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> it's the only kind of organization that can reasonably address the problem. I agree with your broad point. Which is why we should let the gov do whats necess

> it's the only kind of organization that can reasonably address the problem. I agree with your broad point. Which is why we should let the gov do whats necessary, and get it out of everything else because of how wildly it is inefficient. We need to get it out of: - health care - education - providing pensions Its no coincidence that the areas were there is the biggest mix of gov and private are also some of the worst industries to deal with.

entee 11y ago
I think I can see a case for getting out of providing pensions, but I would respectfully disagree about broadly getting out of healthcare and education. Certainly in certain subsections of those areas there is much to improve and perhaps less government involvement would be good, but I think overall it's not a great plan. My reasoning is as follows: For healthcare it's hard to see how a system that is even more privatized than the one in the US would do well. Healthcare is an area where there are massive information asymmetries and where price discovery is hard to do. If I need a trauma surgeon or a broken leg fixed, then I'm not going to "shop around" for the best one. For less time sensitive problems you end up with issue 2: It's a sector where it's not obvious how to measure quality. Is the doc with the fewest patients that die the best one? Maybe he's the guy who gets the sickest patients because he's actually the best at handling the complicated cases, so more of his patients die because they start out sicker! Education faces some of the same problems. It's notoriously hard to measure great teaching, though I'm sure we've had great teachers and "we'd know it when we see it". It's also an area where the feedback between the service you buy and the result of the service is highly decoupled in time. It can take years after you've finished your education to figure out if it was a good deal or not. Now I'm sure there are ways in which government should leave these sectors. I have heard interesting arguments (though personally I don't agree with them) about getting out of financing student loans, or doing it differently (those I'm usually more in agreement). It's harder for me to see how I would want less government in my healthcare, I think we have a far too private system as it stands, but maybe in terms of HIPAA. I think medical data should have strong privacy protections, but I've definitely seen how the protections currently enforced are counterproductive. I also think it makes it way too hard to get a hold of your own data for personal use. Anyway, these are issues where plenty of people have different opinions. It's good to talk them out and debate :)
- randyrand 11y ago
  > I think we have a far too private system as it stands Its a public private mix. Not nearly as private as say the restaurant industry, tech industry, or even airlines industry, etc. Definitely very high up there on the 'regulated' scale as well. It's funny you admit the government is inefficient, but want it to run all of healthcare? Why? What is fundamentally so hard about having a competitive healthcare economy? You bring up a good point about information asymmetries. I think private audit and review companies would do very well in this information economy. Perhaps the government if anything could disseminate this information freely. ECU perhaps needs to be handled different though the majority of healthcare spending is not ECU.
  - entee 11y ago
    My argument is not that government is inefficient and so it shouldn't be used, my argument is that despite inefficiencies it's appropriate to use in certain cases because the alternatives are worse. I think with regards to healthcare, the private insurance market has proven to be insanely inefficient. We have a patchwork of insurance laws across states, profit motivated insurance companies, and just overall opacity at every level of the system. All this and if you look at more centralized government managed systems, overall outcomes seem no worse and in some cases better. It's hard to measure quality in healthcare, as I mentioned above, but by many of those metrics the US system isn't doing radically better than, say, European systems which are largely single payer government organized or close to it. All that despite paying as much as 30% more. There are lots of questions and issues in healthcare, it's a really complicated question. One thing that's pretty clear is that as much as 50% of your entire lifetime healthcare spend will be spent in your last 6 months of life. At that stage how can a private market work? "Hey, I'm dying let me shop around for the best ICU"? All of the alternatives involve tradeoffs, usually in autonomy in deciding care (single payer can become a huge HMO) and difficulty in ensuring appropriate supply (waiting months for a CT scan you actually needed yesterday). I believe there are ways to solve those even with a centralized system, and I'm fairly convinced that our private market has done a poor job serving the majority of patients (unless you're fairly wealthy, and even then the structural inefficiencies of a fragmented system get in the way). Re. private audit and review companies: It turns out a lot of docs are on Yelp and other similar services. I'll admit to looking at them when I look for a provider. But those systems have really perverse effects as well. People usually don't know what the is best thing for them to do medically, but they love it when the doc agrees with them. As a result a doc is pushed toward being more agreeable, prescribing what the patient wants instead of what they need. Patient says, "I want antibiotics". Doc says, "but it's likely viral". Patient says, "I want antibiotics". The doc who caves gets better reviews. Good medicine is hard to evaluate, and a patient is poorly equipped to evaluate relative quality, but he/she is also poorly informed as to what is a good price. You could say, "let's get rid of opacity." But one of the drivers for opacity is the private insurance system. No insurer wants what they're paying for X procedure to be known by their competitors, that complicates their negotiating position. You could force regulation that would open all this up, but then aren't you just growing government involvement in healthcare regulation? With so many asymmetries and so much opacity it's hard to see how a private system does better. That said, it's worthy of discussion and a complicated topic, so I really enjoy learning of other opinions.
losvedir 11y ago
- health care I disagree with this one. First, we effectively have government mandated healthcare now: hospitals aren't allowed to turn people away. Would you like to change that? Have people dying in the waiting room if they can't prove insurance? Or people not being picked up by an ambulance because they were out for a run and didn't have their insurance card on them (or worse, being profiled about whether they're likely to pay)? I think most people, when it comes down to it, think some level of healthcare is a service everyone in the U.S. is entitled to, just because we can provide it and nobody wants to see people dying on the streets or in hospital waiting rooms. If you disagree with that, then I guess we can just agree to disagree. But assuming you agree that everyone should be guaranteed some level of care, then it's just a matter of efficiently providing it. Here we get to where "insurance" is a fundamentally flawed system for delivering health care. With insurance, risk is spread out so everyone pays (cost of healthcare) * P(need of health care). The issue is everyone has dramatically different P's so it's impossible to pool the risk effectively. If you have a pre-existing condition, then your P is 100% and no insurer in their right mind is going to want to accept you. If you get diagnosed with something, you won't be able to change insurance providers, you'll be desperately tied to your current provider, etc. Now the government could step in as it has now with Obamacare in the U.S., and stop insurers from blocking pre-existing conditions, but then to make that economically viable you need to require citizens to pay for health insurance... So all told, if you come from the perspective that we're a rich enough country to provide some level of health care to our citizens, then the best, most efficient way to do it, is to have the government involved.
- randyrand 11y ago
  Start a hospital and your obligation to accept all ECU patients will be the smallest of your worries - a law which I agree with. Every. Little. Detail. about healthcare is regulated. From the years of doctors education, from where they must go to school, to who can do what procedures, to how many volts your power supply can ripple, to the brand of emergency generator your hospital is allowed to use, to they types of investments your hospital is allowed to make, to the types of antiquated file formats your hospital records must support. I am not even scratching the surface. It's not that the regulations are bad intentioned or even bad ideas, its that following them is huge, huge overhead that prevents innovation and competition. Heck, the state has essentially conspired with the AMA to limit the number of doctors. It's a classic barrier to entry exmaple that professions lobby for. And it's the reason a highly trained doctors still need to perform the majority of simple procedures. Because that how the doctors want it. Depending on your state, there are between 800,000 and 1,500,000 pages of health regulations. The affordable care act is 20,000 pages alone, and that is just one regulation among hundreds. Healthcare is the most over regulated industry in the United States. Bar none. And it has been a disaster. AS for preexising conditions, my stance is that If the taxpayers want that, then the tax payers are more than welcome to foot the bill. It doesn't even make sense to have insurance companies, which insure against risk, to provide it.

