One that I’ve been working on over the last year is one where the concept of “crowdfunded healthcare” evolves into a dystopian game show where people go on TV and share their sob story on why they need money. Then the viewers at home get to choose who gets the show’s prize money each season through a bracket style voting system that crowns a champion at the end.
I had to stop working on it as it got really, really dark the more I wrote.
On that note, I find it supremely fucked up that people have to turn to crowdfunding to get their unexpected healthcare costs covered by benevolent internet citizens.
And one of the most delusional CEOs was the Hooters guy. He was talking about how he would be perfectly fine with his daughter working at Hooters. Then the manager where he was undercover was found to be a total pig. Making the waitresses compete for time off by eating canned beans with their hands behind their backs. He also talked about "inspecting" the "product" on a daily basis to make sure the customers stay happy. It was a gross display of abuse.
Of course, he didn't even fire the manager later. Had this episode not been 10 years ago, I think #metoo would have had both the manager and the CEO fired within a week of the episode airing.
I'm only about halfway through, but the central thesis appears to be that the powerful, even if they truly want to make a good-faith effort to improve the world, will naturally gravitate towards forms of social change that don't challenge their power. He describes this kind of thinking as "win-win" in that only solutions that don't involve those in power sacrificing the conditions that made them powerful will be considered by the philanthropic class. These "win-win" solutions then displace more direct "win-lose" solutions that actually address the underlying power dynamic.
The arguments put forth ring pretty true to me, and this GoFundMe stuff fits the model perfectly.
I thought it rather interesting that he was able to hold this kind of talk at Google - after all, his audience there probably consists of people that are probably part of the "winners" he is talking about.
"We are living in interesting times; in fact, they're so interesting that it is not currently possible to write near-future SF." -- Charlie Stross, Sep 2008
If you could add some good mob rule hurt-the-bad-guys to your mix, it could be a hit. And that's messed up.
Take it up a level; I think quite a lot of people believe there's a serious gap in the oversight of law enforcement agencies in the US. Where's the public accountability?
So - a reality show that follows police units, and lets the audience vote on which officers should be promoted, sacked, or jailed....
So sure. Find the gap, tell the sad story, then follow enforcement folks as they find the people responsible -- with the audience voting for whomever that is and what the punishment should be.
In the end the weak and vulnerable are rewarded, the evildoers punished. It's basically every Hollywood movie you've ever seen except the audience gets to vote on the outcome and real people are involved -- the ultimate in reality TV.
This from the Wikipedia article got a groan out of me:
"Often the request was for medical care or therapeutic equipment to help a chronically ill child, or might be for a hearing aid, a new washing machine, or a refrigerator. Many women broke down sobbing as they described their plights."
And then this:
The show became popular enough that NBC increased its running time from 30 to 45 minutes to sell more commercials, at a then-premium rate of $4,000 per minute
That would violate a strong trend in the reality competition genre.
Do it with access to healthcare and you sure turn the intensity up on elimination.
But bracket-style voting prevents the drama of upsets where a candidate most people think is good-but-not-best gets eliminated while a candidate widely seen as poor but with a dedicated fan base who would easily get clobbered in a bracket (or sensibly aggregated ranked preference) system gets spared by the perversity of an inverse first-past-the-post system.
Which drama is no doubt why inverse FPTP is so dominant in the genre, where audience voting is involved.
> Do it with access to healthcare and you sure turn the intensity up on elimination.
Oh, sure, I'm not arguing against that, just that brackets in particular would be a surprising choice.
Well I'm convinced.
A cheap fear factor knock off, where the contestants compete for a green card, in the form representation from an immigration attorney. This usually has the contestants eating a platter of worms in the form of tacos or a taco shell bowl and their final challenge is proving that they can be functioning member in the United States by selling sodas or something of the likes in a public space. There might have been physical challenges, but it was mostly the worms and selling stuff that I recall.
The idea that we could care for one another without a state is both obvious and perplexing. People have always cared for themselves somewhere in the world even if some societies have been highly centralized.
All this said, I have been fostering a deep appreciation for socialism as a utopian ideal to be discussed rather than either a bogey man or as something that requires the expansion of state power to realize. Many well meaning leftists have empowered authoritarians in their effort to force their desired outcomes. At the same time, the state as it stands today could be used to materially improve the lives of many impoverished people.
I think the answer is to use the state as needed in the short term to help those in need, while recognizing the “technical debt” it creates by ultimately undermining freedom. Any work done with the state should be done cautiously and with the understanding that the state power will need in the long term to be eclipsed by power organized by the people. And we cannot simply advocate for state power - long term we must build these structures inside our society, not rely on state power to enforce our idea of a just society.
But we must fight for socialism. I’ve enjoyed these two videos by Murray Bookchin recently.
This critique of the left from 1986 is hugely applicable to today (he even mentions Bernie Sanders briefly):
This video gets at the way our fantasies about technology can ignore our own desires as human beings, and presents an interesting contrast between then notion of futurism and utopianism:
"Libertarian socialism" is practically a form of anarchy and has nothing to do with the modern usage. If you want to make it acceptable and frictionless for people to voluntarily offer their services for free, I don't think you'll get much push back.
Basically trying to lump both unrelated ideas under the umbrella of "socialism" does nothing except confuse people.
Anarchism (or libertarian socialism if you prefer) isn't just about "offering services for free". It's about a lack of hierarchy. You don't have billionaires. Americans today are not ready to embrace anarchism.
If you want a good sci-fi novel that explores practically how anarchism could evolve from the current US state, The Dispossessed by Ursula K Le Guin is a classic.
