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Comment by pascalmemories | Hacker News Reader

> One solution could be to get rid of insurance scam (yes I call it a scam) and then lets hospitals/doctors compete with transparent pricing in a free market.

I don't understand the American (and it is American) obsession with having a free market in healthcare.

Why do Americans not look at public provision, paid for via your tax system? Canada does it, so it demonstrably does work in North America, Europe does it, with varying degrees of efficiency, but it basically works.

No-one in Europe or Canada lives "in fear having an accident or getting sick" because they know healthcare is provided by the state in the same way as education, fire services and police service are all provided as a public service, for the general good of society, via taxation.

Americans are happy to send their children to school, to be able to call the fire department or the police (we'll set aside the clear problems of US policing - you generally still call the police when you see a bank robbery, so there is a degree of confidence in them still).

So why is healthcare the exception? What sort of mentality says I am to blame for getting sick and told if I cannot afford medical treatment, I should not have become ill?

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I Lived in Spain for a couple of decades, and I much prefer their government run hospitals to the way the US works. However, I do not believe that the US could just flip a switch and go to a public hospital system, so I would be happy with a more transparent, more competitive hospital system.

The question here is not what system to create in a vacuum, but the road in the middle. I live surrounded by a whole lot of ultra-expensive, luxurious hospitals, staffed by extremely well paid professionals (and not so well paid residents), which, in many cases, have six figures worth of debt for the privilege. To move to a public system, all of those things would have to change: Those luxurious, privately owned hospitals are never going to give great prices to a single payer system. The doctors are not going to be happy with lower wages. Medical schools would have to change drastically, so they can actually provide a number of doctors that resembles the rest of the western world. This level of disruption is what makes major changes like that in a system that employs so many people unpopular: It's a bit like how the US military can't take big cuts, as they are political suicide.

So overall, the change would be huge, and would be hard to make slowly. Therefore, I'd much rather solve it in the US through markets. Once the system has a whole lot less rent seeking behaviors, and the incentives are better aligned, a public option would actually be easier than from the catastrophe we live on now, where prices are secret, and yet, a hospitalization will often involve 10 to 20% coinsurance.

You do a public system for all and then a private system for whomever wants to buy in. You incentivize the private option by levying a tax on those in upper incomes who do not buy private health cover. This is the Australian system and it's the most reasonable option for the US but I guess in America we can never admit to looking to other countries and have to pretend nobody else has figured out healthcare.

Wouldn't all of the best doctors only treat rich people? Why would you expect them to do the same work for less money over at the public hospital?

Two-tier systems work well in a lot of places, for instance in France.

Doctors everywhere else are public servants. They do their jobs because the love it, because it's their calling and because they still get paid very, very well. Canada pays their doctors $232,000 to $676,000 gross (speciality averages, low to high).

Then because malpractice insurance is also socialized (Canadian Medical Protective Association), their costs are significantly lower too. OB/GYNs usually pay the most, and in Manhattan their annual malpractice insurance premium is $125,000. $176,000 in Long Island. [1] The highest in Canada is Ontario, at $44,000 CAD ($34,000 USD).

[1] https://www.excellusbcbs.com/wps/wcm/connect/b7cdbf66-dd6b-4...

[2] http://www.amednews.com/article/20100503/profession/30503993...

The public hospitals in Australia are often really good and prestigious institutions used for teaching as well. So, while you don't get a private room and luxurious amenities you do see top doctors. I can't comment as to why they stick around the public hospitals. I don't know that they make less money doing that.

Procedures under the public system are scheduled by urgency, so for example you might have a 9 month wait for a torn ACL surgery. That's why most will carry private insurance. Private cover starts around $70 a month so it's much more affordable than US insurance and importantly much simpler to navigate.

> I guess in America we can never admit to looking to other countries and have to pretend nobody else has figured out healthcare.

There are some problems which exist in America which don't exist in other countries.

Take for instance, when the rest of the world talks about how they ban guns and therefore they have no gun crimes, giving that advice to America is like if Chinese people were giving advice to Australia that they banned Kangaroos, and now they don't have a Kangaroo problem, so why can't Australia do the same?

America will not have universal healthcare like all these other countries for many reasons, which are very American in nature:

* Americans won't accept the huge tax rates which will follow it, calculations show that there would be a 20% tax increase across all income groups to fund it.

