I'm always fascinated when health care discussions start up on HN; watching Americans argue amongst themselves about single-payer or nationalized health care systems as if those systems are dangerous thought experiments are mesmerizing.
No matter how many people say "but a well regulated mandatory multi-payer type of system is working in Germany" or "nationalized medicine is working in Canada" it's all just ignored and the argument continues anew.
>No matter how many people say "but a well regulated mandatory multi-payer type of system is working in Germany" or "nationalized medicine is working in Canada" it's all just ignored and the argument continues anew.
I don't think their problem (at least of one side of the debate) is whether it will work or not.
Their issue is a moral one, whether they should ever pay into a health care pool for the benefit of other people.
Those that think they can manage on their own don't see why that should happen. And as a protestant inspired culture that took it even further than the original protestants, they find this appalling.
They'd rather see people die in the streets and step over them on the way to brunch, than have themselves, hardworking "good" persons that they are, contribute for the health of the poor and the "losers". Even more so if it's mandatory. Charity from their magnanimous heart, they can consider.
1 - A significant portion of our economy is healthcare middlemen. With single payer or nationalized care, all of our Blue Crosses and Cignas (and the jobs associated) would evaporate overnight.
I'm not arguing that we need trillions of dollars of our GDP locked up in middlemen, but it's very hard for a man to understand something when his salary depends on his not understanding it.
2 - We hear about long wait times in other countries. And the stories are mostly true. There's nothing wrong with waiting, but we've been conditioned to expect near-immediate resolutions.
People in the United States with high-quality private insurance* can usually be seen by a specialist within a few weeks regardless of how severe or immediate their problem is. The truth is that unless that person has some kind of advanced or rapidly progressing disease, they could wait for months without any problems. But that would be a major change to the way we think. It would mean allocating care based on need, not based on ability to pay.
*High-quality private insurance is usually one of the perks of working for a great company. I would argue that only a small minority of Americans have truly high-quality coverage. But all of the people who don't have high-quality coverage envy the others and vote with them, a la "temporarily embarrassed millionaire."
It's complicated. The US spends more per capita (PPP) than any other country by good margin [1]. Of that, the US government pays roughly 50% of the total cost [2]. The net effect is that the US government already pays as much per capita as many European countries with socialized medicine.
In short, we have a cost problem that's not being tackled. Pharmaceuticals are often targeted, but they're about 8% of our total healthcare costs. We really need politicians that will tackle the other aspects of cost.
The countries that finance public healthcare have tax systems that are considered regressive by US standards. Some states have sales taxes, but we have no national VAT. As I understand it, some countries like Sweden have income taxes on lower income workers, whereas in the US, roughly 45% of households pay no federal income tax.
You can only squeeze so much money out of the wealthy, but the numbers don't add up to cover the projected costs of nationalized healthcare in the US. Taxes would need to be raised across the board. It's easy for campaigning politicians to propose pie-in-the-sky plans, but proposing a financially plausible one would be political suicide.
Yup. The UK has a particularly vicious variant of this - the nationalised state-provided monotlithic system has its weaknesses, but everybody in the media only ever discusses American-style privatisation rather than all the various hybrid models. The mere existence of the American system is kind of a threat to our system which currently has zero healthcare bankruptcies.
(People also misleadingly claim that the UK system excludes private provision - it doesn't, it's just that only a small fraction of the population has it and the tax advantages are nonexistant. Optical and dental are also mostly private.)
It's not ignored. I don't know much about the German system, but I'm an immigrant from the UK and I much prefer the US system to the NHS, and I hear similar horror stories about Canada. Which is not to say the US system is good, just better.
In the US, when I need a doctor, I get to see one right away. If the doctor recommends an MRI or ultrasound, I get it right away. No six month waits, no cancelled surgeries, no doctor strikes (!), no government deciding how to prioritize my medical needs, etc.
What it ultimately comes down to is that medical resources are scarce (and always will be while medical technology is improving and thus some care is expensive), and having the government allocate them can be inefficient (governments are generally inefficient due to lack of competition, as are systems where the customer is disconnected from the cost).
And yes, I care more about my own health care and that of my kids than I do about the health care of some stranger thousands of miles away. I have okay corporate health insurance and so the system works better for me than for some. (Some would argue that regulation rather than economic freedom are to blame for those people's worse experiences, but I'm not going to get into that other than to acknowledge it.)
You might disagree with some of my perspective, but the snooty attitude that Americans are oblivious morons is unwarranted.
The same thing happens for everything. If it hasn't happened in America, Americans argue as if it is a theoretical idea that has never before been tried on Earth.
