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I am an immigrant from a socialist, ex-communist country in the Balkans, where socialized medicine is the norm, as is having really good doctors. The few times

I am an immigrant from a socialist, ex-communist country in the Balkans, where socialized medicine is the norm, as is having really good doctors. The few times I’ve had to go to the doctor there, either to be seen myself or to help my grandmother, was an awful experience. I’ve had to spend 2 weeks going from office to office until I could finally get an appointment (just an appointment!) for my almost-blind grandmother, for a simple cataract procedure. The procedure was scheduled ONE YEAR from the time of appointment, which meant she was blind in one eye for a whole year. That’s the absurdity of a socialized system. Everyone already knows the absurdities of this system here so I’ll skip that part of my rant. This issue is so polarizing, it occurred to me - why don’t we have a medicare-type system (call it m4a) for those who want it, and not for those who don’t? It’s about a 50-50 split anyway. The catch is, if you don’t pay tax for m4a, you can’t use it. This way, those who are concerned about “paying for others and receiving inferior service” don’t have to, and those who can’t or don’t want to deal with a privatized system are free to use it.

rootusrootus 6y ago
> This issue is so polarizing, it occurred to me - why don’t we have a medicare-type system (call it m4a) for those who want it, and not for those who don’t? It’s about a 50-50 split anyway. I've been thinking about this a lot myself lately too. It seems like there is critical mass for the people who want universal healthcare, so why can't we make it happen? It doesn't seem that unreasonable to set up a dual system where people who want their taxes to pay for healthcare can get it, and the rest can make their way with the private insurance companies. Win/win. The difficulty would probably be in keeping the tax pools separate. And deciding at what point someone paying into the single payer system gained permanent eligibility even when unemployed. Things like that.
- ajsnigrutin 6y ago
  Probably because people earning less than average will want to be in the shared pool, and people earning more than the average will want individual insurance schemes.
- shagie 6y ago
  A dual system where we chose to have our tax dollars go where we want... why stop at healthcare? If I don't want my tax dollars to go to... say the military? Can I defund the federal flood insurance because I feel we need to disincentivize living on the coast as sea levels raise (and personably live 900' above sea level)? Having individual discretion over what tax dollars goes to leads to an unmanageable mess for those trying to actually create a budget. Additionally, sometimes a national priority and the hard choices that goes with that means having taxes spent on things that aren't necessarily popular with the entirety of the electorate. The control over the budget comes (in theory) with voting on a house member who aligns with your goals for the budget. Yes - in theory.
  - mirkules 6y ago
    I see healthcare as a special case, though (the rule about exceptions becoming the rule, notwithstanding). The healthcare system is interwoven with rules and regulations. For instance, we already have tax rules depending on your yearly FSA/HSA contributions, tax deductions based on how much money is spent, and most importantly the Obamacare rule that one must have insurance or suffer penalties. Would another exception break the system?
  - rootusrootus 6y ago
    > A dual system where we chose to have our tax dollars go where we want... why stop at healthcare? I think a bit of differentiation could be good, but I draw a distinction here. You get to choose among choices available to you. So unless "not paying for the military" was an option written into law by congress, you could not select that option. And it would be unlikely to be offered, for many reasons, not the least of which is that everyone benefits from the military just by virtue of living within the borders of the US. I don't think it should be a menu where each citizen gets to select from a huge range of options. I think for some things that would work, but there are many things too fundamental to let people opt in and out.
