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Comment by cntainer | Hacker News Reader

It's interesting to see that "Health care consumes 18% of GDP in America" compared to ~10% in most developed countries. In my (non-american) opinion part of that difference comes from the fact that healthcare is already a consumer product in the US. Maybe not entirely, but much more than in Europe, where universal healthcare sponsored by the state is the norm.

Another point is that US healthcare is considered the most expensive and worst-performing in terms of outcomes compared to the other developed countries.

So you basically get the worst performing being also the most expensive. Which doesn't really fit the view that less government involvement results in a more efficient system. Well, I guess it is more efficient if the expected outcome is a larger profit for different private companies and middlemen and not the well-being of the rest of the population.

My hope is that this new-found energy in healthcare products doesn't follow the traditional VC-backed approach of building a product, taking over markets through aggressive marketing and shady closed-door dealings and operating at a loss only to then monetize the shit out of everything.

Theranos really embodied some of these fears, and I'm not sure we'll live in a better world if our health will be in the hands of people that have a financial incentive to tell us we're more sick/healthy than we really are.

View on HN

The problem is that "market" is a really bad fit for meeting healthcare needs, and doubly so when it's intermediated by insurers. People get the amount of healthcare they can afford from their discretionary budget and work their insurers for - not the amount they need. So they may get "more" (or at least more expensive) care than they need, or less.

Note that many of the European systems are semi-private, so you retain choice of providers. It doesn't need to be a full state-run system, which is vulnerable to undercapacity (which the UK is currently suffering from).

There's also an informational problem; in a fully free speech environment it's much easier to sell people unreliable cures, Theranos passim.

Market is a fine fit for every healthcare need that doesn't start with a trip to the ER which is the overwhelming majority of healthcare dispensed in the US.

Using insurance, government or some other centralizing layer (e.g. the church) for routine activity would raise massive "you're pissing money away" red flags in literally any other context. We shoehorn so much economic activity (healthcare) though a middle man (insurers) and then act surprised that they take a fat cut. The solution isn't to government-ize the middle man. That will almost certainly just be a wash. It's to get rid of the middle man where possible.

There's no reason someone shouldn't be able to get a physical or a colonoscopy the same way cosmetic surgery and dental care are done. These are cookie cutter outpatient services. The deviation from instance to instance is small and predictable so insurance should not be needed on the consumer side.

Edit: Anyone wanna do me the courtesy of explaining why I'm so wrong?

The healthcare industry already pisses away huge amounts of money. Its evident in all those stories we hear about people getting a huge $5000+ medical bill, then calling the hospital and suddenly its $100 or less. That $4900 is literally all wasted

  > Edit: Anyone wanna do me the courtesy of explaining why I'm so wrong?

just a guess, but it might be because of...

  Market is a fine fit for every healthcare need that doesn't start with a trip to the ER which is the overwhelming majority of healthcare dispensed in the US.

... one of the reasons most visits in the us is the er is precisely because preventative care is so expensive/hard-to-get in the u.s and people put off visiting the doctor regularly since its so expensive... the market isn't very amenable to these extra costs in the short run, whereas a state-run system might not have the same short-term cost concerns and encourage/subsidize regular visitation/preventative-care...

Preventative care in the US isn't expensive or hard to get for most patients. Under the Affordable Care Act (Obamacare) there are a wide range of preventive services that must be covered at no cost to the patient. While some coverage gaps remain, those plans cover the majority of US residents.

https://www.healthcare.gov/coverage/preventive-care-benefits...

What about treatment for severe conditions such as cancer or chronic conditions such as life-long disabilities where the expense is significant to the point that it may well be crippling for an individual but is rare enough that it's only a moderate cost spread across a society?

These are the cases where insurance is a perfect fit. The issue with letting it be market-based insurance is that (as you say) it allows insurance providers to take a fat cut. The obvious solution is to regulate insurance costs. At which point you might as well state fund it. Which leads us to the system we have in most of Europe.

As these system seem to work quite well, why do you think a market-based approach would be better?

> routine activity

But as you observe yourself, that's not the majority of healthcare, which is emergencies and unforseeable needs. Hence there has to be an insurer of some kind.

> There's no reason someone shouldn't be able to get a physical or a colonoscopy the same way cosmetic surgery and dental care are done. These are cookie cutter outpatient services. The deviation from instance to instance is small and predictable so insurance should not be needed on the consumer side.

Sure, whatever, the small part of the healthcare market that actually functions like a market - consumer choice, legible prices - can be left to get on with it. Let's not let that get in the way of a functioning provision of necessary care to the majority of people.

I misunderstood your comment on first read, and looking at other replies others did as well.

> Market is a fine fit for every healthcare need that doesn't start with a trip to the ER which is the overwhelming majority of healthcare dispensed in the US.

I think most people are interpreting this as “market is a fine fit for every healthcare need [except for those that start in the ER] which is the overwhelming majority...”

I.e. that you’re advocating the market for the majority of healthcare rather than the majority.

I think your actual recommendation is the opposite. Maybe this would be clearer if you just laid it out like, “Most healthcare is non emergency, cost is a primary concern which insurance makes worse, markets are good at solving cost issues.”

Responding to your actual argument, however, I see many people claim that insurance companies are taking a “fat cut”, but I see very little evidence of higher than expected ROI/ROE in Aetna / United / etc. (ref: United’s net margin is ~5%, ~15B in net income on 300B of revenue). ROE is ~20% which doesn’t seem ridiculous for an insurance business.

The bigger problem seems to be personnel spending in healthcare (admin, support staff, billing), and generally a systemic culture that’s not even knowledgeable about what prices they charge, let alone price conscious in the services they deliver.

> ~20% which doesn’t seem ridiculous for an insurance business.

I think the issue with healthcare insurance companies in the US is that they collude with the hospitals to artificially inflate the cost of things so that their 20% is 20% of 10x the actual value of the treatment.

> a full state-run system, which is vulnerable to undercapacity (which the UK is currently suffering from)

That's more because we've had decades of deliberate underfunding due to the "austerity"/"capitalism++" lunatics in charge than a natural consequence of a state-run system though.

Greed unfortunately seems to be an endemic issue. It creates these fanatics that want to leech on every part of the system imaginable, even if it means people die

But how is that not "expected"? Feels like the argument that "communism is good, it just wasn't implemented well anywhere so far". Well, sorry, but by this point I chose to believe that a full state-run system is vulnerable to under-funding in the long term.

So we should just expect people to be greedy and try to ruin systems for their own benefit. That raises the question of how to make these systems more robust to defend against that sort of attack.

Exactly. Expecting people to be generous and collaborative and selfless and whatnot is just asking for trouble.

Note that I'm not saying that people are not/ cannot be generous, selfless etc. I'm saying that relying on them being so is a crappy strategy. You need a system that continues to work in the presence of greedy people.

That is the pro of a market system. A market with a malbehaving dominant party is liable to be upset by a new contender who will undercut them, thus depriving the misbehaving party of income.

That's assuming that the methods used to undercut are beneficial when in reality they're just optimizing for profits over health outcomes. People don't have enough of a choice for it to matter, most people can't just find new providers. Same with ISPs

Yet we have cities with multiple ISPs which have incredibly cheap internet at blazing speeds. In my city we have 1Gbps fiber for $70/mo and the price goes down quickly as you reduce the speed. That's better than some areas of SF I think, and we only have 2 major ISPs here.

Amazing what a little competition can do. The city was smart enough when the competitor moved in to install the capacity for more ISPs to utilize the existing conduits in the future.

Just because there are a couple exceptions doesn't mean you can write off the rest of the country's experience as irrelevant or incorrect

We can ask why those areas with no competition are so, and it is due to overwhelming anti-market bias that makes it hard for other ISPs to compete or even outlaws it directly. Meanwhile cities that have setup one touch laws or fixed right-of-way have seen robust competition emerge.

One area where markets do poorly are where the cost of service exceeds profit, like rural areas. This is an area where government intervention in the form of subsidies can help, but these can also cement single ISP marketplaces if not managed well.

Sounds to me like ISPs should be regulated or managed the same way as telephone and electricity providers

Along with healthcare

People don't seem to have issues getting electricity service or telephone service in those regions. In this case, the special treatment of those services means that people don't get left out

Rich people aren't the only ones who deserve healthcare or good internet

In Romania competition + initial lack of regulation and lucky timing led to incredible speed + cost (my ISP just launched 10Gbps fiberlink for 10EUR/mo; 2.5Gbps is 9EUR/mo, 1Gbps is 8EUR/mo, 500Mbps is 6EUR/mo and the slowest option). That said, I think we just got incredibly lucky and I wouldn't advocate "lack of regulation" in general.

That's what would happen theoretically.

In the real world what will happen is the malbehaving dominant party will capture the market by any means available to them. In thoroughly corrupt countries they will bribe legislators, in less corrupt countries they donate to the legislators' election campaigns.

This is true, but I haven't seen any coordinated efforts at market based healthcare reform. Some of the needed reforms are patently obvious (eg make arbitrary post-facto charges illegal, like every other industry), and yet there are no popular campaigns advocating for them. There are a few comments in this thread chiming in with lists of reforms, and I could write one of my own, but politically it's crickets (likely because the Parties are partially employed by the healthcare industry).

Instead I'm forced to reluctantly support single payer healthcare, despite it being a huge corporate giveaway. It's really saying something when "have the government take it over" is the clearest path to restoring a more functional market.

