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Comment by Pfhreak | Hacker News Reader

This is a prime example of a feel good story that is papering over systemic problems. We're meant to read this and think this doctor is a good person (and they are, at least for this act) rather than, "how is it possible there was this much medical debt for cancer treatment to forgive?"

Yes, debt forgiveness is great and something we can all do as mutual aid, but we also need to acknowledge that the deeply flawed idea that healthcare should be a "marketplace" rather than just a baseline good for everyone is the real story here.

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Exactly.

I feel the same way about GoFundMe campaigns for medical bills. On one hand, I'm happy that some of them can get outside help, on the other hand why is a GoFundMe campaign necessary to stay afloat?

What’s so ironic about GoFundMe is that it’s basically a diorama of how socialized medical care would work (minus the cost savings), and yet nobody has any political objections to socialized funding when it happens there.

I recall debating with a friend who was against socialized healthcare recently, and then seeing them promote a GoFundMe campaign for a mutual friend’s medical bills on Facebook a few days later.

The irony was lost on him. I think the key is that Americans love to dream of themselves as wealthy philanthropists (no matter how poor they actually are).

If there was a way to make paying taxes feel more like philanthropy, maybe we could solve this. Maybe it’s as simple as giving everybody a certificate with a list of anonymized names and what treatments they helped pay for, so they can brag about it on Facebook.

“I helped pay for a child’s chemotherapy” instead of “the government took my money”

Taxes in the US are labeled (accurately, but perceived negatively) around what you have — income tax, property tax, sales tax. For the most part, they aren't labeled for what they _do_ (other than Social Security and Medicare taxes, programs to which cuts are political poison).

If federal taxes were broken down to, say, defense taxes, infrastructure taxes, health taxes, administrative taxes, and people saw how much of what they pay goes into each fund, it would be much closer to what you describe.

For instance, people would be more aware that twice as much of the tax-derived budget goes into defense and international security than to safety net programs.

And people might also be more wary of actions that grow the federal debt — both spending and high-income-earning tax cuts — if they saw that more of their tax money goes to paying off its interest than toward funding infrastructure, education, and science and medical research combined.

Instead, that information is buried in federal reports and reported with the perception of being policy wonkery. It doesn't have a personal impact. Seeing what you remit to the government broken down by what it's spent on would drive it home much as having Social Security and Medicare as line-items on paystubs does.

> For instance, people would be more aware that twice as much of the tax-derived budget goes into defense and international security than to safety net programs.

do you not consider medicare, medicaid, and social security to be safety net programs?

> I recall debating with a friend who was against socialized healthcare recently, and then seeing them promote a GoFundMe campaign for a mutual friend’s medical bills on Facebook a few days later.

> The irony was lost on him. I think the key is that Americans love to dream of themselves as wealthy philanthropists (no matter how poor they actually are).

I'm not sure I see the irony either. if I'm understanding correctly, your friends pooled their own money together to help someone they knew and cared about. how is this similar to socialized healthcare at scale?

Because at scale, countries are also just a group of people pooling resources to achieve greater outcomes.

The only difference between micro-socialized funding (GoFundMe) and macro-socialized funding (government healthcare) is that the government version results in massive cost savings for the entire system.

Micro-socialization is the worst of both worlds. No cost savings, no preventative care, and only the most sensational and dramatic ailments receive GoFundMe support from peers.

For proof of the cost savings, look at the cost of X given procedure in any developed country with socialized care (Australia, Sweden, Germany, etc.) and then compare it to the US.

In the US it will cost anywhere from 2X-10X more to do X given procedure. It's not even worth citing any research since there's mountains of studies proving this.

> Because at scale, countries are also just a group of people pooling resources to achieve greater outcomes.

