Comment by jaco6 | Hacker News Reader

Comment by jaco6 | Hacker News Reader

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The problem with American healthcare is the attempt to compromise between healthcare as a universally available public utility and healthcare as a commodity on the private market. (Arguably this is a legacy of pre-modern healthcare, where hospitals were operated by charities run by nuns and funded by aristocrats and royal families, hence all the “Saint” names in hospitals nowadays).

There’s a variety of weird examples of this mixed system:

>Poor people use ERs for every day healthcare, usually they get away with paying nothing, no insurance

>Working people with insurance pay more to enable this access for the destitute (or criminal) portion of the population

>Old people are sort of entitled to free healthcare. They get medicare, but if they want everything, they have to pay for “supplements.”

>Young people pay for the old people’s healthcare twice, on their payroll taxes and in the form of higher premiums. A 25 year old male should absolutely not have a $300/mo health premium. But he does, because his premium is paying for other’s care.

This is a system pretending to be private, but it’s actually just inefficiently public. It would be more efficient to pay for it using taxes, both income and sales taxes, rather than letting some groups—the poor and the elderly—off the hook arbitrarily.

Alternatively, abolish health insurance altogether—a notoriously inefficient and exploitative industry that does not suit the classic purpose of insurance (boat accidents and fires)—and see what happens. This is obviously a rather unpalatable option due to the chaos that would ensue, but it’s probably the best option.

> It would be more efficient to pay for it using taxes, both income and sales taxes, rather than letting some groups—the poor and the elderly—off the hook arbitrarily.

I don't think this is true. Some countries with public healthcare are far more efficient than our system.

But there are countries that have systems similar to ours that are far more efficient as well.

We just have a really shitty system, and who pays for it isn't going to change that. It's a hard technocratic problem that doesn't have any easy answers. (Besides increasing the number of residency slots, removing the bachelor degree requirements and allowing foreign physicians to practice which are basically freebies.)

> But there are countries that have systems similar to ours that are far more efficient as well

Typically, those countries have BOTH a public system and a private sector. This means the private sector actually has to be really competitive, because they're competing with "free" (or close to it). This isn't the case in the US, there's no competition.

> But there are countries that have systems similar to ours

Really? Which ones are they?

Israel, Switzerland, and the Netherlands all rely on private insurance as well and still have vastly better systems than our own.

Netherlands has a mostly public system with heavily subsidized mandatory non-profit insurance under government oversight: Health insurers receive compensation for high risk individuals from the government,[5] and government subsidies pay about 75% of insurance costs. https://en.wikipedia.org/wiki/Healthcare_in_the_Netherlands

Israel also has a public healthcare system in practice. Mandatory participation in 1 of 4 non profit insurance programs looks like private insurance but … https://en.wikipedia.org/wiki/Healthcare_in_Israel For the health tax, wage-earners and the self-employed must pay 3.1% of their monthly salary up to 60% of the average prevailing market wage (appx. NIS 6,300 in 2020), and 5% of anything earned above it.[25] Employers are legally obligated to deduct insurance contributions from their employees' salaries, while the self-employed must arrange payment on their own. Pensioners have contributions deducted from their pensions, as do those receiving unemployment benefits. Those who are not working but have income must pay 5% of their income in health tax, while those who are not working and have no income must pay NIS 104 a month.

Switzerland has a similar system with mandatory participation and non profit insurance programs. https://en.wikipedia.org/wiki/Healthcare_in_Switzerland

Yes health care is very different in every country in the world. There are a 1000 ways to do it well but the US is unique in having insane healthcare costs. Having non profit insurance companies isn't the difference, having mandatory health insurance isn't the difference. It's not that easy to fix.

Each of things individually is lowering healthcare costs. Medical billing is a significant multiplier for US healthcare costs, and going to a highly regulated nonprofit only system would help.

There’s other factors like our obesity rate, but we’re basically intentionally shooting ourselves in the foot when it comes to healthcare costs because cost savings is lost profits for someone else.

The unifying factor of ~all other developed-world systems is price controls, de facto (e.g. government monopsony or [near-]monopoly) or de jure (outright pricing sheets)

Seems like you’re misrepresenting these countries in stating that they “rely” on private insurance (these are countries with public healthcare).

Are you able to point to a completely private system that is insurance based and works well?

Or what do you think public systems that also include private insurance add to the table that is missing from the US market?

In what sense does the Netherlands or Switzerland have public healthcare?

> It's not that easy to fix.

Medicare for everyone seems like an "easy" fix but we have too many red state neanderthals in the US who oppose policies that clearly benefit them claiming "personal responsibility" though they oddly still think schools, police, fire departments, etc. are just fine...

Medicare for everyone fixes the under and uninsured problem. It doesn't fix the cost problem, only moves it from paying private insurance companies to the government. It's true Medicare pays less per procedure but that is not because those procedures are more efficient it's because relies on pricing power. Many hospitals would go out of business or have to layoff a significant amount of their staff if they were exclusively paid Medicare rates.

NL may be better than what's in the US but it's quickly deteriorating after the 2006 reforms. We've got dozens of competing health insurance companies big and small, but their base coverage package is the same because that's legally required. So the main thing they differentiate is with nonsense; minor differences between competitors, but mainly marketing, bullshit apps, etc. That is, a nontrivial portion of health insurance payments is spent on marketing.

Then there's the other big problem. Base insurance, which btw goes up to €150 / month next year (per adult), only covers cheap generics whose purchase prices are negotiated by the government (or something like that). The consequence now is that the manufacturers are not willing to pay the import fees for their generics, because the profit margins are too slim. Thousands of types of medications are now no longer available, difficult to get, or will only be available again in X months. This is stuff like basic painkillers, adhd, diabetes, etc.

The system is failing, is all I'm saying.

US population is 300M, whereas Israel/Switzerland/Netherlands population is about 10M.

You would expect healthcare cost to scale pretty linearly with population size, I think? Number of doctors, hospitals, drug prescriptions etc. are entirely population-driven.

Medications also don't cost more or less based on population size. Although in a single-player market monopoly, I suspect a larger country should have greater cost negotiation power, so this should actually benefit a larger country like the U.S.

A greater factor than population size may be demographics. Countries with older and less healthy citizens would have a larger cost burden.

A poorly designed government structure could also disadvantage a large country like the U.S. This has been observed in the U.K., where successive Conservative governments have centralized the healthcare system over the last two decades, reducing efficiency and increasing cost. Not sure about Switzerland, which is also a federation of states (cantons).

Switzerland has a private insurance model IIRC. Israel and the Netherlands, too, according to Wikipedia.

Switzerland has individually mandated, state-approved, non-profit private insurance.

Totally unlike the US's private insurance in every way that matters.

It’s kind of like Obamacare without a huge number of compromises

> non-profit private insurance

Only base/minimum coverage, the same companies still offer extended/supplemental plans with no such limitations.

Also is the for profit part really that important? Profit margins are capped and even if all insurance companies became non profit and costs went down went down by another 5-10% or so at most, would that fundamentally change anything? The extreme inefficiency seems like a mich bigger issue.

And people in the Netherlands are paying more and more for their healthcare.

There is the idea of elite over production. We have private health insurance in order to create a couple thousand upper class jobs. With a half dozen billionaires running things.

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