Most Medicare recipients do get supplementary private insurance though? It's called "Medigap."
Medicare pays for 80% of patients' costs, but even the remaining 20% is a lot. (You get a $100,000 procedure -- you're on the hook for $20,000.) That's why people get Medigap coverage.
In a Medicare-for-all scenario, the individual price of a given procedure doesn't need to be so high, because the reimbursement is guaranteed. Right now, the "list" price of the procedure has to be high to subsidize the uninsured and Medicaid who lose money.
I'm sure there are single payer health insurance countries in which people still purchase insurance, which should inspire debate about the universal insurance cost-sharing.
Regardless, the only viable solution in the US is a single payer insurance model.
To use car insurance as an example, it would be like if we had a government program for cars over 150k miles. You have to pay for both private and government insurance. The private company collects more money than the government, but the government pays for all the expensive stuff because that's when cars break down. It's completely pointless.
If you want a medicare-for-all scheme where working people have a higher cost-share than children/retirees, fine, that's reasonable. Having private companies rake in profits from a system that has no business being a profit enterprise is insane.
I strongly think that covering everyone in the existing system is not the best way to go.
The existing system is designed to cost as much as possible, and we have way too much demand for treatment (as is) and not enough supply. ER wait-times aren't 2-4 hours just because.
First, that needs to break.
Then, you can cover everyone.
We simply do not have enough doctors for how many old and unhealthy people we have. We should be thinking about how to keep people from going to the hospital that don't really need to be there. Do you really need to go to the ER because you stubbed your toe? If you didn't have insurance, you'd go to a low-cost clinic and get the same treatment for 1/10th the price.
We are slowly getting there already. Low cost clinics weren't widely available, but they are becoming more and more available as the cost of health care even WITH insurance is too high for most people.
The infrastructure for the bottom ~50% of people needs to exist to break free from a system that is not designed for them BEFORE they can move off it.
It's almost there.
Since One Medical became widely available, I basically have not gone to the hospital in 5+ years. Before, you kind of needed to go even for routine things (or at least I didn't know of a viable alternative). More and more places like this are springing up all over the US.
ER wait times are long because ERs are the only place in the country where we effectively have medicare for all, albeit in a particularly perverse and dysfunctional form. Everyone gets treated at the ER even if they're broke & uninsured as long as they're willing to wait long enough. Now imagine if those folks could go to any primary care doc or even use One Medical, CVS walk-in clinic etc. That would go a long way toward fixing our overloaded ERs. We've legislated quazi-medicare for all but only in the most inappropriate part of the system.
Where else are some people supposed to go? Maybe that toe is starting to change colors… is it broken? Do I need to have it set? Is that possible for toes?
People have valid medical questions and don’t want to wait weeks to see their primary care. They might not live near an urgent care. The urgent care may have terrible hours, or they made the mistake of mentioning chest pain for their heartburn incident and now they are forced to the ER.
It’s a chicken and egg problem. Faster medical answers will lead to reduced ER wait times. Reducing ER wait times lead to faster medical answers.
We're going to need to make more doctors. To do that we'll need to identify kids in high school that would be good candidates and offer full-ride scholarships where needed. And we need to improve science education at the high school level to help with all of this.
We could import them.
We have tons of options. But the medical industry likes a shortage, because they like high wages, so I won't hold my breath.
They pick the rules. The rules favor them.
That's going to remain true for the foreseeable future, and on the list of problems, that's at the absolute bottom of things to fix that would actually move the needle.
The cost you spend on DIRECT HEALTHCARE is only ~20-30% of all spending. The rest is administration, drugs, insurance overhead, profits, ACTUAL insurance costs, cost overruns due to insurance making everything as expensive as possible to scrape 15% off the top, fraud, legal fees, etc.
The biggest benefit to moving to a centralized insurer is that fraud is centralized.
If you're a Republican and skeptical of government, you might assume the government will let massive fraud slip through to insiders, and you don't like that.
If you're a Democrat, and think the government can generally be good, you think the government can catch a lot of the fraud and cut total costs by 10% to get to fraud levels that are similar to other advanced countries (with similar systems).
I've watched friends go through it here in the US and I have zero interest in working 24 hour shifts and sleeping in break rooms, working 80+ hour weeks for years. There just is no need other than hazing and keeping artificial scarcity of doctors for inflated wages. There are plenty of brilliant, scientifically minded, hard working people that care about others that probably could be great doctors, but the US training system is just hostile towards most people.
I hate to break it to you but insurance is meant to be a tax on the entire risk pool. What changed after the ACA is we couldn’t kick anyone out of the risk pool for getting sick.
You didn't read the post.
The sick are mostly the old (if you're looking at total spending), and they are already covered by Medicare.
The sick young are a minority, and are often times covered by Medicaid.
If the state covers the tail end and assuming they aren't covered already by Medicaid, there just isn't that much spending remaining.
