Uh oh. Someone is sounding like a socialist.

(note: I did not say this was a bad idea.)

Some people think that the fix to the medical system is to make it more socialist and others think it should be made more capitalist. What we have right now is somewhere in the middle.

Whatever ideological team jersey we want it to wear, the root cause is that medical insurance has gone from being insurance used in case of emergency, and gone to being a middleman skimming as much as humanly possible.

The only way out of this is to remove the profit motive sparking this avarice: either nationalize the healthcare, or ban healthcare insurance and regulate hospitals so tightly that they aren't allowed to profit as a business, the executives have capped pay, and the business can't be publicly or privately traded.

The laissez-faire approach to healthcare has completely failed in the US. Given it is the wealthiest country in the world, I cannot think of a more damning result.

> The laissez-faire approach to healthcare has completely failed in the US.

Why do you think we have a free market approach to healthcare? Why can I only sign-up once per year unless I have a QLE? Why can I contribute a certain amount to an HSA which is triple tax advantaged with an HDHP but I can't with a PPO? If I have an HDHP+HSA why can I also contribute pre-tax dollars to an FSA that is use-it-or-lose-it for dental or vision only but if I have a PPO I can have a limited purpose FSA that can be used for medical, dental, and vision? Why are there contribution limits? Or even more basic, why is healthcare tied to employment?

The reality is we don't have a free market when it comes to healthcare at all, we have a hampered market where over the years we have politically regulated it into the abomination it is today with some of the worst incentives possible. We can certainly have the debate of whether a free market or nationalized healthcare is best, they both have trade-offs, but it's fallacious to assume we have the former and discount it entirely thus leaving either more regulation or nationalization as the only alternatives. More regulation is almost certainly the worst possible option, we've been on that path since WW2.

The answer to all of your questions is that if you are obscenely well off, all of these restrictions go away with enough money. Private insurance exists, or hell - just paying out of pocket. It is a free market, but only for those with enough money to pay.

The average person cannot pay. Health insurance is designed to maximize extraction of wealth from the non-wealthy, while doing just barely enough that they don't immediately get register away. The reason for this is greed: sure, greed drives efficiency in capitalism, but if it isn't reined in via regulation we wind up with the abomination we have today.

> sure, greed drives efficiency in capitalism, but if it isn't reined in via regulation we wind up with the abomination we have today.

This is exactly where we part ways though. You specifically said "laissez-faire", i.e. "leave it alone" in French; economically this is anti-interventionist, let the markets sort themselves out without interference from government. You are saying regulation is required for the market to function or it leads to what we have today and I'm pointing out that we already have enormous quantities of regulation in healthcare. I pointed out several very easy examples to identify with but by no means is that an exhaustive list of healthcare interventions. The very thing you are advocating for, regulations, has been increasingly attempting to "fix" this market for the past 80 years and our current system exists because of it, not in spite of it. It is not a free market in any sense of the word, and doubling down on more regulation will not improve it. I am more than happy to debate an actual free market or nationalized healthcare model, but further regulating this "free" market is misdiagnosing the system we currently have and assumes the same good intentions that have failed to improve it for four generations will somehow produce better results this time.

>employers can't discriminate by race

Seems to be flaunted in tech.

What is the market value of your mother's morbidity and mortality? Your spouse's? Your children's? Trying to apply a market to healthcare can become macabre rather quickly.

When governments make these decisions, it's just as macabre.

https://globalnews.ca/news/11812425/alberta-family-fights-fo...

https://globalnews.ca/news/11801531/bc-denies-funding-drug-c...

Assuming a nationalized healthcare model, should the entire productivity of the nation be dedicated towards keeping a single person alive and healthy at the expense of every other conceivable economic activity such as building houses, growing food, manufacturing water treatment facilities, etc? Would it be macabre to deny them any amount of healthcare?

All economic systems allocate scarce resources which have alternative uses and thus rationing must always exists regardless of whether it is a free market, mercantilist, socialist, or as yet unknown economic system. Prices are a rationing mechanism within markets[1] but every other system will have its own set of one or more rationing mechanisms such as by-status, by-lot, by-need, by-survivability, etc. That necessarily means that there aren't enough resources to treat everyone for everything under all circumstances. Do you believe that all economic systems are thus macabre? If so I agree if only because life itself gives us hard choices, never utopic solutions.

[1] In terms of emergency healthcare by-need tends to be used even in market systems.

[delayed]

Every medical system in the world "ghoulishly den[ies] health care" to patients. If it's not an insurance company, it's the charity providing the care or a government bureaucrat.

And the least accurate label to apply to the US health care system is "laissez-faire approach", since the government is involved in literally every decision.

Most of hospitals are non profit. If you choose HMO insurance, its will probably be non profit as well like Kaisser. Some of big PPOs are also non profit like blue cross blue shield. Problem seems like over complicated billing and accounts receivables which leads to large administrative staff hospitals have to employee. Lack of medical professionals nurses and doctors which lead to increased salaries.

The largest expense in the medical system is caregiver wages; administrative wages are the 'foreign aid' of the medical system (very unpopular, but not a major cost-driver). Reducing doctors' and nurses' salaries is very unpopular even though the USA pays those two groups much more than any other country in the world (by almost any measure).

