[ddingus]

I agree with you on decoupling the insurance from employment. Great move! This would immediately clarify what cost and risk exposure means to people too. Bonus!

I disagree on cost and risk exposure. Ask around both employer and employee about cost growth this last decade, for example... not getting lower, often are digit increases.

Regulation?

Well, the cap that limits margin dollars is easily dealt with by owning more of the chain of care. Opponents of this tepid method of cost control predicted it and it has happened. They can do billing with themselves and it works like tax shelters do and film studio accounting do to show compliant profit numbers.

From where I sit, being one of the really screwed set, I found some of what you put here clarifying, but did not find myself sold on the idea we are improving at all.

In fact, one way to differentiate the US profit motive from the rest of the developed world, is our continuing move toward market based care despite a lot of information

[bhupy]

> did not find myself sold on the idea we are improving at all.

I don't think we're improving either; as long as we have an employer mandate and privileged tax treatment for group health insurance plans, I don't see this changing any time soon. All I'm saying is that the market/private nature of it has little to do with it. It's the "employer sponsored" nature of it that has everything to do with it.

> In fact, one way to differentiate the US profit motive from the rest of the developed world, is our continuing move toward market based care despite a lot of information

That the US is somehow undifferentiated in its pursuit of market based healthcare is not true at all; see Switzerland and the Netherlands. Both have purely private health insurance systems, and there's no sign of that changing any time soon, and both enjoy excellent health outcomes with broad approval of their respective healthcare systems. They're almost exactly as regulated as the US health insurance market, except with one glaring difference: the private health insurance is predominately purchased on the individual market. (https://www.forbes.com/sites/theapothecary/2011/04/29/why-sw...)

Not only that, Singapore has one of the most market-driven healthcare systems on the planet, and enjoys the status of being the most efficient healthcare system with some of the best outcomes:

https://www.bloomberg.com/graphics/infographics/most-efficie...

[ddingus]

>I'm saying is that the market/private nature of it has little to do with it.

I appreciate that. And still do not agree.

Either the goal is fixing sick people, delivering care, or it is not.

If the US were to improve DRAMATICALLY on labor policy, among many areas needing improvement, perhaps we could show for profit being able to work.

Fair enough.

[bhupy]

> Either the goal is fixing sick people, delivering care, or it is not.

That's an odd dichotomy. You could apply this to literally any good or service. With food, either your goal is nourishing hungry people, or it is not; and yet the private sector provides food just fine.

At the end of the day, price signals and market forces ensure that producers meet the needs of consumers. There are certainly instances of market failures, especially in the case of externalities. But with healthcare, there's really no evidence that markets and the private sector cannot deliver world class healthcare, and in fact we see evidence to the contrary, both domestically (in Medicare Advantage) as well as globally (in Switzerland and the Netherlands).

[ddingus]

YES you can!

Not only is it interesting, it's reality.

You are making a market argument fundamentally.

With food, for example, people have lots of options, and while the need for food is absolute, wants for food can be ignored and or vary widely. Food wants is a great market. People can participate or not. They can prepare their own food or not.

Food needs are not as good of a market, though again, people have options, and are rarely in a must buy scenario.

That difference matters.

Notably, there is a cap on how big of a risk there is in the whole thing, and it's not all that big of a risk.

With food, one can end up in a weak scenario where one gets the least value for the most dollars. But, it's not typically life changing, and there are a lot of options for most people in most cases.

Contrast that with health care.

Let's talk about wants first, just like food. Cosmetics are a great example. People can choose not to do it. They may have options, depending on what the scenario is. This makes for a reasonable market. And, depending, people can make their own. I did that for a prosthetic a while back. Saved thousands of dollars. But, that is rare more than not. Still, we could empower people to some degree like we do with food.

Someone having a heart attack will need treatment, or let's say they are out of the market. It's not like they can shop around either. I could go through and compare / contrast with food, but here's the main point:

Unlike food, that doctor visit doesn't really have a cap on risk. 5 figure? 6 figure? 7 figure? All can and does happen.

