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?
> 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?
Because health shouldn't be run like a business, just like the fire department shouldn't be run like a business. The only metrics that should matter are patient outcomes and cost.
I think the problem with never-ending healthcare costs is that it isn’t run enough like a business. Any normal business decreases costs to survive. It appears healthcare is at 20% of GDP and rising forever.
There are three options. I'll call them options E, S, and G.
Option E is to run healthcare entirely as a business. Payment up front, and refusal to treat anyone without payment.
Option S is to take option E, but avoid immediately attributable deaths. Treat somebody at the emergency room, even if they don't have a line of credit with them. Patch them up enough to walk out the door, but don't treat the underlying issues without additional payment.
Option G is to treat patients before they reach death's door, when it is cheaper to do so. To give the preventative care that keeps costs down, even if somebody isn't able to pay for it. To treat public health as a public good, rather than as a series of purchases.
Option E is evil, to let people die unnecessarily. Option S isn't openly evil, but is stupid. It is where the US is now, and inflates the costs tremendously. Option G is to actually be good.
Preventative care might not save money, but in a nationalized system which is funded by tax collection, having participants healthy so that they can live longer and pay more taxes sounds like a good idea.
I feel like it's not only a moral argument, instead it's a better alignment of those who pay and are served by the system. At present, the goals of insurers and providers are very different from patients, partly due to profit-seeking, partly due to the disconnect in who pays for it (49% of US population receives employer-covered healthcare).
Huh, thank you. I hadn't known that. I tend to go with the monetary argument first, since it helps to convince people who are primarily self-interested. I definitely think that there is a moral argument for option G, and will stick to those arguments overall in the future.
you've inappropriately reduced this into three bins, ignoring all nuance which is the actual hard part of the problem.
in option G, how much $ do we spend on terminally ill patients in order for them to have a few more days with their loved ones?
or how about smokers who will as a result of their actions will cost spades more than "good souls"? or type 2 diabetics on dialysis?
this false trilemma is largely useless and only presents one side of a moral choice and even then ignores the other prickly of it (read: the people paying for this glorious utopia and where the lines are drawn when it comes to saying no)
Either the system we have today works because we put enough money into it, and therefore would continue to work if we nationalized; or our system has unjust failures that we should seek to rectify.
We already pay for our healthcare in the US, we just do it predominantly via employer-contributed job benefits, and existing Medicare/Medicaid. The money for the bulk of healthcare is already there, but there are people falling through cracks all the time.
Is your position that bringing everyone's healthcare up to Medicare's baseline is too expensive? Where is the extra cost coming from?
> Either the system we have today works because we put enough money into it, and therefore would continue to work if we nationalized; or our system has unjust failures that we should seek to rectify.
That is very bad reasoning. Most things don't get cheaper when they get nationalized. There is some evidence healthcare may be different in this regard, but the point is: costs are not invariant under nationalization.
> Is your position that bringing everyone's healthcare up to Medicare's baseline is too expensive? Where is the extra cost coming from?
Cost of providing the existing service is not the only cost worth considering. The other issue is opportunity cost of innovation. Right now there are powerful incentives for people to innovate in the healthcare space, particularly in pharmaceuticals. But also in prosthetics and the procedural space. Nationalization is likely to crimp those incentives, and thereby lead to less innovation over time.
> in option G, how much $ do we spend on terminally ill patients in order for them to have a few more days with their loved ones?
Zero. They would be explicitly avoided care if they are known being unable to return to work nor parent somebody (higher-order parenting such as grandparents, uncles, aunts count too).
I would argue that dedicating a larger part of a nation's output to healthcare is not bad in itself. In fact the better futures I can imagine all have very significantly broader healthcare provision. And we'd be spending more on health because we can.
Efficiency matters, of course, and a higher fraction of GDP spent on healthcare isn't per se better, either.
One problem with private provision of anything is that a company only cares about the revenue it can actually capture itself. Nationalised provision, using tax as a revenue stream, can look at whether something is beneficial on the whole even if it isn't directly paid for.
sorry but how then should the fire department be run? both seem resource constrained at both the macro and micro level.
my understanding is that at a macro level firefighters routinely "trade" regions for sake of better defending bigger or more important regions. it will have to be the same for health care: not everyone can afford a legion of 24/7 ICU nurses and ER physicians on standby when the end comes, even if .gov is footing the bill.
IIRC dems got killed for "death panels" when ACA was getting played up. there will always be death panels - someone who decides whether or not an additional dollar is warranted for any particular individual - so what inputs should we use to make those decisions in your opinion?
Look back at how fire fighting was when it was fully private. The whole thing seemed kind of stupid to everyone.
Multiple companies would show up at a house on fire, check insurance plaques, and then head home if they hadn't paid them.
If no one had paid them they'd let things burn, which sounds fine conceptually, but it's much cheaper to put out a fire early, and it has that awkward tendency to spread.
Exactly. Currently they're for-profit death panels in the insurance industry. And their metric is profit, not minimising death and suffering.
