I don't think Democrats (or Republicans when they take power) are clever/smart/kind/honest enough to offer universal single-payer healthcare without rationing. Is there an intent to take my health care choices away, and is that intent benevolent or malicious?
You paint a very abstractly wonderful picture, so let's assume yes and benevolent if rationing is to be expected given the finite tax base. I still need more details before I get on board with your plan.
First of all, my employer and I pay through the nose for my decent healthcare right now. Under your universal single-payer healthcare system, will I still be able to pay quadruple-through-the-nose to buy supplemental insurance such that I can still continue to get halfway decent service when I want it? Or, am I going to be stuck with everyone else waiting for rationed care out of fairness?
Also, are you planning to cap salaries of doctors and profits of hospitals and insurance companies out of fairness? (You think it's hard to get quality specialist care now??)
A different opinion from yours goes something like this: US health care is so expensive and inaccessible to 10% of the population because government got involved. The federal government twisted the HC system into a bureaucratic pretzel with no market forces to control costs. The absurd system we have now is a consequence of letting busybody crusaders and insurance company cronies write the laws.
I am not saying that viewpoint is accurate, but it's worth getting diverse voices into the discussion so that we don't wind up with an unhealthy progressive monoculture here on HN.
If we talk to each other like friends that have differing opinions, then we can find lots of little improvements that a majority of us can agree on, like maybe up-front pricing in hospitals or tort reform. If we can bring costs down and make health care more accessible to more people, then maybe we won't feel forced to take risky steps like forcing everyone to cede their personal health care choices to indifferent government pencil pushers.
Reaching out to you as a friend, I feel we both want the same thing - to have the maximum number of people possible receive quality care. I feel we're both frustrated that the current system is so unfair in so many ways.
I'm not opposed to setting up a safety net, as long as it doesn't get out of hand cost-wise or turn into a racket for the cronies. I'm thinking like mending broken bones, treating infections, vaccinations, most generics, and addiction treatment all should be abundant, cheap and/or free. Panacea it would not be with a fixed budget so that as a program it cannot grow to crony levels. You could sell me on providing basic health services like that because it just makes sense economically and public health-wise.
And I hope you're not opposed to weeding out waste, fraud, and abuse as one approach (of many) to fix a broken system. If we can get costs demonstrably down, maybe you'd even be open to deep cuts in existing nondiscretionary programs like medicare that have insane unfunded liabilities and will eventually crush us.
Maybe there is a middle ground that satisfies between us politically such that we can move forward together rather than lurching crazily right and left every 8 years.
check out Australia's healthcare system as a middle ground then. I've lived in the UK (free, single-payer, government-run) and Australia's, and I prefer Australia's because it has a mix of both government and market.
The basic principle is that the Australian Federal Government subsidises healthcare by a fixed amount for each procedure. So iirc, it was AUD$45 for a visit to the GP. That's enough for some GP practices to be able to offer a free service (referred to as "bulk billed" because they only billed the government). Obviously those services become popular, so to get a free appointment you have to wait a while. Or, you can pay a bit yourself to get an appointment with a doctor who charges more than the government rate and are therefore less in demand.
In Australia I could usually get an appointment next day if I paid $25-50 or so. In the UK it was usually a 1-2 week wait, but free.
This goes for everything (except dental care for some reason, I don't know what's up with that). So an X-Ray costs $200, or nothing if you can wait until next week. And so on.
Health insurance covers the additional costs, and I paid $25/month for a plan that meant if anything serious happened I'd be liable for the first $250. And it also gave me dental cover, so I could claim some (but not all) of my dental care from my health insurance - a net gain for me most years.
The NZ system is similar. GPs are subsidised (your primary health provider) but hospitals are run by the government and are free. The unfortunate thing is you have to go through the GP to get a referral to the Hospital (unless you go into A&E).
The other interesting system that NZ has is something called ACC which also pays for rehabilitation and loss of income when someone has an accident. If you are paralysed and can no longer work then ACC will pay you something like 80% of your income until you manage to find another job. That could be for the rest of your life.
my employer and I pay through the nose for my decent
healthcare right now [...]
Under your universal single-payer healthcare system,
will I still be able to pay quadruple-through-the-nose
to buy supplemental insurance
Here in the UK, the private health insurance arranged by my employer costs them $450 per year.
I don't know how much US insurance costs your employer, but I assume it's several times more, rather than several times less, than mine pays!
After all, in the UK private medical insurance doesn't have to cover ambulances or emergency surgery or pre-existing conditions or chronic illnesses or old age or organ transplants or childbirth.
> I don't know how much US insurance costs your employer, but I assume it's several times more, rather than several times less, than mine pays!
You also likely make half what I make and that's before taxes (my wife is from the UK, I looked at jobs over there and rural US IT salaries can beat London IT salaries). I prefer my deal to yours.
That’s true, but how much of that extra money you get to keep in the long run is determined by the health lottery. If you end up having cancer for 5 years, you can kiss it all goodbye.
But yes, one thing that's tough for Europeans who haven't lived in the US to comprehend is that Americans really do prefer being able to buy a bigger TV to having proper security when it comes to health care.
>Most employer sponsored healthcare plans in the US have a maximum out of pocket the patient can be charged per year.
Yeah, but that's irrelevant if you have to use an out of network provider in an emergency situation, or if you need a treatment that your insurance provider refuses to cover.
The lack of global insurance policy for actual emergencies is a crime of this insurance system you have in the US.
This is where the government is supposed to step in. Nobody is in any position to predict where they will be taken for emergency care, and copays for random amounts is essentially ransom.
