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Comment by jjoonathan | Hacker News Reader

You beat me to it! (For those who don't know, the PPACA is sometimes called "Obamacare" although it should be noted that the name is more a result of political maneuvering than the result of particularly close affiliation with Obama.)

I still think we should go all the way to single-payer. Other countries have had such success with this model that it's becoming very difficult to argue that it's inherently flawed (rather than the other way around). If the US health industry had to compete directly with any of these systems, it would go out of business tomorrow, since they offer similar care (in terms of outcome rates) at half the price per person. That doesn't even include the effects on entrepreneurship and employment!

While the ACA did little to fix the "US health care costs twice as much and doesn't deliver better outcomes" problem, it does have a good shot at fixing the preexisting condition and individual insurance debacles.

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I agree it's not really a proper solution. My move from the U.S. to Denmark has been smooth when it comes to healthcare; I've been very impressed at the lack of paperwork and lack of stress over my coverage. But nonetheless I grudgingly supported PPACA, despite it seeming like a mess, because I can't see another way to solve the tied-to-employers issue that's politically feasible, at least for now.

It may become easier to reform healthcare if/when people see that PPACA doesn't Ruin Everything Forever.

The kind of sentiment that breeds that ignorant opinion is propegated by those that don't want to see single payer because it hurts their profits. The health insurance / for profit hospital / big pharma lobbies are aburdly massive, and like many (most nowadays) industries, they abuse their wealth to exploit faulty political process to see what they want instituted brought into law and to keep advances that invalidate their profit centers from being legal.

If you have a plan to fix the entire American political system, I will happily listen. I just spent 2.5 years working tech in US politics and it did not fill me with optimism.

When you have eliminated the implausible, whatever remains, however distasteful, must be endorsed.

I recall even Ted Kennedy somewhat later in life commenting that not reaching a compromise with Nixon's health-care proposals in the '70s, flawed as they were, was one of his major regrets, because the end result of holding out for proper reform was that here we were decades later, and nothing had gotten passed at all.

The Nixon proposal is an interesting one in retrospect. In some ways it's "left" of PPACA, despite at the time being opposed by Democrats, who preferred a real public plan and criticized Nixon's as a sellout to insurance companies. Although it wasn't single-payer, one of Nixon's proposed compromises would've actually included a public plan as an opt-in possibility (but not the default), reminiscent of the "public option" that more liberal Democrats unsuccessfully tried to include in PPACA.

Single payer is not necessary to have a good health care system. Proof: Switzerland [1].

[1] http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/c...

That link gets UK healthcare wrong. There is private insurance in the UK too, and you can directly buy private treatment. We have a mix of both. Most people do without because the NHS covers everything they need.

There is a relatively insignificant amount of private coverage in the UK; something like 5bn versus 110bn in public coverage, and the NHS is a very large component of that 5bn (as a buyer) as well.

Massachusetts already has much of what PPACA provides as "RomneyCare", a.k.a. the Massachusetts Health Connector and MassHealth. It's exactly what allowed me (as a Type II diabetic) to strike out on my own without much concern.

I pay ~$430/mo (early 30s, single) for a high-deductible plan with low co-pays from a major carrier with no co-insurance. Do I wish my costs were less? Yes. Is it better than having to be someone's employee? Hells yes. Providing this to the entire country isn't the ideal solution for everyone, but it's a big step in the right direction.

> Other countries have had such success with this model that it's becoming very difficult to argue that it's inherently flawed ...

The British NHS discovered that by not feeding hospitalized patients they could realize tremendous savings in food, shortened length of hospital stay, followup costs, etc.

> half the price per person

Health care spending will dramatically increase under Obamacare. Americans spend a lot on health care as a lifestyle choice. Obamacare is nothing more than an attempt to recreate the housing bubble using health care.

> The British NHS discovered that by not feeding hospitalized patients they could realize tremendous savings in food, shortened length of hospital stay, followup costs, etc.

