This is a real concern for me because people credit the ACA with making a big dent in the healthcare problem here in the US, but it feels more like it just created a massive legal protection for these exploitative middlemen when the necessary solution was to blow up the entire industry with a true public option that could out-compete every profit-driven money-extraction system by simply not being profit-driven.
Not every system becomes more efficient with profit incentives, and this really seems like just such a case.
epistasis 3 days ago [-]
The ACA was the best compromise that could be struck at the time, with a large portion of the population being dead set against better healthcare if it meant allowing Obama to be able to take credit for it.
This is the dirty part of the political process: people sacrifice better outcomes for all, merely for the pursuit of more power in the future. And those who want better outcomes for all must somehow gather a coalition that can achieve those outcomes.
Nobody, least of all the architects of the ACA, thought it was the best possible system. It was merely the best system that could get through the democratic process of our government.
Which means we need iterative design on these programs. It's not pass once and done forever. We need maintenance legislation for bug fixes and feature improvements. However, every culture war battle that we fight can be used to distract from actual reform, like a nefarious form of bike-shedding.
toast0 3 days ago [-]
I wish we'd just say ok, people like Medicare, let's drop the age of enrollment by 1 year every year for ten years and see how that goes. If that works out, drop the age of enrollment by 2 years every year for the next ten years. Then figure it out from there. Could start as a paid option rather than just lowering the age when you get coverage based on work history, too.
Maybe something for children too, start with making Medicaid or something automatic for the first N months of life, and increase it every year too.
soks86 3 days ago [-]
We'd still be waiting for healthcare with this kind of plan.
Before the ACA it simply was not a choice to be an independent professional and have health insurance.
If people could understand why it is unacceptable to force independent professionals and entrepreneurs to give up healthcare they would see the ACA was necessary in whatever form it could be passed.
3 days ago [-]
franktankbank 3 days ago [-]
You don't need to have insurance for the vast majority of care, yet it gets used as such. Let's drop that nonsense, it tangles up the billing process.
mistrial9 3 days ago [-]
when you fall from a bicycle in traffic and need more than ten stitches, you probably want clean conditions and high skill people ready. Ordinary daily care is done by ordinary daily care people because there is so much of it to do. It is fairly rare to need ten stitches from a bicycle accident. This is an example of people in ordinary good health. When you get to chronic care and elder care, things change again.
this call for "less reliance on insurance" lacks context and is overly-simplistic IMHO
franktankbank 3 days ago [-]
Doctors can't exist without insurance? Hell we don't need doctors to diagnose strep etc. My argument is to remove insurance from the common. I've never crashed a bike requiring 10+ stitches probably never will, but might be a good reason for to carry insurance for it. However I don't want it plugging up the bill flow when I go to get antibiotics for a routine illness.
lotsofpulp 3 days ago [-]
This is the point of High Deductible Health Plans with access to HSA contributions.
jordanb 3 days ago [-]
Obama started from the idea that the private insurance industry would continue to exist (and grow!) and therefore anything that would eat into their business was out.
Medicaid expansion was allowed only because it was insuring people the the private companies didn't want as customers.
prepend 3 days ago [-]
Everyone I know on Medicare does not like it and would prefer something else.
I think people like Medicare like they like Comcast. They have it, it performs a service they want, they hate everything about it, and would never leave.
jordanb 3 days ago [-]
> Everyone I know on Medicare does not like it and would prefer something else.
I have UnitedHealtcare through my employer. I don't like it and would prefer something else.
prepend 2 days ago [-]
I’ve actually never met anyone who pays for their healthcare who likes it. Over the years I’ve used United, Aetna, KP, BCBS and didn’t like any of them. I switch when I can.
epistasis 3 days ago [-]
There are very very serious financial problems with going down this route. Private insurance pays for a lot of Medicare, because Medicare reimbursement rates do not cover the costs of Medicare patients in many parts of the country.
One of the better sources of information I have seen on this is actually a YouTube video, something I don't normally recommend, but getting a wholistic viewpoint is somewhat difficult otherwise:
We could increase the medicare contribution cap (samething like only the first $175k of income has medicare tax applied to it), but I'm not sure that's going to fill the massive gap. Perhaps increasing the rate would also work.
There could be some good things about this process, I just want to bring up that it's not a magic bullet because we will run into access problems unless we also solve the funding side of things. And when there are access problems, the people who lose access will be those with the least to pay.
pxmpxm 3 days ago [-]
Some 30% of NY state and ~48% CA population is already on medicaid. Are you gonna make a whole middle-america flyover town work an extra shift to pay for that plan?
projectazorian 3 days ago [-]
Both of those states are net contributors to the federal budget, unlike many "middle-america" flyover states.
BTW, your stats are way off, CA is at 33-34% Medicaid utilization. Below several red states.
In any case, I don't see how the state net revenue balance is relevant as a justification for this - all that's saying is california has fatter tail on the income distribution. You don't "own" those rich people, as the high-tax states are coming to find out with the mass exodus to florida.
Definitionally 4/10 of california residents cannot be in poverty.
fumeux_fume 3 days ago [-]
As silly as agile government sounds, if it forces our legislators to take part in the misery of a daily standup, I'm all for it.
epistasis 3 days ago [-]
Legislation is literally the code of society.