* Universal Healthcare would be the single biggest issue on which Democrats and Republicans will fight, win/lose elections, on whether to cut its funding, whether to expand it.

* America is ethnographically different than other countries. Currently our biggest 'universal' service is Courts and Police. Add Healthcare to it, and next thing we know there is an added accusation of systematic racism against certain minorities.

I dont believe there would need to be a 20% tax rate increase because we already pay far more per person in the US than anywhere else in the world (mostly)

I think it's mostly not going to work here because a lot of people will have to take paycuts (not just doctors / nurses but "administrators" "billing co-ordinators" drug companies and drug resellers, etc etc ...) always follow the $$$

Reasons are historic and idelogical. A free market is considered sort of a religion here. In other words we don't usually evaluate and consider things based on their own merit (what is the best way to provide healthcare, what is the best way to fix infrastructure, like bridges, etc), but rather how will this make free market happy. We treat it as sort of a deity and if we don't abide by its likes we'll be severely punished.

Reminds me of this interesting wiki article, "American Civil Religion" https://en.wikipedia.org/wiki/American_civil_religion

Or brilliant. That explains exactly how I understand it. Didn't know the phenomena had a name associated with it.

This article is great. It explains the reverence for the constitution and the founding fathers.

The healthcare "market" is anything but free. From insurance companies, negotiated prices, all the way down to the AMA limiting the supply of doctors and all the other things they do to keep prices high. It seems the only thing free about it is the freedom to get screwed over. So in those terms, I'm not sure what sort of diety it is that we're worshipping.

> The healthcare "market" is anything but free.

It is "free" in the propaganda domain. That it is sold to the voters as "free, therefore efficient and better than government controlled"

Are you arguing that 'negotiated prices' are not part of a free market? I mean, sure, negotiated prices are a way to hide information, but as far as I can tell, the less regulated a market is, the more "negotiation" is involved in pricing.

Frankly, it's one of the larger reasons why I don't want to be in business for myself. As a consumer? At least outside of healthcare, most of the prices are set, more or less, the way commodities are. There are laws saying that when I get to the cash register, I'm entitled to the lowest marked price in the store. Hell, even with things like cars, which are notorious for ripping off consumers, you are paying at most like 20% more than your neighbor. If you are buying, say, bandwidth, or nearly anything else sold to businesses? It is completely normal for the initial quote to be 200%-400% more than what you end up paying after negotiation.

Now, how much does this have to do with it being a business, and thus having the expectation that you have professionals on hand to do the money-dance, and how much of this is that there's a lot less regulation in the business sphere than in the consumer space? I don't know. I don't think it has as much to do with the cost of the goods involved as you think; I think the biggest contract I signed was around a third of a million bucks for a five year lease; Well under twice what someone doing what I do, only as a worker would pay for rent in my area. Most of my contracts were in 'mid-priced car' range, and still there was a tremendous difference between initial quote, and what I was actually expected to pay.

If you want a market make it transparent not "free". Patients have no chance participating in the US health care market because they have insufficient information.

And it's impossible to get "sufficient information" or negotiate anything when you're being loaded into an ambulance. The whole idea of negotiating healthcare at the personal level is patently absurd.

I do not have an ideological bent towards having a public health care system.

But what this article indirectly points out, is the sheer, utter incompetency of US health care providers.

The whole justification for a private system is supposed to be greater efficiency. In many markets, for whatever reason, this seems to work. Goods became cheaper and better due to competition, the invisible hand, etc. etc.

"My cousin was triaged immediately. Within two minutes a nurse checked her ankle, gave her codeine, and then sent her off to an urgent care clinic. She wasn’t even registered in the ER."

"The urgent care clinic had a few people ahead of us. It took about 10 minutes to check in and then no more than 15 minutes to be seen. A lovely nurse named Leslie triaged my cousin and agreed an x-ray was in order and made the arrangements. My cousin did not need to see a doctor or a nurse practitioner to get an x-ray. I’m not sure I’ve ever seen that happen in the U.S."

"The nursing triage was wonderful and actually doing nursing (I hate seeing nurses relegated to charting)."

