
YC Research: Universal Healthcare - craigcannon
https://blog.ycombinator.com/yc-research-universal-healthcare/
======
TuringNYC
(Full-time co-founder of a healthcare startup here): W/r/t the US
specifically: it seems there is no shortage of inefficiencies and obvious
solutions to the inefficiencies in the US healthcare system. To me, the real
problem seems to be a system that has almost diabolically evolved to create
competing interests that deadlock all sides into a sub-optimal solution.
Specifically-- patients, payers, physicians, pharma, facilities and insurers
almost all have indirect but competing interests much like the Dining
Philosopher's problem we're familiar with in Computer Science.

I'm not sure what the solution is short of a total swamp draining, but our
startup went overseas to develop/trial our product in a country with a single
payer system. Not perfect, but much more amenable to finding efficiencies.

~~~
warcher
In the united states we can't successfully implement _negotiation on drug
prices for MediCare_. They literally can't negotiate with their suppliers. By
law.

Anybody thinking software is going to solve that is way in a bubble.

[http://healthaffairs.org/blog/2016/09/19/the-politics-of-
med...](http://healthaffairs.org/blog/2016/09/19/the-politics-of-medicare-and-
drug-price-negotiation/)

~~~
chimeracoder
> In the united states we can't successfully implement negotiation on drug
> prices for MediCare. They literally can't negotiate with their suppliers. By
> law.

On the flip side, Medicare sets reimbursement rates for services essentially
by fiat[0], which can be _below_ the marginal costs of providing service. Most
providers cannot legally refuse to treat Medicare patients, so they are forced
to accept the rates that Medicare sets (they have no ability to properly
negotiate). Medicaid is a whole different system, but in this aspect, it also
works the same way.

This turns into a system in which privately insured patients subsidize
Medicare patients through their premiums[1] (separately from their tax money,
which also goes towards Medicare)[2]. Medicare has no incentive to change
this, because it allows them to increase their (effective) operating budget
without requiring Congressional approval.

The reason Medicare drug price negotiation was blocked is that people (both
pharmaceutical companies and policymakers) were afraid that it would turn out
just like Medicare's "negotiated" rates for inpatient and outpatient services.

[0] And private insurers are legally prohibited from reimbursing less than
Medicare does

[1] And uninsured patients receive the same (inflated) bills that private
insurers receive. (Whether or not they actually pay their bills is a separate
matter).

[2] If you've ever wondered why the sticker prices for inpatient services seem
so high, this is the underlying reason. Privately insured patients and
uninsured patients aren't just paying for their own care (and for the care of
others in the same risk pool). They _also_ have to cover the amount of money
that providers lose on Medicare and Medicaid patients.

~~~
khuey
> Most providers cannot legally refuse to treat Medicare patients

My understanding is that doctors can choose not to take Medicare patients. Do
you have a link or something that explains this?

~~~
chimeracoder
> My understanding is that doctors can choose not to take Medicare patients.

Sort of. For example, most emergency rooms in which physicians have admitting
privileges to an associated hospital are required to take Medicare[0]. And
those emergency rooms are prohibited from refusing patients based on insurance
status. So right off the bat, that's an enormous source of patients who could
be publicly insured (Medicare/Medicaid) or uninsured, and they have no legal
way to refuse them. (Once a patient is in the ER, if they need to be admitted,
you can't (legally!) refuse to admit them based on their insurance status).

I'm kind of oversimplifying, because there are a lot of tricks that hospitals
try to use to stop the bleeding - for example, Bellevue is a public hospital,
and it operates an emergency room, but its private counterpart that is
literally _across the street_ does not. NYU can do some (perfectly legal)
maneuvering to keep most of the patient population of Langone limited to
privately-insured patients. As a result, Langone has undeniably better[1]
care, despite having access to the same set of medical staff[2] and being
associated with the same medical college.

It's true that private practices can refuse Medicare for outpatient services
easily. And incidentally, many _do_. There's a reason that, except in
"critical access" areas[3], most of the top physicians who operate purely
private practices don't accept Medicare. However, private practices are a
dying breed, so that's a moot point in 2017.

[0] Conversely, free-standing emergency rooms are _prohibited_ from accepting
Medicare. A rather cynical view of this would be that Medicare does not want
to encourage free-standing emergency rooms, because it's much more difficult
to use private emergency care to subsidize Medicare care than it is to use
private inpatient care to subsidize Medicare care (the orders of magnitude in
costs are vastly different).

[1] More expensive, but _vastly_ better

[2] Well, sort of. Staff isn't shared between the hospitals day-to-day (a
nurse at Langone will typically only work at Langone unless he or she also has
a job at Bellevue), but the allocation draws from the same pool _a priori_.

[3] Rural hospitals that Medicare pays handsomely, because otherwise those
regions would have no medical access at all.

~~~
dragonwriter
> Staff isn't shared between the hospitals day-to-day

It probably is; it's quite common for fair numbers of hospital staff (e.g., OR
staff that are needed only for certain types of procedures), AFAIK, to be
provided by third-party contractors that provide service to multiple hospitals
in the same area, and the same staff may work at different hospitals on
different days based on need.

~~~
chimeracoder
> It probably is; it's quite common for fair numbers of hospital staff

Sort of, yes - in NYC, nurses are almost all members of 1199SEIU, for example,
and the shift-work nature of nursing makes it easy for them to be employed
simultaneously by multiple hospitals. Though my point is that this is usually
handled on an individual level (by the nurses who choose where to work),
rather than the hospitals themselves directly coordinating staff schedules in
tandem.

