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GoFundMe CEO: ‘Gigantic Gaps’ in Health System Showing Up in Crowdfunding (khn.org)
244 points by aaronbrethorst 9 days ago | hide | past | web | favorite | 281 comments





I like to write short stories in my free time.

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.


The show Undercover Boss is kind of like that. Every episode some CEO realizes that all of their employees are underpaid, picks one with an especially sad story, and gives them some money to pay for their kid's surgery or college tuition.

I thought the same thing. And they never seem to come to the realization that maybe a lot of their employees are underpaid. No, it's just the ones with stories that go best with violin music playing in the background.

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.


The CEO was a the son of the founder, and was very shy and not very competent for sure. The manager deserved to be fired for sure and probably more.

I think you need to take what you see on reality TV with a grain of salt. That's the size of the moon.

So Hooters worked with the tv show to paint an extremely unflattering picture of their business? Or the show misled viewers and Hooters made no effort to correct the record?

So you think what was portrayed was wholly accurate with no spin?

There's an interesting book on this topic of individualized philanthropy by the powerful and its effect of masking the deeper systemic problems. It's called "Winners Take All" by Anand Giridharadas.

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.


Google is a good example. They start with search. Become king of the search hill and then search goes into the background. Are the people running Search in charge of Google? Nope. The empire defense people get put in charge. Who then spend more time and resources on Chrome and Android. They don't create knowledge. Humanity does. But the empire defense folk, get it into their head they need to own the knowledge graph and rent it out to humanity. No questions or debate. Now imagine if StackOverflow or Wikipedia decided to pull the same bullshit.

StackOverflow was created in response to Experts Exchange, for which I am thankful. It doesn't work forever where information is concerned. Information wants to be free.

For those interested, he held a Talk at Google about this topic: https://www.youtube.com/watch?v=d_zt3kGW1NM

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.


or as Johann Heinrich Pestalozzi put it: "Charity is the drowning of rights in the shithole of mercy."

The fact that it disturbs you so much is indicative of its value, I think. A lot of people were disturbed by the first Black Mirror episode, but I think it had less to do with the inherently disgusting conceit and more to do with how undeniably realistically events unfolded. It disturbed us because it shone a light on an aspect of our being that should disturb us, and we'd otherwise be content to ignore.

Jesus, this blew my mind. Not because the concept is outlandish, but because it wouldn't surprise me at all if it actually existed, and I think it would be immensely popular.


Yes! It was supposed to be over the top satire with a comical tone, but then it just ended up depressing me because it started to feel far too realistic...

FWIW, it's not just you. And it's not new.

"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

http://www.antipope.org/charlie/blog-static/2008/09/avalanch...


Well Black mirror process this is untrue. I don't think I could be a writer for that show though, just watching it makes me sick.

It reminds me a bit "Running Man" by Stephen King. I think King probably had the better idea by having the audience be able to punish wrongdoers instead of helping the downtrodden.

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.


I think the reason a reality show for funding healthcare is so plausible is that it would be filling a gap left by a corrupt and failing system. I don't think anyone believes that there is a gap in the administration of law enforcement and punishment in the US.

> I don't think anyone believes that there is a gap in the administration of law enforcement and punishment in the US.

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....


I haven't seen an internet discussion yet where, whenever a gap is identified, somebody doesn't say something like "How can these people get away with this! There should be a law..." or something similar.

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.


I had seen The Running Man (https://en.wikipedia.org/wiki/The_Running_Man_(1987_film)) but didn't realize it was set in 2019! That silly trivia aside, it sounds like your would be a great short story in the rich tradition of dystopian art and literature.

I too immediately thought of The Running Man.

Reminds me of this comic from a few weeks ago: http://www.smbc-comics.com/comic/speciation

Your idea of people competing for who has the biggest sob story is pretty much exactly the 1950’s TV show “Queen For A Day” (except that the studio audience did the voting).

Incredible, turns out I'm WAY behind the times I guess! - I had never heard of this before.

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

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


Oddly, the only hard to believe thing I see about that scenario as an actual, real thing in the US’s very near future is the use of bracket style voting rather than whole-field voting where some number are eliminated each episode.

That would violate a strong trend in the reality competition genre.


Well, the entire genre is built around the concept of competitive elimination.

Do it with access to healthcare and you sure turn the intensity up on elimination.


> Well, the entire genre is built around the concept of competitive 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.


There is actually a real game show on TruTV like this except for student debt

https://www.trutv.com/shows/paid-off-with-michael-torpey/ind...


Not exactly this, but in Brazil there's actually a TV show called "In the red", where the requirement for being a contestant is that they must have debt that they can't pay off. The winner gets to pay off their debt, losers go home empty handed.

I will be down-voted to hell, but I have worked in health insurance company. Large insurance companies have doctors and layers that basically sit down and make decisions about how much they will pay (if ever) for treatment. Your scenario has real life basis.

Isn't that how it has to work, if you want your insurance premiums to be finite?

In normal countries treatment guidelines are set by an independent committee of physiciant and ethicists. Britain has the NICE committee. Having the insurance company decide on what treatment will be paid only guarantees infinite payouts to the CEO.

As far as I know NICE decisions are public whereas in the US you can’t know whether they will decline you or not. No transparency

> I have worked in health insurance company

Well I'm convinced.


