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It’s worse. They know what they want, it’s just impossible to provide. They want walk-in world class healthcare for cheap. They want it for cheap if not free. They want to walk into a doctor’s office, get seen quickly, then go to a specialist, pay twenty dollars each for the office visit including any tests, get a prescription for pills that they then pick up at Walgreens for less than $50 for a bottle of name brand life-saving drugs.
I don’t care how you re-engineer our health care system, the system cannot provide what the public wants. No system can. If it’s fast and doesn’t ration care to patients, it cannot be cheap. If it’s cheap, it’s because you either wait or you push the very sick out of the system (likely both). People want fast, world-class, cheap healthcare. At best, we can provide ONE of those things. If you want cheap healthcare, it’s going to be long waits and heavily rationed. Most orthopedic care is going to be reserved for tge very rich. You can expect to wait months for an office visit. And if you need something more than the primary care physician can do, that’s another couple of months to see whoever can fix the problem, and another couple of months to actually get anything done about it. If you want fast medicine, you have to pay for it. Likewise if you want to give everyone world class care without heavy rationing.
It’s a hard sell because people want all three and are assuming corruption or profit is the reason they can’t have cheap healthcare on demand. And politicians can’t or won’t tell people that they are asking something impossible, so the insurance companies get the rap fo4 doctors not being willing to work for the pay of store clerks and drug development costs being high.
Fast and cheap is at least theoretically possible. A big chunk of healthcare is walk-in in China, where the life expectancy already exceeds that of the United States. Appointments with specialists are easy to get, with most wait times measured in days to weeks rather than months.
There may be some state subsidization going on, but the direct cost to the consumer, along with overall cost of care is much lower than in the west. Overall I admit not knowing how their system actually works.
There is something resembling health benefits by employers, but as far as I can tell it's literally just a health savings account that the employer contributes some money in every year rather than insurance.
If you adjusted for the life expectancy hit of air pollution, they'd be comparable to SK and Japan in longevity, so their public health actually seems to be effective. Big gains in the past decade as well.
Reasonable government health care is a part of the East Asian package.
It's an emergent trait of demographics, and not really something that is replicable in a Western context.
For similar reasons, there is essentially no violent crime in any East Asian country. It's not government policy, it's a fundamentally different society.
Actually Australia manages to do it as well. It is entirely replicable in a Western context, though maybe not in the USA as it is currently constituted.
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There's a way to do it, it's the sausage principle - don't look how the sausage is made. You redefine "cheap" as "no payment at the point of consumption" (or a nominal payment) and you hide the real costs. The best way to do it is through taxation since nobody reads the budgets and nobody is able to figure out how much exactly money is spent on what, and even if somebody does that, it's no longer your money, it's some abstract tax money and you can always demand that the billionaires pay more - it has nothing to do with you. If for some reason the obvious way is not available, you can at least separate payment and consumption by calling a pre-paid subscription scheme "insurance" and by deducting the payments in a way that you never get to touch the money before payment (e.g. payroll deductions) so you don't feel it's your money - it's just your employer provides you the service for free, how generous of them.
You can redefine "fast" as "you can talk very fast to somebody who is in no position to help you". Many healthcare organizations do that - e.g. to get an appointment to a specialist, you need a "referral" from your primary care doctor, and maybe the primary doctor will see you next week, and then the appointment to the real specialist will be in another couple of weeks, and so you waited almost a month or so without even noticing it. And there's no guarantee that specialist can do anything for you either - maybe they will refer you to some tests, then to another one and so on - and you can spend many months in this without even getting as much as initial diagnosis. Of course, added value of this is each interaction must be paid for (sometimes several times over - you can't just put lab technician pay, lab materials pay and visit pay on the same bill, we're not some kind of savages!) but "insurance" covers it so you never actually know how much does it cost, not that it'd help you since you can't elect to use another lab technician anyway if you thought this one charges too much, and in fact nobody is going to tell you how much it costs anyway - because that's exactly what was asked for from the start.
And there's no "rationing" - it's just the doctors are very busy. And for some reason there's never enough of them. As for the quality, if you have to wait several months to see a specialist, and there's no other one in 500-mile radius of you, how much are you in the mood to refuse to visit one because you think they're not world-class enough? How do you even know what's world-class - how many ENT specialists or podiatrists have you seen in other countries to be able to know the difference? It certainly costs a lot, and it seems to be a lot of demand, so it must be very good, right?
So the system is actually going out of it's way to provide exactly what is being asked for. It's just since, as you noted, it's not possible to actually provide it, it works very hard at making it appear as if it's doing it. Because that's exactly what we're pushing it to do. And it is delivering that to us as much as it can. People think it's a hostile system - but very often it's not, it's just reacts to our demands of it within the limitations placed on t and tries to deliver what it can.
