Why Can’t America Have a Grown-Up Healthcare Conversation?


Good morning, Hank. It’s Tuesday. So, you know the Obamacare insurance exchanges that, depending on your political perspective, are either the cause of or the solution to so many of America’s health care problems? Only about six percent of Americans actually get their insurance through those exchanges. Now, that’s obviously very important to those six percent of people, but it’s by far the smallest slice of the American health insurance pie. And I think the relentless focus on them in our political discourse speaks to a larger inability to have, for lack of a better phrase, a grown-up conversation about health care. OK, so health care is very complicated and I’m going to paint this in the broadest possible strokes. If you want far more information about health and health care, please check out Healthcare Triage. But let’s start with what health insurance does. Health insurance takes money from healthy people and uses it to buy care for sick people. you can do this through private insurance, which pools people together and takes money from them in the form of monthly premiums, oror you can do it through a public insurer which pools people together and takes money from them in the form of taxes. In the United States, we have both: Almost everyone over the age of 65 is in this publicly funded insurance pool called Medicare. Many military veterans are in a similar pool run by the Veterans Administration and there’s a third public pool that covers many low-income and disabled Americans called Medicaid but just over half of Americans get their insurance through private insurers This includes the six percent of people covered through the Obamacare exchanges, but mostly people who get their insurance from their employers. Because large companies are required to offer health insurance plans to their employees. Then, you have the nine percent of Americans who don’t have any health insurance at all. That number has dropped a lot in the last five years, but it’s still higher than any other wealthy nation’s. So, the current U.S health care system is widely considered to be, if I can use a technical term, bananas. We spend so, so much on health care. About eighteen percent of our total economic output goes to health care. The average among other wealthy nations is closer to twelve percent. And we also don’t get particularly good health care outcomes. Like, we come up short in many, many metrics, including life expectancy, where we trail countries like Chile and Slovenia, both of which spend less than ten percent of their GDP on health care and, for the record, both of which also have higher rates of tobacco usage. Now, you would think with lots of private participation in health care markets, costs would be driven down, right? Like, private companies can make refrigerators or cars much better than governments can make refrigerators or cars. But health care’s a weird market on a few levels. First, there’s the problem of inelastic demand. Like, if I need a medicine to keep me alive, I can’t effectively negotiate the price of that medication because, in the end, I’m going to pay whatever it costs. And then there’s the problem of competition being something of an illusion. Like, for instance, if you’re having a heart attack, it’s generally not considered a good idea to call around to a bunch of area hospitals to find out who has the best deal on heart surgery this week. There should be competition among private insurers but plans are often extremely confusing. Like, you might pay less up front and think you’re getting a good deal, only to find out later that what you need to be covered isn’t covered. Like, it’s hard to compare cell phone plans effectively, let alone health insurance plans that might or might not cover literally thousands of different procedures. Plus, having your insurance status depend partly on whether you work for a big company is a huge disincentive to innovation and entrepreneurship. It tells people, “Don’t start a new business,” “Don’t strike out on your own because you won’t be able to get affordable health insurance.” So, all in all, we’ve ended up with a health care system where more tax dollars per person go to publicly funded health care than in most other countries and yet we don’t have publicly funded health care for most people. And most Americans agree on this: only about thirty-two percent of us think that our health care system is good or excellent. And yet, around seventy percent of Americans think that their personal health care is good or excellent and therein lies the problem. Most serious reform proposals would involve big changes for many people in that seventy percent. And, as the Republican party has lately learned, it’s easy to talk about health care reform in the abstract but when you put pen to paper, it gets complicated. So all health care reform boils down to three factors: Quality, cost, and access. Obamacare sought to improve access: It didn’t do much to change quality or cost. And to do that, it spent a huge amount of money. Like, a trillion dollars in the first decade. Now, it increased some taxes and cut some spending, so as to be deficit-neutral, but it spent a lot of money to get a lot of people health insurance. So today, fewer people are uninsured, but it cost a lot to get there: That was the trade-off. The Republican bill sought to reduce government spending on health care, but that also comes with trade-offs. In this case, it would have resulted in millions of people losing their insurance, which was a hard sell to moderate Republicans, so the GOP bill offered tax credits to help people buy private insurance, but that meant more spending, which made it a hard sell to conservative Republicans. Like the ACA itself, the GOP bill would not have done a lot to address the overall cost of health care in the United States or the fact that our quality of care isn’t great. Because to have those conversations, we need to accept, that, as Healthcare Triage always says, “Tradeoffs are inevitable.” Side note: I just realized my collar is turned, so I fixed that, but I bet it was annoying to a lot of you; sorry. Right: So the most commonly cited solution to the US health care problem is a single-payer health care system, or Medicare-for-all, as Bernie Sanders calls it. In this proposal, all Americans would be able to get the publicly-funded insurance that seniors now get and studies have shown that this would lower overall U.S. health care costs, although probably not to the rate seen in most European countries. Still, there would be less money spent on administration and advertising and also on care itself, because a bigger insurance pool can negotiate prices more aggressively and this would be, like, a huge insurance pool. But there are trade-offs: Like it’s accurate to say that Medicare-for-all would lower overall U.S. health care costs, it’s also accurate to say it would cost hundreds of thousands of jobs. And many of them would be good-paying jobs: From medical device sales people to insurance adjusted to marketing managers. And with less money being spent per procedure, lots of other people would see their incomes go down, including many doctors and nurses. Also, it would be good to spend twelve percent of our GDP on health care instead of eighteen percent if we could get similar outcomes, but there is a word for what happens when six percent of your total economy goes away overnight: Recession. Now, the economy would recover and reallocate capital fairly quickly, but it wouldn’t be painless. It’s also important to note that we currently have a single-payer health care system in the United States: in Medicare, and it’s not a bargain. Compared to other single-payer systems around the world, it’s very expensive because we resist the kind of government regulations and price controls that are ultimately necessary to rein in spending. So a single-payer system on its own would not solve all of our problems and there would be trade-offs. Alternative, some on the right have argued that to increase competition and let market forces work, it’s necessary to dramatically scale back or even eliminate government funding for health care. And that, too, might lower prices, but at the cost of many millions of people losing insurance. Similarly, decreasing regulation might lower prices, but it increases the risks of being treated by an inadequately trained professional or taking an unsafe medication: Trade-offs. We can talk about over-regulation or tort reform or market places or competition, but none of them will be a magic bullet. Because there is no magical solution with our health care system where everyone wins and no one loses. Now, we can continue to make incremental changes, like the ACA or alternatives to it, but as Dr. Carol put it on Twitter, however you want to reform healthcare, there will be tradeoffs. Those who promise you everything are lying. If we want a better health care system in the United States, we need to talk openly about those trade-offs. Because when we allow ourselves to be pandered to, our elected leaders seem more than happy to oblige us. Hank, I’ll see you on Friday.

