You can get the free market back in health care once you can convince society in general that it's acceptable to let poor people die of treatable diseases. Until then, it's simply a question of how it'll be heavily regulated, not if.
"Posting prices publicly" is not the same thing as "completely deregulating the industry" or "repealing EMTALA."
Even the healthcare professionals can't estimate the price of care before providing it, because it depends on the outcome of things like surgery and reaction to treatments which cannot be predicted. So there's no way to tell the patient beforehand that their care will cost x amount. In addition to this the customer often doesn't know what they want and has no basis for making an informed choice before seeing a doctor. This is fundamentally different than (for example) selling products in a supermarket where costs are known up front, shops can vary prices and quality, and people can shop around. So the benefits of patient choice of hospital and treatment etc are questionable.
Other countries spend far less using a single-payer system with comparable or better outcomes than the US according to the statistics on life expectancy and expenditure per capita on healthcare, so IMHO the US should have more and better regulation of the healthcare market, not less. Cutting out the insurance companies completely would be a good start, as at present they run a racket extracting billions from the US tax payer for questionable results.
I call B.S. -- unless you're calling B.S. on the data.
There's something called "estimation" which comes in very handy when you don't know something with certainty.
If you have absolutely no idea, then you just guess the average cost for each patient with a similar background, with a disclaimer that it may not be accurate.
Problem solved, unless you don't want to do it because then it'll prevent you from ramping up the prices unnecessarily later.
This happens all the time in software. Non-techies put a project out for bid. They will get estimates from a variety of consulting companies. The estimates could easily vary by an order of magnitude. Do they go with the lowest, because they are the most efficient operation? Or is the low price a sign that they're the dumbest, and are underestimating? Do they go with the highest, because in a market economy price is correlated with value? Or are those guys just the gougers?
And medicine is worse, because things are so contingent. Complications get complicated indeed. And the person trying to make the decision is pretty likely to be sick. I tell you true: deciding what to do about cancer is hard enough without trying to organize and judge a multi-round competitive bidding process.
What exactly was I trying to prevent others from trying?
The conversation was about the role of the free market in health care.
User curt said that the only way to solve health care pricing was through the free market via individual choices. Mikeash said that would only work if we were happy to let people die of treatable diseases. Anonymoushn said that was a distraction, that the market would be fine if people could know prices up front. Grey-area said that predicting costs was basically impossible, so the market-based solution was unworkable.
You jumped in to say that prices were predictable through this new thing we hadn't heard of called "estimation", saying that this solved the problem. The problem, presumably, being how price opacity and unpredictability make a hash of individual-choice market mechanisms.
So I have no idea what you were trying to do, but as far as I can tell, it was either a) pushing people back toward an unworkable market-based solution for health care, thus preventing them from moving toward a solution that doesn't fit with the fundamentalist liberarian ethos so popular on HN, or b) you're doing this: http://xkcd.com/793/.
Given that you ignored the meat of my point twice in a row with nitpicky comments, as well as doing the same to the previous poster, I'm figuring b.
Predicting costs is a benefit regardless of whether or not we have a free market -- I was saying that nothing is completely unpredictable; estimating based on the average value of a treatment gets you much further than knowing nothing at all.
Claiming costs are inherently unpredictable is equivalent to calling B.S. on this report -- that the values in the report are meaningless. Clearly, they're quite meaningfull.
I never claimed estimation = "problem solved", I just said that it's a step forward that needs to happen. But you came along and just dismissed the idea because it wasn't a solution.
And my reply, which you thought was ignoring your comment, was that a step forward doesn't have to be a solution -- you can't just dismiss it because it doesn't stamp "Problem solved" on the bottom of the page.
Unless you or others are claiming that being given an estimate of costs HURTS anyone, I don't see how you can argue it's a bad idea. "Problem not solved" never solved any problem.
Predicting costs is not an inherent benefit. That only is useful if somebody will change a decision based on the prediction. Otherwise, it's wasted effort. My mom was on Medicare throughout her cancer treatment, and I promise you: not knowing the costs was perfectly fine.