If I lived in the London with the salaries they wanted to pay I'd be poor either way. It was enough to live in a tenement block. take public transport and eat cheap food. In the US I own a home, two cars, and support my entire family from just my salary. If I got cancer in the US I'd have be forced to live in a tenement block. take public transport and eat cheap food just like if I was "lucky" in the UK.
I'm not sure exactly what you mean by a "tenement block", but a typical tech salary in New York or San Fransisco isn't going to be enough to live in a town house. If you're in a city, you're going to be in an apartment, and that apartment is probably going to be in a block of apartments.
>If I got cancer in the US I'd have be forced to live in a tenement block. take public transport and eat cheap food just like if I was "lucky" in the UK.
That's an interesting perspective on public transport. Public transport is a far more pleasant way to get around London than driving :)
But, no, you could end up in a far worse situation than that in the US. Medical costs are very unpredictable and bear no relation to your wealth. You could easily end up bankrupt and unable to pay for vital medical treatment. I realize that most Americans like to live in complete denial of this fact, but it's inarguably true.
Also, even taking what you say at face value, it's quite incredible that you're satisfied with this. Why should you have to take a massive hit in living standards just because you get sick?
>but a typical tech salary in New York or San Fransisco isn't going to be enough to live in a town house.
That's true, but then I'd be talking about salaries that aren't double of what is offered in London but 5 or 6 fold higher. I own my home and support my wife and daughter by myself in a low crime suburban area in the US, that isn't possible anywhere I could find in the UK. Did I also mention I didn't go to college?
>But, no, you could end up in a far worse situation than that in the US. Medical costs are very unpredictable and bear no relation to your wealth. You could easily end up bankrupt and unable to pay for vital medical treatment.
When you get that sick you end up on socialized medicine, SSDI and medicaid cover those costs at that point. Also while you will receive medical bills you don't actually have to pay them while hospitals are not allowed to refuse you life saving treatment.
Tech salaries in NYC and SF aren't 5 or 6 times higher than tech salaries in London.
>I own my home and support my wife and daughter by myself in a low crime suburban area in the US, that isn't possible anywhere I could find in the UK.
I'm not sure what you're saying at this point. I grew up in a low crime suburban area in the UK. My Dad worked, my mom stayed at home. They owned the house. My Dad works as a programmer.
>When you get that sick you end up on socialized medicine, SSDI and medicaid cover those costs at that point.
Erm, no. You will not likely meet the eligibility requirements for medicaid. That's just wishful thinking. If that's how the system worked, medical bankruptcies wouldn't happen.
>Also while you will receive medical bills you don't actually have to pay them while hospitals are not allowed to refuse you life saving treatment.
They're not allowed to refuse you life-saving emergency treatment. They sure can refuse to give you chemo, refuse to give you reconstructive surgery if you've been badly burned, etc. etc.
It's astonishing how unaware you are of how the health system works your own country. America has a lot of work to do on this issue.
> Tech salaries in NYC and SF aren't 5 or 6 times higher than tech salaries in London.
I've seen 75k USD salaries commonly in London and 400k+ is not unheard of in fang companies.
>Erm, no. You will not likely meet the eligibility requirements for medicaid. That's just wishful thinking. If that's how the system worked, medical bankruptcies wouldn't happen.
If I have money and insurance why do I need assistance? The disaster situation you were describing seemed to imply that I would no longer be working and have insurance. If I'm working and have insurance I'll just pay my copays and get care that way. If I have no income due to a disability, I'd get SSDI and medicaid.
>They're not allowed to refuse you life-saving emergency treatment. They sure can refuse to give you chemo, refuse to give you reconstructive surgery if you've been badly burned, etc. etc.
>I've seen 75k USD salaries commonly in London and 400k+ is not unheard of in fang companies.
You're just comparing a typical dev salary in London to an unusually high dev salary for NYC or SF. I don't see what insight you hope to gain by doing that. (The people making big money as software developers in London work as independent consultants rather than employees, by the way, as it's more favorable from a tax point of view and - lol - you don't have to worry about not having health insurance.)
>If I have money and insurance why do I need assistance?
Because you don't have enough money. There's no cap on medical bills. See for example the article I linked to regarding the $500,000 bill for dialysis. The person in question had insurance.
>Care to cite a time where that ever happened?
Holy crap, you really mean it. It happens all the time, as you can find out just by googling. Hospitals are under no obligation to give you chemo if you can't pay for it.
>You're just comparing a typical dev salary in London to an unusually high dev salary for NYC or SF.
If you make much less than that in SF or NYC, there is no point in living in such an expensive place. Go make that London salary working in a rural area of the US.
>Because you don't have enough money. There's no cap on medical bills. See for example the article I linked to regarding the $500,000 bill for dialysis. The person in question had insurance.
From your article: "A few days after the treatments began, an insurance case manager called the Valentines warning them that since Fresenius was out-of-network, they could be required to pay whatever the insurer didn’t cover. The manager added that there were no in-network dialysis clinics in Montana, according to Jessica’s handwritten notes from the conversation. (The insurance company disputes this, saying that its case manager told Jessica there were no in-network dialysis clinics in Missoula.)
Jessica repeatedly asked both the dialysis clinic staff and the insurer how much they could expect to be charged, but couldn’t get an answer.
Then the bills came."
So basically, insurance said they would not pay for the clinic this person selected and since they have zero agency they kept going and got the bill that they were told they were going to get. So sad. Did they actually pay the bill? Of course not. They took a credit hit.
>Holy crap, you really mean it. It happens all the time, as you can find out just by googling.
What was one individuals name who this happened to. Not a study. Not "we think it happens". What is the persons name?
>If you make much less than that in SF or NYC, there is no point in living in such an expensive place. Go make that London salary working in a rural area of the US.
The median household income in New York is $50,000. I would rather live in London than in a rural area of the US - thanks. You talk as if people have no preferences besides maximizing the salary to cost of living ratio.
