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Comment by dbpatterson | Hacker News Reader

It's amazing that someone can go through this and come to the conclusion, at the end, that the solution is that this is a business opportunity that would make a lot of money if someone could just make it more efficient. Trying to make money off of healthcare is exactly how we have gotten the absolute mess that is the American medical system. All the incredibly complex rules exist so that health insurance companies can elect _not_ to pay for things that were deemed necessary by a medical professional. If insurance companies would be willing to pay for the services that were needed, there would be no 1600 page rule books. Of course, a system that actually paid for the care that people needed wouldn't be so obscenely profitable for them, and so they lobby massively against it.

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Theoretically, then, there should be a niche for an insurer who covers more, who treats you less shitty, but costs more.

Consider the example the OP gives is a patient who they're paying thousands of dollars a day for, rather than hundreds. They're paying several people to work for days just to figure out how the rules work. It's only marginally working for them.

And let's not forget that they are also fighting profiteering on the other side; is it inherently wrong that your insurance might not pay for a new brand-name medicine that costs 100x as much as a generic with only the barest minimum difference they could sneak past the FDA and get a patent for?

I have Kaiser. Kaiser is a special beast, but one thing it does do pretty well is talk to itself. Combining providers and insurance under one roof provides a lot of upside in knowing what will be covered (though it has the downside that you really don't have options if Kaiser isn't getting the job done).

I recently had the experience of setting up a procedure done by an entirely private (accepts no insurance) practice, because Kaiser wasn't coming through for me. I was shocked how easy it was.

In one phone call, I was able to set up a consult, and even a tentative date, for a fairly complicated (day-long) surgery. Craziest of all? I got a price estimate. (It was 5 figures, but I expected that)

That was something I thought just wasn't possible in the medical world. There's so many variables, they haven't seen my X-Rays, etc, etc, etc. But still they did that. Entirely for profit, though.

I'm not saying for profit is the answer to everything or anything - someone less fortunate than me wouldn't even be able to consider going outside of Kaiser. Just that there aren't any easy solutions. I'm surprised by the system almost every time I interact with it.

> Theoretically, then, there should be a niche for an insurer who covers more, who treats you less shitty, but costs more.

There is something like this for the wealthy [0]. Obviously, concierge medical services are very expensive, and morally questionable imo.

[0] https://www.nytimes.com/2017/06/03/business/economy/high-end...

Let's not forget that most people get insurance through their employers, which really limits the choices.

Paying up front for medical services - especially in today's "Chargemaster" world where nobody has a clue what anything really costs - requires you to be REALLY rich. A straightforward appendectomy for me required an overnight hospital stay which was billed at a $17K (the surgery, etc, was more).

Funny thing about that link. It has a chart of "The average number of days to get a non-emergency doctor’s appointment". Los Angeles is pretty flat around 23 days. Guess what time limits the state of California places on that legally? (hint, it's less: http://www.dmhc.ca.gov/HealthCareinCalifornia/YourHealthCare...)

The American medical establishment is the ONLY one I am aware of that should you want a service, you go into the arrangement rarely, if ever, knowing how much you might pay on the other side.

I refuse to p(l)ay. My wife is medical and we have insurance, but I go to the indigent clinic for any infections I may get and buy a $4 prescription. This same experience with a doctor in a nice area would be lots more, even with insurance. Sure, you can tell these bastards you want no tests, etc., but some won't treat you without them, and most are not needed. Think I have strep? That's one test that's cheap. That and flu a/b. Any others are ridiculously pricey.

I spoke to one of the indigent doctors and asked him how he stays in business making $25, $25 there. He says he's not in it for the money. I believe him. He told me that in everyday doctors' offices, the doctors are convinced by the pharmaceutical sales reps to push product. They can win cruises, cars, etc., based on much drugs they push out the door in RX, so the desire to make money trumps being minimalistic in care. Give me only what's needed for the time being. I don't want long-term drugs and refuse to take them. I will only take antibiotics if I need them and only antibiotics. I will never take meds for high blood pressure, cholesterol, etc. Look at the numbers. The threshholds for these numbers have been lowered in the last decade or two to push RXs.

Like I mentioned in another post, the Americans doctors are the Ferengi of medicine. I refuse to pay more than $25 to see the doctor. I've even had stitches for $25. Try getting that price going to a non-indigent clinic. And, the Mexican and Indian doctors at the clinic have been doctors for over 20 years each. I've never been misdiagnosed.

