6 ms·

Also a fiscal conservative, I completely agree single-payer would be much better than what we have now. What I think would be best though, is to eliminate medi

Also a fiscal conservative, I completely agree single-payer would be much better than what we have now. What I think would be best though, is to eliminate medicare/medicaid, hand people cash, and get out of the way. The high-order problem with medicine isn't coverage or insurance. It's price. There are only two ways to get price under control: meaningful competition, or government price controls (e.g. single payer). Single payer would end up like public schools: one choice for everyone, probably OK quality, but not great. I think we could do so much more here if we just created a cash market and handed people money. It's what Singapore does. It would let doctors compete on -- even discover -- what actually matters to consumers -- wait times, when procedures take place, even how comfortable the office is. I would much rather have a market with choice and variety than one that straitjackets everyone into a one-size-fits-all system that might work for some but probably won't for others. I know people are going to worry about rare (expensive) conditions not being covered, and this is indeed a problem. I don't have an answer to this. One good thing about competition though, is that it drives innovation. Provider prices will absolutely be set based on what they know people can pay. If people can't pay as much, the only thing for them to do is drop prices. It's funny. In a community where people are so focused on innovation, and startups, and choice, I see a lot of support for a national single-payer scheme. I would much rather take the collective energies of this community and apply them to innovation in this market, with meaningful choice and competition. Medicine needs more of a startup mindset. And for those roasting me about how it's different/dangerous/risky: what we have today is KILLING us, economically.

jimmaswell 6y ago
Patients would still decide where to be treated based on those factors, the only difference is the insurance is standardized. Nobody in countries with socialized health insurance seems to complain about lack of choices or any of that, and rich people in those places can still get private insurance to get their nose job done right away from a private practice. For everyone else I get the impression it works just fine.
- eldavido 6y ago
  I'm less convinced. The NHS, Britain's version of this, is constantly underfunded, and has long wait times for a variety of procedures. The Economist writes about this frequently. https://www.economist.com/britain/2018/06/28/the-three-myths-of-the-nhs https://www.economist.com/britain/2018/06/28/the-three-myths...
jfk13 6y ago
> I know people are going to worry about rare (expensive) conditions not being covered, and this is indeed a problem. I don't have an answer to this. One good thing about competition though, is that it drives innovation. Provider prices will absolutely be set based on what they know people can pay. If people can't pay as much, the only thing for them to do is drop prices. I don't think so. If providers can't expect to be paid adequately (in relation to their capital investment, research costs, operating costs, etc) for dealing with "rare (and expensive) conditions", because people don't have insurance (whether private, medicare, or whatever), just a modest amount of cash in any given patient's pocket, do you really think they'll want to stay in that market?
jimbob45 6y ago
You’re advocating for the same system that ruined colleges: guaranteed loans. Also coverage is also a huge deal in the US, although it may not be a problem for you specifically. Obamacare covered millions who otherwise might have stayed home instead of seeing the doctor. The problem with US health is scoping. Insurance companies are effectively “certifying” which hospitals and doctors you can see instead of actual certification bodies.
- aksss 6y ago
  > Obamacare covered millions I was one of the people who lost insurance starting a new business - too rich to get subsidized (cutoff was/is >~50k/yr), too poor to pay the equivalent of a second mortgage for individual insurance because of runaway premiums on individual market post-ACA. And penalized a few grand for it come tax season until the mandate was effectively rolled back. Was more than supportive of that rollback. It’s a risk management game for new business owners, and a big incentive for people to keep working for the man.
- eldavido 6y ago
  I never said anything about loans. What I'm suggesting is food stamps. Everybody can pay cash. If you can't, you get government assistance in the form of a cash-like subsidy that can be spent anywhere food is sold. It's a fast, efficient way of ensuring universality of care while benefiting from the market discipline you get from having a (mostly) competitive, cash market. Not to mention, there is no insane "food insurance" bureaucracy. You swipe the card at the checkout line and you're good.
ska 6y ago
aside: Singapore is a weird case and probably not a good comparitor for most healthcare systems. > If people can't pay as much, the only thing for them to do is drop prices. Or not offer the product at all. One problem with this entire area is that "healthcare" is really not one service/product area, and it is probably a mistake to treat it as such. To be transparent, I don't share your optimism about market solutions to problems like this in general (more about their implementation in practice than theoretical benefits) but I can see how it might help with parts of the routine healthcare. However, when you are talking emergency and major treatments, it's well into the range where direct consumer driven decisions are more likely going to mess up the incentives badly. If you are lucky enough to have the time (often not true), most people can become reasonably expert in their own disease state and treatment options. But that is a tiny slice of what is going on in a hospital system for example, and it's completely unreasonable to expect people to become informed enough to make good decisions there. If we want to benefit from market forces here, it's probably much more effective to have large (or single) payers who understand what the standard of care should be, and can encourage price competition from providers. It's worth noting that in theory this is what the insurance industry does in the US, though, but is an expensive mess. Another confounding factor is that many obvious price discovery mechanisms will be completely unacceptable to most people. Honestly, it's a mostly faith-based argument that a cash-based market approach can find a better global solution than universal health care, at least in a relevant amount of time. It's really hard for me to see why the country should take that risk when there are well understood and well modelled approaches (albeit imperfect) that should be able to reduce costs by at least 1/2, probably more. Why not start there?
- eldavido 6y ago
  The main thing I take on faith is that people are different and one-size fits all solutions don't produce good outcomes. We have different car brands, grocery stores, non-health insurance companies, package delivery companies, retailers, and housing options. Some people want fast and cheap. Others want to drive an hour to save a few bucks. This isn't some technical academic point. Without a range of choices, you actually can't know what people truly want. So things don't get better. People can't signal what's truly important by voting with their wallet. > If we want to benefit from market forces here, it's probably much more effective to have large (or single) payers who understand what the standard of care should be, and can encourage price competition from providers. I don't get this at all. There are so many markets where complex, highly-paid specialists do work customers might not understand: estate/trust lawyers, auto repair, even dental care. We don't have nearly the same problems as in medicine due to this culture of treating doctors like God. They aren't. They're just a person doing a service, just like a chef or a guy painting a house. What actually bothers me most about this whole thing is that nobody is willing to get serious about the tradeoffs their system entails. Health care in the US is failing right now. Companies are trying to stay beneath ACA limits because health insurance would crush them. My premiums are $380/month as a healthy, 36-year old nonsmoker with no rare conditions. That is INSANE. There's ever-more incentive to keep people off of W2 employment because premiums have gotten so out of control. If you take the current system, where bankruptcies are the norm, this monster is devouring almost 20% of our GDP, and every time I go to the doctor it's a major hassle, I'll come out and say that yes, maybe I'd prefer to fix that even if someone can't get a $150,000 drug anymore. >aside: Singapore is a weird case and probably not a good comparitor for most healthcare systems. Umm...why not? You can't just hand-wave that away.
jackson1442 6y ago
I don't think the "free market" can ever truly work in practice in the medical field, except for elective procedures and visits. Sure, if doctors want to compete on giving me a low price for vaccines and office visits, etc., I can see that working. However, any emergency service essentially has a captive audience. Most people who need an appendectomy or are having a heart attack are not in a position to price-shop. They need close, immediate care. Hell, quality probably doesn't even matter in these situations... not dying is the goal. This is where the free market doesn't work because there's no true consumer choice.

