5 ms·

I see the same issues here in the states. I think no matter what the economic model, we need to take a long hard look at the overhead and complexity of healthca

I see the same issues here in the states. I think no matter what the economic model, we need to take a long hard look at the overhead and complexity of healthcare. And by and large, I suspect the insurance companies will be found to be at the root of it. I can't believe I of all people am calling for less regulation, but the amount of bullshit it seems like doctors have to go through to provide basic service seems counterproductive.

lurking15 2y ago
I think people will hit a breaking point and it will be undeniable that heavy regulation and subsidization is the root of dysfunction and deterioration of most important aspects of life. It's hard not to see the parallel between healthcare and education where the parasitic overhead has been completely unchecked and enabled by federal subsidies. There's a similar deal with food, housing and other areas. It's absurd the amount of money that has been spent by the federal government in these areas with so little to show, the average person feels not only a lack of progress but decline.
- ses1984 2y ago
  Much of the regulation you’re saying is to blame was written in blood. Want to know what food and housing was like before regulation? Read the jungle. Do you think we have deteriorated since then? Maybe the prosperity you think has deteriorated was not due to lack of regulation, but due to black swan events like… i dunno conquering and industrializing the entire North American continent, all peer nations blowing each other to bits in two world wars, etc?
  - lurking15 2y ago
    > Want to know what food and housing was like before regulation? Read the jungle. Not convincing since you're reducing the entire time period to The Jungle which was sensationalized fiction, effectively political propaganda. But to your broader point, things improved directly from capitalism and markets. My reading recommendation? Deirdre McCloskey "Why Liberalism Works" on the absurd increase in living standards brought about through innovation enabled by capitalism, we're talking some 3,000% in average income over the course of time you're referring to.
    - ses1984 2y ago
      Where you have 3000% increase in income do you also have absolutely no regulation? I don’t think you can just factor out the regulation, assign it none of the credit for how things turned out, and assign all the credit to unchecked capitalism. Maybe the jungle is sensationalized, what was really happening roughly concurrently: Triangle Shirtwaist Factory fire, homestead steel strike, Pullman strike, tenement housing, etc If you prefer less dramatized further reading, https://www.dol.gov/general/aboutdol/history/mono-regsafepart05 https://www.dol.gov/general/aboutdol/history/mono-regsafepar... I don’t think liberalism doesn’t work. I’m just responding to someone saying it’s “undeniable that heavy regulation and subsidization is the root of dysfunction and deterioration of most important aspects of life”. Some regulations are bad, either intentionally or unintentionally, but a lot of regulation exists because the prior unregulated state was horrific.
  - NumberWangMan 2y ago
    I agree that all regulation is written in blood. But at the same time, regulation can result in bleeding, and we don't always carefully weigh the costs and benefits of regulation. There may be a law that saves 100 lives a year, but that indirectly causes 150 deaths due to knock-on effects. It's not easy to inject nuance into a discussion that feels like you have millions of people on each side of a tug-of-war rope that goes from "MORE REGULATION" to "LESS REGULATION". I think housing, which you mention, is an excellent example. Yes, we need regulation in housing because without it, people will die from shoddy structures collapsing on them, electrocution, gas leaks, etc. But at the same time, in the USA there are absolutely regulations in housing with very little benefit and absolutely massive costs, where we have examples of first-world countries without those regulations that do just fine. I'm talking about things like the requirement that all apartments have 2 stairwells. Or mandatory setbacks and minimum lot sizes and parking requirements. edit -- and of course zoning codes, where we've shifted the market toward building housing that's so big that people can only afford to share it with strangers. And while people used to live in crowded, cramped tenements, driving housing prices up by restricting supply leads to people living on the street. In medicine, there are diminishing marginal returns to making doctors go through more schooling, and the cost is simply that fewer people choose to be doctors, and people just go without health care. And even within that simple dilemma of "should we make it harder or easier to be a doctor", i'm sure there is a universe of alternate