To those who are sick of paying out the nose, look for the cheaper clinics that serve immigrants. They prefer cash, don't need insurance, and actually treat you like a human being.

> and morally questionable imo.

Why?

And what do you think of medical tourism?

I can get a flight to/from Taiwan from (say) SFO for ~USD$450. I can get a fairly complicated dental procedure done for (uninsured, out-of-pocket), USD$400. (The same thing can be done w/ Panama, fwiw, but I understand Han culture and communication better than Latinx)

Is that wrong?

Q2: Why should people be denied treatment that they can (and are willing to) pay for? Because not 100% of the people are able to? If so - where does that reasoning go? Rich people shouldn't buy a Tesla because poor people can't afford a Tesla? Rich people buying Teslas ultimately drive the price down, right? Then more and more people can buy them, right? If immortality cost $1M/year (not much money, actually) - more and more people would get it and sooner-or-later it would be $10K/year (this happened with fax machines in the 80s). Then $5K/year -- or whatever. I believe that rich people subsidize R&D (for selfish reasons) that benefit us all in the future.

Do you disagree? If so - why?

It isn't profit-seeking what makes healthcare what it is. Its the incredibly burdensome regulation and restrictions.

If profit-seeking destroyed markets for profit, we would all be starving.

No, it is profit-seeking that created this cluster-fuck. It only seems to be a problem in third-world nations like the US; the rest of the world seems to be blissfully free of broken profit-seeking institutions that cannot talk to other profit-seeking institutions so that they can collectively figure out the least amount of healthcare they can provide to the patient (so that both can maintain their profit.)

I am from a partially socialist country that has free healthcare. I have had private healthcare, along with most of my socio-economic class, my entire life.

Making it socialized does not mean it will be better. Coldly, see it as a different system with different consequences. Bringing it to the US: look at how much medicare costs today: 3.6% of gdp, servicing 56 million americans. If you extended medicare to the entire population at the same per capita, it would be 26% of GDP.

Actually, the first world nations that have socialized healthcare systems experience better outcomes than the United States with less per capita spending.[1] Medicare as it is currently formulated is specifically targeted towards at-risk populations that have higher incidences of medical usage than the general population; you can't just apply the exact same per capita spending across the American population. 80 year-olds use more health care than 25 year-olds.

[1]: http://www.commonwealthfund.org/publications/issue-briefs/20...

I live in a "first world nation" and 10 years ago (before the global financial crisis even) public vs private healthcare meant the difference between leg amputation and implantation. The public system is only good for routine diagnosis and minor surgery. For everything else, care quality goes down the toilet. Not to mention on the effectively complete lack of dental care.

I'm not sure where you live and you're not providing any links or statistics to back this claim up, so it's difficult for me to respond to what you're trying to claim here. If you read the link I provided, you would see that they use cancer, heart disease, and diabetes mortality as a shorthand for patient outcomes in significant health events, and that while the US healthcare system ranks reasonably well in cancer treatment, it is significantly behind other developed nations in treating heart disease and diabetes. They also provide statistics regarding mortality rates in various populations, and the US lags other developed nations in basically all of those populations.

Your point about dentistry is interesting, although also mostly unsupported, and I'm having a difficult time finding good statistics about dental care, spending, and outcomes. Anecdotally, dental care in the United States is sharply linked to money; people with money have good/great teeth and excellent dental care, people without it frequently have major issues with their teeth. I don't know how that compares to other countries.

What country is this?

> Actually, the first world nations that have socialized healthcare systems experience better outcomes than the United States with less per capita spending

It is beyond question that the healthcare market in the US is terrible, because its expensive and ineffective. That is out of discussion for any reasonable debate.

What is also out of debate are many reasons why is it so expensive today: restrictive immigration of doctors, importation restrictions on drugs, self imposed gov restrictions on bargaining, hospital building regulations, malpractice legal costs.

Government taking full control of the system fixes NONE of the problems listed above, which are by and large some of the biggest price drivers. It might make them worse, because all of the ones above are exclusively decisions of the government.

> you can't just apply the exact same per capita spending...

I agree, tho at the same time you cant expect the government to be more efficient as it increases its scope of scare. Economies of scale dont work for the government. 10x service might cost 50x. It should be clear however that its a reasonable order of magnitude: more than barely double digits. A 20% gdp cost on healthcare will come with cuts in service, I guarantee that.