------
tyre
We sell to governments, which is similar to healthcare.

I cannot stress this enough: technology is not the hard part.

Do they have outdated software? Yes.

Can you build better software? Yes.

None of that matters if you can't get it into their hands. Procurement is the
hard part. Can you empathize with the needs, fears, desires, quirks, and crazy
of ten different stakeholders? Pry proprietary API specs from the cold-dead
hands of one-off contractors? Educate users who's technological proficiency
peaked at SMS to manage a full-featured SaaS product in 2017?

Don't focus on the software. That isn't the hard part. People are the hard
part. People are _always_ the hard part.

~~~
ones_and_zeros
I think the point of this project is to replace the people, not necessarily to
make software for people to use. Software is just means to an end.

~~~
nightski
If that is true, how is a pilot project in the developing world going to help
at all in that sense? It doesn't seem like it is particularly relevant to the
goal of reducing bureaucracy in the United States. Or do they really believe
making a software platform is the missing piece here?

~~~
dsjoerg
I didn't see anything in OP about the goal being to reduce bureaucracy in the
United States. Everything in OP seems explicitly global.

------
yummyfajitas
Interestingly, we already discovered a mechanism for drastically reducing the
cost of healthcare back in 1986. It's a way of crowdsourcing the problem
called _high copays_. Basically, you have to pay out of pocket for 90% of your
health care up to a (high) cap.

It turns out that patients are very good at figuring out which health care
will improve health and which won't - the high copay group had no
statistically significant difference in health from the low copay group, and
spent about 30% less money. What a crazy magic bullet, huh?

[http://www.rand.org/health/projects/hie.html](http://www.rand.org/health/projects/hie.html)

We ran a directionally similar experiment in 2008, and got much the same
result: low copayment causes people to consume a lot more medicine, but with
no objectively measurable improvement in health. (Subjectively, people with
insurance _feel_ healthier even if they never go to the doctor.)

[https://www.nber.org/oregon/](https://www.nber.org/oregon/)

In both cases we ignored the result because we don't like it.

~~~
whyileft
Almost smells like the ACA, doesn't it?

Edit: My apologies for sounding a bit antagonistic. The ACA is currently
making use of high copays for that reason and more. It also hopes to force
more transparency as well as most people want more than a icd-10 code when
they have to write a check for $4k.

~~~
grzm
Healthcare discussions can quickly devolve into flame wars. Please take extra
care to comment civilly and substantially.

~~~
whyileft
That's a valid point. I've updated it to be less flippant. Appreciate you
bringing that to my attention as there is a lot of great discussion going on
in this thread.

------
Eliezer
It boots nothing to subsidize that which is in restricted supply. So long as
there are only 350 othodontists allowed to graduate per year, there's a
corresponding limit on how many patients are allowed to have straight teeth
regardless of who pays for what or what software is used. Improve the
software, and the price of orthodontia must still equalize demand to the
limited supply.

Offer free dollar bills, and a line will form until the cost of staying in
line burns more than $1. Medicine isn't costly because it's inefficient,
rather it can end up inefficient because the limited supply means it must
_somehow_ end up costly.

It is not possible to solve the healthcare crisis without somewhat
deregulating the supply of healthcare and allowing it to increase. Until then,
every subsidy just raises the price, and every efficiency improvement just
creates room for more inefficiency elsewhere.

You can't solve the housing problem in San Francisco by building more
efficient software for selling houses. _Only_ interventions that somehow
increase the _total_ supply of living space can cause more total people to be
able to live there.

~~~
lkbm
The article claims that 40% of the cost is operational inefficiencies, fraud,
and ineffective care citing [0]. If all orthodontists are fully occupied and
there's no demand being cut, then yes, removing those inefficiencies will just
boost orthodontic pay.

But it sounds like at least _some_ of those inefficiencies involve: 1\. People
getting unnecessary orthodontic treatments (eliminating those cuts demand [not
just quantity demanded]) 2\. People getting ineffective treatments and needing
a second treatment (same as 1) 3\. Orthodontists being allocated in a way that
lowers their overall productivity--empty time in their schedules, doing stuff
they're less skilled at, etc.

If my orthodontist spends less time on administrivia or repeat procedures, he
can fix more people's teeth without us training a second orthodontist.

Similarly, if there are apartments sitting empty for a month because it's hard
to match people with apartments, better software can fit more people into San
Francisco. (Going deeper, my bedroom is empty 12+ hours a day. I could totally
sublet it to someone who works the night shift. I just need an efficient
system to find such a person who's as interested in saving money as much as I
am. Or as much as I was a few years ago. Now, I might not opt for this plan.)

[0]
[http://www.who.int/whr/2010/10_summary_en.pdf?ua=1](http://www.who.int/whr/2010/10_summary_en.pdf?ua=1)

------
lumberjack
Universal healthcare is already much more cost effective than fully or semi-
privitised health care.

Sorry, I forgot to pretend that all the other developed countries haven't
figured out healthcare already.

Geez.

\----------------

Oh and btw, when you have a universal healthcare system payed by taxes (none
of that bullshit insurance crap that only ends up being costly
regulation/financial bloat) you can have entire and fully private hospitals
and health clinics where you can get service for cash, and surprise, surprise,
it's ridiculously cheap because it has to compete with the effectively free
public healthcare system.

