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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. Certain

by 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.

by entee 11y ago

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.