> make arbitrary post-facto charges illegal,

Hospitals now are required to make pricing transparent and surprise bills (out of network charges) are now prohibited, both are recent reforms.

Out of network charges are only one possible surprise, and it's yet to be seen how the cartels wriggle out of the new regulation.

As far as I am aware, you're still unable to get straightforward answers for questions like "how much will this procedure cost?". Furthermore, this "transparent pricing" revolves around publishing a fake list of inflated prices that nobody actually pays and so is effectively useless.

Meanwhile in every other industry you either get a flat fee ($30 for an oil change), or at the very least an estimate and a contract that fixes the rate (the shop rate is $80/hour, we think this will take 2 hours). Materials are often overcharged (eg $140 for a part that is easily available for $100, because it's delivered from a special supplier) but still within a workable bound, unlike say fraudulent aspirin.

This is a straightforward reform - the reason healthcare doesn't operate like this is they bought laws creating the ability to charge you without needing to establish a contract.

Long term everything fails, Malthusian pressure gets us all.

But in the medium term, the NHS was doing pretty well until Austerity became the dominant U.K. policy:

https://fullfact.org/election-2019/ask-fullfact-nhs-waiting-...

https://ifs.org.uk/publications/15557

(That said, I don’t have longer graphs to hand, and I am slightly concerned by the convenient start date on the graph in the second link).

NHS was a great initiative and idea!! I'm not advocating against public healthcare, at all. I'm saying is that it's not surprising it became underfunded - there needs to be constant effort to prevent (or compensate) that tendency, because it _is_ the natural tendency of such systems.

Fair enough, I assumed you were trying to differentiate it from private sector given the use of the quote about communism :)

It's clear that a strong public system is needed, to keep the private ones in check. But e.g. Italy shows that they can co-exist well, and maybe that's a better solution?

No doubt. I know nothing of the Italian system; I’m in Germany now, which seems to be not just what all the left wingers I know in the U.K. are afraid the Tories want to do to the NHS, and what all the right wingers in the USA have been complaining about when they say Obamacare is too socialist, and what the one British anarcho-capitalist I knew didn’t like about UK National insurance: there are a bunch of private healthcare providers, insurance of some sort is mandatory, the providers don’t have clear differences beyond branding, it’s not called “a tax” despite being on end of year tax forms, and rich people are allowed to do some sort of shenanigans that makes it cheaper.

But… it works.

The NHS is cheaper, but — and here I wander dangerously into opinion — I suspect that’s short-term benefits with long-term problems which will bite the U.K. in the backside rather than better overall cost-benefit decisions.

I would rephrase that argument as, "communism is good, it has just been ruthlessly sabotaged by capitalist interests every time an ideologically communist regime forms".

In the case of the NHS, my understanding is that neoliberal politicians have been pushing to privatize it, and have underfunded it to make it look like it's not working in order to make privatization more appealing. The same is true for many programs in the US too.

Nah, Stalin and the communist leadership were perfectly capable saboteurs, didn't need help from capitalist interests. In a system where "the state" has the capability to enforce "public good" policies above anything else, it's only natural that the following will happen:

- individual freedom will be suppressed (because "public good"; can't have greedy people doing greedy things, them weeds need to be killed early).

- since individual freedom is suppressed the regime is naturally going to be autocratic, which means that "the state" is actually a handful of people... who now get to freely decide how they define "public good".

The fundamental error of communism is that in any implementation, it doesn't really have mechanisms to "punish" greedy leadership, only greedy individual citizens. Which is an idea as good as it sounds.

The Bolshevik revolution was carried out under the assumption that world revolution would follow, particularly in Germany. This assumption did not hold, and Russia did not have the needed technological developments to sustain themselves.

Cuba is the best example of a successful communist-ish state. Most if its struggles are due to sanctions imposed by the US and enforced via its allies across the world.

> This assumption did not hold

"if the entire world is a sh*thole, nobody will be able to tell it's due to communism"?

I fail to see what "needed technological developments" would West Germany give them.

> Cuba is the best example of a successful communist-ish state

Successful as in "not completely failed, unlike all the others". Look, I sympathize with their struggles being so close to the US & all, but the fact that this is the best-case for you have should give you a bit of pause, because Cuba is by no means close to being a paradise.

To put things in context, both the largest & most populated countries in the world used to be communist. They both had to abandon it & switched to a form of crony capitalism, which, as bad as it is, seems to actually work better for them than the alternative.

Actually, forget I said anything about communism. My intent was to address the original topic, but I just couldn't resist inserting my take on communism to the original analogy used.

Why wouldn't a private system suffer from the same price pressures?

Because government actors have agency, parent is implying that they made the choice to underfund the NHS. Such a choice was not inevitable. Contrary to “true communism has never been tried” the NHS was successful, and would be if the dominant austerity ideology had not taken hold.

I agree. The "everything is a market" ideology had a good run of almost half a century, but it should be heavily criticized in hindsight.

Institutions like healthcare, education, public transport, prisons(!) and so on are more efficient, less corrupt and of higher quality when they are in large parts collectively and democratically organized and funded. The "in large parts" is important here: A community should agree on what that means and let the market play out on the edges, or the bureaucratic costs become too heavy _and_ unfair. Decentralization is key here.

> The "everything is a market" ideology had a good run of almost half a century

But that never actually happened. Externalities were never part of the market.

Are you suggesting that healthcare-as-a-market would start working if externalities were priced in? How would that help?

I suspect the argument is "Healthcare has never been allowed to be a market" Given how many legal restrictions are placed on it, I tend to agree.

> I suspect the argument is "Healthcare has never been allowed to be a market" Given how many legal restrictions are placed on it, I tend to agree.

Emergency services aren't a good fit for markets. For markets to work, people really need the luxury to shop around with some leisure.

Wasn't there some Roman oligarch that ran a private fire department, and basically just used it to extort property owners when they had a fire? Truly market based emergency medical care without legal restrictions would likely frequently resemble that with some frequency.

Edit: Yep: https://en.wikipedia.org/wiki/History_of_firefighting#Rome

> The first ever Roman fire brigade was created by Marcus Licinius Crassus. He took advantage of the fact that Rome had no fire department, by creating his own brigade—500 men strong—which rushed to burning buildings at the first cry of alarm. Upon arriving at the scene, however, the firefighters did nothing while Crassus offered to buy the burning building from the distressed property owner, at a miserable price. If the owner agreed to sell the property, his men would put out the fire, if the owner refused, then they would simply let the structure burn to the ground.

I will also comment that when we talk about "healthcare being a market", we need to separate out providers of healthcare, with insurers of healthcare. Insurers of healthcare are much closer to a market (in that I can generally find out what the cost of the insurance is, and what it covers), but providers aren't (in that prices lists are hidden, it's not clear what is covered vs what isn't, etc). We talk about the cost of the insurance, but that's artificially high because of the practices of the providers (themselves incentivized to behave that way because of the insurers).

And that's the open market; it gets even more cloudy when we talk about employers being involved, so we have an agency problem as well.

It's a system unlike any other, and I don't think general theories really apply very well as such.

Here's a theory: Insurance companies argue and refuse to pay out to hospitals because it's an adversarial relationship.

Hospitals increase rates to cover the overhead of dealing with hostile insurance companies. Insurance companies raise rates to match increased hospital billing. Ironically both industries are incentivized to raise rates on customers while trying to gouge each other.

Is it any wonder healthcare is a scam?

>> The "everything is a market" ideology had a good run of almost half a century

> But that never actually happened. Externalities were never part of the market.

But isn't the essence of an externality that it's a social cost not factored into the market price?

It becomes a social cost because it was not accounted for as a market cost.

It may be that some of these cannot in principle be accounted for, and even more which cannot in practice be accounted for.

But I imagine the majority of externalities could be accounted for if we tried.

> But I imagine the majority of externalities could be accounted for if we tried.

The irony is if you actually came close to achieving that (e.g. accounting for all externalities in the market price), you'd have something like central planning. That's why externalities are usually managed through other mechanisms.

Also, externalities are only one kind of market failure.

Employer-based healthcare was won by an alliance of corporate and healthcare industry lobbies against a state healthcare plan in the 1950s when the so-called “free market” healthcare system was failing the public. Prices were increasing and the New Deal corporate powers pacified the public with social security and employer-based healthcare.

Edit: updated 1960s to 1950s per info in replies

In the US healthcare was intentionally tied to employment as a means of controlling wage inflation during the 1950s by Eisenhower. He had pushed for the "middle way" of private nonprofit health insurance that could be purchased individually or by employers. As inflation began to spike, the administration added new tax benefits to encourage employers to compete on providing benefits rather than higher base salaries.

Roosevelt also tried to institute a national scheme in the 30s but labor unions were split on notional vs. employer provided and it became a wedge issue that scuttled the plan. Truman's push for that same national health insurance plan was shot down in ~1949, partially killed by AMA lobbying.

You’re right. It was earlier than I thought. I updated my comment per your reply.

Heaven forbid “wage inflation!”

Was the AFL pushing for employer-based and the CIO pushing for national? I don’t even know where to find history like this. It’s virtually impossible for an average person to learn about the history of the American labor movement.

> Heaven forbid “wage inflation!”

I realized after double checking that it was actually a 1942 Roosevelt bill, and they were trying to figure out how to keep a lid on rising prices during the war. It's also not uniformly good if prices also rise quickly. Inflationary spirals are real, and very bad for regular people.

> Was the AFL pushing for employer-based and the CIO pushing for national?

I'd have to double check.

> It’s virtually impossible for an average person to learn about the history of the American labor movement.