~~~
ameister14
>Universal healthcare is already much more cost effective than fully or semi-
privitised health care.

That's not true. Most developed countries have some form of privatized system,
falling into your 'semi-privatized' definition. It's more cost-effective.

~~~
TheSmiddy
In Australia we have a universal healthcare system for everybody and a private
system that runs alongside that essentially gets you a more comfortable bed
and the ability to jump the queue for non-critical surgery.

~~~
dguaraglia
Even an economic nightmare like Argentina manages to run on the same idea (I
grew up there.) The level of complexity and inane amount of paperwork you have
to do in the US to get the simplest care is still baffling to me. I get it
that it's the inefficiencies that make this system profitable to some, and
that's why you might get the "best doctors in the world", but it could
definitely use some modernization.

~~~
prawn
All the money involved means that the companies and their lobbyists have too
much at stake and have to mobilise against change. Huge shame when it impacts
hundreds of millions.

------
toomuchtodo
This is fantastic news. Congrats Watsi!

It has always seemed like this was the end goal; to build a proof of concept
healthcare delivery platform for the third world. Very exciting!

EDIT: Sidenote: Thanks YC for funding Watsi as your first non-profit and
attempting to tackle a hard social problem.

------
alexmingoia
What does this have to do with universal healthcare?

We know how to make healthcare more efficient. We know how to remove the
administrative overhead. Other countries already have these systems in place.
Look at Taiwan for one example. They have digital medical records and an
extremely low administrative overhead because of universal care.

Healthcare will continue to be broken no matter how many YC research programs
there are - because the US population lacks the desire and political will for
universal healthcare.

~~~
TillE
If you look at polls that go issue by issue, you inevitably come to the
conclusion that the "US population" at large (55-60%) would support a broad
agenda of social democracy.

The problem isn't the people, it's the politicians. Specifically the
Democrats, who refuse to push for anything but the weakest, most ineffective
compromise policies.

~~~
Al-Khwarizmi
Then why did people vote for Hillary Clinton and not Bernie Sanders in the
primaries?

Honest question from a non-American (in the social democrat Europe, Sanders
seemed like the no-brainer option to like 99% of the people I know...).

------
temp-dude-87844
I applaud this initiative of collecting more data on this, by starting a small
trial in an area with fewer confounding factors, and later applying those
lessons learned in places with more interconnected systems in place.

One unfortunate fact is that a small proportion of people 'consume' most of
the medical care. Operational inefficiencies, the concept of health
_insurance_ , a byzantine cost structure, and in the US, after-the-fact
billing conceal -- or at least spread out over time -- some of the financial
pain of care. This is a sort of societal compromise to avoid confronting the
problem: a society either shoulders (i.e. subsidizes) the cost of care for its
most unhealthy, or lets them perish outright.

Today, most civilized societies tiptoe around this subject by subsidizing
medical care for the elderly for political expediency, where the marginal
benefits (even for the particular individual) of life extension until funds
finally run out quickly diminish, while leaving folks of prime working age
bear a large portion of their own costs in case of misfortune, to say nothing
of underserved minorities and the economic poor.

Perhaps the best value of conducting this trial in a developing country isn't
solely to get away from the political machinery of a mature healthcare system,
but to escape the political baggage of a post-industrial society and see if
technological solutions can work if morals and politics aren't in the way.

~~~
monk_e_boy
> civilized societies tiptoe around this subject > by subsidizing medical care
> for the elderly for > political expediency

It is the same with car insurance. The elderly are almost as bad as drunk
drivers for accidents.

------
esfandia
Healthcare definitely seems like the land of process inefficiency, even in
developed countries like here in Canada, so there's plenty of opportunity for
major improvement. There's still plenty of paperwork done on... paper,
information that constantly has to be repeated when you go from one provider
to another, and plenty of mistakes made.

Some time ago Ontario spent a massive amount of money on computerizing
healthcare and it yielded nothing. I figure all the regulations, privacy
issues, and overall complexity of the system makes it a tough Goliath to
handle. And whatever happened to Google Health?

I feel that the solution has to come from the grassroots: get a bunch of
health care providers to sync up for certain simple services, and go from
there. Keep adding features little by little, keep expanding the number of
participants. Do it using published and open source APIs and software. Don't
try to be everything to everyone. Break a few rules, ignore some complicated
standards if it can help get you there quicker. Hmmm, maybe for the latter to
be possible it makes sense to start in less sue-happy countries.

~~~
soperj
What are you basing the yielded nothing on? Canada is well on it's way to
Electronic Health Records.