Please don't post unsubstantive comments here.

This is very much the premise of the Judge Dredd story 'Sob Story' about such a game show, in which the character Otto Sump first appears - https://en.wikipedia.org/wiki/Otto_Sump http://dreddalert.blogspot.com/2013/12/judge-dredd-sob-story...

I saw a couple people link to the student debt stuff, which is way more relevant, but it reminded me of the Latin American community having Gana La Verde[0] since 2004.

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.

[0] https://www.imdb.com/title/tt0421032/


Please finish that story! It sounds really good, reminds me of a Black Mirror episode.

One thing I’ve been studying a lot on my free time is the deep history of the concept of socialism. Not a particular implementation but the idea that it would be a good idea for us to intentionally build a world where everyone has certain basic needs met by society at large. In particular there is a rich history of “libertarian socialism” which advocates for direct social support of one another without a state. Typically it is advocated that this be done via organizational structures that do not require any individual to reach in to their pocket when another is in need, but by arranging society such that things like medical care are simply abundant, and only ever putting effort in to unnecessary developments (luxuries) once the basic needs of all people have been met. Obviously doing this is nontrivial and could only be achieved through a long process of repeated democratic decision making.

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): https://youtu.be/kBP_BMOblzc

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: https://youtu.be/wS3-PffLKqM


Most people's gripes about socialism are about central control. That's a vital part of the policies proposed by the left in the USA, especially the Green New Deal. And the worst aspect of Venezuela.

"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.


Most people's gripes about socialism are senseless whataboutism. "But Venezuela!"

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 definitely want to read the Disposessed as it has come up a few times in discussions lately.

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.


“Libertarian socialism” in the historical literature is synonymous with “anarchism”, and that is my intended usage. Contrary to popular belief, anarchism is a specific idea for the organization of society that typically advocates for worker control of the means of production, direct democratic control of society, mutual aid between people, care for those that need care (“to each according to their needs”), and disintegration of most of the hierarchies of our current world.

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.


If someone can figure out how to fix the free rider problem without central control I think everyone would be happy. The problem with the libertarian solution -- purely voluntary charity -- are that a) it is proportional to sympathy rather than need, as many are observing above and b) it amounts to a tax on the generous and a self-reinforcing transfer of economic power and opportunity to the least pro-social members of society. The latter is the free rider problem. When people look back on the golden age of the 19th century or whenever when charity was voluntary, they're remembering the comfort of the fortunate, not the success of this system at buffering the shocks of misfortune.

I don't see how using the state for welfare guarantees a better solution to (a)? It's just that in a democracy (a) goes by sympathy of the voters instead of sympathy of the rich.

Well, there’s libertarians and there’s libertarian socialists, and the latter focus hard on how to solve these problems. I’d say first of all that we haven’t solved these problems under capitalism so we only need to beat what we have, and also that I am a robotics engineer and I believe robotics can be used to provide a basic level of material well being to all members of society and free up people like doctors to see whoever needs care without charging them etc.

My current world view is that socialism implemented via central authority ruling over a very large group (i.e. socialistic government of USSR) is not working, because personal relationships connections are broken when helping each other is outsourced to some abstract entity. It is that entity being praised and hated when someone gets help or someone doesn't. The fact that it is neighbors, other region people, etc actually are involved in that is lost. No longer you can shame your neighbor for not helping a neighbor, or when they help - they get no word of appreciation. It is all abstracted away behind "They" - "why They did not fix roads?", "They healed my child from cancer", "They produced enormous GDP". This is the opposite of "my neighbor took my wife to the hospital when her waters broke and my car broke too", "our neighborhood resurfaced our road".

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...


This is a very interesting idea. I've been thinking that one of the big problems with government today is that most people do think of it as a 'they' instead of an 'us', but I think the reason is more complex than personal relationships being broken.

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 totally agree and trying to point it out all the time when I hear "they". But the reality is - when some person sits looooong away in Washington and makes some rules - they are hardly connected to the people they represent. Smaller and more compact governing bodies I think would resolve the problem, where we would still get a benefit of a dedicated person working on organizing life in the region, and yet not too disconnected to be called "they".

> But the reality is - when some person sits looooong away in Washington and makes some rules - they are hardly connected to the people they represent.

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 tech people embrace micro-services despite complexity trying to arrange things to work. We do it because this way we are forced to deal with it, to negotiate between teams and services. We embrace that complexity and uncover it.

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.


I don't think it makes it look like it's not happening, but it is easier to manage some things at higher levels than others. If you're a business, every single governmental entity you have to deal with adds complexity into the system. You need to keep track of various sales taxes, regulations, etc. Increasing the number of jurisdictions you have to deal with increases the complexity quite a bit.

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.


What you are describing is mostly independent of socialisms in the sense of 'who owns the means of production'.

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.



Are you sure there aren't any TV shows that fit that dystopian game show description already? It seems like a no brainer winner for TV stations -- it's a glorified lottery mixed with lots of emotions, and bonus revenue if users vote by SMS. Surely some producer did that somewhere.

Sounds like a black mirror episode? Maybe submit it?