In our wonderful US free market system, we have very highly trained professionals spending staggering amounts of their time on bureaucratic paper work and busy work, while the NHS just skips straight to treating patients efficiently and professionally.

With a system this bad, people at every level of the health care industry should be getting fired every day for their gross incompetency. From the insurance companies to the health care executives to the health care professionals, they simply suck at their jobs and need to be held accountable.

If a public system can deliver the benefits in reality that a private system is supposed to deliver in theory, let's go with the public system.

Which is very near the top of my list with annoyances with the Republican party, by the way. They are so obsessed with the theory and ideal of private market capitalism, they don't care to observe whether their theory matches up with reality.

"My cousin did not need to see a doctor or a nurse practitioner to get an x-ray. I’m not sure I’ve ever seen that happen in the U.S."

I've had a few internet discussions with this particular doctor before and what I've learned is that she's used to things in California because what she describes above is definitely something that I've seen and experienced in the US. Kid fell off bike. We went to ER. Doc & tech met us in triage. Went right back to x-ray. We were in and out of the ER with imaging taken care of in less than 90 minutes.

Also, being punted to urgent care isn't always a good thing. This is how Kaiser missed a damaged disc in my lower spine. They had a habit of turfing me to urgent care and brushing it off as sciatica. It was when I moved to Texas that a Baylor ER did an MRI, revealing the true source of the problem, and was shocked that in all the years before, nobody had ever done that.

Health care systems aren't identical in every state, as I've found out the hard way.

"The nursing triage was wonderful and actually doing nursing" This might be another reason things are so expensive. Not every single aspect of emergency department care needs a full blown RN to take care of it. But when attempts by other levels of provider (LVN, LPN, EMT-Paramedic) are made, nursing unions come in like a hawk and lobby to crush whatever efforts are being made. It's frustrating to see happen.

This simply shows the power of a union. If physicians operated more effectively there would be no NPs prescribing.

It cuts both ways. I do not begrudge nurses their income, they sure as hell earn it for the most part. Put an investment banker in a nurse's job at County and see how long they last, then tell me it costs too much.

and it shows what happens when you lack a union too. :/ Us folks in EMS run into this often. There's IAFF which we can join, but they actively seem to hate any private EMS at all. Yet fire departments don't want to do the stuff that us in private EMS do. so we're kind of caught in between.

Texas recently made some legislative changes that will allow facilities to utilize paramedic level providers to their full scope in an emergency room setting, though. that's a huge plus.

Go Texas! (First time I've ever said THAT in my life...)

Not everything here is perfect but there are a lot of things that I like. Good example in my line of work is that it's a "delegated practice" state, like South Carolina. This means that different EMS services can use their own medical director instead of how it was in California where the county had one that all of the providers had to use. This allows a lot more flexibility and for more progressive pre-hospital protocols.

It's been a pretty good system.

> while the NHS just skips straight to treating patients efficiently and professionally.

NHS clinicians have brutal amounts of paperwork. That tends to be done out of sight of patients, but it's there.

Some things are helping: digital dictation; "mobile working" (community staff being able to do electronic paperwork on laptops in the car between appointments).

So do clinicians in our system. When a senior attending who is also a full professor in an academic medical center is still filing reports at 11pm on a Friday (not on service), something is rotten. Especially when that's every Friday.

>> "I don't understand the American (and it is American) obsession with having a free market in healthcare."

I think part of it is the culture of believing you can be anything you want to be. It's the same reason the poor often vote against their interests in the US - they believe that soon they'll be rich and want low taxes and few regulations. That they are the exception.

If you want those people to change how they vote you need to stop talking down to them. "Hey stupid! You're voting for people that hurt you."

Or then again, maybe they just have a different opinion than you on what is important to them?

Surely nobody can be tricked onto supporting positions contrary to his interests. That would be impossible, since people are rational, educated and perfectly informed.

There is a minority of people who are actually completely out of touch with reality, so-called demagogues and populists, and to a less extent all politians: they are completely deluded in thinking that by repeating a point a thousand times they can mislead those perfectly informed masses.

If someone continuously keeps getting tricked into voting against their own self-interests, with the belief that their vote will actually benefit them, then yes, they absolutely deserve contempt.

