Insurers rely on doctors whose judgments have been criticized by courts

I think this is related to fundamental attribution error. The system is messed up and therefore attracts messed up people in leadership positions, not the other around.

Are the 9 out of 10 big pharma companies who spend more on marketing than on R&D also "cherry picked"?

> How exactly would doctors fund their own residency programs?

I said hospitals. You'd do your residency and then have a commitment to keep working at the hospital for say 3 years (or otherwise repaying the training).

> In game theory terms this is essentially a free rider problem

Yes, this is exactly what I mean by founded on negative sum interactions. Every player is focused on avoiding costs rather than providing value. In a sane market, when a business can't find employees they offer higher wages, overtime, train new employees, etc. That's positive sum that grows the industry, rather than just throwing their hands up and letting the shortages build.

> There have been some attempts to introduce market dynamics such as high-deductible health plans (HDHP) with HSAs

I guess if you squint really hard, just subjecting patients to even more unknown charges is some kind of attempt? I'm talking about things like making providers beholden to the basic legal norms of commerce that apply everywhere else. End this nonsense where providers won't answer questions about how much anything costs, but then shake you down after the fact with a volley of fraudulent bills - that foundation is already askew from how every other industry works.

Imagine going to the grocery store, and then receiving bills over the next year from the cashier, shelf stocker, distributor, etc, all claiming that you're also responsible for paying them. Healthy industries work by consolidating costs and making prices legible. The healthcare industry is stuck in a state of doing the exact opposite, but yet has managed to entrench itself with the entitlement of still getting paid.

If providers want to be able to bill patients directly then they need to do the work of forming actual contracts based on fixed price services, estimated work, hourly rates, etc (once again like every other industry). Or if you've got a healthcare plan and go to providers they point you to, the only entity you should ever be receiving bills from is the plan itself.

> Thus the only way to constrain total system costs is by artificially limiting supply and imposing some sort of rationing. So the real argument ends up being about how we do the rationing.

So just scrap the entire concept of individual agency? Are you a doctor or something?

And lest people jump on me for not just toeing the party line of "single payer" - as I said this is orthogonal to who may be ultimately paying. Furthermore, if we're going to be paying for a base level of care with public funds (which we're already doing for a large part), then we want to be spending that money wisely and not squandering it on a system sick with organizational cancer.

We are rationing. But not in the binary yes/no sense you will get from a bureaucracy designed flow chart. It’s economizing which allows substitution and sharing across supply and demand.

At least you agree it’s a resource problem and we don’t have infinite healthcare.

The point about rich folks being price insensitive is demonstrably false. One key here is that rich and reckless exists, but is a much rarer breed than rich and careful.

> much easier for a bureaucracy to handle

Navigating bureaucracy favors elite groups even more strongly as it requires education in law, politics, and communication skills most lacked by disadvantaged groups.

The biggest problem is if your voice isn’t loud enough you literally have no alternative.

The insurance pleading nightmare is exactly this system. They are a rationing bureaucrat.

The US has unique demographic problems where the bottom quartile of health and well being demand most healthcare resources. So the sales pitch for European style healthcare sounds like “we are going to make everything slightly worse for responsible people and remove higher end options, so we can better cover super users”.

> This is logic of post-2008 fail-capitalism instead of 1970’s and China’s aspirational, problem solving capitalism.

No, this is reality. It does not matter if you're working under capitalism, socialism, communism, mercantilism, or some as yet unknown system since economics is the “study of the allocation of scarce resources which have alternative uses.” You cannot deny resource scarcity anymore than you can deny natural selection or gravity. To do so leads to a lot of tragic consequences.

> You don’t address shortages of healthcare, housing or food with an elegant and fair system to decide who starves and dies.

Food is an excellent example to use. In order to guarantee that no one goes hungry, or is well fed, or whatever metric you want to use how much food should be produced? Please find a way for this seemingly simple solution to not devolve into rationing by some mechanism.

> You expand supply to make sure no one has to. You examine supply chain and figure out the bottlenecks.

By expanding supply of healthcare you are taking resources away from somewhere else. Everyone can become a doctor and the nation will have very cheap and plentiful healthcare. Of course no one will be building houses, repairing roads, generating electricity, making MRI machines, refining helium, building the equipment to do the above, or countless other economic activities required for society as we know it to exist. There are limited resources, people, and time. You can’t do everything all at once.

> For example China has started mass producing MRI machines, that’s one way you adress a problem.

How do you know how many MRI machines you need? How do you know if you have too many? What about doctors, nurses, gloves, defibrillators, etc… Prices are actually a mechanism that communicates where more resources need to be allocated and where less are needed. What you’re talking about sounds more like central planning or some subset of it.