~~~
esfandia
It was a big time scandal in around 2009:
[http://www.cbc.ca/news/canada/toronto/ehealth-
scandal-a-1b-w...](http://www.cbc.ca/news/canada/toronto/ehealth-
scandal-a-1b-waste-auditor-1.808640)

Things may have changed since.

~~~
soperj
There was a scandal only in Ontario, doesn't mean that good work hasn't been
done in that province, or other provinces.

------
EGreg
I have argued in favor of Single Payer systems on the basis of
[https://en.wikipedia.org/wiki/Monopsony](https://en.wikipedia.org/wiki/Monopsony)
. When buyers don't compete on price, then the price goes down. This is also
known as "collective bargaining power".

You can see this borne out in the fact every developed country with a
universal healthcare plan gets cheaper prices, often for the same or better
outcomes than the USA. Including number of doctors per capita, which disproves
the "shortages" myth. Domestically in the USA, Medicare squeezes doctors far
more than other insurance companies. A "medicare for all" would do even
better.

After the libertarians and anarcho-capitalists try to claim superior economic
knowledge eventually they must admit simple supply and demand drives prices
down in a single payer system.

But then I get the following objection: what about all the R&D that we do?
Perhaps all that expensive health care in the USA results in better procedures
and medical equipment, better trained doctors etc. ?

To this I say ... OPEN SOURCE DRUGS!
[http://magarshak.com/blog/?p=93](http://magarshak.com/blog/?p=93)

If you can introduce a patentleft movement in drugs the same as you have done
in software, then innovations can come from anywhere.

And failing that, we can always do this compensation model:
[https://qbix.com/blog/index.php/2016/11/properly-valuing-
con...](https://qbix.com/blog/index.php/2016/11/properly-valuing-
contributions/)

------
koolba
> For the initial project, Watsi will fund primary healthcare for a community
> in the developing world and build a platform to run the system
> transparently.

Have they decided what country (or countries) in which this will take place?

While I'm sure there are many worthy candidates worldwide, applying the same
type of program to under served communities within the USA would be great as
well.

------
judah
Love the ambition. Bring some transparency, reduce fraud, use technology to
reduce cost where possible. Great idea, hope it works.

I'm skeptical it could reduce healthcare costs significantly simply because of
the massive effort required to change the healthcare behemoth in even small
ways. However, given the exorbitant costs of healthcare (currently paying
$1800/month for a family of 4), it's worth certainly trying.

Is there a time frame on this experiment?

------
rsync
If you went back in time - say, 20 or 25 years ago - and you picked up a
progressive, left leaning magazine - say, adbusters or mother jones - you
would very regularly read warnings about the manufactured needs of medicine
and healthcare and pharmaceuticals.

Barely an issue of such a periodical could pass without dire warnings of a
future in which big pharma and insurance interests would convince us, through
advertising, that we were foremost consumers of "healthcare".

What happened ?

The progressive left is now fully, _fervently_ convinced that "healthcare" is
a basic priority of human life. It is a rampant consumerism that reaches far
beyond - and profoundly deeper - than the fears that good people have always
had.

It didn't have to be this way.

~~~
hackuser
Healthcare has long been seen as a basic right in many places and even the
Republican Party in the U.S. now supports health insurance for everyone.

The parent seems to conflate healthcare with pharmaceuticals and other
specific forms of healthcare. IIRC, the warnings were that big pharma was
pushing pills on people, something that has some evidence behind it. As an
analogy, I think an effective military also is essential, but that doesn't
mean I don't think big military contractors don't push needless or dangerous
products on the public.

------
abalone
_> Watsi’s goal is to improve the efficiency of funding, making universal
healthcare possible._

Universal healthcare is already possible.[1] Reducing waste is a noble goal
but this is a startling sentence from a health tech startup team. It implies
that the primary obstacle to universal care is cost, not political will, which
fails to comprehend how universal care was achieved in most of the
industrialized world.

[1]
[https://en.m.wikipedia.org/wiki/List_of_countries_with_unive...](https://en.m.wikipedia.org/wiki/List_of_countries_with_universal_health_care)

------
intrasight
>Currently, up to 40% of all healthcare funding is wasted on operational
inefficiencies

Your inefficiencies are someone else's revenue.

Or to say another way:

Healthcare is ~20% of US GDP

Reduce spending by 40% would reduce US GDP by almost 10%. That's a tough sell
politically you have to admit.

~~~
dragonwriter
> Reduce spending by 40% would reduce US GDP by almost 10%.

No, it wouldn't, because most of that would go straight back to labor and
result primarily in increased consumer spending, and secondarily in increased
consumer investment (which leads to increased business spending.)

It's not like the money not being spent on healthcare inefficiencies is going
to just vanish out of the system.

~~~
intrasight
I'm not sure. At what point does automation lead to a big drop in GDP?

~~~
dragonwriter
Never; except perhaps when the fact that it results in greater concentration
of wealth isn't mitigated and leads to destructive, violent revolution, which
cuts GDP.

But that's not really analogous to eliminating health care inefficiencies.

------
dkonofalski
I wonder what the long-term on this is going to look like. It would seem to me
like an amazing irony if the receiving nation ended up with better and cheaper
healthcare than the US considering that YC and Watsi call the US home.

~~~
maxerickson
I imagine they will discover that many efficiencies correlate with individuals
as much as with processes and then run out of funding.

------
mikekij
Founder of healthcare startup here too:

This sounds like a great project. I love the idea of building technology for
healthcare in a small, controlled, active care environment, and then scaling
those tools to a larger audience.

The bigger issue in healthcare IMHO is that the American healthcare model,
while hugely inefficient, seems to be the system that best incentivizes
innovation. We pay 10x what Sweden pays for medical devices, but the US market
is the only reason those device companies can be profitable. If we move to a
single-payer system in the US, the economic incentives for innovation go way
down.

