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Comment by mcv | Hacker News Reader

It's not so much that the US forgot what antitrust is for, it's that the current powers that be disagree with it, and have a tendency to pervert anything they disagree with, rather than being honest about their opposition to it.

Same thing with health care and other measures that are meant to benefit the general public. Opposing things that benefit the general public doesn't win them votes, so they need to put a clever spin on their opposition to it. But ultimately, they want things that benefit rich people, particularly party donors.

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The unfortunate/fortunate truth is that law must always be altered in letter or interpretation to work against those that would willingly circumvent it.

What if we state that a monopoly that makes up 75% of market is worthy of being broken up? Then some wealthy business owner will gladly split their company into two companies which they both own before hitting the 75% mark. And that doesn't solve monopolies as we know it - it just hides it from public view.

Enforcing the law and producing the law simply becomes a big cat and mouse game. If we were smart, we would simply state that we know someone is not following the spirit of the law and we have evidence to that effect and that should still be punishable, though maybe not to the same extent until it's been established in caselaw.

Diversification of ownership and change in management. The larger an organization is the more it becomes a social institution.

Over some multiple of the poverty line an individual should only be allowed to own so much of a company and industry. I own company A and lists company B as a competitor Then you can only own so much of the competition.

The largest companies and institutions should have term limits on upper management, board seats, and consulting arrangements.

Also, the larger it is the more shareholders it needs. And there should be only one class of stock.

Or communism 2.0? But who am I? I haven't even read the Gulag Archipelago!

There is nothing socialist or communist about the parents proposal. Capitalism needs controls, we as a civilization are clearly failing at that.

> What if we state that a monopoly that makes up 75% of market is worthy of being broken up? Then some wealthy business owner will gladly split their company into two companies which they both own before hitting the 75% mark.

That's a "trust". That's explicitly what "anti-trust" is for.

But anyone knows how this works. If high income is taxed, the rich will figure out how to get benefits without the high income. Humans are all somewhere between the compliance/noncompliance spectrum. In game theory, much of the time, the evaders win, but it's never a guarantee. If it was, everyone would do it.

> we know someone is not following the spirit of the law and we have evidence to that effect and that should still be punishable

Uh, that's pretty much how Common Law works already.

The problem is typically not the law, but finding someone who really wants to enforce it. Aka, political will.

Is that why there's a law against having an ice cream in your back pocket?

No, that's because Kentucky is Kentucky.

The job of judges to a large extent is in protecting (their interpretation of) the spirit of the law - as can be seen with the recent situation on Brexit: Boris Johnson was apparently entertaining the idea of sending an extension request, then immediately follow up with a "disregard that, I didn't mean it!" letter to technically fulfill the extension law without really asking for an extension.

When a Surpreme Court judge was asked about that in an interview, the response was the diplomatic version of "you really don't wanna fuck with us".

I think the DAO fiasco also illustrated the opposite case: A community believing that the letter of the law is enough and deliberately not enforcing the spirit at all - until someone found a loophole and the community had to scramble to protect the spirit in an ad-hoc fashion.

My feeling is that situations like the above where laws are interpreted opposite to their intended goal are more a sign of regulatory capture and of groups gaining power that are fundamentally opposed to the goal - and not so much a fundamental property of laws.

Who are the "current powers?" The current view of antitrust law has been operative since the 1980s, and has encompassed administrations on both sides of the fence. It's rooted in a large body of academic scholarship that has withstood the test of time.

Your comparison to health care is telling. You make it seem like it's "rich" "party donors" who are opposed to single-payer healthcare. In reality, just 21% of the public supports abolishing private insurance (which single-payer healthcare necessarily would require): https://www.mrctv.org/blog/cnn-poll-only-21-favor-getting-ri....

There is a rhetorical tendency to blame American public policy on conspiracies rather than honestly attempting to figure out why people vote the way they do. In the context of healthcare, for example, isn't it possible that people (1) reasonably believe that single payer won't be a magic bullet that lowers our healthcare costs to European levels; and (2) don't want to pay the additional taxes required to pay for universal coverage, when most people who aren't on Medicare receive healthcare from their employers?

There is, in fact, good evidence that those factors, rather than "rich people" and "party donors" are responsible. You'll notice that no Democrat that supports Medicare for All has offered a serious health care proposal, i.e. one that raises taxes sufficiently to pay for it. That gives you a remarkable insight into voter dynamics! Even Sanders is afraid to propose the $30 trillion in new taxes that will be required to pay for Medicare for All. (His menu would raise just $10-12 trillion, even if all options were adopted.) And while he is quite happy to propose tax rates on the wealthy *higher than those in France—51% versus 45%—he is unwilling to propose raising taxes even on people making up to $250,000 to anywhere near French levels. What does that tell you about what people want? Who is he afraid of? The rich? Or the suburban married couple making $125,000?

Maybe Americans aren't irrational. Maybe they like having 50% higher disposable income compared to Germany or France. Maybe they don't want to pay a 20% VAT, the OECD average. Maybe they don't want their FICA contributions to double or triple, bringing those in line with social insurance taxes in Germany or France. Maybe they don't want 40%+ tax brackets to kick in well under $100,000, like in Germany, France, Sweden, etc. With respect to antitrust, maybe they like the rock-bottom prices enabled by the scale of companies like Wal-Mart and Amazon. Maybe they don't support carbon taxes because they like $3 gas, road trips, and SUVs? Maybe they are voting for the "powers" that give them what they want?

