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Comment by xenadu02 | Hacker News Reader

Price discovery requires pricing some people out of the market. Period. There is no "free market" healthcare system that can or ever will deliver required health services to everyone.

Furthermore when the alternative is death or debilitation, the price a "consumer" is willing to pay is effectively everything they possess and can borrow. That is both a massive distortion and non-optimal for the economy as a whole.

There are certainly regulatory inefficiencies and other inefficiencies in healthcare markets, but a truly "free market" in healthcare not morally justifiable.

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> Price discovery requires pricing some people out of the market. Period. There is no "free market" healthcare system that can or ever will deliver required health services to everyone.

There is no economic system that can deliver all of the health care to everyone who wants it.

Fundamentally, health care resources are limited: doctors, beds, MRI machines, etc.

Desire for health care is much less limited.

The question is not whether to give everyone what they want, but instead how to imperfectly ration what we have.

"Don't let The Perfect be the enemy of The Good."

We are overspending on the quality of health care we get today. Further there is a lot of fear mongering about socialized medicine.

I've experienced medicine in both the UK and the US. I can tell you, there isn't a difference in quality. Further, when I got a cold and went in, wait time wasn't 6 hours or whatever other BS people claim. Wait time was ~10 minutes. In fact, the time to see a doctor in the US is almost always longer. Why? Because half the time you have to fill out forms and provide proof of insurance and a whole host of other information for them before they will put you on the waiting list.

What did I have to fill out to see a doc in the UK? A card that had my name and current address. Even that, they told me, was optional.

Cheaper medicine for less money is a reality. The only people that lose with socialized medicine are admin and insurance. Everyone else in the nation wins.

I've had different experiences from you. My experience in the UK was wait 90 minutes in a waiting room and when it was finally close to my turn I was told I could only see a nurse and she wasn't allowed to proscribe any medicine so if I wanted to see a doctor I should go down the street to the private doctor. This was in London near Soho.

In Japan the first time I went to a doctor it was for stomach pain. He gave me on ultrasound and declared I had hepatitis. My personel department at my company decided to take me to another doctor. Had to weight 2.5 hours in a room with around 250 other sick people. Was finally told I had food poisoning.

I am not defending the USA system but both the UK system and the Japanese system have issues as well. I've spent the most time in the Japanese system. What I like is it's easy to see a doctor and relatively cheap. Prices are apparently set by the government. Conversely a large percentage of Japanese doctors are quacks and would be unqualified to practice in the USA. It's a common topic of conversation for foreigners here to tell their horror stories of all the crazy experiences they've had with doctors here. Also, top doctors, or rather surgeons are known to require bribes in the $XXXX-$XXXXX range beyond the decided on fees.

I’ve had to wait 3 hours in an ER in America - also have had to drop providers because they only had appointments weeks out.

The decision to go to a doctor is a financial one in the US, sometimes superceding a health one. Our life expectancy is dropping as well. It’s a broken system and adding more of what is broken about it won’t work, if the goal is for society to be healthy.

The UK system isn't amazing, unless you're evidently having an "emergency", you can be waiting for hours (once waited for 4 hours with a broken wrist for example) - that being said, the triage is pretty solid and you'll cycle through intermediate steps in the meantime.

I think the best part is not having the mental burden of potentially going bankrupt afterwards...

There are severe problems with the English NHS, but we need to remember that it costs the tax payer a lot less than the US system.

That's the thing I don't understand: they pay more in tax, and they pay more in insurance, and they don't get universal coverage and have worse outcomes across a range of measures.

Was this with your GP or did you just turn up at the A&E with minor ailments - turning up at the A&E with something you should be seeing a GP with will mean you got the back of the queue.

I have never had a problem getting a appointment to see my GP.

> In Japan the first time I went to a doctor it was for stomach pain. He gave me on ultrasound and declared I had hepatitis.

Ultrasound? That is absurd.

I can't speak for UK/US/Japan but in India situation is quite similar. Opaque pricing along with quacks (or maybe genuine doctors) out to milk as much as they can, especially if they know that you have insurance.

A colleague of mine who had stomach pain was told that he had to get his appendix removed. When he refused the doctor actually threatened him with a write-up to ensure that he doesn't receive any insurance money. After the company got involved he was moved to another hospital, only to be told that he had stomach gas.

When were you in the UK system? I've noticed a lot of variance between people's opinions based on the fact that there's been a sort of sabotage campaign against the NHS in recent years (it's dropped ten places in the worldwide healthcare rankings in the last five years). So people that had experiences with the UK system in the early 2000's generally had a good time, whereas later, it became a lot more mixed.