I wonder if we really have to wait a full generation with the "new conditions" (such as national healthcare) already in place for the bickering to taper off. That is, the discussion about how much downtrodden-ness is OK as long as shareholders get increasing value.
I mean, at one point for the hospitals to continue to operate at ever more profits you basically have to stop curing people and make them come back. You can combat that with more choices, but nobody is breaking up the banks, so why would they break up the big hospitals?
The Netherlands has private healthcare and private insurance companies and has the second best healthcare system in Europe. The price per capita is on Northern/Western European average at 5300 USD per person. World-wide we are the 8th most expensive country per capita which seems fair given our high wages.
So even though we have the second best healthcare system and pay an average price for it, people still want to nationalise our system and revert the privatisation. Because "privatisation bad". It truly baffles me that people think it will be for the best. Perhaps the price will go down to the 4100 USD per capita that the nationalised UK system has has but I'm sure our quality would also drop to UK levels (16th place in Euro Health Consumer Index).
Well,anecdotally,I am friends with a family where one of the spouses grew up in Canada. Their advice when we were planning a trip to Canada was to make sure not to get seriously ill while we were there. Not the first time I have heard of this attitude from Canadians or people from UK.
I do not have anything good to say about our "system" (except that the doctors and nurses themselves are many times exceptional), but I also have seen enough of government run systems to know that that is not not an answer.
What you (and most Americans) fail to understand is the states are separate entities, more similar to the EU than the provinces of Canada.
If California wants to have socialized health care for all it's residents, literally nothing is stopping them. Many states already have 100% government medical insurance for the poor.
The reality is, government run systems are an absolute nightmare. Similar to government housing, you only use it if you can't afford the alternative.
>No matter how many people say "but a well regulated mandatory multi-payer type of system is working in Germany" or "nationalized medicine is working in Canada" it's all just ignored and the argument continues anew.
Practically nobody is saying that a single payer system or tightly regulated multi-payer system hasn't worked anywhere (we all know Canada exists) or can't work in the US.
Everyone is arguing about the specific implementation because those are the details that make or break it. Anything would work on paper. Even free market with some good regulations to promote competition would probably work. It's the specific details of actually implementing something that works (and the ability of the people who would be doing the implementing to get those details right and not be corrupted by existing interests) that everyone is arguing over.
Everyone with a brain realizes that when it comes to big systems involving lots of moving parts the fine tuning is what makes or breaks them. Look at all the various social services programs that were kneecapped over the years because someone came along and made a few small changes or some key feature was compromised out of existence. Everyone is bickering over every detail because every detail has the ability to cause massive amounts of hardship when applied at a societal level if said detail is done wrong.
Simply put, healthcare is a hard issue because the stakes are so high that nobody is apathetic about it making compromise and consensus hard to reach.
Has there literally ever been a case where a merger actually improved things for customers to the extent suggested by the merging companies? I certainly can't think of one.
In the case of hospitals, a system occasionally takes over a bankrupt hospital. That isn't particularly worse for the people that continue to have proximity to the services available at the hospital.
A lot of people think that tmobile and metro PCS merger really benefited the mobile carrier industry.
While there were more companies before the merger, verizon and at&t were dominating that a long tail of small companies was not true competition.
When tmobile merged, it started to add a true 3rd competitor to the scene and they were the first to do a lot of stuff with unlimited data. Many people attribute verizon and at&t following suit to their initial move.
Of course this is speculation as no one can prove casual linkage between these events, but it seems pretty plausible.
I'm not sure if economists have developed some sort of model that would show when a consolidation would be beneficial in the long term for consumers, but I'd sure like to see one. We tend to not like it when firms collude with each other to control prices or stave off competition, in fact, we make it illegal to do so. But we rarely give them much trouble when they want to merge, which really isn't any different from collusion, don't you think?
If marginal services or businesses essentially /need/ to merge to survive it could improve things certainly, but in that case the extent suggested is usually slim to none since the alternative is foregone insolvency for both.
There are studies that a fragmented hospital landscape wit too many small hospitals are increasing risks here in Germany. Whether mergers would make matters any better I don‘t know.
Though it's definitely the exception, I found it nice when Patreon and Subbable merged. Everyone being on one platform, and the payment structure being consistent, was a plus.
It would be nice if the FTC did their job of breaking up conglomerates and preventing monopolistic competition. But Washington is like a plutocracy and the FTC wouldn't be serving the interests of all that network of money and favors being passed around.