JumpCrisscross 3 days ago [-]
Sort of. It’s more akin to design guidelines.
epistasis 3 days ago [-]
By "literally" I mean that the name for it is the Code of Law, with a civil code, and a criminal code. And this usage of "code" predates computer programming by many centuries!
6510 3 days ago [-]
is it safe?
epistasis 3 days ago [-]
Absolutely not. It regularly performs invalid rights on unallocated memory and even kills people.
6510 2 days ago [-]
does it map closely enough for an obvious replacement ...uhhh language?
joquarky 2 days ago [-]
So let's put it in a code versioning system.
gatlin 3 days ago [-]
> with a large portion of the population being dead set against better healthcare if it meant allowing Obama to be able to take credit for it.
This is a fiction people repeat with no citation. A large portion of the population wants m4a when it is explained to them. This "system" failure was specifically our elected reps - bipartisanly - ignoring the needs and wants of the people at the behest of their donors. The democratic process failure was when the two parties solidified.
It wasn't pitchfork wielding illiterate rubes (or whatever undoubtedly out of touch "data driven" parody of what an average person is we're operating with) trying to deny a Black man his legacy, it was that Black man's party collectively wanting to be reelected that gave us the "Buy Insurance Or We Fine You Through Taxes" Act.
jtmarl1n 3 days ago [-]
You say the comment you replied to cited no sources while making an assertion you disagree with. Then, you go on to do the very same thing.
jordanb 3 days ago [-]
> The ACA was the best compromise that could be struck at the time,
That's not he way the ACA went down. Obama had this idea that the best way to reform an industry was to have it write its own reform legislation and pretty much let the industry have first draft.
> with a large portion of the population being dead set against better healthcare if it meant allowing Obama to be able to take credit for it.
The ACA was initially popular but it became increasingly unpopular during the months of horse trading, the explosion in length of the law, the jettisoning of most of the good parts (drug price controls, public option, etc), retention and expansion of industry giveaways (tax penalties), and yes, relentless Republican opposition and propaganda against it.
But even the latter was Obama's fault for not being prepared to anticipate and deal. He actually spend the first several months pushing for a "bipartisan" deal with Republicans that gave them room to delay and attack.
> with a large portion of the population being dead set against better healthcare if it meant allowing Obama to be able to take credit for it.
Obama had a filibuster-proof supermajority in congress. Yes, Republicans were going to oppose his agenda, but he didn't need them. For some dumb reason he loaded a gun, pointed it at himself and handed it to them.
There were lots of comparisons to Medicare/Medicaid being made at the time. That law was a fraction the size of ACA, the implementation phase was like a year instead of a decade for the ACA, and its effect on the public was immediate and profound.
The failure of the Obama administration was the failure of technocracy. Obama thought he could have "experts" develop the ultimate "win-win" policy. What you ended up instead was a bunch of naked self-dealing by craven opportunists who either worked for the industries they were regulating or intended to do so in the future. People saw through this and it lead directly the the rise of Trump
jjav 3 days ago [-]
> This is a real concern for me because people credit the ACA with making a big dent in the healthcare problem here in the US, but it feels more like it just created a massive legal protection...
Both are true! The ACA is a literal life-saver and bankrupcy-avoider for a significant percentage of the population. So it is a huge win for the common person.
At the same time, yes, it perpetuates the corrupt insurance system, which is bad. But at least makes it more widely available, which is good.
> Not every system becomes more efficient with profit incentives, and this really seems like just such a case.
Health care can only ever get worse with profit incentives. The best way would be to eject all the profiteering out of the system so that only the people who provide actual care (doctors, nurses, medical technicians,etc) get paid. Remove all profit from the hangers-on that do nothing useful (insurance middlemen).
The path to get there is obvious, but politically quite impossible in the US (and only in the US, since every other country has it figured out.)
JumpCrisscross 3 days ago [-]
> a true public option that could out-compete every profit-driven money-extraction system by simply not being profit-driven
We can solve pharmaceuticals without bringing in the miasma of the broader healthcare debate.
Three things:
1. Let Medicare directly negotiate pricing on all drugs;
2. Make it easier for generics producers, including foreign manufacturers, to sell into America; and
3. Reform PBMs [1]. Transparency on pricing. Spun out of monoliths.
While we’re at it, maybe someone can figure out how to cut the $1bn it costs to get a drug to approval to something lower.
It made a massive difference in the day to day lives of the most affected people — the chronically ill.
I cannot emphasize enough how much of a death sentence being chronically ill before the ACA was. No protection for preexisting conditions meant one unfortunate incident could cost you your job could cost your your healthcare could cost you your ability to get back on solid footing to get another job.
Webstir 3 days ago [-]
Love how people try to rationalize these vultures.
The elite and their PMC toadies are just corrupt.
That’s it.
The united states is corrupt to it’s core because we allowed the elite to run things.
indymike 2 days ago [-]
> we allowed the elite to run things
I'm pretty sure that being elite is a symptom of running things, not the cause of running things.
JumpCrisscross 3 days ago [-]
> because we allowed the elite to run things
By definition, a society’s elites always run things…
forgetfreeman 3 days ago [-]
True. How's that worked out so far?
