We Need to Design Health Care Reform That Puts Patients Before Profits | Hacker News Reader

We Need to Design Health Care Reform That Puts Patients Before Profits

rooseveltinstitute.org

85 pointshoward941199 comments

The U.S. spends $3.5 trillion annually on healthcare. Worldwide profits for the 112 publicly traded healthcare industry companies amount to $50 billion per quarter: https://www.thefiscaltimes.com/2018/11/12/Chart-Day-Big-Phar.... Even if all those profits are allocated to the U.S., that's about 5.7% of healthcare spending. (And completely consistent with most other industries.)

Hyper-focusing on profits is misguided. Many countries with costs much lower than ours have for-profit hospitals, pharmaceutical companies, etc. Public operation of the health system would surely eliminate the profit, but why do we have reason to believe it will reduce the other $3.3 billion? We can point to European countries that have much lower costs overall, but those countries seem to provide many public services at much lower cost than we do (education, transit, etc.). Canada's government expenditures (excluding defense for both countries), is somehow slightly lower than the U.S., even though Canada offers universal healthcare.

The public rhetoric frustrates me as someone who favors universal healthcare. Demonizing corporations and rich people is red meat for partisans, but it’s not a solution. How do we pay for this system? How do we cut costs? Making healthcare into a public service in the US risks turning into the same thing we have with education, transit, and infrastructure. We spend tons of money, often more than European countries, and get very little in return. And the only solutions folks offer are to dismantle the public system (on the right), or to demand even more funding (on the left).

In 2017 (from https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...):

 Hospital Care (33 percent share)

 Physician and Clinical Services (20 percent share)

 Retail Prescription Drugs (10 percent share)

 Other Health, Residential, and Personal Care Services (5 percent share)

 Nursing Care Facilities and Continuing Care Retirement Communities (5 percent share)

 Dental Services (4 percent share)

 Home Health Care (3 percent share)

 Other Professional Services (3 percent share)

 Other Non-durable Medical Products (2 percent share)

 Durable Medical Equipment (2 percent share)

Hmmm. What is profit? If a company pays its CEO 10 million dollars, it is not stated profit, but that's a cost we could live without. If a CEO can write off a few million, a few 10s of millions in corporate gala spending, it is not stated profit, but that's a cost we could live without. I am sure if we dig deeper into cost per patient between Medicare and between lets pick a company, you will realize that you can do without maybe 20% of this 3.5 trillion easily. And that is before we start looking at many other factors such as abuses in the system (looking from the other side and looking at freeloaders to say it very bluntly and quickly).

While I look at the CEO's multi-million salary, I also wonder how much tax they pay. Did the 10 million salary lead to 3-3.5 million in taxes or ... we probably can guess the answer. It is a double / triple whammy.

Message: Look at the total loot, not the stated profit.

First of all I don't trust profit numbers of any large corporation. There are so many ways that large corporations can hide profit.

So lets pay attention to revenue. UnitedHealth alone generated $200 billion in 2017. https://www.modernhealthcare.com/article/20180116/NEWS/18011...

Yeah there might be some fat there.

There is at most 20% of "fat" there, by law (ACA).

Assuming your distrust is true then the article's point of attacking profits is futile.

So there’s the profits, and there’s the costs of the profit system. Which is why you have to look in places like administrative costs which are something like 17% in private insurance. Profit is the money over revenue - costs, so yes the profit is a center of waste, but there’s a ton of waste in the costs department that would not be necessary in a universal system.

There’s also a lot of makework jobs wrapped in there too, so it’s no doubt a complicated problem.

By the numbers you just cited --- higher than the numbers I found, but only by single digits --- if you zeroed out administrative costs, eliminating not just insurance but any money paid anywhere to administer health benefits --- you would bring the cost of a low-deductible family health plan down by about $100/month. That is simply not enough, not nearly enough, to address the problem. Our national health care problem is not that plans cost $100 too much.

I mean I'm at 20% in 2 cost centers (ill give you back 3 single digits but not a digit more), and there's more math on how you actually save money in a single payer system than just those 2 things. I don't know where the average family low-deductible plan costs $500 (maybe with employer subsidies? again, not a fair comparison), but 20% is a lot more than the 5% the parent discussed.

I'm going to hold you to your own 17% number just to keep things simple.

In Chicago, for a family of four, the lowest-priced ACA bronze plan, Blue Cross with a restricted network ("FocusCare") and a $15,000 family deductible, after zeroing out 17% of expenses, you are paying $976/mo. I think health insurance is very valuable, but can say confidently that the average family in Chicago does not view $976/mo with a $15k deductible and a limited network as "affordable". The numbers get even harder if you select a more reasonable plan.

Doesn't your argument suggest that a functional national health care policy should focus on both controlling payer-side costs and provider-side costs? Like the Swiss system does—payer-side costs are capped as a fraction of household income, and provider-side costs are tightly managed so that the total economic burden remains reasonable.

To me it seems that both sides are presenting a false dichotomy where none need exist. We should bring our health care costs under control, and we ought to simplify Medicaid from a patchwork of state laws that are "mostly, kinda" universal to truly universal, like the Swiss system. I suspect that, in terms of raw dollars, Medicaid spending is already sufficient to fund basic health insurance for everyone who can't afford it; it's just distributed inefficiently and in need of reform. Replace the patchwork of state laws with a flat subsidy for those who can't afford basic insurance, and replace the punitive individual mandate with automatic enrollment.

I'm receptive to all reforms! Reforming health care administration is worth doing; even if it doesn't make health care "affordable", these are big numbers we're talking about, and percentage-point changes in administration costs still generate money we can use on other things.

Where we get into trouble is when we start contemplating radical reorganizations of the existing system without a clear goal or path to achieving that goal. So I could be receptive to single-payer if there was some clear idea of how it would get our costs in line with European systems. But no such clear idea is in evidence; rather, Democrats seem to believe that reorganization will somehow automatically solve that problem. More cynically --- and realistically --- I believe Democratic single-payer advocates think that once the government becomes the single payer, nobody is going to care about the costs anymore. I think there's an element of truth to that, but I'm not one of those people; I care that we're paying 2-3x what we should be paying.

> So I could be receptive to single-payer if there was some clear idea of how it would get our costs in line with European systems.

This here.

I think most Americans who say they're in support of M4A would be perfectly fine with the Swiss system, or really any health care system that is universal. The differences between single-payer and private subsidized insurance with automatic enrollment are fairly wonkish to ordinary folks. Most people just want to feel assured they'll have insurance when they go to the doctor and are less interested in the details of how that works. I suspect that polls of M4A are really measuring that instead of support for single payer per se.

(My personal feelings are along these lines; I think a Swiss-style private universal system is more likely to work than single-payer in the US, so I favor a private system, but I wouldn't describe myself as an opponent of M4A.)

The problem is not the raw number for how much profit is made; it's how much waste is generated in pursuit of that profit.

For example, the entire concept of "negotiated rates" as they apply to the US healthcare system is based around various entities trying to maximize profit, rather than maximize provision of care.[1][2][3] This results in patients being stuck with enormous bills, and services not being provided, or being provided at unreasonable costs.

And this is just one area where this is the case. Costs for prescription drugs (especially new/non-generic ones) are another great example. Because of the system's desire for profit, much of that $3.5 trillion is being spent to try to pump up that $50 billion -- and it's not even doing a particularly good job, as you note yourself, since other nations with for-profit systems have much lower costs.

I'm not saying that no for-profit system could exist that wouldn't be better. But whether that theoretical new system is for-profit or not-for-profit (or, as it most likely would be, a hybrid as we see in many developed countries), we'd have to rip out a substantial amount of the current system to get it.

[1] https://www.policygenius.com/health-insurance/what-is-a-nego...

[2] https://www.americanprogress.org/press/release/2019/06/26/47... (note: American Progress is a liberal-skewed source, but their stats should be good)

[3] https://www.bu.edu/questrom/2018/12/04/insurers-negotiated-r...

Negotiated cartel rates and lack of price insurance sure do seem like a plausible component of our health care debacle. But other countries have for-profit providers and private insurance and they don't have these problems. Why is that?

The prescription drug market is dysfunctional. But what did the last breakdown you look at say about the percentage of our health dollars swallowed by prescription drugs, compared to caregiver salaries, hospital procedures, and long-term care costs?

> Negotiated cartel rates and lack of price insurance sure do seem like a plausible component of our health care debacle. But other countries have for-profit providers and private insurance and they don't have these problems. Why is that?

I'm reading your question as slightly rhetorical. If that's the case, and you have some thoughts, you should share them.

For my part, I'd start by looking at the way other privatized systems are managed and regulated, such as Sweden's: https://www.theguardian.com/society/2012/dec/18/private-heal...

> But what did the last breakdown you look at say about the percentage of our health dollars swallowed by prescription drugs, compared to caregiver salaries, hospital procedures, and long-term care costs?

I'm not making the point that prescription drugs are the largest or even a particularly substantial contributor to the overall number. I'm arguing they're an easy-to-see example of the overall problems that most facets of the current system face.

(By the way, the breakdown another user higher in the chain posted puts prescription drugs at 10% of overall costs, so that's a big chunk.)

> The public rhetoric frustrates me as someone who favors universal healthcare. Demonizing corporations and rich people is red meat for partisans, but it’s not a solution. How do we pay for this system? How do we cut costs?

There are already two pieces of legislation, the Jayapal and Sanders bills, they account for their costs. Tim Faust’s new book likewise walks through all of these concerns in detail:

https://www.mhpbooks.com/books/health-justice-now/

And I don’t think people are “demonizing” corporations, so much as they are being more and more exposed to fundamental cruelty and parasitism of the American healthcare system. As costs spiral out of control and inequality compounds in the US, a far greater swathe of people are finding themselves on the receiving end of its violence and deprivation. I’d suggest you look at the work of disability activists like Ady Barkan to get a better picture.

The Sanders bill plans to pay for Medicare for All with taxes that are much lower than the social insurance taxes in France or Germany. That is pure fantasy. That gives me little comfort that its accurately accounting for costs.

> The Sanders bill plans to pay for Medicare for All with taxes that are much lower than the social insurance taxes in France or Germany.