As the saying goes: "Fool me once, shame on you. Fool me twice, shame on me." A large part of the American populace has been getting fooled repeatedly for decades.

If someone continuously keeps getting tricked into voting against their own self-interests

It has not been established that they are voting against their own self-interests. You are just assuming you know what their interests are better than they do.

It's the same reason the poor often vote against their interests

Wow, into being condescending much? How about this... maybe, just maybe those people know what "their interests" are better than you or I. Have you considered that?

Not sure why this offends you so much, but drive an hour outside the Triangle and it is pretty easy to find people at or near poverty level who want the government to cut social programs and taxes even though they are the ones who mostly benefit.

Nobody's arguing they aren't possibly voting for something that isn't in their immediate economic interests. But we can argue about their motivations.

Someone's said that it's because one day they think they'll be rich, and suggested that this was foolish. An alternative explanation is that they're voting for it because they've considered the question very carefully and are voting for what they think is morally the right thing, even though it'll harm them. In which case it's far from foolish.

I think the offence was taken in assuming the foolish explanation instead considering the one where people were making a sacrifice to do what they think is the right thing.

We don't know unless we ask them, of course.

I'm not offended at all, just wondering why somebody would choose such a condescending tack. Again I ask, have we considered that maybe those poor people that you're referring to, know what is in their "best interests" better than we do. Perhaps they have perfectly rational reasons, maybe other than simple economic self interest, for voting against social programs and taxes.

This whole mindset of "you're too stupid to know what's good for you, so just let us smart people be in control and make things OK" is something that is very condescending and is repugnant to many (most?) Americans. Which is one good reason it's hard for politicians pushing such policies to gain ground. It might be better to actually, you know, talk to those people and try to understand what their principles, goals, and motivations are, instead of assuming that they're stupid.

>>Again I ask, have we considered that maybe those poor people that you're referring to, know what is in their "best interests" better than we do.

I have considered that notion for a long time, but ultimately dismissed it as pure nonsense. The fact of the matter is that people can be tricked and be taken advantage of. It is not condescending to point that out when it happens.

If someone gets conned into transferring all the money in their bank account to a stranger in Nigeria on the belief that it will "free up" millions that will be theirs, you cannot possibly make the argument that pointing out they got conned is condescending, that maybe that person knew what was actually in their best interest. They thought they knew, but they were, frankly, wrong.

The exact same thing happens with many poor people in our society: they get conned into voting for politicians who will absolutely screw them over. Furthermore, it doesn't happen once or twice. It happens repeatedly. And again, pointing this out is not condescending. It's just the truth.

I have considered that notion for a long time, but ultimately dismissed it as pure nonsense.

Alright, glad we have you here to save all the stupid poor people from themselves. After all, if someone is poor, they must be stupid. Or lazy. Or both. FSM knows, they need some philosopher-kings to come along and show them the light.

Please respond to the entirety of my post instead of cherry-picking, thanks.

I'll reply to what I feel like replying to, thanks.

You realise you're the only person in this thread that is classifying poor people as 'stupid'? Nobody else has. You're the one making lazy generalisations and it's not adding anything to the discussion.

Let's not get into silly quibbling over language... "I didn't explicitly use the word stupid, so I didn't say they were stupid". Right. Language doesn't work that way. If you say somebody is stupid in an indirect fashion, you're still saying they're stupid.

Implied in every single sentence of this paragraph is and underlying sentiment of: "this is a false belief and they are stupid for holding it."

And ALL of that aside, nobody has really responded to my question of "why assume these people are wrong?" Except that camel guy who basically said "no, they're stupid so there is no reason to consider that."

So we're back where we started. I say that poor people who vote for lower taxes and the like, may actually be making a perfectly rational decision. It may not be a optimal decision if you only take financial outcomes into consideration but it may still be rational... because the people making the decision may not be basing it on financial considerations to exclusion.

I live in the Triangle, and driven to such far-flung locales in NC as Advance, Roxboro, and Eden. The people I've interacted with (however limited) are ardently political in the conservative direction for reasons other than fiscal.