JumpCrisscross 3 days ago [-]
> How's that worked out so far?
Pretty damn well in the long run!
voakbasda 3 days ago [-]
Worked great for the French too, right up to the Revolution.
JumpCrisscross 3 days ago [-]
> Worked great for the French too, right up to the Revolution
Each of the French Revolution’s successive governments had their own sets of elites. (La Révolution itself had its elites.) Arguing against elites as a category is arguing against hierarchical sociology. It’s inchoate. We don’t have an example of a society without elites; we barely have examples of social animals without hierarchies. (Zebra herds.)
And speaking of the French Revolution, the elites ex post facto were not only mostly the same as before, they escaped with so much money and wealth that it’s actually debated if they increased their wealth share through the chaos [1].
Nah, one day we'll just have flat societies with AIs to replace the beaurocracy and elites and manage everything for us. Nothing could go wrong with that! </sarcasm>.
conductr 3 days ago [-]
Nothing in this article was a byproduct of ACA and it all predated it. But also in no way did it reduce costs, that’s a lie. Who even says that? Unless you’re only considering very specific benefits like birth control. Overall it increased costs, even when Medicare of any government program announces a reduction or sequestration the industry just raises prices everywhere else to offset. I’ve been in those decisions when I worked in the industry. We never let it flow through to bottom line, we always found a way.
SoftTalker 3 days ago [-]
As if a "public option" would not have a middle tier that evaluated, and then approved or denied claims?
AuryGlenz 3 days ago [-]
That doesn’t matter when it’s subsidized by the government. When people talk for a public option all they’re really talking about is one option, because no company would be able to compete.
ljf 3 days ago [-]
We have free at point of need healthcare here in the UK, and still have a lot of choice in private healthcare if you want it.
In the nearest city to me there are 3 major private hospitals, and if you head into London there are loads of them.
Private is still able to compete and to be profitable. Just no one needs to die from preventable diseases.
(not saying NHS is perfect, it is a shadow of what it should be right now)
ajb 3 days ago [-]
Sort of. My understanding is that private hospitals largely opt out of most of the difficult stuff, because the NHS is there to take it on. So they're good if you're waiting around for a hip replacement but not so much for other things.
tialaramex 3 days ago [-]
Right, essentially every private hospital's response if, say, a patient they're giving a boob job suddenly becomes unresponsive is to... call the NHS. Yeah, the medical staff will be better than your neighbour or some random passing guy in the street when it comes to knowing how to put you in recovery position or attempt CPR but those hospitals won't have a crash protocol beyond too bad call the NHS.
I spent eight hours at an Accident & Emergency department at my city's hospital a couple of weeks ago (Those electric scooters look easy enough, I have a driving license, I watch the training video, then at midnight I thought I'd try one, signed it out, crashed into a lamp post within seconds, broke my hand and busted my head open. Oops. Signed the scooter back in, walked to the Urgent Care, it shuts late at night, walked towards hospital, saw a cop - "Hey, I can't see my head, I can feel the wound, is it bad?" "You should get a taxi to A&E. I'll call you one"). There is no private emergency care, private cosmetic surgery sure, and lots of private non-urgent care, like knee replacement or whatever - but no emergency care.
Eddy_Viscosity2 3 days ago [-]
The middlemen would never allow a public option and they have enough money to stop it happening. US policy is the will of the rich not the people.
DarkNova6 3 days ago [-]
Profit-chasing never makes systems more efficient. It’s competition.
throwawayqqq11 3 days ago [-]
> a true public option that could out-compete every profit-driven money-extraction system by simply not being profit-driven.
Much like amazon did in the early days.
When the problem is incentive structures -- of profit seeking corporations or compensation seeking individuals -- what options do you have? (IMO its only regulatory enforcement with democratic oversight and transparenct.)
I think we as a society still have to figure out ways to restructure sprawling institutions and i dont like it when people only put the blame on public or private ones while ignoring the other.
neuralRiot 3 days ago [-]
>Not every system becomes more efficient with profit incentives
Maybe it does but not for the right people.
renewiltord 3 days ago [-]
Public option would lead to pure fraud like in the ABMT treatment for breast cancer. Asking for trouble. Especially in the US where people believe that no one should trade grandma for a dollar.
In the UK, they fortunately have a notion of money spent for QALYs earned (adjusted to boost life extension at end of life) but in the US everyone believes that we should spend arbitrary amounts of money on people and if we don't, we should pay their relatives extraordinary amounts to compensate for the fact that we didn't spend a few aircraft carriers worth of money on them.
Put simply, so long as US ethics remains "there is no sum of money that is too high to save an arbitrary person's life", we have to oppose the public option.
krapht 3 days ago [-]
I'd like to see proof that Medicare does not evaluate QALY and spends unlimited money in general.
renewiltord 3 days ago [-]
The percentage of the federal budget that is spent on dialysis and the life of the patient preceding when they're put on dialysis.
Even without that, when Cuomo in NY said he wouldn't trade grandma for a dollar, there was thunderous applause across the US. And many here argued that the economy isn't as important as any life lost. That's enough to cement it for me.
roenxi 3 days ago [-]
Typical US profit margins are somewhere in the area of 8%. If dropping healthcare costs by 8% is what people are arguing over then I've been badly mislead about the problems with the US healthcare system.