A bunch of this stuff is available in more popular history and online now. "The Devil Is Here in These Hills" is supposed to be good, but I haven't read it.

Blaming employer-based healthcare on the stabilization act sounds suspicious to me.

It was intentionally tax incentivized via the tax code. There’s mountains of writing about it. See https://www.nytimes.com/2017/09/05/upshot/the-real-reason-th...

It's not Eisenhower's administration that's to blame, it's FDR's. Employer based healthcare is a result of the stabilization act of 1942. Health benefits were offered as incentives to workers because employers could not raise wages.

Yeah, I realized on a second pass that I had jumbled the "middle way" stuff with the Roosevelt era bill.

> Employer based healthcare is a result of the stabilization act of 1942. Health benefits were offered as incentives to workers because employers could not raise wages.

Employers can raise wages, and have been able to for some time, so that's not why we still have it.

We still have it because of tax and other incentives, and because government keeps making policy decisions to protect, and even extend it (e.g., the ACA employer mandate), not because of the employers need to offer health benefits to compete because they can't offer more wages because of WWII-era wage controls.

Employers love employer-based healthcare because it gives them insane amounts of control over their employees’ livelihoods. And as a result, wage competition is far less influential.

The fear of losing healthcare coverage a severe fear that people in other countries don’t have to worry about.

I think a lot of employers find it to be a giant headache. It’s expensive and tricky to administer and has nothing to do with your core competency as a business.

I did not state that this is why we currently have employer based health insurance, just why it came into existence. Many consider this to be the "original sin" of US healthcare policy.

Re: prisons - This isn't necessarily the case. Florida's private prisons have air conditioning and the public ones don't in part because of democratic control and the private ones have fewer deaths from heat stroke as a result.

One thing to note about US healthcare is that it seems almost deliberately engineered to not be a market.

I've never received significant health care in another country, so I can't say how the US system differs from others with any expertise. But I can say how US health care differs from just about anything else I spend money on:

1. I don't really get to shop for health insurance providers. My employer picks one, maybe two plans, and I can take it or leave it. If I leave it, I am leaving at least $10,000/year on the table, so I generally take it.

2. Even when I am on the market, the phenomenon in #1 does weird things. Once upon a time, when I was choosing my own health insurance, I started a new job with health insurance benefits that I did choose to take. But my start date was toward the beginning of the month, my old insurance wouldn't let me do a partial month, and the new employer wouldn't let me delay opting for coverage. So I was essentially forced to own two health insurance plans simultaneously for a period of time.

3. Nobody knows what care will cost ahead of time, which makes it impossible for me to make any informed economic decisions. I need to see a physical therapist. I called a few places to shop for prices. They all know what the rate for uninsured people is, but the only way we can find out what it will cost with my insurance is if I receive care, they submit a claim, and then we all find out together what the price was, after the fact.

4. #3 creates a situation where they can hide all sorts of excessive charges. When my first child was born, I got lessons on how to give him a bath and change his diaper. Both of which I already knew; I was really just going along with the lessons to be polite. I certainly wouldn't have said yes if the hospital had been transparent and up-front about the price tag on this lesson: about $2,000.

5. And sure, insurance covered most of it... but that didn't make it free; it just means the price was amortized over a large number of health insurance premiums. Unfortunately, I think that this setup makes it all too easy for us to think of these things as free, which, in turn, reduces public scrutiny over where the money comes from or where it goes.

And it just keeps going like that. Compare with signing up for cell phone service. It's a famously sleazy business, but, even with all the hidden fees they like to tack on, at least they're up-front about the basic price of service. With US health care, every fee is a hidden fee. That makes it impossible for consumers to make free, informed decisions, which is the most fundamental precondition that must be satisfied in order for a capitalist market to form.

All good points. In my mind, a market lets me make informed choices and choose from multiple options for something that meets my needs. As you noted, the only real choice is whatever your employer offers, or something more fantastically expensive. In terms of care, there are lots of choices but not enough information to actually choose. It's more of a choose your own adventure where you have to guess and hope you got it right.

For #4 on your list, I remember the insane bills we got when our first child was born. It was also insane the sheer number of bills that we got.

First we received a bill for the stay in the hospital. And then we received a bill for the doctor performing the delivery. Okay, fine, it makes some amount of sense, that doctor supports multiple hospitals and isn't technically part of the hospital and staff at that maternity ward that is there 100% of the time.

And then the separate bill for lab work, and another for the pediatrician, and another for our baby's stay in the hospital (this one really got me, why?! we were all in the same room), and then another for the lactation consultant, and, and, and...

I don't remember each one specifically at this point, but I believe it was 7 separate bills.

Edit: typos

I'm still getting bills from various groups almost a year after having a child. Being so far out from the event always makes me cautious about immediately paying them; I'm rather worried about getting a fraudulent bill that looks real, as many of these bills come from central billing offices several states over. It then takes me time to truly connect the dots from the service and looking at insurance history to ensure this bill is legitimate and that I technically do owe that.

A lot of this was covered by the Libertarian Party's position on healthcare reform in the last election, which I thought was interesting: https://www.foxnews.com/politics/jo-jorgensen-big-idea-marke...

There are probably ways that we could combine aspects of greater and lesser privatization to achieve the best of both worlds. I have some thoughts that I've been mulling around for a while:

1. Expand the government to achieve universal healthcare coverage.

-- a. ACA public option.

-- b. A conservative UBI, with the twist that uninsured individuals would be automatically enrolled in the public option and have their premiums taken out of their UBI. (Tangentially, for similar reasons, also pay out a portion of each UBI disbursement in the form of food stamps rather than cash.)

2. Shrink the government and quasi-public entities (insurance providers) to unshackle the invisible hand.

-- a. New regulation to ban copays and set a mandatory floor on deductibles (say, $10k). While major emergencies still need to be covered, and while there still needs to be an entity in between the patient and provider eating the risk of non-payment, it's also desirable from an efficiency perspective for patients to be kept aware of the costs of their care — and therefore incentivized to select more cost-efficient options. The market would then naturally find a more reasonable equilibrium without the need for price fixing, in theory.

-- b. Set up a system of tax deductions and credits for out-of-pocket medical costs. (Preferably such that the poorest would have their costs fully covered in most or all cases, depending on what's fiscally realistic.) This must strike a balance between non-disruption of market forces and ensuring that the poorest in society aren't shy about seeking the care they need. My thinking is that the annual nature of tax filings would be enough to address the former, as patients would still be be out of pocket for up to a year waiting on their refunds, representing an opportunity cost that would be difficult to ignore. To address the latter point, set up a standardized/regulated process for the insurer to send the patient something resembling a credit card bill, which they could pay either up front or up to a year later with accumulated interest.

Parts 1 and 2 are essentially unrelated, and could hypothetically be implemented independently of each other. However, #1 on its own doesn't attempt to address the efficiency issue (thus saddling the government with even greater new expenditures), and #2 on its own doesn't address what happens or who gets left holding the bag when an uninsured patient can't pay their bill (which wouldn't be an issue with truly universal coverage).

I also have a lot to say about what the state should and shouldn't be doing to maximize the general health/nutrition/fitness of the population, but we can leave that for another post :).

> New regulation to ban copays and set a mandatory floor on deductibles (say, $10k)

I like everything here except this. Won't a significant amount of healthcare (grouped by specialization, hospital, etc) still be funded by insurance and be outside the reach of market forces?

I am also curious whether there are barriers to producers of medicine, healthcare supply, etc from disrupting existing overpriced producers.

Possibly; I'm not at all an expert on the subject. My goal more directly with that was to ensure that insurance premiums would ultimately be used only to pay for emergency care rather than routine/preventive or elective care. Someone with deeper subject matter knowledge might be able to tweak or flesh it out to better achieve the intended purpose.

If I understand your last point, I really like this approach in the context of my proposal: https://www.rubio.senate.gov/public/index.cfm/2021/3/rubio-s...

"And sure, insurance covered most of it..."

Apologies for asking, but when faced with a medical situation do you have any idea when you have insurance what your maximum liability could be?

NB I'm not from the US so I very little understanding of how the system works.

Many (most? I always take employer-sponsored, not an expert on all plans) health insurance plans in the US have a concept of out-of-pocket max. This is a yearly amount that is essentially your maximum yearly liability. That amount can vary from plan to plan and year to year. Usually a lower out of pocket max means higher premiums, similar to the idea of having a lower car insurance deductible usually means higher premiums.

It looks like all plans sold through the healthcare.gov marketplace is required to have out of pocket maximums.

https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...

Thanks for answering - one last question!

Is that a hard limit and you'll never have to pay more than that?

Though the practice is now largely prohibited, there are instances where insurers will have caps on how much they will pay out, either over a lifetime or within a year.

So it is not an absolutely hard limit in all cases, no.

Edit: originally wrote year twice.

Trick question... - Some policies have a cap on benefits. So, your max out-of-pocket might be $10,000/person, but there's also a max benefit of $2,000,000 (made up numbers). This type of plan language was mostly banned with the ACA (Obamacare), but there are some grandfathered plans.

- Balance billing - there is no guarantee that the insurance provider will actually pay what the hospital bills. Insurance companies usually have negotiated rates with some providers. So, if you end up at an ER that's out of network (no negotiated rates), your insurance might pay what they think is reasonable and the hospital bills you the excess. Several California-based hospitals are notorious for this. It also happens with helicopter ambulance transport - frequently, they'll bill $50,000 for a ride, insurance covers $25,000, and the patient is stuck with a $25,000 balance (again, made up numbers).

