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Comment by ThomPete | Hacker News Reader

I do question the sustainability of the french system though and that of many other european systems.

Its important to remember that in a state economy where healthcare is free or semi free it's operated as a cost center and thus has budgets that are politically mandated not determined by market demand at least not directly.

This leads to a number of limitations on what kind of care patients can get what machines they can buy, what medicine etc.

Not saying the US system is better but all systems have drawbacks.

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Good point. I'm not too worried about France, they seem to have their priorities straight there, other countries are less stable. Especially in former Eastern European countries there are disasters happening right now, and many Western countries will have to come to terms with the cost of health care and attempting to take commerce out of it.

NL had a very good system which got replaced by something much less efficient, ostensibly because the 'market' would have been better at making things efficient where the only real change is that healthcare is now much more expensive and options are as limited as they were before.

Personally I feel a good society should take care of its sick, poor, elderly and inmates even if it costs but that's an opinion that seems to be out of fashion.

My personal suggestion for a good balanced system is that most people pay most of the cost for normal healthcare costs like going to the doctor for a checkup, most of the cost for one of things like a broken leg but that society pays for more serious and longer term situations like cancer, heart surgeries where you are supposed to stay at the hospital for a longer time.

I.e. no one should be bankrupted because they get a serious illness.

With regards to France healthcare system here is an article who seems to think it wont survive though.

https://www.bloomberg.com/news/articles/2013-01-03/frances-h...

Yes, those poor people with recreational broken legs really should pay for their own work. That's only about 25K or so in a bad case without further complications... /s

Please read what I actually wrote instead of just knee-jerk reacting to your own prejudice.

I said MOST people should pay MOST of the bill. Do you really think I am talking about those with least amount of money.

You wrote:

> most people pay most of the cost for normal healthcare costs like going to the doctor for a checkup, most of the cost for one of things like a broken leg

Most people are poor. Wealthy people are the exception and most people would not be able to pay for even the simplest procedures.

They typically can't pay for a new washing machine if their current one breaks down.

Most people in the west aren't poor just like most people aren't wealthy. Most people are in the middle.

There is a large number of people who can't afford to buy a washing machine but it's not most people.

> Most people in the west aren't poor just like most people aren't wealthy. Most people are in the middle.

Wrong, income distribution isn't normal, it's bottom-heavy, and most people are well below the mean.

https://www.ssa.gov/cgi-bin/netcomp.cgi?year=2015

Exactly. In 2015, most (50.08666%) wage earners earned less that $30,000/year.

While it isn't a majority, the fact that 3-in-10 (29.72726%) earn less than $15,000/year is a travesty.

Most people are in the middle

Of the income or wealth distribution - not a hope, it's Pareto all the way. You've got a really warped view of the world there.

This is why I liked the health care system in Belgium, where my wife and I lived for almost eight years.

In Belgium, you are charged based on your income, and they don't ask you how much you can pay when you get admitted.

As US ex-pats, we made enough money that we were in the top payment bracket.

Yet, for a significant surgery that kept my wife in the hospital in a private room for two weeks, we still paid less for the whole surgery plus hospital room WITHOUT insurance, than we would have paid in the US but with insurance.

That kind of social medicine does actually work, and work pretty well.

Belgium is pretty fair. NL requires you to pay between 100 and 150 euros per month or so (kids are free) and that covers everything, the rest is paid from the tax base so you already pay the income dependent part. The only bit that's nasty about it is the deductible, they really screw the poor people on that because of course only the cheap plans have high deductibles so those that can afford the least will end up with the highest costs when something does go wrong.

The problem is that people then tend to forgo preventive care & routine checkups if they don't have to (especially poor people), and in the long term end up costing a lot more when they do get treatment once their situation is far worse.

No thats actually not true which Denmark has lots of data to show.

It's 100% free to go to the doctor yet a lot of people don't go for checkups it's not a common thing to do.

Furthermore the situation is even worse for men over 50.

So access to healthcare has very little to do with that.

Earlier you write:

  > Its important to remember that in a state economy where
  > healthcare is free or semi free it's operated as a cost
  > center and thus has budgets that are politically mandated
  > not determined by market demand at least not directly.

and later write:

  > My personal suggestion for a good balanced system is that
  > most people pay most of the cost for normal healthcare costs
  > like going to the doctor for a checkup, most of the cost for
  > one of things like a broken leg but that society pays for
  > more serious and longer term situations like cancer, heart
  > surgeries where you are supposed to stay at the hospital for
  > a longer time.