> So basically, insurance said they would not pay for the clinic this person selected and since they have zero agency they kept going and got the bill that they were told they were going to get.
I can’t figure out exactly what you’re trying to say here. It seems you are trying to find some way to convince yourself that these people deserved to get a $500,000 bill so that you can kid yourself that this could never happen to you. Yes, it’s their fault for failing to fly to another state in the middle of a medical crisis to find an in network provider, in the absence of any clear information regarding treatment costs from from medical staff or the insurance company.
> Did they actually pay the bill? Of course not. They took a credit hit.
We don’t know from the article how much they ended up paying. In any case, taking a credit hit is not a trivial thing. In your earlier comments, for example, you clearly placed a large value on home ownership. It’s difficult to buy a home with bad credit.
>What was one individuals name who this happened to. Not a study. Not "we think it happens". What is the persons name?
This article collects a number of stories involving named individuals:
You are citing bustle who is in turn citing tweets with that article. That's your best evidence? Can't find a AP article anywhere? Shouldn't there be thousands and thousands of examples to pick from?
There's a documentary about the Mayo clinic on netflix. In it, a woman finally recieves a diagnosis of her mysterious and debilitating illness, of which she is pretty sure she would die from without diagnosis or treatment. She responds to initial treatment, which makes her hopeful the quality of life will finally approve. Then she no longer has money, and cannot have treatment anymore. She leaves the clinic and we never know what happens to her.
From what I'm told should be thousands of stories like this, why can't you find one where you can prove that the person died? It's all rumor and second hand stories. If someone in my family died due to someone refusing them medical care I'd be all over the media about it.
From the first example: "By the time Portillo found out about a small county program that sends health workers to the homes of low-income, bedridden patients, her father had been at home without pain medication for two and a half months. The nurse practitioner who came, spurred by Aquilino’s obvious suffering, rushed to order medication to make him more comfortable. Two days later, when the morphine had barely had a chance to soothe him, he was gone."
There was a program, they didn't use it until the end, he was going to die anyway. He did not die due to lack of medical care.
I'm not going to go through each one, give me your best example.
>??? There are studies that directly show that not having insurance is deadly.
Also that tobacco doesn't cause cancer, guess what those studies have in common?
"Also that tobacco doesn't cause cancer, guess what those studies have in common?"
No, please do tell me exactly what those studies have in common, with citations.
You asked for something that isn't rumor and second hand stories. I provided. Now you move the goalposts and ask for my single best story. Please clarify your behavior and your motivations in engaging in this discussion: Do you actually wish to process data that is contrary to your belief on how the world functions?
The people who produce them benefit from the result.
Who says we need massive governmental spending in healthcare? Why governmental healthcare authorities of course! I'm skeptical, especially when the specific examples provided don't match up with the rhetoric.
Also the burden would not even be that people die from lack of healthcare in the US, it would be that more people die from lack of healthcare in the US than people die from healthcare rationing in the UK. He's a case of someone who actually died from that[0].
It’s dishonest to refer to the Charlie Gard case as an instance of healthcare rationing. Doctors refused (experimental, zero-chance) treatment for purely medical reasons: it wasn’t the best thing for the baby. The resulting court case was over the question of whether doctors are required to (a) act in accord with the best interests of the child or (b) do whatever the child’s parents want. The answer turns out to be (a). Financial considerations never entered into the decision. The deciding factor was medical: a series of epileptic seizures which reduced the chance of a successful outcome to ~0. It isn’t ethical to torture a baby with ineffectual treatments just because the parents are (understandably) not ready to accept that the baby is going to die.
"The people who produce them benefit from the result."
Can you cite specific studies, their specific researchers, and their specific funding grants?
"Also the burden would not even be that people die from lack of healthcare in the US, it would be that more people die from lack of healthcare in the US than people die from healthcare rationing in the UK"
This is not what you claimed. Please clarify the contradiction between your statements.
At least one reader certainly doesn't. You're asking everybody for evidence that could stand up even in court while you respond with anecdotal data and personal experience based on biased, incomplete, or generic data.
"I live and work in rural US and suddenly I can afford a lot more than I could if I had one of those jobs I found after an internet search for London" does not pass the bar you expect other people's evidence to. Not by a long shot.
To make this anecdote into a data point the GP should post his whole financial history. E.g. how much they made and spent. What do they own and then we can also check what can they buy.
For example, can he buy a typical hip surgery, which over time is likely? CLL treatments? Medical transport should it be necessary?
Hire a nurse? Get a broken limb in a cast?
... Not lose a job because they cannot get to it for a month because of bum leg?
Cost of each of these can be actually checked ahead of time, for UK and for US. Including a split between in network vs out network in the US.
If people are dying, we can count deaths due to causes that would be preventable in UK and in the US, as well as cost in each case.
No, he would have to say something just slightly more specific like: "rural means a suburb of City X". Or "I'm a programmer working remotely for a Fortune 500 company". Anything that can make the rest of the statement meaningful. I mean I understand not wanting to give out personal details but then don't bring it up if it's so generic.
I can tell you rural Kazakhstan can pay 5 times more than the same job in US. But without giving you details it will seem like an exaggeration or flat out lie. It's not, just a cherry picked example.
If a study comes up with figures that don't have particular names attached (data protection and all that) then unless you have some evidence to disprove it we can take it at face value. Fighting it with empty hands and generic unverifiable counterarguments feels like trying to save face.
If you consider that study data bad so be it. But then accept that your data is equally bad at best. And I'm being generous here, you provided no "data" to speak of. No aggregate data, no study, not even a hint of specificity.
On one hand you talk about London (very specific), on the other it's "rural US" (97% of US!). Nothing about the actual job or its conditions, what you looked at to compare, etc.