In fact, not knowing was better. The cognitive load of a major illness is huge. Not knowing is also better for most medical personnel. Their goal should be to maximize patient outcomes. Asking them to juggle some sort of cost-benefit tradeoff in the middle of treatment adds an insane and impossible burden.
Also, you quite literally did say "problem solved" after proposing SWAG estimation as a solution to a problem. Maybe you wanted me to have some other understanding, but I have no idea what it would be. And, since you admit you are off on some sort of tangent, I don't really care.
In fact you can do that before the need for care is even known, and you can call it insurance.
If I don't have insurance, I may be swayed by the $100,000 price, but either way they'll have to sue me to get all of the money that they ask for.
Not all emergency room decision-making happen with blood pumping out of your pulmonary artery. There are parents who take their babies to ERs, and through repeat business decide to like one better (maybe because it's cheaper, maybe because it's a bit more expensive, but never have any waiting time) than the other. There are consumer reporters who will look into why one hospital is cheaper than the other. Smart phone "Yelp for hospitals".
EDIT: Forgot the conclusion: This will drive down prices in the general case, which will also result in lower prices for the emergency case, even if in an emergency you don't have the luxury of calmly evaluating all the options.
> Also, how shall people make an initial determination on care when no diagnostics have yet to be performed?
The same way you decide which restaurant to go to before you know exactly which dish to have: Ranking by a general cost/quality scale.
But maybe I'm projecting, since my experience with ERs tends to be "Oh shit... get me to a hospital now Google Maps" rather than "I should Yelp some reviews of hospitals, because I have time."
Some people will live 10 minutes from one ER and 45 from the next. But some will live 25 from one and 30 from another. Or have three within 15 minutes (ie. short enough that they're equidistant for "the baby has colic"). Some will have more time than money and drive 45 minutes if it means saving $20.
But there's another factor in free markets you're not accounting for: new entrants. If an ER charges high rates because they're the only player in the area, someone could set up a competing ER and charge less.
I'm not in the medical industry (but my g/f was seeking out her own insurance recently), but I would guess that the ER would work similar to a car mechanic. Where the paperwork you're already signing upfront includes a flat price you're paying for diagnostics. Then after the diagnostics (or possibly at the same time you signed the diagnostic paperwork), you agree to a price range for treatment/tests. It would itemize the fixed costs and estimate the variables. If things go outside of that range, there's an amendment. You walk home with the bill.
etc etc.
That way patients can ask the doctors if the tests are actually needed.
You're right that emergency care becomes a lot more complicated.
I really think a big part of the problem in healthcare pricing is insurance company policies regarding networks and guaranteed volume. Your auto insurance doesn't demand you use a certain body shop, why should your health insurance?
Here's a practical example that recently came up for me. My wife is a nurse at a few clinics. At one clinic, she's got health insurance and that clinic provides IUDs via their hospital, which she wanted to get. At this clinic, the price billed to her insurance would be $4700.
At another clinic she works at, she could get the same IUD brand and procedure for $600.
When she asked her insurance about it, they said they would pay 100% of $4700 in-network but 60% of $600 out-of-network. Obviously, being selfish, she decided to let the company eat the $4100 they would otherwise save so that she would pay $0 instead of $240.
It may well be they paid less than $600 for a procedure that lists at $4100.
And of course the government numbers don't take this into account, so what they've published is pretty much worthless.
I don't disagree with you that insurance companies negotiate different discounts, though, which is what I was trying to get at in my post regarding pricing.
You know what is wild though? Federal employees aren't insured by medicare but instead the federal govt pays private insurers to insure them!
If the Feds went to single payer for its employees, things would change quickly.
How does this work? If a doctor prescribes a blood test, he's already said it's needed. Put yourself in a doctor's shoes for a minute. You told the patient he needs a blood test. Then he asks you whether it's actually needed.
How can you possibly say "Nah, just kidding. We don't need that one"?
If they have absolutely no idea what the possibilities are then they wouldn't be ordering tests anyway.
No they don't, except in very rare cases. Doctors order tests to make a diagnosis. The treatment follows from that.