100 Replies to “Why Can’t America Have a Grown-Up Healthcare Conversation?”

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  2. this video is 2 years old. i am dutch and we had in that time the best health care system in the world. well the top 3. right after UK and Australia. It still way to expensive here. but still. at least we have a health care system.

  3. problem is. your government doesnt care for their citizens. they rather spend money on false flags and creating more terrorist groups then creating a social system for their own citizens. and since that will never stop americans will always have a horrible social/health care system.

  4. Actually really fair and balanced conversation. Addressing the cost of care is a MUST before considering universal healthcare. The Healthcare industrial complex would fight to the death implement those changes as would the food industry, the root cause of most healthcare problems. What we put in our faces ultimately determines our health.

  5. As someone who has purchased insurance from healthcare.gov for 3 years now, my health insurance has been awful, my premiums are more expensive, and my deductible is sky high. Sure it was easy to get, but 6-7 years ago having the same job, my employer provided great coverage. Then after the ACA the coverage my employer provided was too high to afford and because I make above the poverty line but below $60k or $70k my only choice is to go through the marketplace and somehow my wife, my son and I are all on three different plans, because dealing with people at the marketplace is more convoluted than any other government entity I’ve ever dealt with. Wish I could get the insurance I had in 2010, basically for nearly a decade it’s done nothing but get worse for healthcare

  6. Growing up with the NHS I kinda always thought you guys were crazy or selfish or both when I heard about your system. This video is the first time I've actual understandable reasons why brining in universal health care is complicated and possibly bad for you guys. So I still think your crazy for getting into this mess but I get it, it's complicated. Good luck figuring this all out.

