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Both in rich and poor countries, universal health care brings huge benefits (economist.com)
339 points by nopinsight on May 2, 2018 | hide | past | web | favorite | 523 comments



When a person gets a life threatening disease they ought not worry about whether or not their treatment will leave their family in penury. This is especially so in a nation as wealthy as the U.S. The American healthcare system is immoral and I hope it drastically changes.

Americans need to change their underlying notions of what it means to be a society. An author was once made fun of for suggesting that it takes a village to raise a child. When it comes to public funding for public goods we tend to worry about some poor person getting something they don’t deserve. The go it alone I’ve got mine, fuck you attitude is unhealthy.

Until we change our collective view in what the purpose of a government and society is things won’t change significantly. Even so called champions of progressivism in the U.S. Senate voted against allowing the importation of medicine from Canada. It seems the public interest is subordinate to private interests and often times with immoral consequences.


> It seems the public interest is subordinate to private interests and often times with immoral consequences.

This perspective of public vs private interest is rather puzzling to me -- it's more a matter of short-term vs long-term thinking. In the long-term, it's in the private interest of those having sustainable companies to have a broad base of educated and healthy workers to employ. The short-term interest of any single firm has a different calculus, but all private companies would benefit from a stronger public education and health system.

The goal of government, in my opinion, is to focus on long-term objectives: ensuring a sustainable healthy and educated population.

It's similar case for education. It's not that I'm paying for someone else's kids school so much as I'm paying so that one day, when I need a smart educated nurse to take care of me... it'll likely happen at a reasonable price because there are so many educated people who have decided to be nurses.


> In the long-term, it's in the private interest of those having sustainable companies to have a broad base of educated and healthy workers to employ.

Immigration affects this calculation significantly.

If your long game is to be an attractive destination to healthy educated immigrants, investing in the "land of opportunities" mythology has better ROI than investing in universal healthcare.


> If your long game is to be an attractive destination to healthy educated immigrants, investing in the "land of opportunities" mythology has better ROI than investing in universal healthcare.

Sure, but it's not a dichotomy either. I suspect they both have better ROI than average for government spending.

If you want to attract, say, a young PhD with a spouse and kid, the guarantee of healthcare for the family - even if they change jobs - is a huge selling point. Anecdotally at least, I've known several international students who left the US after college for Canada, France, or England and cited this as a factor. (The ridiculous artificial barriers like "go home to file this form and come back" don't help either.) And with non-open immigration, e.g. the Canadian model, there's no special economic burden to this approach.


Well, in this age, good luck finding enough "healthy, educated immigrants" who do not find the state of US healthcare system absolutely bonkers.

Maybe that's a good thing. Invite enough educated immigrants, and America will have more people saying "You know what, my country had a saner healthcare system thirty years ago when ordinary people couldn't afford air conditioners. What the hell is wrong with you America?"

(Yes, I'm speaking from my own experience.)


My problem with you isn’t that you want to fund long term interests, my problem with you is that you want to force me to fund your idea of long term interests with your preferred long term fund (i.e. whatever our moronic legislators can cook up).

It’s not about the goals, it’s about the coercion.


Isn’t this part of being a member of a society? Sometimes laws and goals of society don’t align with yours. So advocate for your goals and participate in society.

Sometimes one decides to leave the country because the misalignment of goals becomes intolerable. But there is no substitute for a properly functioning government. At least not at our current level of our collective psychology.


To frame it in a libertarian context :

I would assume that if you live on someone’s land, you would agree that their property rights mean you must pay rent, otherwise you must move.

The government is sovereign over the the land of the nation. If you live there, you must pay “rent” in the form of taxes. You aren’t respecting the property rights of the nation otherwise. You can always move.


I agree with the long term / short term dichotomy.

I believe the same dynamic is at work WRT the concentration of wealth in the US. I understand the short term desire to accumulate wealth. I do it myself. It seems to me that if trends continue, there will be less and less income for the other 99% to spend. (Yes, I'm mixing income and wealth here because I believe that the desire to increase wealth on the part of the wealthy results in downward pressure on income for the rest of us.) In my Econ 101 class they spoke of the velocity of money - how much gets spent. It seems to me that the velocity has to go down as earnings go down and at that point, the ability to accumulate wealth would start to decrease.

(These thoughts ignore the possibility that those who are not wealthy could provoke social upheaval. I don't know if that's a real possibility.)


I think it is a possibility, the wealthy are building doomsday bunkers. There is writing on the wall, they just need to outlast the uprising and then come out and buy up everything really cheap.


> The goal of government, in my opinion, is to focus on long-term objectives: ensuring a sustainable healthy and educated population.

You can't ensure health unless you have wealth in the first place. You can see that things moved in that order in the past 300 years: the more wealthy a country was, the longer people lived and the better they could face different conditions. The greatest strides against mortality were accomplished long before the welfare state as an expression ever existed.


You should read the article more carefully. Poorer countries are working under difficult constraints, but leaving $1 on the table because you don't want to spend 10 cents is not helpful. There is a line of thought poorer countries are poor because they don't invest in healthcare, education, infrastructure, ... and that the real problem is governance.


Why is the age of the expression relevant?


>This perspective of public vs private interest is rather puzzling to me -- it's more a matter of short-term vs long-term thinking.

I actually think a long-term vs short-term view is insufficient. Let's step away from firms and take the case of the rich and the poor individual. For the poor individual it is in their interest in the short and long-term interest to have universal healthcare. For the rich individual, it is in their short and long-term interest to prevent universal healthcare. According to the investment theory of party competition [1] this rich vs poor divide becomes reflected in our politics as both parties vie for the donations of the wealthy.

[1] https://en.wikipedia.org/wiki/Investment_theory_of_party_com...


> For the rich individual, it is in their short and long-term interest to prevent universal healthcare.

Not necessarily, although it does depend on the definition of "long-term":

* Reducing ER visits for preventable issues lowers hospital costs

* Higher demand for supplies should lower costs

* A larger market creates stronger incentives to research and address rarer diseases

* Eliminating individual medical debt reduces crime rates, increases education/competition


There's a simple thought experiment that helps:

- an american citizen break his leg, he is not insured. Do you A: let him die B: take care of him ?

if your answer is A - you are a terrible person, but you hold a consistent position. if your answer is B - the only question that remains is what is the most economic, efficient way to take care of this person ?

b is universal health care. if you think you can do A with emergency care, consider how inefficient and expensive this is, and who ends up paying for it.


Unfortunately this simplistic model plays out like insurance doesn't exist.

Any tragedy works like this: a fire, a life lost to chance, etc. The point of insurace is to pay beforehand to reserve a fund and to distribute the chances in a pool.

One more argument: normally its spoken as is government is the solution to this problem, but the government does not prevent the legs from breaking in this analogy. It just decides B for you and everyone else.


That person will not be denied care. It will cost a lot, but nobody is in any danger of dying in this situation.


What if they're not an American citizen? What if they're also in a different country?


I'm a Belgian national, living in France (under the French health care regime). If I need medical assistance while I'm in in Spain or Germany, the care will be reimbursed per the local rules, by the French health care system.

Quoting Wikipedia:

The European Health Insurance Card (or EHIC) is issued free of charge and allows anyone who is insured by or covered by a statutory social security scheme of the EEA countries and Switzerland to receive medical treatment in another member state free or at a reduced cost, if that treatment becomes necessary during their visit (for example, due to illness or an accident), or if they have a chronic pre-existing condition which requires care such as kidney dialysis. The term of validity of the card varies according to the issuing country.

The intention of the scheme is to allow people to continue their stay in a country without having to return home for medical care; as such, it does not cover people who have visited a country for the purpose of obtaining medical care, nor does it cover care, such as many types of dental treatment, which can be delayed until the individual returns to his or her home country. The costs not covered by self-liability fees are paid by the issuing country, which is usually the country of residence but may also be the country where one receives the most pension from.[1]

It only covers healthcare which is normally covered by a statutory health care system in the visited country, so it does not render travel insurance obsolete.

https://en.wikipedia.org/wiki/European_Health_Insurance_Card


My position is to take care of that person, like weve been taken care of visiting while other countries, but trying to avoid the illegal/undocumented immigrant strawman for clarity.


Okay, but what about people in other countries? Why don't we have an obligation to help them, to?


I would say yes. I've read where the UK does this as do other countries. Of course, any mass migration for free health care would bankrupt us, so we would need some sort of protection against that.


We do, if we can. We are not obligated to try impossible things, like caring for everyone in the world.


That's a different question which is outside of the scope of healthcare in the US IMO.


So let's talk about healthcare in the US. Don't Britons have a moral obligation to get taxed and that money get sent to the US to pay for the US healthcare system?


The underlying reasoning for universal healthcare is based on a principle, does this principle end at the US border, which I'm told is just some arbitrary, meaningless line right?

If it's not clear, my tongue is firmly in my cheek as I say that, but where it isn't in my cheek is when I'm telling you some people don't just buy your simple pro-universal-healthcare argument wholesale, especially when you refuse to defend it against valid questions like this.


I live in the US and I pay taxes in the US, so yes - healthcare for US citizens/residents paid for by US/citizens residents ends at the borders. If there is a better, more efficient system that is morally right (i.e. provides basic healthcare for it's citizens) than universal healthcare I would like someone to propose it ?


Why is it morally right for me to contribute to healthcare for someone who lives in America but doesn't pay taxes, but not morally right to pay for someone who lives in a different country and doesn't pay taxes?


That's a nice saccade you've made from "you are a terrible person" to "healthcare ... ends at the borders."

Universal healthcare would be great if it was cheap and covered everything.


It might be a little hard for you to understand - but on the other side of the USA is... another country ! And they are free to do whatever they want, which in the case of developed countries is universal health care !


Ah, the confidence of a young liberal, it fills the heart with hope !

I'll offer some advice, although I doubt you think you have much more to learn in life. If you're walking around looking for donations or support towards a cause, perhaps mocking those who may not share the identical philosophical beliefs as you isn't the optimum approach.


Care for them under the universal system, but bill the cost of the universal system directly.


My mom got injured while hiking in a country with universal care. She hobbled to the next town, found a clinic, and got treated. Then she wanted to pay. First, the person at the clinic said: "What do you mean, you don't pay for health care." My mom explained that she was from another country. It turned out they didn't even have the means to take her money.

Treating a few foreigners for free might actually be cheaper than setting up a billing system.


Evidently she was not hiking in Canada, where they definitely will treat you and then make sure you the tourist does pay the sizeable (though not USA exorbitant) bill. The Canadian system in fact does have many payers; federal, provincial, private insurers, are all payers.


I'm a Canadian, but accidentally let my health card lapse right around the same time I had a fall that tweaked my wrist. At the clinic I went to, they explained that I would have to pay cash for the visit and to keep the receipt because it would be reimbursed by the provincial ministry of health once I got my card renewed.

Had a visit with a GP, he sent me next door for Digital X-Rays, and then I went back to to the GP where he looked at them and sent me home with a brace (no break).

GP visits: $25 X-Rays: $25 Brace: $15

I don't think I ever ended up submitting the receipts to SaskHealth... Just wasn't that big of a concern :)


I'm a Canadian, living in America and therefore not a benefactor of Canada's healthcare system, even if I'm visiting Canada. On a trip to Canada a near car accident caused abdominal pain for my pregnant wife and a subsequent trip to urgent care to confirm if everything was OK. The bill was $600.


