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> The issue with American healthcare is the profit-seeking capitalists. Profit seeking capitalists would be fine if healthcare was a competitive market, like g

> The issue with American healthcare is the profit-seeking capitalists. Profit seeking capitalists would be fine if healthcare was a competitive market, like grocery sale. But it isn't, and I honestly don't see how to make it one. Full price transparency would help, but I don't believe classical free market selfregulation can work out for the healthcare sector, by design. You need good ability of healthcare customers to judge quality of treatment/medication, to know prices beforehand and to have sufficient choice for market dynamics to work, and every single one of those points is somewhere between really difficult and impossible.

rtkwe 1y ago
An embedded requirement for a rational market is that the customer has to be able to make a rational evaluation of the costs of the good vs the quality, which just doesn't exist in medical fields. Patients don't know enough to make that choice and evaluate the efficacy of many potential choices of providers. Not being able to do that fundamentally kneecaps the implicit assumptions in the already faulty model that underpins the 'competitive market' analysis. We should just accept that and stop trying to treat it as one and provide it as a public good.
- TheOtherHobbes 1y ago
  That's a cart-before-the-horse analysis. Labelling markets "rational" is pure rhetoric. There's nothing even remotely rational about a market system, because the moral basis of calling markets "rational" is... greed. Just greed. Nothing else. All of the failed outcomes, deaths, pollution, lost opportunities, distortions of democracy, and other damages are a direct consequence of this moral system which claims that greed is rational - when in fact unfettered greed is clearly and objectively sociopathic, with predictable sociopathic outcomes.
  - 20after4 1y ago
    I agree with you but this website is sociopath central so I'm not surprised this got down votes. A lot of Ayn Rand fans here. But you know that already, judging by your karma score.
  - nickpp 1y ago
    We're all greedy. We all want to get the most for our money, time and effort. Greed and desire push us to spend our energy, otherwise we'd simply conserve it. It's normal, it's natural and it works. It's human (and animal) nature. Altruism works fine in individuals and small organizations. But large systems based on altruism uniformly failed to provide the most basic necessities (like food) for their citizens. Can't work against human nature.
    - nosianu 1y ago
      > We're all greedy. We all want to get the most for our money, time and effort. We are? For example, I never file taxes. I'm certain I could get quite a bit back. I am far from rich, I earn medium pay in Germany - medium overall, not medium in IT. (Because I deliberately took a more rewarding and relaxing job, but that's besides the point.) I will not fill my mind with "money" stuff. Even if that costs me some of that money. I am sure, given that the terms used are as fuzzy as can be, you can twist and shake the words until you can claim that I am "greedy", the problem with this rationality discussions is how extremely flexible the words used are, making it quite impossible to win or lose an argument. All one has to do is insist on one's own definitions... but taking a relaxed view, I don't see good way to make not-at-all-rare positions such as mine as a form of "greed", without severely twisting the commonly understood meaning(s). I think a lot of that world view is self-fulfilling. When I was a kid I LOVED working like the adults. That includes taking one to four week stints in factories, as a teenager in school. That was common in East Germany and encouraged, early acquaintance with work life. I did the same helping out my craftsman grandfather and my shop-owing grandmother. Work was FUN! But now, the reason I don't just go - which I would LOVE to do! - and work a few hours low-level jobs here and there, is because it's all been heavily commercialized. You just don't do that! Work has to be pain, and you get paid. Only an idiot would work for free! During university, during a semester break, I took a job in a chocolate factory. I did not actually need the money! My parents paid (divorced, but both paid). I actually had a lot over at the end of university (cheap dorm housing and no fees for the university itself sure helped). I took the job because I wanted to work in a factory again. It is FUN!. Until that middle manager a..ole appüeared. I had just optimized my in-between assignment of taking care of some machine chocolate thing, some mixing, I forgot the details. I had set everything up perfectly and now had to just wait a few minutes for the machine to finish. In comes that.... manager guy. Immediately, seeing me sitting there he yelled at me why I'm not working. FU manager guy. That was the day I realized work now is WORK, not fun. You are not supposed to have fun. You now need middle manager person to keep your lazy ass in check! By yourself, without continuous pressure, you would not move a hand! Right? At least for the "lower" jobs, which are the majority. > It's normal, it's natural and it works. It's human (and animal) nature. You are definitely not speaking for a lot of people, and what you see is NOT the one natural outcome. Expectations and behavior towards people determine theirs (behavior). The culture I describe existed all around me in East Germany. Yes we were waaayyy backwards with everything, but work culture was really good. I learned a technical profession in a large chemical factory before studying. Everybody worked, useful stuff too, all day. The ancient machinery in the crumbling buildings needed a lot of attention to keep them running. There was hardly any slacking off anywhere I looked. Sure, it was relaxed, but it was work, work, work. I've seen waayyy more slacking off in the offices of large American IT companies. What you describe as "natural" is natural only in the context the current society has created.
