GOP keeps selling the status quo successfully ;-( In fairness - polls do indicate a majority in favor of UHC - but it's a complicated debate so that's as far as we get ;-(
GOP keeps selling the status quo successfully ;-( In fairness - polls do indicate a majority in favor of UHC - but it's a complicated debate so that's as far as we get ;-(
I've long supported single-pricing - for all of healthcare - but that would require legislation. That's the bottleneck. Not economic (or moral) logic. What's surprising is Mark's promotion of GOP logic - which is tilted to the status quo of "4 profit" healthcare. The evidence doesn't support it.
Footnote: If you eliminated PBMs - the effect on pricing would be nominal. Mark's solution generates a LOT of publicity - but it's NOT a total solution. For one thing - many generics are so low price - his 15% margin + $5 shipping is higher than 20 locations I can source locally. #Medsky
If you ELIMINATED PBMs - you wouldn't eliminate tiered pricing - which for Branded/Specialty Rx is uncapped (AND often patent protected). PBMs know this - and why they're shifting their biz model. Generics are high volume but low margin. Branded/Specialty is where the BIG margins are. #Medsky
"Campaign finance reform isn't the biggest problem facing the country - but it's the first." @lessig.bsky.social We can't keep trying to navigate AROUND these issues. That's what solutions like CostPlusDrugs is doing. It works - BUT - it has consequences AND it doesn't solve the systemic issue.
Lobbying. Pharma doesn't want that - anymore than the rest of the system wants single-pricing. The profits are ginormous - and those would be severely curtailed (not eliminated). We do this today for utilities - and it's time we thought about extending monopsony (one buyer) pricing to healthcare
PBMs are a reflection of the whole problem. Tiered coverage to support tiered pricing. For commercial Rx coverage - PBMs do that. BUT. Generics = high volume/low margin. Branded+Specialty Rx is the real elephant in the Rx room and direct pay can't solve patent protected pricing.
I agree - b/c we've designed a "for-profit" system w/ uncapped commercial pricing - and the system is working as designed. We need to change the design. UHC is that system design change. But this is also an 80yr battle going back to the Truman administration. The HC INDUSTRY keeps winning ;-(
Mark's CPD is great at EXPOSING highly variable pricing - but it's not a solution b/c the variable pricing applies to every aspect of healthcare not just Rx - and the cost of one surgery w/ a 3-day hospital stay can easily eclipse $100K. Billionaires can afford to self-fund that - can you?
Can't tell if it's intentional - but this view of eliminating payers in healthcare (the ONLY group that's heavily regulated) in favor of employers is a GOP political POV - NOT an economic or healthcare one. We can easily afford UHC - and get employers OUT of the HC biz. hc4.us/esi20 #Medsky
... and we can/should absolutely use that CMS software more broadly! We'd have to change the pricing (Medicare/Medicaid/VA are all too low) - but let's have THAT debate. Not who's covered. hc4.us/oneprice
Generic Rx = subset of a subset and we need to stop carving out slices of HC to force into a cash/consumer model b/c it has a consequence on coverage rates - and you can't ELIMINATE pooled risk. We've already done that with dental, vision - now we're aiming to do that w/ Primary Care & Rx. Dumb.
... why not VA4ALL? That's UHC - which I absolutely support/lobby for. Pricing would need to be debated (VA and Medicare pricing are too low), but we should have THAT debate. Not who's covered. We don't need single-payer healthcare - but we absolutely need single-pricing. hc4.us/oneprice
The RAND study also verified that Nat'l avg (~250%). Which is insane. My surgery could easily be 2.5X my neighbors simply b/c we're in different coverage tiers. Just nuts. But that's what commercial rates (mostly thru ESI) supports: hc4.us/esi20
... we need EMPLOYERS out of the healthcare business. Here's 11 reasons why - there are more. hc4.us/esi20 #Medsky
PBMs is the wrong argument. Yea - they profit - BUT the systemic flaw is TIERED coverage - which we've tied (as an accident of history) to employment. These rates are accurate - and destined to do one thing. Always go higher. Why? Because commercial rates for HC delivery are uncapped.
