[ramblerman]

You are jumping from one extreme to the other. Creating a public institution with no pressure to make profit is a disaster waiting to happen.

You can certainly keep a 'competitive' environment which is regulated with incentives. And I do agree healthcare needs this, and shouldn't live purely by the free market.

[psergeant]

> Creating a public institution with no pressure to make profit is a disaster waiting to happen.

This is the model many rich country healthcare runs on, and provides measurably better outcomes for less expenditure than the US.

[alistoriv]

In addition, the best healthcare system in the world, according the WHO, is in Cuba, where it certainly isn't run on a for-profit basis. Moving medicine away from the private sector allows for a stronger focus on preventative care, which is significantly less profitable.

I think that worrying about removing the profit motive entirely misses that fact that not only is the profit motive not the only motive for doing things, but oftentimes not even the determinate factor.

[rusk]

As much as I wanted this to be true it doesn’t really stand up to scrutiny. Yes “day to day” access to healthcare is far superior but it’s very week on the high end stuff. Even Castro in his final hours was treated in a Spanish hospital. Ideally we would want some kind of reasonable alternative that exists between these two extremes ...

[hhw]

Correlation != Causation

The more likely explanation for Castro seeking treatment in Spain is that Cuba is a relatively small country of only 11 million, and it should be expected that they're not at the very forefront of the world on every area of medical expertise.

[rusk]

My substantial point still stands.

[spydum]

I may be ignorant on this, but don't many of those countries benefit by the r&d funding happening in the US?

[tscs37]

R&D doesn't happen in non-profit government corporations either (atleast not largely). Most R&D comes from the manufacturers where the state (or relevant institution) buys the drugs from.

However, in a single payer or similar systems, if a drug company decides to hike the price, the state (or institution) can swallow the cost and continue medical services to citizens until the situation is resolved (either by legislation or court cases). Since the state (or institution) is not a for-profit it doesn't matter as much if they sink a lot of cost as long as everyone can get their medical treatment.

[Can_Not]

Another thing is that people want to measure success in profit or less taxes paid. A proper healthcare system should have it's success measured in how many citizens are able to be productive because they're not chained down with accommodatable disabilities, curable chronic illnesses, and extreme medical debts.

[Slansitartop]

> R&D doesn't happen in non-profit government corporations either (atleast not largely). Most R&D comes from the manufacturers where the state (or relevant institution) buys the drugs from.

IIRC, the research typically comes from state-funded academics, and the development comes from the manufacturers.

[neuromantik8086]

The research only comes from academics when it's actually reproducible. Otherwise it is dutifully ignored and companies perform their own research.

[TomK32]

It's all multinational these days. Only 4/10 of the big players are in the US https://www.tharawat-magazine.com/facts/10-largest-pharmaceu... and that's quite logic if you remember that the European market is pretty much harmonized and twice as populated as the US.

[ekianjo]

The EU market is far from being harmonized medecines regulation wise. it always takes longer to get approval across all EU countries vs one approval in the US. Pricing of drugs is not harmonized at the EU level either and thats a hard block for any launch.

[mbesto]

"in the US" is a misnomer. It all depends on if the cost allocation (e.g. HR is pharma's largest cost) has and is attributed to the US.

[aaavl2821]

the US market is the primary market for all big pharma companies regardless of where headquarters are bc it is the biggest

And big pharma companies don't do early stage research. Small companies do. Most of those are in US

[chopin]

They may, but these institutions are keen on cures and not on treatments.

I am completely on the side of having government agencies developing cures and licensing out to companies then. This would avoid the perverse incentive of the OP. It also would stop the pervasive argument that patents are necessary to get new pharmaceuticals developed (I don't believe in patents benefit to society).

[lmm]

Some of the extra money does go to R&D (though that's somewhat misleading: a lot of "R&D" spending is unnecessary duplication of safety trials because the FDA doesn't recognise any foreign medical safety standards, not even e.g. the EU). But a substantial chunk of it is wasteful inefficiencies due to multiple layers of middlemen (there are typically 5 layers between the insurance company that's paying and the company that makes the drug/device) with opaque pricing structures (there are hidden rebates in both directions at every one of those layers). National healthcare systems still have bureaucratic inefficiencies but they do avoid having intermediaries with a direct incentive to bamboozle each other.

[themaninthedark]

"unnecessary duplication of safety trials because the FDA doesn't recognise any foreign medical safety standards, not even e.g. the EU)"

I would say in some cases that is a good thing. https://en.wikipedia.org/wiki/Thalidomide

[lmm]

It's very hard to argue against a safety trial - of course if you duplicate safety trials then there will be occasional cases where you catch something that the original trial missed. But ultimately far more people have died or suffered because a medicine wasn't available yet than been killed or hurt by medicine being approved too early.

