8 ms·

The first part of the article talks about Healthcare with this: "Which is why, on the healthcare island, the conversation is about costs. Your preferences don't

The first part of the article talks about Healthcare with this: "Which is why, on the healthcare island, the conversation is about costs. Your preferences don't matter, except where they are aligned with the objectives of those on the island. Substitution doesn't matter; there are no competing services. Obscene profit margins don't invite competitors; they invite consolidation. Justifying costs to third party payers, instead of prices to patrons, is the name of the game. It's a bizarre world that doesn't make any sense to people like Goldhill when they take a critical look at it." I haven't read the book, but it looks to me they're making the age-old argument that 'third parties' shouldn't pay for healthcare because thats why its screwed up now. But, this is far too simplistic to be true. Healthcare is not a product, its a service. That service changes depending upon the person. Its not mass-producable or competable down because of demand in many cases. And, even if it were a product, you still have the eternal problem that people cannot negotiate for their own healthcare. You can't. You physically need it, and may die without it, and there is no process by which to negotiate or even many times know what price you will be paying. That is what universal healthcare strives to solve in other countries, and does so decently.

canes123456 9y ago
The vast majority of health care decisions are not life and death. Many times it is still hard to know how much something will cost and it is hard to price shop. But the same thing applies to auto repair. You need a car to get around and it is extremely expensive to toll your car to other body shops. You need to take the price the person offers you a lot of the time. But in medicine some times it is not time critical and you can shop around. We don't do it know because we don't pay.
- CPLX 9y ago
  All healthcare decisions are life and death. Just not necessarily directly. That fact complicates matters significantly.
  - paulddraper 9y ago
    All decisions are life decisions
  - hnal943 9y ago
    That's not true. I have mild allergies. It's not a life and death decision to get care or not. If the costs outweigh the benefits, I will opt out.
  - canes123456 9y ago
    By that logic, so it auto and food decisions. Postponing changing brakes has bigger life and death decisions than skipping the marginal medical test.
- devwastaken 9y ago
  But this isn't a car. The attempts at trying to simplify healthcare discussion only contribute to muddying it, because there's significantly more factors than that. A healthcare decision doesn't have to be life or death for it to still be something you need. Diseases can hurt, or they can kill you slowly, and its not a simply 'yes or no' when it comes to what /could/ happen to you without treatment. So, yes, you have to have treatment. Everybody will be convincing you that you need treatment, and you most likely do. Meaning, you have a guaranteed market. In a guaranteed market, even if you have bad quality, even if you do the wrong things, it doesn't matter, you're still going to get customers, because they need it, and thats exactly what happens in healthcare today. Get a knee operation and the problem comes back a year later? Get another operation. Because you don't have the option of not doing so. No, you don't. Quitting work and not making money, or not being able to contribute to society around you, is not a realistic or beneficial option, and certainly not one that can be advocated for with any consciousness of socioeconomics. "But the same thing applies to auto repair. You need a car to get around and it is extremely expensive to toll your car to other body shops. You need to take the price the person offers you a lot of the time. But in medicine some times it is not time critical and you can shop around. We don't do it know because we don't pay." What kind of 'shopping around' are you advocating for? A car is replaceable if something goes wrong, you have insurance on that car even. On your body, if something doesn't go right, thats not on the hospital. Thats you, you are irreplacable, and because of that, whatever service is perceived to be better will be used. Typically, in the form of cost, as it is now. Thats assuming competition would just 'rise up' if we could pay directly, which as I said before, was already happening and we still had the same issue. With universal care, the root costs of care, such as equipment and devices, are more standardized and leveraged in bulk. You need 10,000 hip replacements for your hospitals in the coming years? 