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Comment by HourglassFR | Hacker News Reader

I would ass a fourth reason: health is a very much a public (as in collective) issue, not a sum of individual medical problems. Something that is fundamentally at odds with the dominant ethos of how to deal with problems in america in the past 50 years or so.

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That is what I was trying to convey on my second point, but perhaps I didn't do a good enough job at it. Yes as a European I see it as a mere "efficiency" thing. My (admittedly, very simplistic) thinking goes like this:

> In a population of 1000 perhaps 10 will get a Really Bad Health Issue that requires Really Expensive Treatment that costs 100. So those 1000 people pool their resources up and each pays 0.1 so that if they happen to be one of the unfortunate 10 they are covered. Given that this is a shared risk for those 1000 people, the higher possible entity (the state) is put in charge.

It seems the Americans thinking starts the other way around:

> Anything public is awful and should be avoided at all costs. I'd better take my chances with a private entity (even if that means grouping with another 100 people instead of 1000, and that the private entity takes one cut, so we end up paying 2 each instead of 0.1) because the alternative is just awful.

... But then they are fine with having a very well publicly-funded military and police departments.

A risk pool being split among multiple companies doesn't actually increase the average amount that each group would have to pay. For the group of 100 in your example, only one tenth of a person is going to have to get one tenth of the expensive treatment, so each one still has to pay 0.1. As long as each underwriter has a sufficiently large group to ensure that the average cost incurred by its members is sufficiently close to the population average, the relative sizes of those groups isn't going to affect their members' premiums. Insurance administration is not an economy of scale so competition in the marketplace would ensure downward pressure on prices. In contrast, a state provider would have little incentive to cost-cut or innovate since they wouldn't have to earn people's business, and any public option would necessarily be attempting to balance the interests of multiple groups (such as public sector unions/government employees, health care providers, and health care consumers) at the expense of the consumers whose interest would have been prioritized in a competitive market. Taking that into consideration, it's doubtful that the lack of shareholders in a public system would represent enough of a benefit to actually lower costs for consumers. Americans have enough experience with poorly managed government programs to intuitively understand that a socialized health care system isn't going to be an improvement over our current system.

And yes, since national defense and law enforcement are desirable services that can't be provided by a competitive market, we are fine with the government providing those specific services in a constitutionally-limited way. That preference is actually more ideologically consistent than your preference to socialize our healthcare system unless you're going to advocate for abandoning capitalism entirely.

> For the group of 100 in your example, only one tenth of a person is going to have to get one tenth of the expensive treatment, so each one still has to pay 0.1

That makes no sense. It will be one person. Not a tenth. And also if that was true the private insurance would raise their quota to 1.9. And then deny treatment to that unfortunate person anyway because it’s cheaper to pay a lawyer to litigate the expensive cases than to pay them.

Your last bit makes no sense to me at all. It is clear that health care is desirable, and can’t be provided by a competitive market. The richest country in the world can’t pull it off. You lose much more people per week to health care unavailability than to wars. From the point of view of mere efficiency of capital it makes no sense.

And are talking as if there was no proof that socialized care works in other countries. It’s right there if you’re willing to look for it.

If your state agencies are poorly managed and you go private, that is a self-perpetuating cycle. Fewer people will use them, they will get budget cuts, and get worse. The solution is to revolt, strike, demand better, and help each other, even if they are poor.

Abandoning some aspects of capitalism is completely possible and rational.

It does make sense. A smaller group will have a correspondingly smaller number of people who will end up needing treatment, so the expected value for an individual's cost doesn't actually depend on the number of people in the group, just the probability that any specific person will end up requiring treatment and the cost of the treatment. Maybe you are confused because you chose a specific example wherein the expected number of treatments required is less than one? Are you thinking that because it's not possible to have only a fraction of a person require treatment that we need to round up to 1 person? That's not how probability works and if you simply extend that logic to a group of a single person then your error should become immediately apparent. While it's true that only whole numbers of people can get sick, when you take repeated samples of small groups you will find that occasionally one group member will require treatment, but much more commonly than that, zero group members will require treatment. When you weight each case by its relative probability of occurring, then you get the same expected cost per person that you calculated for the large group.

Your lack of intuition about such a simple linear relationship should be extremely concerning to you. It suggests that you are approaching the question with an emotional attachment to a particular outcome that is blinding you to the extremely simple and intuitive correct answer.

