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Comment by peatmoss | Hacker News Reader

If this isn't a ringing endorsement for single-payer "medicare for all" health insurance, I don't know what is. As a society we're aghast at the notion that people might be discriminated against due to their genetic pre-conditions. Why the heck do we let our values slug it out in an inefficient, non-competitive, quasi-market?

Also, because it's Hacker News and a lot of folks here are engaged in start-ups, I wonder why I hear relatively more from tech about basic income than single-payer health. While basic income goes further, single-payer health removes a major burden / friction for creating a start up.

Also, from a labor standpoint, decoupling health benefits from work allows start-ups to play with less-than-full-time employment arrangements. Having more people fractionally employed might be just the safety valve we need until automation job loss is more comprehensively addressed. But I digress.

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Single payer is one of several good ways to insulate citizens from the costs of individual health events. Another approach removes even the shadow prices used by single payer, and provides health care as an infrastructure element.

Imagine if all roads were turnpikes with tolls. Single payer has the government pay those tolls. But for local roads, we would rather remove the toll booths and allow free and easy access. The same could be true of preventative care, basic access to an NP or similar, well child care, and such.

> The same could be true of preventative care, basic access to an NP or similar, well child care, and such.

I never thought of the issue that way but now that I hear it I absolutely agree. I do not plan on having a child... ever so this may sound a little trollish but please bear with me here.

Anyone who is against gender discrimination (or thinks there is no discrimination against women based on gender) should be FOR free of cost and generally available quality child care for all. I think a lot of bias against women in the work force will go away if we don't have a mindset that women will quit the workforce once they have children.

> Anyone who is against gender discrimination (or thinks there is no discrimination against women based on gender) should be FOR free of cost and generally available quality child care for all.

I'm not sure I follow?

Sorry I'm not very good at explaining things in general but it is even worse right now because as I admit I didn't put two and two together until your grandparent comment talked about it.

If families have access to free of cost quality child care, they are now making a choice based on their preference as opposed to a decision bring made for them by environmental circumstances. This might help decrease perception of hostility.

>> Single payer has the government pay those tolls.

On our behalf, collectively, with our money. Some people still haven't processed just what "single payer" means.

Sure, but I think the distinction lies in if toll booths (hospitals) are still private, meaning carte blanche payment from government money to private actors.

Carte blanche only if there is no ability for government to negotiate prices, or set up hospitals themself. There is also of course the protectionist bias of government licensing of doctors. (Doctors from the EU, Canada, Australia, Scandinavia,etc. aren't able to practice in USA, no matter how qualified, unless they undergo residency program in US, which have strict quotas).

Come to Europe, you'll like it.

(this assumes, perhaps incorrectly, that you live in the US)

Difficult for family reasons right now, but having lived in New Zealand w/universal health care, I know first-hand how many things improve in a society with safety nets.

Your employer shouldn't have anything to do with your health care; the majority of economists across the political spectrum would agree. Single payer is not the only alternative to that. There are people who can't afford enough food, so we give them either food stamps or cash rather than trying to make it free for everyone.

The margins and economic incentives in medical care are very different from those in food and housing. It's of limited use to compare solutions in these two spaces.

"Medical care" is a broad category though. Of course emergency medicine will never work like food. But I wonder what percentage of spending, say, goes to things that are closer to food than to emergency medicine?

Almost none of the spending in medicine is analogous to spending on food. The closest would be things like regular checkups. For just about everything else the goal of payers is to minimize usage of the product they sell, not maximize it.

In food, grocers are (roughly speaking, here) analogous to insurers and food is analogous to care utilization. Grocers want to maximize sales of food at the best price possible: they make more money by moving their product. Insurers want to minimize utilization: they make less money by "moving" their product.

In the case of food, the grocers' and buyers' incentives are aligned: people need food, and grocers want to provide it. In the case of medicine, this isn't the case: people need care, and the access providers don't want to provide it.

Caveat: I have no idea what I'm talking about.

It makes sense to me that an insurer would never be a good analogy for a grocery store, but that problem seems specific to the insurance model, rather than to medicine itself. That's more what I meant to ask about. If we imagine that hospitals and patients work like grocery stores and their customers, a few obvious problems come up:

- Healthcare is too complicated for patients to make informed choices. - Emergency medicine is too urgent for patients to have much choice anyway. - Demand for care is unevenly and unfairly distributed, because of conditions people are born with.

So I guess my question is, how much of medicine (in terms of dollars) hits those problems? Cancer treatment seems to hit at least two out of three. But on the other hand, a lot of dentistry seems not to.

That's why countries regulate it. So you don't have "incentives" where care should be provided.

So you don't have "incentives"

Of course you have incentives. Hospital administrators want to cut costs, doctors want to redirect patients to their private offices, suppliers want to increase profits (and will offer kickbacks to doctors and administrators), etc.

If you have humans, you have incentives. Regulation can change some, but not eliminate them.

It's a strong argument against employer funded healthcare, but I get the impression that no one really takes the "employer funded healthcare is great and I would design it that way even if I were starting over from scratch" position. Does that sound right?

