[deepthaw]

I see the same issues here in the states. I think no matter what the economic model, we need to take a long hard look at the overhead and complexity of healthcare. And by and large, I suspect the insurance companies will be found to be at the root of it.

I can't believe I of all people am calling for less regulation, but the amount of bullshit it seems like doctors have to go through to provide basic service seems counterproductive.

[lurking15]

I think people will hit a breaking point and it will be undeniable that heavy regulation and subsidization is the root of dysfunction and deterioration of most important aspects of life.

It's hard not to see the parallel between healthcare and education where the parasitic overhead has been completely unchecked and enabled by federal subsidies. There's a similar deal with food, housing and other areas. It's absurd the amount of money that has been spent by the federal government in these areas with so little to show, the average person feels not only a lack of progress but decline.

[ses1984]

Much of the regulation you’re saying is to blame was written in blood.

Want to know what food and housing was like before regulation? Read the jungle.

Do you think we have deteriorated since then?

Maybe the prosperity you think has deteriorated was not due to lack of regulation, but due to black swan events like… i dunno conquering and industrializing the entire North American continent, all peer nations blowing each other to bits in two world wars, etc?

[NumberWangMan]

I agree that all regulation is written in blood. But at the same time, regulation can result in bleeding, and we don't always carefully weigh the costs and benefits of regulation. There may be a law that saves 100 lives a year, but that indirectly causes 150 deaths due to knock-on effects.

It's not easy to inject nuance into a discussion that feels like you have millions of people on each side of a tug-of-war rope that goes from "MORE REGULATION" to "LESS REGULATION".

I think housing, which you mention, is an excellent example. Yes, we need regulation in housing because without it, people will die from shoddy structures collapsing on them, electrocution, gas leaks, etc. But at the same time, in the USA there are absolutely regulations in housing with very little benefit and absolutely massive costs, where we have examples of first-world countries without those regulations that do just fine. I'm talking about things like the requirement that all apartments have 2 stairwells. Or mandatory setbacks and minimum lot sizes and parking requirements. edit -- and of course zoning codes, where we've shifted the market toward building housing that's so big that people can only afford to share it with strangers. And while people used to live in crowded, cramped tenements, driving housing prices up by restricting supply leads to people living on the street.

In medicine, there are diminishing marginal returns to making doctors go through more schooling, and the cost is simply that fewer people choose to be doctors, and people just go without health care. And even within that simple dilemma of "should we make it harder or easier to be a doctor", i'm sure there is a universe of alternate ways to move the needle in different dimensions. Requiring more or less schooling, more or less time in residency, changing limits on the number of hours doctors and nurses can be scheduled in a week, tightening or loosening malpractice law in different ways, etc. Each of these has some positive and negative effects, and I'm sure we have a ways to go before we hit the optimal point. And even then, you have to choose how to balance quality of patient care against doctors and nurses quality of life!

Or take drug approvals. There are drugs in development that show lots of promise, that probably should be made available to people who are dying anyway and want to try them. The FDA does not allow that. We have to balance against companies trying to scam people with fake medicine. No policy is 100% without harm. I believe that, even for policies I strongly advocate.

Or laws that were originally targeted at local environmental protection, that are now being used by nearby residents to stop solar farms from being built, stopping us from reducing fossil fuel usage. Those regulations were written in the blood of wildlife -- and now they're cause much more harm than good to wildlife all across the world.

So if you are asking if we've deteriorated since The Jungle, in many ways, no, of course we've improved safety of working conditions massively, and lots of other things. But in other, important ways, we've gone somewhat backwards. I believe it's absolutely possible to improve our society by removing some regulations, but I think it takes a lot of careful, small, targeted tweaks, where we've carefully weighed the costs and benefits. Though in rare cases, like as in parking minimums, the evidence is that they are so harmful that just scrapping the regulation entirely is the way to go.*

[ses1984]

This is a lot more nuanced than your original post.

Your op uses stronger language that makes it sound like all we have to do to solve social problems is deregulate everything.

Is there a parasitic overhead over healthcare? Yes.