ways to move the needle in different dimensions. Requiring more or less schooling, more or less time in residency, changing limits on the number of hours doctors and nurses can be scheduled in a week, tightening or loosening malpractice law in different ways, etc. Each of these has some positive and negative effects, and I'm sure we have a ways to go before we hit the optimal point. And even then, you have to choose how to balance quality of patient care against doctors and nurses quality of life! Or take drug approvals. There are drugs in development that show lots of promise, that probably should be made available to people who are dying anyway and want to try them. The FDA does not allow that. We have to balance against companies trying to scam people with fake medicine. No policy is 100% without harm. I believe that, even for policies I strongly advocate. Or laws that were originally targeted at local environmental protection, that are now being used by nearby residents to stop solar farms from being built, stopping us from reducing fossil fuel usage. Those regulations were written in the blood of wildlife -- and now they're cause much more harm than good to wildlife all across the world. So if you are asking if we've deteriorated since The Jungle, in many ways, no, of course we've improved safety of working conditions massively, and lots of other things. But in other, important ways, we've gone somewhat backwards. I believe it's absolutely possible to improve our society by removing some regulations, but I think it takes a lot of careful, small, targeted tweaks, where we've carefully weighed the costs and benefits. Though in rare cases, like as in parking minimums, the evidence is that they are so harmful that just scrapping the regulation entirely is the way to go.*
- maxerickson 2y ago
  You don't have to deregulate to move away from demand side subsidies as your main intervention.
- consteval 2y ago
  This isn't due to "heavy regulation", it's due to the free market. Insurance companies have an incentive to make medical care as awful and inefficient as possible. There's a tug-of-war here: doctors want to provide the highest quality care as fast as possible; insurance companies want to provide the least amount of care as rarely as possible. Well... they're the ones paying. These doctors are struggling to deal with "regulations" - they're struggling to deal with insurance. The sheer administrative overhead of medical insurance is staggering. You can go ask doctors, any of them will tell you.
toomuchtodo 2y ago
We need more doctors and nurses [1], full stop. Anything that prevents an aggressive increase in supply of these workers is something that needs to be actioned against. Healthcare is a utility masquerading as a profit based industry. Squeeze the profit and inefficiency out, any comp should be going directly to systems and people providing care. Insurance companies? Gone [2]. Pharmacy benefit managers? Gone [3]. Lock private equity out of owning anything healthcare related [4] [5] [6]. I don’t want to knee jerk “union” for individual contributors, but you need some sort of governance mechanism so the CEO of a non profit hospital isn’t taking home $1M/year [7] [8] [9] while doctors and nursing are fighting for proper compensation and work life balance (including patient ratios, which are used to increase labor load without increasing labor costs or hiring more practitioners [10]). [1] https://thehill.com/changing-america/well-being/prevention-cures/4225960-the-us-is-suffering-a-healthcare-worker-shortage-experts-fear-it-will-only-get-worse/ https://thehill.com/changing-america/well-being/prevention-c... [2] https://penncapital-star.com/uncategorized/americans-suffer-when-health-insurers-place-profits-over-people/ https://penncapital-star.com/uncategorized/americans-suffer-... [3] https://www.ftc.gov/news-events/news/press-releases/2024/07/ftc-releases-interim-staff-report-prescription-drug-middlemen https://www.ftc.gov/news-events/news/press-releases/2024/07/... [4] https://www.amjmed.com/article/S0002-9343(23)00589-2/fulltext https://www.amjmed.com/article/S0002-9343(23)00589-2/fulltex... [5] https://www.washingtonpost.com/business/2024/10/17/private-equity-steward-hospital-bankruptcy/ https://www.washingtonpost.com/business/2024/10/17/private-e... [6] https://www.theguardian.com/business/2024/oct/10/slash-and-burn-is-private-equity-out-of-control https://www.theguardian.com/business/2024/oct/10/slash-and-b... [7] https://www.npr.org/sections/shots-health-news/2024/08/19/nx-s1-5078495/nonprofit-hospitals-ceo-compensation-community-benefit-uninsured-mission-tax-exempt-management https://www.npr.org/sections/shots-health-news/2024/08/19/nx... [8] https://www.audacy.com/wwjnewsradio/news/national/revealed-ceos-of-tax-exempt-hospitals-are-making-millions https://www.audacy.com/wwjnewsradio/news/national/revealed-c... [9] https://arstechnica.com/health/2023/10/nonprofit-hospitals-skimp-on-charity-while-ceos-reap-millions-report-finds/ https://arstechnica.com/health/2023/10/nonprofit-hospitals-s... [10] https://healthjournalism.org/blog/2023/09/a-primer-for-covering-the-nursing-and-hospital-battle-over-mandatory-minimum-staffing-ratios/ https://healthjournalism.org/blog/2023/09/a-primer-for-cover...
