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Comment by thanatos_dem | Hacker News Reader

We all do! Something something single payer.

Edit: not sure why the downvotes, that’s the reality of things. If you want a more fully fleshed out thought, here you go:

We would all contribute to the payment of expensive operations via taxes in a single payer system. In the current system we have insurance payments. It’s effectively the same, paying a small fee regularly, to subsidize the costs for expensive procedures for yourself and (surprise) others. What do you think happens if you pay into insurance your whole life and never need an expensive operation? You’re subsidizing others. Otherwise the insurance companies would be out of business.

But with single payer, we cut out companies in the middle pulling a heafty profit for effectively the same system as we could get via taxes.

Better?

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> We would all contribute to the payment of expensive operations via taxes in a single payer system.

That's just insurance, managed by the state.

> But with single payer, we cut out companies in the middle pulling a heafty profit

Oh boy. Lets say I concede, for the sake of argument, that government can run a private business with the same efficiency, and that the profits it would make as private are given back to its consumers (healthcare.gov cost almost 2 billion dollars to make, remember that. Or Blue shield is actually a non-profit, and its not gobbling up the space by reinvesting its supposed profits).

To add to that, the profits of healthcare insurances companies are not that large: they have a 6% operating margin, lower than other insurance companies. Cumulatively, the big companies must have around 20~30 billion dollars a year in profits. It's a staggering number, but in the healthspace thats nothing: only the subsidy of tax-exemption for insurance benefits is estimated to be 260 billion a year. You could eliminate that benefit and expand medicaid: but that would help the poor, and wreck the rich and the middle class together, which is often politically unfeasible.

https://www.axios.com/profits-are-booming-at-health-insuranc...

https://www.verywellhealth.com/health-insurance-companies-un...

I’d still prefer the state over private insurance companies (Medicare is well run and popular).

As Steve Jobs said about Dropbox, you’re a feature (insurance companies) not a product.

> I’d still prefer the state over private insurance companies (Medicare is well run and popular). And I vote accordingly.

Thats perfectly reasonable, but no need to make a single payer system for that. Just allow medicare to compete in the open market. Thats a much smaller program with a lot less risk.

Unfortunately the chances of such a plan to succeed are nil. Thats why big healthcare reform proposals want to strong-arm the position, with single-payer proposals. Its true medicare is popular, but remember it's free insurance for its patients today. If you eliminated the medicare payroll tax and made it a monthly payment, I assure you old people will not have the same opinion on the topic.

The NHS “competes in the open market”, so to speak - you pay taxes to get free healthcare for everyone, then you can get private insurance which picks and chooses what it wants to treat and dumps complex cases back on the NHS. Routine treatment is also dealt with by some combination of the NHS and private pharmacies (for flu jabs etc), generally speaking.

Unsurprisingly, private health insurance is not very popular here. It’s mostly just something people get through work.

And I’ll remind you that we spend less per capita on our healthcare than the US does. I’m sure that if there was actually demand to meet that spending, private insurance here would happily eat it up - but there just doesn’t seem to be.

If you get private health insurance, do you get your NHS contribution back? Thats what would make it "competing" in the open market. If you have to pay for it no matter what, there is no competition, there is double charging.

There isn’t double charging, because private health insurance universally doesn’t cover the same things as the NHS does, and universally depends on the NHS to work with for anything they think might be too expensive to cover.

Given that we spend less money on healthcare than countries that do have healthcare “on the open market” like you suggest, I’d say this is a system that obviously works.

If there were an imbalance between what those countries provide and what we provide, and people were willing to pay for it, you’d see private healthcare providers successfully taking more money (up to what Americans spend) to make up the gap in service - but they’re not. Do you have an explanation for why that’s not happening?

If there are general practicioners in the private market in the UK, that means their patients pay for the NHS and also for the private GP, thus double charging. Particularly with your primary care provider, continuity is important in medical care, not everything is replaceable like a cog.

> Given that we spend less money on healthcare than countries that do have healthcare “on the open market” like you suggest, I’d say this is a system that obviously works.

Sorry but this is a ludicrous claim. Argentina spends 2% less of GDP than the UK, and 70% of its care is private. And not only that, it gives free healthcare services to other countries, including organ transplants.

Then the private insurers would be incentivized to recruit healthy patients and dump chronically ill customers into Medicare.

I know this because I’ve already heard HR complain about too many pregnancies in a year caused the company contributions to go up.

This is a real economic problem: adverse selection. But universal coverage doesnt solve it, it just makes everyone pay.

That’s exactly what insurance is for, to spread the risk among the entire pool of participants. And the best way to expand the pool as large as possible is with universal healthcare (ie “everyone”).

Everyone pays because everyone should pay.

> Everyone pays because everyone should pay.

But if everyone pays the same you just conceded the entire victory to adverse selection: people that do not participate in a risk pays for the risk in someone else. The most obvious demonstration of this effect is double-paying in countries that have both private and public healthcare services: you pay twice, once for the public you don't use, and then for the private one.

Society has some costs you can’t opt out of.

That a common and fine approach, but that doesnt make it cheaper, it makes it a whole lot more expensive.

From my point of view, lowering the expense is the #1 priority. Expanding coverage, and adding new layers of taxation for it will increase expenditures.

There are also many alternatives to adverse selection, my favorite is high deductible plans.

Which country has a parallel public/private healthcare system?

Most countries with public healthcare have a private supplement that build on top of what the national system already provides: in home care, private hospital rooms, dental and vision, and concierge service. I've yet to see a private system attempt to replace a functional public system.

> Which country has a parallel public/private healthcare system?

Most that I know of. Unless the state has absolute monopoly on primary care providers/General practitioners, you will have both systems in place.

> Unless the state has absolute monopoly on primary care providers/General practitioners

Yes, that is what single-payer means. There is no parallel payment. You pay for basic service through taxes. You pay for better service through private. Private insurers like BUPA can only extend healthcare options. They don't replace it.

That system is not inherently cheaper: people that go private pay twice (pay for public through taxes and then pay privately).

I dont think its palatable in the US to make policies that could increase national healthcare spending.

You realize Medicare Part C and D are entirely run by private companies right?

I am. Part C is optional (Medicare Advantage, akin to an upgraded private insurance plan in European universal healthcare systems), and D is prescription drug coverage that a single payer system can administer as part of its system for all participants.

Part C is not an upgrade, it’s soup to nuts. The gov’t just writes the check to the insurer.

A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits.

We’re splitting hairs. It’s an upgrade in the sense it replaces primary Medicare coverage while also including supplements (vision, dental, and other such coverage).

You're original comment says you prefer government run insurance and give Medicare as an example, but neglect to note that 36% of Medicare is privately run.

Fair point.

In Canada, 16% of the money spent on health care is spent on administration; in the U.S., 28%. Tell me again how the free market is more efficient?

The US healthcare market is not a free market. I know this well enough to commit to a challenge: name me any two actors in the space and I can name you how each one is screwing the other one thanks to a law or regulation.

Maybe the problem there is multiple actors rather than regulations.

Sorry? could you rephrase this sentence, I didn't quite get it.

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