[delayed]

The top line bill in US medicine is almost entirely fictitious. Hospitals and insurers built a system to defraud people on percentage plans. If you're on an 80/20 plan, for example, and the bill is $100, in theory you pay $20 and your insurer pays $80.

But what actually happens is you pay $20, the insurer pays $80, and then the hospital has to remit a large block discount back to the insurer at some point (it's either the end of the quarter or year. I can't remember). I haven't looked into this in awhile, but when I did local area hospitals were discounting payments by almost 80%, meaning the insurance company actually pays $16 on that bill and the plan that's supposed to have you paying 20% of the bill actually has you paying 55.6% of what the hospital receives. Like I said, it's fraud. It may not meed the legal definition of fraud, but it's still fraud.

Are you saying the insurance company is not paying the 80% of the negotiated rate? Why would a hospital defraud people when they are non profit entities?

AMA is a literal cartel restricting supply. Most of a doctor's job can be done better by ChatGPT (or a regular individual with a 4 year degree with specialized training for that matter), so it is obvious the licensing and supply is a major issue.

Yes, we should apply anti-trust law to the whole system, but this doesn't really pass the smell test. First, consider what proportion of medical costs is corporate profits. Maybe 5-15% as a guess? Then, excess monopoly profits would have to be a subset of this (what, 20%?). Sure, it would be nice as a one time adjustment but it's not going to fix the problem over decades.

The problem is, with the way things are right now, it's basically impossible to tell how much is profit.

Profit, for various entities, is baked in at every level, in multiple ways that are very difficult to disentangle from the actual costs without getting real auditors on the ground with access to all the data.

And it's not just profits, it's inefficiencies (in the service of making profits) everywhere.

A whole ecosystem of unnecessary middlemen baked into laws and policies.

which the government is notoriously excellent at solving!

The underlying revenue is ballooned.

Revenue can explode under perfect competition.

[delayed]

The administrative grift is a large part of the waste. Profits are just the grease for the shareholder.

Hot take: stop funding biomedical research. Turn the tap off from which bleeding edge but super expensive therapies emerge. People won't demand what doesn't exist.

GLP-1 treatments alone are responsible for a plurality of the rise in costs this year and next. Over $7000/per/year for a huge fraction of the population.

I guess nixing patents might have the same effect, but it'd be easier to get Republicans onboard an approach that simply cuts outlays rather than one that ruins the wet dreams of biomedical research private equity.

It’s counter intuitive but totally valid. Another angle on this would be to lower the standards for clinical trials. The fact that it costs billions of dollars to run a drug trial is a key part of why everything is so expensive the FDA standards are extremely high. The result is safe drugs but it also makes the R&D market extremely skewed towards the big entrenched players. There is also no room for physicians or patients to take calculated risks. Sure it all falls into a sensible self consistent philosophy of “do no harm” but the side effects of that principle are extreme cost and actually slow innovation. In this modern era data collection should not be this expensive.

We have continuously overcorrected in the hundred years since we banned snake oil medicines.

Sure, people should know what they are taking, and they should take things that are safely manufactured and safe to use.

But, there needs to be room for a person to make decisions as part of their body autonomy. I personally want to wait before taking peptides because they're so new, but people who see the initial results and want to be human guinea pigs should be allowed to.

There really needs to be a middle ground between a decade of testing on the off-chance that 1-in-1,000,000 parents gets an upset stomach, and ordering who-knows-what research chem from a sketchy website.

Phase 2 clinical trials establish safety. IMHO anything that passes phase 2 should be prescribable. Phase 3 is the expensive one.

Generally we should be lowering costs, but if lowering development costs results in more therapies, even if they're cheaper our aggregate cost trajectory could remain the same.

We're an incredibly rich society with a near universal ethos that cost should be no obstacle to life saving treatments, and by extension life prolonging treatments. Despite our many inequities we'll blow millions on treatments that extend life by 5 months. Sometimes (often?) we don't, and it gets roundly criticized as a moral failure, but nobody seriously suggests maybe our target standard of care should be something other than everything possible. (Ivory tower proposals abound but most of us regress to the mean when push comes to shove.) Examples of treatment unavailability that are scandalous here are the norm almost everywhere else, because countries carefully throttle the introduction of expensive therapies at their borders.

In this environment of course our healthcare costs will skyrocket, so long as there's a steady stream of marginally better therapies. We don't need fraud or corruption or misaligned incentives. Those things accelerate the situation and contribute to inequities, but the fundamental trajectory is just perfectly predictable and in a sense unfixable without either changing our shared ethos or fooling ourselves into rationing [future] care by sabotaging the pipeline of new therapies.

"Pace the frontier"

paying for GLP-1 is a net benefit to insurance pools, because obesity (and other uncontrolled hunger-like cravings) have very expensive downstream symptoms.

And yet, they still won't cover them for basically anyone

Which means they, who are in the literal business of doing math on these things, probably don't agree with the GP's assessment of "net benefit."

Let's do that, but also let's tax the rich.

Funny. They used to say the only way to fix the budget is to stop spending less on defense.

Now that is the number three or four. Depending on how you count, we're going for the actual number one, which is unfunded Medicare.

Unfortunately, the second highest expense now is interest on the debt accrued.