  7. Because there are more children who don’t want the responsibility of adulthood. Instead they wish to get “free” shit.
    More government. More rules. More regulations. More cost.
    Funny how the more government gets involved, costs increase while providers decrease.

  8. It's late for CDT dwellers (dwellers "In time"? "land regions on the globe, effected by time"). I just see that photo of W. Guthrie (Woody, Woodrow Wilson..whatever), and it's like he is looking back at me like a kindred ghost (he isn't literally that…), like Joe Hill's ghost in that song about Joe Hill.

  9. I like the way we have it here in Canada. Hospital and doctor visits are covered, as well are the things that go inside hospitals. You won't pay for your surgery but you will pay for your bed. We do have to pay for the dentist, medication, eyecare, but that's what our medical insurance companies help us cover.

  10. 🇨🇦Doctors are paid by what the provincial government pays them. With free healthcare, prepare to have a huge boost in pharmacists and pharmaceutical technicians, and floor employees in pharmacies. Bernie Sanders is not lying when he says free healthcare is possible. You are spending 2x what we are. Where is that money going? Who is pocketing it?

    I’ve watched some of your vids, and it’s ice you are trying to help people, but please admit, at least to yourself, that you are coming from a rightist bias. That bias is clear in your other vids.

  11. The problem is not the insurance coverage. It is the fact that the cost of medical coverage universally "marked-up", because medical companies know that insurance companies will cover it. It is a "lose-lose" for insurance companies and people that are not insured. https://youtu.be/CeDOQpfaUc8

  12. Thanks for the video. I am still for Medicare for all as the Republican plans are pretty much to benefit companies, but you provided excellent counterpoints. We need price controls and other laws in order to support Medicare for all.

  13. I just want to say keep in mind that "9%" of people that have no health insurance is probably much higher. This is because I personally (and I'm sure MANY other people) reported that we had health insurance on my taxes because I didnt have to prove it, and I would have to pay a huge fine that I of course couldn't afford because I couldn't afford the monthly premiums either. I am not offered a plan through my work, and adding myself to my husband's insurance was very expensive as well.

  14. You said it best at the beginning of the video:

    Health insurance, in practice, takes money from healthy people and spends it on unhealthy people.

    Now the reason universal healthcare will never work in THIS country is because the only true way to fix the healthcare system would involve legally requiring everyone to cease and desist all unhealthy and unsafe behavior, and that wpuld be unconstitutional. Consider, for example, what happened when New York attempted to ban 32 oz sodas as fast food restaurants.

  15. That 6% reduction in GDP doesn't disappear, it goes to other sectors such as consumer which will boost the economy even more.

  16. The pay or die concept combined with the unlimited resources of the healthcare lobby is making it impossible to have a decent "grown-up" discussion. We pay more than any place else, and we are far from the top in quality or availability. As long as we continue to yell at our insurance company (who are far from blameless, but I digress), and not wonder why the hospital is allowed to charge $125 for an ice pack in the first place we will continue to argue the wrong aspect of the problem.

  17. Maybe it's you? What is more important to you— having Medicare for All, or promoting some ideological term "socialism"? I'm asking, because Medicare isn't socialism. Federal spending =/= socialism. Medicare is public finance, private delivery. It's no more "socialism" than producing 50,000 Sherman tanks in WW2.

  18. Watching/listening/reading things about the American healthcare system always infuriates me. The sheer inhumanity of those same rehashed, transparent "arguments" (against universal healthcare) that provide that momentary, but highly disturbing, glimpse at unbridled, naked greed. I'm not even American, so I can't imagine what those bankrupting themselves in the hope of extending the life a loved one by another month–maybe two–must feel.