Yeah this could definitely be one..it's a lot like the bicycle episode though so not sure they would do it so direct. Maybe they would make one about the stories of individuals who start the crowdfunding campaigns and how they're interconnected, like shut up and dance.


Came here to post this. Go Fund Me for health, best sob story gets the cash!

YC funded too.


> 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.

Keep in mind the percentage of folks who abuse this method of fundraising, instead of being truly needy.


Citation?

Personally I've seen plenty of crowdfunding initiatives that seem honest, but when looking closely you discover something with less integrity.

As I imagined, this isn't unique to my own circle:

https://www.nbcnews.com/news/us-news/arrests-gofundme-homele...


I think the exact opposite. Without that venue to ask for money the answer is: "get your affairs in order".

What is your answer to heavy health expenditures/


Universal healthcare. It works well in the majority of civilized world.

In universal care you dont get access to 'clinical trials and research and things like that, where people need access to leading-edge potential treatments'

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.


Clinical trials are mostly free for the patients who are chosen for them. But I think what you’re saying is government healthcare won’t pay for experimental treatment (currently in a trial stage). However, that is true even for private insurance here in the US. My regular insurance doesn’t cover experimental treatments. I have a separate add on that pays for some experimental treatments.

Its a direct quote from the article, not delving deep into clinical trials.

Access to leading-edge potential treatments is a minor concern in health care: few need it, fewer qualify, and fewer are helped. Even then, your statement is false: leading edge medical research is carried out in all countries with universal health care.

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.


Can't access, or don't?

Medicaid will pay for prenatal care, and there are other options as well.


Can't. The U.S. has well documented problems with the working poor being unable to afford insurance or qualify for medicare; even if they qualify, medicare is not universally accepted (because it doesn't pay market rates) and there's no legal requirement for medical professionals to do so.

Its a quote from the article.

> government officials are seldom generous

If government officials are using the same healthcare system as everybody else, they have incentive to make it good.


They have the incentive to make the ones they use good.

This idea has shown to not happen in real life. Public schools, for example, do not deliver a "uniform" service.


No, Government officials in the US are afforded socialized medicine. "The Federal Employees Health Benefits (FEHB) Program is a system of 'managed competition' through which employee health benefits are provided to civilian government employees and annuitants of the United States government."

Strange contradiction: you are show a case on how federal workers have an undue benefit in comparison to the population, which is what my original argument was. This program seems to be about selecting insurances tho, not an actual insurance. It's tangential.

No, I'm saying it's strange having the people in charge of the government touting a privatized health program for the entire nation except themselves. If private care was so much better than socialized government care, why are the senators, the house members and everyone in the armed forces so staunchly in favor of keeping their socialized care? Don't you think if socialized medicine was murder and death panels and bad outcomes and high costs, that the senators and house members would be on private plans? Why are they so in favor of staying on the government's program? Is it because socialized medicine is in fact better than private care?

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.


This program is about selecting insurance, it doesnt provide healthcare. It doesnt have doctors that work for the program, its just an insurance selection scheme.

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.


I was mistaken, on two counts. One being the FEHB and what it is, you're right; also the FEHB was replaced with exchanges as part of the affordable care act, although the government does subsidize them. Of course many of them are old enough to end up in Medicare.

[1] https://www.marketplace.org/2017/07/17/health-care/ive-alway...


> where people need access to leading-edge potential treatments'

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.

https://www.bmj.com/content/357/bmj.j2097


I'm not making a judgement on the clinical validity of experimental treatments. That was a direct quote from the article.

Absolutely wrong. There's nothing that says people living under a socialized medical system don't have access to clinical trials. Government is an extension of the people. If you want generosity you vote for generosity. In Canada, where I grew up, it works wonderfully. In the rest of the civilized world, it works wonderfully. There's no reason it won't work in America. Moving to America the scariest thing in the world was giving up my OHIP card (my Ontario government socialized medicine card). Still is, honestly.

> In universal care you dont get access to 'clinical trials and research and things like that...

[citation needed]


The US has substantial incoming medical tourism. If it really were strictly worse to european alternatives (more expensive or lower quality) europeans would not go to the US.

> if it were strictly worse...

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.


It means there are things the US healthcare provides that universals systems don't, and in a practical way that affects people, not purely in the world of ideas.

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.


Do you know what else affects people in a practical way, and not purely in the world of ideas?

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.


I disagree, I think this is the real-world consequence of the US regulatory environment.

How, exactly, has regulation driven the price of a drug we've had for decades up hundreds, even thousands, of percent, most of which increase happened after it was out of patent protection?

Who stops you from buying insulin outside the US and re-selling it in the domestic market?

Fascinating that drugs in Canada are perceived as so much cheaper than in the US, and yet, you know that Canada doesn't have a socialized prescription drug program? Instead, provincial health programs negotiate drug prices. You know who can't do that? Individuals. Also, Medicare.

Purely because of government intervention..

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?


Yes. At some point making tiny adjustments to an overwhelmingly backwards and world-leadingly inefficient system is going to be harder than starting fresh.

Okay, but if the small changes were disastrous, whats the guarantee that the big ones will not be?

