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Comment by raganwald | Hacker News Reader

Single-payer or government provided healthcare? Pretty sure that no one would identify the government as the picture perfect example of efficiency. Plus, putting elected officials or their appointees in charge of handing out goods and services doesnt seem to be sustainable.

It seems odd to me that so many Americans seem pessimistic about their own government. I could understand if the attitude was, "We could make universal, socialized healthcare work. We could make it cheaper than Canada's. We could make it better than Sweden's. We just don't want to for ideological reasons."

But how can it be that the attitude is, "It would never work here?" You're the greatest empire in the history of civilization. What is this word "can't" and why is it in your vocabulary?

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Well, we do already spend more than the UK on providing health insurance (divided by total population), but we're just providing it to seniors and poor people.

The problem is the morass of laws we've accumulated around healthcare over the years for various reasons that now interact in complex ways that nobody foresaw. Like the law designed to make Medicare or Medicaid (I forget which) drugs cheaper that ended up making it illegal to give free birth control to college students.

We also have the laws from when people believed that competition increased costs and so tried to ban competition between hospitals. Or the committee that sets doctor's reimbursement rates for Medicare procedures based on the *$%@# labor theory of value. And the laws designed to prevent people from overcharging Medicare that means that everybody has to worry about those rates across the industry. Or the way that the makeup of that committee means that primary care physicians gets shafted.

And the fact that we allow so few schools to teach medicine means that they can charge an arm and a leg, which means that those poor shafted PCPs need the kickbacks they get for assigning specialist care in order to pay off their student loans and malpractice insurance.

And I could go on.

And now we have this system that's incomprehensibly complex. So Congress has no way of figuring how to fix it on their own. There are people who've spent years figuring out how all of this works, but that's their job and if the system was actually fixed their job would be gone and that understanding they spent years acquiring would be useless.

Which isn't to say that this is entirely hopeless. There have been some efforts at the hospital level like Kaiser Permanente's to ameliorate the perverse incentives in the system and capture some of the value unlocked by that. And there are some laws that could be changes or repealed (like the one against hospital competition) without really breaking anything. So I think that gradual reform might be possible, but it's going to be a long road that doesn't particularly involve the issues that people tend to talk about around healthcare.

Instead of a gradual reform, what about enabling a new medical system , bound to new relaxed laws and new people to control it, to exist side by side to the current system, that would focus on low cost healthcare ?

Maybe it would be "lower quality", but least it would offer choice for many , and be a great research lab for low cost healthcare.

In slightly less words and with slightly less accuracy, you're unwilling or unable to wipe the slate clean and start from scratch.

To an extent I wonder how much of that is due to lack of recent experience with starting from scratch. The United States hasn't had a revolution, a war on its territory, or a regime collapse in a long time.

What first-world country has?

Germany and Japan were rebuilt from the ground up after 1945, France is now on the fifth republic, Spain, Portugal, and Greece shed dictatorships in the 1970s, some of Eastern Bloc now qualify as first world and have undergone a major change in 1989-91...

What's even more bizarre is that we have a single-payer system that's wildly popular among the 48 million people it serves and has demonstrated an excellent ability to control costs. It's called Medicare. It's currently restricted to those over 65 and certain people with disabilities, but expanding it to cover everyone would be a relatively easy task, it seems to me, compared to the gyrations we're going through trying to fix the private insurance system.

It's not just that many Americans have been persuaded that a single-payer system works for the old and disabled, but for some reason isn't right for everyone else. Rather, many Americans have been brainwashed into simultaneously supporting Medicare and opposing a generalized single-payer system, with equal fervor, without noticing the contradiction.

(Yes, really. I saw a photo a year or two ago of a protester at a rally carrying a sign that said "NO SOCIALIZED MEDICINE / DON'T TOUCH OUR MEDICARE", or similar language.)

It's because of "American Exceptionalism." Single payer health care was not invented in America, therefore it could not possibly work in America. Education is similar. There are always at least 20 countries ranked ahead of the USA in primary and secondary education. Yet none of the successful approaches used in those countries can even be experimented with in the USA, because they "would never work here." Things are just different here, you see.