Most UHC countries have reciprocal deals where a citizen of one has all the same rights as a citizen of the other when travelling. Its just a lot cheaper than having to ship people around or delay treatment or all the paperwork.

The US has no such deals because it does not have a UHC system to deal with. However, most UHC systems that do not charge aren't going to pay out for setting up a billing infrastructure for the occasional American. The ones with co-pays etc already have a billing structure in place, and may charge you. Or not, it would be pretty mortifying to have to charge someone for health care.


For small stuff almost certainly, but if you get medical "tourists" explicitly travelling for say cancer treatment?


If you are a legal resident, you are covered. If you are a visitor it depends on what deal your national UHC system has with the nation you are visitng. Normally there would be little reason to go to a foreign country for treatment.


Keep treatment free only for accidental injuries or harm caused by third parties.

If a country has cheap treatment though, they could earn a lot through medical tourism.


What about organ donation, can foreigners get on the donor list?


What if they aren't? Are there criteria that can be met that make the decision to leave someone injured on the side of the road morally sound?


We aren't on the side of any roads here.


Fine. Sidewalk, in the middle of a restaurant, in your livingroom, at the airport. Pick a location and then feel free to explain what selection criteria make ignoring the injuries of another moral.


Okay. I pick any of the injuries of others that you're ignoring right now.


I am not currently actively or passively ignoring anyone's injuries. I'm a trained first responder, registered organ donor, and actively lobby my local, state, and federal government for universal healthcare and robust international humanitarian aid. It is instructive to note that two attempts to shift goalposts and distract with trivia have been made while nobody seems willing to take a crack at what is a very simple question.


You haven't helped care for my injuries. Lobbying for international (paid for by others) is like calling a taxi when you've got an injured man by the road and telling the cabdriver to deal with it.


You intentionally confuse turning a blind eye with limited ability to render aid, further attempting to obfuscate the central question. Again I am not that easily distracted. Last time, for the cheap seats, what criteria make ignoring others' injuries a moral choice?


The most economically efficient way to pay for B is to allow the free market to drive the cost of care so low that the person is either able to pay for it, or the cost through charity is trivial. This has the double benefit of not attempting to rectify one moral wrong (person does not receive care) by committing another (violent coercion by the state).


   The most economically efficient way to pay for B is to allow the free market to drive the cost of care so low that...
Talking about free market efficiencies is a bit like talking about the effect of Newtonian forces on a spherical cow. Very useful to learn from in an undergrad setting but rarely sufficient to capture real world systems.

What you actually want from policy is something like a trajectory toward the best expected result in existing markets over reasonable times. This is much more practical than a provably optimal result in an oversimplified model. Models can be very useful, but the map is not the territory.


>What you actually want from policy is something like a trajectory toward the best expected result in existing markets over reasonable times.

What I don't want from policy is you* deciding for me what results should be aimed for and then forcing me to maximize your personal pet project. If you have good arguments that something should be funded, you don't need to force me to do it.

*: The you here is proverbial. Feel free to insert Donald Trump as an example of the type of person who would have a say in my healthcare options.


I suspect this comment is largely mistargeted, policy is in no way equivalent to force, though some policies may engage it.

Unless you are arguing for a fairly pure form of anarchism (good luck with that, if so) you have policy work and the desire to improve it. It is a reasonable expectation that doing so empirically will vastly outperform doing so ideologically in any scenario like healthcare reform.


The point of this report is that the empirical evidence contradicts your hypothesis. These sorts of broad-strokes, ultra-rationalist arguments should be set aside whenever data is available.


Data is available on rapid price inflation that coincides with central planning initiatives in the US. Data also exists showing the systemic risks to nations created by these systems, such as the looming global demographic crisis created by the combination of social welfare systems and the baby boom.


We aren't talking about those abstract ideas, we are talking about health care and it's associated access and cost. As such, the data shows us the United States fares worse than similar countries on the measures of access and cost (both to the individual and the state)[1]. The United States also has the most "free market-like" system of comparable countries. How can it be that costs are so high and outcomes are no better if we are closer to a free market than others?

[1] https://thumbor.forbes.com/thumbor/960x0/https%3A%2F%2Fblogs...


Causes of price inflation and the looming demographic crisis are not "abstract ideas."

For literally decades the US did not open a single medical school due to lobbying from the medical industry. Even though we've tried to reverse the trend since the 90s, there are still fewer medical schools today than there were 100 years ago. When the government decides how many doctors there will be, it may get the number right or it may get the number wrong. But that's nothing akin to "free market-like." And it's a major part of the explanation why US doctors make 2x+ what their counterparts in countries like Germany make.

During the New Deal era regulations wage caps were put on workers in the hopes of staving off inflation. Employers, wanting to entice good employees to work for them sought to get around these wage caps by offering health insurance. This then spread like wildfire, coincides with the time healthcare inflation separated from general inflation, and began the trend towards a lack of price transparency.

Most of the differences in outcomes between us and other wealthy nations amount to lifestyle/culture much more-so than affordability and availability. Americans are very obese. Not having to pay a copay to visit the doctor is not going to change that. But obesity means we'll have more problems with newborns, lower life expectancy, etc.


Start with the data!

> there are still fewer medical schools today than there were 100 years ago... it may get the number right or it may get the number wrong... And it's a major part of the explanation why US doctors make 2x+ what their counterparts in countries like Germany make.

http://www.nationmaster.com/country-info/stats/Health/Physic...

> Most of the differences in outcomes between us and other wealthy nations amount to lifestyle/culture much more-so than affordability and availability. Americans are very obese. Not having to pay a copay to visit the doctor is not going to change that. But obesity means we'll have more problems with newborns, lower life expectancy, etc.

https://obesity.procon.org/view.resource.php?resourceID=0043...

> During the New Deal era regulations wage caps were put on workers in the hopes of staving off inflation. Employers, wanting to entice good employees to work for them sought to get around these wage caps by offering health insurance. This then spread like wildfire, coincides with the time healthcare inflation separated from general inflation, and began the trend towards a lack of price transparency.

Except, of course, in the countries where it didn't spread like wildfire. Why all this crazy post-hoc history-building when you can just... empirically observe how the natural experiment played out?

Your modus operandi in this thread is the start with an ideology and then derive conclusions that are often wholly inconsistent with observed reality. There's nothing wrong with premises or theory-building, but when the data flatly contradict your conclusions... well, that's the difference between reality and fantasy.


>http://www.nationmaster.com/country-info/stats/Health/Physic....

By your link we're 52nd in doctors per capita. That's not great. Plus I'd already noted that we've made a concerted effort to undo the damage since the 90s. Are you suggesting that supply and demand has no impact whatsoever on the wages doctors are capable of demanding? Do you believe that artificially restricting the supply for decades has had no impact on wages whatsoever?

>https://obesity.procon.org/view.resource.php?resourceID=0043....

https://medicalxpress.com/news/2018-01-mortality-obesity-sta...

But obesity is not the only issue, general issues related to poverty are:

https://www.newyorker.com/tech/elements/why-america-is-losin...

Higher adolescent pregnancy rates, higher rates of HIV, etc.

=== Most experts estimate that modern medical care delivered to individual patients—such as physician and hospital treatments covered by health insurance—has only been responsible for between ten and twenty-five percent of the improvements in life expectancy over the last century. The rest has come from changes in the social determinants of health, particularly in early childhood.===

So best case scenario access and affordability to healthcare accounts for about 25% of improvements in life expectancy. Except the majority of people already have access to healthcare in the US. It's not as available and affordable as we'd like, and we're talking about how best to improve availability and affordability, but it's a tiny fraction of the problem of why US health outcomes are so bad.


It's clear you still don't understand my critique.

> By your link we're 52nd in doctors per capita. That's not great.

I think this sort of argument is innumerate. Statistical sciences provide us with many ways of testing the correlation between "value of care per dollar spent" and "average doctor salary".

None-the-less, I am tempted to point out that Cuba is #2 on this metric ;-)

Regarding the rest of your post, consider actually reading that New Yorker piece. The things you think it says, it DEFINITELY does actually not say.


== And it's a major part of the explanation why US doctors make 2x+ what their counterparts in countries like Germany make.==

That is a nice thought, fortunately NPR has done the actual reporting on this. It seems like the answer is government interference [1]:

"But the biggest reason German health costs are so much lower, experts say, is that doctors are paid less. This largely reflects Germany's concerted efforts to keep costs down over the past two decades."

On administrative costs it seems like government mandates on benefits and payment rates keep those costs 50% lower. Also, they have an employer-based system:

"On top of that, administrative costs are almost 50 percent lower. That's not because the German health system is simple and streamlined. With its employer-based system, multiple insurers and ever-changing rules, German health care is as complicated in many ways as the U.S. system. But administration is much simpler because nearly everybody gets the same benefits, payment rates are uniform and virtually everybody is covered."

==Most of the differences in outcomes between us and other wealthy nations amount to lifestyle/culture much more-so than affordability and availability.==

You have provided no evidence to back up this claim. What makes you so certain that it's true?

==Not having to pay a copay to visit the doctor is not going to change that.==

Might this encourage more people to visit health providers more frequently? This might lead to earlier detection/treatment and lower long-term costs. Why have you dismissed this potential outcome?

[1] https://www.npr.org/templates/story/story.php?storyId=919310...


>"But the biggest reason German health costs are so much lower, experts say, is that doctors are paid less. This largely reflects Germany's concerted efforts to keep costs down over the past two decades."

Yes, this supports my statement. I said the medical lobby has artificially constricted the supply of doctors. Limited supply means higher wages. I'm not familiar with the German system, they may have done other things such as price fixing to keep wages lower. Personally, I'd prefer having "too many" doctors. This would give me more personal choice to choose the one I like the most while simultaneously keeping prices reasonable.

>You have provided no evidence to back up this claim. What makes you so certain that it's true?

Here's the first article that came up when I googled the subject. https://www.newyorker.com/tech/elements/why-america-is-losin.... It talks about issues of poverty, adolescent pregnancy, etc.

===Most experts estimate that modern medical care delivered to individual patients—such as physician and hospital treatments covered by health insurance—has only been responsible for between ten and twenty-five percent of the improvements in life expectancy over the last century. The rest has come from changes in the social determinants of health, particularly in early childhood.====

>Why have you dismissed this potential outcome?

As noted above the majority of improved health outcomes are not the result of access to healthcare at all. Let's be generous and use the highest percentage in the stat provided above: 25%. So now we're only at 25% of healthcare gains at all, and the fraction of that that isn't actually affordable either by the individual themselves, through their insurance coverage, or provided by charity. We're talking a really tiny fraction of gains here.


== I said the medical lobby has artificially constricted the supply of doctors.==

In the free market, money equals influence. As long as AMA determines who is/isn't a doctor, they have an incentive to make it as hard as possible to become a doctor.

==The rest has come from changes in the social determinants of health, particularly in early childhood.==

Now you have to prove that free and easily accessible access to health care won't have a positive impact on the social determinants of health. It stands to reason that part of America's reluctance to visit doctors is rooted in the historical costs associated with visiting doctors. If we can remove that stigma through cheaper and more accessible care, it stands to reason that we can improve the social determinants of health over the long term.

Here's an example: In Canada, one can visit a dietician as part of their health insurance, this could have a positive impact on obesity, which would lead to healthier population.


