Comment by galeaspablo | Hacker News Reader

Comment by galeaspablo | Hacker News Reader

How do we compare apples to apples (between countries)? Compare health expenditure per capita (public and private) with multiple health indexes. I.e. get the bang for buck.

In the list of nations with the best bang for buck healthcare programs, you will notice that top 20 healthcare programs are mostly single payer.

http://www.who.int/healthinfo/paper30.pdf

But there are single payer healthcare systems with bad health indexes, you might say... Well, combine single payer healthcare systems and add some transparency in healthcare and you now have an unmissable correlation.

https://www.transparency.org/whatwedo/publication/global_cor...

The top 20 bang for buck healthcare programs (mostly single payer systems), have an average ranking in terms of healthcare transparency of 18.7.

Are you from the USA? Notice the countries with universal healthcare, who have a similar healthcare transparency ranking to that of the USA: Luxembourg, Canada, Germany, France, Belgium, Ireland, and Chile. Their bang for buck rankings are 16, 30, 25, 1, 21, 19, 33 respectively. All of these countries have a better bang for buck ranking than the USA's 37.

In one sentence... Universal and transparently managed healthcare consistently gives more bang for buck.

And now to quote the original article... "It is a bedrock economic principle that if we can find a way to do something more efficiently, it’s possible for everyone to come out ahead."

EDIT: Check page 18 in the first source. Check chapter 11 in the second source.

"And now to quote the original article... 'It is a bedrock economic principle that if we can find a way to do something more efficiently, it’s possible for everyone to come out ahead.'"

That's a really important "possible" though. It is a near certainty that if were to transition to single payer healthcare we would not do the transfers to hold everyone profiting from the current system harmless (e.g. health insurance employees). In any realistic scenario there would be winners and losers which is why you see fierce lobbying on both sides of the issue.

It's the difference between Pareto and Kaldor-Hicks (See this prior comment for the definitions: https://news.ycombinator.com/item?id=14605477 )

That's a matter of policy.

You can set a cap of how much tax someone pays for healthcare, such that rich people don't get screwed.

The question here is what's more efficient... And the numbers are there. Single payer + Healthcare transparency = Efficiency.

(see sources and explanation in original comment)

Why do rich people need a cap in order to not "get screwed?"

Like I said, that's a matter of policy. I.e. should rich people pay more tax?

But I'm not here to answer that question.

This is interesting data...

https://ourworldindata.org/the-link-between-life-expectancy-...

The US is pretty divergent... and not in a good way.

I advocate single payer, vs single provider. What Canada has, more or less, vs Britain's NHS.

http://www.pnhp.org/single_payer_resources/health_care_syste...

Plus a good dash of capitation, to incentivise wellness thru prevention, vs fee-for-service.

This simplification seems disingenuous. Would switching to single payer solve your last sentence / quote from the article? Aka, would putting the US government in the middle make things simpler and more efficient (and cheaper) for the end user (health care patients)? I can't say I'm convinced.

Compare with the current system, where any given user is still effectively dealing with a single payer -- their insurance provider. Their insurance provider is one level of removal from the health system that has to be paid.

Now, the idea of transparency? That's lovely, and would force accountability and that sort of thing which could potentially have impact. I can't disagree with that. I'm not sure that just putting the government in the middle fixes that either, though.

As /u/frgtpsswrdlame points out, we have the most expensive health care, which seems like the bigger issue that isn't addressed. If we lessened the cost of health care in the US, that would probably be a better start, imo. Does single payer fix that? I would think that private, competing companies would seek out better deals vs a single government entity who couldn't really negotiate, but perhaps I've got that backwards.

I'm not disagreeing with the thought on the whole, I just don't see how single payer fixes these problems.

I lived in Italy for a number of years, and the Italian government is no nordic model of efficiency and propriety. And the health care system is still mostly better than in the US :-/

You're right that costs need containing though, and it's not quite as simply as "just" switching to a singly payer system.

>I would think that private, competing companies would seek out better deals vs a single government entity who couldn't really negotiate

That's the biggest advantage of single payer, one buyer can negotiate better deals with suppliers because there are no other buyers. It's basically a reverse monopoly.

The term for that is monopsony.

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

I want proof. I only see numbers. Everything else is conjecture.

Transparency in healthcare + Single payer (by the government) = Efficiency

(see sources and explanation in my original comment)

So yes, putting the US government in the middle is what I'm suggesting. Or is the US government not a leading force in fighting corruption anymore?

> I want proof. I only see numbers. Everything else is conjecture.

