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> A therapist can induce infinite demand on a patient, by just doing follow-up sessions ad-infinitum. In argentina for example, people go to the same therapist for decades!!

You know people who take insulin are on it for the rest of their lives, but that doesn't make it the fault of their doctors.

Therapy actually works. "Hundreds of studies have found that psychotherapy is an effective way to help people make positive changes in their lives," Nordal says. "Compared with medication, psychotherapy has fewer side effects and lower instances of relapse when discontinued." [1]

> The second part is that as a patient, if the insurance covers your cost, you might as well go to the most expensive therapist you can find, and consume the infinitely. Also, you know more than the insurance company if you plan on using or needing this care, thus you have a very strong adverse-selection situation going on with any plan that is generous on mental health.

This is a very strange American perspective on health care. If it was suddenly available to everyone, there's a perception that we'd all be like kids in the candy store getting 1 of everything at the doctors office. That's just not how it works. Nobody in Canada goes to their GP and asks for the immunotherapy and a few casts. People go to doctors because they're sick, and they need treatment and would rather be literally anywhere else.

It's not as though we're socializing the electronics section at Best Buy.

> Economically speaking, mental health should not be part of an insurance scheme. It should be cash pay. To help people that could not afford mental health and they need it, you would do better to provide state-run service, that is low-cost high-effective-value and cover the lower side of the population.

Sold, but it should cover everyone.

[1] https://www.apa.org/monitor/2013/02/therapist

> You know people who take insulin are on it for the rest of their lives, but that doesn't make it the fault of their doctors.

The bet on diabetes has to happen before it is diagnosed to make actuarial analysis. If you want to guarantee that all diabetes patients get access to insulin, what you want is charity, not insurance.

Insurance is risk pooling.

> This is a very strange American perspective on health care. If it was suddenly available to everyone, there's a perception that we'd all be like kids in the candy store getting 1 of everything at the doctors office

The science has already shown that is true. Over and underutilization of healthcare are studied effects, ones insurance companies pay very close attention to because if they don't, they will go bust. That is also why countries with free healthcare also have copays.

> People go to doctors because they're sick, and they need treatment and would rather be literally anywhere else.

I think you are have an outsider's view on how healthcare provision works. No doctor i met would ever agree with this statement.

> The bet on diabetes has to happen before it is diagnosed to make actuarial analysis. If you want to guarantee that all diabetes patients get access to insulin, what you want is charity, not insurance. Insurance is risk pooling.

Yep! That's why health insurance is a misnomer. There's no guarantee my house will catch fire, so I insure against it. There is a 100% chance each and every human will catch a terminal illness. That makes it at best a structured payout program. The amount of the payout can be reduced through preventative care, and yes, maintenance drugs like insulin. That's the best case for why it should be socialized.

It's not insurance, and it's not charity, it's a service in the public interest. And of course people should have access to the medication they need to live, we're not savages.

> The science has already shown that is true. Over and underutilization of healthcare are studied effects, ones insurance companies pay very close attention to because if they don't, they will go bust. That is also why countries with free healthcare also have copays.

Insurance companies get paid in advance, and their goal is not to provide the best care but to return the largest amount possible to their shareholders. Co-pays keep people out of hospital, especially lower-income folks, which allows insurance companies to make more money. Same with high deductibles. Their goal is not care, it's profit.

The UK and Canada (the systems I know best) don't really have co-payments, certainly not like in the US. The vast majority of services are co-payment free [1] (UK: "Out-of-pocket payments for general practice are limited to some services, such as examinations for employment or insurance purposes and the provision of certificates for travel or insurance", in Ontario going to the hospital you only pay for parking or 'upgrades' like private rooms - [2], [3] is the entire fee schedule). Same with Australia [4] who in 2015 rebelled over an AU$7 co-pay. You get sick, you go to the doctor, they take care of it.

Think about it, if you could access any procedure right now, what would you get done? Nothing, because it's not fun, it's not rewarding. If it's medically necessary, you'll get it done one way or the other, if it's not, literally why are you at the hospital? Yes, use goes up a bit. IMO, that can be offset by creating clinics and guiding people to them for minor ailments as in the UK.

> I think you are have an outsider's view on how healthcare provision works. No doctor i met would ever agree with this statement.

Respectfully disagree. Both my parents are doctors, and I grew up in numerous medical systems all over the world. I've benefitted hugely from socialized medical systems and not having one right now is downright terrifying even though I'm well 'insured'.