Is it “undeniable that heavy regulation and subsidization is the root of dysfunction and deterioration of most important aspects of life”?

And you played the lack of nuance card after writing that…

[lurking15]

> Want to know what food and housing was like before regulation? Read the jungle.

Not convincing since you're reducing the entire time period to The Jungle which was sensationalized fiction, effectively political propaganda.

But to your broader point, things improved directly from capitalism and markets. My reading recommendation? Deirdre McCloskey "Why Liberalism Works" on the absurd increase in living standards brought about through innovation enabled by capitalism, we're talking some 3,000% in average income over the course of time you're referring to.

[ses1984]

Where you have 3000% increase in income do you also have absolutely no regulation?

I don’t think you can just factor out the regulation, assign it none of the credit for how things turned out, and assign all the credit to unchecked capitalism.

Maybe the jungle is sensationalized, what was really happening roughly concurrently: Triangle Shirtwaist Factory fire, homestead steel strike, Pullman strike, tenement housing, etc

If you prefer less dramatized further reading, https://www.dol.gov/general/aboutdol/history/mono-regsafepar...

I don’t think liberalism doesn’t work. I’m just responding to someone saying it’s “undeniable that heavy regulation and subsidization is the root of dysfunction and deterioration of most important aspects of life”.

Some regulations are bad, either intentionally or unintentionally, but a lot of regulation exists because the prior unregulated state was horrific.

[consteval]

This isn't due to "heavy regulation", it's due to the free market.

Insurance companies have an incentive to make medical care as awful and inefficient as possible. There's a tug-of-war here: doctors want to provide the highest quality care as fast as possible; insurance companies want to provide the least amount of care as rarely as possible.

Well... they're the ones paying.

These doctors are struggling to deal with "regulations" - they're struggling to deal with insurance. The sheer administrative overhead of medical insurance is staggering. You can go ask doctors, any of them will tell you.

[maxerickson]

You don't have to deregulate to move away from demand side subsidies as your main intervention.

[simonsarris]

People say this a lot but it feels unlikely to me. I think the biggest causes of the problem love the idea that insurance is to blame.

Hospital admin, doctors orgs, pharmacy benefit managers are all much more interested in things being overly complex, under-staffed, etc. Insurance companies just want to sell insurance with the % profit that is typical of insurance (eg Cigna's profit margin is the same as Allstate).

Besides, if insurance was to blame, it would work better in Canada and other countries that rely on private insurance less. But Canadians don't seem very pleased with their longer waits.

[waveBidder]

I'm fairly certain a large chunk of the problem is demographic shift. healthcare is one of those industries most used by the elderly, and the proportion of the population in that demographic has skyrocketed

[Ekaros]

Also I would guess that there is more healthcare, more options, more procedures, more drugs. Length of stays in hospitals might have shortened due to less invasive procedures, but if more procedures are done and there is not increase in staffing, time is spread over larger number of patients.

[throw10920]

> And by and large, I suspect the insurance companies will be found to be at the root of it.

At least in the US, this is true. The pervasiveness of interaction with insurance and the power they wield turns them into a rent-seeking layer with the massively negative economic effects of socialism.

Insurance is meant to insure you against massive economic damage caused by unlikely events, like breaking your spine. It is not meant to be used for routine care appointments. It's meant to be risk-pooling, not cost-sharing. The very fact that you have to pull out your insurance card at a yearly doctor checkup should tell us that something is very wrong.

[throwway120385]

> Insurance is meant to insure you against massive economic damage caused by unlikely events, like breaking your spine. It is not meant to be used for routine care appointments. It's meant to be risk-pooling, not cost-sharing. The very fact that you have to pull out your insurance card at a yearly doctor checkup should tell us that something is very wrong.

The problem with this model is that often very catastrophic things can be caught during routine care, so it actually makes a lot of sense for insurance to pay for a yearly physical. Otherwise a lot of people are going to wait until their spine is blown out and their knees need replacement to seek any kind of care at all, at which point their care is 100x more expensive than if they did a yearly.