But wait, is this not conjecture, since it doesn't currently exist? Sure, you have sources where it has worked, but the proof would only be implementing it here.

> Or is the US government not a leading force in fighting corruption anymore?

What? I don't understand what you're getting at here. My point isn't that the government is corrupt, it's that it's inefficient.

> But wait, is this not conjecture, since it doesn't currently exist? Sure, you have sources where it has worked, but the proof would only be implementing it here.

Universal and transparently managed healthcare consistently gives more bang for buck. Note that I said "consistently", not just in a few places.

Yes, obviously you can't know what's going to happen in the US until you try it. But if it has consistently worked around the world, the best guess is that it will work in the US as well. Surely your argument, can't be... "how can I know this ball is going to fall into the Earth, if I haven't dropped it yet".

> What? I don't understand what you're getting at here. My point isn't that the government is corrupt, it's that it's inefficient.

And my point is that transparency in healthcare + single payer makes the system efficient.

Are there other countries that have transitioned from a high-cost system like ours to a single-payer system? How quickly did their costs go down?

For example (according to the first Google links for "usa/uk average doctor salary"), the average doctor salary in the UK is $128,500, compared to $189,000 in the US. How are we going to cut salaries by 32%?

My guess is that there are salary discrepancies across the medical industry.

> transitioned from a high-cost system like ours to a single-payer system? How quickly did their costs go down?

I did not look this up. But I know one thing, eventually you will save money. I don't suppose that it would take longer than 20 years to save money, but I frankly don't know. Maybe you could look it up to expand on your point:-D

> average doctor salary in the UK.. Compared to... In the US.

That is not apples to apples. There are countries with lower and higher pay, both overall and relative. Plus you have think of differences in cost of living, taxation, malpractice insurance, and even their own medical insurance.

Here's a link I found covering a bit of that. The chart would be the tldr. https://www.forbes.com/sites/theapothecary/2013/05/28/are-u-...

"Or is the US government not a leading force in fighting corruption anymore?"

Um...

Put it in perspective (compared with every country on Earth).

https://www.transparency.org/news/feature/corruption_percept...

The US is 18/176 on the list on that page; not even in the top 10%. Personally, I would say the top 5% or so could reasonably be called leaders. Where would you draw the line?

Interesting. Why is the U.S. less corrupt than most? Would giving the U.S. government a big bump in the amount of power it weilds in the form of single payer health care improve the curruption situation or make it worse?

0xffff2 - that's correct. Personally I am more lenient, given that my country of birth struggles.

But in the context of the conversation, I think #18 is good enough to make the cutoff for single payer. After all, other countries with lower healthcare transparency are still more efficient with their universal systems.

krupan - I don't have the data for what has happened with transparency when countries implemented universal healthcare. So I don't have the answer for that.

>Or is the US government not a leading force in fighting corruption anymore?

Was it ever?

In the grand scheme of things, yes.

https://www.transparency.org/news/feature/corruption_percept... http://www.worldaudit.org/corruption.htm http://www.espn.co.uk/espn/feature/story/_/id/14767250/the-e...

This is a really good point. One problem I think though is that not everyone will come out ahead in a single payer system. Our system is explicitly organized around the fact that you must pay for care and we have the best and most expensive care in the world. Our system is setup so that those at the top of the economic ladder can buy a level of care they could not get anywhere else. They will undoubtedly receive worse care were the US to switch to a system which diminished the effect of personal wealth.

>They will undoubtably receive worse care were the US to switch healthcare systems.

If the US switches to mostly single payer, but still allows for private insurance and private doctors to exist, the wealthy will probably have to pay more to access them, but they'll still be able to access them.

That is conjecture. I could similarly hypothesize that things would improve under a single payer system, even for the rich... because of the compounding scientific advances of government backed healthcare.

BUT we could go back and forth all day with conjecture... Give me some apples to apples numbers; that's what I joined HN for.

Actually, the 1% would have private healthcare, i.e. pay twice.

This is directly analogous to private primary education: the wealthy still pay taxes to fund public schools, while paying addition for private schools as well.

Something else the conservatives want to fix with school vouchers....

This is not true, and can be trivially observed to be not true by counterexample, viz. looking at other countries that have a hybrid public/private system e.g. here in Australia.

Incidentally, "level of care" is almost meaningless in most first-world systems. The difference I experience, due to my private health insurance here, is not in outcomes, but in time to service for elective procedures, and access to private facilities (most notably a private room for overnight/extended hospital stays). And that time-to-service difference vanishes for emergency care.

