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Comment by old-gregg | Hacker News Reader

Yes you can. As a 6th largest economy in the world [1] California can negotiate prices down by 50-60% to be comparable to Canada/UK. [2]

Besides, the existing state program (medi-cal) already covers over 1/3 of CA residents [3]. So it looks like if we lower the cost by 60% we can get pretty close to normal healthcare situation using the existing budget.

[1] https://en.wikipedia.org/wiki/Comparison_between_U.S._states...

[2] https://www.washingtonpost.com/news/wonk/wp/2013/03/26/21-gr...

[3] https://en.wikipedia.org/wiki/Medi-Cal

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I don't think California will negotiate prices down by 50%, and I would bet on that (conditional on this bill passing). Anyone - old-gregg? - want to take that bet at even odds? I suggest using the total cost of one each from the list of medical services in old-gregg's second footnote - angiogram, office visit, angioplasty, etc. I'm also open to other terms.

(Studies show[0] that people answer politically-charged questions more accurately when paid for accuracy, so I think we'd have better debates if people bet on their predictions.)

[0] http://www.pewresearch.org/fact-tank/2013/06/17/political-vi...

It sounds fanciful to say that we'll just use our existing Medi-cal budget but now it will cover everyone.

If the government had so much bargaining power, then Medicare and Medi-cal would already have far smaller costs. We don't really see that.

Also, who exactly, would we be negotiating with? I don't know that you can squeeze the budgets of hospitals in California by 50% and have everything carry on like normal.

Except that the lawmakers in Washington actually wrote the laws to forbid the government from negotiating for special rates for Medicare and Medicaid, unlike the UK or Canada. Which is why drugs there, for example, are so much cheaper than in the U.S.

Hmm, interesting. I know medicare reimbursement rates are still quite low compared to private insurance, so I wonder how that squares with a 'no negotiation' policy.

Edit: One study from Texas found that Medicare reimbursement rates were 70-80% below the private average. https://www.texmed.org/June16Journal/

> can negotiate prices down by 50-60%

You can only do that by paying Doctors less.

Good luck with that. If you did it anyway, good luck finding enough Doctors.

When people think "negotiate prices" they usually think of drugs, but Doctors is the real problem.

Medi-Cal (and Medicaid in general for all states) only works because the regular rates subsidize the under-market charity rates. That only works up to a point, then it doesn't.

That BTW is why hospitals never publish rates - they need the higher rates to subsidize the charity rates.

Until you change that, you will never have single payer, it's impossible to do.

Physician pay (last I checked) only makes up about 20%, including the costs of them practicing. They see about half of it in the end. There is even more spent on administration, which makes up about 25% of spending. Compare that 25% to the 9% in Canada and it becomes pretty obvious where you can save money.

> Physician pay (last I checked) only makes up about 20%

Does that number include specialists? Nurses? Lab technicians?

If not, why are you excluding them?

You basically have 4 expenses: Durable Equipment, Medication, Salary, Facilities.

I suspect that Salary is the largest one, and the hardest to reduce.

Costs across the board are higher due to structural and incentive factors - more intervention, more fee for service, etc. also, specialists' income has risen ridiculously vs. GPs .

http://www.healthbeatblog.com/2008/01/health-care-s-1-2/

http://www.vox.com/a/health-prices#chart/11

The pharma and medical instrument pricing racket is unbelievable. Took a look at the cost for our last delivery - of the $36k+ cost billed, facilities, equipment and medication were way over the billed rate of the doctors/nurses/anesthesiologists.

That number includes specialists and lab techs. It doesn't include hospital care (i.e. nurses).

You are just ignoring the profiteering done by the drug and insurance companies and the savings due to streamlining administration that a single payer system would bring.

The driver of the cost of insurance is the cost of care, and I haven't seen much, even in the form of rhetoric, paid this way.

So, can they really? Part of the reason places like Canada and the UK can do this is they can threaten to run around the industry when they try to fleece their citizens. Ultimately CA may be unable to do anything to combat the costs of medical care because the laws that give pharmacies and the AMA their monopoly in the field are enacted at the federal level.

Why can't California do the same and refuse to cover medications unless the sellers cooperate on price?

There is also no reason why you cant operate a single payer scheme AND a private insurance scheme in parallel, its just that EVERYBODY should contribute to the single payer scheme, whether they need it of not.

Some of the numbers for [2] confuse me. How can an office visit cost $30 in Canada? When I go in for an office visit, it typically takes about 30 minutes of staff time, around 15 minutes with a medical assistant and 15 minutes with a doctor. If that's $30, the implied wage is $60/hr for the medical staff, if you assume that all the money goes to staff. That just doesn't seem feasible.

Some of the other numbers seem more reasonable, though I should point out the charts are a bit misleading as they list the US 95th percentile in addition to the averages, which makes the difference appear larger than it really is.

Some office visits are shorter then others. (Although less scrupulous doctors in Canada aggressively optimize for faster visits - more money for them, worse outcomes for their patients.)

It's around $50 for 'off plan' visits (your not a canadian resident, or it's not covered by the healthcare plan).

The math should be $120/hr for the office. The assistant gets $20/hr and the doctor gets $100/hr. If you use the $50 rate, then it's $200/hr. If the doctors share an assistant, it becomes even more efficient. Because of the lower prices, there are less doctors, so they get higher utilization rates for the ones that are there.

A doctors visit isn't a good example. Folks don't go bankrupt from doctors visits. The important stuff is drugs and hospitals.

For example an asthmatic in any other country in the world pays ~$10 for a Ventolin inhaler (including tax and a % of profit), Americans pay $55-$65 and that price is increasing.

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