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Comment by SamuelAdams | Hacker News Reader

To quote a great play: “what comes next”?

What’s always missing from these calls to action is: what are you replacing it with? There are a number of healthcare programs across the world and every country has a variety of different problems. There are no silver bullets.

If you want a great read about a few different countries, I recommend The Healing of America by T.R. Reid. It has some suggestions, but in general it is great at illustrating how treating the same illness in different countries can be varied in terms of treatment and cost.

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This is true, but some of the problems show up in outcomes and some don’t. Sure, I’d rather not wait six weeks for an appointment. But if you can’t show me any sort of worse health outcomes related to those waits, then that seems like a reasonable tradeoff for single digit percentages of gdp.

If it were me I would do baby steps. Make it so health insurance isn't tied to your employment first.

How would this work for the majority of people? Most people live paycheck-to-paycheck. Even those who make more than enough not to. It's a habit. If health care isn't baked in, will people pay for it? If not, how will they avoid bankruptcy?

How about not tying choosing health insurance to employers. Let’s permit employers reimburse insurance for employees, but put the choice of insurance to employers into the marketplaces. I think it would improve state of things significantly by tying beneficiaries and customers into same person again.

Part of the issue there is group policy. Insurers by the nature of their business prefer blended groups vs individuals, especially when individuals have a choice among insurers.

Or to put it another way, any insurer offering a "better" policy (in terms of more coverage for less money) will attract the highest-consuming patients, individually.

If they sign up groups with less choice, they're more likely to get a balanced cohort of consumers / non-consumers, young / old, etc. etc.

> Most people live paycheck-to-paycheck

Not in any meaningful sense.

https://www.noahpinion.blog/p/paycheck-to-paycheck-and-five-...

> In other words, a number of government surveys just contradict LendingClub’s survey. Why does [politician] choose to believe a survey by a payday lender with a secret methodology, instead of multiple surveys by the U.S. government with transparent methodologies? I guess being ...

I wish people would stop linking Noah Smith substacks. He makes a strawman out of the LendingClub survey and then beats it with surveys that do not contradict the original survey. In fact, a lot of his writings are strawman beatdowns.

Living paycheck to paycheck has low bearing on savings. The LendingClub survey is self reported, and includes people whose finances fluctuate seasonally (they overall live paycheck to paycheck but wind up with random windfalls) and people who maintain a small pile of cash but are always counting on the next paycheck to avoid dipping into their savings. The report even mentions that a chunk of the paycheck to paycheck people are superprime credit consumers, but Noah refuses to stop and think about why that is the case.

I personally know people who very well off who are riding the razor’s edge so to speak- they have huge savings but 100% of income does straight to bills.

Wow 40 percent of Americans have THREE months instead of ONE month of expense money saved up. Truly thunderous debunking by Noah Smith.

Public funding. Plenty of countries do this.

Instead of US-style employer + individual paying insurance premium...

... you increase taxes and fund universal insurance directly from those revenues.

In the end, it should hypothetically balance out ($1 for healthcare == $1 for healthcare), except employment would no longer be a precondition for having access to affordable insurance.

The NHS in the UK costs less per capita than CMS currently spends.

Fire many administrators and managers over there, put a lot of them in prison and tell them to start again.

Putting a lot of people in prison sounds expensive, but still cheaper than American health care.

Need to do something with all the savings over the current system.

We have one of the worst healthcare systems in the developed world. "What comes next" doesn't matter when most alternatives would be better.

Careful there - it’s quite likely the incoming administration will pick one of those few that isn’t better

>"What comes next" doesn't matter when most alternatives would be better.

It really does matter. I'm no fan of our current system either, but by and large people do receive quality healthcare on it. If you rip out that system, you need to replace it with something that's at least meets the same standard.

Most people won't agree on what that next system is so there isn't enough momentum to change it.

Do you have a source for that — what makes our healthcare systems "one of the worst"?

Lower life expectancy, higher infant and mother mortality, large numbers of untreated diabetes and other treatable illnesses

For example: https://www.kff.org/health-policy-101-international-comparis...

But a basic google search returns hundreds of sources

As your source notes, the US tends to do average on point of care metrics (e.g. hospital outcomes, versus other similarly developed countries), but worse on lifelong metrics that would conceivably be impacted by income disparity (e.g. life expectancy, maternal mortality).

The metrics the US does poorly on seem like they're more of an access problem (than acute care being bad), which suggests broadening access to affordable healthcare would be the best redress -- i.e. universal healthcare.

The US health system seems like it would be better served by explicitly breaking it into a multi-tier one.

Basic tier: universal health care for basic access and procedurings, including proactive health measures

Everything else: private health insurance available (not attached to an employer)

All for the highest cost per person, in the world

To be fair, there's an extremely strong correlation between GDP and absolute health care spending, regardless of underlying funding money.

And the US is near the top of the GDP rankings.

GDP and health spending is correlated and forms a nice line (see diagram below), but US spending is nowhere near that line.

https://www.kff.org/health-policy-101-international-comparis...

cost and outcomes. In aggregate, Americans pay much more and get worse outcomes

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