That's a lie. Try checking your facts next time:

http://fullfact.org/factchecks/nhs_malnutrition_death-28806

Oh, and by the way, the NHS costs us less than US public healthcare costs. Meanwhile, I can get zero deduction, all additions, money for any nights spent in an NHS hospital, private health insurance for $150 a month. How much does yours cost?

The story was covered extensively by bloggers over 5 years ago, and appeared in the press periodically since. Basically, the local NHS trusts fired a lot of hospital staff to save money. They replaced them with service contractors.

So instead of a trained nurse feeding helpless patients, a gormless food deliverer drops a tray off at the patient and leaves. On paper they are still being fed, but in reality patients were starving during the trickiest few hours of recovery. But look at the costs drop!

Similar cost cutting was done for the building caretakers and similar staff. On paper everything is the same just more efficient, but in reality the floors are not getting cleaned, nobody is bringing round tea for the surgeon in the middle of a 12 hour procedure. But look at the costs go down! Look at the readmission rate drop!

Even if true, this seems like it's focusing on one tiny aspect of NHS administration and blowing it up to declare that universal healthcare is somehow ineffective. I'm sure you can find a multitude of issues in private healthcare where cost cutting measures are systematically impacting end patient health.

When looking at whole system costs and value delivery, it's really difficult to conclude that the American healthcare system is anywhere near as efficient as other national universal health care systems.

Well, yeah, except that the starving patients bit never actually happened. That's the bit you're missing.

I know that they had some problems with some NHS trusts as they went more "efficient private sector", mainly with cleanliness, but this was not pervasive throughout the NHS and suggesting it was commonplace is a flat out lie.

Once again, I am not talking about the recent media fight about arguably-cooked statistics. I'm talking about reports from a variety of sources starting in about 2007, including nurses and doctors. If it was a disinformation campaign, it was curiously extensive for not having been used in a media campaign of the day.

Links, fact and numbers. Not "I heard it on the Internet so it must be true". If you're going to accuse the nurses and doctors who work in the NHS of criminal negligence, you ought to have the decency to at least check your facts!

And you never got around to answering my question: is your private insurance cost competitive with UK private insurance?

I see from your linkedIn profile you are a defense contractor in Oklahoma. As is typical of defense contractors I encounter, you yourself make your money from a large, taxpayer supported industry while criticizing other nation's taxpayer supported industries that actually fucking do something, instead of supporting a standing army that is 5 times bigger than it needs to be.

I have nothing against defense contractors, but I do hate ones that have hypocritical small government, conservative political views. Please feel free to put your money where your mouth is and go work in a free market industry. The taxpayers pay your company, and therefore your salary and health insurance.

You appear to be reading rather a lot between the lines. I am not, and nothing in my comment suggested, that government involvement in health care is inherently bad. Nor was there any mention of conservatism, small government, etc.

I merely pointed out that nationwide programs tend to go horribly wrong. Obamacare in particular failed before it was introduced since American health care is already cheap, and any good ideas it might have incorporated were destroyed by its secret process of creation and lack of feedback.

Incidentally, defense workers are ideally positioned as experts on national health care schemes. We have seen exactly how large one-size-fits-all programs almost always destroy themselves.

American healthcare is already cheap? Compared to what industrialized nation? Every metric out there shows this to be wrong. Instead of talking the abstract "healthcare", instead talk about the cost of individual procedures.

http://www.economist.com/blogs/democracyinamerica/2013/07/hi...

Regarding "one-size fits all programs destroying themselves", please explain to me how Obamacare is a one size fits all scheme? It's a conservative policy, designed by the Heritage Foundation think-tank on K Street in DC. (I have a buddy who works at the Heritage Foundation. They all loved Obamacare when Romney was implementing it, and were disappointed that it was only for a single state at the time. Suddenly when President Blackenstein was implementing it, it became evil and socialist.