I would say price discovery is one of the main problems just as you've identified. The other is inelasticity of demand. To put it in a crass way, what's the market value of the morbidity and mortality of your child? I suspect the answer is often all you have and more and I think plenty of actors in the system are happy to take advantage of that.

The other side of the "market" is also not very "free". Health care facilities are heavily regulated - and I don't just mean for safety. Try opening an MRI facility or other capital-intensive facility... You'll be required to obtain a certificate of need from a state board. That board will be heavily lobbied by existing supplies to minimize competition from upstart facilities. IIRC, around 2/3 of states have these laws in place.

https://www.usnews.com/news/best-states/articles/2021-07-09/...

Another sleazy behavior I've noticed is that when I receive care, and state that I'm uninsured, the provide chargers me a different rate then had I handed over my insurance card.

The way this plays out is that if I hand over my insurance card, the provider will attempt to extract as much money as possible and bill an outrageous amount. The insurance provider has maximum limits it's willing to cover for each billing code and so only covers some lesser amount. You pay the difference.

This is such scumbag behavior.

In my book, it’s a big red flag when a market is intermediated by anyone. The whole point of markets is to crowd source decision making, so if you remove the crowd, then what is it that you actually have left?

Rent seeking oligarchs?

US healthcare is a four-party arrangement since employers are also intermediaries. Employers select the plan (or plan options) and they pay the bulk of the premiums. Their check is always bigger than yours even if you pay more for your policy than they do. As such, most of the sales effort by health insurance companies is directed at the employer and they exercise a lot of judgment. In contrast, I have never once spoken to a representative of the health insurance company during open enrollment, it is always HR.

Furthermore, a lot of employers self-fund and use the insurance company only for management and possibly secondary insurance.

This whole situation would be solved by a simple change to the tax code. Managed healthcare (health insurance) can no longer be purchased via employers with pre tax income.

Everyone gets funneled to healthcare.gov where they can choose.

The whole buying things (life insurance, gym membership, retirement savings) with pre tax income if it is bought through an employer system needs to go in the trash.

> the fact that healthcare is already a consumer product in the US

I would strongly disagree with this. Healthcare in the US is currently a cartel system, not a consumer product/market system. If healthcare were a consumer product then:

  1. It wouldn't be tied to or dependent on my employment.
  2. Prices for medical treatment wouldn't be hidden/obfuscated by medical providers.
  3. Insurance providers wouldn't be restricted by arbitrary/geographical boundaries.

I think the debate over weather healthcare is a human right is an interesting one, and I personally haven't come to any conclusion on that yet.

If you think healthcare is a basic human right then a single-payer system is probably the most reasonable solution, although I don't think single payer isn't without it's share of problems.

If you think healthcare is not a basic human right then I think a real free-market solution is the most reasonable solution, again I don't think this is without problems either.

I don't believe there is a "perfect" solution. But I think either a true free-market system, or a single-payer system would both undoubtedly be 100x better than the current system in the US. I would be in favor of moving to either of these solutions as my political stance isn't D or R but "lets make improvements" regardless if those improvements are seen as left or right.

I only put this out there because I feel it needs to be, but we can't just put all of health-care into a single basket. Emergency medicine should be separated out of these discussions as there is no "Free Market" option, just as there is no real free market option for police or fire services.

For optional surgery or cosmetic treatment, sure. You can argue a free market option, but that's why I always think there should be separate baskets, for lack of a better term.

This is very fair point and distinction.

Which I think and correct me if I am wrong, is currently the norm for most developed countries?

It is sort of strange it needs to be explicitly written out, at the same time for those of us not from US we just took it for granted and never think much about the system.

Preaching to the choir, but you might be surprised at how many of us in the US don't think these things through. Now, I do think a lot of this has to do with political marketing, so to speak. Let's not kid our selves, the health care industry makes fairly large corporate donations to both political parties and there is no real discussion to get rid of privatized, emergency medicine. Even our "radicals" like Bernie Sanders, who aren't even that far left, are loathe to bring that up in the US as the indoctrination has been dug so deep =[

The Japanese system is not a single payer healthcare system and in terms of outcomes vs. cost is one of the best in the world, so I am not so sure that single-payer is the most reasonable solution. Particularly in the US where voters are averse to giving up their private insurance.

Japanese system does have a public option and much tighter price controls, which we are missing here.

What the US is missing to achieve that is japanese culture. It can't work the same or even similar.

I totally agree that culture is a big factor. I just think the conversation in the US around healthcare is kind of limited to pro or anti “Medicare for all” when there are actually many ways of doing things which do not require a single payer. Japan is just one example, Germany is another.

Obviously we shouldn’t just exactly copy the system of other countries, but it’s equally shortsighted to not learn take away anything from other existing systems. The possibility for universal coverage and higher cost efficiency without the need for single payer I think is a valid thing to take away from those examples.

It's not (just) about whether healthcare is a human right. E.g., interstate transportation on surface roads isn't a human right, but markets lost out to collective action. Why? Because building a well-functioning market for 8 lane interstates across an entire mostly-rural country was impossible in the 20th century (and probably still is).

So, the other important question to ask is the following: how feasible is it to create a well-functioning market for this product?

So far, we don't have an existence proof that such a well-functioning market is possible to construct in the healthcare space.

> E.g., interstate transportation on surface roads isn't a human right, but markets lost out to collective action. Why?

Because if there is a public option funded by taxation (whether you use it or not) and a comparable or even marginally superior private option which you have to pay use fees for (on top of the taxes), the public option will win every time. Simply put, do you want to pay once or twice for the same service? It's not like one car taking the toll road instead of the public road reduces that driver's tax burden by any noticeable degree. In antitrust terms, the government is using its monopoly in one area, "protection" (mostly from itself, as with any protection racket), as leverage to create a monopoly in another area, transportation. The surprising part is that there are some areas where the public roads are just so bad that you can actually run a profitable toll road alongside them. Level the playing field by requiring the government to fund the construction and maintenance of its interstate highways exclusively through use fees and I expect you'll see a very different result.

It's the same with any other bundled service. Having decided to subscribe to a certain service package one tends to stick with the included services, even if on an individual basis there are better services available at lower cost elsewhere. It only becomes viable to switch to the better service provider if you can replace all the bundled services. Except in this case that isn't even an option since there is no opting out of (paying for) the tax-funded package.

To add to the other comment about public-private competition (another example is schools - parents in private schools pay for both), the mostly-private industry managed to build inter-city railroads and local streetcars just fine. It is not obvious that it wouldn't eventually build highways if there was vision and/or existing demand.

Who knows, it might have even achieved a reasonable balance between the two, instead of forcing a car-centric environment everywhere like the public option? ;)

One point that gets skipped over a lot - the US is also one of the most unhealthy countries in the advanced world.

This is a big /part/ of the "worst outcomes" in the "highest cost, worst outcomes".

It is possible that you can spend a ton of money on healthcare - yet smoke and drink, drive everywhere and not exercise at all, and eat trash - that the healthcare spending is doomed to fail.

Europeans walk & bike more and don't eat as much garbage. Most Asians exercise much more, eat healthier, AND smoke and drink less.

Maybe the healthcare part is secondary to just generally taking care of your health?

It is well understood how terrible obesity is for you. Why should we expect the US to have better healthcare outcomes than Vietnam when Vietnam is 2.1% obese and the US is 42% obese. You can take all the heart medicine in the world. It would be better to simply not be obese in the first place!

This never seems to be a talking point. Have the statisticians controlled for all this when they come to these conclusions??

This is a good point, and it's important to also remember that these ideas aren't independent. How people interact with the healthcare system over their lifetimes has an impact on how they think about their health, and the health impacting decisions in their lives.

> Most Asians exercise much more, eat healthier, AND smoke and drink less.

Tobacco consumption in Asia is incredibly high: https://en.wikipedia.org/wiki/Tobacco_consumption_by_country

Alcohol consumption is fairly high too.

https://worldpopulationreview.com/country-rankings/alcohol-c...

Though I suppose China and India, which combined probably comprise the biggest block of population, are a slightly better shade of red than the US and Europe.

Just look north. Canadians are basically the same people, eat the same diet, but they have free health care, and live 3-4 years longer on average.

Maybe you want to control for the cold weather too?

Not basically the same people. Canadian and US culture aren't the same. And the racial makeup is quite different.

57% of the USA is white, compared to 73% of Canada. Nearly 20% of the USA is hispanic, compared to 1% of Canada. There are many more Asians in Canada and much less people of African origin.

I don't reasonably consider that we can attribute black people and hispanic people simply existing to an additional 8% of GDP in healthcare consumption. That seems like a huge claim with no evidence provided.

I'd like to first see evidence that people of different race has a causality effect on healthcare consumption.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4181672/

I'm not blaming races, I'm just saying the people are different. Even white Americans and Canadians are not the same.

Per the CDC:

Among men, the prevalence of obesity was over 8 percentage points lower in Canada than in the United States (24.3% compared with 32.6%) and among women, more than 12 percentage points lower (23.9% compared with 36.2%)

In the United States, the majority of the nonwhite population is black or Hispanic for whom the prevalence of obesity is higher than it is for the white population (3). Among nonwhite Canadians, the largest group is comprised of East/Southeast Asian persons for whom the prevalence of obesity is lower than it is for the white population

Canadians don't eat the same diet. The obesity rate is 36% in the USA but only 29% in Canada. I suspect that the difference in life expectancy is influenced more by obesity than by the healthcare system.

