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Comment by pwthornton | Hacker News Reader

It's insurance, not a payment plan.

Anyone at any time can get sick, get hit by a car, etc. That's why everyone needs it.

Technically, the utility of health insurance is greatest when you are youngest and least when you are oldest. Saving an 8-year-olds life could mean allowing them to live to 80. A 72-year-old that can't get medical care will have at least lived to 72.

The U.S. health care system has it backwards. We should at least be giving heath insurance to the young. You could argue that it is moral to provide for health insurance for retirees, even if they spend way more on health insurance than everyone else and won't get much additional utility from it, but the idea that you would only give guaranteed health insurance to the oldest (and wealthiest age bracket) makes no sense.

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Are you serious? Everyone regardless of age should get medical care. It's as simple as that.

> Everyone regardless of age should get medical care. It's as simple as that.

This is debatable. Most of one’s healthcare expenses will be incurred in the final months of life. The population to whom this statistic doesn’t apply is doctors—they know when the marginal benefit of treatment isn’t worth it.

If I had a choice between burning my kids’ estate to sneak out a year in agony or die with dignity, I know which I’d choose. The compassionate response isn’t always the right one.

The dichotomy you present is false. Only in the absolutely insane US system one needs to burn through savings to get paleative care.

Health, just like fire fighting, should not be a for-profit business.

> Only in the absolutely insane US system one needs to burn through savings to get paleative care

End-of-life care is intensive, chronic, risky and generally involves cutting-edge techniques (since yesterday's death sentence is today's extendable life). This is fundamental to the cost of care. As a result, end-of-life costs are similar across the board [1].

If there is a unique American angle to this, it's doctors afraid of being sued spending too much on dying Americans.

[1] https://www.forbes.com/sites/cjarlotta/2016/01/19/end-of-lif...

TANSTAAFL

Fire fighting still cost money. non profit medical still costs money. And yes, there is only so much medical care to go around.

> Health, just like fire fighting, should not be a for-profit business.

US has a reasonable share of non-profit hospitals and other medical institutions, but the prices are not drastically different.

Random googling suggests that average doctor salary in Los Angeles is in the range $195,335–$254,517. Across the pond average doctor salary in Ireland is quoted at €48,020. For context, a registered nurse in California is making on average $94,120.

European or Asian medical professionals go to medical or nursing school with the goals of joining the middle class. In the US "graduated med school" is synonymous with raking in cash.

"US has a reasonable share of non-profit hospitals and other medical institutions, but the prices are not drastically different"

Your mistake is to think that nonprofit means that they don't make profit. They still pay a ton of money to their administrators and doctors. And the rest of the profit goes into fancy buildings.

> If I had a choice between burning my kids’ estate to sneak out a year in agony or die with dignity, I know which I’d choose.

It's a false choice. The U.S. is the wealthiest country in the history of the world, and other, poorer countries provide universal health care. The choice isn't between providing health care to old or to young people, but between providing health care to everyone or (putting more money in some people's pockets? probably not even that when the cost of uninsured, unhealthy people is factored in).

> The population to whom this statistic doesn’t apply is doctors—they know when the marginal benefit of treatment isn’t worth it.

I would really like to have a source for this. Cynical me thinks this makes too much sense to be true...

It holds in survey results but has not been conclusively demonstrated in treatment data. It does not hold in Medicare data, but those could be limited for this population.

"In a Stanford study, 88 percent of responding physicians said they would avoid invasive procedures and life-prolonging machines. But a newly released comparative study of Medicare recipients, as well as a longitudinal study and separate analysis of Medicare data published in January, suggest that the actual differences between end-of-life treatments that doctors and nondoctors receive are slight."

The other data point is the story of "La Crosse, Wisconsin," which "spends less on health care for patients at the end of life than any other place in the country, according to the Dartmouth Health Atlas" [2]. The cause? "Some 96 percent of people who die in La Crosse have an advance directive or similar documentation" while "nationally, only about 30 percent of adults have a document like that."

[1] https://well.blogs.nytimes.com/2016/06/30/at-the-end-of-life...

[2] https://www.npr.org/sections/money/2014/03/05/286126451/livi...

Everyone should get medical care, but the amount of medical care does not need to be equal across ages.

That was a great idea when healthcare was relatively cheap. But now we live in a world where keeping people alive can easily cost 1,000,000+ per year. We are hitting the point that universal healthcare (everyone gets everything) may no longer be possible. If we are to ration, measurements like "years saved" rather than "lives saved" may be necessary.