I mean it's absurd to discredit a study with sources and actual figures but try to pretend your claim looks like anything more than an impulse comment.
Please clarify: What is your point? You asked for any evidence, and when provided, denied it as evidence, reiterated that you had always asked for specific evidence.
Nobody can seem to find a specific person who died due to lack of healthcare with anything more than a tweet to back it up. Lots of "almost" cases but no definitive deaths. Why do you think that is given you claim this is happening all day every day.
It's not just about dying. It's about living. I have had minimal to no access to quality medical care in America since I went through this. I have had to choose NOT to seek care for things I needed to because I cannot pay for it. I have been denied many things a reasonable person would expect to receive. There is only one reason people defend this system...ego. They cannot accept that American Capitalism isn't the best thing ever. Their pride matters more than other people. It's shameful.
Four weeks. No sick days part of the four weeks. None but I can afford to support her while she is home with our daughter for as long as they need. None besides about 5 job offers in my inbox per day.
You're privileged enough to be in the right industry in the right location, with the right skill sets and experience, at the right time. If things were different you'd get no holidays, no job security, etc. I know people in tech on the east coast of the US who struggle to get two weeks leave and struggle to change jobs. Four weeks is something the rest of the world just takes for granted. I also know people that have been bankrupted because of health costs, this was my uncle who was a millionaire and had the best insurance money could buy. His wife got cancer, they fought the insurance company, sold the business and the car collection and houses, she died, he went bankrupt. It was very sad.
I used to work in the bay area but ultimately decided to come home. Here in NZ in the tech industry I earn a couple of hundred thousand which is admittedly less than I'd learn in the US but while things like employment protection aren't important to me right now I also take comfort by the fact that if I get hit by a car ACC will cover my loss of income and rehabilitation, I simply don't have to worry about getting sick or injured. I also take comfort by the fact that everyone, be it a barista or a barrister, has the same perks (like four weeks paid leave, sick leave) and protection that I do.
Another example: a company I worked for in NZ was a US multinational, they did a big restructure where they laid off thousands. Because of employment law most of the lay offs were people in the US, South America, and Asia. Europe and New Zealand were almost completely unscathed, it was just easier.
On one hand you ask for exact names of people who have gone through unfortunate health or medical bills related moments but on the other hand you compare esoteric "identical jobs" with no consistency or transparency. One in London which barely pays for an apartment in a tenement building, public transport, and nothing else. The other is in "rural US", pays double, you can afford a house, 2 cars, and to support your whole family by yourself, and a whole list of other benefits (some unusual for the US).
Are they really the same job? Are the 2 salaries/conditions representative of the job or you just got lucky? Are they actually identical (what happens if you're sick for 6 months?)? Are the salaries that you could find published on the internet representative for London? What's "rural" US? Are you working from home for a big company or do you have to be on site? If you have to work in your town/suburb what other career opportunities are available for you and your family there compared to London? You may be happy with your salary now but if there's no room to grow, or you have no choice if you lose you job/company goes bust, then it's not quite ideal.
I understand you may not want to provide details about your personal life but as it stands you have anecdotal evidence that may or may not be based on flawed data (cherry picked examples or low quality information), while everyone else supported their claims with actual links.
Just in case: I'm not British, nor do I live there.
Health care is always "rationed". In the US it's rationed by ability to pay. This is far worse both ethically and practically than any means of rationing it via a cost/benefit calculation.
As far as I know, no presidential candidate is proposing to stop people from buying private medical insurance, so your worries seem entirely unfounded in fact. Even in the UK, you can get private medical insurance if you want to.
There is a lot of abstraction in your statements culminating in an attempt to paint me as unethical. I wish we could just talk like friends who happen to disagree on policy.
I don't believe a functional health care market where providers must compete on price and quality is as static as the system we have now. The "rationing" you describe that we have today is because we don't have a functional market or insurance system.
> As far as I know, no presidential candidate is proposing to stop people from buying private medical insurance, so your worries seem entirely unfounded in fact.
Rewatch the debates and listen to the policy statements and their implications, I don't think you're correct.
>I wish we could just talk like friends who happen to disagree on policy.
I think it's a terrible mistake to treat this as a wonky policy issue rather than an urgent ethical issue. That conception of things is part of the reason that it's been so hard to reform the system.
> I don't believe a functional health care market where providers must compete on price and quality is as static as the system we have now. The "rationing" you describe that we have today is because we don't have a functional market or insurance system.
I've read through this a couple of times but can't really make any sense of it. As long as people have to pay for their own treatment, people with more money will be able to get better treatment. That's a form of rationing, and it wouldn't go away if the "market" were to get more "efficient".
>Rewatch the debates and listen to the policy statements and their implications, I don't think you're correct.
If one of the candidates is proposing to ban private health insurance, it should be easy for you to reference a statement to this effect.
> I think it's a terrible mistake to treat this as a wonky policy issue rather than an urgent ethical issue.
Your passion is admirable, but no need to insult, friend. I'm not a policy wonk, I just disagree with you. I don't have the same faith in government's ability to deliver services as you do. America is especially bad at delivering services, given our tendency towards crony capitalism and a disengaged public. It is possible to make things worse than they are now with totally well-meaning, but flawed, economic and social policies.
> it should be easy for you to reference a statement to this effect.
I searched on DDG, got tons of good hits for "debate ban private health insurance" and I picked the first link. The socialists (who aren't looking too hopeless in the polls and actually stand a chance at being the nominee) want to run things soup to nuts, no surprise here. Harris walked it back afterward, Sanders stood his ground and beat her over the head for a lack of conviction.
