6 ms·

If this isn't a ringing endorsement for single-payer "medicare for all" health insurance, I don't know what is. As a society we're aghast at the notion that peo

If this isn't a ringing endorsement for single-payer "medicare for all" health insurance, I don't know what is. As a society we're aghast at the notion that people might be discriminated against due to their genetic pre-conditions. Why the heck do we let our values slug it out in an inefficient, non-competitive, quasi-market? Also, because it's Hacker News and a lot of folks here are engaged in start-ups, I wonder why I hear relatively more from tech about basic income than single-payer health. While basic income goes further, single-payer health removes a major burden / friction for creating a start up. Also, from a labor standpoint, decoupling health benefits from work allows start-ups to play with less-than-full-time employment arrangements. Having more people fractionally employed might be just the safety valve we need until automation job loss is more comprehensively addressed. But I digress.

IncRnd 10y ago
Why do you believe that the possibility that people may be discriminated against due to their dna is a ringing endorsement for single-payer "medicare for all" health insurance?
- wavefunction 10y ago
  We are all a part of the human race and we owe it to ourselves and our fellow humans to take care of each other.
- tghw 10y ago
  Because a single payer would, by definition, cover everyone. Private insurance companies and employers (the two places most Americans get their health insurance from) may not want to pay for the higher costs associated with higher risk people like this. Employers would be especially susceptible to this sort of discrimination if proposed legislation allowing employers to demand genetic tests of their employees passes. https://www.washingtonpost.com/news/to-your-health/wp/2017/03/11/employees-who-decline-genetic-testing-could-face-penalities-under-proposed-bill/ https://www.washingtonpost.com/news/to-your-health/wp/2017/0...
  - vonmoltke 10y ago
    The discrimination referenced in the article is not just about insurance costs. Even if health care costs were totally removed from employees they would still have reason to discriminate on genetic factors.
- rtb 10y ago
  ELIZA, is that you? Because a single-payer health system (like the NHS) largely prevents this discrimination.
  - IncRnd 10y ago
    Do you think I am ELIZA? Would you like me to be ELIZA? Seriously though, I quoted the reference exactly in my question, since I knew people would be touchy about the subject. Based upon other people's reaction to my question, some people are very touchy about the subject even when addressed elliptically and without pre-formed notions. Thank you for your answer.
- pnutjam 10y ago
  Because the nature of the current system has incentives for employers to have a healthy "pool". When you have larger pools with a single payer, that goes away. With the current system, those people will end up either getting care that isn't paid for and gets picked up by taxpayers, probably not enough to survive. Or, those people will be shunted to high risk pools, which will be largely paid by taxpayers.
oconnor663 10y ago
It's a strong argument against employer funded healthcare, but I get the impression that no one really takes the "employer funded healthcare is great and I would design it that way even if I were starting over from scratch" position. Does that sound right?
- arca_vorago 10y ago
  I think that does sound right. I never understood why healthcare was so tied to employers in the first place. Healthcare should be entireley independent of employment status in my opinion... but, and I'm sure given HN demographics I'm likely to be in the minority, I find the ACA to be unconstitutional, specifically the mandate, so I have recently been trying to bone up on the legal discussion surrounding the general welfare and commerce clauses to understand the nuance left there for single payer but without a mandate.
  - orangecat 10y ago
    I never understood why healthcare was so tied to employers in the first place. Wage controls during WW2: http://www.npr.org/templates/story/story.php?storyId=114045132 http://www.npr.org/templates/story/story.php?storyId=1140451...
    - arca_vorago 10y ago
      Which if I remember correctly were very highly contested on constitutional grounds as well.
      - pdonis 10y ago
        Yep. Here's the Supreme Court decision that upheld them: https://en.wikipedia.org/wiki/Yakus_v._United_States https://en.wikipedia.org/wiki/Yakus_v._United_States
  - nshepperd 10y ago
    Because employers can provide group health insurance plans. Without either the individual mandate (which is itself a half-assed approximation to single payer healthcare) or group health insurance (through employers or some other non-health-related cooperative), people put off getting health insurance until they get sick, the risk pool stops being a pool and the whole concept of "insurance" falls apart.
brians 10y ago
Single payer is one of several good ways to insulate citizens from the costs of individual health events. Another approach removes even the shadow prices used by single payer, and provides health care as an infrastructure element. Imagine if all roads were turnpikes with tolls. Single payer has the government pay those tolls. But for local roads, we would rather remove the toll booths and allow free and easy access. The same could be true of preventative care, basic access to an NP or similar, well child care, and such.
- pooper 10y ago
