Pediatric ER doc here. There are many countries with modern healthcare that is high quality (as good as USA), available, cheap. It is DOABLE … that should be our North Star!
One thing we as citizens and voters really need to consider in evaluating a policy proposal like “will Medicare for All work?” is that the system is SO interconnected. We probably shouldn’t conceptualize Medicare for All as “everyone just goes onto Medicare instead of their private insurance” and everything else in the healthcare stays the same … I agree that would probably flop hard (hospitals/clinics will just go out of business). But if you institute Medicare for All AND make sweeping changes in hospital regulations, tort/malpractice law, administrator/executive salaries, burdensome privacy laws, how drug development works (ie capitalism/beholden to make money for shareholders), end of life care, long term care, mental health support and care, primary care provider salaries, EMTALA law, reimbursements that outlandishly favors procedures, childbirth support, etc etc etc … then yeah I think it has a shot! It needs to be a big package or multiple-area reform all at once though, which btw is a project this GOP and administration doesn’t have close to the leadership skills to pull off (Trump has been in presidential politics 9 years and he has “concepts of a plan” give me a *bleeping* break.)
I was too young at the time to see this but it’s why Obamacare was such a leadership triumph IMO. It HAD to be such a massive bill - remove one piece of that and it financially falls apart (insurers go bankrupt or hospitals go bankrupt or impossibly high premiums for any normal citizen).
My family had Medicaid for a season and I’d say my experience was the exact opposite - it was the absolute best health insurance we ever had and made me wish for a Medicare for all option even harder.
I have a very dear friend who is on Medicaid and just had a very difficult pregnancy involving lots of specialists leading to a baby who needs lots of specialists because of feeding issues. If it weren’t for Medicaid, they’d be drowning in medical debt now. I am on the plan offered by my husband’s Fortune 500 company, and I’m out of pocket $12,000 this year after premiums, a couple fractures, and three of us needing some pretty basic PT. I am dreading the new year and being back to zero on the deductible, which is higher for 2025. I don’t begrudge my friend her care at all, but I am wildly jealous of her access to it.
While I agree that there is no quick fix to the current US healthcare system, Medicare and Medicaid are two different things. Medicare is federal, while Medicaid is joint federal + state. Medicaid can vary widely between states. I would be curious to know which state the anecdote mentioned occurred in. I work in healthcare (PT) and my good friend is a social worker. We both highly recommend straight Medicare for patients of the applicable age/diagnosis. Previously working on the border of ND/MN, the differences in Medicaid benefits were quite evident. I had a former patient who was a young adult with complex medical issues, none any fault of their own, their body just did not want to work correctly for them. Their family moved to ND, and this patient “followed them as far as they could” to the border of MN, due to health benefits being significantly better in MN.
That’s interesting. My MN kids have been on Medicaid most of their lives and it has been really great. The only weird thing was that they approved braces for one kid and not the other whose teeth were clearly worse.
Don’t we all! The U.S. system is so complex that the majority of Americans don’t understand it (myself included), much less other systems throughout the world that we could emulate. A good starting point, though, is understanding that Medicare, Medicaid, Medicare Advantage plans, and private insurances are all different.
Ashley, just want to give you tons of solidarity and share my similar experience. The factors going into your family's decisions are so familiar to what I have been grappling with as well! My husband's employer offers a high deductible plan that has decent premiums for him but Soooo much higher if you add on a family, so we've been paying a monthly premium to access Medicaid for our children and that part has worked out great. We've been able to access providers and medicines and I love how well everything is just covered, very simple. Now for me, I can't justify spending such a huge premium to add me to my husband's insurance when it still doesn't cover anything until we meet a huge deductible. And we wouldn't qualify for ACA subsidies. So I've been doing a Christian health sharing plan that has a small premium but it doesn't cover anything unless a particular incident is over $5,000. So that is completely useless to me unless I have a huge healthcare crisis. So I basically don't do any health care for me because it's also hard to pay out of pocket when I could just "deal with it". Every direction I turn I don't see a path forward for me. My husband and my kids get healthcare but it sure does a number on my self-esteem that I don't. Needless to say, I'm 100% supportive of government healthcare for all.