Any other kind of care like going to the doctor because you're sick is entirely the point of insurance. It covers your medical care for unanticipated problems.

[phil21]

Getting sick is not an unanticipated problem. A major illness or injury is.

Insurance has no business paying out for you going in for strep throat or the Flu or an annual checkup. These are normal things everyone gets multiple times throughout your lifetime, and should easily be taken care of via market forces for a very reasonable fee.

The problem with US healthcare can be entirely boiled down to a principle agent problem. Someone else is always paying, so no one actually really cares that much about the cost of things and the incentives always are to increase costs and use more services since there is no actual market competition.

[bluGill]

Worse than that, nobody gets a choice anyway. If don't have to take the insurance my boss offers me - but if I don't I'm throwing away more than ten thousand dollars in subsidies they offer. It is really hard for anyone to compete with that deal - there are things I don't like about my insurance but it isn't worth shopping around as nobody can come close to the price/service they are giving me.

I have long wanted to get rid of the insurance/employer tie, but I'm a minority and so nothing gets done.

[throwway120385]

What are you saying? That because I can take steps to avoid getting a cold that I should just avoid getting a cold and insurance should not pay out on it? That's a big stretch considering you can literally get diseases from mosquitos and wild animals.

You're making a bald assertion that "insurance has no business paying out for you going in for strep throat or the flu or an annual checkup." Imagine, for a moment, that you run an insurance company, and you have a lot of people who need knee surgery or hip replacements or spinal surgery or who have triple bypasses or COPD or name any chronic or acute disease that requires expensive treatment.

Think about how many of those people wouldn't need that treatment if they went to the doctor every year. If your company had to pay out for treatment on every single one of those cases, wouldn't it be smart to spend a small amount every year to try to prevent people from becoming one of those serious cases?

What are the "market forces" that you cite here? Is this another one of those magical invisible hand arguments? Have you considered that insurance companies offering these yearly physicals is a result of some market force where business-people figured out that it was cheaper to do that then let peoples' minor problems blow up into major problems and then pay out on that instead?

[bluGill]

It is valid for insurance to give you a discount if you get your yearly checkup. They can even calculate how much discount you should get for this.

[toomuchtodo]

We need more doctors and nurses [1], full stop. Anything that prevents an aggressive increase in supply of these workers is something that needs to be actioned against.

Healthcare is a utility masquerading as a profit based industry. Squeeze the profit and inefficiency out, any comp should be going directly to systems and people providing care. Insurance companies? Gone [2]. Pharmacy benefit managers? Gone [3]. Lock private equity out of owning anything healthcare related [4] [5] [6]. I don’t want to knee jerk “union” for individual contributors, but you need some sort of governance mechanism so the CEO of a non profit hospital isn’t taking home $1M/year [7] [8] [9] while doctors and nursing are fighting for proper compensation and work life balance (including patient ratios, which are used to increase labor load without increasing labor costs or hiring more practitioners [10]).

[1] https://thehill.com/changing-america/well-being/prevention-c...

[2] https://penncapital-star.com/uncategorized/americans-suffer-...

[3] https://www.ftc.gov/news-events/news/press-releases/2024/07/...

[4] https://www.amjmed.com/article/S0002-9343(23)00589-2/fulltex...

[5] https://www.washingtonpost.com/business/2024/10/17/private-e...

[6] https://www.theguardian.com/business/2024/oct/10/slash-and-b...

[7] https://www.npr.org/sections/shots-health-news/2024/08/19/nx...

[8] https://www.audacy.com/wwjnewsradio/news/national/revealed-c...

[9] https://arstechnica.com/health/2023/10/nonprofit-hospitals-s...

[10] https://healthjournalism.org/blog/2023/09/a-primer-for-cover...

[moduspol]

> We need more doctors and nurses, full stop. Anything that prevents that is what needs to be actioned against.

I agree we have a shortage, but to offer a counter-argument:

We shouldn't need a 100% full-blown doctor for everything doctors do today. We could also help address the shortage by splitting out some responsibilities that are restricted to just doctors among professionals that only have 80% (or 60%, or 50%) of the training / certifications of an MD.