  > The same could be true of preventative care, basic access to an NP or similar, well child care, and such. I never thought of the issue that way but now that I hear it I absolutely agree. I do not plan on having a child... ever so this may sound a little trollish but please bear with me here. Anyone who is against gender discrimination (or thinks there is no discrimination against women based on gender) should be FOR free of cost and generally available quality child care for all. I think a lot of bias against women in the work force will go away if we don't have a mindset that women will quit the workforce once they have children.
  - thescribe 10y ago
    > Anyone who is against gender discrimination (or thinks there is no discrimination against women based on gender) should be FOR free of cost and generally available quality child care for all. I'm not sure I follow?
    - pooper 10y ago
      Sorry I'm not very good at explaining things in general but it is even worse right now because as I admit I didn't put two and two together until your grandparent comment talked about it. If families have access to free of cost quality child care, they are now making a choice based on their preference as opposed to a decision bring made for them by environmental circumstances. This might help decrease perception of hostility.
- 10y ago
orangecat 10y ago
Your employer shouldn't have anything to do with your health care; the majority of economists across the political spectrum would agree. Single payer is not the only alternative to that. There are people who can't afford enough food, so we give them either food stamps or cash rather than trying to make it free for everyone.
- sidlls 10y ago
  The margins and economic incentives in medical care are very different from those in food and housing. It's of limited use to compare solutions in these two spaces.
  - oconnor663 10y ago
    "Medical care" is a broad category though. Of course emergency medicine will never work like food. But I wonder what percentage of spending, say, goes to things that are closer to food than to emergency medicine?
    - sidlls 10y ago
      Almost none of the spending in medicine is analogous to spending on food. The closest would be things like regular checkups. For just about everything else the goal of payers is to minimize usage of the product they sell, not maximize it. In food, grocers are (roughly speaking, here) analogous to insurers and food is analogous to care utilization. Grocers want to maximize sales of food at the best price possible: they make more money by moving their product. Insurers want to minimize utilization: they make less money by "moving" their product. In the case of food, the grocers' and buyers' incentives are aligned: people need food, and grocers want to provide it. In the case of medicine, this isn't the case: people need care, and the access providers don't want to provide it.
      - oconnor663 10y ago
        Caveat: I have no idea what I'm talking about. It makes sense to me that an insurer would never be a good analogy for a grocery store, but that problem seems specific to the insurance model, rather than to medicine itself. That's more what I meant to ask about. If we imagine that hospitals and patients work like grocery stores and their customers, a few obvious problems come up: - Healthcare is too complicated for patients to make informed choices. - Emergency medicine is too urgent for patients to have much choice anyway. - Demand for care is unevenly and unfairly distributed, because of conditions people are born with. So I guess my question is, how much of medicine (in terms of dollars) hits those problems? Cancer treatment seems to hit at least two out of three. But on the other hand, a lot of dentistry seems not to.
EGreg 10y ago
I think many people working on Basic Income would do well to focus their energy on pushing Single Payer + voucher systems for everything. Basic levels of healthcare, food, etc. It makes far more sense than single payer, because it cannot be traded away easily by the recipients during bad decisions, so it is a stronger safety net. But it is also far cheaper and more efficient than basic income, because buyers don't compete so prices don't go up across the board "patio style".
zerebubuth 10y ago
Single-payer systems are not without problems either. Unless we're rich enough, as a society, to pay for perfect healthcare for everyone then there will be some people who get less than perfect care. In an individual-pays system, those with expensive conditions or those who are poorer lose out. In a government-pays system those without political leverage lose out - often still those who are poorer. The British NHS, for example, has been the target of much ire due to different (and arbitrary-seeming) spending priorities in different parts of the country, often called the "postcode lottery".
- Retric 10y ago
  If a society is not able to pay for 'perfect healthcare' then it will not pay for 'perfect healthcare' under any system. However, as your reduce the cost of providing healthcare with single payer systems you increase society's ability to provide high quality healthcare. Remember, if a doctor sees 1000 people a month then you can detect fraud by randomly sampling 20 cases. However, if 10 companies each need to check for fraud they may investigate 10 cases each, but with 10 X 10 that's still more effort. Further, they are each going to try and cost shift to the others, which is an expensive zero sum game.
  - icebraining 10y ago
    However, if 10 companies each need to check for fraud they may investigate 10 cases each, but with 10 X 10 that's still more effort. Or they'll coordinate to avoid the duplication, usually by having some kind of industry society/non-profit that does the checking.

