[gizmo686]

How many people are you willing to let die to get to that revolution.

Then, once the revolution comes, how many people are you willing to let die while you iron out the operational bugs in your new system.

Fixing the US healthcare system is going to be like changing an engine mid flight. It will require long term planning and consist of a lot of bandaids and ducktape while we work on it. Unfortunately, our political system is by-polar, so plans need to be designed not by what will work best, but by what cannot be dismantled when leadership changes.

[notjesse]

I'm not sure it needs to be like that.

Most developed nations have a public health system. Akin to how the US has public schools and emergency services.

The revolution could be the government bitting the bullet, and spending a fortune on bootstrapping a public health system that undermines insurance and private health.

Yes, it will hurt that sector a lot, it won't happen overnight, it will cause huge deficits, and it will inevitably cause higher taxation. But it's ultimately what needs to be done. We just need to give up on the sunk cost fallacy and go with proven models.

[gizmo686]

At some point, you need to decide if you want a revolution or incrementalism.

We already have a public healthcare system, it is called medicare. We can expand medicare so that private insurance takes up a smaller segment of the total market. I believe that approach will provide incremental improvement and give policy makers leverage for further incremental improvement, but it is not a revolution.

While many of our politicians are talking about revolution, what they are all proposing is incrementalism. The reason for that is very simple; revolution is a bad idea and incrementalism has a proven track record of working.

As an aside, medicare-for-all is still a long way away from a public healthcare system; it makes one area of the healthcare system public.

[jeswin]

> The reason for that is very simple; revolution is a bad idea and incrementalism has a proven track record of working.

Is there any empirical evidence to back this up? There are enough successful examples of revolution and incrementalism from around the world, but I can't find stats.

[ars]

> We already have a public healthcare system, it is called medicare. We can expand medicare

No we can't. Medicare pays below cost of care, and hospitals make it up from private payers. You can't just switch everyone to Medicare, you would have to reduce expenses somehow (which means firing people).

[cheerlessbog]

Perhaps it just pays realistic prices and "below cost of care" is the provider's way of saying "reduces the income I am accustomed to.".

The regular pricing also builds in an assumption that some patients can't or won't pay. If they can more easily get Medicare, less padding is necessary.

[pauljurczak]

This and oversupply created by for profit motive. Costs are driven up by putting a new MRI machine on every street corner, building boutique hospitals and medical buildings at the density well above of what's required. A business model a la Mattress Firm.

[ars]

Call your local hospital and ask what the wait time is for an appointment for a non-urgent MRI. If it's more than a week there is undersupply, not oversupply.

It's probably actually at least a month of waiting time.

[ars]

> is the provider's way of saying "reduces the income I am accustomed to.".

The "provider" is not a single person. So to reduce the income of the organization, you have to fire people or reduce their salary.

I think you are thinking you can reduce their profits, but you can't. Instead if you feel they are charging to much, that directly translates into lost jobs or lower pay.

It might be necessary, but just as long as you know what you are advocating.

Can you imagine a politician running on a platform of firing healthcare workers?

[gizmo686]

We have politicians running on a platform of abolishing insurance companies. That is as close to a platform of fireing people as you can get.

[cheerlessbog]

They would run on a platform of "pay less for Healthcare" and concern for Healthcare Jobs would not play a major role in the debate, if history is a guide.

[joe_the_user]

The revolution could be the government bitting the bullet, and spending a fortune on bootstrapping a public health system that undermines insurance and private health.

Or, uh, "Medicare for all", since medicare is an existing, functional single payer system (not actual "public health system" but still, there, works already for a significant fraction of the population, is an existing proposal.

We just need to give up on the sunk cost fallacy and go with proven models.

This, definitely. It's worth saying "sunk cost" arguments often go more with entrenched interests than any actual benefit. Unfortunately, this doesn't make them easier to counter.

[DoreenMichele]

and spending a fortune on bootstrapping a public health system that undermines insurance and private health.

I think we could start by expanding military medical benefits. For example, give lifetime benefits to all honorably discharged service members, not just those who made it to retirement. We already have a government funded and run system. It has some excellent assets, such as Walter Reed, a research facility. We could just start quietly expanding that in a way that people could get on board with.

(Changed "honorably discharged veterans" to "honorably discharged service members" for clarity.)

[sailfast]

We already have a system for that called the VA. Their track record over the last ten years in providing care is pretty abysmal. I am not confident your suggestion would result in a different outcome but I’m open to ideas.

[r00fus]

That’s mostly because we started two wars without costing in the trillions it would cost to care for battle vets.

Then we continued to underfund the VA.