... which is one of the arguments for UHC. How UHC is FINANCED is highly variable - but Germany (pop 80M) does it pretty well. Employers/employees have an almost 50/50 split of the tax - which would be FAR less than the uncapped commercial rates we load onto employers/employees today.
This is a political POV - NOT an economic or HC one. Payers ARE heavily regulated. They do make a profit - but they also adhere to the MLR regs - AND there are state insurance commissioners that review/approve rate increases annually. The systemic flaw is TIERED commercial coverage by employer.
Universal Health Coverage. We're the only country w/o it. We're the outlier - and the metrics prove it. We spend way MORE than other countries and the results show that we've built a sickcare system (for profit) - not a healthcare system. How UHC is financed is variable - but it's still UHC.
... and in the spirit of full transparency - you will share your evidence publicly? As it develops? Right? Beyond just the glowing (but anecdotal) consumer testimonals?
This is beyond fictional - it's delusional. Insurance (public or private) is a risk-pooling system - and w/o it, too many people would face financial ruin. Median balance in transaction accounts (savings, checking, MM, etc.) is around $8,000. Cost of 1 surgery w/ 3-day hospital stay is ~$100K.
... like so many that came before ... "trust me."
I have to admit ... "I'm going to disrupt a $5 trillion/yr - largely services industry (that employs ~22M Americans - larger than Mfg and Retail), by breaking even." ... is a novel strategy. Can't wait to see - you know - the actual evidence ;-) #Medsky
Lethal force against a civilian vessel in international waters is a war crime if not in self-defense. If not in self-defense, only non-lethal actions, such as warning shots or disabling fire, are allowed. "Not yielding to pursuers" or "suspected of carrying drugs" doesn't carry a death sentence.
The greatest trick the fascists ever pulled was convincing everyone that moderation was useless
Nobody knows if civil conflict will start in US. But this is certainly how a civil war could start. The breakdown of constitutional mechanisms to resolve tensions, leading to use of coercive and even lethal force by both ‘sides’. Yep, civil conflict is one foreseeable outcome of this escalation
... yes, but that's a feature (for enormous profits) not a bug - and transparency isn't THE fix. Transparency works for predictable, shoppable services, but not for complex, life-threatening, or catastrophic scenarios that drive the bulk of healthcare cost and spending.
" ... and we don't want to step into the business of states, counties and municipal governments." Right.
In a market (healthcare) where demand will always exceed supply - and where pricing is uncapped (and often patent protected) I would simply argue that .. .. you're gonna need a bigger boat ;-) [ie - bigger than A/B/C, Google and Microsoft - which have all taken BIG swings at healthcare] #Medsky
Whether it's Direct-to-Consumer (DTC) or Direct-to-Payer (DTP), making money as a new venture in healthcare isn't the real challenge. The real challenge is lowering the TOTAL cost of care for all. ... and for that challenge, the politics of profits are the *real* bottleneck. #medsky
For lowering Rx costs - there's more than one way to skin the PBM's. @mcuban.bsky.social is betting on Direct-to-Consumer w/ @costplusdrugs.com - but there's also Direct-to-Payer and a new venture just landed a $6B valuation w/ that model. #Medsky reports.endpoints.news/107e23d7/d84...
... but it remains a THEORY w/out evidence - and I would argue the evidence clearly supports health insurance. Our MODEL of tiered coverage has been rigged to deliver profits - but that can (and should) be changed.
FWIW - AI doesn't support your theory either. * HC costs are Catastrophic & Unpredictable * People Under-Save 4 Risk * Chronic Care is long-term and expensive * Cash-only models favor people w/ disposable income Our MODEL of insurance has been designed for-profit - but we can/should change that.
Never said that mark. I said MCCPD wasn't disruptive - and it isn't - b/c NO direct/cash pay model is. It's just another coverage tier (called self-funded - which billionaires often do). I'm also evidenced based. Show me ONE other country that's succeeded w/ a cash only model - and I'll STFU ;-)
AND ... If you endorse/support individual Employer Sponsored health Insurance - you're anti worker. Why? B/C commerical pricing is uncapped - and the AVG PPO cost for an American family of 4 is now over $35K - per year. [AND ... insurance companies profit - but they don't SET HC prices]
NB: China moved to UHC in about 10 yrs. 2003: Only ~20% of the pop covered 2013: ~95% of the pop covered .. and the population hadn't grown much over those 10yrs: 2003: ~1.3B 2013: ~1.35B Granted it wasn't very comprehensive coverage at the start - but it's improved a lot over the last 10yrs.
