Medicare for all is not a panacea and would cause dramatic breaks in care in other places. The fragmented private model sucks, but the belief that single-payer would fix much of anything is faulty.

Reform should happen, but it shouldn’t be based on a bumper sticker, and it should be thoughtful about the vast differences between SF, NYC, West Texas and Southern South Dakota. “Fixing” things for people in major cities while crippling/destroying rural care (more than it already has been) is a bad solution.

Rural healthcare is being crippled in part due to state politicians posturing for political clout. Major reforms like medicare for all shouldn't be held back because they're not perfect, because otherwise we're going to continue having the same problems we've been having where compromised half-assed bills make the system overall worse.

I’m not saying we shouldn’t reform - I’m saying we should be careful about what that reform is, and what its goals are. I would generally suggest that CMMI and provider groups is/are more heavily involved than big city voters who know very little about a very, very complicated issue.

Lastly, rural healthcare is in trouble because reimbursements are bad (especially Medicare reimbursements), FFS (fee-for-service) is a failed model, there’s a massive credential shortage, and given those, the credentials that exist would prefer to work in desirable places, not Pine Ridge, SD. If you’re serious about fixing healthcare, you should start by fixing education. State politics, specifically around Medicaid, are, generally, not driving the hospital closures and OB/GYN deserts.

State politics absolutely are driving hospital closures and OB/GYN deserts because the 'desirable places' metrics includes places that won't prosecute doctors for routine prenatal care. That's literally why we're seeing Texas and Florida suffer from an increasing lack of OB/GYN care.

I don't dispute the rest of your arguments about healthcare, but you cannot fix education and/or brain drain without fixing state politics.

These issues were occurring before Dobbs - suggesting that’s a major driver in the long term creation of care deserts is incorrect.

Hospitals are not closing because of shitty prenatal laws. They’re closing because reimbursement rates are insufficient, in part, because we’ve allowed too much consolidation, in part, and because there aren’t doctors/nurses who want to live in the sticks and make peanuts.

Why is it Medicare’s problem to fix that educated people choose not to live in certain places?

So your solution to healthcare in this country is to light rural America on fire so that you, personally, can have cheaper care?

That sounds workable.

That’s not what I said at all.

Then perhaps you should use your words and explain what you actually mean, lest it be assumed to be ill-informed snark.

Why would I bother arguing with someone who misconstrues what I say?

In a typical conversation, if someone misunderstood you, you wouldn’t give them an angry middle finger, you’d clarify your meaning. But you do you.

I think what he's saying is far more comparable to:

"If you choose to live on an obscure island or corner of alaska unreachable by land, should the government be obligated to keep a doctor living and working nearby you?"

To which I'd then imagine the thought process is more sometimes you'll just have to move to a more urban / developed area if you have a really severe disease, or deal with long drives or getting plane flights.

> If you choose to live on an obscure island or corner of alaska unreachable by land

This is a sort of disingenuous way to talk about rural America. Pine Ridge is two hours from Rapid City, not the middle of nowhere, Alaska, and the discussion isn’t about specialty care, but normal primary care, hospital and Ob/Gyn services.

Saying “suck it you stupid rubes, move to a city” is going to make it difficult to get anyone to agree with your version of healthcare reform, assuming it was even going to work.

Wouldn't proper regulation of the health-insurance industry be easier to achieve than Medicare for all? It's not like single payer is the only real option. A 100% privatized system can work just fine with proper regulation. US could more or less just copy paste the Dutch insurance system..

You provide no examples of your statement. I say Medicare for all is a panacea and will cause no breaks in care.

That was easy.

I didn’t realize you were looking for a sourced essay.

Medicare-for-all extends a fee for service model that results in poor care, poorer outcomes, massively increases expense, and simultaneously lowers physician reimbursements. Given the increasing doctor shortage, that’s an issue that will be immediately exacerbated. Further, the FFS model incentivizes throughput, not quality of care. Your care won’t get better.

So how do places like Hong Kong make this work? Because they do. My out of pocket expenses there uninsured are less than my copayments fully insured here.

https://journals.lww.com/jcma/Fulltext/2015/10000/Overview_o...

I suspect every reason you will cite is something we could both address as a nation and we will refuse to do so because freedom or some other idiocy. I truly give up. I threw money at family's medical crisis and prevailed. Most can't. More should be able to do so.

Even California is looking to places like Houston to mine ideas for improving their raging homeless problem. If you're not going to steal from the best, why bother doing anything?

Do you think there might be other differences between Hong Kong and the United States that could account for differing challenges in providing healthcare?

I’m not clear why you’re giving up - it’s not an intractable problem. Some folks need to give up on “healthcare only for the rich/cities” and some folks need to stop having strong opinions about a very, very complicated industry they don’t understand at even a surface level (not directed at anyone specifically - it’s a common US problem with healthcare discussions/solutions).

Cost/utilization/availability challenges are fully solvable, if one is committed to a solution and not a message.

I've literally never been about only healthcare for the cities or 100% medicare for all, I literally said it ought to be a baseline on which to build something better. It's much like how we can't even agree as a nation that coal sucks and replace it with renewables/nuclear/natural gas on the way to something better.

So here we are, paralyzed indefinitely, throwing more money at a broken system annually. But also, so many in tech build things from strong opinions about very complicated things, and they are inadequate, but at least they're not doing the same thing over and over and expecting a different result.

I will say this though. I have yet to see private equity do anything besides make an existing problematic situation worse. And if that's what you mean by a difference between America and Hong Kong, yep, I agree.

Neither comment was directed at you and I’m sorry if they read that way - M4A (specifically) discussions usually center on people who live in a big city and are solving only for that. I’ve also agreed in several comments that single payer is a likely component of the right solution, but that current proposals are woefully insufficient, to the point of not even being solutions. I’m all in for incremental improvements (the ACA was certainly one), but not if it just trades my pain point for creating five new ones for you.