The US has much weaker non-healthcare social insurance than France or Germany, and a much larger per-capita economic activity to tax, so lower social insurance taxes for equivalent healthcare seems to be expected rather than suspicious.

France’s healthcare tax is 20%. Sanders’ proposal is about 14.4%.

As to per capita economic activity—the assumption is that we’ll be as cost efficient as France in absolute dollar terms, not even just percentage of GDP terms? When we spend 30% more on primary education per student than France?

You're using "account for their costs" in a different sense than I think Rayiner meant. When Sanders "accounts for his costs", he means that they've added up the total projected costs of their plan and then accounted for it with tax revenue.

That's fine, but it doesn't address the fundamental problem of US health care costs, which is --- regardless of "who pays" --- "why does it cost so fucking much". If all we do is move our exorbitant costs off customer bills and invoices and into our tax code, we haven't actually solved anything; in fact, in some sense, we've provided cover to the inefficiencies and incompetencies in the system that are overcharging us.

Single payer or private system or something in between, I don't much care, but I'd like to see a proposal about US health care that is serious about reducing cost, not about accounting for existing costs differently.

As I mentioned to Raiyner, you should really read Tim Faust’s book to understand how single-payer can drive down costs, but I’ll highlight this from one of his articles:

“ As the sole purchaser, the federal government is immediately able to set just prices for health care services (for example, by negotiating the cost of drugs). With the weight of the full cost of health care falling squarely on its shoulders, it has an incentive to develop infrastructure and provide accessible primary care for all people, diverting money from low-frequency crisis care to high-frequency primary and preventive medicine.

It can also create evidence-driven guidelines for how to handle episodes of complex care and adjust payments based on adherence to these guidelines. This promotes good care for all patients and respects providers’ agency to provide the best care they can, instead of the current mess, where payment per-service can incentivize unscrupulous providers to bilk payers by either ratcheting up individual unnecessary services (when paid per-service) or providing less care (when paid per-patient).”

https://www.jacobinmag.com/2017/10/single-payer-medicare-for...

I'm very familiar with this argument, but it's unpersuasive, because we already have a national health insurance system for the (huge) most expensive cohort of Americans, and it has been unable to contain these costs, despite playing a powerful role in the structure of the system itself.

Why aren't private health insurance systems incentivized to create evidence-based care plans? Wouldn't they, if anything, be more incentivized to do that?

If you’re referring to Medicare, it does control costs through its fee schedule, but is limited in efficacy because it doesn’t cover everyone. Nevertheless, the Trump administration is currently trying to jack up how much it pays out to non-Medicare levels to prevent even this downward pressure. And of course it’s barred from negotiating drug prices for the same reasons.

As to why insurance companies don’t pursue evidence-based treatment plans, it’s cheaper and easier in the US to just deny care and profit from it. Why do something more difficult, requiring additional investment, when they can just deny more claims. ACA plans already deny 1 in 5 claims.

Wait, Medicare covers the most expensive cohort of patients in the country, which you'll easily see in any breakdown of health costs by age. It already has responsibility and authority for prices in the most important segment of the market. Why hasn't it controlled their costs?

I think your answer on evidence-based care is superficial and a little bit facile. For instance, a major component of evidence based care is in fact the denial of procedures with limited demonstrated efficacy; see, for instance, the story about cardiac stents for otherwise stable patients. If anything, both private insurance and Medicare are allowing too many of these kinds of procedures. Why?

Hasn’t done what? Apologies, you’ll have to elaborate. Medicare fee schedules do put downward pressure on costs, which is why they’re under attack, but lack sufficient power to push down prices because they are not universal and exclude drug costs. Japan has universal price controls (and cheaper healthcare) for precisely these reasons.

As to your second question, fee for service is too perverse of an incentive. What you end up with is an arms race where healthcare providers try to extract as much value as possible through as many procedures as possible and healthcare providers, in turn, try to make money by denying as much as possible (as well as pushing sick people into the government plans). The result is poor quality, expensive care, as the two factions devote more and more resources to waging this battle and less and less on creating good quality and affordable care.

What does universality have to do with it? They already cover virtually everyone in the most expensive segments of the market. They're not controlling costs for those patients; Medicare overpays, hugely, both compared to other countries and in historical terms (costs have skyrocketed over the last 20 years). I think the burden of proof is on you for this argument.

"Excluding drug costs" can't be the problem, because drugs --- no matter what their provenance --- are a small fraction of total health care costs.

Your response to my second question doesn't respond to my point. I was specific. You've responded with abstractions. Can you be more specific about what you meant by evidence-based care, and Medicare's unique ability to provide it?

What does being the sole payer for services give you, besides a monopoly on payments and all the leverage that comes with it? It should be self-evident, but the ability to negotiate far better prices from healthcare suppliers. Medicare for All’s (not Medicare’s) “unique ability” is this ability to say do these things or you won’t get paid or paid as much. It’s a big part of what single payer systems do around the world to drive down costs and what allows for consistent care to prevent the development of more expensive conditions.

Medicare doesn’t have this advantage because it is not “universal” in any regard and doesn’t have this leverage. The cost pressure from the ever escalating supplier-insurance war further down the chain bleeds into it, as thaumaturgy outlined. Not the very least in the form of lingering injuries and chronic illnesses in its beneficiaries that could’ve been better managed through a universal system before they came onboard.

Which is related to your point about drug costs - the inability of Medicare to collectively negotiate drug prices allows them to be as ridiculous as they are in the US, which of course leads to horrible outcomes for managing care. When people can’t afford medicine, ration it, etc, their conditions worsen and become more expensive to treat. Even if the medicines themselves are not a large, direct source of upward pressure on costs, their inaccessibility creates the circumstances (and need) for more expensive care. And this happens throughout the system as people self-ration various, necessary forms of care.

TLDR; Because Medicare isn’t universal coverage and it and it’s beneficiaries don’t exist in a vacuum.

Are we talking about the same Medicare? Because Medicare today absolutely does have the ability to say "do these things or you won't get paid".

Yes, and as I already mentioned, the existing leverage Medicare has in this regard already puts downward pressure on costs. But it’s insufficient relative to how costs are being driven up further down in the system and quite obviously an orders of magnitude smaller amount of leverage than a universal system and a monopoly on payments.

Medicare is the near-exclusive provider of medical services to the most lucrative and demanding segment of the market. You're going to need to explain, with specifics, why they've had such a limited ability to hold down costs. Adding a bunch of 30 year olds who see a doctor once every 3 years isn't going to do that automatically.

They can’t hold down costs because they’re just a competing payer in a large, dysfunctional system whose overall costs are determined by the sum total of this dysfunction and the general trajectory of healthcare outcomes it produces.

I’m sure you’re quite aware of this, as well as the difference between having a monopoly on payments, continuity of care, and “adding a bunch of 30 year olds” to the system, but feel free to waste more time with these obfuscations. A defense of the status quo isn’t really helped by them.

No. Medicare does not in fact meaningfully compete with private insurance in the markets it serves. It is a universal entitlement for US senior citizens.

Yes, I should’ve been more precise in saying they are one payer in a system of many payers vying for lower prices from healthcare suppliers.

But as I’ve stated multiple times and what you seem to be purposefully ignoring to defend your position, the overall costs of these services are determined not only by how they’re consumed by Medicare beneficiaries, but by overall functioning of the healthcare system and continuity of care throughout its beneficiaries’ lifetimes.

You can very clearly understand that the price of any given procedure is not determined by how it is consumed and paid for by one segment of the market, but by all of its consumption and the interactions around it. A given surgery or hospital stay is is not something consumed exclusively by Medicare beneficiaries so they are not the sole determinants of its price.

These are just general concepts. It’s on the same level as “the market will drive down prices because hospitals and insurers will compete.” What I’m talking about is actual data about what is entailed, for example in “bilk[ing] payers.”

Then see thaumaturgy’s comment above about how suppliers and insurances do this in the current system.

> That's fine, but it doesn't address the fundamental problem of US health care costs, which is --- regardless of "who pays" --- "why does it cost so fucking much".

A doctor named David Belk set out to find answers to this question. He presented what he found at http://truecostofhealthcare.org/. You can start with the introduction (http://truecostofhealthcare.org/introduction/) or skip straight to the conclusion (http://truecostofhealthcare.org/conclusion/), or explore his findings on a category-by-category basis.

Or, if you prefer, the LA Times ran an article a while back that examined the single case of a dislocated shoulder: https://www.latimes.com/business/story/2019-09-12/medical-eq...

A deep dive into the specifics is well outside the scope of a comment on an HN thread that's already gone off the front page, but the summary is that the US system has a large number of profit-motivated groups involved in every step of the health care system, and those costs balloon rapidly as a result, and health care recipients are the least powerful group politically so none of this is changing for the better.

Based on the findings like these and the plethora of other articles I've read on the subject, I'm extremely skeptical of a < 5.7% profit margin number for the health industry. Given that that figure seems to be coming from companies' self-reported profits, I'd bet there's some Hollywood accounting going on.

Either that, or all the US health care corporations are really impoverished, every article on the subject that has faulted obscene profits is wrong, and all other countries are somehow propping up a rather large section of their social services with tax rates only marginally higher than the US overall rate.

I don't have an opinion about profit margins in the US health care system and am receptive to arguments that profits in the system are themselves exorbitant (it's Rayiner who consistently argues for perspective about comparative profits; ironically, Rayiner supports a national health plan, and I oppose it).

My argument is orthogonal: it's that there is a payer side of the system and a provider side, and the national discussion about health care is focused almost entirely on the payer side, with the exception of prescription drugs, which are not the major driver of health costs. If the answer to this problem is "nationalize the profit-seekers", OK, I can hear that argument out --- but it has to be about doctors and hospitals and long-term care facilities, not about "greedy insurance companies".

Sure, and that's one of the reasons I like Belk's site: he tries to explore more facets of the overall US health care clusterfuck than most other researchers and journalists.

For the hospitals' portion of the mess, he finds that despite an overall decline in hospital stays [1], the amount that hospitals bill over what they actually collect has grown dramatically [2]. This in turn is caused by differences in incentives between Medicare/Medi-Cal and private insurance companies; private insurance companies are less motivated to drive down costs, and even have some incentives to pay hospitals more than Medicare/Medi-Cal would for the same services.

