Post-apocalyptic life in American health care

>The reason why inefficiency is tied to equitability in the real world is because equitability is enforced, which means you spend resources to achieve it

Now you're switching around your causality. Earlier you said: "inefficiency tends to harm both equitability and value/cost"

So you don't believe that inefficiency causes equitability, just that equitability causes inefficiency?

>No..if it had, we wouldnt be talking about a problem of healthcare in the US. Its grown disproportionately here. But the whole point is that 50-60 years ago, healthcare was cheap and it was private.

So, in response to demographic changes across the western world (like an aging population) a bunch of countries made their systems more public and were able to keep costs down and the US has kept theirs more private and costs have ballooned. Maybe the answer is self-evident.

>I will be more practical then. What do you think are the top 3 issues that make healthcare expensive?

I think there is basically one cause: the existence of for-profit insurance companies. In a public system where government provided healthcare there would be a large monolithic body which could assert it's power to keep prices down. In a market with multiple insurance companies, they'll never have enough individual power to keep prices low. That's how the market is supposed to work by keeping power divided, it's just that healthcare is a terrible place for markets.

>Mine is that lightly regulated free healthcare markets will be efficient (though might not be equitable).

So to get you to change your mind that public systems are better than private equitability never comes into play? What is the point of efficiency if not to help people? If the point of efficiency is to help people then how is equitability not important?

> So, in response to demographic changes across the western world (like an aging population) a bunch of countries made their systems more public and were able to keep costs down and the US has kept theirs more private and costs have ballooned. Maybe the answer is self-evident.

I've had private insurance my entire life in a western country with free public healthcare. I have practical experience of the trade-offs of public vs private as a consumer and a tax-payer. The demographics changes hit my home country just like any other, but it didnt make public more efficient than private, nor more effective.

> I think there is basically one cause: the existence of for-profit insurance companies.

I have mentioned 2 counter examples: my home country (argentina) and historical US. You can also see Germany also has public/private mix systems. Health insurance companies actually have very low profit margins. Lower than the general market, lower than insurance companies, etc etc. They are not raking it in. The ones that are raking it in are providers.

> In a public system where government provided healthcare there would be a large monolithic body which could assert it's power to keep prices down. In a market with multiple insurance companies, they'll never have enough individual power to keep prices low. That's how the market is supposed to work by keeping power divided, it's just that healthcare is a terrible place for markets.

There is some contradiction in the previous statement (for profit) vs this one. You are arguing insurance companies cant negotiate prices down because they are not a monopoly, not because they are for profit. If there were only 1 insurer, they could definitely keep prices down, particularly the price of providers. But its hard to think a monopoly is the solution to a market problem.

Moreover, you say the state would have the power to drive prices down. This contradicts reality today, where Medicare by law cant negotiate prices. The government is eager to put itself a restriction on negotiating, and is politically unable to remove it. If it cant change medicare when its a fraction of the market, do you think it will change more when its 10 times its size?

The state can, in 24 hours, reduce healthcare prices by just removing economic consented bad regulation. Read what the healthcare economists say: allow free trade for drugs and doctor immigration and you solve such a massive part of the cost immediately. The government has full power today to solve those problems and it cant. Doesn't that make you lose any faith in the government's capacity to solve healthcare?

Do you remember the Obamacare website debacle? Do you think medicare will make a kickass insurance website?

HMOs were a minor player 50 years ago. They are a euphemism for the corporate cancer that maximizes profits at the expense of the sick. Even when I started working in Mass 25 years ago, it was one of the few states with HMOs. They have continued to morph and are now ripe for purchase by the more profitable corporations (pharma) CVS buying Aetna is the first shot. Although Aetna is an insurance company, they offered many stripped down 'products' = HMO like plans.

Is this the average doctor or some specialist? The fact that some specialists can hugely profit from the system the same way the hospitals, pharma companies and insurance do, is likely port of the point of the previous comment. The important takeway is the average doctor does likely also not see much of that overhead money that goes to the pockets of a couple individuals and already rich companies.

This is a systems interface essay. The lede is buried very deeply:

It’s like one those post-apocalyptic science fiction novels whose characters hunt wild boars with spears in the ruins of a modern city. Surrounded by machines no one understands any longer, they have reverted to primitive technology.

Except it’s in reverse. Hospitals can still operate modern material technologies (like an MRI) just fine. It’s social technologies that have broken down and reverted to a medieval level.

Systematic social relationships involve formally-defined roles and responsibilities. That is, “professionalism.” But across medical organizations, there are none. Who do you call at Anthem to find out if they’ll cover an out-of-state SNF stay? No one knows.

The author recommends hiring a consultant. I'd like to suggest an alternate approach.

In complex disputes between parties, we have several systems or dispute resolution. One is to engage the services of an alternative administrative system: the courts.

While Anthem may be governed by 1,600-page rule-books, a judge is not. Or rather, a judge has a different set of rule books and considerable autonomy to make decisions independently.

(With provisions for review.)

One way of considering this is as a collapsing of complexity: where a system becomes too complex to function reasonably, a third party is called in.

The U.S. healthcare "system" has become vastly too complex to function with any semblance of sanity. It is in desperate need of a complexity constraint being applied to it. What we might in other political contexts call a revolution. Perhaps a reform.

But it seems vastly beyond the realm of incremental change.