Frankly, Obamacare isn't the best solution. I would have much preferred a national, single payer system coupled with private providers, like the system in Canada. You know, the one that has vastly higher approval ratings among its patients than the one in the US. But no, the Republicans scared the old people into thinking they would lose their free, socialist medical care if people under 65 got in on the action, so we got stuck with insurance subsidies.

> American healthcare is already cheap?

Yes, dirt cheap. As in we could abolish all payment plans and life expectancy would barely budge. Vaccines and generic antibiotics give you the lion's share of what is possible. Blood pressure and diabetes control gives you most of the rest. If you want to get extravagent, add trivial insurance for broken bones, treatable cancer, and the like.

Obamacare is one size fits all because it tries to give everyone the same treatments. There is simply no way to give $400/month anxiety pills and $100k preventative cardic caths to every dirt farmer in Mississippi. Either the poor will get a heavily rationed version of Medicaid or the budgets will explode.

I think the Massachusetts program is a pretty good idea. I have even considered moving there to get on the rolls. If it actually works in the long run, other states would naturally have adopted similar programs. The only reason to try a single national program is to pander to voters.

One of the big problems in American health care is price manipulation. Obama could have become the first black Republican president by proposing that no Medicare provider may render services to anyone else except according to a uniform fee schedule. (If you think a Latino single mother is pissed off about a $300 aspirin, try talking to a country club Republican.)

So, regarding the uniform fee schedule, what you mean is that any provider who accepts Medicare is required to have a uniform price list which is the same for all non-Medicare/Medicaid customers? As opposed to the nightmarish price variance given based on the clusterfuck of negotiated prices between consolidated provider organizations and insurance companies?

I like that idea. It would have never, ever made it past the medical provider lobby.

Did you see the Time magazine article "The Bitter Pill"? Fascinating, and the article actually provoked the CMS agency in the Federal Gov't to release their data on the "chargemaster" prices at various hospitals vs. the negotiated Medicare/Medicaid price (which is itself negotiated to ensure it covers a hospitals labor/materials for any given procedure).

That sounds interesting. Can you explain more about the bubble angle?

Government officials find something popular, promise unlimited amounts of it to get votes, then create a program to deliver it with total disregard for economic consequences.

Last decade they bought votes with easy mortgages. After all, even an idiot could see that home ownership was a sound investment. They won two or three rounds of elections with mortgage policy.

This decade it is health care for all! Even an idiot can see that health care for everyone is a sound investment. Just look at these scary charts of runaway growth of medical costs. And the votes roll in.

In reality, most health care consists of vaccines, blood pressure pills, diabetes pills, and the occassional antibiotics. That gives most of the benefits and costs almost nothing.

Most of the costs come from ludicrous end-of-life procedures on old people, most of the rest comes from ludicrous $500k courses of treatments for this like multiple sclerosis and stage 29 recurrent cancer. These are lifestyle choices for well-off people who would rather pay a doctor than leave an inheritance.

Trying to extend this lifestyle to every waitress will destroy the economy. It's no different than last decade's plan to put every hairdresser in a $700k mansion.

As far as "ludicrous end-of-life-procedures for old people", I agree Americans spend far too much on those, but the bulk of that is people who are 65 or older, which is outside PPACA's purview, since they are already covered by Medicare [1]. If you want to argue for Medicare to reform how it treats end-of-life coverage, I'd support that, but anyone who argues that Medicare should spend less on end-of-life heroics runs into hysterics about "death panels" refusing to pay for an extra 10 days of granny's life support. PPACA is trying to fix a fairly different problem, the under-65 segment, where end-of-life treatment is a much smaller proportion of costs.

[1] About 80% of Americans who died in 1997 were covered by Medicare at the time of death: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1282187/

To eliminate the problem of end of life heroics would it be possible to add something to Medicare like you get x dollars you can leave to your family if you forgo the heroics. Where x is day 10% of the cost of the heroics?

Then people have an incentive to save money but death panels aren't needed.

Of course this is assuming the heroics rarely work.

Any references to support any of your claims?

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