> Here's the first article that came up when I googled the subject... [cites article laying down the case for increased social welfare funding, which doesn't even justify the stated claim]

Oy... talk about (not quite) winning a battle but losing the war.

Also, this whole methodology toward argumentation just reinforces the top-level critique. The important word in "start with the data" is not "data", it's "START". I.e., begin by understanding the problem. Then solve the problem. Don't walk around with a hammer trying to bash things.


Taxation is not violent coercion by the state and it is disingenuous to describe the former as the latter.


I would argue it is coercive, but so is the property system underpinning the market in the first place. Adding a redistribution element to a system of private property doesn't introduce violent coercion, it merely changes how it is being used to allocate resources.


As Adam Smith wrote: "Civil government, in so far as it is instituted for the security of property, is in reality instituted for the defense of the rich against the poor, or of those who have some property against those who have none at all."


That quote doesn't mean what you think it means. Taken in context, that quote is talking about the origins of civil government and how it is often corrupted as stated in that quote. It is used as an argument for why there must be a separation of powers to ensure fair judgement and protect the property rights of both the poor and the wealthy.


https://www.health-tourism.com/medical-tourism/usa-research/

The ultimate market victory - completely avoiding the destroyed free market healthcare system and travel abroad to parasite on universal healthcare.


I assume you are also pushing for multiple roads between 2 towns, all competing on toll price.


The competition is before the road is built..


Regarding "violent coersion of the state", by this, I assume you mean.. taxes.

At this point in the world's history, we are not individuals who can wander off into the wilderness on our own, to live and die as God might have intended. We are members of a vast, global social fabric. We benefit from it. We pay into it. There's no way to avoid the coersion/evils or really deny the benefits/goods that this society provides. We can only discuss things relatively speaking, on a whole, in balance.

I think a productive use of our time is thinking about (and experimenting with) how information technology could better support our emerging social fabric so that we could make the best collective decisions: that is, enable even more personal freedom.


Law is violent coercion. This isn’t libertarian philosophy class, it’s the real world.

In many places in the real world, universal government insurance is already in place. This isn’t some hypothetical.


The fact that some people or nations behave in a particular way does not in any way determine whether that behavior is moral.


States in and of themselves aren’t moral under your framework because they can only exist by threat and use of force.

But some of us are interested in solutions for the real world instead of the debating the merits of unfeasible utopias.

I, too, would enjoy a stateless peaceful utopia of equitable commerce, but that has zero bearing on how we should decide public policy. Foraging for utopias is the same kind of naïveté Marxists trot out again and again and were it ever enacted at scale it would lead to the same kind of human suffering.


[flagged]


Fair enough. What is that minimum?

The proposed minimum is always to grant the needed power to cover unlimited property rights, but not universal healthcare.


It would be difficult to impossible for me to try to think of every feasible scenario in a HN post, but here's some off the top of my head: national defense, stopping people from physically harming others, enforce voting rights, establish trade agreements with other nations, etc.


No, but the fact that it results in demonstrably better outcomes in pretty much every case does.


I don't see how you can define the state taking money from the wealthy to buy healthcare for the poor as violently coercive but not also define a corporation withholding necessary care from a poor person as violently coercive.


Doing nothing is not violent or coercive. It may be morally wrong for a person to do nothing, but it's not violent or coercive.


If you are able to help them, and you refuse to do so unless they do something for you (i.e. labour to earn money to pay your fees) then it is absolutely coercive.


By that measure any salary a doctor demands, whether it's paid for by the patient or the state, is coercive. Or for that matter, any salary any person demands in exchange for work is coercive. I feel like it ceases to have a useful meaning when used in this way.


It's only coercive when we're talking about the means to survive. If you offer someone a choice between death or some action, you are coercing them to act.

And I don't think that "ceases to have a useful meaning". I think it just doesn't let you argue that your system is better based on absence of "coercion".


I don't believe for a second that you understand the word "coerce" to be limited only to situations of life and death.

Do you or do you not believe that doctors in the UK are coercing the government by demanding a fair salary in exchange for the lifesaving services they provide?


>I don't believe for a second that you understand the word "coerce" to be limited only to situations of life and death.

I don't think it's necessarily limited to that, but I do think all such situations are coercive. Whether someone is having a gun pointed at them, or being denied healthcare, they are being coerced. That said, I do think most coercion does ultimately amount to the threat of death or suffering, even if it becomes very indirect in practice.

>Do you or do you not believe that doctors in the UK are coercing the government by demanding a fair salary in exchange for the lifesaving services they provide?

Trying to evaluate the actions of individuals in a wider system is not very helpful. Are the doctors being coercive? Yes. But they're also being coerced in turn by the individuals they rely on for survival (i.e. the people they buy food from) so it's hard to ascribe blame. It's the system as a whole which is coercive.

And this is my point. Both market based healthcare and state provided healthcare rely on coercion to function, so you can't distinguish them morally on that basis.

The only hypothetical system I know of that would actually be free of coercion would by something like anarcho-communism, where people have free access to the means of survival, and it is produced by people's free choice to work for the benefit of others. But I'd guess you think such a system wouldn't work.


>And this is my point. Both market based healthcare and state provided healthcare rely on coercion to function, so you can't distinguish them morally on that basis.

Can you honestly not see the moral distinction between me intentionally shooting you with a gun and me not applying first aid after someone else has intentionally shot you with a gun?


I disagree with the asymmetry. Withholding care isn't actually 'doing nothing' and has the ability to be violent or coercive. Take a life-saving but expensive pill. 'Doing nothing' in the case of someone who needs but can't afford the pill would be actually doing nothing - that person could waltz in, walk behind the counter, take the pill, swallow and walk out. Bada-bing bada boom, problem solved no violence or coercion. Healthcare providers don't actually do that though, someone who tried to walk in and take the pill would be met with violence in order to prevent them from accessing the pill until they had paid. That violence is coercive.

----------------

Since the mods are rate-limiting me, here's my reply to your post below:

>Otherwise every person in every situation who demands to be paid for their work, including doctors who demand to be paid by the state in a universal healthcare system are all being coercive.

I agree that this is coercion.

>When taken to that level, the word coerce ceases to have a useful meaning.

Well no, when taken to that level coerce retains it's meaning perfectly, it just happens to illustrate that the market system has coercion baked into almost every aspect. Here, this guy says it better than I can:

But there is no neutral construction of “coercion” that would ever support such a distinction. As Hale aptly demonstrates, coercion occurs when there are “background constraints on the universe of socially available choices from which an individual might ‘freely’ choose.”

In a world of scarcity, all economic rules–including rules that create private property ownership, contract laws, and so on–impose background constraints on the universe of choices individuals can make (e.g. the choice to move into a building and sleep in it without paying anyone anything). When we talk about the economy, we are not arguing about whether we want coercion. We are arguing about what coercion we’d like.

http://www.demos.org/blog/10/28/13/libertarians-are-huge-fan...


Demanding to be paid for your work is not coercive. Otherwise every person in every situation who demands to be paid for their work, including doctors who demand to be paid by the state in a universal healthcare system are all being coercive. When taken to that level, the word coerce ceases to have a useful meaning.


If you think the private healthcare system is immoral, you should take a look at the 100% government ran healthcare system that is the VA. You literally couldn't make up worse things than their administration has been caught doing with little or to consequence.

If the VA is the best the US government can do, with some of the most sympathetic citizens, then it is incapable of doing better than our private system.


> You literally couldn't make up worse things than their administration has been caught doing with little or to consequence.

I literally could. The scandals you're referring to basically come down to them having been cooking books about care records. Bad, but not exactly in the realm of "literally nothing worse" hyperbole.

In fact the VA tends to produce health care outcomes that are well within the range of US citizens in the same income bracket (which is to say, not great relative to the rest of hte industrialized world, but not bad) at a cost that is much less than that of private insurance.

Really, you could do a lot worse. The criticism of the VA tends to be very similar to the criticism of the NHS in the UK. It's valid as far as it goes, but... neither UK citizens nor US vets are suffering serious catastrophes here. They're getting care and living decent, healthy lives by any reasonable standard.

Literally.


Also the problems with the VA generally stem from the reality that US politicians "support the troops" right up until they're home and maybe not so enthusiastic about the war anymore.


The VA was a good system not too long ago, but the past couple decades has seen it get extremely underfunded in a starve the beast strategy. It used to be a black eye in the Republican's view of healthcare, but they sure fixed that.


The VA is much the same as all the other US healthcare setups. A system with the controls taken off, trying to operate in a jungle of different systems and bureaucracies.

IN most nations with a VA-style (Beveridge) setup, there is great media interest in the least failing or hint of scandal. And they mean politicians lose a lot of votes. The VA hasn't enjoyed that feedback system until recently.


> The VA was a good system not too long ago, but the past couple decades decades has seen it get extremely underfunded in a starve the beast strategy. It used to be a black eye in the Republican's view of healthcare, but they sure fixed that.

While it's tempting to blame any failure of national healthcare on Republicans, this is simply not factually accurate.

It's been at least two generations since the VA was anything resembling a good model for healthcare, and it's not simply the Republicans to blame for that, nor is it merely a problem of funding.


I mean, sure, the defunding started in the early 80s with Reagan, but we only started to see the effects of that in the past 20 years or so.

And sure, I blame the neoliberal third way Democrats as much as the Republicans. Their whole "let's move the party right and follow the Republicans" really muddies the waters here.


> I mean, sure, the defunding started in the early 80s with Reagan, but we only started to see the effects of that in the past 20 years or so.

The problems with the VA date back to the 60s, although they've accelerated in the last couple of decades.

> And sure, I blame the neoliberal third way Democrats as much as the Republicans. Their whole "let's move the party right and follow the Republicans" really muddies the waters here.

It sounds like you're rather committed to the belief that right-wing ideology is responsible for destroying otherwise-viable public healthcare models. There are plenty of other places where the data might support that belief. The VA is not one of those cases; the VA has gone from bad to worse over the last 50 years, and it's not simply a partisan problem.


First off, the VA isn't as bad as you're making it out to be.

https://www.rand.org/news/press/2016/07/18.html

"Quality of Care in VA Health System Compares Well to Other Health Settings"

A lot of the bad press around it's deficiencies are because it, as a public institution, publishes a lot of information that the private healthcare system isn't required to publish.

And yes, having been from Newt Gingrich's district, and seeing the failed 1994 HEART act, that ended up being turned into Romneycare, and then morphed into the ACA (in order to steal the Republican's thunder in 2012), yes I do blame the right wing for the current state of healthcare.


> First off, the VA isn't as bad as you're making it out to be.

From your own link, which is a press release by the firm which sponsored the research:

> Researchers say there were few studies [included in this meta-analyis] to evaluate equity, efficiency and patient-centeredness, and that the quality of the available studies vary.

Incidentally, those are three of the four main issues for which people typically criticize the VA.

In other words, that meta-analysis more or less confirms that the VA probably does well at the things people already knew it was good at doing, without looking into any of the areas where it's known to have problems.


> From your own link, which is a press release by the firm which sponsored the research:

I mean, it's the Rand Corporation. It's not like it's some fly by night 'you pay us and we'll say whatever you want' firm. The link to the real study is right there.

> Incidentally, those are three of the four main issues for which people typically criticize the VA.

That statement was for the whole study, including the private side. Once again, the VA publishes quite a bit of this information, when was the last time you saw average wait times for the private side?