Hospitals, healthcare, should not be a business. If money is the end goal, cheap + efficient medicine will be thrown away, it might not even be profitable ! A curse for a businessman.
Competitive markets tend to optimize large profits away. If someone is charging lots for less effective treatment, the expectation in a market economy is that a competitor will step in.
The analysis you present is not uncommon, where the businessman somehow gets to choose how much money he makes in a vacuum, a situation that doesn't really exist.
Ironically, lots of US regulations prevent providers from entering markets, letting providers that already have regulatory approval charge more. Some regulations are literally written with this as the goal (CONs, Medicare reimbursement rules designed to prop up small hospitals with emergency rooms).
Hospitals are not a “business”. They are non profit companies that rake in revenue and billions in profit while undermining the cost of care to Americans.
There aren’t sufficient amount of people willing to do the highly undesirable work of caring for sick, contagious, handicapped, possibly dangerous people without money as the end goal.
The two best healthcare systems in Europe are in Switzerland and the Netherlands. They went from nationalised to privatised. Nationalised healthcare systems tend to rank lower on the quality index.
And while the Swiss system is expensive, can you really put a price on your health? I'd rather have a good system (Switzerland) than a cheap system (UK).
Many on the left despise mergers and consolidation, and anything that has a hint of monopoly power. Except when it comes to government, education, and healthcare! Doesn’t a single centralized monopoly providing everyone’s healthcare seem like a bad idea? Why is it so bad in business and so good for health?
I can't read the article. Does it get into whether the hospitals actually merged process in any useful way? I worked at Kaiser when they were attempting to get their hospitals to share medical records (through SOAP). It taught just how home spun every hospitals IT is. Frankly, I'm a little skeptical much progress could have been made as a result of a recent merger.
Consolidation of IT systems should make them easier to protect but in practice it seems like the net result is any IT problem ends up harming multiple hospitals instead of just one. When the same chain owns multiple hospitals in a single market, all of them having IT problems at the same time is dangerous as the others can't pick up the slack.
IT consolidation only happens when it is prioritized, and in many cases you end up with some hybrid system of bastardized mapping/integration tiers rather than a pristine single environment. Healthcare IT also has the challenge of ridiculous amounts of highly specialized and largely turnkey systems, interop with other hospital and research organizations and of course the ever-present regulatory requirements that must be maintained throughout.
Didn't read the article but the headline is absolutely not a surprise.
Unintended consequences of PPACA made the system significantly worse. They let multiple industries consolidate using PPACA as an excuse. Yet no one will talk about it for political reasons. This happened across the board not just among hospitals. I am surprised UNH didn’t start buying out biotech companies to make drugs exclusive to their plans.
Quality? The peeps who are already make big money running hospital corporations are mainly interested in making more money. Where I work patients are actually to as customers in some interoffice emails...
Nor do business mergers in general. The benefit of mergers is that bigger companies have bigger benefits for top executives. For example, higher status, bigger paycheck and better car for the CEO.
I recently realized that hospitals in the US are for profit. So probably, the mergers do increase returns for investors? Which was probably the goal of the merger anyway.
The reason you want smaller entities in private healthcare is that is reduces the size and impact of bankruptcy risk. Same reason you want smaller banks.
If you want competition to work you have to have sufficient excess capacity in the system to allow entities to fail and fail fast.
Not so much a case of big enough to cope, but small enough not to matter that much in the grand scheme of things.
That ought to be the rule of thumb for any competition authority - if this new entity went pop, would we notice?
Capitalism without the threat of bankruptcy is like Catholicism without the threat of hellfire. It no longer works as a concept.
In before, “This is proof positive free markets don’t work for healthcare”.
Excellent material for those interested, an actual cash only, price listed, customer facing hospital. Shiver ye comrades for the devil capitalist is and has been here.
[+] [-] Ensorceled|6 years ago|reply
No matter how many people say "but a well regulated mandatory multi-payer type of system is working in Germany" or "nationalized medicine is working in Canada" it's all just ignored and the argument continues anew.
[+] [-] coldtea|6 years ago|reply
I don't think their problem (at least of one side of the debate) is whether it will work or not.
Their issue is a moral one, whether they should ever pay into a health care pool for the benefit of other people.
Those that think they can manage on their own don't see why that should happen. And as a protestant inspired culture that took it even further than the original protestants, they find this appalling.
They'd rather see people die in the streets and step over them on the way to brunch, than have themselves, hardworking "good" persons that they are, contribute for the health of the poor and the "losers". Even more so if it's mandatory. Charity from their magnanimous heart, they can consider.