Personally, i am against most organ transplants. The massive cost to save one life there could save thousands if spent on vaccinations overseas. Even at home, people die for lack of basic treatments every day.

Re: Organ transplants, national healthcare plans are funded by taxpayer revenue for the benefit of people living in-country. National healthcare systems will never be expanded to cover non-tax-paying patients the world over, for obvious reasons. So within the set of people that a national healthcare system can cover, it may well make sense to cover an expensive organ transplant for a relatively young person if it extends life by decades.

Even under nationalized systems such as Britain's NHS, they have to make utility decisions about how to allocate spend: a life is not of infinite value, and the NHS has to estimate the value of various types of care, because it simply isn't feasible to say "we'll spend and spend and spend, no matter what, for someone to stay alive."

For example, saving a person's left eye is less valuable if they still have their right, because they can still see, versus someone who was already blind in their right eye that would leave them completely blind. So they're willing to spend more to save that person's left eye if they would otherwise be completely blind.

Similarly, saving the life of someone young is of higher utility than someone old, because their life expectancy is longer.

These sorts of calculations bother some people, but it is a practical reality that these decisions have to be made. I actually think NHS works pretty well and it's better to be open and transparent about these sorts of decisions, versus the American system.

Then make the calculations based on cost like the NHS does and not by age. I totally agree that we should be wary of paying 100s of thousands for some cancer cures.

But we shouldn't tell old people "you are useless therefore go somewhere and die". It's hard to imagine but most of the young people here will also get old one day. And they won't be wealthy enough to pay health costs out of pocket.

Yes, but age is part of the utility. If we can save someone that would be expected to live another 50 years, it's more valuable than saving someone who will live another six months.

That doesn't mean they won't get any care, but it would mean that the maximum that would be spent to save them would be less than someone who was expected to live much longer because of the care.

The NHS bases their cost-effectiveness calculations on the increase in quality-adjusted life years that the treatment is expected to add. That measure will absolutely prioritize treatment of younger patients over treatment of older patients because there is more time over which the benefits of the treatment can be realized.

Paying hundreds of thousands of dollars to save a ten-year-old from cancer will be accepted because it could add decades to their life. Paying hundreds of thousands of dollars to save a ninety-year-old from cancer will not because it is unlikely to increase their lifespan very much.

> But we shouldn't tell old people "you are useless therefore go somewhere and die".

No one is saying that or advocating for that. I think you're unfairly assuming malice or ambivalence on the part of commenters who are trying to clarify the practical reality of the situation.

Consider for a moment, regardless of how unrealistic you feel it may be, the utility of funding the care of a 20 year old with cancer versus a 90 year old with cancer. All things being equal, a system with finite resources should prioritize the 20 year old, because the younger person will likely be less expensive to save long term and can generate more productivity for society afterwards. We'll call this our Socratic baseline.

Now obviously in the real world two patients' ailments are never equal. But if you can agree to this baseline, we can proceed to haggle as conditions more closely approximate reality and things stop being so equal.

We should not leave the elderly out to die or abandon them. But we have to be honest and balance that moral imperative with the unfortunate, practical reality that we only have finite resources. That doesn't mean we kill anyone off. It means we make nuanced decisions about how much to invest in their care - and how to do so - given their prognosis. Age is a fundamental measure of prognosis.

All fine and good. What I hear a lot is that young people shouldn't pay for old people. That's extremely short sighted.

I am on board with taking age into account for coat of treatments. But you also need to accept that older people need more care and that that's ok. It's a difficult balance.

This is quite literally the definition of triage.

You have finite resources. You have requests for resources which exceed your capabilities to service. You need to determine an order.

In an ideal utopian world, no one would ever need these services. In a less ideal world, everyone who needs these services would be serviced quickly and effectively with only positive outcomes.

In the real world, you have to make choices. These are very hard choices, and they have longer term impacts. It is literally "the good of the many vs the good of the few."

Well, literally triage is "decide the order of treatment of (patients or casualties)" without much of the finance input.

The NHS stuff is done by the National Institute for Health and Care Excellence based on quality-adjusted life years and they have a guideline of £20,000 per year. So if a cancer treatment lets you live ten more years in ok condition it's worth spending £200k to do it https://en.wikipedia.org/wiki/National_Institute_for_Health_...