> I mean, it's the Rand Corporation. It's not like it's some fly by night 'you pay us and we'll say whatever you want' firm.

...okay? The point is that the primary reference itself shows that the study isn't relevant to this conversation at all: by its own account, it doesn't attempt to investigate the issues that we're talking about. It doesn't attempt to study the issues that make the VA a bad model for healthcare (and have since the 60s).


What makes you think universal healthcare would be any different? If you recognize the VA's failings, and you blame Republicans for it, what's to stop them from doing it to every "good" idea you have?

If a few motivated politicians can ruin the lives of millions those politicians shouldn't have that power in the first place.


>What makes you think universal healthcare would be any different?

Because America isn't the entire world and there are many places where socialized healthcare of various forms have been very successfully implemented for a long time. The idea peddled by conservatives in America that the only options for socialized healthcare are inevitable failure or tyranny is simply, demonstrably nonsense.

It's exactly this kind of parochial, limited mindset that needs to change.


Oh yes. Everyone who disagrees with me has a limited mindset. You could have used your open mind to read about a European (within this comment thread) who is having trouble with "the right" in his country:

> This is a principal reason why the US was crossed off my list of countries where I would work and live. I fight against the privatization that is occurring within healthcare in my native country, Iceland. We used to have the Scandinavian model but decades of attacks from the right-wing Independence Party has broken our healthcare system. The next phase described by Chomsky is handing it over to private capital since people are outraged that it doesn't work anymore. I'm sickened by the development and feel a little like an old man screaming at the desert wind.

It's exactly your kind of Utopian mindset that needs to change. Please read the news of countries other than the US. You might be surprised at the amount of controversy that surrounds universal healthcare systems.


The controversy that surrounds universal healthcare systems goes something like this:

"I am disappointed by my treatment in the system!"

"Do you want to privatise it?"

"Absolutely not."


In the US, the first sentence holds true, it just costs a lot more.


How many people out there would honestly be willing to trade their universal healthcare system for a US style system?


Alfie Evans' parents probably would...as would some of the people waiting months to get a simple MRI.


Alfie Evans didn't have a brain anymore, and would have probably been pulled even quicker in the US system. Insurance agencies are quick to deny funding.


So because Republicans will fuck up any government in an effort to prove that government doesn't work, we shouldn't have government?


No, in the first place, you shouldn't have a significant percentage of elected officials in the government who will fuck up any government in an effort to prove that government doesn't work.

If you do have that, then it is highly unlikely that your country will be able to implement a health care system that is competitive with Canada, Japan, Netherlands, etc.

But beyond that, it's very unlikely that your country will be able to implement other fundamentals, such as uncontaminated drinking water, safe schools, etc.

In other words, if your country has three branches of government, and the party that controls the executive, legislative, and judicial branches really is willing to fuck up any government in an effort to prove that government doesn't work... then, I'm afraid you are really pretty fucked.


Ya, that about covers how I feel about it. The GOP strategy is to "starve the beast," unless the beast is military or police spending.

https://en.wikipedia.org/wiki/Starve_the_beast


That's a single argument in favor of what appears to be some call to remove power from government. The easy counter example is Medicare - we have universal healthcare already for people over the age of 65. Would you say that because the VA doesn't work great in your judgement (people are already coming up with counterexamples within that thread) that we should shut down Medicare?


I think the OP covered this when they said

> Until we change our collective view in what the purpose of a government and society is things won’t change significantly.

So yeah, if we don't change our collective view, then the republicans (or whomever) will continue to undercut these government run programs as much as possible for their broken ideology.


That's not an argument. You can literally say that about very government institution.

Governments require somewhat good will from politicians and voters to do their job. Some news.

The only reason that system fails is because voters don't care about it. There's nothing exceptionally bad about the US that would not make it so.


For a large number of different outcomes, the VA is superior to private care. It has a disproportionate footprint because "The VA does something bad!" is national news, while "SmallSizeMidwestCity Memorial does something bad!" isn't.

It's not perfect, by any means, and struggles with cost constraints (veterans are sympathetic, but sympathetic doesn't mean well supported), but many of its quality outcomes are superior.

See, for example, https://jamanetwork.com/journals/jamainternalmedicine/articl...


Your getting downvoted for this, and I have no idea why.

Have other folks actually stepped inside a VA facility? Many of them are old/outdated/underfunded it's true. But some of them truly do offer superior care to a typical private hospital (in staff, facilities, and outcomes). The VA system could use significant improvement, absolutely. But if the fear-mongering 'worst case scenario' is that everyone gets VA levels of healthcare, that's still a huge win for all of America. That's a great baseline standard to start with, that no one should ever fear falling below.

If an uninsured American is critically injured, the options today are "A: Die" or "B: Bankruptcy". Having a new option "C: Universal VA-levels of healthcare" would be a win for literally every American, even for Americans who are lucky enough to already have great private insurance and who would never need/use this option themselves.


> But some of them truly do offer superior care to a typical private hospital

Which ones? Because that has not been my experience at the hawaii facility. From my appointment time being written down on a piece of paper then they send me my actual appointment date a few months later to the doctor being an hour+ late, my personal experiences have been subpar.

Add in how doctors/nurses at multiple hospitals do comically incompetent things like reusing insulin pens/colonoscopy bags/not washing equipment, the general sense of incompetence when they lose my records every few years, or talking to my buddies who got out and ended up working at the VA and have told me that they'll never get treated there, and I do not have the same sense of "superior care" that you're talking about.

If I want hep C, I'll go to the VA. If I want medical care, I'll go anywhere else or just not go to a doctor.


"Add in how doctors/nurses at multiple hospitals do comically incompetent things like reusing insulin pens/colonoscopy bags/not washing equipment"

I work in hospital infection control research - if you think your private hospital isn't making many of those same mistakes, I have some very bad news for you...


I would think it would be safe to say that the best VA hospitals are better than the worst private hospitals. I don't think that's a stretch.


I’d love to hear from anyone who actually uses services from the VA whether they’d trade that system for the “pay or die” system the rest of us get.


My dad is a veteran and now uses the VA for everything he can now.

His first experiences weren't that great, but you could easily tell it was because they were understaffed and underfunded.

Once they got to the point where he could start seeing specialists and whatnot, everything since then was a breeze.

He had a surgery on his stomach. It wasn't life threatening, but he was in some pain. The VA was able to get him an appointment with a Dr. and schedule the surgery within a few days to a week or so.

He also needed eye surgery. This one he had to wait for his eye to get to a certain point before surgery. The VA was able to get him to see an eye Dr the same day he went in for something else. Then less than a month later he was going to go in for surgery but something came up so he had to have it rescheduled. They were able to reschedule the surgery for the following week.

I would consider this a success story. He was hesitant on getting the eye surgery because of costs that were told to him by the previous company, but the VA told him he would not be paying anything, and he didn't.


This is one of the straw men that is often brought up. There are a million reasons why the VA is messed up, most of which have NOTHING to do with healthcare.

Congress has underfunded our troops for decades, related to healthcare and not. Something as simple as body armor is often purchased with personal money. A woman that works for me is high up in the Marines and I hear stories that disgust me. I do not know how Congress gets away with this. The stories are out there, but the American people seem to not give a you know what.

Please don't conflate the problems of the VA with Universal Healthcare.


I'm curious why there are more than one public health system. There's the VA, the IHS (Indian Health Services), and of course medicare/medicaid. Why are these not all the same system? It's not like we're different species....

edit, If this is a benefits/paperwork thing, then shouldn't that be separate from the care provider network?


It's the nature of the beast, in the US, I think. I believe if there were a Universal system, all of the others would go away. That would be a good thing.


Fun fact: Those systems cost more tax money than most other developed nations spend on full UHC. Either per person or as a per cent of GDP.


I haven't heard these stories and would like to. Where can I find more?


Here's one

https://www.military.com/daily-news/2016/02/26/lacking-basic...

Do a search for "us troops buying own". You'll find lots.


> "If the VA is the best the US government can do..."

It's not the best Uncle Sam can do. It's the best it wants to do. It's the (minimal) "best" is has to do.

Sure there's plenty of verbal grandstanding - by both politicians, the public, and the private sector (e.g., NFL) - about supporting the vets and their families, but actions speak louder than words. (Verbally) supporting the vets is good branding. It's that simple. That's all it takes.

Put another way, if the US brought back the draft and the armed forces made up a wider cross-section of society (i.e. poor, rich and in between) priorities would change. Actions would speak louder than the words.


The people on TRICARE don’t seek to leave the system, do they? That’s a government run healthcare system.

Do Medicare recipients seek to leave it? That’s a government run healthcare system.

Universal healthcare can be implemented poorly but it doesn’t have to be. It can be done right. There are lots of examples of this.


>Do Medicare recipients seek to leave it?

No, because it's free, but 1/3 of Medicare recipients opt to receive their coverage through private insurers that typically add on additional coverage, an indicator that Medicare alone is not enough for a large segment of the population, or that they prefer a private insurer even with government subsidization.

https://www.kff.org/medicare/fact-sheet/medicare-advantage/


Excellent. We are in agreement that the American government can and does provide a health insurance program that covers lots of people and has the property that people don’t seek to leave it.

Perhaps the idea that everyone be covered in such a system is not so far fetched.


Why would anyone refuse free money? Are you sure you understand the parent's point? They are taking the money but using private networks, which indicates they prefer private providers.


In the absence of Medicare/Medicaid there would not be universal coverage for the elderly. The elderly do not advocate dismantling this coverage. The coverage is a government program. We are in agreement that a U.S. government program can cover lots of people and maintain the property that those people don’t want to the program to be dismantled. It’s not, then, hard to imagine everyone being covered by such a program.


I did not support the ACA but I use the healthcare exchange because it is in my best interest to do so. I get free money from others to pay for my family's health insurance. In fact, I get a 100% subsidy. But the reason I get a 100% subsidy is because I am affluent enough to live comfortably on only a small portion of my income and funnel the rest into tax-advantaged accounts that reduce my AGI to a fraction of my actual income. It would thus not be in my interest to advocate the ending of the ACA. This is the same reason the elderly (who are the wealthiest cohort) do not wish to see Medicare/Medicaid dismantled. But is this what's best for society? Everyone gaming the system to benefit at the expense of everyone else?


I feel sorry for you that you think this way. There’s a reason Medicare came into being. It simply isn’t profitable to treat people near the end of their lives. One illness, calamity is enough to wipe out a lifetime of savings and leave one penniless. The absence of a government program for providing healthcare to the elderly would be horrific and immoral. Some things ought not be profit driven. You wish to make our already horrible system into something worse.

I’m glad your view does not prevail. I would hate to live in a country in which the majority shared this opinion.


How can it both be unprofitable to treat people near the end of their lives yet also wipe out a lifetime of savings? If end of life care transfers the life savings of the elderly to the providers, that sounds quite profitable. Why shouldn't the elderly pay for these services? They have most of the money! And the dying have the least use for it whereas the young (whom you would tax for these services) have plenty of life and obligations yet to pay for. How is taxing the poor to pay for the healthcare of the rich moral?


How can it both be unprofitable to treat people near the end of their lives yet also wipe out a lifetime of savings?

It's unprofitable for an insurance company to insure someone near death and still provide a decent level of services. It's why there used to be pre-existing condition exclusions and why health insurance companies like Aetna went out of their way to try to deny claims.