It’s interesting to note that at the time the Microsoft antitrust decision came down, polls showed that people were opposed to breaking up Microsoft 54-35. That was the case even though a majority of people thought it was a monopoly! I don’t think people usually can articulate a specific opinion on antitrust issues, save for high profile cases like that, but people don’t vote for specific policies, they vote for an ideology. And for decades, they’ve been voting for a deregulatory ideology that features less government intervention in the economy.

I only wanted to address one thing you mentioned: polling varies widely on abolishing the private insurance system.

The Kaiser Family Foundation does extensive health care polling on a continual basis, and their recent poll suggests that 37% favor single-payer where private insurance is abolished.

Also, there certainly is room -- and I think even the staunchest advocate of socialized medicine acknowledges this -- for elective procedures to be covered by private insurance under a single-payer regime, so it's maybe inaccurate to say that one (single payer) necessitates the other (abolishing private insurance). Several countries I'm aware of split it up that way successfully.

Lots of other interesting information here:

https://www.kff.org/slideshow/public-opinion-on-single-payer...

When people are polled about “private insurance” I don’t think they’re thinking about private insurance for elective procedures. I think the point shows that the large majority of people want, at most, a public option as an alternative to their existing private insurance. And that solution is unlikely to have much impact on costs.

At the end of the day, the thing that came out of the political process (ACA plus Medicaid expansion) is probably the closest thing that has been proposed to what people are actually comfortable with.

I'm certainly not comfortable with the ACA. I'm old enough to remember what health insurance was like before Obama came along. The sudden and dramatic increase in premiums, deductibles, and co-insurance was effectively a massive pay cut for the entire American middle class.

The government took a bad situation (the US healthcare system) and managed to make it a lot worse.

Yes and no.

Eliminating the pre-existing conditions restrictions was life-changing for me and a lot of people I know; I'd had a surgery in 2005 that, up to whenever Obamacare was passed, excluded me from buying any health insurance from a private insurer.

They all declined me as having had a pre-existing condition (having been operated on). Obamacare taking that away? A good thing.

The medicaid expansion was significant for several of my friends, too. Suddenly, they qualified for medicaid! Again, big improvement in their quality of life.

Lots wrong with the ACA, and for my part I wish we'd had the public option, but overall I don't think it made health care worse; just changed the good and bad to affect different people.

I've been buying insurance on the individual & small-group markets for almost 20 years. I've done this across three states. Which is to say I am keenly aware of how much healthcare has cost in both the pre-ACA and post-ACA timeframes.

> The sudden and dramatic increase in premiums, deductibles, and co-insurance was effectively a massive pay cut for the entire American middle class.

This is just a misrepresentation (or overgeneralization) of facts. One thing that was true before the ACA is that insurance rates increased monotonically every year, often by large percentages. This also applies to deductibles and co-insurance.

What changed was compounding. In 2002, a 20% increase on a $150/mo policy added $30 to the price. The same 20% increase in 2007 might have been on a $400/mo policy, so it added $80. A 25% increase in co-pay from $40 to $50 is barely noticeable, unless you're old enough to remember when insurance didn't have co-pays. (As an aside, that pre-ACA policy might not have covered actually getting sick or needing medical care.) This compounding had been going on since at least the 1980s, and it was inevitable that it would get large enough to notice at some point.

Anecdotally, the policies on offer here (GA) on the individual market are markedly less expensive than the trend line circa 2007 would have predicted for 2019. And they cover more, since the fake insurance has been outlawed.

Curious what others have noticed, but this has been my experience.

The ACA was probably literally life-saving for a lot of people in my cohort, who were maximally affected by the 2008 crisis and could stay on their parents' insurance plan after graduating university and before finding full-time employment.

The same goes for people who were uninsurable due to pre-existing conditions.

It might have been inconvenient for you if your policy rates went up, but the system was not working before the ACA. It's still not great, but at least less people are shut out of the system completely.

> And that solution is unlikely to have much impact on costs.

How do you reach that conclusion? National health insurers almost always pay less item-for-item than private plans, because they represent a large proportion of income for healthcare providers and thus have immense bargaining power. Medicare, for example, pays less for medications and procedures than almost anyone else. There's no reason to believe they wouldn't get an even better deal if more of the population was under their coverage.

"figure out why people vote the way they do"

Because they are being conned to believe it is not the bankers or the corporates or those who's coatpockets are brimming with money that took their share of the wealth, it is the dirtpoor immigrants.

Ah yes. Americans are just dumb and easily duped. (Meanwhile, rich people and “corporates” are unable to dupe people in Europe, because reasons.) It has nothing to do with the fact that they live in houses twice as big as those in France, can drive around large SUVs, and have $15,000+ more per year in disposable income at the median than the French. Nothing to do with that at all.

> It has nothing to do with the fact that they live in houses twice as big as those in France, can drive around large SUVs, and have $15,000+ more per year in disposable income at the median than the French

pretty sure we spend that extra money on our worse health outcomes and SUVs are terrible to drive.

Is it so crazy to believe there are ways to make healthcare better through the free market?

US Healthcare as it stands is a non-free market run by private entities. It isn't immediately obvious that a non-free market run by the government is the way to go. It might be possible to get the best of both worlds by going to a free market run by private entities. The potential to have low costs and the economic edge from low taxes is surely quite enticing.

> Is it so crazy to believe there are ways to make healthcare better through the free market?

Yes, it is. Any market you're forced to participate in, lest you die, is not and cannot ever be a "free market".

I think grocery stores are evidence to the contrary

OK, so the wording needs to be adjusted slightly.

Any market in which you, at the moment you need its goods or services, cannot reasonably be expected to evaluate multiple options, due to the urgency of the need, cannot be considered free.