entee 11y ago

I think I can see a case for getting out of providing pensions, but I would respectfully disagree about broadly getting out of healthcare and education. Certainly in certain subsections of those areas there is much to improve and perhaps less government involvement would be good, but I think overall it's not a great plan. My reasoning is as follows: For healthcare it's hard to see how a system that is even more privatized than the one in the US would do well. Healthcare is an area where there are massive information asymmetries and where price discovery is hard to do. If I need a trauma surgeon or a broken leg fixed, then I'm not going to "shop around" for the best one. For less time sensitive problems you end up with issue 2: It's a sector where it's not obvious how to measure quality. Is the doc with the fewest patients that die the best one? Maybe he's the guy who gets the sickest patients because he's actually the best at handling the complicated cases, so more of his patients die because they start out sicker! Education faces some of the same problems. It's notoriously hard to measure great teaching, though I'm sure we've had great teachers and "we'd know it when we see it". It's also an area where the feedback between the service you buy and the result of the service is highly decoupled in time. It can take years after you've finished your education to figure out if it was a good deal or not. Now I'm sure there are ways in which government should leave these sectors. I have heard interesting arguments (though personally I don't agree with them) about getting out of financing student loans, or doing it differently (those I'm usually more in agreement). It's harder for me to see how I would want less government in my healthcare, I think we have a far too private system as it stands, but maybe in terms of HIPAA. I think medical data should have strong privacy protections, but I've definitely seen how the protections currently enforced are counterproductive. I also think it makes it way too hard to get a hold of your own data for personal use. Anyway, these are issues where plenty of people have different opinions. It's good to talk them out and debate :)