I will say that if you devise a system where no one can become a billionaire but you don’t expressly say that, I think a lot of people would in principle support it. If you say people will live and work in one location, they will own that land and the facilities, and they will cooperate to produce output and they have agreed to share the output as needed between their community members, most Americans I think would say they do not oppose you doing that, and many leftists I think would be interested in joining.
It is difficult to achieve from where we are but by no means impossible. It certainly seems fair and worthwhile, and it is my goal to realize this in the US.
And you’re right! Most people who oppose socialism actually just oppose centralized control, so we have many unknowing allies in the US and that makes it more realistically achievable here.
In fact... The same thoughts probably apply to most modern and developed countries, as most of them has a significant amount of socialistic elements already...
At the core, whatever the reason for it, government is not, in fact, a 'they'; it is an 'us.' Many of us insist otherwise, and give many, many different reasons for it, but at it's core government is the mechanism we have for figuring out how to live together.
I don't have proof of this, but I suspect that any other mechanism we come up with is going to inevitably converge towards becoming a government.
I don't think that is the reality. I think that is the illusion that shelter in. It's easy to see them as completely disconnected, but they're not really. Many times, this is a result of having to deal with much greater complexity the larger the scale, and people not taking the time to understand or appreciate that complexity.
We live in a globally connected world. There is no way to get rid of that complexity. Smaller governing bodies might solve some problems, but they will also create problems when considered at a global scale.
In governing we are trying to cover up this complexity with moving decision making into higher levels. Such covering up does not solve complexity, it just makes it look like it is not happening, but it is still out there.
To reduce that complexity, you might get a lot of jurisdictions to band together and decide 'hey, businesses must interact with us via this standard way we all agree on." Congratulations, they have just created a government.
I think managing this complexity is incredibly difficult, no matter which strategy is used, and I don't think there is any one strategy available that solves these problems.
In some cases, it makes sense to keep the jurisdictions as small as possible. In other cases, the opposite is true, especially when considering things related to the Problem of the Commons and the like.
A welfare state in an otherwise mostly capitalist society, like Scandinavia or Germany, has worked better in practice for these aims. Mostly because the pie is bigger than in the socialisms tried so far.
YC funded too.
Keep in mind the percentage of folks who abuse this method of fundraising, instead of being truly needy.
As I imagined, this isn't unique to my own circle:
What is your answer to heavy health expenditures/
You are also not eliminated the need to get funds, you are changing who you are asking them from. And let me tell you that government officials are seldom generous.
The U.S. has an infant mortality rate worse than 43 other countries because large numbers of pregnant women can't access routine prenatal care. That's but one example of what real health care concerns are like.
Medicaid will pay for prenatal care, and there are other options as well.
If government officials are using the same healthcare system as everybody else, they have incentive to make it good.
This idea has shown to not happen in real life. Public schools, for example, do not deliver a "uniform" service.
Further if they don't want to get off the socialized program because it's better than the private plan, why don't they work towards extending that to the average citizen like every other developed country in the entire world? Political expediency probably.
Don't worry about the senators: they are all using private healthcare. Probably even the opposite of your speculation: if they use state solution due to their age, its medicare advantage.
Those leading edge potential treatments tend to be both very expensive and ineffective, and often cause additional harm on top.
That's from the analysis of a leading oncologist in the UK.
Ohai goalpost. When did you get there?
The existence of .eu-to-.us medical tourism is utterly orthogonal to the availability of research in those countries. If you honestly took ten minutes to try, you'd be able to find dozens, if not hundreds of trials in every .eu member state, plenty of which are at least comparable to, if not more advanced than what's available in the US.
I could go to .eu or .in or .mx or .th, or any of dozens of other countries, to get access to medical treatments and procedures that are by many, if not most, measures superior to their alternatives available here, but which aren't available here (just one, token example: RISUG), or are vastly more expensive here, but have comparable — or, again, better — outcomes there.
Most of those places offer varying degrees of socialized, if not universal, medicine.
The great folly of the world universal is that it implies everything would be available, and its a step in the opposite direction: a set of things will be made available, and the things that aren't will be delivered by the private market. Private care is still a thing in most universal care countries. And even with private and public, us still produces something for people that could get free treatment.
Having to choose between medicine and the rest of life's necessities. "Can I afford both my kid's insulin and my rent this month?"
That's a real-world consequence which, offhand, only the US healthcare system offers.
The medicare example is quite an interesting one as well. The US doesn't have the political momentum to let medicare negotiate pharma prices, and before such a basic thing is even changed, you want to hand over the entire health care insurance industry to the government?
Making small adjustments to a doomed system is just akin to rearranging the deck chairs on the Hindenburg.
I'm suggesting maybe fixed-wing aircraft that aren't full of Hydrogen.
You will not get the canadian health insurance by signing a law that says you will. You will get the american version of it.
Please bear in mind medicare itself is also more expensive than canadian health services as it is, thats what the american state gives out.
I addressed where cost savings come from in another post you may have missed, another reply to your comment with specific examples, we can take that over there.
>> You will not get the canadian health insurance by signing a law that says you will.
Funny, that’s how we got ours in Canada in the 1970s, you should read up on it and on Tommy Douglas. No need to be defeatist.
We had a for profit system, and it was the worst, so we changed it. I’m not sure why America would be incapable of that when we weren’t. Further as in Canada, the system can be defined as the federal government requires minimum standards of care and the states execute in the way that makes sense for them.
Obviously Medicare is more expensive. America doesn’t have a free market for healthcare. The young, healthy and cheap to insure obtain cover in the private markets. All the worst customers (the sick, the old, the dying) are removed from the market and their care is already socialized. This is the definition of a manipulated market: privatized gains, socialized losses. The cost to cover for Medicare will drop substantially when the healthy pay for the sick directly the way it’s supposed to work.
