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Comment by k-mcgrady | Hacker News Reader

I'm in the UK and we also have these same free public services. No matter how many ways an American explains it to me I cannot understand how their system can ever work better. In fact it seems barbaric to me. I think that in theory, in a perfect world, a completely free market or a libertarian society could work - but in reality it's never going to. The societies with the best standard of living in the world are ones like France that have social services that every one pays for through tax. I guess we have the added benefit in Europe that if we truly don't like our tax system and want a more private system based country we are free to move and work in any other EU country that meets our needs.

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Yet the ironic thing is that everyone in the US is paying for a healthcare system via taxes and they pay far more per capita than, say, the UK or Denmark (yes, US public health spending expenditures are higher despite not resulting in universal care). On top of that, they then pay a second (private) time to get any actual coverage unless they're disabled, old or young.

Update: The data for my claim above - http://www.theguardian.com/news/datablog/2012/jun/30/healthc... - the US had the 4th highest per capita government spending on health in 2010 behind only Luxembourg, Monaco and Norway.

Wow, I never realized that... and it's crazy!

I believe the "problem" with the US system is the very idea that the private sector can manage and provide such essential services better than the government could. And at the same time run the services for profit, profitably. It's a capitalist fantasy. Its a successful power play by our deluded wealth. We have a sad state, this US of A, with our population completely brainwashed into accepting this absurd situation.

IANA economist, but as I see it, the problem is that healthcare is mostly a captive market, i.e. not having it when you need it is not an option. With such an inelastic demand and relatively high entry barriers for providers (making competition scarce), it's expected that prices skyrocket. So socialized healthcare is a big win for the people and a big loss for the moneymakers.

Living in another country with socialized helathcare, each time the situation in the USA is described, I'm really glad I don't live there.

Another issue is the lack of information. Most consumers in the healthcare industry rely on others (doctors, hospitals, pharmacists) to tell them what they need and the people giving advice having conflicting motives (helping the patient, making money).

Simply put, you don't make a business from treating sickness. When people are sick, they are least able to pay. Also, when one is sick, there is no incentive to insure him/her because it doesn't generate profit.

You're half right - the countries with the best standards of living in the world are the ones that have social services that are paid for by publicly owned oil profits, then other resource extraction profits, then taxes. Scandinavia and Canada are routinely the best. Another important feature of these countries is not a nationalised health service like the UK, but a guaranteed minimum standard insurance with a competitive market for provision. See http://www.oecdbetterlifeindex.org/.

Denmark doesn't live from oil profits.

Sorry, but you're mostly wrong on both counts.

Only Norway has a substantial amount of natural reserves in the Scandinavian countries, with Denmark a distant second.

Also, the healthcare system you talk about is the Swiss, the Scandinavian and Canadian systems do NOT have anything close to an insurer (except the State itself).

Perhaps I'm wrong about the oil-wealth thesis.

Re healthcare: I was talking about Scandinavian and Canadian systems. Government pays the cost but private companies provide the service. Contrasted to the UK where government provides the service.

I wish people would stop saying Scandinavia as though it were a country. It is not and the differences between the countries in Scandinavia are substantial. For instance: Oil and gas: Norway has lots, Denmark a little, Sweden none. Mineral resources: Sweden has lots, Norway has some, Denmark almost none. Forestry: Sweden has lots, Norway has some but it's uneconomic because of the terrain, Denmark very little (except Christmas trees). Hydropower: Norway has lots (98% of electricity), Sweden has some, Denmark almost none. Land area:Sweden twice the size of the UK, Norway 60% bigger than UK, Denmark half the size of the UK.

I can't speak for Sweden and Denmark but here in Norway whilst private institutions provide services (X-rays, MRI, etc.) under contract to the state, the hospitals are nonetheless public institutions (barring a few, and as far as I can tell not very successful, private hospitals).