There is a real issue with regulatory capture. Making the system purely public is not going to result in the regulators suddenly purging their souls of all corruption. It'll still be a disaster just without any pretence of an alternative. There are literally people on HN every day who would happily improve on the US healthcare system's costs and outcomes if well meaning busybodies hadn't banned them from doing so by overregulating.
foolswisdom 3 days ago [-]
That's nominal profit margins. It doesn't take into account the way that different parts of these conglomerates take money from one pocket and put it in the other (e.g. insurance and Healthcare providers), which means it doesn't show up in the profits for your first pocket. This is why the fact that Healthcare platforms are vertical monopolies (not just horizontal monopies) is important to this conversation.
(separately, profit capping rules means that once a monopoly is cemented, once a company has moved as much as it can from one pocket to the other, there's an internal incentive to spend money on bureaucracy).
roenxi 3 days ago [-]
Because the regulations encourage vertical monopolies. Replacing that with a state mandated vertical monopoly unconstrained by market forces isn't going to help. In fact it'll probably make the situation worse. There is no reason for there to be monopolies in healthcare and if they are emerging that strongly suggests misregulation. Giving the regulators more power in that sort of situation is the opposite of helping.
ThePowerOfFuet 3 days ago [-]
Are you seriously arguing against single-payer healthcare?
roenxi 3 days ago [-]
Which part of the argument strikes you as frivolous?
ThePowerOfFuet 2 days ago [-]
Not frivolous, but outright incorrect.
roenxi 2 days ago [-]
So far it's beating your argument pretty handily. I'm not sure why you think it is worth writing that without including one; but my advice would be if your going to post a comment disagreeing with someone you should include some actual arguments or evidence. It helps keep the threads from rambling on.
lotsofpulp 3 days ago [-]
>That's nominal profit margins. It doesn't take into account the way that different parts of these conglomerates take money from one pocket and put it in the other (e.g. insurance and Healthcare providers), which means it doesn't show up in the profits for your first pocket.
This is nonsense. UNH’s profit margin is all net income divided by all revenue.
Same with Elevance, CVS, Cigna, Humana, Centene, and Molina. There is a reason all these businesses aren’t at the top of the market cap rankings. Not even in the top 100.
UNH is up there due to sheer size and the fact that they sell high profit margin software and healthcare. Otherwise, you will not get rich starting a managed care organization. Even Warren Buffet, Jeff Bezos, and Jamie Dimon ran away with their tail between their legs:
The profit margins are not the only thing. There are tens or hundreds of thousands of people working on billing jobs at doctors and insurances that shouldn’t exist.
AuryGlenz 3 days ago [-]
And you think a government run system would be more efficient? It’s still going to have people in each side verifying claims, preauthorizing stuff, etc. To do otherwise invites massive fraud.
ljf 3 days ago [-]
Government run systems are alot cheaper all across Europe. So yes.
Unless you are saying there is something exception about the US and profit extractions?
rqtwteye 3 days ago [-]
Government run is not the only alternative. We should start at standardizing and simplifying things. Less variations in insurance plans. Standard data exchange. Same pricing for same procedures. Price transparency. It doesn't make any sense that a drug or procedure costs less in cash than through insurance.
ForTheKidz 3 days ago [-]
> There are literally people on HN every day who would happily improve on the US healthcare system's costs and outcomes if well meaning busybodies hadn't banned them from doing so by overregulating.
I trust the market to provide healthcare about as much as I expect america to suddenly blast off to join the moon. And i trust vc/finance a hell of a lot less than that.
roenxi 3 days ago [-]
Do you feel the Trump & Musk dynamic duo are going to do a better job of handling it? They're cut from similar cloth.
ForTheKidz 3 days ago [-]
No, of course not, this is just more extreme of the same behavior.
slt2021 3 days ago [-]
high cost of healthcare can be solved overnight: just mandate insurance companies to pay for healthcare for foreign hospitals (at rates not exceeding US rates).
so that Americans could travel overseas and get healthcare expenses reimbursed over there.
watch prices drop...
rickydroll 3 days ago [-]
Does that include airfare and living expenses? I figured out that if I needed two crowns, it would be cheaper to fly to Estonia and use my friend's dentist than to go to a US dentist.
On prescriptions, reimbursement for drugs bought from cost plus would also help drive down pharma prices
rqtwteye 3 days ago [-]
The whole system is infuriating. Even when you assume a free market is what you want, it's pretty clear that this is far away from a free market. Unless you view non-competitive monopolies as free market.
I don't understand why vertical integration is not made illegal. An insurer should not own a PBM or providers. They all should have an adverse relationship so they put cost pressure on each other.
Also, providers should charge the same prices for the same procedures no matter who pays. Ideally everybody should be mandated to follow Medicare prices. If these prices are too low to survive, then there should be a discussion about adjusting the prices.