> The only difference between micro-socialized funding (GoFundMe) and macro-socialized funding (government healthcare) is that the government version results in massive cost savings for the entire system.

there is a key difference though. in one case, a group of elected representatives is deciding what to do with everyone's resources. in the other, individuals are deciding what to do with their own resources. at a high level, they look pretty similar: a group pooling resources to help someone. but the control over allocation is completely different. this is a really important distinction to understand. most people are a lot more willing to give their resources to friends/family than to random strangers. your (compelling to me!) argument about efficiency will not convince people if you don't acknowledge the allocation part.

right, the gofundme is voluntary socialized medicine is mandatory. People don't like being told what to do but, given the chance, will usually volunteer.

>nobody has any political objections to socialized funding when it happens there.

Nobody in your filter bubble.

There's plenty of people who don't like "internet panhandling"

It was for 200 people. Works out to about $3k per person on average.

Which is a fortune to many (most?) Americans. That's like 5% of the median income.

And these people just had cancer, so it's less likely they've been able to hold down steady work.

That's less than most Americans spend on food per year, without which you die.

That's how I felt. Just like stories on how everybody pitched in, or the boss giving an employee that walked to work a car, or the one where a boss allowed (!) an employee that lived in their car to park in their shop's parking lot overnight, or the one where employees "donated" their paid time off days to another because of circumstance (or the apparent fact that paid time and sick days off are such a weird concept in the US).

Frankly it seems like the doctor got screwed out of his pay by the system too. He should be as mad at US healthcare as his now bankrupt patients.

Nothing about this feels good.

This ^

It's a depressing story, anyone who thinks this is a positive story is ignoring the whole context.

Yeah, maybe I'm cynical in that regard, but I had to unsubscribe/block r/mademesmile and r/wholesomememes or what they're called on reddit, as I found it more depressing than nice to read these kind of stories.

Agreed. I'm reminded of a tweet I saw:

> Every heartwarming human interest story in america is like "he raised $20,000 to keep 200 orphans from being crushed in the orphan-crushing machine" and then never asks why an orphan-crushing machine exists or why you'd need to pay to prevent it from being used.

https://twitter.com/pookleblinky/status/1309325764739858432

These heartwarming stories are like a bandaid on a gunshot wound. Not even making a dent in the problem.

It was for 200 people, that's an average of $3250 per person.

Posted this above, but that's a lot of money. The median household income in the states is about 60k. And these folks may be less likely to have held stable employment while they battled with cancer.

Exactly. If that was the debt at the end of his practice, just imagine how much debt he bestowed during the 30 years it ran. I wonder how many patients went bankrupt... seriously, with the leading cause of bankruptcy in the US being medical. But that wouldn't be a story. That's just every clinic in the USA. And who wants to be reminded of that?

It's amazing that their kindness has touched so many lives but yes, the need for it could have been avoided in the first place.

> the deeply flawed idea that healthcare should be a "marketplace"

It should be a marketplace. instead, it's a racket.

And an insurance should be, well, an insurance. What is referred as "health insurance" is more like "health care plans" (insurers even call it "plans"). Just consider how comprehensive auto insurance is different from health insurance in practice.

Overall health is not insurable. It’s a misnomer.

There is a 100% chance of everyone needing healthcare in the future. US health insurance does a few things:

1) premiums partially serve as a tax to transfer wealth from young and healthy to old an sick

2) insurers healthcare recipient from the big costs (over out of pocket maximum - $7k to $13k per year), subject to in network providers

3) Negotiates pricing and determine appropriate level of healthcare, I.e. acts as informed agent for uninformed buyers

The last one is controversial, but it’s funny since people complain about high insurance premiums and then also complain about insurance companies denying what might be frivolous charges by healthcare providers.

> There is a 100% chance of everyone needing healthcare in the future.

1) that's not true. One can die in an accident and not cause an future healthcare costs.

2) health care costs are of course insurable, why not? Just because everyone will create costs with a high chance does not mean that everyone will always create the same costs. The insurance is there for when you have some illness that causes more costs than you could afford.

I didn't feel like writing 99.9999% chance at the time, so I rounded up to 100%.

