less money than people who died earlier.

Absent specific citations, I'm assuming you;re basing this (or that the study authors are basing this) on the RAND experiment, which had severe experimental limitations and has been questioned extensively in print over the last decade or so. 'Moral hazard' is, at best, a questionable hypothesis.

Outside of stuff like vaccines , a lot of interventions don't cost less in the LONG term. Note: this does not mean you shouldn't do it, because many of the interventions mean healthier, more productive citizens who are less of a burden for longer periods of time, but the money spent to achieve said health isn't gained back as dollars saved, but rather as dollars earned.

Analysis of health care cost-effectiveness is tricky; news at 11.

To put it simply. Public health measures at societal levels have much more of an impact on health outcomes than letting everyone see a doctor. It was public attacks on smoking that drove down smoking rates, not clinical smoking cessation.

Hence, barring some sea change in technology and techniques, I question whether increased access to healthcare will cut costs. The easy bits have already been done.

The worst part of this discussion is that you're completely correct; the easy bits are in fact already done. The problem now is to support experimentally validated and objectively more efficient population-level health measures, instead of the current bizarre mix of excessive, wasteful testing and absolute neglect.

Edit: or we can shut debate down and revert this to a me too thread that the US should go single payer because it's horribly unequal in access.

Well, that and because it'll save the US hundreds of millions of dollars, if not more per annum.

[PainRack]

"

I... didn't? My point is that, although the US is good at certain preventative programs, we're shooting ourselves in the foot by not applying them more broadly. This is evidenced by the fact that US incidence and prevalence of most chronic diseases are massively higher than other first-world nations. I apologize if that wasn't clear. And the topic, as per the title of the thread, was 'Why [should we adopt] Single Payer in the US?' I feel that increased equality of health care access and reduced overall costs are fairly good reasons.

While half of older adults are up to date with vaccines or recommended cancer screening,
http://www.cdc.gov/pcd/issues/2005/jul/pdf/05_0021.pdf
An international survey suggests Americans receive the same percentage of preventive care as others.

http://www.ncbi.nlm.nih.gov/pubmed/15513956
Yes. The same survey states data cost related access is poor and etc but we were talking about gleaning out cost savings from preventive care.

Yes, I'm well aware. This, in fact, is rather the point of switching to an [objectively more] efficient health care system; national-level savings could be used to support healthier cities.

From where? Bernie Sanders healthcare plan is being attacked for unrealistic financial savings from preventive care as it is. Again, for said savings to appear, you need a massive investment because the US healthcare capacity as it is is going to shrink due to retirement and expected uptake in use from boomer retirees. This ISN'T me saying you don't need to change however, it's pointing out that you can't just save ideology around and pretend it work. What are the specifics on proposed investment to cut costs?

Furthermore you quoted the section of my reply that says more welfare is needed to realise health gains. Will shifting to single payer automatically realise said welfare goals? No?

Absent specific citations, I'm assuming you;re basing this (or that the study authors are basing this) on the RAND experiment, which had severe experimental limitations and has been questioned extensively in print over the last decade or so. 'Moral hazard' is, at best, a questionable hypothesis.

Dude. I gave you the full citation including page number. You don't get more bloody specific than that.

http://www.nejm.org/doi/full/10.1056/NEJMp0708558
It's a meta analysis of various interventions, vaccines and cancer screening being two examples.

The worst part of this discussion is that you're completely correct; the easy bits are in fact already done. The problem now is to support experimentally validated and objectively more efficient population-level health measures, instead of the current bizarre mix of excessive, wasteful testing and absolute neglect.
[/quote
Yadda yadda, I will build that wall and the Mexicans will pay for it.

Details? The ACA does have a plethora of details on incenvtising care, like, the penalties of Medicare for repeated admissions and opening up the healthcare data market to free enterprise for innovation .

Or how the ACA is trying to enact IT and other policies from the IOM to err is human report, pursuing medical errors as a cost saving measure.

[PainRack]

Just as a reminder that improved health need not lead to increased savings.
http://www.nejm.org/doi/full/10.1056/NEJMsa020614

Expenditures amongst those more healthy as defined by functional status was around the same as those more ill, they lived longer lives with better QUALYS but spent the same amount of Medicare dollars.


It's not for nothing that the saying is we pay for gains in health, be it whether it's from treatment or prevention.

[Esquire]

That's true... among patients aged 70 and over. There's a reason why it's the "Biblical threescore-and-ten;" things start to fall apart around then. We can fix many of them now, but joint-replacement surgery (as an example) is very expensive. The study authors themselves say: "Health-promotion efforts aimed at persons under 65 years of age may improve the health and longevity of the elderly without increasing health expenditures."