Are you a UK/EU citizen and were you registered where at the GPs you went to?

Assuming you are not an EU citizen, you are don't get free healthcare in the UK anyway. They probably told you to go to the private doctor because if you are non-EU you would have health insurance which would cover this no?

That's not how this works. If you are from outside of EU you are not limited to private doctors and hospitals - you can still go and be seen by any NHS doctor, but you have to disclose the fact that you are not covered by national insurance - they will simply ask you for personal details and send you the bill few weeks later(well, if it's worth if - if you're only seeing a doctor about a cold or a broken wrist they will not even bill you anything because it's not worth the time spent filling out documentation, and pretty much no hospital even has a billing department).

> I've experienced medicine in both the UK and the US. I can tell you, there isn't a difference in quality.

My experience was very different. In January-February this year I had to visit (unfortunately) both the Emergency Room in NYC and the A&E in London. While the quality of the medical equipment in London matches the one in NYC, the understaffing is much more severe. In neither place was my wait time only 10 minutes, but in NYC I had to wait for about 1 hour (including paperwork), while in London for about 6 hours.

I talked with other people in London about my experience that the medical system is severely understaffed, and all agreed. On the plus side, I did not have to pay anything in the UK (they didn't even care that I was not a UK resident). In the US I had to pay north of $1000, despite having insurance.

My Girlfriend managed to stick her finger in a blender in January. We went to a London hospital, got seen by a doctor within 1 hour (she had stitches within 20 minutes of arriving) and she had plastic surgery on her finger that evening. For free.

Different A&E departments have different problems. The NHS is the largest employer in Europe, and it's reductive to say "all London hospitals are understaffed". They are not. Part of the problem is seasonal and even daily shifts in A&E visits, you can't staff for the worst case all the time. And January/Feb is known to be a busy couple of months.

In Boston I recently had to wait in an emergency room for 5 hours with multiple broken bones. This was at one of the best rated hospitals in the country.

I recently moved to a new state and I’m trying to get set up with a new primary care provider. I’ve been trying to get an appointment for six months, but they keep bumping my appointment back. Did I mention that I had to settle for a nurse because none of the doctors in my area are accepting new patients?

Nurse or Nurse practitioner?

I think for most people in the bottom 80-90% of earners would happily take a six hour wait to avoid a $1000 fee.

This weekend I was feeling incredibly sick and there were ketones in my urine (potentially deadly for me). We got there at 9p.m and weren't seen until 2a.m. They stuck us in the room where they keep patients with potential mental health issues because they were so full so I didn't even have access to a charging outlet. We have good insurance. The US healthcare system is often times just as understaffed. Both can be terrible experiences but one can potentially bankrupt me.

>> I talked with other people in London about my experience that the medical system is severely understaffed, and all agreed.

That is because NHS spending is being slashed viciously. Obviously, if socialised medicine is being dismantled, it can't be expected to work all that well anymore.

Insurance is complicated in the US in no small part because of government intervention.

Starting with the fact that employers pick insurance plans for their employees, eliminating enormous market power: and this happens because the government doesn't tax the money that is spent on insurance plans.

Why did you go to a doctor for a cold? That seems to be a problem. You send someone to school for 10 years and they spend their time talking to patients about a runny nose due to a common cold. And for what? To write a prescription?

To get an absence note for school/work? To make sure it's a common cold?

For a cold, just wait a week or two. There's nothing medicine can do for you anyway. If it's still there, then it's worth checking. Also, you shouldn't need a sick note unless you are off for more than a week (your legislative framework may vary).

It depends entirely on the employer. Some places will require a doctors note if you miss more than two shifts. So in places like that, people typically go to work sick, and just spread the disease. This includes most fast food restaurants so think about the implications of that.

Still, it's their fault for not seizing political power and installing a better legislative framework.

Wait a week or two? That's what they told to my father in the military some 40 years ago. He's still fighting the consequences of that pneumonia.

I wondered the same thing. My mother was a registered nurse who rarely ever took us to a Dr unless we were very sick for several days. For colds she simply treated the symptoms. If we had a fever it meant bed rest and sipping 7-Up to help settle the stomach. The only time she took me was for ear infections and tonsillitis.

>> The only people that lose with socialized medicine are admin and insurance.

Presumably they too need healthcare, so even they win, in the long run.

That assumes that the desire for health care is unbounded like other consumables.

