[dv_dt]

Regulations can put pressure on prices (and if you look at epipens in particular, part of the regulations allowing the increase of their price have nothing to do with monopoly and a lot to do with getting policy placed into areas where organizations are required to keep an epipen on hand by regulation...).

But in terms of overall effect, one can't ignore other nations which pay much lower prices for healthcare with both regulation for drug patents, as well as regulation on drug prices. That combination manages to deliver better care at lower costs than the US (we pay on average double per capita). So I don't think one can generically fault "regulation" for a poorly performing health market in the US.

[alexanderstears]

So I don't think one can generically fault "regulation" for a poorly performing health market in the US.

You're absolutely right, however, I do think the worst parts of our medical system exist as consequences of regulation.

The mandate that emergency rooms treat anyone who enters is onerous and there's no free lunch, paying customers are stuck with the bill.

The licencing system isn't optimal for cost effective care.

There's a lot to be desired for people who favor supply side solutions to expensive problems.

[dv_dt]

> The mandate that emergency rooms treat anyone who enters is onerous and there's no free lunch, paying customers are stuck with the bill.

I don't think that's onerous, I think that is a minimal, and admittedly imperfect, expression of our societal intent that people shouldn't die unnecessarily in emergency rooms - either from lack of being able to pay; nor from a practical standpoint, lack or delay of on-hand proof of ability to pay.

Removing those regulations would cause all sorts of other problems. Someone arrives in an ambulance near-death, if I lack morals then one level of maximized extraction price is to have those patients commit to pay a value that represents the earning potential for that person for the rest of their life. They have to agree before getting admitted. Even more profitable, if I judge that person as having a well connected social network, I can charge even more because I know their friends and colleagues would chip in to save them... I'm not sure how a competitive market with no regulation changes the worst case for this transaction - if someone is near death then moving on to another emergency room is out of the question.

I see universal healthcare with a shared cost-pool as the lowest overhead way to provide for our social moral desires (but then I'm not in fear of the regulation with may be needed to implement that policy).

Insurace with a shared risk pool is a technically workable, but adds even more overhead, and ends up a more expensive way to do the same thing... but again regulations are involved (and fixing very flawed ones at that).

[AnthonyMouse]

> Someone arrives in an ambulance near-death, if I lack morals then one level of maximized extraction price is to have those patients commit to pay a value that represents the earning potential for that person for the rest of their life. They have to agree before getting admitted.

Actual markets don't work that way. If you could actually make that much money then someone would open a competing emergency room right across the street, let everyone know that they charge $1 less and take all the business. Then the first emergency room would charge $2 less to take it back, until they're both charging reasonable prices.

It's the same reason you don't have to sign your life away to buy food even though you would die without it.

The problem in the US is that the regulations on the market for medical services work almost the exact opposite of that. There is no price transparency at all so you have no idea which facilities are more expensive. And if someone wants to open a competing facility, they have to get a Certificate of Need proving that the existing facilities don't have enough capacity. Even though having enough capacity doesn't preclude charging outrageous prices in the absence of competition.

> I see universal healthcare with a shared cost-pool as the lowest overhead way to provide for our social moral desires (but then I'm not in fear of the regulation with may be needed to implement that policy).

The existing US system is pure corruption. It's heavily regulated but the regulations are a result of regulatory capture by insurance companies (who want higher costs because higher costs means more vig), and all the industries the insurance money pays for like pharma.

The result is that medicine in the US is outrageously expensive. But the expense doesn't go away even with universal coverage unless you fix the regulations, and if you did that then people would be able to afford medicine out of pocket without insurance.

[dv_dt]

> Actual markets don't work that way.

Isn't that exactly what's happening in slower motion with the incredible price hikes in many drugs such as insulin? And you assume that the neighborhood can sustain two emergency rooms - a second competitor isn't going to arise if the setup costs are high and the competitor can't undercut and survive the competition phase. This is exactly why there aren't multiple competitors to residential ISPs, because after the risk and costs are factored in setting up overcapacity for a market isn't a good investment.

Further if you look at the drug markets, sufficient cost and time barriers exist and allow even makers of generic drugs (with no patent monopolies) to charge inhuman rates for drugs. And generally investors are not going to back efforts to fund a head-to-head competitive slugfest when the market of users for a given drug is basically of fixed size. Again building overcapacity is generally avoided in these markets because of the high entry barriers.

https://www.nytimes.com/2017/04/14/business/lannett-drug-pri...

