[colechristensen]

Why with single payer would there not still be instances of treatment being denied?

>rather than deal with faceless automata at health insurance companies

Would this not be replaced with faceless automata in government?

Just look at how the VA is run and complains about it. Looking at that I have exactly zero confidence in the government being able to run things better than the shit show at the insurance companies.

Businesses do need to compete with and overthrow the current middlemen in the medical world. It's just difficult and a very slow process.

[flatline]

The government is mostly just there to manage contracts, the actual work would be done by the same doctors that are doing it today. You would just pare n profit-seeking entities down to one principally administrative entity. If you wish to pay for your own medical procedures out of pocket there will be nothing stopping you. That is not to say this does not have problems.

Insurance is anti-competitive on top of that. You have a Sophie’s choice of who you want to pay to buy into this crazy system. There’s no transparency in how services are priced or provided. You as a consumer have no insight into how prices are negotiated between the insurer and providers, nor how providers are paid out. Good luck making an informed decision.

[AnthonyMouse]

> You would just pare n profit-seeking entities down to one principally administrative entity. If you wish to pay for your own medical procedures out of pocket there will be nothing stopping you.

Nothing except that it creates a monopoly and a monoculture.

There are many procedures you may not be able to afford out of pocket, so the only way to get them is to choose a provider that covers it. If there is only one provider and they don't cover it, you no longer have that option.

And because nobody else does either, that medical procedure stops being offered because there aren't enough patients to justify it if they all have to pay out of pocket and most can't afford it, even if you were one of the few willing to scrape together the money. Which might not have happened if some insurers had covered it, even if many didn't.

> You have a Sophie’s choice of who you want to pay to buy into this crazy system. There’s no transparency in how services are priced or provided. You as a consumer have no insight into how prices are negotiated between the insurer and providers, nor how providers are paid out.

The existing system is a dumpster fire to be sure. So why not fix it?

Eliminate even the concept of negotiating prices, as if medical pricing is something to be haggled over at a bazaar in Calcutta. Require every provider to publish their price, and then that's their price, and anyone can compare providers.

Which gets rid of the concept of "in network" and all of that nonsense. The insurance pays e.g. 90% of the median price of that procedure within 100 miles of your home, the equivalent of a 10% copay. Then you can choose any provider you want, anywhere you want, and pay their published price. The difference comes out of your own pocket, so you have the incentive to be price sensitive -- but if you want to pay a little more to save yourself an hour drive, you can do that too. And if you pick one that charges less than 90% of the median price you can put the rest in your HSA.

The thing about regulations is that the most important thing they can do is to ensure that markets are competitive. The existing healthcare regulations in the US not only don't do that, they do the opposite. But they don't have to.

[jimberlage]

This is a really thoughtful and useful comment! Worth calling your representative about. I love the observation that price transparency starts with providers, I so rarely hear that mentioned.

[colechristensen]

People keep talking about this and it's a clear sign that people don't know what they're talking about. Price transparency has been the law for 3 years now. [1]

Here's a 226 MB csv file from the Mayo Clinic with... lots of prices [2] and a human friendly search tool [3]

It is extraordinarily frustrating trying to discuss these things with people when folks just make things up and have no idea what they're talking about.

1. https://www.cms.gov/priorities/key-initiatives/hospital-pric...

2. https://mcorgstatic.blob.core.windows.net/cms-price/41094460...

3. https://estimator.mayoclinic.org/mychartguestpay/GuestEstima...

[Wytwwww]

You can still have an entirely "private" but heavily regulated system like those in the Netherlands or Switzerland.

[cyberax]

> Why with single payer would there not still be instances of treatment being denied?

The most common failure mode for single-payer is scarcity. You won't be denied, but you'll have to wait many months for an appointment.

> Would this not be replaced with faceless automata in government?

They are controlled by politicians, who are directly responsible to their electorate. Brexit is a good example, using money sent to EU for NHS was one of the more influential ads. Of course, the outcome turned out to be... different.

With the current insurance system, you don't have ANY levers. You can't usually change your insurance company because it's provided by your employer. And even if you want to buy medical insurance yourself via the ACA, you can switch it only once a year. With no way to tell in advance if your new company is going to cover your treatment.

You also can't even sue your insurance company if it denies you the treatment because _all_ insurance companies require binding arbitration. And arbitrators basically always side with the insurance company, because your contract says that the insurance company is always right. That's how UnitedHealthcare can get away with just randomly denying treatment.

[colechristensen]

>They are controlled by politicians, who are directly responsible to their electorate. Brexit is a good example, using money sent to EU for NHS was one of the more influential ads. Of course, the outcome turned out to be... different.

Calling out Brexit is an... interesting way to argue here.

If you're proposing my options for heath care are going to be taken away and given to the single option controlled by the electorate who are liable to do things like Brexit... no thank you, I'll take marketplace competition where I can "vote out" the idiots by making a different choice for myself.

People here are like "isn't it awful that personal medical choices are being made by politicians and popular vote" with respect to abortion, gender-affirming care, etc... and those same folks are damn near excited to give away all of their health choices to a government entity.

Do you want your health care options to be dictated by an executive order the first day a new president enters office?

[cyberax]

> Calling out Brexit is an... interesting way to argue here.

Why? It's an example of directly affecting healthcare via political pressure.

> If you're proposing my options for heath care are going to be taken away and given to the single option controlled by the electorate who are liable to do things like Brexit... no thank you

That's the thing, it can also be fixed by the electorate.