Yes, obviously, we all need food, but I have some in my refrigerator now, and I ate breakfast this morning, so I have some time to decide whether to go to Price Chopper, Wegman's, or Hannaford to buy my next week's meals. Even in the most urgent circumstance (someone who is literally starving right now), the choice of which grocery store to go to to purchase the food that will save their life is a fairly small decision: most will have something that can serve that need for a vaguely reasonable price, and then that decision will be done, and they'll have the time to consider, "But do I want to go to that one for my next food purchase, or is one that's farther away a better option?"

Healthcare can sometimes be like that. We have some freedom to shop around and choose where to get elective surgeries, ongoing maintenance/preventative care, etc. But if I get hit by a bus tomorrow, even assuming I were conscious and coherent enough to make such a choice, I wouldn't be in a position to say, "No, I don't want to go to the closest hospital; I want to go to the one three counties over, because their trauma ward is better." If I waited that long, I'd die.

Furthermore, the vast majority of Americans don't have any meaningful choice in their health insurance provider. They get it through their employer, paying out of pocket would be prohibitively expensive, and the employer isn't just going to give you what they'd be paying for your plan so you can buy another. For those who have to pay out of pocket, there still aren't great options, because the vast majority of insurance plans that are remotely within reach of people who don't have the absurd luck to get six-to-seven-figure Silicon Valley-style salaries are high-deductible plans, meaning you're still going to be paying thousands upon thousands of dollars out of pocket for care if anything happens. And then there's the issues with figuring out what's in-network and what's not...

Put simply, the healthcare "market" in America is not merely un-free because it is fundamentally coercive, it is also deliberately obfuscatory in terms of what you get for your money, and even how much you'll have to pay in many cases—and remember, a free market absolutely relies on full information.

It totally can. My mum needed spinal surgery; it was moderately urgent, certainly mandatory and she still found time to shop around. She was overjoyed with the surgeon she dug up too.

As for the idea that only non-essential markets can be free - I live a pretty spartan existence. All the markets I participate in are basically at threat of death or catastrophic lifestyle disruption except for my internet connection and book collection.

In particular that point falls apart when food is considered. We had an inquiry into the price of milk in Australia because the greedy corporations were setting it too low. One of my favourite bits of parliamentary theatre ever.

Your average voter does not spend that extra money on either insurance premiums or "worse health outcomes." 2/3 of people who aren't on Medicare have employer-provided health insurance. For those people, employers pay 82% of premiums, leaving employees to pay about $1,250 per year for individuals, and about $5,600 per year for families: https://www.peoplekeep.com/blog/what-percent-of-health-insur.... Note that the median household income for a married couple with kids under 18 is $95,000 in the US: https://www.cnsnews.com/commentary/terence-p-jeffrey/number-....

As to worse health outcomes: Minnesota has a life expectancy comparable to Sweden. Asian Americans in the United States have a life expectancy longer than Asians in Japan, Hong Kong, or Singapore. Looking at the averages skews the fact that much of our disparities in outcomes is not across the board, but the result of disenfranchised minority groups having much worse outcomes than the majority of the population. But your average voter skews more white, older, suburban, married, wealthier, etc., than the general population. The health outcomes for these people are not appreciably, if at all, worse than in Europe.

What you're chalking up as some conspiracy by "the rich" against "everyone else" is better understood as white middle class voters voting for policies that benefit themselves at the expense of disenfranchised minorities. It's not the "rich people" and "corporates" (which Europe has too!) but rather the majority's treatment of the disenfranchised minority (which comprises a much larger fraction of the U.S. population than in most European countries). (In that sense, I'd say that the extreme left wing has a better argument than the moderate left wing. In a world where white Minnesotans have similar health outcomes to white Swedes, while predominantly African American Mississippians live the better part of a decade less, race is a much more important issue than economic policy. And you can't blame the "corporates" for that.)

I wonder to what extent those average numbers for American out-of-pocket costs are skewed towards the overall majority health outcome (no serious, expensive chronic illness until around Medicare age), and whether the American health situation is drastically worse if you are sick, and Americans just don't price that possibility in.

I strongly suspect that is the case, and Americans aren’t pricing in the possibility of chronic illness (or job loss, etc.)

> pretty sure we spend that extra money on our worse health outcomes and SUVs are terrible to drive.

The health outcomes in the US are better than the EU for people who have health insurance. The mean outcomes are worse in the US because of people without health insurance significantly bringing down the average, but people in the US who do have private insurance are not wrong to want to preserve their own (higher) quality of care while finding a better solution for those currently uninsured. (There are also some other factors like lower population density increasing emergency response times, so the outcomes in rural areas are worse and the US is more rural, which would obviously not be remedied by single payer.)

And "SUVs are terrible to drive" is trivially empirically testable -- if both SUVs and smaller vehicles are available and people willingly choose SUVs anyway, we know what they prefer. If you want to argue against SUVs then make the environmental argument about externalities that might actually hold water, not "SUVs are terrible to drive" which is a subjective opinion that millions of people evidently disagree with.

At least in the USA, public support for any given policy is usually a function of how much money is poured into promoting it. It's no surprise that policies that benefit the rich, get promoted by the rich, and consequently end up with sufficient public support.

I have no idea how it works in France, but if I were a rich person trying to find the country with the best ROI for my influence-dollars, it would be a large powerful country rather than a small one, and one where the law is set up specifically to encourage unlimited financial contributions to political causes.

What you pointed out in your initial comment is totally true, though. The "current powers" have nothing to do with what side of the political fence they're on. There are rich people on both sides and they tend to support and fund things that keep them rich. And that's what we end up with as policy, regardless of what letter is next to lawmakers' names. The red-vs-blue distinction is manufactured tribalism and doesn't really have much of an effect on who public policy actually ends up benefiting.