I had a convo with my mom the other day talking about my 50 year old brother (who lives with her and she largely supports because he is a pizza delivery driver) who has a health insurance plan through the ACA. He pays nothing, but she said she saw his statement and it is subsidized at $800 a month. He made an urgent care visit and ended up with a $600 bill. She’s talking about him quitting his job to go on Medicaid so he can get some other health issues taken care of. I have no idea what my brother’s policy is and whether or not he could have avoided that $600 bill, but I thought it was interesting because she is a Trump voter. She called the health insurance plan (which he pays nothing for) a racket.
My family has been “self-insured” (i.e. no insurance bc we’re small business owners who can’t access group insurance, make too much household income for meaningful ACA subsidies but not enough to pay over $1000/month for a Bronze plan) for a few years and it’s been mostly fine except for the weight of knowing at any moment we could have an accident or a diagnosis that would completely ruin us financially. But this year I couldn’t take that weight anymore so I signed up for a plan during ACA open enrollment that has a huge deductible, high premiums, and covers nothing but the mandated care until we meet our huge deductible. Oh and none of our current providers are in-network. So that’s my experience with private insurance. Can you tell I’m in my feelings about this topic?
Also last year I had a procedure done and the office told me the cash price was higher than if I’d had insurance. So no. Self-insurance isn’t the answer to this.
I recently spoke to someone in health care who runs his own practice. He would like to see universal health insurance, but he also says that Medicare for All would have to be significantly different than current Medicare. He says that for his specialty the reimbursement rates are low for Medicare, and his private insurance patients are subsidizing his Medicare patients. He would go out of business if the same insurance was provided to everyone. I know that people who study health insurance policy for their jobs understand this, but the question is how to address it and move from the system we have now to universal health care. It will likely have to be incremental to keep our whole health care system from collapsing.
For me, “Medicare for all” is shorthand for single-payer, universal healthcare that is at least as good for the insured as what people on Medicare get. I’d love to see the whole system revamped but at this point I’ll take any version of universal healthcare that is politically feasible. Since I’m not a provider I can’t speak to the reimbursement side of things.
I feel like Healthcare gets lumped in with guns in this country. Basic consensus - oh this is just too big of a problem that went unchecked for too long, nothing we do now will address it. And it's an excuse for those who can do more to not. I have no solutions or real meat to my comment just venting LOL. Between the CEO murder and the murders in the school in Madison yesterday, I'm just a bit heavy. It's an unwelcomed feeling 8 days from Christmas.
I feel this too. And I keep thinking, if this is the weight I feel now, then what the heck is January 21st going to feel like. I’m bracing myself for next year and how to deal with the onslaught of negativity and worry. I’m glad to have this community and I know Sarah and Beth will be helping to lead us through in a balanced and clear-eyed way. But I’m very anxious about the cumulative weight of it all.
I think it's why I'm trying to figure out ways to do less b/c I know I'll need to. I think I'm just going to have to stay distracted. My anxiety and worry around the last election, didn't change a gosh darn thing except upset ME. Life is too short and the next 4 years are pretty big ones. After this administration my oldest will be graduating college, my daughter will be entering high school, my son into middle school. I'm not going to stress away some of the most precious time in my little family's timeline - DJT and his terrible goon squad aren't worth it. I am just going to have to wait it out and see what happens and worry in the present versus worry about what is to come. It's the best I can do. I may not channel it right a 100% of the time. Ex: I spent 2 hours trying to figure out the nicest way to clean my toilet for the environment ...... but ya know what ? At least that was productive in some way lol.
(Total tangent but if anyone has tips for restoring hard-water stained toilets, I'd love to hear them. I live in an old old house and have never found anything that really removes that stuff.)
I have no help but I hope someone does for you. I am really debating cutting all social media minus this group. I can't think of anywhere else I get to share my angst on the world & honestly thinking of a way to help remove hard water stains in a toilet all in the same breath. It's just a nice reminder of there is macro-LIFE and there is micro-LIFE hahah. A very outside of politics for us ;) If you haven't tried, anytime I google natural ways to clean things the internet basically tells me the entire world could be properly cleaned with enough vinegar and/or baking soda.