- 2y ago
meowster 2y ago
My best friend since high school is a doctor. Hearing all the bullshit that she had to go through, the different selection processes, abuse (scheduling), etc; it's crazy. It doesn't weed out people who will be bad doctors, it weeds out people that can't handle the abuse.
throw10920 2y ago
> And by and large, I suspect the insurance companies will be found to be at the root of it. At least in the US, this is true. The pervasiveness of interaction with insurance and the power they wield turns them into a rent-seeking layer with the massively negative economic effects of socialism. Insurance is meant to insure you against massive economic damage caused by unlikely events, like breaking your spine. It is not meant to be used for routine care appointments. It's meant to be risk-pooling, not cost-sharing. The very fact that you have to pull out your insurance card at a yearly doctor checkup should tell us that something is very wrong.
- throwway120385 2y ago
  > Insurance is meant to insure you against massive economic damage caused by unlikely events, like breaking your spine. It is not meant to be used for routine care appointments. It's meant to be risk-pooling, not cost-sharing. The very fact that you have to pull out your insurance card at a yearly doctor checkup should tell us that something is very wrong. The problem with this model is that often very catastrophic things can be caught during routine care, so it actually makes a lot of sense for insurance to pay for a yearly physical. Otherwise a lot of people are going to wait until their spine is blown out and their knees need replacement to seek any kind of care at all, at which point their care is 100x more expensive than if they did a yearly. Any other kind of care like going to the doctor because you're sick is entirely the point of insurance. It covers your medical care for unanticipated problems.
  - phil21 2y ago
    Getting sick is not an unanticipated problem. A major illness or injury is. Insurance has no business paying out for you going in for strep throat or the Flu or an annual checkup. These are normal things everyone gets multiple times throughout your lifetime, and should easily be taken care of via market forces for a very reasonable fee. The problem with US healthcare can be entirely boiled down to a principle agent problem. Someone else is always paying, so no one actually really cares that much about the cost of things and the incentives always are to increase costs and use more services since there is no actual market competition.
fallingknife 2y ago
I had a prescription for 1 20mg pill a day. Pharmacy didn't have 20mg but they had 10mg. They couldn't give me 2 10s instead of 1 20 because regulations didn't allow that. Yeah, we need less regulations.
- phil21 2y ago
  There is likely no regulation that says this. Doctors and pharmacists have very broad legal authority to prescribe whatever they see fit. It’s almost assuredly an insurance/PBM billing issue, not a regulatory thing.
simonsarris 2y ago
People say this a lot but it feels unlikely to me. I think the biggest causes of the problem love the idea that insurance is to blame. Hospital admin, doctors orgs, pharmacy benefit managers are all much more interested in things being overly complex, under-staffed, etc. Insurance companies just want to sell insurance with the % profit that is typical of insurance (eg Cigna's profit margin is the same as Allstate). Besides, if insurance was to blame, it would work better in Canada and other countries that rely on private insurance less. But Canadians don't seem very pleased with their longer waits.
pcthrowaway 2y ago
I think there are things that could do with less regulation in Canada that would be easy wins. Like for people with recurring prescription meds, maybe don't require them to make an appointment every month to get their meds? Even if we consider extreme examples like opiates, it's not like cutting off drug abusers or people selling their meds does anything to curb the opiate crisis. Opiates are already available everywhere and the supply is much more dubious and dangerous.
waveBidder 2y ago
I'm fairly certain a large chunk of the problem is demographic shift. healthcare is one of those industries most used by the elderly, and the proportion of the population in that demographic has skyrocketed
- Ekaros 2y ago
  Also I would guess that there is more healthcare, more options, more procedures, more drugs. Length of stays in hospitals might have shortened due to less invasive procedures, but if more procedures are done and there is not increase in staffing, time is spread over larger number of patients.