Hospitals likewise have had steadily growing profits overall (in the 5% to 8% range) over recent decades, although most US hospitals are non-profit business entities. (This doesn't mean they don't make money, of course.)

This really funky interplay between governmental health insurance, private health insurance, and hospitals is the main driver of the shocking, headline-grabbing bills people receive. They aren't the prices the hospital is expecting to actually collect, they're the prices that hospitals have invented in the hopes of collecting 30% of it from Medicare, and private insurance companies are playing along because it gives them a justification for raising their pricing for coverage. In a sense, a lot of what people are arguing about is phantom prices.

Unfortunately, uninsured and under-insured get caught up in all this absurdity and that ends up driving around 60% of bankruptcies [3]. And while there are often arguments that hospitals have to charge more because there are more people unable to pay their bills, the number of uncollected bills hasn't really changed for a long time [2].

Thus a lot of the discussion around this issue ends up coming back to "greedy insurance companies" because they really are a major contributor to the problem. Prescription drug pricing likewise affects a disproportionate number of fixed-income people (whether retired or disabled).

I'll try to keep yours and ~rayiner's different positions in mind in the future.

[1]: http://truecostofhealthcare.org/admissions_data/

[2]: http://truecostofhealthcare.org/hospital_financial_analysis/

[3]: http://www.cnn.com/2009/HEALTH/06/05/bankruptcy.medical.bill...

>although most US hospitals are non-profit business entities. (This doesn't mean they don't make money, of course.)

Where I used to live...

https://www.wpr.org/data-shows-la-crosses-gundersen-hospital...

I always cringed when I heard them asking for donations for capital improvements to build their new hospital wing.

"why does it cost so fucking much"

Isn't it because there are so many people's salaries and companies products/services involved with the "unnecessary" overhead? The last ten times I went to the doctors office/clinic there were 3 to 5 check-in receptionists all sitting behind nice new desks and computers with no one in line. How many people at the clinic are just trying to figure out insurance coverages and costs, and how many people at the insurance company review what's submitted, and how may people's job exists to "fight" the charges? Sadly, too many people rely on and depend upon expensive health care for putting food on their table. Until we come up with a plan (free training/education in other industries, sectors, and areas of need/demand?) people will cling to what they know and their JOBS. Look at accounting and tax reform. The complicated-ness of it is by design according to those that lobbied for and those that implemented it.

I don't want or need health insurance to cover routine health care/maintenance. My car insurance doesn't cover oil changes. I think we need to start with getting to affordable routine health CARE [checkups]. The fact that many family insurance plans cost $1000s a month in premiums and don't kick in until $10,000+ of deductible is spent first is ridiculous. People that have coverage still don't go to the doctor until they are very sick to avoid the high costs, this compounds things because the cost to deal with a minor respiratory issue is drastically less than when/if it turns into pneumonia.

Publicly traded is a tiny fraction of the healthcare industry. Of the dozen or so hospitals in Seattle, for example, only one is owned by a publicly traded company.

Even if they're technically non-profit, that doesn't mean they don't realize a profit. It just means that the profit needs to be spent elsewhere. This is model that most university medical centers use: make a shit ton of money in healthcare, and then use it on the school or pay fat paychecks to the board of directors.

I think when people talk about profits they aren't talking about GAAP profits, they're talking about rent seeking. There is a shit ton of that everywhere. For example, when I went to the ER for a kidney stone at a non-profit hospital, I ended up getting 8 bills. One was from the hospital. Then I got one from the lab that ran the CT Scanner, one from the Radiologist that analyzed the ct scan, one from the pharmacy that provided the drugs I was given, and four bills from the four ER doctors making their rounds through the ER, asking how I was feeling, and then checking a box on the chart. Each 5 minute visit was rounded up to the hour. That's all "profit" in the colloquial sense, but it wouldn't show up in the P&L of a publicly traded company even if the organization was publicly traded.

The problem with US health care is that it costs too much.

The elephant in the room in US health care costs is inefficiency on the provider side. Payer-side reforms have limited impact, because contrary to rhetoric from both sides of the debate, we could probably zero out administrative costs entirely and still deliver little more than a grocery store discount to American consumers.

However we structure payment, we're still going to have overprescription of outpatient procedures, a shortage of doctors who as a result make drastically more than their counterparts in Europe, bed vacancies in inefficiently provisioned hospitals, diagnostic procedures that vary wildly between providers just a few miles from each other, and a total lack of price transparency to enable consumers (and their doctors) to collaborate and make decisions about care.

There's not much evidence that our government-run health programs (Medicare in particular) is up to the task of solving these problems; Medicare has a central role in how the current health care system is organized, and some of these problems stem directly from decisions made by Medicare.

There’s always room for critique, but millions of Americans need something to change. How can we get coverage to the poorest people effectively?

I think it's easy to misread what I wrote as saying that the current system is OK, or there aren't giant, urgent problems that need to be addressed. There are huge problems. The concern I have is that payer-side reforms are a sideshow.

Sorry, I didn’t mean to suggest that you had taken this position. I just really want to move the conversation forward. So there are problems with Medicare, but you seem to know about this so I’m curious what you would suggest we do to provide coverage to millions of poor Americans currently going without. I’m no policy expert and I thought M4A is a great idea. Thanks!

I don't know. What I'm advocating is that any discussion of the US health care problem start with a breakdown of where the money is going in our system. There are competing breakdowns, but any of them would be better than the default presumption we seem to have that the problem with health care is "insurance companies and prescription drugs". No breakdown I've seen on any side of this debate shows that either of those things are the true driver of costs in our system.

I'm not defending either the current private health insurance system, which I think needs drastic reform, or the market for prescription drugs, which is dysfunctional in a bunch of ways. But I am unconvinced that the public intuition about the overall health care problem is well informed.

Ah I see. Thanks for sharing that. It’s all so vague to me. There’s so many different analyses and so many experts who will attest to competing facts.

My priorities are just:

1) Ensure universal coverage for all Americans.

2) Structure it so costs are at least as reasonable as those in other countries with similar systems.

So for me, universal coverage immediately is a hard requirement and of course it must be done as fiscally responsible as we can manage. But we can always refine the system to lower cost later. We can’t replace the lives lost due to inadequate coverage.

>How can we get coverage to the poorest people effectively?

Reform the entire economy so there aren't 10s of millions of people who can't afford health care insurance. The current medicaid solution for the poor is a joke like all governmental welfare programs for the poor, they exist so that the rich can benefit from this distribution of taxpayer dollars (like snap/food stamps, section 8 housing, etc..), meanwhile it gives the politicians enough examples of success to point at and pat each other on the back. Meanwhile for the poor who need these services, because to these services often function more like a lottery which you may or may not get the benefits, rather than acting as a program you can depend on.

The poorest people generally have public coverage, Medicaid.

well said imo. the fact that most jobs in health care are administrative (never see a single patient) is telling that the incentives aren't good: we aren't increasing physicians per capita, we're just ... adding admins, very similar to what's going on in US universities.

for example, we know most growth in medical "jobs" are administrative in nature, and thus not helping per-capita physician rate or anything like that: https://hbr.org/2013/09/the-downside-of-health-care-job-grow...

it adds up, e.g. https://www.nejm.org/doi/full/10.1056/NEJMsa022033 where it's 3x cost of canada.

however there's a huge parasitic class of administrative jobs that exist due to this, so it's gonna be painful to excise. that pain will increase every day it's not done, unfortunately.

Administration on both the provider and payer side of this system accounts for, depending on the estimates I've seen, 12-17% of total health care costs. You can't in reality zero those costs out (even Medicare's much-vaunted 2% administration cost would shoot up if it had to deal with every patient in the country), but even if you could, you wouldn't have made health care in the US affordable.

why estimate? i linked a study you must not have read that says:

> After exclusions, administration accounted for 31.0 percent of health care expenditures in the United States, as compared with 16.7 percent of health care expenditures in Canada.

or did you have a problem with that study or something?

Sure. For starters, that paper is using 1999 numbers, and there has been a sea change in health costs since then --- we pay almost 3 times as much in total health costs today as we did in 1999.

Intelligence Squared hosted a debate last week on M4A vs. private health insurance, and had two extremely motivated and well qualified debaters on the pro-M4A side, including Adam Gaffney, president of Physicians for a National Health System; their central argument was that Medicare has a lower administrative cost than private insurance, and their estimates were Medicare at 2%, private insurance in the teens. Not 30%.

thanks, that's helpful for recalibrating

> The elephant in the room in US health care costs is inefficiency on the provider side. Payer-side reforms have limited impact, because contrary to rhetoric from both sides of the debate, we could probably zero out administrative costs entirely and still deliver little more than a grocery store discount to American consumers.

Certain kinds of payer-side reforms (e.g. single payer) could allow the providers to be bullied by the payer until they're forced to get their acts together.

The only thing that couldn't really address is doctor shortages, but that can (slowly) be addressed by a change in medical education regulation. Right now it's basically controlled by the AMA (basically the doctor's union), which limits the supply of seats to keep graduate salaries up.

This is a very popular argument in favor of single-payer. But Medicare already has authority over the most expensive and intensive segment of the health care market and has not effectively "bullied" providers down. It's not my argument that a single payer system can't do this, but rather that it doesn't appear to matter whether you have single payer or not; either way, radical change will be required from providers, and those changes are not intrinsic to the payer system.

Those are two separate questions: whether the payer has enough power to bully the providers into reforming, and whether it actually chooses to use that power to do so. Medicare may have the power, but may not have the will to use it (for instance, IIRC, it's forbidden by law to use its market power to secure better drug prices). A payer reform like single-payer will get us a lot closer to solving provider cost problem, but it won't get us all the way there.

That's a dodge. How does it get us any closer to solver provider costs, when the evidence available suggests it has never done so before despite having enormous authority to do so in the existing system?

Remember that the argument isn't that single-payer is bad. It's that it's not actually relevant to the current problem. There may be a variety of reasons why single-payer is better than private; "will automatically solve provider-side costs" can't, from what I see, be one of them. If there's some reform that occurs after M4A that gets provider costs in line, let's just do that reform first.

It isn't a dodge, and I'm not claiming a single-payer system "will automatically solve provider-side costs" (which is an odd thing for you to put in quotes, since I said no such thing). What I am saying is that such a system opens up avenues to pressure providers that aren't available in other systems (or are more easy for providers to escape [1]), and that potential gets us closer to solving those problems. After that, it's a question of political will to use those powers.