Unless "you" doesn't mean someone like me.
But then I do. Just not exactly legally.
Focusing on the last:
> conanbatt: the price goes up because of regulation
> HN: how did regulation make insulin expensive
> conanbatt: what makes you unable to import cheap insulin?
> HN: Law
However you look at your "example", it's not good for the US.
- Canada has universal healthcare
- Canada has government regulations
- Despite all that, insulin in Canada costs less than in the US
So the original question still remains and is valid: why is insulin in the States so damn expensive? Given that the US is one of the largest insulin manufacturers in the world. And it's produced by literally the same companies.
The US has a similar relationship with Mexico; there are a string of clinics along the Mexican border offering unproven cancer treatments that would be difficult or impossible to market under US regulations.
The second part of the sentence alludes to something I did not intend to imply.
Are you not aware of how much fundamental drug and medical research is actually conducted on the taxpayer's dime at the university level, and then exclusively licensed to private enterprise for commercial exploitation?
I've seen a number of sources make a compelling case that "big pharma"'s number one line item is marketing, not research.
Not only does it do all the subsidizing, but it also makes it expensive by putting extremely costly regulation.
But thats a whole topic on its own: government funding of healthcare research is not efficient and does not make it cheaper in any way.
Big Pharma's #1 expenditure is always going to be protect its patent monopoly process with the FDA.
I would find it better that patents in pharma were eliminated, but also that the FDA approval process should be optional. If you want to save lives, you need to loosen up.
You also kill people by not giving them the medication they would want to get, or making it to expensive for it to exist. There is no "clean-hands" solution on this.
> here's a reason we have an FDA approvals process and it's not because the barbershop surgeons and snake oil salesmen were doing so well that big government needed to step in and ensure we didn't save so many.
Yes, the 1920's of medical licensing, restricting doctors supply, hospital grants etc. You can see how medical expenses became an issue right after that.
What's happening in the US healthcare system now, however, is that it's on the order of twice or more as expensive as anyone else's — and climbing — with worse outcomes than many of those, and are getting worse.
No matter your views on who should pay for it, you can't be in favor of that.
Out of interest, how do you feel about vaccines?
Can you imagine having diets having to be clinically approved by the FDA? 10 years plus billions of dollars to say you should eat less sugar.
When someone dies because they can't afford insulin, they are paying with their life for your sense of security.
But! There is also a way to satisfy your desires, and satisfy mine. You buy your FDA approved drugs, and the ones that don't want to...don't. You get your security, and I get cheap medication.
Mine cost more under your model than they do now because lower volumes will drive up prices. The market further segments, only the wealthy can afford real medicines and the poor, barely able to afford medicine in the US as is are forced to risk their lives on unregulated garbage snake oil. This is just a way to kick the poor harder but with extra steps.
It's a pointless argument. This is right up there with Antivaxx and crypto enthusiasm, and it's a libertarian pipe dream. You acknowledge the lack of regulation has led to a pile of worthless garbage and your argument is let's keep doing more of that, instead of lets regulate the homeopathic medicines and male enhancements, and yes, diets. If you want to claim your diet is effective, then we should have that statement approved. It'd kill the industry because they're largely all baloney. And I'd be totally ok with that.
We live in a society, believe it or not, and yes your unregulated garbage does interact with my regulated medicine via market economics. As I explained. You're basically just arguing we accelerate the path to Elysium. That's an argument you can make, though let's be honest about it.
That system is great for the poor, most expensive to middle class.
I can also tell you what I think are reasons why US healthcare is so expensive, and they are not fixed by universal care programs.
A first step would be to make all prices transparent so people can actually compare.
In my view the biggest problem in the US is that the billing aspect of health care is intentionally opaque.
The main reason pricing is opaque is because patients dont have freedom to compare between insurance companies, and because insurance companies are not a good model for frequent care. If you had High-deductible plans, you would make a much better system but people hate those plans.
You need a big change in popular sentiment to make pricing work well. (i am all for HDPs)
Price opaqueness is a big issue, but there is no transparency with so much distortion.
A bigger problem to me than transparency is distortion: the value of the service being public means little if the patient is not paying for it. A patient that has 20% co-insurance or 20$ copay have completely different price sensititivities. They are also price-insensitive when they select insurance because they get it through the employer that picked it and payed it for them.
As a patient, the price tag on a service is relevant to you depending on insurance: validating insurance is much more important than seeing the price.
A socialized medicine scheme will have the same problem: if a patient is shielded from the actual cost of the visit, then he is more likely to use it and thus over-use it.
Complex dermatology assessment in Ontario (A020)? $49.95CAD
I visited family in Canada and went in without insurance for a small hour-long outpatient procedure. Nothing major. They billed me $90CAD ($67USD) -- and were incredibly apologetic they charged me in the first place.
>>> A socialized medicine scheme will have the same problem: if a patient is shielded from the actual cost of the visit, then he is more likely to use it and thus over-use it.
That's the most patently absurd argument proponents of the current model utilize. This isn't some ice cream shop. Nobody goes to the doctor and demands one of each with sprinkles. If I told you all your healthcare was free what on earth would you get done?! Are you planning on shattering your femur just to maximize the value you draw from the system? If the answer is some legitimate healthcare procedure, go with God, you have my full support. If not, I'd imagine this is similar to the "5 million illegals voted last time" -- did you see one? nope! But I know in my gut they're there. Feel free to cite me some studies though.