5 companies get to compete with who can make and sell them the cheapest. But they better be safe, tested, and work. Atleast, in the U.K. thats how it works. But what this does is creates an entity that negotiates on your behalf, to predict the majority of costs and reduce them. Without that, you are at the mercy of whoever is setting the prices, because you're not going to get to 'shop around' when your medication is sold from one entity.
  - canes123456 9y ago
    This post is muddying arguments by mixing everything in healthcare together. Lasik has gotten much better AND much cheaper because people shop around. There are many more things that can be handled like this. Instead, doctors and patients tests to be on the safe side because it is "free". Lets take a quick aside for MRIs. The machine has a high fixed cost but the margin cost is pretty low. Just the time of the operator and 2 minutes of a doctors time to read it. They actually cost between 1k-12+k. Why is there such a huge cost difference? This would not happen anywhere else. Yes, MRI might be required right now but they can also be required in a few days, or weeks. Some cases you can wait and see if it is needed at all. All of the people could shop around and go to the 1k place. Right now there is no incentive to shop around. If there was an incentive, the 1k places would get way more business. Some people would still be willing to pay 14k but it much smaller. Eventually they would need to lower prices to stay in business. In all markets, most people are willing to pay more than the list price. However, the list price is determined by the marginal customer. Eventually the person that would have paid 100k would still only need to pay 1k. Your example of knee surgery works the same way. If you are paying the whole cost or even 25% of the cost, you will care about the cost. You will want a good doctor that will actually fix your knee. But you would not want to pay 2x the going rate from a slightly better doctor. With other big expenses like buying a home, car, getting married, or even buying a computer, people read reviews, consider several options, and look for a good value. With healthcare, they only care about quality since there is no price. People need many goods beyond healthcare. They need food, water, and shelter. We still can have prices for all those things. I am baffle by your definition of a guaranteed market. Yes there is guaranteed market for food but that does mean that any given supplier will get that market. It seems like you are assuming a monopoly or something. Finally, none of this precludes supporting health care of poor people or have insurance to protect people from getting huge amounts of healthcare debit.
- emodendroket 9y ago
  Frankly that's just not true. Many people are uninsured, in the first place, and even if they weren't, insurers are shifting more and more costs to patients (think about something like co-insurance where you're subject to a lot of the risk the insurer would be subject to in a traditional co-pay situation). What mostly happens when you shift costs to consumers is they don't get necessary care. Incidentally, one reason I find this singularly unpersuasive is that the United States is unique in the degree to which you are directly responsible for your medical bills and yet spending is wildly above what you see in other OECD countries. We don't have to rely purely on theory here.
  - canes123456 9y ago
    We don't have prices. We have a few huge companies trying to justify higher and higher cost. Consumers have no way to predict what hospitals are cheaper than others.
    - emodendroket 9y ago
      But neither do any of the places where government insurance prevails and costs are way lower.
deleted 9y ago
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deleted 9y ago
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LeifCarrotson 9y ago