[arnoooooo]

Most R&D, in the US as elsewhere, make massive use of public funds.

[cies]

Which is weird, as that is not factored in the purchase price when buying the product when developed.

[TomK32]

yes, you might ask your democratically elected representative about that...

[refurb]

No, that's not true. Private R&D is almost 10x what public R&D is, at least in biotech.

[cage433]

Nope - that's not true.

https://en.wikipedia.org/wiki/Medical_research#Privately_(in...

Private R&D is around 60% - however a large part of that is making minor changes to existing molecules in order to obtain fresh patents.The bigger, riskier research is done by the NIH and other publicly funded bodies. See

https://marianamazzucato.com/entrepreneurial-state/

Also - the quality of privately funded research is much worse, with non-reporting of negative results, data dredging and other dodgy activities being routine - see

https://en.wikipedia.org/wiki/Bad_Pharma

[neuromantik8086]

Intriguing. I've often speculated about how private sector research compared with public research, especially in the context of the reproducibility crisis since I assumed that a lot of pharma companies knew that some research couldn't be replicated behind closed doors. I wonder what the quality of proprietary / unreleased studies is- do the links you provide take that into account?

[refurb]

Your source is all medical research. Not biotech specifically.

[howard941]

Including the R&D tax credit?

[oblio]

https://www.urmc.rochester.edu/news/story/4233/u.s.-slipping...

[spydum]

Interesting that funding only started to fall when the concept of Affordable Care act began to get traction? If I'm an investor, that sort of thing gives me cause for pause.

[cat199]

Like what?

Novartis? AstraZenica? Gsk? Bayer? Siemens? Hitachi? Philips? Olympus?

this works quite very much the other way as well..

[merb]

> This is the model many rich country healthcare runs on, and provides measurably better outcomes for less expenditure than the US.

well I'm living in Germany and I agree with that it is cheaper, but "better outcomes"? I do not think so.

I mean in Germany treating Diabetes means taking Insulin for a life long. However newer studies, actually found out that a treatment where the patient should be dieting and starts to do more sport can actually reduce the needed insulin dose or patients can even completely dismiss insulin or are cured from it completely in rare cases. (not a lot of doctors would actually help the patient or even tell them that this would be beneficial to them, hell not even the public health care sector cares)

However the thing is if you can sell Insulin for a life long to somebody who will probably die earlier you make a profit. On multiple fronts. Treating it means that once the person is cured, he will probably live longer, will have less problems and will probably cost the overall system less (but that's not something that should happen).

So basically in "richer" countries the system is equal to the US, it's just more hidden. care system and government are systems that benefit from each other if patients take treatments over a long time and probably have a reduced life-time. i.e. treatment > healing, at least from a business perspective.

[ekianjo]

lol you are acting like the rest of the world is developing medecines. The US market is the driving force for 95 percent of drugs developed worldwide, by a very, very wide margin. This is not random.

[hexane360]

First: You're not wrong that the U.S. is a leader in pharma.

That being said, the only source I can find for your claim is a throwaway sentence in an op-ed on Forbes (https://www.forbes.com/sites/paulroderickgregory/2012/07/01/...).

I found some more realistic (and sourced) statistics here: http://blogs.sciencemag.org/pipeline/archives/2010/11/09/whe...

That has the U.S. at 47% of drugs developed. Keep in mind those are based on drugs approved by the FDA, so it skews towards the U.S., and especially away from countries like Japan. Adjusted for population (I'm not entirely sure this is fair), that puts us neck-and-neck with the U.K., behind Israel, and far behind Switzerland.

[saas_co_de]

You are talking about providing health care. Not inventing new treatments. Those countries are all using treatments invented developed and funded by the market model which is mostly paid for by us consumers, which is part of why us prices are so high.

The US has the best outcomes in the world if you have money. Which is why rich people from all over the world come here for treatment. We just have lower average outcomes because of access disparities.

[Retric]

[Citation Needed]

The US has average healthcare when money is no object. The weathty often seak treatment outside the US and occasionally wealthy people come to the US on a case by case basis.

The core problem is treatments entail risk, so doing more eventually results in worse outcomes. Further the incentives are around doing more, putting the healthcare system in opposition to heathy patients.

[TomK32]

Saldy when you are in need of healthcare, money is the only negotiation power you can have. An insurance company dealing for you has a lot more power, but if you are on your own you have no power to say "right, this vital heart op is too expensive, I'll drive 300 miles for a cheaper provider. ggrrrrl".

That's why universal healthcare is the better solution for everyone.

[fsloth]

"Creating a public institution with no pressure to make profit is a disaster waiting to happen."

Why?

Schools are not for-profit institutions (well, not everywhere). Police don't make a profit. Nor does the fire brigade. Or the military, for that matter.

Are all of these disasters waiting to happen?