    - shagie 6y ago
      I would contend that everyone/society benefits from having the population, as a whole, being healthy. More people who are able to be productive members of the workforce, better mental health from improved financial security, and less cost from preventative rather than responsive treatment. That also gets to the heart of the problem - not everyone recognizes the benefits that I've suggested from a more universal healthcare system. I would also contend, that I don't see the benefits from the level of military spending that we have.
- Jarwain 6y ago
  My main concern here is: what happens if someone who isn't paying for insurance ends up at the hospital? First of all, does the hospital delay care until they can verify that the patient has insurance? What if it's an emergency? If the hospital doesn't delay care, and afterwards the patient is found to not have insurance, they'd be billed right? What if they can't pay it, and they default? How does the hospital make up for that loss? Under the current system, I believe the hospital eats the cost, and adjusts their rates accordingly, so the insured end up footing the bill Anyways. A socialized system formalize this, and distribute that cost across everyone instead of just the people who pay for insurance/healthcare.
vore 6y ago
I have a few thoughts on this: - If the waiting times are too long, then ultimately it's a supply issue which can be solved by increasing supply (i.e. more funding). Of course, this is obviously easier said than done but it's not really an inherent problem of the system. - What would your grandmother do in a situation with a privatized system and she couldn't afford surgery? This isn't theoretical: this happens in the US all the time. While I agree that being blind for a year is not acceptable, it's only in certain positions of privilege in the US in the current system where you would even be treated and again is more inherently about funding than it is about an inherent fault of a socialized system. - I think that if you don't force everyone to pay in the system and allow for private healthcare, people (and politicians!) don't have incentive to improve the system because they can just take private insurance and ignore a languishing public system. The public system doesn't have to be bad, but creating a two-tier public/private system incentivizes people to not care about public healthcare.
- mirkules 6y ago
  The issue is that of incentive, to put it bluntly. What is the incentive of a medical provider to provide The Best Care Possible, when they know for sure there is no competition? You end up with a system whose only raison d’etre is to continue working as little as possible with no real progress. Yes, not being able to afford it is obviously a bigger issue than being blind for a year. In this case, she had the option to go to a private surgeon and get it taken care of for much more money. As for your last point, in a socialistic type of service, “progress” serves to elect public officials. In a capitalistic service, “progress” serves to make more money. Both of these approaches have their flaws; however, I would argue that progress is faster and service of higher quality when a government is not involved. The gov’t advantage is that it’s “cheaper” and thus more accessible to everyone. As a commenter posted below, I think we have a critical mass of folks (half the country, basically) who would be willing to go the public route. I really have to think this through, though, bc it would create some interesting incentives to sign people up to one or the other.
jakeinspace 6y ago
Well, that means that poor people will likely have a large incentive to buy in, while the upper 5-10% would opt for private insurance rather than paying additional income tax. Unfortunately, the poor and middle class probably will not be able to fund a well functioning level of health insurance by themselves.
- mirkules 6y ago
  I’m not entirely sure this is the case. I suspect (but can’t prove) it’s mostly split among party lines, with an equal pool of wealth between them. That is, there are plenty of rich Democrats that could bankroll this.