[+] [-] slumdev|6 years ago|reply
1 - A significant portion of our economy is healthcare middlemen. With single payer or nationalized care, all of our Blue Crosses and Cignas (and the jobs associated) would evaporate overnight.
I'm not arguing that we need trillions of dollars of our GDP locked up in middlemen, but it's very hard for a man to understand something when his salary depends on his not understanding it.
2 - We hear about long wait times in other countries. And the stories are mostly true. There's nothing wrong with waiting, but we've been conditioned to expect near-immediate resolutions.
People in the United States with high-quality private insurance* can usually be seen by a specialist within a few weeks regardless of how severe or immediate their problem is. The truth is that unless that person has some kind of advanced or rapidly progressing disease, they could wait for months without any problems. But that would be a major change to the way we think. It would mean allocating care based on need, not based on ability to pay.
*High-quality private insurance is usually one of the perks of working for a great company. I would argue that only a small minority of Americans have truly high-quality coverage. But all of the people who don't have high-quality coverage envy the others and vote with them, a la "temporarily embarrassed millionaire."
[+] [-] nhebb|6 years ago|reply
In short, we have a cost problem that's not being tackled. Pharmaceuticals are often targeted, but they're about 8% of our total healthcare costs. We really need politicians that will tackle the other aspects of cost.
The countries that finance public healthcare have tax systems that are considered regressive by US standards. Some states have sales taxes, but we have no national VAT. As I understand it, some countries like Sweden have income taxes on lower income workers, whereas in the US, roughly 45% of households pay no federal income tax.
You can only squeeze so much money out of the wealthy, but the numbers don't add up to cover the projected costs of nationalized healthcare in the US. Taxes would need to be raised across the board. It's easy for campaigning politicians to propose pie-in-the-sky plans, but proposing a financially plausible one would be political suicide.
[1] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
[2] https://en.wikipedia.org/wiki/List_of_countries_by_health_ex...
[+] [-] pjc50|6 years ago|reply
(People also misleadingly claim that the UK system excludes private provision - it doesn't, it's just that only a small fraction of the population has it and the tax advantages are nonexistant. Optical and dental are also mostly private.)
[+] [-] endtime|6 years ago|reply
In the US, when I need a doctor, I get to see one right away. If the doctor recommends an MRI or ultrasound, I get it right away. No six month waits, no cancelled surgeries, no doctor strikes (!), no government deciding how to prioritize my medical needs, etc.
What it ultimately comes down to is that medical resources are scarce (and always will be while medical technology is improving and thus some care is expensive), and having the government allocate them can be inefficient (governments are generally inefficient due to lack of competition, as are systems where the customer is disconnected from the cost).
And yes, I care more about my own health care and that of my kids than I do about the health care of some stranger thousands of miles away. I have okay corporate health insurance and so the system works better for me than for some. (Some would argue that regulation rather than economic freedom are to blame for those people's worse experiences, but I'm not going to get into that other than to acknowledge it.)
You might disagree with some of my perspective, but the snooty attitude that Americans are oblivious morons is unwarranted.
[+] [-] freddie_mercury|6 years ago|reply
[+] [-] fwsgonzo|6 years ago|reply
I mean, at one point for the hospitals to continue to operate at ever more profits you basically have to stop curing people and make them come back. You can combat that with more choices, but nobody is breaking up the banks, so why would they break up the big hospitals?
https://3.bp.blogspot.com/-XZHRqu2UjeE/U7LUMgY49HI/AAAAAAAAP...
[+] [-] systemtest|6 years ago|reply
So even though we have the second best healthcare system and pay an average price for it, people still want to nationalise our system and revert the privatisation. Because "privatisation bad". It truly baffles me that people think it will be for the best. Perhaps the price will go down to the 4100 USD per capita that the nationalised UK system has has but I'm sure our quality would also drop to UK levels (16th place in Euro Health Consumer Index).
[+] [-] whodidntante|6 years ago|reply
I do not have anything good to say about our "system" (except that the doctors and nurses themselves are many times exceptional), but I also have seen enough of government run systems to know that that is not not an answer.
[+] [-] linuxftw|6 years ago|reply
If California wants to have socialized health care for all it's residents, literally nothing is stopping them. Many states already have 100% government medical insurance for the poor.
The reality is, government run systems are an absolute nightmare. Similar to government housing, you only use it if you can't afford the alternative.
[+] [-] dsfyu404ed|6 years ago|reply
Practically nobody is saying that a single payer system or tightly regulated multi-payer system hasn't worked anywhere (we all know Canada exists) or can't work in the US.