I haven't read the book either (yet) - but I agree with you for the most part. I disagree, though, with the lumping together of all health care as something that cannot be negotiated. Preventative care, elective care, and other voluntary work could, in theory, be negotiated. I could choose where to get a physical, flu shot, dental cleaning, or glasses/contacts/lasic, choose whether or not to have a child (currently dealing with the outrageous costs of that right now...). A wrinkle in this idea is that while it sounds nice for people to be able to choose between a nice doctors' office with an espresso machine in the lobby and a doctor available 24/7, or a more frugal office with a drinking fountain and third-party call center doctors after hours, a likely outcome is that some will be stuck with a choice between making rent and getting preventative care at all. But you're right for some kinds of care, though: Even if care for an emergency was going to be relatively inexpensive, I don't have the time or mobility to negotiate when an ambulance arrives or when I get to the ER. And if that happens, my ability to pay should not matter in a modern, civilized society. And more obviously, I do need health insurance in case I fall victim to a rare, unlikely, expensive disease or accident and need care worth more than my net worth. For this reason, I would gladly put a bit of money into a fund to mitigate this risk; that's the point of insurance. I'd be a little annoyed if others who are likely to take more from the fund (smokers, obese people) got to pay the same amount in but were statistically likely to draw more out of it - but not so annoyed or so petty that I would want to exclude them from the group. That fund can be private insurance, or government insurance, but insurance of some kind is needed.
dreamcompiler 9y ago
Disagree. Services compete all the time, and most healthcare procedures are not life-and-death emergencies. The problem really is that the customer of healthcare in the US is not the entity paying for the service, and hospitals have a huge incentive to price their services differently to individuals than to insurance companies and not to price services transparently. There was a time in the past when US healthcare was not considered costly. That era (before the 1970s) was different in three ways: 1. Most people paid for healthcare out of their own pocket. 2. Most healthcare providers were non-profit (hospitals) or small businesses (independent doctors' offices). 3. Prices for services rendered were the same for every customer of a given provider and available in advance.
- igk 9y ago
  I think this is missing the point.There was a time where health care costs for German, British or any other citizen of countries with single payer healthcare were reasonable, without any of your 3 points (ok,maybe number 3). This time was just about a millisecond ago.
  - dragonwriter 9y ago
    Germany (like every OECD country but the US) has universal healthcare but not (along with several other non-US OECD countries) single-payer healthcare. US reform advocates often confuse the two.
    - igk 9y ago
      True, I was imprecise Though I feel like the laws and incentives our Germany closer to the single payer end of the spectrum, contrasting with Switzerland which also has universal healthcare but different incentive structures, which lead to them being #2 in health care costs
  - dreamcompiler 9y ago
    I'm not suggesting single-payer can't work. One existence proof that it can is right here in the US with Medicare and the VA. I'm suggesting that the invisible hand of the market can work too, because it has in the past. What we have now is neither single-payer nor market-based capitalism.
noetic_techy 9y ago
I disagree with your conclusion that universal healthcare for all is the logical end point. What if we did mandatory catastrophic insurance for everyone (I'm not against the mandate). All other non-life threatening services are negotiable and free market. Its as simple as that. You can even have the government pay for this insurance for every American as sort-of a quasi universal service via taxes. The government will save your life and maybe even pay to "get you back on your feet". The rest is up to you. You can still buy private plans for better high end treatment, but take the lowest barrier out of the picture. This solves the issue of not turning away people at emergency rooms with life threatening conditions, and allows competition to drive down prices for everything else. Deregulate the rest, remove onerous standard of care requirements that stifle new and innovative treatments, and let the bad apples get google/yelp/whatever reviewed out of existence.