EDIT: additional insider tip. If you have private health cover in such a system, and are being treated for a major medical issue, ask for a private room in a public hospital, because that is where our clinicians spend most of their day-to-day. If you are in a room in a private hospital, there are often no specialist clinicians on site. Whilst this may make no difference for most cases, any sudden complication may be dealt with much more quickly. This is possible in our hybrid system because the hospital is a separate institution from the state and happily does both public and private billing.

Word salad.

Our system (the USA) maximizes rent seeking, thru obfuscation, disjoint regulation, spotty oversight and enforcement.

> They will undoubtedly receive worse care

You're going to have to provide a lot more support for that claim. All you've really provided is the implication that "most expensive" = "best". But expense is also a result of inefficiencies, and we "undoubtedly" have a less efficient system (more administrative overhead.. I can cite sources if anyone doubts it).

Other single-payer systems, for example, also provide complementary or supplementary private options.[1] And since these private options have to compete with a baseline of quality public care, they may be more affordable.

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

> And since these private options have to compete with a baseline of quality public care, they may be more affordable.

In such a hybrid system the public hospitals also experience competitive pressures. I can confirm pretty much first-hand[1] that this is why pathology turn-around times in a major metropolitan Australian public health service are measured in hours, whilst in the UK they are measured in weeks.

[1] I am married to the medical director of this service.

Indeed. One of the core ways single payer systems achieve such great results in terms of bang-for-buck is by not covering treatments that offer bad value for money, and this is almost certainly not politically viable in the US. For example, I understand the ACA specifically forbids assessing the cost-effectiveness of treatment based on dollars per QALY, which is how the NHS in the UK rations care to reduce costs.

It simply does not follow that, because single payer systems offer better value in terms of benefit gained for the dollars spent, those efficiency improvements mean it's possible for everyone to come out ahead. Those last few iotas of healthcare improvement are a lot more expensive than the lower-hanging fruit.

This is flat wrong mis-statement of both the facts and the outcomes.

The NHS does not assess cost-effectiveness of treatment in the UK in that fashion, and does not deny it on that basis.

Cost-effectiveness by QALY is one factor included in assessments by a separate body, NICE, which a) is not part of the NHS and b) does not inhibit NHS bodies from offering any particular treatment. If NICE gives a treatment option the green light, then the NHS trusts are obliged to offer it in applicable circumstances. If NICE does not, then individual (local) NHS trusts can make their own assessment. If there is a local cost constraint, that is considered as a matter of simple necessity.

It is a common falsehood often repeated by opponents of single-payer systems that doctors in such systems are directly prevented from offering treatments by faceless beancounters. It simply isn't so. Quite the opposite. The assessors may say "you must offer this treatment". They do not say "you must not".

However, QALY itself is IMO a terrible metric mainly because it is sufficiently describable to non-practitioners to become a political football.

Part of running an "efficient" healthcare system is that cost constraints are always a factor. Sure, NHS trusts are legally allowed to offer treatments that aren't approved by NICE, but they have piles of money lying around to do expensive things beyond the basics that are required of them at the best of time, and this isn't the best of times - like many countries the UK has a healthcare funding crisis right now.

At best, requiring a treatment rejected by NICE leaves your fate up to a postcode lottery where your location determines whether you have access to it. At worst, nowhere will cover it. Also, cost per QALY is one of the main factors NICE uses, and the ACA means it and similar measures cannot be used as any kind of factor at all in the US.

NICE was founded to reduce that postcode lottery by creating a base set of what is nationally achievable. Over time, that set grows. It's grossly unfair to misrepresent it as some kind of net-negative body, or to suggest that doctors won't treat a patient. Indeed one of the effects is to encourage research into more affordable treatments. This is in antithesis to the US system where, for example, the drug companies are incentivized to R&D long-term treatments for symptoms, not cures for diseases.

I like the incentives that NICE creates instead. Over time, it's a strong net national benefit.

The failure to include such a mechanism in the ACA seems more to do with US politics than any intrinsic characteristic of single-payer systems.

The NHS has apparently been under-funded for decades, far too long a period to call it a "crisis". I would maintain it is simply grossly inefficient at spending the money it does receive, due to horrible management. Again, this is not an intrinsic characteristic of such systems.

> ACA specifically forbids assessing the cost-effectiveness of treatment based on dollars per QALY, which is how the NHS in the UK rations care to reduce costs.

This.

And lets put it in concrete terms.

If you are 40 and get cancer you get treatment.

If you are 82 and get cancer you get pain meds.

And there is no US politician that is going to fall on that grenade.

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