> Ah yes. Americans are just dumb and easily duped.

I wouldn't say dumb or easily, but a large portion of us I would agree are being duped. I mean you have entire swaths of the country that believe "pull yourself up by your bootstraps" is actually serious advice, and not the sarcastic and ridiculous statement it was originally coined as. The streak of individualism present in most places but especially in the States has been hijacked to great effect to make people more willing to vote against their better interests in the name of what's sold to them as "freedom."

Balanced by TGV and the fact that infant mortality rates don't depend upon which zip code (or arrondissement) you live in.

Why do you think my comment was aimed at Americans? The EU has the exact same situation.

> Because they are being conned to believe it is not the bankers or the corporates or those who's coatpockets are brimming with money that took their share of the wealth, it is the dirtpoor immigrants.

Perhaps they're both problematic!

If all you have to add is "my opposition is stupid and uninformed" perhaps you should refrain from commenting.

Immigration is a complex issue and can be problematic in many ways. But blaming the poorest of the immigrants for taking away the share of the wealth of the bottom 80% of the lopsided Pareto distribution is disingenuous.

Of course only 21% of the public favours abolishing private insurance. There's been a huge and incredibly well-funded PR campaign to persuade them of that.

https://theintercept.com/2018/11/20/medicare-for-all-healthc...

Americans don't need to be irrational - they just need to be misled about the relative benefits of taxes vs the personal security and relief that could be provided by paying higher taxes.

The reality is that the private medical insurance industry in the US is the single biggest cause of personal bankruptcy, and is responsible for incredible emotional and financial suffering. It takes a lot of spin - not to mention outright dishonesty - to paint that as a good thing.

But when the industry makes as much money as it does, the costs of generating that spin are relatively cheap compared to the profits it secures.

Meanwhile in those countries groaning under the yoke of oppressive taxation, there is absolutely no popular support for moving to the "benefits" of a US system.

Because there are no benefits. And that's a straightforward, simple, unarguable fact. Not only are higher taxes absolutely worth the value they buy - guaranteed health care, with no worries about bankruptcy or "competitive" price gouging - but the total cost over a lifetime, inclusive of taxes, is vastly lower than the equivalent cost in the US system.

The other reason only 21% of people are against abolishing private insurance is that lots of people are insured through their employer, and thus the true cost of their healthcare coverage is hidden from them. If they really knew how much it was costing them (because benefits are part of “total compensation”), they would sing a different tune.

And yet another is they don't have confidence in the public sector running it well.

Because for at least the past 4 decades, one major political party has been running an enormous propaganda campaign to convince the country that "public sector" == "wasteful, inefficient, ineffective, and corrupt" and "private company" == "efficient market-driven utopia".

They've been so successful, they've even convinced themselves—so much so that every time actual evidence to the contrary is presented, they pretend it doesn't exist and try to make everyone else do the same.

That, along with peoples’ actual experiences with their government. The NYC MTA is better funded than London’s or Paris’s transit systems, yet has on the brink of system failure. Amtrak is similarly funded (adjusted for differences in passenger volume) to European rail systems. Yet it offers decrepit equipment and unreliable service. We spend more per student on education than all but a couple of other countries (like Switzerland), but our test scores are at the bottom of the pack. American cities like Baltimore and San Francisco are full of crime, homelessness, and drug use, even though they’ve been controlled by “the other major party” for decades.

It should also be noted that, with the notable exception of healthcare, most of Western Europe has followed the trend of privatization, deregulation, and reliance on market mechanisms. Macron is talking about privatizing SNCF—not even Trump is talking about privatizing Amtrak.

You are being disingenuous. Why don't you look at government-run programs in the actual sector we are discussing?

Medicare and VA healthcare programs are both well-run and immensely popular among their recipients. They aren't without problems, but looking at them objectively should dispel any notion that "the government cannot run healthcare efficiently and effectively."

> They aren't without problems, but looking at them objectively should dispel any notion that "the government cannot run healthcare efficiently and effectively."

I think that wouldn't dispel the notion that "the government cannot regulate healthcare efficiently and effectively". Unless you expect all hospitals and doctors to be direct employees of the government, you need to look at how they regulate the sector, they won't be running it. I shouldn't have used "running" in my original comment as it implied more direct control than would be the case.

That is exactly how it works now. While VA hospitals do exist, there are no Medicare hospitals.

Amtrak is already privatized (in the USPS model). If it were any more privatized it would be bankrupt and nobody would be providing the service. If someone were trying to compete with Amtrak, the country is ripe with old, falling apart cargo-only rails that haven't seen passengers in a century or longer.

(It would also probably cost a fraction of what Musk, et al have thrown into silly pie-in-the-sky fantasies like the "hyper-loop" to old fashioned public transport planning with existing, proven modern technologies such as Japanese "bullet" train tech.)

I think I agree with upthread. Probably more than anything what America needs in public transport is good propaganda again. There was a time that civic responsibility saw public transport as a public good to connect cities and Americans and make dreams happen. (Old 19th Century train ads were things of beauty.) The "American Dream" probably needs to shake its collective love affair with the automobile before anything real could be done for good, trustworthy public transport.

Amtrak isn’t at all privatized. It’s a government owned corporation. Not only that, it’s operated by the government. It cannot for example stop servicing unprofitable routes without Congressional approval. (USPS isn’t privatized either.)

"Government Owned Corporation" is still way more privatized than predecessor versions that were directly public entities. The point, if it flew past, by directly comparing it to the USPS, is that privatization is not a binary, but a spectrum.