The whole system is basically a huge bureaucracy that wastes a lot of money but some of the waste is enough profit for a lot of people to fight tooth and nail to keep the status quo.
jimt1234 3 days ago [-]
I can't speak for all providers, but I can say that, in many cases they're getting squeezed by the insurance companies, too. My girlfriend is a provider of services for young people with disabilities. The insurance companies fully dictate how much she can charge (how much the insurance companies will pay) and even what specific services she can provide (what they'll specifically pay for). It's infuriating. Up until about 7 years ago, she was fully funded by the state through the California Department of Education, and it was simple. She met with a single person from the state monthly, they reviewed her billable hours, made some corrections here and there, and she got paid. Simple. When private insurance was introduced it became a nightmare. She had to hire a full-time employee just to manage billing with the insurance companies. One insurer won't even talk to providers at all. Nothing. Nada. She has to fax them. Yes, fax. And their fax machine only answers during business hours; it's powered-off outside of business hours. Why? Because fuck you, that's why. It's obvious that the insurance companies make it as difficult as possible for providers to get paid, which is not too different from patients. Weird...not.
pimlottc 3 days ago [-]
> And their fax machine only answers during business hours; it's powered-off outside of business hours. Why?
In some cases, privacy laws require that fax machines be actively monitored so that sensitive personal information is not just left sitting around in the open for hours.
Yes, there could probably be alleviated with sort form of purely digital fax system, but for regular fax machines, this could be why they are only available during staffed hours.
rqtwteye 3 days ago [-]
It's almost the same when you deal with billing departments in hospitals. They give you the runaround, "lose" things repeatedly, ignore you. The whole US health system is abusive but there is so much money flowing around that it's worth it to many participants. I know doctors who complain about their workload but they would never consider moving from 600k salary to 400k in exchange for a straight 40 hour week.
toast0 3 days ago [-]
I dunno, I used to have Kaiser which is vertically integrated and the nice thing was there wasn't the thing where the Doctor says we should do X, but your insurance won't pay for it, so we'll do Y. Or my favorite where the doctor writes a prescription, and the pharmacy doesn't fill it because it's not covered, and you have to convey what is covered to the doctor so they can write that instead.
Kaiser would sometimes tell me that we have to try X first before we do Y, but then the X's worked sometimes, so it seemed like they were asking for reasonable things to reduce cost.
droopyEyelids 3 days ago [-]
I think kaiser is pretty widely regarded as the best experience possible with healthcare in the USA. Unfortunately its not widely available
Taikonerd 3 days ago [-]
There are other organizations with the same "payvider" model (combining payer and provider). For example, Geisinger and Intermountain. It's slowly getting more popular.
"Unlike the traditional healthcare model, which often pits payers against providers in a bid to control costs, the payvider model merges these roles..."
> I don't understand why vertical integration is not made illegal.
Well I decided that would be extremely inconvenient for me if that was the case, so I’m going to call this “bad regulation”, and say it’s against the “Free Market” so if you support it you are a communist.
If later on I decide this is good for me, then I will call it “good regulation” that supports the “Free Market” and you are in the clear.
All sarcasm aside, if you don’t define what your minimum set of regulations are for you to consider it a “Free Market”, then you are consigning yourself to endless bike shedding over what a “Free Market” really is
matthest 3 days ago [-]
[flagged]
lowbloodsugar 3 days ago [-]
lol. No we’re dealing with unregulated capitalism.
matthest 3 days ago [-]
[flagged]
dh2022 3 days ago [-]
I think you are describing free markets, not capitalism. Capitalism means accumulation of capital through any means possible. Sometimes monopolies are examples of capitalism.
matthest 3 days ago [-]
I guess it depends on which definition you use at this point, but Adam Smith's original definition of capitalism fundamentally required free markets.
Of course, what we have today is not Adam Smith's capitalism.
robertlagrant 3 days ago [-]
[flagged]
fzeroracer 3 days ago [-]
> This makes it extremely difficult for new competitors to enter the space. Which means the existing players can collude to raise prices.
> That's not capitalism. Capitalism requires heavy competition. Think restaurants for example. Extreme competition drives prices down and keeps prices fair for consumers.
No, that absolutely is capitalism. No True Scotsmanning capitalism when we see this as an end result of capitalism doesn't work as an argument.
For example, in the gig economy which is largely unregulated we see incumbents to the market get destroyed by economy of scale. Did you know Austin had its own non-profit ride-sharing app called RideAustin? Did you know that it blew up after Uber and Lyft completely pushed it out of the market?
I could go on with other examples of these issues. Like for example Bartells in Seattle being bought out by Rite Aid only to be decimated by Rite Aids shitty practices, with little to no ability for incumbents to fill the void due to the costs of rent and rising bootstrap costs. Or the way grocery companies merge and combine until we have five different brands all operating under the same owner.
Capitalism is controlled by the winners who have the most capital. Competition only vaguely exists as a way for capital to exert control.
matthest 3 days ago [-]
Those are valid examples, but conflated with the problem that there is limited competition in all the industries you mentioned. Which makes monopolies much easier for the existing companies with power.
Counter examples of capitalist industries that have lasted centuries without corporate concentration: restaurants, spas, bars, tailors, car washes, barbers, almost anywhere small businesses exist.
Adam Smith's original capitalism required free markets, which fundamentally require high competition, low barriers to entry.