But here

  > It's 100% free to go to the doctor yet a lot of people don't go for checkups it's not a common thing to do.

you allude to Danish data that show prospective patients do not take advantage of healthcare even if that cost is 100% subsidized.

So which is it? Does healthcare that is 100% subsidized distort demand so that people seek unnecessary care, or is demand so inelastic that people and populations who would benefit from it decline to use it?

EDIT: add third in situ quotation. Add comma in last sentence/question. Change pronoun to conjunction in last sentence; pluralize noun.

The ranking member of US Senate intelligence committee said

"1000 paid Russian trolls are spreading disinformation on US social media"

And recently said

>Be careful what you read on the internet because paid trolls are influencing what is discussed.

Perhaps parent poster is getting his info from disinformation sources like RT, Breitbart, Fox News, IJR, Limbaugh etc.

Not sure exactly what you are confused about.

I was responding to a post who claimed that if there isn't free checkup for all then people wouldn't go to get checked.

I simply pointed out that even in a country like Denmark which is 100% free people thats not the case.

So you would have to show causation between general checkups and cost of healthcare I don't think you will be able to find that.

My confusion comes because in my first two citations you suggest requiring patients to pay for most of their basic/non-life-threatening healthcare. You say this, if I'm not mistaken, because "free or semi free" healthcare is "operated as a cost center". That is, by requiring patients to pay for most of their basic healthcare, that cost center will be reduced because patients will be discouraged from seeking "unnecessary" healthcare.

On the other hand, in Denmark where basic healthcare is free, the data you allude to (but do not present) show that even then "a lot of people don't go for checkups [because] it's not a common thing to do." Additionally, you write "Furthermore the situation is even worse for men over 50."

So my confusion comes from your contradictory assertions about the effects of fully subsidized basic healthcare. Either free healthcare generates cost overruns because people seek out unnecessary treatment, or free healthcare does not generate cost overruns because people do not seek out even necessary treatment.

Your assertions about the effect of free healthcare are paradoxical, hence my confusion.

EDIT: fix typo, recast first sentence of penultimate paragraph. Remove redundant prepositional phrase from last sentence.

I am saying that because then they start paying for when they go to get treated or for checkups which allow for more money being possible to use on more serious situations.

I am not sure where you get that I want less people to go to the doctor. I just want to be able to pay for the situations you can't afford by asking for money in situations where most people can. And yes if you don't have any money then you should get help, but for people who make enough it should cost something.

So there is nothing paradoxial going on here. You just assumed I wanted fewer people to go to the doctor which I never said anything about.

That makes better sense, but covering costs of extraordinary care isn't an issue in state-provided health insurance (single payer), nor is it an issue with private healthcare insurance.

With single payer, taxes cover the cost of care for everyone. With private insurance, the costs for more expensive care is covered by the premiums of healthier individuals, which is sort of like what you suggest but does not financially punish people who get sick.

What you propose may not be workable (or humane, for that matter) because it distributes the costs of extraordinary care to people who already have more-than-routine care. Presumably these people already have paid their premiums and now would shoulder most of the cost for maladies such as broken bones.

EDIT: add missing word "workable".

It actually is an issue in both systems which is why in state-provided systems there are limits to what kind of treatments at what stages etc and in privet insurance systems there are limits to coverage.

The main premise of this discussion is that it's not possible to pay enough for healthcare. I.e. even if you taxed people 100% there still would be things they couldn't get because it has to be available to everyone and there are always new treatments being developed, new machines, new drugs.

Whether you find it humane or not is based on what you consider the end-game of healthcare.

That article is from 2013 and predicts crisis in as little as 3 years. It's 2017.

Be careful with articles about single payer healthcare systems in the US. Most similar countries to the US have functional single payer plans. It's a false talking point pushed by conservative media that those systems don't work well. Conservative media pushes those falsehoods because the media is funded by the very wealthy and those who want to cut taxes to line their own pockets at the expense of most Americans.

And the french started cutting benefits already in 2014 to make sure that didn't happen.

Right. So you're saying the French single payer system works, with political modification as needed over time.