To reiterate further, Amtrak is as far further down the privatization spectrum already than is good for it. The USPS generally has sometimes had annual profits (from which Congress can skim), so it mostly will continue to operate, but is in the worst of both worlds situation where it has rarely ever had a chance to reinvest its own profits back into itself. But Congress has an incentive to keep USPS running mostly smoothly because they wouldn't have profits to skim without it.

Amtrak has the exact same worst of both worlds situation without even the excuse of occasional profit, so it shares all of the control from Congress, but none of the responsibilities of any attempt at good stewardship from Congress because it's nothing but a "cost center" on the federal books, but also "someone else's problem" because shouldn't it be the Amtrak corporate board making good decisions and leaving Congress to focus on stuff that matters?

Further privatizing Amtrak doesn't make any sense, because the current worst of both worlds privatization has already mostly killed Amtrak. Further privatizing Amtrak is just gifting on a silver platter some private equity firm (vulture capitalists) a far too cheap leveraged buy-out and eventual hugely profitable to the equity firm and hugely expensive to the American people Amtrak bankruptcy and break up into a lot of little parts. Probably would mean the entire end of passenger rail travel in the country, because our lazy cargo train operators would love nothing more than such an easy bit of extra free margin in their operating schedules.

How do American test scores shake out if you compare like-for-like with SES factored in?

That may be one minor reason of many, that may not. But this speculation that peoples' beliefs, such as my own, are propaganda driven needs to stop being presented as objective. Many people have statistical and empirical evidence to support their beliefs especially concerning issues such as health policy/regulation. When you disagree, those you disagree with are not automatically swayed by propaganda any more than your beliefs of the significant PR effects are propaganda-based themselves.

Medicare, Medicaid and the VA manage to be cheaper per capita despite specifically insuring the old, the poor, and veterans.

What's your statistical and empirical reasoning and why should we ignore that elephant of a top line number?

There isn't any. Not a single private health plan manages to be more cost-effective than the 3 government health plans, despite private health plans having the ability to pick-and-choose the cream of the crop and to offload unprofitable customers to government health plans.

BUT (when they actually provide health care) private health plans usually provide health care faster than government health plans. VA wait times, for example, still exceed 12 months in many parts of the country.

> BUT (when they actually provide health care) private health plans usually provide health care faster than government health plans. VA wait times, for example, still exceed 12 months in many parts of the country.

I had a severe wrist injury from a car accident. I was told to start PT "ASAP", and given referrals within 24 hours of the injury.

I was then told that I'd be waiting 10-12 weeks for a PT slot.

Yet we're not going to see a big raise because we switch over to a single payer system. It's not unreasonable for people to be skeptical of such a massive change when their current situation works fine (for them.) A change like this would be far more beneficial to the under/uninsured than those of us with existing, comprehensive plans.

I'm not making an argument either way. Personally I'm for single payer, but that's largely due to the issues my mother had when she became ill.

> Yet we're not going to see a big raise because we switch over to a single payer system.

Californian legislators released a study last year about the costs of moving to single-payer healthcare in the state. In total it would be $400 billion, requiring $200 billion in new tax revenues after accounting for the existing $200 billion in federal, state, and local expenditures. Diverting existing employer and individual premium payments would still leave anywhere from a $50 billion to $150 billion gap. California's existing budget is ~$200 billion, so covering that gap would require significant new taxes.

Anybody telling you that you can get single-payer for free is lying to you. That would only be possible if we could significantly reduce costs, but we don't know how to reduce costs. Any suggestion you've heard is almost certainly part of the ACA/Obamacare in some form or fashion, and the strategies aren't working as well as originally believed. But this was predicted. The ACA was always intended to be a process of experimenting with cost reducing strategies, which is why there were supposed to be panels that could rewrite the rules as new information came in. But nobody is interested in the hard work of figuring out what those solutions are; all the electorate on both sides is interested in voting for are feel-good solutions. And they'll believe whatever they need to believe in order to support their political tribe.

> we don't know how to reduce costs

I am pretty sure administrators of health systems that are cheaper could tell us. Like just directly to our face.

If you could magically wave a wand and instantly replace a multi-trillion industry, maybe. But you can't. And so even the most radical of possible reforms will necessarily be incremental.

The other part of it is that Americans want mutually exclusive things--low prices and end-of-life services that will spare no expense. In the end any equitable system will have to choose the former, just as every other national system has. However, the people in those systems were never given the choice; their healthcare systems just evolved in that direction decades before modern revolutions in incomprehensibly expensive medical care. So Americans are being forced (by partisan politics) to make a decision no democracy can be reasonably expected to make.

The ACA was largely based on Hillary Clinton's 15+ years of footwork. The ACA is based on extensive examinations of foreign healthcare systems. If Democrats can't make the ACA work--because they can't overcome Republican opposition, because they're fickle and have turned their backs on it--then what hope is there of even more radical reforms?

I'm not saying single-payer isn't possible in the U.S. It's just not possible now. We'd have to wind our way there. But that's too much of an ask from our modern politics. The ACA could have been a stepping stone, instead leftist and populist Democrats just want to chuck it and start over, ignoring the fact that they'd be facing all the same impediments and problems of the ACA and a whole lot more, yet without any better answers.

"Other people do it" isn't an answer. Can I expect you to become a Warren Buffet or Bill Gates merely because they and you both exist? It's a non sequitur. You can't simply ignore path dependencies.

A young man is walking down a dusty country road, putting out his thumb for each passing vehicle. None stop.

An hour goes by and a old red truck rolls past him, ineffectually coming to a soft halt, front brakes obviously worn out years ago.

The old guy in the truck asks him where he is going. The kid points to a location on the map. And the old guy says, "oh they blew the bridge up years ago. You can't get there from here, at least not anymore."