Also, this is a 13-year-old study using 18 to 24-year-old data. There have been significant improvements in both elder-specific and general care efficiency since 1992. That's beside the fundamental flaw in your logic; better health outcomes for the same amount of money is explicitly not 'paying for gains in health.'

[MKSheppard]

The push for single payer will come SOON [tm] as the ACA grenades within the insurance market start detonating over the next few years (they can't keep pushing off various taxes within the ACA indefinitely.)

[PainRack]

That's true... among patients aged 70 and over. There's a reason why it's the "Biblical threescore-and-ten;" things start to fall apart around then. We can fix many of them now, but joint-replacement surgery (as an example) is very expensive. The study authors themselves say: "Health-promotion efforts aimed at persons under 65 years of age may improve the health and longevity of the elderly without increasing health expenditures."

Also, this is a 13-year-old study using 18 to 24-year-old data. There have been significant improvements in both elder-specific and general care efficiency since 1992. That's beside the fundamental flaw in your logic; better health outcomes for the same amount of money is explicitly not 'paying for gains in health.'

Lol. Except the argument is about preventive care reducing healthcare expenditures, remember?

There is no such thing. You pay money to gain health, period. It's worth it based on the fact that a healthier population is better off, not because it saves money. That and a healthier population is more productive than a sicker one.

The clinical health based interventions that are cost effective are vaccinations. And that's not something a single payer US system will fix.

Health promoting interventions aimed at younger populations aren't clinical based but societal, targeted at social engineering to reduce obesity, increase physical activity and other healthful habits like increased consumption of fresh fruits and vegetables. Note that none of this are going to be solved by a single payer system automatically. Hell, we know this explicitly because clinical based smoking cessation programs were very ineffective, especially when compared to hypertension control and it was the social and legislative backlash against smoking that improved public health outcomes.

[Esquire]

Right, look. The Department of Health and Human Services, the Office of the Surgeon General, and the Centers for Disease Control all say that preventative interventions are more cost-effective than treatment for many conditions. There are dozens of articles in academic journals that confirm these findings. Obviously not all preventative interventions are cost effective, I would have thought that was so blindingly obvious as to not need mentioning, but many are.

A single-payer system will reduce overall system costs as a logical necessity, because whole layers of profit will drop out of the system. The Federal government has no shareholders to appease and is in an excellent position to negotiate for better rates from providers and pharmaceutical companies; this is why Medicare/Medicaid repayment rates are so low relative privately-insured ones. That position would only get stronger under a single-payer system.

Moreover, who do you think funds a huge chunk of community-based health interventions now? It's the government, primarily through various grant programs. With less money being spent on direct treatment, more will be available for these sorts of programs. Newsflash: clinical care is not the entire health care system. We know that community interventions are better for lots of prevention efforts, and it would be stupid not to use that knowledge.

[K. A. Pital]

Um... Single payer in other countries produces better or equal health outcomes with less expenditures.

Full stop. There is no further argument to be had here. Single payer universal care is more cost-efficient.

[PainRack]

Right, look. The Department of Health and Human Services, the Office of the Surgeon General, and the Centers for Disease Control all say that preventative interventions are more cost-effective than treatment for many conditions. There are dozens of articles in academic journals that confirm these findings. Obviously not all preventative interventions are cost effective, I would have thought that was so blindingly obvious as to not need mentioning, but many are.

Really? Name them. Because what you just did was quote my exact SAME ARTICLE back to me.

The EXACT SAME one that states that most preventive care don't cut healthcare expenditures.

As for what the CDC and etc are saying, no they are not. They saying it's cheaper to treat problems before they become more severe, they did not say it will cut down health expenditures which will be remarkable since the HHS IS asking for more money to do public health!
Are you reading the same texts?

A single-payer system will reduce overall system costs as a logical necessity, because whole layers of profit will drop out of the system. The Federal government has no shareholders to appease and is in an excellent position to negotiate for better rates from providers and pharmaceutical companies; this is why Medicare/Medicaid repayment rates are so low relative privately-insured ones. That position would only get stronger under a single-payer system.

Yes. But nowhere does it state that public health care will cut healthcare expenditure. The actual data and studies that are coming in say otherwise. Investing in preventive care of public health is an investment in health, not a cost cutting saving measure.

I note that you ignored the portion where I asked where the investment in said pre entice care will come about. Are there going to be more home based dementia care services? Or welfare to give people meals, or install grab bars in homes? The ACA does allow for retirement and assisted living villages, but is the capacity enough given the known supply crunch NOW, much less expected uptake due to aging population?