The issue that might make single payer difficult in America is we don't trust our political system to manage good programs, because the GOP is committed to destroying government (to benefit the super rich) rather than trying to get things done.

No I am saying what I said originally that there are issues with the single payer system as it's based on tax money and thus can't make it's own money.

I'm not so sure about "have their priorities straight there". Using the state to manage healthcare brings up strange priorities: "Should we cover kidney transplants or should our soldiers have real bullets in their guns this year?", "Should we build the new transit line or increase coverage to include penile transplants?", etc.

I don't want people voting based on their appendix, their bad knee surgery, or a skin rash. Involving government in healthcare inevitably leads to possible futures wherein a country is brought to it's knees by colonoscopies. One's enemies can only laugh.

You say it's inevitable. Surely, then, you have some evidence of this trend actively weakening countries?

It's easy to sketch convincing strawmen. But if you could actually point to somewhere that is choosing between kidney transplants and bullets, I'd eat my hat.

No single payer system spend all the money they could on their healthcare system. I think this is what most people are missing. You could tax people 100% and you still wouldn't have enough to make your system as good as it can be.

Plenty of single payer systems decides how long they are going to keep someone on treatment, what kind of products they allow them to be treated with etc.

A single payer system is based on a budget which means that budgets size is based on how it's prioritized.

You're right that the budget is tighter, however the healthcare budget is separate from the main state budget, and you can't have a situation where for example you'd allocate less to health to pay for schools or army or something like that. The money still comes from taxes though and there is enormous pressure currently due to the economic situation in Europe, especially from businesses, to lower those taxes. It can be sometimes hard to get people to defend this system when they have never had a big health concern before.

However when you switch to a for-profit healthcare then the interests of the operators stop being aligned with those of the population. Even if there is more money, like in the US where the budget per person is about double that of France, it is not necessarily spent in a way that benefits the patients. State-run health avoids multiple administrative costs due to multiple actors, it avoids having to pay dividends to share holders, and as a single payer it has much more power over the pharmaceutical industry to lower costs. Overall it is a more efficient use of people's money.

It's not separate from the reality that they have to decide what kind of ex. treatment they are going to support for how many etc.

That seems more a theoretical or ideological objection. Yes there may be some outlying cases where people can't their treatment paid for and have to resort to going private, but the vast majority of citizens in countries with state healthcare enjoy free and effective healthcare for their entire lives.

I do question the morality of the US system, and the sustainability of inflated prices it creates.

Its also important to remember that in for - profit healthcare, its operated as a profit center and thus has profit margins that are corporately mandated and not determined by need, at least not directly.

This leads to a massive inflation of price and decrease of quality of service, medicine, machines etc.

Not saying the EU system is better, but then that depends whether you are a shareholder or a patient.

I am unconvinced any of the systems are sustainable.

The US system isn't better it's different. The inflated prices aren't due to it being more privately driven but because of lobbying which can be dealt with.

EU systems get much better outcomes for a fraction of the cost, and you think that's 'unsustainable'? 'lobbying' can be dealt with a either side of the pond, the only thing you are arguing for is making profit from the poor and sick.

Better outcomes doesn't shield you from in-sustainability if your cost still is bigger than the money you can afford to put into it.

The problem with healthcare is that you can never spend enough money on it. There are always methods, never and better machines. In a singlepayer system the taxpayers pay for that which means there need to be political mandate behind the budgetting. You can only spend money in a singlepayer system.

In a system more driven by market you can actually make money.

It's finding the right balance between those two I consider the most interesting part of this discussion. Unfortunately it's impossible to have this discussion because people either see you as a singlepayer proponent or a 100% marketdriven proponent.

"cost still is bigger than the money you can afford to put into it." - so spending even more would be super sustainable, so long as it enriches the wealthy shareholders?

"you can never spend enough money on it" - i say again, 'enough' is defined differently, a 'socialist enough' is enough to please the people; where a 'capitalist enough' is the smallest number that can sustain profit. these 'enough's are radically different.

"In a system more driven by market you can actually make money." - only by denying treatment. this is the cornerstone of the market model, those who can't pay don't matter.

"It's finding the right balance between those two" - In the UK, we are bringing private companies into contracts within the NHS, its always been a disaster, costing much more money that the services needed to cost, the inefficiency inherent in private companies (from bloated wages of CEOs to dividends) drag the whole system into financial crisis. The people who pay for the profits at the top are always the poor users of the service.