In response to the last paragraph about the reduced rate for cash appointments, my experience is that now the situation is the opposite. My son’s providers recommended OT but insurance wouldn’t cover it. The practice refused to give us our insurance company’s contracted rate and we had to pay the full amount. I do wonder about how the incentives around health care would be different if people paid more things out of pocket.
I am almost done with this episode of Plain English on health care in the US. If you enjoyed Beth's pharmaceutical series, I highly recommend this episode. It opened my eyes to a lot of things. Basically, the health insurance companies are just a tiny cog in the wheel of why our health care is so expensive and difficult to navigate. And that no matter the system, there are going to be limits and refusals to authorize. It is more obvious in the US for a variety of reasons that the podcast goes into. https://open.spotify.com/episode/4aUbSacde585V314YK9cF9?si=qK6xIOXQQn6G6rNu-jy7fA
My perspecitve as a pediatrician who switched from 10 years of private practice with privately insured patients to now working at a clinic with primarily Medicaid patients is that the story described about the inhaler is much more common with private insurance than with Medicaid. From the physician perspective, with Medicaid, we can at least know what the formulary is and work with it (and go through approval processes when needed). For private insurance, it is really hard to determine what medicines are on formulary for which patients (and believe me, insurance companies have very strict formularies too). Patients can all have a Blue Cross / Blue Shield plan, but it will depend if they have "HMO Blue" or "PPO Blue" or "my Blue", etc. Private insurances send me something in the paper mail telling me that I have 72 hours from the time the letter was sent to protest their decision (which I rarely receive within the window) and then deny the medication and blame me to the patient. It is a hot mess.
The listener's comment was jarring to me because my colleague has an opposite story. Some of the people at my workplace have kids on Medicaid because my employer only subsidizes individual coverage, which makes the family coverage quite expensive. One colleague says she wishes she had her daughter's insurance because more is covered and there is more on the formulary than in our private insurance. Do different states have different formularies? I am in NY, which has more generous Medicaid than many states, but I have no idea how the Medicaid formularies work.
Yes, different states Medicaids are very different. However, I am in Texas (not known for generosity) and I still think Medicaid coverage is better than a lot of private plans.
Is it okay to ask questions about listener comments?
The letter, from the listener implied that Medicaid is a “racket” (illegal way of making money) because they did not cover the medication her son was taking and pushed another option (hard agree that off label use is bad, they should not have done this). Is the “racket” part an accusation that Medicaid workers are taking bribes for using some medications and not others on the formulary?
Also, how is car insurance better? If you’ve been in an accident and the other person’s insurance has to pay I am sure you would see that all insurance is not the same and not really better than health insurance.
Where was the trick? Formularies do change, to save money, to reflect new products, etc. I’m not sure that is going to go away. If the change in the list is caused by bribes, definitely it’s a trick or dishonest scheme. But a change for cost purposes is not something that seems like it would be any different no matter what system we use. Medicaid is going to need to be cost conscious because it is funded by taxpayers. I think the fact that she appealed and won it the real lesson.
I read "racket" not necessarily about illegal money making, but in the 4th definition that Dictionary.com gives me: a dishonest scheme, trick, business, activity. Which, giving people the runaround about what is covered and changing the rules at the last minute - yeah, that feels dishonest and unfair to me.
No great answers on health insurance from me. It's a huge source of stress to me as the leader of a 2 person non-profit, where I live in a different state than the organization is headquartered in. I have been on marketplace insurance and won't go back, and I've spent the past 2 years fretting I will have to leave a job I really enjoy because of health insurance. Glad to see thoughtful and respectful commentary from this group, including the listener story from the newsletter.
How can I get a cameo for someone?
Pediatric ER doc here. There are many countries with modern healthcare that is high quality (as good as USA), available, cheap. It is DOABLE … that should be our North Star!
