Hacker News Reader

Comment by neilwilson | Hacker News Reader

It’s not a matter of profit. It’s a matter of costs.

From the graphic the insurers take in $371.6b and pay out $241.9b in medical services costs.

That’s $130b on a pointless activity that uses up physical resources that would be better deployed elsewhere in the economy.

Healthcare needs to be provided as a matter of course, and “competition” won’t improve it or control it because there is always a supply side shortage of provision.

That’s a difficult problem to solve, but solving it by forcing a huge bill on expectant mothers and cancer victims, etc in a futile attempt to control demand is not the way.

Which is why the rest of the world charts a different path.

View on HN

> “competition” won’t improve it or control it because there is always a supply side shortage of provision.

Why is there always a supply-side shortage?

Because the American Medical Association artificially restricts residency spots in hospitals. There's really not much more to it. This explains the proliferation of NPs, PA-Cs, etc acting as GPs. In reality, we simply need more doctors, so we should uncap the # of spots.

This can't be stated enough. I should have my comment w/ citations on standby, but I don't.

The AMA was concerned in the 90s re: "oversupply" of doctors and the impact on doctor salaries, lobbied the Republicans (around the "Contract with America" timeframe) and got language limiting NIH-funded residency slots codified.

The AMA is backpedaling on that stance now but the damage is already done.

A reasonable compromise would be a scheduled increase in the number of slots until it is eventually uncapped. Yes, this will reduce doctors salaries in the long-term. You know what else reduces doctor salaries? Importing medical doctors from foreign countries with worse wages and working conditions, and then grinding these individuals to the ground under the threat of immigration. The market finds a way, whether the AMA wants it or not. As Americans get richer, many are even just going to foreign countries to get treatment. I know several 'third world' countries have fairly good medical care available for very cheap.

Doctors salaries should be reduced, as should nurses and dentists. We pay them nearly twice as much in the US as in countries with socialized medicine.

As part of a policy position, I'm guessing that, "Doctors and nurses make too much money" ain't exactly a slam dunk.

Foreign doctors have to go through residency in the US.

What does the AMA have to do with the Clinton-era cap on federal DGME and IME residency payments? New York spends billions every year, California spends none. These are choices that Congress and California make every year, not the AMA.

Because human labor is supply side constrained.

There's only so many doctors, only so many MRI machines, so many valve stents, so many syringes.

Everything on earth is supply constrained.

It’s neither a matter of profits nor costs. It’s a matter of incentives. The basic principle of capitalism can’t work if the buyer doesn’t have a choice, if the buyer is not the one who usually pays, and if the payer has a way of avoiding responsibility to pay. The privatized health insurance system is truly and completely fucked up.

By definition a free market in healthcare requires forcing some people to die from a treatable injury or condition to discover the optimal price. That's part of the definition.

Because the supply is constrained I feel like that's the case regardless of how the system is financed. (There are only so many providers, facilities, etc.)

It seems like the core problems with US "system" come from having a "shadow" socialized system (by way of EMTALA[0]) that offloads costs onto the "free market" (read: patients or insurers who can pay) and a shocking inability to have a mature public conversation about how care will be rationed. (That conversation still happens but it's between providers and insurers and not subject to public scrutiny.)

[0] https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...

Only if free means pure or academic here.

Free market usefully means both sides can choose to participate in transactions which means price is how they do that. It is a useful concept but it doesn't cover everything, like what you mentioned and things like if emergency patients are shopping around hospitals or if the average consumer is capable of being well informed in such a market.

The buyer and sellers are frequently wrong. The buyer isn’t the patient, it’s the employer. The insurer is either charging a premium for risk or servicing work for a self-pay employer.

The biggest buyer is the Federal government and by law they are required to get the best deal, the government also restricts the supply of providers. It’s not a capitalist system at all. It’s a weird hybrid command economy with a consolidating cartel of providers and administrators.

> That’s $130b on a pointless activity that uses up physical resources that would be better deployed elsewhere in the economy.

No, it's much worse than that. How much time and money is spent by medical providers dealing with the billing?

Arguably at least twice as much -- the insurers have economy of scale that providers can't match.

And that's before you even get to the direct time and stress impacts on the consumer from bullshit denials.

The rest of the world has private healthcare on top of the public ones because the public ones are often inadequate.

Just go look for the local debate in any country with government healthcare and look for the parties who are pushing for change and their complaints.

Then ask yourself if you really would want the current administration in charge of your healthcare... if you'd like every four years to be a coin toss for how your healthcare was going to be for the next four years.

People arguing for public health care, are you ready to say you want Donald Trump to be in charge of your health insurance instead of a private provider? (because we're not in a magical fairy land where government is efficient and agrees with everybody's priorities)

The fact that a single person is "in charge" of the government, with the other two branches largely deferring all power to that one person, is a recent aberration from the norm in the USA. I'm for a single-payer health system that is administered by a well-checked regulatory apparatus and institutions that are not subject to wild policy swings at the whim of a single king-like leader.

