[arcticbull]

Free markets generally work better the less leverage one party has over another. When the negotiation is "pay up or die" then it's de facto not a free market [1] and the government has a responsibility to step in and address it.

The minimum viable remediation is a two-tier system in which the government takes the "or die" out of the conversation. The best approach IMO is single-payer where the government takes the "pay up" part out too, as it allows the system to be globally optimized.

At the end of the day health insurance isn't insurance, it's at best a structured payments plan. You buy insurance against things that may or may not happen. You will get sick and you will die. That's not insurance.

[1] https://corporatefinanceinstitute.com/resources/knowledge/ec...

[meheleventyone]

It’s also a poverty of imagination that death is the worst thing that can happen.

Further there is also a general societal argument that we all benefit more from having a more healthy population than dealing with the external costs of a less healthy one.

[winston_smith]

Ironically the proposed solution is usually to put the government in charge, which is far larger and more violent than any private company.

[arcticbull]

Every medical insurance claim denied in bad faith is an assault if it leads to delay in care, and if it leads to death, is a murder. I suspect if you take that lens, you will see that the government insurance is not the violent one here.

45,000 people die each year in the US without care. Ending that would go a long way to reducing government violence. [1]

[1] https://news.harvard.edu/gazette/story/2009/09/new-study-fin...

[nradov]

That's a non sequitur. Even single payer systems deny certain treatments or force patients to wait in order to control costs. Every healthcare system has some form of rationing.

[arcticbull]

I said denied in bad faith - not due to capacity constraints - which roughly amounts to claims denied with the intent of maximizing profit instead of upholding the duty of care.

[winston_smith]

And if you define paper cuts as murder, then libraries are the real killers. Do you really want to put your insurance paperwork on the same level as innocents getting bombed?

[arcticbull]

If they're dead either way, then the same liability should exist. Does it really matter how?

[8note]

Who's dying of paper cuts? It's easy to see who's dying of denied insurance

[conanbatt]

Why doesn't the pay-up-or die model apply to food or shelter?

[three14]

If you found yourself in a situation where getting food or shelter now was a matter of life and death, and you effectively had only one supplier, it would. But you usually have time to find alternatives, and usually can skip the shelter altogether, and the markets are so large that it's usually hard for a supplier to form a monopoly or a few to form oligopoly.

On top of that, even "pay-up-or-die" doesn't mean that the price will be a billion dollars. Instead, it means that it's the price that maximizes total profits. Suppose that no one could ever pay more than $30,000 for the medical helicopter. Then the helicopter people would set a price that prompts people to pay as close to $30,000 as they can. Perhaps if patients see a bill for $50,000 they negotiate down to $30,000, but if they see $500,000, they go to court and only at the end pay $30,000. Similar dynamics can limit food prices in areas that really only have one food supplier - there's only so much you can charge, and if you charge more than that, you won't succeed in squeezing more out of them, but you may attract all kinds of trouble - violence, or legislation, or competitors, etc.

[conanbatt]

So you think that farmers sell corn at the prices because they fear they will get robbed or plundered otherwise, but hospitals fear no plunder?

[three14]

No. I think I covered that with "the markets are so large that it's usually hard for a supplier to form a monopoly or a few to form oligopoly."

[conanbatt]

Healthcare market is really big as well. Why is it easy to build a monopoly there?

[arcticbull]

It's really not. Generally you're limited to two or three insurance providers in a state and in range of your car accident, about one hospital.

[unishark]

Personally I've never been told to pay up before receiving treatment at a hospital. Especially when I arrive there unconscious. And Herb Cohen would say once you've received the service, you're actually in a great negotiating position. People actually negotiate hospital bills all the time. Especially in those crazy stories you hear about.

And you need a citation for your claim about when free markets do and don't work.

[arcticbull]

> Personally I've never been told to pay up before receiving treatment at a hospital.

Of course you have. The first thing you did when you walked in was hand them your ID and coverage info. You think hospitals operate on the honor system?

As a Canadian I've never been asked to pay up before or after receiving treatment [edit: at the point of care].

And before you jump into taxation, Canadians pay less per capita in taxes than Americans ($13K vs $14K), and that's before you factor in the $600 per month in private tax you directly (or indirectly via employer) have to pay your insurers.

