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> And if government got out of the business of healthcare --other than ensuring a fair and safe market-- these people would not have to make that choice. I don

> And if government got out of the business of healthcare --other than ensuring a fair and safe market-- these people would not have to make that choice. I don't follow. As far as the people I'm talking about are concerned, the government is not in the dentistry business, so what business are you imagining them getting out of? And how would said getting-out make dental treatment affordable for these people? In fact, dentistry seems to be managed more or less on the same basis as vision in this country, i.e. the ceiling on cost is relatively constrained and either you pay for it yourself or you have insurance that's separate from any standard health insurance you may or may not have. With regard to your LASIK example, as far as I can tell, lots of things in dentistry—e.g. orthodontic treatment—have gotten easier and cheaper and more effective, but they haven't invented an automated dentist-bot yet, and I am very skeptical of your (apparent) implicit claim that government meddling in the dentistry industry is to blame for that. It seems a lot more likely that different problems are different, and some are less amenable to technological breakthroughs and automation than others.

robomartin 6y ago
Please think this through. I have already said the variables, or points of influence, are significantly greater and deeper than just one item. Government has its paws in dentistry and eye care just as much as it does everywhere else in the medical field. Let's take three of those layers. First: By guaranteeing exorbitant student loans it causes people to graduate with $300K+ in hard costs for their degrees. Medical education is not a free market in that sense. Universities can charge whatever they want because they have guarantees from the federal government. It's easy for an 18 year old to enter into a $300K+ commitment without having a clue what that means in the long term. Second: Government has known that our tort laws are in real need of modification. The cost of malpractice insurance varies from specialty to specialty, yet it can be in the tens of thousands of dollars per year. It is important to note that, when you walk into a hospital, the entire medical staff has to be on malpractice insurance and the hospital itself has a set of umbrella policies. Third: If you are going to face attorneys, you need attorneys of your own. Hospitals have expensive law firms, attorneys on staff or more. Fourth. Medical device and drug regulatory costs are insane. I tried to develop a simple hearing assist device years ago. The FDA costs to get this super-simple device (that would have potentially helped tons of people) was easily in the tens of millions of dollars. Massive. It also required years of pounding your head into the FDA wall to push it through. This is one of the reasons for which we have lots of bright engineers working on how to get people to click on ads rather than on developing medical solutions. Fifth: The tort reform issue extends into the medical device and pharmaceutical industries. Let's say I did make that simple hearing assist device. Well, I would have had to have a sizable amount of cash devoted to both liability insurance and simply paying attorneys a ton of cash to defend from lawsuits. This is a sad reality of any industry in the US and it is particularly worse in the medical domain. Our companies get sued all the time, and it cost a ton of money to defend yourself and your company. This is why most of them try to settle and avoid courts. It's expensive, yet cheaper. In fact, this could be a sixth point, how the government has fucked-up courts, but I'll leave that one out. There's more, a lot more. I haven't just had a casual look at this. I've been running businesses my entire life. I am very much used to deep analysis of the cost structure of things before reaching conclusions. Most people don't do this. They look at something like "raise minimum wage" and think of it as a single variable problem rather than the complex multivariate system of equations it represents. The medical industry is governed by financial equations as well. And just like in any other industry, the cost of goods sold (COGS) drives the cost of products and services end-users pay. Just like nobody is going to sell you a laptop or an iPhone at a loss, nobody is going to perform surgery or see a patient at a loss. Each layer in the chain has costs, families, loans, responsibilities to look after. At the most basic level the problem is simple: If you increase COGS, prices go up. And then there's the need for profit. Yes, I did say "need". I know some think profit is evil. Well, get over it. It is a necessity. Have you ever had to keep people employed, leases and rents paid, mortgages paid, student loans paid, for, say, six months or a year because of some event that led to an economic downturn? Most people only think of this pandemic as such an event. Not so. This kind of thing happens every so often in business due to a range of reasons. I had to take a second mortgage on my home and fill-up a bunch of credit cards to keep people at my company employed back in 2008~2010. We had a bunch of money (from profits) saved-up, yes. It wasn't enough. We were coming out of a couple of years of capital intensive R&D and were not ready for what happened with the economy. Profit --business and personal-- leads to savings which leads to stability. In a nutshell, a person graduating with hundreds of thousands of dollars in student loans, needing tens of thousands of dollars per year in malpractice insurance, with hundreds of thousands of dollars (or more) in additional debt (home, cars), etc., will demand a high salary. Not because they are greedy, because they could not live without it. When your base burn is $15K to $20K per month, you can't work for minimum wage. This leads to healthcare costs being high. You have millions of medical professionals and millions of medical clinics of all kinds who's financial equations are driven by exorbitant costs that are a direct result of government action or inaction for decades. These are not new problems. They've been talking about them every election for as long as I can remember. It's just talk. Nobody does a thing about it. Just like gun control. Talk, talk, talk. People vote for you and then you do nothing about it. I don't understand why millions of people don't rise up and protest the abject incompetence and dishonesty of our elected officials. They have been talking about fixing this and fixing that for over fifty years and do nothing. Our political system is badly broken. And we pay for it in more ways than one. You might disagree with me because, perhaps, you like government to run everything. Yes, government is necessary, and yet it has to be controlled and in moderation. Reality doesn't change because you don't like what you just read. And our reality is that our healthcare system has the government's fingerprint all the way to the starting point, when a well-intentioned 18 year old decides they want to become a medical professional. We have friends who have literally sent their children to other countries to study medicine (they can because they have dual citizenship) because they can graduate with a good medical degree at a small fraction of the cost of what the equivalent education would be here in the US. That, to me, says it all.