Everyone is arguing about the specific implementation because those are the details that make or break it. Anything would work on paper. Even free market with some good regulations to promote competition would probably work. It's the specific details of actually implementing something that works (and the ability of the people who would be doing the implementing to get those details right and not be corrupted by existing interests) that everyone is arguing over.
Everyone with a brain realizes that when it comes to big systems involving lots of moving parts the fine tuning is what makes or breaks them. Look at all the various social services programs that were kneecapped over the years because someone came along and made a few small changes or some key feature was compromised out of existence. Everyone is bickering over every detail because every detail has the ability to cause massive amounts of hardship when applied at a societal level if said detail is done wrong.
Simply put, healthcare is a hard issue because the stakes are so high that nobody is apathetic about it making compromise and consensus hard to reach.
[+] [-] 0xcde4c3db|6 years ago|reply
[+] [-] maxerickson|6 years ago|reply
In the case of hospitals, a system occasionally takes over a bankrupt hospital. That isn't particularly worse for the people that continue to have proximity to the services available at the hospital.
[+] [-] gretch|6 years ago|reply
While there were more companies before the merger, verizon and at&t were dominating that a long tail of small companies was not true competition.
When tmobile merged, it started to add a true 3rd competitor to the scene and they were the first to do a lot of stuff with unlimited data. Many people attribute verizon and at&t following suit to their initial move.
Of course this is speculation as no one can prove casual linkage between these events, but it seems pretty plausible.
[+] [-] baron816|6 years ago|reply
[+] [-] ma2rten|6 years ago|reply
[+] [-] warent|6 years ago|reply
[+] [-] Nasrudith|6 years ago|reply
[+] [-] heisenbit|6 years ago|reply
[+] [-] ironmagma|6 years ago|reply
[+] [-] wallace_f|6 years ago|reply
[+] [-] Heyso|6 years ago|reply
[+] [-] maxerickson|6 years ago|reply
The analysis you present is not uncommon, where the businessman somehow gets to choose how much money he makes in a vacuum, a situation that doesn't really exist.
Ironically, lots of US regulations prevent providers from entering markets, letting providers that already have regulatory approval charge more. Some regulations are literally written with this as the goal (CONs, Medicare reimbursement rules designed to prop up small hospitals with emergency rooms).
[+] [-] bobobob420|6 years ago|reply
[+] [-] noelsusman|6 years ago|reply
[+] [-] lotsofpulp|6 years ago|reply
[+] [-] tehjoker|6 years ago|reply
[+] [-] systemtest|6 years ago|reply
And while the Swiss system is expensive, can you really put a price on your health? I'd rather have a good system (Switzerland) than a cheap system (UK).
[+] [-] asn0|6 years ago|reply
[+] [-] seibelj|6 years ago|reply
[+] [-] qrbLPHiKpiux|6 years ago|reply
[+] [-] jayd16|6 years ago|reply
[+] [-] neonate|6 years ago|reply
[+] [-] Ice_cream_suit|6 years ago|reply
[+] [-] Mountain_Skies|6 years ago|reply
[+] [-] jcims|6 years ago|reply
Didn't read the article but the headline is absolutely not a surprise.
[+] [-] bitxbit|6 years ago|reply
[+] [-] RaceWon|6 years ago|reply
Quality :)
[+] [-] known|6 years ago|reply
[+] [-] huijzer|6 years ago|reply
[+] [-] amelius|6 years ago|reply
[+] [-] paulddraper|6 years ago|reply
This is the real reason for rising healthcare costs.
Pro tip: go to a smaller clinic or hospital and save $$
[+] [-] teekert|6 years ago|reply
[+] [-] killjoywashere|6 years ago|reply
[+] [-] modmans2nd|6 years ago|reply
For profit (in my exe) has always been lower quality.
[+] [-] neilwilson|6 years ago|reply
If you want competition to work you have to have sufficient excess capacity in the system to allow entities to fail and fail fast.
Not so much a case of big enough to cope, but small enough not to matter that much in the grand scheme of things.
That ought to be the rule of thumb for any competition authority - if this new entity went pop, would we notice?
Capitalism without the threat of bankruptcy is like Catholicism without the threat of hellfire. It no longer works as a concept.
[+] [-] whb07|6 years ago|reply
Excellent material for those interested, an actual cash only, price listed, customer facing hospital. Shiver ye comrades for the devil capitalist is and has been here.
https://www.econtalk.org/keith-smith-on-free-market-health-c...
[+] [-] petjuh|6 years ago|reply
[+] [-] BlameKaneda|6 years ago|reply