And things people require? When people have to participate in the market, they pay the most and get the least value for the dollar. See insulin prices in the US?

Now, for a nation that has it's priorities in order and those priorities are not making money first and foremost, that price is a small fraction of what gets charged here in the US.

This is a shitty market. People are forced to buy, their choice is often limited, risks are crazy variant, costs not transparent, and on and on it goes.

At a minimum, most nations break these out making sure people who find themselves sick or hurt have baseline options that are not life changing, and market type options for those health care related things that make better sense.

Boil all that down, and what do we get?

Making money IS NOT THE TOP PRIORITY. Fixing sick people is.

When we examine all this in detail, we will find those shining examples of for profit health care actually working out are very well regulated, and that means they are forced to fix sick people first and foremost.

If they were not, then people would be tipping over for lack of ability to participate in the market, which isn't really even a market in a need scenario. It can be a market in the want scenario.

All of which is precisely why I frame it in those terms.

Which is it then?

Currently the US has chosen to make money first and foremost and look at the carnage!

[bhupy]

> With food, for example, people have lots of options, and while the need for food is absolute, wants for food can be ignored and or vary widely.

Wants for food absolutely cannot be ignored. Without food, you starve and die. Along with healthcare, food is the quintessential example of a good/service with price inelastic demand.

Now, you’re absolutely correct that in most food markets, there is a variety of options; that’s exactly what’s needed for a market to function. Unfortunately you haven’t demonstrated that private health insurance markets are inherently devoid of such options by nature of their being private. Medicare Advantage is an extremely healthy market, as is the individual market in Switzerland.

> Unlike food, that doctor visit doesn't really have a cap on risk. 5 figure? 6 figure? 7 figure? All can and does happen.

You’re just talking about catastrophic risk here, and as I’ve already mentioned, there’s nothing inherent to the private insurance model that makes this unworkable. This isn’t based on guesses and conjecture, it’s based in empirical outcomes: see Medicare Advantage, Netherlands, and Switzerland. Also keep in mind that nobody here is arguing against subsidies for poor or unhealthy people; we’re just talking about whether that money is used to purchase plans are created by actuaries that work for the government, or for private sector organizations, and the merits of each.

> And things people require? When people have to participate in the market, they pay the most and get the least value for the dollar.

That’s true in the US. That’s not true in Switzerland. Both have private healthcare markets. Therefore, it’s impossible to conclude just based on US outcomes that private-ness is the root cause. It’s clearly something else.

> See insulin prices in the US?

The unfortunate reality here is that government-enforced patents allow insulin prices to remain bloated. Again the root cause isn’t the profit motive, that’s just a side effect.

> This is a shitty market.

Absolutely no disagreements there. The US healthcare market is indeed shitty (outside of Medicare Advantage at least), unlike Switzerland.

> People are forced to buy, their choice is often limited, risks are crazy variant, costs not transparent, and on and on it goes.

Agreed. Again, nothing to do with private-ness.

> When we examine all this in detail, we will find those shining examples of for profit health care actually working out are very well regulated, and that means they are forced to fix sick people first and foremost.

This is also true of the US. Health insurance is by far the most regulated industry in the country. Profit margins are capped by ACA, plans are regulated by ERISA, health insurance has minimum standards thanks to the ACA, insurers cannot deny access based on pre-existing conditions, and employers are mandated to provide health insurance — all thanks to the ACA. From a regulatory standpoint, the US is virtually identical to Switzerland, except for one notable difference: employer sponsored care.

[cloudfifty]

> Again the root cause isn’t the profit motive, that’s just a side effect.

That's just utterly naive or politically biased. The profit motive is what causes those regulations in the first place! It has always been like that, especially in the states.

Don't try and create some sort of a fairy tale place where the profit motive won't try to rig regulations in their favor, they will always try to, this is what the incentive to make more and more profit creates.