One thing we as citizens and voters really need to consider in evaluating a policy proposal like “will Medicare for All work?” is that the system is SO interconnected. We probably shouldn’t conceptualize Medicare for All as “everyone just goes onto Medicare instead of their private insurance” and everything else in the healthcare stays the same … I agree that would probably flop hard (hospitals/clinics will just go out of business). But if you institute Medicare for All AND make sweeping changes in hospital regulations, tort/malpractice law, administrator/executive salaries, burdensome privacy laws, how drug development works (ie capitalism/beholden to make money for shareholders), end of life care, long term care, mental health support and care, primary care provider salaries, EMTALA law, reimbursements that outlandishly favors procedures, childbirth support, etc etc etc … then yeah I think it has a shot! It needs to be a big package or multiple-area reform all at once though, which btw is a project this GOP and administration doesn’t have close to the leadership skills to pull off (Trump has been in presidential politics 9 years and he has “concepts of a plan” give me a *bleeping* break.)
I was too young at the time to see this but it’s why Obamacare was such a leadership triumph IMO. It HAD to be such a massive bill - remove one piece of that and it financially falls apart (insurers go bankrupt or hospitals go bankrupt or impossibly high premiums for any normal citizen).
My family had Medicaid for a season and I’d say my experience was the exact opposite - it was the absolute best health insurance we ever had and made me wish for a Medicare for all option even harder.
I have a very dear friend who is on Medicaid and just had a very difficult pregnancy involving lots of specialists leading to a baby who needs lots of specialists because of feeding issues. If it weren’t for Medicaid, they’d be drowning in medical debt now. I am on the plan offered by my husband’s Fortune 500 company, and I’m out of pocket $12,000 this year after premiums, a couple fractures, and three of us needing some pretty basic PT. I am dreading the new year and being back to zero on the deductible, which is higher for 2025. I don’t begrudge my friend her care at all, but I am wildly jealous of her access to it.
While I agree that there is no quick fix to the current US healthcare system, Medicare and Medicaid are two different things. Medicare is federal, while Medicaid is joint federal + state. Medicaid can vary widely between states. I would be curious to know which state the anecdote mentioned occurred in. I work in healthcare (PT) and my good friend is a social worker. We both highly recommend straight Medicare for patients of the applicable age/diagnosis. Previously working on the border of ND/MN, the differences in Medicaid benefits were quite evident. I had a former patient who was a young adult with complex medical issues, none any fault of their own, their body just did not want to work correctly for them. Their family moved to ND, and this patient “followed them as far as they could” to the border of MN, due to health benefits being significantly better in MN.
That’s interesting. My MN kids have been on Medicaid most of their lives and it has been really great. The only weird thing was that they approved braces for one kid and not the other whose teeth were clearly worse.
Glad to hear you’ve had an overall good experience! That is strange about the teeth, though. 🤔
Thank you for that clarification around Medicaid and Medicare! I need a whole dang primer on that and this is really helpful.
Don’t we all! The U.S. system is so complex that the majority of Americans don’t understand it (myself included), much less other systems throughout the world that we could emulate. A good starting point, though, is understanding that Medicare, Medicaid, Medicare Advantage plans, and private insurances are all different.
Ashley, just want to give you tons of solidarity and share my similar experience. The factors going into your family's decisions are so familiar to what I have been grappling with as well! My husband's employer offers a high deductible plan that has decent premiums for him but Soooo much higher if you add on a family, so we've been paying a monthly premium to access Medicaid for our children and that part has worked out great. We've been able to access providers and medicines and I love how well everything is just covered, very simple. Now for me, I can't justify spending such a huge premium to add me to my husband's insurance when it still doesn't cover anything until we meet a huge deductible. And we wouldn't qualify for ACA subsidies. So I've been doing a Christian health sharing plan that has a small premium but it doesn't cover anything unless a particular incident is over $5,000. So that is completely useless to me unless I have a huge healthcare crisis. So I basically don't do any health care for me because it's also hard to pay out of pocket when I could just "deal with it". Every direction I turn I don't see a path forward for me. My husband and my kids get healthcare but it sure does a number on my self-esteem that I don't. Needless to say, I'm 100% supportive of government healthcare for all.