>If they have absolutely no idea what the possibilities are then they wouldn't be ordering tests anyway.
I'm not sure a doctor would have "no idea what the possibilities are" unless you don't have any symptoms. If you don't have any symptoms, why are you at the doctor's office?
What I said didn't contract what you said. If test => diagnosis => treatment then test => treatment.
I don't believe that. Over the years I've had to fight to get tests that turned out to be important, and I'm suspicious of government studies showing "overtesting" right when the government is in the process of taking over health care.
You can certainly eliminate a lot of testing without affecting mortality rates significantly. But that's because in absolute terms a lot of extra people have to die before mortality rates are affected significantly.
Right.
And that's just plain immoral.
That something is subjective doesn't mean that it's unknowable. Justice is subjective, but that doesn't mean we should abolish the courts and the police. Those institutions will never be perfect, but we can nonetheless always work toward perfection.
We evaluate the legal system in large part by whether the outcomes are just. For example, the revision of the three strikes law in California is happening because a number of people have received obviously unjust sentences. And we got the law in the first place because many people thought that letting serial offenders free to harm people again was unjust.
"Equitable" is another one of those ideals, and that it is just as subjective as justice or health. But we can work toward it.
One could just as easily ask "Which is the greater moral disservice - a global food distribution network that ensures every person will have safe sustenance, or letting people starve because of regional droughts, tyrannical governments, and currency speculators?" but the question does not apparently lead to any actionable policy decisions.
Just like health care works better when it is provided by a single payer.
* In the case of shelter, temporary shelter for those who need it is also provided free of charge, but that is not the normal situation for most people.
I'm a pretty big fan of the swiss model, I think it contains the best of both worlds:
You're forced to buy a certified policy with a certain (broad) coverage. If the cost of such a policy exceeds 8% of your annual income, government makes up the rest.
Both insurers and providers are regulated heavily for quality control, but compete freely for their business.
The result is a generally consumer driver system, as opposed to an insurer driven (US) or state-bureaucracy driven (most of Europe) model.
We've still got all of our previous healthcare systems (Medicare, Medicaid), but the ACA added mandatory insurance with specified minimum coverage, and helps pay for the insurance of the poorest people.
There are only two measures of effectiveness.
Per capita costs and life expectancy.
How does Switzerland rate?
Uh, no. Health care is a lot more than keeping people alive.
Cost: More expensive than the European average, quite a bit cheaper than the US.
Life expectancy: second in the world, at 81.81.
https://en.wikipedia.org/wiki/Healthcare_in_Switzerland
https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...
EDIT: And, since it apparently wasn't clear from context, by "best of both worlds", I mean that it manages to get a competitive, consumer oriented system without sacrificing universal coverage and regulation of quality.
Adopt the phrase "patient oriented system" and I'm totally on board.
It may correlate reasonably well, but there are plenty of ways life expectancy can be the same for systems with very different level of "wellness". For a long time, Sweden had special wards for people in persistent vegetative states because there was no provision for ending care, for example, resulting in people being kept alive for years long than they otherwise would. I believe they loosened the requirements for ending care quite a while ago. But there are plenty of other ways that life expectancy can correlate badly with "wellness", e.g. poor treatment of patents with long term conditions such as dementia where patients can often easily survive for a decade or more but where quality of life can be massively different depending on treatment.
I've spent much time in critical care, as both a patient and an advocate.
Quality of life is of utmost importance. I support DNRs, euthanasia, and so forth.
But I would not presume to impose my values on anyone else.
In the free market you could argue that 'customer satisfaction' is the only measure of effectiveness you need to consider. Equating customer satisfaction with best solution fails in everything from automobile ratings to elections.
For example if you increase the tax on cigarettes you increase life expectancy.
And if you increase immigration, and therefore decrease the average age of your population, you will decrease per capita costs.
>Per capita costs and life expectancy.
This is laughably wrong. The biggest influence on life expectancy isn't the medical system at all - it's the lifestyle habits of the populace. Genetics play a big role as well.
They also need to keep their cost under control, as their cost determines their profitability: The rate they get paid to take NHS patients is set across the board.