- somenameforme 1y ago
  For the overwhelming majority of things people to go to the hospital for, where you go doesn't really matter, because the treatment and diagnosis is extremely routine. This includes very serious things like cancer. My mother, through a variety of fortuitous events, was able to have her breast cancer treated at one of the top ranked cancer specializing hospitals in the US. She had acquaintances that had theirs treated at the local university/training hospital. They ended up receiving literally the exact same treatments. Same for my own stuff. The first time one of my children got sick it was terrifying, so I naturally took him to the most premium pediatric healthcare institution. And what did they do? Basic tests to rule out anything particularly nasty, and fever management. The exact same thing the cheapest hospital does, except I got the privilege of paying 10x more for it and feeling like a complete sucker. From that point on - 'oh he's sick? shall we go to the university hospital, or the religious nonprofit?'
  - owenthejumper 1y ago
    Unfortunately it does matter. NCI designated cancer centers simply do have better outcomes than local hospitals.
    - deleted 1y ago
      [deleted]
    - somenameforme 1y ago
      This is not entirely clear. Elsewhere in this thread I found a couple of studies on this exact topic. The first [1] is just for breast cancer and after normalizing across a wide array of variables, found no improved survival rates except for black women, which I think is suggestive of further biases. The second [2] is for all sorts of cancers, but is a large observational study without much effort to control for biases. It found an overall increase in five year survival rates of 3.6% (64.3% in NCI centers, vs 60.7% in non-NCI). That's certainly something, but it's fairly certain that biases would bring that down a healthy chunk. However there were significantly better outcomes in more rare/lethal cancers. For instance in hepatobiliary cancers, the NCI survival rate was 33.8% vs 18.7% for non-NCI centers. And that is largely the point I'm making. For the overwhelming majority of things, care is mostly commoditized and you will be fine wherever you go. The value of high end institutions is mostly only realized in the case of rare/serious issues, for which transfer is always an option anyhow. --- Though I'd also add here that these examples, cancer, are on the fringe extremes of what my point was. That there is a strong argument to be made that even cancer falls within it, just further emphasizes the point. If your local hospital can competently treat cancer, they can certainly treat the overwhelming majority of reasons people go to the hospital, which are relatively far more commoditized. [1] - https://pmc.ncbi.nlm.nih.gov/articles/PMC8462568/ https://pmc.ncbi.nlm.nih.gov/articles/PMC8462568/ [2] - https://pmc.ncbi.nlm.nih.gov/articles/PMC4892698/ https://pmc.ncbi.nlm.nih.gov/articles/PMC4892698/
- DangitBobby 1y ago
  Most markets fail here. I can't even make good decisions about which electronics or appliances to buy, which restaurants to visit, which mechanic to use, and it's not for lack of research or unwillingness to pay. Advertising allows brands to build undeserved market reputation, and brands regularly sabotage their own legitimately established brand reputation for financialization.
  - rtkwe 1y ago
    I think it's particularly bad in medical decisions though because it's so much more advanced and cases are so varied it's difficult to compare doctor performance on different procedures. At least with products you generally get similar items each time so people can test multiple products in some scenario and a buyer can know what they buy should perform similarly.
ModernMech 1y ago
The further you get from a perfect market, the less free market dynamics work. And even if they did, there's nothing in the theory that would minimize for patient deaths. The theory says that as patients die, people who are living would go to hospitals with better outcomes. But to achieve this outcome 1. patients need to be able to actually choose where to go. If they are incapacitated they have no choice in where they are taken. 2. we have to endure an unknown number of deaths for an undetermined period of time while we wait for the market to reach equilibrium. So it's pretty clear free market dynamics are not the way to go when it comes to the healthcare marketplace.
coredog64 1y ago