If someone can figure out how to lower costs, while still providing a
profitable market in which drug and device companies can innovate, we'll all
benefit.

~~~
dikdik
> We pay 10x what Sweden pays for medical devices, but the US market is the
> only reason those device companies can be profitable.

Lies, lies, lies, and more lies. This is always quoted, especially in the
context of pharma. It's wrong. Americans pay for advertising (which is illegal
in most first world countries) and for the yachts and islands of the big
healthcare execs.

I work at the intersection of biotech and healthcare. Currently working on a
healthcare product that will be rolled out in the EU before the US and will be
profitable from day 1 without being "subsidized" by Americans.

~~~
mikekij
Being intimately familiar with the COGS and Average Selling Prices of more
than a few devices in various geographies, I respectfully disagree. That's not
to say you can't have a profitable EU-first product. It's just easier to be
profitable with US-first at the moment.

~~~
dikdik
Disagree with rolling out a product EU first or disagree that companies need
the American healthcare industry to become profitable?

I can't go too much into the product, but there is a solid strategy behind the
rollout.

And of course it's easier to be profitable in the US, there is a gravy train
of money in healthcare here. While great for healthcare companies, it is AWFUL
for consumers.

With respect to the initial comment I replied to, everyone (ie government
officials and business owners) claims that changing the US healthcare industry
will decimate innovation and every pharma/medical device/etc company will
utterly fail!

I've been in this industry less than a decade and have experienced this
rhetoric often whenever certain bills come up at the federal and state levels.
Everyone freaks out! And then the bill passes....and everything is fine. We
just have to innovate a little more, which is a great thing for the consumer!

------
Animats
"For the initial project, Watsi will fund primary healthcare for a community
in the developing world and build a platform to run the system transparently."

Start with Tuskegee, Alabama, poorest town in the United States.

------
buyx
The article doesn't mention which developing country the trial will be in, but
South Africa would make an interesting candidate. It has a public healthcare
system that's in shocking condition, and a world-class private healthcare
system, funded by health insurance, that's becoming more unaffordable (despite
being funded and mandated by employers) each year because of high medical
inflation. There are clear parallels to the US healthcare system, and the
commodities downturn has stymied the government efforts to introduce universal
healthcare, so there would be an ideological willingness to experiment.

------
benologist
I read the other day that here in Costa Rica the health care 'caja' has 1
employee per 85 people, it's more like working there is the plan. I can't wait
to see what Watsi does next.

------
KeepTalking
How much of the problem is actually the way (big) pharma conducts research? (
I know that I am over simplifying and dozens of startups are focused on
improving the way research is done)

From a manf process standpoint, there are cheaper ways to create these
compounds. Generic drug manufacturers have proved that ignoring the cost of
research, the drug itself costs next to nothing to make, market and sell.

From an economics standpoint, healthcare costs are a significant part of GDP.
In an ideal model if all research is funded directly via government grants and
the key research is licensed through a free licensing - It should create a
very competitive drug cost model.For a healthcare practice standpoint,
legislation can really help. Stripping down some of the malpractice laws are a
good starting point.

Additionally, the monopoly on medical education should be broken - Making
medical education a national priority is a key step. We also need to make
sure, that doctors are not the only healthcare providers. Enabling
entrepreneurship among non doctor(nurses, mid wives etc) medical practioners
can increase the market supply.

These 2 actions in theory should create more doctors and reduce the cost of
practicing medicine.

~~~
temp-dude-87844
Research is expensive because it is conducted by well-paying professionals
over multiple years, then taken to several rounds drug trials, which come with
risks of serious side effects.

Negative outcomes resulting from drug trials -- as well as approved drugs --
are routinely litigated by the aggrieved parties, which result in expensive
settlements or the risk of high damages (in some cases, punitive).

Further, to promote public interest, patent protections on medication in most
countries usually expire after 20 years, which limits the window of time in
which the makers can recoup the cost.

'Tort reform' proposes (among others) to reduce the monetary risks associated
with drug trials by limiting lawsuit payouts of limiting grounds to sue -- to
its promoters, this benefits society at large (and the drug companies) while
hurting a few individuals who happen to have found themselves embroiled in
such a case.

To its opponents, tort reform is an instrument to dismantle regulatory
protections and results in little to no societal benefit, perversely
incentivizing drugmakers to both a higher absolute quantity of drugs to drive
overall revenues, while reducing the average quality of drugs to be less safe,
and leave seriously injured people with no viable recourse. It's a complex
problem with no easy answers.

------
fuzzfactor
Universal Healthcare is when a society is actually "rich" or "wealthy" in
terms of truly having more than enough resources to perform essential care
wholesale at no cost to patients,

and after that, when society chooses to prioritize the health care of all its
citizens high enough to give equal care to all.

This doesn't usually happen, even in societies where the consistent waste of
resources exceeds the total cost of universal healthcare.

Considering the resource shortage or surplus, when healing treatments are not
denied to any needy members of society, that could be a fundamental marker of
civilization, and an obvious measure of which societies are more advanced and
which are more retarded.

------
Kluny
I was thinking about this lately. Can universal health care be solved by the
free market, if the free market decides to enforce checks and balances on
itself?

That is to say, could someone start a not-for-profit health insurance company
that offers excellent coverage for affordable rates, and build it from the
ground up with a culture of clarity and transparency? At a bare minimum they
should have a searchable database where you can type in "broken arm" and find
out what price this company has negotiated for casts, x-rays, and doctor time,
and what it will cost you in co-pay.

