[TechnicolorByte]

So what are practical solutions for the US? The rest of the developed world has already shown that socialized medicine is the only way. Details like private/public mix or not don’t really matter as long as there’s a guarantee of free-at-service healthcare for everyone.

The main question is how do you actually go about making the change in the US with so many entrenched vested interests in keeping the status quo? How do you get people to agree to effectively fire millions of admin and health insurance actuaries? Seems like an impossible problem, especially given the political state of the country.

[rayiner]

You’re mistaken about what the European systems have in common. It’s not being “socialized,” and it’s certainly not “free at service.” France, for example, requires 30% co-insurance, and most people get private insurance to cover that. Obamacare is structurally very similar to the Dutch and Swiss healthcare systems.

What the European systems have in common is price controls. The major difference between the Dutch and Swiss systems and Obamacare is that the Dutch and Swiss systems directly regulate the price of services.

[TechnicolorByte]

Very useful comment, thanks. I’ll need to read up a Wikipedia article to get the details but the emphasis on price controls is noteworthy.

Besides my lazy and misleading usage of the term “socialized,” I guess the question still stands: how do we change our system to more closely reflect these other systems? Highly discouraging to think about.

[rkuykendall-com]

We have two or three systems that already work more like this, for the elderly, the poor, and the military. To me it seems the easiest way would be to gradually improve and expand one or all three. This can be done with minimal fear from the general public because you aren't ending the previous system so much as building a better alternative. I don't follow any of this closely, but I know there is a bill to expand coverage for the poor and elderly to include vision and dental. As for price controls, the recent Inflation Reduction Act allows Medicare to negotiate drug prices like European systems.

[mdnahas]

I read a good book that says the US has many socialized medical systems. Medicare for the old is similar to Canada’s system. VA for veterans is similar to England’s system. Most salaried workers insurance is similar to Germany’s system, except the German insurers are all non-profits. (In the US, the insurers were all non-profits back in the 1970s.)

I started in tech, but went back and got an econ degree. A market for insurance works well for unpredictable things, like broken legs. But it doesn’t work well if some can predict their need, like life-long conditions. So, there is a role for non-market solutions. At that point, you need to address how to keep patients from consuming “too much” healthcare, because they’re not paying the full cost.

Many countries spend less and have longer lives. But it is hard to get the US to implement one of those systems when healthcare companies spend more than $1 million per member of Congress on lobbying and campaign donations.

[schemescape]

I suspect change will have to begin at the state level.

Does anyone know which state has taken the most steps toward universal health care?

[xtracto]

The US government has to start providing a social health system that is A) cheaper than the alternative, b) better than the alternative.

Then people would stop paying crazy amounts of money for insurance and treatments. Some will continue to do it, but if the Public system becomes good enough, it will make all those private parasites disappear.

[refurb]

> The rest of the developed world has already shown that socialized medicine is the only way.

This is false. Plenty of very good systems around the world have private health care systems.

[tim333]

In practice most countries are mixed having private and government funded ("socialised") care, including the UK and the US I think - medicare is I think government funded?

The issue in the US seems more that the system has been corrupted by special interests. I guess the fix is maybe more fixing the political system a bit?

The whole term "socialised" is a bit indicative of the politics. You don't call other stuff that is government funded socialised like US's socialised road construction or socialised military?

[sneak]

> The rest of the developed world has already shown that socialized medicine is the only way.

That’s not remotely true at all.

[Analemma_]

Every single other developed country has 1) socialized medicine in some form or another, be that the UK-style NHS or German-style mandatory insurance with a public option, 2) better health outcomes than the United States on pretty much every measure and 3) spends less of their income on healthcare, even after taxes are included. I'm not sure what conclusion other than the GPs you can possibly reach.

[AnthonyMouse]

> socialized medicine in some form or another, be that the UK-style NHS or German-style mandatory insurance with a public option

This is not actually true. Some other countries have private insurance and those countries also have lower costs than the US. The US system is unusually mismanaged/corrupt.

> better health outcomes than the United States on pretty much every measure

This is also not true. The main way universal systems get better numbers on some metrics is that people with no coverage often have extremely poor outcomes, which when averaged in results in poor averages. But the average for people in the US with insurance is better than it is in many systems with universal coverage, which is an important metric because the large majority of people in the US do have insurance and their own outcomes is very much a thing that they care about.

You could bring about a large improvement in average outcomes in the US merely by providing an insurance subsidy for lower income people to increase the number of people with coverage. That wouldn't affect the cost much though -- it might lower it a little if it converts some emergency care to preventative, but only for that small percentage of the population that doesn't currently have insurance. The cost issue would still remain in general.