The low barriers to entry component is missing from the examples you described, which is theoretically where government should step in (and lower those barriers for new companies looking to enter the market).
In healthcare, however, government is essentially working with the companies to raise barriers to entry.
fzeroracer 2 days ago [-]
There's limited competition in the gig economy? I don't know what you think a free market is supposed to look like then because the gig economy is fully unregulated outside of a couple states and the barrier to entry was being able to write an app on your phone.
You literally cannot get more unregulated than that. What is your vision here?
matthest 2 days ago [-]
Well let's look at ridesharing as an example. It's basically dominated by Uber and Lyft, i.e., minimal competition.
The nature of the market is that you need a large network of drivers to succeed. That network is a powerful barrier to entry. And it likely requires a lot of funding to achieve.
A government could foster more competition within the industry by funding new start-ups, in an effort to bring the market closer to free market status.
This is what China does with many of their industries, and they do it really well. Despite their "communist party" brand, they are actually doing capitalism much better than the US in many areas.
fzeroracer 2 days ago [-]
That's not a 'free market' though, especially not by the majority standards in the US. That's the US government attempting to pick a winner by funneling money into startups.
Mind you, it's not something I particularly disagree with, but the only way this works is by imposing regulations on the dominating market forces to prevent them from buying out the competition or using their network advantage to crush them. And regulation is considered the antithesis to a free market.
matthest 2 days ago [-]
Gov wouldn't need to pick a winner - it just needs the market to reach a critical point of competitiveness, at which the sheer amount of competition would be self sustaining, as it is in the restaurant industry, for example.
My dad used to have a job where he’d basically go around to failing small-time family practices and help the doctors there figure out their financials. I remember him telling me that in an extremely typical scenario, he’d walk into their office and somewhere in there he would find a huge stack of unfiled insurance claims.
Usually when he’d ask them about this, the process of filing these claims with the insurance companies was so onerous, they just fell way behind on the process. Typically you could resolve this by bringing in someone with a LOT of experience filing these claims I believe.
This was back in the 90s, so maybe the advent of computers has improved this particular part of the game (I’m not in the industry myself), but at least back then, it was infuriating doctors too.
I am not surprised in the least to hear that, like every other system in this economy, it seems to have gotten massively more complicated for approximately zero real-world improvement
kacesensitive 3 days ago [-]
One of the rare bipartisan areas of agreement in Congress right now is the need to rein in these Pharmacy Benefit Managers (PBMs). Both Republicans and Democrats had rallied around reforms to increase PBM transparency, which could lower costs for employers and, eventually, consumers.
But just as a major PBM reform bill was set to pass last December, Elon Musk fired off a series of tweets opposing it. Within hours, what had been near-unanimous support collapsed. Five days later, Musk tweeted, "What is a pharmacy benefit manager?"—as if he had only just learned about the issue.
This isn’t about whether Musk was right or wrong on PBMs (though evidence suggests reform would lower costs). The bigger issue is how a single billionaire’s influence can derail democratic processes that were functioning as intended. When a reform has broad bipartisan support, expert backing, and clear public benefits, yet can still be nuked by one well-placed tweet, that’s not just a policy failure—it’s a governance problem.
Tech billionaires reshaping policy via social media whims should concern anyone who cares about democratic accountability. If Musk can tank a bill that helps millions save on prescriptions, what else can be undone with a midnight tweetstorm?
jimt1234 3 days ago [-]
I worked for a PBM in the late-90s. I wish I would've sold crack cocaine and guns to children. I would've felt better about myself. ... Hyperbole, indeed, but wow, that company, and PBM industry, was shady as fuck.
That whole situation was so strange to me. I was in my mid-20s at the time, trying to make sense of the "adult world". Then they tell me something is both illegal and legal at the same time, depending on how your label it - like Schrodinger's cat, but dumber.
And that's when I really started to feel dirty about working for the PBM. I knew the company was part of the machine, helping push drugs onto people, purely driven by profit, not actual need. Like, I dealt with drugs dealers a bunch in college (weed, ecstasy), and none of them ever tried to push drugs onto me. They just sold it, and that was it. But I really started to see how this whole machine operated, and I was part of it. :'(
pstuart 3 days ago [-]
> what else can be undone with a midnight tweetstorm?
I'm sure we'll find out soon enough.
Such a pity that this is "easily" remedied via campaign finance reform and revoking Citizens United.
error_logic 3 days ago [-]
It's not that easy. The deeper issue is plurality voting and duverger's law, with people being incentivized not to vote for something but to vote against a perceived evil, as that's what the campaigns get more traction with on the whole.
Plurality voting applied to the tragedy of the commons, i.e. the nash equilibrium decision matrix, results in the worst possibility if there's no basis for trust. If we could vote on the results of that matrix, by replacing {+1, 0, 0, 0...} voting with {+1, +0.5, -0.5, 0, 0, 0...} voting, things might actually improve with 3-4 viable, local parties, with smart selection of candidates actually representing districts constructively and campaigning accordingly.
But we don't have that. I fear its absence at all scales from local right on up to resolution of international conflict may end up being the Great Filter: The coordination problem of solving the tragedy of the commons in all its forms.