Totally different things. It's like saying if I tweak this nob and it goes bad, well, why should I switch to a completely different system three counties down? Especially when that totally different system three counties down works for every other developed nation in the entire world. And also some of the developing ones. You should be defending why the American system is better than every other country in the world in spite of their lower costs, better access and better healthcare and better outcomes across the board. Private care in the US costs two times as much per capita as socialized care in Canada, doesn't cover everyone, and yet Canada's outcomes are better and Canada places higher in WHO rankings.

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.


The american health system is worse than other countries for intense regulatory capture and regulation, thats my assessment and one shared by many economists in the healthcare space. Socialized programs dont resolve that. Having medicare for all does not abolish patent law, or creates doctors out of thin air, or reduces the cost of medical school, those are recognized problems. The socialized medicine plan is mostly hiding away the cost and paying it all through taxes: not making it cheaper. That way, the only way you can do it cheaper is by reducing the state offering.

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.


>> The american health system is worse than other countries for intense regulatory capture and regulation, thats my assessment and one shared by many economists in the healthcare space.

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.


Laws.

Unless "you" doesn't mean someone like me.

But then I do. Just not exactly legally.


As far as I know the FDA will stop you.

Precisely...

[flagged]

conanbatt 8 days ago [flagged]

You need to work on your reading skills.

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

dmitriid 8 days ago [flagged]

Yup. Instead of answering the question “how did regulation make insulin expensive” you did what?

Give an example

It wasn't an example. Instead of answering, you moved goalposts and asked "why don't you import stuff from Canada".

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.


Because the government grants the insulin manufacturer a monopoly over its citizens and enforces it with the law.

The same monopoly exists everywhere because there are very few insulin manufacturers in the world.

Try again.


And I assume that the existence of US to Thailand and India medical tourism means that the medical systems there aren't strictly worse than the US?

The main driver for EU-US medical tourism is the much weaker regulation in the US. In the best case, people from the EU travel to the US for innovative new treatments that aren't yet available in the EU; more often, they're suckered into paying huge amounts of money for quackery.

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

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.

https://en.wikipedia.org/wiki/Clinica_0-19


That doesn't mean those tourists are getting effective or even safe treatment. It just means the US hospitals are good at marketing to desperate and wealthy people.

The funny paradox of argumenting people are stupid is that inevitably you will be put in the same category.

I'm not saying those people are stupid. I'm saying there's an information asymetry that doesn't benefit the patient customer.

Why not? Clinical trials in the US tend to be free from the patient's point of view.

Because governments dont spend nearly as much as private investment into the medical field, and have a very different alignment in terms of costs/revenues.

The second part of the sentence alludes to something I did not intend to imply.


> Because governments dont spend nearly as much as private investment into the medical field...

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.


At great cost to society. There should be no federal funding on this. This is one of the gravest reasons why healthcare is so expensive in the U.S. It subsidizes big corpo, big hospitals, then subsidizes richest employees, eliminating the most basic price mechanisms for competition.

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.


You have a fascinating perspective on medicine and research. Research should be paid for by the people and made available in the public interest. If a private entity does pay for the research they are entitled to protect their inventions for 20 years via the patent program. That doesn't mean buyers or buying organizations shouldn't be allowed to negotiate.

Research should be paid by the people with an interest to pay for research. And the government should put as little stops and costs into that process as possible.

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.


Oh, I see, having a conversation here probably won't be very productive. "If you want to save people, you should just let people try any old untested medical device, procedure or supplement, and wish them the best if that's what they want." That's how you kill people. There'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.

> That's how you kill people.

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.


I wonder what happened to the slope of the graphs for rates of various adverse outcomes over time did right around then, too. I think price, by itself, is an absurdly meaningless metric. If it gets more expensive, but gets better, that's potentially worthwhile.

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.


Imagine if every late-night "male enhancement" pill was instead a cancer treatment. That's what the world of snake oil salesmen was like. That's the world you're advocating for. God help us all if you get your way. It's like how the rivers dont catch fire anymore so we don't need an EPA </scarcasm> I bet you the costs of disposing of dangerous waste products went up exponentially after the EPA was established, and yet, nobody cares because it's better all around.

Out of interest, how do you feel about vaccines?


The world of people advocating for ineffective cures is already here, you have homeopathy, and you also have plenty of actual pharma that have much bigger placebo effects than clinical effects, or the overstated claims about the latest diet, paleo, keto, pescatarian, vegan, vegetarian, gluten-free.

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.


No, I get medication and you get unregulated death pills.

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.


Funny that my unregulated deathpills have nothing to do with yours, but you want to ban them so your meds are cheaper!

You're not giving them insulin either, you're giving them who knows what. That's the problem. Regulations aren't there to hold the little guy down, they're there because life was the worst before, and little by little, we pushed back until it was pretty good.

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.


So you believe the US healthcare system is better than, say, the United Kingdom?

I dont know the UK health intimately to compare confidently. I can tell you what it looks like with Argentina. that has universal care. Normally anyone with a dime goes private. Public is a lower-quality, cheaper service.

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.


No, they absolutely are fixed by universal healthcare, as they are everywhere else on earth.

How is universal care going to reduce the shortage of primary care doctors? How is universal care going to eliminate patents for pharma? How is universal care going to make non-profit hospitals cheaper? How is universal care going to eliminate fee-for-service, which has the administrative costs that are the woes of care providers? How is universal care going to reduce healthcare spending?

