I do recognise though that it’s an unsolved problem, and will lead to some form of regulation as our understanding is lacking.

I think only harmful monopolies should be broken up by force, since they’re a legitimate market force. I’m conceding some ground on that because I’m not prepared to claim that monopolies aren’t always harmless.

Australians have a weird sense of humour - it's clear from here that most aspects of US economics are decidedly not free markets but so many US citizens never shut up about "free markets" and have such a bicameral Capitalist v. Communist view of the world that it makes sense to just deadpan nod along.

Maybe reread https://news.ycombinator.com/item?id=41856242 and ask yourself if the article really thinks the US health system is a proper Adam Smith free market .. or just a "US free market" with extra heavy air quotes.

market, maybe, "free" market? I doubt it.

It's not a very free market when there is such a large power differential between the buyer and the seller. You can't exactly shop around for the ambulance or the hospital when you need it, nor can you realistically circumvent the artificially constrained supply [1] of doctors to get cheaper healthcare (unless you live next to the border).

When the alternative is a one-sided market like this, government becomes rather more appealing.

1. https://en.wikipedia.org/wiki/American_Medical_Association#R...

The vast bulk of health care is by appointment, not a dash in the ambulance.

It’s not shopping for a tv. You can’t choose not to buy. It’s often time sensitive even if by appointment. Pricing is incredibly complex as are the details of the product. Your average person does not have the information necessary to navigate the market.

How did we collectively decide that it's okay for insurance companies to overrule medical professionals?

All of that cost savings makes US healthcare cost double what it does anywhere else in the world.

If we want to hold down costs then we'll have to put a greater focus on preventative care, stop expensive treatments for terminal patients, impose price controls on providers, and stop subsidizing drug development for the rest of the world. None of those measures are politically popular.

Some states have recently passed laws which limit the authority of health plans to conduct medical reviews or deny payment for services that providers deem medically necessary. This will reduce hassles and expenses for some patients, but it will also accelerate the inflation of insurance premiums paid by everyone else.

This is my main argument against private healthcare: there's no real choice involved. Without even getting into what a free market is and perfect information etc, the main advantage of a capitalist society is you get to choose what you like. Nobody chooses healthcare (at least, not the super expensive part).

Is your argument that there is choice involved in public healthcare? Or simply that it's not even a question?

> Nobody chooses healthcare

Yeah, they do. Root canal vs implant vs dentures, for example. Ozempic vs diet+exercise, for another.

a basic heart ultrasound cost me over $1k while my vasectomy cost me a $60 copay. i was expecting those prices to be flipped.

and don’t get me started on labs. i’ve gotten bills for basic screens years later for thousands of dollars.

you can’t shop around if you don’t know what you’ll pay until months after it happens. if you call the insurance company beforehand you wait on a static filled line with a call center in india, and even with the CPT code they can’t give you a straight answer.

All you gotta do is ask.

It works every time I asked.

This is why it's sometimes cheaper to have no insurance than insurance.

if you ask the insurance company you’ll never get an answer. providers are usually more helpful about what “should be covered”, but that’s not guaranteed.

seems like prior authorization is the only way to really make sure charges are covered but takes forever. but even then, if your insurance covers $x and they bill $y, you might get a balance bill in the mail.

point is, the market is heavily skewed against the consumer.

While they do have a competitive market, the government very much does pick and choose winners and loosers here like Huawei, resulting in consolidation into a few large conglomerates like every other country. Their (software) tech scene certainly dosen't like more particularly "capitalist" than Big Tech, nor is the Fed pumping subsidies to Tesla like BYD, if anything they're sidelining Elon Musk.

Right up until the moment that the CCP decides to purge your entire sector, sure. I don't know if it counts as "free" if the government stands ready to nuke the sandbox they so generously let you play in.

https://www.reuters.com/technology/beijings-regulatory-crack...

They proactively forced interconnectivity and limited the ability for companies to make "walled-garden peudo-monopolies", as we have in the US with Apple and Google.

If the same happens here (through act of congress, or legal outcomes), you can expect their market caps to decline as well. A decline in market cap doesn't speak at all to whether it's beneficial to the industry or consumers

WeChat is the inspiration for the idea of the "everything app" that so many US companies want to create but have always failed to. Has it somehow been newly limited in its ability to control an absurd percentage of all Chinese internet-connected activity?

https://asia.nikkei.com/Business/Technology/Beijing-asks-Ten...

"Beijing asks Tencent to lower WeChat's mobile payment market share"

https://www.forbes.com/sites/zennonkapron/2022/11/09/chinas-...

https://www.business-standard.com/world-news/china-may-impos...