JumpCrisscross 3 days ago [-]
> just as a major PBM reform bill was set to pass last December, Elon Musk fired off a series of tweets opposing it
Hold on. That bill contained the PBM stuff, but that doesn’t mean he was wrong about it being full of pork - though I don’t know one way or the other.
They certainly could have just done the PBM reforms in a separate bill instead of shoving it into something else…but then they potentially wouldn’t be able to get their own choice cuts of pork passed.
Anyways, seems odd to blame Musk directly for that even if his tweet did kill the bill.
JumpCrisscross 3 days ago [-]
> seems odd to blame Musk directly for that even if his tweet did kill the bill
Musk tanked a bill he obviously didn't read with zero plans for its replacement. So instead of a $1.7 trillion bill in December, we get roughly the same bill (that's what a continuing resolution is) plus $100bn in giveaways in March minus the PBM reforms.
Musk killed PBM reform. The fact that he was too high to know what he was doing isn't exactly redemption.
__MatrixMan__ 3 days ago [-]
The billing system has cancer, it's time to schedule a biopsy.
3 days ago [-]
notyourwork 3 days ago [-]
Biopsy? I think you mean amputation.
__MatrixMan__ 2 days ago [-]
I love the thought, but where do you stop? Doctors and nurses still need to be paid. Or are we just getting rid of money entirely? (If so count me in.)
Y_Y 3 days ago [-]
You heard him doc, amputate the brain
Rendered at 08:53:14 GMT+0000 (Coordinated Universal Time) with Vercel.
Not every system becomes more efficient with profit incentives, and this really seems like just such a case.
This is the dirty part of the political process: people sacrifice better outcomes for all, merely for the pursuit of more power in the future. And those who want better outcomes for all must somehow gather a coalition that can achieve those outcomes.
Nobody, least of all the architects of the ACA, thought it was the best possible system. It was merely the best system that could get through the democratic process of our government.
Which means we need iterative design on these programs. It's not pass once and done forever. We need maintenance legislation for bug fixes and feature improvements. However, every culture war battle that we fight can be used to distract from actual reform, like a nefarious form of bike-shedding.
Maybe something for children too, start with making Medicaid or something automatic for the first N months of life, and increase it every year too.
Before the ACA it simply was not a choice to be an independent professional and have health insurance.
If people could understand why it is unacceptable to force independent professionals and entrepreneurs to give up healthcare they would see the ACA was necessary in whatever form it could be passed.
this call for "less reliance on insurance" lacks context and is overly-simplistic IMHO
Medicaid expansion was allowed only because it was insuring people the the private companies didn't want as customers.
I think people like Medicare like they like Comcast. They have it, it performs a service they want, they hate everything about it, and would never leave.
I have UnitedHealtcare through my employer. I don't like it and would prefer something else.
One of the better sources of information I have seen on this is actually a YouTube video, something I don't normally recommend, but getting a wholistic viewpoint is somewhat difficult otherwise:
https://www.youtube.com/watch?v=QqrpFICtqpQ
We could increase the medicare contribution cap (samething like only the first $175k of income has medicare tax applied to it), but I'm not sure that's going to fill the massive gap. Perhaps increasing the rate would also work.
There could be some good things about this process, I just want to bring up that it's not a magic bullet because we will run into access problems unless we also solve the funding side of things. And when there are access problems, the people who lose access will be those with the least to pay.
BTW, your stats are way off, CA is at 33-34% Medicaid utilization. Below several red states.
In any case, I don't see how the state net revenue balance is relevant as a justification for this - all that's saying is california has fatter tail on the income distribution. You don't "own" those rich people, as the high-tax states are coming to find out with the mass exodus to florida.
Definitionally 4/10 of california residents cannot be in poverty.
This is a fiction people repeat with no citation. A large portion of the population wants m4a when it is explained to them. This "system" failure was specifically our elected reps - bipartisanly - ignoring the needs and wants of the people at the behest of their donors. The democratic process failure was when the two parties solidified.
It wasn't pitchfork wielding illiterate rubes (or whatever undoubtedly out of touch "data driven" parody of what an average person is we're operating with) trying to deny a Black man his legacy, it was that Black man's party collectively wanting to be reelected that gave us the "Buy Insurance Or We Fine You Through Taxes" Act.
That's not he way the ACA went down. Obama had this idea that the best way to reform an industry was to have it write its own reform legislation and pretty much let the industry have first draft.
> with a large portion of the population being dead set against better healthcare if it meant allowing Obama to be able to take credit for it.
The ACA was initially popular but it became increasingly unpopular during the months of horse trading, the explosion in length of the law, the jettisoning of most of the good parts (drug price controls, public option, etc), retention and expansion of industry giveaways (tax penalties), and yes, relentless Republican opposition and propaganda against it.
But even the latter was Obama's fault for not being prepared to anticipate and deal. He actually spend the first several months pushing for a "bipartisan" deal with Republicans that gave them room to delay and attack.
> with a large portion of the population being dead set against better healthcare if it meant allowing Obama to be able to take credit for it.
Obama had a filibuster-proof supermajority in congress. Yes, Republicans were going to oppose his agenda, but he didn't need them. For some dumb reason he loaded a gun, pointed it at himself and handed it to them.