Countries with universal care also usually have tight regulations on what can be charged and how.

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.


Medicare is justs as opaque, and also distortive: Medicare costs 11k a year, but retirees pay less than half its cost as it is.

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)


With a high deductible plan they still will give you no estimate or something like "between 1000 and 200000 dollar". All actual prices that got paid need to be published.

Above the deductible it doesn't matter. Below the deductible is easier to manage. Primary care generally has public pricing.

That doesn't match my experience. Do you have direct experience? Your other responses sound more ideological than direct experience.

Yes, for example sutter health has public pricing on their Primary care services (https://www.sutterhealth.org/for-patients/health-care-costs-...). They treat millions of patients so its a pretty big driver.

Price opaqueness is a big issue, but there is no transparency with so much distortion.


Transparency is kind of irrelevant, if I'm bleeding out unconscious somewhere in the street, I'm in no position to make hospitals compete for my business. This isn't buying a new cell phone, these are peoples' lives.

Transparency is important to choose any service and care is one of them. The vast majority of healthcare services are not urgent. There's a case for price insensitivity for emergency care, but that is also resolved by choosing insurance before hand: the same way there is price sensitivity to life insurance.

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.


Well good news! Here's the entire fee schedule for the province of Ontario's socialized insurance system OHIP (http://www.health.gov.on.ca/en/pro/programs/ohip/sob/physser...) and for Quebec's system RAMQ (http://www.ramq.gouv.qc.ca/SiteCollectionDocuments/professio...). Turns out that's not mutually exclusive with a socialized system, some would say it's kind of a cornerstone. Looks like you're coming around after all ;)

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.


Most Americans can’t afford $500 in case of an emergency, which is why high deductible plans are a non starter to provide coverage. For them a $5000 deductible is as good as not being covered in the first place.

Health insurance costs 800$ a month so not having 500$ means you dont have insurance. Thats another level of poverty, for the which there is medicaid and a different set of programs and way to deal with those cases.

That's not true. First of all $800/month is what you'd expect to pay if you were young and healthy and with moderate deductibles. Good luck being older or sicker. The $500 that I'm referring to is $500 beyond what they budgeted for after their monthly expenditures. No, Medicaid doesn't always apply to these people, you should look into it. It also requires extreme levels of financial hardship. Medicaid takes a lien against your house to recover their costs. Not to mention the donut hole for whom having their house taken isn't even an option. It's brutal.

When I said most of America, I meant it. It's fifty seven percent of America. [1] 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. [2] 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 [3]. 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?!

[1] https://www.cbsnews.com/news/most-americans-cant-afford-a-50...

[2] https://en.wikipedia.org/wiki/Personal_income_in_the_United_...

[3] https://www.prnewswire.com/news-releases/us-median-rent-hits...


It doesnt change the math to charge 5000U$S in advance through a payroll tax, than to have a 5000U$S deductible afterwards. The key metric is if the healthcare services are better utilized and are cheaper.

Sorry, would you require everyone get a raise in the amount of their health insurance benefits? Sounds like interventionist overreach into the free market to me. Remember how the 2017 tax windfall for companies would yield huge raises for everyone, but instead, only lead to stock repurchases? What makes you think this would be any different?

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.


(1) How is universal care going to reduce the shortage of primary care doctors?

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. [1] 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. [2]

[1] https://equotemd.com/blog/obgyn-medical-malpractice-insuranc...

[2] https://www.washingtonpost.com/news/fact-checker/wp/2017/09/...


Further to (2) by affording preventative care to everyone, people in the early stages of serious diseases can obtain preventative care and coverage thereby eliminating expensive treatments later on. In the US if you walk into a hospital near death they're required to look after you -- not so much if you walk in seeking preventative care. Imagine if they spent the $5 early on to treat you instead of the tens of thousands when you're near death? It's yet another reason why universal healthcare is a good, cheaper thing to have.

Since you specifically wanted me to answer about this topic: Preventative care has some nuance. Increased preventative services are not necessarily better, there is an actual ongoing debate about annual physicals in the medical community (http://time.com/5095920/annual-physical-exam/)

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)


You're absolutely right about that. Also with regards to increased frequency of tests; finding the inflection point between where the risk and adverse effects of false-positive tests out-weight the benefits of early detection. Point taken.

> 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.

So not cheaper.

> It won't, and it shouldn't. Patents for pharma don't preclude successful implementations of universal healthcare anywhere else.

So not 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.

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. [2]

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.


You can forcefully restate your opinions all day long, but facts are facts. The first world countries that offer socialized medicine do strictly better than the US on basically every metric. Pick one. Access to treatment? Better. Infant mortality? Better. Mothers mortality? Better. Life expectancy? Better (the US used to be 1 year above average, it's now 2 years below, and falling). Bankruptcies due to medical bills? Better. They’re also cheaper. Your opinions do not line up with reality.

America’s at the bottom of the OECD for many of these things, and at the top by a country mile for cost. [1]

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.

[1] https://www.oecd.org/unitedstates/Health-at-a-Glance-2017-Ke...