- caconym_ 6y ago
  You’re complaining about our government’s systemic dysfunction, which is not something I’ll argue with. I think we are circling the drain and already totally fucked, honestly. So when I talk about making some aspect of our society work better (e.g. healthcare) I’m presupposing that we’ve managed to sort out a government that’s halfway interested in making things work. Put another way: it’s a false dilemma to say we can either accept the non-attempts of our non-functional government to fix issue X, or throw Americans to the capitalist wolves and trust them to build us a libertarian utopia where the free market solves all ills. The latter is extremely naive. Despite what you seem to assume about me, I do believe in capitalism up to a point, actually. I think it’s the best way to bubble up drive and vision to a place where the individuals so endowed can move us forward as a civilization. But, when we’re talking about administration of a broad application of settled technology (in the broadest sense), the advantages of capitalism tend to be subsumed by blind profit motive; this gets us monopolies, it gets us rent-seeking and racketeering, it gets us abuse of consumer “rights” and outright human rights in many cases. I really don’t buy that all of this is the government’s fault; corporations with unchecked power have done some pretty horrible things. Your claim that profit is necessary isn’t true, either, except in the broadest reference frame. One example: public transit is a huge economic enabler for dense cities where driving isn’t practical. It’s fine for it to lose money considered on its own, because it drives overall growth. Now, do we need to do a better job at the interface between public and social services (e.g. the people who run the trains) and private enterprise (e.g. the people who manufacture the trains)? Yes, we do. The same would go for an expanded socialized medicine program, or just an attempt to stop the bleeding with our current system. But this brings us back to the same place: everything is broken, and the outlook is bleak. And the proposed solution of a “well regulated” (imagine I’m waving my hands around) free market does not convince me, simply because profit motive does not necessarily align with human happiness and well-being. History is full of examples of just how incompatible those two things are, and the present has some good ones too.
  - robomartin 6y ago
    > One example: public transit is a huge economic enabler for dense cities where driving isn’t practical. It’s fine for it to lose money considered on its own, because it drives overall growth. As I said before, and I'll add a little bit: Please, grab a spreadsheet, start to develop the financial equation for anything you care to look into and think it through. Public transportation probably has a much larger profit motive than any private enterprise. You have to look at the financial equation that drives the thing. They don't call it "profit", and yet it is exactly the same thing. What form that it take? Go research benefit and pensions. People in these government organizations get life-long pensions that they did not pay for. They also get life-long health coverage...they did not pay for. These pensions are unsustainable without the "profit" in the form of ever-increasing taxation, bonds and other methods. It's money in excess of the cost of goods sold. Same thing. Different name. I think you misunderstood my perspective on this. I am not proposing some crazy scenario where capitalism runs rampant doing as everyone might wish and make an even bigger mess out of healthcare. Not at all. My point of view is very simple: Government is bad at executing on just about everything. Their role should be to engage in creating the legal and regulatory framework within which entrepreneurs have to function in order to deliver goods and services. They should not be in the business of implementing any of it. They fuck it up more often than not. Look at the mess the Trump administration made out of the vaccine deployment as a recent and painful example. This isn't a Republican or Democrat thing, they all suck at getting things done correctly, effectively and efficiently. They should have grand debates (in public) exploring how to engineer a legal and regulatory framework for healthcare that allows our entrepreneurs to deliver excellent products to everyone. No monopolies. No exclusions. Etc. Of course, they also need to make sure their rule-making deals with all relevant elements of the financial equation. Simple example: You cannot, positively cannot, lower the cost of healthcare in the US if a medical education costs hundreds of thousands of dollars, malpractice insurance tens of thousands, and a hospital has more lawyers than doctors. It's crazy. So, again, for example, get out of the student loan business and education costs will come down. There's a lot of "structural" work that needs to be done before any insurance entity, public or private, can reduce costs. I've been saying this all along. This isn't magic. It's math. There's a financial equation for everything and you can't force lower end-user costs if the cost of goods sold is high. It's the no-free-lunch principle. Probably the fundamental law of the universe, right up there with gravitation.

