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Comment by diogenescynic | Hacker News Reader

It's astoundingly clear we need a single payer system in the US (like every other developed country). We simply pay more for the same (or worse) quality as other developed countries.

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Isn't medicare effectively a single payer, because the rates are mandated and can't be negotiated?

I am not sure about this. Government healthcare has longer wait times, less flexibility, less quality due to reduced talent levels, and less incentive for innovation. I absolutely hate dealing with the government healthcare workers who think they’re above patients - some aren’t just rude but abusive, which I have direct knowledge of (at least in parts of Europe and Asia).

I do think the US healthcare system is expensive and sometimes fraudulent (overcharging for supplies, extra billing codes, etc). But we can fix these things with tweaks like forcing transparent pricing for healthy competition, creating transparency and consequences for billing or Medicare fraud, and other such ideas. I don’t think it requires as big a change as a single payer system.

Transparent pricing/competition is not going to move the needle. The overwhelming majority of costs come from a small percentage of people (80% of costs from 20% of people) whose overall medical spending is so high that they are far beyond any notion of shopping. Those people are well beyond their OOP Max and not even responsible for the costs anymore, and have serious conditions where any incentive to shop is basically non-existent anyway.

We also have gobs of data showing that people associate price with quality and often don't want to be price-conscious consumers in the first place (the classic "if your kid gets cancer are you going to the cheapest cancer treatment center, or looking for the best?" You will pay the same 10k OOP max either way). The types of health care that could be price-sensitive are a tiny percentage of overall spending.

I don’t know, is Switzerland civilized country? We don’t have single payer. Neither are most of Europe (except Nordics).

Switzerland is paying 70% as much for healthcare as the US. They are #2 in the world on healthcare spending.

What they have is essentially Obamacare, that is, mandatory health insurance.

But insurance doesn't care about limiting healthcare costs. Increased healthcare costs just leads to increased premiums, which is really increased revenue for an insurance company.

There are no high-quality single payer systems that are currently functioning at or above American health care quality. This is doubly true if you're looking for a 300M+ person system.

It is true that other countries achieve their broken health systems at a lower cost than the US does.

What makes you think the US health system is of a superior quality to that of any other in the world?

Nope. The GP asserted something without evidence so I am engaging with that same standard.

What makes you think "every other developed nation" has higher quality (and single-payer) healthcare systems?

Again, every other developed nation has roughly the same outcomes as the US, but at a much lower cost per person. And a substantial portion of our population has no access to health care, which is not true in those other countries.

This is not a policy prescription or advocacy for anything, it's simply factually describing the situation.

In my opinion, more innovations (which the rest of the world’s public systems do benefit from), better customer service, better patient care (far fewer rude or abusive nurses and doctors), higher standards (quality of facilities and attention to detail and time spent with patient), flexibility (between providers, in scheduling, and even in the care/procedures you receive), etc. Oh and the ability to receive the care you are willing to pay for at all, instead of being denied. I do think there are lots of flaws too but feel they’re addressable with targeted legislation instead of some massive change.

This is not true. The US does not have better overall outcomes than the rest of the western world. We are better in some areas, worse in others, but overall outcomes are roughly the same, at a much higher cost per person

I do agree that US costs are much higher per person.

It is not true that countries with our scale (population) are at or above our healthcare quality (scale matters).

For reference, here are the countries I am talking about: India, China, Indonesia, Pakistan, Nigeria, Brazil, Bangladesh, Russia, Mexico.

Those are the Top-10 most populous countries (with US at number 3, after China). Mexico at #10 has 200M fewer persons, so calling that the same scale is generous.

I have no doubt that Norway or Singapore has better healthcare than the US.

Scale does not matter. If anything scale makes it easier. Those countries are not peers with the US when it comes to wealth and resources.

>scale does not matter

The actual data seems to indicate the exact opposite. Countries with large populations aren't able to provide inexpensive healthcare, while countries with smaller populations achieve better outcomes at a lower cost

edit: I've read some of your other comments on this post and I really enjoy the deep level of understanding you're bringing on the actual article's topic. I just think you're wrong about the specific scale thing that I'm talking about

I would argue that the quality of governance of those countries and the strength of their economies relative to the US dramatically outweigh looking at size alone. Size makes things easier. The more scale the more predictable the costs.

We have a single payer system for everyone 65+, because we had the political will to do it, and it remains funded and functional because it is an important and powerful political bloc. A lot of people make a lot of money from the dysfunction of the system for everyone else and they fight tooth and nail to keep that gravy train flowing.

I feel like it's apparent why comparing healthcare in the US with healthcare in, well, any of the aforementioned countries, is problematic. If you look at Western Europe (a bit less populous than the US) or the EU as a whole (a bit more population than the US) they have functional healthcare at much more reasonable rates than the US. Scale matters, but scale is also a matter of division. If a single system can't serve 300+ million people then it can be broken down into regional systems or state systems. That being said medicare already serves something like 60 million people. I'd argue that scaling a system to support 5x the number it currently serves is significantly more doable than scaling anything from zero.

The US is not comparable to W Europe or the EU on this topic, since neither of those are political units responsible for a healthcare system. However, that brings us to your next point

>scale is also a matter of division...

This is a great point. However, for whatever reason, we have never seen a successful single-payer system in a US state. Even very blue, wealthy states have not achieved this.

>scaling a system to support 5x...

Again, the data does not support this. I don't have a reason why, just observing that it's not supported by real life.

