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I know that private medicare advantage plans are coming to be worse than gov't medicare plans and the private healthcare fights many improvements in medicare ad

• AnthonyMouse 3y ago
  > "Free market or not" is mostly an immaterial distinction imho. I don't think this is the right conclusion. What you need is a competitive market. An uncompetitive market doesn't work. But a government is going to be a monopoly, which is the thing that doesn't work, whereas a market has the possibility of being competitive even if it is possible to screw that up. US healthcare is a case in point. The healthcare system is highly regulated and the regulators are captured by the incumbents, so the regulations are designed to inhibit price competition between providers and keep costs high because those costs are the incumbents' profits. In order to achieve the benefits of competition you would need rules that actually facilitate it. For example, if providers were required to publish pricing and then insurance would deposit into your HSA 90% of the median cost of a procedure among every provider within 100 miles of your address (equivalent to a 10% copay), and then you can choose where to go. Now there is no such thing as "in network" anymore and the patient has the direct incentive to be price sensitive, which in turn requires providers to publish competitive prices. But we don't do that, because it might work.
  • dv_dt 3y ago
    To be a bit glib there is no competitive market to give me an emergency surgery if my appendix has burst. But in a sense I think we have some agreement that it’s much more interesting to discuss a set of characteristics than can make markets work to deliver value. I just think “free” isn’t a useful distinction because it’s approached usually a shorthand for free of regulation. I think that all markets are artificial and require rules to form a functional marketplace of exchange.
    • AnthonyMouse 3y ago
      > To be a bit glib there is no competitive market to give me an emergency surgery if my appendix has burst. This is what everybody resorts to when trying to claim that this can't work, but it's really more an excuse to not even try. The large majority of medical spending isn't emergency care. You can't shop around for an appendectomy doesn't mean you can't shop around for a joint replacement. > I just think “free” isn’t a useful distinction because it’s approached usually a shorthand for free of regulation. I think that all markets are artificial and require rules to form a functional marketplace of exchange. There are a couple of different dimensions along which you can measure this. One is the type of regulation that exists. Markets need externalities to be priced, otherwise companies will dump industrial waste in the river. That's one type of regulation. Another is paternalism. You can't buy a huge soda because it will make you fat. That's not an externality. You're the one choosing to buy and drink the soda and you're the one who gets fat. You're the one who buys the poorly insulated house and you're the one who pays the heating bill. This isn't Alice doing something that hurts Bob, it's Alice doing something that hurts Alice. It's a different type of thing, and we could do without it entirely and still prohibit companies from polluting the rivers. Likewise, some regulations are, shall we say, petty. Some might say illiberal. You can't put an addition on your house or finish your basement because then more people might live in it. You can hypothetically frame this as an externality, because then there might be more traffic or something, but the underlying premise would have to be that this is something other people have a legitimate right to prevent and that interest should override another person's interest in having somewhere to live. We could do entirely without this type of regulation too. The other dimension is that regulations of actual externalities can be unnecessarily burdensome. You can pass a law against dumping mercury in the river and then fine anyone caught dumping mercury in the river. Or you can pass a law against manufacturing products without testing each and every one of them for the presence of mercury, even if you don't use any mercury in your manufacturing process, and then fine anyone who doesn't pay for testing, coincidentally by a testing company owned by a legislator's brother which employs a lot of people whose unions made some generous campaign contributions. Or just establish administrative agencies with too many bureaucrats who run out of anything legitimate to do and start to micromanage everything. Regulating externalities efficiently is a hard problem and claiming that you can't have a free market unless you can remove externalities without any inefficiency is basically claiming that you can't have a free market. We could certainly do better than we do right now, and there is value in the attempt, but it's never going to be perfect. Whereas the rules that are purely paternalism and politics? If the claim is that a market with those kinds of rules isn't a free market, that's a fairly legitimate claim.