My dad refused to work in the US because he felt the healthcare system here was inhumane. He wanted to provide people care based on their needs not what they could afford. It took me until I lived here to understand he was exactly right. There's a lot of this apologist: "there must be some reason the American system is better" -- sorry, it's just not better.

[1] https://international.commonwealthfund.org/countries/england...

[2] https://www.qch.on.ca/hospitalcharges

[3] https://www.qch.on.ca/uploads/Finance/Hospital%20fees%20Webs...

[4] https://transferwise.com/au/blog/healthcare-system-in-austra...

> That makes it at best a structured payout program.

This is what prepay's are, and HMO's. You have 2 opinions on HMO: they love it because pricing is transparent, they dislike it because they ration service. An example of that with Kaiser: they put severe barriers on their own mental health services. An industry gossip for you: one of the biggest consumer of mental health services at Kaiser is Kaiser doctors.

> Insurance companies get paid in advance, and their goal is not to provide the best care but to return the largest amount possible to their shareholders...

At the same time, insurance has an interest in controlling how much the insurance is used, something governments can fail at pretty hard. Remember Medicare insurance already costs 1k per person per month. That's the socialized system america has now, and it won't be more efficient by being bigger.

> Think about it, if you could access any procedure right now, what would you get done? Nothing, because it's not fun, it's not rewarding.

This is just not the reality. It's a well studied effect, denying it is depriving the science behind policy analysis from any legitimacy.

> Respectfully disagree. Both my parents are doctors, and I grew up in numerous medical systems all over the world. I've benefitted hugely from socialized medical systems and not having one right now is downright terrifying even though I'm well 'insured'.

They told you that patients never go to the doctor for superfluous reasons? I won't believe it. I am in the industry and I can see every case imaginable.

We have had this argument before. The U.S. socializing healthcare will not bring out-of-us healthcare results. It will get something else, because what makes healthcare suck is not private vs public, it's the regulatory framework.

> This is just not the reality. It's a well studied effect, denying it is depriving the science behind policy analysis from any legitimacy.

You are correct. People do go more often, and to counter it programs exist in the UK which drive people with less severe issues to local centers where they can get looked at without taxing the hospital system to the same extent. [1] It's not that big an issue. All that and they still deliver better health outcomes for a much lower price.

FWIW the NHS actually offers free mental health services with no co-pays too [2]. It looks like it's managed via GP which is a good middle ground IMO between co-pays and unlimited fee-free access. Canada does not as a rule, though it's an active conversation [3] and has been for years -- and it enjoys a (razor thin) majority of support with 51% in favor. Psychiatry is covered today, therapy is not.

> They told you that patients never go to the doctor for superfluous reasons? I won't believe it. I am in the industry and I can see every case imaginable.

No, they told me the US healthcare system is inhumane. I may have misread your post if I wasn't replying to the right section :)

> We have had this argument before. The U.S. socializing healthcare will not bring out-of-us healthcare results. It will get something else, because what makes healthcare suck is not private vs public, it's the regulatory framework.

The US is already at the bottom of the OECD, do you have reason to believe it'll get worse? We've got a lot of models that show it'll be better and really nothing to point to that shows it'll get worse. Socialized systems are cheaper and control costs better, even here.

[1] https://www.newdevonccg.nhs.uk/file/?rid=109734

[2] https://www.nhs.uk/using-the-nhs/nhs-services/mental-health-...

[3] https://globalnews.ca/news/5276022/canadians-mental-health-s...

Psychologist here.

The arguments you're making could really be applied to healthcare in general. Others have pointed out the comparisons to insulin, etc. I think you've basically made an argument for single-payer government healthcare.

However, it's really not true that the typical mental healthcare user is a chronic user. The modal number of visits per outpatient therapy client/patient is 1. Many people feel better after one visit, or decide they don't need it, or it's not worth it (some of it is probably related to availability too, to be fair--they'd like to come more but can't afford it or can't get into the therapist's schedule). You can extrapolate outward from that. Many people come for a few sessions, and then stop without any explanation because they're feeling better but don't want to have an awkward conversation about stopping.

The current zeitgeist with therapy is to taper off or terminate as soon as possible, and reinitiate as needed, at least in the US. My sense is the pendulum has swung too far in the shorter end of the spectrum, and a lot of people would benefit from more sessions, but even when they can afford it, are being cut off as soon as possible by therapists who are afraid of being seen as stringing people along. In some ways this is a good thing, but therapy length should really be dictated by need (short or long).

> The arguments you're making could really be applied to healthcare in general.

For many areas sure. Most importantly to primary care. I believe primary care should not be part of an insurance model. It's been brought to this for some good reasons and some bad reasons.

