What I think would be best though, is to eliminate medicare/medicaid, hand people cash, and get out of the way.

The high-order problem with medicine isn't coverage or insurance. It's price. There are only two ways to get price under control: meaningful competition, or government price controls (e.g. single payer). Single payer would end up like public schools: one choice for everyone, probably OK quality, but not great.

I think we could do so much more here if we just created a cash market and handed people money. It's what Singapore does. It would let doctors compete on -- even discover -- what actually matters to consumers -- wait times, when procedures take place, even how comfortable the office is. I would much rather have a market with choice and variety than one that straitjackets everyone into a one-size-fits-all system that might work for some but probably won't for others.

I know people are going to worry about rare (expensive) conditions not being covered, and this is indeed a problem. I don't have an answer to this. One good thing about competition though, is that it drives innovation. Provider prices will absolutely be set based on what they know people can pay. If people can't pay as much, the only thing for them to do is drop prices.

It's funny. In a community where people are so focused on innovation, and startups, and choice, I see a lot of support for a national single-payer scheme. I would much rather take the collective energies of this community and apply them to innovation in this market, with meaningful choice and competition. Medicine needs more of a startup mindset. And for those roasting me about how it's different/dangerous/risky: what we have today is KILLING us, economically.

Also coverage is also a huge deal in the US, although it may not be a problem for you specifically. Obamacare covered millions who otherwise might have stayed home instead of seeing the doctor.

The problem with US health is scoping. Insurance companies are effectively “certifying” which hospitals and doctors you can see instead of actual certification bodies.

What I'm suggesting is food stamps. Everybody can pay cash. If you can't, you get government assistance in the form of a cash-like subsidy that can be spent anywhere food is sold.

It's a fast, efficient way of ensuring universality of care while benefiting from the market discipline you get from having a (mostly) competitive, cash market. Not to mention, there is no insane "food insurance" bureaucracy. You swipe the card at the checkout line and you're good.

I was one of the people who lost insurance starting a new business - too rich to get subsidized (cutoff was/is >~50k/yr), too poor to pay the equivalent of a second mortgage for individual insurance because of runaway premiums on individual market post-ACA. And penalized a few grand for it come tax season until the mandate was effectively rolled back. Was more than supportive of that rollback.

It’s a risk management game for new business owners, and a big incentive for people to keep working for the man.

I don't think so. If providers can't expect to be paid adequately (in relation to their capital investment, research costs, operating costs, etc) for dealing with "rare (and expensive) conditions", because people don't have insurance (whether private, medicare, or whatever), just a modest amount of cash in any given patient's pocket, do you really think they'll want to stay in that market?

https://www.economist.com/britain/2018/06/28/the-three-myths...

> If people can't pay as much, the only thing for them to do is drop prices.

Or not offer the product at all. One problem with this entire area is that "healthcare" is really not one service/product area, and it is probably a mistake to treat it as such.

To be transparent, I don't share your optimism about market solutions to problems like this in general (more about their implementation in practice than theoretical benefits) but I can see how it might help with parts of the routine healthcare. However, when you are talking emergency and major treatments, it's well into the range where direct consumer driven decisions are more likely going to mess up the incentives badly.

If you are lucky enough to have the time (often not true), most people can become reasonably expert in their own disease state and treatment options. But that is a tiny slice of what is going on in a hospital system for example, and it's completely unreasonable to expect people to become informed enough to make good decisions there. If we want to benefit from market forces here, it's probably much more effective to have large (or single) payers who understand what the standard of care should be, and can encourage price competition from providers.

It's worth noting that in theory this is what the insurance industry does in the US, though, but is an expensive mess. Another confounding factor is that many obvious price discovery mechanisms will be completely unacceptable to most people.

Honestly, it's a mostly faith-based argument that a cash-based market approach can find a better global solution than universal health care, at least in a relevant amount of time. It's really hard for me to see why the country should take that risk when there are well understood and well modelled approaches (albeit imperfect) that should be able to reduce costs by at least 1/2, probably more.

Why not start there?

This isn't some technical academic point. Without a range of choices, you actually can't know what people truly want. So things don't get better. People can't signal what's truly important by voting with their wallet.

> If we want to benefit from market forces here, it's probably much more effective to have large (or single) payers who understand what the standard of care should be, and can encourage price competition from providers.

I don't get this at all. There are so many markets where complex, highly-paid specialists do work customers might not understand: estate/trust lawyers, auto repair, even dental care. We don't have nearly the same problems as in medicine due to this culture of treating doctors like God. They aren't. They're just a person doing a service, just like a chef or a guy painting a house.

What actually bothers me most about this whole thing is that nobody is willing to get serious about the tradeoffs their system entails. Health care in the US is failing right now. Companies are trying to stay beneath ACA limits because health insurance would crush them. My premiums are $380/month as a healthy, 36-year old nonsmoker with no rare conditions. That is INSANE. There's ever-more incentive to keep people off of W2 employment because premiums have gotten so out of control. If you take the current system, where bankruptcies are the norm, this monster is devouring almost 20% of our GDP, and every time I go to the doctor it's a major hassle, I'll come out and say that yes, maybe I'd prefer to fix that even if someone can't get a $150,000 drug anymore.

>aside: Singapore is a weird case and probably not a good comparitor for most healthcare systems.

Umm...why not? You can't just hand-wave that away.

I think this is why I suggested looking it as two markets. Your examples (estate lawyers, auto repair, dental care) look a bit like a visit to your GP's office. None of it looks much like some of the other things healthcare provides for us (e.g. many major and emergency procedures). And it's not like all of those markets are working particularly well currently (auto /house sales/ opticians/ etc. suck)

I don't think anyone would disagree that one-size-fits-all is the right approach, which is why nobody really tries that. What you are essentially saying is that you think is that you will get more flexibility if you open that market further, and that it will be both a better solution for more people, and not a horribly worse for any significant number of them (which is probably not acceptable here).

