[testfoobar]

Public health insurance in the US without reforming the delivery, cost, and regulatory structures would be exceedingly expensive.

Lets say that you want to start public health clinics to treat non-emergency, routine care. Imagine your system of clinics misdiagnoses a few patients who later get very sick and die. Those patients' families will sue for vast amounts of money from the clinic.

The mere threat of these lawsuits requires every interaction, every medical history change, every diagnosis update, all of it to be meticulously documented and tracked. It leads to doctors agreeing with patients asking for expensive and invasive testing. It leads to doctors agreeing with patients who request medication, etc.

At end of life, it leads to doctors agreeing to many, many expensive interventions.

How does end-of-life care/cost compare in Europe with the US?

[theptip]

Worth noting that "public health insurance" ("single payer" or "public option") is different than "public healthcare" ("socialized medicine"); I'm advocating for the former, not the latter. If I'm following you correctly it seems like you're analyzing the public healthcare option, which is a much more substantial change.

I agree with your point that you'd need to dramatically overhaul the regulatory framework to implement socialized medicine (i.e. the government opening clinics), but I think you would need to do significantly less work if the healthcare delivery remained privatized. Of course in both approaches you could reduce healthcare costs by reforming liability laws.

The main decision in my opinion is between true "single payer" (i.e. private health insurance is not permitted for services covered by the public insurance) and "public option" where private insurance can compete with the public option for coverage on core services. The details here are pretty complex and there are options all across the spectrum in the EU to compare; e.g. Germany has a hybrid approach where below a certain income you must take the public option, and above the threshold you can buy private coverage. Canada has a true single-payer system it seems (though you can supplement for additional coverage that the core single payer system doesn't cover). Etc. (See for example https://www.griffinbenefits.com/blog/how-does-healthcare-in-... for a bit more detail).

Either way there's extremely high support for some sort of public option in the US; it's around 80% supporting medicare for everyone who wants it, and that reduces to something like 60% if you ask specifically about "medicare replacing your insurance" i.e. true single payer.

> How does end-of-life care/cost compare in Europe with the US?

I'm not familiar with those numbers, would be interested in comparisons if anyone has data they can link. I'd guess at low confidence that it's better in the EU, since they are more likely to use utilitarian measures like QALY for allocating healthcare spending, and that framework should discourage excessive end-of-life care expenditures.

[testfoobar]

Single payer / public option would be a great solution. Separating out health insurance from employment at an affordable price would be another. I understand the spectrum of choices from the EU/Germany hybrid to Canada and the UK.

I just don't see how we get there in the US. According to the World Bank, the US spent 16.89% of GDP on healthcare vs 11.43% of GDP in Germany.

That difference in spending represents billions in revenue and millions of jobs. The businesses capturing that revenue and those workers will not give up their livelihoods because the German model is more efficient.

Healthcare spending in the US is a massive political force and I see nothing on the horizon that will take it on in any meaningful way. We've discussed Obama's ACA plans many times on this site.

The realist in me says that uneven outcomes and health emergencies bankrupting families is actually a stable political outcome. E.g. Most people have no fear of medical bankruptcies - simply because it hasn't happened to them. So a politician promising a solution to medical bankruptcy isn't going to win votes. Instead that politician is inviting opposition from the medical industry. By the time someone faces medical bankruptcy it is too late for systemic change. They just go bankrupt.

From a game theory perspective, we would all collectively benefit from a better distribution of medical spending and insurance. Channelling that collective will is nearly impossible because the motivation for change doesn't become obvious until you have to pay $5K/month for medicines to survive.

Motived, ethical political leaders could do it. But you don't reform 17% of GDP spending without risking your political future, speaking fees, or board seats.

[theptip]

I understand the pessimism -- and I think you're right that lobbying and economic inertia are the reasons that change has taken so long.

However I think there is cause for reserved optimism; the ACA moved the Overton Window on this subject. Sanders and Warren made Medicare For All a core part of their platform, and did not get killed for it. Biden supports a public option (Medicare buy-in, not single payer), but that is now the moderate / bipartisan position in terms of voter support.

We will probably not get a single payer solution in this administration, but the public option could capture some of the market, and make further changes more tractable.