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>No matter how many people say "but a well regulated mandatory multi-payer type of system is working in Germany" or "nationalized medicine is working in Canada"

>No matter how many people say "but a well regulated mandatory multi-payer type of system is working in Germany" or "nationalized medicine is working in Canada" it's all just ignored and the argument continues anew. Practically nobody is saying that a single payer system or tightly regulated multi-payer system hasn't worked anywhere (we all know Canada exists) or can't work in the US. Everyone is arguing about the specific implementation because those are the details that make or break it. Anything would work on paper. Even free market with some good regulations to promote competition would probably work. It's the specific details of actually implementing something that works (and the ability of the people who would be doing the implementing to get those details right and not be corrupted by existing interests) that everyone is arguing over. Everyone with a brain realizes that when it comes to big systems involving lots of moving parts the fine tuning is what makes or breaks them. Look at all the various social services programs that were kneecapped over the years because someone came along and made a few small changes or some key feature was compromised out of existence. Everyone is bickering over every detail because every detail has the ability to cause massive amounts of hardship when applied at a societal level if said detail is done wrong. Simply put, healthcare is a hard issue because the stakes are so high that nobody is apathetic about it making compromise and consensus hard to reach.

Retric 7y ago
> Even free market with some good regulations to promote competition would probably work. One of the really interesting things about US healthcare is how much is spent on bureaucracy. Consider, the average surgeon does ~400 operations per year and they generally make less than 600k/year. That’s 1,500$ per operation for the surgeon. Even with support staff, infrastructure, and materials, the average surgery should be under 10k. Now let’s take an insurance that’s paying say 80% of it’s premiums for medical care. That’s 1 / 0.8 = a flat 25% price increase directly on top of whatever they add to healthcare provider’s costs in terms of additional paperwork and negotiation. Similarly, before it goes to insurance the cost is inflated at the healthcare provider level to cover administrative costs like unpaid bill collections etc.
- zxcmx 7y ago
  From my POV its fair for the support services to cost a lot. The theatre or the nurses or the equipment or really anything we can account to facilities or administration might cost a lot and thats generally kind of ok. A junior programmer costs $250/hr from booz allen or whatever and I think a lot of people here understand why that is. They might not be able to fizz buzz so well but we expect the system to fizz and buzz eventually and expensively. You can't add up what a plumber spends on beer or pays an apprentice and try to say what he should charge for his business. What sucks is that despite the rhetoric theres actually no market. Want a market? Let people actually choose and make costs transparent.
  - Retric 7y ago
    By should I am speaking in terms of competitive markets resulting in prices reflecting the cost of production + minor profits. Cosmetic surgery prices are generally reflective of costs including advertising etc. It’s not cheap by any means, but you simply avoid overhead occurring in other parts of US healthcare. Dentistry is another example where prices are generally reflective of costs, at least compared to say hospitals.
ianleeclark 7y ago
> Even free market with some good regulations to promote competition would probably work. That's not a free market then. This is the hardest part of the entire discussion: everyone is attempting to not exercise political power because they have these grand notions that politics can be done for the benefit of all. I'm not saying M4A is impossible (in fact, I would prefer it if I still lived in the states), but the fact of the matter is that the donor class will feel the sting of this transition, so we go off and Chase fairy tales where both the donors and the people rationing insulin can both coexist. Ultimately you end up with contradictory notions like a regulated free market.
- zxcmx 7y ago
  There are plenty of regulated free markets. Examples would be everything which uses mains power, phone lines or radiates rf. Or stuff you eat or medicine. Or occupational products. Or... actually I think more things are regulated than aren't. I guess my point is that when regulations apply to everything around us, is that really the sticking point or is it the potential for regulatory capture and limited user choice?
  - ianleeclark 7y ago
    > There are plenty of regulated free markets. I think we're talking about different definitions of a free market then. To me, a free market is a market which is self-regulating or free from external regulation. It would seem to me that you define a free market as having some, arbitrary amount of regulation. If the amount of regulation is "under," that arbitrary bar, then it would be free. I don't really think this definition works, as the bar for what's "free" is arbitrary and would vary person-to-person, nation-to-nation, so it becomes a meaningless term.
    - zxcmx 7y ago
      I do have a prior, which is that I don't think any "free" markets exist in western nations due to broad consumer laws, plus applicable domain specific laws but interested in your perspective. There are severe limits on what any of us can buy and/or sell and how we talk about it. A good kick starter for discussion would be an example of a free market as you see it. If you are doing things with widespread societal impact generally society will have some things to say about that and their (perhaps slow and ham-fisted) means of expressing opinions about that is law and regulation. As a consequence of seeing all fields as essentially regulated, I have a pretty low bar for free markets which is mostly "multiple parties can meaningfully compete and politicians do not completely determine that. Also consumers have a genuine choice.". This excludes China but kind of includes the USA, in many fields. But health care is weird. As an example of my point of view, I think we can have laws that regulate carbon, material waste or other externalities and might be "onerous" but still have "free markets".
Ensorceled 7y ago
> Nobody is saying that a single payer system or tightly regulated multi-payer system hasn't worked anywhere or can't work in the US. Everyone is arguing about the specific implementation because those are the details that make or break it. They are certainly arguing that such systems won't be effective in ths US in this discussion: > Many on the left despise mergers and consolidation, and anything that has a hint of monopoly power. Except when it comes to government, education, and healthcare! Doesn’t a single centralized monopoly providing everyone’s healthcare seem like a bad idea? Why is it so bad in business and so good for health? > That is very bad reasoning. Most things don't get cheaper when they get nationalized. There is some evidence healthcare may be different in this regard, but the point is: costs are not invariant under nationalization. > We can't provide everyone with all the healthcare that they should get. There are never going to be enough doctors, equipment or hospitals. Sickness is literally an endless source of suffering and we all die of something - there cannot be enough medical assistance to deal with everything even if we devote everything we have to the healthcare industry. Rationing access to healthcare by people's economic contribution to society is just as fair as any other sort of rationing you care to come up with. > There aren’t sufficient amount of people willing to do the highly undesirable work of caring for sick, contagious, handicapped, possibly dangerous people without money as the end goal.
bart_spoon 7y ago
Healthcare isn't a hard issue because the details are hard to figure out. Healthcare is a hard issue because millions of Americans work for companies and industries that are dependent on the status quo. One of the primary reasons for skyrocketing healthcare costs is the explosion of administration staff/costs in healthcare systems. And the private insurance industry has given rise to some of the largest companies on the planet. Its difficult because the system has evolved to a place where the parasites in the relationship have grown so large that they can't be removed without serious damage to the host. Not overhauling the system is unsustainable, but doing so will absolutely incur huge economic consequences for a large part of the population.