robomartin 6y ago

Please think this through. I have already said the variables, or points of influence, are significantly greater and deeper than just one item. Government has its paws in dentistry and eye care just as much as it does everywhere else in the medical field. Let's take three of those layers. First: By guaranteeing exorbitant student loans it causes people to graduate with $300K+ in hard costs for their degrees. Medical education is not a free market in that sense. Universities can charge whatever they want because they have guarantees from the federal government. It's easy for an 18 year old to enter into a $300K+ commitment without having a clue what that means in the long term. Second: Government has known that our tort laws are in real need of modification. The cost of malpractice insurance varies from specialty to specialty, yet it can be in the tens of thousands of dollars per year. It is important to note that, when you walk into a hospital, the entire medical staff has to be on malpractice insurance and the hospital itself has a set of umbrella policies. Third: If you are going to face attorneys, you need attorneys of your own. Hospitals have expensive law firms, attorneys on staff or more. Fourth. Medical device and drug regulatory costs are insane. I tried to develop a simple hearing assist device years ago. The FDA costs to get this super-simple device (that would have potentially helped tons of people) was easily in the tens of millions of dollars. Massive. It also required years of pounding your head into the FDA wall to push it through. This is one of the reasons for which we have lots of bright engineers working on how to get people to click on ads rather than on developing medical solutions. Fifth: The tort reform issue extends into the medical device and pharmaceutical industries. Let's say I did make that simple hearing assist device. Well, I would have had to have a sizable amount of cash devoted to both liability insurance and simply paying attorneys a ton of cash to defend from lawsuits. This is a sad reality of any industry in the US and it is particularly worse in the medical domain. Our companies get sued all the time, and it cost a ton of money to defend yourself and your company. This is why most of them try to settle and avoid courts. It's expensive, yet cheaper. In fact, this could be a sixth point, how the government has fucked-up courts, but I'll leave that one out. There's more, a lot more. I haven't just had a casual look at this. I've been running businesses my entire life. I am very much used to deep analysis of the cost structure of things before reaching conclusions. Most people don't do this. They look at something like "raise minimum wage" and think of it as a single variable problem rather than the complex multivariate system of equations it represents. The medical industry is governed by financial equations as well. And just like in any other industry, the cost of goods sold (COGS) drives the cost of products and services end-users pay. Just like nobody is going to sell you a laptop or an iPhone at a loss, nobody is going to perform surgery or see a patient at a loss. Each layer in the chain has costs, families, loans, responsibilities to look after. At the most basic level the problem is simple: If you increase COGS, prices go up. And then there's the need for profit. Yes, I did say "need". I know some think profit is evil. Well, get over it. It is a necessity. Have you ever had to keep people employed, leases and rents paid, mortgages paid, student loans paid, for, say, six months or a year because of some event that led to an economic downturn? Most people only think of this pandemic as such an event. Not so. This kind of thing happens every so often in business due to a range of reasons. I had to take a second mortgage on my home and fill-up a bunch of credit cards to keep people at my company employed back in 2008~2010. We had a bunch of money (from profits) saved-up, yes. It wasn't enough. We were coming out of a couple of years of capital intensive R&D and were not ready for what happened with the economy. Profit --business and personal-- leads to savings which leads to stability. In a nutshell, a person graduating with hundreds of thousands of dollars in student loans, needing tens of thousands of dollars per year in malpractice insurance, with hundreds of thousands of dollars (or more) in additional debt (home, cars), etc., will demand a high salary. Not because they are greedy, because they could not live without it. When your base burn is $15K to $20K per month, you can't work for minimum wage. This leads to healthcare costs being high. You have millions of medical professionals and millions of medical clinics of all kinds who's financial equations are driven by exorbitant costs that are a direct result of government action or inaction for decades. These are not new problems. They've been talking about them every election for as long as I can remember. It's just talk. Nobody does a thing about it. Just like gun control. Talk, talk, talk. People vote for you and then you do nothing about it. I don't understand why millions of people don't rise up and protest the abject incompetence and dishonesty of our elected officials. They have been talking about fixing this and fixing that for over fifty years and do nothing. Our political system is badly broken. And we pay for it in more ways than one. You might disagree with me because, perhaps, you like government to run everything. Yes, government is necessary, and yet it has to be controlled and in moderation. Reality doesn't change because you don't like what you just read. And our reality is that our healthcare system has the government's fingerprint all the way to the starting point, when a well-intentioned 18 year old decides they want to become a medical professional. We have friends who have literally sent their children to other countries to study medicine (they can because they have dual citizenship) because they can graduate with a good medical degree at a small fraction of the cost of what the equivalent education would be here in the US. That, to me, says it all.

