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Comment by OzzyB | Hacker News Reader

One thing that upsets me when such topics arise is the non-mention of how Health Insurance plays a huge part in all this.

This might be something that UK/EU folks might not be able to empathise with, but for US workers, the need for health insurance is a crucial factor in how they choose to stay/leave/accept any job.

To say folks should just "up and leave" if they feel they're under appreciated is not so clear-cut when your medications, nay your family/spouse/child's health is on-the-line while you try to run off in search of "greener pastures".

In my mind, one very real reason healthcare reform has failed in the US is that companies[1] are very aware that being the main/sole provider of their workforce's healthcare provides very strong leverage over them.

Now having said that, it is true that healthcare costs companies alot of money, and it may be something that a large percentage of them would like to avoid -- a possible factor in their preferrence for a younger workforce perhaps -- but to ignore healthcare and its effects psycologically on our society and workforce as a whole is doing us a disservice.

[1] I guess I'm really thinking of "big" companies with a need for a large dependable workforce, not your mum & pop/start-up/entrepreneurial kind...

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I've taken and stayed at crap jobs precisely for the health insurance. When I was consulting, I was self-insured thru my state's insurance of last resort. Expensive, while it was available.

The cost of health insurance is an active deterrent to me risking my own startups.

Hypocrisy and contradictions from the free market zealots is nothing new.

And yet I remain stunned that the same freaks who say they want a flexible work force, ya know, that whole "free market" thang, actively oppose the single biggest enabler to a mobile work force, universal health insurance.

"And yet I remain stunned that the same freaks who say they want a flexible work force, ya know, that whole "free market" thang, actively oppose the single biggest enabler to a mobile work force, universal health insurance."

I'm stunned that people that hate monopolies seem to be fine with a government-run one. In all cases, innovation stops and quality declines because nobody really has a choice.

When you can assure me this won't happen, I might start supporting universal health care.

I can barely trust the bloated and inefficient government to run un-important things..I sure as hell can't trust them to run something as important as health care.

I don't have a lot of data points, but I've lived in both the U.S. (non-public healthcare) and Denmark (public healthcare) and the quality and convenience of the latter is quite good in comparison, imo. The amount of sheer bureaucracy is much lower in Denmark as well; I don't have to file reimbursement forms for a half-dozen different doctors, worry about copay rules or what precisely constitutes a "preexisting condition", or spend time on the phone with insurance agents to figure out why a bill was rejected. It just works: you go to the doctor, you never receive a bill, the end. Outcomes seem on par or better than in the U.S. as well.

However I would be open to a voucher-type system where the actual providers are private, competing for customers who pay into a common risk pool. It's the tying of the risk pool to employers that's most problematic to me, and which imo severely weakens other parts of the free market, by reducing labor mobility. That might actually improve some free-market elements of healthcare, since the actual customers would choose providers, rather than their employers doing it for them.

Everyone I know that lives in a country with public health care says the same thing:

1) long wait times for any major surgery 2) sub-par equipment/hospitals 3) elderly patients don't get treated as well as they should

Nearly all of them come over to the US and pay for major surgery.

I also find it strange that in any of these discussions, nobody that lives under universal health care will talk about the bad things.

Without this sort of honesty, I will never want a public system in the US.

Do you know anyone who lives in Scandinavia? And, beyond anecdotes, have you looked at any actual studies or statistics?

I don't think every public health system is well run, but I think the better ones are better-run than the US, and lead to much greater peace of mind, because I don't have to worry if I'm covered or not--- I know I am. The total expenditures are actually lower, too, because the U.S. spends a lot of money on public healthcare, just very inefficiently. Perhaps I'm part of some evil conspiracy to lie about how I like living in Denmark, but the numbers seem to back me up. There's plenty of other things I'll be happy to complain about about Denmark and Danish culture, too, but the healthcare system isn't one of them.

I don't think I've been treated well in the US healthcare system, in any case, and there were long wait times and subpar equipment. I also had to change doctors when I changed jobs, something that Denmark doesn't require me to do. And I had to spend a lot of time on the phone with insurance companies, who seemed to always make mistakes and miscode things; anyone who thinks governments are bureaucratic hasn't tried to deal with a large corporation's phone tree.