[1] e.g. by refusing to accept Medicare patients or by charging non-Medicare patients more to compensate. The alternatives to the single-payer for providers (e.g. concierge medicine) are likely to be far more limited.

Sorry, I didn't mean to attribute those words to you, but I could have been clearer.

What I'm saying is that there's no evidence that an M4A system would have any more ability to push back on provider costs than new federal regulations that didn't switch to a single payer model wouldn't be able to do, and further, no evidence that any of the existing M4A plans really target costs at all.

As an American with 2 rare immune-mediated neurological diseases, that affect my peripheral nervous system, I can almost guarantee you that decent health care reform will not happen in the foreseeable future.

By the way, both of these diseases are in pharmaceutical remission, due to taking a blood product that has immunomodulatory properties. I will have to take it for life. My medical insurance literally pays hundreds of thousands of dollars per year, under contract, for it.

The Affordable Care Act is practically guaranteed to be either partially or completely overturned next year (Summer 2020), based on previous rare cases in modern history where the Solicitor General did not defend a case at the Supreme Court.

My whole life is literally riding on whatever the Supreme Court churns out next year, due to the complexity of my care. In the case of a partial or complete overturn, I will most likely have to leave the US. But, I am fortunate to be an EU citizen.

I have been making plans for leaving the US for a couple of years now. The matter is extremely complicated with my health care needs, and I literally cannot afford to make a mistake.

Frankly, I do not feel welcome anymore in my homeland (the United States) either.

Do be sure to check that any new country will pay for the same thing.

Single-payer/socialized healthcare can mean “Just Saying No” to expensive interventions.

Yes, and this is one of the main issues. Overall it is a logistical disaster. But, I have to say that engineering school helps you tackle logistical nightmares like this.

I know a medical provider who works for a small family medicine practice recently purchased by a large hospital group in our area. They're being told, "You guys need to be sending more people to our hospitals."

So for these organizations, patients who are sick and suffering are seen as a product.

A day of reckoning is coming for these organizations because the sick and suffering are getting fed up with being treated like a product.

Not holding my breath on that one. The current health care system is institutionalized and is going resist reform every step of the way.

I get the sense that "reckoning" in this case will be a little more "exciting" than reform.

Large hospitals systems have been forming regional monopolies for the last few decades. First they would buy other hospitals to increase negotiating leverage with insurers, then they started buying outpatient clinics to control patient flow. They can also increase the amount they charge at outpatient clinics once the larger hospital system buys them.

Hospital spend represents 30% of US healthcare spend, and physician spend represents 20%. Physician employment by hospitals is at an all-time high. Busting local healthcare monopolies would do a ton to lower healthcare costs

Unfortunately that is difficult. The hospital lobby spends about as much as the pharma lobby. But the hospital industry has much more "soft" political power. Hospitals are one of the biggest employers in almost every county. So for a politician to fight hospitals would mean fighting their largest employers.

Hopefully more people become aware of this behavior by hospitals. You dont read much about it in the media. I'd imagine this has is because no one is incentivized to call out this behavior by hospitals

Healthcare stocks comprise a not insignificant part of many Americans' 401k portfolios, the downstream economic effects of dismantling healthcare would extend way beyond the hospital/pharma industry.

That 401k isn't going to be very useful if you can't afford healthcare.

And even less useful if you're bankrupted by it.

Less than half of the population have stocks of any kind, so this is not an issue. For the ones that do, re-balance.

Hospitals & hospice are the ones who're gonna suck up all that sweet 401k money eventually anyway, in most cases. Inheritance is dead for the middle class—the elderly are, in the best case, sustained by their retirement accounts until they get sick in the last 5-10 years of their life and the healthcare industry siphons off all their money.

So yeah, go ahead and hit my retirement account for 20% in exchange for fixing healthcare—properly, like a real friggin' modern country I mean. Seems like a bargain.

Are you sure that we should be going after hospitals rather than the insurance companies? I've been told by a doctor friend of mine that the price of treatment in hospitals are often affected by how much insurers are willing to pay. They bill an insurance company X, the insurance company only a fraction of that and the hospitals just have to deal with it. So suppose they get more leverage and they increase how much they charge--is that an increase in how much insurance companies pay or how much patients pay? Or both? And how does this compare to the actual costs of treatments before and after such an acquisition?

Except, as I understand it, it's more like this:

Hospital bills Insurance Company $XXX,XXX.XX and Insurance Company says, "No, we'll only pay $XX,XXX.XX" so Hospital pays it. What's not mentioned is that it only cost Hospital $XXX.XX for the procedure so while they're complaining that the insurance companies only pay them a fraction of what they billed for the procedure, they're still making a massive margin.

That's not to suggest they don't have real, valid expenses. That's not even to suggest their expenses aren't high but, how would we know? They won't even tell us, the patients, how much any given procedure costs. It all seems like a wink-wink-nudge-nudge between them and the insurance companies to me while the rest of us get screwed.

That would imply hospitals are a very profitable business. However, only 18% of hospitals are for profit in the first place, and nearly a hundred hospitals (mostly rural) have closed in the last year. The operating margin of NFP hospitals in 2017 was 1.7%. The average operating margin of the S&P 500 was 10.7%. And id bet insurance companies are looking better than hospitals as well.

Plus hospitals cant just charge for procedures at cost. There are revenue sinks hospitals have no choice to deal with. If someone without insurance and no source of income gets hurt and has to go the ICU, it can cost upwards of 10k a day. Who pays the bill? The hospital. And they cant discharge such a patient until they're healthy.

The dynamics between hospitals and payers depend on market and negotiating leverage. A small hospital in a competitive market will struggle, while a large hospital system in an unsaturated market will do very well.

Are hospital failures due to payers, or due to competition from other hospitals? If a payer is getting squeezed by a big hospital system, it may in turn squeeze a smaller hospital or provider.

One of the biggest for profit hospital chains, HCA, generates 20-25% EBITDA margins. Many non profits are very powerful and make lots of money, they just spend more on salaries so their net income is lower. But yes many hospitals do struggle.

Insurance companies must spend 80% of their premium revenue on healthcare services. So their profits are in effect capped.

> "You guys need to be sending more people to our hospitals."

This is true even in a socialized system like the military or VA, where the folks in leadership positions are seen in their own system. And that saves money, in no small part by reducing the amount of testing, improving continuity of documentation, etc. That savings doesn't just pad some executive's bank account. It makes it easier to give the nurses a raise, or keep a few more on staff through a recession. Makes it easier to buy that new 3 Tesla MRI for better resolution imaging, etc.

Until Americans find Physicians (and Pharmacists) as the enemy, it will never happen.

They(AMA and APA) are top lobbyists that entrench themselves using monopolistic practices.

Sure school can cost 500k, but with 200 to 300k+ per year salaries, they can kill that debt. (This is their common defense)

So you mean ... the government that enables such licensing, monopolistic behavior, and moat building?

Bingo. But we will still see more regulation implemented to attempt to resolve this.

I don’t know any pharmacist making $200k, and their pay is getting crushed right now due to tons of supply since there is no limit on the number of new pharmacists. Anyone currently pursuing pharmacy is in a poor ROI situation, especially if they’re paying for school.

Their pay is in now way comparable to doctors, who have a structural advantage due to the limited number of new doctors each year.

I think you're stumbling on a root cause of America's healthcare crisis. I think most American's don't understand just how much physicians make--and where did you get those figures because clinicians I know make a good deal more than 200-300k

It's an uncomfortable subject because the vast majority of front-line medical professionals like doctors, specialists, surgeons, nurses etc. are doing that job with passion and honesty to help people.

But it's also true, and I think well-known at least in a vague sense, that one can make a pretty good living in the medical field.

For-profit insurance companies come in for the most hate since they are in the position to deny care. But their profit margins are not sky-high. Whether or not one believes that private health insurance is a terrible idea, the facts are pretty clear that there is a lot more to the high cost of U.S. healthcare than just private insurance.

There is a lot of cost everywhere in the medical system... that's the other side of those professionals making a good living.

I'm not going to pretend I have a good answer to this.

> It's an uncomfortable subject because the vast majority of front-line medical professionals like doctors, specialists, surgeons, nurses etc. are doing that job with passion and honesty to help people.

don't take this personally, but: this is an oft repeated meme that, in my experience, not really true, at least for MDs and nurses (to include doctors, specialists and surgeons). it certainly contributes to the sort of hero status of health care workers though.

physicians in the US earn a ton for a high-prestige, high social power, high earnings, generally safe career. in return they must sacrifice these earnings and social status for most of their 20s due to ridiculous quotas and standards in medical school, propped up by AMA; this makes the system higher prestige and sought after, a nice vicious (or virtuous for them) cycle.

the AMA also has them on the hook in a debt-slavery sort of way, because normal wages would never repay their ridiculous medical debt (see e.g. mid/low tier lawyers and law school outcomes when that got popular)

nursing, likewise, is seen as a j o b that offers some safety/consistency in return for investing time into education.

that these individuals """help people""" is generally of tertiary or lesser concern; much more "help" could be done by opening an affordable grocery store in a food desert. all but the most naive students either readily admit this or cop to it once asked.

Average salary of physicians from the bureau of labor statistics [1]:

Anesthesiologists $267,020 Surgeons 255,110 Obstetricians and gynecologists 238,320 Psychiatrists 220,380 Family and general practitioners 211,780 Physicians and surgeons, all other 203,880 Internists, general 196,490 Pediatricians, general 183,240

Doctors go through 4 extra years of school and then 5-7 years as a resident where they are paid an average of 60k and work ridiculous hours. During that period they're always on call, work twice as much as average workers in other industries, and don't get regular holidays. I have a surgical resident friend who regularly works over 100 hours a week, sometimes having as much as three 24 shifts in a week--and frequently he'll have <8 hour periods to go home and rest before returning to work. Plus, doctor's expenses can include medical malpractice insurance premiums if not provided by their place of work, which, depending on state and specialization, can range up to several hundred thousand dollars (!!!)[2].

I just don't see how doctors are overpaid considering the amount of training they have to go through, their work conditions, and the risks involved.