lurking15 2y ago

I think people will hit a breaking point and it will be undeniable that heavy regulation and subsidization is the root of dysfunction and deterioration of most important aspects of life. It's hard not to see the parallel between healthcare and education where the parasitic overhead has been completely unchecked and enabled by federal subsidies. There's a similar deal with food, housing and other areas. It's absurd the amount of money that has been spent by the federal government in these areas with so little to show, the average person feels not only a lack of progress but decline.

ses1984 2y ago
Much of the regulation you’re saying is to blame was written in blood. Want to know what food and housing was like before regulation? Read the jungle. Do you think we have deteriorated since then? Maybe the prosperity you think has deteriorated was not due to lack of regulation, but due to black swan events like… i dunno conquering and industrializing the entire North American continent, all peer nations blowing each other to bits in two world wars, etc?
- lurking15 2y ago
  > Want to know what food and housing was like before regulation? Read the jungle. Not convincing since you're reducing the entire time period to The Jungle which was sensationalized fiction, effectively political propaganda. But to your broader point, things improved directly from capitalism and markets. My reading recommendation? Deirdre McCloskey "Why Liberalism Works" on the absurd increase in living standards brought about through innovation enabled by capitalism, we're talking some 3,000% in average income over the course of time you're referring to.
  - ses1984 2y ago
    Where you have 3000% increase in income do you also have absolutely no regulation? I don’t think you can just factor out the regulation, assign it none of the credit for how things turned out, and assign all the credit to unchecked capitalism. Maybe the jungle is sensationalized, what was really happening roughly concurrently: Triangle Shirtwaist Factory fire, homestead steel strike, Pullman strike, tenement housing, etc If you prefer less dramatized further reading, https://www.dol.gov/general/aboutdol/history/mono-regsafepart05 https://www.dol.gov/general/aboutdol/history/mono-regsafepar... I don’t think liberalism doesn’t work. I’m just responding to someone saying it’s “undeniable that heavy regulation and subsidization is the root of dysfunction and deterioration of most important aspects of life”. Some regulations are bad, either intentionally or unintentionally, but a lot of regulation exists because the prior unregulated state was horrific.
- NumberWangMan 2y ago
  I agree that all regulation is written in blood. But at the same time, regulation can result in bleeding, and we don't always carefully weigh the costs and benefits of regulation. There may be a law that saves 100 lives a year, but that indirectly causes 150 deaths due to knock-on effects. It's not easy to inject nuance into a discussion that feels like you have millions of people on each side of a tug-of-war rope that goes from "MORE REGULATION" to "LESS REGULATION". I think housing, which you mention, is an excellent example. Yes, we need regulation in housing because without it, people will die from shoddy structures collapsing on them, electrocution, gas leaks, etc. But at the same time, in the USA there are absolutely regulations in housing with very little benefit and absolutely massive costs, where we have examples of first-world countries without those regulations that do just fine. I'm talking about things like the requirement that all apartments have 2 stairwells. Or mandatory setbacks and minimum lot sizes and parking requirements. edit -- and of course zoning codes, where we've shifted the market toward building housing that's so big that people can only afford to share it with strangers. And while people used to live in crowded, cramped tenements, driving housing prices up by restricting supply leads to people living on the street. In medicine, there are diminishing marginal returns to making doctors go through more schooling, and the cost is simply that fewer people choose to be doctors, and people just go without health care. And even within that simple dilemma of "should we make it harder or easier to be a doctor", i'm sure there is a universe of alternate ways to move the needle in different dimensions. Requiring more or less schooling, more or less time in residency, changing limits on the number of hours doctors and nurses can be scheduled in a week, tightening or loosening malpractice law in different ways, etc. Each of these has some positive and negative effects, and I'm sure we have a ways to go before we hit the optimal point. And even then, you have to choose how to balance quality of patient care against doctors and nurses quality of life! Or take drug approvals. There are drugs in development that show lots of promise, that probably should be made available to people who are dying anyway and want to try them. The FDA does not allow that. We have to balance against companies trying to scam people with fake medicine. No policy is 100% without harm. I believe that, even for policies I strongly advocate. Or laws that were originally targeted at local environmental protection, that are now being used by nearby residents to stop solar farms from being built, stopping us from reducing fossil fuel usage. Those regulations were written in the blood of wildlife -- and now they're cause much more harm than good to wildlife all across the world. So if you are asking if we've deteriorated since The Jungle, in many ways, no, of course we've improved safety of working conditions massively, and lots of other things. But in other, important ways, we've gone somewhat backwards. I believe it's absolutely possible to improve our society by removing some regulations, but I think it takes a lot of careful, small, targeted tweaks, where we've carefully weighed the costs and benefits. Though in rare cases, like as in parking minimums, the evidence is that they are so harmful that just scrapping the regulation entirely is the way to go.*
maxerickson 2y ago
You don't have to deregulate to move away from demand side subsidies as your main intervention.
consteval 2y ago
This isn't due to "heavy regulation", it's due to the free market. Insurance companies have an incentive to make medical care as awful and inefficient as possible. There's a tug-of-war here: doctors want to provide the highest quality care as fast as possible; insurance companies want to provide the least amount of care as rarely as possible. Well... they're the ones paying. These doctors are struggling to deal with "regulations" - they're struggling to deal with insurance. The sheer administrative overhead of medical insurance is staggering. You can go ask doctors, any of them will tell you.