But I suspect you are putting ideology above any actual interest in rationally evaluating different healthcare systems based on evidence.

Since we're comparing anecdotes, friend #1 went to Thailand for eye surgery ($5k vs a gajillion dollars), friend #2 went to India for Lasik (sic?).

Yes, like all other systems, universal health care has problems. Canada definitely has a shortage of specialists in rural areas.

So what? The USA has plenty of shortages.

If you desire "honesty" in a policy debate, I encourage you to start with the widely published, thoroughly vetted, and oft cited comparative studies. If you're feeling very daring indeed, and want to learn something, you could start with google.

http://www.google.com/search?q=health+care+costs+per+capita

http://www.google.com/search?q=life+expectancy+by+country

TL;DR: Canadians spend 1/2 per person and live 2 years longer.

Is Medicare a monopoly?

They're just the payer. There's still an entire ecosystem of value-add private entities. Clinics, hospitals, specialists, pharmaceuticals, equipment mfg, labs, etc.

I understand everyone's reservations about bureaucratic inefficiency. The key is in the incentives.

Single payer enables the capitation model of service, where people are rewarded for staying healthy. Versus the current model where everyone profits from disease. That's why single payer is (generally) cheaper per capita with better results.

> Single payer enables the capitation model of service, where people are rewarded for staying healthy.

Please explain how capitation will get people to cut way back on carbohydrate consumption and exercise every day. Those two factor cause the majority of morbidity and mortality in the US.

Fructose (et al) consumption is the result of distorted farm policy. Removes the subsidies, nutritional value of food supply will (hopefully) return to "normal", public health will improve.

Stil, it's a pretty good question.

Doctors generally don't push nutrition. I think that's changing as the best available science continues to improve and be more broadly accepted. I personally evangelize the "cave man diet", probably to the point of annoyance.

But the real driver is coming from public awareness and social change. There are now serious efforts to limit, tax, regulate, remove sugars from a public policy standpoint. Examples are taxes on candy, removing vending machines from public schools, etc.

Capitation, by focusing a wellness and efficiency, would accelerate that trend.

Too much simple carbohydrates of any type cause Type 2 diabetes, with devastating health damage. Sugars may be somewhat worse than starches, but you can eat yourself to death with grain and potatoes just as easily. Sugar policies are not a silver bullet.

Capitation gives the same payment whether diabetics are cured or ignored. What we need are ways to preemptively deploy extra money to diabetics. They need to go to fat farms and have visiting nurses nag them at home.

Government run monopolies are a big problem.

I have to pay for police and yet I don't even get a say in what color cars they have, the same with firemen. And don't get me started on the way the navy never asked me what to call their new aircraft carrier.

Big business gets to choose which congressmen to buy - why shouldn't I get a choice as well?

"Government run monopolies are a big problem."

I'm glad we agree.

"Big business gets to choose which congressmen to buy - why shouldn't I get a choice as well?"

a choice which makes it so the rest of us can't choose?

You live in a democracy. The government is run by the people. Now, if your democracy wasn't so dysfunctional then you probably wouldn't have such a big problem with "government monopolies". So perhaps the first thing you have to fix is non-compulsory voting so that your government is actually representative of the people it governs, then you can get to healthcare.

Or find a way to make the people who actually know what they are doing vote in larger numbers than those who have no idea what they are voting for (or against).

"I'm stunned that people that hate monopolies seem to be fine with a government-run one. In all cases, innovation stops and quality declines because nobody really has a choice."

In all cases where there is no longer an intrinsic or external incentives to maintain quality or innovate, sure, those things tend to drop off. A private monopoly has no near-term financial incentives, and are left with whatever intrinsic motivation the owners may have. This isn't true of a public monopoly run by a democratic government, however -- there's always incentives there, even if they aren't market incentives.

And speaking of incentives, it's a real mistake to assume that the same kinds that often work to produce effective products/services in other markets are at work in insurance. In most cases, vendors make money the more operational efficiency they have and the more utility people derive from what they're offering. In insurance, there are issues of operational efficiency, of course, but they're limited and quite secondary to the fact that insurance pools do better the less participants need them. The incentives that insurers have are to screen and pick their customers from among those as likely as possible to get the least utility out of the product. And, of course, to provide the minimally acceptable utility.