And if/when the NHS sees the cost of providing certain care drops across the board, they can and do push the price they are willing to pay for it down.
The UK incidentally has a healthcare system that is substantially cheaper than the US, yet ranked substantially higher by the WHO.
[ I'm assuming that you mean 'insurance providers' and not 'medical care providers.' ]
Strictly speaking, they don't.
But they have a strong incentive to limit costs because of insurance company reimbursement policies and the conditions for getting "in network" for HMO-style plans.
Good question, I don't actually know. Surely the insurers will make them compete, but that should also happen in the US, and obviously not fixing the problem.
This already happens if you have poor dental health.
For Want of a Dentist http://www.washingtonpost.com/wp-dyn/content/article/2007/02...
Man Dies From Toothache, Couldn't Afford Meds http://abcnews.go.com/Health/insurance-24-year-dies-toothach...
Obamacare, AFAIK, excludes dental care. Dental care is somehow considered "vanity" medicine, even if prosthodontics are medically valid.
I would imagine that the US is also among the greediest countries in the world.
Odd how it can work out that way with percentages.
[edit: grammar]
From http://www.charitynavigator.org/index.cfm?bay=content.view&#... we learn that:
- Total giving to charitable organizations was $298.42 billion in 2011 (about 2% of GDP). This is an increase of 4% from 2010.
- Giving by individuals (which includes bequests and family foundations) is critically important as it represents nearly 9 out of every 10 dollars donated.
- 32% of all donations, or $95.88 billion, went to religious organizations (down 1.7%). Much of these contributions can be attributed to people giving to their local place of worship. The next largest sector was education with $38.87 billion (up 4%).
- Donations were up to health charities (2.7%), to public benefit charities (4%), to arts, culture, humanities charities (4.1%), to International charities (7.6%), to human services charities (2.5%), to environmental and animal charities (4.6%).
For comparisons to Europe, check out: http://www.american.com/archive/2008/march-april-magazine-co...
- Per capita, Americans give 3.5x than the French, 7x Germans, 14x Italians.
- Americans are 15% more likely to volunteer than the Dutch, 21% more than the Swiss, 32% more likely than the Germans.
The pattern holds true across many demographics (education, age, income).
Second, while many of the donations were to religious organizations, many food banks, shelters, etc are run by the same institutions. Assuming those categories are mutually exclusive is risky at best.
My observations are that Americans definitely look out for themselves. People tend to give (as you stated) in ways that directly or indirectly benefit themselves.
These are broad generalizations but having lived here for 30 years I'd not consider our society to be generous by any stretch of the imagination.
Now, in the techy world I work in, I can find a wealth of self centered pretentious types who are more concerned about how their seen that what they see.
No charity has, or ever will, end major problems like hunger or poverty.
Make a Wish Foundation crows about spending 76% of funds on programs. If the SSA were as efficient as Make a Wish Foundation, it would have an overhead of an additional $185 billion a year (i.e. approximately equal to all federal payroll expenditures).
The government probably has a worse QALY because it runs Medicare, but that's not the government's fault -- anyone who runs the medical care program for old people is going to have horrible numbers there.
(You are more likely to die if you are on Medicare than if you are uninsured. This isn't because Medicare is killing you, it's because old people are on Medicare.)
In addition, we'd have to examine marginal-QALY versus average-QALY. Depending on the question one or the other could be more important.
Americans freak out whenever anyone tries to do QALY measurements, so we don't know just how good (or bad) our various programs are, public or private.
"Medicaid" is the program you're looking for, not Medicare. Anyway, Americans did willing give money to "help the poor" get medical treatment. There were various organizations that operated charity hospitals (Shriners and the Catholic Church come to mind) where you paid what you could pay, and Americans donated generously to keep those hospitals running. It was normal for doctors to put in some amount of unpaid time in charity clinics because that was considered the right thing to do.
But the government crowded all that out, and since it's been a few generations people don't remember.
>I would imagine that the US is also among the greediest countries in the world.
This isn't even close to being right.
Don't remember where I read it, but someone had a good line about youth pastors essentially playing the role of cruise ship activities coordinators.