The link I posted does suggest that economies of scale do, in fact, work for other governments, and that despite covering 100% of their population, they see significantly better efficiencies than our system does. If you're going to claim that economies of scale don't apply here, you're going to have to provide some evidence that contradicts the lower per capita spending/better outcomes we see in other systems.

Medicare has more patients than the population of england, or spain, or many of the european first world countries.

It is already visible that medicare is not efficient.

You still haven't actually laid out a metric showing that Medicare is inefficient; you just keep asserting it is not efficient in the face of evidence that single-payer systems are in fact pretty efficient. To add more evidence to the "you are incorrect and single-payer systems are in fact pretty efficient" pile, here's another potential efficiency metric we could compare: Medicare spends significantly less (approximate 1.4%) on overhead costs, compared to private insurers that average around 12.4%.[1]

So, again: the US as a whole, using a primarily market-based healthcare system, spends more money per capita for worse results than most other developed nations, most of which are using single-payer systems. Within the American healthcare system, there is a limited single-payer system that only covers a particularly high-risk patient population, and yet despite that patient population, runs more efficiently as an organization than the market alternatives. What evidence are you offering to make the argument that that limited single-payer system is actually more inefficient than the private alternatives?

[1]: http://www.politifact.com/truth-o-meter/statements/2017/sep/...

> You still haven't actually laid out a metric showing that Medicare is inefficient; you just keep asserting it is not efficient in the face of evidence that single-payer systems are in fact pretty efficient

Medicare is an example of a government run healthcare service in the US. Its way more relevant to compare to Medicare than to compare with foreign countries health results. Its also revelant because single payer proposals in the US are basically expanding Medicare. So even if every single single-payer system in the world were efficient, if Medicare isnt, it wouldn't matter.

> Medicare spends significantly less (approximate 1.4%) on overhead costs, compared to private insurers that average around 12.4%.[1]

Sure, thats because it doesn't do price-fighting like private providers have to with insurance companies. It has the basic incentive to cede at every corner as an institution. But lets look at other reasons why healthcare is spending and how medicare solves them. How about pharma costs, doctor salary costs and legal costs. Is medicare cheaper on these other predominant reasons why healthcare is expensive?

You will find that Bernie sanders understands well that pharma is expensive because government restricts its importation. So if as an organization the government is strained to even bring drugs from abroad, a problem it has unique power and responsibility to solve today and no-one else can do except for 'retail smuggling', and we are supposed to put our entire faith into the same hands that cant solve that?

If you just eliminated restriction of drug importation, you would drop healthcare costs enormously in 24 hours. The only thing you have to do as a government, is to stop doing a thing. How simpler can it be.

The core idea here is that the debate of public vs private is a red herring. Healthcare is not expensive in the us because of private vs public. Its expensive for its own particular policies, which economists have consensus on and are hard to take on due to lobbying, or lack of public interest, or mere gubernamental complexity. The topic is presented as two black bentos, where you can only see the results in the faces of people eating them. But they really aren't. You can see what each has and why.

You know those regulations are there for a reason right? Would you like to go back to the days where people are kicked off insurance for extremely dubious pre-existing conditions?

>If profit-seeking destroyed markets for profit, we would all be starving.

It depends on what you mean by 'destroy markets.' The market is functioning well in the sense that healthcare stocks keep going up. It's functioning poorly in the sense that it's the ill who have to die or go bankrupt to support it.

>You know those regulations are there for a reason right?

The road to hell is paved with good intentions.

> It depends on what you mean by 'destroy markets.' The market is functioning well in the sense that healthcare stocks keep going up. It's functioning poorly in the sense that it's the ill who have to die or go bankrupt to support it.

The measure of the health of a market is not the profits of the industry in it. A better rule of thumb would be how many people get serviced and at what relative cost. In that sense, the american healthcare market is very unhealthy.

>The road to hell is paved with good intentions.

Oh come on, this platitude applies to people saying 'less regulation' just as much as it does me.

>The measure of the health of a market is not the profits of the industry in it. A better rule of thumb would be how many people get serviced and at what relative cost. In that sense, the american healthcare market is very unhealthy.

Sure, but in that sense we can look around and see that healthcare markets are generally less healthy when they are (1) more private and (2) less regulated.

> Oh come on, this platitude applies to people saying 'less regulation' just as much as it does me

I didn't argue that regulations are good because there was a purpose to them nor its opposite. So it doesnt really apply to my stance so far.

> Sure, but in that sense we can look around and see that healthcare markets are generally less healthy when they are (1) more private and (2) less regulated.