It's not insurable in the sense that at some point, the losses are so large and so frequent, that the insurer needs to collect premiums from almost everyone in order to cover the costs. At that point, the premiums start to resemble a tax. I actually do consider the premiums a tax for the following reasons:

1) there is a mandate to purchase health insurance (although now neutered in most states due to removal of federal tax penalty)

2) the maximum premium is set to 3x the lowest premium (means young people subsidize old people)

3) premiums can only vary based on age and tobacco use

4) there is an annual in network out of pocket maximum

Another example of an uninsurable risk is insuring homes on the Florida and other Gulf states coastline for flooding. No private insurer would touch this market since the losses are so high, so the government created the National Flood Insurance Program, which is the federal taxpayers taking on the liability for flood damage for those homes.

> It's not insurable in the sense that at some point, the losses are so large and so frequent, that the insurer needs to collect premiums from almost everyone in order to cover the costs. I actually do consider the premiums a tax for the following reasons

Could it be that you limit your perspective onto only the US at the current point in time? Otherwise what you say just doesn't make any sense and your points can't be generalized. And even in the US, health insurance is not mandatory (as you say yourself), hence I would still not call it a tax.

> No private insurer would touch this market since the losses are so high, so the government created the National Flood Insurance Program, which is the federal taxpayers taking on the liability for flood damage for those homes.

Yeah, so if you don't talk about flooding being insurable in general but that there just isn't any company that is doing it for Florida then I agree. And to be honest, I think it's not good that the taxpayers are paying here. The nice thing about insurance is that it gives incentives, such as "don't live somewhere if you can't afford the dangers at this place".

>Could it be that you limit your perspective onto only the US at the current point in time? Otherwise what you say just doesn't make any sense and your points can't be generalized. And even in the US, health insurance is not mandatory (as you say yourself), hence I would still not call it a tax.

What I mean by insurable and uninsurable is that an entity can come in and sell insurance which can benefit the buyer alone, and is not an explicit subsidy to the other insureds in the risk pool. However, for health, it's a no brainer to opt out of health insurance between ages 20 and 40 (maybe not if you're a woman that's going to have kids). This makes the risk pool completely full of people experiencing losses and that point, it's just a cost sharing arrangement.

I.e. Auto insurance premiums reflect the loss the insurance company will experience from your driving. Home insurance premiums reflect the loss the insurance company will experience from damage to your home. Life insurance will reflect the loss the insurance company will experience from your death. But health insurance (as implemented in the US) premiums explicitly reflect the loss the insurance companies experience from older, sicker people due to the various stipulations I listed in my posts above.

>And to be honest, I think it's not good that the taxpayers are paying here. The nice thing about insurance is that it gives incentives, such as "don't live somewhere if you can't afford the dangers at this place".

I agree, and that's why I don't like using the word insurance when it's not really insurance in the conventional sense. It's a tax, which I'm not opposed to, but I think there is value in recognizing that health insurance premiums are explicitly going to pay for healthcare for other people.

This manifests itself every time someone complains about ACA causing health insurance premiums to increase, as if the law or insurers caused the premiums to go up.

What really happened is the law allowed more healthcare to be provided to more people, and the way it funded it was by increasing health insurance premiums and having everyone pay (i.e. the mandate to purchase health insurance), and I think we'd be better off if we referred to this as a tax and recognize that the increase in insurance premiums is going towards benefiting others by giving them access to previously inaccessible healthcare.

> I agree, and that's why I don't like using the word insurance when it's not really insurance in the conventional sense.

Once again: that might not how it works in the US, but the US is not the world and hence irrelevant for the _general_ concept of insurability for healthcare. If you only want to talk specifically about how it is _right now_ and _only in the US_ then I agree with your sentiment.

I'm just answering to your post because I have the impression that you are making very general statements.

> What I mean by insurable and uninsurable is that an entity can come in and sell insurance which can benefit the buyer alone, and is not an explicit subsidy to the other insureds in the risk pool.