Spending even more is whats unsustainable you can't keep spending more and more money in a single payer system as it will either affect other areas or you will have to tax the citizens even more. There is a limit to that.

If you get more and more treatments available and what people consider being part of healthcare and you are running a cost center then your system gets more and more expensive.

No enough here is meant as there will always be things you can spend to make your system better than it is. It's not a matter of opinion it's a matter of what kind of treatments are available compared to how many you can offer.

The single payer system is also denying treatment exactly because it can't pay if everyone used it. It's just another way to say some people don't matter enough.

In the UK system is also deciding which drugs it will prioritize and which it wont.

You are mixing two things together. Yes there are plenty of issues with the US system but the single payer system have issues too and they are not the same.

"Spending even more is whats unsustainable" - nationalized healthcare spends less for the same or better outcome, if your problem is price, then your problem is private healthcare.

'cost center' Vs 'profit center' <why would the profit center be cheaper? its the same as a 'cost center' with an added money drain and incentive to inflate prices..

'[denying treatment] because it can't pay if everyone used it' - This is just false, moneys going into a countries nationalized health system is high return (due to taxes), its also cheaper (due to group union prices). So long as its a healthy part of a healthy GDP (12%) it should have capacity for everyone in the country. compared to the US system which costs over 40% of your GDP and still does not have capacity for all your citizens.

'which drugs it will prioritize' - true, but this is done mostly on evidence of usefulness, not price.

I largely agree with your last statement, but whatever problems a socialist system has, they pale in comparison to the misery caused by Laissez-faire in our health system.

I am not sure why you talk about socialist system vs. Laissez-faire. Single payer doesn't mean socialist neither does private mean Laissez-faire. Those kind of oversimplifications doesn't really add anything useful to this discussion.

Switzerland has universal healthcare but it's based on private insurance. In other words it's not that simple.

In general I find this discussion hard to have because you are assuming so many things about what I say or mean, that simply aren't true.

I am not saying that a profit center is cheaper than a cost center I am saying that its able to make money which gives it flexibility.

The incentives that drives the US healthcare system are pretty shitty but they aren't incentives which are unique to a private system. On top of that in the public healthcare systems you see more and more new public management to hold down cost, which itself is expensive. But it's not something that's set in stone. It's not a property of the system it can be changed.

Changing the US healthcare system to patient outcomes incentives would do a lot to fix the incentives and there is an active program trying to do that.

And no it's not false that there are limits to a public healthcare system. Believe me I have lived in one and it doesn't only get realized by not doing certain treatments it also reflect in waiting time for operations, to see a specialist etc.

In Denmark if you go to the dermatologist you have to wait 3 week. In the US I went straight in.

In Denmark my biopsy had to be done at the hospital. In the US they made it right away at the dermatologist the same day.

With regards to drugs it's actually based on the cost, the rarity of the decease etc. I think it's in the UK where they have a list in order to prioritize.

There are outliers but most systems fall between two extremes of regulation, the heaviest regulation is basically a socialist system, owned by the people, run as a public service and so directly regulated. the lightest regulated is a private system, in a country that believes in free trade, unimpeded, Laissez-faire. As a general rule, the latter gives you worse outcomes at higher prices and is, from a patient perspective, unsustainable. the former gives you better outcomes at lower prices and scales with the countries needs (along side GDP) and is very sustainable.

Switzerland has very heavy regulations, everyone is covered by a national insurance system like other EU countries, but the very fact that its private companies that carries out the health care show in the stats, they pay almost twice the GDP of the UK for about the same outcomes, same with Germany, which has a similar system, its about 18% of GDP (and their GDP is higher per person).

"I am saying that its able to make money which gives it flexibility" - if this is really what you are trying to say, then you should have started with "Private, profit driven health care is fine for rich people", which i would have agreed with.

"waiting time for operations, to see a specialist" - this is a bad example, how many Americans wait all there lives for an operation, or never see a specialist because of the price. if you factored this in the average waiting times in a private unregulated system would dwarf a socialist waiting list(which by definition includes everyone).

"With regards to drugs" - in England we have 'NICE' which is a public board mandated to approve drugs and procedures on the NHS, with the fist stipulation that the drugs or procedures are shown through proper trials to work. This system is not perfect, but its a hell of a lot better than a private board incentivized to approve any BS treatment on profit basis alone.