randyrand 11y ago
> I think we have a far too private system as it stands Its a public private mix. Not nearly as private as say the restaurant industry, tech industry, or even airlines industry, etc. Definitely very high up there on the 'regulated' scale as well. It's funny you admit the government is inefficient, but want it to run all of healthcare? Why? What is fundamentally so hard about having a competitive healthcare economy? You bring up a good point about information asymmetries. I think private audit and review companies would do very well in this information economy. Perhaps the government if anything could disseminate this information freely. ECU perhaps needs to be handled different though the majority of healthcare spending is not ECU.
- entee 11y ago
  My argument is not that government is inefficient and so it shouldn't be used, my argument is that despite inefficiencies it's appropriate to use in certain cases because the alternatives are worse. I think with regards to healthcare, the private insurance market has proven to be insanely inefficient. We have a patchwork of insurance laws across states, profit motivated insurance companies, and just overall opacity at every level of the system. All this and if you look at more centralized government managed systems, overall outcomes seem no worse and in some cases better. It's hard to measure quality in healthcare, as I mentioned above, but by many of those metrics the US system isn't doing radically better than, say, European systems which are largely single payer government organized or close to it. All that despite paying as much as 30% more. There are lots of questions and issues in healthcare, it's a really complicated question. One thing that's pretty clear is that as much as 50% of your entire lifetime healthcare spend will be spent in your last 6 months of life. At that stage how can a private market work? "Hey, I'm dying let me shop around for the best ICU"? All of the alternatives involve tradeoffs, usually in autonomy in deciding care (single payer can become a huge HMO) and difficulty in ensuring appropriate supply (waiting months for a CT scan you actually needed yesterday). I believe there are ways to solve those even with a centralized system, and I'm fairly convinced that our private market has done a poor job serving the majority of patients (unless you're fairly wealthy, and even then the structural inefficiencies of a fragmented system get in the way). Re. private audit and review companies: It turns out a lot of docs are on Yelp and other similar services. I'll admit to looking at them when I look for a provider. But those systems have really perverse effects as well. People usually don't know what the is best thing for them to do medically, but they love it when the doc agrees with them. As a result a doc is pushed toward being more agreeable, prescribing what the patient wants instead of what they need. Patient says, "I want antibiotics". Doc says, "but it's likely viral". Patient says, "I want antibiotics". The doc who caves gets better reviews. Good medicine is hard to evaluate, and a patient is poorly equipped to evaluate relative quality, but he/she is also poorly informed as to what is a good price. You could say, "let's get rid of opacity." But one of the drivers for opacity is the private insurance system. No insurer wants what they're paying for X procedure to be known by their competitors, that complicates their negotiating position. You could force regulation that would open all this up, but then aren't you just growing government involvement in healthcare regulation? With so many asymmetries and so much opacity it's hard to see how a private system does better. That said, it's worthy of discussion and a complicated topic, so I really enjoy learning of other opinions.

losvedir 11y ago

- health care I disagree with this one. First, we effectively have government mandated healthcare now: hospitals aren't allowed to turn people away. Would you like to change that? Have people dying in the waiting room if they can't prove insurance? Or people not being picked up by an ambulance because they were out for a run and didn't have their insurance card on them (or worse, being profiled about whether they're likely to pay)? I think most people, when it comes down to it, think some level of healthcare is a service everyone in the U.S. is entitled to, just because we can provide it and nobody wants to see people dying on the streets or in hospital waiting rooms. If you disagree with that, then I guess we can just agree to disagree. But assuming you agree that everyone should be guaranteed some level of care, then it's just a matter of efficiently providing it. Here we get to where "insurance" is a fundamentally flawed system for delivering health care. With insurance, risk is spread out so everyone pays (cost of healthcare) * P(need of health care). The issue is everyone has dramatically different P's so it's impossible to pool the risk effectively. If you have a pre-existing condition, then your P is 100% and no insurer in their right mind is going to want to accept you. If you get diagnosed with something, you won't be able to change insurance providers, you'll be desperately tied to your current provider, etc. Now the government could step in as it has now with Obamacare in the U.S., and stop insurers from blocking pre-existing conditions, but then to make that economically viable you need to require citizens to pay for health insurance... So all told, if you come from the perspective that we're a rich enough country to provide some level of health care to our citizens, then the best, most efficient way to do it, is to have the government involved.

randyrand 11y ago
Start a hospital and your obligation to accept all ECU patients will be the smallest of your worries - a law which I agree with. Every. Little. Detail. about healthcare is regulated. From the years of doctors education, from where they must go to school, to who can do what procedures, to how many volts your power supply can ripple, to the brand of emergency generator your hospital is allowed to use, to they types of investments your hospital is allowed to make, to the types of antiquated file formats your hospital records must support. I am not even scratching the surface. It's not that the regulations are bad intentioned or even bad ideas, its that following them is huge, huge overhead that prevents innovation and competition. Heck, the state has essentially conspired with the AMA to limit the number of doctors. It's a classic barrier to entry exmaple that professions lobby for. And it's the reason a highly trained doctors still need to perform the majority of simple procedures. Because that how the doctors want it. Depending on your state, there are between 800,000 and 1,500,000 pages of health regulations. The affordable care act is 20,000 pages alone, and that is just one regulation among hundreds. Healthcare is the most over regulated industry in the United States. Bar none. And it has been a disaster. AS for preexising conditions, my stance is that If the taxpayers want that, then the tax payers are more than welcome to foot the bill. It doesn't even make sense to have insurance companies, which insure against risk, to provide it.