Many are hunters, or serve(d) or have family in the armed forces, or just grew up around guns. They remember, before the big-box stores came along, when the town hardware and general stores sold shotguns, rifles, and ammo. They see the liberals in SF Chicago and NYC wanting to stop their multi-generationally deep and rich tradition in hunting and defending and baring arms. If there is one rail that should never be touched, one single-issue that will move that type of voter, it is preserving the 2nd amendment. I mean, sure, you don't have to worship it and Hillary won't have to sit there holding an AKM-74 with 100-round drum mag to pander for votes, but just don't go after it with such vigor and I can bet dollars to donuts that you can win over at least 40% of the voters 1 hour outside the Triangle.

They vote republican not for their non-existent tax breaks or wait in bated breath for their drip of the trickle-down. They're savvy enough that that junk has been tried all over the country and has mostly failed (in the case of Kansas, utterly and miserably with negative job growth). They just don't want you to mess with their traditions.

I mean, these folks don't even care to fight over marriage equality, either. You don't see much gay-bashing in these areas. They simply don't care. Ditto abortion. Sure, there are ardent bible-thumpers, but on the whole, they are nuanced enough to know that we don't want a nation filled with unwanted children.

So, really, don't mess with THEIR rights (guns), and they won't vote against their own interests. I can't get why a lot of democrats (both politicians and voters) can't see that. I _know_ that democrats and liberals are about as far from single-issue voters as you can get, so they'll be kinda-sorta bummed that guns aren't the big focus for legislation, but it would certainly NOT be the end of the world.

I didn't read that as condescending towards poorer people, but more an critical observation of the US political system.

> Canada does it, so it demonstrably does work in North America, Europe does it, with varying degrees of efficiency, but it basically works.

Without going into the politics, size and population/density are two major differences:

- Canada has about 10% of the population of the US with much of it clustered around a handful of major cities so the vast majority of citizens can be covered by having good systems in a handful of places.

- Compared to Europe, the difference is even more striking. Just considering Texas: it is roughly the size of France but with half the population despite having 3 of the top 10 biggest US cities. And that's still not even 10% of the US population.

Whatever approach is tried in the US needs to take these differences into account.

There's no secret to solving this problem, and it works basically the same way everywhere

Yes, in France you might be 1h/2h by car from a hospital depending on what you need

You have a tiered system: 1st level is "everyday stuff", 2nd level is regional centers (so you get routine surgeries and more complex stuff), and at the 3rd level you got your excellence centers for specialized stuff (think transplants, major surgeries, etc)

In the US case yes, you might want to have a 3rd level center per state (might not be exaustive)

Per state? Try per region. My department serves a tertiary referral facility and there's another one across town. Of course, "town" is 18 million people, but you get the idea.

I guess I could see having one tertiary center to serve say VT and NH but if memory serves even they have one apiece.

The US "free market" health care system doesn't fix this. Outlying areas still have shitty hospitals and major cities still have world-class hospitals clustered together. If you're too sick for your local small town hospital they pop you in an ambulance and take you to the city.

Texas might be "roughly the size of France" but a huge chunk of that is uninhabited desert.

Because it's worked pretty well for Medicare and Medicaid? Large portions of both were privatized through Medicare Advantage and Managed Medicaid. The gov't pays private companies a flat rate per patient who selects their plan.

A majority of Medicare coverage is provided through private companies (100% for the drug benefit). Last I saw 80%+ of Medicaid patients are covered by a private plan.

What are the benfits? The private companies take on the risk. If the lump sum the gov't gives them isn't enough to cover costs, tough, the company takes a loss. Gov't loves it as it makes budgeting easy.

The other benefit is choice. A patient can select from a multitude of plans that benefit them the most. Want a top doctor? Pick a plan where his/her hospital is in network. Have a chronic disease where you take a lot of meds chronically? Pick a plan with better drug benefits.

Medicare Part D - the drug benefit created in 2005 that is entirely private - came in dramatically under cost forecasts.

> Because it's worked pretty well for Medicare and Medicaid? Large portions of both were privatized through Medicare Advantage and Managed Medicaid. The gov't pays private companies a flat rate per patient who selects their plan.

Yeah, Original Medicare is pretty awful - I wouldn't recommend it to anyone who's able to get a Medicare Advantage plan. It's not just the cost-of-care and the overall expense to the patient (even though Medicare Advantage tends to win out on both of those aspects as well). It's that Original Medicare is a horribly frustrating experience for the patient as well.

