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Comment by linsomniac | Hacker News Reader

Our collective reaction to this event makes it clear that there is substantial support for massive changes to the for-profit insurance industry. But every time we've tried to make it a public benefit, those attempts have fallen flat. Sure seems like the industry is able to lobby and market it's way to staying alive, despite the ire of the people paying them.

Decades ago I recall a previous attempt at moving towards a one-payer system, and it having some traction. My mother had some fairly serious health issues, and had many battles with getting insurance claims paid, living month to month in a single mother salary. Yet she also was firmly of the opinion that a one-payer system would be terrible, parroting the marketing of the industry advertising campaigns. Despite having a daughter in law that was Canadian, who's mother went through cancer and had superb care under a single-payer system.

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> Decades ago I recall a previous attempt at moving towards a one-payer system, and it having some traction.

Obamacare had a public option up until the last moment before passage. It was dropped because they were one vote Senate vote shy of the required 60 votes.

Lieberman was heavily lobbied by the insurance industry and promised to join the Republicans and filibuster Obamacare entirely if they kept the public option in.

It's a frying pan or the fire situation. The frying pan is government healthcare. The collective US thinks the government run program is a garbage fire. Obvious reasons are that (1) it's really hard to fire bad employees government wise since employment is seen as a right and (2) it's really hard to get anything done since people think of 9999 ways to "be nice" as rights. Then, clearly for-profit institutions are also a garbage fire since they make that extra 10% revenue off of unnecessary suffering.

There is a great counterexample that is Kaiser. They are a private health insurance org that provides massive savings by simultaneously also running a network of hospitals and outpatient facilities. Notably they are not-for-profit. So that's perhaps what we're shooting for "all the goodwill of government, without the mucuousy bureaucratic slop in any government institution"

If only all the private sector orgs were Kaiser, not for profit and for the well being of humanity. Kaisers of the world are a flash in the pan, "don't be evil" googles only to become "be evil" googles.

I would simply recommend to look at how Singapore does things and copy that, after all, that's what China did and look how well they have done economically.

It's complicated. Health insurance is expensive because healthcare is expensive. Different countries have approached this differently. In the UK the doctor will see you in 5 years, in China the government sponsors snake oil ( traditional Chinese medicine), and in Canada they introduced MAID (the 'just kill yourself now' health plan).

But it seems obvious that inserting a group of middlemen into an already expensive system is going to make it more expensive. The complexity of dealing with all the insurance companies is literally overwhelming.

It is so confusing to me that "socialized healthcare" is such a dirty word, when the whole purpose of insurance is, a it's core, introducing socialism into healthcare. If you are anti-socialism, cancel your healthcare and just private pay for your healthcare. :-)

Sadly, we in the US seem to be sliding in that direction with the noises being made about "healthcare pools".

Yes, insurance is effectively a form of voluntary socialism implemented on top of the free market. That's why it sucks so much in the first place. (Which isn't to say a purely market based system would be better; people buy insurance for a reason.)

As I see it, health insurance is uniquely bad for a few additional reasons:

1. People don't treat it as insurance against catastrophic events so much as a subscription for ongoing care, which greatly expands the scope of what costs are socialized.

2. It's often paid for through employers, which reduces consumer choice in deciding what plans to purchase.

3. Demand for healthcare services is relatively inelastic and with modern medicine there's often almost no limit to how much it can cost. If you wreck your car, at most your car insurance company is on the hook for the cost of the vehicle (and perhaps some additional costs up to a fixed limit). But if you're suffering from some disease with no known cure, you could easily spend tens of millions trying hundreds of different procedures trying to find something that will work to mitigate the effects of the disease, and that's an ongoing cost that goes on forever until you're either cured or dead. Somebody has to decide which procedures are worth it or not, and if you're not paying for it yourself that "somebody" isn't going to be you, which creates lots of inefficiencies and is heartbreaking for everyone involved. This is also why we end up with systems such as "in network" and "out of network" providers, and government regulations intended to make things more fair at the cost of even more layers of inefficient bureaucracy.

A few other thoughts:

> If you are anti-socialism, cancel your healthcare and just private pay for your healthcare.

Even for those who might be inclined to do so, this often isn't viable because of #2; they'd be leaving a bunch of free money on the table. I've also heard stories of some healthcare providers charging private individuals many times what they'd charge an insurance company for the same thing, though I'm not sure how common that still is today.

> inserting a group of middlemen into an already expensive system is going to make it more expensive

This is true, though note that government healthcare just replaces one set of middlemen with another.

> Yes, insurance is effectively a form of voluntary socialism implemented on top of the free market.