"China is planning to introduce a new mobile payment regulation aimed at reducing the market share of Tencent Holdings' WeChat app, similar to efforts made by the National Payments Corporation of India to curb Google Pay and Phone's growing dominance in the market"

China's methods are more authoritarian than are viable in the west. But the general premise of a competitive market being better for society than dominance by a small number of firms is supported well by history

Those are 2 different things.

Monopoly doesn't mean "more powerful than the government". I'm not sure what that means, since the CCP disappears or coerces anyone who might threaten the supremacy of the CCP (or Pooh Bear) in any way.

Capitalism results in a single winner, for many industries. CCP prefers kingmaking in various industries, because it's easier for the government to control a few players than a multitude. This isn't what "fair market" means, in context. It's modern communism. State owned companies that are directed by government, rather than direct investment or day to day management. China learned from Russia's failures, I would say. I would also concede it's less regulated, under a political lens.

>market, maybe, "free" market? I doubt it.

The consumer of healthcare is doubly removed from the price of healthcare. This is the opposite of a free market.

The patient did not pay the doctor, the insurance company does. In most cases the patient does not pay for insurance their employer does.

So the normal pricing forces of a free market are removed.

Then we need to talk about certificate of need laws which restrict the supply...

If you’re poor, you’re fucked. If you’re old you’re ok. If you work for the government or certain companies, you have access to world class care. Everyone else is on a spectrum from high quality PPO to the shittiest Cigna plan.

Ignoring risk and consequences doesn't make them go away.

The entire system only works if healthy 30 year olds are putting in somewhat similarly (it will be cheaper regardless). Insurance is based on the idea of spreading risk. Without it insurance cannot function.

To put it into more technical, economic terms: why should the individual tobacco consumer bear the full cost of their externalities while the tobacco company does not?

Because people are well aware that smoking is dangerous and can freely choose to smoke or not.

Actually it's much worse than that. The tobacco company is not just selling tobacco products, it's marketing them and actively encouraging their use!

How would that even work? Any such tax would be priced in into the price of the product. It doesn’t really matter if the government is collecting it directly or through the tobacco companies.

Or if we wanted tobacco companies to pay for all the damage they did retroactively they would just go bankrupt, since they don’t have even remotely enough cash/assets to cover it.

https://www.cms.gov/marketplace/private-health-insurance/mar...

There's a deeper philosophical question here about how we should spread risks and costs across society. Like should some plan members pay more because they have a history of cancer, or because they engage in risky activities like flying light airplanes?

It depends on what your goals are. The reasoning behind why the ACA ("Obamacare") is the way it is:

> Suppose you want to make health coverage available to everyone, including people with pre-existing conditions. Most of the health economists I know would love to see single-payer — Medicare for all. Realistically, however, that’s too heavy a lift for the time being.

> For one thing, the insurance industry would not take kindly to being eliminated, and has a lot of clout. Also, a switch to single-payer would require a large tax increase. Most people would gain more from the elimination of insurance premiums than they would lose from the tax hike, but that would be a hard case to make in an election campaign.

> Beyond that, most Americans under 65 are covered by their employers, and are reasonably happy with that coverage. They would understandably be nervous about any proposal to replace that coverage with something else, no matter how truthfully you assured them that the replacement would be better.

> So the Affordable Care Act went for incrementalism — the so-called three-legged stool.

> It starts by requiring that insurers offer the same plans, at the same prices, to everyone, regardless of medical history. This deals with the problem of pre-existing conditions. On its own, however, this would lead to a “death spiral”: healthy people would wait until they got sick to sign up, so those who did sign up would be relatively unhealthy, driving up premiums, which would in turn drive out more healthy people, and so on.

> So insurance regulation has to be accompanied by the individual mandate, a requirement that people sign up for insurance, even if they’re currently healthy. And the insurance must meet minimum standards: Buying a cheap policy that barely covers anything is functionally the same as not buying insurance at all.

> But what if people can’t afford insurance? The third leg of the stool is subsidies that limit the cost for those with lower incomes. For those with the lowest incomes, the subsidy is 100 percent, and takes the form of an expansion of Medicaid.

* https://archive.is/HzS1G / https://www.nytimes.com/2017/07/10/opinion/obamacare-repeal....

* https://thehealthcareblog.com/blog/2023/02/15/all-three-legs...

The goal of the ACA in the US was getting closer to universal coverage, and that means 'subsidizing' bad behaviour to a certain extant.

