[const_cast]

The insane cost of small business is because of the existence of a private insurance industry. There's thousands of insurers and you need to work with a lot of them. Every single thing you do needs to be authorized and ran through them.

They decide your medications you can prescribe, when you prescribe them, who can have them, how long your visits will be, when you should have those visits, how many visits you need to make a diagnosis, and on and on and on and on. Every single detail - multiplexed across thousands of insurers.

So, you need administration, and lots of it. The system is so horribly fragmented that all hopes of efficiency are lost. A single-payer solution is orders of magnitude more simple, and thereby more efficient. A lot of problems just go away when you only have one person doling out recommendations, one person doing care, and one person paying.

Also, the doctors who are making most of the decisions around your care aren't the doctors you go to. It's dozens of doctors, mostly nameless, working for your insurer making those decisions. How this isn't considering practicing medicine is beyond everyone.

[throw10920]

> So, you need administration, and lots of it. The system is so horribly fragmented that all hopes of efficiency are lost.

You're misattributing the cause of the complexity. The cause of the complexity is not due to the existence of private insurance, but the fact that it's changed from being insurance, that insures you against catastrophic financial loss due to an expensive surgery (that is, risk pooling), to a subsidization layer that permeates all healthcare, including routine visits to the doctor. That is what causes the complexity, because then you're right, that change evolves a massive amount of paperwork that imposes huge burdens on small businesses.

> Every single detail - multiplexed across thousands of insurers.

This is false, intentionally or not. Smaller practices rarely interact with more than a dozen insurers or so insurers, by the very nature of the fact that they're small, so this is off by about two orders of magnitude.

> A single-payer solution is orders of magnitude more simple, and thereby more efficient.

...and by "single payer" you mean the patients, right?

I have several years of working with a large federal government. Unless you're referring to a small state like Finland, the idea that a large government managing healthcare payments will make things "orders of magnitude more simple" is so naive as to be beyond laughable. The government makes even the most simple things (filling out paperwork to be reimbursed for staying in a hotel for a single night) insanely complex, and take far longer, and use far more resources (funded by taxpayers), than it does in private industry.

Yes, you're right that the interface between the medical practice and the insurance system becomes less complex when you have a single insurer, but the actual handling of claims becomes orders of magnitude more complex with the government, so the claim that it'll become "more efficient" is an extreme stretch.

If you live in the US, it's already trivially false, as it's extremely easy to see how incredibly inefficient many of the federal agencies are (I'm not going to use non-Western countries as other examples). Those agencies perform necessary functions, which is why they still have to exist, but anyone remotely familiar with the US government knows how bad of an idea it would be for it to handle health insurance. If they manage to figure out how to manage bureaucracy at a large scale, then single-payer health insurance becomes feasible. But until then, any suggestion of it is either extremely naive or flatly malicious.

[const_cast]

> You're misattributing the cause of the complexity.

I agree with you, but IMO it's completely unavoidable.

The concept of health insurance in strict terms of insurance was never possible. Not long term, anyway. Health is complex and chronic conditions cost a lot of money over a lifetime. The idea of insurance "just in case" doesn't work, period. Health is fundamentally different from car accidents or home hail damage.

> Smaller practices rarely interact with more than a dozen insurers or so insurers, by the very nature of the fact that they're small, so this is off by about two orders of magnitude.

Sure, but which dozen insurers they interact with isn't the same place to place. There's not a ton of knowledge transfer or business practice reuse here. You need billing specialists. So, across the entire industry of small private practices, it is thousands of insurers.

> The government makes even the most simple things (filling out paperwork to be reimbursed for staying in a hotel for a single night) insanely complex

Right, but the reason these tasks because insanely complex is because they're taken and split into 1 million pieces, which are then scattered across multiple levels of government, multiple agencies, multiple private contractors, who then have their own contractors, and multiple laws across multiple decades.

Our government, the US government, is not centrally planned where it matters. Every chance we get, we outsource as much as possible to the private sector. So one problem will become 1 thousand.