Newsflash: clinical care is not the entire health care system. We know that community interventions are better for lots of prevention efforts, and it would be stupid not to use that knowledge.

News flash, that's NOT PREVENTIVE CARE. Public health and preventive care are linked but different. And that aspect is being done quite well by the US HHS and it won't be improved by a single payer system. Improved by welfare yes, but NOT single payer.

Single payer is a finance system. It's not a miracle worker. Note that the HHS IS saying that the ACA will coordinate strategies between different agencies and provide funds to rationalise and incentivise primary care and public health.

[PainRack]

Um... Single payer in other countries produces better or equal health outcomes with less expenditures.

Full stop. There is no further argument to be had here. Single payer universal care is more cost-efficient.

They more cost efficient because they take out the profit factor and simplify administrative costs.

What it does not do better is in preventive care reducing healthcare expenditures, because increases in health is paid for by money. You invest money to gain health.

The idea that there is excessive disease burden that will be reduced by clinical preventive care is only marginally true. The U.S. And most developed countries has taken the low hanging fruits already, it's why life expectancy is rising everywhere in the world. And if increased access to healthcare is provided via single payer, we can expect increased expectancy and better functional status or QUALY, but we should not expect this to cut healthcare expenditure. Cost savings on the individual level will be offset by community investments in health.


This btw is what the HHS defined as clinical preventive care as mandatory by the ACA.
https://www.healthcare.gov/preventive-care-adults/

Immunisation and heart health are the only cost saving aspects of this care. The rest are costs intended to bring about better outcomes, and offset by increased productivity of the population.

[K. A. Pital]

Even taken so narrow, I think that the burden of treatment of a heavily progressing disease should be decreasing if said disease is discovered at an early stage where less expensive treatments can still work, bring about remission and/or return to full health.

That seems to be a logical conclusion. The opposite (that there are no savings from early treatment and prevention) is counter-intuitive.

[Esquire]

Um... Single payer in other countries produces better or equal health outcomes with less expenditures.

Full stop. There is no further argument to be had here. Single payer universal care is more cost-efficient.

Firstly, this exact thing. There's overwhelming [admittedly ecological, but still overwhelming] evidence in favor of single-payer health care systems as both an economic and a common-decency measure; Painrack, please provide any credible evidence whatsoever that this wouldn't be true in the US as well.

Really? Name them. Because what you just did was quote my exact SAME ARTICLE back to me.

I apologize for that last bit; I read probably two dozen journal articles a week and sometimes I lose track of which came from where.

More to the point, $355 are saved in lifetime treatment costs per HIV infection prevented, "medical costs are reduced by approximately $3.27 for every dollar spent on workplace wellness programs" (SGO), "tobacco screening is estimated to result in lifetime savings of $9,800 per person" (SGO), and "an investment of $10 per person per year in community-based programs tackling physical inactivity, poor nutrition, and smoking could yield more than $16 billion... annually... a remarkable return of $5.60 for every dollar spent, without considering the additional gains in worker productivity, reduced absenteeism at work and school, and enhanced quality of life" (CDC). Nobody said that all preventative interventions are net-savings generators; that would be stupid. All of them, though, are by definition net quality of life generators.

The EXACT SAME one that states that most preventive care don't cut healthcare expenditures.

... So we use the savings from the ones that do to pay for the ones that don't. Why is this controversial?

As for what the CDC and etc are saying, no they are not. They saying it's cheaper to treat problems before they become more severe, they did not say it will cut down health expenditures which will be remarkable since the HHS IS asking for more money to do public health! Are you reading the same texts?

Yes, the difference is that I'm not reading them from a (deliberately?) pedantic viewpoint. If it's cheaper to treat problems at a subclinical level, then by definition doing so will cut down on system expenditures. I'm sure you're thinking 'but Esquire, not all funding has to come from the government now!' Well, so what? The source of all funding is ultimately the citizenry/taxpayers/consumers, and it's objectively less efficient to funnel that funding through multiple profit-generating corporations instead of doing it directly through a centralized administration. As K.A. Pital said, we know this from comparison with... let's see, literally every other appropriate comparison nation.

[Nowhere] does it state that public health care will cut healthcare expenditure. The actual data and studies that are coming in say otherwise. Investing in preventive care of public health is an investment in health, not a cost cutting saving measure.

I note that you ignored the portion where I asked where the investment in said pre entice care will come about. Are there going to be more home based dementia care services? Or welfare to give people meals, or install grab bars in homes? The ACA does allow for retirement and assisted living villages, but is the capacity enough given the known supply crunch NOW, much less expected uptake due to aging population?

