Everyone hates the electronic medical record

You're right, management was simply the messenger relaying customer priorities.

I will point out that enough consumers are willing to pay for a quality products that many niche companies exist to serve them. Many citizens choose to move to countries/states with better services even if they have to pay higher taxes. There are employees who reject higher-paying jobs that require interacting with poor-quality software or processes. (I work for a niche company that makes and uses high-quality products in a high-tax / high service state so I know many people like this!)

> citizens as users need to demand better.

I get what you mean, but as you point out many people's revealed preferences show that they don't actually want quality in which case they already do "demand better" -- it's just that for them "better" means cheap, fast, and convenient.

Things are far better than they were before the government intervention. The consolidation had started happening before the ACA was passed (e.g. Bill Frist and Rick Scott both became rich enough to be senators thanks to hospital consolidation in the 1980's and 1990's), and now that there are regulations the individual insurance market is passable rather than the continuous death spiral that it was in before.

And of course as I didn't say in that message but is obviously true, the ACA has led to far more people carrying health coverage than before. It's just that instead of the exchanges, it's the Medicaid expansion that has led to this. Even with Robert's unprincipled last minute rewrite and the 10 states that are still allowing their rural hospital system to be utterly gutted rather than giving Democrats the win, a higher percentage of people have health coverage than at any point in American history before the ACA, and that is entirely because of Obamacare. So that is why reinforcing the successful part (government insurance) and abandoning the failed part ("market reform") is so attractive.

The problem is that the health care market isn't a truly free market. Uwe Reinhardt, Princeton economist, wrote a lot about how it was a broken market, which is why every other developed country (including fairly libertarian states like Singapore and Chile) has significantly more government intervention than the US does- since it's not really much like a free market, unless you are willing to accept many, many more deaths for people like my mother, which I am not.

You one of their phone sales people?

I totally disagree except to the degree the provider is broke, close to broke in which case capitalism can yet help. When you're worried about money one may manage for money the exclusion of all else. It's a distortion only not a counter argument for capitalism.

The issue, ultimately, is crappy management. The need for, the good outcomes that could be achieved profitably, are insane in possibilities. Many country's demographics now include a lot of retiring people.

I continue to think basic TQM (which has gone out of vouge unfortunately) would help a lot.

Look at psychology in the US: a lot of providers will not even get involved in the insurance side of the equation. Patients pay cash. The patient is stuck with the insurance and re-imbursement, if they can figure it out.

The supplier side --- medicine and insurance and to some degree politicians --- made the paperwork system extremely bad. Simplification and elimination have got to be on the table.

Part of the problem is the patient is dis-intermediated The supplier deals with insurance directly --- hospitals in the main:

* the supplier can bill the patient's insurance wrong, for the wrong procedure, for stupid high amounts, and so on. The patient is not empowered to push back on that because the patient doesn't hold the checkbook

* hospitals and outpatient stuff like MRIs etc. don't publish a price list for the patient. Granted this is changing slowly. But why has that taken so long? Because the patient doesn't have the checkbook so why bother? Payment is done out of sight between the supplier and insurance company. It doesn't matter what the customer thinks.

The stuff where capitalism works better is when the customer knows the price, the supplier has no choice but to be upfront about it, and the customer will fire the supplier, refuse payment, or dispute payment for crappy supplier quality. The supplier can't get payment no matter what if the customer isn't going to provide it. Conversely, the supplier can refuse service for bad customers. This way both parties are encouraged to act smartly.

If I could wave my magic want I'd like to see a scenario in which,

* Customers pay insurance premiums to insurance companies in return for a bounded amount of access to a cash account.

* The customer must deal with out-of-pocket and co-insurance to eschew abusing the insurance company, fraud, and feckless spending. There must be bounded access to cash so the customer prioritizes what needs work and what doesn't.

* The supplier presents the customer with an itemized bill

* The customer --- and only the customer --- pays the bill electronically to the supplier through the insurance company's B2B payment system.

* Patients must get involved in, and start owning up the fact they can't refuse to take a zero on the dollars and cents of the care they're getting.

HypoNa --

I think you made a throwaway account for this reply, but I would really appreciate continuing this conversation with you. My email is available under my profile.