[danachow]

I’m not saying freer markets in some aspects of medicine would be better - but the libertarian dream in medicine is probably very naive and fails to learn from history to boot (medicine, especially pharm was much freer 120 years ago - it didn’t work out too well).

And of the big problems in medicine - a prescription for glasses (which isn’t really a medical service in the US - optometry is not a medical profession) just doesn’t register for me - you can order glasses online without a prescription if you are so inclined.

Meanwhile there isn’t any realistic libertarian solution to allocation or access to complex medical care - and just hand waving “free markets” doesn’t make it so.

[adam_arthur]

You can't order corrective lenses online without a prescription. You can order frames, or reading glasses. You need a prescription for both contacts or the lenses themselves.

Contacts would certainly be much cheaper without that hurdle.

And I bring up vision, because it's a common problem and for less well off folk with families it can be a big expense, basically entirely unnecessarily so. Imagine making 20k/year and you have to pay $500-$1000 a year for vision correction for your family. That's 2.5-5% of your pretax compensation

There's no handwaving here. Competitive markets require complete information. Information about costs to the consumer is basically entirely opaque. Over 90% of medical costs are non emergency, so if people could comparison shop, costs would go down. Also requires skin in the game (e.g. marginal cost per visit).

Look at plastic surgery for a good example of how free market/non insurance based medicine can fare. Many procedures are quite cheap, and while many are still expensive, much cheaper than necessary medical care covered by insurance. Also the number of doctors is still limited by the AMA, so even this is not fully competitive. There's an arbitrary cap on number of providers

[danachow]

> Also the number of doctors is still limited by the AMA, so even this is not fully competitive. There's an arbitrary cap on number of providers

This is an old trope but hasn’t even been superficially true for years. The AMA does not have the authority to limit the number of doctors. In any event their political influence has become less and less relevant for decades now, so even their ability to influence the number of docs is quite limited - I am not even am AMA member - I was only during medical school to get discounts on test prep. I don’t believe most of my peers are AMA members either - they belong to their specialist groups. Meanwhile the number of medical schools and students in the US has increased substantially in part due to AMA and AAMC. Meanwhile internal medicine residencies still have to fill their ranks with imported talent (foreign medical graduates) - only the lucrative subspecialties are the ones that remain limited and competitive. There are also forces at work to limit the number of MD jobs available that have nothing to do with the supply of MDs (replacement of positions with midlevels). The limit on residency positions is a partisan federal funding issue going on for years and only recently has much headway been made.

On eye care, I can of course self prescribe but even so for contact lenses I usually end up purchasing overseas from reputable retailers because of the price fixing of contact lenses - and I’ve never been asked for a prescription. It’s not that hard to get eyewear without a prescription.

[weird-eye-issue]

No you don't need a prescription for corrective lenses. I've ordered them without and just had to confirm there would be no returns and such

[adam_arthur]

I'm pretty confident it's not possible, as I was specifically looking for this recently.

But please link me to a US site where I can legally buy contacts without providing proof of prescription, if there is one!

[InvaderFizz]

I looked into this, apparently it is a legal requirement in the US for contacts.

That said, for normal eyeglasses, there are many sites that offer eyeglasses without proof of prescription. I've been buying eyeglasses from Zenni Optical for almost a decade for my whole family. Most recently in 2021. I have never once even been asked for proof of prescription, I just punch in my numbers and hit order.

[Scoundreller]

Dunno if they ship to USA, but all of the Canadian online shops shipped to me without sending over any proof.

One province de-regulated dispensing of corrective lenses and anyone could get in the game, and many did!

[adam_arthur]

Oh, well yeah, other countries have less regulation. It's not possible in the US right now.

But good to hear you can in Canada!

[teslabox]

Some online shops make an effort to validate vision prescriptions, others do not. My most recent contact order was through Lens Direct, who did not validate. 12 years ago I gave an incorrect phone number for the optometrist. They tried to call but did not connect, and sent me an email: 'we're going to send your contacts anyways...'

The optometrist I went to recently put me in the strongest prescription I'd ever had. Instead of using that prescription, I ordered contacts using the prescription of the glasses that I thought were fine.

There's two numbers on the contacts... diameter of the pupil (doesn't matter for most people I think) and an angle (Edit: 'Base Curve'. The third number is the power of the contact, aka 'sphere'. Glasses prescriptions have power and astigmatism, but don't have diameter or base curve). I got these off my prescription. If you don't already know how to use contacts it's important to get instructions and a followup. I read of a guy who didn't know he had to take the contacts out at night - the contacts had started to grow into his eyes?

(Edit: you can get a set of "trial lenses" from Ebay if you want to try to come up with your own prescription, or to try out your prescription before buying glasses.)

My previous comments on ordering contacts:

https://news.ycombinator.com/item?id=13691768 / https://news.ycombinator.com/item?id=29366816

Edit: I live in the United States.

