Comment by tptacek | Hacker News Reader

Comment by tptacek | Hacker News Reader

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Give me a break. Republicans are anti-public health care because public care sets in motion a process that moves care decisions into federal bureaucracies, which is absolutely a problem that Canada and the UK have.

Also, health care is ineluctably two things: a vital necessity and a commercial service. With a single payer, the commercial service objective is warped: patients and doctors are motivated to make care decisions that are inefficient or even harmful, and customer service or premium care for people who want it is eliminated.

Finally, from a philosophical perspective, single-payer implies that the government sets rates for care. Health care is not a natural resource; we don't sell land rights to extract health care to people who drill for it. Doctors spend years and years driving themselves into debt to become care providers, and drug companies sink billions into research for pharmaceuticals. The market for health services is fucking gigantic. It is legitimately daunting to consider replacing that market with a command economy!

I am pro-public-option. But don't pretend that Republicans, conservatives, libertarians, and people who understand health care economics are crazy or corrupted for opposing single-payer.

There is a big difference between single-payer and a nationalized healthcare system. In the latter, doctors are government employees. The UK and Canada work that way, and choose to spend very little money on healthcare. But most peer nations have single-payer non-nationalized healthcare systems and choose to spend more than Canada and the UK, but much much less than the US.

With a single payer, the commercial service objective is warped: patients and doctors are motivated to make care decisions that are inefficient or even harmful, and customer service or premium care for people who want it is eliminated.

See, this is not true at all. Consider the French system. Basic care is provided by a government plan, but doctors don't work for the state and everyone can supplement with private coverage if they want to pay extra.

Single payer implies that negotiations, budgeting, and coverage decisions are made by the government, who is the "single payer" the term refers to. That doctors ostensibly work for private companies doesn't ameliorate the Republican concern here.

But the existence of the French or Japanese or Dutch healthcare systems do. At some point, empty theorizing has to give way to observation of how these systems actually work in practice. In practice, all of these systems provide care that is much much cheaper than the US system with very high levels of public satisfaction.

Also, I think you're wrong in claiming that the Republican party rejects single payer for those reasons. The Republican party loves single-payer healthcare for old people. They expanded the single-payer program for old people massively and they make political hay out of any efforts to reduce its spending.

This comment does not respond to the issues I brought up in my comment at all. In fact, my comment ends with "I support single-payer". Did you think I was arguing that it was unworkable? My issue was with the mischaracterization of the Republican position.

The Dutch system, for what it's worth, strongly resembles the trajectory we are on with PPACA: guaranteed-issue private health insurance and Medicare.

Note, for what it's worth, the Dutch system does not work as well as that of our neighboring countries. Here people often have to wait a long time to have something done, whereas for example in Belgium you are helped much quicker (resulting in some Dutch people going to Belgium for healthcare).

It appears that the model for the US more closely matches that of Switzerland, for what it's worth. That might just be me idealizing it, though.

There are lots of different systems of health care. Even though in most places the government pays the bill, the method of implementation varies widely.

"doctors are government employees"

Not all doctors in the UK are government employees working in the NHS - there is a private health care system here as well. Nobody makes you go or work for the NHS - but you do have to pay for it - I have private health insurance from my employer (I would never pay for it myself although I could afford it) and I'm quite happy to pay for the NHS.

NB My son was born in an NHS hospital, when he has had an accident it's the dedicated NHS childrens hospital he gets taken to, when my wife got seriously injured climbing it was an NHS hospital that treated her - all of which were awesome. The NHS is far from perfect but I like knowing that everyone in this country can get a decent standard of healthcare free at the point of delivery "In Place of Fear":

http://en.wikipedia.org/wiki/Aneurin_Bevan

The entire private health care budget in the UK is £5Bn. The second largest purchaser of private care in the UK is... wait for it... the NHS. The NHS budget is over £100Bn. The government has overwhelming control over the health care market of the UK.

But as a consumer of health care in the UK I'm struggling to see what the problem is - the NHS is cost effective and generally available and if you want a slightly nicer room and to jump the NHS waiting queues (which do happen) then you can go private and get any kind of treatment pretty much when you want it.

I'm not saying there is a problem with it, I'm just saying that the existence of a PH market in the UK is not a strong counter to the Republican concern about a government takeover of the market for health services.

Sorry I was reacting (probably a bit emotionally) to the assertion by another poster that all doctors in the UK are government employees - which makes it all sound far too much like some kind of Soviet bloc nightmare.

Indeed, and that is perhaps one of the two coherent claims made by republicans against a decent public options (single payer or otherwise).

Coherent Claim 1: The existence of a public option harms the viability and structure of a private option

Coherent Claim 2: A healthy, careful individual should not be forced to subsidize an individual who does not take care of their own health - but is forced to by a public option.

Both claims are a matter of opinion; It is my opinion that it is no different than police, school or war. (1: The existence of police harms private security; the existence of public schools harms private schools; the existence of the US army harms private mercenaries. 2: I should not be forced to pay for protecting someone who does not make an effort to protect themselves; I shouldn't be forced to subsidize teaching to anyone; I shouldn't pay for a war I didn't ask for).