And yes we absolutely should control for climate, or at least for incidence of extreme heat waves. It's well known that heat waves kill a lot of frail elderly people.

Obesity is also very high in the United Kingdom (~27 % versus ~35 % ) and not the same problems ( https://www.bbc.com/news/uk-42950587 ).

US is also a super bad infant mortality rate compared to other countries:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4856058/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5844390/

which too seems like it's probably a complicated issue, from one of your papers.

> Consistent with past evidence that has focused on comparing the US with Scandinavian countries, we find that birth weight can explain around 75% of the US IMR disadvantage relative to Finland or Belgium. However, birth weight can only explain 30% of the US IMR disadvantage relative to Austria or the UK

> US is also a super bad infant mortality rate compared to other countries:

Access to healthcare is quite low in the US compared to most of the 50 countries ahead of us. We also have higher levels of poverty, ESPECIALLY for a lot of parents/children.

GDP is irrelevant. The paper says:

> In 2013, the US infant mortality rate (IMR) ranked 51st internationally, comparable to Croatia, despite an almost three-fold di erence in GDP per capita

If you have high GDP per capita, and more poor people per capita, and health care is not free - you're going to have more people not accessing health care and suffering the consequences.

In this world - I would expect infant mortality to be much higher even when the healthcare systems are equal.

I am so sick of null hypothesis studies and random statistic slinging. It means nothing. Average obesity rates do not tell the whole story (even so an 8% increase is HUGE). You have to look at variance. If the U.S. has a much wider variance then there would be a greater amount of people with extreme obesity which would definitely affect health care outcomes.

> This never seems to be a talking point. Have the statisticians controlled for all this when they come to these conclusions??

I never see this as a talking point of folks who are in favor of universal / state-funded healthcare, but it is often a talking point for those who are opposed. They point to the links between state-funded healthcare and the soda tax in the UK as an example of how allowing the government to control your healthcare results in more aggressive and manipulative social policy to control health outcomes societally. Many people opposed to state-funded healthcare feel rather strongly that you should be able to do pretty much whatever you like with your body as long as you're paying for it yourself. I consider this take to be missing quite a lot, but it does seem to be a common one. I am personally in favor of universal single-payer healthcare systems, so I've had this conversation a lot due to my surroundings and have heard just such this argument many times.

That's a good point, life style does play a major part.

But I think this point also opens another subject, preventive healthcare. Many modern healthcare systems are starting to focus on prevention for 2 main reasons: increase quality of life and reduce long-term healthcare costs.

For example, in Finland public tobacco smoking is(was?) considered a public health issue. The government got actively involved to reduce consumption and this resulted in better overall outcomes in their healthcare systems for diseases caused or exacerbated by smoking.

IMO, obesity is a problem affecting the healthcare systems of many developed countries (Vietnam is not yet considered a developed country) arguably not at the same levels as in the US. But this again is part of how government chooses to get involved in fixing the healthcare system by enforcing policies or passing laws that help with prevention.

The "metabo law" in Japan appears to have been somewhat successful in preventing obesity. But it probably wouldn't be politically acceptable in the USA.

https://www.theatlantic.com/health/archive/2012/09/big-gover...

Spot on.

My father is getting old and our healthcare system has done a great job at keeping him alive while he can still eat shit loads of pizza, drink beer and be a 80lbs overweight.

All this medication and treatment he takes is not just to keep him alive but to keep him alive without having to change a single bad habit.

There is so much wrong with the US healthcare system, from physical therapy centers, ambulance companies and prosthetists, to hospitals and surgery centers, to doctors, to insurance companies, to drug companies, to laws, patents, and the US government. Maybe you don't know the system well?

> Another point is that US healthcare is considered the most expensive and worst-performing in terms of outcomes compared to the other developed countries.

In what way is it the worst-performing? I mean, what are the outcomes that are measured to determine its performance?

Yes, healthcare is a lot cheaper in Europe (even if your employer wouldn't pay their part) compared to the US, but the quality of the service is rather poor with very long waiting lists, stubborn doctors who don't want to perform certain tests (as simple as a Vitamin D or a testosterone test) so they don't have to justify it to the insurance.

> but the quality of the service is rather poor with very long waiting lists, stubborn doctors who don't want to perform certain tests (as simple as a Vitamin D or a testosterone test) so they don't have to justify it to the insurance.

That's exactly like US healthcare if you aren't either a wealthy private-pay client or someone with top-flight private insurance; we just pay twice as large a share of GDP and even a higher multiple per capita to have the same normal experience and many more people uninsured than any other developed economy (and we've only recently through the ACA, gotten it so the that your top-flight insurance plan wouldn't look to retroactively cancel your insurance when you got an expensive-to-treat condition, leaving you uninsured and uninsurable.)

> leaving you uninsured and uninsurable.

This one is pretty messed up indeed. What's the purpose of being insured to begin with if it will fuck you over when you need the insurance?

It has not been true for 10+ years.

Affordable Care Act (ACA) outlawed denying insurance to anyone, regardless of how much their future healthcare expenses will be.

It is one of the reasons that everyone complained about ACA increasing health insurance costs - it had to because more people were getting more healthcare.

ACA also outlaws pricing insurance on anything other than age, smoking status, and location. Even the pricing due to age is capped so that the premium for the oldest (riskiest) age is only allowed to be 3x the young age premium.

ACA also implemented out of pocket maximum for in network care, so that there is a maximum cost per calendar year you would be responsible for. Recent law that went into effect Jan 1, 2022, extends this out of pocket maximum to all healthcare providers in the US if it is an emergency.

Finally, ACA also instructed an appeal process if you think the insurance company is denying payment for treatment justified with evidence:

https://www.healthcare.gov/appeal-insurance-company-decision...

> That's exactly like US healthcare if you aren't either a wealthy private-pay client or someone with top-flight private insurance;

My local very not fancy clinic schedules within 48 hours (within 8 hours if you pay the $10 convenience fee) and has always done a very good job.

Do you have any citation that US healthcare typically has very long waits?

It's a consistent finding, usually measured in some form of healthcare outcomes per dollar spent.

Here's a recent report that measures: - Access to Care - Care Process - Administrative Efficiency - Equity - Healthcare Outcomes.

US comes last in all but Care Process among developed countries. https://www.commonwealthfund.org/publications/fund-reports/2...

Unless there are some clear symptoms of deficiency, vitamin D or testosterone tests aren't usually justified from an evidence based medicine perspective. Insurance companies usually won't cover such tests unless the patient meets their medical necessity criteria. However in many countries you can order such lab tests yourself and pay for them out of pocket.

As a separate issue, there is now significant clinical evidence that hypovitaminosis D is a major risk factor for COVID-19. So I hope that medical guidelines will be updated to make those tests a routine part of preventive care screening, in the same way that we test for lipids and blood glucose levels.

https://vitamin-d-covid.shotwell.ca/

>the quality of the service is rather poor with very long waiting lists

I can get in to see an Urgent Care doctor in any major US city within 30 minutes of walking in the door. If it's not urgent, who cares what the wait is?

> Which doesn't really fit the view that less government involvement results in a more efficient system

The government may not pay for the actual service but there is huge government involvement and mountains of regulations to climb.

I would argue some of those regulations are moat building explicitly to ensure healthcare as a commodity.

You hit the nail on the head.

> So you basically get the worst performing being also the most expensive. Which doesn't really fit the view that less government involvement results in a more efficient system. Well, I guess it is more efficient if the expected outcome is a larger profit for different private companies and middlemen and not the well-being of the rest of the population.

Healthcare and Big Pharma have captured regulators at various federal health institutions. The mission is maximizing profit outcomes not health outcomes.

US Healthcare is not the 'worst performing', that's a perennial clickbait theme.

Health issues are bad in the US, and people use that as 'evidence' for quality of the Healthcare system, but that's not fair.

People shooting each other, not eating well or exercising, isn't so much a function of the US Healthcare system.

The US system is probably the most economically inefficient, but that's also expected at the highest end of quality.

The US has most of the best quality systems in the world, it's just expensive and messed up financially, but the quality itself is something to behold.

While I share your reservations about 'privately backed things' - for example, advertising arcane drugs in the US is ridiculous, this whole 'Ask Your Doctor' is an excuse for pushy patients to 'prescribe themselves' over the will of tired Doctors caving in ...

... that said, Theranos is the opposite example. If it had worked, it would have been because of VC backing and it would have been very beneficial to people. And there are many things like that.

Like anything, it's complicated, and we need nuanced thinking about it.

We probably should welcome a lot more VC spend, think of ways to empower doctors with the deluge of information, to empower individuals but at the same time get them to understand that they are not medical professionals and shouldn't be self-diagnosing, etc..

There are huge variations in performance depending on what metric you look at. The US is at or near the top in 5-year survival rates for most types of cancer.

It's not all bad to spend more - consider the extra hospital capacity that so far has helped absorb COVID shock impacts better than neighboring Canada. Hopefully we don't hit the limit of that, even, though. https://www.bloomberg.com/news/articles/2022-01-06/hospital-...

US health outcomes also aren't so bad for those who have affordable access to the system, as I understand it.

But the spending is something to keep in mind when anti-healthcare-for-all advocates say things like "do you want to have to wait months for procedures like in Canada" - if the US continues to spend more money per person, there's no reason it can't continue to have more capacity.

idk canada has 806 covid deaths per 1M and usa has 2573, it's not exactly screaming 'success story' to me.