What does seem to unite the three Scandinavian countries is a general belief that we really are in it all together. When a rich owner of a chain of supermarkets started making a noise about moving to Switzerland because he was fed up of paying high taxes he was immediately told to " off then" not just by us poor peasants (of course there aren't many genuinely poor here) but also by other seriously rich people. It wasn't long before he was back here.

I don't think your theory is very good re: natural resources. Sure, some developed countries have a lot of natural resources, but most don't, include many associated with the highest standards of living and socialized care.

Percent of GDP from natural resources:

Norway: 13.6

Canada: 5.1

Denmark: 2.4

US: 1.7

United Kingdom: 1.5

Sweden: 1.2

Germany: 0.3

Italy: 0.2

France: 0.1

Japan: 0.0

Switzerland: 0.0

http://data.worldbank.org/indicator/NY.GDP.TOTL.RT.ZS

Yeah, upon reviewing the data (as opposed to my own mental impression of these countries' wealth sources) it doesn't hold up very well.

Also, see "resource curse". Norway is one of the few countries to escape it wrt oil.

For completeness I must chime in and declare the Australian system shares more similarities with the French, UK, Canadian, German, New Zealand... The list goes on- countries than we do with the US system

This is true but its worth noting that the Australian system has been moving towards the US version consistently for the past couple of decades. Private healthcare is common and seen in some circles as something not to be done without. Public services have been sold off and new infrastructure is privatised (telecommunications particularly). etc.

Yep, and as an Aussie I find it extremely worrying. I'm fine, I have private insurance, and my family and myself are not struggling financially. But that's not the case for some of my best friends and their families... And those are the people that are going to suffer.

Also, screw Translink. I still can't fathom why a 15% increase in price for a worse service makes sense. Sigh

No. The US system is distinguished by healthcare insurance being tied to employment, and the absence of free options.

Australia has not been moving towards that model.

Private health care options have always been a significant part of the Australian healthcare system. In the current Australian settlement: (1) there is a catch-all system that's available to everyone; (2) if citizens want to chose a chosen private option, the government subsidises this.

There's a similar dynamic in school funding.

The result is that people can choose to funnel money towards the education and health system that's in addition to what they pay in their taxes. Their choice also reduces load on the free options. People spend money on health and education that would otherwise be spent on new cars or more ludicrous mortgages, and have done this through an exercise of freedom, rather than having had the government tell them what to do.

Australia is one of only a handful of countries with both solid education and health systems, yet a contained federal government debt situation.

I think you misunderstand my point. I'm not saying that Australia is exactly like the USA in this (yes, health care very sesnibly isn't provided by employers). But the 'dual' system you describe in both schooling and healthcare is definitely a step towards the american (privatised) way of doing things from a 'socialist' model (as exemplified in Australia by the Whitlam era approach). The simple test of the socialist model is if the poor don't get the same healthcare or educational opportunities as the rich. Australia has moved towards this and leans more in this direction than most other first-world countries. Whether this is a good thing or not is not my point (obviously you believe it is - I think there are arguments either way).

Privatisation of infrastructure (and a general lack of building new national infrastructure) is also a key sign that the system is not very 'socialist'

You appear determined to find a way to paint the recent history of Australian health reform as being somehow American. But it's not - it's its own thing.

The US system is a tangle of health systems provided by every level of government and charities. It's different state by state. There's a major veterans scheme. Some states have systems a bit like Medicare. The majority of people get their care through a employment tied insurance. It doesn't serve as an example of freedom, privatisation, variations in levels of care. It's just a big complicated mess.

I think it'd be more straightforward if you just stuck with 'less socialist' rather than trying overloading America as the standard for those qualities.

Not sure that Australia has evolved that way though. There was a recent reform to introduce means-testing to medicare. And the new hospital in Adelaide - 1.7 billion dollars, 120 extra beds.

