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Comment by creaghpatr | Hacker News Reader

Would you rather the market or the government make that choice for you?

We have lots of examples of governments doing this with ranges from poor to fair to good results. To my knowledge, the US is the only widescale attempt at market-based health care, with results of 2x the OECD average of health care cost per capita [1].

[1] https://read.oecd-ilibrary.org/social-issues-migration-healt...

The US is required to treat all critical condition patients under EMTALA since 1986. So the market does not currently decide in the current setting.

What would you propose as being a "market-decides" approach to health care, beyond abolishing any-party insurers and revert to a 19th-century model?

19th century healthcare was relatively affordable, or at least the costs were streamlined and transparent.

Perhaps keep 3rd party insurance but ban it as an employment perk, that would incentivize the market to play to the greater public instead of just white collar salaried employees.

But it’s hardly a market-based system with the third party payers. Consumers aren’t making informed decisions about what they buy, have little ability to comparison shop, and state-level regulations intentionally limit the number of providers in a market. With those attributes, the poor outcome of the “market” system is entirely predictable. We need to go in one direction or the other, but having the worst elements of centrally managed care and the worst elements of a market solution makes for rotten outcomes.

How do I make an informed decision when I'm bleeding out in the back of an ambulance?

Lots of ER visits aren't that dire. There are three hospitals within range if I broke my arm. I'd totally comparison shop if it were even remotely possible to call each up and ask how much. But getting even an estimated price for x-ray and bone set over the phone? Hahahahaha.

In which country in the world do patients regularly call up 3 hospitals to inquire about the price of setting your broken bone?

A lot of the regulations are there to protect existing players in the market as well. It seems that the market-based approach degrades when it comes into contact with democracy, probably because the equilibrium the market is trying to achieve is incompatible with our values.

The market would just let them die, so if those are the only two options then I'd go with the government.

Would I rather this market decide if I die from a treatable illness? No way.

The evidence overwhelmingly suggests that the market fails to make this choice, and governments - for the most part - have done a good job.

It it’s erroneous to call the American system a market-based system. It commonly is referred to as that - I know - but it doesn’t operate as such. Gov. regulation artificially and intentionally limits supply, supply shortage limits competition, limited competition inflates cost. Third party payer systems abstract the consumer from the supplier. Their buying decision is based on proximity of service center, not cost, because they often just see a $10 co-pay. So they aren’t making informed comparisons. If there’s a market there, it’s certainly not a free market, or anything close.

Definitely the government.

People with severe disabilities may not be profitable, but I'd still like them to have the option to live.

This. What good is advanced technology if profitability calculations stop it from being used for all but those that can pay full price.

When cost-cutting needs to happen... and it's inevitable, the people with severe disabilities will be the first ones to get cut.

Government-funded health care suffers from all the same economic problems that privately financed health care suffers from, and the government is just as corrupt as any private organization, plus there tends to be little incentive for efficiency, so government programs tend to be extremely inefficient and wasteful.

I appreciate (and agree with) your concern for the disabled, but letting the government be in charge is a recipe for making everything worse.

> I appreciate (and agree with) your concern for the disabled, but letting the government be in charge is a recipe for making everything worse.

Except we have pretty much the entire developed world's healthcare systems to debunk that claim. They have similar life expectancies, medical outcomes, infant mortality, access to care, wait times, etc. for half the cost.

Similar, sure, but US is ranked:

* 31st for Life Expectancy [1]

* 32nd in infant mortality [2]

* 5th for colorectal cancer survival [3]

* 1st for breast cancer survival [3]

* 19th for cervical cancer survival [3]

* 7th for heart attack mortality [3]

The actual numbers are reasonably close, but the cost is also about 25% more per captia [4] than the second highest-spending country.

[1] https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...

[2] https://en.wikipedia.org/wiki/List_of_countries_by_infant_an...

[3] https://en.wikipedia.org/wiki/List_of_countries_by_quality_o...

[4] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...

Government-funded health care suffers from all the same economic problems that privately financed health care suffers from

Except the biggest one: the need to maximize the extraction and distribution of profit to shareholders, while funding the cheapest and least amount of care possible without jeopardizing that imperative.