So you end up with a product where the vendor has strong incentives not to sell it to those who need it most, and to try and aggressively market to groups who are statistically most likely to need it the least (say, those who are usually able to go into work five days a week).

When the natural incentives for a given product don't line up right, no amount of market freedom is going to mean a better product. If there's going to be insurance products that are truly helpful for most everyone who needs them, heavy regulation and public monopolies are pretty much the only option.

Under such circumstances, even people who don't otherwise like monopolies might well get behind a public one.

How is it a monopoly? In countries with strong national healthcare systems (eg Ireland, the UK) there's private insurers as well. And from the consumer PoV, you get sick, you get treated, there may a small copay, the end. The amount of administration that gets shoved onto patients in the US is staggering, and health insurance companies are about the least customer-responsive businesses I have ever encountered.

When you can assure me this won't happen, I might start supporting universal health care.

Why don't you just go somewhere that has it available and observe the results for yourself, instead of making up hypotheticals? It costs some more money in taxes, but delivery of service works nicely in practice and patients aren't required to become expert in billing administration.

"In countries with strong national healthcare systems (eg Ireland, the UK) there's private insurers as well"

Private companies are there, but it essentially makes it so only the very, very rich can afford them..so we have only one choice.

This is categorically untrue. Private health insurance in Ireland is a few thousand Euro a year at most. Both my (retired) parents have it, and while they're not poor they're nowhere near rich, unless you count owning your own home and one car as 'very very rich'. See for yourself: http://www.hia.ie/ci/health-insurance-comparison/search-form...

I'm sure you could find some equivalent comparison page for health insurance in the UK, or examine offerings from BUPA, the leading firm in that market.

The US government already runs a fine universal health insurance program. It's called Medicare. I was the advocate last year for a family member with a serious illness, and it worked beautifully: she got the care she needed, and we never had to deal with a bill, a co-pay, or a question about whether insurance covered something.

The only evidence I saw of government bureaucracy was when the hospital send somebody around to make sure everything was fine because it was especially important to them to make sure Medicare patients were getting all the care they needed.

"The US government already runs a fine universal health insurance program. It's called Medicare. I was the advocate last year for a family member with a serious illness, and it worked beautifully: she got the care she needed, and we never had to deal with a bill, a co-pay, or a question about whether insurance covered something."

When 90% of the US population is on this program, I guarantee you it won't be like this.

Well heck, if some anonymous dude on the internet guarantees it, who needs facts or logic?

Or I could, and maybe this is crazy, listen to any one of my friends who has actually lived in a country with universal health insurance.

I never understood how so many people can say that government-provided health care is necessarily problematic when there are a whole bunch of real-world counterexamples sitting over in Europe, not to mention one directly north of the US.

With single payer health care, how are prices set? I am asking this purely out of curiosity, and not to try to argue one side of the debate or another.

With an ideal free market there is at least reasonable theory about how price signals will get sellers to produce the goods and services people want. So with single payer, does that payer just work very carefully to make sure the prices they offer for various medicines and services are good enough that enough doctors and hospitals will be willing to do the things that people need done?

In all cases, innovation stops and quality declines because nobody really has a choice.

This is really an easily falsifiable statement. Australia has a government run Medicare. Innovation has not stopped because of it. There is still medical research being done within Australia. For example, there has been spray-on skin invented for burns victims, the Cochlear implant was invented here, and numerous other innovations in medical care.

Interestingly, Australia also has private medical insurance, with a large uptake. It's just that we don't force those who can't afford it to use it just to get basic healthcare.

It won't happen, as long as the government still allows private hospitals and doctors to work. Because then the private sector needs to compete with a functioning healthcare system that's essentially free for any citizen. If the expensive private clinic doesn't give you better care than the free government one, you'll never use them. Having universal healthcare raises the baseline above which private health companies have to be, in order to compete. And sure, government healthcare sucks. Sometimes the doctor doesn't even smile at me when I see him. Their equipment is frequently not the absolute latest possible. But they'll see to your cough, set your bones, fix your teeth, check your sight and more for essentially free. Which forces the private hospitals to do it better, faster and for a reasonable price.