We've already presumably been doing this in the US with physician assistants and nurse practitioners. It hasn't solved it, but the problem would undoubtedly be many times worse without them.

[toomuchtodo]

Great call out, I agree. NPs [1] are the NCOs (non commissioned officers) of the medical field. Where applicable, level up folks with the desire and aptitude from RN->NP. This specific pain point is a talent pipeline health and structure challenge. MD feelings around this are going to be something to consider, to note when preparing for the opposition [2].

[1] https://en.wikipedia.org/wiki/Nurse_practitioner

[2] https://www.ama-assn.org/practice-management/scope-practice/...

[dematz]

If you said "Where applicable, level up folks with the desire and aptitude from IT support->senior engineer. This specific pain point is a talent pipeline health and structure challenge. SWE feelings around this are going to be something to consider, to note when preparing for the opposition" people would go wait, maybe the occasional fresh bootcamp grad or ITsupport technician has the potential to do strong work or manage a team, but in general their education has not prepared them. Of course if you ask a doctor "could the RN or NP run this floor" there's a conflict of interest when they tell you "no", but they're also correct.

Having a nurse is probably better than no medical care at all, so a tiered system where poor people get nurses without realizing they're worse than doctors would have that advantage, but the right overhaul imo would be reducing the years of schooling required to become a real doctor (undergrad, med school, residency, maybe fellowship, finally attending). If doctors skipped undergrad and cut out some med school or fellowship requirements, they'd start working earlier and could afford to choose specialties that pay less. As well as expanding residency slots and moving insurance compensation to family medicine and pediatrics.

edit - here's a good example, https://old.reddit.com/r/medicine/comments/1f6m5i9/its_scary... the good news is they'd agree with you that midlevels do have a role, the problem with scope creep is defining what that role is, and the assumption that the training is 80% or even 50% there

[dctoedt]

> the CEO of a non profit hospital isn’t taking home $1M/year while doctors and nursing are fighting for proper compensation and work life balance (including patient ratios).

In Houston, the renowned Texas Children's Hospital did layoffs — after paying millions to their CEO and other executives. FTA: "Over a seven-year period from 2016 – the earliest year of data published by the Internal Revenue Service – to 2022, the average pay for Texas Children’s 10 highest-paid leaders ballooned from $963,971 to nearly $2.2 million, an increase of 125%. (The latest tax filings do not reflect how much leaders at Texas Children’s earned this year, after the hospital reported major financial losses.)" [0]

The usual response defending such high compensation is something like, "We have to pay our execs so much because we're competing for talent with the for-profit hospitals." OK, one possible solution might be returning marginal income tax rates — across the board — to what they were in the 1950s. That would help neutralize the constant craving for more money as one of the main ways that execs judge their personal career success. "The top income tax rate reached above 90% from 1944 through 1963 ...." [1]

[0] https://www.houstonchronicle.com/projects/2024/texas-childre...

[1] https://www.wolterskluwer.com/en/expert-insights/whole-ball-...

[fallingknife]

I had a prescription for 1 20mg pill a day. Pharmacy didn't have 20mg but they had 10mg. They couldn't give me 2 10s instead of 1 20 because regulations didn't allow that. Yeah, we need less regulations.

[phil21]

There is likely no regulation that says this. Doctors and pharmacists have very broad legal authority to prescribe whatever they see fit.

It’s almost assuredly an insurance/PBM billing issue, not a regulatory thing.

[pcthrowaway]

I think there are things that could do with less regulation in Canada that would be easy wins.

Like for people with recurring prescription meds, maybe don't require them to make an appointment every month to get their meds? Even if we consider extreme examples like opiates, it's not like cutting off drug abusers or people selling their meds does anything to curb the opiate crisis. Opiates are already available everywhere and the supply is much more dubious and dangerous.

[meowster]

My best friend since high school is a doctor. Hearing all the bullshit that she had to go through, the different selection processes, abuse (scheduling), etc; it's crazy.

It doesn't weed out people who will be bad doctors, it weeds out people that can't handle the abuse.