In the US everybody would scream "death panels" if they had something like NICE who tries to get some reality into the discussion. Instead the work of NICE is done by insurances. There is no open and rational discussion in the US about these things.

That's what I'm saying.

Considering that medical businesses are free to set their own prices, and occupational licensing prevents doctors from cheaper English-speaking countries (India, UK) from moving in and setting up a practice, how far are you willing to take that maxim?

* Everyone should get medical care when a routine physical costs $100?

* Everyone should get medical care when a routine physical costs $1,000?

* Everyone should get medical care when a routine physical costs $10,000?

I don't even understand what you are getting at. Why would a routine physical cost 10000?

The question makes as much sense as asking "Should we have a military if soldiers have a salary of 250 billion dollars each?"

"everyone should get medical care" suggests a system where one party (the taxpayers) are automatically covering a bill for medical service, while the other party (healthcare system) has every incentive to milk the system via over-testing, over-prescribing, over-scheduling routine visits and just plain old raising prices.

The soldier analogy doesn't quite apply, as it doesn't require complex skills and providers of the service are not in short supply. A potential candidate can surely hold out for a starting salary that's 10x the average, but others eyeing his position will likely be content with the average.

An anesthesiologist, on the other hand, or an MRI lab, might be the only game in town, and if they say the prices are going up by 10% next year, the prices are going up. One is welcome to drive to the next town over, but with taxpayers covering the expense, why bother?

What cost constraints exist in "everyone should get medical care" system to prevent healthcare providers from consuming 100% of GDP?

Somehow plenty of countries are doing fine while even consuming less of GDP than the US. As far as I know Medicare doesn't consume 100% of GDP either.

Medicare doesn't cover everyone, and some people in the article experienced high copays on Medicare.

Meanwhile, https://www.cms.gov/research-statistics-data-and-systems/sta...

"Health spending is projected to grow 1.0 percentage point faster than Gross Domestic Product (GDP) per year over the 2017-26 period; as a result, the health share of GDP is expected to rise from 17.9 percent in 2016 to 19.7 percent by 2026."

Yeah, but laws are made by older folks, who vote at 3-4 times the rate of younger folks in midterm elections.

This is slightly off topic but I really rile up some of my more passionately Democrat friends when I point out that one senator from CT is responsible for not having a public option in Obamacare. Why? Because the senator was beholden to the donations of the insurance companies.

http://www.slate.com/articles/news_and_politics/prescription...

Insurance is big business in CT. It's his job to represent his constituents interests and a booming insurance business is certainly in their (they = the people in CT who control who gets elected) interest even if it screws the rest of us. It's a classic case of doing what the people who decide whether or not you get to keep your job want you to do even when it's not ideal for the big picture.

Edit:

Down-voted because this isn't how things work or just because it's uncomfortably true?

If you think CA representatives won't side with the tech industry over the good of the nation then you're probably going to be proven wrong in the next few years.

It’s also his job to do what’s best for the people of this country. We have a lot of people in Washington who aren’t doing their jobs who continue to get elected because their constituents are either satisfied or apathetic.

No, you're being downvoted for amorality.

Where did I imply that I liked it or thought it was good and/or moral? I'm just saying that the incentives are not to vote for what's good for the nation when the alternative will make a lot of money for a lot of people in your state, some of whom will bankroll your election campaign.

It's not clear the supreme court decisions would have all played out the same way if a different bill passed.

This is a very good point. Thank you.

Getting hit by a car is covered by the auto insurance of the person hitting you.

That's just not true in many cases; such as in hit-and-runs, or if the motorist that strikes you has no insurance. Or perhaps you're involved in a car accident from inside the car, such as a simple loss of control, and your parents have no insurance.

You are assuming the other person has insurance. The only accidents I have been in I had to use my uninsured motorist policy to cover an accident that was someone elses fault!

Good on you for electing it. Uninsured coverage should almost always be taken at the max policy limit offered.

In theory yes. But the minimum required coverage is around 25000 USD, and whoever carries just that is very likely uncollectible anyway. Besides, in states like Florida and Mississippi 25 % are uninsured. It's quite third-world-like, in fact.

> It's insurance, not a payment plan.

It's the whole point of insurance that most people who don't need payouts cover ruinious expenses for those who need it.

That's the problem with healthcare. At some point everyone will need it.

The proper way of handling the cost of health care is at a nation or world level of single payer.

Fight a war on disease, not drugs.

What about life insurance?

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