I disagree with that statement, and I am sure that you will find examples of private markets that are more efficient than public markets, of the which you only need 1 to disprove the idea that public > private on health.

>I didn't argue that regulations are good because there was a purpose to them nor its opposite. So it doesnt really apply to my stance so far.

I mean 'the road to hell is paved' is just an argument against trying to do anything good, it's not exactly relevant.

>I disagree with that statement, and I am sure that you will find examples of private markets that are more efficient than public markets, of the which you only need 1 to disprove the idea that public > private on health.

Well no, because I'm speaking in general. But I'd love to know your example.

> Well no, because I'm speaking in general. But I'd love to know your example.

Instead of wasting time with examples that dont go for the core of your stance, can you share what would change your mind in the general?

Mine is that lightly regulated free healthcare markets will be efficient (though might not be equitable).

>Mine is that lightly regulated free healthcare markets will be efficient (though might not be equitable).

And what is 'efficient'? I think a major component of a well functioning healthcare system is that it's equitable. Our problem with healthcare is driven by the generalized problem of 'economization.' A rich person doesn't have some intrinsic quality that makes them more deserving of quality healthcare.

A healthcare system which is extremely efficient at treating the rich and letting the poor die isn't really what I'm looking for. Efficiency and equality must be balanced. What I'd say is that the US is pretty terrible at both and that's sad.

>Instead of wasting time with examples that don't go for the core of your stance, can you share what would change your mind in the general?

Some evidence that shows that mostly private healthcare systems generally function better than mostly public ones or some evidence that healthcare regulation in the US has led to worse outcomes and not better ones would at least give me a jumping point. But I'd also ask you to answer your own question here.

> What I'd say is that the US is pretty terrible at both and that's sad.

Right, inefficiency tends to harm both equitability and value/cost(loose efficiency definition), but the US market is not what it is because it is efficient or because it is equitable, which is a classic dichotomy of microeconomics.

> Some evidence that shows that mostly private healthcare systems generally function better than mostly public ones or some evidence that healthcare regulation in the US has led to worse outcomes and not better ones would at least give me a jumping point.

I see. So the challenge here is that we can only compare apples to oranges over and over again: we could try to see east germand and west germany, but for other reasons the economics were different. We can compare same country public and private like Germany and Argentina, and get to different conclusions (in germany, private is for the rich, in argentina, public is for the poor). We can compare England to the US, but how do you adjust for cultural and income differences?

For example, healthcare in the US was relatively very cheap 50 years ago, where it was still private. What happened in the middle?

Instead of looking so broadly at private vs public, its better i think to focus on why its expensive. And I can assure you that the top 5 reasons why healthcare in the us is expensive is due to government irresponsibilities. If the government cant even fix its own mistakes, how is it going to handle a much larger responsibility?

> But I'd also ask you to answer your own question here.

I did.

>Right, inefficiency tends to harm both equitability and value/cost(loose efficiency definition)

Well no... Inefficiency is totally independent of equitability.

>For example, healthcare in the US was relatively very cheap 50 years ago, where it was still private.

This increase in healthcare expenditure across time has happened in all western countries has it not?

>Instead of looking so broadly at private vs public, its better i think to focus on why its expensive.

Broadly looking at private vs public is a very good way to guide our focus to what makes our healthcare in the US so expensive.

>And I can assure you that the top 5 reasons why healthcare in the us is expensive is due to government irresponsibilities.

You mean how the government has failed to regulate more? How the government has failed to de-privatize certain portions of the American healthcare system? How the government has hamstringed public options (like Medicare) to prevent the american public from realizing how much cheaper the government can provide care than can a private system? Totally agreed!

>If the government cant even fix its own mistakes, how is it going to handle a much larger responsibility?

What are you talking about? Private healthcare companies make mistakes all the damn time. The reason we trust government is because we get a voice in it. If your point is that american government needs to be more democratic and responsive to the wishes of individuals and cut the crap when it comes to sponsorship by large insurance conglomerates then I'm all with you.

>I did.

Did I miss it? Maybe you could post it again here. I'm just looking for what could change your mind.

> Well no... Inefficiency is totally independent of equitability.

The reason why inefficiency is tied to equitability in the real world is because equitability is enforced, which means you spend resources to achieve it, and that is the successful case of enforcement. i.e. forcing everyone to take insurance to give coverage to the sickest can increase sickness because there is no economical consequence to unhealthiness.

> This increase in healthcare expenditure across time has happened in all western countries has it not?