> but I don't believe classical free market selfregulation can work out for the healthcare sector, by design. That would come as news to the French. The TL;DR of the French system is that you pay for your outpatient care at the point of service. Later, your insurance company will reimburse you for 80% of the "reasonable and customary" charges for the service. It's up to you to pick the provider that matches your budget. Emergency care is understood as not amenable to the free market, and that doesn't have the same payment flow. Having said that, I could tell you some stories about folks who wound up worse off because the care was still rationed, just by the state instead of an insurance company. I'll preempt the common next argument, and that is that emergency care is ~ 10% of US medical spending, so it's probably not Pareto efficient to start with that case when designing how this all works.
- kelseyfrog 1y ago
  > I could tell you some stories about folks who wound up worse off because the care was still rationed, just by the state instead of an insurance company. I wish this would stop being used like it's a credible argument. The truth is that we can find these cases in any healthcare system. The only valid evidence when weighing system versus system is aggregate numbers.
- myrmidon 1y ago
  For the record: With "classical free market selfregulation" I mean something that is quite far from any civilized system. Standards of care, education of caregivers and even pricing levels to some degree are all regulated in your example (which I think is a good idea). I would literally expect overpriced snake-oil from actual free market healthcare, and there is significant empirical evidence that this would happen from my point of view.
tptacek 1y ago
In what sense do you mean that healthcare isn't a competitive market? Are you talking about locales with only one nearby hospital? I'm in a big city and I have 3 of them, and the choice of 5 different major provider chains. I don't like the system (I think provider abuses are the major cause of health spending problems in this country), but one thing I can't say is that I don't have options.
- myrmidon 1y ago
  What I mean is that the dynamics of healthcare are not conducive for a competitive market. Compare grocery shopping: You have frequent/repeated interactions; if you always get ripped of by one shop, you can go to another. Before you go grocery shopping, you will have a decent mental model for: prices levels at each shop, quality of produce and accessibility/distance. You also have the full choice in where to go, basically every time. Hospital interactions (especially ER) is the polar opposite: You will have few interactions with it over your lifetime (hopefully), costs are basically impossible to know beforehand (and difficult to compare, too), quality of treatment is extremely difficult to judge as patient (because every case is somewhat unique, and outcomes can easily come down to luck/individual doctor). Especially in the ER case, you often don't even have a real choice of hospital and even in cases where you could (and had all the info) there might be throughput limitations on "desirable" hospitals that prevent you from switching (=> having to wait for 5 months). Another factor I think is that hospitals gain less from being "good": As a "good" grocer, you get to steal market share from your competition at low cost and risk to yourself; for the hospital, scaling up is more difficult and risky, thus "good" competitors are also less threatening comparatively (thus less of a motivation to improve things).
  - tptacek 1y ago
    So I understand where you're coming from, and there are certainly major market distortions in health in the US (employer-provided health insurance being the most obvious). But where I live, "which ER will you go to" is a major, market-driven conversation. I have 3 obvious options, and 2 of them are competitive, and if I go look for conversations and "reviews" I'll find plenty of opinions quickly. To me, it's at least as competitive as the market for plumbers.
thisislife2 1y ago
> ... would be fine if healthcare was a competitive market. But it isn't, and I honestly don't see how to make it one. The "mixed economy" model - introduce government run hospitals to create competition. Indian healthcare industry is experimenting with such a model. There are free to cheap government hospitals (along with medical colleges that provide cheap labour in the form of student interns) and smaller public health clinics, that work somewhat like the UK NHS model. But as they tend to be over crowded, or have high wait times to see experts, people with money (and / or insurance) tend to prefer good private hospitals. Private hospitals do charge a lot, but where there are good government hospitals, they have to be mindful that they do not charge too much. Affordable insurance (along with socialised government insurance) and medicines also make access to quality healthcare possible.
- smj-edison 1y ago
  Huh, I really like this approach. My economics knowledge isn't great, but I do know that healthcare is quite inelastic because people are willing to pay high prices to be healthy. A mixed model would siphon off the most desperate to a good option, and inject local competition. I advocated against universal healthcare for a long time, since I was worried that it would cause stagnation in health innovation, but now I see a need for universal healthcare for the 80-90% most common procedures (and leave private clinics to innovate). The only downside I can think of is less dependence on insurance, which has the potential to drive up premiums. But, if that means taking care of the poor for the most common ailments, then it's a worthwhile tradeoff.