> Especially when I arrive there unconscious.

You either have insurance or you're driven into Chapter 11. Further I suspect this is not due to good will but rather government intervention.

> And Herb Cohen would say once you've received the service, you're actually in a great negotiating position.

The debt was incurred once the service was rendered, and you are now liable. 66.5% of all bankruptcies in the US are medical -- are they just bad negotiators? I'm not sure what point you're trying to make but it's not in good faith.

> People actually negotiate hospital bills all the time. Especially in those crazy stories you hear about.

That sounds the worst.

> And you need a citation for your claim about when free markets do and don't work.

Voluntary contractual exchange is one of the undisputed key pillars to a free market economy. If you're being told you will die without the service it is a coercive exchange and therefore violates one of the key tenets. [1]

If I hold a gun to your head and tell you to buy my oranges for $1000 or I kill you, is the free market price of oranges $1000? If I tell you that you have cancer and you'll die unless you get $48,000 worth of chemotherapy, is that a free market? [2]

A free market requires both the voluntary production and voluntary consumption of services.

[1] https://en.wikipedia.org/wiki/Free_market

[2] https://www.asbestos.com/featured-stories/high-cost-of-cance...

[unishark]

> The debt was incurred once the service was rendered, and you are now liable. 66.5% of all bankruptcies in the US are medical -- are they just bad negotiators?

The overwhelming vast majority of people have health insurance. However, due to taxation of privately-purchased insurance but not insurance that's a work benefit, people are driven to get insurance through their job. This was the government's fault, by the way. If people lose their job, they lose their insurance along with it. People without jobs have lots of financial problems. If they have a medical problem this situation gets far worse and results in a lot of bankruptcy. You seem to think bankruptcy is worse than negotiating. Clearly, it is often preferred.

As for your oranges question, no.

For the cancer one, possibly.

[arcticbull]

> For the cancer one, possibly.

Do go on. Why is dying due to an explicit action any more of a free choice than dying of an explicit inaction? Why is one any more coercive than the other?

The only point I'm making is that healthcare is not a free market due to lack of voluntary agreement between buyer and seller. Once you accept that it's not a big jump to say the system should be remediated.

[unishark]

> Do go on. Why is dying due to an explicit action any more of a free choice than dying of an explicit inaction?

Because one is coercion and the other is simply an economic system. Which by the way is also used for all the other necessities of life too. How about food?

The whole point of a free market is competition, so if you were at least arguing for emergency situations there's be something to talk about since it's rather hard to shop around. But we'd still need to compare it to how well the government handles economics of emergencies. So far we have the govt driving up the cost of emergency care by requiring the ER to provide primary care for everyone without insurance.

[arcticbull]

I provided two examples of a coercive economic system. Just because it's an economic system doesn't make it any less coercive. The dictate is clear. A free market requires a voluntary participation of both the buyer and the seller. Threat of death is not voluntary participation, so it is not a free market. In a car crash you are not in a position to negotiate or make providers compete for your business.

In functioning systems the government drives down the cost of emergency care by setting the price and insuring everyone, and the results are clear. Canada's health care system costs $5447 USD, and Americas costs $10224. That's basically all I'll say about that.

Other necessities like food are in fact subsidized or socialized.

- The freeways? Socialized.

- The schools? Socialized.

- The police? Socialized.

- The fire stations? Socialized.

- The army? Socialized.

- The post office? Socialized.

- Healthcare for 40% of Americans? Socialized. (Medicare, Medicaid, VA). Medicare is socialized medicine. [1]

Food is also very much provided for if needed. SNAP and food banks provide socialized food to the poor. Americans pay less for food than anyone else on earth in no small part because the Farm Bill subsidizes production of corn and soy to the point these staples are sold at below cost to end users.

Either way that's a distraction and a red herring. Americans pay less for food than anyone else and more for medicine than anyone else. Eyes on the prize here, and stop carrying water for the insurance companies taking advantage of you :) All we're talking about doing is moving the percent of Americans covered by socialized medicine up from 40% to 100%.

[1] https://en.wikipedia.org/wiki/Socialized_medicine

[8note]

Coercion is simply an economic system too?