OK. understand that you don't like my use of 'american' as the opposite to 'socialist' here. Simplifications like this can be difficult and probably will h healthcare we are less overtly 'like america: although still a ways from being strongly 'socialist' (in the Scandinavian sense)

That is probably because American isn't the opposite to socialist. The USA has many socialist aspects, it just doesn't like to think of them as socialist. Free education is socialist. Medicare for the elderly is socialist. The NFL has many aspects of socialism. The laws on state funded research being made available to the public are socialist. NASA is socialist.

This is true but the USA is still, of all first world countries, the one which takes the least socialist approach on many issues and this is the sense in which I use it as an example.

This risks being brutal, but you didn't have an email in your account details, and I left it a week so the forum would clear. I have tough but fond memories of being called out on things like this when I in my 20s. I think I'm well-intentioned.

Something that ribs me about the political culture in Australia: the intelligentsia will never miss an opportunity to claim their identity as being distinct, yet they judge themselves from a very American world-view. In this sense, the Australian identity is like a rebellious teenager - desperate to be making a break from mum and dad, but unaware how its rebellion is defined entirely by mum and dad's world-view.

You are welded to the (American) popular culture myth that American is an antonym for socialism. This is more important to you than the fact that it isn't. Even after we've discussed that there are better ways to express the idea, after you've gone through the pain of admitting you could have done this differently. You've then recanted, pulled back into your shell and defended your original expression. You won't grow if you do this.

It's not just you. But you can fix it. Turn off the television, blank your mind, read, travel, think, build your ideas on this foundation.

I think you hit the nail on the head in 2 ways. First, s completely free market might work in healthcare, but what we have in America is so far from that, that most people don't even know what they are fighting for. Second, you do have much more freedom to move for tax purposes. The US demands its citizens everywhere to pay income tax, globally, even for 2 years after renouncing citizenship.

A potential downside to the world (maybe good for Americans) would be if changes in American healthcare reduces funding overall for drug research and development. I've always heard we fund most of R&D.

A completely free market in healthcare will absolutely not work. Insurance companies will drop everyone who has shown any form of uncommon illness - this is their natural incentive in the absence of regulation. Many serious and expensive illnesses are so rare that most insurance companies would severely curtail support towards these illnesses, with cheaper premiums and more customers as a result.

Libertarians are suffering from the same delusion that the communists did: In a world where humans are perfectly ethical towards each other and always put the public good ahead of their own interests, it will work perfectly. In the real world, it won't.

Would it be possible for charities to fund the medical costs of people with uncommon illnesses?

Of course, but then you're right back at where you started: Taxation.

Charities are much more common in the US than in Europe, because they cover services and treatments which are provided by the public sector in European countries. In the US, many of these services are based on voluntary donations and volunteering.

Of course, if the state is as corrupt as it is in the US, I understand the reluctance to pay more taxes. But in effect, charities do the same thing, except veiled by the fact that contributions are voluntary.

I'm having difficulty parsing your prediction. Are you saying that in a free market, nobody would offer insurance against the possibility of developing a rare, expensive medical problem? Or that once you've developed an expensive medical condition, you'll no longer be able to get insurance against it? Or something else?

Its not just that.

The problem is that for the insurance to work optimally everyone have to chip in so that those that are healthy offset the cost of those that aren't.

In the US the young aren't getting insurance which is one of the reasons for the Offordable Healthcare Act. To force everyone to have an insurance so that economics become better.

Of course in reality the best possible system would be a single payer (tax based) healthcare system with some payment for usage but where no one can go bankrupt or be dropped or fall under the deadly pre-existing conditions clause.

Or a mandated private insurance like in Germany & Switzerland. Obamacare is one step of that way but it's so alien to US culture and have been so poorly implemented that on could fear for its future.

> Or a mandated private insurance like in Germany [...]

There is no mandated /private/ health insurance, there is just mandated health insurance in Germany.

See e.g. http://www.slowtravelberlin.com/guide-health-insurance-germa...

