There are a bunch of ways to rebut that argument. First, you can look at private systems that don't have these problems (ie: all the rest of the private systems). Second, you can note that Medicare, our single-payer system, interacts with the same structurally inefficient provider system. And, of course, if we switch to single-payer tomorrow, we're still going to be doing most care on an outpatient basis (because we should), and are still as a result going to be overprescribing procedures to patients.

> Second, you can note that Medicare, our single-payer system,

Medicare is not a single payer system, but a partial-subsidy voucher system for highly-regulated private insurance with (for the core inpatient and outpatient components) a fully-paid public option.

Fair enough. Consider my rebuttal so revised.

Let me expand on that: Medicare has recognized the problems you mentioned and has, fairly recently, begun directing efforts through payment system at the first broad class (inefficient interventions) through adoption of a variety of quality-incentive payment systems. But those aren't going to be as broadly effective, even for Medicare fee-for-service patients, as they could be if delivery systems and practice is shaped by conflicting incentives from different payers (who may be involved in covering some of the same claims, because coordination of benefits is a real thing, and even when they aren't for the same claims, will often over time be for treatment of the same patient.)

The VA is the best example of single payer system in the US, it does not suffer from either of these problems (though for demographic reasons it suffers from a host of others).

As for the private options do any of them have the weird employer provided health care indirection?

I think employer-provided insurance at scale is a uniquely American problem, and agree that it is problematic, but I don't see how it produces more overconsumption and less centralization than a purely individual market would. In fact, if you maintain a system of private providers (even with a public payer), I don't see a connection between funding and these structural problems at all.

Nearly 150 million people in the states get their medical funding chosen for them by an HR analyst III & their favorite consultant buddy. Then it gets paid for in a combination of literally hidden payments, pre-pay deductions & tax subsidies. The idea that there isn’t a connection between this and costs is incredible. That’s before talking about the impacts on small businesses, long term care & the like.

Lack of price transparency is a problem. But by what I (off the top of my head) understand to be an overwhelming margin, Americans who get their health insurance from their employers like that insurance; it's also hard to see how the HR rep at your company is influencing decisions about how many hospitals to build or how many MRIs to prescribe.

I'd probably report I liked my car insurance if it included a twice a year detailing and paid for my lyft rides from the bar. Especially if the real cost of it was hidden from me. That is to say, the consumer of health care being unable to accurately judge the quality and efficiency of the funding of that care is at the heart of the problems with the market based approach to health care funding.

The fact that one of the major players in the funding space have an intermediary as a customer instead of the health care recipient is a further distortion of the market.

Imagine if we got our car insurance the way we get our health insurance. What impact would that have on efficiency of that industry?

Our health insurance system is inefficient, and some of that inefficiency does come from the way employer-provided private health insurance works. My point though is that the numbers suggest that there are larger structural factors that operate independently of that inefficiency.

It's possible that the pathologies of our system created those other structural flaws; like, if we had an NHS instead of private insurers, we wouldn't have built all these inefficient hospitals. But whatever the cause, we are where we are, and switching to single payer won't undo those problems.

Which sums up my concern about single-payer: it might be a good way to lock in a lot of structural problems for a long time. Meanwhile, if you just directly address the problems themselves --- stabilize the markets, enact strong price transparency rules, aggressively incentivize efficiency --- you might not need single-payer (an immense, disruptive change) in the first place.

Also, if we want cost outcomes approaching that of the NHS, we have to do more than simply enact single-payer. We also have to aggressively set rates, reduce compensation for doctors, fire a lot of nurses, and make people wait years for knee surgery.

You’ll note most of my commentary centers around employee provided health insurance. That’s because it’s the outlier. Other countries have similar systems to ours on the provider, Medicare & Medicaid side. Employee provided insurance is, as far as I know, unique. And it’s a dramatically stupid way to fund health care.

Further, it’s a less dramatic thing to change. We’ve already been through a much more impactful change in living memory in the form of moving away from pensions.

My position is that changing that are of funding brings price transparency to the biggest segment of the population & it derisks the migration.

It's not clear to me how it does that.