By extension, it seems like the key difference between "elective" and "non-elective" care is that one of them is elective... it's going to be a very different market when a consumer can choose to buy something or not buy it at all, vs. when they have to buy something and may not even understand what or why they're buying it. It's not necessarily that consumers are shopping prices more or being stronger negotiators, it's partially just that demand naturally falls if prices start to rise too much.

Agree that the patient-provider relationship today is usually "I'm a doctor and I'm going to tell you to do this, this, and this" regardless of cost, and we go with it because if we're insured under today's system it means marginally more out of pocket dollars for us. If you had an high deductible plan with an HSA (i.e. paying pre tax dollars out of a health savings account), I'd bet psychologically you'd be more choosey when shopping around for healthcare and/or ask more questions of your provider around "is this really necessary?" or "is there a cheaper option?"

With healthcare, it's not just about "what's the cheapest option", it's also "who will deliver the best service"... given the relatively limited ability to optimize the first, I generally will focus on the second, and I think that's what most folks do - they go with providers they trust.

It all comes back to my original point: healthcare, particularly non-elective healthcare, is not well-suited to a free market solution.

If you're unable to discern whether your doctor's preferred solution is the best one, then what is the purpose of asking your doctor in the first place? Or how would it be beneficial if the "worst" provider was forced to charge you the same as the best provider?

If I was qualified to discern if my doc's preferred solution was the best one, I'd be a doctor. I ask my doctor because he's been specifically trained to make that determination.

> Or how would it be beneficial if the "worst" provider was forced to charge you the same as the best provider?

You've got that backwards. Right now, we basically allow the worst provider to charge as much as the best one, because we don't really have any way to differentiate the best from the worst. There's no need to force any business to charge more.

TIL there's no testing, rating, or regulating in the medical industry.

>I ask my doctor because he's been specifically trained to make that determination.

I agree, so this concern of yours is alleviated. The market provided you an expensive option which is the one your trusted advisor recommends, and there's a cheaper one which may offer lower quality service. You are now empowered to make your own decision on the matter.

>You've got that backwards. Right now, we basically allow the worst provider to charge as much as the best one, because we don't really have any way to differentiate the best from the worst. There's no need to force any business to charge more.

Moving to single payer does not help you differentiate the best from the worst. All it does is force the good provider and the bad provider to charge the same. The current insurance regime is not better, because your provider can choose the worse provider for you if they're cheaper, leaving you no option at all.

I can't believe we're going with car analogies here. HN is now the Slashdot of yore.

I do hope you realize that people use fundamentally different methods of choosing things in life depending on the importance and consequences of that choice, and hence asking about how one chooses cars doesn't apply to choosing a healthcare provider.

Unless you are, in fact, a robot, in which case I welcome our new, ah nevermind.

There is no magic here just because healthcare is more important than car choice. You're no more or less safe because you're paying out of pocket. It's not as if paying out of pocket means you're going to be getting healthcare from Joe the crackhead in the back alley. It will still be doctors, NPs, etc. all licensed in your state.

You can speak for yourself. I bought my Honda Fit because I saw a video ad on Youtube.

Worked for me, I love the thing. And if I didn't? No biggie, would have sold it off on Craigslist and bought something else.

Would I select a doctor based on an ad? No, no, and no. Which is my point, actually.

No, the idea that people who have no skin in the game--regulators and bureaucrats--can make better decisions than the people directly involved, particularly about matters with as much at stake as health care--is one of those zombie ideas that just don't die. No regulator or bucreaucrat ever suffers any negative consequences because of bad decisions about other people's health care.

As for people being poor at judging for themselves whether procedures are necessary, another comment upthread already addressed that: there are plenty of other areas (auto repair, for example) where most people don't have the technical knowledge to judge for themselves whether procedures are necessary, yet markets seem to function in those areas. Furthermore, under the current system in the US, people have little incentive to become more knowledgeable, because they are not going to be given a choice anyway; they're going to get whatever their health insurance provider says is the standard care. Under a market system, people would have much more of an incentive to actually learn about the various options. And there would also be much more of an incentive for independent third parties to provide information, particularly information that health care providers might not want people to know.

More generally, the reason market advocates, like me, advocate markets is not that they always give optimal outcomes. They don't. But in cases where they don't, non-market alternatives give outcomes that are even worse.