jimmaswell 6y ago

Patients would still decide where to be treated based on those factors, the only difference is the insurance is standardized. Nobody in countries with socialized health insurance seems to complain about lack of choices or any of that, and rich people in those places can still get private insurance to get their nose job done right away from a private practice. For everyone else I get the impression it works just fine.

eldavido 6y ago
I'm less convinced. The NHS, Britain's version of this, is constantly underfunded, and has long wait times for a variety of procedures. The Economist writes about this frequently. https://www.economist.com/britain/2018/06/28/the-three-myths-of-the-nhs https://www.economist.com/britain/2018/06/28/the-three-myths...

jfk13 6y ago

> I know people are going to worry about rare (expensive) conditions not being covered, and this is indeed a problem. I don't have an answer to this. One good thing about competition though, is that it drives innovation. Provider prices will absolutely be set based on what they know people can pay. If people can't pay as much, the only thing for them to do is drop prices. I don't think so. If providers can't expect to be paid adequately (in relation to their capital investment, research costs, operating costs, etc) for dealing with "rare (and expensive) conditions", because people don't have insurance (whether private, medicare, or whatever), just a modest amount of cash in any given patient's pocket, do you really think they'll want to stay in that market?

jimbob45 6y ago

You’re advocating for the same system that ruined colleges: guaranteed loans. Also coverage is also a huge deal in the US, although it may not be a problem for you specifically. Obamacare covered millions who otherwise might have stayed home instead of seeing the doctor. The problem with US health is scoping. Insurance companies are effectively “certifying” which hospitals and doctors you can see instead of actual certification bodies.