They can get private insurance to cover the under $10k per year - but there's not really a product that covers that effectively - so unless a new insurance evolves, it still wouldn't make much sense.
The sick, young, non-medicaid tail is VERY small compared to the rest of the tail the state already covers. Just add it in. A 1% global tariff could easily cover it. You've still got 9-14% left to spend on more bombs, tax breaks for the rich, paying people to get underwater basket weaving degrees, whatever.
I highly recommend you read the book "We've Got You Covered." It's an economist's view of health systems and how we can rearrange government spending to provide coverage for everybody and prevent medical bankruptcies.
One Medical looks interesting, but I wonder how they keep the price that low. Is it subsidized? Are they putting constraints on physicians and what they can do in the same way BetterHelp messes with the therapists? Are they servicing only the young and healthy?
Their senior care plans tell an interesting story. They only work with Medicare Advantage plans, specifically those known for up-coding, excessive pre-authorization requirements, and high rates of care denials. Medicare Advantage is an interesting failure in the marketplace in that it costs the government significantly more than classic Medicare and provides worse-quality care.
For the rest of us, we can skip the ER by going to an urgent care. But around here, urgent care offices are owned by private equity, have deceptive billing and are part of the reason why medical care costs so much.
You are clearly not in the bottom 50% of health care spenders. You would be in the group that would keep private insurance and be happy.
> One Medical looks interesting, but I wonder how they keep the price that low. Is it subsidized?
No.
> Are they putting constraints on physicians and what they can do in the same way BetterHelp messes with the therapists?
The vast majority of their "doctors" are Physician's Assistants. You can see whoever you want for whatever you want (that they provide).
> Are they servicing only the young and healthy?
Mainly. It's a clinic. You can't go there for Open Heart Surgery and cancer treatments. They'll just (cheaply) refer you to a specialist (who will be expensive and require insurance).
What you can do is avoid huge wait times and get good enough treatment for ~90% of what the mostly healthy group of ~50% of the population needs for fair up-front prices - which previously did not exist.
Many of my health needs are not expensive, but my body's reaction to treatments is. Frequently, cheap drugs are all side effects and no benefit. Also, private insurance has bizarre coverage gaps. For example, ambulance costs. When I had a heart attack, I drove myself for 45 minutes to the nearest hospital with a cath lab rather than take an ambulance and end up with God knows how many thousands of dollars in uncovered ambulance fees. Then there are things like cardiac rehab, which go a long way toward restoring cardiac health. 12 weeks, three times a week at $50 copays, was an expense I wasn't counting on. When I qualified for Medicare, the quality of care improved significantly. Usually, wait times for service are much lower than with private insurance.
I also resent private insurance because my premium dollars go toward enriching stockholders rather than providing care for all policyholders.
I think you want a third solution - but that seems highly unlikely to be available in the mid term - and it doesn't look like anything is changing in the short term.
Who knows, my crystal ball doesn't work any better than anyone else's.
See, for example, “Dying of Whiteness: How the Politics of Racial Resentment Is Killing America’s Heartland” by Jonathan Metzl
This subset does exist, but is smaller than the percentage of people who think the system is broken - and the solution is not to just open up the floodgates and make it even more broken and even more expensive.
You FIRST have to fix the system before you open up the floodgates.
I am on your side that I think it would actually cost LESS to move all high-cost patients off of the ER and onto Medicaid.
But that's not a big enough problem to actually move the needle. In the rosiest scenario, you might save 2% per year. That's still like $20-40B, so nothing to scoff at - but in realistic scenarios, I'm doubtful it would save >$10B.
Even if they had Medicaid, they're so conditioned on going to the ER for everything, a lot of them might still go there instead of somewhere cheaper. For one, they might be convinced they get better care there (and maybe they would).
There's way bigger fish to fry.
I don't see any reason to fix the system on a nationwide level. Let the individual states figure it out. There's things that the top 5 US states for healthcare have in common, and there's things that the bottom 5 US states have in common [0]. They know how to talk to each other if they want to know more.
[0]https://www.commonwealthfund.org/publications/scorecard/2025...
It's a problem because the nation already ineffectively covers the tail.
The state shall not fix what is not a problem for the state.
The more critical, and yet smaller, subset is the people making bank from the current system. Get their money out of politics and watch resistance crumble.
"Blood libel" refers to a specifically anti-Jewish trope of alleging that Jews murder Christians, especially children, to use their blood for religious rituals. Grandparent comment is 100% not blood libel.
The Medical Loss Ratio (MLR) requirement established by the Affordable Care Act (ACA) is 20%.
Typically it's closer to 15%.
As these are private companies, some percentage of that is obviously profit.
It doesn't cost that much more to run private insurance than Medicare.
The problem is the incentive of insurance to drive up cost to get a larger fixed cut, and the lack of a public option (which would require private insurance to actually be worth it).