rootusrootus 6y ago

> This issue is so polarizing, it occurred to me - why don’t we have a medicare-type system (call it m4a) for those who want it, and not for those who don’t? It’s about a 50-50 split anyway. I've been thinking about this a lot myself lately too. It seems like there is critical mass for the people who want universal healthcare, so why can't we make it happen? It doesn't seem that unreasonable to set up a dual system where people who want their taxes to pay for healthcare can get it, and the rest can make their way with the private insurance companies. Win/win. The difficulty would probably be in keeping the tax pools separate. And deciding at what point someone paying into the single payer system gained permanent eligibility even when unemployed. Things like that.

ajsnigrutin 6y ago
Probably because people earning less than average will want to be in the shared pool, and people earning more than the average will want individual insurance schemes.
shagie 6y ago
A dual system where we chose to have our tax dollars go where we want... why stop at healthcare? If I don't want my tax dollars to go to... say the military? Can I defund the federal flood insurance because I feel we need to disincentivize living on the coast as sea levels raise (and personably live 900' above sea level)? Having individual discretion over what tax dollars goes to leads to an unmanageable mess for those trying to actually create a budget. Additionally, sometimes a national priority and the hard choices that goes with that means having taxes spent on things that aren't necessarily popular with the entirety of the electorate. The control over the budget comes (in theory) with voting on a house member who aligns with your goals for the budget. Yes - in theory.
- mirkules 6y ago
  I see healthcare as a special case, though (the rule about exceptions becoming the rule, notwithstanding). The healthcare system is interwoven with rules and regulations. For instance, we already have tax rules depending on your yearly FSA/HSA contributions, tax deductions based on how much money is spent, and most importantly the Obamacare rule that one must have insurance or suffer penalties. Would another exception break the system?
- rootusrootus 6y ago
  > A dual system where we chose to have our tax dollars go where we want... why stop at healthcare? I think a bit of differentiation could be good, but I draw a distinction here. You get to choose among choices available to you. So unless "not paying for the military" was an option written into law by congress, you could not select that option. And it would be unlikely to be offered, for many reasons, not the least of which is that everyone benefits from the military just by virtue of living within the borders of the US. I don't think it should be a menu where each citizen gets to select from a huge range of options. I think for some things that would work, but there are many things too fundamental to let people opt in and out.
  - shagie 6y ago
    I would contend that everyone/society benefits from having the population, as a whole, being healthy. More people who are able to be productive members of the workforce, better mental health from improved financial security, and less cost from preventative rather than responsive treatment. That also gets to the heart of the problem - not everyone recognizes the benefits that I've suggested from a more universal healthcare system. I would also contend, that I don't see the benefits from the level of military spending that we have.
Jarwain 6y ago
My main concern here is: what happens if someone who isn't paying for insurance ends up at the hospital? First of all, does the hospital delay care until they can verify that the patient has insurance? What if it's an emergency? If the hospital doesn't delay care, and afterwards the patient is found to not have insurance, they'd be billed right? What if they can't pay it, and they default? How does the hospital make up for that loss? Under the current system, I believe the hospital eats the cost, and adjusts their rates accordingly, so the insured end up footing the bill Anyways. A socialized system formalize this, and distribute that cost across everyone instead of just the people who pay for insurance/healthcare.

vore 6y ago

I have a few thoughts on this: - If the waiting times are too long, then ultimately it's a supply issue which can be solved by increasing supply (i.e. more funding). Of course, this is obviously easier said than done but it's not really an inherent problem of the system. - What would your grandmother do in a situation with a privatized system and she couldn't afford surgery? This isn't theoretical: this happens in the US all the time. While I agree that being blind for a year is not acceptable, it's only in certain positions of privilege in the US in the current system where you would even be treated and again is more inherently about funding than it is about an inherent fault of a socialized system. - I think that if you don't force everyone to pay in the system and allow for private healthcare, people (and politicians!) don't have incentive to improve the system because they can just take private insurance and ignore a languishing public system. The public system doesn't have to be bad, but creating a two-tier public/private system incentivizes people to not care about public healthcare.

mirkules 6y ago
The issue is that of incentive, to put it bluntly. What is the incentive of a medical provider to provide The Best Care Possible, when they know for sure there is no competition? You end up with a system whose only raison d’etre is to continue working as little as possible with no real progress. Yes, not being able to afford it is obviously a bigger issue than being blind for a year. In this case, she had the option to go to a private surgeon and get it taken care of for much more money. As for your last point, in a socialistic type of service, “progress” serves to elect public officials. In a capitalistic service, “progress” serves to make more money. Both of these approaches have their flaws; however, I would argue that progress is faster and service of higher quality when a government is not involved. The gov’t advantage is that it’s “cheaper” and thus more accessible to everyone. As a commenter posted below, I think we have a critical mass of folks (half the country, basically) who would be willing to go the public route. I really have to think this through, though, bc it would create some interesting incentives to sign people up to one or the other.

jakeinspace 6y ago

Well, that means that poor people will likely have a large incentive to buy in, while the upper 5-10% would opt for private insurance rather than paying additional income tax. Unfortunately, the poor and middle class probably will not be able to fund a well functioning level of health insurance by themselves.

mirkules 6y ago
I’m not entirely sure this is the case. I suspect (but can’t prove) it’s mostly split among party lines, with an equal pool of wealth between them. That is, there are plenty of rich Democrats that could bankroll this.