Surely you aren't suggesting that having more hospital beds per capita in the US is causing more deaths? Capacity is hardly the only factor in how Covid is hitting the population (and having more hospital capacity reducing pressure to lock things down will itself affect the rate of spread).

For instance, per https://ourworldindata.org/grapher/total-covid-cases-deaths-... Canada has seen 66K cases per million and 807 deaths per 1M cumulatively. The US is at 180K and 2515. Slightly different numbers than yours, but close enough. Deaths/cases to date is very similar, 1.4% in US and 1.2% in Canada. So the difference in total deaths is largely policy and behavioral, the aggregate policy across the US has largely been one of "at this point we can't eradicate it so we need to live with it as best we can" where even the liberal US states remain quite open compared to initially in 2020 in the face of recent surges. Whether or not that's the right policy is separate from whether or not that policy would've even been realistic without as much health care capacity.

no im suggesting that 'yolo lol we have more beds' is meaningless if u end up with worse outcomes. and let me be clear that 66k per 1M cases and 807 deaths per 1M is better than 180K per 1M And 2515 per 1M.

You won't really know which is better until 2025, 2030, sometime like that for total deaths due to COVID numbers. Canada is hardly out of the woods. Push the date to 2040, 2050 if you look at things like what were the long-term impacts on different policies on people who didn't die of COVID.

You still aren't engaging with the point under discussion, though, which has become publicized due to COVID but exists independently of it. Spending more on healthcare contributes to having an overall better health care system, but the US suffers due to large problems of access and distribution. Regardless of payment structure, I would argue in favor of continuing to spend more on health care than other nations; we have the money, it's a good use of it.

> Well, I guess it is more efficient if the expected outcome is a larger profit for different private companies and middlemen and not the well-being of the rest of the population.

My favorite example of this is when I had to get an MRI. The lab imaging said it would be $800 if they billed it through insurance, or it would be $600 to just pay for it directly out of pocket. So the cost of having to deal with my insurance (which always advertises the "discounts" they negotiate and the "lowest cost") was actually more than what the insurance would actually cover.

This is always extra annoying because it might be a false savings to pay cash there. Let's say your MRI says you need a $5500 procedure, and your plan's deductible is $3000, 90% coverage after, and out of pocket max is $6000, and there's nothing else you've spent on the plan this year.

Pay $800 for MRI with insurance, you'll then pay $2200 for the procedure to hit the deductible + 10% of the remaining $3300, so $2530 total for the procedure. $3330 total for the year between the two things.

Pay $600 cash for MRI, you'll then pay $3000 for the procedure to hit the deductible, and 10% of the remaining $2000, so $3200 total for the procedure. Now you've paid $3800 total, so you've spent $470 more despite the MRI being "cheaper"!

If you have other expenses so your out of pocket max comes into play, that difference approaches the full $600.

Do you folks have to perform these calculations every time someone in your family gets sick or injured?

Usually no, most people just use doctor-suggested or in-insurance-network providers and billing because it's easier than calling multiple places and hyper-optimizing on the math.

But we have to pay the bills after the insurance company does the calculation, which often results in annoying surprises.

The better your insurance, the less nasty surprises, which largely in the US means "the better you're paid, the less you have to pay out of pocket for health expenses" which is a nasty thing because then the people most likely to be hit with a big bill are those who can least afford it.

Yes, unfortunately so. You have to play the stupid game of "expected medical expenses".

For example, am I going to do something major like have a baby this year. Then yes it probably makes more sense to get me to my deductible and pay the extra money to go with insurance. Or if you (or someone on your plan) has an ongoing medical issue where you know you will meet your deductible. Or on the flip side, I met my deductible one year and was going to physical therapy. Since I met my deductible the physical therapy visits were cheap, but going in to the next calendar year now my deductible reset. Could I have used more PT? Maybe, but the visits were about to be 5x more expensive.

But "expected medical expenses" is just the dumbest thing.

No. I know that my total expense in a given year will never exceed $X (Premium + out-of-pocket max). Worrying about every single transaction is not worth it.

Yes, so. The typical American response to that is: "the government controls everything. Let the free market do its job!"

And then wonder why they get shit care for a huge price BUT swith nice marketing and a smiling "health dealer" getting you a 0% lease... oh sorry, we got you confused with a Chevvy!

And also, "we have the best care in the world because our docs are better selected". This one never fails to make me laugh, as a swiss MD

Yes, that's the response, but healthcare in America is far from a free market. It's more a circle of sloppy middlemen, in much the same way that I hear privatized passenger rail in the UK described.

in 2019 I would have agreed with you. In iceland you will not be charged for cancer treatment, but the medical costs of getting a long term illness in Iceland are not trivial. Add that to loss of income and the situation for many chronically ill is actually so terrible that laughing at the US is not something Iceland can afford. And covid has painfully displayed exactly how poorly managed the hospitals are and how starved the health care system really is. The equivalent of a bus accident will put the healthcare system on its knees or 80 people needing intensive care.

of course Iceland has more hospital beds than 80, but it cannot handle a disease that may put 80 people in ICU ( not counting ventialtion here at all, just intensive care ).

I think many in Iceland, myself included, are a bit in shock of exactly how poorly managed and starved the health care system is.

Up until 2019 I laughed at the dumb americans and their awful health care, man did I get my sit-upon whopped in the past 2 years.

Icelands is so bad that we are regularily filling hospital break rooms and garages with patients. THat is on a normal non-influenze season. Let alone sars-cov-2 introduction.

I suspect Canada is having a similar realization as we are. Free care in all its honour. Starved free care, heh...... Shame on us. Really. Shame on us.

Another point is that US healthcare is considered the most expensive and worst-performing in terms of outcomes compared to the other developed countries.

Not that your thesis isn't correct but be careful there. You're combining the cost of care for the people who get care with an average outcome that includes people who don't get care. The quality of care for Americans who can afford care is excellent.

> You're combining the cost of care for the people who get care with an average outcome that includes people who don't get care.

Well that's the point, I think everybody should be taken into account in order to paint a comprehensive picture of the quality of the system at country level. The resulting stats reflect the health of a society as a whole not just of the part that can afford it. Not having universal healthcare is still part of the system, even if we don't like it.

I get it that health outcomes of those left out are probably very different. But leaving those numbers out of the comparison doesn't really work with these type of statistics.

At that point how could you compare it to the other countries that take everyone into consideration? The stats are GDP/capita percentages, should I remove the ones who can't afford healthcare from the GDP stats as well to not skew the ratio? I don't really like where I might end up taking this route.

I don't have any experience with US healthcare and I'm sure the quality of the services is really high, but the fact that you need to afford basic healthcare and it's not guaranteed by the government for everyone makes me see it as closer to just another "consumer product" compared to other systems.

Yes, but anyone in US that has healthcare in US and reads the paragraph above will come to a conclusion along the lines of 'Wait, my experience wasn't bad; what am I missing?'. As a result, you may end up making an opposite of the point you are trying to make.

When it comes to healthcare in the US, a lot of people who can afford it don't care about people who can't afford it. Hence the common belief by the middle class that the US has the best healthcare in the world. (That's before you add in a large dose of American exceptionalism.)

That may be the case, but that system is quite poor because it leaves most people without good care.

> the people who get care

There is a sad trend where the small doctors -- who can't survive without group power -- join conglomerates, the conglomerates buy hospitals, and finally the conglomerates close the less performant facilities. You get large states with vast underserved geographies.

The OP headline is we are careening towards a luxury retail arrangement like Trader Joes: they will only have "outlets" in the richest areas. There's no regulation around closing hospitals so this is coming fast. Two in my county closed this year and I am far from rural.

Well that's the thing, for profit health care requires making cuts to maintain profit. That's why it's a bad idea.

You can't just say you can't close this hospital, you have to find a way to pay the bills on it.

> The quality of care for Americans who can afford care is excellent.

As a Canadian who knows many Americans, works for a US company and has extended US family, this is not quite true.

Most Americans "who can afford care", maximum 70%, have access to medical care that is on par with Canadian health care, but is fraught with peril; "booby traps" such as out of network costs, high co-pay fees that can bankrupt, surprise billing (though 2022 is starting to deal with that). Care may be excellent, but losing your house if you get cancer seems unnecessary.

A few percent of Americans (the rich and the very well insured; FANNG/MAMAA, investment bank employees, etc.) have access to the possibly best health care in the world.

20% of Americans are uninsured or under-insured and have access to the worst healthcare in the G20.

I think it's strange to want to only include the first two categories in the outcome calculation. Strange may not be the right word here ...

Also, this idea that Elon Musk is going to wait in line to get a checkup is ridiculous. Those who can afford it will always be able to buy premium care. But we have millions of people who are waiting to be financially ruined by an act of God.

The very rich in Canada mostly go to the US for extraordinary health care (surgeries etc.), the very rich will always find a way to skip the line.

I’m interested in this worst performing stat. By what measure? Because I’ve always read that when controlling for the relative poor health of the us population regarding diseases related to poor eating and exercise habits, the US was a top performer for heart and cancer treatments.

I am pushing 50 years of age and one constant in my life is people shitting on the US healthcare system.

I have family in Canada with family members the same age on both sides.

Canada is great if you are a healthy broke college student.

No one in their right mind would ever pick Canadian health care over the US though if you are 60+.

There is no way you would rather have cancer in a country with free health care.

"There is no way you would rather have cancer in a country with free health care."

Unless you can't afford for-profit healthcare. Then any sane person would 100% prefer one of the fifty or so developed nations with free healthcare.

also safe to say that a vast majority of ppl on the planet can't afford for-profit cancer treatment

At the very least, by billing transparency and paperwork load. Even Americans who are happy with their healthcare hate that.