canes123456 9y ago

The vast majority of health care decisions are not life and death. Many times it is still hard to know how much something will cost and it is hard to price shop. But the same thing applies to auto repair. You need a car to get around and it is extremely expensive to toll your car to other body shops. You need to take the price the person offers you a lot of the time. But in medicine some times it is not time critical and you can shop around. We don't do it know because we don't pay.

CPLX 9y ago
All healthcare decisions are life and death. Just not necessarily directly. That fact complicates matters significantly.
- paulddraper 9y ago
  All decisions are life decisions
- hnal943 9y ago
  That's not true. I have mild allergies. It's not a life and death decision to get care or not. If the costs outweigh the benefits, I will opt out.
- canes123456 9y ago
  By that logic, so it auto and food decisions. Postponing changing brakes has bigger life and death decisions than skipping the marginal medical test.
devwastaken 9y ago
But this isn't a car. The attempts at trying to simplify healthcare discussion only contribute to muddying it, because there's significantly more factors than that. A healthcare decision doesn't have to be life or death for it to still be something you need. Diseases can hurt, or they can kill you slowly, and its not a simply 'yes or no' when it comes to what /could/ happen to you without treatment. So, yes, you have to have treatment. Everybody will be convincing you that you need treatment, and you most likely do. Meaning, you have a guaranteed market. In a guaranteed market, even if you have bad quality, even if you do the wrong things, it doesn't matter, you're still going to get customers, because they need it, and thats exactly what happens in healthcare today. Get a knee operation and the problem comes back a year later? Get another operation. Because you don't have the option of not doing so. No, you don't. Quitting work and not making money, or not being able to contribute to society around you, is not a realistic or beneficial option, and certainly not one that can be advocated for with any consciousness of socioeconomics. "But the same thing applies to auto repair. You need a car to get around and it is extremely expensive to toll your car to other body shops. You need to take the price the person offers you a lot of the time. But in medicine some times it is not time critical and you can shop around. We don't do it know because we don't pay." What kind of 'shopping around' are you advocating for? A car is replaceable if something goes wrong, you have insurance on that car even. On your body, if something doesn't go right, thats not on the hospital. Thats you, you are irreplacable, and because of that, whatever service is perceived to be better will be used. Typically, in the form of cost, as it is now. Thats assuming competition would just 'rise up' if we could pay directly, which as I said before, was already happening and we still had the same issue. With universal care, the root costs of care, such as equipment and devices, are more standardized and leveraged in bulk. You need 10,000 hip replacements for your hospitals in the coming years? 5 companies get to compete with who can make and sell them the cheapest. But they better be safe, tested, and work. Atleast, in the U.K. thats how it works. But what this does is creates an entity that negotiates on your behalf, to predict the majority of costs and reduce them. Without that, you are at the mercy of whoever is setting the prices, because you're not going to get to 'shop around' when your medication is sold from one entity.
- canes123456 9y ago
  This post is muddying arguments by mixing everything in healthcare together. Lasik has gotten much better AND much cheaper because people shop around. There are many more things that can be handled like this. Instead, doctors and patients tests to be on the safe side because it is "free". Lets take a quick aside for MRIs. The machine has a high fixed cost but the margin cost is pretty low. Just the time of the operator and 2 minutes of a doctors time to read it. They actually cost between 1k-12+k. Why is there such a huge cost difference? This would not happen anywhere else. Yes, MRI might be required right now but they can also be required in a few days, or weeks. Some cases you can wait and see if it is needed at all. All of the people could shop around and go to the 1k place. Right now there is no incentive to shop around. If there was an incentive, the 1k places would get way more business. Some people would still be willing to pay 14k but it much smaller. Eventually they would need to lower prices to stay in business. In all markets, most people are willing to pay more than the list price. However, the list price is determined by the marginal customer. Eventually the person that would have paid 100k would still only need to pay 1k. Your example of knee surgery works the same way. If you are paying the whole cost or even 25% of the cost, you will care about the cost. You will want a good doctor that will actually fix your knee. But you would not want to pay 2x the going rate from a slightly better doctor. With other big expenses like buying a home, car, getting married, or even buying a computer, people read reviews, consider several options, and look for a good value. With healthcare, they only care about quality since there is no price. People need many goods beyond healthcare. They need food, water, and shelter. We still can have prices for all those things. I am baffle by your definition of a guaranteed market. Yes there is guaranteed market for food but that does mean that any given supplier will get that market. It seems like you are assuming a monopoly or something. Finally, none of this precludes supporting health care of poor people or have insurance to protect people from getting huge amounts of healthcare debit.
emodendroket 9y ago
Frankly that's just not true. Many people are uninsured, in the first place, and even if they weren't, insurers are shifting more and more costs to patients (think about something like co-insurance where you're subject to a lot of the risk the insurer would be subject to in a traditional co-pay situation). What mostly happens when you shift costs to consumers is they don't get necessary care. Incidentally, one reason I find this singularly unpersuasive is that the United States is unique in the degree to which you are directly responsible for your medical bills and yet spending is wildly above what you see in other OECD countries. We don't have to rely purely on theory here.
- canes123456 9y ago
  We don't have prices. We have a few huge companies trying to justify higher and higher cost. Consumers have no way to predict what hospitals are cheaper than others.
  - emodendroket 9y ago
    But neither do any of the places where government insurance prevails and costs are way lower.