rtkwe 1y ago

An embedded requirement for a rational market is that the customer has to be able to make a rational evaluation of the costs of the good vs the quality, which just doesn't exist in medical fields. Patients don't know enough to make that choice and evaluate the efficacy of many potential choices of providers. Not being able to do that fundamentally kneecaps the implicit assumptions in the already faulty model that underpins the 'competitive market' analysis. We should just accept that and stop trying to treat it as one and provide it as a public good.

TheOtherHobbes 1y ago
That's a cart-before-the-horse analysis. Labelling markets "rational" is pure rhetoric. There's nothing even remotely rational about a market system, because the moral basis of calling markets "rational" is... greed. Just greed. Nothing else. All of the failed outcomes, deaths, pollution, lost opportunities, distortions of democracy, and other damages are a direct consequence of this moral system which claims that greed is rational - when in fact unfettered greed is clearly and objectively sociopathic, with predictable sociopathic outcomes.
- 20after4 1y ago
  I agree with you but this website is sociopath central so I'm not surprised this got down votes. A lot of Ayn Rand fans here. But you know that already, judging by your karma score.
- nickpp 1y ago
  We're all greedy. We all want to get the most for our money, time and effort. Greed and desire push us to spend our energy, otherwise we'd simply conserve it. It's normal, it's natural and it works. It's human (and animal) nature. Altruism works fine in individuals and small organizations. But large systems based on altruism uniformly failed to provide the most basic necessities (like food) for their citizens. Can't work against human nature.
  - nosianu 1y ago
    > We're all greedy. We all want to get the most for our money, time and effort. We are? For example, I never file taxes. I'm certain I could get quite a bit back. I am far from rich, I earn medium pay in Germany - medium overall, not medium in IT. (Because I deliberately took a more rewarding and relaxing job, but that's besides the point.) I will not fill my mind with "money" stuff. Even if that costs me some of that money. I am sure, given that the terms used are as fuzzy as can be, you can twist and shake the words until you can claim that I am "greedy", the problem with this rationality discussions is how extremely flexible the words used are, making it quite impossible to win or lose an argument. All one has to do is insist on one's own definitions... but taking a relaxed view, I don't see good way to make not-at-all-rare positions such as mine as a form of "greed", without severely twisting the commonly understood meaning(s). I think a lot of that world view is self-fulfilling. When I was a kid I LOVED working like the adults. That includes taking one to four week stints in factories, as a teenager in school. That was common in East Germany and encouraged, early acquaintance with work life. I did the same helping out my craftsman grandfather and my shop-owing grandmother. Work was FUN! But now, the reason I don't just go - which I would LOVE to do! - and work a few hours low-level jobs here and there, is because it's all been heavily commercialized. You just don't do that! Work has to be pain, and you get paid. Only an idiot would work for free! During university, during a semester break, I took a job in a chocolate factory. I did not actually need the money! My parents paid (divorced, but both paid). I actually had a lot over at the end of university (cheap dorm housing and no fees for the university itself sure helped). I took the job because I wanted to work in a factory again. It is FUN!. Until that middle manager a..ole appüeared. I had just optimized my in-between assignment of taking care of some machine chocolate thing, some mixing, I forgot the details. I had set everything up perfectly and now had to just wait a few minutes for the machine to finish. In comes that.... manager guy. Immediately, seeing me sitting there he yelled at me why I'm not working. FU manager guy. That was the day I realized work now is WORK, not fun. You are not supposed to have fun. You now need middle manager person to keep your lazy ass in check! By yourself, without continuous pressure, you would not move a hand! Right? At least for the "lower" jobs, which are the majority. > It's normal, it's natural and it works. It's human (and animal) nature. You are definitely not speaking for a lot of people, and what you see is NOT the one natural outcome. Expectations and behavior towards people determine theirs (behavior). The culture I describe existed all around me in East Germany. Yes we were waaayyy backwards with everything, but work culture was really good. I learned a technical profession in a large chemical factory before studying. Everybody worked, useful stuff too, all day. The ancient machinery in the crumbling buildings needed a lot of attention to keep them running. There was hardly any slacking off anywhere I looked. Sure, it was relaxed, but it was work, work, work. I've seen waayyy more slacking off in the offices of large American IT companies. What you describe as "natural" is natural only in the context the current society has created.