  19. What I think a lot of the discussion promoting M4A as a policy tends to ignore is that the people who are arguing against it (particularly from the left) are not trying to defend the actions of insurance companies, or the fact that we spend so much, or the fact that we have so many uninsured people. They're expressing that they're scared of making such a large, rapid change. Changing over to M4A would be a very large change, would have to happen relatively quickly, would affect lots and lots of people, and no matter what your favorite politician says, there is no way to guarantee every individual affected by it that their life wouldn't be disrupted or negatively impacted by that change. So people are scared. Arguing for M4A by giving people unknowable guarantees, explaining to them that their job security is worth sacrificing for the greater good, spouting off endless dollar amounts and statistics, or telling them to "just suck it up" and "don't be so afraid–it's only going to hurt the Bad People" are tone-deaf, unsympathetic counters to a position that's held out of fear of personal disruption.

  20. Um, Americans tend to eat too much.

    Not enough fruits and veggies.

    Way too much meat…

    Not enough water.

    Also, try fasting…break the idea that you have to have three meals a day…you don't have to eat, just because you're hungry.

  21. Could u explain why u believe medical staff pay (Drs. And Nurses etc) will go down? Funding for Bernie’s M4A plan doesn’t come from their salaries, it comes from tax revenue. I’m missing the connection

  22. Could u explain why u believe medical staff pay (Drs. And Nurses etc) will go down? Funding for Bernie’s M4A plan doesn’t come from their salaries, it comes from tax revenue. I’m missing the connection

  23. Could u explain why u believe medical staff pay (Drs. And Nurses etc) will go down? Funding for Bernie’s M4A plan doesn’t come from their salaries, it comes from tax revenue. I’m missing the connection

  24. So the problem with single payer is it drives costs down of a grossly inefficient system. That's supposed to be a problem. That's like saying technology that's more efficient is an overall economic problem. It wouldn't lead to recession because it takes years to drive down costs, plenty of time for the saved money to be spent elsewhere.

  25. I pay 45 percent tax and still have to use private insurance as socialist medical system NHS is rubbish not a model to copy and Canada's is even worse

  26. I’ve often wondered why a push to move to a single pay system would not involve bringing support from large companies- along with a willing tax paid by them

    If you offer a five year lock at 75% of what they pay currently on paying out on healthcare currently – then the tax grows tied to inflation there after

    This would help move the payment to cover the change from willing business partners who would see a predictable savings going forward

  27. Are America's poor health outcomes purely a result of higher healthcare costs, or at least partially a result of a culture of poor diet, high obesity, racial economic disparities, etc.? Obesity rates are still climbing & average life expectancy stalled even after adoption of Obamacare (maybe you could argue they'd be even worse without Obamacare, but the trends I've seen are pretty grim). Would health outcomes be even worse in a single payer system? I know what happened in Communist countries when many goods were subject to strict price controls: long lines & rationing due to demand exceeding supply.

    Would price controls negatively impact innovation in pharmaceuticals, medical devices, and health care delivery? John didn't mention the argument (right or wrong) that the U.S. having a large, free market for drugs & medical devices has encouraged innovation for both American and European drug companies, and allowed countries outside the U.S. access to cheap drugs without funding the R&D costs.

    What I don't get is why health insurance companies get labeled as the bad guys. Health insurance companies help sick people obtain health care they couldn't normally afford, and also negotiate lower prices with hospitals & providers on behalf of the insured. If the government allowed big insurance companies to merge, they'd have even more clout for negotiating with hospitals. 🙂 However, in truth many hospitals are on a fairly tight budget & cannot slash prices much more.

    BTW I think a transition to a single payer system may result in insurance company layoffs but not necessarily mass unemployment – rather lots of people currently employed with private insurers (like myself at Cigna!) will get jobs working for the government insurance program or continue on with private insurers in some capacity (if we adopt a hybrid private/public system like in The Netherlands, for example).

  28. Having gone through several different types of insurance in America from being an unemployed/part-time teen with no health insurance, then government funded insurance while still part-time and well into full-time, to becoming a full-time employed adult with employer-sponsored benefits… yeah. It's all a huge, confusing, awful mess here.
    I don't even want to think about health care in retirement, that's a whole different game.