I had a convo with my mom the other day talking about my 50 year old brother (who lives with her and she largely supports because he is a pizza delivery driver) who has a health insurance plan through the ACA. He pays nothing, but she said she saw his statement and it is subsidized at $800 a month. He made an urgent care visit and ended up with a $600 bill. She’s talking about him quitting his job to go on Medicaid so he can get some other health issues taken care of. I have no idea what my brother’s policy is and whether or not he could have avoided that $600 bill, but I thought it was interesting because she is a Trump voter. She called the health insurance plan (which he pays nothing for) a racket.
Please give us Medicare for All. Please.
My family has been “self-insured” (i.e. no insurance bc we’re small business owners who can’t access group insurance, make too much household income for meaningful ACA subsidies but not enough to pay over $1000/month for a Bronze plan) for a few years and it’s been mostly fine except for the weight of knowing at any moment we could have an accident or a diagnosis that would completely ruin us financially. But this year I couldn’t take that weight anymore so I signed up for a plan during ACA open enrollment that has a huge deductible, high premiums, and covers nothing but the mandated care until we meet our huge deductible. Oh and none of our current providers are in-network. So that’s my experience with private insurance. Can you tell I’m in my feelings about this topic?
Also last year I had a procedure done and the office told me the cash price was higher than if I’d had insurance. So no. Self-insurance isn’t the answer to this.
I recently spoke to someone in health care who runs his own practice. He would like to see universal health insurance, but he also says that Medicare for All would have to be significantly different than current Medicare. He says that for his specialty the reimbursement rates are low for Medicare, and his private insurance patients are subsidizing his Medicare patients. He would go out of business if the same insurance was provided to everyone. I know that people who study health insurance policy for their jobs understand this, but the question is how to address it and move from the system we have now to universal health care. It will likely have to be incremental to keep our whole health care system from collapsing.
For me, “Medicare for all” is shorthand for single-payer, universal healthcare that is at least as good for the insured as what people on Medicare get. I’d love to see the whole system revamped but at this point I’ll take any version of universal healthcare that is politically feasible. Since I’m not a provider I can’t speak to the reimbursement side of things.
I feel like Healthcare gets lumped in with guns in this country. Basic consensus - oh this is just too big of a problem that went unchecked for too long, nothing we do now will address it. And it's an excuse for those who can do more to not. I have no solutions or real meat to my comment just venting LOL. Between the CEO murder and the murders in the school in Madison yesterday, I'm just a bit heavy. It's an unwelcomed feeling 8 days from Christmas.
I feel this too. And I keep thinking, if this is the weight I feel now, then what the heck is January 21st going to feel like. I’m bracing myself for next year and how to deal with the onslaught of negativity and worry. I’m glad to have this community and I know Sarah and Beth will be helping to lead us through in a balanced and clear-eyed way. But I’m very anxious about the cumulative weight of it all.
I think it's why I'm trying to figure out ways to do less b/c I know I'll need to. I think I'm just going to have to stay distracted. My anxiety and worry around the last election, didn't change a gosh darn thing except upset ME. Life is too short and the next 4 years are pretty big ones. After this administration my oldest will be graduating college, my daughter will be entering high school, my son into middle school. I'm not going to stress away some of the most precious time in my little family's timeline - DJT and his terrible goon squad aren't worth it. I am just going to have to wait it out and see what happens and worry in the present versus worry about what is to come. It's the best I can do. I may not channel it right a 100% of the time. Ex: I spent 2 hours trying to figure out the nicest way to clean my toilet for the environment ...... but ya know what ? At least that was productive in some way lol.
(Total tangent but if anyone has tips for restoring hard-water stained toilets, I'd love to hear them. I live in an old old house and have never found anything that really removes that stuff.)