somenameforme 1y ago
For the overwhelming majority of things people to go to the hospital for, where you go doesn't really matter, because the treatment and diagnosis is extremely routine. This includes very serious things like cancer. My mother, through a variety of fortuitous events, was able to have her breast cancer treated at one of the top ranked cancer specializing hospitals in the US. She had acquaintances that had theirs treated at the local university/training hospital. They ended up receiving literally the exact same treatments. Same for my own stuff. The first time one of my children got sick it was terrifying, so I naturally took him to the most premium pediatric healthcare institution. And what did they do? Basic tests to rule out anything particularly nasty, and fever management. The exact same thing the cheapest hospital does, except I got the privilege of paying 10x more for it and feeling like a complete sucker. From that point on - 'oh he's sick? shall we go to the university hospital, or the religious nonprofit?'
- owenthejumper 1y ago
  Unfortunately it does matter. NCI designated cancer centers simply do have better outcomes than local hospitals.
  - deleted 1y ago
    [deleted]
  - somenameforme 1y ago
    This is not entirely clear. Elsewhere in this thread I found a couple of studies on this exact topic. The first [1] is just for breast cancer and after normalizing across a wide array of variables, found no improved survival rates except for black women, which I think is suggestive of further biases. The second [2] is for all sorts of cancers, but is a large observational study without much effort to control for biases. It found an overall increase in five year survival rates of 3.6% (64.3% in NCI centers, vs 60.7% in non-NCI). That's certainly something, but it's fairly certain that biases would bring that down a healthy chunk. However there were significantly better outcomes in more rare/lethal cancers. For instance in hepatobiliary cancers, the NCI survival rate was 33.8% vs 18.7% for non-NCI centers. And that is largely the point I'm making. For the overwhelming majority of things, care is mostly commoditized and you will be fine wherever you go. The value of high end institutions is mostly only realized in the case of rare/serious issues, for which transfer is always an option anyhow. --- Though I'd also add here that these examples, cancer, are on the fringe extremes of what my point was. That there is a strong argument to be made that even cancer falls within it, just further emphasizes the point. If your local hospital can competently treat cancer, they can certainly treat the overwhelming majority of reasons people go to the hospital, which are relatively far more commoditized. [1] - https://pmc.ncbi.nlm.nih.gov/articles/PMC8462568/ https://pmc.ncbi.nlm.nih.gov/articles/PMC8462568/ [2] - https://pmc.ncbi.nlm.nih.gov/articles/PMC4892698/ https://pmc.ncbi.nlm.nih.gov/articles/PMC4892698/
DangitBobby 1y ago
Most markets fail here. I can't even make good decisions about which electronics or appliances to buy, which restaurants to visit, which mechanic to use, and it's not for lack of research or unwillingness to pay. Advertising allows brands to build undeserved market reputation, and brands regularly sabotage their own legitimately established brand reputation for financialization.
- rtkwe 1y ago
  I think it's particularly bad in medical decisions though because it's so much more advanced and cases are so varied it's difficult to compare doctor performance on different procedures. At least with products you generally get similar items each time so people can test multiple products in some scenario and a buyer can know what they buy should perform similarly.

ModernMech 1y ago

The further you get from a perfect market, the less free market dynamics work. And even if they did, there's nothing in the theory that would minimize for patient deaths. The theory says that as patients die, people who are living would go to hospitals with better outcomes. But to achieve this outcome 1. patients need to be able to actually choose where to go. If they are incapacitated they have no choice in where they are taken. 2. we have to endure an unknown number of deaths for an undetermined period of time while we wait for the market to reach equilibrium. So it's pretty clear free market dynamics are not the way to go when it comes to the healthcare marketplace.

