It's clear that there needs to be some degree of nationalization, though. Middlemen are literally killing us (and now, in a shift that might actually induce a change, getting killed).
Like, "Expropriate all property used in healthcare delivery." wouldn't work for my old dentist who had an office in a retail mall. Or, what of a rural nurse who uses her personal vehicle (reimbursed) to make house calls. A car is property. Or the on-site medical office for a large factory? (True story: I feel off the bike on the way to work on day, doing some contract programming work for a large company. Not only did the medical office check me over, but I got a tetanus shot, both free since I was working there.)
Are acupuncturists part of healthcare delivery?
> Make medical licensing contingent on public employment.
The TV series "The Love Boat" taught me that a large oceangoing cruise ship has a doctor on board, and that seems to be true still. Will this doctor be a public employee? State or federal? Or perhaps a joint employee?
> compulsory public housing accommodations
That sounds like you want to force all health care people to live at their workplace. Plus, what does "involved in healthcare delivery" supposed to include: the janitorial staff? The IT support staff? The food services staff?
> Establish healthcare unions
I've learned that's entirely too underspecified. A company union isn't an effective at negotiating for workers, for example. Plus, repeal Taft-Hartley.
> to justify any treatment allowed on a first come first served basis
That too needs some examination. How does one measure 'quality of life years'? Do rich people have a higher quality of life than poor? Do blind people have a different quality of life than sighted? What about someone bedridden? In a coma?
How are error estimates incorporated? How do we justify a novel experimental treatment which has no use evidence?
Is cosmetic treatment included? How do we measure quality of life for a nose job? For Lasik surgery?
The goals are great, don't get me wrong, but the taskforce is going to need work out the details better than an HN comment, and you might use my feedback to tweak your wording.
If an activity requires a healthcare license, only allow the government to pay for it. Some things are required for healthcare delivery and are not of value outside of those activities. Apply imminent domain law to expropriate those things to prevent fraud on the part of their owners.
The examples of extra-scientific or optional healthcare activities are likewise simple. Establish a lottery for such procedures using any resources not expended to improve existing quality of life years. Current private provision of healthcare resources bids up the fixed pool of providers and causes us all to pay more for life-continuing care.
Ancillary nonmedical services are red herring. Charge back the cost of those services against provider payments. Much of health IT exists as an elaborate method by healthcare providers to justify payments from payors and can be eliminated.
I noticed, for example, that you haven't actually answered my questions.
How do we measure quality of life years in any operationally useful way?
Which healthcare is optional?
Is acupuncture - which requires a healthcare license in some states - included? Why or why not?
How does one expropriate the health care services provided on a cruise ship, and how does it prevent fraud when there is a sole provider of power, water, etc. to said services which can charge whatever they want? Surely you need strict cost controls, but in that case you don't need to expropriate in the first place.
I don't follow what you suggest by the solution to the red herring, so here's a concrete example. I was near-sighted, and paid for new prescription glasses every few years. I decided to get Lasix surgery, which I don't regret, though now I need to get (much cheaper) reading glasses every few years.
Is Lasix for this case non-medical? Who is the provider which would be charged? For that matter, are prescription glasses part of health care, and if so, do people only get basic glasses (like US Army slang "Birth Control Glasses"), or are fancier glasses included, and who pays for the cost difference?
Are breast implants ancillary nonmedical services? Some women find that having larger breasts improves the quality of their lives. Does that make it ancillary or not? What about for women who had a double mastectomy and are depressed about the loss of her breasts? What about gender affirming care for transwomen? What about that guy I saw on TV who got breast implants because he lost a bet?
There are similar issues for cosmetic dental treatment, where fixing a chipped tooth may depend on personal vanity and external perceptions - a model's career may be negatively affected by an ugly-looking tooth. Do we factor in the difference in potential earnings when figuring out quality of life years?
And on and on.
These are not simple problems, and there is no simple answer.
Life’s complications are certainly soluble through relatively simple algorithms. For example, what to do on a cruise ship? Start with “is the care under the jurisdiction of this healthcare regime?” If no, then it is not addressed and entirely up to the individual. If yes, then the person must make their way to the nearest government healthcare facility. I would expect a significant uptake in medical tourism in this form.
Examples like “birth control glasses”: just do the math. Minor likely benefit over a likely long time period for a medium cost. Same for any other example. Will people be unhappy because they value something at more than a standard deviation from the mean? Absolutely, same as people are unhappy now. Not very interesting.
0. https://en.wikipedia.org/wiki/Gish_gallop
I thank you for pointing out QALYs. I had not heard of it. I have read now a few journal articles, and none of them say that QALYs stand alone. For example, https://onlinelibrary.wiley.com/doi/10.1111/j.1524-4733.2009... says:
> Aggregate health gains, measured by conventional QALYs, are one of many inputs to the processes of individual clinical decision-making, societal or programmatic audit, or resource allocation. The other considerations, including equity and fairness, need to be considered separately in the conventional QALY approach.
Or https://www.valueinhealthjournal.com/article/S1098-3015(24)0... is more recent article, from earlier this year, titled "Quality-Adjusted Life Years, Quality-Adjusted Life-Year-Like Measures, or Neither? The Debate Continues"
> The assessment of effectiveness is not and can never merely be a technical exercise. Whatever measure of effectiveness is chosen—even one that has the seeming appeal of being “objective,” such as a clinical endpoint—implies a value judgement about the importance of the various aspects of treatment outcomes.
> It is also important to remember that QALYs and their use to estimate incremental cost-effectiveness ratios inform, rather than dictate, decisions. Limitations of QALYs—or, indeed, any chosen alternative to them—can in principle be handled via careful deliberative processes or addressed by the consideration of other kinds of evidence and decision rules, as is typically the case in the HTA processes of many jurisdictions.
My gallop gave specific examples which require value judgements, and therefore cannot be made with "relatively simple algorithms".
"Same for any other example."
You don't seem to understand that no matter what system is used, it's fundamentally driven by political decisions of what is appropriate.
We know that politics means some healthcare systems will prohibit gender affirmation therapy. Can the person go elsewhere, where that is allowed, and pay for said therapy, or does the other system have to accept anyone who shows up, on a first-come-first-served basis?
Your proposal seems to say that there can be no healthcare outside the government system, so those who want chiropractic treatment, those who want acupuncture, etc. are forbidden by law from even using their own money. (I picked these two because while the science doesn't support their efficacy, often require licensed practitioners because doing it wrong can kill people.)
There are not simple solutions, and the longer you insist it's true the more cold shoulders you'll receive.
100%: Nationalize all healthcare providers and facilities. Forgive any outstanding student loans. Expropriate all property used in healthcare delivery. Make medical licensing contingent on public employment. Set up compulsory public housing accommodations at healthcare facilities for every person involved in healthcare delivery. Establish healthcare unions to negotiate working conditions and wages. Use evidence based scientific measurement of expected quality of life years to justify any treatment allowed on a first come first served basis. Anything less is anti-ethical and unhuman.