[weird-eye-issue]

I used framesdirect.com. I didn't say I bought contacts though, it might be different

[beaconstudios]

isn't forcing hospitals to post prices a form of regulation? In a free market (I'm interpreting this to mean laissez-faire - a market setup maximise competition and consumer choice must be regulated) nobody will post prices unless they have to or the procedures are elective, like plastic surgery is.

[adam_arthur]

Yes, I'm not advocating a free market, but a competitive market.

Fully free markets can lead to negative externalities like monopolies, pollution etc.

What leads to good societal outcomes is competitive markets. It just happens that free and competitive overlap a lot of the time. Information hiding makes a market less competitive, but is permitted under a full free market mentality. This is an area where regulations are warranted and useful.

Competitive capitalism should be the goal for most areas in modern society. Which in almost all cases only requires light regulation.

[mchusma]

I actually think requiring to give prices is consistent with libertarian approaches. I like good clear contract law. I think being able to give prices is basically required for good contracts. This is why every other industry does this, and nobody just says "we will charge you whatever we like".

If you were in another industry, and went to a judge and said "this person defaulted on their agreement to pay me whatever I want." Then I think the judge would basically tell you to get lost. And that is a good thing. The only oddness here is that somehow the medical industry has been getting away with this for a long time.

That is what the fix should be too, IMO. Basically, legislation that states unless someone expressly agrees to a price for a medical procedure, they are not liable for it.

[adam_arthur]

Yup, there's a lot that can be done to foster more competition in the medical space. Important that consumers have some skin in the game too. Another big problem is that the structure of insurance plans often warp incentives such that people either under or over-consume care.

Certainly there's a good case to be made for having safety nets for those that can't afford, but for the vast majority of people, a competitive system would bring down costs substantially. The US actually pays the most for healthcare per capita than any other country, I believe. Largely goes to inefficiencies rather than health outcomes. A truly well structured and competitively designed healthcare system could greatly improve QOL for the public.

Whether it's "libertarian" or not is a matter of semantics. The free market extreme would have no regulations at all... but clearly that can lead to certain negative outcomes (monopoly being classic example). Certainly there are different flavors of libertarian... and I would consider myself one, but am in favor of regulations that encourage competition between businesses. However, not needed in most spaces, healthcare in particular seems very warped/not rationally structured.

A rule of thumb for whether a sector is competitive/efficient are whether margins are broadly high across the board. I'm definitely a capitalist and not anti-business, but in a competitive market you should expect margins to be relatively constrained in the long run. Of course first movers, and those that truly out compete the rest can attain high margins... but over time these advantages should erode as new and better players come along.

Certain SaaS is pretty interesting example, because cost of switching can be high, creating "utility-like" businesses. DocuSign, for example, is really easy to dump for a competitor, low cost of switching. But something like AWS is much more difficult... need to invest potentially millions of dollars and months of time to rewrite your systems/design learn a new cloud environment, very high and painful costs of switching. It's often cheap to choose one of many competitors, but then you're entrenched in that environment.

Anyway, long tangent, but I expect law to recognize these kind of things eventually...

[robbedpeter]

Where's the "didn't work out too well" come from? Prohibition never works, whether it's restricting coffee or cocaine.

Combine education and free access to everything with reasonable daily unit limits and per-substance licensing. You want meth, you go through meth safety training and get a yearlong endorsement allowing you to buy up to the daily limit at a pharmacy, no prescription involved.

Set up due process that limits or eliminates legal access to substances based on criminal or medical situations.

Drug abuse - using in inappropriate situations leading to misbehavior - can be treated as a medical issue. Misbehavior that rises to the level of criminality is already handled.

It's absurd to think that any adult in a free country has any business whatsoever telling other adults what they can ingest or do in private.

Some variation on these notions are already demonstrated across the world. The current schedule system and drug laws in America serve only the bad guys, whether it's commercial prison slave labor, drug cartels, big Pharma, or the alphabet jackboots.

[claudiulodro]

> Where's the "didn't work out too well" come from?

I believe they were referring to the snake oil craze of the 19th century, not prohibition:

> The term comes from the "snake oil" that used to be sold as a cure-all elixir for many kinds of physiological problems. Many 19th-century United States and 18th-century European entrepreneurs advertised and sold mineral oil (often mixed with various active and inactive household herbs, spices, drugs, and compounds, but containing no snake-derived substances whatsoever) as "snake oil liniment", making claims about its efficacy as a panacea. Patent medicines that claimed to be a panacea were extremely common from the 18th century until the 20th, particularly among vendors masking addictive drugs such as cocaine, amphetamine, alcohol and opium-based concoctions or elixirs, to be sold at medicine shows as medication or products promoting health.

> https://en.wikipedia.org/wiki/Snake_oil