How is this an issue? Germany implemented UHC circa 1941 when the population was ~70M. Their population has grown since then (now ~84M) - but what's the issue? It was "cheaper" to implement then - ok - but the cost to keep it has grown since then too.
My surgery shouldn't be 2.5X the cost (Nat'l avg) my neighbors - simply b/c we're in different coverage tiers. That's the insanity - and ACA doesn't fix that. It just extends coverage into the systemic flaw of tiered pricing.
ACA just another commercial tier. Even w/ all those who are uninsured added (somehow) to ACA coverage it would not be the same as true UHC - which is the delivery mechanism for SINGLE pricing. Tiered coverage is the delivery mechanism for tiered (and uncapped) pricing. THAT'S the systemic flaw.
I believe this is what the kids call performative
*Ahem*
Just not true. ACA is NOT a UHC plan and we absolutely don't NEED single payer. Granted, single-payer works. BUT as a delivery mechansim for single-pricing so does multi-payer [see Germany]. Ultimately, no one really cares how many payers there are. What's CRITICAL is UHC. hc4.us/oneprice
Footnote: Here's the quote from noted healthcare economist Uwe Reinhardt (RIP).
Putin did more than eat Trump’s lunch in Alaska. He ate Trump for lunch and swallowed him whole. The losers? Ukraine, the EU, NATO, and the United States of America.
Nope. ACA was meant to ADD a commercial coverage option for those who didn't have ESI. It was NEVER intended to REPLACE ESI - and w/ ESI - we'll never have true UHC. What we have is tiered coverage to support tiered pricing. That's never going to be UHC - and the ACA is just another commercial tier.
We need employers - including unions - out of the healthcare biz. Until that happens - we're just rearranging deck chairs. hc4.us/esi20
No - we don't have UHC - and the ACA is just another tier of commercial coverage - not UHC. HC benefits through unions is better than many individual employers - but we still need employers (incl uinons) out of the HC biz. Until that happens - we're just tweaking cost & coverage. hc4.us/esi20
... how far we've fallen.
Here he goes.
Reality starts with ESI. "We need to eliminate employer-sponsored insurance." Mark Bertolini [former CEO of Aetna / CEO of Oscar Health] The reasons are many (at least 11). But billionaires/employers (like Cuban) still insist that employers should stay in the healthcare biz. hc4.us/esi20
Really important new study on the tax rate of billionaires from @gabrielzucman.bsky.social et al Upshot: The top 400 ultrabillionaires: 23.8% Avg Americans: 30.2% Yes, the superrich pay far less in taxes than the rest of us. www.nber.org/papers/w34170
Ez to fantasize ... but it's not real. We need *sweeping* changes to campaign financing AND the tax code to support any form of UHC - and neither of those are in the wings. "Campaign finance reform isn't the biggest problem facing the country - but it's the first." @lessig.bsky.social
Ronald Reagan [joke]: "I’m from the government, and I’m here to help." Donald Trump: “I am the government and I'm here to take over."
And there it is. That GOP talking point. "... the right to care they can afford." In most countries - healthcare is treated as a basic human right - not a commodity one has to budget and "afford."
... but it's a fiction - heavily promoted by the GOP to distract from the real culprit - uncapped/unregulated PRICES. About $0.90 of every $1 is paid out in medical claims. And you think that last $0.10 is where we'll get the most ROI to reduce avg commercial premium? Now $35K+ (family of 4).
That's the GOP fiction - if only consumers could see "the price." All to support the GOP fantasy of consumers "shopping for healthcare." No one wants the Walmart price for THEIR healthcare! ... AND ... unlike other markets ... theirs NO demand elasticity for you know - life/living.
... with uncapped pricing - of *COURSE* prices/premiums will escalate. Imagine what you're kWh rate would be if they weren't regulated? If power companies could tier your rate based on your ability to negotiate as a single - or small group of homeowners? You'd think that was insane - right?