Yes, I remember some right wing US rag saying the following in 2009:

People such as scientist Stephen Hawking wouldn't have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.

Forgive me while I laugh uncontrollably

Yup. Investor's Business Daily.

https://en.wikipedia.org/wiki/Investor%27s_Business_Daily#Er...

> In July 2009, an editorial in Investor's Business Daily claimed that physicist Stephen Hawking "wouldn't have a chance in the U.K., where the [British] National Health Service (NHS) would say the life of this brilliant man, because of his physical handicaps, is essentially worthless." Hawking has always lived in the United Kingdom and receives his medical care from the NHS.

To hell with profitability. I'm infinitely glad my son's right to live wasn't an option or a choice. Today he's an healthy 7 normal years old Canadian who had the top infant cardiac surgeons in the world for multiple surgeries.

So, yes, the government. It may not be monetarily profitable but money shouldn't matter to build a humane society.

Single payer system still make financial decisions about who gets care and who doesn't.

"It's crazy that I live in Canada, but now I'm looking at having to sell my house for coverage of my medication."[1]

[1]http://www.cbc.ca/news/canada/british-columbia/a-tale-of-2-f...

That doesn't seem to be the issue:

> Helen Anderson, provincial lead for systemic therapy for the BC Cancer Agency, said that Ibrance is currently under active review for coverage in B.C.

Does help her much right now, does it?

There are several expensive medications that the Canadian health system has elected not to cover.

Here is another example where if the husband didn't have drug coverage through his employer, he would have been on the hook for the entire cost. Eventually he had to shell out $3,000 per month.[1]

At first, he says, his company insurance covered the price of the drug. But years later – Gary’s employer changed insurers and he was now on the hook to pay more than $3,000 a month.

[1]https://globalnews.ca/news/1654757/canadian-patients-struggl...

> Does help her much right now, does it?

No, but if that's the standard, I'm fairly certain we can find a lot more "no insurance, couldn't get treatment at all" stories in the US than we can "Canadian needs unusual, not-yet-approved medication" ones.

> There are several expensive medications that the Canadian health system has elected not to cover.

You'll find the American medical system does the same.

https://www.mercurynews.com/2007/12/21/teen-dies-hours-after...

https://www.today.com/news/man-battles-health-insurer-drug-c...

All medical systems will have rules and timelines for approval of drugs and procedures. Sometimes they'll lead to unfortunate situations.

In the US, though, approval's just the first step. You might then have to scrape together the $6k deductible for your family's bronze plan. You might have to wait until next year to switch insurers to one who covers that particular med.

Commercial insurers in the US cover far more new and experimental treatments than the Canadian system does. The drug mentioned in the CBC article? Full coverage in the US, from the day of approval.

Covered in Canada? Maybe never. And that's one of the best drugs out there to treat that type of cancer.

I'm not arguing the US system is better than Canada's. Just calling out there are trade offs with single payer systems. If American's think they can move to a single payer system and keep all the bells and whistles they have now, they will be deeply disappointed.

And your 2nd link actually proves my point. The drug in the article is not covered in many Canadian provinces at all. The guy in the article is being denied the drug because it's not approved for his mutation. Most people with the correct mutation do get coverage for that drug (again, a new, state of the art drug).

> Covered in Canada? Maybe never.

Sure, but that's true in the US here, too.

No insurance? No med. ERs aren't gonna give you it.

Can't make your $6k bronze plan deductible? No med. Maybe you'll qualify for a patient assistance program from the drug company, maybe not.

> If American's think they can move to a single payer system and keep all the bells and whistles they have now, they will be deeply disappointed.

It's entirely possible to have a supplemental private health insurance system for the experimental or unapproved stuff. You can get private coverage for stuff like IVF in Australia, for example.

A lot of America's bells and whistles are already inaccessible to a large portion of the population.

> And your 2nd link actually proves my point. The drug in the article is not covered in many Canadian provinces at all. The guy in the article is being denied the drug because it's not approved for his mutation. Most people with the correct mutation do get coverage for that drug (again, a new, state of the art drug).

As the article mentions, the insurer approved their sibling with the same mutation for the same medication. Private insurance can be just as capricious as a single-payer's approval system.

