Comment by bart_spoon | Hacker News Reader

Comment by bart_spoon | Hacker News Reader

Everyone in this thread rightfully outraged by insulin prices needs to look into the rebate system and PBMs in America. Its an absurdly complicated environment, born out of a desire to drive drug costs down, that paradoxically drives them up. There's plenty of approaches to tackling drug prices, but dismantling the rebate system needs to be included.

And frankly, the best way to dismantle the system is through some form of publicly available, universal health insurance. I believe in the power of healthy, free markets as much as anyone, but the current healthcare system is anything but. The lack of a non-profit seeking provider of health care, in a space where customers options are to pay whatever is charged or simply die, is not a functioning market. The rebate system was born out of what was a legislative bandage over this issue. Continuing to try and come up with cute solutions that avoid government provided healthcare for all will see similar results. Its why Americans spend so much more on insulin, and most other forms of healthcare services, than the vast majority of the world.

There are a number of states where the largest insurer is a not-for-profit organization.

There’s not one simple fix for this. If it’s truly going to be fixed, it’s going to require a lot of very tough fights against entrenched interests to eke out 5% here and 3% there.

You realize that the rebate system exists in the public systems (Medicaid and Medicare) today?

Public healthcare won’t get rid of it.

> ...in a space where customers options are to pay whatever is charged or simply die

Look...I agree with the majority of your point, the majority of healthcare doesn't deal with such an obvious binary...and we aren't going to make progress on this issue unless we're willing to also have the conversation about healthcare within your control - e.g. individual responsibility for your healthcare.

A number of close family members are doctors / surgeons of various kinds, so I've heard so many issues & complaints about the system. And while I would happily pay taxes to fix healthcare issues that are preventative (e.g. cancer screenings,) educational (e.g. nutrition,) and overall unpredictable (e.g. surprise brain aneurysms or the like,) I have no desire in paying for:

- Someone who drank so much and annihilated their liver, requiring significant & expensive surgery

- Someone who couldn't stop eating at McDonald's and hasn't touched a vegetable in a decade now wants lifetime insulin and kidney transplant

- A hypochondriac who wants to see their doctor for every scratch, off-color skin mark, etc.

- Someone voluntarily jumping off planes, doing dangerous sports, etc. without insurance, and expecting someone else will foot the bill

- Someone who wants every and any blood test because they coughed once

etc. etc. etc.

Again...overall I agree with a more central payer system, but you won't get the conversation started with all the groups involved unless you acknowledge that there's some element of individual responsibility that you need to control for as well.

Ultimately the choice will come down to creating a system in which the unfortunate are protected at a cost of also subsidizing the irresponsible, or sacrificing the unfortunate for the sake of punishing the irresponsible.

None of us want to be taken advantage of, but I weigh protecting the most vulnerable and unfortunate, of whom there are many, more heavily.

Ultimately the moral debate is purposeless. Our health care system is designed and run by predators, and propped up by a sentiment that we're willing to pay twice as much to support a system that includes the most vulnerable and unfortunate, and the wealthy, but impoverishes or excludes the working classes.

The easiest way to find out if someone lacks health care access is to ask them if they work with their hands.

So how much money are you willing to spend on doctors who are doing nothing but figuring out which patients were "too irresponsible" versus which ones will get covered?

I think you are in line with how many people feel. The problem is that whether you like it or not, you are footing the bill for all of these people under the current system. My health insurance is $600/month because I'm in a pool of people who are mostly healthy, but the insurance company runs the risk that one or two of us could cost a fortune. In fact, I'd probably pay a lot less towards healthcare if the government was the payer since they can leverage their size for much better prices.

Sometimes the cost of trying to avoid that type of misallocation of resources costs more than simply paying for it.

The classic example is drug testing welfare recipients which was proven to cost more than just giving it out.

Sometimes you have to chalk some of this stuff up to "the cost of doing business."

What if paying for all of those things resulted in overall lower health care costs for you? If, theoretically, we all pulled our resources and collectively provided healthcare for everyone and, as a result, your overall health care costs went down (i.e. your share to cover everyone was less than your current expenses to cover yourself + whatever taxes you currently pay) would you be willing to pay for those things in your list?

So what should be done for all of those people? Just go to the ER every time they need healthcare? Start denying ER access to those that can't pay?

Good AIDS vs. Bad AIDS

https://www.dailymotion.com/video/xc3x84

Why keep your moral condemnation limited to taking health risks? What constitutes healthy behavior is very fuzzy at the edges, I would prefer to condemn people based on who they vote for, or their religion. Why would I want to support the continued lives of people who I think cause health problems in other people?

Inheritance tax can pay for that. Use undeserved money to pay for underserved care.

> - Someone who drank so much and annihilated their liver, requiring significant & expensive surgery

That’s called an addiction. It’s a disease. And that should (and can) be fixed by a doctor.

> - Someone who couldn't stop eating at McDonald's and hasn't touched a vegetable in a decade now wants lifetime insulin and kidney transplant

Same thing + metabolism issues, aggravated by voluntarily aggressive marketing. Can and should be fixed by a doctor.

> - A hypochondriac who wants to see their doctor for every scratch, off-color skin mark, etc.

Psychiatric issue with real psychiatric or physical pain : can and should be fixed by a doctor.

> - Someone voluntarily jumping off planes, doing dangerous sports, etc. without insurance, and expecting someone else will foot the bill

Just make insurance mandatory for extreme sports like in most countries.

> - Someone who wants every and any blood test because they coughed once

Same as above. Hypochondriasis is totally documented as a real suffering and psychiatric issue.

All your examples are situations that can be prevented with preemptive medicine which is the norm in countries where you can see a doctor long before being sick. I’m not saying it’s easy or perfect, but it’s easier for doctors to prevent diabetes if they can follow patients regularly and check their vitals than if they only see them once a year or less because they can’t afford it.

All those people still deserve healthcare. Just about every other developed nation has no problem supporting everyone, so I don't see why things should be so different for us. Treatment of others shouldn't be determined by your personal morals. What if that extended to everything else that is socialized in our system?

From a purely selfish perspective, countries with universal health coverage pay less than Americans do for healthcare, and those countries have better healthcare outcomes, quality of care, shorter wait times and they manage to insure everybody. You'd enjoy not only lower prices, but better care adopting such a model.

But yours isn't even a selfish perspective, but a moralizing one. You don't like the idea of someone getting healthcare that you feel doesn't deserve it, and it seems like you don't care if that means you pay more for healthcare or receive worse healthcare outcomes as long as those people can't see a doctor.

As a society, we already pay for this and then some. Prevention and continued care is much cheaper than emergent or reactive.

In a largish corporation (5k people) there's pretty good odds at least one or more of your co-workers has a drinking problem, or a significant weight issue, or is a thrill-seeking skydiver on the weekends. If you have healthcare through your employer, and you pay part or all of the premium, then you're already subsidizing those things.

Why this only becomes a problem when done at a state or national level, is not something I can fathom.

> Why this only becomes a problem when done at a state or national level, is not something I can fathom.

If anything, the larger risk pools would drive costs down.

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