[fjsolwmv]

Your examples are all local government with local accountability to a small group of local voters. At nation-scale the story is different

[fsloth]

I don't follow you. How is providing fire brigade services any different from providing health care? Or providing a functional justice system different from providing health care? They all provide concrete but hard-to-quantify value to the society around them, and aim to serve the public good.

As further examples of state level institutions we could also look at coast guard and customs service. And, of course, the tax officials (what ever their local name happens to be in various countries).

A modern nation state is full of public institutions with dedicated personnel to carry the institutions mission.

Public institutions work just fine around the world in various countries, performing a multitude of missions. That's not to say they are immune to various pathologies, but that applies to all organizations, public, private, for-profit or non-profit. Public institutions work fine when they are fulfilling a legally defined obligation under a democratically chosen government.

The thing everyone wants to avoid is pathological cronyism. The key to this is to make sure the political power pool has churn - so there is no predictable kingpin with executive power around whom the power and corruption accumulates. Which, democratically chosen governments provide (with varying capacity, but even two parties is probably enough).

I agree, no one wants to funnel tax payer money just to amass state power. But some things that improve life really cannot in any obvious way be guided by profit mechanism, and some things are just too capital intensive to be able to do on a small scale. The obvious place to look for capital for large scale projects that add value to the general public is the state.

Note: although monarchs do exist as mostly figure heads, modern monarch seldom have executive power. Compare this to some countries with dictators or monarch with actual executive power.

[Zooper]

Tell me the different national-scale story, and why if that's not working, it's not the fault of the nation's law or systems of governance?

[ekianjo]

You have never heard of private military companies? They are extensively used byvthe US mostly for non combat situations. They are very effective, for profit, and much less costly than the regular army.

[fsloth]

That a private company works better at some locations does not imply logically that a public institution is a disaster waiting to happen, which was the original claim.

Let's make it a bit more ridiculous and extreme. Would it be a good idea to privatize US nukes? What would profit incentive provide there?

Remember, we are discussing the claim "creating public institutions without a profit incentive is a disaster waiting to happen".

[Slansitartop]

> private military companies...are very effective, for profit, and much less costly than the regular army.

[citation needed] My understanding is that they are more expensive than uniformed soldiers.

[pjc50]

These guys? https://www.amnestyusa.org/themes/military-police-arms/priva...

[rectang]

It's refreshing to see skepticism of both market-based and government-based solutions. Too often I feel like I am being presented with arguments which require either blind faith in the "invisible hand" or denial that inefficiency increases in the absence of competition.

> You can certainly keep a 'competitive' environment which is regulated with incentives.

This is my preferred approach as well. It's worst weakness is the potential for regulatory capture. I tend to believe that should be addressed by not giving corporations as much power as they currently enjoy in the US: enforcing constraints on participation in politics and requiring transparency, disconnecting health insurance from employment status, enabling clawback of executive bonuses, etc.

[nomorenomore]

> It's refreshing to see skepticism of both market-based and government-based solutions.

This in my opinion is a false dichotomy. The government can be owned/operated by coorporations or by the people or can be an entity in itself.

What I feel is missed by people leaning towards the idea of competition is that it is not a sustainable model under the current framework of ideas. If you optimise a society purely based on profitability, competition is the enemy, since it hinders individual businesses from maximising their profits. Hence the massive business consolidation we have seen in the last decade across the globe.

If you want competition because you want different ideas to be tested, then we need to explain what we want entities to compete for. Focusing on optimising one variable only, i.e. profit, will not work. We need new ideas.

[GiorgioG]

> Creating a public institution with no pressure to make profit is a disaster waiting to happen.

We seem to have no problem with throwing $700 billion per year on the military and nobody is pressuring them to make a profit. Is that a disaster? No? "But that's different!" It's only "different" because that's what we've been led to believe.

[rectang]

The US military is spectacularly inefficient, and the US military-industrial complex is a parasitical behemoth per Eisenhower's critique. It's not like the problem is unknown; the issue is that the state has to have a monopoly on violence, so we live with the inefficiency. Encouraging a marketplace of competing militia would not a viable approach. :)

[salawat]

Uh huh... I'm guessing you aren't a fan of the 2nd Amendment then? Not trying to derail things, but assuming the State MUST have a MONOPOLY on violence is a terrible idea.

We give the government the leeway we do, because it is the best way to provide for the common defense of the nation. NOT because ONLY the State should have violence open to it as an option.

Anyway... Back to healthcare... The type of structure that made the military industrial complex problematic was specifically that the industrial part was doing everything they could via lobbying/bribery to maximize profit. A shift to a model where we attempt to minimize waste, and maximize effective treatment/cures turns the quality equation on it's head. You still run into the issue where riskier grants that 'may work' are going to have a harder case to make in order to be issued, but I think that once one gets away from trying to build industrial supply chains predominantly for treatments that don't result in cure, you would start to see materials and expertise to get industrial supply chains built period may become more easily accessible if not perhaps become much cheaper.