"In Denmark if you go to the dermatologist you have to wait 3 week. In the US I went straight in." Try to put your personal feelings aside and look at the stats; http://www.nationmaster.com/country-info/compare/Denmark/Uni...

I am sure you don't notice it yourself but you are basically trying to argue through painting things into extremes.

It's either socialist or Laise-Faire, Switzerland is heavly regulated, Public boards are based on rationality, private boards are based on greed alone.

No a taxpayer paid healthcare system does not make it a socialist system anymore than a taxpayer police force or army does. And the US system isn't laissez faire just because it's broken in many ways. Most economies are mixed economies.

So I am not sure what you are trying to prove here. The fact remains that public healthcare has it's own issues regardless of whether you personally think they are better issues to have and any honest dive into those the countries systems will show you that. You can't both have your cake and eat it. Switzerland is heavy regulated you claim (which is wrong) but they pay twice the GDP for about the same outcome. So what is it? A system governed by the state, a system that's private or something in between? With regards to Germany most of their insurance is covered by public healthcare 80% if not more. So why is that?

Furthermore the US is a huge country with hundreds of millions of citizens and millions of illegal immigrants and spread out over a huge area. Based on it's circumstances it's not doing too shabby regardless of the statistics.

It's just not as simply as you would like to paint it in those extreme corners.

There is an interesting discussion around Medicaid vs. private insurance in the US you can read about here:

https://www.forbes.com/sites/sallypipes/2014/08/14/no-really...

My point was never to say one thing was better than the other yet thats what we are really discussing here.

My point was that there are tradeoffs in both systems.

There's no question about it morality - it's immoral. Creating a system where whether you live or die is premised on your income is immoral. Even more so when single-payer systems demonstrably achieve better health outcomes at lower prices.

The reality is that that so many people in this country have bought into some kind of Capitalist Calvinism, where the suffering is not only pre-ordained by "market forces," but considered salutary itself, that it's sickened our culture beyond the capacity for reason. We'd really rather watch our friends, families, and neighbors die in sickness and poverty, than admit the failure of the grotesque just-world fallacy that is our economic ideology.

It's not that simple. Single payer systems also decide who to treat and for what sicknesses, what machines to buy etc.

The reason why the US system is so expensive is because of perverse incentives given to the industry.

As long as you can afford it I would rather be treated in the US system than the French or Danish system.

>It's not that simple. Single payer systems also decide who to treat and for what sicknesses, what machines to buy etc.

So does the US, they just use one's wealth as a proxy to arrive at demonstrably worse results for everyone overall.

If you want to have a system where one's income determines their ability to survive because you have enough money and that works for you right now, go ahead. But at least drop the pretense that it's in any way just or moral.

Thats a different discussion though.

You can be of the opinion that everyone should get access to the same treatment or you can be of the opinion that they shouldn't and that people who can afford better treatment should be able to.

All I was doing was point out that a single payer system has it's own issues as well.

Whether you are a fan of one or the other is more a political discussion.

" [] systems also decide who to treat and for what" - in privately owned companies, this decision is made to maximize profits, in publicly owned companies this decision is made to please constituents.

"The reason why the US system is so expensive" - Is because an individual with a health condition is in a poor position to negotiate the price of a treatment for themselves. To the extent a private company could give fair prices, they would have to be regulated heavily.

"As long as you can afford it I would rather be treated in the US" - You believe this because much of the massive profit margins goes into advertising.

NO I say this because I have lived both i Denmark and currently live in the US and have had two melanomas and are expecting more because I have more than a thousand of them. So I have a pretty good idea of the capabilities of the US vs. ex the Danish system.

Sorry about your problems, but you are a study of one, your experiences might be typical or atypical, flip a coin.

On the other hand, you will likely have been on the receiving end of millions in advertising, and since your 'opinion' is in line with that advertising... its a good bet it is the result of it.

if you are interested in some conflicting 'studies of one' have a watch; https://www.youtube.com/watch?v=thkBLpRwdSM

And you a study of one too.

I know the documentary but what does that have to do with whether the US system have access to more advanced healthcare than most other places.

I don't need a documentary to tell me the many issues with the US system just like I don't need one to tell me the many issues with the Danish system.