IncRnd 10y ago

Why do you believe that the possibility that people may be discriminated against due to their dna is a ringing endorsement for single-payer "medicare for all" health insurance?

wavefunction 10y ago
We are all a part of the human race and we owe it to ourselves and our fellow humans to take care of each other.
tghw 10y ago
Because a single payer would, by definition, cover everyone. Private insurance companies and employers (the two places most Americans get their health insurance from) may not want to pay for the higher costs associated with higher risk people like this. Employers would be especially susceptible to this sort of discrimination if proposed legislation allowing employers to demand genetic tests of their employees passes. https://www.washingtonpost.com/news/to-your-health/wp/2017/03/11/employees-who-decline-genetic-testing-could-face-penalities-under-proposed-bill/ https://www.washingtonpost.com/news/to-your-health/wp/2017/0...
- vonmoltke 10y ago
  The discrimination referenced in the article is not just about insurance costs. Even if health care costs were totally removed from employees they would still have reason to discriminate on genetic factors.
rtb 10y ago
ELIZA, is that you? Because a single-payer health system (like the NHS) largely prevents this discrimination.
- IncRnd 10y ago
  Do you think I am ELIZA? Would you like me to be ELIZA? Seriously though, I quoted the reference exactly in my question, since I knew people would be touchy about the subject. Based upon other people's reaction to my question, some people are very touchy about the subject even when addressed elliptically and without pre-formed notions. Thank you for your answer.
pnutjam 10y ago
Because the nature of the current system has incentives for employers to have a healthy "pool". When you have larger pools with a single payer, that goes away. With the current system, those people will end up either getting care that isn't paid for and gets picked up by taxpayers, probably not enough to survive. Or, those people will be shunted to high risk pools, which will be largely paid by taxpayers.

oconnor663 10y ago

It's a strong argument against employer funded healthcare, but I get the impression that no one really takes the "employer funded healthcare is great and I would design it that way even if I were starting over from scratch" position. Does that sound right?

arca_vorago 10y ago
I think that does sound right. I never understood why healthcare was so tied to employers in the first place. Healthcare should be entireley independent of employment status in my opinion... but, and I'm sure given HN demographics I'm likely to be in the minority, I find the ACA to be unconstitutional, specifically the mandate, so I have recently been trying to bone up on the legal discussion surrounding the general welfare and commerce clauses to understand the nuance left there for single payer but without a mandate.
- orangecat 10y ago
  I never understood why healthcare was so tied to employers in the first place. Wage controls during WW2: http://www.npr.org/templates/story/story.php?storyId=114045132 http://www.npr.org/templates/story/story.php?storyId=1140451...
  - arca_vorago 10y ago
    Which if I remember correctly were very highly contested on constitutional grounds as well.
    - pdonis 10y ago
      Yep. Here's the Supreme Court decision that upheld them: https://en.wikipedia.org/wiki/Yakus_v._United_States https://en.wikipedia.org/wiki/Yakus_v._United_States
- nshepperd 10y ago
  Because employers can provide group health insurance plans. Without either the individual mandate (which is itself a half-assed approximation to single payer healthcare) or group health insurance (through employers or some other non-health-related cooperative), people put off getting health insurance until they get sick, the risk pool stops being a pool and the whole concept of "insurance" falls apart.

brians 10y ago

Single payer is one of several good ways to insulate citizens from the costs of individual health events. Another approach removes even the shadow prices used by single payer, and provides health care as an infrastructure element. Imagine if all roads were turnpikes with tolls. Single payer has the government pay those tolls. But for local roads, we would rather remove the toll booths and allow free and easy access. The same could be true of preventative care, basic access to an NP or similar, well child care, and such.