It’s only logical that it’s where it is.

Some of us foretold this from before the wars.

[TheBeardKing]

And the VA is run by government employees, which are just not cost efficient. Source: I am one and work with thousands of them.

[sailfast]

To be a bit snarky: why haven't you quit to give the job to somebody more cost efficient? Do you think that if you were given your job as a private citizen you would do better / be more efficient?

I agree that certain jobs do not have to be done by the government and in that way, doing them via government gives rise to all sorts of bad incentives and inefficiencies, but I would not want to paint anything run by government employees as cost inefficient (especially if it's a core government competency) compared to the private sector alternative without some clear evidence.

[dsfyu404ed]

One politican's inefficiency is another politician's jobs program.

[verall]

I think this is just media spin. If you interact with VA much I think you find its staffed by a lot of vets and they try hard to do their best. There are problems of funding and staffing and more, esp in poorer areas, and I have heard some bad stories, but it hasn't been my experience.

If you're speaking from personal experience I'm interested what happened.

[sailfast]

Mostly speaking based on my hearing first-hand from those working there to some of the technology horror stories / treatment backlog issues. There are also some fairly comprehensive issues with specific hospitals that I recall from the news, but maybe that's media spin.

My point is not that interacting with folks at the VA is bad (generally folks try to do their best) but that at a certain point if a single organization runs a specific function incentives get turned around to the point where you lose the ball somehow, and there's no pressure to improve. This seems to have happened to a certain extent at the VA and I see the pattern happen a lot across large institutions, generally. ESPECIALLY if they are not in a competitive environment.

[koolba]

I’d rather go the other direction and expand Medicaid by allowing anyone to “buy in” to it regardless of income level.

[Spooky23]

It won’t happen. If you visit different cities in the US, not the big 5, look around at the buildings in the central business district.

Usually you’ll see a couple of regional banks, the local big bank outpost, and insurance companies. That’s lots of money and lots of jobs, lots of votes.

Unlike banking, the arcane processes actually created more middle class jobs while banks nuked jobs over the last 30 years. If Clinton couldn’t push universal care in the 90s, nobody is going to do it in the foreseeable future.

[ArtDev]

High salaries are justified by the absurd cost of medical school. A solution would be to create new public medical schools where tiotion a fraction of the price. Publicly trained doctors can work at cheaper public hospitals.

There is a lot of profit in medicine yet almost no competition around prices.

The simplest fastest solution, for now, is to pass a law requiring transparent prices!

[saagarjha]

Any plan like that is going to have a portion where you convince the part of the country openly hostile to it that you're not bringing in socialism.

[Tracist]

seems like its an education or media-bias problem more than a healthcare problem.

If a majority of the poor in America are not educated enough to understand how public healthcare will benefit them and the country, or are educated enough to understand but not educated enough to realise media outlets have a politcal agenda and might not be reporting accurately, then public healthcare is still not going to happen.

(and they might not want socialism, but it seems like they dont understand that democracy has problems too. and healthcare is the living example. but again, it circles back around to being educated enough to understand that democracy is good, but it isnt perfect, and no system is)

[brewdad]

See, even someone who should know better gets the argument confused. Socialism is not opposing democracy. Much of Europe is more socialist than the US and have democracies as strong or stronger than the US.

[Tracist]

Too true! I'm college educated but (in my defence) not American, so I'm not surprised I got the details confused.

[ajmurmann]

> and they might not want socialism, but it seems like they dont understand that democracy has problems too

Isn't the contrast between capitalism and socialism? It seems like I could have democracy with either.

Of course it doesn't help the conversation that Americans use term socialism differently than Europeans or Marx himself did.

[flyingpenguin]

Or convince them there is nothing more wrong with socialism than capitalism and the world needs more balance and nuance.

[jakeogh]

Having the gov decide who gets what care is incompatible with a free society. Alfie Evans is a striking example.

[lazyasciiart]

A "free society" doesn't require that parents be given free reign to torture their children. You may wish to argue whether that's what was happening, but that's the reasoning the state gave for their actions. If you'd like to argue that a free society does require this, go ahead, but I don't think most people agree.

[pjc50]

The Alfie Evans case could well have had the same outcome with fully private care, since it was a case about the rights of the child rather than about funding for treatment.

(Besides, we can probably find a lot more cases of dead children in the US where they were simply denied or unable to afford coverage ...)

[jakeogh]

I agree. Thanks. It was a mistake to use his case as an example of my concern.

[DanBC]

In the US the doctors would have done exactly the same thing: they would have proposed a treatment plan; the parents would have disagreed; the doctors would have gone to court and probably would have won.

