[evrydayhustling]

The most important factor in this analysis doesn't get called out by name: healthcare costs. When Cowen mentions entitlement growth forcing spending reduction and tax increases, healthcare is both the most certain and the biggest culprit by a wide margin.

If you were going to do one thing to extend American prosperity, it would be disruptive structural improvements to our healthcare system. That's structural reform, not new biotech (except as allows you to disintermediate care). The fact that our total expenditure is so high relative to other countries with similar quality of care is evidence that the economic models, not the technology available, are to blame.

[internet_user]

Attack exorbitant salaries of physicians, and watch them suddenly forget how to treat your medical problems. And probably refuse to treat your family too, just to teach you a lesson.

How long are you willing to go without medical care just to make a political change? Not sure that geriatric politicians will be skipping their monthly appointments.

[Bartweiss]

This entire line of argument distracts from the real issues and makes progress harder to achieve. Physician salaries are one of the worst possible places to start addressing this issue.

US doctors apparently earn about 2x the average for other comparable nations. That's not a small number, but doctor's salaries in toto are only about 8% of US healthcare spending. A 50% reduction would bring our salary spending in line with everyone else, but only save $100 billion out of a $3,300 billion cost.

Meanwhile, outright waste in medical supply spending costs $765 billion per year. That's drugs discarded at expiration dates which are known to be too restrictive, spending on combination drugs which are identical to the sum of cheaper components, and supplies thrown away by hospitals for non-sanitary reasons (e.g. vendor change, or drugs allotted for a patient but never issued or opened). Changing some parts of this would involve challenging the profits of drug companies, but in many cases not even that would be required. A handful of regulatory changes could save enough to offset the entire cost of paying doctors.

The situation with unnecessary or ineffective medical treatments is comparable. Some of the most common surgeries performed are known not to work, suspected not to work, or known to be more risky than inaction for standard patients, but they're still carried out at enormous expense. Adjustments to medical publication standards, physician statistical training, and and malpractice risk profiles could massively reduce the number of unnecessary and even net-harmful surgical procedures performed every year, cutting costs while directly improving care.

Framing medical expenses as a conflict between consumer expenses and doctor's salaries is false and harmful. It literally can't solve the problem, but it's excellent at derailing the work that could.

https://www.propublica.org/article/the-myth-of-drug-expirati...

https://www.propublica.org/article/what-hospitals-waste

https://www.theatlantic.com/health/archive/2017/02/when-evid...

[internet_user]

I know this is an unpopular view, but who are you to decide what level of risk should a patient accept? Literally every step, including inaction has risks. Can patients decide independently what should be done with their own body, or are they presumed to be too dumb and must obey your decisions?

Should patients be consigned to disability immediately without even attempting some procedure, simply because the chance of success is too small in your arbitrary definition?

You have never been seriously sick.

[Bartweiss]

> You have never been seriously sick.

For a comment arguing that I'm being dismissive of sick people, this is a genuinely insulting and exceedingly false assumption to make. Yes I have, yes I am, and those experiences absolutely support my point.

> Who are you to decide what level of risk should a patient accept? ... Are they presumed to be too dumb and must obey your decisions? ... Should patients be consigned to disability immediately without even attempting some procedure, simply because the chance of success is too small in your arbitrary definition?

I did not say any of this at any point. I did not say anything remotely resembling "people should be consigned to disability because some procedures rarely work". None of what I am proposing is about denying patients treatments they make informed requests for.

Please actually read that Atlantic article. It is not in any way about denying medical care to a sick patient who wants it because "doctors know best". It is exactly the opposite - a patient was being railroaded into major heart surgery that made sense as a malpractice precaution but not as patient care. He did his own research, obtained multiple opinions, and independently decided to what should be done with his body.

That is what I want more of. In a discussion of cost-cutting I focused on the straightforward case of expensive treatments being pushed on patients without giving them full information, but over-treatment and under-treatment both happen. If it would make you happier, I can list some of the ways I think we can get better care at lower costs by providing more treatments and emphasizing patient wishes over current medical consensus.

I'm painfully aware that the 'patients are clueless' attitude you're attacking exists. I mean that literally, as a result of that attitude I'm in pain right now. But you read an entire worldview into one sentence, in the face of examples that specifically disagree with it. The thing you're objecting to is terrible and deserves opposition, but you're picking a fight with someone who already agrees about that.

[gooseus]

This is, indeed, a silly way to frame the argument, a better approach would be to restructure the malpractice law so that doctor's insurance premiums are lowered and they (hopefully) pass that on to the consumer. Let the malpractice lawyers eat some of the cost of the savings, not the doctors.

[internet_user]

Why would they pass that on? There is no real competition. Wait times are measured in weeks, or months.

It's easier to get appointments with CEOs of SP500 companies than with your own doctor sometimes.

[dalbasal]

With the exception of the military economy, how many successful restructurings have there been of major industries? Is it possible for a polity to decide such a thing and do it?

As an outsider getting occasional (and highly combative) tidbits of the last american health system debate... It seems like a tall order. Doesn't seem possible to make a reform that (a) half the people don't think is the devil's work and (b) works in theory, which is important to Americans and (c) works in practice.

[bdamm]

* Telecom industry * Utility industry * Road-building industry * Railroad industry * Oil & gas industry

Seems to me that governments, including American Federal and State governments, do it all the time. In fact, it's so common, that I wonder if that's the main function of government.

[evrydayhustling]

Yeah, I am pessimistic about the polity being the source of change. Classically, top-down reform from a polity involves some form of nationalization, which our last reform cycle attempted.

Excluding ethics / philosophy of that kind of seizure, it's just a hard computational problem to orchestrate a centralized reform of something so complex. It becomes impossible when the system being reformed gets involved, buying politicians on both sides to impact the future and influencing public perception. And how could they not? It's hard to even fathom the stakes: a highly centralized industry capturing 10% of US GDP.

That's why, at the risk of being a tech culture charicature, I think business innovation from outside the industry is more likely to make a dent than politics.