I think that does sound right. I never understood why healthcare was so tied to employers in the first place. Healthcare should be entireley independent of employment status in my opinion... but, and I'm sure given HN demographics I'm likely to be in the minority, I find the ACA to be unconstitutional, specifically the mandate, so I have recently been trying to bone up on the legal discussion surrounding the general welfare and commerce clauses to understand the nuance left there for single payer but without a mandate.

> I have recently been trying to bone up on the legal discussion surrounding the general welfare and commerce clauses

You will find that the jurisprudence surrounding those clauses bears no resemblance whatever to what the clauses actually say. For example, look up Wickard v. Filburn and see if you think that Supreme Court decision used a reasonable interpretation of what Congress can regulate under the guise of "interstate commerce".

Interestingly, though, the clause under which the individual mandate was found constitutional was actually the Taxing Clause--the Supreme Court said it was not constitutional under either the Commerce Clause or the Necessary and Proper Clause, which was how the government had argued the case. In other words, the Supreme Court said that, while it was not constitutional to require everyone to purchase health insurance, it was constitutional to tax people who didn't. Go figure.

The full opinion is here:

http://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf

Yeah I disagree with the pivotal point they used for that decision, that it wasn't a direct tax, it seems very much like a direct tax to me.

I never understood why healthcare was so tied to employers in the first place.

Wage controls during WW2: http://www.npr.org/templates/story/story.php?storyId=1140451...

Which if I remember correctly were very highly contested on constitutional grounds as well.

Yep. Here's the Supreme Court decision that upheld them:

https://en.wikipedia.org/wiki/Yakus_v._United_States

It started during World War II when employers were prohibited from offering wage increases to poach employees, and used medical insurance as an incentive to job-switch.

Because employers can provide group health insurance plans.

Without either the individual mandate (which is itself a half-assed approximation to single payer healthcare) or group health insurance (through employers or some other non-health-related cooperative), people put off getting health insurance until they get sick, the risk pool stops being a pool and the whole concept of "insurance" falls apart.

You can't put off insurance until you get sick, unless the insurance can't deny you for having a precondition.

Yes, that's the problem.

Single-payer systems are not without problems either. Unless we're rich enough, as a society, to pay for perfect healthcare for everyone then there will be some people who get less than perfect care.

In an individual-pays system, those with expensive conditions or those who are poorer lose out. In a government-pays system those without political leverage lose out - often still those who are poorer.

The British NHS, for example, has been the target of much ire due to different (and arbitrary-seeming) spending priorities in different parts of the country, often called the "postcode lottery".

If a society is not able to pay for 'perfect healthcare' then it will not pay for 'perfect healthcare' under any system.

However, as your reduce the cost of providing healthcare with single payer systems you increase society's ability to provide high quality healthcare. Remember, if a doctor sees 1000 people a month then you can detect fraud by randomly sampling 20 cases. However, if 10 companies each need to check for fraud they may investigate 10 cases each, but with 10 X 10 that's still more effort. Further, they are each going to try and cost shift to the others, which is an expensive zero sum game.

However, if 10 companies each need to check for fraud they may investigate 10 cases each, but with 10 X 10 that's still more effort.

Or they'll coordinate to avoid the duplication, usually by having some kind of industry society/non-profit that does the checking.

I think many people working on Basic Income would do well to focus their energy on pushing Single Payer + voucher systems for everything. Basic levels of healthcare, food, etc.

It makes far more sense than single payer, because it cannot be traded away easily by the recipients during bad decisions, so it is a stronger safety net.

But it is also far cheaper and more efficient than basic income, because buyers don't compete so prices don't go up across the board "patio style".

Why do you believe that the possibility that people may be discriminated against due to their dna is a ringing endorsement for single-payer "medicare for all" health insurance?

Because a single payer would, by definition, cover everyone.

Private insurance companies and employers (the two places most Americans get their health insurance from) may not want to pay for the higher costs associated with higher risk people like this. Employers would be especially susceptible to this sort of discrimination if proposed legislation allowing employers to demand genetic tests of their employees passes.

https://www.washingtonpost.com/news/to-your-health/wp/2017/0...

The discrimination referenced in the article is not just about insurance costs. Even if health care costs were totally removed from employees they would still have reason to discriminate on genetic factors.

We are all a part of the human race and we owe it to ourselves and our fellow humans to take care of each other.

Because the nature of the current system has incentives for employers to have a healthy "pool". When you have larger pools with a single payer, that goes away. With the current system, those people will end up either getting care that isn't paid for and gets picked up by taxpayers, probably not enough to survive. Or, those people will be shunted to high risk pools, which will be largely paid by taxpayers.

ELIZA, is that you?

Because a single-payer health system (like the NHS) largely prevents this discrimination.

Do you think I am ELIZA? Would you like me to be ELIZA?

Seriously though, I quoted the reference exactly in my question, since I knew people would be touchy about the subject. Based upon other people's reaction to my question, some people are very touchy about the subject even when addressed elliptically and without pre-formed notions.

Thank you for your answer.

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