looking at the jobs numbers............

[dcarrigg]

Re: looking at the jobs numbers............

1. a graph showing only physicians and admin staff leaves out the rapidly growing numbers of physician's assistants, advanced practice nurses and nurse practitioners, who act as physician extenders.

2. the admin staff growth is for the most part a reflection of our screwed up system, where insurance companies hire people to deny claims while health deliverers hire people to fight with the insurance companies. iirc about 25% of u.s. expenditures goes to this nonsense.

3. the electronic record has just driven up costs and not improved outcomes. this is because a. the electronic system is designed to generate the maximum bill, not to facilitate care, b. the electronic system makes it very easy to order more tests, c. systems don't talk to each other - e.g. yale-new haven hospital in ct and mount sinai hosp in ny both use a system called epic, but there is no possible communication between their systems, d. care itself is fragmented both locally and nationally- there are few standardized algorithms outside of established cancer protocols.

4. the cost of drugs is an enormous part of overall costs, and the medicare part d law, shepherded through the house by billy tauzin [then a rep from la. who soon resigned to become the multi-million reimbursed head of phrma- the drug industry lobbying group] forbade medicare - the single biggest payer for services- from negotiating drug prices. btw, trump just backed off from an earlier pledge to have medicare negotiate drug prices.

1. There are surprisingly fewer PAs and NPs than you might think--fewer than I thought anyways, but you're from up my neck of the woods, right? Maybe they're overrepresented in New England. Latest BLS numbers (2017) say there are 109,220 physician's assistants (up from 59,530 in 1997) and 166,280 nurse practitioners. Compare that to 2,906,840 RNs earning $33.65/hr at the median (up from 1,719,710 in 1997 earning $30.46/hr in 2017 dollars at median), and you'll see that even though they are growing, they don't represent such a huge overall numbers increase or growth rate increase from an overall workforce perspective--although compared to physicians, of whom there are 666,490 of varying professions (up from 407,170 in 1997)--there are a good and growing number of PAs and NPs. Who gets squeezed? The lower-middle. Used to be 1 LPN for every 3 or so RNs in 1997, now there is 1 LPN to every 6 or so RNs. There were 1,018,700 nurses aides in 1997, there are 1,453,670 as of 2017.

2. Look at the admin and support numbers. They're staggering. There are 3,075,510 health technologists and technicians now--more than 1 out of every 50 jobs in America. These are more prototypical middle class jobs. Median is $20.95/hour (there were about 950,000 earning a median $28.10 in 1997--inflation adjusted to 2017 dollars). But you can do a lot of them with just a certificate. These are basically the factory line jobs of 21st century America. They have taken a pretty big pay cut over the past 20 years though. There's also another 1,428,220 doing miscellaneous healthcare support jobs--equipment preparers, transcriptionists, phlebotomists, these sorts of things. These are not as good jobs. You might get $18/hr if you're at a dentist's office as an assistant, but otherwise you're looking at probably $13/hr. These positions also payed better in the past, even though there are many more of them now.

3. You've got another almost quarter-million doing IT and records management, mostly around $20/hr.

4. Maybe a half-million pharm techs and aides pulling $14-$15/hr (compared to almost none in 1997), and a bit north of 300k pharmacists pulling in about $60 per hour (compared to a bit north of 50k pharmacists pulling in $46.42 in 1997--inflation adjusted to today's dollars). This is a huge jump, even not counting the corporate side of pharma.

What's the take-away? There are a lot more jobs and there's a lot more money going into healthcare. But not everyone was a winner. The technologists and technicians blew up in numbers, but watched their earning power erode, and LPNs definitely got screwed. Pharma and the top end made out like bandits. RNs grew fast in numbers but watched their salaries generally tread water (they are up 10% in real terms, but the irony is that's probably all eaten up by increased healthcare premiums). Physician numbers grew, but didn't keep up with overall health job growth rates, and although PAs and NPs did, so odds are you're seeing them more often these days.

{btw, in case it's not obvious, the point of this post wasn't at all to disagree with you, just to augment the points you were making with jobs figures}

[jk]

Re: looking at the jobs numbers............

some years ago i reluctantly concluded that the u.s. needed a single payer system. i think it's the only way to get a grip on costs, especially by cutting down on the administrative costs. [don't tell me about the cost of gov't bureaucracy - medicare has a much lower admin cost than any private plan.]

[shiny!]

Re: looking at the jobs numbers............

some years ago i reluctantly concluded that the u.s. needed a single payer system. i think it's the only way to get a grip on costs, especially by cutting down on the administrative costs. [don't tell me about the cost of gov't bureaucracy - medicare has a much lower admin cost than any private plan.]

I've reluctantly come to the same conclusion. If we had something like Medicare for all, it seems like the costs would be offset by the financial relief afforded to citizens, when they are no longer burdened with obscene insurance premiums and deductibles, and bankruptcies caused by medical expenses. I don't know anyone who objects to their elderly parents getting Medicare, but they scream bloody murder about the evils of socialized medicine for the rest of us. Is there something obvious I'm missing?

[vt]

Re: looking at the jobs numbers............

We need to look at the actual economics of medicare before proposing it for all:

Medicare is paid into for between 40 and 50 years by employed individuals and their employers before it is ever used by those who live that long.

About 30% of workers will die before they can collect their medicare from early deaths, but they will have still paid in until they die.