> But when the industry makes as much money as it does, the costs of generating that spin are relatively cheap compared to the profits it secures.

In H1 2018, the largest 8 insurers combined made $16.6 billion in profits: https://www.fiercehealthcare.com/payer/from-aetna-to-wellcar.... Facebook, by itself, is about on the same level, at $10 billion.

Are you saying that Facebook alone somehow makes sufficient profits to convince an entire country to vote for favorable policies? Including the thousands of businesses, shelling out $1 trillion+ for private health insurance coverage?

Are you saying that Facebook alone somehow makes sufficient profits to convince an entire country to vote for favorable policies? Including the thousands of businesses, shelling out $1 trillion+ for private health insurance coverage?

Facebook owns $50b of the ad market revenue. So, yes? The company literally is built on selling ads to target demographics.

If Facebook has so much influence, why does nobody seem to like it very much?

Both Google and Facebook combined should have even more influence. Both spend a lot of money on healthcare (for their employees). Why wouldn't they use their influence to make healthcare cheaper?

I mean, I don't want to lay all of the blame on the citizenry, but America also leads the world in obesity, anxiety disorders and cocaine use. I understand that correlation doesn't equal causation, but there is a correlation. Personal responsibility has to lie in there, somewhere. It isn't an "all or nothing" equation.

Also, when the US gets compared to these European countries, they are, quite literally, the size of one of our states. It's a tough comparison. Sure, lines can be drawn, but people do have to take into account a difference in scope and culture. It might not be Apples and oranges, but maybe look at it like lemons and oranges?

>America also leads the world in obesity

I've found three sources that have us at 16 or 17 (and they all use BMI, which is ok I guess, but not great.)

https://en.wikipedia.org/wiki/List_of_countries_by_body_mass...

>anxiety disorders

Upper middle of the pack by region. Anxiety also correlates to wealth.

https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-...

>and cocaine use

#5 per the latest data I can find.

https://en.wikipedia.org/wiki/List_of_countries_by_prevalenc...

Two comments deep and we’re solidly into red team vs blue team politics. Surely there’s a way to have an intelligent conversation about an interesting and relevant article without throwing a match into a pool of gasoline?

To be fair, the article poured the pool of gasoline and lit the match. It was pretty clearly blue-team material, and bound to generate exactly this response.

Best one can do is flag and hope the mods mod.

Would require some semblance of respect for one another, for the spirit of the site, and perhaps a more active moderation of those that stray.

Unfortunately we have a politically slanted article, and those who wish to comment on it to throw out their slanted opinions instead of having an intelligent conversation.

Honestly, I don't think so. Particularly on issues that can further develop into VSA vs. "Europe". Every point has a "right" answer, any deviation from that answer puts the commenter in the opposite camp, and the majority opinion controls the discussion by downvoting dissent into whiteness.

> just 21% of the public supports abolishing private insurance (which single-payer healthcare necessarily would require):

Why? In the UK, there's both single-payer healthcare and (extra) private insurance.

How is that "single-payer"? That sounds more like "public option", unless you mean that the NHS has an enforced monopoly on certain aspects of heath care. If that is the case, then raynier's statistic is still relevant.

The difference is that there is main payer and extra insurance that not everybody has. Or rather, most people don't. Think Medicare but actually cheap and working.

Maybe I misunderstand how the UK system is set up. I thought the NHS was not just the payer, but also the provider. How does extra insurance affect services that people go to the NHS for?

The NHS provides and pays for NHS services.

One can also buy medical care privately, outside of the NHS - paid for either with cash, or by private medical insurance (paid for either with cash, or by your employer)

Services outside of the NHS may have more luxurious facilities, shorter waiting lists, and more flexible appointment times. Some doctors will do both NHS work and private work.

If you need fertility treatment, a physiotherapist to look at your sport injury, speech therapy, or a 10 minute doctor's consultation over video chat at 7pm, the private medical system can provide that.

On the other hand, many services are unavailable outside the NHS; there are no private ambulances or accident-and-emergency facilities.

That description makes the NHS sound like a two-tiered system, not a single-payer system. Digging into this on Wikipedia[1][2] and seeing the same health systems referred to as "single-payer" and "two-tier" depending on the context now has me royally confused about what "single-payer" actually means.

[1] https://en.wikipedia.org/wiki/Single-payer_healthcare

[2] https://en.wikipedia.org/wiki/Two-tier_healthcare

I don't think that "single payer" means anything concrete at all... it's just a question of, can a "normal person" get most of his potential medical needs covered without paying through the nose, going bankrupt, getting substantially sub-standard service, etc.

For example, AFAIK in Switzerland, it's again completely different - everyone is obliged to buy medical insurance (privately, employers cannot offer it), hospitals (and insurance companies) are private, what you get depends on how much you pay (though everyone gets really good care, it's more like, do you share a room with other patients or not), the government covers if you're too poor to pay... Is this single payer or not? It doesn't matter, as long as most everyone is covered and happy. (Admittedly, Switzerland is in a privileged position with high salaries and cost of living, being the world's bank... not sure if other countries can afford to replicate their system.)

Sure, call it anything you want. But by your logic, there's no "single payer" anywhere on Earth because I can always just fly to the US and pay a doctor out of pocket (so I'm the "other payer").

No, because the world isn't a single health care market. Our ability to get health care outside the countries of our citizenship or legal residence is limited. Single-payer is only relevant for a single market. How else could you possibly describe it?

The UK isn't the only place that does this. I'm in the US, but my understanding is that the public gets a minimum level of heathcare, provided by the state. You can additionally decide to pay extra money for fancier care if you want more than what you're getting.