> I'll take marketplace competition where I can "vote out" the idiots by making a different choice for myself.

Except you can't. Go on, read your insurance contract if you don't believe me. You're at the total whim of death panels, who can just tell you to go and die.

[AnthonyMouse]

> That's the thing, it can also be fixed by the electorate.

In theory it can but in practice it usually isn't, especially for things like this. It's all too easy for some bureaucratic rule to be killing people who have e.g. a particular type of cancer, which makes that 0.5% of people care about it very much, but it takes 51% of people caring about it to change the law.

Meanwhile some other rules are each killing some other 0.5% of people and when you add them all up it's a large-scale disaster but it's also many independent problems. The details matter but the electorate doesn't have the bandwidth to even understand, much less solve everybody's different problems.

You want as much as possible for people to be able to affect their own circumstances rather than relying on the bureaucracy to care about them.

[atombender]

Those rules are completely hypothetical and borderline reductio ad absurdum, since they have never been in place anywhere in the world, and you could make the same argument about anything the government does.

You seem to pretend that people in countries with universal healthcare don't have any agency, but of course they do. Public healthcare doesn't preclude private healthcare. We see this in Western countries that have high-quality universal healthcare, which have successfully managed to strike a balance.

There will of course always be gaps not adequately covered by the public option — new, unproven modalities that aren't offered, or unacceptably long wait lists, or a certain drug being denied that might help improve quality of life over a more conservative drug. In those situations you always have the option to seek alternative private healthcare at higher cost, and you always have the option to get private insurance. So many commenters on HN (presumably American) paint universal healthcare as some kind of draconian Big Brother regime where it's either all or nothing, and the public option will "take away my rights," when nobody has ever proposed such a thing.

In the US, you are under the thumb of private insurance companies whose profit motive is, indisputably, not aligned with patients' healthcare needs. Sure, you can shop around for insurance plans, but realistically, when faced with a health crisis, that's not an option. Which means you have to deal with a system that doesn't care about your health and tries to wriggle itself out of paying anything more than the minimum they're obligated to cover, and that minimum isn't known until the bill arrives. To my mind, having lived under both types of systems, the American scheme is much more restrictive.

Under a universal healthcare scheme, there's no profit motive to cloud the quality of care. There's a cost reduction motive that can affect quality of care, but as the other commenter points out, the democratic model helps balance that. The world over, in places like Scandinavia and the UK, funding of healthcare is a big concern that gathers a lot of public debate and figures heavily in election campaigns; it's not swept under the rug. It's not perfect, but it feels much more of a "we are all in the same boat" kind of environment than the American one where every day we have newspaper articles about huge hospital bills, health bankruptcies, drug epidemics caused by greedy pharma companies, and widening wealth inequality.

[cyberax]

> Just look at how the VA is run and complains about it.

The VA system has on average delivers better outcomes than private insurance: https://www.rand.org/news/press/2018/04/26.html

It's the usual "review effect", you only see negatives about the VA, not positives.

[colechristensen]

>when compared to commercial HMOs, Medicaid HMOs and Medicare HMOs.

That's not all private insurance, just some of it.

That's also talking about the average.

>although there is high variation in quality across individual VA facilities

...

>It's the usual "review effect", you only see negatives about the VA, not positives.

You're saying in rebuttal to a negative review of private insurance, which isn't even what's at issue. Difficulties getting things covered and being buried in beurocratic nonsense isn't really connected to "health outcomes on average".

Your source doesn't make the argument well.

[AnthonyMouse]

> That's also talking about the average.

It's worse than that. The VA can't be compared to the average insurer because all of their patients are people who could at some point in their adult life satisfy the military's physical fitness requirements, which is not the case for the population at large.

[Thadawan]

It could be argued that the veteran population had a higher likelihood of exposure to dangerous chemicals (agent orange, burn pits), higher rates of mental illness-triggering situations (leading to their own homeless, PTSD, and drug addiction epidemic), and physical wounds from shrapnel IED’s and gunfire.

[cyberax]

> all of their patients are people who could at some point in their adult life satisfy the military's physical fitness requirements

TriCare covers military spouses and children.

[cyberax]

> That's not all private insurance, just some of it.

There are other studies with similar results. Comparisons with HMOs is especially illuminating because of the similar models (vertically-integrated organizations).

> Difficulties getting things covered and being buried in beurocratic nonsense isn't really connected to "health outcomes on average".

Of fucking course it is! WTF you're even talking about? People absolutely get inferior care because they can't wade through bureaucracy.

[AnthonyMouse]

> People absolutely get inferior care because they can't wade through bureaucracy.

But those people don't get counted in the statistics because they failed to navigate the system so the bureaucracy doesn't even know they exist.

[light_hue_1]

So you've never used VA healthcare. Compared to the insanity of the rest of the system it's pretty amazing. Some locations are better than others though.

[op00to]

The denials would not be based in a profit motive in a single payer solution.

[dukeyukey]

> Why with single payer would there not still be instances of treatment being denied?

Typically no - what treatment is used might be different, but that treatment is needed and will be supplied is not usually up for discussion.

> Would this not be replaced with faceless automata in government?

In 29 years living in a single-payer system I've never needed to do this. The government does not get involved in healthcare, they just fund it.

[justin66]

What was your experience like with the VA?

[colechristensen]

Hearing first or second hand stories of veterans waiting months or years for important care or struggling to get something addressed at all.

[justin66]

No experience then. Okay.