Retric 7y ago

> Even free market with some good regulations to promote competition would probably work. One of the really interesting things about US healthcare is how much is spent on bureaucracy. Consider, the average surgeon does ~400 operations per year and they generally make less than 600k/year. That’s 1,500$ per operation for the surgeon. Even with support staff, infrastructure, and materials, the average surgery should be under 10k. Now let’s take an insurance that’s paying say 80% of it’s premiums for medical care. That’s 1 / 0.8 = a flat 25% price increase directly on top of whatever they add to healthcare provider’s costs in terms of additional paperwork and negotiation. Similarly, before it goes to insurance the cost is inflated at the healthcare provider level to cover administrative costs like unpaid bill collections etc.

zxcmx 7y ago
From my POV its fair for the support services to cost a lot. The theatre or the nurses or the equipment or really anything we can account to facilities or administration might cost a lot and thats generally kind of ok. A junior programmer costs $250/hr from booz allen or whatever and I think a lot of people here understand why that is. They might not be able to fizz buzz so well but we expect the system to fizz and buzz eventually and expensively. You can't add up what a plumber spends on beer or pays an apprentice and try to say what he should charge for his business. What sucks is that despite the rhetoric theres actually no market. Want a market? Let people actually choose and make costs transparent.
- Retric 7y ago
  By should I am speaking in terms of competitive markets resulting in prices reflecting the cost of production + minor profits. Cosmetic surgery prices are generally reflective of costs including advertising etc. It’s not cheap by any means, but you simply avoid overhead occurring in other parts of US healthcare. Dentistry is another example where prices are generally reflective of costs, at least compared to say hospitals.

