YC Research: Universal Healthcare

My point, more specifically, is that the US healthcare system is in a state of regulatory capture due to various market failures in our implementation of employer-based health insurance. I would go further and say that employer-based health insurance is intrinsically unsound, and the only thing propping up our failed system is massive government subsidy.

This is literally our system:

When you're healthy, you get for-profit health care through your job. If you become infirm and cannot work, usually through age, but for whatever reason, you get expensive health care through the state after you have bankrupted yourself.

The entire premise of health insurance is having healthy people pay for the sick people to spread out the risk. But our system is "private insurance takes all the profits and the government takes all the costs".

And people wonder why things aren't working out.

> I find it difficult to consider healthcare a true market

I can see why -- I've had the same terrible experience with billing shrapnel -- and I almost put a clause in my comment knowing this kind of response was almost inevitable.

What I did put in instead was that a lot of our details are different kinds of clothing on the fundamental incentives.

I strongly suspect that if you started a system from scratch around the central assumption that medicine should be handled as a market for medical products/services and the financing behind it should be private & for-profit, my guess is that you'd get very much the same thing.

The skill investment required for some interventions would lead to several consequences: required specialization to be effective, and a proliferation of specializations. Since the skill investments are costly, those costs are passed on in the form of high service rates. Few people know in advance which interventions they'll need, which makes planning for financing care risky, so an insurance market would develop. Insurers would have the same basic incentives to sell to those who are least likely to need their services, avoid those who are likely to need them completely, and independently negotiate their own payout deals with providers, which of course, varies by insurer, so few patients are going to be really sure how much anything costs even if they do understand how all the specialists interact in a given intervention.

And at that point, you have the recipe for the billing shrapnel problem everyone hates.

Alright, I can't continue this, because it's too dizzying to try and follow what you're saying, as it changes with every comment.

You were the one who brought up costs and patient outcomes:

> get in the middle and increase costs while reducing patient outcomes.

So I responded to that claim by talking about Medicare Advantage (Part C), at which point you bring up Part D, confusing it for Part C:

> Patients like Medicare Part D because millions of patients couldn't afford their drugs and now they can, not because of insurance companies or the market is privatized.

After I explain that, no, I'm talking about Part C (which provides Part A/B benefits) as opposed to Part D, and that the advantages to Part C are lower wait times and higher-quality doctors, which both lead to better outcomes, you go back and say that outcomes (which you initially talked about) aren't necessarily good, illustrated with an anecode:

> Outcomes is a buzz word... Just one example where a quality metric has both positive and negative patient effects simultaneously...

but don't actually propose any alternative metric to measure instead. I asked you to do that, and you demur, talking about costs but again dismissing outcomes, along with some other factual inaccuracies about Medicare

> Every single Advantage patient is enrolled in "oringinal medicare" parts A and B... additional benefits and cost savings by law.... but I'll be damned if I call that a "good outcome".

I correct those factual inaccuracies, and then you bring up insurance networks (which are related, but not the same as quality of care), and also go back to talking about wait times. You also say that this is "watered-down care", but don't actually define what that means (the only thing that's clear is that you don't mean "medical outcomes"):

> Define it however you want, it leads to watered down care.... you say improved outcome, I say yes for many but also watered down care for many

I say that no, your statement about wait times is wrong, and remind you that you still haven't defined the metrics that you're actually using to measure quality or effectiveness of medical outcomes. You respond by complaining that I haven't addressed your example of a bad metric:

> You completely ignored the metrics about I mention about: [1] 30 to 90 Rx transfers; or [2] Rx transfer to generics (including Statin which for Medicare Advantage Diabetes patients which is clinically proven fatal in a few cases out of every million).

...except that I'm actually willing to engage your point that some metrics are flawed - my whole question for you is what you're using to define medical quality if you're not using the industry-standard measures?

And to top it all off, you respond to my comment about wait times by saying:

> Please show me the data supporting any notion that on average Medicare Advantage patients have larger doctor networks than Original.

Except that I never said anything about larger doctor networks. Nor, for that matter, did you! I was responding to your claim about wait times, which is not the same thing as the size of the network.

I don't mind correcting misunderstandings about the fundamental structure of Medicare, because I understand that it's rather esoteric and most people here don't have any experience with it. But doing that while also trying to chase your goalposts in circles is immensely frustrating, and I don't have the time for that. Sorry.

Technically there are four different NHS', one for each nation in Britain. Wales, Scotland and NI each report to their government rather than Westminster.

It's sad because I am frustrated as well, and I believe we likely could have had a more civil and informative conversation, maybe in person or another medium. I'll leave it at this myself:

>So I responded to that claim by talking about Medicare Advantage (Part C), at which point you bring up Part D, confusing it for Part C:

You used Advantage and I did respond using Part D, but its not for any misunderstanding. Literally there is no Part D without Advantage/Part C, and Part D is included in 82% of all Advantage/Part C Plans. Moreover, the rule is that Advantage Plans include Part D, it is the exception for Advantage to not have Part D. The truth is this point doesn't even matter, It just keeps getting in the way of proper discourse, it makes me believe you are minimizing the importance of drug coverage in Advantage Plans and it makes you think I don't understand the structure of Medicare.

>And to top it all off, you respond to my comment about wait times by saying:

I also responded to your comment about wait times with CMS patient data that shows Advantage/Original patients are equally satisfied for primary care wait times and Original are more satisfied with specialty wait times.

Its clear you know a good deal about Medicare, but I question your intimate knowledge of how the following and is gamed in the interest of claiming better medical/patient outcomes: Star Ratings, Quality Measures, MACRA, MTM, Managed Care, ACO, CPT codes, etc...

>my whole question for you is what you're using to define medical quality if you're not using the industry-standard measures?

I think that is a very fair question, because I didn't expressly state a new or better set of measures/metrics/outcomes, mostly because I don't believe in a one size fits all solution to care, it must be individualized (i.e. its not always an improved outcome to switch a Chronic Care Advantage patient to a Statin; or even though 90 day Rx may improve medication adherence of patients on average it also shows patients show up to the doctor less so in the case of Chronic Care patients the 90 day Rx should be a quality measure/improved outcome). However, in a one size fits all approach I would say it is a bad patient outcome when Insurers shrink their networks, patients lose their doctor(s), and patients are funneled to Insurance owned practices (I think you issue is that those measures/outcomes are unrelated to "quality of care" as you put it, but neither are many of the current measures most of which are based on costs or medication adherence, though I would argue the quality of care has gone down when a patient loses their doctor of years).