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Comment by bgnn | Hacker News Reader

not an American, but it seems to me that the reason is purely ideological. They like a small state, especially the federal government. This would give too much power to the government. The idea of federal government providing care for citizens is not acceptable to people.

Now, weird thing is this doesn't work for the military somehow.

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The federal government already pays (either directly, for Medicare and Tricare) or indirectly (Medicaid) around 45% of healthcare expenditures in the United States, and regulates nearly every aspect of healthcare delivery in some form or fashion.

There’s an awful lot of small-government posturing that goes on, but it is not accurate to say our system is the result of a small government approach.

To provide just one concrete example: in the 80s, we had problems with hospitals “dumping” indigent patients. In some cases, they would literally take homeless people who showed up needing medical attention to some random part of town and drop them off on the side of the road.

Naturally, there was public outrage about this. Demands that it stop.

There are, of course, many ways a society could address this problem: a single payer system, a nationwide indigent care fund, etc.

Here’s what we did: as part of the Consolidated Omnibus Budget Reconciliation Act of 1986, the federal government stipulated that any hospital which accepts Medicare/Medicaid[0] and which operates an emergency department must provide “stabilizing care” to anyone who shows up at that emergency department with an "Emergency Medical Condition" before inquiring about the patient’s ability to pay[1].

This law did not stipulate that those hospitals, or the doctors who practice at those hospitals, be reimbursed in any way for providing that stabilizing care, just that they provide it.

Naturally, doctors and hospitals consider this an example of a heavy handed government engaging in cost-shifting. CMS countered with a paper written by one of their economists that what they do here is not technically “cost-shifting” for reasons.

Hospitals now employ staff to get uninsured patients who qualify for Medicaid signed up so they’ll get paid.

(I haven’t seen stats on this in several years, but the last numbers I saw were that around half of US hospitals lose money on an operating basis. They make up the balance in the gift shop, cafeteria, endowment if they are lucky enough to have one, local taxes, or bankruptcy court.)

0 - that’s basically “all hospitals”

1 - the actual rules are more complex, but that’s the gist of it

The US should not be used as an example of a small government. Some people in the US may profess to wanting a small government, but they definitely don’t have one.

Haven’t run the numbers but I would suspect the US government is the largest government in human history.

You goto seperate the imperial machine of world policing (paid in the dollats used and held by the world for trade)from the government managing the citizens of the us (parially paid in taxes by the citizens)

I’m not sure how one would define “the size of government” but the ILO says differently at least:

https://worldpopulationreview.com/country-rankings/public-se...

(Wikipedia has a similar page, but not as navigable imo)

I scroll through a lot of European countries before getting to the US at 13.4%.

I think the healthcare (and other) systems suck because they are complex. There are two ways to hid information: lock it up (lack of transparency) OR dilute it amongst noise. The latter is what complex systems of whatever do. Complex systems create opportunity for those with enough resources to locate and exploit eddies of wealth in the system. While those without the time and resources to spend understanding the complex system just decry it because it is too difficult to understand.

Well clearly absolute staffing numbers would work, but I would go by absolute money spent.

I think it's ironically reductive to simplify a complex problem to a general problem of complexity.

I'm not sure what your point is, we appear to agree that the system is corrupted and that there is regulatory capture. My point is that the US government shouldn't be used as an example of a small government in general and for healthcare specifically. Even if I was to agree that the US should adopt an European healthcare system I don't see how to uncorrupt the existing system to enable that to happen. This notion that a government takeover will take the money out of the system and diminish opportunity for greed is fanciful.

Isn't US military alone the biggest money spending governmental organisation (well, technically multiple organizations), in history.

This is fair. I personally agree that US government is small, or should be small for that matter. A lot of EU countries have much more efficient governments.

My original comment was about the neo-conservative ideology, which was either directly in power or heavily influencal in governmental policy in US since Reagan. It's, like anything ideological, mostly symbolic. I think the whole healtchare debate is just one of the symbolic points of this ideology. Ideologies change, and I certainly hope this for US and rest of the world that it changes.

Something like 20% of population get their health care from government Medicare too

We don’t have a small state. It intentionally meddles in everything from mail delivery to medical care, to make them worse for the masses and better for the agents of the state.

Those agents really just being normal self selecting biology like everywhere else.

Functional illiteracy where people can only understand life through a job and paying bills is a carefully crafted propaganda. America been at the forefront of converting wartime propaganda research into advertising and marketing. A big government military industrial complex is the backbone of the economy. We just look away because wtf else we gonna do?

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