It seems like insurance companies are so universally bad and corrupt that
there would be no trouble signing up a critical mass of users by simply being
a _little_ better than the norm, and once it's the biggest insurance provider
in the US, start applying muscle to hospital administration.

Yes, I know I'm oversimplifying it. Can anyone think of a way that it might be
possible, though?

~~~
sean_appleby
I'm not at all an expert, but from my limited perspective this looks like a
problem that blockchain could potentially help with in the future.

It seems like someone could implement an open source system of smart contracts
that automatically pay out healthcare costs and distribute expenses in a
transparent and agreed upon way. The organization could have an extremely
decreased overhead compared to a physical company because it would need almost
no staff or infrastructure, and if everyone can see the source for how money
moves as well as the distributed ledger for how spending works it would be
highly corruption resistant while still allowing for security of doctor-
patient confidentiality due to the encrypted nature of blockchain.

Of course it would by default being extremely susceptible to external abuse,
would have a ton of complexities in interfacing with the healthcare system,
and wouldn't be viable until/unless blockchain and related tech matures and
gains mass market acceptance.

I could be totally wrong about the approach, but I'm really hopeful for the
tech world to be able to make a dent in this mess. Hopefully some people with
more experience have better ideas.

------
kriro
Good choice for YC research investment.

I hope they don't try to reinvent the wheel in some areas (sounds like it from
the post). It would probably be a good idea to benchmark how hard it is to set
up a functioning and operational GNU Health system in community X for example.

There's a lot of potential for replacing nothing/no doctors with machine
learning, especially in developing countries. Especially in areas where mobile
phones are spread I can think of a couple of use cases. Take a picture of your
swelling/strange looking skin/whatever and have a classifier tell you what it
could be. Last time I checked the algorithms actually beat expert panels (for
skin cancer). Could probably be coupled with a "doctor as a service" system
that optimizes routes based on this sort of data.

The more I think about it the more I should catapult working in this area up
my job application list :)

------
dominotw
Why can't we import more doctors like UK and other countries in EU. Isn't that
a low hanging fruit?

~~~
nickff
Because scarcity raises doctor salaries, and healthcare professionals are very
good at organizing and negotiating. HN always gets riled about how H1B visas
may lower wages, but doctors actively prevent foreigners from being allowed to
practice medicine in their jurisdiction.

~~~
chimeracoder
> healthcare professionals are very good at organizing and negotiating

Hardly - if that were the case, we wouldn't see so many private practices (and
even hospitals) going straight out of business.

> but doctors actively prevent foreigners from being allowed to practice
> medicine in their jurisdiction.

This isn't really true either - it's true that there are restrictions around
practicing (e.g.) in the US without completing a residency here. But contrary
to popular belief, that restriction isn't within the control of physicians or
any representative body of physicians. And physicians are generally rather
apathetic about the topic - they don't like the idea any more than HN likes
the idea of foreign developers working in the US, but physicians themselves
aren't inclined to take much action on the topic.

~~~
nickff
Doctors without borders disagrees with your assessment in the USA.[1]

[1]
[https://www.theatlantic.com/health/archive/2014/11/doctors-w...](https://www.theatlantic.com/health/archive/2014/11/doctors-
with-borders-how-the-us-shuts-out-foreign-physicians/382723/)

~~~
chimeracoder
> Doctors without borders disagrees with your assessment in the USA.

Not really - I didn't say that the barriers don't exist. I said that doctors
aren't the ones responsible for them.

Requiring one year of residency in the US is not an unreasonable requirement,
for a number of reasons. But the bottleneck in the number of residency slots
is the funding for them (which is subsidized by Medicare), and doctors aren't
even responsible for this requirement anyway.

The AMA, by the way, is _not_ a representative body of doctors - only 25% of
doctors actually belong to the AMA.

~~~
nickff
Saying that doctors are not responsible for restrictions on physician training
and certification is like saying that banks are not responsible for credit
card and payment processing restrictions and regulations. The government is
enacting and enforcing the restrictions, but the doctors are campaigning for
them (under many different justifications and tactics).

