I agree. The "everything is a market" ideology had a good run of almost half a century, but it should be heavily criticized in hindsight.

Institutions like healthcare, education, public transport, prisons(!) and so on are more efficient, less corrupt and of higher quality when they are in large parts collectively and democratically organized and funded. The "in large parts" is important here: A community should agree on what that means and let the market play out on the edges, or the bureaucratic costs become too heavy _and_ unfair. Decentralization is key here.

One thing to note about US healthcare is that it seems almost deliberately engineered to not be a market.

I've never received significant health care in another country, so I can't say how the US system differs from others with any expertise. But I can say how US health care differs from just about anything else I spend money on:

1. I don't really get to shop for health insurance providers. My employer picks one, maybe two plans, and I can take it or leave it. If I leave it, I am leaving at least $10,000/year on the table, so I generally take it.

2. Even when I am on the market, the phenomenon in #1 does weird things. Once upon a time, when I was choosing my own health insurance, I started a new job with health insurance benefits that I did choose to take. But my start date was toward the beginning of the month, my old insurance wouldn't let me do a partial month, and the new employer wouldn't let me delay opting for coverage. So I was essentially forced to own two health insurance plans simultaneously for a period of time.

3. Nobody knows what care will cost ahead of time, which makes it impossible for me to make any informed economic decisions. I need to see a physical therapist. I called a few places to shop for prices. They all know what the rate for uninsured people is, but the only way we can find out what it will cost with my insurance is if I receive care, they submit a claim, and then we all find out together what the price was, after the fact.

4. #3 creates a situation where they can hide all sorts of excessive charges. When my first child was born, I got lessons on how to give him a bath and change his diaper. Both of which I already knew; I was really just going along with the lessons to be polite. I certainly wouldn't have said yes if the hospital had been transparent and up-front about the price tag on this lesson: about $2,000.

5. And sure, insurance covered most of it... but that didn't make it free; it just means the price was amortized over a large number of health insurance premiums. Unfortunately, I think that this setup makes it all too easy for us to think of these things as free, which, in turn, reduces public scrutiny over where the money comes from or where it goes.

And it just keeps going like that. Compare with signing up for cell phone service. It's a famously sleazy business, but, even with all the hidden fees they like to tack on, at least they're up-front about the basic price of service. With US health care, every fee is a hidden fee. That makes it impossible for consumers to make free, informed decisions, which is the most fundamental precondition that must be satisfied in order for a capitalist market to form.

All good points. In my mind, a market lets me make informed choices and choose from multiple options for something that meets my needs. As you noted, the only real choice is whatever your employer offers, or something more fantastically expensive. In terms of care, there are lots of choices but not enough information to actually choose. It's more of a choose your own adventure where you have to guess and hope you got it right.

For #4 on your list, I remember the insane bills we got when our first child was born. It was also insane the sheer number of bills that we got.

First we received a bill for the stay in the hospital. And then we received a bill for the doctor performing the delivery. Okay, fine, it makes some amount of sense, that doctor supports multiple hospitals and isn't technically part of the hospital and staff at that maternity ward that is there 100% of the time.

And then the separate bill for lab work, and another for the pediatrician, and another for our baby's stay in the hospital (this one really got me, why?! we were all in the same room), and then another for the lactation consultant, and, and, and...

I don't remember each one specifically at this point, but I believe it was 7 separate bills.

Edit: typos

I'm still getting bills from various groups almost a year after having a child. Being so far out from the event always makes me cautious about immediately paying them; I'm rather worried about getting a fraudulent bill that looks real, as many of these bills come from central billing offices several states over. It then takes me time to truly connect the dots from the service and looking at insurance history to ensure this bill is legitimate and that I technically do owe that.

Another sleazy behavior I've noticed is that when I receive care, and state that I'm uninsured, the provide chargers me a different rate then had I handed over my insurance card.

The way this plays out is that if I hand over my insurance card, the provider will attempt to extract as much money as possible and bill an outrageous amount. The insurance provider has maximum limits it's willing to cover for each billing code and so only covers some lesser amount. You pay the difference.

This is such scumbag behavior.

The other side of the "market" is also not very "free". Health care facilities are heavily regulated - and I don't just mean for safety. Try opening an MRI facility or other capital-intensive facility... You'll be required to obtain a certificate of need from a state board. That board will be heavily lobbied by existing supplies to minimize competition from upstart facilities. IIRC, around 2/3 of states have these laws in place.

https://www.usnews.com/news/best-states/articles/2021-07-09/...

