Hacker News Reader

Comment by thr0wawayf00 | Hacker News Reader

As long as the public isn't interested in seriously considering alternative systems like Medicare for All, nothing is going to change.

There's a reason that private equity has consumed our healthcare sector: it's incredibly lucrative and inherently disadvantages both the patient and provider through vast amounts of process.

Pretty much every healthcare startup in the US is just trying to figure out how to insert itself into this endless bureaucracy and draw money out of the system while trying to add value in some way.

View on HN

Public support isn't the question. The public does support Medicare For All[1] but that doesn't matter given the election and decision making process of congress - essentially that it's controlled by forces that profit from the present system.

https://morningconsult.com/2021/03/24/medicare-for-all-publi...

This 100%. You have to flush out the reps who won’t vote for it regardless of constituent support and desire. Determine how many you need to replace, identify the weakest incumbents/most likely races to win, select challengers, fund them, and you hopefully unfuck US healthcare in the end. Maybe you need a few candidates to pull a “reverse Sinema”; run as a Republican, win, and then turncoat and vote for Medicare for All (with the understanding you’re probably only serving one term, but who cares if you get the policy done, 1.8 million voters over the age of 55 die every year, you’re just pulling progress forward with some political sacrifice versus waiting for cohort succession). Politics hacking and social engineering at its core.

If you’re not one to wait, the only other option is moving to a better country.

Public support for Medicare for All is going to look much more interesting in a few years when the Medicare trust funds are running out and they have to cut costs by 15% or more, and it’s clear there’s actually a price tag on the proposal.

And then we'll see the corner we've truly painted ourselves into.

I could imagine a scenario where an angry public demands the government take control of hospital finances.

Not that it's necessarily a good thing, but I could see it panning out that way.

Acting like social security or Medicare funding levels are fact of nature rather than a political football is parroting right wing talking points. The social security trust fund has been raided by congress multiple times and if it or the Medicare gets low, they can put that money back.

More broadly, by having a single payer, a reasonable Medicare For All program would in total save Americans vast amounts of money though of course as a program it would have a cost.

Politicans hiding the cost of things is the fact of nature. No proposal for Medicare for All that has ever been floated has ever seen a realistic price tag attached. The trust fund's depletion is no fact of nature, it is merely an occasion when this will become a little clearer to the public.

When this happens, voters will not like what they are being offered quite as much as they do now, when the costs are some distant abstraction; there will be a whole lot more hesitation and skepticism. And if pointing this out is a "right wing talking point" then go ahead and call me Margaret Thatcher.

Sadly politics today is endless arguments about minutiae rather than actually solving problems. The culture wars exist for a reason. The longer we are at each other’s throats the longer the wealthy can reap the rewards of rent seeking behavior.

Medicare for All can't function well as a single payer system - single payer doesn't work because it kills off the benefit of market-competitive forces; in single payer systems there are gatekeepers who decide what's covered, what's not covered, who might be eligible and what the criteria for them to be eligible is - which all acts as a single point of failure.

I like Andre Yang's proposal - where you allow private insurance but you also have a government offering to compete - both the government option and private options acting as counterweights against the other in terms of competitive forces.

This has the unfortunate failure mode where the well-off, powerful or influential get much better private insurance, which means that no one with means is advocating for the quality of the public option, so it declines or becomes uncompetitive in marketplace bidding.

Private insurance alongside public could work if it followed a strict "school-voucher" model, i.e. it gets the same funding per-head that the public option does and the customers have to show means to self-insure for any coverage shortfalls vs. the public option.

There are quite a few countries that do not have single-payer and do just fine. According to the book The Healing of America, these include France, Germany, and Japan, all of which get top-ranked results at much lower cost. The key difference is that the government sets the price list for all services.

That would be a big change for the US, but not as big as nationalizing the entire industry.

"doing fine" is a pretty bold claim. I doubt there is a healthcare system without issues. Germany is changing a lot, and not for the better, because the system was not really sustainable as it was.

Well ok, "doing among the best in the world, as of the book's publication." If our standard is perfection then nobody measures up.

Thing is, we didn't have socialized medicine in say the 1970s, and I don't remember things being this bad or regulated. What happened?

Maybe just "time" happened? It takes time for the rot to properly develop.

» Thing is, we didn't have socialized medicine in say the 1970s, and I don't remember things being this bad or regulated. What happened?

Or even more simply, we grew up. I was born in the late eighties. I was simply too young to understand that the civil war was not about states' rights. It was about slavery. I thought adults knew everything and as I became an adult I realized I knew nothing.

That or a lot of what was previously swept under the carpet or dog whistled is now out in the open.

Back to the topic though, I agree with you Probably the easiest explanation is healthcare is now a bigger slice of a bigger pie about 20% of a USD 20T GDP iirc. There is simply too much money to be made here. There is only so much investment opportunity that has any good return so smart money will chase anything that resembles guaranteed returns.

Thoughts?

EMTALA was passed under the Reagan administration. This forced hospitals to treat the uninsured, but it provided no funding to pay for those treatments. So the uninsured who don't pay are subsidized by high costs to the insured who do pay. In the 1970's, hospitals would just let the uninsured die in the parking lot / street.

So that's the change.

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

"This forced hospitals to treat the uninsured, but it provided no funding to pay for those treatments. So the uninsured who don't pay are subsidized by high costs to the insured who do pay. "

They are way overcompensating for this. I think it's just a BS excuse like pharmaceuticals having to be outrageously expensive in the US because other countries are negotiating better prices. I have read some studies where they concluded that the losses through uninsured people aren't really that high. They are only high on paper because they account for them with their chargemaster prices which are way higher than what they would get from insured people.