Also, if the expense of coverage is greater than the amount of money a person has then it won't be profitable to treat them whilst still bankrupting the person.


I doubt that people actually doing this are concerned with the morality of it, just the profitability. It’s not moral, but it’s easy, because they’re old and dying and desperate. I don’t think there’s more to it than the usual greed and expediency.


> We are in agreement that the American government can and does provide a health insurance program that covers lots of people and has the property that people don’t seek to leave it.

People literally are leaving it, to the fullest extent that they legally can.

It's not a small number, either. About 40% of Medicare patients aren't on the government-run system at all, and that number has consistently grown over the years.


They supplement it, I don't believe they are leaving it, unless they are wealthy and can afford to pay out of pocket because they want to use a doctor that is not participating in the medicare program. Do you have a cite?


> They supplement it, I don't believe they are leaving it, unless they are wealthy and can afford to pay out of pocket because they want to use a doctor that is not participating in the medicare program. Do you have a cite?

No, this is wrong. Private Medicare plans fully replace Original Medicare. If you are on a privately-managed Medicare plan, you receive none of your benefits from Original Medicare (the government-run program).

Unfortunately, you're still subject to some of the care delivery restrictions that Medicare sets, which means people moving from privately-managed plans (without Medicare) to Medicare Advantage (privately-managed Medicare plans) will typically experience a drop in coverage, because private insurers tend to be more forgiving with these limits.

> they want to use a doctor that is not participating in the medicare program

I'm not sure what you're referring to here. Though yes, one of the big advantages of Medicare Advantage is that it's dramatically easier to find in-network providers, even for Medicare Advantage plans that don't cost anything out-of-pocket above what Original Medicare does.


> No, this is wrong. Private Medicare plans fully replace Original Medicare.

Uh, no. "Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans." [0] So although the Advantage plans are privately managed, the premiums are subsidized. I don't think this counts as "leaving" Medicare.

[0] https://www.medicare.gov/sign-up-change-plans/medicare-healt...


> Uh, no. "Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans." [0] So although the Advantage plans are privately managed, the premiums are subsidized. I don't think this counts as "leaving" Medicare.

By that logic, there's no way to leave Medicare, because you can't stop paying taxes for it or "disable" your eligibility for it (and all of the restrictions that Medicare eligibility brings for people on private insurance).

People leave Medicare to the full extent allowed by law. Unless you want to claim that people using school vouchers for private schools is a demonstration of their satisfaction with the public school system in their area, you can't view their use of Medicare Advantage as a demonstration of their satisfaction with Original Medicare either.


> people using school vouchers for private schools is [not] a demonstration of their satisfaction with the public school system in their area

It certainly doesn't indicate dissatisfaction with the fact that the money for those vouchers comes out of tax receipts! The primary education system is a single-payer system, and the use of vouchers doesn't change that.


> It certainly doesn't indicate dissatisfaction with the fact that the money for those vouchers comes out of tax receipts!

You're basically arguing a tautology: Because there's no legal way to fully opt out of the system if they dislike it, people can't leave it (by your definition), and you're then saying that, because people don't fully leave the system, that means they don't dislike it.

40% of people choose not to use Medicare, to the extent that's legally possible. The program that they choose to use instead outperforms Medicare on every key performance indicator (medical outcomes, cost, patient satisfaction), while also underperforming the same private insurers on those same indicators. It takes some real contortions to look at that data and use it as evidence in favor of a single-payer system, or even evidence that patients like Medicare, but if you're fully committed to interpreting available data in a way that supports that end goal, I guess that's all we can really say.


In both cases — Medicare Advantage and vouchers — people are accepting a government subsidy in a form that allows them more choice than the default form. You're the one trying to make some kind of point based on that. I see it as evidence of nothing more than the fact that people like to have choices. I'm not arguing that it proves that they like the system as a whole; I'm just rejecting your claim that it somehow proves that they don't. I do tend to agree that a system that allows them those choices is better than one that doesn't.

> The program that they choose to use instead outperforms Medicare on every key performance indicator (medical outcomes, cost, patient satisfaction), while also underperforming the same private insurers on those same indicators.

Cost to whom? I don't see how Medicare Advantage can cost less to patients than Medicare; nor does it seem likely that the premiums for a private plan are less than the subsidized Medicare Advantage premiums. (Re the latter, I guess you didn't see my other reply to you: https://news.ycombinator.com/item?id=16979926)


> Cost to whom? I don't see how Medicare Advantage can cost less to patients than Medicare

How do you think Medicare works? Do you think that, once you're covered by Medicare, you just show up at a doctor or hospital, flash your government-issued Medicare card, and receive free treatment for any covered services, without having to pay anything out of pocket?

(For the record, that is not how it works. Medicare is not free for patients. Premiums are neither your only nor your largest expense.)


My mother is supplementing her medicare with insurance. GAP insurance is I think what she calls it. I mean I'm sure what you are describing exists, but it's not universal.


> My mother is supplementing her medicare with insurance. GAP insurance is I think what she calls it. I mean I'm sure what you are describing exists, but it's not universal.

I am talking about Medicare Advantage. Medigap is different.

What I am talking about isn't "universal", but it's what about 40% of Medicare patients use in 2018. It's not universal because people have to choose to opt into Medicare Advantage, but it's an option for everyone: everyone[0] who's eligible for Original Medicare is eligible for Medicare Advantage.

[0] well, there are a couple of small exceptions, but I'm 100% sure your mom doesn't fall into those categories, based on what you've already said


> No, because it's free, but 1/3 of Medicare recipients opt to receive their coverage through private insurers that typically add on additional coverage

They don't simply add on coverage; they replace it. Most people on Medicare Advantage don't opt for coverage above what Medicare itself can provide - they simply receive their benefits from a private entity instead of Medicare, because Medicare provides such a bad experience for patients.


You've repeated this claim in several places so I'll just link to my rebuttal: https://news.ycombinator.com/item?id=16979565

While you may have a good argument against a "single-manager" health care system, this doesn't seem like an argument against a single-payer system. In fairness, I guess a lot of existing universal-coverage systems, such as the UK's NHS, are also single-manager (someone will correct me if I'm mistaken), but the very existence of Medicare Advantage shows an alternative possibility. I think that, far from being an argument against single-payer, it shows how single-payer can be made to work even better, through premium subsidies (and, I would guess, reinsurance for catastrophic losses) to private insurance companies, for those who are willing and able to pay additional premiums for better care.


The NHS is what is called a Beveridge style system. I think that is what you mean by single managed. Similar systems are used in Spain, the Nordics, etc. They are often managed at local levels though and may include private hospitals and treatment that gets reimbursed by the payer at the same level as public ones. The VA is an example of this type of system although other nations have far more oversight and performance control than the VA does.

A competing setup is the Bismarck style of insurance company administered management, either for-profit or non-profit. Germany, the Nederland's, Switzerland, etc runs this sort of system. Always with a lot of legislation and safeguards to ensure that people do not fall outside the system. It is similar to the US employer-provided insurance setups.

Other systems are National Insurance, as used in Canada and Japan. Similar to Medicare. Canada is fairly unique in its hostility to private provision.

And then there is out of pocket, like rural Africa does it. That's basically like being uninsured and not qualifying for Medicaid.

Thing is, the US accumulated massive bureaucracy and costs by h\trying to run every system at the same time with little attempt at standardization and lots of billing and gatekeeping. Everyone else picked one system and stuck with it, letting private providers fill in the gaps. (Except Canada for the last)


> I guess a lot of existing universal-coverage systems, such as the UK's NHS, are also single-manager (someone will correct me if I'm mistaken), but the very existence of Medicare Advantage shows an alternative possibility. I think that, far from being an argument against single-payer, it shows how single-payer can be made to work even better, through premium subsidies (and, I would guess, reinsurance for catastrophic losses) to private insurance companies, for those who are willing and able to pay additional premiums for better care.

I don't think you understand how Medicare Advantage works. There's really nothing about it that suggests a single-payer system would work. The premiums are not subsidized. (Reimbursements are, but that's a separate matter.)

Medicare is the fullest extent to which people can legally opt out of Medicare, short of claiming religious exemptions (rare), working for a foreign government while in the US (rarer and legally questionable for citizens), or surrendering US citizenship altogether (drastic). Medicare Advantage outperforms Original Medicare on the top performance indicators (medical outcomes, cost, patient satisfaction), though underperforms the same exact private insurers on those same metrics, despite the latttermost also being saddled with the burden of subsidizing Original Medicare reimbursements.

If you still want to advocate for single-payer healthcare on philosophical grounds, okay. But from an empirical standpoint, Medicare is not the place to look for data to support that stance.


I already quoted from medicare.gov [0], but I'll repeat: Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans.

How is that not a premium subsidy?

[0] https://www.medicare.gov/sign-up-change-plans/medicare-healt...


Private entities contract with Medicare to provide insurance that covers what Medicare covers (and perhaps more). Would said insurers cover everyone that Medicare covers in the absence of Medicare? The answer is no.

How many of these people on private Medicare plans pay for Medigap? Everyone who get kicked off a private plan can go back to the original Medicare. Your point is disingenuous. Medicare is the universal insurer of last resort for elderly. Their lives would be much worse without this last resort insurer.


> Medicare is the universal insurer of last resort for elderly. Their lives would be much worse without this last resort insurer

That's a far cry from "people don't seek to leave Medicare", which is literally the original claim. By and large, people do seek to leave it, to the extent that they can, both legally and financially.

Yes, for people who can't access anything better, having Medicare is better than literally nothing, but nobody's arguing that. That doesn't mean that Medicare provides a good model of what would best suit everyone else, and that's the relevant question when talking about a single-payer system.

If you want to talk about a single-payer system and use Medicare as an example in support of it, you have to address the fact that privately managed plans consistently outperform Medicare on the top three performance indicators, and that patients themselves prefer all the alternatives to Medicare except "no coverage at all".


> Do Medicare recipients seek to leave it? That’s a government run healthcare system.

Since you asked - yes, yes they do. Medicare patients can opt to receive their inpatient/outpatient benefits from a private insurer in lieu of traditional Medicare benefits, and an increasing number of people do so.

Privately managed Medicare plans, incidentally, outperform Medicare on the three key performance indicators: medical outcomes, cost, and patient satisfaction.


The point isn’t really to compare it to the current best that the US governmeny can do. With the US’s historic view on universal/“free at the point of access” health care it is hardly surprising that the VA is a mess. What you should compare it to is the best that other governments have done, in which case there are many examples of excellent universal healthcare from public insurance based all the way through to the UK’s NHS - which does an excellent job despite below inflation budget increases and endless media hyped scandals.


The VA is far from perfect and is really noticeably worse than many other country's nationalized health systems. But it's not obviously worse than private health insurance in the US and generally veterans are as happy with their health care as other people. I think the VA example tends to dispel the notion that single payer would save that much money but it works about as well as other approaches, of which the US has way too many.


> The VA is far from perfect and is really noticeably worse than many other country's nationalized health systems. But it's not obviously worse than private health insurance in the US and generally veterans are as happy with their health care as other people

If you want to convince people to support a single-payer system, this is quite possibly the worst argument you could use. Any veteran or anybody who has had any experience whatsoever with the VA will instantly assume you don't know what you're talking about.