No, its not. Socialism is when the working class exercises control of the (non-financial) means of production. Insurance is neither about workers qua workers or control of the non-financial means of production.

Using disproportionate control of financial resources to sell risk-leveling as a service and therebu increase your disproportionate control of financial resources isn’t socialism.

... which is why I put quotes around my use of the term above. Single-payer plans are often referred to as "socialized healthcare", whether it fits the dictionary definition of socialism or not.

So, can we focus on problems and solutions and not argue about definitions? I don't think it brings anything to the table.

> Single-payer plans are often referred to as "socialized healthcare"

This is mainly an Americanism which is grounded in a similar mistake about socialism, though in a society which is actually democratic and predominantly working class, a State directed use of resources for a particular public service is at least not-entirely-unrelated to socialism (though if it is a single payer atrangement where the payees are private owners of the means of production actually employing providers of service, it is still not socialism; actually socialized medicine is, for example, where the worker-controlled state controls the hospitals, equipment, and other capital used in providing healthcare, and employs the doctors, nurses, etc. directly), whereas a commercial offering by a private capitalist profit-making entity is... nothing like socialism.

> So, can we focus on problems and solutions and not argue about definitions?

You are literally attributing a problem specific to capitalism to “socialism” and badly twisting the definition of socialism to do it. That’s not really a sign of being interested in “problems and solutions”, but of being interested in promoting ideological fantasies about capitalism.

If you were interested in what works, you'd look at why the problem is unique to the US and what distinguishes the US healthcare system from those of other developed economies.

I don't know if I'd call it a mistake... I'm pretty sure the phrase "socialized healthcare" was deliberately selected to help try to demonize the idea, supporting the insurance industry lobbying.

> People don't treat it as insurance against catastrophic events so much as a subscription for ongoing care

_People_ don't treat it this way, it IS this way.

Health insurance resembles insurance in almost none of the important ways.

Picture health insurance models laid on top of your car:

Imagine your car gets totaled. Your insurer says, "Hey, we're going to pay out $25K for your vehicle. So you have a $1,000 deductible, so that's $24,000, and then your copay for a total loss is $2,000, so that brings us down to $22,000. For total losses, your coinsurance as your contribution for your vehicle coverage is 20%, which is $5,000, so here's a check for $17,000. But that's only if you're buying a Hyundai, otherwise the vehicle is out of network and you'll get a check for $8,500 instead."

(And to be clear, I'm not saying auto insurance is without its own issues and sketchiness, just that it at least conforms to actual "insurance").

I think a better analogy to my point would be if making insurance claims for oil changes was considered a normal and accepted practice.

But you're right, that's part of the reason we end up with things like copays. My 3rd point above is also responsible for a lot of this.

And your insurance works with a mechanic:

How much is this oil change going to cost?

-- Can't tell ya. you have insurance though, right?

I have Geico. The oil change was $25 last year. Let's just do it, you're telling me it's necessary.

-- Great! It'll be done in about 25 minutes.

...

-- That'll be $1895.00, I'll send you the bill. But if you take care of it right here, I'll lower the price to $425.00.

WHAT!? 425 for an oil change? What a RIP! $125 is all you're getting from me.

-- Pleased doing business with you. See you again next year!

Simplifying the system should be the goal for lawmakers IMO. But that would never really get much traction. Getting care to people who need it has an obvious priority, so we layer more and more complexity over the current system.

Capitalism with transfer payments (the Nordic model) and socialism (Union of Soviet Socialist Republics model) are two very different things.

Regardless of how we might wish it to be, it's an observable fact that the latter sense is how the word socialized is understood in the USA. And yeah, people rightly object to totalitarian control over their health care, whether it's by a government or a for profit cartel that has managed to achieve a stranglehold on medical payments.

Most working people in the US are on private healthcare. What you are saying makes no sense. Most everyone agrees our current system isn’t working and needs fixing.

It's not that complicated. Healthcare is expensive, sure.

It's made more expensive by allowing the private healthcare industry to operate in such a parasitic way.

Americans and their employers pay an obscene amount of money to insurance companies every year for "health insurance". In turn, those companies use that money to employ people full time to find ways to deny people the coverage that they pay for based on technicalities. They do this so that they can pay people like Brian Thompson more money.

It's a disgusting and immoral system that should not be allowed to exist.

It is worse than that now, though, because they own doctors as well through Optum under the united health group umbrella corporation.

>In the UK the doctor will see you in 5 years

I get your point but for reality's sake the last time I saw a doctor, on the NHS in the UK it took one day. The service is a bit ropey but in strange ways.