Especially as under socialized systems medically unnecessary treatments such as purely cosmetic plastic surgeries aren't covered, for exactly this reason. This risk is further limited because most socialized systems use a Kaiser-type model where a primary care physician refers you to a specialist. Self-referring to a specialist is a very private medicine thing -- you're not a doctor, you've got no medical training, you have no idea whether you should be using the valuable time of a specialist -- let alone which one, so we defer that decision to someone who is: your GP or primary care physician. More waste reduction, cost reduction, efficiency improvement.
This horse has been beaten so long its basically a horseburger now; these are very much solved problems. By all means, have at those windmills though.
When I said most of America, I meant it. It's fifty seven percent of America.  Are you going to put them all on Medicaid and take their houses? I thought you were arguing for private cover :) This is the kind of thinking that pushes up costs. Creating barriers to seeking care early makes everything more expensive as the longer you wait, the more it costs to resolve.
Let's be rational about this. The US median individual income is $39,336.  Your take-home pay would be approximately $2614 per month after tax assuming you save nothing toward your retirement. Taking out $800 leaves you with $1814. The US median rent is $1500 per month . This leaves you with $314 for food, gas, transportation, electric, water and sewer combined. And this is the best possible case: you're single. Then you want them to handle a $5000 deductible?!
Since you also suggested in a different thread that it'd no longer be tax deductible, that $5000 would drop immediately to $3000 or less -- $250/mth. That's still dancing on a razor's edge.
Your key metric of "cheaper" and "more available" and "better utilized" is provably solved with a socialized model. There's no active private care model that outperforms one of the OECD socialized models, or else you'd have at least mentioned it by now. Instead, we keep revisiting unsubstantiated ideological libertarian talking points. I've got real world implementations to support my theories.
I don't know enough about the reason for the shortage of doctors but I'd go out on a limb and say its probably not because they don't get paid enough.
(2) How is universal care going to eliminate patents for pharma?
It won't, and it shouldn't. Patents for pharma don't preclude successful implementations of universal healthcare anywhere else. There's a perception that in Canada "drugs are cheap" -- prescription drugs administered outside of hospitals largely aren't covered by OHIP. Provinces act as bulk buying groups and negotiate prices with pharma companies. You want to partake in the market, great, let's figure something out. It works surprisingly well. Patents are your temporary monopoly on creating an invention in exchange for sharing it with the world.
(3) How is universal care going to make non-profit hospitals cheaper?
By regulating fees for services, by lowering the price of drugs via negotiation and bulk purchase agreements, by eliminating marketing budgets, by eliminating insurance billing departments and by capping executive compensation. Hospitals and doctors are public servants elsewhere in the world, not elite rockstars who can bill as they so choose. That doesn't mean they're not well compensated.
Oh, and by socializing malpractice insurance. In the US high-cost states OBGYNs pay $85-200K/yr just in medical malpractice insurance.  In Ontario it's around $70K CAD.
(4) How is universal care going to eliminate fee-for-service, which has the administrative costs that are the woes of care providers?
By having a single table of rates that apply to everyone. Ideally with a single payer. This makes billing much, much easier.
(5) How is universal care going to reduce healthcare spending?
Everything I indicated above put together. If you want a concrete example Medicare does most of the above (they can't negotiate drug prices, and they're not single payer, and they haven't socialized malpractice insurance) but they're substantially more efficient. Medicare spends 2-5% of the budget on administrative, where private plans spend 12-18%. That's without recognizing some of the other savings I pointed out. 
From an economic perspective, its not clear pushing for preventative will lower cost or increase quality. (many times it even has negative value, as reassuring a patient of being healthy when they aren't).
Fundamentally, if preventative cares are good people will naturally choose to invest in their own health. There is research showing that people are pretty good about healthcare utilization if they bear the cost (except poor peoeple)
So not cheaper.
> It won't, and it shouldn't. Patents for pharma don't preclude successful implementations of universal healthcare anywhere else.
> By regulating fees for services, by lowering the price of drugs via negotiation and bulk purchase agreements, by eliminating marketing budgets, by eliminating insurance billing departments and by capping executive compensation. Hospitals and doctors are public servants elsewhere in the world, not elite rockstars who can bill as they so choose. That doesn't mean they're not well compensated.
Rationing. (It makes it cheaper, but also reduces the amount of care given out). Shutting down hospitals is probably not the way to go on the space, but its one way to reduce spending.
> By having a single table of rates that apply to everyone. Ideally with a single payer. This makes billing much, much easier.
Also rationing. If you have a single table of rates, you can get 3 results: you pay less than today, and thus you will have rationing of services (for example, less convenient locations, less services, etc), you pay the same (so no gain) or you pay more (more spending). Billing is a big pain, but billing medicare is the biggest pain of all. Medicare pays less and has more admin costs for providers, which is a big part of why its not covered.
Its virtually impossible in the US to force doctors into single rates, so what you would get is that insurance has very low coverage, and cash-pay will dominate healthcare services.
> Everything I indicated above put together. If you want a concrete example Medicare does most of the above (they can't negotiate drug prices, and they're not single payer, and they haven't socialized malpractice insurance) but they're substantially more efficient. Medicare spends 2-5% of the budget on administrative, where private plans spend 12-18%. That's without recognizing some of the other savings I pointed out. 
Medicare uses these statistics with great trickery. First of all, medicare does not do collections administration: its hidden in other government agencies that collect the payroll tax. Second of all, these statistics have some other biases like using total cost of spending but not per patient, where medicare is actually not that much ahead. And finally but not least, what people will always love about medicare is that its dirt cheap to the patient: the average social security benefit is 1400~, and the standard premium of medicare is 135. But turns out that medicare costs about 11k a year per patient: if you took away 1000 out of those 400, you would not find great support for medicare from retired people!