Certainly smokers and such should practice more (so-called) 'personal responsibility', but there are a lot of situation where the pre-existing condition is not smoking or other lifestyle choice, but something genetic / congenital. So unless we want to get into (social) Darwinism and leave those folks on the sidelines, the lifestyle folks can end up coming along for the ride when society decides to protect other non-lifestyle pre-existing people.

Yes, therefore separating people's lifestyle choices from the plainly obvious risk and consequences involved.

But if you can socialize your losses (banks) or bad decisions (people) and avoid some of the consequences, I get it.

Last year, my wife died from a recurrence of metastatic melanoma. If insurance was rated like general liability insurance, she would have been dropped 8 years ago when the original cancerous lesion was removed.

I would have bankrupted the entire family to fight for the 60% survival rate in a few months, and she would have suffered even more without adequate care at the end.

By your standard, that suffering was her “fault”, because she failed to use sunscreen as a teenager. Fuck that noise.

We have Medicare “socialism” because social security was allowing the elderly to support themselves and live longer. Many were neglected and dying in inhumane ways, or saddling families with the burden of being a full time caretaker. It’s gross that we live in a society drowning in riches, but we take a principled stance to avoid taxation for rich people, at an incalculable human cost.

Those "civilized" countries universally have very long wait lists that make health outcomes worse.

If anything, healthcare and insurance have almost completely perpendicular incentives. No wonder then we have the world's most inefficient system.

Then you get into the wonderful world of getting receipts for every procedure and manually submitting them, only for them to be rejected so you have to call and tell them to provide the service they promised you. The insurance isn't even cheap! My monthly deduction would be close to the same price as an Obamacare plan, and that doesn't include the employer contribution. Healthcare is such a racket.

Not really true, as the employer could otherwise pay that money to the employee who would then shop for his own insurance. So the employee pays, but doesn't have a choice.

and salaries are stagnant. why would they pay extra? at least they're obligated to provide insurance, even if it's terrible and impenetrable

The entire reason health insurance got so mixed up with employment was as a workaround to WW-II era wage freezes. Employers couldn't pay more salary, so they offered other benefits including insurance to attract and retain employees. Now we're stuck with that.

Thankfully you can often get denials reversed after the fact by calling and complaining, but that takes an hour and is another roll of the dice. The only people who like the US system are wall street people who own stock in the companies.

When I am psychotic I cannot exactly choose which psychiatric hospital I want to check into and ponder about the price to put it off for another day.

And this is what the free market did to psychiatric hospitals: https://www.wral.com/holly-hill-hospital/21507953/

Back in the 1970s the AU Government was running campaigns such as Life. Be In It: https://www.youtube.com/watch?v=GNjEge3Awl8 (many short segments airing with commercials on TV).

Planning requirements typically require open spaces, walking paths, sporting facilities, etc.

A "healthcare system" needs to be more than simply "immediate care for the injured, sick, and|or dying".

    > Part of the Australian national, state, and local health care system is policy to encourage healthy life styles and to discourage, limit, or ban food additives, tobacco, etc.

see: https://theconversation.com/why-isnt-dental-included-in-medi...

, realise that mental health services also had poor inclusion at times and that "gambling" is being implied to fall under mental health services (and hence not addressed).

On a more serious note, gambling in Australia has some serious industry influence that's preventing it being properly addressed - see: (for example) Media Watch -s2024e31- Monday 2024-09-09 They're Addicted

If this is going to be an exception, it'd be truly interesting.

I think you mean diet and exercise when you say 'normal'. Its not possible to have that much 'normal weight loss' in the 'same period'.

'Normal weight loss' here refers to eating the same amount of calories without taking Ozempic. You should lose weight at the same speed as with Ozempic, because it's the calories that matter when it comes to fat loss.

Unless Ozempic causes significantly more muscle loss than other ways of losing weight, that news isn't really news.

The only people who don't are people who lose weight through resistance training. Which is a small minority - because we have a HUGE diet culture!

You think paying vastly more for much worse outcomes is a good thing??

Boy do I have a GREAT used car for you!

Or its a ticking time bomb: 39.6% of Americans are Obese(BMI 30 or higher). Fast forward 15 years and this will probably collapse the country. It certainly will be the No 1 issue in the country bar none. Ozempic may actually give the country a chance of some sort of future.

The US has massive government regulation and dysfunctional state intervention in healthcare if not directly then vicariously with rules around Medicare. The US government helps make the dysfunction that private equity later exploits.

So I’m not sure that it would be correct to use Aus and the US as examples of the either end of the private / public continuum.

I would use UK or France as an example of a public system and Singapore as a light touch private, and perhaps India or Turkey as a laissez-faire system.

The UK and France systems appear to be degrading and do not appear long term affordable and I think they will soon be adopting Canadian style Maid systems to cut cost.