No, they don't. The balance of evidence says that not all preventative interventions are cost-saving, which nobody claimed in the first place. We are obviously not talking about the current legal and policy environment, but rather an idealized one, so the bit about the ACA is irrelevant. Current capacity is absolutely inadequate... which can only be solved by a paradigm shift in the holistic system model, since at present the economic incentives support the least-efficient possible care-delivery structure. Again, this is objectively true; compare per-capita health care costs and outcomes in the US and, say, France.

Newsflash: clinical care is not the entire health care system. We know that community interventions are better for lots of prevention efforts, and it would be stupid not to use that knowledge.

News flash, that's NOT PREVENTIVE CARE. Public health and preventive care are linked but different. And that aspect is being done quite well by the US HHS and it won't be improved by a single payer system. Improved by welfare yes, but NOT single payer.

Single payer is a finance system. It's not a miracle worker. Note that the HHS IS saying that the ACA will coordinate strategies between different agencies and provide funds to rationalise and incentivise primary care and public health.

Don't be pedantic. Any time an illness or injury becomes clinically-significant, it's an admission of failure for every system that bears on the specific condition. If you want to specifically define preventative care as necessarily taking place in a clinical setting, it may in the most narrow-minded of technical senses be different from public health, but that's a ridiculous and, as regards this discussion, utterly pointless line of argument.

Moreover, public health is explicitly not being done well in the US as current; you can tell because our rates of nearly all preventable diseases are higher than all other comparable nations. In a single-payer environment, every dollar currently lining the pockets of insurance CEOs would be available for public health measures*, improving both cost efficiency* and, more importantly, population quality of life.

You keep saying that we pay for gains in health. Fine, but if we can** pay less for equivalent or larger gains in health, that's exactly the same as a savings; how do you think division works? 2 value-units for 1 cost-unit is better than 1 for 1.

*The cost-effective ones, obviously.

**And we can, see above.

[PainRack]

Even taken so narrow, I think that the burden of treatment of a heavily progressing disease should be decreasing if said disease is discovered at an early stage where less expensive treatments can still work, bring about remission and/or return to full health.

That seems to be a logical conclusion. The opposite (that there are no savings from early treatment and prevention) is counter-intuitive.

The reason why I'm contentious about the argument that preventive care will cut healthcare expenditures is because when that reason is used, cost cutting becomes a criteria in public expectations, something that doesn't occur in real life. The NHS saw a rise in healthcare expenditure, ditto to the US when CDMP became popular. The effects on costs were primarily arrests in healthcare inflation as opposed to cutting costs, a significant budgetary boost but not actual reduction in expenditure.

And choosing to go for experimentally proven cost effective preventive care...heh. That debate led us to Avastin and macular degeneration from NICE. NICE calculated that the costs of Avastin was too high and not backed up by clinical trials to support its off label use to treat degeneration of the eyes to prevent blindness unless one eye had already lost visual acuity.

There's a lot of fudgy definitions because Avastin is used off label and while case studies show that it works, at least temporarily, we didn't know what the guidelines were as no clinical trials then. But, it WORKS.
And in terms of rationale, using it to preserve only one eye was due to calculating functional disability versus the cost of a temporary for unknown period of time then fix.

The people of Britain rightfully protested the sacrifice of disability in favour for costs a decade ago.


And this itself is not alone. Avastin and breast cancer, where the drug prolonged disease free state but did not statistically significantly prolong life. The debate that ensued when insurance companies sought to cut it was significant in the US.


But of course, you could say that these are where healthcare is too complex for us to make a simple decision. Let's revert, dementia care services, mental health services. We know that the existence of these services, follow up calls and etc, reduce rates of institutionalisation. For dementia, they delay the stage when a nursing home is needed. The savings however are paid for by "free" caregivers at home.The NHS realised this, which is why it's invests heavily in providing support, respite care and welfare subsidies for caregivers.

But this all adds up to there being savings yes, but no CUT in expenditure. It's sound counter intuitive but that's why I reminding everyone, you pay for health period, be it through treatment or prevention.
It's worth it because your population is healthier, hence less miserable and more productive, but it's an investment, not a cost cutting technique.

The cost cutting interventions are already done, the only area where the U.S. might squeeze more efficiencies is from hypertension and hyperlidemia control, but the measures needed to increase compliance there also require heavy investment initially. Most people dont takes drugs willingly.

[PainRack]

Firstly, this exact thing. There's overwhelming [admittedly ecological, but still overwhelming] evidence in favor of single-payer health care systems as both an economic and a common-decency measure; Painrack, please provide any credible evidence whatsoever that this wouldn't be true in the US as well.