In reality most healthy individuals want a limited amount of care, sick individuals want the least amount of care required to return them to health - and there are fundamental limits on the amount of care that can be provided to those who are beyond the help of current technology.

As such you would expect a finite level of demand from the economy as a whole if everyone was allowed as much healthcare as they desired. Any attempt at rationing care will both reduce efficiency, and constrain supply - driving up prices. The most market oriented system would leave supply unconstrained and provide universal and automatic coverage allowing more suppliers to enter the market until supply outstrips demand and "prices" naturally fall.

No, the demand for healthcare is basically infinite.

I got a cold yesterday with a crazy bad sore throat, I thought of maybe popping into the doctor. But it turns out to be just a regular cold. My mother would have 100% gone to the doctor. The clinics here in Canada are chock full of kids with the flu and people coming in 'because'. Maybe that's beneficial due to the risk 'it could be something bad'. Or maybe the economics don't make sense i.e. for really mundane things it's better to just stay home and take Tylenol.

But the demand is super high. Once people cross 50, there are always problems. Always something. And it's all expensive.

That’s finite demand as the effort of going to the doctor is non zero. People in good heath are not going to waste their time.

Assuming the average doctor’s visit is 15 minutes and the average person goes to the doctor every month. That’s only 1 GP per 640 people. After that point they might send you to a specialist some fraction of the time, but it’s still finite.

Consider dental insurance is ~15$ a month and most people go to the dentist twice a year. That’s about what GP side of heathcare costs. It’s the care after that point from people with actual issues that gets expensive. Yet, without the vast overhead of insurance you cut the costs of providing actual heath in half. Which more than covers the costs from people that are currently turned away.

PS: And yes billing is ~50% of current US costs when you include Doctor time dealing with paperwork. Remember the entire insurance industry and their profit is pure added cost, but so is the medical billing people inside each provider.

> Maybe that's beneficial due to the risk 'it could be something bad'.

I would assume it's detrimental because it results in doctors' waiting rooms full of people with colds (making it a dangerous place for anyone who is immunosupressed and really needs to see the doctor).

Oh yes :-) there is a reason renal units are often in separate areas.

Even if people go to the doctor for every minor cold, it is still not INFINITE demand.

The problem in the US is that you can't just go get your throat swabbed for a strep test in that situation. That could take 5 minutes and cost less than $50, but nope.

All demand is always infinite: you can always get more. (i.e. I want my cold to be checked out by a panel of CDC experts

Are you saying that the richest country in the world can't accomplish something that already exists in plain view in some of the poorest countries in the world?

There is no country on earth that gives people all the healthcare they might want with no limits and that is not what we should be aiming for. There are many that give people enough healthcare and that is what we should be aiming for.

You really should get the facts on how those systems actually operate.

I'm currently living in an european country that has a national health service that supposedly ticks all the socialist talking points, including free (in theory) access to emergency care, but not only is the service largely inoperational with year-long waiting periods for surgeries, including cancer treatments, but also has a disgruntle workforce who systematically complains they are underpaid and overworked.

The situation is so appalingly bad that the national health service even routes patients to private hospitals and clinics, ending up paying a hefty bill for the services they were supposed to provide in-house but are largely unable to provide.

While I understand your point, I don't know if it could be distilled that succinctly. I have friends who have worked in European countries with universal healthcare that was sub-standard by a U.S. perspective. What I'm curious about is whether this is directly attributable to the healthcare system structure or if it's more causally related to other factors like GDP, access to a trained workforce, or basic infrastructure. Meaning, if we look at two very similar countries that happen to have different healthcare systems would the same effect you outlined still hold?

While I also come from a country like the one you described, there is a very simple fact that cannot be ignored - when my dad got cancer 8 years ago, every single one of his operations and all the drugs(including incredibly expensive Glivec) were 100% free. He was even reimbursed for the cost of travelling to the hospital for his monthly check-up.

If he had the same disease in US, he would die much earlier than he did, I'm 100% certain of it, because quite simply there is no way he could afford the treatment or the premiums that americans are paying for their healthcare. Even when he was sick enough that he couldn't work anymore, he was still 100% covered and didn't have to pay anything for anything ever.

My point is - there are people in our countries who are probably dying because they have to wait months to be seen by someone. True. But there are also people in US who are dying because they cannot afford the treatment they need. I feel like this is far worse than the first situation - after all, we only have a finite number of doctors, a finite amount of hospitals, and limited capacity to add more(for reasons other than financial too). But US is the richest country in the world - and its citizens die because they cannot afford cancer drugs? That's abhorrent.

