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> patients, payers, physicians, pharma, facilities and insurers but competing interests I think this is made harder to see by a certain stripe of market fundam

> patients, payers, physicians, pharma, facilities and insurers but competing interests I think this is made harder to see by a certain stripe of market fundamentalism that almost blends into the background for many people at this point. At this level of analysis, it's assumed that every transaction is cooperative in nature and competing interests are correctly balanced if not aligned by the time a transaction takes place. Since that's the general assumption, of course it's the specific assumption that the market will do the right thing (regulated or unregulated -- the regulations are just clothing on the incentives). I'm talking about the general level of lay discourse that defends the recent history (and even the ACA status quo), of course. Scholarship and policy research recognizes the problem.

TuringNYC 10y ago
"Assumption that the market will do the right thing" I find it difficult to consider healthcare a true market, since you get to find out the price/cost many weeks later. You generally have transparency over primary care visit prices, etc, but anything complicated is a total crap-shoot w/r/t what you'll be charged, by whom, and whether everyone involved is in/out of network. Ever have surgery? You get bills from parties you've never heard of all of them coming independently and its rocket science to even figure out deductibles at that point since there is no centralized ledger or central party to deal with.
- wwweston 10y ago
  > I find it difficult to consider healthcare a true market I can see why -- I've had the same terrible experience with billing shrapnel -- and I almost put a clause in my comment knowing this kind of response was almost inevitable. What I did put in instead was that a lot of our details are different kinds of clothing on the fundamental incentives. I strongly suspect that if you started a system from scratch around the central assumption that medicine should be handled as a market for medical products/services and the financing behind it should be private & for-profit, my guess is that you'd get very much the same thing. The skill investment required for some interventions would lead to several consequences: required specialization to be effective, and a proliferation of specializations. Since the skill investments are costly, those costs are passed on in the form of high service rates. Few people know in advance which interventions they'll need, which makes planning for financing care risky, so an insurance market would develop. Insurers would have the same basic incentives to sell to those who are least likely to need their services, avoid those who are likely to need them completely, and independently negotiate their own payout deals with providers, which of course, varies by insurer, so few patients are going to be really sure how much anything costs even if they do understand how all the specialists interact in a given intervention. And at that point, you have the recipe for the billing shrapnel problem everyone hates.

TuringNYC 10y ago

"Assumption that the market will do the right thing" I find it difficult to consider healthcare a true market, since you get to find out the price/cost many weeks later. You generally have transparency over primary care visit prices, etc, but anything complicated is a total crap-shoot w/r/t what you'll be charged, by whom, and whether everyone involved is in/out of network. Ever have surgery? You get bills from parties you've never heard of all of them coming independently and its rocket science to even figure out deductibles at that point since there is no centralized ledger or central party to deal with.

wwweston 10y ago
> I find it difficult to consider healthcare a true market I can see why -- I've had the same terrible experience with billing shrapnel -- and I almost put a clause in my comment knowing this kind of response was almost inevitable. What I did put in instead was that a lot of our details are different kinds of clothing on the fundamental incentives. I strongly suspect that if you started a system from scratch around the central assumption that medicine should be handled as a market for medical products/services and the financing behind it should be private & for-profit, my guess is that you'd get very much the same thing. The skill investment required for some interventions would lead to several consequences: required specialization to be effective, and a proliferation of specializations. Since the skill investments are costly, those costs are passed on in the form of high service rates. Few people know in advance which interventions they'll need, which makes planning for financing care risky, so an insurance market would develop. Insurers would have the same basic incentives to sell to those who are least likely to need their services, avoid those who are likely to need them completely, and independently negotiate their own payout deals with providers, which of course, varies by insurer, so few patients are going to be really sure how much anything costs even if they do understand how all the specialists interact in a given intervention. And at that point, you have the recipe for the billing shrapnel problem everyone hates.