> You can forcefully restate your opinions all day long, but facts are facts. The first world countries that offer socialized medicine do strictly better than the US on basically every metric. Pick one. Access to treatment? Better. Infant mortality? Better. Mothers mortality? Better. Life expectancy? Better (the US used to be 1 year above average, it's now 2 years below, and falling). Bankruptcies due to medical bills? Better. They’re also cheaper. Your opinions do not line up with reality.

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.


>>> Why doesn't medicare, the already socialized medicine of the US, have the same results as socialized medicine in other countries?

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!

Definitely :)

>>> 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 [2].

Tommy Douglas who championed socialized medicine in Canada was in 2004 named the greatest Canadian haha. [1]

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.

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

[2] https://www.kff.org/health-costs/poll-finding/kaiser-health-...


Read up some more on the Canadian system from the perspective of a doctor in Canada. I'd love your thoughts: https://www.npr.org/2017/09/24/553336111/a-canadian-doctor-e...

> 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.

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.


All the countries that have tried it are less in the red than the U.S. by any financial measure, and have longer life expectancies/lower infant mortality rates/better aggregate outcomes than the U.S., which is typically at the bottom of the scale for first world nations where medical outcomes are considered. And they spend less public dollars per capita than the U.S., which is an ironic twist.

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.


If it's such an affordable and great idea, why don't CA & NY implement it independently of the rest of the states and let their residents utilize the system?

Why does it have to be an every-state solution?


They could, and in fact the medicare block grants in Obamacare are for that purpose. States accepting the block grants expanded access to medicare, massively reducing the number of uninsured. It doesn't have to be an every-state solution, but like any insurance it benefits from economies of scale.

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.


The US is the only major developed country that doesn't have universal healthcare and they are still deep "in the red".

And we spend more per capita in public funds than any country providing public universal healthcare and, IIRC, about middle of the road in public healthcare spending as a share of GDP for countries providing universal healthcare, and then slightly more in private spending on top of the public spending. The US is literally paying, in public funds, for full universal healthcare (or more!), and paying more in private funds on top.

Exactly. Everyone's 'in the red'. What are people getting for that debt, and who benefits? Elite will always be 'elite', but most other countries people don't have to worry about considering bankruptcy if someone gets an illness requiring hospitalization. For some bizarre reason, we've enshrined "health care" as a "benefit" which is only morally accessible by "employed" people who have "good employers".

At least the US is developing new drugs. About 99% of other countries produce none.

- 30% of drugs in the US are funded by taxpayer money [1]

- 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 [2]. The reason is simple: these are wealthy countries.

[1] https://news.ycombinator.com/item?id=19264699

[2] http://www.hbmpartners.com/media/docs/industry-reports/Analy...


Citation?

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.


>So who should pay for it? All taxpayers instead?

Let's compare/contrast your own countrymen. The Department of Veterans Affairs (colloquially known as "the VA") is entirely funded by the US budget[0]. Guess where the US budget comes from.

The VA, among many other services, provides "free" healthcare to veterans who are 50% or more disabled[1]. 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[2] and the program is designed to reach the poorest (children) in the nation.

Then, of course, you have Medicaid[3].

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[4] but this cost is about 1,725 quid[5] 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?

[0] - https://www.va.gov/budget/products.asp

[1] - https://en.wikipedia.org/wiki/United_States_Department_of_Ve...

[2] - https://en.wikipedia.org/wiki/Children's_Health_Insurance_Pr...

[3] - https://en.wikipedia.org/wiki/Medicaid

[4] - https://www.citizensinformation.ie/en/health/health_services...

[5] - https://www.realself.com/lipoma-removal/cost


The US is deeply in the red and has per capita the highest health care expenditures by far. Universal care saves money.

We all pay for it now, just not necessarily through taxes.

We also pay for it now through taxes: uncollectible medical debt from those who can't afford to pay their medical expenses will be written off at tax time.

>Or the Tennessee couple who want to get pregnant, but whose insurance doesn’t cover the $20,000 worth of “medications, surgeries, scans, lab monitoring, and appointments [that] will need to be paid for upfront and out-of-pocket” for in vitro fertilization.

Would an ideal healthcare system cover in vitro for anyone, full stop? Took a buzz through the NHS requirements[0] 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.)

[0]: https://www.nhs.uk/conditions/ivf/availability/


Agreed. Were the US to adopt a system similar to the NHS, I would hope that electives like IVF would continue to not be covered. Presumably it was chosen because the number is more shocking than the typical $500-2,000 request to cover a deductible or the less kindly viewed request to cover living expenses during a medical situation.

[deleted]

That’s the same link as the one in the comment I replied to.

Missed it due to being cut off on mobile. My apologies.

NHS coverage is a mixed bag. Other countries that offer full coverage of at least one cycle would be Sweden, France, and Belgium. A good like, half of Europe has some kind of at least partial public coverage of IVF.

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.


From my perspective, it shouldn't. Yes, its cold and heartless to say so, but wanting children isn't a health issue.

Could you not argue that it is a mental health issue?

I feel like people go more crazy as a result of having kids than as a result of not having them.

Speaking as someone with infertility working on kid #2 via IVF right now, nothing positive comes out of wanting kids but not being able to have them. (Also with the big disclaimer that adopting children costs just as much if not more, in some way or another...)

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.