The average couple retiring today will pay $266,000 in out of pocket costs:

"A 65-year-old, healthy couple can expect to spend$266,600 over the course of their retirement on Medicare premiums alone, according to HealthView Services. An estimate from Fidelity is a little less:$245,000. Neither include out-of-pocket expenses or long-term care costs."

[touchring]

Re: looking at the jobs numbers............

Found something interesting - http://www.marketoracle.co.uk/Article62273.html

This article claims that real interest is only 0.7% and real interest was 2.4% when the 2008 recession started. This means 10 year yield can easily rise to 4.5% and real interest will still be lower than back then?

[dcarrigg]

Re: looking at the jobs numbers............

We need to look at the actual economics of medicare before proposing it for all:

Medicare is paid into for between 40 and 50 years by employed individuals and their employers before it is ever used by those who live that long.

About 30% of workers will die before they can collect their medicare from early deaths, but they will have still paid in until they die.

The average couple retiring today will pay $266,000 in out of pocket costs:

"A 65-year-old, healthy couple can expect to spend$266,600 over the course of their retirement on Medicare premiums alone, according to HealthView Services. An estimate from Fidelity is a little less:$245,000. Neither include out-of-pocket expenses or long-term care costs."

Doesn't seem plausible, VT. If you worked and paid into Medicare for more than 10 years of your life, part A premiums are $0. If you worked between 7 and 10 years they are $232 per year. They are $422 per year if you worked less than 7 years in your life. Part B premiums are $134 per year. Part D premiums average $420 per year. Medicare Advantage (Part C) optional additional coverage averages about the same.

So let's say you're on the very, very high end. You pay $422 per year for part A, $134 per year for part B, and $1,000 for parts C and D optional coverage per year (above average). We're talking $1,500-$1,600 per year. At the high end. So let's just say it's $1,600. That's $133 per month. And let's round up further--say you're in a high-cost-of-living area and you have higher than average expenses and you didn't work your whole life. Let's round it to $150 per month. Even $200 per month--say you're an extreme outlier.

And let's say you live to 95 years old and are on Medicare from 65 on. That's still only $72,000 in premiums. For 30 damned years. So double it for the couple, and now you're at $144k. Which isn't even close. They must be also adjusting it for future inflation or something. There's no way to even approach such a high number in premiums alone in 2018 dollars.

But what's the alternative?

Say the private sector offered insurance for the 65-95 years (they don't typically).

I mean, minimum prices for Medicare-type coverage you're looking at premiums at least 1,000% higher.

So it's not about comparing it to a perfect world.

It's about comparing it to the alternative.

Government healthcare is the absolute worst healthcare there is:
Except for every other type of heath system that has ever been tried by man...

[jk]

Re: looking at the jobs numbers............

premia for part b go higher based on your ongoing income, not just years worked.
2018

then you need to buy a supplement plan. i recommend g [F is full coverage but is being closed so holders of that coverage are going to age as a cohort and have rising costs since no new members will be allowed into those plans.. then you need a part d. and you have copayments in part d [medication coverage] and may not have certain drugs in your formulary.

once you're in a medigap plan you may well be captive to that plan - attempting to switch plans allows the new plan to underwrite your coverage - i.e. they can refuse to cover you if you have pre-existing conditions. medigap plan G requires you pay a $160 or so deductible each year and then you have full coverage for whatever medicare covers provided your doctor participates in medicare. in my state plan G may cost as little as $190/mo and as much as $335/mo. you may sign up for a cheap provider now but be captive to price rises later.

medicare d where i live can be as little as 12.60/mo, as much as 33.40/mo, but with different deductibles and copays, as well as different formularies and different likelihoods of being able to get off-formulary drugs covered if needed.

[dcarrigg]

Re: looking at the jobs numbers............

I suppose you have a point there. I was thinking fixed-income retiree--not someone pulling in $80k+/yr income. And sure, there are plenty of other out of pocket costs, but over a quarter-mil in premiums alone still seems a stretch.

[vt]

Re: looking at the jobs numbers............

DC, you may have been confused of the reason for my post. A previous post asked why we just didn't extend Medicare to everyone. I was trying to show how people pay into Medicare for years before even starting to use and some die before using.

To extend the program to everyone there would be enormous extra costs on top of traditional premiums so extending Medicare to all is really ignoring the huge extra costs.

This is not to say that single payer couldn't work in America. I do think being able to buy insurance across state lines, significantly reducing administrative costs, letting the market compete with less restrictions, stopping fraud,stopping drug companies from charging Medicare retail, and other reforms could make the current system work more efficiently and less expensively.

[Techdread]

Re: looking at the jobs numbers............

Don't get the argument, just have a two tier system, like we have in the UK, single payer system which covers all, and still retain private health care system for those whom want the option to jump the queue, get the best medical care etc.

The government run system would push down premiums for the private sector.

[FrankL]

Re: looking at the jobs numbers............

Don't get the argument, just have a two tier system, like we have in the UK, single payer system which covers all, and still retain private health care system for those whom want the option to jump the queue, get the best medical care etc.

The government run system would push down premiums for the private sector.

Maybe NHS was good when it started, but these days it's falling apart at the seams.
I suggest looking at continental European countries for better single payer healthcare systems. e.g. my experiences with the French system show it to be light-years ahead of the NHS (although I'm sure that system is on a downward slope too, like the rest of the western world).