Hm, with regards to the difficulty of scaling these systems specifically and really the whole topic at hand more generally I don't know that there is sufficient domain specific data to justify a viewpoint either way. I mean how many examples of scaling a national healthcare system (public, private, or otherwise) to support 300+ million people do we have? Literally three, right? The US, China, and India. Each of which has such significantly different circumstances that comparing them is less apples to oranges than it is apples to giraffes to glaciers. That being the case I feel like it's only reasonable to draw upon non-domain specific data wherein so far as I'm aware and in my experience we see a pattern of scaling existing systems being simpler than originating new ones.

You're right that we only have a handful of countries operating at this scale (~150M+ populations) so it's not exactly "data" in the common tech-sense of that word.

I want to get back to my original point: it's not "astoundingly clear" that the US should have a single-payer system (not your words, I know). My own thoughts are that this is mostly a scale problem as well as an inability to properly assess the performance of other systems (e.g. I would call both Canada and UK healthcare broken, but others see those as successful).

I agree that the US system seems broken from both an "Outcomes vs Cost" and a "Cost over Time" perspective. I just disagree that nationalizing healthcare, either through a single-payer system or the current Obamacare system is the answer.

> We are better in some areas, worse in others, but overall outcomes are roughly the same, at a much higher cost per person

What if you limit yourself to Americans with health insurance?

First, it wouldn't be an apples to apples comparison because the Americans without insurance are not randomly selected, so you'd be carving out a population with other confounding variables. And second, if doing so showed better outcomes here than elsewhere, we'd be saying "we have the best care, but 10% of the country doesn't get to have it. Tough luck!". Third, our overall spending is so much higher, we'd be admitting that we spend way more money to not even cover everyone.

We also have an unhealthier society because we have different jobs, standards of living sedentary lifestyles, etc. For example we have more obesity. So depending on how you are measuring overall outcomes it could be that the US system is in fact better, but is just dealing with patients with a different initial health level.

Having lived in a number of European countries with single payer systems some of which are in a state of collapse, that's not even remotely true. I would characterize the level of care I receive in the US (fully paid by my employer) as absolutely top notch.

> fully paid by my employer

A privilege not everyone enjoys

> privilege not everyone enjoys

55% of Americans [1], and, I’d guess, a commanding majority of likely voters.

[1] https://www.census.gov/library/publications/2020/demo/p60-27...

I don't see anything in that link about "fully paid" so the number of people with employer-provided health insurance fully paid by the employer is probably much lower.

> In 2019, the percentage of people with employer-provided coverage at the time of interview was slightly higher than in 2018, from 55.2 percent in 2018 to 55.4 percent in 2019

> don't see anything in that link about "fully paid" so the number of people with employer-provided health insurance fully paid by the employer is probably much lower

You’re right. Tough to find statistics, in part because “fully paid” is ambiguous. (Saw this [1].)

The figure I should have referred to is 72% of Americans being happy with their own healthcare [2]. You’re not going to get single payer without convincing them they’re trading up.

[1] https://www.peoplekeep.com/blog/what-percent-of-health-insur...

[2] https://news.gallup.com/poll/468176/americans-sour-healthcar...

In my city (Pittsburgh) over half of the workers who work at our largest healthcare provider surveyed have some kind of debt to that same entity. My own mother is one of those people and she has been climbing for years. Funny how that works.

https://www.beckershospitalreview.com/finance/union-raises-c...

I am included in that 55% but my deductible and OOP max are too high for my salary so i still can’t go to the doctor because i don’t have an extra $8k per year to spend on it.

You can't go to the doctor for your free annual visit because your OOP max is too high?

What is the point of limiting the scope of discussion to a single visit per year? Am I missing some context from the article that makes this relevant to things like the expense of follow-up visits to confirm/treat complex diagnoses such as secondary hypoaldosteronism, discussed in the article?

In my case, I have multiple conditions that require expensive monthly or annual visits, which I’ve severely lapsed on.

I'm counted in that group but still pay several thousand a year out-of-pocket.

So 45% do not, and that’s ok?

Or the huge percentage of that 55% where their coverage is high deductible, so it’s functionally just a “you won’t be instantly bankrupted if you have a heart attack” not basic healthcare?

The bizarrely antisocial and frankly sociopathic “I’ve got mine, other people can get fucked” attitude people like you have is sickening.

You are very hostile in this thread. The GP didn't say anywhere that it was ok for people to be uninsured. Neither did they say they were among the 55% figure.

Secondly, it's easy to find some official figures - [0]

From January through June 2023, among people of all ages, 7.4% were uninsured, 40.7% had public coverage, and 60.8% had private coverage at the time of interview

And:

The percentage of adults who were uninsured decreased from 14.7% in 2019 to 10.7% in the first 6 months of 2023. Public coverage increased from 2019 (20.4%) through the first 6 months of 2023 (23.6%). No significant trend in private coverage was observed between 2019 (66.8%) and the first 6 months of 2023 (67.7%)

In other words, the majority of people in the US (> 90%) have insurance -- private, public, or both.

[0] - https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202312....

In my experience in the US,”employer-provided” is not the same as “fully paid for by my employer.” Generally there is an employee-paid portion of the monthly premiums.

That is true. It's just not clear to me that we need a system where everyone has "free" (taxpayer-funded) healthcare.

Maybe you should ask the people who currently aren't covered if it's a good idea

So why not make everyone pay full economic cost? Ban employers from giving out insurance. Make everyone pay for their own fully.

I don't really follow European health-care policies, but the friends of mine who do seem to think public health care with a private-option (e.g. France) is better than single-payer.

I've also heard that the German system works reasonably well, which is also not a single-payer system.

I’d wager you have a copay, a deductible and a maximum amount your plan will cover. And if you are laid off you have nothing unless you sign up for COBRA which charges huge amounts monthly.

The European single payer systems are underfunded intentionally by “conservatives” who want to skim off the top by privatization and loath offering it to the poor & working class.

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