Finally but not least, medicare services have severe rationining elements, and potentially cost shifting: doctors make 1/2 with medicare than without. This means that: doctors that offer medicare are the ones starving for patients, and doctors that take a bit of medicare are actually putting some of the cost unto regular insurances.
America’s at the bottom of the OECD for many of these things, and at the top by a country mile for cost. 
There's no medicare statistics trickery lol, all those government services being leveraged have to do almost nothing incrementally to support medical fees. They're still collecting payroll taxes, they're still collecting income taxes, one way or the other. By your own measure this makes the work they do duplicative of the insurance industry making the insurance industry the wasteful one. This is also failing to take into account the waste of employers managing employee healthcare -- why on earth are they doing that?
OF COURSE medicare is expensive we already addressed that in another thread. The US doesn't have free market healthcare. The young, healthy and cheap are forced into expensive market plans, privatizing the gains, while the old, sick and poor are handed off to the government to look after, socializing the losses. It's absurd. The young, healthy and wealthy should be paying for the old, sick and poor. You can’t saddle the socialized program with all the worst customers, hamstring it’s ability to negotiate drug prices then point to how much it costs.
Doctors in Canada make hundreds of thousands of dollars per year providing socialized cover. They're civil servants. They do fine. So what if it's less than doctors are paid now, the question is are they compensated fairly, and they are.
Last I couldn’t help but notice you totally sidestepped my point about reduced costs by offering preventative care.
Why doesn't medicare, the already socialized medicine of the US, have the same results as socialized medicine in other countries?
> There's no medicare statistics trickery lol, all those government services being leveraged have to do almost nothing incrementally to support medical fees
You could also use payroll taxes to pay private insurance, that's not a benefit of medicare, it's a benefit of the current tax implementation that is granted monopolistically to medicare. I know of at least one country that collects payroll taxes that go to private health companies.
The question is: is medicare administration truly cheaper that private administration for the same service.
> This is also failing to take into account the waste of employers managing employee healthcare -- why on earth are they doing that?
Because the federal government makes it tax exempt to give healthcare through the employer, which is a 260 billion a year regressive tax benefit, denounced and criticized decades ago by prominent economists. You dont need to socialize medicine to stop that, you just need to stop handing out federal money. In fact, the tax-subsidy is higher than the combined profits of all insurance companies together.
> The US doesn't have free market healthcare.
Glad we agree on that one!
> The young, healthy and cheap are forced into expensive market plans, privatizing the gains, while the old, sick and poor are handed off to the government to look after, socializing the losses. It's absurd.
The poor also pay medicare taxes for the rich. The sick that don't make it to retirement ages pay medicare tax their entire life and die before receiving any benefit. Taxes always have this thing that they make things unfair for someone by law.
Adverse selection and information asymmetry are real issues, but socialized medicine brings other issues like reduced coverage, rationing, etc. I am always surprised how the debate over healthcare ends up being arguing about capitalism as a method of efficient economic organization. It works for almost everything else, yet the arguments for socialized medicine are like arguing capitalism doesn't work. Its bonkers, and easy to refute because otherwise you would have to argue the same for food, for education, for transport, for everything, and none of those work better run by the government.
> ...Doctors in Canada make hundreds of thousands of dollars per year
To make doctors in the US root for socialized medicine, the state will have to offer greatly increased income. Thats how it happened historically in europe a century ago. Considering the AMA has killed socialized medicine laws multiple times in history, I would say the "screw the doctors" policy has a high chance of failure.
Again, we addressed this. It's literally all the old, sick and dying in a single pool allowing private insurers to be profitable. It's not comparable. It's like asking why a government-run fire insurance program that takes in only buildings that are already on fire is expensive. They only insure buildings already on fire against fire damage and they're not allowed to negotiate the price of water used to put the fires out. That's not how risk pooling works. It's not insurance, it's just a structured payouts program for the country's worst customers.
>>> You could also use payroll taxes to pay private insurance, that's not a benefit of medicare, it's a benefit of the current tax implementation that is granted monopolistically to medicare. I know of at least one country that collects payroll taxes that go to private health companies. The question is: is medicare administration truly cheaper that private administration for the same service.
Now the government is being leveraged to further enrich private industry instead of the people. The incremental cost is almost nothing. The only distortion of statistics here is that the private insurers don't have to deal with bad customers because they get socialized away (poor to Medicaid, old and sick to Medicare). I'm pretty sure you're thinking of Switzerland, which is the second-most expensive country in the OECD (they still manage to cover everyone, though).
And yes, it's cheaper, every other country shows that. Even the "$32T" cost estimate of medicare for all is actually lower than what's being spent today over the same time period.
>>> Because the federal government makes it tax exempt to give healthcare through the employer, which is a 260 billion a year regressive tax benefit, denounced and criticized decades ago by prominent economists. You dont need to socialize medicine to stop that, you just need to stop handing out federal money. In fact, the tax-subsidy is higher than the combined profits of all insurance companies together.
Yes I agree, it's regressive and should be removed. Socializing cover is good for other reasons as stated above.
>>> Glad we agree on that one!
>>> The poor also pay medicare taxes for the rich. The sick that don't make it to retirement ages pay medicare tax their entire life and die before receiving any benefit. Taxes always have this thing that they make things unfair for someone by law.
Yep, that's not ideal. It should be charged progressively like it is in other countries.
>>> Adverse selection and information asymmetry are real issues, but socialized medicine brings other issues like reduced coverage, rationing, etc.
It doesn't, though. Rationing is fine. There's either not enough to go around or you make the pool bigger, both are options. It's explicit, it's done fairly and it's done impartially. Rationing by making care too expensive is cold and unfair. I'm also unclear on why you think there's a finite pool of medical care.