> Harris and U.S. Senate colleague Bernie Sanders were the only two candidates to raise their hands during Thursday night’s second Democratic debate when asked, "Who here would abolish their private health insurance in favor of a government-run plan?"
> On Wednesday night, U.S. Senator Elizabeth Warren of Massachusetts and New York City Mayor Bill de Blasio were the only two candidates to raise their hands when asked if they would scrap private insurance.
Please just watch the debates and don't give anyone a pass. I'm counting on you and others to not pick an unelectable wacko to run against Trump. Full disclosure, I didn't vote for Trump (or Hillary) in 2016.
Ethical disagreements exist. You may not think that this is an urgent ethical issue, but I do. I'm not going to say that your position is ethically acceptable just because it would make you feel better - sorry.
You're really selling the US short if you think that it can't implement any one of the multitude of healthcare systems that exist in other first world countries - all of which are superior both in terms of outcomes and in terms of basic decency. This kind of pessimism is just a convenient excuse for doing nothing while people are dying.
I believe there will come a time when the right to healthcare is no more up for debate than, say, women's right to vote (no longer a "policy" issue). But, clearly, we're not there yet. You still seem wedded to the idea that the system has to be set up in such a way that a person's access to health care is significantly limited by their wealth. Thus, only certain basic treatments will be "abundant and/or free" even in your ideal conception of how the system should work! And you talk about giving the "maximum possible" number of people in the US access to high quality care - as if this maximum were somehow obviously less than 100%! When you can't get care, it's "rationing". When 15% of the population can't get it because they're too poor, then, well, gee, that's just the market at work I guess.
The bottom line here is that Americans still see healthcare as a job perk rather than as a right. That's ethically obscene, but it's still the mainstream point of view, so you're by no means alone. If you are happy with your own personal situation at present, then by all means sit out elections and float pie in the sky market-based schemes as alternatives to actionable policy proposals that would actually make a difference.
Thank you for your detailed response, I'll try to honor it.
> Ethical disagreements exist. You may not think that this is an urgent ethical issue, but I do. I'm not going to say that your position is ethically acceptable just because it would make you feel better - sorry.
Yes, we do disagree. But, we have to go forward together by dealing with each other honorably and not operating from the default assumption that the other is below reproach or sub-human in their thinking. We need to hammer home that the perfect should not be the enemy of the good (myself included.)
We have to make deals and compromise to implement any policies that will be durable and maintain their original spirit. Think Medicare and SS as examples of big compromise bills that lasted, and the ACA as a contra-example. If you don't believe in your bones that we need to compromise on the big stuff, then life will be full of disappointments.
> superior both in terms of outcomes and in terms of basic decency
What about our obesity epidemic, isn't that a factor contributing to our outcomes? Do all countries use the same measure when tallying outcomes? What are our comparative outcomes for health care at the extremes? Like, when your twins are born 2'10" and 2'11" respectively and still live and are healthy after 7 years?
I'm sorry, but respectfully, that talking point is so cherry-picked, and ignores so many factors, that it is meaningless. It is only intended to shock and to shame. Reality is more complicated than just "outcomes are worse." Do not insult my intelligence.
> I believe there will come a time when the right to healthcare ...
Medicare turns people away all the time, it's actually hard to get them to pay a claim. A right is a only truly a right when it can't be denied. Just start asking simple questions, and the 'HC as a right' concept falls apart.
Like, which health care procedures are a right and which are elective? Sex reassignment isn't a right ... this year ... maybe next year ... until the Republicans take power again ... see what I mean? A service like health care isn't so simple, nor black and white, as you paint it.
I do not believe you can make your "100% covered" math work AND pay doctors and hospitals such that they will continue to work for you such that you don't wind up with a doctor shortage and induce rationing.
I do believe that my "maximum possible" can reach an effective "100% covered". Think of how cheap technology and process changes can make things over time. The world is not a static system, it's dynamic and fluid! For example, Amazon.com, a recent phenomena, is being described as an anti-inflationary force across the entire economy because they are so effective at driving down costs and haggling on prices!
> pie in the sky market-based schemes
Come now... Consider there is no rationing of food. Food on store shelves regularly goes bad and we have to throw it out, we produce such an abundance.
Consider the US manufactures 8x the amount of clothes that actually gets sold. If it weren't for Africa taking, basically for free, all of our excess clothes, we would be incinerating the excess at the end of each fashion season.
Consider veterinary services and how much affordable they are relative to comparable human health care. Like, vet services paid out-of-pocket, no insurance at all affordable. Why? How?!
Consider health care and student loans - both seeing spiraling cost increases. What's the connection? Heavy government involvement and crony influence.
What I'm saying is ...
Market forces perform! Pay people up to what the market will bear, and you'll never have a shortage of workers to provide a service. Then, encourage competition and allow people to shop based on price and quality. Next, the market will control for excess and will find a stable value for each service that will be as optimal as it can get. Finally, if you can ease up on regulations, then the cost of providing a service goes down further and businesses will reinvest in themselves, which can further lower the costs.
It's economics. The model for how to unleash market forces and make services cheap and accessible exists in standard textbooks.
The fact that health care is currently expensive and people's lives hang in the balance makes this discussion more than just economics. I think that's mainly what you are driving at. And I respect your passion in that regard. Honestly, I get you on that! Your whole paragraph there is full of bitterness for me, but why can't you get me, friend?
I'm passionate too AND I don't want anyone to suffer! Like, no one normal wants other people to suffer. You know that, right? Finally, if it is true that I actually want to alleviate suffering just like you ...
A market system means that you get what you pay for. Poor people get crap healthcare while rich people get great healthcare - for as long as their money lasts. Unless you think that MRIs are going to become as cheap as paperclips, there's no market mechanism that will level the playing field in that respect.
