Hacker News Reader

Did you read it? Also, are you familiar with any modern nations where a single-payer healthcare system has been tried? Perhaps we could use them to predict the effects.

> Is waste, fraud, and abuse taken into account at all in this study?

From the paper: "In addition to savings on overheads, a comprehensive database of health-care charges would facilitate detection of fraud, which extracts $85·7 billion every year. Following the transition to a single-payer system in Taiwan, an 8% reduction in overall national expenditure was attributed to the reduction in fraud. By moving from a fragmented health-care payment system to a unified system, irregularities in provider claims can be more easily detected. For example, under the fragmented system excessive claims for physician time can be spread across patients with several different insurance providers. However, acknowledging that improvements have been made in fraud detection since Taiwan's transition, we conservatively assume that the improved fraud detection would garner savings amounting to half that observed in Taiwan, corresponding to 4% of total health-care expenditure."

https://www.thelancet.com/journals/lancet/article/PIIS0140-6...

> People who have a proclivity to go to the doctor too much will go even more when its 'free'. Younger people who eschew doctors because it interferes with their current lifestyle will feel even safer continuing bad health habits because free care will be there for them later in life.

Is this a significant problem in countries with single-payer systems?

> Why should I subsidize other people's bad decision making?

You already are? That's how health insurance works. What this study is showing is that you'll have to subsidize other people less, because the whole system will be less expensive.

> You already are? That's how health insurance works.

I am not a defender of the insurance system. It blows. But single-payer is not the only other choice.

I want a freer healthcare market where prices are known before consuming services. Real market competition could actually occur to bring down prices. For drugs, research and development for less profitable cases could be a very worthy target of government funding. I don't have all the answers but neither does single-payer.

Healthcare is not and cannot ever be a free market. You cannot have price transparency when a buyer may be unconscious at the time of "purchase". You cannot have price competition when buyers are frequently forced to immediately purchase a good or service if they don't want to die. Hospitals are chosen by proximity, not price. These are the consequences of being mortal human beings. If we were all immortal, and "healthcare" was nothing more than voluntary cosmetic surgery, a free market might make sense.

> You cannot have price competition when buyers are frequently forced to immediately purchase a good or service if they don't want to die.

The number of instances where this dire case occurs is minimal compared to every other instance. Sure, when its life and death its not practical. Perhaps those sorts of situations is where single payer or insurance makes sense.

For humdrum things like physicals, wellness visits, cold and flu checks, vaccinations, routine labs and imaging, etc. a free market could work very well.

Hospital care is the largest spending category by far: https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

While the other things you list are technically not immediate life-or-death decisions, they still are not voluntary purchases. The presence of any kind of coercion distorts a free market.

Also, I don't want to live in a society where individuals must decide between vaccinating their newborn children or paying their electricity bill that month. Or between getting a flu shot and buying groceries for the week. The externalities of these "individual" decisions are obvious, and a free market has no answer.

Finally, let's imagine a system where emergency care is covered by a national single payer, but "humdrum things" are available in a free market. Now the poor can't afford basic physicals and flu shots, so we all end up paying more into the single payer system to cover such people being hospitalized for conditions that could have been prevented by regular medical checkups.

It doesn’t matter if it’s better. It’s fundamentally impossible to get to there from here directly. You can’t do it politically or economically, and honestly, given how much of our economy is built on healthcare spending, it’s pretty stupid to try. But again, it doesn’t matter, you can’t do it in a democracy. Just like a carbon tax, if you make too much of the population hurt in the short term, they’ll just replace you with someone who won’t.

The public option is the only thing that has a snowballs chance in hell of working.

How did FDR accomplish the New Deal in a democracy? How did the UK implement the NHS in 1948? How did Canada pass the Canada Health Act in 1984? How did Taiwan institute National Health Insurance in 1995?

Somehow, the current US health system is the most expensive on the planet [0], for outcomes that aren't better (and in some cases worse) than the rest of the developed world. Have you considered the possibility of waste, fraud, and abuse being high in the present system?

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

I am not defending the current system. My point is that insurance and single-payer are not the only 2 possible models. A freer healthcare market, not encumbered by the inefficiencies of insurance, could actually put market forces to work in the industry. If prices were known prior to service competition would begin and people could vote with their feet. Right now we have a overly consolidated monstrosity in the insurance and drug industries sucking profits out of the public, and these guys just want to switch it out for a different monstrosity.

> Somehow, the current US health system is the most expensive on the planet

You know why? Because we pay for most of the R&D, done by industry, that the rest of the world benefits from. For example, other developed nations like Canada have been able to benefit from new drugs invented in America's more capitalist system by restricting prices in their country even though we don't.

US pharmaceutical company R&D spending is ~80B per year [0]. Healthcare spending is ~3.6T, making pharma R&D about 2% of overall healthcare spending.

Based on the above back-of-the-napkin math, I'm inclined to think pharma R&D isn't really the main factor.