Either way your argument holds no water when every other program in the OECD is socialized, cheaper, and performs better on every metric.
>>> To make doctors in the US root for socialized medicine, the state will have to offer greatly increased income. Thats how it happened historically in europe a century ago. Considering the AMA has killed socialized medicine laws multiple times in history, I would say the "screw the doctors" policy has a high chance of failure.
Doctors in Canada hated the idea of socialized medicine in the 1970s too. You won't find a single one speaking out against it today. It was a huge fight. And yet, the entire country loves their system. Everyone in America hates theirs. There's something to this. Take a deep breath, it'll be okay. 60-75% of Americans are now interested in a public plan .
Tommy Douglas who championed socialized medicine in Canada was in 2004 named the greatest Canadian haha. 
FWIW, a socialized option does not preclude private care. Single payer isn't the only way forward, many European countries offer two-tier care. Australia offers two-tier care. If you're so sure that private care is less expensive, better and more efficient, why not allow it to compete with a government run plan? I speculate that it's because it's just not.
Sorry, man, you're on the wrong side of this one. The evidence shows it.
So who should pay for it? All taxpayers instead? All countries that have tried that are now in the red. The only good solution, I think, it to work to make healthcare a lot cheaper in the long run.
The pure, brute facts show that taxpayer-funded universal health care is a vastly superior means of making healthcare accessible, effective and less expensive than any other setup, especially the American one. Your health care system is an insane joke that annually kills tens of thousands of Americans needlessly.
Why does it have to be an every-state solution?
Why don't they? There's a lot of people in CA and NY who don't think it's more affordable and better, notwithstanding 20 or 30 countries who have done it successfully. The private insurance industry is, understandably, a huge lobby against it since it would likely reduce or eliminate their business (the mandate to buy insurance, under Obamacare, was pretty explicitly a payoff to the insurers to accept it because they would receive a huge influx of new customers), etc.
- true, the US is producing about ~50% new drugs (sometimes more, sometimes less). Europe and Japan account for the most of the rest of the drugs . The reason is simple: these are wealthy countries.
Also, it's usual when comparing countries to restrict one's comparison to economic peers. If Lesotho or Vatican City aren't funding drug development, this doesn't say a lot about the relative merit of the U.S. system.
Let's compare/contrast your own countrymen. The Department of Veterans Affairs (colloquially known as "the VA") is entirely funded by the US budget. Guess where the US budget comes from.
The VA, among many other services, provides "free" healthcare to veterans who are 50% or more disabled. Sure, it's not entirely universal healtcare but...
Then we look at the Children's Health Insurance Program (colloquially known as "CHIP"). Again, not entirely universal healthcare. However, the federal government matches states governments fundings and the program is designed to reach the poorest (children) in the nation.
Then, of course, you have Medicaid.
Essentially, for the disadvantaged, there is some level of concern and you have an approximation (if not out-right full) universal healthcare for some of them; otherwise, enter the "pull yourself up by your own bootstraps" mentality comes into play.
Apologies for the seemingly long diatribe of a soapbox but it seems hypocritical to say that taxpayers paying for healthcare is a bad thing when you - quite literally - do it for a sub-group of your populace.
>The only good solution, I think, is to work to make healthcare a lot cheaper in the long run.
As a comparator, surgery to remove a lipoma in the Emerald Isle costs about 800 quid but this cost is about 1,725 quid in the states.
So, there's an argument to made that Universal Healthcare can make the overall costs of healthcare far cheaper.
...and this is not to mention the gratuitous amount of money you'd be saving on the budget by condensing all of those government departments down into a much smaller government, yeah?
 - https://www.va.gov/budget/products.asp
 - https://en.wikipedia.org/wiki/United_States_Department_of_Ve...
 - https://en.wikipedia.org/wiki/Children's_Health_Insurance_Pr...
 - https://en.wikipedia.org/wiki/Medicaid
 - https://www.citizensinformation.ie/en/health/health_services...
 - https://www.realself.com/lipoma-removal/cost
Would an ideal healthcare system cover in vitro for anyone, full stop? Took a buzz through the NHS requirements and there are definitely restrictions. And in vitro is certainly not an uncontroversial procedure.
I just thought that was a strange example to use. There are always going to be gaps in what a health system will cover, right?
There's always gonna be a market for crowdfunding health stuff, and that's not inherently a bad thing. (Which is my only point, not trying to comment on the broader issue.)
Compare to the US where only a dozen(ish) states have requirements that group insurers offer infertility coverage, and those dozen are all over the place. California doesn't require IVF coverage while Illinois does. If you buy a Marketplace plan, I guess... sucks to be you, zero coverage.
Anyway, I will say that literally all of my reproductive health issues that were causing issues elsewhere in life were uncovered in the process of being diagnosed with infertility after literally 15 years of a dozen doctors that had no fucking clue, and that it's a big shame that not even that is covered for a lot of people in large parts of the US - which is a far cry from covering a $20k+ IVF cycle.
There's parent nights out and dates with my partner to rant about toddlers being shits that are nice to have, but my fertility clinic has an MFT on staff and my old fertility clinic had referrals out for therapy and support groups facilitated by therapists. After almost 18 months the first time, too, I worked out a lot of depression and anger through 1:1 therapy weekly for months. I'm heavily relying on those old coping mechanisms, this time around.
Just. does. not. compare.
Obviously, it is not clear cut. At the very least likely there is an upper limit how many citizens country can support, but certainly, it is not a 100% undesirable for the state to fund such procedures.
The question of what reproduction society should support is entirely distinct from that of getting health care for your reproduction.
The same thing is happening in education: universities know that a large percentage of students are getting financial aid, so the true costs are buried in a layer of bureaucracy.