So if you imagine that USA was healthy then health outcomes look great?

> Another point is that US healthcare is considered the most expensive and worst-performing in terms of outcomes compared to the other developed countries.

Considered by whom?

But isn't it the government that allows the healthcare system to hold you financially accountable for opaque and arbitrary bills?

>>e most expensive and worst-performing in terms of outcomes compared to the other developed countries.

That is only true if you cherry pick statics that over sample for life style choices, and under sample of actual health care.

If you look at statics that are directly attributable to the care provided, not the life style choices of the patients then the US Healthcare system is far better than any other nation

I'm curious how you can suggest the US government spends the most money in the world, by far, on healthcare and the simultaneously suggest there's less government involvement.

The government is involved in every step of American healthcare. As you can imagine of a system that gets all of its funding thru companies completely overseen by regulatory bodies or thru social programs.

Compared to a single-payer socialized system, this is less involvement - even if it is a lot of involvent.

by what metric?

I didn't really suggest that the US Government spends money on healthcare, I was merely quoting the article: "Health care consumes 18% of GDP in America"

Please note that the wording implies that 18% of GDP is spent on health care overall not that the US Government is spending all that money out of its pocket directly on yearly budgets. The way I understand it is that it includes both money spent by public and private actors for all health related service.

I see this type of stat a warning that something might be dysfunctional within the system, and it's the government's job to get to the bottom of it.

There is some crazy amnesia here about the US healthcare system. Some 40% of the US are already covered through Medicaid/Medicare - "socialism" is long here!

Much like US Defense spending subsidizes the rest of the globe, US for-profit healthcare spending spurs massive investment in pharma and biotech research that benefits the rest of the world. Are there inefficiencies and waste? Yes. But outcomes overall are much better for it.

i mean, why waste effort on curing ppl that contribute to global overpopulation.

The us healthcare system is not capitalistic. If I get my flu shot I have no idea how much it cost my insurance company. CVS, Walgreens, Safeway all the same to me for a flu shot.

If instead we use health insurance like home insurance for unforseen major issues, and had price transparency. Then prices would go down as people would shop around.

What you're describing is the lack of a normal market, and even that only applies if you have insurance. For the millions of people without insurance, they do indeed shop around. It is very much a capitalist system, since the ownership (& control) of the system is not in the hands of the workers - in insurance companies, hospitals, pharma, etc - but in the hands of wealthy shareholders.

To be fair, I suspect your definition of capitalism is very different from mine...

Those without insurance are quoted prices different than what insurance companies pay.

Even getting a price quote is often impossible.

Government should enforce the same pricing to all parties or allow everyone to get the same prices Medicare negotiated.

> So you basically get the worst performing being also the most expensive. Which doesn't really fit the view that less government involvement results in a more efficient system.

The US healthcare is an example of the government being massively over-involved and creating massive inefficiencies.

Counter point: the NHS in the UK has more government involvement than the US healthcare system.

The NHS (despite fairly extreme under-funding) has better health outcomes for patients than in the US.

“Better outcomes” needs more detail:

Medical bankruptcies per year: ~200k in US, ~0 in UK. Caveat: bankruptcies often don’t have one clear root cause, the other ~600k bankruptcies per year in the US may or may not have an aspect of healthcare costs.

Cost of triple bypass heart surgery: US: $110,000, UK: £8,500 (paid by the taxpayer, not by the patient at the point of care - free for them). (P.s. private healthcare is available in the UK too - the procedure costs around £20,000 privately, payable by the patient or their insurance)

Life expectancy… you get the idea.

> NHS (despite fairly extreme under-funding) has better health outcomes for patients than in the US

The American system’s problem is exclusion, not quality of care. If you get care in America, your outcomes are among the best in the world.

Yeah you’re right, s/patients/citizens/

Someone told me this a few years back and it stuck with me.

"American healthcare is the best in the world like sportscars- Ferrari, Lamborghini, BMW, Bugatti, etc. are the best cars in the world. Surely they both are the bests in the world- but only for the small percentage of people that can actually afford them."

This is sad.

(Many, including me, wouldn't buy a sportscar even if they could afford one, and sportscars aren't the "best" in their opinion. But this comparison drives the point home.)

I would argue a care that is beyond my affordability is bad quality of care.

I think you're mostly right. Although there are exceptions. Consider to opioid crisis. That's a case where profit motive directly leads to poorer quality care.

Regardless of that, high quality care isn't much good if you can't access it.

The US government is involved in ways that make it inefficient. For example, I don't get to choose my insurance, the government has ensured that instead my company does for me. While I can in theory get insurance elsewhere I lose a large subsidy in doing so, no insurance I can buy can possibly be a better deal for me, even the company insurance is bad.

The incentives for insurance are to ensure that I don't quit, not that it is good healthcare or a good deal.

  > I don't get to choose my insurance, the government has ensured that instead my company does for me.

how did that happen?

I don't know what my company pays for my insurance, but if I opt out of that insurance that money is lost. I know I pay $100/month (not the real number but close), and plans on the government health market start at $800/month (after the tax credit), plus by using the company plan they kick in another $100/month in a HSA match, and HSA money is a tax advantaged investment (AFAIK you can only get in an HSA from your employer). So by using my companies insurance it is like getting an additional $800/month in income (some of which is invested!).

I didn't look into details of the insurance market plans, but there were 40 different plans available there for me to choose from (as opposed to the 2 my companies gives me). I suspect that something similar to my work plan is more expensive than the one I listed above. I also suspect that if I was to look at all 40 plans I would choose something that wasn't not similar to the choices I have now. However with the amount of money I'd lose it isn't worth my time to examine my options.

WWII Wage Freezes is where it started, the government regulated that employers could not raise wages so employers started offering services to attract talent, in those days it was having a doctor on site at the factory, or office that employees and there families could see for free.

years later that transitioned to comprehensive benefits packages

> the government has ensured that instead my company does for me.

How does the government ensure that?

Tax law

> The NHS (despite fairly extreme under-funding) has better health outcomes for patients than in the US.

It really isn't underfunded. It's grossly inefficient, which is what happens to most if not all publicly funded bodies. It is actually ok to criticise the NHS organization.

They're a monopsony, so actually get absolutely gouged by the pharmaceutical companies. They (currently?) refused to recycle crutches, plastic casts and so on. They'll use their own (hospital pharmacy) drugs if you get admitted, and then discharge you with them, even if you have your own dosette box and refuse to take theirs back. My father was discharged with something in the region of £3-5000 pounds of drugs that we threw away on several occasions.

As a percentage of GDP, it's roughly the same as most other western countries.

Of most interest though is figure 3 in [2] - 80% of UK (NHS) funding came from public money, i.e. tax, and 20% from private money (e.g. insurance). For the US, it's 50% public money (tax), and 50% private money. I'm not sure how much more money the UK general public really thinks the UK government can come up with to keep giving the NHS "more!" money. There's a limit to how much people can be taxed. And compound interest (increase the NHS by 10% per annum!!) means we'd spend all our GDP on the NHS at some point rather quickly.

[1] https://www.statista.com/statistics/317708/healthcare-expend...

[2] https://www.ons.gov.uk/peoplepopulationandcommunity/healthan...

>They're a monopsony, so actually get absolutely gouged by the pharmaceutical companies.

You've got that exactly back to front. NHS's immense buying power lets them negotiate lower prices for drugs, exactly as medicare used to (before pharma lobbying stripped them of that power).

Pretty much any trade deal negotiations with the US involve the UK being asked to dial down NHS buying power on behalf of pharmas by making hospitals responsible for purchasing.

>As a percentage of GDP, it's roughly the same as most other western countries.

50% of the US - not because the UK is especially efficient but because the US healthcare is essentially legalized extortion.

>I'm not sure how much more money the UK general public really thinks the UK government can come up with to keep giving the NHS "more!" money. There's a limit to how much people can be taxed.

The UK public adores the NHS and is one of the few things polls say that people would be happy to fund with tax raises. It's very very popular. In no small part because we can see how much of a racket the US is.

The ruling party does not like it, however, which is why it has been slowly degrading service over time as preparation for full privatization in 10-15 years. Part of this has been done by handing over chunks of the NHS to be run privately and incompetently by friends and donors of the party. The problems caused by this backdoor privatization will later be "fixed" with privatization. Whatever the problem, privatization will forever be the answer.

The tories argued for an American style healthcare system in 1948 and while they give tacit acknowledgement of the popularity of the NHS their views havent changed (Christopher Chope is a good bellwether of their more unsightly "hidden" views), they still want a US style system.

> You've got that exactly back to front. NHS's immense buying power lets them negotiate lower prices for drugs, exactly as medicare used to (before pharma lobbying stripped them of that power).

In principle, you're correct. In practice the fact that they're the only buyer, means in many cases that they pay at whatever a drugs company sells at since there's no "but company X is only paying Y, why are you charging us Z" as a comparison, particularly in the case of non-generics.

> The UK public adores the NHS and is one of the few things polls say that people would be happy to fund with tax raises.

And that was exactly my point. The UK public might "adore" the NHS, but they have a pretty poor understanding of how it is funded. If the government kept funding the NHS by an extra X percent every year, we run out of public funds.

> The ruling party does not like it, however, which is why it has been slowly degrading service over time as preparation for full privatization in 10-15 years.