This shouldn't be a surprise. An individual is going to not make very good decisions about how healthcare dollars are allocated over the course of their life. They're going to usually tend to underspend on preventative care (which has the highest ROI) and tend to overspend on end-of-life care (which has a lower ROI). You can see this played out in things like the US's infant mortality rate (3X other developed nations) and life expectancy (31st worldwide, declining).

I think this "conclusion" depends strongly on how you define "worse outcomes".

> An individual is going to not make very good decisions about how healthcare dollars are allocated over the course of their life.

Not if they have no incentive to learn how, no. And our current system gives them no such incentive, since they don't control the dollars to begin with.

In other words, the system complains that people don't do something that the system prevents them from doing.

> In other words, the system complains that people don't do something that the system prevents them from doing.

Uh, this has nothing to do with the system, and mostly everything to do with behavioral economics and risk pooling. People are poor at investing in preventative care, because the benefit is extremely hard to perceive at the individual level. And they over-invest in end of life care, because, well, they don't want to die. That's not the result of "the system", that's human nature. Attempting to build a healthcare system on how we "should" act instead of how we actually do isn't a plan.

This also ends up being a pretty unfair way to apportion care because a rich man couldn't care less about a $100 fee and a poor man can find it prohibitive.

One example would be how the US has one of the worst infant mortality rates in the developed world.

If you stratify by income then the lower end of the income scale have it far worse than equivalent cohorts in many other developed countries.

I mean sure if you are upper middle class and work for a large national or international company then healthcare is probably up there with world class but that's not a lot of people percentage wise.

The person who has the most skin I the game, the patient and premium-payer, is not in the room when payments are negotiated. I don't think the U.S. is an example of enforcing skin-in-the-game.

Because if you wait until you need it, it's going to be a pretty bad time to negotiate.

Further, "skin in the game" is mostly a euphemism for increasing out-of-pocket prices for care to encourage patients to be "discriminating consumers," a concept I've already detailed my objection to.

> Further, "skin in the game" is mostly a euphemism for increasing out-of-pocket prices for care to encourage patients to be "discriminating consumers," a concept I've already detailed my objection to.

First "euphemism" implies some ulterior motive. I don't think people are trying to make people poorer. Hanlon's Razor would have us presume everyone at least thinks they have a mostly good idea.

Next, if people were somehow using their own money, they'd also have the option of choosing something 10 or 20 percent more affordable, keeping the difference for other valuable things, like paying off a house, paying for grandkids' college, buying those plane tickets to see their cousins, etc. The reason there is no downward pressure to save on individual things (even predictable, non-emergency things like deviated septums) is because there's no best viable alternative. We don't keep the three grand we save by saying, "Hmmm... maybe I'll just lose 15 pounds instead." That's how things are supposed to work.

But don't take my word for it; here's the Rand Corporation offering a studiously even-handed assessment and giving a definition of the term matching the one I suggested: https://www.rand.org/pubs/research_briefs/RB9672/index1.html

> These plans are intended to give consumers more "skin in the game" — that is, to make them responsible for a greater share of spending. Proponents of this approach contend that consumers in such plans will have more incentive to make prudent, cost-conscious decisions about using health care, which, in turn, should drive down overall health care costs. Critics, however, have voiced concerns that consumers lack information needed to reduce spending without reducing quality of care.

---

> We don't keep the three grand we save by saying, "Hmmm... maybe I'll just lose 15 pounds instead." That's how things are supposed to work.

Well, first of all, that's false, in the sense that, increasingly, deductibles are substantial (a few thousand, at least), co-pays are higher, and co-insurance (where it's difficult to even predict what you'll owe) is becoming more common. Almost nobody has a plan where they don't have to pay something for medical care.

But besides that, maybe in your scenario someone decides to lose weight. But let's think of another scenario. I start to experience some pain but I haven't really got the money for the doctor's visit. I decide I can tough it out. I keep doing this until the pain is truly unbearable and then I go to the doctor and find out I'm terminally ill and I waited too long to be treated. Or I forego preventative care and miss an opportunity to catch and treat cancer early. There aren't outlandish scenarios; they're the result of a system where patients have to shoulder more of the cost of care out-of-pocket, especially when combined with a state of affairs where a great many Americans do not have the savings to pay an unexpected expense of a few hundred dollars out-of-pocket.

No. They are just cherry picked. There are very few scenarios now where the consumer benefits from saying "no" or "less" to their doctors. Single payer doesn't solve that. They just have an unelected government official saying no. And the patient doesn't benefit in that case. I haven't heard any reply about the moral hazards of turning healthcare decisions into lobbying efforts. Do we not think the well-connected and otherwise favored will still benefit over people in poverty? I'm skeptical.