> I'm in the US, but my understanding is that the public gets a minimum level of heathcare, provided by the state. You can additionally decide to pay extra money for fancier care if you want more than what you're getting.

Sorry if this comes off as snarky but,

"fancier care" like, for example, the required dose of insulin?

http://nymag.com/intelligencer/2019/07/another-person-has-di...

It’s not snarky at all; this is an issue that affects me personally, my partner is type 1 and so I interface with this particularly disgusting aspect of American healthcare all the time. I could rant endlessly about how much of a travesty “care” for folks with diabetes in the US, especially compared to Europe.

I think you’ve misunderstood my comment though; I’m saying that’s how it works in many countries, and not in the US. The US clearly does not offer an acceptable base minimum of healthcare to its citizens. (EDIT: It's also a shame you've been downvoted, though, I think that this is a completely reasonable reading of my comment, even though it's not what I meant.)

I personally am of the “Medicare for all is not enough” persuasion. I’m left by European standards, and off the charts for the US.

Thanks for the clarification. I misread your comment, too, so odds are it wasn't as clear as it could be.

Yeah, I totally get it now; it's kinda funny because I don't think of the ACA as even being universal healthcare, so what I was trying to say was "I live in the US so I don't know as much about Europe's various healthcare systems as folks who live there, but this is what I know about it", thinking it would be obvious. Oh well! I'll be more careful next time.

> I personally am of the “Medicare for all is not enough” persuasion.

In what ways is "Medicare for all" not the "acceptable base minimum" you refer to?

Not in amount, but in degree; I would want a higher level of care than Medicare.

That being said, "Medicare for all" is kind of a slogan, rather than a single, uniform plan. Obviously it all boils down to the details. All people should get the care they need without fear of being bankrupt.

> my understanding is that the public gets a minimum level of [healthcare], provided by the state

That's my understanding as well. I was interpreting rayiner's statistic as people not wanting to rely on the state for even that minimum amount of care, though what it means is heavily affected by the way the poll was worded.

> In reality, just 21% of the public supports abolishing private insurance (which single-payer healthcare necessarily would require)

This is 100% false. I know this for a fact.

> There is a rhetorical tendency to blame American public policy on conspiracies rather than honestly attempting to figure out why people vote the way they do...snip...

Or maybe they just think that single-payer means having to get rid of private insurance, which is not true.

> There is, in fact, good evidence that those factors, rather than "rich people" and "party donors" are responsible.

So, considering what you have said is not true, those factors are in fact lies and misinformation.

> There is, in fact, good evidence that those factors

So, if your premise you started off on is 100% false, and you have "evidence" to support that premise, than by definition, that evidence is not good.

> Maybe Americans aren't irrational.

Your comment demonstrates they are misinformed.

> There is a rhetorical tendency to blame American public policy on conspiracies rather than honestly attempting to figure out why people vote the way they do.

Poor incentive structures and feedback loops can create and perpetuate bad systems far more effectively than any quid pro quo conspiracy could ever dream of. There is no conspiracy required if the system rewards unethical behavior.

Basically this: https://slatestarcodex.com/2014/09/14/does-class-warfare-hav...

and

this: https://en.wikipedia.org/wiki/Manufacturing_Consent

Is there a reason you chose a link to the Media Research Center for the polling on healthcare rather than the poll itself[1]? The Media Research Center (MRC) is unapologetically opposed to left-wing ideas. From their About Us[2] section:

>The Media Research Center is America’s premier media watchdog. Since 1987, the MRC has worked to expose and neutralize the propaganda arm of the Left: the national news media."

Is that a source that we should trust to have a balanced view of a left-wing policy proposal? While the poll does show that only 21% support abolishing private insurance, it also shows that only 32% oppose abolishing private insurance. So you have a lot of people that aren't committed either way when it comes to private insurance. Overall, 56% support a national program even if it leads to higher taxes (vs 40% oppose). So the underlying data is quite different from what you are presenting.

[1]: http://cdn.cnn.com/cnn/2019/images/07/01/rel8a.-.democrats.a...

[2]: https://www.mrc.org/about

Here is a similar point made by an unapologetically left-wing rag: https://www.vox.com/policy-and-politics/2019/7/29/8910387/me...

> Bernie Sanders’s Medicare-for-all plan, as currently written, would cancel every private insurance plan in the country. Polling suggests that’s lethal: When told that Medicare-for-all would abolish private insurance, respondents flip from favoring the plan by a 56 percent to 38 percent margin to opposing it by a 58 percent to 37 percent margin.

> $30 trillion in new taxes that will be required to pay for Medicare for All

Citation needed.

Here's mine. Global healthcare spending is currently $8 trillion per year, projected to rise to $10 trillion in 2022.

https://www2.deloitte.com/global/en/pages/life-sciences-and-...

US healthcare expenditure is a fraction of the global total.

Certainly a large portion of taxes to fund single-payer would be offset by reduction of payments to private insurers.

It's $30 trillion over 10 years (according to CBO).

So if global healthcare is $8-10 trillion/year, and US Medicare-for-all would be $3 trillion/year, then US Medicare-for-all would still be insanely expensive compared to the rest of the world.

Yes. Cost does not change with provider.

> The current view of antitrust law has been operative since the 1980s,

So since the beginning of the Regan/Thatcher era and the birth of Neoliberal politics? Interestingly, that timeline lines up pretty well with the rise in income inequality (https://www.forbes.com/sites/louiswoodhill/2013/03/28/the-my...) and when wages became decoupled with productivity in the US (https://www.forbes.com/sites/timworstall/2016/10/03/us-wages...).

> and has encompassed administrations on both sides of the fence.