toomuchtodo 2y ago

We need more doctors and nurses [1], full stop. Anything that prevents an aggressive increase in supply of these workers is something that needs to be actioned against. Healthcare is a utility masquerading as a profit based industry. Squeeze the profit and inefficiency out, any comp should be going directly to systems and people providing care. Insurance companies? Gone [2]. Pharmacy benefit managers? Gone [3]. Lock private equity out of owning anything healthcare related [4] [5] [6]. I don’t want to knee jerk “union” for individual contributors, but you need some sort of governance mechanism so the CEO of a non profit hospital isn’t taking home $1M/year [7] [8] [9] while doctors and nursing are fighting for proper compensation and work life balance (including patient ratios, which are used to increase labor load without increasing labor costs or hiring more practitioners [10]). [1] https://thehill.com/changing-america/well-being/prevention-cures/4225960-the-us-is-suffering-a-healthcare-worker-shortage-experts-fear-it-will-only-get-worse/ https://thehill.com/changing-america/well-being/prevention-c... [2] https://penncapital-star.com/uncategorized/americans-suffer-when-health-insurers-place-profits-over-people/ https://penncapital-star.com/uncategorized/americans-suffer-... [3] https://www.ftc.gov/news-events/news/press-releases/2024/07/ftc-releases-interim-staff-report-prescription-drug-middlemen https://www.ftc.gov/news-events/news/press-releases/2024/07/... [4] https://www.amjmed.com/article/S0002-9343(23)00589-2/fulltext https://www.amjmed.com/article/S0002-9343(23)00589-2/fulltex... [5] https://www.washingtonpost.com/business/2024/10/17/private-equity-steward-hospital-bankruptcy/ https://www.washingtonpost.com/business/2024/10/17/private-e... [6] https://www.theguardian.com/business/2024/oct/10/slash-and-burn-is-private-equity-out-of-control https://www.theguardian.com/business/2024/oct/10/slash-and-b... [7] https://www.npr.org/sections/shots-health-news/2024/08/19/nx-s1-5078495/nonprofit-hospitals-ceo-compensation-community-benefit-uninsured-mission-tax-exempt-management https://www.npr.org/sections/shots-health-news/2024/08/19/nx... [8] https://www.audacy.com/wwjnewsradio/news/national/revealed-ceos-of-tax-exempt-hospitals-are-making-millions https://www.audacy.com/wwjnewsradio/news/national/revealed-c... [9] https://arstechnica.com/health/2023/10/nonprofit-hospitals-skimp-on-charity-while-ceos-reap-millions-report-finds/ https://arstechnica.com/health/2023/10/nonprofit-hospitals-s... [10] https://healthjournalism.org/blog/2023/09/a-primer-for-covering-the-nursing-and-hospital-battle-over-mandatory-minimum-staffing-ratios/ https://healthjournalism.org/blog/2023/09/a-primer-for-cover...

