Comment by rscho | Hacker News Reader

Comment by rscho | Hacker News Reader

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Absolutely true. As a doc, the US problem boils down to a cultural issue that can be summarized as:

"there is no reason my money should pay for the care of others, but if I personally need care, then it should be of the absolute best quality and should be provided until my last breath no matter what"

The people maintain the system themselves by insisting on that, and that is the root of every other problem. Before alleviating restrictions for med school, US people should think about pulling the plug on the legions of evidently terminal patients receiving maximal care that just prolongs their intense suffering every day around the country.

Why do you think your doc does every exam under the sun as soon as you step foot in the office?

1 - if solo, more money; if networked, makes you look better for the "employer" (insurance company/hospital/HMO, etc.)

2 - if you have too many exams, you will complain on the internet. If you have too few exams and something goes wrong, you will drag the doc into court.

Weigh the incentives and I think even the most conservative person should see a problem.

You: "if I personally need care, then it should be of the absolute best quality and should be provided until my last breath no matter what"

Your healthcare industry: "if you personally need care, then it should be of the absolute best quality and should be provided until your last cent no matter what"

"there is no reason my money should pay for the care of others"

Isn't the cultural issue largely a idealogical issue - things like the UK NHS are avowedly socialist? In the words of Aneurin Bevan, founder of the NHS:

" A free health service is pure Socialism and as such it is opposed to the hedonism of capitalist society."

https://en.wikipedia.org/wiki/Aneurin_Bevan

Personally, at least when it comes to healthcare, I'm a socialist:

"The collective principle asserts that ... no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means."

Indeed, I think so too. Ironically, people essentially tend to ask for freedom of choice above all in the US healthcare system (I want complete price info, yada yada...) when the US system is evidently already the one offering the highest level of patient autonomy, probably worldwide (regarding the ethics principles of beneficence, nonmaleficience, Justice and autonomy). But guess what? That has a price, who would have thought?!

Another point is that IMO, you can't go extreme on one principle without impacting the others. Nonmaleficience is clearly a problem in the US.

Indeed, its why I dislike ideological based arguments - once people commit to an ideology they will stick with it way past the point where it is clearly not effective (and this goes for right wing and left wing ideologies).

People want complete price information because we don't have price controls, like they have in Germany, France, and Japan. Having a "free market" in healthcare without showing prices in advance of providing services is sort of obviously the worst way to get a reasonably priced healthcare system.

That's somewhat mitigated by negotiations between insurers and providers, but not entirely given out-of-network charges.

Agreed, however there is a solid base of evidence (as solid as medical evidence can be, which is not saying much) that health can't humanely be handled as a commodity.

Plus, providing complete price info itself is not free. Talk about administrative inflation!

So then, go with price controls. We have multiple examples of that working just fine. The answer cannot be that we make people responsible for payment before telling them what the price will be, and it's unsurprising that by doing that, we have the most expensive healthcare system in the world.

Kind of. As a Brit I don't think the UK is especially socialist. Also we don't generally think of the NHS as socialist more than Americans would talk about having a socialist army or police force. The fact that the above are funded by the government from tax in my view doesn't really make them socialist. It's more just a common sense way of funding some stuff.

The dictionary has socialism as "means of production, distribution, and exchange should be owned or regulated by the community as a whole" and I've never thought of health care as a "means of production". Now if the government tries to own all the factories that's socialism.

Healthcare is broadly a service and thus what hospitals, GP surgeries, etc. produce in the economy.

The NHS is a socialised system based on socialist ideas and indeed can be seen as a socialist construct within a capitalist overall economy. Nothing inherently wrong with that, that's just objectively the way it is. Bevan just said it the way it is.

Now, the military and police are regalian functions of the state. The government and regalian functions cannot really be labelled 'socialist', that would make much sense.

"regalian functions of the state"

Sorry to nitpick, but does "regalian" mean something else than emblems or insignia of royalty?

A credible sovereign state generally needs some force projection capability within it's political domain, hereditary monarchy or not.

Hence military is definetly in a different category than healthcare.

The etymology of the term indeed comes from the prerogatives of the sovereign.

"Regalian functions of the state" is a common term that means the basic powers of the state (monarchy or not) that used to be the prerogative of the sovereign. I.e. law & order, military, and taxation. You could also call these "inherent powers of the state".

"Hence military is definetly in a different category than healthcare."

Why is that - one is defending the citizens of the state against external threats and the other is defending the citizens against medical threats?

The military is a regalian function (and arguably its first function is to defend the state, not the citizens...), while healthcare is not usually considered a regalian function.

The line must be drawn somewhere.

You can imagine healthcare being provided fully by the private sector without state intervention (how that works for the poor is another issue) but the military has to be controlled by the state even if in fine the state hires mercenaries.

> "Regalian functions of the state" is a common term

It's really not; I mean, I've got a poli sci degree so I've seen it, but it's not really a common term.