The AMA is like many other trade organizations, in that it often acts as one
of many lobbyists for industry interests.

~~~
chimeracoder
> but the doctors are campaigning for them (under many different
> justifications and tactics).

My point is that they're _not_ campaigning for them. Either directly or
indirectly.

> The AMA is like many other trade organizations, in that it often acts as one
> of many lobbyists for industry interests.

The AMA is not really a trade organization, because (a) only a small minority
of doctors actually belong to it[0], and (b) they don't really consistently
advocate for physicians' interests.

Even the very article you link doesn't really implicate the AMA at the source
(or even the enabler) of these restrictions:

> Even if the AMA were to magically produce a few thousand more residency
> slots, it would barely make a dent in 91,500 projected doctor shortage.

[0] and most that _are_ members of the AMA aren't members because they want to
receive any representation from them, but because AMA membership is required
to gain access to the paperwork required for certain types of billing (AMA
holds the copyright on the paperwork).

------
bawana
hospitals are BIG business. They will never let their inefficiencies be
addressed by an external force. They do not even share their price lists. Can
you imagine going going into best buy and not knowing what anything costs? But
having to get the price by researching it on the net?

------
X86BSD
I love this, its like Kiva but for third world healthcare procedures, just
fantastic.

They need to make browsing for potential patients easier. After 22 pages of
"View more patients" my browser starts to bog down.

A search would be good. As well as a map to select a country to view those in
need.

IMO.

But really great startup!

------
WalterBright
> up to 40% of all healthcare funding is wasted on operational inefficiencies,
> fraud, and ineffective care.

Any system where the consumers, the providers, and the payers are not
accountable to each other is never going to operate efficiently.

------
egonschiele
I love this idea, and this seems like the right way to do it. Operational
inefficiencies are a huge burden and it would be great to find a solution for
it. I really like the idea of starting this in a small community and scaling
up.

------
maceo
US spends over $8,000 per capita on healthcare, compared to about $4,000 in UK
and Japan, both of which have universal health care.

This isn't a problem tech can solve. It's a problem only politics can solve.

------
20years
I would love to see more transparency in where the costs for dr visits is
going. A recent 1/2 hour visit to my daughters doctor for a basic checkup and
a couple of shots resulted in a $1500 bill to the insurance company. We paid a
fraction of that but it still blows my mind that the bill was so high. I am
assuming most of that was for the shots. If watsi can develop software that
makes these costs more transparent maybe then we can address ways to lower
them.

------
mtrn
Glad to live in a country that has something close to universal health care.
Everybody _needs to_ contribute a monthly share (independent of their
condition) which amounts to over 200B per year in total. This seems enough for
modern infrastructure, equipment, prophylaxis, medication.

That said, it's not super efficient and the incomes vary greatly between
employees with strong lobby groups and laborers covered by legislation only.

------
narrator
The prices in the U.S system are wildly divergent from the rest of the world
and enhancing international competition is a good way to remedy this. Thus,
one way to implement universal health care is to allow import of any
prescribed drug and the government will pay for any medical procedure + plane
ticket if that cost is less than it is in the U.S. Perhaps a doctor visa would
also help with costs.

~~~
dandare
doctor visa is a terrible idea, a) it would undermine the salaries of US
doctors, b) it would drain doctors from poor countries where they are needed
more than in the US.

~~~
devwastaken
IIRC, doctors already work on visas, and I don't think you would be 'pulling'
doctors from other countries, not unless you're really good, which at that
point you're only staying in your home country because you want to, not
because you need to.

------
a3n
> Once the platform is in place, Watsi will start to experiment with improving
> the quality of care and reducing the cost – e.g., by streamlining
> operations, minimizing waste and fraud, and identifying medical errors in
> real-time.

That sounds like any politician ever, campaigning for office by promising to
do the above, for government in general, the Defense or Energy or Education
department, etc.

Good luck, and I sincerely hope it works. This time.

------
joshuaheard
I think the problem with our health care system is economic and political, not
technological; unless you are talking about some new revolutionary technology
like this:
[https://www.sciencedaily.com/releases/2017/02/170207092724.h...](https://www.sciencedaily.com/releases/2017/02/170207092724.htm)

------
jclos
Pardon my cynicism, but I don't like the idea of choosing a patient you're
going to "spend your money on" as a replacement for a basic universal
healthcare. Healthcare shouldn't be a popularity contest. As an addition to a
normal "basic" healthcare it's fine, but please don't replace existing systems
with this stuff.

~~~
jrowley
I urge you to read the announcement. Watsi is going into a different space
than before - integrated healthcare (including preventive action) as opposed
to their traditional funding a single patient model.

~~~
jclos
You're right, I got the bad habit of skipping blog posts and going directly to
the main website when the announcement was the actual news.

------
kumarski
I'm a patient with an auto-immune disorder. I'm going to share some of my
lessons/surprising things I learned in healthcare/drug discovery.

I did YC fellowship with a healthcare startup in the clinical trials space. I
am one of Watsi's biggest fans(zero hedge) and excited to see them go after
this.

Here's some hard things I learned over 8 months entrenched in industry,
meeting everyone from Hospital execs to drug development experts.

* The top of the funnel is screwed by food environments in the USA. Completely preventable metabolic syndrome accounts for a large percentage of clinical trials research.

* One of the unfortunate realities in the USA is that a lot of our advanced drug research is financed by metabolic syndrome related drugs. There's 8K clinical trials a year and a non-trivial percentage are from metabolic syndrome related problems.

* We have a patent system that encourages developing drugs that interact with a small number of enzymes and molecules that we already know and understand how they operate. Low, if not zero risk.

* The rules around patenting pathways, treatment methodologies, research tools, and assays are flawed/seem poorly designed. As an outsider looking in, these things seem like a paralyzing bottleneck for the industry. These need to be looked at much closer.

* GPO Squeezing. The manner in which GPOs squeeze medical device companies to create an artificial monopoly and drive prices up has to be examined in a much closer way.

* Ground game & Synthetic chemistry- The reason startups in the pharma space get acquired based on my dicussions with R&D folks at multiple Fortune 500 pharma companies is two fold. 1/ The drug companies have enough sales reps to push product fast. There's massive room for some sort of disruption here to allow small scale medical device and pharma startups to push product. 2/ This one's tough, but the large pharma companies have enough money to do all the synthetic chemistry to go from lab to scale. That's changing though. What used to be a $400M requirement has shifted to a $100M requirement, but we'll see how this evolves. It's a lot different from software. The know-how is extremely well hidden behind private walls.

* Aggregated healthcare and genomic data has little value. There's 68,000 genetic marker tests on the market and 8-10 new ones come out each day. Knowing what they do and/or how they create proteins that block/assist efforts is a monstrously tough problem that isn't waiting for computation, but is waiting for actual experiments on humans.

* The mathematical complexity of drug discovery is hard. Even if the data is maximized, the throughput of discovery is low. We have 7Bn people, 15K diseases, and 3Bn genetic base pairs. Bonferonni Corrections and Family wise error rate abound. We're not waiting for super computers or for an ease of aggregating data.

* The tricky part of selling to hospitals is that you have to create ROI within 6 months.

If anyone here is building a healthcare venture or drug discovery venture and
believes I can help, don't hesitate to reach out.

Godspeed.