The ruling party, being the Tories, that have been "in charge" of the NHS for the majority of its 70 or so years? And who on earth would buy a loss making healthcare system that's funded to the tune of a billion or so a week? Apple?

>> If the government kept funding the NHS by an extra X percent every year, we run out of public funds

Lets say the uk gov allocated 10x to the nhs in the next budget - to be clear, this would put just nhs spending at more than total govt income for the year. If this were a company we’re talking about, they’d be insolvent.

But we’re talking about a govt with a sovereign currency. So what would happen in this scenario? It doesn’t go bankrupt…

How is money created? What is fractional reserve lending? How is money destroyed? Can a country issue a fiat currency without an associated public debt? Or to put that last bit another way - could you settle your tax bill in GBP if there was £0 public debt?

The govt has rules for borrowing from the capital market, and that's (mostly?) for national infrastructure projects. It will never (hopefully) borrow from the capital markets to fund the NHS, and then continually pay it off.

That leaves tax or private money to fund the NHS, and we can't tax people much more. So in your comment "how is the money created?" Answer, tax, and there's a maximum limit to how much we can fund the NHS.

>> The govt has rules for borrowing from the capital market

Yeah it does. The UK govt has had 6 different sets of rules in only the past 10 years.

The current rules followed by Rishi Sunak are actively opposed to what you say - he’s been celebrating beating borrowing forecasts of the OBR by £26bn, and he makes a big song and dance any time he can stating excessive public borrowing is immoral. He found the magic money tree instead…

The scope of quantitative easing has increased massively since it was introduced. On top of this, the bank of england does not publish a report on which govt bonds have matured - but we know some have already without having been sold.

So, the govt borrowed from the govt (bank of england bought out uk govt bonds held by non govt entities) then held them to maturity (so the govt paid the govt back), while remitting the coupon payments back to the govt. All while we can’t see inside the machine - none of this is available via public reporting.

It’s not quite “printing money” but it definitely qualifies as a magic money tree.

It’s how govt’s corona responses are paid for today and it’s the reason NHS funding is constrained not by tax receipts but by policy, political decision.

>In principle, you're correct. In practice ...

It sounds like you are disputing empirical evidence as well as standard economic theory regarding monopsonies.

>The UK public might "adore" the NHS, but they have a pretty poor understanding of how it is funded.

Not really. It's mostly funded with taxation.

They are not so aware of the corruption going on underneath with taxpayer money.

>If the government kept funding the NHS by an extra X percent

"X" percent? Is this a serious point? That "X" is demanded by the public and X is also too costly? Where "X" is undefined?

What is even the point of that sentence?

>The ruling party, being the Tories, that have been "in charge" of the NHS for the majority of its 70 or so years?

A) If it is a majority of years it's a fairly slim majority and B) they werent there when it was set up.

>And who on earth would buy a loss making healthcare system

Somebody who knew that they could start charging either customers or government through the nose and make it fantastically profitable.

Richard Branson is one example (Virgin Healthcare sucked £2 billion out of NHS coffers, yay for crony capitalism).

> It sounds like you are disputing empirical evidence as well as standard economic theory regarding monopsonies.

When there are multiple sellers of generic drugs, you're correct. When there is one seller of a non-generic, life saving drug with no alternative, the NHS is going to pay whatever the one seller, which by definition is a monopoly, is going to charge. [1]

> What is even the point of that sentence?

That we cannot keep increasing NHS funding exponentially. Some people seem to find that fact hard to grasp - there's an upper limit. Another commenter talks about the UK raising debt to fund the NHS. Thank goodness there's a set of rules for government borrowing in the capital markets.

> A) If it is a majority of years it's a fairly slim majority and B) they werent there when it was set up.

Both parties campaigned for the NHS in the 1940s. Labour won. Blair, in power for over a decade promised to "fix the NHS" whatever that meant, but he didn't do it. Thatcher/Cameron/Johnson, all in charge for 2 decades or so, still haven't "sold it off".

> Somebody who knew that they could start charging either customers or government through the nose and make it fantastically profitable.

Except it will never happen. The government would not introduce a commensurate tax cut since they're no longer funding the NHS, so your cost of living would go up, and even in the UK, I think people would get rather upset.

> Branson is one example (Virgin Healthcare sucked £2 billion out of NHS coffers, yay for crony capitalism).

Did he really? Evidence? 2 billion of private money paid by companies into Virgin Healthcare, sure. But did he take £2bn from the NHS?

> They are not so aware of the corruption going on underneath with taxpayer money.

What corruption? Surely the police should be involved if there's true corruption?

I won't defend the NHS. I'll defend the staff that treated my father, but the organization itself needs fixing.

[1] https://www.bmj.com/content/368/bmj.l4627

>When there are multiple sellers of generic drugs, you're correct. When there is one seller of a non-generic, life saving drug with no alternative, the NHS is going to pay whatever the one seller, which by definition is a monopoly, is going to charge.

This is incorrect. If the price is too high they refuse, depriving the company of all income. This has been done for certain cancer drugs.

Even if they dont refuse their pricing power lets them beat down prices.

>That we cannot keep increasing NHS funding exponentially

It's barely even increasing in line with inflation.

>Some people seem to find that fact hard

They really dont.

>Both parties campaigned for the NHS in the 1940s.

This is provably false. The tories wanted an insurance based system rather than the system we have modeled on the soviet union.

I think Im gonna leave this discussion here. We clearly dont live in the same plane of reality.

>> It's grossly inefficient

I think it’s more nuanced than that. There’s inefficiencies for sure but we need perspective to assess them against.

E.g. A triple heart bypass, the most common major heart surgery in the world, costs:

Approx 110k USD in the US system

Approx 50k EUR (56k USD) in Germany

And just under 9k GBP (12k USD) in the UK

>> I'm not sure how much more money the UK general public really thinks the UK government can come up with to keep giving the NHS "more!" money

Can you clarify what you mean by “come up with” in the context of the GBP which is a fiat currency?

>I'm not sure how much more money the UK general public really thinks the UK government can come up with to keep giving the NHS "more!" money. There's a limit to how much people can be taxed.

Relevant: Private Eye on "24 Hours to Save the NHS": (<https://twitter.com/KulganofCrydee/status/833654730849136641>)

"better outcomes" when talking about health should be things like 5 year cancer Survival rates, Wait time for Surgery, Wait time for Heart Stints, 5 year heart Attack Survival rates, Wait time for Specialist Care, etc

Not bankruptcy statics, or costs

You’re assuming universal access to healthcare then, which is not the case.

What is the 5 year survival rate for someone who cannot afford cancer care?

I am not assuming anything at all, people that attempt to inject affordability into the care debate are doing so for disingenuous reasons.

The question of affordability is different from the question of quality care, we can solve the affordability problem with out having to lower the over all standard of care which is what you are advocating for, the bringing down of the overall quality of care in an attempt to increase accessibility of care. Ironically putting that faith in the US Federal Government will only result in 1 of those happening.

>> people that attempt to inject affordability into the care debate are doing so for disingenuous reasons

What exactly is disingenuous about wanting more people to live longer with higher “quality of life” for less overall spend on healthcare? You can’t achieve this without resolving the affordability issues.

>> which is what you are advocating for, the bringing down of the overall quality of care

With all due respect, you’ve made that up to fit with your world view. It’s certainly not something i’ve advocated for.

Those triple heart bypass operations i started the thread with - the 10x more expensive US procedure results in 3 year shorter life expectency post operation.

It costs more, and it’s not as good a result?

(I am being slightly disingenuous at this point - the reason the US outcomes are poorer despite being 10x more expensive for the same operation are due to differences in the health of the average patient - in the UK because healthcare is free at the point of access, there tend to be earlier interventions, in the US there is a marked difference in severity of presentation - ostensibly people wait longer until they’re really unwell before accessing healthcare)

To add a little nuance, look at the survival for various cancers in the NHS vs the US. Cancer care for example is measurably better in the US in terms of overall survival, early detection, and access to drugs. You "get what you pay for" when it comes to highly specialized care.

>> look at the survival for various cancers in the NHS vs the US

The figures i can find ignore people who can’t afford to become cancer patients in the US - there’s an unknown, but suspected large, number of people cut out of the figures in the US making that stat unfairly stacked vs UK (where everyone regardless of affordability gets access). The people who can’t afford in the US are typicslly the ones more pre-disposed to adverse outcomes in that statistic.

As opposed to what, the Singaporean system where you get sent to jail for charging above government mandated price caps?

American healthcare has the least involved government of any first world country.

Only an overly credulous interpretation of Koch-style market-knows-best propaganda would make you think that the "level" of government involvement was the root cause of its problems.

Less involved, more corrupt. It's over-involved because it's corrupt. Giving the government more power will only increase corruption.

> Only an overly credulous interpretation of Koch-style market-knows-best propaganda would make you think that the "level" of government involvement was the root cause of its problems.

Not an appropriate tone for HN discussion.

I guess my initial phrase is a bit superficial, from my European-centric point of view the US government seems less interested/involved in the health of their healthcare system compared to what I'm seeing in europe.

The point I was trying to make is that government involvement is needed to make sure that the right incentives are in place at all times for all involved actors (public or private). And if the system becomes dysfunctional or is abused it's the government's job to fix it.

Most of the countries that have universal healthcare in Europe have their own take on how it should be done: - France has state funded insurance and (mostly) state funded services - Switzerland private insurance and private/public services

Two totally different takes with arguably very similar (good) results.

The goal of government involvement should be to make sure everyone has access to basic healthcare and avoid double standards and abuse.

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