No..if it had, we wouldnt be talking about a problem of healthcare in the US. Its grown disproportionately here. But the whole point is that 50-60 years ago, healthcare was cheap and it was private.

> You mean how the government has failed to regulate more? How the government has failed to de-privatize certain portions of the American healthcare system? How the government has hamstringed public options (like Medicare) to prevent the american public from realizing how much cheaper the government can provide care than can a private system? Totally agreed!

I will be more practical then. What do you think are the top 3 issues that make healthcare expensive? Concretely, not abstractly. What are the 3 things that if didn't happen, healthcare would be much cheaper, and I challenge that all 3 of them are the result of regulation. That is, the government made it expensive.

> Did I miss it? Maybe you could post it again here. I'm just looking for what could change your mind.

> what would change your mind in the general? > Mine is that lightly regulated free healthcare markets will be efficient (though might not be equitable).

>The reason why inefficiency is tied to equitability in the real world is because equitability is enforced, which means you spend resources to achieve it

Now you're switching around your causality. Earlier you said: "inefficiency tends to harm both equitability and value/cost"

So you don't believe that inefficiency causes equitability, just that equitability causes inefficiency?

>No..if it had, we wouldnt be talking about a problem of healthcare in the US. Its grown disproportionately here. But the whole point is that 50-60 years ago, healthcare was cheap and it was private.

So, in response to demographic changes across the western world (like an aging population) a bunch of countries made their systems more public and were able to keep costs down and the US has kept theirs more private and costs have ballooned. Maybe the answer is self-evident.

>I will be more practical then. What do you think are the top 3 issues that make healthcare expensive?

I think there is basically one cause: the existence of for-profit insurance companies. In a public system where government provided healthcare there would be a large monolithic body which could assert it's power to keep prices down. In a market with multiple insurance companies, they'll never have enough individual power to keep prices low. That's how the market is supposed to work by keeping power divided, it's just that healthcare is a terrible place for markets.

>Mine is that lightly regulated free healthcare markets will be efficient (though might not be equitable).

So to get you to change your mind that public systems are better than private equitability never comes into play? What is the point of efficiency if not to help people? If the point of efficiency is to help people then how is equitability not important?

> So, in response to demographic changes across the western world (like an aging population) a bunch of countries made their systems more public and were able to keep costs down and the US has kept theirs more private and costs have ballooned. Maybe the answer is self-evident.

I've had private insurance my entire life in a western country with free public healthcare. I have practical experience of the trade-offs of public vs private as a consumer and a tax-payer. The demographics changes hit my home country just like any other, but it didnt make public more efficient than private, nor more effective.

> I think there is basically one cause: the existence of for-profit insurance companies.

I have mentioned 2 counter examples: my home country (argentina) and historical US. You can also see Germany also has public/private mix systems. Health insurance companies actually have very low profit margins. Lower than the general market, lower than insurance companies, etc etc. They are not raking it in. The ones that are raking it in are providers.

> In a public system where government provided healthcare there would be a large monolithic body which could assert it's power to keep prices down. In a market with multiple insurance companies, they'll never have enough individual power to keep prices low. That's how the market is supposed to work by keeping power divided, it's just that healthcare is a terrible place for markets.

There is some contradiction in the previous statement (for profit) vs this one. You are arguing insurance companies cant negotiate prices down because they are not a monopoly, not because they are for profit. If there were only 1 insurer, they could definitely keep prices down, particularly the price of providers. But its hard to think a monopoly is the solution to a market problem.

Moreover, you say the state would have the power to drive prices down. This contradicts reality today, where Medicare by law cant negotiate prices. The government is eager to put itself a restriction on negotiating, and is politically unable to remove it. If it cant change medicare when its a fraction of the market, do you think it will change more when its 10 times its size?

The state can, in 24 hours, reduce healthcare prices by just removing economic consented bad regulation. Read what the healthcare economists say: allow free trade for drugs and doctor immigration and you solve such a massive part of the cost immediately. The government has full power today to solve those problems and it cant. Doesn't that make you lose any faith in the government's capacity to solve healthcare?

Do you remember the Obamacare website debacle? Do you think medicare will make a kickass insurance website?

>I've had private insurance my entire life in a western country with free public healthcare. I have practical experience of the trade-offs of public vs private as a consumer and a tax-payer. The demographics changes hit my home country just like any other, but it didnt make public more efficient than private, nor more effective.

...wait wait wait. How much experience do you have with the American system?