> that means the basic powers of the state (monarchy or not) that used to be the prerogative of the sovereign. I.e. law & order, military, and taxation.

The pre-modern-limited-governnent prerogatives of sovereigns were much broader than law enforcement, defense, and taxation. And, in fact, the principle thing denoted by regalian power is the fundamentally ownership of all land which is superior to all private title, which is the root of all the other (essentially unlimited) powers associated with sovereignty, in a “my house, my rules” kind of way.

The term “regalian functions”, though, is most often used to refer to the three functions Adam Smith identified as essential to the sovereign in The Wealth of Nations, which are still much broader than what you suggest:

“The first duty of the sovereign, that of protecting the society from the violence and invasion of other independent societies, can be performed only by means of a military force.” [0]

“The second duty of the sovereign, that of protecting, as far as possible, every member of the society from the injustice or oppression of every other member of it, or the duty of establishing an exact administration of justice, requires two very different degrees of expense in the different periods of society.” [1]

“The third and last duty of the sovereign or commonwealth, is that of erecting and maintaining those public institutions and those public works, which though they may be in the highest degree advantageous to a great society, are, however, of such a nature, that the profit could never repay the expense to any individual, or small number of individuals; and which it, therefore, cannot be expected that any individual, or small number of individuals, should erect or maintain.” [2]

> Hence military is definetly in a different category than healthcare.

This is true, not in the sense of not being subsumed within “regalian functions”, but in the sense that the military is the first regalian function identified by Smith while healthcare delivery systems that broadly and effectively serve the whole population are in the third.

[0] book V, chap. 1, part 1

[1] Ibid, part 2

[2] Ibid, part 3

> while healthcare delivery systems that broadly and effectively serve the whole population are in the third.

That's your interpretation but that's really a political view, and indeed the definition of that third duty is highly subjective. As I wrote in another comment, the line must be drawn somewhere.

Note that my point wasn't to discuss regalian functions in general but to counter the argument that calling the British NHS 'socialist' was like calling the police or the army 'socialist'.

(Btw, I heard the term "regalian functions" in secondary school/high school...)

> That's your interpretation but that's really a political view

Smith's concept of regalian functions is just as much a “political view”.

> and indeed the definition of that third duty is highly subjective.

So are the definition of what particular actions of sovereign are within the boundary of the what is essential within the other two (and all three expressly vary by context, including available physical and social technologies, as perusal of the relevant parts of the Wealth of Nations makes clear.)

> Note that my point wasn't to discuss regalian functions in general but to counter the argument that calling the British NHS 'socialist' was like calling the police or the army 'socialist'.

Which the reference to regalian functions fails to do: all fall within the broad ambit of what could be considered those functions, and whether the dpecifics of either do is debatable, and, in any case, whether or not a function is within the scope of regalian functions is irrelevant to whether or not it is socialist.

It is very relevant otherwise one might indeed draw a parallel with the police and the military, as already said.

As also said, health are is a productive service that has the potential of being 'socialist'.

I'm not here to argue for the sake of it and I don't see any actual argument on the original points in your replies...

Note that Bevan isn't saying that UK society is socialist (although he was probably in favour of it) - rather than the spirit of the NHS is socialist. Note that I would agree that it seems "common sense" for us in the UK and I'm definitely not keen on basing arguments on ideologies but it clearly doesn't seem "common sense" for people in the US.

And yet, in the U.S. we have a system like the NHS for veterans, plus a system like Canada's for everybody over 65.

Yes, I believe the US government spends more per capita on government provided healthcare than the UK does - even though the end results are only available to a subset of the population.

Doesn't that annoy people?

Paying for the care of others is also the insurance model, which is not socialism. I think where you lose support from part of the population is when the system is being abused. I understand France for instance has an abnormally high number of depressions, as it is a common way for a lazy employee to take some time off at the expense of the system. In the US I understand there is an abnormally high number of people on disability benefits.

The hostility I think comes not from the fact that it is mandatory, but from the fact that if it is managed by the state, it will be badly managed, abused by a minority, and you end up over-paying while getting a bad service yourself the day you need it.

Fact, you say? I think you're right about the psychology here but if you're going to assert that state management is factually bad please provide some support to that.

> but from the fact that if it is managed by the state, it will be badly managed, abused by a minority, and you end up over-paying while getting a bad service yourself the day you need it

Fact you say? Sounds like an opinion to me.

I think have a socialist healthcare improves the capitalist opportunities for people in those countries. Having your job tied to your health insurance means people are less likely to change jobs, thereby not giving their true optimal output to a capitalist society.

A worker who is free to offer his labour to whomever he wants knowing that his healthcare is not tied into their employment has more options and choice to them then someone who can't change jobs.

A point on your last point, people would argue that even in the US you can still access the emergency room when you have no money so no one is turned away due to lack of means.

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