Yeah but many people wait months to see specialists in the US that will only give them 10 minutes of their time...

The NHS is crumbling under a decade and a half of underfunding and intentional mismanagement to designed to prove it doesn't work by the Tories, and even then, it isn't as bad as you make out. There are 100% unacceptable wait times for some things and some procedures, but I'd take having an annoyingly long wait to see my GP over people I care about not having healthcare at all, and realistically it isn't as bad as you are making out.

In 2022, the British government spent £3.5k ($4.4k) per person per year on healthcare. The US spent $13k per person per year in 2022, of which $6.2k was government (national+state+local)[2]. The UK government spends less per person than the US government on healthcare, even before the amount paid privately.

Even if you think the UK's healthcare is worse than the US (which I fundamentally disagree with), you have an extra $2k to play with and do better than the UK before it costs more than the current system to the government, and then another $6k of extra tax before people would be more out of pocket than with private healthcare.

Healthcare is complicated, all systems have flaws and all are vulnerable to being manipulated. None of that changes that the US has the worst system, run in the worst way, with the least efficiency. And that's without even getting to the obvious point that a country where people are healthier is worth paying for: my friends and family, colleagues, people I interact with being well, living longer, and not having diseases is very worth paying for and I want to be taxed to achieve that.

[1]: https://www.ons.gov.uk/peoplepopulationandcommunity/healthan... [2]: https://www.cms.gov/data-research/statistics-trends-and-repo...

>"In 2022, the British government spent £3.5k ($4.4k) per person per year on healthcare. The US spent $13k per person per year in 2022, of which $6.2k was government (national+state+local)[2]. The UK government spends less per person than the US government on healthcare, even before the amount paid privately."

The difference in medical spending is largely due to wage costs being much higher in the USA than the UK; healthcare insurance companies are not as profitable as it may seem (they're about as profitable as other insurance businesses). Pharmaceutical prices don't explain much of the difference either, because they’re only a single-digit percentage of healthcare spending (in the USA).

It isn't about the profit margin of the insurance companies it's about their purpose. What value do they add to the healthcare industry?

Aren't healthcare insurance companies intrinsically an inefficiency that could be outright eliminated?

If there is to be some control on healthcare spending, and/or policing of fraud, someone must approve and decline payment for services. This is the function currently fulfilled by the insurance companies. You can eliminate the companies, but anyone performing the service will consume some amount of overhead.

Well whatever is going on in America[0] it just isn't working.

https://en.m.wikipedia.org/wiki/File:Life_expectancy_vs_heal...

It isn't intrinsic. In any modern healthcare system, someone has to manage resource allocation and risk pooling. Some countries have government perform those functions, which can be more efficient but isn't necessarily so. In the USA, even the government run Medicare health plan outsources much of the administrative work to for-profit companies.

@nickff shouldn't that be a not-for-profit watchdog capability then? Not a massive money making middleman?

(Can't reply that deep)

Even if that is true, how does that change anything about what I said? The government can evidently do this more effectively, fairly, and efficiently.

That may be true; what are you basing this view on? How do you evaluate those three criteria?

> what are you basing this view on?

Every other developed nation?

It seems that it's not as clear to me, so could you please explain how one should evaluate those criteria?

The most obvious criteria is cost per citizen. The US has, by far, the highest cost per citizen. And also the lowest quality care.

I explained in my original post. The fact the UK government spends less than the US government on healthcare per-capita, despite the fact it gives everyone healthcare rather than just a subset of the population is pretty damning. How can anyone possibly argue the US system is working more efficiently given that?

The UK has private health insurance available for purchase too, right? I'd be curious to see what that per capita amount is. Does UK private insurance mean you opt out of the public system, or does it provide coverage for more things on top of the public system?

Yes, it's not opt-out, just additional coverage or the use of private facilities. Apparently about £1k per capita[1], I'd suspect a lot of that is probably dental due to a huge shortage of NHS dentists.

Historically private healthcare here was just about fancier rooms, better food, etc... Now it's often "the NHS said I need to wait 6 months to get this procedure, if I pay I can get it next week". A lot of the time with the same doctors and same facilities as if you went NHS.

In general, if you weren't waiting a long time for NHS healthcare, people were happy with it: five or so years back I worked for an American company that offered private healthcare as standard, even in the UK, and the healthcare company offered you £50 a day while you got NHS treatment rather than actually using their services while you had coverage, as it was obviously much cheaper for them, and everyone I knew took that deal every time.

Increasingly this is less true though, a decade and a half of being slowly throttled, then Covid, and you can feel that everyone is rushed and stretched to breaking point.

[1]: https://www.statista.com/statistics/283221/per-capita-health...