deleted 9y ago

[deleted]

deleted 9y ago

[deleted]

LeifCarrotson 9y ago

I haven't read the book either (yet) - but I agree with you for the most part. I disagree, though, with the lumping together of all health care as something that cannot be negotiated. Preventative care, elective care, and other voluntary work could, in theory, be negotiated. I could choose where to get a physical, flu shot, dental cleaning, or glasses/contacts/lasic, choose whether or not to have a child (currently dealing with the outrageous costs of that right now...). A wrinkle in this idea is that while it sounds nice for people to be able to choose between a nice doctors' office with an espresso machine in the lobby and a doctor available 24/7, or a more frugal office with a drinking fountain and third-party call center doctors after hours, a likely outcome is that some will be stuck with a choice between making rent and getting preventative care at all. But you're right for some kinds of care, though: Even if care for an emergency was going to be relatively inexpensive, I don't have the time or mobility to negotiate when an ambulance arrives or when I get to the ER. And if that happens, my ability to pay should not matter in a modern, civilized society. And more obviously, I do need health insurance in case I fall victim to a rare, unlikely, expensive disease or accident and need care worth more than my net worth. For this reason, I would gladly put a bit of money into a fund to mitigate this risk; that's the point of insurance. I'd be a little annoyed if others who are likely to take more from the fund (smokers, obese people) got to pay the same amount in but were statistically likely to draw more out of it - but not so annoyed or so petty that I would want to exclude them from the group. That fund can be private insurance, or government insurance, but insurance of some kind is needed.

dreamcompiler 9y ago

Disagree. Services compete all the time, and most healthcare procedures are not life-and-death emergencies. The problem really is that the customer of healthcare in the US is not the entity paying for the service, and hospitals have a huge incentive to price their services differently to individuals than to insurance companies and not to price services transparently. There was a time in the past when US healthcare was not considered costly. That era (before the 1970s) was different in three ways: 1. Most people paid for healthcare out of their own pocket. 2. Most healthcare providers were non-profit (hospitals) or small businesses (independent doctors' offices). 3. Prices for services rendered were the same for every customer of a given provider and available in advance.

igk 9y ago
I think this is missing the point.There was a time where health care costs for German, British or any other citizen of countries with single payer healthcare were reasonable, without any of your 3 points (ok,maybe number 3). This time was just about a millisecond ago.
- dragonwriter 9y ago
  Germany (like every OECD country but the US) has universal healthcare but not (along with several other non-US OECD countries) single-payer healthcare. US reform advocates often confuse the two.
  - igk 9y ago
    True, I was imprecise Though I feel like the laws and incentives our Germany closer to the single payer end of the spectrum, contrasting with Switzerland which also has universal healthcare but different incentive structures, which lead to them being #2 in health care costs
- dreamcompiler 9y ago
  I'm not suggesting single-payer can't work. One existence proof that it can is right here in the US with Medicare and the VA. I'm suggesting that the invisible hand of the market can work too, because it has in the past. What we have now is neither single-payer nor market-based capitalism.

noetic_techy 9y ago

I disagree with your conclusion that universal healthcare for all is the logical end point. What if we did mandatory catastrophic insurance for everyone (I'm not against the mandate). All other non-life threatening services are negotiable and free market. Its as simple as that. You can even have the government pay for this insurance for every American as sort-of a quasi universal service via taxes. The government will save your life and maybe even pay to "get you back on your feet". The rest is up to you. You can still buy private plans for better high end treatment, but take the lowest barrier out of the picture. This solves the issue of not turning away people at emergency rooms with life threatening conditions, and allows competition to drive down prices for everything else. Deregulate the rest, remove onerous standard of care requirements that stifle new and innovative treatments, and let the bad apples get google/yelp/whatever reviewed out of existence.