I would say price discovery is one of the main problems just as you've identified. The other is inelasticity of demand. To put it in a crass way, what's the market value of the morbidity and mortality of your child? I suspect the answer is often all you have and more and I think plenty of actors in the system are happy to take advantage of that.

"And sure, insurance covered most of it..."

Apologies for asking, but when faced with a medical situation do you have any idea when you have insurance what your maximum liability could be?

NB I'm not from the US so I very little understanding of how the system works.

Many (most? I always take employer-sponsored, not an expert on all plans) health insurance plans in the US have a concept of out-of-pocket max. This is a yearly amount that is essentially your maximum yearly liability. That amount can vary from plan to plan and year to year. Usually a lower out of pocket max means higher premiums, similar to the idea of having a lower car insurance deductible usually means higher premiums.

It looks like all plans sold through the healthcare.gov marketplace is required to have out of pocket maximums.

https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...

Thanks for answering - one last question!

Is that a hard limit and you'll never have to pay more than that?

Trick question... - Some policies have a cap on benefits. So, your max out-of-pocket might be $10,000/person, but there's also a max benefit of $2,000,000 (made up numbers). This type of plan language was mostly banned with the ACA (Obamacare), but there are some grandfathered plans.

- Balance billing - there is no guarantee that the insurance provider will actually pay what the hospital bills. Insurance companies usually have negotiated rates with some providers. So, if you end up at an ER that's out of network (no negotiated rates), your insurance might pay what they think is reasonable and the hospital bills you the excess. Several California-based hospitals are notorious for this. It also happens with helicopter ambulance transport - frequently, they'll bill $50,000 for a ride, insurance covers $25,000, and the patient is stuck with a $25,000 balance (again, made up numbers).

Though the practice is now largely prohibited, there are instances where insurers will have caps on how much they will pay out, either over a lifetime or within a year.

So it is not an absolutely hard limit in all cases, no.

Edit: originally wrote year twice.

A lot of this was covered by the Libertarian Party's position on healthcare reform in the last election, which I thought was interesting: https://www.foxnews.com/politics/jo-jorgensen-big-idea-marke...

There are probably ways that we could combine aspects of greater and lesser privatization to achieve the best of both worlds. I have some thoughts that I've been mulling around for a while:

1. Expand the government to achieve universal healthcare coverage.

-- a. ACA public option.

-- b. A conservative UBI, with the twist that uninsured individuals would be automatically enrolled in the public option and have their premiums taken out of their UBI. (Tangentially, for similar reasons, also pay out a portion of each UBI disbursement in the form of food stamps rather than cash.)

2. Shrink the government and quasi-public entities (insurance providers) to unshackle the invisible hand.

-- a. New regulation to ban copays and set a mandatory floor on deductibles (say, $10k). While major emergencies still need to be covered, and while there still needs to be an entity in between the patient and provider eating the risk of non-payment, it's also desirable from an efficiency perspective for patients to be kept aware of the costs of their care — and therefore incentivized to select more cost-efficient options. The market would then naturally find a more reasonable equilibrium without the need for price fixing, in theory.

-- b. Set up a system of tax deductions and credits for out-of-pocket medical costs. (Preferably such that the poorest would have their costs fully covered in most or all cases, depending on what's fiscally realistic.) This must strike a balance between non-disruption of market forces and ensuring that the poorest in society aren't shy about seeking the care they need. My thinking is that the annual nature of tax filings would be enough to address the former, as patients would still be be out of pocket for up to a year waiting on their refunds, representing an opportunity cost that would be difficult to ignore. To address the latter point, set up a standardized/regulated process for the insurer to send the patient something resembling a credit card bill, which they could pay either up front or up to a year later with accumulated interest.

Parts 1 and 2 are essentially unrelated, and could hypothetically be implemented independently of each other. However, #1 on its own doesn't attempt to address the efficiency issue (thus saddling the government with even greater new expenditures), and #2 on its own doesn't address what happens or who gets left holding the bag when an uninsured patient can't pay their bill (which wouldn't be an issue with truly universal coverage).

I also have a lot to say about what the state should and shouldn't be doing to maximize the general health/nutrition/fitness of the population, but we can leave that for another post :).