Who wants doctors out of the loop? I want them more in the loop.

Doctor-patient relationships don't work that way. If they did, we wouldn't have people getting illicit prescriptions from doctors. Doctors, surprise, do listen to their patients wishes and accommodate them when they're OK with what the patient wants.

Doctors should be advising us, "Here are your options (with prices). What do you want to do?" One option on the table for "laceration on your back" should be "have an uglier scar and give a big check to your son as a wedding present". Right now, with good insurance, there's no incentive not to treat you like an underwear model that needs scar-free skin and do experimental scar-lightening UV treatments.

If a procedure (or doing nothing) is foolish, of course good doctors won't put that on the table. But single payer doesn't have doctors and patients making these decisions. They would instead look at a pre-determined schedule of options as handed down from the Bureau Of Wellness. Maybe, because of lobbying and political infighting, "uglier scar" is the only option. "Check for my engaged son" certainly isn't on the schedule.

A guy with a minor cut on his back is bombarded with a 24/7 targeted ad campaign for ScarAway!TM, that convinces him this experimental...er..."cutting-edge!" UV treatment is the only thing standing between him and a constant stream of fawning, eager females twenty years his junior. He then obtains this treatment from his "true believer" local doctor at the low, low price of a $2,000 "co-pay" for himself and $20,000 from his insurer. After three months of ScarAway!TM his back is of course completely disfigured and looks far worse, at which point his own wife refuses to sleep with him, necessitating years of therapy. A decade passes and he is diagnosed with melanoma from the UV he was exposed to and dies one year and one million USD in healthcare costs later. The most memorable moment of his son's wedding is a tearful toast to his deceased father, whilst each of the doctors involved in his "treatment" as well as the ScarAway!TM salesman cut checks to their engaged children.

> I don't know why people keep setting up false equivalences and false dichotomies in these discussions.

Maybe it's fun? I honestly don't know. This scenario is certainly vivid. It's not the only option other than... I'm not sure what alternative people are planning, as I said above. They tend to gloss over who actually decides when a procedure isn't worth it. And they gloss over how normal people without lobbyists get the system changed when it stops working.

>There are very few scenarios now where the consumer benefits from saying "no" or "less" to their doctors.

is totally off base. The primary benefit to saying "no" is avoiding damage to your health from dangerous and unnecessary treatments that American doctors have a financial incentive to sell. People in the U.S. have their life expectancy reduced every day because we, almost uniquely among developed countries, have removed nearly all limits on the cultural acceptability of medical professionals and the medical industry as a whole treating patients as sales marks rather than patients. If you would like to experience this firsthand, respond to any AdWords or TV advertisement for a medical treatment. The sleaze is limitless.

>They tend to gloss over who actually decides when a procedure isn't worth it.

Salaried civil servants with advanced degrees who have an interest in cutting through BS to protect the health of the country. If you want to reduce people like Frances Kelsey to "unelected government officials" be my guest, but you're only showing how naive you are.

Could it be that the model is wrong?

The example of an automobile doesn't seem apt. Are you going to trade in Grandma for a new one when the treatments prescribed get too expensive and they can't figure out what's wrong with her?

Ask any doctor, and there's a reason they personally do not want to go anywhere near a hospital at the end of life. It's usually the children/grandchildren who live far away and never visit who insist that every last thing be done prolonging their grandparents' suffering in my opinion. The ones who live nearby and spend plenty of time are usually okay with letting them go.

Another problem is that procedures and appointments that could be considered routine maintenance in other areas are paid for by insurance. You don't use car insurance to pay for oil changes or new tires. Services such as annual physicals/check ups, vaccinations, etc should be cheap enough to pay for out of pocket.

That would leave insurance to pay for the more expensive forms of care, just like one would use car insurance to pay for damage as a result of a collision.

The flip side of that is that they aren't contributing much to insurance premiums. At a policy level it may be worth a slight increase in cost if building it into insurance significantly increases the number of people that actually get the shot.

Can we be certain of that? That is, even if the vaccination costs $30 to $40, will the insurance be billed for that amount, or do they get billed something like $300 instead?

I haven't tried to pay for a influenza vaccination out of pocket recently, so I don't know what most places would charge.