~~~
kumarski
I'm wrong on a few elements of this.
[https://twitter.com/datarade/status/829181877915234304](https://twitter.com/datarade/status/829181877915234304)

So much for vetting out naivete.

------
alkonaut
Would there be legal issues (apart from political will) with forming a
publicly owned health insurance company for the general public in the US,
rather than a subset like Medicare etc?

It seems that if you just form a large enough public insurer it could soon
start undercutting the prices of the private insures.

------
jankotek
In Central Europe triple bypass hearth surgery costs ~ $6000. Until you fix
the cost, there is no help.

------
tabeth
Great news. Once it gets going I'd be interested in seeing the strategy to
make it sustainable. I believe donation models are inherently _unsustainable_
so it'll be a challenge.

------
dpflan
Cool and interesting. I'm not very familiar with Watsi, but is its innovation
mainly in business processes for healthcare non-profits - mainly improving
information and resources flows?

~~~
toomuchtodo
[https://watsi.org/about](https://watsi.org/about)

They accept donations to fund healthcare for people in the third world, while
being radically transparent (there is a Google Docs link out there with the
details for every procedure they've funded).

They're also exceedingly good at weeding out fraud, and are transparent about
that as well (when fraud has occurred, the resolution, and how they fix the
problem moving forward).

They are, quite frankly, how you would build a single payer healthcare system
as a startup.

~~~
dpflan
Thanks for the information! Your concluding sentence is really interesting.

------
mkaziz
I really wish Congressmen didn't have federal healthcare, and they had to use
the same insurance us plebeians use. That would help them fix up the system
real fast.

~~~
dragonwriter
> I really wish Congressmen didn't have federal healthcare, and they had to
> use the same insurance us plebeians use.

They do; through 2014, like other federal employees (and most employees of
large businesses) they had a choice of the private plans contracted by their
employer. Since 2015, they've been limited to ACA exchange plans.

[http://www.factcheck.org/2009/08/health-care-for-members-
of-...](http://www.factcheck.org/2009/08/health-care-for-members-of-congress/)

~~~
mkaziz
Ah I didn't know that. Super cool, thanks for sharing

------
dandare
TIL: US healthcare is completely nuts

------
Jyefet
Invest in value-based healthcare - it's the future (in like 15-20 years, that
is)

------
pebblexe
GNU health is a good starting place

------
xyzzy4
Healthcare isn't truly 'universal' until it is also applied to non-humans.

~~~
Kevin_S
Uh.... can we go over what you mean here?

~~~
xyzzy4
Animals

~~~
InitialLastName
Next time a non-human asks me where it can find a doctor, I'll take it to the
vet myself.

~~~
xyzzy4
Do infants ask?

~~~
InitialLastName
Infants usually have individuals called "guardians" who we accept as
responsible for their healthcare.

The ones that don't probably have bigger problems than access to healthcare.

------
whb07
Unless you remove people out of the equation, universal healthcare will never
work. There's no incentive for anyone to be efficient, more frugal, work
harder, provide a better service in universal healthcare. Humans arent wired
for this.

~~~
dragonwriter
> Unless you remove people out of the equation, universal healthcare will
> never work.

Every OECD nation except the US has universal healthcare; many have generally
comparable outcomes and all have lower costs (both per capita and as a share
of GDP) when compared to the US.

So, I'm not sure what your binary standard of "work/not work" is, but
universal healthcare can and often does work better than what we have in the
US.

~~~
djsumdog
America is really interesting in that it traps people in jobs via healthcare
(and other things, but health care is a big one).

I spent over a year backpacking after being out of the US for four years. I
never worried too much about health care, because the few times I needed to go
to a doctor, they'd tell me prices up front for uninsured foreigners. In one
country, even though I wasn't a resident, my work visa did give me a discount.

I've been back in the US for a year and want to go a big road trip. I have a
ton of savings, but my health care is terrible. I got a contract job with a
$19/week "minimal effective coverage" plan (preventative only; the 'legal for
less' type car insurance plan that is ACA approved).

After three months they gave me the PPO plan options which started at
$400/month. Thankfully I haven't broken an arm, but in the 12 months working
and not getting on that overpriced PPO plan, I've saved enough money even
after tax that I could probably pay for a broken arm out of pocket.

I looked at ACA plans, but they were $200+/month with $6k deductibles. By not
going that route, I've saved enough to actually pay that deductible.

When I quit my job this spring, I _might_ be able to get a real plan by saying
my yearly income was what I earned up to that point. But I don't plan on
staying in this state at all, or any state for more than 2 ~ 3 weeks after.
Since so many of these plans are tied to states/networks, what good is that
anyway?

In the US you have to work .. work work work just to have basic health care.
Either that or just be desperately poor. No other high income country requires
this. They take care of all their people.