coredog64 1y ago

> but I don't believe classical free market selfregulation can work out for the healthcare sector, by design. That would come as news to the French. The TL;DR of the French system is that you pay for your outpatient care at the point of service. Later, your insurance company will reimburse you for 80% of the "reasonable and customary" charges for the service. It's up to you to pick the provider that matches your budget. Emergency care is understood as not amenable to the free market, and that doesn't have the same payment flow. Having said that, I could tell you some stories about folks who wound up worse off because the care was still rationed, just by the state instead of an insurance company. I'll preempt the common next argument, and that is that emergency care is ~ 10% of US medical spending, so it's probably not Pareto efficient to start with that case when designing how this all works.

kelseyfrog 1y ago
> I could tell you some stories about folks who wound up worse off because the care was still rationed, just by the state instead of an insurance company. I wish this would stop being used like it's a credible argument. The truth is that we can find these cases in any healthcare system. The only valid evidence when weighing system versus system is aggregate numbers.
myrmidon 1y ago
For the record: With "classical free market selfregulation" I mean something that is quite far from any civilized system. Standards of care, education of caregivers and even pricing levels to some degree are all regulated in your example (which I think is a good idea). I would literally expect overpriced snake-oil from actual free market healthcare, and there is significant empirical evidence that this would happen from my point of view.

tptacek 1y ago

In what sense do you mean that healthcare isn't a competitive market? Are you talking about locales with only one nearby hospital? I'm in a big city and I have 3 of them, and the choice of 5 different major provider chains. I don't like the system (I think provider abuses are the major cause of health spending problems in this country), but one thing I can't say is that I don't have options.

myrmidon 1y ago
What I mean is that the dynamics of healthcare are not conducive for a competitive market. Compare grocery shopping: You have frequent/repeated interactions; if you always get ripped of by one shop, you can go to another. Before you go grocery shopping, you will have a decent mental model for: prices levels at each shop, quality of produce and accessibility/distance. You also have the full choice in where to go, basically every time. Hospital interactions (especially ER) is the polar opposite: You will have few interactions with it over your lifetime (hopefully), costs are basically impossible to know beforehand (and difficult to compare, too), quality of treatment is extremely difficult to judge as patient (because every case is somewhat unique, and outcomes can easily come down to luck/individual doctor). Especially in the ER case, you often don't even have a real choice of hospital and even in cases where you could (and had all the info) there might be throughput limitations on "desirable" hospitals that prevent you from switching (=> having to wait for 5 months). Another factor I think is that hospitals gain less from being "good": As a "good" grocer, you get to steal market share from your competition at low cost and risk to yourself; for the hospital, scaling up is more difficult and risky, thus "good" competitors are also less threatening comparatively (thus less of a motivation to improve things).
- tptacek 1y ago
  So I understand where you're coming from, and there are certainly major market distortions in health in the US (employer-provided health insurance being the most obvious). But where I live, "which ER will you go to" is a major, market-driven conversation. I have 3 obvious options, and 2 of them are competitive, and if I go look for conversations and "reviews" I'll find plenty of opinions quickly. To me, it's at least as competitive as the market for plumbers.

thisislife2 1y ago

> ... would be fine if healthcare was a competitive market. But it isn't, and I honestly don't see how to make it one. The "mixed economy" model - introduce government run hospitals to create competition. Indian healthcare industry is experimenting with such a model. There are free to cheap government hospitals (along with medical colleges that provide cheap labour in the form of student interns) and smaller public health clinics, that work somewhat like the UK NHS model. But as they tend to be over crowded, or have high wait times to see experts, people with money (and / or insurance) tend to prefer good private hospitals. Private hospitals do charge a lot, but where there are good government hospitals, they have to be mindful that they do not charge too much. Affordable insurance (along with socialised government insurance) and medicines also make access to quality healthcare possible.

smj-edison 1y ago
Huh, I really like this approach. My economics knowledge isn't great, but I do know that healthcare is quite inelastic because people are willing to pay high prices to be healthy. A mixed model would siphon off the most desperate to a good option, and inject local competition. I advocated against universal healthcare for a long time, since I was worried that it would cause stagnation in health innovation, but now I see a need for universal healthcare for the 80-90% most common procedures (and leave private clinics to innovate). The only downside I can think of is less dependence on insurance, which has the potential to drive up premiums. But, if that means taking care of the poor for the most common ailments, then it's a worthwhile tradeoff.