Fees and administrative fees continue to go up and the universities will always get their money.
The students are then on the hook to pay the loan back. If the Universities actually had to worry about students defaulting, they would be forced to reduce costs or they would go under.
This is not correct. Insurance is a very valuable service to prevent high-risk events, and applying insurance is a very hard problem. You need to do economics, operations, fight fraud, etc.
What does create price insensitivity (and thus doesnt allow for the competition that drives down prices and increases value to happen naturally) is that you use healthcare for menial transactions like annual checkups or sick visits. I find it incredible when people complain about the 150U$S annual fee on OneMedical, when a basic check-up visit is billed between 300 and 500 dollars. Or when people get surprised that a cancellation fee for a primary care visit is 100 dollars, when "their copay is only 20 bucks".
In addition, another thing is that its tied to the employer, which means that you dont get to choose the insurance you want. If people had to choose their own insurance, insurances would cater to patients not to companies. This is probably the single most important change to do on healthcare reform, and one thing both Bernie Sanders and Republicans could agree with.
Given a choice between death and bankruptcy, most people will choose bankruptcy. There is no downward pressure on the cost of medical care because there is no alternative. It's a situation that capitalist market dynamics are just not equipped to address.
A state-run apparatus is the only thing that seems to work.
> Given a choice between death and bankruptcy, most people will choose bankruptcy. There is no downward pressure on the cost of medical care because there is no alternative
This is a common trope in this debate, but its not an economically sound argument. First of all, people choose this all the time: a european person does not sell their home and get indebted to pay for a trip to the us to get bleeding-edge 1% rate of success medical care for his unique condition. Second, its not medically sound. Medicine is absolutely practiced with economic considerations in mind. Care is not the same in the U.S. than say, an African country with hospital shortages. The doctors recommendation changes based on the patients sensibility to prices (for example, a doctor will not recommend highly expensive vitamins to the unemployed, or wont indulge in expensive out-of-coverage procedures for people who would find great economic suffering for the test alone).
This latter part is a key missing education link that for some reason the public seems to misunderstand. Its strange because in actual education people understand that prices give different qualities, but someone reject the idea that healthcare doesnt behave that way.
I have other counter-arguments to this notion of downward pressure, but fundamentally what makes prices low is competition. Any one would prefer bankrupcy to starvation, but thats not a problem with food isn't it.
People should be getting insurance from insurable events - i.e. accident, heart attack, etc. Not from routine vaccination, annual checkup, seasonal cold.
High-deductible plans are a hack to get people to pay for more of routine stuff and I think it moves into the right direction.
There is no up-front price. There is no market pressure. You still don't know what you will need to pay until weeks or months later.
In this way the insurance is actually an insurance like a car insurance, and not some bastardized medical payment plan where incentives of different parties aren't aligned.
I feel like you lump in a lot of preventative care in that statement. If your routine checkups / vaccination prevent necessary emergency care and thus save money down the line, not incentivization people to do so seems stupid to me. The insurance company would have to pay for it regardless, unless they manage to cut those cases from the body of their insured. That would feel a lot like preexisting conditions to me...
Having individuals pay for vaccinations also ignores the value of lost herd immunity, due to a prisoners dilemma like situation. But this mean vaccinations have to be provided by insurance. Directly funding it though tax money might be a better option.
"When the time came for his second round of DTaP, doctors talked with the family about the need for vaccinations. Surviving tetanus, unlike some other diseases, does not offer immunity in the future.
But despite an “extensive review” of the risks, and the benefits of vaccination, the article said, the family declined the second vaccination — or any other recommended immunization."
You need to be up to code to the last detail, you will be under scrutiny for your documentation, you have no bargaining power and medicare pays 20-50% less to providers than private insurance.
It is also not the same as PPO's (which most employees in HN must have) you will have a lot fewer options for care. (remember, you can only get a doctor that collects a much smaller fee, so forget about swanky offices and convenient locations)
Edit: not sure why the downvotes, that’s the reality of things. If you want a more fully fleshed out thought, here you go:
We would all contribute to the payment of expensive operations via taxes in a single payer system. In the current system we have insurance payments. It’s effectively the same, paying a small fee regularly, to subsidize the costs for expensive procedures for yourself and (surprise) others. What do you think happens if you pay into insurance your whole life and never need an expensive operation? You’re subsidizing others. Otherwise the insurance companies would be out of business.
But with single payer, we cut out companies in the middle pulling a heafty profit for effectively the same system as we could get via taxes.
That's just insurance, managed by the state.
> But with single payer, we cut out companies in the middle pulling a heafty profit
Oh boy. Lets say I concede, for the sake of argument, that government can run a private business with the same efficiency, and that the profits it would make as private are given back to its consumers (healthcare.gov cost almost 2 billion dollars to make, remember that. Or Blue shield is actually a non-profit, and its not gobbling up the space by reinvesting its supposed profits).
To add to that, the profits of healthcare insurances companies are not that large: they have a 6% operating margin, lower than other insurance companies. Cumulatively, the big companies must have around 20~30 billion dollars a year in profits. It's a staggering number, but in the healthspace thats nothing: only the subsidy of tax-exemption for insurance benefits is estimated to be 260 billion a year. You could eliminate that benefit and expand medicaid: but that would help the poor, and wreck the rich and the middle class together, which is often politically unfeasible.
As Steve Jobs said about Dropbox, you’re a feature (insurance companies) not a product.
Thats perfectly reasonable, but no need to make a single payer system for that. Just allow medicare to compete in the open market. Thats a much smaller program with a lot less risk.