But in the US there would have been the additional funding step: the parents would have had to get insurance companies to pay for futile treatment, and no compnay would do so, or the parents would have had to crowd-fund this treatment.

Here, for anyone interested, are some of the legal documents (in date order) around the Alfie Evans case. They clearly show that parents have a right to a family life and to care for their child as they see fit, but that this right isn't total because the child is also human and has his own human rights. The paramountcy principle mean that the rights of the child come before the rights of the parents.

Please note that because of the involvement of the Christian Legal Centre in some of the court cases there's been a lot of misinformation spread about the case.

I know that there's nothing I can say to change your mind: you have an ideological viewpoint, and that's okay. But I think you should at least acknowledge that your opinion is not based on fact.

https://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWHC...

https://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWCA...

https://www.bailii.org/cgi-bin/format.cgi?doc=/eu/cases/ECHR...

https://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWHC...

https://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWCA...

https://www.bailii.org/cgi-bin/format.cgi?doc=/eu/cases/ECHR...

https://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWHC...

https://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWCA...

https://www.supremecourt.uk/docs/in-the-matter-of-alfie-evan...

[jakeogh]

I accept you are correct about the paramountcy principle. I have read about the case in the last hour, and realize I was wrong to equate it with murder.

The details make me uncomfortable (with the court decision), he had an offer from a qualified intuition for help.

Thank you.

[schrodinger]

The problem is that those who need healthcare most (i.e. those that would be let to die) are those that are most opposed to universal healthcare!

[flowersjeff]

Very true. The level of disconnect that we have in this nation around this is just unreal.

[iamnothere]

One could argue that we are currently stuck on a local maxima, and that the broader political system is designed such that any significant improvement will first require massively disruptive changes that will indeed lead to deaths. In this sort of situation, the end result of a change will save many more lives over the long term, but it will require short term sacrifices. Not just sacrifices of money; unfortunately, some people won't make it through the process.

Opposition from incumbents ensures that any change will be a difficult process, and a "new normal" will not come easily. Any long-term planning efforts will be sabotaged and subverted toward capture of profits. The best we can hope for is a series of smaller disruptive shifts (each followed by a resettling) that eventually improves the situation.

Something needs to happen. Increasingly it looks like dissatisfaction with the current system will boil over and force a major shift, but other events (wars, for instance) could pop up and distract the public for a time.

[Gibbon1]

Before the ACA San Francisco implemented Healthy SF which eventually came to cover every family making up to 500% of poverty levels. It was just slowly phased in over about 5 years.

Key thing I've noted about was it was designed to get people covered and to stay that way. That's the opposite of neoliberal ACA which is designed to be annoying and has traps designed to rat fuck people.

[iamnothere]

The media likes to associate the ACA with Obama, who was at least nominally on the left. This conveniently covered up the fact that the ACA was based on Romneycare, a vehicle from the neoliberal "center" designed to prevent truly disruptive reform.

The ACA was a stalling tactic, and it has been rather successful in that role. People are starting to see through the ruse though.

[Gibbon1]

> designed to prevent truly disruptive reform.

That's been my opinion, more or less the ACA was just to set the take by the Insurance/Health care parasites to 17% GDP no more no less.

Healthy SF was really about access and outcomes.

[notjesse]

That's a great way of looking at it! I've never thought of it like that.

[maxerickson]

If you want to frame it like that, you also have to ask how many people you are willing to let die in the meantime.

[krferriter]

It would take a number beyond reckoning, thousands to change our minds.

Tens of thousands.

But my lord there is no such force.

> looks at US uninsured death rate and medical bankruptcy rate.

> horn blows.

A new power is rising. Its victory is at hand.

[fragmede]

> Tens of thousands.

Not to be callous but if they're poor, is that enough?

Because 64,000 Americans died of drug overdose in 2016, and 72,000 in 2017 (200/day). (2018 stats not yet out.) 2/3rds of those are linked to the opioid epidemic, but those numbers haven't been enough to engage with the same sort of cultural change in other areas of the American psyche, as socialized healthcare would be. (NOT proffering an opinion on that here, just pointing out the body count may not be enough. Sadly.

[erentz]

Well also putting aside the terrible opioid problem which is partly economic in cause, purely on a healthcare issue we already do have thousands dying from lack of access! Its been estimated that approximately 40,000 people die due to lack of access to healthcare each year. But these are poor people so we don’t see them or hear about them and thus no revolution yet. (Although a majority of Americans want Medicare for all so somehow we just need to get representatives that represent voters not donors.)

[ozzyman700]

A few million