Single-payer cannot fix over-utilization. The iron triangle of healthcare: cost, quality, access. If access is unlimited, cost will go up. (Over-utilization a term commonly understood for the use of resources for very low marginal returns).

> The modal number of visits per outpatient therapy client/patient is 1

Even more sensical to make it cash pay! I would agree that cash pay in the current system probably leads to underutilization. Which is why a low(access x quality) x low(price) solution from the state would be great to help the bottom ranks and the rest can pay for it themselves.

> The current zeitgeist with therapy is to taper off or terminate as soon as possible, and reinitiate as needed, at least in the US

This brings another argument on utilization: if you look at it across cultures, it's going to be radically different. It's not something reasonable to insure against.

Long term, freeing therapy from insurance works in the favor of therapists: as a political body I would ask tax exemptions that match what insurance companies get and be on your own. (I would recommend the same strategy to primary care doctors, and they are already doing it with the DPC model).

Mental health is no different from any other health on this regard.

People can have mental health needs that can be improved or resolved in a finite time frame. They might have a difficult life event for example.

People can also have non-mental issues that are chronic and require lifelong attention—diabetes for example.

It's its own case because of the subjectivity of the diagnosis and the effectiveness and length of treatment. I'm sure that a bunch of other healthcare services have the same issue, like acupuncture or physical therapy.

Also, mental health is not particularly expensive to treat itself: why put the insurance company in the middle. Pay the provider directly..

I have a lot of criticism for the Scandinavian economic model, with 50% of the working population employed in the public sector and a >50% tax burden on average. This will be visible if someone happens to read my HN comments once in a while.

But I have to say that this purely market economic view of life-saving healthcare, concluding "there is no economically viable way to ensure that everyone has access to life-saving aid, because participation has to be voluntary and that means insurance will be prohibitably expensive" is deeply cruel. Honest question, is it broadly representative for Americans to take this view without considering the human consequences to someone who is unlucky with genetics, family or circumstances? Or is the question just ignored until a problem hits?

It's really very simple to solve this in a humane way. Government pays for all healthcare that's necessary to survive and thrive to a humanely minimum standard of care, either providing the services themselves or employing private-sector partners to do so. This is paid through taxation of everyone, spreading the cost on the entire population. Private insurance or paying for elective procedures is still an option for those who have the means and wish to do so.

There will be some upheaval because the insurance sector and treatment centers will be in a dramatically worse negotiation position, but it's worth it for the public good.

> Honest question, is it broadly representative for Americans

I don't think so, but what is unique about americans and the healthcare market is very unique sensitivity to quality and access: the idea that you could to a second rate doctor goes very contrary to american culture, but is common currency in socialized health systems, where you are numb to quality as everything has the same price. The US has a private offering called HMO which basically covers everything, and it's had mixed results: even Michael Moore made a documentary where people said "HMO's are evil". Why? Because the idea that you have to be put on a waiting list or might be denied care you want on utilization is unthinkable for americans.

That is one cultural aspect, but there are many more that make America Health system unique.

> Government pays for all healthcare that's necessary to survive and thrive to a humanely minimum standard of care...

It's a solution. Maybe because of the above, no democrat has put it forward: it would be unpopular to tell people they will get free sub-standard, sub-access care. This solution already exists: the VA is basically that. A very low quality service but highly effective.

I don't have much sympathy for H. insurance, but if the state wanted to abolish them, they should buy them, not outlaw them. This is so out of how America operates that I don't think it could go through the senate.

Personally, i think insurance is the last thing to look at in the space..

So what if they need it ? I will see a physiologist all my life as I need it, because of a premature autoimmune disease. The described system is broken.

Insurance on chronic disease is absolutely doable and it has to be done before diagnosis.

I wonder if the market offers a low cost health insurance from the moment a person is born dedicated to chronic diseases. I know life-insurance does ,and rather cheaply.

State run will be cheap and I'll tell you right now that cheap mental hospitals are not high value. They are prison lite™.

It probably makes sense financially though.

I don't want to pay any premiums to help out people with asthma, multiple sclerosis, diabetes, birth defects, and so on if we are going to do this though.

I would be fine with that setup. Its pretty ridicolous to me to keep all the crazy homeless people crapping on the streets of san francisco: very low standards of care will yield fantastic results for them, and not be extended to users that can pay better care somewhere else.

This duality is most common in countries with socialized healthcare: allows for the affluent to spend more, and for everyone to have a base level. (An UBI for healthcare!)