Unfortunately the chances of such a plan to succeed are nil. Thats why big healthcare reform proposals want to strong-arm the position, with single-payer proposals. Its true medicare is popular, but remember it's free insurance for its patients today. If you eliminated the medicare payroll tax and made it a monthly payment, I assure you old people will not have the same opinion on the topic.
Unsurprisingly, private health insurance is not very popular here. It’s mostly just something people get through work.
And I’ll remind you that we spend less per capita on our healthcare than the US does. I’m sure that if there was actually demand to meet that spending, private insurance here would happily eat it up - but there just doesn’t seem to be.
Given that we spend less money on healthcare than countries that do have healthcare “on the open market” like you suggest, I’d say this is a system that obviously works.
If there were an imbalance between what those countries provide and what we provide, and people were willing to pay for it, you’d see private healthcare providers successfully taking more money (up to what Americans spend) to make up the gap in service - but they’re not. Do you have an explanation for why that’s not happening?
> Given that we spend less money on healthcare than countries that do have healthcare “on the open market” like you suggest, I’d say this is a system that obviously works.
Sorry but this is a ludicrous claim. Argentina spends 2% less of GDP than the UK, and 70% of its care is private. And not only that, it gives free healthcare services to other countries, including organ transplants.
I know this because I’ve already heard HR complain about too many pregnancies in a year caused the company contributions to go up.
Everyone pays because everyone should pay.
But if everyone pays the same you just conceded the entire victory to adverse selection: people that do not participate in a risk pays for the risk in someone else. The most obvious demonstration of this effect is double-paying in countries that have both private and public healthcare services: you pay twice, once for the public you don't use, and then for the private one.
Most countries with public healthcare have a private supplement that build on top of what the national system already provides: in home care, private hospital rooms, dental and vision, and concierge service. I've yet to see a private system attempt to replace a functional public system.
Most that I know of. Unless the state has absolute monopoly on primary care providers/General practitioners, you will have both systems in place.
Yes, that is what single-payer means. There is no parallel payment. You pay for basic service through taxes. You pay for better service through private. Private insurers like BUPA can only extend healthcare options. They don't replace it.
I dont think its palatable in the US to make policies that could increase national healthcare spending.
From my point of view, lowering the expense is the #1 priority. Expanding coverage, and adding new layers of taxation for it will increase expenditures.
There are also many alternatives to adverse selection, my favorite is high deductible plans.
A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits.
The solution has hit negative marginal returns though and the only way out is a more fundamental change to health care, possibly in the form of price controls on drugs or the 150% of Medicare reimbursment maximum price on all procedures. This sort of predictability of costs will obsolete a whole layer of insurance price game players at the hospital and insurance companies that add to health care costs.
Do I feel guilty? Not really. But the lesson is that the number you see on some bill from a hospital or provider is not non-negotiable, and in general unlike the IRS they don't exactly have any power to garner your wages to collect.
If you find yourself in a position where you're getting some ridiculous bill, you should definitely hire a trusted lawyer to negotiate down a bill on your behalf.
1. Ignore all bills except the most persistent ones. Look at which ones are still being sent 3 months later.
2. Triage and sort the bills. Prioritize the ones that are related to the primary care facility where you were treated. Call them and negotiate to pay less.
3. Wait until 6 months and see if any bills are still coming. If they are, look at them again in order of priority, seeing if any of them are still reasonable and you have actually received the service/care.
After 12 months, if you haven't been receiving any care, toss any bills.
I have some notes to write about "the predicaments of old people". Both my grandfathers lived an extra few years thanks to the pacemakers Medicare paid for. But they just suffered for those final years.
A lot of old people's problems are related to excess alcohol consumption. IMHO, there would be much more funds available to spend on the gaps experienced by younger people, if doctors assumed their elderly patients are drinking heavily and treated them for that instead of blowing the programs' budgets on treating the down-stream effects of heavy alcohol consumption [edit2].
I have some friends who lived in Canada for a while. They said the Canadian system doesn't go all-out to keep people alive who are going to die anyways...
A few years ago I stopped by to see one of the passengers whom I'd given a free ride to a few years before. She told me she was pregnant. "But I thought you were becoming a man?" She wasn't a he yet, and she'd gotten with a cis-male... They'd called it off before too long, but that's how she'd gotten knocked up. She also said it had a heart defect (she was maybe 4 months along?). This was caused by the hormones she'd been taking to transition.
I was pretty sure the baby wouldn't survive long, but didn't say anything... I followed them on teh Facebook. ... Scheduled c-section, a half dozen heart surgeries, after maybe four or six months the infant died anyways.
I think other countries' health systems are more careful about how they allocate their health resources .
 How Cubans Live as Long as Americans at a Tenth of the Cost - https://www.theatlantic.com/health/archive/2016/11/cuba-heal...
[edit1: minor edits]
[edit2: changed this from quip about keeping people alive for an extra month or two]
Yeah, when you can go for free to a doctor your entire life and your prescriptions are free or subsidized because the government can negotiate prices in bulk, the end result is that you get better results spending less.
It's not perfect, but it leads to a better outcome than when people only see a doctor when it's an emergency because they are too afraid to go bankrupt or because they are poor enough that they can't even pay for a simple visit to do an yearly check up.
So there's no market for cheaper but somewhat less effective health care?
Given that medical bills are the number one cause of personal bankruptcy in the USA, it seems really odd that all those people who's lives are getting seriously messed up by this wouldn't want some form of cheaper health care, even if it wasn't the no.1 most effective option.
There are nuances. The insurance model trains people to not care about the cost of the services they receive.
> So there's no market for cheaper but somewhat less effective health care?
I think healthcare that focuses on actual problems instead of downstream problems is more effective in addition to being cheaper.
Unless people just expect 'the rich' to pay for everything.