Knowing this, if one really wanted to implement single payer care in America, it would be more likely to succeed if the program was marketed as something like "Super Patriot America Care, just like our boys get in the US Military!" rather than calling it single payer care, which is some Euro/Canada not-invented-here thing that can't possibly ever work, because of America.

The funny thing is that the "father" of socialized welfare is Bismark, and the German system is largely private, and that too works far better. It doesn't have to be single payer: Pretty much every model that has set out with the requirement of providing universal coverage, in a country with enough money to fund it decently, has ended up better.

Freedom at the point of delivery.

To echo Raganwald, I too don't understand a blanket unwillingness to even seriously consider the single-payer model. Like you'd be a socialist or a communist for even considering having private doctors and hospitals paid by the government instead of the patient.

From what I understand, drugs are much cheaper in Canada. Almost all medical procedures are cheaper here. I met a couple from Texas who flew up here for something, and they said it was cheaper for them buy plane tickets, stay here in a hotel for two weeks, and all other travel expenses, and get the procedure done here than to do it at home (uninsured). They still saved thousands of dollars after all that. That's craziness.

Maybe there's no perfect system. But the United States spends the most on health care per citizen, and has the lowest percent of government support. [1] You should at least consider what others are successfully doing to get the costs down and increase the quality of care for the uninsured and poor.

[1] http://en.wikipedia.org/wiki/Health_care_compared#Internatio...

Well, Americans don't really vote, they prefer the government stay far away (imagine someone in Wyoming viewing a Federal solution kind of like Brussels solving Greece's health care problem), moneyed interests/cartels have a lot of sway, and some groups don't like paying for other groups' healthcare.

Local solutions don't really work for medical care, in terms of the legalities and economic structure, you have to require everyone to participate.

In this case, size and diversity work against us, it's just a lot easier in a small homogenous Scandinavian country.

Anyway, we have Obamacare gradually being implemented, where all employers above a certain size are supposed to offer insurance, and everyone else is supposed to buy it (the 'mandate' which the Supreme Court says is really just a tax).

So, maybe a minimum level of health care will start to be universal. But in order to get it through they made sure everyone was well greased. If the doctors, the hospitals, the insurance companies, or the pharmaceutical companies had to tighten belts a notch that would have been enough to sink it. So, it's going to stay very expensive.

> size and diversity work against us

I really think that people don't appreciate this fully for a lot of problems that the US has which have been 'solved' in other countries -- usually smaller European ones. Mail delivery, rail transportation, healthcare, etc. The US has a very unique blend of very urban and very rural areas that makes it hard to scale lots of services easily to everybody.

It may be a vicious cycle at this point, Americans have no faith in their government, and their government proves itself unworthy of their faith.

I find that Americans hold the attitude that the government is not the picture perfect example of efficiency except in the case of the military. Spoiler alert: we have a quasi-single-payer system for the military.

Part of the reason that the military is able to do a relatively good job providing healthcare is that they can do a lot of sensible cost-saving things that are illegal in most places. Like using nurse-practitioners instead of MDs where appropriate.

Nurse practitioners are used in many countries with great results. Why is using them illegal ? of course it's because of regulatory capture and the general power doctors hold, which is probably the biggest reason why healthcare is so expensive(and also not very good).

You see it in million places: The limited number of medical schools, The lack of nurse practitioners doing the simple routine jobs in most specialties(dental, family, colonoscopy, anesthsia. Many others could exist), The lack of automation and expert systems[4] and automated patient interview[3] tools, the fact that family practitioners could replace a lot of the specialists work at lower costs[1], Many medical jobs could be done with a lot less training[2], the lack of use of proven processes like checklists[5], etc.

All those changes could save a lot of money, and raise quality. We know what to do, But how do we implement it ?

[1]http://www.rwjf.org/en/grants/grantees/project-echo.html

[2]Because there's a brain drain in africa to the west, some countries have started a 3 year surgeon degree program. Doctors who finished this degree seem to have equivalent results to fully trained doctors in simple/medium complexity surgeries.