The VA is, on the whole, atrocitous. There are a couple of regions which do relatively well, because the system is federated, but on the whole, it's almost universally considered to be a disaster, even by people who are supportive of the program's existence.

If you want to convince people that a single-payer system wouldn't end up like the VA, start by acknowledging the problems with the VA, not denying them.


> The VA is, on the whole, atrocitous. There are a couple of regions which do relatively well, because the system is federated, but on the whole, it's almost universally considered to be a disaster, even by people who are supportive of the program's existence.

Yeah, this is bullshit. The VA and its effectiveness has been studied quite a bit. Its quality has been found to generally exceed the quality of private hospitals. The media and conservatives paint this idea that the VA is "atrocious" but it has no basis in reality.

The scientific evidence for universal healthcare is overwhelming. The only "controversy" -- exactly like the "controversy" around climate change -- exists within people who have carefully decided to ignore the evidence and buy into the propaganda. The problem here is not the VA. The problem here is that many Americans have abandoned reality.


> Its quality has been found to generally exceed the quality of private hospitals. The media and conservatives paint this idea that the VA is "atrocious" but it has no basis in reality.

That's certainly one way to summarize the research around the VA, but it's a highly misleading one. It's easy to cherry-pick the metrics on which the VA performs well, but they're not representative of the big problems that the VA has: massive disparity between regions, accessibility of care, timeliness of interventions, adherence, and so forth. This is why VA hospitals have dramatically worse patient satisfaction rates than their non-VA counterparts. (They actually got in trouble a couple of years ago for misrepresenting and hiding the data around this for a while, until independent studies were done which forced them to admit that they'd redefined their internal metrics to make themselves look better).

As someone who has experience with Medicare and the VA, both on a personal level and on a professional level, nothing makes me more skeptical of arguments advocating single-payer healthcare than people willfully ignoring the vast documented problems that exist with both of those systems. That doesn't mean they're not fixable problems. If you want to advocate for single-payer healthcare and argue why these problems could be fixed in a single-payer system, fine. But don't go around pretending that they don't exist - you can't fix a problem by ignoring it and hoping it will go away.


Your response to scientific studies that demonstrate the VA actually provides better care than private counter parts is to dismiss them all as dishonest cherry picking. You offer up no studies or data of your own. You have no evidence for your claims except vacuous appeals to personal anecdote. You've somehow reached the conclusion that the entire VA, a $200 billion dollar program that cares cares for ten million of Americans, is "atrocious" based on ... what?

I think this pretty much proves the point.

The point here by the way is not that the VA is perfect. Nobody has claimed that, though you seem to keep insisting that people must admit something they don't claim. The actual evidence we do have shows the VA has problems but still offers better care so I'm not sure how we're "ignoring" anything. It seems like you're the one ignoring the plain facts and have chosen to buy into a convenient falsehood. Until people like you are willing to even look at the evidence -- and the evidence for universal healthcare is overwhelming at this point -- real discussion is pointless.


> Your response to scientific studies that demonstrate the VA actually provides better care than private counter parts is to dismiss them all as dishonest cherry picking. You offer up no studies or data of your own.

To be entirely honest, you alluded to research around the VA (but did not offer up any studies or data of your own). I responded by alluding to research around the VA which provides a different conclusion (but did not offer up studies or data either, although I did at least state the actual metrics used to draw said conclusion).

> Until people like you are willing to even look at the evidence -- and the evidence for universal healthcare is overwhelming at this point -- real discussion is pointless.

We're not discussing scientific evidence here. At best we're discussing your interpretation of (possibly-scientific) research that you've seen in the past but haven't actually named.

There is one point on which we do agree, though: that it's pointless to continue. It's pointless for me to continue a discussion with someone who starts a thread with bold claims and no supporting data, and then criticizes someone who responds in kind for the exact same thing. To be honest, it's also pointless to continue discussions of healthcare policy on Hacker News beyond a certain point too, because of the inherent political makeup of the site. Even the most well-researched comments which reference primary sources alongside research published in peer-reviewed journals are routinely downvoted because they express skepticism of monopsonic healthcare models. Instead, the top comments are usually low-effort criticisms that contain no rigor, depth, research, or citations, but do contain witty, biting criticisms of US healthcare and political soapboxing. In that sort of environment, there's not much of an incentive for people with domain knowledge who've studied these issues to participate in earnest.

So I guess that's one thing we can agree on: the futility of continuing this comment subthread.


"If you think the private healthcare system is immoral, you should take a look at the 100% government ran healthcare system that is the VA"

Or you could actually read the linked Economist article


This is a lie. By virtually every measure the VA is the most cost effective and best quality care that Americans can get.

* The VA is very cost effective. It is much cheaper than any private sector health plan or Medicare. Instead of buying into the propaganda go straight to the source [1] and look at the actual facts.

* The VA enjoys very strong customer satisfaction. You wouldn't know this because the media and conservatives work together to denigrate the VA every chance they get but you should actually talk to people on the VA plan. Surveys of actual VA customers [2] indicates they're quite happy with their free, comprehensive government healthcare. (Shocker.)

* Study [3] after study [4] has shown that VA hospitals are better than private, profit-driven hospitals.

Most Americans would kill for VA coverage. It far exceeds anything they will ever receive unless they make it to the 1%. And this is why it's so very important to keep spreading this lie that the VA is this gross, evil system where all the patients are just waiting to die and ignored by incompetent and indifferent government bureaucrats.

And this is the real problem. You can't have real discussions about health care in America because, frankly, most Americans don't live in the real world. They've been led to believe objective nonsense and you simply can't build anything off such a foundation.

[1] https://www.cbo.gov/publication/49763

[2] https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2537

[3] https://link.springer.com/article/10.1007/s11606-016-3775-2

[4]https://jamanetwork.com/journals/jamainternalmedicine/articl...


The VA has gotten a lot of bad headlines, but I work with a vet who absolutely loved the VA. He brags about the quality and speed of his healthcare all the time. This is in Charlotte, NC. Different offices might be different.


The thing with the VA isn't that it's all bad. It's that the percentage of completely inept people seems higher than in a normal hospital.

Normal hospitals don't have multiple scandals of reusing insulin pens on different people, reusing colonoscopy bags, killing people, paralyzing people and periodically losing all of our records.

A lot of veterans who are covered by the VA are like me. Technically covered because of service connected disabilities, but I will never use it.


Again, this is not true. Read the studies comparing VA care to private care. You're actually better off going to a VA hospital than most private hospitals.


I've been to a VA hospital. My brother/dad/uncle have been to the same VA hospital. Our experiences have all been poor.

If you were told that you'd get an appointment some time in the future and they sent you a notice randomly in the mail a few months later, you probably wouldn't be happy with the service. If your doctor was over an hour late, you wouldn't be happy. If you had a friend that was paralyzed after a spinal tap (my dad's buddy) then you probably wouldn't hold the VA in high regard.

You are the first veteran I've ever met who had good experiences at the VA and who doesn't know anyone that has been crippled by the VA.


>If your doctor was over an hour late, you wouldn't be happy.

Doctors aren't on time in privatized offices either. It's always a long wait for me. But you're right about the not being happy about it.

>If you had a friend that was paralyzed after a spinal tap (my dad's buddy) then you probably wouldn't hold the VA in high regard.

Yes, but that happens in private hospitals as well. They aren't all that great in the US either.

>f you were told that you'd get an appointment some time in the future and they sent you a notice randomly in the mail a few months later, you probably wouldn't be happy with the service.

Ya that sucks. Private industry has solved the scheduling problem with DSS and template based schedules. My uncle didn't have a good experience with the VA either. He had dementia and the nurse questioned him about it and he said "I have diabetes," which he did, but he didn't know what was going on. The nurse of course said, "we don't treat diabetes," or something like that and sent him away. All the while his sister was telling her about the dementia, she just didn't want to hear it.

I could tell you horror stories about private hospitals too and how after being admitted, they shipped him to a nursing home an hour away wearing nothing but a gown in winter. No calls, no nothing.

I guess the bottom line is right now, the US sucks at healthcare, period. I'm sure being a highly politicized wedge issue doesn't help matters much. (The VA, universal healthcare, skyrocketing costs in the private industry, etc).


> He brags about the quality and speed of his healthcare all the time. This is in Charlotte, NC. Different offices might be different.

The VA is run in a federated fashion, so there is a massive variation in how well they operate.

The problem with the VA isn't that literally every hospital is terrible. The problem is that:

(1) a lot are bad

(2) the bad ones are really terrible

(3) the bad ones are consistently bad over time, with no success in improving them

Part (3) is the really damning one, because it's not like there haven't been efforts to fix the issues with the VA. But because the US is such a heterogeneous country, the successes of Portland don't translate well to Memphis.


But other countries can do this. So the hard question then is, why is the US government so uniquely bad at doing things that it doesn't want to do?


Is the issue the US government? Or the lobbying to protect special interest groups?


From a far enough distance, they look like interconnected parts of the same system.


no reason why single-payer means government-run hospitals


>If the VA is the best the US government can do

Who said it was?


> When a person gets a life threatening disease they ought not worry about whether or not their treatment will leave their family in penury.

You can't start any economic argument by saying that paying any cost is a must. You will get fleeced.

It is not true that universal healthcare pays for everything. The most expensive and experimental treatments will not be covered ever by the system, and it shouldnt.


It is a well known fact that all medical care systems ration care. A person in America who gets cancer, say, often times faces bankrupt and financial ruin. The same can not be said of people in other wealthy nations.

I fail to see your point. All healthcare systems ration care. Not all of them lead to financial ruin at the rate the American healthcare system does. My statement stands. A person ought not face financial ruin. It may be the case that there aren’t enough resources to treat the disease it this does not negate the belief that they shouldn’t face financial ruin.


> A person ought not face financial ruin.

The logical consequence of this is that any cost must be paid. And if the person cant pay it someone else does. So if someone gets a rare cancer whose treatment has 1% effectiveness and costs millions, it should be paid by someone else.

The principle is wishful thinking, not economics. We as people every day make trades of our life for money. We pick a means of transportation riskier than other to save some money, we choose to use a bike to be physically healthier in the long run but expose to short term risks. We eat those cheese french friends with a beer, or smoke. Etc etc.

We are no strangers to paying our pleasures with our life.

- It is the tendency of all men to magnify their own services and to disparage services rendered them, and private matters would be poorly regulated if there was not some standard of value. This guarantee we have not (or we hardly have it), in public affairs.

Americans often believe that universal healthcare is this pristine ideal that will solve everything, but thats because you haven't analyzed the consequences of it and its real life consequences.

The problem of healthcare in the us is not public-vs-private, its the extreme regulatory environment.


Your first paragraph is false and indeed can not be true in any system that rations care. All health care systems ration care since no soceity has enough resources to cover and pay for all possible needed health services. Here resources includes number of qualified workers.


If its rationed then some people are going to be left out, and the moral argument crumbles, as people that need it don't get it.


The rationing can be in a moral way or in an immoral way. All systems ration care. Most do so in a much more morally palatable way than the U.S.


I think you have half a point. A lot of people favoring universal care say things like "health care is a right". I would much prefer the statement that "basic health care is a right". We don't want to talk ourselves into a system where we feel obliged to try to cover absolutely everything.


They don't face financial ruin, unless they don't have health insurance and or they opt for various drugs that aren't covered by their plan. Before everyone screams that all things should be covered please consider that due diligence has actually been done and the drug was considered to either not be effective or not needed based upon other existing treatments.