caconym_ 6y ago
You’re complaining about our government’s systemic dysfunction, which is not something I’ll argue with. I think we are circling the drain and already totally fucked, honestly. So when I talk about making some aspect of our society work better (e.g. healthcare) I’m presupposing that we’ve managed to sort out a government that’s halfway interested in making things work. Put another way: it’s a false dilemma to say we can either accept the non-attempts of our non-functional government to fix issue X, or throw Americans to the capitalist wolves and trust them to build us a libertarian utopia where the free market solves all ills. The latter is extremely naive. Despite what you seem to assume about me, I do believe in capitalism up to a point, actually. I think it’s the best way to bubble up drive and vision to a place where the individuals so endowed can move us forward as a civilization. But, when we’re talking about administration of a broad application of settled technology (in the broadest sense), the advantages of capitalism tend to be subsumed by blind profit motive; this gets us monopolies, it gets us rent-seeking and racketeering, it gets us abuse of consumer “rights” and outright human rights in many cases. I really don’t buy that all of this is the government’s fault; corporations with unchecked power have done some pretty horrible things. Your claim that profit is necessary isn’t true, either, except in the broadest reference frame. One example: public transit is a huge economic enabler for dense cities where driving isn’t practical. It’s fine for it to lose money considered on its own, because it drives overall growth. Now, do we need to do a better job at the interface between public and social services (e.g. the people who run the trains) and private enterprise (e.g. the people who manufacture the trains)? Yes, we do. The same would go for an expanded socialized medicine program, or just an attempt to stop the bleeding with our current system. But this brings us back to the same place: everything is broken, and the outlook is bleak. And the proposed solution of a “well regulated” (imagine I’m waving my hands around) free market does not convince me, simply because profit motive does not necessarily align with human happiness and well-being. History is full of examples of just how incompatible those two things are, and the present has some good ones too.
- robomartin 6y ago
  > One example: public transit is a huge economic enabler for dense cities where driving isn’t practical. It’s fine for it to lose money considered on its own, because it drives overall growth. As I said before, and I'll add a little bit: Please, grab a spreadsheet, start to develop the financial equation for anything you care to look into and think it through. Public transportation probably has a much larger profit motive than any private enterprise. You have to look at the financial equation that drives the thing. They don't call it "profit", and yet it is exactly the same thing. What form that it take? Go research benefit and pensions. People in these government organizations get life-long pensions that they did not pay for. They also get life-long health coverage...they did not pay for. These pensions are unsustainable without the "profit" in the form of ever-increasing taxation, bonds and other methods. It's money in excess of the cost of goods sold. Same thing. Different name. I think you misunderstood my perspective on this. I am not proposing some crazy scenario where capitalism runs rampant doing as everyone might wish and make an even bigger mess out of healthcare. Not at all. My point of view is very simple: Government is bad at executing on just about everything. Their role should be to engage in creating the legal and regulatory framework within which entrepreneurs have to function in order to deliver goods and services. They should not be in the business of implementing any of it. They fuck it up more often than not. Look at the mess the Trump administration made out of the vaccine deployment as a recent and painful example. This isn't a Republican or Democrat thing, they all suck at getting things done correctly, effectively and efficiently. They should have grand debates (in public) exploring how to engineer a legal and regulatory framework for healthcare that allows our entrepreneurs to deliver excellent products to everyone. No monopolies. No exclusions. Etc. Of course, they also need to make sure their rule-making deals with all relevant elements of the financial equation. Simple example: You cannot, positively cannot, lower the cost of healthcare in the US if a medical education costs hundreds of thousands of dollars, malpractice insurance tens of thousands, and a hospital has more lawyers than doctors. It's crazy. So, again, for example, get out of the student loan business and education costs will come down. There's a lot of "structural" work that needs to be done before any insurance entity, public or private, can reduce costs. I've been saying this all along. This isn't magic. It's math. There's a financial equation for everything and you can't force lower end-user costs if the cost of goods sold is high. It's the no-free-lunch principle. Probably the fundamental law of the universe, right up there with gravitation.