[jval]

The problem is that the United States isn't a 'country' in the way the UK, or Denmark, or Australia is. The entire population of Denmark is 5.59 million, the size of a single second or third tier city in the US. Australia is 22 million, the size of the NYC metro area. You can socialise and centralise healthcare in countries on such a small scale, but it becomes exponentially more difficult to do in a country like the US (pop: 313 M).

The United States is an enormous country comprised of 50 separate state governments, where the powers of the federal government are extremely limited (both by the constitution itself, and by the fact that it is practically impossible to do anything at that kind of scale).

As a result, it is extremely hard to pass any sort of massive reforms. Can you imagine how difficult it would be to pass one single, uniform system of health care for all Europeans?

Talking about solutions that work well in smaller countries is all well and good, but the reality is you need different solutions if you want them to work at scale. It's the same reason why most of Facebook's backend is now written in C++ instead of PHP. It is much more painstaking to work with and harder to pick up but when you're building a huge system of interconnected parts you want something that isn't going to fall over and die suddenly.

The supposed chaos and gridlock of the US political system is a feature, not a bug. It's the reason why if you look at a list of the world's oldest nations the United States is right at the top, and is one of the largest.

EDIT: Sorry - not saying the US's healthcare system is the best it can be and didn't make that clear enough. Just saying that comparing it to other countries won't help as the US has a unique political reality.

[Spooky23]

The Feds pretty much mastered the "how do I make 50 states do stuff" problem -- they give the states money and threaten to take it away.

We've had Medicare and Medicaid for almost 50 years now, and it works reasonably well, despite significant differences in administrative practices between states. So it absolutely can be done.

We've figured out how to build a national road system, healthcare for old people, healthcare for destitute people, a national tax collection system, and 1,000 other examples. It's a solvable problem.

[jval]

Not saying it's impossible, just saying it's difficult and comparisons with other countries are not helpful in addressing those difficulties.

[ceejayoz]

> You can socialise and centralise healthcare in countries on such a small scale, but it becomes exponentially more difficult to do in a country like the US (pop: 313 M).

First, as with the EU, the US is divided into fairly independent states who already manage most parts of their own healthcare/insurance systems.

Second, the idea that 30 million versus 300 million makes a huge difference in scaling healthcare is pretty silly. Sure, a healthcare system for 1,000 people would have different challenges than one for 1,000,000 people, but on nation-sized scales? You have regional divisions to keep it manageable.

What exactly makes Australia or the UK's system unscalable to the size of a US state?

> It's the reason why if you look at a list of the world's oldest nations the United States is right at the top, and is one of the largest.

Massive amounts of minimally populated land to expand into likely played a more significant role, as well as a lack of aristocracy - if you look at European upheaval it's usually an issue of one of the two.

[hvidgaard]

I can understand the political barriers to socialized healthcare in the US, for starters it would require a federal tax.

However, I am not buying the scale argument. What exactly makes it hard to scale? The only argument I've heard is that managing all doctors and hospitals, but that is trying to control everything, something that never works when you try to scale out, and isn't necessary either.

If anything the scale enables you to build large and very specialized hospitals that only deal with one particular aspect, e.g. cancer, and do some serious research as well.

[jval]

Politics is all about the money. Obviously administration is worse at scale too, but it comes down to political will in having the money to do it.

The way you keep a political union together without having it break apart is by limiting the amount of things the members of the union have to share. If you start taxing rich states and funnelling the money over to poor states, you give people a reason to want to break out of the union. Ultimately people only stay if they're getting a good deal.

Taxpayers in New York will definitely be happy if their money goes into the military, as having a New York rather than a US military wouldn't work. But to have all their money go into universal healthcare in Idaho would just piss them off, because people in Idaho can pay for that themselves. That's why healthcare is largely a state matter in the US - you'll find some states have great healthcare, others don't.

I'm not saying the US can't do it better (they clearly can), I'm just saying comparisons with other countries are useless because they don't take into account the unique political realities of the United States.

[hvidgaard]

New Yorkers aren't going to "pay for Idaho". NY may be paying more in tax for the entire state, but their budget would also be much larger. For obvious reasons NY can be more efficient, but that doesn't mean that they'll be paying a significant amount of the budget in Idaho.

[mcguire]

Well, actually, they would, for the same reasons that the postal service will make money in populated areas and lose money in less populated areas.

Say you need a trauma center within 1 hour of anywhere in the country. A trauma center in Manhattan is going to see a lot of traffic, while one in Clayton, NM, isn't. But the centers have the same basic cost in staff and gizmos.

[ThomPete]

It's not a once size fits all. You would of course look at the size of the area and the amount of traffic. So areas with higher traffic would get more resources allocated.

The real problem with healthcare is that you can never have enough. Even if everyone paid 100% in taxes it wouldn't be enough.

[DanBC]

> But the centers have the same basic cost in staff and gizmos.

Hang on: A busier unit is going to have more staff. Staff is not a trivial cost.