The difference between HK and the US starts at the fact that one is 1100km^2, and the other is 9.8 million km^2. Solutions that work well in what’s essentially a really dense city don’t, necessarily, work across a massive country with a distributed, diverse population that faces very different, area-specific challenges.

I’ll add, apropos of nothing, that the fastest way to make healthcare in this country better is to fix education costs. If we dramatically increase the number of people in med school/nursing school, and simultaneously dramatically decrease what they owe upon graduation, you will see far more high quality providers enter the system who will be far more able to practice in places that really need them.

So healthcare providers would be fine with significantly lower incomes just because the government tell them to suck it up?

Also, it's not like the fact that the private insurance model failed in the US means that it can't work at all. For instance, not all countries in Europe have single payer. In some the health insurance system is privatized to a much higher degree than in the US, no equivalent of Medicaid/Medicare with governments directly subsidizing insurance premiums for low-income individuals.

The chief problem is here is asserting healthcare must be either entirely Medicare For All or the current inadequate privately funded system when the two can coexist. Just like legalizing drugs won't cure crime and unhappiness on its own, I doubt a baseline (note I said baseline) Medicare For All fixes healthcare on its own, but to assert neither are a step in the right direction seems absolutely absurd.

There are clear problems with the current system, and we paid quite a bit out of pocket to evade substandard care this past year with our insurance company threatening to not cover it at all at every step. We called their bluff by enrolling in clinical trials and they folded. Most can't afford to do so, and some never will, but I wish I lived in a country where more could.

And sure, a more transparent private system could work, in fact, utter transparency should be a requirement from the get-go given what is happening with the public/private mix in Canada. But we have 50 individual states in which to experiment yet good luck with that in the current media/political environment. Not giving either party a break here.

> The chief problem is here is asserting healthcare must be either entirely Medicare For All or the current inadequate privately funded system when the two can coexist

I'm certainly not asserting that. However, first of all, 'Medicare For All' only makes sense if it's mandatory, which means additional taxes. Yes, considering the social, political, and economic reality, the likeliest outcome would be a two-tier system, with those who can afford it getting additional insurance in some way. I'm not sure what's so great about that?

> And sure, a more transparent private system could work, > experiment yet good luck with that in the current media/political environment. Not giving either party a break here

Would passing an extended ACA II with way fewer compromises and more effective regulation than the Obamacare version be really harder than instituting Medicare for All (so either a significant increase in federal income tax or a new tax altogether)?

>Would passing an extended ACA II with way fewer compromises and more effective regulation than the Obamacare version be really harder than instituting Medicare for All (so either a significant increase in federal income tax or a new tax altogether)?

My marginal rate in California is 53+%. That IMO is ludicrous given the horrendous condition of California and its budgetary planning. But...

I don't think the marginal rates are the real problem here. I think they're just peachy. The problem is we have an effectively ~20 page tax code with 4,980+ pages of bespoke deductions for individuals, corporations, and economic segments. Lose them all and start over with alt-min with far fewer exceptions (if any). I'm already taxed higher than most of the world* including most European Socialist Democracies without any of the perks and returns. It's not about the marginal rates. Which is to say we don't need new taxes, we need fewer loopholes to escape the existing tax rates. And we're not going to get that either. It's way too nuanced and esoteric a platform to gain traction with the sorts that think anyone making $100K in 2023+ is a plutocrat, so once again, I... give... up...

Also, California just loves multiple agencies competing for the same table scraps of tax money, but that's a different thread because all those redundant bureaucrats are getting paid on our dime.

*https://nomadcapitalist.com/finance/countries-with-the-highe...

> higher than most of the world* including most European

I'm not sure that's true in general. e.g. at around 300k the effective income tax rate in CA is ~34% (26% + 8.0% state) +5% (SS etc.) = 39%. That's quite low by European standards, if you go down to 150k the total is just 35%.

In Germany for instance you'd already be paying ~42% on 100k

Anyway, that wasn't my point at all, I'm just unsure how politically feasible it would be to accomplish this on the federal level.

> European Socialist Democracies

There is not a single country in Europe left which would describe itself as a "socialist" democracy (thankfully most of them collapsed around ~1990).

>Anyway, that wasn't my point at all, I'm just unsure how politically feasible it would be to accomplish this on the federal level.

Sure, every so often, someone publishes an article about how to balance the federal budget and it always comes down to neither being a republican nor a democrat. And that's why it won't happen. Compromise is dead.

The problem is that a public option must necessarily spend a lot more of its focus on preventative care that keeps people from developing serious chronic illness in the first place, for budgetary reasons. There are a lot of people staking their career prestige, high pay, and lifestyles on Americans having the freedom to get sick, seriously sick, on a regular and consistent basis. I'm happy to throw them under the bus, but I imagine some will be more than happy to defend them.

EDIT: Geez, here's one now: https://news.ycombinator.com/item?id=38759502

Every single study I have seen refutes your point, which was commonly brought up during the Obamacare discussion days and never had any merit to begin with. Here's the NIH itself estimating a 13% savings compared to today: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8572548/

What you're missing is that the current "system" is so utterly wasteful and inefficient that even if we cover people's shitty lifestyle habits it would still be cheaper than what we have today. Which is basically what TFA's main point is about.

Fair, though we're generally in agreement. My point is that there are many who don't want the savings, because the over-payment is what fills their bank accounts. I was trying to point out that their last refuge, even when things improve objectively and across the board for the vast majority of Americans, is that single-payer or even a public option would hurt their pocketbooks. Like I said, I'm happy to throw insurers under the bus.