Germany is a weird one because it seems like half the doctors there are homeopaths and the Germans love their insurance but I’m not sure if they get value for it.

Personally I’d prefer the Australian or Singaporean style systems but I’d classify those as mostly private.

The current system grew out of a more fully public system under a many years past Whitlam government, people like the universal health for all aspects and wanted additional private services in the mix. It's evolved from there, with government oversight directed towards keeping things accessable and fair.

The US appears to have "massive government regulation and dysfunctional state intervention" as the end result of a lot of fingers in the pie bending regulation toward "middlecare" providers that don't apply splints or save lives, just diddle about with insurance schemes. (Admittedly that's just an impression from afar).

> The US government helps make the dysfunction that private equity later exploits.

My feeling is the US government is largely an arm of private interests in many matters.

Health Care in Australia embraces public policy such as Food Regulation to ban and limit additives, parks and sports grounds to encourage exercise, limiting access to tobacco, and some interesting national level drug acquisition deals to keep pharmacy costs low.

These cause a flow on of less per capita input into the medical side; lower heart disease, less smoking related issues, etc.

I'm assuming the rational behind drawing the distinction between the US and Aus systems is to somehow inform what the US should do, I don't think giving an already corrupted government system more power will help. It's very hard to uncorrupt things and because of that reason I think the US would benefit from a more laissez-faire system.

Additionally Australia has many advantages that the US does not and the US could not emulate Australia even if they wanted to. I don't know how long that'll last either - mathematically I would assume a country could not get rich and stay rich repeatedly selling houses to each other but it does seem to have lasted a very long time. I assume at some point the Aus government will run out of ways to prop up the housing market. The combination of negative gearing and all sorts of first home buyer grants is just insane.

The upside was that if you needed, say, a brain transplant for ten million Euros, as long as it was medically necessary they would pay for it.

Now I have a policy elsewhere that is cheaper, still covers me when I go to Europe, and has a much better copay structure while being 100% private. Downside is I can’t afford that brain transplant, but I’ll probably be OK for everything else.

I was an employee so this didn’t apply to me, but for my freelancer friends it seemed very unfair that they had to use private.

When you're very sick you hardly have time, money and energy do deal with a lawsuits so that you can get the care you desperately need. By the time you win your lawsuit you could be dead or your condition worse from the stress.

What do you mean by this? Fatalities among the young will have a much larger impact on lowering nationwide life expectancy than fatalities among the elderly.

( Describing various systems in various countries as either communist of free market capitalist is pretty simplistic, it's not much as a linear spectrum either )

I'd also argue that the foundation for a high life expectancy doesn't start with good health care for seniors .. unless the metric is "life support via artificial means" .. life expectancy is grounded in healthy living and excerise from an early age well maintained with good health programs.

For non-seniors, the medical insurance system certainly sometimes doesn’t feel like a free market from the consumer perspective, but the insurance companies are private for-profit institutions, and the medical providers are too, so it may well fit the definition.

> she will have a much higher chance of survival in the US.

Without a deep dive it looks ballpark the same, to be honest.

AU Cancer Survival Rates:

    The 5-year survival for cancer in 1991–1995 was 55% and by 2016–2020, the rate had increased to 71%. Even with decreasing mortality rates and increasing survival, the number of deaths from cancer has been increasing.

US Cancer Survival Rates:

     Five-year survival rates have also been increasing for an even longer period of time. The overall cancer survival rate was 49 percent in the mid-1970s. It currently sits at 68 percent

A few years back my Mum in Australia was diagnosed with stage 4 lung cancer, given 12 months to live.

For just shy of 3 years she had radiation, chemo, trial drugs worth nearly a million a pop all in a brand new cancer Center. Because she lived a couple of hours away she got free transport to and from and free hotel. Not pay and claim it back, fully free.

She was on an enormous cocktail of drugs that dad would get at the pharmacy that raised a lot of eyebrows for the strength of the opiates among other things.

For three years they never paid a cent. They never paid a cent of health insurance, never had private cover, never had a deductible. That would all be the same if they had never worked or took a decade off to pursue some hobby.

Trust me when I say it was stressful and emotional enough without adding money or paperwork or insurance into the equation

The comparison to my friends in the US who couldn’t get a separated shoulder fixed because it was “out of network” or had to move hospitals the day after a C section because the insurance didn’t want to pay anymore is downright disgusting.

For real people living their lives the two systems are vastly different.

Could this also (partially) be explained by the cost of healthcare? Something like a downwards spiral where average people end up poor either due to direct costs of healthcare or neglecting their own healthcare due to cost?