> New regulation to ban copays and set a mandatory floor on deductibles (say, $10k)

I like everything here except this. Won't a significant amount of healthcare (grouped by specialization, hospital, etc) still be funded by insurance and be outside the reach of market forces?

I am also curious whether there are barriers to producers of medicine, healthcare supply, etc from disrupting existing overpriced producers.

Possibly; I'm not at all an expert on the subject. My goal more directly with that was to ensure that insurance premiums would ultimately be used only to pay for emergency care rather than routine/preventive or elective care. Someone with deeper subject matter knowledge might be able to tweak or flesh it out to better achieve the intended purpose.

If I understand your last point, I really like this approach in the context of my proposal: https://www.rubio.senate.gov/public/index.cfm/2021/3/rubio-s...

Re: prisons - This isn't necessarily the case. Florida's private prisons have air conditioning and the public ones don't in part because of democratic control and the private ones have fewer deaths from heat stroke as a result.

>>> Institutions like healthcare, education, public transport, prisons(!) and so on are more efficient, less corrupt and of higher quality when they are in large parts collectively and democratically organized and funded.

>> Re: prisons - This isn't necessarily the case. Florida's private prisons have air conditioning and the public ones don't in part because of democratic control and the private ones have fewer deaths from heat stroke as a result.

> Extremely suspicious comment. Please elaborate on “democratic control.”

Yeah. Also the GP weirdly collapses "more efficient, less corrupt and of higher quality" into "has air conditioning: Y/N." You have to evaluate those things holistically, and it's quite possible that he holistically-better solution is actually worse in some specific areas.

Also I don't have any specific knowledge about Florida prisons, but private prisons are a new(ish) phenomena [1], and "hav[ing] air conditioning" might simply be an unintended consequence of that, because building standards have changed.

[1] You know what I mean, don't nitpick with some ancient example.

> The "everything is a market" ideology had a good run of almost half a century

But that never actually happened. Externalities were never part of the market.

>> The "everything is a market" ideology had a good run of almost half a century

> But that never actually happened. Externalities were never part of the market.

But isn't the essence of an externality that it's a social cost not factored into the market price?

It becomes a social cost because it was not accounted for as a market cost.

It may be that some of these cannot in principle be accounted for, and even more which cannot in practice be accounted for.

But I imagine the majority of externalities could be accounted for if we tried.

> But I imagine the majority of externalities could be accounted for if we tried.

The irony is if you actually came close to achieving that (e.g. accounting for all externalities in the market price), you'd have something like central planning. That's why externalities are usually managed through other mechanisms.

Also, externalities are only one kind of market failure.

Employer-based healthcare was won by an alliance of corporate and healthcare industry lobbies against a state healthcare plan in the 1950s when the so-called “free market” healthcare system was failing the public. Prices were increasing and the New Deal corporate powers pacified the public with social security and employer-based healthcare.

Edit: updated 1960s to 1950s per info in replies

In the US healthcare was intentionally tied to employment as a means of controlling wage inflation during the 1950s by Eisenhower. He had pushed for the "middle way" of private nonprofit health insurance that could be purchased individually or by employers. As inflation began to spike, the administration added new tax benefits to encourage employers to compete on providing benefits rather than higher base salaries.

Roosevelt also tried to institute a national scheme in the 30s but labor unions were split on notional vs. employer provided and it became a wedge issue that scuttled the plan. Truman's push for that same national health insurance plan was shot down in ~1949, partially killed by AMA lobbying.

It's not Eisenhower's administration that's to blame, it's FDR's. Employer based healthcare is a result of the stabilization act of 1942. Health benefits were offered as incentives to workers because employers could not raise wages.

> Employer based healthcare is a result of the stabilization act of 1942. Health benefits were offered as incentives to workers because employers could not raise wages.

Employers can raise wages, and have been able to for some time, so that's not why we still have it.

We still have it because of tax and other incentives, and because government keeps making policy decisions to protect, and even extend it (e.g., the ACA employer mandate), not because of the employers need to offer health benefits to compete because they can't offer more wages because of WWII-era wage controls.

Employers love employer-based healthcare because it gives them insane amounts of control over their employees’ livelihoods. And as a result, wage competition is far less influential.

The fear of losing healthcare coverage a severe fear that people in other countries don’t have to worry about.