[mcguire]

In my simple model here, staff is per-capita; fixed costs like property, plant, and equipment are per-unit-area. Which wins in this case? I don't actually know, but I don't believe it is a trivial calculation. (Further, the medical events are not necessarily comparable in the two cases---rural means farming and resource extraction, etc., and that shit's dangerous, compared to white-collar work. And then there's transportation costs.)

I do know that in other similar situations, wealthier, more populated areas end up subsidizing poorer, less populated areas.

[rquantz]

New Yorkers are already paying for Idaho, and every other backwards, poor, uneducated, unpopulated state. And we talk about leaving the Union all the time, but that isn't why. It's because those same backwards, poor, uneducated, unpopulated states whose roads, schools, and healthcare we pay for keep blocking our attempts to turn the United States into a modern developed country.

[mehwoot]

The United States is an enormous country comprised of 50 separate state governments, where the powers of the federal government are extremely limited (both by the constitution itself, and by the fact that it is practically impossible to do anything at that kind of scale).

Hold on, if the U.S. is 50 separate governments, each of which have great power (since "the powers of the federal government are extremely limited"), then shouldn't each state be able to pass effective healthcare by itself? Only 2 U.S. states have populations larger than Australia, and none would make it into the top 5 E.U. countries by population.

Talking about solutions that work well in smaller countries is all well and good, but the reality is you need different solutions if you want them to work at scale.

But you just said each state is separate and the federal government has limited power, so why do they need to work at scale larger than anywhere else?

[ThomPete]

I agree that Denmark don't scale. But that doesn't mean that the current system we have in the US is good or that the insurance based version is by any metrics the best possible solution for the US. You could also think in states instead.

If you look at it from a purely financial point of view the problem of the US system is that when given the choice, younger people don't insure themselves because they are healthy and so don't participate in financing those who are sick by costing the system less.

As they grow older and get sicker they end up paying insane prices unless they are paid by employees and even there the quality of the insurance varies and you still have some really absurd pre-existing conditions rules etc. If you don't have an employer to back you up you are basically screwed.

Obama Care is an attempt at solving this issue. It's not single payer but it's closer and hopefully it will help improving the healthcare system for millions of those without either healthcare or proper healthcare.

Now in my mind there is a middle ground where you pay most of your healthcare yourself (the checkups, the sinus infection etc) but you don't end up in endless debt because you become sick, your kid gets born to early and have to stay at a neonathal facility, for a longer period of time and don't have the right insurance.

And having been through the system I must say that if people think it's less beucratic than say they Danish system (which is much more social in its approach) then they would be mistaken. The sheer number of interests involved in any single episode creates complexity way beyond what seems reasonable.

So agree it's not possible to take a small nation and apply what they do, but it is possible to look at the current system and realize that the healthcare system in the US is def not a feature but rather a system with plenty of room for improvement.

[jval]

Sorry - edited my post to make clearer the fact that I'm not saying the US's healthcare system is good. I just think that comparisons with other countries are futile. My comment was intended to be a general one about the way politics works in the US.

[ThomPete]

The countries in the EU which is 400mio serms to be handling this ok and thats even with national laws. You might say the realpolitics will nok make it possible but its not a scale problem but rather a political one.

[Retric]

Insurance is a competing market and companies can discriminate by age so the young don't subsidize the older though the insurance system.

You could argue that the healthy subsidize the sick but that's the point of insurance. It's like saying the living subsidize the life insurance payouts of the dead.

[ThomPete]

They discriminate in so many other ways. Thats all fine and good they are privately owned companies and can do what they want, but it's not a good setup for healthcare.

[VLM]

"50 separate state governments"

I'm not understanding the problem here. Run "git clone" on the Canadian model fifty times. All done.

Furthermore we seem to have "no problem" scaling up central federal control of seemingly everything other than health care, so a comparative explanation would seem necessary, as to why federal social security is possible or federal OSHA or federal EPA or federal militarized police or the federal military itself, but for no provided reason federal health care would be impossible to scale.

[ceejayoz]

The scale argument is fundamentally a copout for folks who ideologically oppose national healthcare, IMO.

[Mvandenbergh]

Healthcare is administered regionally, by the NHS trusts, in the UK.

Also, Germany is a federal country of 80+ million people, that's surely a better comparison than Denmark.

[amirmc]

> "It's the reason why if you look at a list of the world's oldest nations the United States is right at the top, and is one of the largest."

Really? Please can you elaborate on this as it makes no sense to me.

[gyardley]

He's arguing that the United States has had a stable political system for a long period of time because the federal government has relatively few powers, allowing the people in its widespread, culturally-different regions to craft state and local governments to their liking. I suspect he believes an activist, centralized government, imposed on all Americans, would eventually result in the division of the United States.

There's plenty of stuff in there to debate (the US did have a rather bloody civil war, so it's not like it's been perfectly stable), but his argument is plausible enough - I'm not sure why it makes no sense to you. Personally, traveling around the United States has convinced me that there's ten countries worth of distinct cultures in it - one-size-fits-all government isn't going to work well.

[ThomPete]

The size of the country have a much higher impact on the fact that there haven't been more conflicts IMHO.