There's a lot more to unpack here, but I don't have time to address it point by point. You are making a lot of assertions that seem much more reflective of left-wing ideology than actual conditions on the ground. You suggest that consumers demanding better is a solution to public systems that don't actually meet consumers needs, but the very nature of public goods ensures that no individual consumer will ever be in a position to make a demand that administrators will have to prioritize over competing demands from producers and public employees. The nature of democracy gives outsized influence public sector unions and interest groups that can then turn around and contribute a share of those benefits back to politicians campaigns. In contrast, a competitive market affords consumers to actually make demands with some weight behind them. A producer has to take a consumers demands into account lest that consumer simply take his business to a competing producer. The weight of the empirical evidence affirming this fundamental difference between public and private systems is completely overwhelming, and your resistance to the idea that capitalism is a far better system than socialism for the vast majority of goods suggests an emotional attachment to an ideology that has very intentionally been sold to the public in such a way as to make uncritical advocacy for that ideology very self-flattering to those very advocates.

I know that I didn't really address the middle part of your argument but let me assure you that those ideas are just as contrary to reality as any of the ideas that I chose to address. I might come back to those in a future post if I find myself with both the time and the inclination to do so.

> Maybe you are confused because you chose a specific example wherein the expected number of treatments required is less than one?

In my example 10 people out of 1000 required the treatment. If it's 100 people, then 1 will need it. You must have misread.

> Your lack of intuition about such a simple linear relationship should be extremely concerning to you

That's very condescending and a bit ironic. I think you should apologize.

> much more reflective of left-wing ideology

"Left" means different things in different places. In my country, a big chunk of the people on the "right" feel the same way you feel about the army, but about healthcare. Which is that some things like life-threatening problems are too important to let personal gain interfere. More on that in a second.

> actual conditions on the ground

I am writing this from the ground. My son just got treated by our public health system twice this week - the last one today. (His pediatrician was on strike today, actually. That is a bit inconvenient for us but it is fine. It's not life or death). My sister in law got diagnosed with cancer and got treatment for it. This is reality that I am telling you is happening right now. Not a theoretical thing that I am imagining might work on a communist country. It exists, and it works.

For the life-threatening cases at least. It is not perfect - there's sometimes long waiting lists for non-life-threatening ones. That is where private health plays a role. Those who don't want to wait, or want a private room in the hospital, can pay for it.

But if you are poor and you get cancer you don't necessarily die. Your family doesn't have to beg in gofundme for your treatment, nor they are left bankrupt. Which is absolutely a reality in the US.

> The nature of democracy gives outsized influence public sector unions and interest groups that can then turn around and contribute a share of those benefits back to politicians campaigns. In contrast, a competitive market affords consumers to actually make demands with some weight behind them.

I prefer referring to people as people. Or, citizens, in the context of a country.

Perhaps that is where our difference of opinion comes from. I don't see a country as a business. So naturally its people are not "consumers". Poor people may not be able to consume much, but they are still people.

On buying public administrators: in my country, lobbying consists in "having meetings with politicians". It does not mean "giving presents" or "contributing to campaigns". That is called bribing, and is against the law. Again, not a perfect system by any means. There's plenty of corruption, as well as other problems. One of them, and one of the places where I do agree with you, is that that interest groups (especially those sponsored by the extremely wealthy) still have much more levers to pull than the average person.

Where I differ with you is in how to fix this. You propose that "people vote with their wallet". The problem with that is that the money that consumers use to vote with their wallet eventually goes into the pockets of the ones funding the interest groups that eventually make laws against them. This is a problem both in my country and in the US. It gets worse with inequality, which is getting worse everywhere, but especially in the US.

My proposed solution is simply that there's other things besides the consumer-producer relationship. This doesn't necessarily imply a communist regime or an anarchist revolution. It just means Europe, man.

Ok, I see where the problem is. The 10 people requiring the 100 treatment in your example will cost 1000. That's one dollar per person, not one tenth. For the group of 100, 1 person will require the 100 treatment and it is still 1 dollar per person. You very obviously made a mistake and I incorrectly assumed it was in your calculation of the costs for the second group. The underlying point is still the same though, and you should be concerned that such a simple relationship is not intuitive to you. I'm not going to apologize because I still feel that this is indicative of emotional reasoning on your part. If this sounds condescending then that's only because this is about as simple as math can possibly get and yet you still failed to recognize the glaring logical contradiction.

The cost of 100 is the cost of the whole treatment system. That includes doctors, nurses, medical equipment etc. For a capacity of around 10 cases.

But yeah, focus on purposely misinterpreting my arguments all you want. Have a nice day.

If the cost is 100 for 10 cases, then it's going to be 10 for 1 case. Cost per person is still the same. You need fewer doctors, nurses, and medical devices to treat fewer people.

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