[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?

[AnthonyMouse]

> 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.

Basically nobody has money for "custom treatment" -- it takes years to do medical research, if not decades, with no guarantee that it will pan out before you die. If you're rich and you get diagnosed with something, you're getting the same drug as anyone else (because nothing better is known to exist), in a comfier room and possibly with marginally faster lab results. And if you did manage to spend a billion dollars to actually cure the thing, everybody else gets the cure too.

The rich people in other countries come to the US to get largely the same treatment as ordinary people in the US with insurance get, and it's not for no reason.

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

This is a structural problem. The US constitution was drafted with the intent of having a weak federal government and doesn't include the right kinds of checks and balances to thwart corruption when there are large federal programs -- and some of the most important preexisting ones were removed, like requiring federal taxes to be apportioned and having US Senators elected by state legislatures so they would dampen federal overreach.

But it's not clear how to unscrew the pooch. Typically that sort of change happens following some turmoil, but those kinds of events can just as easily make it worse as better. You need to have someone in power who is willing to institute formal limits on their own ability to be corrupt, in a system where those currently in power are corrupt and interested in using their power to maintain that as the status quo.

Also, many other countries have equivalent problems, and some other countries have only solved them in ways that create different but at least equally undesirable problems.

[lmm]

> Basically nobody has money for "custom treatment" -- it takes years to do medical research, if not decades, with no guarantee that it will pan out before you die.

No-one has money for original research, sure, but there's a level that's above "going to the place you would normally be referred to for condition x" where you instead go to the best hospital in the world for condition x, get treated by the world leading expert on condition x, etc.. And that level is not generally covered by regular people's medical insurance in the US, nor by public healthcare systems in other industrialised countries.

> The rich people in other countries come to the US to get largely the same treatment as ordinary people in the US with insurance get, and it's not for no reason.

They do? Are there really more people coming to the US for medical treatment than other wealthy industrialized countries, once you control for size? (Like, I'm sure "the best hospital in the world for condition x" is in the US more often than it's in Switzerland, just as a function of there being more people and hospitals in the US, but I'd be surprised if that's still true once you control for that). And are the institutions they go to really accessible to regular people with in-network rules etc.?