Sure. Repeal and replace failed by 7 votes. Hardly impossible. Impossible would be removing Stephen Breyer, who was confirmed 87-9. You and I have different scales for impossible. But that's fine. Now they're can be calibrated.
This is a purely semantic argument, I think we both understand that the chances that every provision of the ACA is repealed are very low in the foreseeable future despite much rhetoric to the contrary in years previous to, and leading up into election year, and not because of party line votes. Certainly, political stakes can conceivably change, but the fact a majority-GOP congress and president (and a respective constituency as well) who seemed to overwhelmingly advocate "repeal and replace" were unable to do so (despite repealing some portions which did have their fare share of problems, because the ACA was far from an infallible piece of legislation) is a solid indicator that the ground has been shifted.
I generally don't have a problem with a public option competing with private options. The main problem in the future would be those inherent to any monopoly. If the public option was "so good" that it became the sole competitor left in the market, then it holds a monopoly and can then dictate whatever it wants if there are substantial barriers to entry into the market (as there likely are for healthcare since risk-pooling necessitates a big enough pool for the law of large numbers to apply). Further, since tax revenue would be used for this whole scheme, it's easy for the government to raise taxes, skim some of that tax revenue off the top, and use it for other things. Then it could become a giant Ponzi scheme like what Medicare is today. That's an issue for the future and I would be willing to try a public option out and see where it goes. If it gains a monopsony and starts acting like that, then I think protections would be warranted in that case.
OK. Nobody said sole competitor but I see how the government
could use health-allocated revenue for other uses than healthcare (though
this does not go unnoticed by political adversaries.) As for the solvency of private risk pool with a small market share, refer to my post at the bottom of page 4.
That article does not take into account the fact that even though other countries pay into R&D but negotiate down prices, the U.S. still remains a market that does not do so and thus companies can afford to make less in those countries if they can make it up by charging more here. Again, we're subsidizing everybody else. If we also dictate low costs to these companies, who's left to eat the cost? Where can they make it up then? Again, you seem to be under this grand impression that we can both cut costs and make everybody happy at the same time. We can't. You have a small margin with which to work where they'll take reduced profits but after that, you're cutting into R&D and marketing funds - simultaneously.
The difference is that the U.S. is a huge system compared to these other countries. The U.S. is a huge source of revenue for pharma. Take a look:
Pharma revenue: worldwide share by country 2017 | Statistic. All of Western Europe still only makes up 67% of what the U.S. pharma revenue is. It's easy for someone on the outside to say that you can just cut costs. But once you see their balance sheets, it becomes a lot harder. I've been there.
You can't make the industries which profit disproportionately from their products happy by cutting costs, but this does not halt the financial incentive that research elicits, which is the reason that they invest in R&D and (
in some cases, twice as much in) marketing . That the returns on investing on research decrease does not mean that pharmaceutical companies do not still use R&D at home and abroad for the safe market that an exclusively manufactured drug represents. This isn't a change in the incentive system, which is what powers research, it's a change in the profits. Though this depends on the magnitude of the change,
this analysis in Nature (chart under this) shows that "large revenue declines" did not result in a decrease in R&D for most sampled companies, and where there were cuts most of those were exceeded by the administrative, selling and general expenses (meaning that R&D grew as a percent of company budget relative to this.) The
diminishing returns inherent of R&D may present an even more serious existential threat to R&D unrelated to healthcare systems.
This claim also ignores the point made in the previously cited study (
and in this one) that the United State's production of NMEs is smaller relative
to their share of sales in the global market. The implication here is not that the size of the United States market doesn't make it the most important single contributor to global pharmaceutical R&D, it is that, as the chart above also suggests, companies can operate at lower levels of revenue without killing R&D. Could we see a smaller R&D investment independent of aforementioned reasons if the U.S. per capita spending on pharmaceuticals decreased by 30%,
to a level closer to that of Germany? Perhaps, but this doesn't mean a halt on research and it would reduce the burden that that Americans take. If this is disruptive to drug discovery, it is up to the United States but also our European neighbors to make for a more equitable burden and thus avoid an outcome that is to everybody's detriment, because at the present costs are hurting Americans more than they're hurting Europeans (or perhaps than they're even helping Americans by the unquestionable benefit of research.)
It's also worthy of note that 1)a good chunk of pharmaceutical costs are incurred in paying middlemen, including
pharmacy benefit managers and wholesalers, not manufacturers, and 2)the setting of prices at a more reasonable level does not necessitate legislating price controls or profit controls, which some countries do, or for that matter legislating those at any particular level. Even if we assume that these companies are operating on tight budgets and barely making dividends for shareholders and owners, we could lower costs without even touching manufacturers.
A fifth at maximum. As I have already noted, 60% is likely a generous estimate since the vast majority of NIH research is basic science and only a small percentage of that makes it into improving human health. Further, new drugs are costing more. You're citing data from 2010. More recent data:
http://www.sciencemag.org/news/2017...t-share-basic-research-funding-falls-below-50. Not only is U.S. government funding falling, but the private sector spent over $100 billion on R&D in 2015. So government funding of R&D that eventually makes it into clinical use is much smaller than 20%. So yes, it is a small fraction. Talk to anybody - quite literally anybody - with knowledge of the industry and they'll say the same thing. Academics just like to delude themselves into thinking that they are doing most of the work.
Again, you're trying to pin me into something I did not argue. I don't think a fifth is a small fraction, especially considering the amount that fifth is. That the pharmaceutical industry that profits from those breakthroughs invests more is sensible and expected (for the sake of not having to guess, t
his study stressing the importance of private pharma estimates spending in different phases as seen below)
I think that anything termed "single payer" should be used when there is only one payer. Hence "single payer." Imagine how outrageous it would be if I barged into the "single occupancy" stall you were sitting in.
In public consultations and hospitals, there is usually indeed a single payer, and private insurances operate as a separate system from the NHS (with no deductions to those who add them on) which is why its, for the sake of simplicity, called single payer
by some sources. I can see how it can be confusing, however.
Sure, I just wanted to have some sort of number to visualize this. So would this still be the system you argue for if there is 25% intrusion by the private sector (because people wanted the extra coverage)? In other words, say a pharma company sets a drug price at $1000 and the public option won't pay more than $100. But the private insurance market (25% of the total market) will. Is that an acceptable outcome to you?
It's not a desirable outcome for a medication to only be available privately because it excludes 75% of the market in this scenario, but assuming that 25% of the market is private sector and the manufacturer/distributors aren't compelled to lower prices by the prospect of 75% market exclusion and negotiation is unfruitful, yes, that is an acceptable outcome. The idea is to make that outcome as unlikely as possible, since it can incentivize further private inclusion and loss of competitiveness by the public option.
I'm being lax with terms here. As with any public system, a "premium" would be paid directly to the government in the form of taxes. It's just to keep terms analogous between the public and private options here because we would have both. Presumably you would agree with an actuarially-fair premium/tax, community rated?
Provided that this tax offers adequate coverage, yes. Community rating, in the sense of not raising costs on the basis of individual characteristics, appears entirely sound.
Otherwise, I'd like to hear any argument that advocates for a higher premium/tax. And I don't believe that employer-based or professional union-based private options, as is common in Germany and Japan, should be the only options. Why exclude the people who don't or can't work? The private market should have options for everybody who wants to be covered by the private market so there should be a private marketplace.
Didn't say this was the only option, only the most frequent one. About a third of people using private insurance in the UK, for instance, do so on their own and pay for it on their own, which is a real option. The rest do so through employers.