I have no help but I hope someone does for you. I am really debating cutting all social media minus this group. I can't think of anywhere else I get to share my angst on the world & honestly thinking of a way to help remove hard water stains in a toilet all in the same breath. It's just a nice reminder of there is macro-LIFE and there is micro-LIFE hahah. A very outside of politics for us ;) If you haven't tried, anytime I google natural ways to clean things the internet basically tells me the entire world could be properly cleaned with enough vinegar and/or baking soda.
Ha ha, so true! I keep hearing "denture cleaner" too but haven't given that a shot yet.
All the best to you!
In response to the last paragraph about the reduced rate for cash appointments, my experience is that now the situation is the opposite. My son’s providers recommended OT but insurance wouldn’t cover it. The practice refused to give us our insurance company’s contracted rate and we had to pay the full amount. I do wonder about how the incentives around health care would be different if people paid more things out of pocket.
I am almost done with this episode of Plain English on health care in the US. If you enjoyed Beth's pharmaceutical series, I highly recommend this episode. It opened my eyes to a lot of things. Basically, the health insurance companies are just a tiny cog in the wheel of why our health care is so expensive and difficult to navigate. And that no matter the system, there are going to be limits and refusals to authorize. It is more obvious in the US for a variety of reasons that the podcast goes into. https://open.spotify.com/episode/4aUbSacde585V314YK9cF9?si=qK6xIOXQQn6G6rNu-jy7fA
My perspecitve as a pediatrician who switched from 10 years of private practice with privately insured patients to now working at a clinic with primarily Medicaid patients is that the story described about the inhaler is much more common with private insurance than with Medicaid. From the physician perspective, with Medicaid, we can at least know what the formulary is and work with it (and go through approval processes when needed). For private insurance, it is really hard to determine what medicines are on formulary for which patients (and believe me, insurance companies have very strict formularies too). Patients can all have a Blue Cross / Blue Shield plan, but it will depend if they have "HMO Blue" or "PPO Blue" or "my Blue", etc. Private insurances send me something in the paper mail telling me that I have 72 hours from the time the letter was sent to protest their decision (which I rarely receive within the window) and then deny the medication and blame me to the patient. It is a hot mess.
The listener's comment was jarring to me because my colleague has an opposite story. Some of the people at my workplace have kids on Medicaid because my employer only subsidizes individual coverage, which makes the family coverage quite expensive. One colleague says she wishes she had her daughter's insurance because more is covered and there is more on the formulary than in our private insurance. Do different states have different formularies? I am in NY, which has more generous Medicaid than many states, but I have no idea how the Medicaid formularies work.
Yes, different states Medicaids are very different. However, I am in Texas (not known for generosity) and I still think Medicaid coverage is better than a lot of private plans.
Is it okay to ask questions about listener comments?
The letter, from the listener implied that Medicaid is a “racket” (illegal way of making money) because they did not cover the medication her son was taking and pushed another option (hard agree that off label use is bad, they should not have done this). Is the “racket” part an accusation that Medicaid workers are taking bribes for using some medications and not others on the formulary?
Also, how is car insurance better? If you’ve been in an accident and the other person’s insurance has to pay I am sure you would see that all insurance is not the same and not really better than health insurance.
Where was the trick? Formularies do change, to save money, to reflect new products, etc. I’m not sure that is going to go away. If the change in the list is caused by bribes, definitely it’s a trick or dishonest scheme. But a change for cost purposes is not something that seems like it would be any different no matter what system we use. Medicaid is going to need to be cost conscious because it is funded by taxpayers. I think the fact that she appealed and won it the real lesson.
I read "racket" not necessarily about illegal money making, but in the 4th definition that Dictionary.com gives me: a dishonest scheme, trick, business, activity. Which, giving people the runaround about what is covered and changing the rules at the last minute - yeah, that feels dishonest and unfair to me.
No great answers on health insurance from me. It's a huge source of stress to me as the leader of a 2 person non-profit, where I live in a different state than the organization is headquartered in. I have been on marketplace insurance and won't go back, and I've spent the past 2 years fretting I will have to leave a job I really enjoy because of health insurance. Glad to see thoughtful and respectful commentary from this group, including the listener story from the newsletter.