1. https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.h...

2. https://www.gallaghermalpractice.com/blog/post/how-much-does...

Make med school free in return for doctors working for the government, for a decent professional salary. This would also potentially change the mix of people who want to become doctors -- more middle class.

I don't believe that salaries tell the whole story of doctor income. Doctors are well positioned as insiders to make investments in the medical industry, ranging from ownership of clinics and diagnostic equipment, to owning entire provider networks.

An effect of the cost of doctor education is that it favors students from wealthy families, who are also positioned as investors.

Meanwhile, every interest group in the system will cry poor, and claim that someone else is gouging us, which is an almost certain sign that they're all gouging us. I've got a lot of doctors as friends, and I don't pity them.

With my skillset (software engineer) I can easily pull low six figures. And I'm confident that doctors provide more value than I do. I'm pretty sure I've never saved anyone's life. So I have zero problem paying doctors 2 or 3 times my pay, which is about what you're saying they get paid.

Health insurance CEOs make, in some cases, literally hundreds of times my salary, while literally killing people for profit.

I'm going to go out on a limb and say you've misidentified the problem.

Now, certainly bringing down the cost of medical education, and allowing people with less education (i.e. nurse practitioners) to do more, would both help lower the cost of healthcare. But if we're talking about who we should consider "the enemy", it's certainly not doctors.

The entire raison d'être of capitalism is that it's supposedly meritocratic. Are you really claiming that curing illness and sometimes saving people's lives isn't meritable?

not sure what kind of work you do, but if you make tools that save people time and you have many users, it could add up to many lifetimes not spent on some menial task. not quite the same, but I would argue that helping many people allocate their time towards activities they actually value is just as important as saving individual lives.

>I would argue that helping many people allocate their time towards activities they actually value is just as important as saving individual lives.

I think you'd pretty easily get trounced making that argument. People would much rather be alive to do something less efficiently than to... not be alive at all. This argument is a bit insane to me.

think about the people you care about. would you rather live more years or spend more time with them over a shorter life? what would they prefer? it's an inherently subjective question, and I don't think the answer is obvious. I certainly don't think one of the answers is "insane".

Why are you assuming that I would spend less time with e.g. my wife if she were less efficient in performing some menial task? It would take her longer _to complete_, but that doesn't mean she wouldn't still quit working at 5. Besides, most of the software we write is pretty inconsequential as far as most people are concerned.

> Why are you assuming that I would spend less time with e.g. my wife if she were less efficient in performing some menial task?

because "helping many people allocate their time towards activities they actually value" was an important premise I stated in the post you originally replied to? I deliberately excluded stuff that merely improves productivity at work (although not everyone is fortunate enough to have a job where they can just leave at five if the work isn't done).

Then you're going to have to give me some examples. All in all I think doctors and medical scientists are more important to the world than the vast majority of us (since we have to make it an either/or for the sake of argument), so get specific.

I for one am quite grateful to the engineers who implement electronic automatic billing. when I was a kid, it seemed like my dad spent a lot of time sorting through mail and writing/mailing individual checks for services. now it's automatically billed to the credit card, the credit card gets autopaid from checking, and he just has to make sure there's enough in his checking at the end of the month. that's not a huge amount of time and thought saved, but it's not nothing either. there's a lot of this stuff that we take advantage of in our lives without really noticing, I think.

Automatic billing...

Meanwhile, median life expectancy has skyrocketed, in large part due to new medical treatments and early detection methods. Unless your father was spending 20-30% of each day paying bills, I don't think that's going to do it. I remain unconvinced.

Let's also not forget the drain on interpersonal relations that software has brought about. If your father would have spent that time ok on FB instead I'm not sure we gained anything.

We live in a society where people work 40 hours a week, regardless. If people do a menial task more efficiently, the reward isn't going home and spending time with their family, it's more menial tasks. There is an exception: you might get to go home to your family if you get fired because your department is so much more efficient that you are no longer necessary. But given our society also demands that people do 40 hours a week of menial tasks to eat and live inside, it's hard to argue that's a good thing.

The only way increased productivity lets people spend more time for themselves is if it is on menial tasks outside of work, and most individual consumers won't pay for software, so then you're often into violating people's privacy to sell ads, which again is pretty hard to justify.

I'm a freelancer, so I've worked on a lot of stuff. I charge a reduced rate to nonprofits, which has gotten me some genuinely rewarding work, and my software has also had some small part in keeping innocent people out of jail. So I really have no regrets about my career, at least not from a "was what I did meritable?" standpoint. I don't feel like my comment is asking anybody to make me feel better about what I've done with my life. :)

But I'm still going to stand firm on my stance that a doctor, even if they only save a few lives in their career, is providing a more valuable service than I am. There's just no way the time I've saved people has added up to even a few lifetimes.

If we look at the software industry as a whole, it's just very obvious. We're an industry that likes to think we're saving the world, but the reality is that the results of software have been a very mixed bag. Facebook, for example, is pretty much just bad, and there isn't a major company out there that I wouldn't look at as being in some grey area, where it's hard to tell if they are a net positive or negative.

It's a bit much to say individual doctors are the enemy. (I have friends & family who are doctors!) But their organizations are. The AMA severely restricts the number of doctors trained each year. There are more qualified candidates for medical school than they accept-- which is also why there are so many extra hoops medical school candidates are jumping through in order to get in.

It's a classic licensing scheme to restrict competition. Doctors may not be the enemy, but they are financially benefitting from their monopolistic practices, and it is reducing quality of care for Americans.

I think engineers really underestimate the value of their work.

An engineer's impact on a single person might be low, but at scale, it can add up to a lot.

As noble as being a doctor is, their individual contributions can never scale beyond a few people.

While I am at it, can someone explain why being a doctor needs a person to go through 4 years of undergrad in field completely useless in their domain ?

> The entire raison d'être of capitalism is that it's supposedly meritocratic

Not it is not. It may be sold to us like that, but it is more like : "Those who succeed in Capitalism, do so only by the means of their merit....and the infinite privilege or luck that might have instead put them there. "

> An engineer's impact on a single person might be low, but at scale, it can add up to a lot.

> As noble as being a doctor is, their individual contributions can never scale beyond a few people.

Nonsense. If you only scale into saving hundreds of users a few minutes each, you're maybe approaching one lifetime, and that's assuming that your time saving actually improves those users' lives. The vast majority of engineers don't scale beyond that.

Meanwhile, some doctors absolutely make contributions that scale, such as finding cures or vaccines, preventing spread of infectious diseases, or discovering ways to detect diseases earlier. Looking at percentages of world population, the black death killed more people than any of the FAANG companies have users, and that's only one of the diseases cured by the discovery of penicillin. If antibiotics resulting from penicillin didn't exist, it's quite reasonable to guess that more people would die of bacterial infections than FAANG has users.

The smallpox vaccine? A test for detecting HIV? Quarantining the Ebola outbreaks? Each of these saved millions of lives.

And let's not forget that the highest-scale engineers are pretty hit or miss as far as whether the way their work touches lives is even positive. Big pharma isn't innocent, but I don't think anyone would argue we should get rid of them entirely. In contrast, it's pretty unambiguous that the world would be better off without Facebook, and each of the AANG companies has some pretty large negative effects on i.e. small businesses, worker rights, attention, privacy.

In short, you're just comparing the highest-scale engineers to the lowest-scale doctors, and assuming that what engineers are doing is as positive as what doctors do.

> Meanwhile, some doctors absolutely make contributions that scale, such as finding cures or vaccines, preventing spread of infectious diseases, or discovering ways to detect diseases earlier.

and many engineers have invented machines that have saved millions of lives. Let alone the fact that most of the things you mention were discovered either by academics or pure science researchers.

Doctors : Medical scientists :: Engineers : Physicists & mathematicians.

Doctors aren't doing the inventing. They are applied practitioners of their profession. The sycophancy around worshiping doctors is one I can never get my head around. Sure, it is a difficult job to learn and an essential part of any system, but just being the medical profession doesn't give a doctor any moral high ground in their choice.

Being in India, the biggest contributors to saving lives have been policy makers. Funding access to clean water, electricity and roads are far bigger life savers than someone who can do surgery. Google is probably saving more lives by letting doctors web search symptoms, than entire families of hospitals.

I have no delusions about my work. I do it because I like it. I would still do it if it was live saving, or completely irrelevant to society at large.

But, raising certain professions to an innate moral high ground makes no sense to me. Be it doctors, fire fighters, veterans or first responders. If a person needs continuous approval from society to do their job, then they should not be doing it in the first place.

That being said, I will always give every honest job a minimum level of respect and appreciate both hard work and tenacity. So, I am not advocating for being an ass to doctors. However, I respect those values, not some innate virtue of their profession.

I don't understand the axioms you're trying to draw on to derive just compensation for physicians. Why not just look at the worldwide market? Compare US physicians to those in other countries; we pay ours drastically more, and we are not generally more satisfied with the care we receive.

If we look at the worldwide market, health insurance CEOs salaries stand out even more starkly.

It's not clear to me what CEO salaries have to do with anything. Zero them out, and how much money has the American family saved? I haven't done the math, but I presume it's pennies, if that.

To do that math effectively, you'd have to look at which parts of a health insurance company's structure are essentially waste caused by health insurance being private, and zero all that, and I'd presume that's a large portion of premiums. The CEOs are just the most obvious example.

I don't have to do very complicated math to add up (or even wildly overestimate) compensation for CEOs, zero them, and see what that saves. I don't like that CEOs make that much money either, but why would I waste time on them? They're not the problem.

I'm saying that a doctor's contribution to society is a lot more than a health insurance CEO's and yet that is not reflected in their salary.

It wouldn't surprise me if doctor pay was a larger factor in healthcare costs. But doctor pay is an inherent cost of healthcare, and while we can certainly lower their pay, it's not entirely clear to me what a fair pay would be.

Health insurance CEOs, and indeed most of what a health insurance company does, are not only not inherent costs, but active blights on the healthcare system. A fair pay would be zero, with fines for literally killing people. So they're much higher priorities than doctors for the axe.

These are arguments about making people feel better about the system, but not about making the system meaningfully better.

Well, I think removing private health insurance from the equation is the first step. Doctor pay indeed might be too high, but what can we do about it? Health insurance companies are a bit part of what determines doctor pay.