I am fighting my insurance company right now on a charge that I didn't have health insurance when I used their services this January despite having enrolled last September.

The idea that once you have insurance the problems just magically go away is wishful thinking. These companies are predatory and stupid, and if I hadn't taken the time to read every single line for the 4-page, 10-pt font bill they sent me I wouldn't have even known they were charging me as though I was uninsured.


The idea of universal care is that everyone have insurance. Before Obamacare my sister got cancer. She wasn’t lucky enough to have an employer nice enough to provide insurance through her job. Even people with insurance often times face financial ruin. Especially before Obamacare was enacted.


> They don't face financial ruin, unless they don't have health insurance

In the age of high deductible plans I'm not sure this is accurate. For many Americans the $5,000+ for a deductible each year is unsustainable, especially if someone on the plan has an ongoing issue or they have to meet the deductible multiple times (changing jobs or an issue than spans calendar years).


>They don't face financial ruin, unless they don't have health insurance

Without the ACA, this wasn't possible for millions of people. With the ACA it was still too expensive for millions of people. With the ACA minus the individual mandate it will be too expensive for even more.

Also before the ACA, health care plans came with yearly and lifetime coverage limits. Coverage limits that were far below what care would cost in many cases. So even with insurance you could still face financial ruin.


Wrong--it is certainly the case that many insured individuals are left insolvent after necessary but costly medical procedures.


> You can't start any economic argument by saying that paying any cost is a must. You will get fleeced.

... in an open market.


Or in any realm of scarce resources. (Also known as "reality".)


In a government program you get fleeced twice, first by extra taxes, and second by worse services.


I feel like throw-away statements like this almost come out of a different era, like the platform Reagan ran on, "government isn't the solution, it's the problem" or whatever.

They're claims that are so simply phrased, people can repeat them without thinking critically about them, but if you do, and start unpacking them, the claims are either wholly unsupported, or unknowable.

"Taxes == get fleeced" ... no. Or, at least, not as a matter of course. Maybe some taxes are bad, or unfair, but we can judge each tax on its merits.

"Government program provides worse services" ... no. Or, at least, not as a matter of course. Maybe some things the private sector does better? But a huge swath of civic life relies on government services because, well, that's by definition what government provides, the building blocks of civic life.


> "Taxes == get fleeced" ... no. Or, at least, not as a matter of course. Maybe some taxes are bad, or unfair, but we can judge each tax on its merits.

Sure. I pay private healthcare and i also pay a medicare tax. Im already getting fleeced for a service I don't use.

> "Government program provides worse services" ... no. Or, at least, not as a matter of course. Maybe some things the private sector does better? But a huge swath of civic life relies on government services because, well, that's by definition what government provides, the building blocks of civic life.

Government is just unable to provide something more efficiently than the private market, it has to be a very particular case for that to be true. What i can do is provide services no market can provide. (like security, legal, etc). A private legal system would run afowl, private armies would be civil war, etc. But thats not because the government is efficient,its because it cant be provided otherwise. I would never call 3.6 trillion defense spending efficient.

The argument in favor of public run healthcare is that private healthcare is unable to do it not that the government is better at doing it.


> Government is just unable to provide something more efficiently than the private market

Do you have a peer reviewed citation for that?


I can give you a nobel in economics on it if you wish.


You're just stating very wide sweeping statements as if they are facts.


Paying taxes isn't getting fleeced.

I can tell you feel passionately about this, but your feeling that you're being ripped off by your taxes isn't going to translate well to any sort of workable policy.


>>You can't start any economic argument by saying that paying any cost is a must. You will get fleeced.

>Paying taxes isn't getting fleeced.

I think it's fair to accurately address the arguments being put forth, rather than reinterpreting them. Taxes are necessary, and I don’t think any serious person would argue otherwise. The problems come when we get into the details:

Conflating local, state, and federal governments with their respective tax regiments only serves to muddy the waters. Additionally, conflating property, income, and capital gains taxes compounds the problem.

Scaling anything from 60M people to 300M is non-trivial (just ask Twitter, which is pretty simple).

Arguing for a collectivist approach in the US (which was partially founded on individualism), seems to betray the entire reason for our independence from Europe (the old country) in the first place.

Let Europe do Europe, and America do America.

Edit: Just to be clear, individual European countries are 20% of the population of the US at best, so it makes more sense to compare them with US states (e.g. The state of CA is the 6th largest economy in the world). Top-down policies do more harm than good in such a large heterogeneous place as the lower 48.


I've never seen a plausible explanation of why a health care system would work for 60 million (UK) but not for 300 million (US).

Bodies are mostly the same, they break down in mostly the same ways. There isn't a lot of mystery in providing care, either. Nor a lot of mystery in how you'd fund it.

We just aren't doing any of that, cause our politicians are bought so very, very cheaply, and enough people are enriching themselves in small ways through small grifts that changing the system would impact a lot of people who are just well-off enough to be listened to.


>I've never seen a plausible explanation of why a health care system would work for 60 million (UK) but not for 300 million

Scaling advanced systems to large numbers of users is very difficult and is the reason Facebook is worth ~1/2 Trillion dollars.

"James Madison argued, especially in The Federalist No. 10, that what distinguished a direct democracy from a republic was that the former became weaker as it got larger and suffered more violently from the effects of faction, whereas a republic could get stronger as it got larger and combats faction by its very structure."

<our politicians are bought so very, very cheaply, and enough people are enriching themselves

If this were true, we should arbitrage this value-mismatch and create a market for buyers and sellers of this powerful, political influence. "cheaply"? As the saying goes, "Extraordinary claims, require extraordinary evidence."

It is possible that the lawmakers share the same views as the for-profit/non-profit corporate execs, just like I agree with Green Peace(i.e. lobbyists) that we should end the practice of whaling significantly. The sovereign nation of Japan disagrees.


Workable policies that levy taxes abusively are not workable policies. Its institutional exploitation.


Honest question: can you rephrase this? I can't tell what you're trying to say.


The services could be worse but aren’t necessarily worse. It’s foolish to think that any government service is worse than a private one. Also, universal healthcare doesn’t necessarily mean government run.


It's foolish to believe the state is more efficient that private actors, that is just contrary to real life experience.


It’s foolish to believe that private enterprise is always more efficient than a government run program and it’s foolish to think that government is always more efficient. One should not live in a world of such extremes.

Sometimes government is the efficient solution. Sometimes private enterprise is.


It's foolish to believe that private actors can by definition ever be as efficient as the state.

Private actors, by definition, must extract something from any service to pay themselves.

The government has no overhead. It can run with absolutely no profit and that is its intended model.

A private health care company that returns zero profit to its shareholders? Shut 'er down.

A private transit company that returns zero profit to its shareholders? Shut 'er down.

And yet, government services can run indefinitely at break-even because they're not beholden to the market.

Only government can be so efficient--the private sector always loses efficiency through someone scraping something off the top.


> The government has no overhead

Realz.


Like the real life experience of those private Russian mercenaries who went up against the US military in Syria?

Some things governments simply do better; health care is one of them. Denying that fact in the face of the mountain of supporting evidence is nothing but dogma.


And yet, NHS is about twice as efficient than the US's system.


Is Medicare twice as efficient as private healthcare?


It's not a great comparison for a lot of reasons (not least of which the first being that Medicare is legally not able to negotiate drug prices), but despite all of that, yes Medicare is dramatically more efficient.


Medicare is the core of all regulatory and pricing issues in the healthcare space. And if medicare were expanded to the entire population of the us, its expenditures could be 40-45% of gdp.


> Medicare is the core of all regulatory and pricing issues in the healthcare space.

I can't see a reasonable argument for that.

> And if medicare were expanded to the entire population of the us, its expenditures could be 40-45% of gdp.

Even with a naive covered-population-number based extrapolation that ignores that Medicare currently covers the elderly, who tend to have greater medical needs than average, that's not right; national health expenditures are about 18% of GDP, Medicare is about 20% of NHE, and Medicare currently covers around 15% of the population, so a naive population-based extrapolation would put Medicare-for-all at about 24% of GDP.


Medicare is the reason there is fee-for-service, which is the biggest administrative overhead design if there is one. Also all private insurance works based of of medicare in the rates they pay, the way they code themselves etc.

On the extrapolation, of course they are all simplistic and wrong, both mine and yours. You are capping the NHE of GDP to cap medicare, as if the expansion of medicare were going to eliminate out of pocket or private health. Because it doesnt, if it replaced only half of expenditures, the 24% becomes 33%.

Its true Medicare takes care of older patients, but also private insurance subsidizes medicare all along the path to that because it pays more than medicare to every provider, which means on the pool of patients, the medicare patients tend to represent losses and the rest profit. Furthermore there is the argument that if medicare expanded 7 fold, it would also be less efficient the bigger it gets, which is true of private and public organizations alike.

We cant know, its messy and even expert economists cannot get this right: but it has to be in the order of magnitude of 25 to 40% of gdp. That is state-crushing expenditures.


> On the extrapolation, of course they are all simplistic and wrong, both mine and yours. You are capping the NHE of GDP to cap medicare

No, I'm not, I'm using the current expenditures as the projection baseline. I'm clearly not using the current NHE share of GDP to cap Medicare because the projection (24% of GDP) is greater than the current NHE share of GDP.

> as if the expansion of medicare were going to eliminate out of pocket or private health.

No, you made a claim about Medicare expenditures being 40-50% of GDP if it covered the whole population, not other expenditures. Now you're moving the goalposts (and still not supporting your mutating guess with any actual concrete basis.)

> We cant know, its messy and even expert economists cannot get this right: but it has to be in the order of magnitude of 25 to 40% of gdp.

Well, that's a sudden drop in your estimate of what now seems to be total NHE from your earlier claim that Medicare expenditures alone would be 40-50% of GDP. Another round of this and you'll be conceding costs below the current 18% of GDP.


Not only is universal healthcare more moral, it has been demonstrated as more economically efficient many times over. You only need to start by comparing the per-capita costs paid for healthcare in the US vs every other modern nation in the world. The US pays more than double the average of the other nations and we get much less performance for it. There are no modern nations that pay as much as the US in absolute terms, nor as high a percentage of our GDP.

https://www.pbs.org/newshour/health/health-costs-how-the-us-...

The other nation's systems have mixes of full nationalized care to administrative combinations of private insurance, so there is some leeway there. But all of them contain public controls on the cost of drugs and procedures. And that demonstrably works with both better prices, and better outcomes in total measures like life expectancy.

Edit: Btw the PBS article is from 2012, with data up to 2010. In later years, US life expectancy has had years which it has dropped, and even when growing, it lags the nations modern peers (while approaching nations such a Mexico..). There are some forces there that aren't all healthcare, but healthcare is central to life expectancy...

https://www.cnbc.com/2017/02/22/us-life-expectancy-is-low-an...


> When it comes to public funding for public goods we tend to worry about some poor person getting something they don’t deserve. The go it alone I’ve got mine, fuck you attitude is unhealthy.

1/3 of our GDP goes to "the village". We spend trillions every year on the things you want most. Education, healthcare, environmental protections. You name it; we spend money on it!

70 million people use medicaid. 44 million people use medicare. 22 million veterans eligible for the VA. 22 million government employees who receive healthcare benefits paid for by the state.

We are drowning in the healthcare spending you pretend doesn't exist.