Not being able to have children is clearly a health issue.

How so? Some percentage of everything on the planet is infertile and cannot reproduce, thats just the nature of genetics - why should humans get a very expensive special exception? its not as if we have a shortage of people having babies, or a shortage of kids needing a home either. I don't think you have a fundamental right propagate your genetic material.

This is a ridiculous question and you know it.

I'm not sure I agree. I don't want kids myself, so it would be easy for me to say it isn't important to a meaningful life, but it is a significant biological drive and, in a way, denying someone the ability to bear children is condemning them to a form of death.

Should an infertile couple have a right to a surrogate mother

It's a little annoying that it is so impossible to argue that maybe we should consider an issue more deeply without being pegged to an extreme opposite of the consensus.

The Israeli system covers IVF with almost no restrictions, mostly around no longer funding IVF when it no longer makes medical sense.

https://www.health.gov.il/English/Topics/fertility/Pages/ivf...


True. And abortions are also covered, you just need to pass the pregnancy termination committee.

It just happened that I had a paper discussing IVF vs IVM last week. There are some researches, inconclusive, that suggest that state-paid IVF/IVM is beneficial for the country, as a newly minted citizen on average will produce significantly more in the tax revenue than an original bill for the procedure, even if you consider 1/5 chance of success for such procedure.

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.


It's covered to an extent in Canada. It's something we are working on improving.

Health stuff, including IVF, should not be crowd funded. These are by definition universal problems that will be addressed most efficiently collectively.

The question of what reproduction society should support is entirely distinct from that of getting health care for your reproduction.


You can be perfectly healthy without IVF.

Suicide is a complex phenomena and we should avoid simplistic explanations, but fertility problems are a trigger for some people.

In my opinion, if you can't afford the $20k, you can't afford the kid. In my ideal healthcare system, you'd have to put up a bond to prove financial means before being allowed to have kids.

We need to get rid of health insurance companies. They are the reason all of our costs are massively inflated.

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.


> We need to get rid of health insurance companies. They are the reason all of our costs are massively inflated

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.


You're misunderstanding the problem. Americans are not being bankrupted by annual checkups. Americans are being bankrupted by cancer and other serious health problems. And this is in spite of being insured. In practice, private insurance turns out not to be, as you put it "a very valuable service."

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.


There are multiple reasons why healthcare is expensive in the US. Life ending or multimillion dollar diseases exist everywhere and the reasonable solution to that is insurance: that doesnt make healthcare expensive or cheap, or care good or bad. If you have a cancer that is estimated cost of care is 5 million dollars, neither private nor public insurance will make it cost less, and someone somewhere still has to decide if its covered or not. You cant have unlimited health care, because it requires human beings to deliver it. (at least today).

> 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.


I agree, that in a form current insurance companies exists - i.e. perpaid medical discounts plan, they should be removed.

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.


Except even on a high-deductible plan, the provider bills the insurer, they play their games with the price, and eventually you get a bill.

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.


That's why I called it a hack and not proper implementation. While what you described is true - patients are hit with "real costs" instead of $10 co-pays and rising premiums. ideally - yes, most minor stuff would be paid out of pocket - market forces would immediately put things in a right place. And for emergencies - leave that to insurances.

Switzerland does this right: there is an annual excess (which patients can choose, typically between $500 and $2500, and which is reflected in reduced premiums if you choose a higher excess) which is paid entirely by the patient, and after that the insurance kicks in for 90% of costs up to another threshold, after which the insurer covers everything.

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.


This sounds pretty much what high deductible plans are in the USA. Are there some other differences? Perhaps patients file insurance claims themselves?

> Not from routine vaccination, annual checkup, seasonal cold.

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.


Lack of vaccination/etc should be a "pre-existing condition". Otherwise, people who know they will be saved will choose to do stupid things, like https://www.nytimes.com/2019/03/09/well/oregon-child-tetanus...

"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."


Maybe it's naive, but I always thought that Medicare played a big role in our inflated healthcare costs. Think about it: the number one demographic using the system has most/all their expenses covered by an entity that doesn't care how much things cost. Doctors and hospitals then price accordingly, and everyone else paying out of pocket gets screwed because the system is priced to favor its biggest users, who never see the bill.

This concept of "Cost shifting" exists, but there is some academic debate if its actually whats happening. Medicare also does something invisible to the patients: it pays the least and has the highest stringent requirements for providers.

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)


Medicare is very cost conscious. So much so that some care providers would rather not accept it.

Care to explain your logic? Cat repair isn't so expensive even though everyone with a car has car insurance.

Competitive pressure. If your can't be fixed or you don't want to fix it you have alternative forms of transportation or you can purchase another one (either at full price or used). Also, many of us only carry liability.

And it's well known that disreputable repair shops will ask you up front how much your insurance is paying you so they can get the full amount.

You don't need to take a gigantic loan from the government and pay the repair companies for their work.

Even if all the bureaucracy of insurance went away, major operations would still likely be tens of thousands of dollars. How do you suggest people pay for that?

We all do! Something something single payer.

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.

Better?


> We would all contribute to the payment of expensive operations via taxes in a single payer system.

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.

https://www.axios.com/profits-are-booming-at-health-insuranc...

https://www.verywellhealth.com/health-insurance-companies-un...