More than the median american. But even if I had never touched US soil, all the arguments previously presented still hold.

Profit seeking destroys markets with large externalities or where utility isn't readily discernable at low relative cost, and where for either or both of those reasons the rational choice model doesn't reasonably approximate actual behavior in the market.

Lots of real goods don't face that problem, but healthcare definitely does.

Whats the externality of providing healthcare, and in regards to the diffuseness of utility, food has the same problem and its a relatively very efficient market.

> in regards to the diffuseness of utility, food has the same problem and its a relatively very efficient market.

Food is a frequently repeated purchase with significant immediately-apparent utility and disutility, and so discovery of utilities is quick and the market reasonably efficient in terms of immediate utilities. (There are long-term utilities and disutilities that are less immediately experienced with consumption, and the food market is hardly efficient in terms of those.)

Healthcare products are infrequently purchased, and the relative utilities of different options are far from apparent. It's not at all similar to the aspects of the food market that can reasonably be described as relatively efficient.

I would argue that food escapes its measure of utility because otherwise, we would all be eating only the cheapest and healthiest option all the time, but our constant hunger also makes us purchase things against our long term interest. If so, you would expect the market to be really inefficient, but at least in terms of satisfying demand, its very hard to make money producing food.

Its true healthcare has less frequency so you cant be a sophisticated consumer: but its more frequent than a car, which is also a necessity in many cases, and the lack of sophistry does not make it an inefficient market.

Im not even sure healthcare is a special market, certainly not for infrequency, or because you must pay with your life (i.e. that you make a decision of life and death for resources). Not for restrictive application of labor (lawyers have that), not for the high costs of technology in its application (consumer tech? space exploration?).

I think at this point what makes the healthcare market unique is the common belief of the people that it is unique. It forces the consumer to consciously think of the cost of life, a question we are somehow bred all our lives to hate to ask, but that we answer every day unconsciously.

> I would argue that food escapes its measure of utility because otherwise, we would all be eating only the cheapest and healthiest option all the time

Economic utility is subjective; while it includes health effects, to be sure, it also includes things like the taste and other enjoyment factors. It absolutely is not the case that, were food a perfect example of rational choice, we would only be buying options that cost-effectively optimized healthiness.

> Its true healthcare has less frequency so you cant be a sophisticated consumer: but its more frequent than a car

“Healthcare” is a broad class of different products and services, many of which are far less frequently purchased than autos (if you buy open heart surgery more often than you buy a car, you are way out in a tail of frequency-of-purchase distribution of at least one of those items.)

OTOH, cars are also a market in which purchasers take a number of steps to counteract the low frequency. No one is test driving a variety of different surgerical interventions before choosing one.

> Economic utility is subjective; while it includes health effects, to be sure, it also includes things like the taste and other enjoyment factors. It absolutely is not the case that, were food a perfect example of rational choice, we would only be buying options that cost-effectively optimized healthiness.

Sure, I agree completely, but at least nominally the argument that healthcare is unique because its a necessity and it has irrational behaving actors is not qualitatively different than the food market.

> “Healthcare” is a broad class of different products and services, many of which are far less frequently purchased than autos (if you buy open heart surgery more often than you buy a car, you are way out in a tail of frequency-of-purchase distribution of at least one of those items.)

Thats as practical a segregation as saying that the people that buy the same model of a car the same year and with the same gas price tends to be 1 at most, hence almost no car purchases are ever repeated!

> OTOH, cars are also a market in which purchasers take a number of steps to counteract the low frequency. No one is test driving a variety of different surgerical interventions before choosing one.

Not really qualitative differences, just quantitative. Many car purchases are done without test drives (argentina doesnt do test drives often for example).

But again, even if you find some truly unique property of healthcare, which in this debate i don't recognize yet, i dont know how it will show that it should be private but public.

> Sure, I agree completely, but at least nominally the argument that healthcare is unique because its a necessity and it has irrational behaving actors is not qualitatively different than the food market.

“Necessity” wasn't part of the argument, and the argument wasn't really of a qualitative difference so much as them being different degrees of the same issues (food is considerably regulated—even by the same agency involved in much healthcare regulation in the US—for many of the same reasons, though the degree of deviation from ideal market conditions is lesser than for healthcare.)

Libertarian arguments only hold for free markets. Even eliminating all regulations and restrictions imposed by the government, healthcare does not become a free market for two reasons:

1) Information is not symmetric, contractual obligations are made before pricing information can be discovered (thereby compared and moving into market dynamics)

2) Services are requested under the duress of health problems without the ability to end the agreement.