Our spending on healthcare is grossly and immorally inefficient. A change is needed. One reason for the ineffiency is that public welfare is subordinate to special interests. All universal healthcare systems in the world are cheaper on a per capita basis than the American system. A change is needed. I’m not advocating for more money. I’m advocating for a change in perspective by our leaders.


Just because something has worked for other countries does not mean it will work for the US.


That's true, but since there is an example (tens of them, actually) where it does work well, then the prior should be that it could and should work in the US, and if one thinks it wouldn't work in the US, it should come with an explanation.


The explanation is that the US is huge and UK/Germany/Sweden/whoever is not.

Efficiency doesn't scale proportionally to size, unfortunately.


The US has less than 400M people, the EU has more than 500M, so you are factually wrong.

The EU is divided to states, just like the US; healthcare is locally managed with reciprocity between the EU members. Which gives you a model for a scalable US implementation if you desire.

You are entitled to your own opinion, but you are arguing against facts. The US is smaller population wise.


I didn't say that the US was larger than the EU...

I said the US is significantly larger than any one country in the EU, and each country in the EU has its own health care system. What is being discussed in this thread is a US-wide health care system, which is definitely not equivalent to what is currently happening in the EU.


Each country in the EU has its own health care system, but in most senses they are regulated EU wide, and reciprocate with each other - if a French person needs urgent care in Italy, he will get it, and the distinct single payer systems will do the accounting. Said French person can also legally move to Italy, and will be covered by Italian single payer system from day one.

The EU has only one medical "FDA"-like authority, which is - in fact - a huge problem for the UK post Brexit because they have to set one up for themselves now.

The EU has, effectively, a EU-wide health care system. It is more federated than the US, by virtue of only recently become a union. It is also less uniform because of different history, tradition, and languages. These are things that make it harder to build than a US-wide, and yet, it works and is significantly more efficient than the US, while catering to more people.

Of course the existing US-wide health care system is not equivalent; it is dysfunctional. You claim, but fail to demonstrate, that a functional one cannot be built, despite example in the EU that faces harder objective conditions.


If a French person needs urgent care in America they'll get it too. I think you're giving too much credit to "EU reciprocity agreements".

Nowhere did I claim that a functional health care system cannot be built in the US. Good straw man though.


Good straw man yourself! You did claim that whatever works in the EU has no reason to work in the US, and I only Asked why not.

Also, the French man will get treated because of EMTALA but might be bankrupt by the event. It’s just that they buy/get insurance before they come (usually through their credit card issuer).


That, even if true, does not support your argument. You need to show that the inefficiency in a universal care system in a country as large as the U.S is greater than the current system that we have. The evidence is that this is not true.


I don't need to show that, as I am not the one advocating a fundamental restructuring of the status quo.

You need to show that the policies implemented in other countries will continue to work efficiently at the scale of the US, as you are the one advocating that course of action.

"This policy worked well in [some place that is not the US]" just isn't good enough.


This claim, taken ad absurdum, is equivalent to “you can never conclude anything from prior examples because conditions are different”.

And you have, in fact, gone ad absurdum.


You can't definitively conclude anything about example B from the results of example A if the two examples are different.

That's not what I'm saying though. All I'm asking is for you to show me how you will mitigate the problems that will crop up when you try to implement a similar system to the UKs at the scale of the US, because the US has 5x the population of the UK. That's not a negligible difference in scale, and if this can't be shown at all, that is a problem.


You assert that problems will crop up, but fail to mention which problems. You are arguing that any data anyone brings up is irrelevant, without bringing up any data.

You keep comparing the UK to the US, but a much more apt comparison is e.g. UK to CA, and the entire EU to the entire US. UK has twice the population of CA, and better bang/buck and health outcomes. EU compares similarly to the entire US.

The EU is at this point in time, a federation slightly more disjoint but ultimately of similar structure to the US.

Why not build an independent single payer healthcare system in each US state, with reciprocity among them? That is directly comparable to the european system, and has been shown to scale and work efficiently and well.


You asserted an explanation for something. I showed that your assertion was not logically supported by your statements.


Never said otherwise. I made the statement in response to the view that government run necessarily means inefficient. Clearly the converse is true. There are lots of examples.


>Our spending on healthcare is grossly and immorally inefficient.

Yes, because it goes to treat chronic preventable (voluntary) conditions and to keep rich old people alive for a few hours or days longer. The way to handle those freeloading on the system is to abolish the system, not increase its scope.


I see that in the parable of the farm workers you would be the one hired at the beginning of the day.


You're not drowning. You're wasting spending on things that don't matter, like privately funded education and privately funded health care.

The solutions already exist and they're out there. Lowering spending just for the sake of it is not one of them.


> Americans need to change their underlying notions of what it means to be a society.

We want it (https://www.pbs.org/newshour/health/62-percent-u-s-want-fede...)... Our politicians just aren't doing it.


Social security age keeps on rising as baby boomers retire.

America is the wealthiest country on the planet, yet the country where most people go bankrupt or commit suicide because they can’t afford healthcare costs. US spends astronomic amounts on weapons development than keeping its citizens healhy and happy.

Fermi was right. We’ll eventually destroy ourselves before we find another intelligent civilization. May be the great filter is that no one in the universe got healthcare right and they vanished. /s


Universal healthcare benefits people with no coverage, which is good, but it also, in the case of nationalized healthcare, i.e. not privately run, leads also to lower quality care for people already with coverage where experience is people who can afford it, will when other than the most routine things, seek private care.

Given that, it looks like a two tiered system might work best. One which works like the current system and also another for the not quite indigent but can’t afford the current system (indigent are covered by Medicaid).


What works well outside of the US is that the single-payer government run (or at least government mandated) provides a standard level of care, which more often than not includes wellness and life threatening care (and a lot in-between), and one can buy additional coverage in the private market - but the basic standard care is considered a right, and doesn't disappear just because you have some additional coverage.


When you look at other modern nations, all with better performing healthcare systems than the US, there is a mix of arrangements. The common factor is public gov't control of drug prices and procedures. The arrangement of how the administration of the care is allocated varies all across the spectrum, from fully nationalized, to hybrids, to mostly private administration. But I'm inclined to think that public health experts setting cost ceilings by drug & procedure is the critical element.


It's immoral for people to pay for the time and work of others?


Apparently doctors should only work for the public good and accept (relatively) piddling wages but startup tech bros and VCs are absolutely entitled to their billions.


Nice false dichotomy you have there. There are other possibilities than the status quo or doctors getting piddling wages.


I did not perpetrate a false dichotomy, I mocked the hypocrisy of any user of this site seeking to limit the compensation of anyone.


I couldn't agree more. I don't think U.S. has a real progressive party, the choices are off the rails conservatism, or conservative lite. IMO, a progressive/liberal is concerned someone might go hungry, a conservative is concerned that they might miss out because someone got some food they didn't earn/deserve.


Back in 2004 when John Kerry was running for POS (that's President of the United States, he-he), he had a great idea (that I'm sure came from elsewhere, but a good idea is a good idea). The US government would become the "insurer of last resort" and cover catastrophic claims above a certain amount:

http://www.washingtonpost.com/wp-dyn/articles/A16748-2004Jun...

For his efforts, he was practically called a "Commie" by the Republican party, despite the fact that the proposed mandates were fairly mild and the plan worked within the existing employer-provided health insurance system. It was a good crack at the ~20% of the population that accounts for the majority of healthcare spending, and eliminates the possibility of someone losing their home and savings because of a serious illness. Plus, I'm sure that the levers could be tweaked a bit to get better outcomes.


There was a good comment(I have it saved somewhere) explaining this quite well - some places in the world(European nations mostly) got so fucked over by history, over and over and over again that as societies they realized you cannot "pull yourself by your bootstraps" and provide for yourself in all circumstances. Just in the 20th century it was possible to see your country ravaged by two world wars, change ideologies three times, change the dominant religion and ownership of land between major powers few times in just few decades.....the societies have realized that the only way to make it work is by providing certain services to everyone, free of charge, purely because they are citizens with no strings attached(and no, this has nothing to do with communism). Meanwhile, in US, the "pioneer" ideal still reigned - anyone could achieve anything, given enough hard work. That ideal didn't exist in Europe at the time, or was crushed so thoroughly its destruction echoed through society - you could be the most hardworking person in Europe, but if someone decided they were going to pillage your land, rape your family and send you all to concentration camps - that was going to happen. No amount of positive thinking and hard work was going to prevent it. So yes, to my granparents it's absolutely obvious that everyone should have equal chances - healthcare should be funded by the state, as should education and child-bearing. They still get really upset over the fact that despite all education being 100% free in this country students still have to pay for their own housing - why should they? The state wants to have well educated citizens, why the hell should the students be paying anything to study. Once again, this has nothing to do with communism, but I am sure Americans would label it as such.


The US and Europe are not really great comparisons for a bunch of reasons, but the fundamental one is that Europe has been at Malthusian population limits for a long time, whereas North America has had an essentially unlimited, unpopulated frontier that new people could move to and create lives for themselves.

Thus, the American notion of pulling your self up by your bootstraps was a workable one. Since North America was first colonized by Europeans, Americans have moved west and made a future for themselves and their descendants by using hard work to harvest the bounty of nature. But Europe has been full for thousands of years. You can't just move West, work some land, and raise a family; there are already other people wherever you would want to go.


This is a principal reason why the US was crossed off my list of countries where I would work and live. I fight against the privatization that is occurring within healthcare in my native country, Iceland. We used to have the Scandinavian model but decades of attacks from the right-wing Independence Party has broken our healthcare system. The next phase described by Chomsky is handing it over to private capital since people are outraged that it doesn't work anymore. I'm sickened by the development and feel a little like an old man screaming at the desert wind.


>When a person gets a life threatening disease they ought not worry about whether or not their treatment will leave their family in penury. This is especially so in a nation as wealthy as the U.S. The American healthcare system is immoral and I hope it drastically changes.

If no one has to worry about the monetary effects of their health choices, poor health choices are incentivized and those who make poor choices are subsidized by those who make good health decisions. The vast majority of healthcare spending in the US is already on preventable chronic conditions yet everyone keeps gorging themselves further into obesity, diabetes, hypertension, CVD, etc. Almost no one is against paying into a risk pool that hedges against unforeseen health problems even though they may never directly benefit. If I pay my entire life to cover someone else's cancer, that's fine with me. What we are sure as hell opposed to is a creating an entire system based on perverse incentives that punishes people doing their best to save their pool from spending on them and rewards those whose voluntary actions are the driving force behind increased costs. And the US healthcare industry is not some libertarian wild west show, it is highly regulated and dominated by the edicts of CMS yet the state of the public's health continues to worsen in ways our forebears who optimistically, though naively, created these programs could never imagine.


Thank you for exemplifying the attitude I decried. I wish people like would leave the U.S. Live elsewhere. Escape the burden of possibly having your tax dollars help someone else by emigrating.


I invite you to do likewise. We will be quite well enough without ignorant busybodies posturing as moral crusaders hectoring us into enabling further deprivation of our property and liberty.


As the good book says, "For the love of money is the root of all evil". I'm not posturing. I actually do have a moral code that I try to abide by. The fact that all other wealthy nations provide what is colloquially called "universal healthcare" is an indication that yours is the abhorrent view. It would be worth your while to consider why your view, in just about all other advanced nations, is considered a fringe one.


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