You have gone from a hypothetical to concluding that people in the US die because they can't afford cancer drugs.

If your dad was over 65, he would be on Medicare. If he was younger than 65 and impoverished (income between 0 - ~150% of poverty level) he would be on Medicaid or another state plan for low income people. If he's above 150% of poverty level he probably has health insurance available at work or thru ACA. In fact is legally obligated to.

It's entirely possible to have health coverage and still be financially ruined by a health emergency due to deductibles and pre-existing condition loopholes.

Yet some people believe going to a freer market route would dramatically decrease costs

How many of your fellow citizens declare bankruptcy because of of their medical expenses, debts?

That's definitely rising as can be seen in recent research of the topic: https://www.nytimes.com/2018/08/05/business/bankruptcy-older...

Medical expenses, unlike credit card debt or student loans, can still be discharged through bankruptcy. For lower income elderly folks, that coupled with low paying job opportunities usually leads to disaster.

And yet, it's the US where 25 year-olds die of diabetes [1]. Not the "socialist hellholes".

https://www.snopes.com/fact-check/shane-patrick-boyle-died-a...

But does it make sense to exclude coverage based on ability-to-pay or some other criteria?

Say, medical necessity and probable benefit?

We're a long way from those particular decision criteria, presently.

> Furthermore when the alternative is death or debilitation, the price a "consumer" is willing to pay is effectively everything they possess and can borrow.

This is also true with food. What keeps the price down is competition, not price controls.

so when I get into a car accident and am bleeding internally, I can march down the street to the next hospital if I think the bill at the one I'm at is too high?

No; but suppose we agree that emergency response services (fire, medical, police) should be state-run. The goal of such state-run ER is to get you as quickly as possible to a hospital, where care can be provided. The state can then shop around for the cheapest/best private provider for each catchment area. One could also make a case that the state should pay for this emergency care out of tax money - unless the state can show that you were the one responsible (e.g. if you end up in a hospital because of excessive drinking on a night out - taxpayers should not have to pay for you in this case).

But such true emergency response seems like actually a very minor part of all medical care. It would be better for people to have private emergency arrangements through their insurance - but, of course, this is not always viable (if you are bleeding out in a car accident, there is no time to figure out which hospital you have a deal with), so that is one area where the state should probably be involved.

The decision is done before the accident, when you pick insurance.

> Price discovery requires pricing some people out of the market.

I don't see the connection between posting prices and pricing people out of the market.

If no one is priced out and you are operating in the free market then you need to raise your prices. Repeat until you maximize profits.

Does it have an end goal of maximizing profits, though? Couldn't the goal of price discovery be to find the point where supply = demand, without necessarily maximizing profit?

Granted, this ignores the human trait to increase consumption when removed from directly paying all associated costs (e.g., my behavior at Golden Corral)

No, this doesn't really work because other people will ultimately run you out of business with their compounding profit and reinvestment advantage.

Doesn't that imply they compound profits by either 1) raising prices and thus reducing demand for their product in the presence of non-profit maximizing suppliers or 2) creating efficiencies to increase profit margin at an equal-or-lower price?

In situation one wouldn't the advantage go to the non-profit motivated supplier and in situation 2) doesn't it ultimately benefit the customer with lower prices?

I think the point is if one company is making outrageous profits it’s trivial for a competitor to undercut them. The food industry for example rarely makes more than 2% in profit because it is so competitive.

I would agree, but only with industries with a low barrier of entry of commodity businesses. There are also other moats that prevent trivial competition. Examples may be intellectual property, branding, switching costs etc.

If maximizing profits (or, more precisely, maximizing expected value) isn't a terminal goal for all involved parties then it isn't a free market.

I see your point if the term profit is defined in a general sense, but with the exception of "corporations as people" caveat there's plenty of everyday examples where people are trying to maximize outcomes other than capital (sometimes at the expense of capital). I'm not sure that makes it any less of a free market

It does. There's no free market for soup kitchens for the homeless, for example.

There exist entities who are willing to provide soup kitchen services below operating costs in perpetuity (i.e. charitably, for free). The price for services is kept artificially low ($0) by constant infusions of capital from outside the market (charitable donations), which prevents for-profit vendors who don't receive constant cash infusions from being able to compete on a level playing field. The resulting market is thereby warped by the distorting influence from non-market forces, preventing it from operating efficiently. It's not "free", in the technical sense.