Not everything is a free market.

I think we can agree that there are degrees of freedom in a market, and that the us healthcare market is far from a the freest possible version of healthcare.

Im not sure about the information asymmetry argument: insurance companies also lack lots of information. And some of that the patient knows and the insurance doesn't. (pre-existing conditions for example). Also, there's plenty of markets with information asymmetry that dont show the backwardness of US Health care.

> Services are requested under the duress of health problems without the ability to end the agreement.

That is the nature of any insurance market. You cant bargain with your fire insurance when your house is burning down. Well, not effectively, if you look at the richest man in old rome.

Definitely agree that there are degrees of freedom, I'm just not confident that a removal of regulations in the healthcare market would lead to a positive outcome (higher quality/less expensive healthcare).

>> Services are requested under the duress of health problems without the ability to end the agreement.

>That is the nature of any insurance market.

I was actually thinking about when medical treatment is being received. Once you're under a hospitals care you're largely subject to their pricing for services (e.g. I can't choose to use the cheaper MRI machine down the street). There's a bundling of services at a healthcare provider that seems to contradict free market arguments as well, but I was mainly trying to get at the (effectively) binding agreement to use a particular facility once you are checked into it.

Edit: To be a little more concise, you agree to a particular payment structure for services without knowing what the cost of the services are or which services you'll be receiving when checking into a hospital, this opacity in hospital pricing also means that different parties are paying different rates for the same service at the discretion of the billing department.

> Definitely agree that there are degrees of freedom, I'm just not confident that a removal of regulations in the healthcare market would lead to a positive outcome (higher quality/less expensive healthcare).

Economists have a high degree of confidence that some of the rules that are restrictive of a free market account for sizable chunks of the cost: not being able to import pharma and immigrant restriction on doctors being quintessential.

Not being able to import pharma is denounced both by Bernie Sanders and Rand Paul (whereas the first wants to socialize medicine, and the latter remove regulations).

Doctor's immigration restrictions are large but also very hard to politically fight. Also the high cost and restrictions of medical licensing. Friedman was very unsuccessful in turning the public against them.

> I was actually thinking about when medical treatment is being received. Once you're under a hospitals care you're largely subject to their pricing for services (e.g. I can't choose to use the cheaper MRI machine down the street).

This applies only to emergency care: if you have cancer, for example, you have plenty of time to choose going to the cheaper chemo. And even a smaller fraction of emergency care: breaking a leg is painful but it does not incapacitate you to choose one hospital or the other: in fact, we do that all the time by picking which one is closest (choice that must indubitable be made in comparison to another option).

And after that, you have an insurable market, which means that you have all the time in the world to choose between options.

> you agree to a particular payment structure for services without knowing what the cost of the services are or which services you'll be receiving when checking into a hospital, this opacity in hospital pricing also means that different parties are paying different rates for the same service at the discretion of the billing department.

Same as car insurance, or mal practice insurance, or house fire insurance, or renters insurance. Not knowing what you will get is at the core of the insurance service models.

I see a struggle to find what makes heealthcare unique to falter in two regards: first, that finding that quality that makes healthcare a unique market does not show anything other than identity: it might be the quality found points to private healthcare instead of public. But also, the extreme difficulty to find a qualitative difference between health and other markets is due to the fact that it might actually not be qualitatively different at all.

https://www.scientificamerican.com/article/world-hunger-is-i...

We can complain about capitalism all we want, but at the end of the day, in America, we still live in a capitalistic society. Good deeds that cannot happen profitably will not happen here en masse without subsidies, period.

Given that our government has proven incapable of subsidizing healthcare in a way that promotes a combination of efficiency and effectiveness, it makes total sense that people would try to make a profitable business that meets the needs of our citizens. That's just how capitalism works.

Edit: To those downvoting me, can you please explain? What flaw do I have in my logic?

> Edit: To those downvoting me, can you please explain? What flaw do I have in my logic?

The idea that we're in a "capitalistic society". Every country in the world lives somewhere on the spectrum between capitalism and socialism. The US is further towards the capitalistic side than Europe, but we've plenty of non-capitalist aspects of our society.

We already accept a wide array of socialist policies in the form of Medicare, Social Security, etc. We've also plenty of evidence from the rest of the developed world that the socialist approach to healthcare provides similar outcomes at greatly reduced cost. "We're capitalists, deal with it" is a fundamentally silly reason to avoid healthcare reforms.