[rectang]

> I'm guessing you aren't a fan of the 2nd Amendment then?

The 2nd Amendment is completely compatible with the philosophical concept of monopoly on legitimate violence as articulated by Weber.

[mamon]

>> the state _has_ to have a monopoly on violence

I think that the whole point of 2nd Amendment to US Constitution was to prevent government monopoly on violence. The possibility of citizens making successful military rebellion against the state was supposed to keep the government in check.

[GiorgioG]

> The issue is that the state has to have a monopoly on violence

A monopoly on violence in what context? The planet? That doesn't seem to be necessary for most countries. Within the country itself? That's the job of local law enforcement.

[rectang]

"Monopoly on violence" is a term with a lot of history. I'm using it in the same sense as Max Weber, where the state is defined as the "human community that (successfully) claims the monopoly of the legitimate use of violence within a given territory."

https://en.wikipedia.org/wiki/Monopoly_on_violence#Max_Weber...

All the critiques on this thread about competing authorities such as local law enforcement, the second amendment, and so on, none of them invalidate the idea of legitimate use of force defining the state. Weber accounts for all those points.

The closest thing we have to an actual marketplace among authorities wielding violence is the competition between jurisdictions (one municipal police department against the one the next town over, the state police in one US state vs another US state) -- but that's not the same as a commercial marketplace.

The only critique I think is relevant is the idea of mercenaries, a.k.a. private military contractors. But there again, those mercenaries are part of the military-industrial complex, which is an extremely stunted marketplace as it's largely a government monopsony.

We don't use economic competition to determine who holds authority on the legitimate use of violence. As a consequence, we don't get the full benefit of marketplace competition in maximizing the efficiency of our armed forces -- but we also don't have perpetual civil war.

[marssaxman]

> the issue is that the state has to have a monopoly on violence

That is not the case in the USA, where the absence of such a monopoly is written into the federal constitution.

[baursak]

Are you talking about 2nd amendment? If so, that's not a grant to violence by any means. If you want to test if the state really has a monopoly on violence, try being violent, or simply disobedient with an officer of the state.

[scottishfiction]

The state doesn't have to have a monopoly on violence; as the use of private military contractors has proven.

[Chaebixi]

> The state doesn't have to have a monopoly on violence; as the use of private military contractors has proven.

I don't think you know what the "[state] monopoly on violence" means. It does not mean all people authorized to use force are directly on the government payroll.

[fjsolwmv]

Rectang misused it first, by claiming "encouraging a marketplace of competing militia would not a viable approach. " Even though mercenary corporations are in fact competing militia.

[rectang]

Whatever large portion of the military we are not comfortable contracting out is going to continue missing out on the efficiencies induced by marketplace competition.

[DomreiRoam]

"Creating a public institution with no pressure to make profit is a disaster waiting to happen." Do you really think that we should ask the army to be profit oriented? What about the coast guard, Justice, Child protection service? Imagine all of this public institution comming to your house and start the conversation with "You have a nice family, it would be a shame if ..."

To expect results or effects is not the same as making profits.

[toomuchtodo]

You can have a competitive environment without a profit motive. You judge on results, not profitability.

[codehandle]

This. Bothered to login to say what you said.

We talk about AI optimized to create paper clips accidentally running amok and turning the world into paper clips. Why isn't profit a similar problem? Government agencies are just AI running on meat. Give them success parameters different than raw profits.

Honestly, why can't we see this as just a variant of the instrumental convergence problem?

[chestervonwinch]

OTOH, academia is supposed to be this type of meritocratic, results-driven ideal, and look where we are there. I suppose this a consequence of the measure that we use to "judge results". Do we start assigning healthcare R&D companies an "impact factor"? I know the journal impact factor is a bad example since it is criticized for being gameable, but I'm just using it to convey what I mean.

[mar77i]

↑ ... instrumental convergence problem sounds sexy! drool

[andrepd]

>Creating a public institution with no pressure to make profit is a disaster waiting to happen.

Aren't most public institutions non-profits? Don't many of these work well? What makes you think that a (truly) democratically run enterprise wouldn't satisfy the needs of its constituents?

[collyw]

Europe proves you wrong.

[ddingus]

Use the Post Office model. When profitable, it contributes to the general fund. See my other comment here.

Political hobbling and fuckery related to post office operations done to marginalize otherwise exemplary performance aside, the model has merit.

[fjsolwmv]

The post office has a govenrment-granted monopoly on first class mail service, and does pretty poorly when it competes for non-first-class mail logistics.

[ddingus]

A necessary monopoly. Without it, service would not be universal.

[llukas]

DARPA...