[3]Research showed doctors only ask about half of the questions needed in a typical visit. Automated interview systems could at least gather more complete data.

[4]There's research review showing that correct implementation of decision support/expert systems could improve results.

[5]Peter provonost showed that checklists could reduce infection rates in one procedure from 8/12 percent to zero.This was around 10 years ago. I think gawande showed similar results in other stuff. checklists are still not commonly used.

Number 3, absolutely. That's true in the UK too. In fact, if AI consulted the patient, it would catch a lot of things which doctors miss, simply by asking enough pertinent questions.

When I have challenged doctors about this, they tend to say "Ah, but you're focused on data, we focus on diagnosing the patient", which is basically gibberish.

http://en.akinator.com/

That web app can name any person you think of by asking 20 or so questions. Just imagine what you could do if you made that but for diseases.

Let's do it. I had this idea that each medical field could have a sort of Global Subject Expert AI online to make diagnoses, and the more people using it, the more sublime it would become in its assessments.

If you're interested in building something, I think an automated medical interview app, for use by consumers, focused on some subset seems more practical.

That's exactly what Watson is doing these days, right?

Similar things have been done before, for example Isabele health care, and other medical decision support systems.

The lack of adoption of checklists has bugged me for a long time now. I actually haven't heard of them in regards to infection rates, but rather surgery mishaps (I think that was Gawande). It's really disappointing that something so simple, with such clearly positive results, has yet to become mainstream practice. We make our commercial pilots use them; I wish we would mandate that our surgeons used them, too.

Pretty sure us Brits still get a claim on the empire thing. Pretty sure...

He meant the benevolent kind of empire.

Since the US doesn't annex territories for itself and keep them as colonies as part of some Commonwealth Realm.

Although the US could have if it tried, with the slightest flex of a myoblast, in the last great war. It still can.

Pretty sure that's what he/she meant.

Puerto Rico, US Vigin Islands, American Samoa, CNMI, Guam, and most importantly Hawaii are all annexed territories of the United States. Not to mention California and most of the west really.

> Since the US doesn't annex territories for itself and keep them as colonies as part of some Commonwealth Realm.

Nope. Neve happens. (Cough >Hawai'i<, cough)

If you just thought it were Ireland, Wales And Scotland that have an often uneasy relationship with England, you'd be surprised to learn who else bows to the English Crown.

(And yes Scotland has an upcoming referendum in 2014 on the issue of independence from the UK.[1] This is widely believed to be a losing proposition.)

Commonwealth Realm Antigua and Barbuda, Australia, Bahamas, Barbados, Belize, Canada, Grenada, Jamaica, New Zealand, Papua New Guinea, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Solomon Islands, Tuvalu

Crown dependencies: Guernsey, Jersey, Isle of Man

British Overseas Territories: Akrotiri and Dhekelia, Anguilla, Bermuda, British Antarctic Territory, British Indian Ocean Territory, British Virgin Islands, Cayman Islands, Falkland Islands, Gibraltar, Montserrat, Pitcairn Islands, Saint Helena, Ascension and Tristan da Cunha, South Georgia and the South Sandwich Islands, Turks and Caicos Islands

[1]http://en.wikipedia.org/wiki/Scottish_independence_referendu...

"This is widely believed to be a losing proposition." - evidence? I don't know if you're a UK citizen or living in Scotland, but I'd love to explain some of the nuances of Scottish politics. They said, once upon a time, that the SNP would never have a majority leadership (due to the way that the electoral system was designed for the devolved parliament) in the Scottish parliament, but look what happened at the last Scottish general election.

Perhaps what the Scottish people don't like the idea of is the SNP becoming the governing party of Scotland. However, and this is frequently ignored by the unionist press in Scotland, the SNP would not necessarily be the ruling party. There would be a new general election to vote for a new Scottish government in an independent Scotland and that could be Labour, SNP, Tory, Democrat, Greens or whatever.

There is a huge amount of disinformation banded about by Cameron, Osborne and other unionist politicians about Scotland's capabilities.

As an aside, "bowing to the English Crown" - the BAT, South Georgia, BIOT don't actually have any native population, and Pitcairn only has a population of 60.

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