That's right, they will let you get sick enough to need intervention, and if you can't pay, they'll try in the meantime to find a gov't program to foot the bill.
Our current method of deciding is to stick our fingers in our ears and pretend it doesn't matter. Anything has to be better than this.
Give me a proposal that stops poor people from dying of treatable diseases (or at least gives the appearance of legitimately attempting to, as is the current state of things) while preserving market forces, and I'll change my mind. I've yet to see one, though. Not being allowed to refuse treatment screws up too much.
No such proposal exists. Any proposal that does requires a third party to intervene as either an angel to donate whatever resources are needed or as an agent enforcing policy that one group of people must provide services to another group of people regardless of means.
Both of the aforementioned scenarios do not exist within the realm of market forces because market forces cannot make guarantees.
People will always die because they don't have the resources to fix what ails them. We can only hope to lower the amount of resources to get treatment, and "market forces" are absolutely a legitimate solution to that.
But if you're stuck on "stop people from dying from preventable diseases" or "appearing to do so", then you've implicitly ruled out market forces completely.
We are in agreement. My point is that society is stuck on this (note that I have made no value judgment in these comments myself) and until and unless that changes, market forces are implicitly ruled out.
See my comment elsewhere on the swiss model.
It's easy to say a Big Mac isn't worth the cost on the menu, it's harder to say that your mom's life isn't worth the cost.
Keep in mind we're talking purely about economics here, as that is what your post is about. We're not talking about quality of life.
It's easy to say "if you didn't want to be poor, you shouldn't have bought that plasma tv or new smartphone", versus "if you didn't want to be poor you should have let your wife die instead of taking a second mortgage out on your house".
Most people do not have a maximum price on something they consider priceless.
I'd fully support your right to opt out of taxes if you also opt out of each and every benefit society otherwise provides you.
Personally I'm far more comfortable with a board under democratic control setting rules based on clinical considerations for whether or not someone is suitable for care, than having someone with a profit motive to avoid paying for my care making that decision.
In general, I think this kind of decision is highly personal and dependent on circumstance, and cannot possibly be regulated at the federal level.
In the UK this is handled by NICE: http://www.nice.org.uk/
They conduct appraisals of technology and medicine, and the NHS is required by law to provide treatments that NICE recommends.
The NHS trusts may elect to provide funding for additional treatments, though.
A number of their working groups etc. are open to healthcare professionals, and some are open to patient representatives, carers and lay people. Consultations are open to anyone. On top of that they are accountable to their sponsoring department.
Overall, this system works. You hear people complain about wait times for non-essential treatments, but everyone gets treated.
As opposed to the democratic decision that's already being made in board rooms?
Nobody's killing anybody. People die. It happens. Maybe someday I will have a heart attack. On that day, I'm not going to rob somebody at gunpoint and demand they give me $33k. Equivalently, I'm not going to have the government threaten fellow citizens with jail time and garnished wages if they don't pay their taxes to pay for my treatment. And I'd appreciate it if they'd extend me the same respect.
Why bother eating right or exercising? Fuck, why not just off ourselves and save all the hassle.
There's absolutely no difference amongst the different kinds of things people can die from, especially ones that are easy to fix and ones that we can't do anything about.
Hey, we actually came back to the point, kinda! There's a lot of things you can die from that fall in between "easy to fix" and "can't do anything about it". Where you draw the "fuck it, people die" line is hugely variable between different people, and it's not something you'll find a shred of consensus on across the 300,000,000 people in the USA. It's better for people to negotiate coverage with individual hospitals (and voluntary charities) than to have standards of care dictated by a central authority.
I have not heard of my local hospitals refusing care. If anything the ER seems to be majority sniffles or need a ride people.
None of us are born in hock to the needs of others. If we were, that would be moral slavery.
All of us are born incredibly dependent on others. After a long period of investment, we can function on our own. (Well, if by "on our own" you mean "without being directly dependent, but requiring a rich and complicated society where other people take care of most things for us".) Most of us choose to pay that forward by contributing to the maintenance of society and the species.