> spends less of their income on healthcare, even after taxes are included.

This is the legitimate criticism of the US system, but it doesn't tell you what to do about it. For example, Medicare in the US still pays more for equivalent care than many other countries do, so just putting everyone on Medicare without changing anything else wouldn't resolve the high costs in the US. And might even make Medicare look even worse because Medicare is in many ways currently subsidized by the high cost of private insurance.

None of that proves that you can't address the high costs without a socialized system -- but making the necessary reforms isn't easy for the same reason that bringing about your own proposal in the US isn't easy. Either way you'd have to overcome the political influence of all the people profiting from the status quo. Doing that is the hard problem.

[DanBC]

> But the average for people in the US with insurance is better than it is in many systems with universal coverage,

No, this is actually untrue. People who pay for insurance want to see a return on investment, so they want to see lots of testing. This is why over-testing, over-diagnosis, and over-treatment are so common in the US, and why the rates of harm from these things is so prevalent in the US.

This thought - that insured Americans do better - often comes from a misunderstanding of things like 5 year survival rates for cancer. Imagine someone who will die, no matter what you do, from a slow growing cancer at the age of 75. In many countries that cancer is detected when the person is 73 or so, and they move onto a palliative pathway. In the US that cancer may be detected when the person is 67, and their insurance is drained and then their life savings are drained and then they're eventually moved onto a palliative pathway.

[lmm]

> The main way universal systems get better numbers on some metrics is that people with no coverage often have extremely poor outcomes, which when averaged in results in poor averages. But the average for people in the US with insurance is better than it is in many systems with universal coverage, which is an important metric because the large majority of people in the US do have insurance and their own outcomes is very much a thing that they care about.

The large majority of people in the US might lose their insurance at any moment with no recourse, thanks to at-will employment. So they should care about the average outcomes including people without insurance.

> You could bring about a large improvement in average outcomes in the US merely by providing an insurance subsidy for lower income people to increase the number of people with coverage.

Either this wouldn't work or something has gone terribly wrong with your system, since this hasn't been done.

[AnthonyMouse]

> The large majority of people in the US might lose their insurance at any moment with no recourse, thanks to at-will employment. So they should care about the average outcomes including people without insurance.

Employer-provided health insurance is an absurdity which is plausibly responsible for the highest proportion of US healthcare inefficiency of any one factor and should be destroyed with fire.

But it's not because you lose your insurance if you lose your job. In general the people who currently have insurance will continue to have insurance for a variety of overlapping reasons.

And you're still not addressing the issue: Something about the US system causes outcomes to be better for people with insurance than they are in most other countries. And that's while the US system is full of greedy bureaucracies fighting each other and wasting like half the money in the process. What would happen if we extracted the good part of that system and made it more efficient?

> Either this wouldn't work or something has gone terribly wrong with your system, since this hasn't been done.

It costs money. The people it impacts don't have political influence.

The main problem with US government programs can be summed up like this: One party says we would be better off with lower taxes and more money in the pockets of individuals and small businesses, but then they don't actually do this and instead give the money to corporations. The other party says we would be better off with higher taxes to provide services to the needy, but then they don't actually do this and instead give the money to corporations.

Everything makes sense once you understand this. When the US government passes a prescription drug benefit, it's not because they want to help people who can't afford prescription drugs -- the sensible way to do that would be to lower the underlying cost of prescription drugs. The real motive is because they want to increase the amount of money being transferred to drug companies.

The question is how to fix it.

[lmm]

> Something about the US system causes outcomes to be better for people with insurance than they are in most other countries.

No it doesn't? Outcomes for lower-middle to lower-upper class people (people with insurance, but without enough money for custom treatment etc.) are normal for an industrialised high-GDP country, not particularly better than comparable countries.

> The question is how to fix it.

As with so many problems in the US, maybe you could try doing what works in other countries?

[rayiner]

Several developed countries have mandatory health insurance without a “public option.” E.g. Netherlands, Switzerland, Japan, etc.

[TMWNN]

To put another way, the US has more public options (Medicare, Medicaid, VA) than those countries. (Or, say, Australia, which has a public option by default but which really, really, really encourages people to go private.)

[lmm]

Japan has a public option, although employees opt for it at the group rather than the individual level. A given company's employees choose their health insurance provider via their union/representatives, and they always have the option of the baseline national provider. (Non-employees/dependents always have public healthcare via their local government)

[ybessyehs654]

You must know absolutely nothing about the NHS if you consider it a success.

[lmm]

WTF are you talking about? The NHS has an amazingly high approval rating for such a large organisation, and is among the most cost-efficient healthcare providers in the world.