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Honestly, all I want is the same level of care and availability that I can get from a veterinarian, plus the ability to pay for market-rate insurance to cover against genuine catastrophe. I know this isn't what most people want, but it really is all I want out of the system. I have just about arrived at the point where I think people in aggregate would be better off if there was almost no medical regulation and the government paid for nothing other than a few emergency services.
My dog has seizures. When we discovered this, we were able to get her into a vet and get blood work done and meds prescribed at reasonable prices. Now she doesn't have seizures. Nothing about this was massively complicated, no MRIs were done, no insurance was involved, we just put her on barbiturates and now she doesn't have seizures. The number of human medical problems that seem to have roughly comparable complexity and that run about bajillion dollar in bills instead of being handled quickly and easily is mindblowing.
I mean, the question is ‘what’s the relevant difference and is it possible to have it apply to humans’. I’m guessing there’s at least parts of veterinary practices that cannot- if lower liability because they’re just dogs is really a significant part of the puzzle, then we can’t really reduce human medical bills that way.
I'm well aware that it's not actually possible for the American medical system to become an actual market where normal market pricing applies. Liability is a great example of why, along with regulatory burden, licensing requirements, and so on. But still, it's pretty annoying to consider edge cases.
For example, Apple produces the AirpodsPro 2. These are cool and fairly common product, many people own them simply because they're good for normal earbud purposes. Apple, being full of ingenuity, now has a hearing test and hearing aid functionalities on them. Awesome! Unfortunately, those functionalities aren't available yet because implementing that software update transforms them into a medical device that requires FDA approval. So, we have people that own an object that could test their hearing and implement hearing improvements for them. It's all ready to go! But the FDA says you may not use that functionality until they say you can.
I don't know just how many things there are like that, but it's a great example of how ponderous and captured this whole apparatus is.
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I agree that this is true, but it doesn’t mean the public discontent with the current situation is entirely wrong. For example, the ideal balance may be further in the cheaper/slower/worse direction than the current US system.
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Is this supposed to be a description of the worst case under a theoretical cheap system? Because this describes a process faster than what I went through this year in the US with top-tier employer health coverage in a major city. While at the same time I regularly see stories online from people in Europe paying for health care through their taxes being astonished about the concept of waiting for a specialist. Are they lying? Is the care they are getting really that much worse? Surely any place other than the US has health care that counts as "cheap" compared to the US?
Maybe. Different countries in Europe have 'solved' this differently. The NHS in England has a website that lists average waiting times for specialist care.
https://www.myplannedcare.nhs.uk/
18 weeks for Orthopedics in East Sussex https://www.myplannedcare.nhs.uk/seast/east-sussex/specialty/?sname=Orthopaedics
Ireland has a website that shows how long patients have been waiting.
https://www2.hse.ie/services/activity-performance-data/waiting-for-care/waiting-lists/
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I think this is getting at what I mentioned as "the confounding factor of people wanting to use it to transfer incomes or the sheer constitutional (little c) inability of folks to allow people to make choices with prices". I have two thoughts.
First, I'm not sure that fixing that would fix the other irrationalities I mentioned. Regardless of how you pay for it, questions like whether doctors' prescriptions are sacrosanct or whether they're actually dumb and bad will persist, for example. In the comment I linked to, the question of whether doctors should play a gatekeeping role is one that we've sort of stumbled into, via unintended consequences, rather than being a rational, clear, and vision/purpose-driven choice.
Second, I would say that people "want" this for literally everything. Of course people want world-class, free/cheap food provided to them, paid for by someone else. Of course people want world-class, free/cheap housing provided to them, paid for by someone else. Etc. Once you go down the rabbit hole of thinking that you can make some argument to justify forcibly spending other people's money on your consumption (be it because you think there is some 'positive right' involved or have some ideological preference to transfer incomes or whatever), the question reduces quickly to just one of how much you can force them to pay, how much income you can transfer, and how much consumption that will get you before the well dries up or political constraints take hold.
In many of those other arenas, we actually can/do "design" systems that work to give people what they actually personally value (via revealed preferences) - a price system. This usually has to give up on the idea that they're going to strong arm others into paying for it, but it allows consumers to locate themselves on their own pareto frontier, rather than imagining that they can just take more from the imaginary well of other people's pocketbooks and magically push the world to a state far to the top right of the pareto frontier. They can choose for themselves how much they value speed or quality or money. It's when they think that they get to choose between speed, quality, and other people's money that we run into problems; of course they're going to sacrifice other people's money. Guaranteed they'd sacrifice other people's money if they could get away with it to give themselves endless steak rather than spaghetti. No, this problem is not unique to healthcare; it's just one of the domains where we perpetually fail to acknowledge what we've truly figured out about the world and somehow keep being confused about why doing this obviously perverse thing keeps producing the same well-known failures.
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