[AnthonyMouse]

> Isn't that exactly what's happening in slower motion with the incredible price hikes in many drugs such as insulin?

Again, the market for medicine suffers from regulatory capture. The regulations make it prohibitively expensive (literally millions of dollars) for new competitors to enter the market, which allows the incumbents to conspire to fix prices.

If we had the same standards for manufacturing medicine as we have for manufacturing food, that wouldn't be happening.

> And you assume that the neighborhood can sustain two emergency rooms - a second competitor isn't going to arise if the setup costs are high and the competitor can't undercut and survive the competition phase.

All you need is for the profits from entering the market to exceed the entry cost, which is exactly the case when the existing provider is charging outrageously high prices.

It is certainly true that adding a competitor will increase total costs. But that means total costs will at most double. That's not good, but it's not anywhere near as bad as having a monopoly that can demand your lifetime earnings in exchange for saving your life.

And everybody knows that to begin with, which is why you get this:

> This is exactly why there aren't multiple competitors to residential ISPs, because after the risk and costs are factored in setting up overcapacity for a market isn't a good investment.

It would be a good investment if the incumbent ISP was charging $500/month for residential internet service. But they know if they did that then it would open the door to a competitor who could charge $400/month and still pay the cost of duplicating the entire infrastructure.

So instead the incumbent charges $50-$100/month, even in areas where they have a monopoly, because they know that price is low enough to deter new competitors from entering.

A credible threat of competition is enough to prevent prices from becoming completely outrageous even in areas where there continues to be a monopoly in practice. Only monopolies under no threat of competition, like the ones enforced through patents or Certificate of Need laws, can charge outrageous prices without that happening.

[dv_dt]

Did you read the linked article? A generic maker of generic drugs in dramatically increasing prices with no sign of the entrance of competitors. Competition can enter but the barriers are too high - even without any government protection remaining on the generics in question.

The competition doesn't pay the cost of duplicating production - not after the competition has lowered the price. At least the chance of that is why no one tries to enter.

To make even the generics at a reasonable quality is a barrier sufficient in an of itself. And a competitor risks the incumbent lowering the prices to cut off the incumbent - no investor is signing up for that expensive fight as evidenced by the article... generics are rising in price to reflecting the effectiveness of the barriers. (well and lack of price regulation by our healthcare system)

[alexanderstears]

I don't defend the status quo. I think this is the right way to resolve healthcare.

I agree with about 95% of this: https://market-ticker.org/akcs-www?post=231949

We just need smarter regulations:

> every medical facility needs to have a price for each billing code

> every healthcare facility has to publish their prices

> heatlh care facilities must honor their published prices for everyone

> if someone needs car and they can't pay, the government will pay for the care but the government holds a debt and can garnish wages / use tax refunds / credit welfare to cover the debt

If people could shop on price for routine care, medical companies would become more efficient and extend those prices to people in an emergency

[candiodari]

Have you seen healthcare regulations ? The lengths hospitals and drug makers have to go through to prevent ANY mistakes are simply not reasonable.

That's not 1/1000. Not 1/1000000. Not 1/1000000000. Zero. Entire companies get shut down because of a single mistake. Think about how ridiculous that is. A company owns 5 separate factories, and in one of them a product was produced that may, in a panel of doctor's opinions, have caused the death of a patient (mostly one who would have died without the medicine), and all 5 are immediately shut down until an extensive investigation is not just run, but run in an approved manner by outside experts, and the resulting cause was both found, approved by the panel of doctors and the government.

And of course, a company is supposed to take care of any patient they damaged, for life, full treatment for all ailments (not just the one that had something to do with what they did), ...

We used to let people prepare medicines in corner shops with at least a few ingredients they procured themselves. Needless to say, pretty cheap. Mistakes were ... not common, but certainly more so than today.

Until we find a balance between care provided and acceptable risk there will be no reasonably priced healthcare. Until we stop giving health at any cost, and count on "management" mistakes to do cost saving (regulating that people get thrown out of hospital the day after open heart surgery unless there are complications. Well, if you want to survive, you bloody well hope your doctor finds some complication. Needless to say, proposals for making it same day are on the table. Good luck).

And of course, like good capitalists faced with demands like this, companies don't say "are you bloody insane ? This will bankrupt the entire country", they say "How secure do you want it to be ? Perhaps even a bit more ? I mean we can always do better. That'll be $xxx(xxxxxxxxxxxxxxxx)".

[alexanderstears]

I 've seen a ton of healthcare regulations and apprently we're in agreement they leave a lot to be desired.