ianleeclark 7y ago

> Even free market with some good regulations to promote competition would probably work. That's not a free market then. This is the hardest part of the entire discussion: everyone is attempting to not exercise political power because they have these grand notions that politics can be done for the benefit of all. I'm not saying M4A is impossible (in fact, I would prefer it if I still lived in the states), but the fact of the matter is that the donor class will feel the sting of this transition, so we go off and Chase fairy tales where both the donors and the people rationing insulin can both coexist. Ultimately you end up with contradictory notions like a regulated free market.

zxcmx 7y ago
There are plenty of regulated free markets. Examples would be everything which uses mains power, phone lines or radiates rf. Or stuff you eat or medicine. Or occupational products. Or... actually I think more things are regulated than aren't. I guess my point is that when regulations apply to everything around us, is that really the sticking point or is it the potential for regulatory capture and limited user choice?
- ianleeclark 7y ago
  > There are plenty of regulated free markets. I think we're talking about different definitions of a free market then. To me, a free market is a market which is self-regulating or free from external regulation. It would seem to me that you define a free market as having some, arbitrary amount of regulation. If the amount of regulation is "under," that arbitrary bar, then it would be free. I don't really think this definition works, as the bar for what's "free" is arbitrary and would vary person-to-person, nation-to-nation, so it becomes a meaningless term.
  - zxcmx 7y ago
    I do have a prior, which is that I don't think any "free" markets exist in western nations due to broad consumer laws, plus applicable domain specific laws but interested in your perspective. There are severe limits on what any of us can buy and/or sell and how we talk about it. A good kick starter for discussion would be an example of a free market as you see it. If you are doing things with widespread societal impact generally society will have some things to say about that and their (perhaps slow and ham-fisted) means of expressing opinions about that is law and regulation. As a consequence of seeing all fields as essentially regulated, I have a pretty low bar for free markets which is mostly "multiple parties can meaningfully compete and politicians do not completely determine that. Also consumers have a genuine choice.". This excludes China but kind of includes the USA, in many fields. But health care is weird. As an example of my point of view, I think we can have laws that regulate carbon, material waste or other externalities and might be "onerous" but still have "free markets".

Ensorceled 7y ago

> Nobody is saying that a single payer system or tightly regulated multi-payer system hasn't worked anywhere or can't work in the US. Everyone is arguing about the specific implementation because those are the details that make or break it. They are certainly arguing that such systems won't be effective in ths US in this discussion: > Many on the left despise mergers and consolidation, and anything that has a hint of monopoly power. Except when it comes to government, education, and healthcare! Doesn’t a single centralized monopoly providing everyone’s healthcare seem like a bad idea? Why is it so bad in business and so good for health? > That is very bad reasoning. Most things don't get cheaper when they get nationalized. There is some evidence healthcare may be different in this regard, but the point is: costs are not invariant under nationalization. > We can't provide everyone with all the healthcare that they should get. There are never going to be enough doctors, equipment or hospitals. Sickness is literally an endless source of suffering and we all die of something - there cannot be enough medical assistance to deal with everything even if we devote everything we have to the healthcare industry. Rationing access to healthcare by people's economic contribution to society is just as fair as any other sort of rationing you care to come up with. > There aren’t sufficient amount of people willing to do the highly undesirable work of caring for sick, contagious, handicapped, possibly dangerous people without money as the end goal.

bart_spoon 7y ago

Healthcare isn't a hard issue because the details are hard to figure out. Healthcare is a hard issue because millions of Americans work for companies and industries that are dependent on the status quo. One of the primary reasons for skyrocketing healthcare costs is the explosion of administration staff/costs in healthcare systems. And the private insurance industry has given rise to some of the largest companies on the planet. Its difficult because the system has evolved to a place where the parasites in the relationship have grown so large that they can't be removed without serious damage to the host. Not overhauling the system is unsustainable, but doing so will absolutely incur huge economic consequences for a large part of the population.