[bobthepanda]

The American healthcare system is expensive partially because it’s not really a market, you’re tied to the insurance your work offers you and there are all kinds of middlemen like the PBMs.

There were two options that have been debated before:

* Obamacare’s deleted “public option” which would’ve essentially provided the baseline standard coverage introduced by the ACA; this got deleted due to opposition from moderates and so private insurers offer these plans instead

* Medicaid for All just proposes this entirely to remove layers of middlemen, but is even more opposed by moderates

——

The problem really is the linkage of health insurance to work, but it’s political suicide to sunset this since the transition period will be incredibly painful

[buu700]

The American healthcare system is expensive partially because it’s not really a market, you’re tied to the insurance your work offers you and there are all kinds of middlemen like the PBMs.

I've long argued that this is precisely the problem with the American healthcare system. It's the worst of both worlds. The issue is caused by the fact that we use "insurance" to describe something that is not insurance, but rather a middleman subscription.

Could you imagine how broken any other market would be if saddled with the same system? Imagine if you had no idea what any given property actually cost to rent, but instead just paid into a "housing insurance" plan that took care of it for you and socialized the costs. Add on layers of administrative bureaucracy to determine which properties you qualify for based on your needs, and give it a few decades for prices to adjust to the market distortion. One day we'd find that all the properties are owned by multibillion-dollar housing conglomerates charging prices that are completely impossible for anyone poorer than Jeff Bezos to afford without "insurance". Eventually someone ends up shooting a housing insurance CEO in the street over grievances like Luigi's, e.g. maybe he's stuck sharing a single bedroom with his wife and four kids, or couldn't get approved for a property in the same city as his elderly parents. Meanwhile, the public has been gaslit into defending this Kafkaesque central planning as "free market" because it isn't technically run by the government, ignoring any role of the government in creating and actively propping up the system.

I don't think single-payer is necessarily the optimal solution due to the known impacts on supply / wait times under such systems, but if we're embracing central planning of a sector of the economy regardless, I'd rather the benefits be fully socialized alongside the costs. Right now we're socializing the costs while privatizing many of the benefits — great for profiteers of that system, but not so much for the rest of us. Although single-payer could potentially be a much stronger option in the future if optimized by large-scale anonymized economic data collection and AI-driven pricing, so I'm not necessarily opposed to it in principle.

What I'd also want to consider, however, is a wholesale sunsetting of mandatory "insurance" in its entirety. Make patients bear the costs of their care and incentivize them to shop around for the best prices. Force providers to optimize, innovate, and actually compete with each other to provide the lowest rates — negotiating with suppliers, reevaluating compensation structures, cutting administrative bloat, and embracing technologies like AI and telemedicine would all be viable angles for practices to explore. No one would get away with Gilead-style pricing in a free market, particularly if certain price transparency requirements were imposed. Then add a universal progressive cost-sharing system on top of that to ensure that the poorest aren't left out in the cold. As a practical matter, emergency care prices could be set by states or counties to balance local availability against ensuring that ER patients aren't saddled with excessive debt, continually adjusting for maximum public benefit. In this world, health-related insurance products would still be available for people who really wanted them, but they'd function as actual insurance, and be completely optional without being subject to ACA-style regulation.

[bobthepanda]

I understand and agree with most of this. That being said

> I don't think single-payer is necessarily the optimal solution due to the known impacts on supply / wait times under such systems,

At least where I live today, waits for specialists and primary care are atrocious (I once switched out of a medical system with 6 months wait for primary care), so it's not like we're not already seeing this.

[buu700]

Yeah, I don't think any healthcare system is going to be a silver bullet so long as supply is ultimately a bottleneck. Which is a bit broader in scope, being impacted by macroeconomic factors, the educational system, regulatory requirements, technology, and so on.

We should take steps to optimize both supply and demand, but I don't think it'd be accurate to characterize the situation as "single-payer = long waits and multi-payer = short waits". More like higher demand with all else being equal means relatively longer waits, and all else being equal single-payer increases effective demand. But improved health, improved safety, and lower population are all things that drive down demand, all else being equal, so obviously there are a lot of factors here.

Despite not being single-payer, and despite its suppression of effective demand (with high latent demand among those priced out of the market), I'd argue that the current US system is far from optimal at maximizing supply of actual care relative to its full potential.