Of course, most people (especially most people under the age of 65) don't understand the difference, and when they think about Medicare, they think of a publicly-run program, even though around 40% of the Medicare population is on a Medicare Advantage plan.

>Why do Americans not look at public provision, paid for via your tax system?

Because raising taxes is bad, obviously one day you'll be big and don't want to pay health care for all the people down there. And of course it's a slippery slope. Today it's health care, tomorrow it's minimum wage and the day after you find yourself in a Gulag /s

Just look at how hard republican states tried to push against Medicaid.

You mean that the European Union is heading to Gulags?

He is being facetious.

Yes, but some US politicians have literally tried to argue that way ("death panels " etc)

> Why do Americans not look at public provision, paid for via your tax system? Canada does it, so it demonstrably does work in North America, Europe does it, with varying degrees of efficiency, but it basically works.

This article presents a good argument for why Single Payer won't work well in the US: https://www.bloomberg.com/view/articles/2014-04-30/single-pa...

> Americans are happy to send their children to school

Americans are, on average not happy to send their children to public schools

That was a great analysis from Bloomberg, thanks for the link.

Look through all her articles, she writes a lot about US healthcare policy, generally with a skeptical eye toward recent legislative efforts.

Why are the vast majority of US children enrolled in public school if their parents are so unhappy about it?

Because they have no other option.

One of the reasons why Americans are so vehemently against Universal Healthcare because once you go there, you don't easily get to come back.

Once govt starts to provide a certain service, it kills the private sector market for that. Then no matter how terrible govt service is, there isn't much which can be done about it.

It should also be remembered that various levels of the American government have a record with public provision that is at best mixed. Walter Reed, anyone? Psychiatric institutions in the 80s and before?

When you have a distressingly high chance of getting a terrible system, you wind up somewhat skeptical of people who want to tear down what's already in place and do public provisioning. Good and pure intentions are not an adequate substitute for competence.

Of course, you cannot seriously associate "competence" with the current US free market healthcare system.

Depends a great deal on one's definition of "competent". If you define it by outcomes for those with access to service, it does reasonably well. If you define it by access to service, it does poorly.

The fear is that a system that works for some will be replaced by system that everyone can access but works for nobody.

One more comment on the political side:

Note the Bernie phenomenon in the current election. He pulled the entire Democratic party to the left, including public provision of health care. Also note, if current polls are a good indicator, Trump and the Republicans could be headed towards an historic drubbing on election day.

And Bernie drew overwhelming support from young people.

So I think that politically, the US may very well be moving towards supporting public health care.

If the polls are any indication, Trump is heading for a drubbing, and the Senate might go to the Democrats, but I very much doubt they'll win the House (the House favours Republicans for a variety of reasons, but you almost certainly won't get single payer with a Republican House).

You have a point. But Americans generally are not convinced that a Govt. provided healthcare (paid through taxes) is the right solution. I personally don't have a problem with that as long as the main problem of "fear" is resolved. Whatever it takes. The problem is that we are not able to get out of the whole "insurance-company-being-the-middleman-in-everything" business.

No local government in America is required to provide anything more than K12 education. Many rural areas toy have to pay for fire or police.

The US has far more diversity than most of the Western European nations, though this is obviously changing.

Socialism really doesn't work here as well when 'other' people are getting more benefits than you. I'm sure part of it xenophobic, but part of it is actually legitimate.

For example, a bad accident left my credit ruined in my early 20s due to medical bills. I do remember, several times, waiting in agonizing pain in an emergency room full of people who could not even speak English. Essentially, the reason my bills were so high was because the hospital was allowed to recoup the nonpayers' bills by upping mine.

It would cost the average taxpaying couple tens of thousands of dollars to have a child in the US. So we have declining birthrates amongst educated people. In contrast, undocumented (illegal, whatever) purposefully come to the US to have an anchor baby. Those playing by the rules pick up the tab. This can rub even the most socially progressives the wrong way. Same with public education, unemployment benefits, and social security.

I think that you are going to see many social services cut, and move towards the US style, in places like Canada, Western Europe, and Australia as more and more immigration creates a less homogeneous population. The fact that many immigrants purposefully head to the nations like Sweden and Germany with the most generous social systems shows that the end results will not be good for the native population.

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