Why is removing private health insurance the best next step? Medicare also overpays for care, both historically and compared to other countries.

>> With my skillset (software engineer) I can easily pull low six figures. And I'm confident that doctors provide more value than I do. I'm pretty sure I've never saved anyone's life. So I have zero problem paying doctors 2 or 3 times my pay, which is about what you're saying they get paid.

There are many problems comparing software pay to healthcare pay.

- A large portion of software jobs are in the Bay Area, you are not being paid for your software job, you are being paid a giant CoL premium that gets taken away by landowners.

Doctors on the other hand have jobs available all across the country and need not live in super-expensive areas. Further, their pay usually goes UP as they go to less expensive areas .

- Medical salaries/jobs are not cyclical and do not suddenly disappear in droves as tech jobs did in 2001-2003 (countrywide) / 2008-2009 (NY+).

With tech jobs, your low six figure pay is also paying you a hazard premium which i'm hoping youre saving for the next down cycle.

- Many software engineers will tell you about age discrimination -- supposedly it gets harder and harder to find a job as you age. It is an unlicensed field, so there is theoretically unlimited supply. Further, there isnt a cartel-like mechanism (i.e., AMA and residency programs) to constrict supply. Thus, you are like a less extreme football player -- you make low six figures and then you pleateau or go down over time.

Doctors make more with experience and there is no age discrimination that is spoken of.

Depending on how many workers get imported on any given year, there are 300-500% more tech workers imported (e.g., with H1b) than all medical school graduates per year: https://www.aamc.org/data-reports/students-residents/interac...

There are near zero imported medical specialists in the US. There are imported primary care workers, but those arent where the big billings are coming from. There is literally no downward pressure on medical salaries like there is in the US for tech.

Okay. So maybe the multiplier of my salary to get a doctor's salary is 5 or 6 instead of 2 or 3.

The multiplier of my salary to get a health insurance CEO's salary is also now, what, 200 or 300 instead of 100?

Actually, my point was the opposite -- I was noting that software engineers dont make enough compared to doctors and deserve more given the major SWE downsides:

- SWE: Much of the premium might be CoL premium

- SWE: There is a downward slope on earning potential

- SWE: No cartel and constantly expanding pool of workers

I'd argue that SWEs should make more given all these negative aspects.

Okay. It's not a really a point I care that much about, but I'd argue that this is a very SF/NYC-centric viewpoint.

- SWE: Much of the premium might be CoL premium

There are non-SF/NYC software jobs. Before I was a freelancer, I worked only one salary job in NYC. The rest of the time I worked and lived in much lower-CoL areas. And as a freelancer I work remote, getting paid NYC/SF money in a much cheaper place.

- SWE: There is a downward slope on earning potential

There may be a downward slope on earning potential, but that's in part because the SF/NYC markets bump you up pretty high pretty early, without much real justification. These places seem to fetishize the young hotshot "10x" programmer who is willing to work 70 hour weeks, but the reality is that that isn't sustainable, and the work done by kids isn't actually very high quality. That only works for a fail-fast startup model, but most companies outside the NYC/SF bubble aren't actually like that. There are plenty of old greybeard programmers working boring jobs at Dunder Mifflin-type companies in the Midwest, making wages increasing by 3% over inflation every year. Maybe they never peak as high as their SF/NYC counterparts, but they're still making more than a lot of other jobs in their areas. And the workloads of these jobs themselves are more sustainable.

- SWE: No cartel and constantly expanding pool of workers

There's also an expanding job market. Sure, there are cyclical downturns, but the overall trend is up.

One thing that trips a lot of people up is a failure to specialize. If your job is writing Django/Angular apps, that only gets so difficult, and there's not really a reason to pay for someone with more experience beyond a certain point. But Django/Angular apps aren't the peak of software engineering--there are much more complex systems out there which actually do need someone with more experience. I see a lot of people hit the point where they can't progress further with LAMP/.NET/whatever-common-stack and get stuck instead of going back to school or finding a job that will teach them cryptography or networking or FPGA programming or whatever.

There are way more doctors than CEOs. If you’re gonna claim that CEO pay is a more significant factor than doctor pay you should do the math on that.

I'm saying that a doctor's contribution to society is a lot more than a health insurance CEO's and yet that is not reflected in their salary.

It wouldn't surprise me if doctor pay was a larger factor in healthcare costs. But doctor salaries are an inherent cost of healthcare, and while we can certainly lower their salaries, it's not entirely clear to me what a fair salary would be.

Health insurance CEOs, and indeed most of what a health insurance company does, are not only not inherent costs, but active blights on the healthcare system. A fair salary would be zero, with fines for literally killing people. So they're much higher priorities than doctors for the axe.

You are welcome to figure out a way to allocate society’s resources in a way that results in everyone having access to healthcare without the use insurance companies and actuaries.

As far as I can tell, there does not exist a sufficient quantity of healthcare supply to meet the demand, hence the high prices. Without increasing the supply of healthcare, the conversation is moot.

Your logic will work if you put a price tag on a healthy and enjoyable life.

Which is basically impossible for somebody to do for themself, because that's most people's goal in how they use money. If somebody said, "The value of a healthy and enjoyable life for me or my loved one is $X," that'd mean they wouldn't spend their money if it cost over $X. Which is a ridiculous idea, and we've all seen it play out where people or their families shell out most of their wealth for the chance of living another month.

The only two ways I can see around this are:

1. Have an objective evaluator of life (maybe even accounting for differences in each person's value to society, if you really want to be accurate and don't mind the mobs with pitchforks).

2. Drop the idea of including health in the regular economy. Not totally possible, but public healthcare might be close enough.

Iirc, the AMA recently pulled out of the health insurance lobbying group who is a major influence against Medicare for All and all its variants. This due to a vote by its membership.

edit: https://www.commondreams.org/views/2019/08/18/ama-gets-out-w...

One of the key steps that needs to happen is to ditch Intellectual Monopoly laws. If you have a system that provides 100x+ the financial incentive to sell patented drugs, regardless of efficacy, then you will have many more people out hawking harmful drugs than the boring mainstream alternatives. See Purdue for a great case study on this.

Anyone who talks about "drug development cost is expensive" yadada has no clue what they are talking about. The only reason it's expensive is because people are on a fishing expedition for novelties that have at least some contrived way of demonstrating efficacy (you only need to hoodwink the public with your drug long enough for you and your reps(dealers?) to make short run monopoly profits). In the age of big pharma Americans have gotten less healthy. Time for Intellectual Monopoly laws to go.

> We can and must design the next round of insurance reforms with patients as a priority. With low deductibles that actually facilitate the consumption of care, our health care system can directly benefit the well-being of low- and middle-income people—not just the holders of for-profit hospital stock.

No, we need to get rid of private insurance with Medicare for All. The amount of money, corruption, and lobbying insurance companies engage in is staggering, especially given that their whole profit model is designed around limiting or denying access to healthcare. Denying access to treatment for the disabled, the chronically ill, and others, often unto their deaths or bankruptcy.

In a more civilized country, corporations that have behaved like US insurance companies have would have been done away with along time ago.

Other countries, yes even in Europe, have better healthcare than us with multi-payer systems. Medicare for All is a joke.

Other countries have better healthcare with single payer systems also.

Doesn't that strongly suggest that the structure of the payer side is not as outcome-determinative as advocates (for M4A, or for conservative reforms like across-state-lines insurance) make it out to be? What if payer structure really is a sideshow? What if we can make single payer work, or make private insurance work, but doing either job perfectly doesn't make care affordable in the US?

Medicare for all doesn't eliminate other payers, and is more similar to the European system than what we have now.

> Medicare for all doesn't eliminate other payers

The Sanders bill does eliminate most other payers (except for the VA).

Other candidates with plans (or vague descriptions of plans) borrowing the name sometimes do, and sometimes do not, and sometimes are not entirely clear (or consistent over time) as to which category they fall into.

There is no "European system." Many European countries don't have a single payer, or even a "public option." The Netherlands has something quite close to ACA, for example. Germany has non-profit, but numerous, insurance companies.

>No, we need to get rid of private insurance

Insurance works well for rare events. Using insurance for an annual physical (or any other routine thing) is just pissing money away.

Cutting insurance out of routine and preventative care will require far less political capital and should have a massive impact on costs. No need to go all the way to eliminating private insurance. A government option would have benefits but there's no reason private insurance can't exist also.

It’s possible that there could be some boutique secondary private insurance market, like what compliments the NHS in the UK, although I think given the vast, predatory behavior of US health insurance companies, it’s better that they’re just done away with. It’s not as if they haven’t show themselves to be bad actors, preying on the vulnerable as much as is legally possible, time and time again.

Costs and the barrier to care they impose are primary problem in the US. Mixed systems perform far worse at controlling them (look at the history of South Africa’s transition to a mixed system as an example).

Given how far things have gone with costs in the US, I don’t see how a “public option” would resolve them, short of the kind of literal government price setting as is done in Japan, in which case, a single payer system is more efficient anyway.

Seems like a reasonable ask. Gov't pays for preventative care like physicals, flu shots, and STI testing (sort of already happening on the last bit through Planned Parenthood), insurance takes care of traumatic events.

Seems to me though the greatest cost in healthcare, and thus causing the greatest amount of contention, are chronic ailments that can't really be classified as preventative or traumatic, and require constant doctor visits to treat.

Care for the elderly is a similar story since they make up most doctor visits and are the biggest consumers of medications overall.

What if we pay for affordable preventative care, and the government covers the cost of traumatic events?

What about chronic diseases that require frequent treatment?

Good question. Along those lines: care and treatment for developmental disorders.

What about them? The point of collaborative health care is that risks, benefits, and costs are spread out, to everyone's benefit.

There is no magic market finger threatening to push you into bankruptcy and/or an early grave just because cancer picked you instead of someone else, and your co-pays are higher than you can afford. Ditto for chronic congenital conditions. It's all the same.

Yes, you're probably contributing to someone else's care, especially when you're young and healthy.

So what? You won't be young forever, and you probably won't be healthy forever either. Meanwhile whatever care you need is provided to you at lower individual cost than a privatised system - with the added benefit that it also provides significant employment, supports medical research, and provides private-sector opportunities for specialised suppliers of technology, consulting, and other solutions.