2y ago

meowster 2y ago

My best friend since high school is a doctor. Hearing all the bullshit that she had to go through, the different selection processes, abuse (scheduling), etc; it's crazy. It doesn't weed out people who will be bad doctors, it weeds out people that can't handle the abuse.

throw10920 2y ago

> And by and large, I suspect the insurance companies will be found to be at the root of it. At least in the US, this is true. The pervasiveness of interaction with insurance and the power they wield turns them into a rent-seeking layer with the massively negative economic effects of socialism. Insurance is meant to insure you against massive economic damage caused by unlikely events, like breaking your spine. It is not meant to be used for routine care appointments. It's meant to be risk-pooling, not cost-sharing. The very fact that you have to pull out your insurance card at a yearly doctor checkup should tell us that something is very wrong.

throwway120385 2y ago
> Insurance is meant to insure you against massive economic damage caused by unlikely events, like breaking your spine. It is not meant to be used for routine care appointments. It's meant to be risk-pooling, not cost-sharing. The very fact that you have to pull out your insurance card at a yearly doctor checkup should tell us that something is very wrong. The problem with this model is that often very catastrophic things can be caught during routine care, so it actually makes a lot of sense for insurance to pay for a yearly physical. Otherwise a lot of people are going to wait until their spine is blown out and their knees need replacement to seek any kind of care at all, at which point their care is 100x more expensive than if they did a yearly. Any other kind of care like going to the doctor because you're sick is entirely the point of insurance. It covers your medical care for unanticipated problems.
- phil21 2y ago
  Getting sick is not an unanticipated problem. A major illness or injury is. Insurance has no business paying out for you going in for strep throat or the Flu or an annual checkup. These are normal things everyone gets multiple times throughout your lifetime, and should easily be taken care of via market forces for a very reasonable fee. The problem with US healthcare can be entirely boiled down to a principle agent problem. Someone else is always paying, so no one actually really cares that much about the cost of things and the incentives always are to increase costs and use more services since there is no actual market competition.

fallingknife 2y ago

I had a prescription for 1 20mg pill a day. Pharmacy didn't have 20mg but they had 10mg. They couldn't give me 2 10s instead of 1 20 because regulations didn't allow that. Yeah, we need less regulations.

phil21 2y ago
There is likely no regulation that says this. Doctors and pharmacists have very broad legal authority to prescribe whatever they see fit. It’s almost assuredly an insurance/PBM billing issue, not a regulatory thing.

simonsarris 2y ago

People say this a lot but it feels unlikely to me. I think the biggest causes of the problem love the idea that insurance is to blame. Hospital admin, doctors orgs, pharmacy benefit managers are all much more interested in things being overly complex, under-staffed, etc. Insurance companies just want to sell insurance with the % profit that is typical of insurance (eg Cigna's profit margin is the same as Allstate). Besides, if insurance was to blame, it would work better in Canada and other countries that rely on private insurance less. But Canadians don't seem very pleased with their longer waits.

pcthrowaway 2y ago

I think there are things that could do with less regulation in Canada that would be easy wins. Like for people with recurring prescription meds, maybe don't require them to make an appointment every month to get their meds? Even if we consider extreme examples like opiates, it's not like cutting off drug abusers or people selling their meds does anything to curb the opiate crisis. Opiates are already available everywhere and the supply is much more dubious and dangerous.

waveBidder 2y ago

I'm fairly certain a large chunk of the problem is demographic shift. healthcare is one of those industries most used by the elderly, and the proportion of the population in that demographic has skyrocketed

Ekaros 2y ago
Also I would guess that there is more healthcare, more options, more procedures, more drugs. Length of stays in hospitals might have shortened due to less invasive procedures, but if more procedures are done and there is not increase in staffing, time is spread over larger number of patients.