Thats true but I don't think that is as important for the point I am making, but sure.

Assume you were an insurance company executive and you wanted to maximize profit and you were indifferent to the plight of your customers. What would you do?

I'd release new products regularly, while increasing the insurance premiums of old products. Healthy people would just switch to the new product to avoid the price increase, but people with pre-existing conditions wouldn't be eligible so I could price-gouge them.

So you could get insurance against expensive medical conditions - but if you had to claim on that insurance, suddenly your premiums would start rising by 30% a year, and you would have no alternative because of your pre-existing condition.

The companies that didn't engage in this would then look expensive to healthy people and attractive to unhealthy people. And if the healthy (profitable) people leave and unhealthy (subsidized) people join, meaning premiums have to go up further, you could get a chain reaction putting them out of business.

To bolster this example, I hear from my parents that this is more or less what's happened to insurance premiums in Switzerland since some idiot in government deregulated the insurance industry.

I think a free market insurance system would basically end up paying out lump sums for various illnesses and conditions. Hospitals would publish average price lists and then insurers would advertise and pay based on that.

Get lung cancer? Here take $200k courtesy of your insurance. Only going to cost you $150k? "No problem, glad you found a cheaper place. Buy a nice gift for your wife with the difference"

There is no set cost for complex chronic diseases like cancer, so there is no way that could be published. No single case of cancer is exactly the same, and the course of it and how it responds to various treatments varies widely.

Sure it could. They would just have to categorize the major varieties etc. if you mean it wouldnt be 100% accurate well of course not as it is rough aggregate data. But it is very useful aggregate data.

Anyone would pay a slightly smaller premium in exchange for the awarded sum being limited to actual incurred/billed costs

Pretty good insurance company to be able to offer a smaller premium when they have to cover the exact same costs on average when they have 10x the overheads of a company that pays lump sums.

Not to mention you are by necessity limited by the hospital and doctors on the insurance companies approved docs list. No thanks; they don't have my interests at heart.

Not to mention the very real incentive for such an insurance company to stop paying for "problem" clients with long ongoing illnesses.

If 25% of lung cancer cases cost less than $150,000 to treat, 50% cost less than $200,000 to treat, 75% cost less than $250,000 to treat, 99% cost less than $500,000 to treat and 99.999% cost less than $2,000,000 to treat, how much would the insurance company pay out for lung cancer?

A completely free market in healthcare will absolutely not work.

It doesn't work because of other reasons. And libertarianism is quite irrelevant. A good economist can point out the flaws in economic markets...using economics. A marxist alternative is clearly from the wrong century and is irrelevant. The important point that govermnet semi-intervention is part of the problem is perfectly plausible. That is a different point than no co-operation is needed for a viable solution. People co-operate all of the time without the need for a "government solution". Try staring at people in the elevator or invading the personal space of someone on the NYC subway if you want to prove this point to yourself.

It works better for the corporations who benefit from the system with billions of revenues and who can afford to bribe (sorry, 'lobby') US politicians to perform as they please.

One difference between France and the UK is that doctors' salaries are much lower there. The French get more value for their healthcare spending than does the UK.

> I'm in the UK and we also have these same free public services.

You forgot the word "crappy" services. It's widely known that for life threatening conditions in the UK, the NHS has a wait list and you have to wait for your turn no matter what and that be months or sometimes more than a year. Sorry, but I want to have a system that allows me to pay more to get priority (or better treatments).

it is not enough to have a free public service, tho. I have no idea about the Uk, but Canada also has free public healthcare yet it is so quite worse than the french system that it feels like they are not in the same league, imho.

The UK system certainly has problems (long wait times, overcrowding etc.) but I think when it comes down to where I'd rather be if I had a life threatening illness, it would be here, not the US. The fact that I can receive a good level of health care without paying a penny (even for prescriptions) is worth the drawbacks that come with this kind of system. Also, I still have the option of paying to go private if I wish.

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