You may respond that poor people would still be covered by Medicare. But your skepticism of the efficiency of the government should extend to its ability to reliably identify the people who need assistance. And if you are ok with the government paying for some people's healthcare, it seems to me that you've given up the main principle. Why not just have a public option open to anyone, and let "the market" compete with that? If the government is as useless as you say, insurance companies should have nothing to fear.
The problem with student loans in the US is arguably a lack of government regulation. In the UK, for example, there are very strict regulations on interest rates and the repayment schedule. Although student loan debt is still a drag on the younger generation, it doesn't bankrupt anyone.
If you are still looking for inconsistencies in my position, then you haven't yet accepted that I want to find compromise solutions. I am ok with not getting everything I want. We're all walking inconsistencies anyway.
That said, you are right to call me out on that and student loans because I slipped into talking points mode, which was a futile attempt at one-upsmanship. I'm never going to convince you my opinion is the right one, and vice-versa. All that matters is we both have an accurate understanding of the other's worldview so we can discover where the give and take can happen.
> Why not just have a public option open to anyone, and let "the market" compete with that?
My answer is just another weak talking point regarding US states that have tried that and failed. The private market in those states predictably collapsed because employers took the opportunity to dump employees onto the state run plan. Which was, of course, the goal and no one is fooled.
The story ends sadly however, the state tax base couldn't support everyone dumped on the public option and virtually no one remained on the private plans to subsidize the public ones. So, the public options got scrapped. States can't run a debt like the Federal government can, so their plans have to square financially or the whole apple cart gets upturned. There's the harsh reality for ya! <mic drop>
And that was the most pathetic, cherry picked story with zero details that didn't include counter-stats about the thousands of mothers and children getting health care for the first time in those states, etc etc. You sank my battleship! Did I just change your mind about single payer? Of course not, and that's fine by me.
I just hope you are softening to the idea that someone who disagrees with you is not automatically an ogre, and can be well-meaning. There is far too much distrust driving factions in our society, when it is easy to find so much common ground if we just talk.
My position is: the market left to do its thing produces goods/services that are cheap and plentiful. Yours is, I think: the market has no soul and there is corporate greed/corruption and the market will always have losers, so we need to intercede and level the playing field for people. Please correct me if I got you wrong.
See, we both have solid points that the other must certainly agree with - the evidence is clear on both sides. What is not obvious is that one position does not negate the other. There is a right balance to be found between the two.
Here's how we balance as I see it: we don't dare make policy that wrecks the market so we keep the bounty -and- we don't dare leave people to suffer and die when we have all this bounty. BOTH! Not one at the expense of the other. Cautious, tuned, scientific, numbers based, avoid failures from history, and give ourselves grace that we're doing our best and we'll never reach Utopia.
> Poor people get crap healthcare while rich people get great healthcare
The world is not static. Today's crap healthcare and over the counter meds are impossible, miraculous health care if you compare with what people experienced historically. Caesar lived less healthfully than the American lower class. How can we get more good stuff into more people's hands more efficiently?
MRI's won't ever be as cheap as paper clips, but in twenty years TCFT hand scanner technology will make MRI's a blip in history and you will even be able to buy a consumer-grade scanner for a few hundred bucks at Walgreen's. Ok, I made that up, but hopefully you get the point that greater things are coming than the things we have now.
>The world is not static. Today's crap healthcare and over the counter meds are impossible, miraculous health care if you compare with what people experienced historically.
Isn't this just a weaselly way of saying that you're perfectly fine with poor people getting much worse care than rich people? What does it matter that they're getting better care than rich people did 100 years ago?
>Ok, I made that up, but hopefully you get the point that greater things are coming than the things we have now.
I'm sure that is a great comfort to uninsured patients with stage 3 cancer! We could just give them the care they need right now, but I guess it's better to wait some indeterminate amount of time till the market brings the cost of chemotherapy down to $100/month.
>My position is: the market left to do its thing produces goods/services that are cheap and plentiful. Yours is, I think: the market has no soul and there is corporate greed/corruption and the market will always have losers, so we need to intercede and level the playing field for people. Please correct me if I got you wrong.
As far as compromise is concerned, I don't really see any room for it here. There are many ways to provide universal health coverage. I have not insisted on a single payer system at any point in this discussion. However, it seems that what you want to compromise on is not the means of delivery, but the universality itself.
In all of your long and irrelevant discourse on various economic points, I don't detect any concrete statement of what it is about the current system in the US you don't like, and how you'd actually propose to change it. So it seems to me that you de facto support the current system.
No economic system has abolished status or privileges.
Not even Communism. To fight status itself is to fight human nature. People will always try to obtain benefits and pass them down to their children.
200 years ago, all medicine was hospice care. Allocating resources to an industry for which there is infinite demand for - staying alive - will be difficult.
>Allocating resources to an industry for which there is infinite demand for - staying alive - will be difficult.
Will it? The NHS does an ok job. Not perfect by any means, but much better than the US.
I don't demand perfection, just something significantly better than a situation where 15% of the population are uninsured. Do you think that is so terribly difficult?
> Isn't this just a weaselly way of saying that you're perfectly fine with poor people getting much worse care than rich people? What does it matter that they're getting better care than rich people did 100 years ago?
Why do you want to fight, friend? Maybe you perceive moral superiority such that it's easier to tear down than cooperate. Like I said before, that's a recipe for disappointment. Improvements in health care matters because that's a trend that is apparently still continuing. What am I missing?
And I'm not fine with cancer, another insult! Don't you get me yet, my friend?
I do know we're going to definitively cure cancer soon such that the treatment doesn't break the bank as it does today. Until that happens, let's work to bring down the costs AND help out people who can't afford what services are on offer today. Why not both?