But that's not my contention. My contention is whether single payer will CUT costs because of preventive care, my answer is no. It gain health by paying for it.

Proof? CDMP arrested healthcare rise in.inflation along with consolidation during the Clinton administration, it didn't cut it. The NHS went through the exact same thing when it broadly implemented health screening and clinical based services for smoking cessation and chronic disease.

More to the point, $355 are saved in lifetime treatment costs per HIV infection prevented, "medical costs are reduced by approximately $3.27 for every dollar spent on workplace wellness programs" (SGO), "tobacco screening is estimated to result in lifetime savings of $9,800 per person" (SGO), and "an investment of $10 per person per year in community-based programs tackling physical inactivity, poor nutrition, and smoking could yield more than $16 billion... annually... a remarkable return of $5.60 for every dollar spent, without considering the additional gains in worker productivity, reduced absenteeism at work and school, and enhanced quality of life" (CDC). Nobody said that all preventative interventions are net-savings generators; that would be stupid. All of them, though, are by definition net quality of life generators.

None of these are from clinical services, which will be the only factor that's changed in a single payer system. You DO know that these are being done by the ACA now, something that's NOT single payer???

... So we use the savings from the ones that do to pay for the ones that don't. Why is this controversial?

Because your definition of preventive care is too fucking narrow. Dementia care services, meals on wheels, caregiver subsidies are also primary preventive care , they cost money. And you see way more money being spent on adjusting and preventing disability in primary and secondary care, be it through clinical services or other aspects of public health.

Tertiary preventive care or even secondary preventive care is something you left out entirely. For example, breast cancer screening doesn't save money, but it save lives. Preventive care.

Yes, the difference is that I'm not reading them from a (deliberately?) pedantic viewpoint. If it's cheaper to treat problems at a subclinical level, then by definition doing so will cut down on system expenditures. I'm sure you're thinking 'but Esquire, not all funding has to come from the government now!' Well, so what? The source of all funding is ultimately the citizenry/taxpayers/consumers, and it's objectively less efficient to funnel that funding through multiple profit-generating corporations instead of doing it directly through a centralized administration. As K.A. Pital said, we know this from comparison with... let's see, literally every other appropriate comparison nation.

My argument is that these services don't need a single payer to emerge and has been done by non single payer healthcare societies....SUCH as the US. Where the US is lacking is in welfare provisions, again something a single switch to single payer will not resolve UNLESS you put in more money. Which the argument that single payer cut costs is counter productive.

[

Don't be pedantic. Any time an illness or injury becomes clinically-significant, it's an admission of failure for every system that bears on the specific condition. If you want to specifically define preventative care as necessarily taking place in a clinical setting, it may in the most narrow-minded of technical senses be different from public health, but that's a ridiculous and, as regards this discussion, utterly pointless line of argument.

How is this being pedantic? Again. The change to single payer only affects clinical services. Single payer will not increase welfare provisions on it own. It will not improve public health on its own.The sole difference is that it helps improve access by removing payment for services at point of use, I.e, clinical services.

Moreover, public health is explicitly not being done well in the US as current; you can tell because our rates of nearly all preventable diseases are higher than all other comparable nations. In a single-payer environment, every dollar currently lining the pockets of insurance CEOs would be available for public health measures*, improving both cost efficiency* and, more importantly, population quality of life.

You keep saying that we pay for gains in health. Fine, but if we can** pay less for equivalent or larger gains in health, that's exactly the same as a savings; how do you think division works? 2 value-units for 1 cost-unit is better than 1 for 1.

*The cost-effective ones, obviously.

**And we can, see above.

And? How will that change when converting over to single payer, since the major factors are system wide rather than clinical services, the one thing that single payer will change? Or will single payer increase physical activity, reduce harmful behaviors such as unprotected sex or smoking?

On the areas where it does affect preventive care, such as medication compliance, hypertension,or diabetes management, the US pioneered and has widely implemented said clinical services, such that the rest of the world is copying them.
The U.S. Pioneered harm reduction and bench to bedside, zero central lines infection? USA. Even the bloody phone calls and telemedicine was first pioneered by them, not to mention recognising geriatric changes to increase medication compliance and QUALY.
Even the god dann ice cream label test comes from them.
https://uanews.arizona.edu/story/health ... ream-label


Primary preventive care through education and etc is much harder to contrast,because the NHS and US has varying budgetary constraints. The only real answer we get is that states /funds with more money to spend do better in said primary preventive care than those who aren't.