> And yet I remain stunned that the same freaks who say they want a flexible work force, ya know, that whole "free market" thang, actively oppose the single biggest enabler to a mobile work force, universal health insurance.

They don't want a free market. Like everyone else, they want a market that favors them. In their case, that means a market that is corporatist - in favor of large companies and those who are already wealthy.

The real problem is that individually-purchased health insurance is more expensive (or unavailable). While public health care is one solution, it's far from the only solution.

An alternate solution would be to end the favorable treatment of employer-provided health insurance. Once everyone is purchasing their own insurance we will have a reasonably functional market, as we do with auto, homeowner's, and life insurance.

Having been involved in picking health plans for my startup, I am not optimistic. It was a giant pain in the ass. The number of variables seems much larger than car insurance, and the consequences murkier and more severe.

Choice is good. If the number of variables + consequences are too much for you deal with, then there's market opporunity for a startup there.

I agree with parents' feeling that were the regs to be fixed (or a new regulation enacted that stopped this bundling) a better market (as exists in car insurance etc) would develop.

Choice is in fact not an intrinsic good. Read The Tyranny of Choice for more on why.

It's especially not good in cases where the feedback loops are long and highly variable in outcome. Humans are very good at optimizing frequent choices with readily visible consequences, but are terrible otherwise.

> Hypocrisy and contradictions from the free market zealots is nothing new.

It is not hypocrisy to suggest that the people who banned drop side cribs are unsuited to guard the public health.

I think I'm missing something to understand this comment.

The US federal government recently banned all baby cribs whose sides move down, with no apparent consideration of cost-benefit tradeoffs and little public discussion. The ostensible reason was to prevent the few dozen infant deaths per year from defective cribs of this type, regardless of the effects on other sleeping styles that are probably more dangerous.

These are not the sort of people you want in charge of all health care.

Walmart was recently involved in a Mexican bribery scandal, and I'm going to use that fact to conclude that we shouldn't allow profit seeking enterprise anywhere near healthcare.

Rigorous safety standards for consumer goods are one of the things we have the government for. Sure, it can be draconian sometimes. Raw milk, for instance, would have been a much better example for you to bring up then defective baby cribs. Nevertheless, rigorous safety standards are much better than the alternative.

Now please excuse me while I go drink a glass of tap water.

It has nothing to do with rigorous safety standards. It was a blanket ban without regard to crib performance, the cribs were conclusively proven to be safer than cars, and the ban has resulted in shorter women who cannot use fixed-side cribs switching to other baby sleeping arrangements that are less safe.

This is what the US federal government does to almost everything it touches. It operates at too large a scale to make sensible decisions. It kills babies "for the children", it imprisons drug users to keep them from being trapped in an unpleasant situation, it makes education loans non-bankruptable to ensure a good life for students, and so forth.

It would do exactly the same to medicine if given total, absolute control.

This seems like the slippery slope fallacy. You'll have to excuse me if I find your argument particularly unconvicing! You are saying that those who have placed a blanket ban on cribs will make terrible decisions on health care, yet you haven't proven that this one thing will lead to the other.

The crib ban is a health policy decision. So is the entire TSA, the entire war on drugs, and so forth. The U.S. federal government rarely gets health issues right, and often gets them spectacularly wrong.

I don't think that the TSA is about health policy...

Not to mention the assertion that the U.S. government rarely gets health right!

Thank you :)

Free market zealots have been saying for decades that tying health insurance to employment is a horrible system. They would also point out that universal health insurance is not the only alternative.

I'm curious - what are the alternatives?

Legal interstate insurance sales, high deductible insurance, HSA's, Removal of regulations which cause de facto Medicare price controls...

Won't employers still offer health insurance in that case? A group risk pool is still the best way to offer insurance, and large corporations are de-facto the only way to produce a risk pool that doesn't have large adverse selection effects.

Health insurance is a tricky business, since claims are made much more often than against other types of insurance (like renters insurance). As an insurer, in order to have a sustainable business, your risk pool must be more valuable (either in terms of people or prices). If it is possible for insurance prices to drop the point where individual policy purchase is cost competitive with premiums you'd pay via an employer, the competitive advantage of employer provided health care quickly diminishes.