I think a lot of employers find it to be a giant headache. It’s expensive and tricky to administer and has nothing to do with your core competency as a business.

I did not state that this is why we currently have employer based health insurance, just why it came into existence. Many consider this to be the "original sin" of US healthcare policy.

Yeah, I realized on a second pass that I had jumbled the "middle way" stuff with the Roosevelt era bill.

You’re right. It was earlier than I thought. I updated my comment per your reply.

Heaven forbid “wage inflation!”

Was the AFL pushing for employer-based and the CIO pushing for national? I don’t even know where to find history like this. It’s virtually impossible for an average person to learn about the history of the American labor movement.

> Heaven forbid “wage inflation!”

I realized after double checking that it was actually a 1942 Roosevelt bill, and they were trying to figure out how to keep a lid on rising prices during the war. It's also not uniformly good if prices also rise quickly. Inflationary spirals are real, and very bad for regular people.

> Was the AFL pushing for employer-based and the CIO pushing for national?

I'd have to double check.

> It’s virtually impossible for an average person to learn about the history of the American labor movement.

A bunch of this stuff is available in more popular history and online now. "The Devil Is Here in These Hills" is supposed to be good, but I haven't read it.

Blaming employer-based healthcare on the stabilization act sounds suspicious to me.

It was intentionally tax incentivized via the tax code. There’s mountains of writing about it. See https://www.nytimes.com/2017/09/05/upshot/the-real-reason-th...

Are you suggesting that healthcare-as-a-market would start working if externalities were priced in? How would that help?

I suspect the argument is "Healthcare has never been allowed to be a market" Given how many legal restrictions are placed on it, I tend to agree.

> I suspect the argument is "Healthcare has never been allowed to be a market" Given how many legal restrictions are placed on it, I tend to agree.

Emergency services aren't a good fit for markets. For markets to work, people really need the luxury to shop around with some leisure.

Wasn't there some Roman oligarch that ran a private fire department, and basically just used it to extort property owners when they had a fire? Truly market based emergency medical care without legal restrictions would likely frequently resemble that with some frequency.

Edit: Yep: https://en.wikipedia.org/wiki/History_of_firefighting#Rome

> The first ever Roman fire brigade was created by Marcus Licinius Crassus. He took advantage of the fact that Rome had no fire department, by creating his own brigade—500 men strong—which rushed to burning buildings at the first cry of alarm. Upon arriving at the scene, however, the firefighters did nothing while Crassus offered to buy the burning building from the distressed property owner, at a miserable price. If the owner agreed to sell the property, his men would put out the fire, if the owner refused, then they would simply let the structure burn to the ground.

I will also comment that when we talk about "healthcare being a market", we need to separate out providers of healthcare, with insurers of healthcare. Insurers of healthcare are much closer to a market (in that I can generally find out what the cost of the insurance is, and what it covers), but providers aren't (in that prices lists are hidden, it's not clear what is covered vs what isn't, etc). We talk about the cost of the insurance, but that's artificially high because of the practices of the providers (themselves incentivized to behave that way because of the insurers).

And that's the open market; it gets even more cloudy when we talk about employers being involved, so we have an agency problem as well.

It's a system unlike any other, and I don't think general theories really apply very well as such.

Here's a theory: Insurance companies argue and refuse to pay out to hospitals because it's an adversarial relationship.

Hospitals increase rates to cover the overhead of dealing with hostile insurance companies. Insurance companies raise rates to match increased hospital billing. Ironically both industries are incentivized to raise rates on customers while trying to gouge each other.

Is it any wonder healthcare is a scam?

US healthcare is a four-party arrangement since employers are also intermediaries. Employers select the plan (or plan options) and they pay the bulk of the premiums. Their check is always bigger than yours even if you pay more for your policy than they do. As such, most of the sales effort by health insurance companies is directed at the employer and they exercise a lot of judgment. In contrast, I have never once spoken to a representative of the health insurance company during open enrollment, it is always HR.

This whole situation would be solved by a simple change to the tax code. Managed healthcare (health insurance) can no longer be purchased via employers with pre tax income.

Everyone gets funneled to healthcare.gov where they can choose.

The whole buying things (life insurance, gym membership, retirement savings) with pre tax income if it is bought through an employer system needs to go in the trash.

Furthermore, a lot of employers self-fund and use the insurance company only for management and possibly secondary insurance.