The only people who appear to lose out are shareholders. They have to make their money elsewhere. In fact their opportunities are enhanced rather than diminished, because affordable low-risk public health care leaves more money on the table for investment and new business development.

It seems you've interpreted my comment as being against public healthcare, when in fact I am rabidly for public healthcare.

I was pointing out that a part-private, part-public solution still doesn't really handle medical care well. We need a fully-public healthcare system.

In a larger sense, insurance only makes sense to cover events that are both expensive and rare.

1. If an event is not expensive, you can just pay for it yourself.

2. If an event is not rare, then pooling resources doesn't increase your ability to pay for it.

Annual physicals are neither expensive nor rare. But the larger problem is, illness isn't rare. People get sick, and we need to stop pretending that this is some unusual thing.

I really don't see myself staying in the US if we haven't switched to single-payer healthcare by the end of the next presidency. I probably want kids, and I'm simply not going to bring them up in a country where the government and increasingly, the culture itself, cares more about corporate profits than people. We work really hard in this country just to achieve the same standard of living that people in countries with fewer resources have. Healthcare is, in my opinion, the most egregious example of that. It's stupid, and I don't want to inflict it on my kids.

Umm.. a good part of Medicare is run by private insurers. Medicare Part C and D.

Are you saying get rid of those too?

Yes. Medicare for All is different from Medicare and gets rid of the hollowing out of traditional Medicare services through these side channel attacks on it.

https://www.congress.gov/bill/116th-congress/house-bill/1384

Part D leverages the competitive nature of private, for profit markets.

As a result, costs for Part D have been much lower than projected.its a very successful program.

And why do you think that is?

Part C and D have privatized options because it offers gap coverage from Part A and B, so yes, privatized Part C and D would disappear if the gaps are closed.

Coverage gaps? Medicare Part C is just another option to get coverage. So you'd take that option away?

And Medicare Part D is prescription drug coverage. You'd take that away?

At the point where you're saying we simply "close the gaps" in existing Medicare, you're really not talking about Medicare anymore; you're just using it as a synonym for a hypothetical US NHS. That's fine, but you should be up front about it if you do; you're not just expanding Medicare to new customers, but building a fundamentally new system and giving it the old Medicare name.

"Medicare for all" is redefining medicare. You can argue semantics that it's not the same as before but that is the point of the term, that it's a new and improved iteration.

We do need Health Care reform, but I'm not convinced single payer government is going to lead to better outcomes.

> No, we need to get rid of private insurance with Medicare for All.

That would shift the incentivization from maximizing profits, to instead solely minimizing tax payer dollars.

Lobbying would still exist (see defense industry).

Denying care wouldn't be based on health reasons (dubious), but shift to class based reasons (see welfare).

And, our healthcare will instead be subject to the whims of the politics, rather than the profits for Shareholders.

Medicare works because it's beneficiaries are a strong voting block. There are population segments in America who aren't.

>And, our healthcare will instead be subject to the whims of the politics, rather than the profits for Shareholders. Medicare works because it's beneficiaries are a strong voting block. There are population segments in America who aren't.

The point of Medicare for All is also to instantiate this new voting block across as much of the population as possible, to imbue them with this political power and free them from control by their employers and the profit-seeking of healthcare companies.

You have the causation backwards: government provided healthcare among the elderly is what has created their defense of the system. Medicare for All extends the possibility of this defense to everyone.

Medicare works because it is subsidized by private insurance payers. The system in its current form would collapse instantly if every American became covered exclusively by Medicare.

Also subsidized by current tax payers.

I disagree with this. While it may be sometimes true, it is certainly a good thing that there are checks and balances to treatment. Otherwise providers of care are able to get a blank check. That is part of the problem now- say a physical therapist prescribes 5 sessions a week @ $300 per session but in reality the patient only needs 2 sessions a week. Insurance companies provide a checks/balance system with the ability for care providers to fight back when insurance companies deny care.

We have this already to an extent with managed care. The old system of fee for service incentivizes healthcare providers to treat the symptom and not the root cause. As of 2016 over 80% of Medicaid and Medicare patients patients are on a form of managed care plan instead of a fee for service. And Medicaid and Medicare are responsible for about 40% of Americans. Additionally there are systems like Kaiser that have similar incentives in the private market.

There are still plenty of abuses in managed care plans that I've seen (I'm closely related to several healthcare professionals working in home healthcare and in/outpatient service providers).

For example, often times, healthcare professionals are encouraged/pressured to report improvements during the managed care plan at ambiguous levels (lie) to continue regimes to the allowable extent before they're discharged. Those patients are frequently then readmitted for the same or other health problems after new hospital visits. Healthcare providers are often pressured to not report their judgement tells them a specific treatment program won't help a patient much in their professional opinion.

Ultimately, the incentive for continued treatment to maximize profit is still there, the approaches just change/adapt to fit within new rule systems.

It's really down to individual healthcare professionals to resist continual unethical business pressures concerned with profit over patient outcome which can put their employment/livelihood at risk if they don't have their own practice. This happens in large and small healthcare providers from my sample pool of 3 huge national providers, 3 local/regional hospitals, and several in home healthcare from varied business size.

The only leverage healthcare professionals have is that they're in such high demand and under supplied that they can often resist these pressures. If that changes, their hours are often reduced or they're replaced by people with more ethical flexibility.

So we (our society) still don't care about patient outcomes. We can pretend we do and often the healthcare professional working directly with you probably does care about your outcomes (most people aren't sociopaths) but they may have to frequently weight milking you and your insurance provider against their livelihoods which shouldn't be the case (healthcare will always have continual demand, pretty much guaranteed business).

Most of the managed healthcare plans base the patient outcomes on a number of factors, and the doctors report is either not a factor at all or a small factor. If the patients are being readmitted multiple times that will outweigh what is misreported.

But more generally I agree that there will always be financial pressure weighing against ethical issues or patient outcomes. But a managed care plan is strictly better than fee for service in aligning patient outcomes and incentives for healthcare providers. And there is market pressure going the other way, patients can switch healthcare plans or switch providers if they have a better alternative with better outcomes.

Contrarian viewpoint: NOT focusing on the profits is the cause of the problem.

Hypothesis: Prices are high because of inefficiencies in the markets caused by bad laws attempting to subsidize one class of people by another. Hospitals aren't able to refuse treatment by law to those that can't afford to pay for their services and insurance companies are coerced to insure unprofitable people by law and the net effect is to try and coerce people into a redistribution of money from people that require more care from those that require less care to cover these expenditures.

Because there is no mechanism to coerce people to do this willingly that's efficient enough for the increasing demands of those requiring care, both industries to give the invoices to the government (who created the problem) thereby getting rid of the requirement to think about how they will fund their expenditures - making it the governments problem to figure out.

This thereby allows them to continue uncontrolled expenditure resulting in exuberant prices in an ever increasing downward spiral to catastrophe as in effect they are spending 'other peoples money' in the hopes that "eventually these invoices will be paid" through some sort of government sponsored coercion mechanism forcing socialized heath care or some other such method with the same result.

Its really quite simple and clever and funny how it still works.

-5% of the population accounts for more than half of all health spending.

-50% of the population with the lowest spending accounts for only 3% of all total health spending.

Edit: Anytime I share this viewpoint, a bunch of either misguided or prejudiced people downvote me. I'm guessing its because they don't understand the argument completely, or see its logic, but disagree with its implications.

I don’t understand the American obsession with designing new systems yourselves when there’s already plenty of alternatives out there that have been tried and true for generations. Health care that’s affordable, offers longer life expectancy, costs less as a percentage of GDP and available to even the poorest citizens have already been implemented in countries across the globe, in Europe and East Asia in particular but also in Canada and Australia.

Why is it that if a US politician says ”our system is bad, the system from France/Germany/UK/Sweden/Japan is beating us in almost every metric, let’s switch” is met with boos but someone who says ”I have an completely untested idea that’s our old system with some quirks that looks like it was designed by a committee without a vision, let’s try it” is met with cheers?

I have a non-profit healthcare plan and go to a non-profit hospital. It costs the same.

This completely misses the issue.

Honestly, I'm not gonna read this thing. This is just the usual weekly "health care is fucked" HN post. They always say the same thing, they always show the same data, rarely suggest any real path forward (one that works in the context of lobbies, corruption, for-profit institutions, etc). In my book (and I'm not an expert even though I've worked in the benefits industry), 2 things are completely fucked up in this domain: 1) insurance being tied to your employer, 2) not being able to know the cost of a procedure before hand. Fix that, and you're done.

More than that, we need to design a system that puts general health/wellness before health care. That is, we need to live a more healthy and have a prevention mindset.

If we prevent the preventable those resources can be used for the unpreventable. But if overall demand drops, so will price/cost.

Like Japan, reward doctors when they _cure_ patients.

I don't like this because they may unknowingly introduce a biased form of triage.

Don’t let the providing doctor triage.

They should be providing care anyways.

Nurses triage.

It maybe is obvious, or maybe it's controversial, but patients will never be put before profits by for profit corporations.

Agreed, which is why for profit companies should be kept as far away from healthcare as possible.

How does this distinguish healthcare from anything else?

Are you taking into account that health care is being delivered in most western European countries by for-profit doctors, clinics and hospitals? (the UK being the big exception)

Also the U.K. is not one of the better systems out there. I'd rather have the French system (minimal public + private mix), Sweden (minimal federal mandated controlled by their provinces), or German (similar to Obama-care).

I don't hear any U.S. politicians who are really talking about reforming health care. How about tort reform? Patents? Cost transparency? No, all anyone talks about is how the federal government should get more involved, and everyone knows that lobbyist run the federal government, i.e. remember how the people representatives in congress didn't even have time to read the ACA?

Is it obvious? I went to a fancy Japanese dinner last night. It was, obviously, a for-profit venture. At any point during that dinner, was anyone in the restaurant worried about the restaurant putting its "profits" above its patrons?

They weren't worried about it, but it was happening anyway.

I doubt the restaurant was a monopoly with literal powers of life, death, and bankruptcy over its patrons.

Why do other life-or-death markets --- the markets for food, say, or for housing and clothing --- manage to function effectively as markets? Why do we give section 8 vouchers to people to afford private housing instead of continuing to build housing projects, and SNAP benefits instead of government cheese? If anything, those other markets are more critical to life and death than health care, which is needed situationally.