I'm not sure why health care, which is sometimes (literally) a matter of life and death, and about which one has much less control than anything else, would not get a public option when schools do. And I have yet to find a republican who was coherent about why, if public healthcare is a problem, should we not also abolish police departments and public schools. But I guess one might exist.

The bigger problem with the republican standpoint, is that the coherent arguments aren't even made all that often; instead they tend to spread FUD with arguments that are easy to refute if you just care to look at examples - see, e.g. : http://news.ycombinator.com/item?id=4888507

Those two "coherent claims" are so broad that they capture most of the the individual specific arguments made against public health insurance; a conservative could reply that there are only a few "coherent claims" for public insurance too.

And, obviously, Republicans aren't big fans of public schools either. In fact, unlike private health care, which is out-executed by Medicare, public education is generally outperformed dollar-for-dollar by private education. (Note: I am strong, strong supporter of public education and oppose vouchers).

> two "coherent claims" are so broad that they capture most of the the individual specific arguments

That's not been my experience (I linked to a discussion from a month ago, but you can find the same points reiterated in this discussion by others). Those "other points" are not remotely covered by these two claims, and are touted far more often.

> a conservative could reply that there are only a few "coherent claims" for public insurance too.

That's true; perhaps it's just one claim - but it's a matter of fact, rather than opinion:

1. Every western country that implemented single payer spends significantly less for comparable or better results (normalized by just about every attribute you want)

(corollary) 2. Medical bankruptcies (that is, attributable directly to cost medical treatment, rather than, say, the inability to produce income due to sickness) are essentially nonexistent in any other part of the world, yet are the reason for more than 25% of US bankruptcies http://www.factcheck.org/2008/12/health-care-bill-bankruptci...

re: education - I'm with you on that. That's also something that the US can learn from other western countries - where generally, public education (at all levels, including preschool and academic levels) outperforms private education.

Your support of public monopoly education is interesting to me, as your comments on this thread make you sound like a thoughtful, well-informed person. Presumably there are some aspects of public monopoly education you would like to change. Do you support seniority-based pay scales, strong unions, and teacher tenure?

There's a few education economists that have noted that if we could fire the worst 7% of teachers in the US and replace them with merely average teachers, then the US would have the best schools in the world (Eric Hanushek out of Stanford is one). This is a vital and cheap policy for us to carry out, but it is well-known that you can't get fired from government jobs. I can't imaging school systems being the first to change.

Do you think it is politically possible to reform the worst parts of the public monopoly school systems with its current structure? School boards in population-dense areas are often staffed exclusively with union representatives. What model of the world convinces you that these school bureaucracies will do what is right for the students?

I find the arguments for student educational choice to be compelling. In a place like Washington DC, I think it will be much more effective to simply pay for the students to attend good schools than to reform schools that have been horrible (and overfunded!) for decades.

You say that like it's a bad thing.

Most Family doctors in the UK are self employed anf their surgeries have contracts with an local primary care trust. There are other models as well and big changes in the arrangements this year. The organisation of the NHS is complex (this is not a criticism).

No doctor in Canada is a government employee. They are all self employed, and some even receive payments privately.

The issue you are getting at is that for some (most) services, only the Government can be a "legal" customer.

Having a single "customer" and having a boss is a pretty fine semantic distinction, don't you think?

Yes and no. "most" is not equivalent to "all", and there are several private health practices in Canada.

http://falsecreekhealthcare.rtrk.ca/ http://www.csc-surgery.com/

There is an ever increasing grey area in Canada with regards to what procedures can be paid for by entities outside of the Government.

It was actually recently found unconstitutional to deny someone willing to pay directly their medical services.

The UK and Canada work that way, and choose to spend very little money on healthcare.

And yet going to the doctor or the hospital in the UK is a relatively painless experience, other than in the clinical context.

> Republicans are anti-public health care because public care sets in motion a process that moves care decisions into federal bureaucracies, which is absolutely a problem that Canada and the UK have.

I thought that it was supposed to be state bureaucracies, rather than federal? Isn't that why states are supposed to set up their exchanges? (And the feds will only step in if they don't?)

Regardless, republicans say a lot about wanting a small government that gets out of the way, but their actions speak much, much louder than words, and they are not aligned with the "small government" mantra.

I don't think the size and investment costs of physicians and pharma are incomparable to natural resources. Oil companies have great investment costs, their market is huge. Rather I would say it's the complexity, dynamic nature and innovation of healthcare that make it unfit for a command economy.

Advanced technology is the single biggest problem in healthcare today. Expense is damn near the only natural limit on quality of service that can be provided. It's impossible to have a rational conversation over how much we should spend to keep someone alive in their last months.

> Republicans are anti-public health care because public care sets in motion a process that > moves care decisions into federal bureaucracies...

Corporatists oppose "public care" because it's pro-labor. Insurers and pharma oppose anything that will lessen their profits.

I have no idea why any one else would oppose universal health care with a single payer using the capitation model. Probably something they heard on talk radio.

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