I want somebody who benefits from me being healthy on a long term to choose for me.

False dichotomy. Please try to avoid logical fallacies when posting.

People seem awfully confused about who pays for healthcare in the US so let's be clear: either the government or the market (consumers) pays for healthcare, or they do it in tandem.

I don't have a view on who should pay for it, but there are only 3 categories of payers in healthcare: 1 government and 2 private (insurance and self-pay). The compensation is funded by one of those sources.

People also seem awfully confused about how much the government currently spends on healthcare: the US government currently spends roughly as much per-capita on healthcare as socialized systems that cover the entire cost of healthcare for their citizens, and have better measured outcomes.

The crippling healthcare costs borne by individuals entirely consist of rent-seeking. It's also important to say that a lot of that money comes back out in salaries for the massive workforce required for the unnecessary administrative overhead, adding to the economy, and of course in non-imported luxury goods purchased by the rent-seekers themselves.

So, to summarize, the person you replied to above asked what is the reasonable alternative to socialized healthcare that does not include people dying in the streets of treatable maladies. And through your explanation it appears as though you replied with a tautological statement that had no bearing on the question being asked.

So, what is it that you are actually trying to say?

They did not ask 'what', they asked 'if' an alternative exists, invoking the classic 'dying in the streets' motif.

>Is there a reasonable alternative? I'm not trolling, but letting people die of treatable maladies doesn't seem like the right move.

I answered a tautological statement with a tautological question based on the logic the poster omitted.

Can you tell me who besides the government or the market (ie consumers) will prevent people from 'dying in the streets'? Perhaps by kidnapping another country's doctors and compelling them to provide care...

>I'm not trolling

I'm a little offended that you'd assume my question to be tautological, by which I in turn assume you mean rhetorical. Seems to have generated some good discussion.

I feel like even that confuses the issue. The government can only pay for something with money it takes from consumers.

That's inappropriately anthropomorphizing the market. The market doesn't choose anything. I choose, and the market determines my constraints in choice. Since I'm well employed and not poor, my constraints are to my liking. My question regarding those who don't share that set of constraints. For some people, they go to the emergency room in cardiac arrest, having no insurance or ability to pay for critical treatment. Currently, they are treated, and costs are passed on to other consumers. Under single payer, those cost distributions would be made explicit. So besides doubling down on socialism, it accepting the status quo, are there reasonable alternative?

My half-baked opinion is that there should be a two tier system like US education.

Free primary and preventative care along with dental and vision, and have a government subsidized insurance program for hospital/long term illness coverage akin to the public university system (along with the in-state discounts).

And allow for a parallel private system to exist for those who want to pay more and get allegedly better treatment.

Australia works on this model.

So how NHS works in the UK?

No. If you have a private system, the public system gets abandoned; it's the first thing to be cut when budgets are constrained because no one making the decisions knows anyone who uses it. See US public schools.

Public school funding per child increased 33% from 1995-2015.

EDIT: This does appear to be inflation adjusted. Here’s a federal source which is definitely inflation adjusted showing funding increasing in real terms by 27% from 1995-2013. [2]

[1] - http://apps.urban.org/features/education-funding-trends/

[2] - https://nces.ed.gov/programs/digest/d16/tables/dt16_235.10.a...

If it had been tracking inflation, it would have increased 55% in that time [0]

[0] http://www.in2013dollars.com/1995-dollars-in-2015?amount=100

That's a 14% decrease adjusted for inflation.

I mean, there's a separate private system in the UK.

The NHS has survived for 70 years, as has BUPA, so your argument rather falls flat.

For all the justified complaints about the US education system, it does a fairly impressive job moving the bulk of the country's children through a complex system to navigate.

Many of the country's best schools are public, especially at the college-level.

The choice on whether or not people should die because they can't afford healthcare?

The government. Thanks for asking.

As long as markets decide who dies there is still hope. When a government decides who does it is absolutely final.

I've attempted to fight insurance denials. They're pretty final, too.

It’s a matter of finding a way to raise the funds, insurance is only one way.

If the government will not allow treatment and there’s no way to pay and you can’t leave the country, you’re finished.