I'd agree with the first part, but the second requires faith - that in practice the signalling that you are talking about is clear enough (in both directions) and the response time short enough that you arrive at a better solution and in a reasonable amount of time. This is not at all clear. This isn't about treating doctors as "gods" either, they aren't able to make the systemic decisions well either, individually.

> What actually bothers me most about this whole thing is that nobody is willing to get serious about the tradeoffs their system entails.

This I agree with entirely. Two big ones come to mind - we need to have a conversation about appropriate end-of-life care and costs, and we have to be very transparent that our current level of medical capability means that there is an appreciable risk that (to a first approximation) anyone may end up with a medical condition that (a) we know how to cure or mitigate and (b) that person will never be able to afford. To me paying for these (or choosing not to) is quite different than making sure you can get antibiotics when you get strep throat.

You point out some symptoms of the problem currently, but I'm a bit curious about why you are resistant to pursue know solutions that look more like, say France (or Canada, etc.) , than Singapore. Is it just ideological? I'd rather take some known improvements and then iterate to improve rather than NIH syndrome.

Sorry, I should have elaborated. It's a city state with unusually high levels of both social compliance and government control, population is fairly wealthy and fairly evenly distributed. So - small population is a very small area simplifies logistics a ton. Especially ignoring problems related to migrant workers (it's own set of problems), most people have both high social support and some financial depth, there is also little to no housing insecurity.

It's basically unclear if you can successfully scale the Singapore model, nobody has tried. As against, e.g. , the several universal models that are outperforming the US currently, with more comparable populations etc.

However, any emergency service essentially has a captive audience. Most people who need an appendectomy or are having a heart attack are not in a position to price-shop. They need close, immediate care. Hell, quality probably doesn't even matter in these situations... not dying is the goal. This is where the free market doesn't work because there's no true consumer choice.

That is the #1 most effective thing that Americans can do to reduce health care costs. #2 would be to change the standard American diet and eat healthier to reduce rates of obesity and diabetes. Almost every other proposed structural change or intervention we looked at was minimal by comparison.

Universal coverage does not need to incentivise shopping around in a single payer system. Also, the majority of patients are not capable of evaluating quality of healthcare, nor should they be.

Universal coverage on par with Europe would mean we all start consuming less individually (which isn’t a big deal to outcomes but not part of our culture), or we need to have a far more competitive environment for suppliers. Either would be better than what we have today, whether insurance is public, private, or a mix of both.

Better just to go with single payer healthcare, not linked to employment or insurance, and dramatically reduce costs with similar outcomes.

Everyone wins, and those with money can still buy private care or private insurance if they wish, truly shopping around, as they have the means, education and leisure time to do so.

Pharma companies realized and started giving copay vouchers (still charge insurance more, but short circuit the patient incentive). When that loophole got tighter they formed charitable foundations to give the vouchers instead.

I'm not disagreeing with your points, per se. It's just amazing what entrenched interests can manage.

As I understand it, in most EU markets there's no price component, nor much of a choice component and costs haven't skyrocketed.

Now, when I left, the doctors and insurance companies were setting up an analog of the US system: If you saw certain doctors, they would not charge you at point of delivery and there was no co-insurance requirement. It was still new and inconvenient, so I don’t know how that’s worked out.

I don’t have direct experience with the Swiss system, but from everything I’ve read, conversations, etc., it’s a slightly cheaper version of the US system. You buy leveled insurance, you have to pay some out of pocket, etc.

I moved from the US to Switzerland so maybe I can offer some anecdotes here. You're basically right in that it's a slightly cheaper version of the US system. However, some things that I didn't have to pay for in the US such as calling am ambulance without riding in it or seasonal flu shots do cost money here ($500+ for an ambulance to show up in the middle of a large city...), but I think these small lapses are overshadowed by expensive inpatient treatment being essentially completely covered minus some reasonable deductibles as well as outpatient treatment that is usually partially covered depending on the insurance plan.

The positives compared to the US largely revolve around necessary and typically expensive treatment being far more likely to be covered under insurance with relatively low copays and deductibles. The downsides in common with the US are the administrative hassles of dealing with an insurance company and its own billing middlemen (e.g. a COVID test was improperly billed to me which needed to be sorted out), the large monthly premiums for most people (~$250 is typical except for those who qualify for subsidies), and the lack of clarity over what and how much of anything is covered even when the billing is done correctly.

Do I call an ambulance? Do I go in to see a doctor? Will I end up with a massive charge? I'd prefer a single-payer or completely comprehensive system for this last point alone.

Would the same statement be true for food and shelter (also necessary for life)? Should the government be the provider for all food and shelter in order to avoid additional steps?

The same is not true for healthcare. Even when purchasing shelter, people are not sufficiently informed to be able to make a good decision, hence the existence of electrical, plumbing, and structural codes and inspections.

With healthcare, people are extremely uninformed. The costs are extremely high. The government doesn’t necessarily need to vet the doctors’ diagnoses and prescribed remedies, but they could. So could insurance companies, which is what currently happens in the US.

Spend some time uninsured and you become a very discerning consumer.

Further, for every service that requires healthcare advocacy (often provided by family members, btw, not professionals even in existing system) there are probably >five that are commodity services (labs, prescriptions, diagnosis, imaging, etc.)

The difference between an apple being stolen by a homeless and an apple being given to a homeless, is that you don't need to pay for fixing the broken window.