> Single payer systems also decide who to treat and for what sicknesses, what machines to buy etc.

Most (but not all) single payer systems coexist with private payer.

In England you can get all your care on the NHS, or you can mix and match with NHS or private care.

Ah yes, because the "market" for healthcare operates so well...

It's really sad that it's impossible to discuss healthcare without people jumping into their pigeonholes.

Healthcare isn't perfect anywhere in the world whether private or public.

And even the US healthcare system isn't really market driven.

That's my point. Any suggestion which starts with "this is unsustainable because the market isn't driving incentives right..." has completely missed what's going on in healthcare first and foremost: it's your life, and it's worth everything to save it.

Opening with "let's have a market" isn't opening with a cogent position, since rational actor economic theory is completely unable to deal with this (sure, there might be others, but no one making this assertion wants to talk about them).

No I haven't missed anything at all I am just basing my reasoning on a different premise than yours.

My premise is that you can never spend enough money on healthcare. There is always a need for better treatment, more treatment, new machines etc. Even if you taxed people 100% you could still spend more money because as you say it's worth everything to save it.

But a political system is made to prioritize the resources that we have and so a singlepayer system cannot escape to have to come to terms with the boundaries of the budget it's given.

There are many areas where a patient will not be treated or where the system decides it's not worth continuing to pay for some treatment.

In a singlepayer system it gets decided what gets treated in a system which is more open to demand the market decides.

None of these are without fault it's just important to keep their limitations in mind. This is why ex. the french system as much rave reviews it's gotten also sets limits to who it will treat.

We can then have a discussion about whether it's better that everyone gets access to the same treatment or whether it's better that some people can get access to better treatment methods than others.

But to ignore that a single payer system comes with it's own problems such as limits on how many people can be treated and for what and how long, is not taking the discussion serious.

The way I see it is as long as the state provides effective and accessible healthcare, things like hospital choice over equipment or drug supplier is a "nice to have". Prioritizing these things seems like freedom for freedom's sake.

Much of the US has certificates of need which impose limits on who can operate certain machines or have a hospital.

And Medicare makes funding decisions based on what sort of care hospitals provide to patients. Critical access hospitals get higher reimbursement; maintaining that certification means a short average for length of inpatient stays and not growing to meet demand.

This is not the market fault it's the political system and reimbursement rules which creates perverse incentives. Some hospitals have begun to get reimbursed based on how well the patients gets treated called value based treatment.

I was implying that the US doesn't really have a market.

Compared to Europe it does though. I.e. the us healthcare system does't get most of it's payment through taxation. Thats an important distinctions.

I guess.

Medicaid and Medicare are more than a third of spending and don't necessarily cover the total costs of the care provided under the programs (any unmet costs are a hidden tax). The VA is not nearly as expansive as those programs but is another couple whole percentage points of US health spending.

And you've also got Tri Care and some BIA stuff, and state expenditures that are outside of Medicaid.

Not sure we are discussion the same thing.

My point is that a singlepayer system payed by the taxpayers and budgeted by the politicians isn't making money it can only spend less money.

A system like the american overall can make money, it's it's goal to profit.

That's the difference between whether it's a market driven market or not IMO.

For me, to be "market driven", you have to have easy entry on the supply side and not have huge amounts of mandated care on the demand side.

The US has all sorts of constraints on the supply side and a lot of the demand side is treated under various mandates.

Without easy entry on the supply side, there can't really be a market response to changes in demand, hence not really market driven.

When care is provided to comply with government mandates and incentives rather than because it can be priced above cost, not a market driven transaction.

We were talking relative to ex. europe. Not some ideological defintion. Then the US isn't a market driven economy.

Thats not a useful way to look at things.

Creation of new supply seems more in the "words mean things" bucket than the ideological bucket.

> and thus has budgets that are politically mandated not determined by market demand at least not directly.

Why is market demand a good thing?

In the US the government spends more per capita than France, but gets worse health outcomes.

It's neither a good or a bad thing.

The US system isn't the only way a marketdriven system can be and a lot of it's problems are lobby and politics related.

Market demand is a good thing in the sense that it creates better allocation of resources.

The US doesn't have a healthcare market driven by market demand. But the fact is that the US system has more advanced treatment methods.

The problem is that it's not evenly distributed.

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