  29. Having a single payer system alongside a private – insurance – funded industry and saying the single payer system has flaws is a little like saying “ I’ve built a park in the middle of Beijing but the air quality isn’t very good so it’s probably not a good idea to have very large areas of trees on the planet because they’re not good for air quality.” Not a criticism of the video, I just don’t like that argument being used by conservatives to justify a private medical industry.

  30. My estimate, as a healthcare professional, is that >/= 1/2 of all healthcare dollars spent are outright fraud. And the less the person pays out-of/pocket, the greater the percentage of dollars that go to fraud.

  31. Although he noted it, I didn't notice John's turned up collar. I was too busy staring at the hair sticking straight up out of the right side of his head. The central message about trade-offs, however, is important and is one the many politicians, pundits, wags and ordinary Americans miss–accidentally or otherwise.

  32. All this talk about tradeoffs is a distraction, pure and simple. Single payer is the only solution to America's health care crisis, and this sort of whataboutism that paints both sides as being somehow unreasonable or immature is unhelpful at best and actively harmful at worst.

    The Republicans want poor people to die. Full stop. Any discussion that does not focus on that fact is missing the point completely, and leads to the exact sort of circular, never ending compromises-culminating-in-nothing which has defined our politics for the past 30 years.

    Screw the capitalists. Medicare for all now ✊

  33. I am the 6%. I like that people with preexisting conditions can get insurance now, but I now spend more on health care and the quality is worse.

  34. Only in America is "lets try to save every single person's life" met with the argument "but the people who decide who lives and dies would lose their jobs!"

    The jobs that would he lost in the transition to a single payer system are jobs we cant afford to keep.

  35. BTW – the ad on your clip is for GOLF EQUIPMENT – this is the BEST country in the entire NATION!!! — OOPS, but you get my drift, right.

  36. How to lower the cost of health care. 1. Deregulate parts so the government is not holding down the free market. And have more competition so prices go down. As well as breaking up the monopoly aka big pharma. So there can be more competition on drugs so drugs prices can go down

  37. I would love to go work for a friend of mine whose business is struggling, but I can’t. I get insurance from my employer, and he can’t afford to provide insurance. Needs to be fixed.

  38. It blows my mind that Americas 'red scare' was so great they tricked your people out of socialised health care. Capitalists have full dominion over your working class. Scary.

  39. I only wish more people were aware and talking about regenerative medicine. Regenerative medicine can include stem cell treatments, gene therapies, and several other treatments that will greatly reduce and eventually eliminate chronic diseases of aging which is where the vast amount of our healthcare costs go. If you don't get cancer or heart disease or diabetes or lung disease or kidney or liver failure the cost of healthcare practically goes away. How much would that cost? Less than the trillions of dollars we now spend forever. To understand more check out BioViva with Liz Parrish: https://www.youtube.com/watch?v=qh_TbPY8ZnE or Aubrey de Grey https://www.youtube.com/watch?v=AAEsQnoA5-M This is happening far faster than most people know and will dramatically alter the healthcare debate and costs.

  40. The only people that have argued that there is a perfect solution is the left. The ACA was supposed to be this magic bullet and millions of Americans bought into the idea that government had the solution. The best outcome doesn't come at the stroke of a pen, but rather the choices within a free market over time.

  41. As a Canadian it is very difficult to understand the USA's issue with implementation of health care. We think it is wrong to have a baby and have to pay $10,000 for it.

  42. Basic fact is nobody lives forever. If you eat, work, exercise and sleep healthy you throw money away by buying health insurance. Not even 1 person's life has been saved by health insurance on those that died from fatal accidents or fatal diseases ! !

  43. Is health care a right, like the right not to be shot going for an evening jog, or a privilege, like getting to vacation in Hawaii? Your answer determines your ultimate stance on the issue. Of course, whether or not you think you and your family would get adequate care if it were a privilege has a lot to do with your stance, too.

  44. Imagine having to pay or being billed for something like oh idk the fire department coming out and putting your house that was on fire out, oh I don't have to imagine that, in the county I live in, in Arizona, I was charged $1,500 for a fire that was set in my backyard by an intruder. I was not home at the time.