aksss 6y ago
> Obamacare covered millions I was one of the people who lost insurance starting a new business - too rich to get subsidized (cutoff was/is >~50k/yr), too poor to pay the equivalent of a second mortgage for individual insurance because of runaway premiums on individual market post-ACA. And penalized a few grand for it come tax season until the mandate was effectively rolled back. Was more than supportive of that rollback. It’s a risk management game for new business owners, and a big incentive for people to keep working for the man.
eldavido 6y ago
I never said anything about loans. What I'm suggesting is food stamps. Everybody can pay cash. If you can't, you get government assistance in the form of a cash-like subsidy that can be spent anywhere food is sold. It's a fast, efficient way of ensuring universality of care while benefiting from the market discipline you get from having a (mostly) competitive, cash market. Not to mention, there is no insane "food insurance" bureaucracy. You swipe the card at the checkout line and you're good.

ska 6y ago

aside: Singapore is a weird case and probably not a good comparitor for most healthcare systems. > If people can't pay as much, the only thing for them to do is drop prices. Or not offer the product at all. One problem with this entire area is that "healthcare" is really not one service/product area, and it is probably a mistake to treat it as such. To be transparent, I don't share your optimism about market solutions to problems like this in general (more about their implementation in practice than theoretical benefits) but I can see how it might help with parts of the routine healthcare. However, when you are talking emergency and major treatments, it's well into the range where direct consumer driven decisions are more likely going to mess up the incentives badly. If you are lucky enough to have the time (often not true), most people can become reasonably expert in their own disease state and treatment options. But that is a tiny slice of what is going on in a hospital system for example, and it's completely unreasonable to expect people to become informed enough to make good decisions there. If we want to benefit from market forces here, it's probably much more effective to have large (or single) payers who understand what the standard of care should be, and can encourage price competition from providers. It's worth noting that in theory this is what the insurance industry does in the US, though, but is an expensive mess. Another confounding factor is that many obvious price discovery mechanisms will be completely unacceptable to most people. Honestly, it's a mostly faith-based argument that a cash-based market approach can find a better global solution than universal health care, at least in a relevant amount of time. It's really hard for me to see why the country should take that risk when there are well understood and well modelled approaches (albeit imperfect) that should be able to reduce costs by at least 1/2, probably more. Why not start there?

eldavido 6y ago
The main thing I take on faith is that people are different and one-size fits all solutions don't produce good outcomes. We have different car brands, grocery stores, non-health insurance companies, package delivery companies, retailers, and housing options. Some people want fast and cheap. Others want to drive an hour to save a few bucks. This isn't some technical academic point. Without a range of choices, you actually can't know what people truly want. So things don't get better. People can't signal what's truly important by voting with their wallet. > If we want to benefit from market forces here, it's probably much more effective to have large (or single) payers who understand what the standard of care should be, and can encourage price competition from providers. I don't get this at all. There are so many markets where complex, highly-paid specialists do work customers might not understand: estate/trust lawyers, auto repair, even dental care. We don't have nearly the same problems as in medicine due to this culture of treating doctors like God. They aren't. They're just a person doing a service, just like a chef or a guy painting a house. What actually bothers me most about this whole thing is that nobody is willing to get serious about the tradeoffs their system entails. Health care in the US is failing right now. Companies are trying to stay beneath ACA limits because health insurance would crush them. My premiums are $380/month as a healthy, 36-year old nonsmoker with no rare conditions. That is INSANE. There's ever-more incentive to keep people off of W2 employment because premiums have gotten so out of control. If you take the current system, where bankruptcies are the norm, this monster is devouring almost 20% of our GDP, and every time I go to the doctor it's a major hassle, I'll come out and say that yes, maybe I'd prefer to fix that even if someone can't get a $150,000 drug anymore. >aside: Singapore is a weird case and probably not a good comparitor for most healthcare systems. Umm...why not? You can't just hand-wave that away.

jackson1442 6y ago

I don't think the "free market" can ever truly work in practice in the medical field, except for elective procedures and visits. Sure, if doctors want to compete on giving me a low price for vaccines and office visits, etc., I can see that working. However, any emergency service essentially has a captive audience. Most people who need an appendectomy or are having a heart attack are not in a position to price-shop. They need close, immediate care. Hell, quality probably doesn't even matter in these situations... not dying is the goal. This is where the free market doesn't work because there's no true consumer choice.