[0] https://www.bradsdeals.com/blog/where-to-get-a-cheap-flu-sho...

Even so, that's more money that the insurance company is paying out that could just as well be paid for directly everyone who gets the vaccine. If routine care was affordable without having to involve insurance, then insurance premiums wouldn't be as high and the out-of-pocket costs for medical care wouldn't be as high either.

The ability for a doctor (merchant) to refuse service in certain situations just doesn't exist without violating an ethical boundary.

Neither classic Hippocratic oath nor the commonly used Declaration of Geneva (https://en.wikipedia.org/wiki/Declaration_of_Geneva) would go against a doctor saying "the recommended procedure to cure your ailment costs one million dollars; I'll be treating you if and only if you pay that", assuming that the treatment honestly is the best option health-wise. What the oath could prohibit is the recommendation of a treatment that's objectively worse (i.e. less effective, or more likely to have harmful or fatal complications) but is much cheaper; while a person can choose (or be recommended) bread, wine or car that's worse but cheap, the ethics frown upon recommending worse health outcomes.

In planned events and traditional health care your argument makes sense.

I was specifically thinking about emergency care or other situations where communication isn't always possible or made in a timely manner.

If a someone comes into an ER and turns out needs say a stent put in, when do you get clear agreement? (caveat I am clearly not a medical professional and this might be a terrible example).

My assumption is largely the hospital does not wait to validate someone's credit to execute what would otherwise be something done for normal retail transactions of similar size.

Do you really think all healthcare - supplements, eye drops, family doctor visits, LASIK eye surgery - should be centrally controlled instead of using free market principles?

That's quite a claim to make. Cutting the entire healthcare industry off from the free market would only happen through government force.

Are you sure you're not confusing the US insurance system with an oligopoly?

Markets don't exist to magically generate low prices for consumers through competition, because businesses compete primarily for investor and shareholder cash, not to make end users happy.

The most reliable way to generate shareholder value is to create an oligopoly, and then squeeze consumers as hard as they can be squeezed - which is exactly why the US system regularly bankrupts participants, while regulated single-payer systems don't.

Countries with single payer also offer eye drops, family doctor visits, and LASIK... they just tend to pay less for them

You don't need "government force" to change how health insurance works. See Germany, many other countries. All you do is create a government healthcare pool that's large enough to cover risk, fund it, and give folks the option of using it or using a private insurer that will cost a lot more.

Especially since in the U.S., major changes are supposed to go through strict democratic processes that require broad consensus. Beyond good democracy, that's just human decency.

That's why I think there should be a healthcare constitutional amendment before the U.S. government gets involved. If California wants single-payer, they should go for it though.

I don't agree that these are good reasons to make healthcare not a market. It's true that customers don't necessarily have a lot of ability to choose providers or price shop under our current system, but that's certainly not an inherent trait of healthcare. It could be otherwise.

As for not understanding what they're being asked to buy, what I'll say about that argument is it proves too much. Why do the markets for computer repair, automobile repair, etc. not have the problems that you claim would be inherent to a free market in human body repair? Understanding of the subtleties in those areas is equally out of reach to understanding of healthcare.

You are ignoring the part about not having a choice of whether to buy or not. If I buy a car or something else about which I know next to nothing, I can ultimately decide not to buy, if I feel like I'm being scammed. If I get injured or sick, I can't realistically choose not to get treated.

I agree that they aren't perfect analogs, but we're talking tangerines and oranges, not apples and oranges.

EDIT: Downvoters care to comment on where they disagree?

Although it’s awfully close to some of the other threads here, I’m happy we collectively chose to draw the line at an argument honestly comparing computer repair to health care. (I can’t even believe I’m typing this; please don’t ever ask me to explain that again).

I was just comparing the aspect of non-experts making big decisions based on expert advice. I wasn't saying a wiped hard drive is the same as cancer.

But it's also not true that any health problem (getting the flu, cutting your finger pitting an avocado) is worse than any computer problem (losing the only copy of your dissertation, getting phished for thousands of dollars).

Part of the way out of the dialectic gridlock we're having is to stop treating every health issue like it's both confusing and life threatening. But there are certainly edge cases. Nobody wants people dying of cancer due to bad advice or lack of funds.

> I’m happy we collectively chose to draw the line at an argument honestly comparing computer repair to health care

People not listening to people isn't the most human (or soulful) option on the table.