In Canada, 16% of the money spent on health care is spent on administration; in the U.S., 28%. Tell me again how the free market is more efficient?

The US healthcare market is not a free market. I know this well enough to commit to a challenge: name me any two actors in the space and I can name you how each one is screwing the other one thanks to a law or regulation.

Maybe the problem there is multiple actors rather than regulations.

Sorry? could you rephrase this sentence, I didn't quite get it.

I’d still prefer the state over private insurance companies (Medicare is well run and popular).

As Steve Jobs said about Dropbox, you’re a feature (insurance companies) not a product.


> I’d still prefer the state over private insurance companies (Medicare is well run and popular). And I vote accordingly.

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.


The NHS “competes in the open market”, so to speak - you pay taxes to get free healthcare for everyone, then you can get private insurance which picks and chooses what it wants to treat and dumps complex cases back on the NHS. Routine treatment is also dealt with by some combination of the NHS and private pharmacies (for flu jabs etc), generally speaking.

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.


If you get private health insurance, do you get your NHS contribution back? Thats what would make it "competing" in the open market. If you have to pay for it no matter what, there is no competition, there is double charging.

There isn’t double charging, because private health insurance universally doesn’t cover the same things as the NHS does, and universally depends on the NHS to work with for anything they think might be too expensive to cover.

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?


If there are general practicioners in the private market in the UK, that means their patients pay for the NHS and also for the private GP, thus double charging. Particularly with your primary care provider, continuity is important in medical care, not everything is replaceable like a cog.

> 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.


Then the private insurers would be incentivized to recruit healthy patients and dump chronically ill customers into Medicare.

I know this because I’ve already heard HR complain about too many pregnancies in a year caused the company contributions to go up.


This is a real economic problem: adverse selection. But universal coverage doesnt solve it, it just makes everyone pay.

That’s exactly what insurance is for, to spread the risk among the entire pool of participants. And the best way to expand the pool as large as possible is with universal healthcare (ie “everyone”).

Everyone pays because everyone should pay.


> 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.


Which country has a parallel public/private healthcare system?

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.


> Which country has a parallel public/private healthcare 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.


> Unless the state has absolute monopoly on primary care providers/General practitioners

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.


That system is not inherently cheaper: people that go private pay twice (pay for public through taxes and then pay privately).

I dont think its palatable in the US to make policies that could increase national healthcare spending.


Society has some costs you can’t opt out of.

That a common and fine approach, but that doesnt make it cheaper, it makes it a whole lot more expensive.

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.


You realize Medicare Part C and D are entirely run by private companies right?

I am. Part C is optional (Medicare Advantage, akin to an upgraded private insurance plan in European universal healthcare systems), and D is prescription drug coverage that a single payer system can administer as part of its system for all participants.

Part C is not an upgrade, it’s soup to nuts. The gov’t just writes the check to the insurer.

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.


We’re splitting hairs. It’s an upgrade in the sense it replaces primary Medicare coverage while also including supplements (vision, dental, and other such coverage).

You're original comment says you prefer government run insurance and give Medicare as an example, but neglect to note that 36% of Medicare is privately run.

Fair point.

Mutual aid, same as any other problem. Presumably if there aren’t the resources or people or they deserve not having kids they won’t. Anything else is hard to justify at all.

What is mutual aid? I haven't heard that phrase before.

Most people involved in health care, like insurance companies, health care providers, drug companies, doctors and gofundme want more money to be spent on healthcare. That's because it goes eventually into their pockets. The U.S spends double, as a percentage of GDP, on healthcare (16%) as any other country which is good evidence that the solution to healthcare problems being to spend more money is very popular.

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.


I'm on insurance, and to be very real I have gotten bills in the past from providers that I never ended up paying. The reality is that this is more common than not...providers only collect some small % of the part of the bill the patient (and not insurance company) is responsible for. They usually end up selling this debt for pennies on the dollar to collections agencies.

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.


That's become my strategy as well.

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 had an outpatient procedure a few years ago and called to question the bill. It seemed like balance billing at the time and I straight-out said it to the office admin. Apparently that's all it takes, the thought of litigation and bad publicity? I haven't received another bill.

In America health care is supposed to be as expensive as possible. People demand the system spare no expense on their care.

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 [0].

[0] 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]


> I think other countries' health systems are more careful about how they allocate their health resources [0].

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.


When you say "People demand the system spare no expense on their care." is that really all americans?

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[1], 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.

https://www.thebalance.com/medical-bankruptcy-statistics-415...


> When you say "People demand the system spare no expense on their care." is that really all americans?

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.


Every gas station and convenience store I go into has a glass jar with somebody's family picture and a handwritten note pleading for money to help them afford a life saving operation. Most times it's that f*cker, cancer.

I spent a few years in Belize and sadly this is the de facto public health insurance program there. Everyone who gets cancer or has a major accident has local fundraisers to get help from the community.

This is essentially what single-payer is, except people are free to determine who the actually want to cover. A bunch of normal folks setting aside money.

Unless people just expect 'the rich' to pay for everything.


You have an astonishing lack of understanding of what single-payer is.

Really? Single payer healthcare is the same as holding a bake sale so your daughter can be treated for leukemia?

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