> If the government will not allow treatment and there’s no way to pay and you can’t leave the country, you’re finished.

If insurance will not allow treatment and there’s no way to pay and you can’t leave the country, you’re finished.

Side note: private health insurance, private healthcare facilities, and paying out of your own pocket are all possible in countries with socialized healthcare.

Parent poster is talking about the Alfie Evans case.

Alfie is going to die. He has no brain. He was being kept "alive" on life support. The hospital want to end this life support because it's in his best intersts to do so - there's no hope of treatment, and keeping him alive is likely to be keeping him in pain. The parents disagreed with this, and so it had to go to court.

This means there is legal representation for the hospital; for the parents; and independent representation for the child. This is because the child is a human and has rights and his best interests need to be kept in mind.

The parents have rejected the findings of the court, and have made many appeals. They've gone to appeal court several times, the supreme court several times, and ECHR[1] a couple of times.

All the courts agree: it's in Alfie's best interests to let him die, rather than rpolong his suffering when there's no hope of treatment.

Also, all the courts agree that Alfie's parents (and latterly his father) have been given terrible legal advice.

This is causing some consternation in US right-wing nutjobs.

Here are some, but not all, of the court hearings. I might have got the ordering wrong.

http://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWHC/...

http://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWCA/...

http://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWHC/...

https://www.supremecourt.uk/docs/in-the-matter-of-alfie-evan...

http://www.bailii.org/cgi-bin/format.cgi?doc=/eu/cases/ECHR/...

An example of the terrible legal advice (from a non-lawyer too!)

---begin

On 12th April 2018 the father went to the hospital with some other people who included a foreign doctor and air ambulance staff. The father had a letter written to him by Mr Pavel Stroilov of the Christian Legal Centre which, we were told, is a campaigning organisation. In the letter Mr Stroilov, who we have been told is not a lawyer, purported to give the father legal advice. He said that it would be lawful for the father to remove Alfie from the hospital and take him to any other place he chose. The previous order made by Hayden J was said not to have circumvented "your parental rights".

The letter, which was disseminated on social media (presumably with the knowledge and consent of Mr Stroilov), stated that:

"as a matter of law it is your right to come to (the) hospital with a team of medical professionals with their own life-support equipment and move Alfie to such other place as you consider is best for him. You do not need any permission from (the) Hospital or the court to do so".

This letter was misleading to the extent of giving the father false advice. We have been told that it had the most regrettable consequences in that it led to a confrontation in which Alfie was involved. The Police had to be called. An application had to be made as a matter of urgency to Hayden J.

The letter gave false advice because the previous decisions made by the courts in this case have directly addressed whether the parents have the right to decide what should happen to Alfie. The clear answer which has been given is that the parents' wishes are not determinative. The court has also expressly decided that removing Alfie from the hospital as the parents wanted was "irreconcilable with (his) best interests" and that his treatment and care "shall" be given by this hospital. To act inconsistently with or contrary to the court's determination and order would be to act without lawful authority. This includes the hospital which would have been acting in breach of the court's order if they had permitted Alfie to be removed from the hospital.

There is no treatment for Alfie Evans.

All the doctors (even the Italian doctors) agree: Alfie Evans is going to die, and soon. What they're offering in Italy is exactly the same palliative end-of-life care that he'd get in the UK, but with the addition of a long painful trip.

Alfie Evans has had the benefit of world class medical treatment - in the US he'd have been killed by the insurance company a long time ago. He's also had the benefit of free legal representation to make sure his best interests (because in the UK and Europe the best interests of the child are what's important) are looked after.

Also, the government has literally nothing to do with the Alfie Evans case. The government isn't a party to any of the legal cases.

Here's a ranty English lawyer: https://twitter.com/BarristerSecret/status/98919501104352870...

In American English, "government" includes almost any public body. The hospital, the court, and the organization acting as the child's guardian all qualify.

The government. I don't trust the market to create a humane, compassionate system.

I don't even trust the market to create an efficient system.

I trust the market to be adjusted by the wealthy to further enrich themselves.

I also trust the government to be the one organized group of people that can restrain that market, to give the rest of us a chance.

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