I'm not saying that we shouldn't continue pushing for reform. I'm just saying that our government has proven incapable of reformation, and we should be pushing towards non-governmental approaches until they can get their act together. If we can improve the way things are through capitalism, that's still better than just yelling at politicians that don't do anything.

Can you explain your logic about pushing for non-government reform if "government has proven incapable of reformation"? There is no healthcare fix without government reform. If you provide healthcare, you must adhere to government regulation. You must accept Medicare/Medicaid reimbursement rates. If you provide insurance, you are at the whim of the government and what each new year brings [+].

> If we can improve the way things are through capitalism, that's still better than just yelling at politicians that don't do anything.

You cannot improve this with capitalism. You can only improve this by replacing politicians who are married to a broken system through vested interests.

[+] Healthcare startup Oscar is going through the grinder: https://www.bloomberg.com/news/articles/2017-08-15/obamacare...

Gosh I wonder why politicians don't do anything in the interest of the public?

Any theories on why the US government is so much less capable than governments in other countries?

Scale? If you look at governments that are comparable in size and number of citizens to the US, you don't see many that are all that effective.

Most of the comparisons that people like to bring up are European countries the size and population of US states.

Scale is supposed to make things more efficient, not less. That's the whole idea behind "economies of scale".

Sure, if you want to pretend the EU doesn't exist, and that the US doesn't already manage Medicaid on a state-by-state level, there's a significant population difference... but Germany has nearly 100M people. We have strong evidence single-payer healthcare already works with large numbers of people.

> Given that our government has proven incapable of subsidizing healthcare in a way that promotes a combination of efficiency and effectiveness

Massive unsupported assertion. Medicare is very efficient.

Yes, but that doesn't mean that the American healthcare system is efficient overall.

Medicare doesn't cover "everything" though -- nor could it. No health "insurance" whether it is single-payer, private, public, can just open the checkbook for every patient.

Whether Medicare covers the cost of services provided is at least controversial.

If it doesn't, then it just gets the benefit of being mandated to look efficient.

Didn't downvote you, but I do want to point out that health care providers earn a good living in places like Italy, where I lived for some time. My wife's family friend is a local doctor. He's got a nice house, a place in the mountains, a boat... he's doing well.

What's different is all the insurance BS we have in the US is missing.

Also worth reposting this: https://journal.dedasys.com/2017/02/22/entrepreneurship-and-...

I don't feel comfortable laying the abysmal and depressing tar pit of money and productivity that is the US healthcare system at the feet of "capitalism". In my opinion, the clumsy and inefficient interplay between health care providers, insurance companies, employers, the state and (lastly) individual people strikes me as one of the least capitalist-like situations we see today. It's almost a thought experiment: what would the US look like if people could afford to choose an affordable insurance company, peruse the various healthcare providers and choose among them and, lastly, be able to predict (with some amount of reliability) their healthcare costs over time?

Personally, I can't imagine it. All I know is that it wouldn't look like what we have now. Likewise, this argument that any criticism of the US healthcare system is somehow a criticism of capitalism strikes me as particularly unhelpful.

The problem is that you have a marked tendency to turn HN threads into generic ideological tangents, as you've done here, and this takes them in a direction of lower quality. If there's any generalization about HN threads that holds up, it's that one, so would you please take this in and stop doing this here?

This isn't an observation for or against capitalism. It's an observation about ideological arguments on the internet. The specific ideological flavor doesn't matter; it works the same dismal way regardless.

https://news.ycombinator.com/newsguidelines.html

I was responding to a comment that starts "It's amazing that someone can go through this and come to the conclusion, at the end, that the solution is that this is a business opportunity that would make a lot of money if someone could just make it more efficient." It's a pretty direct critique of the use of capitalism in the healthcare industry. How did I make it any more of a generic ideological argument than my parent comment?

edit: Upon review of my recent comments, I'll admit that their quality is poor. I'll try to avoid ideological squabble in the future. If you could still answer my question on this particular post, though, I'd appreciate it.

These things are relative. You're right that the parent comment was turning toward an ideological tangent, but at least it was still moored to the original topic. Yours became unmoored and went fully generic. In both cases it would be better not to do this and to stay more substantive, but we only tend to post moderation comments in the second case, it being the more egregious.

I greatly appreciate your intention to avoid ideological squabble in the future. If only everyone would do the same our happiness would be complete! On that scale at least.

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