What is your support for believing it is the case?

[0] https://www.biopharmadive.com/news/phrma-research-developmen...

"Why should I subsidize other people's bad decision making?"

You already are through record high premiums, deductibles and what not to private insurance companies. The problem is that those companies are in it to make money which means everything is inflated and not to mention the bullshit of in-network/out of network and fighting with billing/administration to get bills corrected. No. I am sick of that and I would gladly pay to subsidize other people's decision making because we all already are.

If you really don't want to pay for other people, then no insurance should exist and everything should be out of pocket straight. Free market baby. But not gonna happen in the US when it comes to healthcare.

Let's take smoking as an example.

You think there are people out there who will smoke, knowing that it causes lung cancer, because they figure government will pick up the tab for the chemo? Bizarre, but ok, if so, why doesn't having insurance give them the same incentive?

My wife's aunt has been on disability for years because she hurt her back and refuses to quit smoking. The doctors said the smoking is preventing her back from healing correctly, and 3 back surgeries later, she still hasn't quit. Because she's poor and on disability, she doesn't have to pay for any of it, and is pefectly content sitting in her trailer watching TV and taking pain killers as her health deteriorates.

And you think if she wasn't allowed to either have private health insurance (which is subsidized by others with health insurance) or have government-paid insurance, that she would suddenly stop smoking?

Insurance and single-payer aren't the only two choices. It is possible to not like either.

I think she'll keep smoking as long as she doesn't face any repercussions for it. Right now, she keeps getting free medical care to fix anything wrong with her, so she has no incentive to get better. If she didn't have that, then she'd have to make the choice between continuing to smoke, or having to be immobile and in pain because she couldn't keep getting medication and surgery to mask the health problems she's bringing on herself.

But... she does have repercussions? She has chronic back pain and deteriorating health...

Pain pills are either A) not going to be strong enough B) harshly addictive. Probably opioids.

Speaking as someone who has parents whom smoke a lot, I think you don't understand the mentality of smokers or the addictive behavior of smoking.

Nothing is going to stop her from quitting smoking, even if she was denied pain medication or surgery. They'd find other ways to numb the pain and just walk straight into an early grave.

Wow, she is living the dream.

This is simply not a compelling argument against reform. It is a sad story and surely there will be people like this abusing any system, but making people face down bankrupts and death of loved ones is not the correct incentive against abuse of socially funded systems in my book.

You must live in a pretty blissful bubble. I have known or known of many people who continue bad habits in their life (e.g. excessive drinking and smoking) using government provided subsidies like disability, medicaid, and local programs.

Besides, if the prospect of lung cancer was enough to scare everyone off tobacco there would be no one smoking still. People are not always rational and yes I can see someone rationalizing their decision to smoke, in part, on the fact that if they do get sick they won't have to worry about paying for it. Or from the other direction if you know doing something could make you sick the prospect of simultaneous health and financial problems will be enough to push a larger portion of the public into making the healthy decision.

My wife is a pediatrician and sees about 80% medicaid patients. People absolutely go in more often than they need to because they don't pay a single cent. I'm talking going to the ER because their kid has a cough or is running a fever. These are usually also the most demanding patients.

I found this part of the paper to be unreasonable:

Available ER visits and hospitalizations can be avert through improved access to primary care

Have you ever gone to a busy urban ER? It is absolutely full to the brim 24/7 with people visiting with chronic ailments that don’t have health insurance, which is literally the most expensive possible way to treat something like asthma or chronic emphysema.

Look up the Oregon Medicaid study. Basically did a lottery, half get Medicaid, half don’t.

No change in outcomes, it just cost more.

Medicaid is not the same as Medicare. Medicaid is literally Free stuff so yea, it can be abused. Medicare is not free. People pay into it through taxes. 2 different things.

Free at the point of sale is what’s important. The fact that I know I theoretically pay for it with my taxes does nothing to curb abuse.

> Why should I subsidize other people's bad decision making?

This is what you already do when you live in America. Other people made a bad decision to make healthcare a private industry, creating a billion dollar insurance business, and you are writing their paycheck out of yours.

And how is writing paychecks for government bureaucrats any different? I would like to pay my doctor, and my hospital, and my pharmacy for my healthcare costs not some borg.

> And how is writing paychecks for government bureaucrats any different?

It's (supposedly) CHEAPER. That's right in the title. If you want to argue whether it's actually cheaper or not, that's another thing, but this kind of feigned ignorance is really not helping the debate.

> I would like to pay my doctor, and my hospital, and my pharmacy for my healthcare costs not some borg.

In South Korea, with its universal healthcare system, I always visited a hospital and paid them directly right there. Usually a few to a dozen bucks for common cold, inflamed ears, that kind of stuff. Here in the free world of America, I go to hospital and three weeks later a faceless insurance company sends me a ridiculous bill and I don't even understand how they arrived at such a price.