    The police did nothing, the fire department also did nothing, because my neighbors had put the fire out already, they still kicked my door in though, and didn't pay for that either.

    Imagine that. Healthcare is the same thing and conservatives are too stupid to realize it.

  45. Healthcare is now about to bankrupt me within the year.
    Fun fun. Even with insurance things like insulin, chemo meds, and visits and bloodwork copays put me in debt last year and my line of credit will run out next year when I start failing to make my mortgage payments. I have negative 1400 dollars in my account. Thank you republicans. I literally blame you. I have worked my butt off 40 hours a week and not missed a day in 20 years except for doctor appointments and I usually only took a long lunch.
    I have spent 60k dollars out of pocket in the last 18 months.
    Thank you big pharma.

  46. To answer your question. the power and wealth of the corporations that operate hospitals and market drugs is the answer. We have a Congress that lives on legal bribery.

  47. Very intelligent analysis. Unfortunately we are unable to get anything even close out of our elected lawmakers. A total failure of our political system.

  48. People's lives shouldn't have a price put on them. Healthcare should NOT be a commercial thing. Also, the borderline inhumane work hours combined with lower pay that many Americans work, combined with institutional racism and sexism takes a huge toll on the body and that results in a greater percentage of sick people. The type of chronic stress that is inevitable in a broken system has many negative impacts

  49. I believe I speak for the rest of the developed world when I say that the American health sector is completely insane, and people's insistence of keeping it that way for fear of "socialism" even more so.
    Look, people are literally dying from treatable conditions, because heeding warning signs and calling an ambulance is an existential economic risk. Seeing a physician should not be a last desperate resort only to be taken when you're half dead, and a family's greatest concern when faced with a severe condition in one of its members should not be impending bankruptcy vs. premature death.

    The most damning thing here is that the solution is readily available and at hand. You see it in variations all across the globe. It's the type of socialised healthcare adopted virtually everywhere. Not flawless systems, by any means, but GALAXIES ahead of "better hope that this lump in my neck is benign, for I cannot afford a visit to the doctor's".

  50. If you are still in doubt, just ask any person with a chronic illness (diabetes, heart conditions, etc) what they have to pay in a country with a real health care system in order to receive what they need: medication, regular check-ups, even occasional ER-visits. The discrepancy with the staggering bills unique to the US will be glaringly obvious, even with the higher taxes.

  51. I was in cancer treatment from 2017-2018 and I am on surveillance now. I have access to the best hospitals in Boston, the best doctors in the world that teach the best doctors in the world at a cost of $2,000 out-of-pocket per year and $22,000 per year in insurance premiums. Is that a good deal? Well, I am quite happy with the results. I noticed that a lot of Europeans go to the same hospitals that I went to – except that they pay full retail prices for healthcare. I also noticed that these hospitals have sizable international office space at their hospitals – I guess medical tourism is a big thing in Boston. Yes, I like my healthcare. Yes, it's expensive. What would the best doctors in the world do if the government set their wages and working conditions?

  52. Makes me think of something attributed to Churchill, "Democracy is the worst form of government, except for all the other forms". Single payer may take us thru a painful transition, and it won't be perfect (talk about grown up, nothing is perfect) but it'll be a huge step up from what we have (in terms of cost, quality and access).

  53. Good info. But talk just a little bit slower. If you are giving good info, without time wasting fluff, I am willing to sit through a video that is 10% longer.

  54. "We" don't resist the things that would make Medicare less expensive. Right-wing politicians do (from both parties). They WANT Medicare to funnel lots of our tax money to big medical companies. And they WANT to make universal coverage seem undoable. You can shoot a lot of numbers really fast to make yourself appear to be unbiased. But this one sentence reveals your true purpose: To continue the myth that we can't do what other countries already do.

  55. No one on the left is "promising everything." You know that. They state loud and clear that Big Medicine will lose lots of money. That is money Big Medicine has been stealing from us for decades.

    Well, now I know why you talk so fast. You are intentionally obfuscating your true goal: To make the problem seem unsolvable.

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