pooper 10y ago
> The same could be true of preventative care, basic access to an NP or similar, well child care, and such. I never thought of the issue that way but now that I hear it I absolutely agree. I do not plan on having a child... ever so this may sound a little trollish but please bear with me here. Anyone who is against gender discrimination (or thinks there is no discrimination against women based on gender) should be FOR free of cost and generally available quality child care for all. I think a lot of bias against women in the work force will go away if we don't have a mindset that women will quit the workforce once they have children.
- thescribe 10y ago
  > Anyone who is against gender discrimination (or thinks there is no discrimination against women based on gender) should be FOR free of cost and generally available quality child care for all. I'm not sure I follow?
  - pooper 10y ago
    Sorry I'm not very good at explaining things in general but it is even worse right now because as I admit I didn't put two and two together until your grandparent comment talked about it. If families have access to free of cost quality child care, they are now making a choice based on their preference as opposed to a decision bring made for them by environmental circumstances. This might help decrease perception of hostility.
10y ago

orangecat 10y ago

Your employer shouldn't have anything to do with your health care; the majority of economists across the political spectrum would agree. Single payer is not the only alternative to that. There are people who can't afford enough food, so we give them either food stamps or cash rather than trying to make it free for everyone.

sidlls 10y ago
The margins and economic incentives in medical care are very different from those in food and housing. It's of limited use to compare solutions in these two spaces.
- oconnor663 10y ago
  "Medical care" is a broad category though. Of course emergency medicine will never work like food. But I wonder what percentage of spending, say, goes to things that are closer to food than to emergency medicine?
  - sidlls 10y ago
    Almost none of the spending in medicine is analogous to spending on food. The closest would be things like regular checkups. For just about everything else the goal of payers is to minimize usage of the product they sell, not maximize it. In food, grocers are (roughly speaking, here) analogous to insurers and food is analogous to care utilization. Grocers want to maximize sales of food at the best price possible: they make more money by moving their product. Insurers want to minimize utilization: they make less money by "moving" their product. In the case of food, the grocers' and buyers' incentives are aligned: people need food, and grocers want to provide it. In the case of medicine, this isn't the case: people need care, and the access providers don't want to provide it.
    - oconnor663 10y ago
      Caveat: I have no idea what I'm talking about. It makes sense to me that an insurer would never be a good analogy for a grocery store, but that problem seems specific to the insurance model, rather than to medicine itself. That's more what I meant to ask about. If we imagine that hospitals and patients work like grocery stores and their customers, a few obvious problems come up: - Healthcare is too complicated for patients to make informed choices. - Emergency medicine is too urgent for patients to have much choice anyway. - Demand for care is unevenly and unfairly distributed, because of conditions people are born with. So I guess my question is, how much of medicine (in terms of dollars) hits those problems? Cancer treatment seems to hit at least two out of three. But on the other hand, a lot of dentistry seems not to.

EGreg 10y ago

I think many people working on Basic Income would do well to focus their energy on pushing Single Payer + voucher systems for everything. Basic levels of healthcare, food, etc. It makes far more sense than single payer, because it cannot be traded away easily by the recipients during bad decisions, so it is a stronger safety net. But it is also far cheaper and more efficient than basic income, because buyers don't compete so prices don't go up across the board "patio style".

zerebubuth 10y ago

Single-payer systems are not without problems either. Unless we're rich enough, as a society, to pay for perfect healthcare for everyone then there will be some people who get less than perfect care. In an individual-pays system, those with expensive conditions or those who are poorer lose out. In a government-pays system those without political leverage lose out - often still those who are poorer. The British NHS, for example, has been the target of much ire due to different (and arbitrary-seeming) spending priorities in different parts of the country, often called the "postcode lottery".

Retric 10y ago
If a society is not able to pay for 'perfect healthcare' then it will not pay for 'perfect healthcare' under any system. However, as your reduce the cost of providing healthcare with single payer systems you increase society's ability to provide high quality healthcare. Remember, if a doctor sees 1000 people a month then you can detect fraud by randomly sampling 20 cases. However, if 10 companies each need to check for fraud they may investigate 10 cases each, but with 10 X 10 that's still more effort. Further, they are each going to try and cost shift to the others, which is an expensive zero sum game.
- icebraining 10y ago
  However, if 10 companies each need to check for fraud they may investigate 10 cases each, but with 10 X 10 that's still more effort. Or they'll coordinate to avoid the duplication, usually by having some kind of industry society/non-profit that does the checking.