What’s the alternative to the status quo, if not single-payer and not the ‘public option’? I have yet to hear a conservative offer one.
In this particular case what puzzles me is why, having raised private money to spend on a treatment…
David Piepgrass

Are you being hyperbolic or have you not actually looked?

I ask earnestly because based on your Medium stories you seem to be fully informed about each side of any argument you participate in. Conservative proposed solutions are out there if you look for them — albeit they’re among heaps of rationing! or jingoistic couched superlatives about the status quo — so it leads me to think you are exaggerating or haven’t looked that hard. A quick google immediately finds:

That’s within 10 seconds of looking.

I didn’t find links for the following, but…

  • Megan McArdle has covered this topic in depth for a decade. In one recent post I can’t seem to find she even laid out her own king for a day “plan.”
  • Reason Magazine has covered the topic from a lot of angles of the years, especially on the certificate of need and scope of practice fronts.

Whether you find them persuasive is a different story.

As someone with a career in healthcare-ish, and also someone who has consumed a reasonable amount of care for my age as a testicular cancer patient, I find McArdle’s “but who in the current system is going to take a paycut?” argument against single payer being able to reduce our per capita expense persuasive. Single payer working on a go forward basis if implemented is different from single payer drastically reducing our current spending levels.

As far as my own views, between the status quo and single payer, give me single payer. It’s like replacing the current welfare state with UBI, just way less friction in the universal approach than there is the ineffective morass we have now.

But if we are talking optimal system I do lean towards freeer market: reduce barriers to caregiving and make customers pay directly for their insurance and much of their “routine” care. I guess it puts me in the Singapore or Swiss camp, conceptually at least. I’m not lobbying for copying any specific system at the moment.

On the barriers to entry front: I am continually flabbergasted at what $20 buys me at a restaurant vs a quick is this persistent cough my child has OK? check up. At the restaurant there is the food, which had to be grown/caught and delivered, the host/waitstaff time, the cooks making you a personal plate of food, then the clean up crew. At the doctor’s office less than 5 minutes of staff time, and if everything is fine (and 3 kids later it seemingly always is) nothing even happens, is a $30 copay and several hundred dollar bill for my insurance company. That’s madness. Hard to believe NPs, RNs or, gasp, even just knowledgeable unlicensed people, couldn’t offer the same service in Walmart or Walgreens for $15 a visit.

Now, I’m not making an argument there are no downsides to that. Keeping protected health info protected, protecting customers, public safety, etc.. There are valid reasons to onerously regulate health care, but we must acknowledge the cost of it. Would people rather have $10 visits from competent professionals or to only see doctors backed by hefty liability insurance?

On the customer bears more costs* front: we’re capable of it in nearly every other insurance arrangement we have, why not this one?

To me, bearing more cost starts with buying health insurance directly ourselves. This isn’t controversial (as Hillary said in the second debate “Look, we are in a situation in our country where if we were to start all over again, we might come up with a [non-employer-based] system.”) Aside from all the obvious and oft-discussed reasons, an overlooked one is just the missed opportunities with employers engaged in the insurance biz. What positive contributions could HR departments everywhere be making if they weren’t all wrapped up in benefit administration and enrollment?

As far as fee-for-services goes, I think we should give way more of a shit what health care costs, and until we pay for it we won’t. I have consumed a lot of care; I have done very little of it with any knowledge of what the cost would be before buying. That’s insane.

You know how at oil change places they up sell you services left and right? And you ask: “what’s that cost?” If car insurance covered all of it we would never ask…that health insurance does is why we don’t ask when buying health care. I know, I know. Sometimes we forgo those car services because of expense and then our car breaks down. We shouldn’t have to choose between our wallet and our health. Still, for as vilified as the health care industry is we sure seem to trust them to never sell us shit we don’t need at a price well above market rate. They’d never act in their economic best interest like the oil change spots do.

That said, we pay a boatload for health care now, we just don’t have a huge incentive, nor real way most of the time given how opaque pricing is, to shop around before we pay. Shopping around or ask cost questions doesn’t help keep our own costs down in the current system, so we dont.

My testicular cancer follow-up CT scans cost me plenty until I hit my deductible. But in our current system what are you really to do? You hit your max out-of-pocket and you accept any care at any price they throw at you. (Incidentally, where I found private pay CT scans out of my market the posted prices were lower than the portion i was paying with insurance! Big shock that when the customer is footing the entire bill the cost is markedly lower.)

All that said, I’ve not found a good argument in favor of a free market approach for emergency or catastrophic care. To prevent gouging or to ensure funding do you do through forced savings, public hospitals/doctors, government set pricing? I don’t know. All I know is the way we are doing it now is costing us a lot. Hard to imagine alternatives being much worse.

*bear more costs in what is already an expensive arrangement seems downright cruel. The core assumption is that the only people with the political will to greatly reduce current health care spending is us when we truly have to pay for it out of our own pocket.

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