The main problem I see is the adverse-selection problem: if it's not via a large group pool like a large company, then there is likely to be significant correlation between poor health and higher insurance-purchase rates, which will in turn drive up prices. In the individual market, if I'm healthy vs. if I fear I will have imminent health problems, I'm more likely to buy insurance in the 2nd case. But if you work for IBM, everyone gets insurance, uncorrelated with their health perceptions--- so insuring IBM is probably a better deal overall, because the risk pool doesn't select for worse risks.

What still mystifies me is how large grocery stores, like Safeway, Albertson's, Kroger, etc can afford to pay 100% medical care for their employees. I was a Safeway employee (and begrudging UFCW member) from 1998-2007, and received 100% paid for medical, dental, vision, and other care merely for working more than 20 hours a month. For family care, employees merely must work more than 30 hours a month.

6 years ago, Safeway's CEO announced they would be requiring preventative care and physicals to cut medical costs: http://www.yalemedlaw.com/2008/11/the-safeway-effect/

After completing college, I've found that the 4 companies I've worked for (mid-level IT for fortune 50 financial/tech companies) claimed they couldn't afford to pay for any medical care. Instead, they reminded us how much compensation they were already providing.

Why are grocery stores able to pay for this when nobody else will?

One word: unions. When all grocery stores are unionized and must pay for this benefit, the costs are simply passed on to consumers.

And each union local (in this case, UFCW) has collective bargaining every couple years to set the rates at which health care contributions must be made on behalf of each employee.

(former actuarial consultant, worked on union health funds)

They're unionized, that's why they do it.

Grocery stores aren't very profitable.

And yet they can somehow pay for 100% medical care when nobody else can?

You should go look up the definition of "profit". It doesn't include salaries and benefits, which are called "salaries" and "benefits".

> This might be something that UK/EU folks might not be able to empathise with

You are absolutely correct. As long as the US is unwilling to socialize its health care, there is very little sympathy for people putting up with soul-sucking jobs because they are against some half-baked notion of "socialism". (And I would argue that many Americans do not know what socialism is - they often conflate it with communism, which is entirely different).

> As long as the US is unwilling to socialize its health care, there is very little sympathy for people putting up with soul-sucking jobs because they are against some half-baked notion of "socialism".

Things aren't so simple as just 'socializing health care'. For a country in which the majority of medical spending is state subsidy, it's hard not to think we already have. And while I might personally be a closer fit to your unsympathetic libertarian strawman, I recognize that I'm a tiny minority in the American population at large. It seems rather harsh to deride a population of people for having to put up with a regulatory environment that clearly isn't of their choosing.

>It seems rather harsh to deride a population of people for having to put up with a regulatory environment that clearly isn't of their choosing.

I used to believe this also but changed my mind after the 2004 elections in the US. We are living in an environment that clearly is of our choosing - we either voted for it or didn't care enough to vote against. While it's true that some people don't like how the current system works, very few people in America seem to believe that it would be worthwhile throwing everyone out of office or demanding real discourse in politics.

It's true that the world is dominated by sound-bytes, etc. but there's a reason that stuff keeps showing up on TV and other media - it sells. When people value thinking about the world they live and realize that good solutions usually are not "partisan" things might change for the better. But that seems unlikely.

The entire thing is a problem because you can pay for your insurance, but only through your company right?

Why the fuck doesn't congress fix that then?

Because then employees would have the freedom to leave one employer for another to get better money/conditions/etc

This would cost employers money.

who do you think pays for congressmen?

Congress won't touch employer-provided health care, because providing health care to employees is a popular corporate tax break.

As to third party insurance: Yes, technically you can buy third-party insurance. But, no, it really isn't a remotely functional market. In short, if you don't really need the insurance, you can probably get reasonable coverage. But if you actually need it, it will be too late and nothing will be remotely affordable and/or cover much.

If you only buy it when you need it, it's not "insurance".

I was referring to things like: when your COBRA runs out. Or when you switch to a job that doesn't offer insurance, but are no longer a 20-something with no real medical history, or when you have children, etc.

Not "the day after you break your leg".