... an idea that first appeared w/ Truman in the late 1940's. ... and given the regulatory capture - I would argue we're further away from that possibility than ever. Bernie and M4A had their shot. Time to move on. Single payer works - but isn't required. Single pricing is.
I disagree - Medicare now has 4 parts so it's already way more complex than UHC. It's also been heavily tarnished by "Medicare Advantage" - and this latest group is now advocating for "Medicare Advantage For All." Not what we want at all.
And we'd also have to unwind ESI. Also not trivial. Best to call it what the real goal is. Not Medicare - but UHC.
They have to. That's the real debate - and it's not trivial. Just saying M4ALL is misleading if we don't talk about how to price it b/c it assumes we just use Medicare pricing. Won't work.
Except that M4ALL is a fiction b/c we already know that current Medicare PRICING alone will not work - and this isn't trivial. How do we know? Maryland - which uses a grandfathered waiver from CMS to pay *more* than current Medicare rates to deliver "single pricing" (for inpatient services).
Footnote: Germany is a great model to mirror. Employers and employees pay in (split 50/50), but it's *far* less than the denominator of individual employers here in the US. AVG cost of PPO coverage in the US for family of 4? Now over $35K/yr - and comp range for docs? Not aligned to health!
Of course not. Pricing would still be variable by region/facility/specialty/procedure/- BUT - we'd lose the ADDED complexity of pricing by tier (to maximize profit over health) .. AND everyone would be "covered." One risk pool. The evidence this works? Every other country that leverages UHC.
Footnote: Healthcare doesn't need to be non-profit. Utilities aren't - but we absolutely need monopsony (one buyer) pricing. My surgery shouldn't be 2.5X (nat'l avg) my neighbors simply b/c we're in different coverage tiers. That's just insane.
Preaching non-profit to a billionaire capitalist. Tough sell ;-) M4ALL is an ok pitch - but it also glosses over too much - especially the enormous debate on pricing - which we know currently doesn't work (see Maryland). UHC is better framing (IMO).
No - they're not. Germany has many commercial health insurance companies and they spend far less on HC. Our problem is tiered coverage - which only serves one purpose - to support tiered *pricing* My surgery shouldn't be 2.5X (nat'l avg) my neighbors simply b/c we're in diff coverage tiers.
All healthcare is rationed. The difference we need to debate is how. We ration based on ability to pay - AND we also ration access by insurance coverage. ~9% of our population is uninsured - and another 23% are underinsured.
One state: ~300K Coloradans are enrolled in ACA plans. By not extending enhanced premium tax credits for the individual market, it is projected that ~100K will lose coverage. For those who remain enrolled, the avg net rate increase for the majority will be 100%+. And for many - closer to 200%.
... helping *some* - not all w/ low-cost generic Rx. It's critical to understand that distinction b/c our whole system is zero-sum (and MCCPD doesn't do anything for branded Rx). The bulk of Rx volume is generic - but the bulk of Rx margin is branded.
Footnote: The Gov should/could implement a system of universal health coverage - but the GOP has fought that successfully for decades - so not likely in our lifetime. China? If measured from the big reform push in 2009 to UHC in 2011, it only took ~2–3 yrs to get to 95% coverage.
Hindsight always 20/20 and selling full economic impact is always tougher than the initial investment: Combined Auto Bailout (GM + Chrysler + Ally Financial) Total assistance: ~$80B Total recovered: ~$70.5B. Net cost to taxpayers: ~$9–10B And we all know what GOP thinks of heavy-handed Gov.
Cheaper drugs for some. Not all. Don't buy the hype.
.. actually longer than 10yrs. The wheels finally came off in 2010 so it only took about 15 years to buy AND own our little republic. .. and you *could* go back to Newt Gingrich (and Pat Buchanan) as the founders of the hostile takeover. .. much of which was forecasted by Carl Sagan in 1995.
FWIW - a "cash price" is just another pricing tier - and it DOES have a direct affect on the other pricing tiers b/c - you know - actuarial math and all.