If you don't want to, godspeed. There is no law preventing you from being a selfish ingrate. You are allowed to opt out at any time and move to a country that is less interested in, say establishing justice, promoting the general welfare, or securing the blessings of liberty for the citizenry current and future.
For example, I hear that the tax rates in Somalia are very reasonable. Do start a blog! And maybe we can start a pool on how long you'll last in a place where helping others to survive is seen as optional as having a new TV.
"Others" as you use it is far too imprecise. A person is born dependent on his parents, who have an obligation to raise him once they've chosen to carry a child to term. That obligation does not extend to people that didn't make the choice to bring the child into the world.
Also, you're attacking a straw man. I'm not an anarchist.
Sustaining a rich and complicated society requires that people act as traders. That entails producing things that are valuable to others, in exchange for things that are valuable to you, quid pro quo. And that requires a government, whose sole duty is to retaliate against people that try to bypass that process by force or fraud. A market cannot exist without an objective arbiter that keeps the peace (which can only be accomplished by having a monopoly on force - private armies, courts, police forces would lead to war) and enforces laws.
I always find that a little depressing with libertarianism, as there's enough useful material there that I hate to see fanatics turning people off to it. There's a giant difference between "an important function of government is" and "government's sole duty is". The latter is appealing to people looking for simple answers to complicated problems, but is actively off-putting to everybody else.
I understand you don't think you're an anarchist, and, for a different reason, I'd even agree. I think the step-over-the-dying school of libertarianism would turn out, in practice, to be indistinguishable from the sort of chaos that people who don't know any actual anarchists think when they say "anarchy". (The interesting sorts of anarchism, like what the anarcho-syndicalists were pursuing, depend upon a human moral sense. Which, bringing this back, include compassion for the ill.)
The reason things will fall apart lies in another gap in your thinking. Parents are the most obvious thing a child depends upon. But try telling a teacher or a grandparent or a cop or a social worker or a neighbor or an aunt that they don't matter, that they don't have an impact on the kids they deal with. It takes, as they say, a village. Or, if you'd like a richer society, a lot more than that. You'll of course wave that away as inconsistent with your chosen theoretical framework. But that you can't perceive the value in something doesn't prove that it's valueless. It only shows you haven't bothered to really understand it.
In this case, though, I'm not expecting anybody to move to Somalia. I'm pointing out that places with no effective social contract or taxation system are hellholes. It's not a literal recommendation; it's a reductio ad absurdum to show that the poster's views aren't thought through.
You're making the mistake of defining "life" as only the things you need to for physiological/material functioning. But there's more to life than metabolism!
A human life also includes art, music, fine cuisine, fresh cut flowers, travel, and an almost endless number of other things, depending on whose particular life you're talking about.
Think of someone that loves movies. He definitely needs a new TV to live, and he's got a right to it as long as he's earned it.
I don't advocate that people not pay taxes. That's just a good way to get fined and/or go to jail. But I do advocate that people fight to abolish taxation, and especially the ethical ideas that support it.
Yuck. Never mind I'd rather not debate this with you.
I'm not an anarchist. We need a government! Without creating the conditions necessary for a market, that market cannot exist. What are those conditions? The only fundamental one is to retaliate against anyone that initiates physical force against another. (Examples of this include murder, theft, fraud, assault, etc.)
And then you'll need a financial system to pay for it, which means you will need some sort of currency combined with laws to regulate counterfeiting and some sort of contract law to let people make deals. Oh, and it might be an idea to have a boundary so people know where the law is valid, as well as a language in which the law is written, which means it's a good idea to educate people in that language.
Then what happens if someone doesn't initiate force against another, but just abandons them - eg a mother abandoning her child. Has she committed a crime? What about international fraud? Better have inter-country arrangements in place. But then you might need diplomats, and maybe an armed force just in case.
I could go on. My dream if ever a libertarian paradise comes to fruition is to buy up a one mile strip of land fully enclosing a village and refuse everyone the right to cross it - food delivery, immigrants, emigrants - everyone, trapping the people inside and letting them starve. After all, I can do whatever I like with my property, and the only law we need to implement is property rights, correct?