> what it is about the current system in the US you don't like
I don't like how the health care insurance covers everything. The cheap stuff should be out of pocket so that individuals shop on price for those services and we build a competitive marketplace on the simple stuff.
I want up-front pricing for services in hospitals, and if I am of sound mind, I must opt into services before they are delivered. Finding out what services cost after I get them is one of the scammiest features of the current system.
I don't like how drug prices are artificially inflated in this country by Medicare and Washington cronies.
If I were a dictator, I'd mandate everyone who takes a salary must save some percentage (6-8%) of every paycheck in a personal medical savings account the way that Singapore does. If you get health services, you have to pay the full freight for the services out of your account, encouraging market forces. When that account runs out, you're screwed.
It's not taxed, and you can leave your account to your heirs. You can also buy catastrophic health insurance so you're not screwed in the event of a big event. The government offers low-income people additional catastrophic health insurance options and charities help pick up the rest of the slack.
We can't force that kind of mandatory savings in the US, it's unconstitutional. But, if we could go the mandatory MSA + catestrophic health insurance route, we would maximize market forces and yield results close to universal coverage that results-wise goes far beyond anything you can propose.
See? I've thought all about it.
I could just as easily say, "you have no realistic plans for controlling costs while delivering high quality service in abundance." But I suspect the life and death aspect of health care is an overriding priority for you, and delving into cost/waste/fraud/abuse is a non-starter. I believe that access to health-care in name only (a.k.a. government-induced rationing) is no health-care at all, though. Affordable, effective, abundant: pick 3.
So, no more insulting my intelligence, and please assume good faith, my friend!
You've written a lot without addressing the key point. It seems that you are fine with poor people getting much worse care than rich people. At least, you've declined several opportunities to indicate that you're not fine with this, and none of the suggestions that you're making would make things any better for Americans who currently lack insurance. Indeed, you're quite clear about what happens to people who can't pay up: "When that account runs out, you're screwed." Charming.
The fact that the cost of cancer treatment may go down in future is totally irrelevant to the question of how we pay for people's cancer treatment today. As far as I can see you only bring it up as a means of dodging the question of how poor people can get cancer treatment now. Rather than indicate how this might be possible now under the system you envisage, you talk about how it might be possible 100 years hence. You may whine about me taking the moral high ground, but can't you see how crass it is for you to play down people's present suffering on the grounds that people 100 years hence may be better off? What sort of reaction were you expecting to comments of that nature?
The concept of "catastrophic" health insurance transparently makes no sense. Any insurance plan that doesn't cover all the expensive treatments is next to useless. So obviously, no-one (either insurers or patients) can save very much money by nickel and diming patients for inessential treatments. Indeed, if these "catastrophic" plans don't cover screenings and other preventative measures, they'll probably end up increasing everyone's costs in the long run.
Bizarrely, you seem to think that the main problem with the current system is that people have too much coverage. This makes so little sense that I'm unable to engage you on that point. This is particularly so given that you are simultaneously so vague about the nature of the system that you favor and so unwaveringly certain that it would deliver better "results" (if, of course, we ignore all the poors).
The countries that pay less for drugs are the countries with a greater level of centralisation and government control. Drug companies are behemoths, and it takes another behemoth to negotiate a good deal.
>I could just as easily say, "you have no realistic plans for controlling costs while delivering high quality service in abundance."
I can point to plenty of existing systems that do this. E.g., the healthcare system of pretty much any European country.
Thank you for a respectful reply. I feel like we're finally talking.
> You've written a lot without addressing the key point. It seems that you are fine with poor people getting much worse care than rich people. At least, you've declined several opportunities to indicate that you're not fine with this, and none of the suggestions that you're making would make things any better for Americans who currently lack insurance. Indeed, you're quite clear about what happens to people who can't pay up: "When that account runs out, you're screwed." Charming.
I said that blunt thing on purpose, partly to draw you out and get you to express yourself, and partly to express my philosophy.
I am not fine with disparity, I just don't believe we can eliminate it through top-down, central planning or through collectivization. That's my bottom line; we probably won't ever bridge this philosophical chasm between us. But I appreciate having the opportunity to explain myself conversationally to you.
Expanding my thoughts a little, in my opinion government is particularly bad at addressing inequity because on the ground there is zero incentive for individuals in government to fully solve problems - that would put government workers out of a job. Yes, some people get aid, there's some salve for the hurt, but on the whole government spending on "programs" tends to be a racket for cronies.
I don't expect you to agree, just explaining my thoughts. If you want to provide contrary notions, and give some depth to your worldview, I'd like to hear it. I would like to know how we solve the problem of poor and rich getting the same quality services without also degrading the services.
Regarding the "screwed" comment - guilty as charged - that was too harsh. Here's the nagging concern that drives my thinking: when there is a natural disaster and community, family, and government structures are stripped away, people are forced to fend for themselves. If they haven't prepared for disaster mentally and with provisions, they can die needlessly.
So, I favor a government whose policies encourage self-sufficiency and resilience that will lead to a robust populace that can be free and happy in their own situation and not make themselves prostrate to others for their survival. Dependency, like debt, is slavery. Freedom is totally worth the trouble we put people through.
In my dictator scenario, I envisioned forced savings for routine medical bills, optional catastrophic health insurance for the unexpected huge claims, and freedom to shop for providers as the route to "well-nigh universal" health care.
You would need to be my advisor though, because there are always destitute people in any society that have no income and have no insurance. We'd would need to provide for them somehow. I'm open to haggling on various points. ;)
> The fact that the cost of cancer treatment may go down in future is totally irrelevant to the question of how we pay for people's cancer treatment today.
Yeah, it's an awful problem! You sound very fed up and in a rush to see action especially on cancer. What would you do as dictator to address this? Make me your trusted advisor!