In my book, it’s a big red flag when a market is intermediated by anyone. The whole point of markets is to crowd source decision making, so if you remove the crowd, then what is it that you actually have left?

Rent seeking oligarchs?

> a full state-run system, which is vulnerable to undercapacity (which the UK is currently suffering from)

That's more because we've had decades of deliberate underfunding due to the "austerity"/"capitalism++" lunatics in charge than a natural consequence of a state-run system though.

Greed unfortunately seems to be an endemic issue. It creates these fanatics that want to leech on every part of the system imaginable, even if it means people die

But how is that not "expected"? Feels like the argument that "communism is good, it just wasn't implemented well anywhere so far". Well, sorry, but by this point I chose to believe that a full state-run system is vulnerable to under-funding in the long term.

Long term everything fails, Malthusian pressure gets us all.

But in the medium term, the NHS was doing pretty well until Austerity became the dominant U.K. policy:

https://fullfact.org/election-2019/ask-fullfact-nhs-waiting-...

https://ifs.org.uk/publications/15557

(That said, I don’t have longer graphs to hand, and I am slightly concerned by the convenient start date on the graph in the second link).

NHS was a great initiative and idea!! I'm not advocating against public healthcare, at all. I'm saying is that it's not surprising it became underfunded - there needs to be constant effort to prevent (or compensate) that tendency, because it _is_ the natural tendency of such systems.

Fair enough, I assumed you were trying to differentiate it from private sector given the use of the quote about communism :)

It's clear that a strong public system is needed, to keep the private ones in check. But e.g. Italy shows that they can co-exist well, and maybe that's a better solution?

No doubt. I know nothing of the Italian system; I’m in Germany now, which seems to be not just what all the left wingers I know in the U.K. are afraid the Tories want to do to the NHS, and what all the right wingers in the USA have been complaining about when they say Obamacare is too socialist, and what the one British anarcho-capitalist I knew didn’t like about UK National insurance: there are a bunch of private healthcare providers, insurance of some sort is mandatory, the providers don’t have clear differences beyond branding, it’s not called “a tax” despite being on end of year tax forms, and rich people are allowed to do some sort of shenanigans that makes it cheaper.

But… it works.

The NHS is cheaper, but — and here I wander dangerously into opinion — I suspect that’s short-term benefits with long-term problems which will bite the U.K. in the backside rather than better overall cost-benefit decisions.

So we should just expect people to be greedy and try to ruin systems for their own benefit. That raises the question of how to make these systems more robust to defend against that sort of attack.

Exactly. Expecting people to be generous and collaborative and selfless and whatnot is just asking for trouble.

Note that I'm not saying that people are not/ cannot be generous, selfless etc. I'm saying that relying on them being so is a crappy strategy. You need a system that continues to work in the presence of greedy people.

That is the pro of a market system. A market with a malbehaving dominant party is liable to be upset by a new contender who will undercut them, thus depriving the misbehaving party of income.

That's what would happen theoretically.

In the real world what will happen is the malbehaving dominant party will capture the market by any means available to them. In thoroughly corrupt countries they will bribe legislators, in less corrupt countries they donate to the legislators' election campaigns.

This is true, but I haven't seen any coordinated efforts at market based healthcare reform. Some of the needed reforms are patently obvious (eg make arbitrary post-facto charges illegal, like every other industry), and yet there are no popular campaigns advocating for them. There are a few comments in this thread chiming in with lists of reforms, and I could write one of my own, but politically it's crickets (likely because the Parties are partially employed by the healthcare industry).

Instead I'm forced to reluctantly support single payer healthcare, despite it being a huge corporate giveaway. It's really saying something when "have the government take it over" is the clearest path to restoring a more functional market.

> make arbitrary post-facto charges illegal,

Hospitals now are required to make pricing transparent and surprise bills (out of network charges) are now prohibited, both are recent reforms.

Out of network charges are only one possible surprise, and it's yet to be seen how the cartels wriggle out of the new regulation.

As far as I am aware, you're still unable to get straightforward answers for questions like "how much will this procedure cost?". Furthermore, this "transparent pricing" revolves around publishing a fake list of inflated prices that nobody actually pays and so is effectively useless.