"US sees youth unemployment at 8.5%, nearly double the national average. Many entry-level roles lost during the pandemic haven’t returned, and the degree-to-job pathway is more uncertain than ever." c @profgalloway.com
... and if you like "live" versions - this one's pretty special ... with no less than Ian Anderson (aka Jethro Tull) on flute - and St Brides Church Choir ;-) The original song (1975) reached #2 on the UK charts - eclipsed only by Queen's Bohemian Rhapsody ;-) youtu.be/tuaRrSVm--I...
“I don’t think I’ve seen a more dangerous decision in public health in my 50 years in the business.” Mike Osterholm University of Minnesota Infectious Disease Expert apnews.com/article/kenn...
"And if you thought this was unimportant to you, remember BLS calculates the CPI used for Social Security COLAs, as well as the headline CPI used to calculate TIPS yields. Oh, also the inflation adjustments to the marginal tax rate thresholds…" #econsky econbrowser.com/archives/202...
Olympic level cognitive dissonance.
"... this is why nothing works for ordinary people. It's not b/c of woke college kids or trans students - or b/c there are interracial couples in cereal commericals. It's b/c the people's elected representatives don't represent the people. They represent the donors."
The payer-provider battle in healthcare has a new frontier - AI. Providers use AI to maximize billing and payers use AI to deny claims. Patients are the collateral damage in our Casino Healthcare.
"Trump realized you don’t have to do things. You just need to say things and then it’s all wrapped in one big burrito of dream and fantasy.” ~ David Remnick
Update: 15-16 million guns were sold in the U.S. in 2024. Before "2007, people in the US never purchased more than 7M guns in a single year. By the time Barack Obama left office, the US was purchasing almost 17M guns a year." In 2020 US consumers "bought almost 23M guns in a single year."
... so you're saying Dems need to lie better? “The ideal subject of totalitarian rule is not the convinced Nazi or the convinced Communist, but people for whom the distinction between fact and fiction … no longer exists.” Hannah Arendt
Tough odds of this happening - but damn. Wish it would. A kind of legal WWE-level smackdown. "Obama should offer to waive his immunity from prosecution for treason, if Trump waives his immunity from prosecution for defamation."
... and the basis of my book - Casino Healthcare ;-) We've gamifies healthcare for profit - not health. We keep fighting actuarial math - and the math always wins.
Also why I gag at the phrase "Medicare for All." Medicare pricing won't work and we know this from Maryland. Footnote: Maryland is single pricing for inpatient only. So guess which state has the highest number (per capita) of ASC's? Maryland.
W/ 1 pool - HHS would essentially regulate price (like Maryland has). Monopsony (one buyer) pricing is the opposite of monopoly (one seller) pricing. This is how every other industrialized country delivers healthcare to their population. We're the outlier - AND only profit-driven system. 2/2
We know MCare pricing won't work - from Maryland (which is All Payer using a grandfathered MCare Waiver). Universal coverage (one pool) is the way to fully leverage the actuarial math AND deliver single pricing. No one cares how many payers there are if they all use same price (eg: Germany). 1/2
2% savings ain't nothing - but why stop there? The systemic flaw (of which PBMs are a part) is tiered coverage - which only serves one purpose. It's the delivery mechanism for tiered *pricing.* The ginormous savings would be from universal coverage - as the delivery mechanism for *single* pricing.
That "may be good for society" is carrying a ton of weight b/c canabalizing news so far has just supported a "choose your own adventure" model that isn't healthy for a real democracy.
... and the fragmentation is corrosive b/c it fosters information bubbles and viral speculation/conspiracies. Democracies rely on a collective source of shared facts, events, and priorities. We're losing that - and (not surprisingly) it's heavily tilted by party affiliation.
The Orbanisation of America: ownership of social and traditional media outlets is consolidated in parent companies owned by Trump supporters. By the time we get to the 2028 election, there will be few independent media left.
... and I wish you all the best proving that theory. I'm sure VCs are eager to fund another Blendle w/ a "better UI" - and less "fatal flaws." ;-)
At $150-$250/yr - Spotify is a subscription model - not really micropayment.
No. It's not - b/c Blendle is a real world example of a micropayment model. That's not me flapping my arms.
Blendle (launched in 2014) is a pretty recent/real world case study. [Article below is from 2023] "The app today looks like a graveyard of no-longer-interested publishers." www.niemanlab.org/2023/08/the-...