I observe cancer treatments are at least improving and we're getting better outcomes. We should at least look for ways to lower costs to make treatments available to more patients. It's not a perfect solution, but it's a start.
> The concept of "catastrophic" health insurance transparently makes no sense.
We just see the utility of insurance differently than you do. I see it as a backstop, not a catch-all. I want people to pay out of pocket for the simple stuff so they search for and demand lower cost options. That lets the market deliver the goods.
> Bizarrely, you seem to think that the main problem with the current system is that people have too much coverage.
No, I don't think that. The US definitely has a dysfunctional way of covering the poor however (emergency rooms that take all comers.) I would love to see some fixes there, because the system we have now encourages the poor to suffer with easily treatable conditions and is very inefficient economically. It's easy to make rational arguments about delivering health care services to the indigent. Frankly, I think such arguments are unassailable.
My position is that health care in the US is overregulated and lacking market forces that could control costs. I don't believe a single-payer system in the US would be accompanied by deregulation, and therefore costs would continue to rise.
> The countries that pay less for drugs are the countries with a greater level of centralisation and government control. Drug companies are behemoths, and it takes another behemoth to negotiate a good deal.
I have heard this argument before and never understood why the blame isn't placed 100% on government. What you describe should have happened decades ago.
Medicare and Medicaid covered 37% of health care costs in the US in 2017.[1] That is HUGE buying power, they can set the worldwide prices for drugs. Noone who is in power at the federal level seems at all interested in negotiating.[2]
That's a very interesting article that takes years to get to the money quote:
> No Negotiation, the Price Is Set
> The major reason for the disparity in pricing is that the United States lacks any sort of central or universal healthcare system or agency that regulates across the board cost. In contrast, negotiations of drug prices between governments and pharmaceutical companies are routine in Canada, most European nations, and most countries in the Middle East and Far East. They have centralized authorities to negotiate more favorable prices with manufacturers, and some also have drug formularies and advisory boards that put restrictions on the use of new and expensive medications.
Wow, sounds good, what's the hold up?? From later on:
> However, by law, the federal government cannot negotiate for Medicare drug prices or obtain any sort of volume discounts.
It was Medicare Part D where the feds jumped deep into the prescription business and this mischief got started. High drug prices in the US is baked into the plan. And there's no incentive to fix the problem because everyone is on the take.
This is where you and I are, I hope, arm-in-arm. Medicare should negotiate with these drug companies such that all Americans get drugs at rates offered to comparable countries! Abolish that corrupt law. I'm not even talking about price controls, I just want the same or better deal that every other country negotiates.
But, Democratic and Republicans are attached like barnacles to the special interest money and that bad law is a worth a fortune. This isn't an abstract issue: people are suffering and dying today because of cronyism. Awful realities like this destroy my faith in government, especially federal. If I am wrong on this, I would love to have you explain it to me.
Thank you again for being so peaceable in your reply. I felt very relaxed replying to you this time.
> As far as I know, no presidential candidate is proposing to stop people from buying private medical insurance
A couple of the variants of Medicare-for-All, including Sanders’, would prohibit normal private health insurance (they would allow private plans for certain non-core benefits, but those aren't what people talking about private medical insurance are mostly talking to about.) I mean, technically, they don't prohibit buying plans, only selling them, but...
> Even in the UK, you can get private medical insurance if you want to
As far as I know, no Presidential candidate is campaigning on a healthcare plan based even loosely on what the UK currently does.
You paint a very abstractly wonderful picture, so let's assume yes and benevolent if rationing is to be expected given the finite tax base. I still need more details before I get on board with your plan.
First of all, my employer and I pay through the nose for my decent healthcare right now. Under your universal single-payer healthcare system, will I still be able to pay quadruple-through-the-nose to buy supplemental insurance such that I can still continue to get halfway decent service when I want it? Or, am I going to be stuck with everyone else waiting for rationed care out of fairness?
Also, are you planning to cap salaries of doctors and profits of hospitals and insurance companies out of fairness? (You think it's hard to get quality specialist care now??)
A different opinion from yours goes something like this: US health care is so expensive and inaccessible to 10% of the population because government got involved. The federal government twisted the HC system into a bureaucratic pretzel with no market forces to control costs. The absurd system we have now is a consequence of letting busybody crusaders and insurance company cronies write the laws.
I am not saying that viewpoint is accurate, but it's worth getting diverse voices into the discussion so that we don't wind up with an unhealthy progressive monoculture here on HN.
If we talk to each other like friends that have differing opinions, then we can find lots of little improvements that a majority of us can agree on, like maybe up-front pricing in hospitals or tort reform. If we can bring costs down and make health care more accessible to more people, then maybe we won't feel forced to take risky steps like forcing everyone to cede their personal health care choices to indifferent government pencil pushers.
Reaching out to you as a friend, I feel we both want the same thing - to have the maximum number of people possible receive quality care. I feel we're both frustrated that the current system is so unfair in so many ways.
I'm not opposed to setting up a safety net, as long as it doesn't get out of hand cost-wise or turn into a racket for the cronies. I'm thinking like mending broken bones, treating infections, vaccinations, most generics, and addiction treatment all should be abundant, cheap and/or free. Panacea it would not be with a fixed budget so that as a program it cannot grow to crony levels. You could sell me on providing basic health services like that because it just makes sense economically and public health-wise.
And I hope you're not opposed to weeding out waste, fraud, and abuse as one approach (of many) to fix a broken system. If we can get costs demonstrably down, maybe you'd even be open to deep cuts in existing nondiscretionary programs like medicare that have insane unfunded liabilities and will eventually crush us.
Maybe there is a middle ground that satisfies between us politically such that we can move forward together rather than lurching crazily right and left every 8 years.