That's how it works though, maybe not in the US but for example in Germany.

> However, for health, it's a no brainer to opt out of health insurance between ages 20 and 40 (maybe not if you're a woman that's going to have kids). This makes the risk pool completely full of people experiencing losses and that point, it's just a cost sharing arrangement.

If by "no brainer" you mean that some or many young people "don't think" and do something irrational, then yeah.

Someone who thinks about it and makes an informed decision will _not_ opt out when they are young. There are two reasons: 1.) Even when you are young, you can get cancer, HIV or other chronic and expensive diseases that exceed your savings by far. 2.) Even if you can pay your diseases out of your pocket, you might get a disease that is cheap when you are young but will cost much more when you get older. If so, you won't be able to pay the price of insurance anymore when you are older. However, insurers can (and do, maybe not in the US) offer contracts where they cannot cancel the contract from their sides just because you get sick or more expensive - however, therefore the premiums are higher (even when young) so that they can cover the costs that statistically will happen. Essentially, if you are young and stay healthy until you die, you will have paid all your life long for the people of your approximate age that also were healthy in their youth but became sick when they got older.

As for your point about calling it a tax in the US:

> I think we'd be better off if we referred to this as a tax and recognize that the increase in insurance premiums is going towards benefiting others by giving them access to previously inaccessible healthcare.

I think both the current and your proposed solution are not optimal. IMGO the right approach is to apply separation of concerns: 1.) Decide for a standardized "minimum" that any insurer can offer and get certified for their plans if they fulfill the criteria 2.) Make this minimum standard mandatory for everyone, but allow for the choice of which exact plan and insurer to choose 3.) Let premiums be premiums which everyone pays to the insurer 4.) If someone can prove they cannot pay, they get supported by the state so that they can pay for a minimum plan (otherwise it can't be mandatory obviously) 5.) Whoever wants to have better insurance can get a plan that covers the minimum + more stuff

Now there is clear distinction between premiums and tax which is used to pay for people who cannot afford health insurance.

Oh, also, the US could stop this strange way of pretty much tying insurance to employer. I never understood how this could happen.

I believe you mean "overall health" as in a continuum of the living being life health. What I mean by insurance is a contract that specifies what risks can be insurance, up to what limit and how much it will cost.

You unlikely to have problems to insure a new car bought off the dealer lot. You will likely have problems insuring a very old car, with missing brakes and flat tires.

Similarly, health insurance is quite possible for healthy folks in their 20ies-40ies (maybe? just an example of the age range). And, like you said, insurance payout becomes likely certain and potentially unlimited if you try to insure someone who is 90 old.

All that doesn't mean that health insurance can not exists as a thing. It just means that insurance is a tool that applicable to a specific scenarios and not a blanket solution for health care. And what discussions happens in the US, somehow it is either health insurance takes care of everything, or it is government takes care of everything.

I think there is a place for both tools (and perhaps even more others i can't think of right now).

EDIT: another thing that bothers me about health insurances in the USA - it is expected that insurance is involved in every single case of working with health care providers. I do not think annual flu shots is a risk that needs to be insured (it is known, and can be planned upfront for). Similarly, a visit to the family practice with a cold or ear infection does not need to be insured. Bringing back car example - it would be like bundling annual oil change, or a flat tire into standard car insurance everyone have to have... In my opinion, health insurance has its place to insure unknown/unlikely events, not routine stuff.

Why it matters, in my opinion. A significant chunk of costs is in administration - both on hospital and insurance sides. And these routine visits are likely getting a large chunk of it. More importantly, when patient pays directly to the health care provider - they are much likely to be more picky about quality, costs, convenience combination, unlike going through the insurance scenario, where the decision is mostly about "who is in the network, and how close they are". Missing such a direct relationship between patients and providers, in my opinion, puts upward pressure on prices (in addition to everything else).

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