Greed happened. Hospitals consolidated and bought up small practices.

There are a ton of reasons why, but here are a couple of the big ones.

The US is still at the forefront of medical research and technology development in the world. However, many other countries won't pay "market" rates for newer technology developed here at home, so companies often overcharge domestically as a way to recoup revenue they can't collect in other places. Note that American hospitals (particularly newer ones) tend to be obsessed with having state-of-the-art technology, and they're damn sure gonna get paid for that.

Another major factor driving healthcare costs is the increasing barriers to access for millions of people. Lots of folks don't realize this, but the US already has a quasi-socialized healthcare system mandated through Federal law. Basically, it's illegal for hospitals to turn ER patients away that cannot prove ability to pay, so folks without insurance often come to the ER for routine medical treatment because its the only way they can be seen, and they know the hospital isn't going to chase them down for their bill because they can't pay for it anyway. Who winds up eating those extra costs? Folks with insurance. I used to work in an ER and I saw this happen all the time.

Do you have any data proving those points? Both are highly questionable from economic PoV. USA is not doing the majority of research, for sure (e.g.EU does a lot too), and it’s not that expensive. Besides that, drugs and equipment are not the only cost drivers. In other countries those who cannot pay for the insurance get it from the taxpayer money, basically the same redistribution just called differently. This does not explain why in USA costs are much higher than in countries where redistribution is codified in the law.

The data on biotech and pharmaceutical patents per nation is easy to look up and firmly supports the parent posters point- Google is your friend here.

Your second point is a false equivalency as from a private payor perspective the cost of providing care to the indignant is reflected on their localized hospital bill, not on their federal taxes. In struggling rural/inner city hospitals the majority of payors don't cover the cost of the care received (and that includes medicare/medicaid patients), which means hospital bills will be highest in poor regions despite higher rates of federal coverage/subsidy.

> firmly supports the parent posters point- Google is your friend here.

Well, you need to change your search engine, because DDG could help you finding this report:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866602/

42% of innovations for 40% of GDP of innovating countries isn’t exactly majority. UK and few other countries are more inventive than USA in relative numbers and the rest of the world - more in absolute numbers.

On second point thanks for clarification. So, if I understood it correctly, it means that this redistribution model is inefficient, because it creates two tier insurance system, with hospitals serving as second tier insurance. This even sounds crazy.

The glory days of the semi-welfare state in the US were indeed the 1950s-to-mid-1970s. A lot of those were regulated monopolies - in the case of health care, Blue Shield was a single, private but regulated insurance company owned by hospitals (some portion of which weren't for-profit). The main way Blue Shield was regulated (and it was definitely regulated) was it allowed to maintain complete control of the health insurance market, so that it operated like "single payer" without officially being "socialized medicine". The elimination of this system indeed brought us to the disaster that we're looking at now.

Boomers are old enough now to fuel the growth of medical profiteering. In the 70's 65+ was 10% of the total population and they spent less time in that age bracket before death. Now they're 16% and living longer.

"As long as the public isn't interested in seriously considering alternative systems like Medicare for All, nothing is going to change."

I resent the Democrats and Biden for not embracing Medicare For All. This would be the most straightforward path to a halfway sane system.

Even if they did completely embrace it it still wouldn't be happening. There are plenty of current Democratic Party priorities that are dead on arrival in the Senate.

>dead on arrival in the Senate

Democrats fully control every single committee.

You can pretend like they’re the problem and resent them as much as you want but which 10 Republican senators are going to vote with the Democrats? It’s endlessly frustrating when ~48/50 democrats would vote for something and 0/50 Republicans and people either “both sides” it or inexplicably blame the democrats?

The Democrats supposedly stand for health care reform. They don't have a coherent plan and they aren't even trying. The Republicans are pretty hopeless in that area anyway.

>inexplicably blame the democrats?

For several periods during Obama's first term, his party totally controlled the legislative process. The Senate Democrat caucus had a filibuster-proof majority. They could have passed Medicare for All, Single Payer, immigration "reform" -- all of it. Ask yourselves why they did what they did instead.

They had a short period with 60 senators until Ted Kennedy died, so they had to reconcile in the senate what was already passed in the house — they had 59/60 senators who wanted to pass Obamacare with a Medicare public option but Lieberman refused and again, 0/40 Republicans helped in any way. So we got the ACA, a flawed piece of legislation but one specifically chosen to engender bipartisan support since it was largely based on the free market Romney/Heritage plan from MA.

And then what health care proposals did the republicans pass when they had legislative control to make things better? Literally nothing. Vote after vote to repeal the ACA and “a plan” to replace it that’s been 6 months away from being released for the past decade. It’s insane people refuse to admit this out loud.

>0/40 Republicans helped in any way.

Republicans had no access to even read the bill draft. They were limited to voting for the proverbial pig in a poke (remember Pelosi: "You have to pass the bill to see what's in it.")

Which is both a misquote of Pelosi and obviously false because they had been working for months to build a bill that Republicans could support. Enzi, Grassley, Snowe were involved from February onwards and Obama addressed a joint session of congress in September and the final bill wasn't signed until the following March.

Why on earth would you believe people who have lied about every other facet of the bill (Death panels! unconstitutional individual mandate that they used to support!, illegal immigrants!) when it comes to their culpability for failing to improve it.

More specifically, Pelosi's quote about understanding the benefits of the bill after it was signed was in March 2010 on the eve of Obama signing it. The bill he was signing was voted on by the House in October 2009, and the Senate that December.

Value optional.

Reply on news.ycombinator.com