The UK approach to this is a board called NICE, which measures effectiveness and tries to set a cost-benefit level. What this means is that the UK is behind on leading-edge cancer drugs which cost a fortune for a few extra months of life, but makes sure that everyone has insulin. The US system is the other way round: some people get the life extension, some people die from lack of insulin.
(A surprising amount of healthcare rationing in the UK is simple waiting)
I think there's a difference between fire brigades that are private businesses and government owned fire brigades that have territorial jurisdiction and which apply common sense to their funding to ensure the most efficient service possible.
For instance, given that fire brigades are commonly city-level in the US and that American cities often have highly irregularly and interlocking shapes, it is plainly more efficient to trade a certain amount of funding to have the other city look after your dog leg. But there is a mandate on them to look after all structural fires in a certain area. They can pay someone else to look after it on their behalf, but the mandate remains. Territory and funds are exchanged. In other places, where fire brigades are run nationally or regionally, perhaps even individual stations will trade — "we specialise in rural fires and you specialise in urban fires, so you should take this newly urbanised region off our hands" "okay, but we will also take your newly urbanised funding off your hands". But it might also occur at the national or regional level and thus be central planning rather than business like.
But a fire brigade that is a private business will look after fires that are cheaper for them to put out than to burn. Perhaps they will put out a fire in a non-member's building since every neighbor is an important member — and then they might sue them for all their worth. But if they have no customers in an area because the people who live there do not have the money, then they might let the fire burn. Or they might say "we are liable for a hundred thousand dollars compensation if we don't put out this fire, but it will cost us at least a million to put out". (The local fire brigade will probably have to let some fires burn because they don't have the resources to put them out — it may be vastly too dangerous to get involved, but of a nature that, after a day of burning, it will be much safer. Here, the difference is the consideration — the question is the relative safety of attacking it vs waiting it out, rather than the relative costs of attacking it vs waiting it out.)
A mediate position could exist, where private corporations are allowed to get involved in the firefighting business, but if that were permitted, it would be a situation where the mandate remains and the private firefighters would be paid by mandatory payments from the property owners of the relevant territory. Unlike most businesses, they aren't free to pick what they do. A private supermarket can decide if they want to stock Mildew Milk or not. But a private regulated/mandatory firebrigade would have to put out the fire at Mildew Milk even though they've had a long running feud.
> The only metrics that should matter are patient outcomes and cost.
But the reason fire departments aren't run like a business is because fires spiral out of control and affect neighbours. That is not really the problem when we are talking about patient outcomes. Obviously we should all get exactly what we want without having to worry about physical constraints. But when we go from what should happen to what will happen the whole physics-and-reality problem sets in.
We can't provide everyone with all the healthcare that they should get. There are never going to be enough doctors, equipment or hospitals. Sickness is literally an endless source of suffering and we all die of something - there cannot be enough medical assistance to deal with everything even if we devote everything we have to the healthcare industry. Rationing access to healthcare by people's economic contribution to society is just as fair as any other sort of rationing you care to come up with.
> Rationing access to healthcare by people's economic contribution to society is just as fair as any other sort of rationing you care to come up with.
What's the thought process for the "fairness" of income based rationing? This doesn't seem that rational from either utilitarian or deontological angles. From my perspective it's a very unfair strategy compared to providing equal care to all people.
There isn't an argument that income based rationing is fair. The argument is that there is no fair rationing process, but we have to pick one. Income at least encourages people to work for what they get.
How else do we ration healthcare? Best looking people first? Oldest first? Youngest first? They all have terrible edge cases that are as bad as richest first.
We can't give everybody what they need because that is physically impossible. I don't want to die, so if we are going by needs I need permanent life support :(. That isn't even slightly practical, so we can't do that either - someone has to do without.
We could directly build more hospitals, train more doctors, etc. It is hard to see what would really change - there would still be horrible stories about edge cases where the system failed and there would still be a great need for more people. We have to draw a line somewhere - why not here? If we can justify going beyond the economic equilibrium, at what point do we stop pouring money into the healthcare system? A serious question which in my view has no satisfactory answer.
You don't see the difference between a private entity that is beholden to no one and a public entity that can be changed through political/democratic means?
You don't see the difference between an entity designed for profit and an entity of the people, by the people, and for the people?
You might not agree its the most efficient solution, but its not a logical contradiction to be against private monopolies but for public entities.
> Doesn’t a single centralized monopoly providing everyone’s healthcare seem like a bad idea?
No. It doesn’t “seem” like a bad idea. Go look at actual countries that do it - it works fine and it’s vastly cheaper than the US’s failed “system”.
That said, you don’t have to go all the way and have a single healthcare provider: a single insurer will do just fine - it works for Germany!
Also: what the heck is a non-monopoly government even supposed to be? Of course a government is a monopoly (it is all of us), you want lots of competing governments running the same things? Now that does seem like a bad idea.
> Why is it so bad in business and so good for health?
Because a business is answerable to shareholders and a government is (theoretically) answerable to the electorate. This keeps the incentives between politicians and people aligned much more than between a monoploy business and people.