To be honest, my problem with the original comment was the lack of clarification and contextualisation. When it comes to sensitive issues (like health and people losing their actual lives), I think it's not OK to forego acknowledging the human aspect and focus on numbers or economic theory alone.

A good point can be made poorly, and it can hurt and alienate a lot of people in the process. Flatly "telling it like it is" does not always benefit mutual understanding or societal healing; it risks driving us further apart. Which is an ironic thing for me to say, because I put my foot in my mouth every other day. I guess it really does take one to know one :)

This is why consumers love warranties and extended-warranties on their vehicles so much - it means they leave this problem to their insurer. It's easier to insure cars than people, though - your risk is essentially bounded by the market value of the car.

The order of causation here is wrong. Many of those problems exist because the market for healthcare is vastly inefficient in the United States.

With regard to elective vs non-elective, only about 2% of all healthcare costs are categorized as emergency care. So there's plenty of wiggle room for people to shop around for a good price or wait for better market conditions.

What I would love to see is taking Medicare/Medicaid and instead of paying for healthcare services we just cut a check for cold hard cash to everyone who would've been receiving government funded care. Then they can spend that money on whatever they want. I guarantee you prices will drop through the floor. Some of those people will choose quality of life over longevity by going on vacation instead of paying for healthcare. I say good for them, do whatever you want it's none of my business.

It is very difficult to shop around for prices in the American health care system. Your average person can't do it and most really capable people could not do it either.

Giving people cash as their Medicare/Medicaid would be a complete disaster. Bulk buying by the government goes right out the window, no cost controls at all and completely ignores what insurance is in the first place. People are generally dumb. If you gave them cash and said this is your medicare, they would take it and spend it on everything but medical care. In the end, they would get sick and die or be crippled or worse, they would still go to the hospital and then leave everyone else with the bill.

We know prices would never drop to the floor because that is the system we have in place now and prices keep going up.

"Market" means "crowd sourced pricing". The alternative is a person or a small group of people setting prices, controlling access, setting standards, etc. Once you think that's a better idea, you are responsible for further clarifying how those people will be held accountable for their decisions.

I don't see a non-market proposal that is honest about the concentration of power and actually tackles the problem of accountability. I don't want a national medical code mess growing alongside our tax code. I don't want new and exciting fields of healthcare law and lobbying opening up. I don't want (pick: Donald Trump or Barak Obama) being the national Hospital-Administrator-in-Chief.

Define "how much something costs?" I can pull up the spec sheet from my insurance company and tell you the in network price and out of network price for just about anything. The crappy system we have now sets the price between you and the insurance company. It's not that the providers don't want you to know how much something costs, they don't know how much it costs.

Conversely, I can go into the local urgent care here, a place that caters to many uninsured. The prices for their services are literally posted on the wall, not unlike the menu at a fast food restaurant. You know exactly how much an x-ray costs, or a cold/flu visit, or a cast, etc. When people are paying for these services with their own money and the prices aren't the result of some individualized, convoluted pay schedule with your insurance provider, then the prices suddenly become extremely transparent.

>and completely ignores what insurance is in the first place.

Insurance is there to help you out in the event of a disaster, not to pay your ongoing day to day costs. So let's make sure we're really talking about insurance.

>If you gave them cash and said this is your medicare, they would take it and spend it on everything but medical care. In the end, they would get sick and die or be crippled or worse,

That is historically incorrect. Yes, people may choose to spend less on healthcare than you would like them to, but why do you feel the need to be so authoritarian about your opinion on what's best for them?

>then leave everyone else with the bill.

Only if people like you force it on us.

>We know prices would never drop to the floor because that is the system we have in place now and prices keep going up.

As was pointed out by another poster the prices for elective surgeries like LASIK which are not covered by health insurance are going down over time. It's funny to me that you have no problem accepting that some people would take their Medicare money and blow it on something else, but you think that healthcare providers would not do anything to try to convince those people to spend their dollars with them.

Except if you go in for a major procedure, you don't know what you'll end up needing off that price list, and often, neither does your doctor. So even if providers were perfectly transparent about what a procedure would cost (and it's well-established they're not - just try calling and asking for prices) the nature of the service being purchased is that you sometimes don't know exactly what you're buying until it's too late to change providers.

A few years back I broke my leg and went to the hospital. Halfway through the process I was offered a couple of Vicodin, which I would later be billed $1,000 for. Was I supposed to haggle about them with that, or take my xray and hobble out down the street to someone who would sell me vicodin cheaper?