Meanwhile in every other industry you either get a flat fee ($30 for an oil change), or at the very least an estimate and a contract that fixes the rate (the shop rate is $80/hour, we think this will take 2 hours). Materials are often overcharged (eg $140 for a part that is easily available for $100, because it's delivered from a special supplier) but still within a workable bound, unlike say fraudulent aspirin.

This is a straightforward reform - the reason healthcare doesn't operate like this is they bought laws creating the ability to charge you without needing to establish a contract.

That's assuming that the methods used to undercut are beneficial when in reality they're just optimizing for profits over health outcomes. People don't have enough of a choice for it to matter, most people can't just find new providers. Same with ISPs

Yet we have cities with multiple ISPs which have incredibly cheap internet at blazing speeds. In my city we have 1Gbps fiber for $70/mo and the price goes down quickly as you reduce the speed. That's better than some areas of SF I think, and we only have 2 major ISPs here.

Amazing what a little competition can do. The city was smart enough when the competitor moved in to install the capacity for more ISPs to utilize the existing conduits in the future.

In Romania competition + initial lack of regulation and lucky timing led to incredible speed + cost (my ISP just launched 10Gbps fiberlink for 10EUR/mo; 2.5Gbps is 9EUR/mo, 1Gbps is 8EUR/mo, 500Mbps is 6EUR/mo and the slowest option). That said, I think we just got incredibly lucky and I wouldn't advocate "lack of regulation" in general.

Just because there are a couple exceptions doesn't mean you can write off the rest of the country's experience as irrelevant or incorrect

We can ask why those areas with no competition are so, and it is due to overwhelming anti-market bias that makes it hard for other ISPs to compete or even outlaws it directly. Meanwhile cities that have setup one touch laws or fixed right-of-way have seen robust competition emerge.

One area where markets do poorly are where the cost of service exceeds profit, like rural areas. This is an area where government intervention in the form of subsidies can help, but these can also cement single ISP marketplaces if not managed well.

Sounds to me like ISPs should be regulated or managed the same way as telephone and electricity providers

Along with healthcare

People don't seem to have issues getting electricity service or telephone service in those regions. In this case, the special treatment of those services means that people don't get left out

Rich people aren't the only ones who deserve healthcare or good internet

I would rephrase that argument as, "communism is good, it has just been ruthlessly sabotaged by capitalist interests every time an ideologically communist regime forms".

In the case of the NHS, my understanding is that neoliberal politicians have been pushing to privatize it, and have underfunded it to make it look like it's not working in order to make privatization more appealing. The same is true for many programs in the US too.

Nah, Stalin and the communist leadership were perfectly capable saboteurs, didn't need help from capitalist interests. In a system where "the state" has the capability to enforce "public good" policies above anything else, it's only natural that the following will happen:

- individual freedom will be suppressed (because "public good"; can't have greedy people doing greedy things, them weeds need to be killed early).

- since individual freedom is suppressed the regime is naturally going to be autocratic, which means that "the state" is actually a handful of people... who now get to freely decide how they define "public good".

The fundamental error of communism is that in any implementation, it doesn't really have mechanisms to "punish" greedy leadership, only greedy individual citizens. Which is an idea as good as it sounds.

The Bolshevik revolution was carried out under the assumption that world revolution would follow, particularly in Germany. This assumption did not hold, and Russia did not have the needed technological developments to sustain themselves.

Cuba is the best example of a successful communist-ish state. Most if its struggles are due to sanctions imposed by the US and enforced via its allies across the world.

> This assumption did not hold

"if the entire world is a sh*thole, nobody will be able to tell it's due to communism"?

I fail to see what "needed technological developments" would West Germany give them.

> Cuba is the best example of a successful communist-ish state

Successful as in "not completely failed, unlike all the others". Look, I sympathize with their struggles being so close to the US & all, but the fact that this is the best-case for you have should give you a bit of pause, because Cuba is by no means close to being a paradise.

To put things in context, both the largest & most populated countries in the world used to be communist. They both had to abandon it & switched to a form of crony capitalism, which, as bad as it is, seems to actually work better for them than the alternative.

Actually, forget I said anything about communism. My intent was to address the original topic, but I just couldn't resist inserting my take on communism to the original analogy used.

Why wouldn't a private system suffer from the same price pressures?

Because government actors have agency, parent is implying that they made the choice to underfund the NHS. Such a choice was not inevitable. Contrary to “true communism has never been tried” the NHS was successful, and would be if the dominant austerity ideology had not taken hold.