Though there's a lot to be said about not being able to get insurance to defray costs of a 'pre-existing' condition. Sure, it's unworkable to allow people to buy insurance 5 minutes after they break their leg and then cancel it 5 minutes after it's set in a cast and their prescriptions are filled. But there's no reason a contract couldn't be drafted, obligating someone to pay for a particular insurance plan for X months, complete with early termination fees and such.

Verizon and Comcast figured this out. Is it really too much for Aetna?

That's an interesting idea, but I suspect there are legal and practical reasons why it would be impossible to implement profitably.

A major medical incident (or worse: being diagnosed with a chronic condition) can cost tens or even hundreds of thousands of dollars. Any kind of "payment plan" would likely bankrupt a good number of subscribers, and then the "insurer" (really, in this case, a creditor) is left having to make up a big loss.

My preferred solution would be for the government to strongly encourage (who knows if a mandate will end up judged Constitutional) everyone to buy into truly catastrophic care coverage, with high annual deductible limits that would be subsidized for the poor. Ideally, you'd end up with a market where everyone's covered privately from birth against actual "insurable" events.

Let employers or private sellers offer "benefit plans" that cover things like Viagra, dentistry and pregnancy with better deals than you could negotiate yourself.

But ACA combines the worst of both worlds: Mandate coverage of every politically popular treatment, often with no communication to the consumer of any price information at all.

> "I suspect there are legal and practical reasons why it would be impossible to implement profitably."

We have any number of exceptions in bankruptcy law to make such debts difficult-to-impossible to discharge. Surely such medical coverage could be worked in. And, yes, morphing coverage into essentially medical credit is the desired effect, as insurance companies negotiate far, far better pricing than individuals and credit for medical expenses is otherwise extremely difficult to arrange.

That said, I do agree to the general concept you're advocating and would prefer that sort of solution. We should just outright tax people to directly pay for the "we're not going to leave you for dead" care hospitals already provide. This makes far more sense than having hospitals eat those costs and over-charge everyone else to make up for it. Further, we should expand that base level of high deductible care to subsidize the basic preventative care that will keep the final costs of such coverage low. [1]

And then allow third parties to provide additional coverage.

Though I would most-strongly advocate a severing of the employer-health care link. If nothing else, that needs to go. The grouping of employees has serious distorting effects on the labor market. Risk pools should be insurer-wide. And insurance contributions by employers can/should be handled like a second direct-deposit. Even if we keep the employers' tax deduction. [2]

But the insurance choices needs to be in the employees hands. The risk groups need to be wider. And changes need to not be forced upon a change of employers.

[1] e.g. Basic doctor visits and generic drug coverage for things like antibiotics to cheaply treat conditions that will otherwise wind up in the ER; provide family planning care; etc.

[2] Though i'd like to see that removed and treated like any other wages from the employer-side, but exempt from income tax on the employee side.

"healthcare costs companies alot of money, and it may be something that a large percentage of them would like to avoid"

They are reducing it, by putting a larger share of the cost on to the employee.

The key here is not that health insurance becomes affordable via an employer, it's that it becomes at all possible via an employer for many employees.

Recognizing that, it just becomes an exercise in how large a share of the cost employers can shift to their employees, factoring in their ratio of young/healthy/mobile workers to old/needy/trapped workers.

You can continue your employer-provided healthcare for 18 months via COBRA.

and pay out the nose for it, from what I've heard...

Absolutely. Go ask your HR rep what your plan actually costs per month. For my small company, the family plan is nearly $3,000/mo.

As a healthy 30 year old, I'm paying 500/mo for a PPO on COBRA.

That's still a bit risky if you have a major health problem. I have a friend with a congenital heart defect, and he treats the 18 months of COBRA as the absolute last-ditch fallback to use only if he ever gets laid off: it gives him a hard deadline of 18 months to find another job with a group health plan. But he wouldn't voluntarily put himself in that position where he has to find a new job w/ good benefits in 18 months, so he would never really quit a job unless he had another one lined up ahead of time (and doing a startup or consulting is out of the question, because the individual health insurance would cost a ton).

Pretty weird/absurd tie-in between professional life and the genetic lottery imo, due to the strange way health risk pools and employment pools have gotten conflated in post-WW2 America. Anyone can be an entrepreneur, as long as you didn't get unlucky in the womb!

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