This isn't necessarily a bad thing, to be clear. The charitable funding system may well provide better aggregate social outcomes than a free market would for any number of reasons, not the least of which being that one of the freedoms that "free market" implies is the freedom for vendors to decide that some of their potential customers are more trouble than they're worth to serve.

You illustrate the point well and maybe I'm just not well versed enough in the topic. You imply that a charity warps the free market by undercutting profit-motivated competitors but in the last statement you give the vendors the freedom of choice in regards to their customers. Is there any reason why this same freedom of choice can't be extended to people who choose a specific social outcome at the cost of less (or nil) profit? For example, are B-Corps fundamentally less "free market"? Or does the very nature of free market imply a profit maximizing function? As an example that comes to mind, I'm curious how not-for-profit and for-profit hospitals interact in a "free market" of healthcare in the United States.

I've never heard your theory of economics before from any faction.

> Furthermore when the alternative is death or debilitation, the price a "consumer" is willing to pay is effectively everything they possess and can borrow

Someone is morbidly obese. They will die and are already debilitated. The cost of having their life back is eating less. Many are not willing to pay that price.

>Price discovery requires pricing some people out of the market. Period.

A well working competitive market doesn't charge the maximum consumers can bear. It charges cost of service plus a profit margin.

No, a well working competitive market reaches a price where marginal revenue equals marginal cost. Unless you are using an unorthodox version of microeconomics.

> There are certainly regulatory inefficiencies and other inefficiencies in healthcare markets, but a truly "free market" in healthcare not morally justifiable

Socialized healthcare has its own "immoral" trade-offs. We essentially reduce per capita quality in favor of all-inclusive coverage. Proponents of free-market healthcare would argue that the inefficient allocation of resources inherent to socialization is immoral. Libertarians would argue that forcing money from one person to give to another for medical care is immoral. It's not really a question of morality, more of preferred philosophy and practicality. Framing it around morality makes the other side seem abhorrent and the situation difficult to find common ground.

> Socialized healthcare has its own "immoral" trade-offs. We essentially reduce per capita quality in favor of all-inclusive coverage

That's a false dichotomy; there are many mixed systems where the government provides a baseline level of care with private insurance providing additional services or benefits (eg: government covers a shared hospital room, private insurance covers a private room).

>Libertarians would argue that forcing money from one person to give to another for medical care is immoral

True libertarians also argue that all taxation is theft (if they're purists anyway), making road construction immoral.

> Framing it around morality makes the other side seem abhorrent and the situation difficult to find common ground.

A "free market" in healthcare requires us to condemn people to death or debilitating injury when they cannot afford care. Unlike nearly every other area, this one literally involves life and death so I believe it must meet a different standard than other activity (economic or otherwise).

> True libertarians also argue that all taxation is theft (if they're purists anyway), making road construction immoral.

No, it doesn't make road construction immoral in the eyes of libertarians. It makes taking money from other people, by force, in order to build a road, immoral. People are totally free to build roads privately and pay for it themselves, and even band together to build these roads.

(Part of where the standard libertarian argument falls apart, in my eyes, is that government in many ways really is just a scaled up version of "people banding together to build a road". There are there are legitimate moral/philosophical questions around opt-in vs. opt-out though).

> Part of where the standard libertarian argument falls apart, in my eyes, is that government in many ways really is just a scaled up version of "people banding together to build a road".

There is a significant qualitative difference in that "people banding together to build a road" is an entirely voluntary activity, whereas government is nothing of the kind. It's not merely a matter of "opt-in vs. opt-out". Even in an opt-out system one can choose not to participate without penalty, but if you inform a government that you're choosing to "opt out" they won't just leave you alone to live as you please. They draw their arbitrary lines on a map and consider everything within those lines to fall under their control. Even if you move halfway around the world and renounce your citizenship, and in doing so cut off all ties to everyone and everything you once knew, you may find that they still claim a share of your income to pay for that road you'll never be able to use.

The "scaled-up" version of "people banding together to build a road" is a co-op or corporation. Such an organization does not have the power to tax or to impose regulations on anyone who doesn't explicitly and voluntarily agree to them.

  > True libertarians also argue that all taxation is theft (if
  > they're purists anyway), making road construction immoral.

Why would you call those people "true" libertarians? There are a lot of people who consider themselves libertarians of various sorts who strongly disagree with this. Some consider property to be theft.

There are many kinds of libertarianism, and the American-style extreme capitalist libertarianism is not the only one, and probably one of the most irrational forms of libertarianism.

Personally, I feel providing essential care to everybody equally does the most to free people from oppression and extortion by those who wield power over them at a time when they're vulnerable.

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