Because message boards are a fertile breeding ground for fundamental attribution fallacies, I'll lay my cards on the table here and point out that I'm an activist Democrat and health care is, after public schools (which I am not in favor of privatizing), one of my most important motivating policy concerns. My problem isn't that I think conservatives are right about health insurance; it's that the countervailing arguments don't cohere.

Your argument is that a nonprofit Japanese restaurant could have delivered a better experience to me?

I'd wager a nonprofit Japanese restaurant could have provided your meal at a lower cost.

How? Why doesn't anyone open a nonprofit restaurant and outcompete the for-profit ones?

Clearly, because profit-seeking infiltrators would sneak in and corrupt the whole affair.

Would it have been the same meal, cooked by people with the same level of talent, served with the same care? "Profit" is not just a disposable line item.

No, my argument is that "putting profits before customers" is a nonsensical thing to worry about.

This is pretty much the same argument that you make sidethread.

Greedy insurers don’t pay your restaurant bill and thus do not control the quality of service (by squeezing restaurant owners for every penny they can save)

You know, my wife holds the contract for occupational therapy services for the school district we're in, which is fairly remote. When she picks me up from work, the drive home is mainly her venting about how no one in the district seems to care about the kids. She routinely underbills and works crazy hours (I know she underbills because she documents her hours on the timesheet I designed for her). As an example, a couple days ago, I got the following text:

"We're going to Thai for dinner with the social worker so I can meet this girl's mom and schedule a home visit. She doesn't have a phone so we're meeting her at her work. They live in a container."

The previous contract awardee was a shell company that charged the district the same per-hour rate for services, but so vastly underpaid their therapist (by a factor of ~7) that she quit and my wife refused to work for them. So no children got services the remainder of that year, until the district worked out my wife's award.

Now, my wife's business is set up as an S-corp, so I guess she's a terrible person?

You don’t need to design anything because that already exists in Europe. It’s called public health care.

The situation is slightly more complex than this article recognizes.

1. When a hospital, either for-profit or not-for-profit, must provide free care to a patient, it comes out of their hide. Enough of this free care can force the hospital to demand higher rates. See https://hmsa.com/portal/provider/zav_pel.fh.DIA.650.htm Medicare and Medicaid foots part of the free care bill. And, yes, patients who turn up at emergency departments get some free care. It makes the news when a hospital kicks patients to the curb because they can't pay.

2. Enough free care can bankrupt a hospital or force it to close. In under-served areas (rural) this is, umm, not good for the community served by the hospital.

3. Corporations -- hey fellow HN readers, our employers -- must offer private health insurance. This is a HUGE pain in the neck for executives (some HN readers, that's you and me). They have to scare up health plans their companies and employees can afford, so they must waste their time doing that instead of, I dunno, designing products or calling on prospective customers. Sure, we get entrepreneurs trying to help with this. Zenefits. Need I say more? It's time-wasting madness.

4. Corporations must pay insane amounts of money for health plans for their people. And it's compound insanity. That's like compound interest, but worse.

5. Employees (that's you and me, HN readers) have to waste our time and spend our money on our part of health insurance costs.

6. "Medicare for all" invokes a health-care payment system that's proven to work at scale, and is reasonably accountable to all its stakeholders. (Except for part D / drugs / the subject of another rant for another day.)

My point: in the long run, being business-centric is the SAME THING as being patient-centric. In this area, Mitt Romney was right: "corporations are people."

I am baffled by politicians' complaints that some kind of government option for paying for health care is bad because it will raise taxes. Don't they know what we know? Paying for health care is already a massive tax on both employers and employees.

It's just hidden by a shell game. It's not actually a tax, it's a tax deduction. If you believe this, maybe I can rent you a some space in the huge dirigible hangar at Moffett Field. Cheap. Send me your bitcoin.

Can you imagine how much more successful a YC company might be if they didn't have to sweat this health-insurance stuff? Can you imagine how much more successful GM and Tesla would be if they knew their workers' health care was covered?

How come captains of industry and bigshot VCs aren't demanding better?

Yeah, some companies will suffer when this changes. But almost all companies suffer now.

the profit motive is what has driven healthcare to what is possible today. if there is an uncoupling of health outcomes and profit motive, the solution is not to delete the profit motive! the government needs to enact only the necessary and sufficient regulation to realign making money with the desired results. avoid regulatory capture, make the information transparent and available.

i dont understand this demonization of capitalism. the world involved in (and adjacent to) capitalism is, by almost _every.single.measure_, vastly better than even as recently as 50 years ago. communist china sure didnt do that.

its capable of corruption! lets fix that corruption and not throw the baby out with the bathwater

public schools and subsidized, inflated, university tuition are examples of roads we dont want to travel down.

This can be done by converting "for profit" corporations into "not for profit" corporations and having them finance investments with debt instead of equity.

And what about the rights of the stakeholders of those for-profit corporations?

What about the right of patients not to be bankrupted by a service they have been paying into for their entire working lives?

Stakeholders don't get a magic pass on this. The polite view is that they're profiting from suffering. The less polite view is that the entire industry is a toxic, possibly even criminal, cartel, and needs to be split up and defanged in the same way that other toxic industries - tobacco, opioids - have been defanged.

If those stakeholders are sponsoring the cash grab mentality that has the health industry so messed up right now, then screw em.

Sell off every private company involved and legally mandate that they can only sell to non-profit entities, and let every shareholder that's gouging everyone else scream or cry or whine however they want. The more noise they make, the more harm you know they were causing.

Sick and tired of greed making all these layers of corporate corruption, market lockup, government process tailoring, and outright deception the status quo.

We could do a debt for equity swap. Set up a Government Sponsored Entity like Fannie Mae to issue bonds equivalent to the market value of the equity. Essentially a government sponsored leveraged buyout.

I'm really not sure why this isn't mentioned:

USA should commission a study of health care systems in other countries. Include costs, challenges, issues of bringing it to scale in US, etc.

Then we can implement something based on real world experience and data.

It seems that these highly complex topics are dealt at the ideological level only. Which is absurd, as details can make anything from any ideology horrible. It makes me think of times when other common sense issues that should be data driven were treated in such a way. In the end, the curvature of the world is really independent of any ideological constructs that were created, but the ideological constructs made discussing the data virtually impossible at the time.

There is plenty of data on this available. It isn't perfect but it's there. The problem isn't lack of data, its lack of awareness of the data. Most people learn about the healthcare system by reading newspapers and other media, and from what I've seen coverage of healthcare in most US media is very political and seldom data-driven

Check out here to start, there are plenty of other resources: https://data.oecd.org/healthres/health-spending.htm

Raw data there is.

I'm talking about a report that says:

After analyzing the health care systems of X, Y and Z countries, a commission suggest A, B and C changes to the US healthcare system. A major commission organized and created by an organization that has proven capable of developing long term, large scale plans for the greater good of the country (think the army corp of engineers, but it doesn't have to be them, just something that is as objective as possible)

I'm also a bit surprised that the ideological bend is so strong, even on 'hacker' news, that net-net I'm getting down-voted on a what I think is essentially a call to look at data and create cohesive reporting to guide public policy.

Maybe there is such a study. I'd be glad to know about it.

That's fair, there are think tanks that do this sort of work, but I think it is a hard problem.

Yes even on HN I find that most people are pretty dogmatic about healthcare. People tend to react rationally to the data when presented, but are also happy to make aggressive statements that are unsupported by data

I don't have much experience with Think Tanks, but I've found the ones I've looked at to be highly partial to those funding them.

This country is very capable of smart, logical thinking. We've basically eradicated the issues of flooding. If we apply that type of thinking/organization, the issue could be tackled. But both sides, left and right, would have to want truth over vindication. We need to demand commissions to investigate, instead of trying to validate pre-conceived ideological notions.

If people reading the article asked for it, politicians would take note and would likely commission a good study. That's the beauty of our system (despite it's glaring flaws)

>It seems that these highly complex topics are dealt at the ideological level only. Which is absurd

If you take the view that the goal is winning instead of solving the problem it ceases to be quite as absurd.

Except it isn't only about winning.

Otherwise, we'd have no objective advancements in medicine.

Saying it's ONLY about winning is just as absurd as thinking it's only about solving the problem. It's about solving problems within the system. That includes winning and a lot of other elements.

I didn't say that was the only goal.

The politicians, the newspaper editors, the online trolls, etc. are all people too and probably want to see everyone get good healthcare at good prices but they're so busy advancing their vision of how that should happen that we can't actually have productive discourse because nobody can change their opinion on any detail.

> The politicians, the newspaper editors, the online trolls, etc. are all people too and probably want to see everyone get good healthcare at good prices

So then it's a good idea to remind people of the absurd, as in the post you answered. Dismissing the absurd as merely being a consequence of not 'thinking about winning' is an oversimplification.

To me such a dismissive, one liner post is designed for ego-gratification, rather than real in depth discussion. No offense, we all do it. Just saying my perspective.

Maybe I'm missing the in depth part though.

The poster you are replying to is a troll, likely. I'd disengage with the poster and not continue the conversation, as they do not tend to comment 'in good faith'. Their HN profile bio as of 8pm GMT states:

"When you read a HN article about some despot in a foreign land having the intellectuals lined up and shot it seems irrational. When you read the comments and you realize the despot might be on to something."

'Ironic' calls to do violence to others for their beliefs and words do not let one assume that the person calling for such pseudo-violence is trying to anything other than get a rise out of people. I'd suggest cat videos instead of wasting time with them.

I understand you're going to use the least charitable reading because you disagree with me but it was supposed to be a comment about the quality of discourse in internet comments.

Have you thought of the irony between the quote, your explanation and the comments you post?

I looked at the last 5-10 comments in your history. Two comments were for articles you clearly didn't read. Others are quick sound bytes thrown at people digging at the truth. It's like your trying to be cool.

I think HN is loved because here there is a higher percentage of people making long, well thought out comments AFTER reading the article. And the comments are generally aimed at furthering understanding, not people's individual ego. Doesn't always happen, but I find it happens here more than anywhere else I've found.

I invite you to contribute in the same line, that's what makes this place special for me.

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