>I'm for a single-payer health system that is administered by a well-checked regulatory apparatus and institutions that are not subject to wild policy swings at the whim of a single king-like leader

And I want to win the lottery, marry a princess, and for my childhood dog to come back to life.

We all want things.

When we're advocating for government changes we need to be realistic and make good choices. Right now throwing an enormous amount of power at a dysfunctional government (public health care) is an insane bid completely disconnected from reality.

We need people to care about the basic functionality of government and for it's various pieces to do their duty. They aren't, so maybe let's shelve the idea of handing over control of our healthcare to them until they can deal with their cowardice in front of an aspirational king.

At least elected governments are in theory accountable to the public through voting. Insurance companies and healthcare providers are not in any way accountable to the public, and the public has zero power (outside of regulation) to affect their actions. Just because public [X] is currently a bad choice doesn't make private, corporate [X] always a better choice.

Who cares about theory when the reality is a corrupt insane government was elected. We're not dealing with theory. Healthcare is too important to propose major changes based on theory instead of reality.

You DO have healthcare choices now. Consider the healthcare option provided when accepting a job is on the table, provide feedback to your employer about their chosen provider (i.e. say NO to United Healthcare). Even though it involves big life choices with private healthcare there ARE options on the table instead of what the electorate chooses every 2/4/6 years.

And people are pretty misguided. The typical HN crowd person would STILL HAVE private health insurance on top of the public care in almost any country today that has the public option. The public option is bad, slow, and has a habit of denying care. You'd be rich, you'd still want better care than what was available for free.

Before we go pushing money into private insurance, we need to define why. We need to understand why the public ones are inadequate and who/what drove those decisions.

A public health care system should be independent of politics. Unfortunately, as the latest administration has shown, even if you designed it to be independent, such as the CFPB, it doesn't matter with an autocrat in charge. On the other hand, private industry does not have all that good a reputation for not effing with your healthcare.

hard to take you seriously when you think we have an autocratic system.

Public healthcare in the US can work. Most seniors on traditional Medicare like it. Make that available to more people, and bob's your uncle.

I propose allowing buy into medicare at 5 years before regular eligibility. And a long phase in of lowering the eligibility age. Drop it by 6 months every year for 10 years, then 1 year every year for 10 years, then 2 years every year until everyone with work credits is eligible.

At the same time, start covering all kids up to some age with Medicaid (after all, kids tend to have no income, so if eligibility was based on their own income instead of household income, they'd qualify). First year, kids get covered until 6 months, next year until 1 year, etc.

When the Medicare and Medicaid ages meet, we have universal health care. It would take a long time to get there on my schedule, but it would be gradual, so everyone could adapt. And if future legislation could adjust the timeline as needed.

Also, clearly someone needs to add more residency slots.

Again, you're disconnected from reality.

Do you want Donald Trump to be in charge of public healthcare? Please stop suggesting we make all of those changes unless you're willing to say you want him to be in charge of it.

I'm thinking much longer-term than Donald Trump. I intend to outlive that orange cretin by a good number of years.

(You are, of course, free to be as myopic as you wish -- just as everyone else is.)

I'm also thinking longer term and am not so optimistic that he's just going to go away and the pattern he created won't be taken up by someone else (and the thing to be afraid of is someone else who isn't quite so stupid).

The dam may well be broken, Congress has proven to be full of cowards and the next aspirational autocrat might well win and do better.

I intend to live longer than that potential outcome, too.

Has he broken Medicare or VA health more than it already was?

I'll acknowledge he's playing games with Medicaid eligibility, but is he messing with the administration of care?

VA:

"Senate Veterans’ Affairs Committee Ranking Member Richard Blumenthal (D-CT) today released a comprehensive report detailing the harm and impacts of the Trump Administration’s draconian directives and cuts on veterans. The report, Breaking the Pact: Impacts of Trump, DOGE, and Doug Collins’ Ongoing Assault on Veterans, was released ahead of the Committee’s oversight hearing with Department of Veterans Affairs (VA) Secretary Doug Collins next week.

Blumenthal’s report reveals historic staffing losses at the Department resulting in dire workforce shortages, increasing wait times for life-saving mental health care, and veterans’ care and benefits being put at risk as a direct result of the Trump Administration’s harmful policies. The Committee report—compiled from extensive reporting, firsthand accounts, and ongoing conversations with veterans and VA employees across the nation—details the Administration’s systemic assault on VA over the past year and the tangible impacts its cuts are having on veterans."

https://www.veterans.senate.gov/2026/1/cuts-cover-ups-chaos-...

There are so many more options than a 4 year administration being hostile to the people it's supposed to represent. Corruption will undermine any collective action amongst honest collaborators regardless of what color their party flag is.

Also, having a baseline of public care and then private as an option on top doesn't sound like the boogeyman this is pitching it as to me. That seems like a great way to reduce the scope of what the state needs to be in charge of.

If the take is that government cannot possibly work for the people no matter what then yeah, all policy is bad.

Reply on news.ycombinator.com