One of two things is going to happen here. One is I have a flat rate for a hospital visit, so the cost is known no matter what I need. Second, if I'm hitting my out of pocket max then that cost is also known.

>A few years back I broke my leg and went to the hospital. Halfway through the process I was offered a couple of Vicodin, which I would later be billed $1,000 for. Was I supposed to haggle about them with that, or take my xray and hobble out down the street to someone who would sell me vicodin cheaper?

The only reason they could get away with even pretending like they would charge you $1k for a vicodin is because of the distorted system we have where everyone pretends the money comes out of the insurance company's money instead of your own.

No.

It's not a "distortion". It's the inherent problem of trying to turn healthcare into a market. The dynamics of service delivery make it impossible for consumes to negotiate or compare prices in the manner necessary to have a functioning market.

I'd also note, that since I've never gone to any other healthcare institution with a broken leg, I have *no way to compare my experience to other providers. This is yet another way in that healthcare does not lend itself to market solutions.

In the midst of your one single incident, no, you would not have been able to negotiate the price of your vicodin. However, two things would change. First, they would not have offered you the vicodin without clearly informing you of the price if the norm was people paying out of pocket for most care. Second, if they charged $1k for vicodin but the urgent care down the street only charged $500, then basically no one is going to the first location. Rinse, repeat, until the prices are rational. So the cumulative effect of everyone paying out of their own pocket for most care is market-wide lower negotiated prices.

Even if they did, I made my decision based on which provider I thought was doing to do the best job... I didn't know at the point I made that choice whether I would need those vicodin, so they wouldn't have been part of my decision. And once I was checked in to the SF General Hospital (after two hours of waiting) I was definitely not going to hobble down the street, trying to compare prices on vicodin.

Also my damn leg was broken. It wasn't really the right moment to break out Google Sheets and create an expected value analysis of my various healthcare provider options.

It's nice to say "if only we had more agency, prices would be lower"... but it ignores the fact you still need risk pooling (insurance) unless you expect everyone to keep savings for the worst case scenario. And pretty quickly a risk pool means someone has to decide how much that pool should pay to help treat a particular injury... and you're back to where you started.

>And pretty quickly a risk pool means someone has to decide how much that pool should pay to help treat a particular injury... and you're back to where you started.

Not someone, EVERYONE. Each individual person must decide for themselves if they want to try pay a middle man insurance company some profit every time they get the sniffles or if they'd rather deal with that on their own, save money, and just get catastrophic coverage.

All of these things you're concerned about... we have an entire history of the healthcare industry before the New Deal where we saw how low healthcare prices were. We distorted the market with New Deal regulations putting caps on salaries, so companies started offering healthcare to employees. We can undo the damage done by the New Deal without getting all authoritarian about it.

Re your medicare proposal, are you suggesting that people who are diagnosed with cancer should get a cash check for the estimated value of the treatment? The incentive for fraud and graft in that kind of system would be incredible - lots of diagnoses are relatively subjective, and you'd be rewarding people for reporting every possible ailment they might be eligible for. If you're saying just give them their dollar average benefits, that pretty much defeats the whole purpose of having a risk pool.

It's very difficult to get quotes because no one is actually paying for it themselves. This would be solved immediately by empowering individual consumers.

>you can't easily compare providers (there's no obviously corpus of "ratings" from other prior customers)

This is because your insurance provider has chosen for you. Once again, this would be resolved by putting peoples' money back into their own hands.

>If you're saying just give them their dollar average benefits, that pretty much defeats the whole purpose of having a risk pool.

In my head I included still providing disaster coverage, but failed to type it. So that should alleviate your fears regarding things like getting cancer.

"Still providing disaster coverage"... is pretty much all of what health insurance does for people over 65. The annual spend on preventative care is dwarfed by a single common incident (fall, flu, cancer) at that age.

Here's a citation that shows emergency care is only 2% of all healthcare. Of course, that's the entire healthcare market, not just elderly care. I'd be interested in any citations you could provide that shows that system-wide preventative care is dwarfed by the system-wide costs of major incidents for the elderly.

http://www.politifact.com/truth-o-meter/statements/2013/oct/...

> I'd be interested in any citations you could provide that shows that system-wide preventative care is dwarfed by the system-wide costs of major incidents for the elderly.