Thanks! So even including the folks who get private insurance on top of NHS, the healthcare spending difference between the UK and US is massive.

I'd add that the point of insurance is to pool risk for rare but costly incidents. Somehow we have a system where it also pays for foreseeable and very likely events. Of course supply and demand market competition breaks down in a non linear S/D case where there is no elasticity of demand. Ideally routine care would never be covered by insurance with full proce transparency like plastic surgery. Further separating health insurance from employment would drastically reduce the number of unique plans offered making it more efficient.

It would also require public non profit manufacturing of drugs to reduce the cost.

If routine and preventive care isn't covered by some form of insurance than low-income people won't be able to afford it at all. Some of those costs are inevitably going to be pooled.

Generic drug manufacturers have very low profit margins. Switching manufacturing of generics to non-profit organizations would have very little impact on total healthcare system costs.

If you're suggesting handing over ownership of patent protected drugs to non-profit organizations, well that would lower costs in the short term. It would also ensure the pipeline of new drug development is slowed to a trickle.

New drug development is largely funded by the government already. There are basically 0 new compounds on the market in the last 20 years. Most of the cost for drug development that is pricately funded is just dealing with regulation, not doing R&D. It is always economically more efficient to develop drugs instead of cures.

The vast majority of drug development costs are are in phase-3 human clinical trials. That's not just regulation, it's essential to prove safety and efficiency. The government provides very little funding for those trials. Stop making things up.

A lot of the reason efficacy is so regulated is that people shouldn't go into debt for snake oil. If on the other hand there is no cost to the patient and minimal cost to the taxpayer the downside for inefficacy is much less and doctors would be freer let patients take a chance. It would also help more drugs get tested faster on more people.

No offense, but I find this comment ignorant at best and purposefully misleading at worst.

I've visited emergency multiple times over the 20+ years I've been living in Australia. The first time I left with crutches, a casted ankle, and a whole slew of scans indicating it was just a serious sprain, not a bone break or tissue tear. I was almost out of emergency before I turned around and uncomfortably announced that I was leaving and yet hadn't paid for anything. A doctor came directly over, pressed the button for the automatic doors, and said "It's ok, this isn't America. You're free to leave, and you don't owe us any payment. Your taxes cover this."

I have severe spinal stenosis. On Tuesday I had an EOS scan. $0. Last year I had both an MRI and CT scan. Both cost me nothing and were covered by the public health system. If I had these 3 scans done in the US without private health care I'd be out of pocket $10k or more.

I've lived in a few countries and the Aussie system is by far the best I've used.

I've also had that "so I've just come out of the doc's, how much do I owe?" at reception, only to be told "nope, you're good, see you in 3 months for your next checkup" shock.

The U.S. spends much more money on health care per capita than any country on the planet, with far less to show for it. This is a uniquely American problem.

https://www.healthsystemtracker.org/chart-collection/health-...

You are confusing two separate issues. A single-payer system would also deny many claims (or refuse to authorize many expensive treatments). Every socialized healthcare system rations care. It might be a net improvement overall, but we see a lot of affluent Canadians coming to the USA as medical tourists to skip the queues back home.

For cancer care, the USA generally has better 5-year survival rates than Canada.

Example of rationing in Canada (posting because I saw the article yesterday): https://ca.news.yahoo.com/halifax-woman-waited-3-years-10000...

I blame Rahm Emanuel, Obama's chief of staff, who threw public health on the pyre as a sacrifice to Mammon, and his minions in the Donor Class.

He comes from a country that does have single payer but doesn't think it's worth doing for people in this country.

What collective reaction? Sounds like you're in a bubble.

I have observed both responses. There are lots of people basically celebrating murder (sometimes veiled behind thin excuses and wordplay). There are lots of people condemning it too. Most people (not terminal social media dwellers) seem to be in the latter group, thankfully.

The vast majority of people I've talked to IRL, conservative and liberal, are thrilled about this. "American hero" is the phrase I've heard tossed around quite often.

Can't say it wasn't the best news of the week, maybe even the past month.

> basically celebrating murder

of a guy who basically runs death panel...

It's a problem of definitions. When you kill hundreds or thousands of people indirectly, as in you do not literally pull the trigger, that is not murder. But if you shoot one person, that is murder.

I've seen people advocate the death penalty for much, much less. If anyone stopped and did the math on how many people this CEO has killed, undoubtedly he would never see the sun again.

However, our system is specifically designed to maximize personal liability while minimizing collective liability. So, one is murder, and the other is good business. Whether or not this particular propaganda has seeped into an American mind depends on the person.

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