[dv_dt]

Healthcare often isn't billable in consistent units. Someone goes in for surgery, and they get opened up, despite pre-imaging, there are complex things that can go wrong and instead of a 1 hr 10k effort, you need to put in a 6 hours 100k effort? how is that billed? are you going to require statistics of probabily of going wrong too? By the time you get all these 'consistent billing units' figured out for all the multitude of ever changing procedures wouldnt have been cheaper just to have covered reasonable costs instead of maintaining a multi-way cost/trust verification excercise?

[alexanderstears]

how is it billed?

Go ask the people who get jobs as billers - most hosptials have more billers than beds, they can sort it out.

Before you go to surgery agree on the price of everything and ask for a video so you can verify the work was done as billed and there wasn't any padding. In an emergency situation, you're entitled to the price they advertise. IF you can't afford it, the government picks up the bill and maybe you pay for it, maybe you don't. If you want insurance, you can buy insurance but let the insurers use every actuarially relevant bit of information so the insurance works as insurance

[Frondo]

That is ridiculous on so many levels.

Several years ago, I had my gallbladder out in an emergency surgery. I was in intense, intense pain. My friends worried I was having a heart attack. They drove me to the hospital, because I could barely stand, let alone drive. Such intense pain I was barely conscious.

In the ER, I remember they did an ultrasound to determine it was my gallbladder, and then pumped me so full of morphine I was fully incoherent. Still in agonizing pain.

Then, a few hours later, they cut me open and pulled it out. It was starting to go necrotic. They said, had I waited a week, I simply would have died of blood poisoning.

At no point was I in any condition to agree to a price on anything--incoherent from pain, and the morphine. I was in no position to shop around. My friends didn't even know what was wrong with me, they just drove me to the ER because we all thought I was dying.

Even if I had been able to agree to anything--which I couldn't, due to pain--having a video recording of the surgery would have done absolutely nothing for me.

Oh, and while I was in the ER, I did see a couple of gunshot victims--fully unconscious--wheeled through from ambulances. What are they agreeing to??

Man, I don't think you've ever really experienced the health system, and I don't think you've thought about your plan.

(Sadly, I also don't think people's real experiences are going to change your mind, either, but it'd be great if you did think about how nonsensical that fix you're proposing is.)

[candiodari]

And what about patients who can't pay ? Whom, therefore the government can't make pay either ?

Secondly, what about people who become destitute because of a medical procedure and do what they sometimes do in Holland ? (if you're fucked on bills and the state comes after you and you would become homeless, simply rob places until you get convicted for 10 years, and stay in prison for 10 years. Free tv and internet, and nobody garnishes any wages. Outside you wouldn't be able to pay rent).

[not_kurt_godel]

That's not how it works. Have you ever had a major medical procedure? You're out of touch and talking about things you don't really know about.

[conanbatt]

I concur. The argument that healthcare in the US is broken because its a market almost triggers me. It has profound regulations that affect its market behavior.

[jeffbax]

"So I don't think one can generically fault 'regulation' for a poorly performing health market in the US."

Well articulated counterpoint: http://slatestarcodex.com/2016/08/29/reverse-voxsplaining-dr...

Also, we live in a country where most places they don't even allow opening a new hospital without the permission of surrounding hospitals, and all of the recent healthcare regulations have encouraged a seriously problematic consolidation just like the big banks.

As an industry, healthcare is so over-regulated it isn't even funny. The good news is that drug prices are still generally falling outside of big examples like Daraprim and Epipens and there are fairly effective solutions to the spikes we could have if the FDA would get onto more reciprocity with other nations: http://marginalrevolution.com/marginalrevolution/2016/02/the...

Also relevant, the US Cost disease: http://slatestarcodex.com/2017/02/09/considerations-on-cost-...

[dv_dt]

I don't find that first link well argued at all: because corporations have achieved some degree of regulatory capture from the FDA, we need to eliminate regulations and let those same corporations run completely rampant and somehow that will result in better performance? That makes no sense to me.

Also, the comparison there in the drug vs the chair market there is poor too. The key difference between manufacturing drugs and chairs (as in the example), is that anyone could enter the chair making with one guys who has had high school woodshop. Manufacturing a drug has a much much higher bar...

[alexanderstears]

I don't find that first link well argued at all: because corporations have achieved some degree of regulatory capture from the FDA, we need to eliminate regulations and let those same corporations run completely rampant and somehow that will result in better performance? That makes no sense to me.

If that's what you got from SSC's cost disease article, you might have some bias in your framework.