95% of healthcare spend is reactive, 5% is preventative[0] Medical spending in the last three years before death accounts for 13.4 percent of aggregate US medical spending.[1] And this ignores major treatments for people over 65 that occur more than 3 years before they die (and on average, people live 20+ years after they turn 65.)

[0] http://www.newsweek.com/health-prevention-worth-money-86075

[1] https://meps.ahrq.gov/data_files/publications/st429/stat429....

You are acting as if paying out of pocket at a price not determined by an authoritarian central planner would suddenly mean nothing in healthcare would be regulated in any way and people would be getting healthcare from crackhead joe in the back alley.

Not everyone will pick the cheapest option all the time. Today there are free clinics in many places. Most people don't go to those. Some people will choose Wal-mart. Some people will choose Macy's. And there will be a myriad of options in between.

I never find this argument compelling, for two reasons:

1. Things are similar in this regard in other OECD countries, yet the US has prices wildly out of proportion with them.

2. Normal people do not have the expertise to know whether they need medical care. That's why they go to the doctor. Making them pay more out-of-pocket simply leads to them foregoing necessary care. Furthermore, if you're bleeding out and need immediate medical attention you're not exactly in any position to "shop around."

If you have an emergency and need immediate care, yes, you can't shop around. That is what insurance is supposed to be for: dealing with unanticipated expenses that you can't pay out of pocket.

However, most health care is not like that. It's either predictable, regular expenses like annual physicals, or unpredictable but small expenses like getting a course of antibiotics if you have an infection. These would seem to be easily bought and sold on a market, yet our health care system insists that we do it through "health insurance", when these items are not even insurable items to begin with.

The third category, and the one that is the hardest to deal with, is non-emergency conditions that require expensive treatment, like cancer. Ideas like having a large risk pool make sense for these kinds of conditions, but again, our health care system insists on doing everything that way, even though it doesn't make sense for other kinds of conditions. And again, this kind of risk pooling is not really "insurance" in the way that covering emergency care is (although there are similarities).

Also, does your plan also allow you to go to any provider for care if you're under your deductible and so are paying out of pocket? If not, you can't shop around even though you are paying the cost. That means you don't really have any market power.

> So what’s the actual proposal here?

I wasn't making a proposal, just highlighting a serious deficiency of the current system. However, the proposal would be obvious: separate out the three kinds of conditions I described and handle them separately.

For emergency care, you would buy insurance, which would work like any other kind of insurance against unanticipated large expenses.

For ordinary predictable expenses and unpredictable but manageable expenses, you would pay out of pocket, just like you pay out of pocket for other ordinary predictable expenses, like food, and other unpredictable but manageable expenses, like household repairs. In other words, it would be just like any other market. And like any other market, there would probably be businesses trying to sell "care plans" where you pay a fixed amount per month and get comprehensive coverage, much like existing plans (and like the extended care plans that car dealers will offer you when you buy a car). But it would be your choice whether to buy them or not, based on your particular circumstances and attitude towards risk.

In such a market there would also be an obvious business opportunity for plans insuring against non-emergency but chronic conditions like cancer. There would also be incentives to widen the risk pool. If there is a place where the power of the government could be used usefully, it would be here: treat all citizens as a single risk pool and negotiate with insurers for coverage of just these conditions based on actuarial data over the entire population. But I'm not optimistic that it would be politically possible to limit the government's involvement to just that.

This opaqueness problem can never be completely solved for healthcare at the consumer level. A significant fraction of healthcare consumption occurs in urgent or outright emergency settings where "shopping around" cannot reasonably occur.

I have no idea what it costs.

The health care professionals treating me tend not to have any idea what it costs either.

Some accountant somewhere in the Trust will know, and will bill the appropriate code to the Clinical Commissioning Group.

But if you compare like for like treatment in England and the US you'll find the cost to NHS England is far lower than the prices charged in the US.

£124bn ($175bn) give or take a few pounds. That does of course include some other people's health care too ! ;)

I wonder if it's possible to buy your own (or a close friend's) medical debt). If someone has to pay $200000 in debt, but could buy that debt for $2000, then that may be the easiest way to "pay it off".

And how would healthcare "consumers" be able to "shop around" while in an emergency situation?

This is the standard free market fantasy. It's all too common among healthcare startups, given that they are nearly all market-based solutions by nature and have a built-in incentive to ignore socialized medicine as a solution.

You'd think if we were really serious about improving our healthcare system we'd, you know, look at stuff that works and is field-tested, like for example the healthcare systems in basically all the other industrialized nations in the world.