The simple reality is that the US has the worst healthcare system in the developed world, and it's not even close. Not only is our healthcare more expensive per person including taxes, it's also significantly worse with worse health outcomes across the board.

Every other developed country figured it out, and so can we. That doesn't mean it will be easy. But that's the truth - our system sucks, and it's because the private sector is far too involved in healthcare. We need to consolidate and collapse multiple parts of the system into one, and the complexity will go down.

The US has a poor government culture and mindset. We really thrive and actually want the inefficiency. It's the military shovel problem. We could produce a shovel for 20 bucks, but we want jobs, no? So we go ahead and outsource that to the private sector so we can get out 150 dollar military grade shovel, and it probably sucks, but we made a lot of people rich in the process. Each little hop from party to party represents a small increase in complexity and a little bit of cash shaven off the top. So naturally, we try to maximize the amount of parties involved. The best part is those contractors aren't even doing the work themselves - they're probably sub-contracting it out for god knows how many levels.

But, this can be fixed. It's not a foundational or necessary part of our government, it's a deliberate choice we make. Other countries don't make this choice, or do it much less.

[throw10920]

> So, across the entire industry of small private practices, it is thousands of insurers.

That's not really relevant. An individual small practice only has to deal with a very small fraction of that total count, and that's all that really matters.

> Right, but the reason these tasks because insanely complex is because they're taken and split into 1 million pieces, which are then scattered across multiple levels of government, multiple agencies, multiple private contractors, who then have their own contractors, and multiple laws across multiple decades.

> Our government, the US government, is not centrally planned where it matters. Every chance we get, we outsource as much as possible to the private sector. So one problem will become 1 thousand.

This is categorically wrong and indicative that you've never worked in the US federal government.

Even tasks entirely handled within a single agency are insanely complex.

This has literally nothing to do with contractors or outsourcing to the private sector, which you appear to be incorrectly pinning the blame on for the complexity.

This is a mix between some intrinsic complexity, partially due to the bureaucratic nature of large organizations, and a very large amount of incidental complexity within the federal government itself.

It's telling that, while I was working in the federal government, I met many people who complained about our healthcare, but not a single one suggested moving any of it into the government - because their personal, first-hand experience with the government's inefficiency and complexity allowed them to understand how extremely bad of an idea that would be.

In theory, it may be more efficient to have the federal government handle healthcare. But in the current state of the government, with the mismanagement and inefficiency and incredible overhead due to internal policies, it will factually not be more efficient for our current government. And trying to push single-payer healthcare on a government that is not ready for it and will result in worse outcomes is just straight-up malicious.

> Every other developed country figured it out, and so can we.

I looked up the most populated countries in the world[1] and the countries with the highest life expectation[2]. None of the top 10 countries in terms of life expectancy were in the top 10 of population - the United States is the 3rd most populous. And out of the top 10 countries ranked by population, the United States had the highest life expectancy of all of them.

The reason for this is because bureaucratic complexity scales superlinearly as the size of the organization, which is a function of the scope of its responsibilities. For a government, that means that complexity is superlinear function of population, scope, and employee count.

The government of United States, with its population of 347 million, is categorically incomparable to the government of Switzerland with its population of 9 million (which is the highest-ranked Western country on that list - Japan, the most populous country in the top 10 of life expectancy, not only has less than half the US at 123 million, but has a wildly different government and culture than any Western country, making it even more incomparable).

So, it's extremely inaccurate, naive, and dishonest to compare the US's healthcare to small European and Asian countries that have longer life expectancy. Our government, in its current state, would make healthcare massively worse, our population (and governmental complexity) is far higher than those nations, and we have the best life expectancy of any of the 10 most populous countries. The system is clearly working adequately, and even if it could be better, nationalizating healthcare or insurance is not the solution, unless and until fixes to the systemic problems in the government are implemented.

[1] https://www.worldometers.info/world-population/population-by...

[2] https://www.worldometers.info/demographics/life-expectancy/