I tell you to do work, and if you don't I shoot you. It's just economics; I'm trading not shooting you for your labour and everyone comes out happy

[unishark]

> Of course you have. The first thing you did when you walked in was hand them your ID and coverage info. You think hospitals operate on the honor system?

They mail you these paper forms known as "bills". I have examples I can show you. Insurance only pays a portion. I suppose you can call it a kind of honor system.

And given your examples, you apparently aren't aware that when it comes to emergence care in the US, hospitals which have an emergency department are required by law to provide emergency care as needed to make sure a patient is stable. One's ability to pay is not a factor.

[arcticbull]

I've lived in the US for more than 10 years. What you're saying there is a mix of half-truths.

One is of course that "I suppose you can call it a kind of honor system," no, you can't, it's enforceable by law and actively collected upon. That's not an honor system.

> And given your examples, you apparently aren't aware that when it comes to emergence care in the US, hospitals which have an emergency department are required by law to provide emergency care as needed to make sure a patient is stable.

Yes, the bare minimum, then ejecting them out the back door as soon as they possibly can. Of course by waiting until they require emergency care you're fleecing everyone. Minor issues that could have been addressed earlier for pennies on the dollar are instead allowed to fester until they become life-threatening, then when the poor can't pay, it's socialized across those who can at the worst possible time for the highest possible price.

Not to mention, this is an argument against the free market approach which would just be to refuse service. This is actually bolstering my case that healthcare is not a free market because of a lack of ability to form a voluntary contract.

> One's ability to pay is not a factor.

Oh come on now. Who doesn't have health insurance? The poor. Who's going to get the bare minimum treatment required be law and getting booted out the back door? The poor. Who's then going to get a bill for it forcing them to declare bankruptcy? The poor.

This is strictly about one's ability to pay.

[throwaway201103]

If you're already poor, bankruptcy isn't really the biggest of your worries. You can't get blood out of a turnip, as the saying goes.

[unishark]

> Yes, the bare minimum, then ejecting them out the back door as soon as they possibly can.

New goalpost eh? No they generally just treat everyone fully and pass the cost on to people with insurance. Trying to transfer uninsured people out leads to lawsuits.

[arcticbull]

Nope, I've only got one goalpost. To express that healthcare cannot be a free market.

This was a digression and exploration of how your specific situation exists because of government intervention. The alternative is to let poor people die outside, and that's distasteful to me, and to most.

[unishark]

> You either have insurance or you're driven into Chapter 11. Further I suspect this is not due to good will but rather government intervention.

You really are making a lot of bold assertions. If you declare bankruptcy, the hospital gets zero. Negotiation is a process by which both sides give something to meet in the middle. Yes they do it.

https://www.cnbc.com/2020/10/28/you-can-negotiate-your-medic...

[winston_smith]

As a Canadian you pay up every time you pay taxes, and you don't negotiate because you take what the government gives you. If they say your orthopedic surgery happens in six months, then that's what you get, or you start shopping south of the border.

[arcticbull]

Re taxes: I explicitly addressed that. The government negotiates with the drug companies and sets pricing for an efficiently functional health system. I don't have to and shouldn't have to negotiate. The system costs half per capita to operate and covers everyone.

Re: waiting times, take it from the horses' mouth, you've been fed a crock [1]. Of course the system could be better, but on the whole you're just wrong. The insurance lobby has spent a lot of time, money and effort to convince you of that.

The data backs that up. A small handful of Canadians go to the US to "shop for orthopedic surgery" out of millions of visits per year in Canada. After all a hip replacement in America costs one hundred thousand dollars. Just how many Canadians do you think there are with a spare $100K USD ($128,500 CAD) kicking around in the old piggy bank for a new hip that'd be free in a few months? [2]

If you see 50-60,000 ish numbers they tend to be the 'snowbirds' - Canadians living in Florida for half the year who choose to seek care close to their winter homes. These are folks wealthy enough to have winter homes, and also maintain private insurance.

[1] https://www.npr.org/2020/06/27/884307565/after-pushing-lies-...

[2] https://www.vox.com/2016/10/9/13222798/canadians-seeking-med...