What is this evidence of exactly? Neither party would be immune to an incentive structure which prioritizes corporate interests.

> It's rooted in a large body of academic scholarship that has withstood the test of time.

"Withstood the test of time" by which measure? Which metrics are targeted by the current approach to antitrust law, and which experiments have been done to prove that the system is working?

> Your comparison to health care is telling. You make it seem like it's "rich" "party donors" who are opposed to single-payer healthcare. In reality, just 21% of the public supports abolishing private insurance (which single-payer healthcare necessarily would require).

Link to poll:

http://cdn.cnn.com/cnn/2019/images/07/01/rel8a.-.democrats.a...

Interviews were conducted from June 28-30, 2019 among a sample of 1,613 respondents. The landline total respondents were 565 and there were 1,048 cell phone respondents. The margin of sampling error for total respondents is +/- 3.0 at the 95% confidence level.

The actual question asked in this poll is:

Do you think the government should provide a national health insurance program for all Americans, even if this would require higher taxes?

56% responded yes.

Then:

And if the government instituted a national health insurance program for all Americans, do you think that program should or should not completely replace private health insurance?

Only 37% responded yes. That's where the 21% comes from. If you're curious how this broke down by demographic, it's on page 38 of the PDF.

But I want to point a couple things out. First, the OP didn't say anything about single-payer, and that's not the only model for universal healthcare. Second, I'm convinced this is largely a case of loss aversion, and the fact that results are skewed among those with private insurance out of ignorance of what their employer pays on their behalf. On loss aversion, just look at how public opinion changed on the ACA. Imagine asking 65+ year olds if they think Medicare should be abolished. Finally, even in the case of Medicare, there is supplemental private insurance. The way the polling question is asked would eliminate that. What American is going to respond yes to a question of the form "do you want to give up choice?"

> Maybe they don't want their FICA contributions to double or triple

How do you think a politician running on this proposal would fair? "We can lower your taxes by 15.3% but we're going to eliminate social security and Medicare."

Of course no one wants their FICA contributions to double or triple, or their taxes to go up in the abstract. And yet the existing entitlement programs are widely popular. Personally, I'd happily trade increased taxes for less uncertainty about paying for health care.

> There is a rhetorical tendency to blame American public policy on conspiracies rather than honestly attempting to figure out why people vote the way they do. ... Maybe Americans aren't irrational.

Here's an anecdotal example of what I think is probably a pretty representative rational American voter:

Caroline Penland, 44, a Republican, said she voted for Mr. Bishop. She is a reliable Republican voter, and a Christian who opposes abortion and favors “keeping God in schools.” She also favors some gun control, after being deeply affected by a 2012 shooting that occurred at the high school from which she graduated. But now, she said, was not a time to stray from the Republican fold. She voted for Mr. Trump and would do so again. “From an economical standpoint he’s doing really well,” she said. “First of all, he’s in my party. And I’m going to stick to my party right now,” Ms. Penland said of Mr. Bishop.

https://www.nytimes.com/2019/09/10/us/politics/north-carolin...

(I picked a Republican here because it was handy. There are equally "rational" Democrats and independents.)

> polls showed that people were opposed to breaking up Microsoft 54-35.

Sure. But that is entirely based on their perception. If you asked "Should Microsoft be allowed to charge Dell a Windows license for every CPU, even Dell ships a different OS?", you will get a different answer.

The real problem is that any case takes 10+ years to litigate, so the landscape is completely changed, reducing the willpower of the public to enforce.

If you think single-payer health insurance "necessarily would require" abolishing private insurance, then you simply have no idea what you're talking about. E.g., Canada, the UK, and France are three examples of single-payer systems where private health insurance still exists. So certainly single-payer does not "necessarily require" no private insurance. I would be very surprised if you could find any sigle-payer system that does not also have a private health insurance market.

If you understand what single-payer health insurance is, then it actually veers close to irrationality to believe that having it would abolish private health insurance.

> just 21% of the public supports abolishing private insurance

That seems like quite a high rate given that it's a relatively extreme position of completely abandoning the current approach. It doesn't exactly suggest the current system is popular.

> In reality, just 21% of the public supports abolishing private insurance (which single-payer healthcare necessarily would require)

Several countries (Australia, for one), absolutely support private insurance in a single-payer world.

The US is remarkably ignorant about other countries, instead preferring to rely on soundbites and other biased drivers.

> Maybe Americans aren't irrational

They are irrational because they want the healthcare and the retirement pensions and everything else but just don't want to be taxed for it. Which is why the U.S. has huge budget deficits.

Or maybe they're just too credulous, believing the tripe sold to them by the have-your-cake-and-eat-it-too brigade who keep lowering taxes but never decrease spending because otherwise they'd be voted out of office.

Competitive free markets are contrary to aristocratic ideology. Competition is expensive to the supplier, it costs them growth and profits. Of course they are in favor of mergers, conglomeration, and anti-competitive practices, and will pay dearly to promote politicians, state and federal attorneys, and judges to not apply competition law and to weaken it.

If consumers aren't paying attention when they vote, they're not just acknowledging their ignorance, they're giving up their one really powerful non-violent opportunity to force competitive markets to exist.

> It's not so much that the US forgot what antitrust is for, it's that the current powers that be disagree with it

Is there really a difference between those things?

As large a difference between genuine ignorance and willful ignorance.

Well, really, it's a result of selective enforcement and interpretation of law. One administration decides it doesn't care for a rule and decides not to enforce, or instead tailoring their interpretation to meet their desired outcome as to not appear asleep at the wheel. The next one comes along and decides it wishes to enforce based on another interpretation.

This is a consequence of human systems, ultimately.

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