- greater usage of surgeries and prescriptions, leading to greater exposure to medical malpractice (the 3rd leading cause of death in the US.)

- higher birthrate. more pregnancies.

- less cultural tolerance of abortion. Greater willingness to take on risky pregnancies

- single parent homes (people with less family support)

- ethnicities which are more susceptible to certain disease and lifestyle risks

- greater exposure to crime in impoverished areas

- more life time spent traveling in cars

- more restricted access to health insurance (as you said only accessing healthcare in dire emergency)

The US is a different world than most countries which tend to be geographically tight and culturally homogenous. It's very difficult to make comparisons, not to mention differences in data collection and reporting ethics.

Not to downplay the malpractice problem, but this doesn’t sound remotely plausible. Do you have some sources to back up this claim?

I googled around a bit and it appears to come from some sloppy misuse of statistics in a journal one time, plus internet amplification.

> The CDC’s published mortality statistics, however, count only the “underlying cause of death,” defined as the condition that led a person to seek treatment.

Because of this political choice the information comes from 3rd parties digging into the accidents category.

https://www.propublica.org/article/study-urges-cdc-to-revise...

> The US is a different world than most countries which tend to be geographically tight and culturally homogenous

I am not sure how much you know about Australia, but homogeneity and geographically tight is definitely not how you would describe it.

So, if this was the issue, you'd probably expect outcomes to be better in less diverse, physically smaller US states. Looking at, say, life expectancy by state (https://commons.wikimedia.org/wiki/File:Life_expectancy_map_...) doesn't seem to bear this out, really; on your theory you'd probably expect, say, West Virgina to be handily beating California or Texas.

Also, of course, _Australia_, which started the thread, could hardly be called either geographically tight or culturally homogenous. Australia is roughly the size of the contiguous United States.

The point about less diverse is that’s it’s easier to operate health programs which match the values of the population.

Not that small ethnic group = healthy.

West Virginia is extremely poor.

For example, Medicare.

https://www.crikey.com.au/author/bernard-keane/

Bernard is well across many aspects of US, UK, and AU political views, government systems, media etc. with his own particular views as we all have.

In context he's writing for an Australian audience about a conservative Australian trope that the Australian health system is weighed down with government meddling and would do better with, for example, a "US free market" approach.

I think we all appreciate that's an illusion, a myth spun for children.

It is a carefully constructed plan that will ensure rich people get a whole lot richer and poorer people get worse care. It’s not an accident or nice story. It’s class warfare

  less likely to die from drug overdoses. Older age groups are also less likely to die from chronic diseases such as circulatory problems and heart disease. Cancer mortality rates are lower in Australia than they are in all other Anglophone countries, except among American men aged over 65. And Australians are also less likely to die in road accidents than other countries

There's likely at least one other major factor, and I would assume that it's some variation of "inability to access high-quality care for financial reasons" given how much of a wealth disparity there is in various healthcare outcomes.

  Older age groups are also less likely to die from chronic diseases such as circulatory problems and heart disease. Cancer mortality rates are lower in Australia than they are in all other Anglophone countries 

  wealth disparity there is in various healthcare outcomes.

Why would it depend just on one factor like hospital access?

The figure I see thrown around is America has a 40% rate of obesity.

Australia looks like it's 32%.

European countries look like 20-30%.

I think these rates alone could explain life expetancy regardless of health care system.

All the medicines they prescribe are merely to manage symptoms. I have GERD and reflux. I was given PPI after many many tests. How does taking PPI extend my lifespan. Whatever has gone wrong with my body is still there.

How is this not obvious to ppl making this absurd correlation between hospital care and lifespan.

Medicine doesn't have shit of new breed of diseases and disorders ppl are dying from. Doctors don't have answers to any of modern illnesses so how does it matter if access to a useless person is govt funded or 'free market'.

It can potentially extend your life by reducing your probability of developing esophageal cancers, improve your quality of life in the meantime, and there are other complications from untreated GERD I can't recall but would negatively impact your life.

In the US, government is elected by people. You can't blame a gvt for not doing what it hasn't been mandated to do.

Are you touring with this material, or is it off the cuff standup?

The healthcare system in the US is far, far from a free market. Most people would describe it as a crony capitalist market. There's a lack of transparency, lack of competition, and lobbyists of established players have too much say in the lawmaking process.

  "less likely to die from drug overdoses. Older age groups are also less likely to die from chronic diseases such as circulatory problems and heart disease. Cancer mortality rates are lower in Australia than they are in all other Anglophone countries, except among American men aged over 65. And Australians are also less likely to die in road accidents than other countries"

Looks like you conflated two unrelated things ?