Market is a fine fit for every healthcare need that doesn't start with a trip to the ER which is the overwhelming majority of healthcare dispensed in the US.

Using insurance, government or some other centralizing layer (e.g. the church) for routine activity would raise massive "you're pissing money away" red flags in literally any other context. We shoehorn so much economic activity (healthcare) though a middle man (insurers) and then act surprised that they take a fat cut. The solution isn't to government-ize the middle man. That will almost certainly just be a wash. It's to get rid of the middle man where possible.

There's no reason someone shouldn't be able to get a physical or a colonoscopy the same way cosmetic surgery and dental care are done. These are cookie cutter outpatient services. The deviation from instance to instance is small and predictable so insurance should not be needed on the consumer side.

Edit: Anyone wanna do me the courtesy of explaining why I'm so wrong?

  > Edit: Anyone wanna do me the courtesy of explaining why I'm so wrong?

just a guess, but it might be because of...

  Market is a fine fit for every healthcare need that doesn't start with a trip to the ER which is the overwhelming majority of healthcare dispensed in the US.

... one of the reasons most visits in the us is the er is precisely because preventative care is so expensive/hard-to-get in the u.s and people put off visiting the doctor regularly since its so expensive... the market isn't very amenable to these extra costs in the short run, whereas a state-run system might not have the same short-term cost concerns and encourage/subsidize regular visitation/preventative-care...

Preventative care in the US isn't expensive or hard to get for most patients. Under the Affordable Care Act (Obamacare) there are a wide range of preventive services that must be covered at no cost to the patient. While some coverage gaps remain, those plans cover the majority of US residents.

https://www.healthcare.gov/coverage/preventive-care-benefits...

What about treatment for severe conditions such as cancer or chronic conditions such as life-long disabilities where the expense is significant to the point that it may well be crippling for an individual but is rare enough that it's only a moderate cost spread across a society?

These are the cases where insurance is a perfect fit. The issue with letting it be market-based insurance is that (as you say) it allows insurance providers to take a fat cut. The obvious solution is to regulate insurance costs. At which point you might as well state fund it. Which leads us to the system we have in most of Europe.

As these system seem to work quite well, why do you think a market-based approach would be better?

I misunderstood your comment on first read, and looking at other replies others did as well.

> Market is a fine fit for every healthcare need that doesn't start with a trip to the ER which is the overwhelming majority of healthcare dispensed in the US.

I think most people are interpreting this as “market is a fine fit for every healthcare need [except for those that start in the ER] which is the overwhelming majority...”

I.e. that you’re advocating the market for the majority of healthcare rather than the majority.

I think your actual recommendation is the opposite. Maybe this would be clearer if you just laid it out like, “Most healthcare is non emergency, cost is a primary concern which insurance makes worse, markets are good at solving cost issues.”

Responding to your actual argument, however, I see many people claim that insurance companies are taking a “fat cut”, but I see very little evidence of higher than expected ROI/ROE in Aetna / United / etc. (ref: United’s net margin is ~5%, ~15B in net income on 300B of revenue). ROE is ~20% which doesn’t seem ridiculous for an insurance business.

The bigger problem seems to be personnel spending in healthcare (admin, support staff, billing), and generally a systemic culture that’s not even knowledgeable about what prices they charge, let alone price conscious in the services they deliver.

> ~20% which doesn’t seem ridiculous for an insurance business.

I think the issue with healthcare insurance companies in the US is that they collude with the hospitals to artificially inflate the cost of things so that their 20% is 20% of 10x the actual value of the treatment.

> routine activity

But as you observe yourself, that's not the majority of healthcare, which is emergencies and unforseeable needs. Hence there has to be an insurer of some kind.

> There's no reason someone shouldn't be able to get a physical or a colonoscopy the same way cosmetic surgery and dental care are done. These are cookie cutter outpatient services. The deviation from instance to instance is small and predictable so insurance should not be needed on the consumer side.

Sure, whatever, the small part of the healthcare market that actually functions like a market - consumer choice, legible prices - can be left to get on with it. Let's not let that get in the way of a functioning provision of necessary care to the majority of people.

The healthcare industry already pisses away huge amounts of money. Its evident in all those stories we hear about people getting a huge $5000+ medical bill, then calling the hospital and suddenly its $100 or less. That $4900 is literally all wasted