There were lots of comparisons to Medicare/Medicaid being made at the time. That law was a fraction the size of ACA, the implementation phase was like a year instead of a decade for the ACA, and its effect on the public was immediate and profound.
The failure of the Obama administration was the failure of technocracy. Obama thought he could have "experts" develop the ultimate "win-win" policy. What you ended up instead was a bunch of naked self-dealing by craven opportunists who either worked for the industries they were regulating or intended to do so in the future. People saw through this and it lead directly the the rise of Trump
Both are true! The ACA is a literal life-saver and bankrupcy-avoider for a significant percentage of the population. So it is a huge win for the common person.
At the same time, yes, it perpetuates the corrupt insurance system, which is bad. But at least makes it more widely available, which is good.
> Not every system becomes more efficient with profit incentives, and this really seems like just such a case.
Health care can only ever get worse with profit incentives. The best way would be to eject all the profiteering out of the system so that only the people who provide actual care (doctors, nurses, medical technicians,etc) get paid. Remove all profit from the hangers-on that do nothing useful (insurance middlemen).
The path to get there is obvious, but politically quite impossible in the US (and only in the US, since every other country has it figured out.)
We can solve pharmaceuticals without bringing in the miasma of the broader healthcare debate.
Three things:
1. Let Medicare directly negotiate pricing on all drugs;
2. Make it easier for generics producers, including foreign manufacturers, to sell into America; and
3. Reform PBMs [1]. Transparency on pricing. Spun out of monoliths.
While we’re at it, maybe someone can figure out how to cut the $1bn it costs to get a drug to approval to something lower.
[1] https://www.congress.gov/bill/118th-congress/senate-bill/297...
I cannot emphasize enough how much of a death sentence being chronically ill before the ACA was. No protection for preexisting conditions meant one unfortunate incident could cost you your job could cost your your healthcare could cost you your ability to get back on solid footing to get another job.
I'm pretty sure that being elite is a symptom of running things, not the cause of running things.
By definition, a society’s elites always run things…
Pretty damn well in the long run!
Each of the French Revolution’s successive governments had their own sets of elites. (La Révolution itself had its elites.) Arguing against elites as a category is arguing against hierarchical sociology. It’s inchoate. We don’t have an example of a society without elites; we barely have examples of social animals without hierarchies. (Zebra herds.)
And speaking of the French Revolution, the elites ex post facto were not only mostly the same as before, they escaped with so much money and wealth that it’s actually debated if they increased their wealth share through the chaos [1].
[1] https://www.jstor.org/stable/650023
In the nearest city to me there are 3 major private hospitals, and if you head into London there are loads of them.
Private is still able to compete and to be profitable. Just no one needs to die from preventable diseases.
(not saying NHS is perfect, it is a shadow of what it should be right now)
I spent eight hours at an Accident & Emergency department at my city's hospital a couple of weeks ago (Those electric scooters look easy enough, I have a driving license, I watch the training video, then at midnight I thought I'd try one, signed it out, crashed into a lamp post within seconds, broke my hand and busted my head open. Oops. Signed the scooter back in, walked to the Urgent Care, it shuts late at night, walked towards hospital, saw a cop - "Hey, I can't see my head, I can feel the wound, is it bad?" "You should get a taxi to A&E. I'll call you one"). There is no private emergency care, private cosmetic surgery sure, and lots of private non-urgent care, like knee replacement or whatever - but no emergency care.
Much like amazon did in the early days.
When the problem is incentive structures -- of profit seeking corporations or compensation seeking individuals -- what options do you have? (IMO its only regulatory enforcement with democratic oversight and transparenct.)
I think we as a society still have to figure out ways to restructure sprawling institutions and i dont like it when people only put the blame on public or private ones while ignoring the other.
Maybe it does but not for the right people.
In the UK, they fortunately have a notion of money spent for QALYs earned (adjusted to boost life extension at end of life) but in the US everyone believes that we should spend arbitrary amounts of money on people and if we don't, we should pay their relatives extraordinary amounts to compensate for the fact that we didn't spend a few aircraft carriers worth of money on them.
Put simply, so long as US ethics remains "there is no sum of money that is too high to save an arbitrary person's life", we have to oppose the public option.
Even without that, when Cuomo in NY said he wouldn't trade grandma for a dollar, there was thunderous applause across the US. And many here argued that the economy isn't as important as any life lost. That's enough to cement it for me.
There is a real issue with regulatory capture. Making the system purely public is not going to result in the regulators suddenly purging their souls of all corruption. It'll still be a disaster just without any pretence of an alternative. There are literally people on HN every day who would happily improve on the US healthcare system's costs and outcomes if well meaning busybodies hadn't banned them from doing so by overregulating.
(separately, profit capping rules means that once a monopoly is cemented, once a company has moved as much as it can from one pocket to the other, there's an internal incentive to spend money on bureaucracy).
This is nonsense. UNH’s profit margin is all net income divided by all revenue.
https://www.macrotrends.net/stocks/charts/UNH/unitedhealth-g...
Same with Elevance, CVS, Cigna, Humana, Centene, and Molina. There is a reason all these businesses aren’t at the top of the market cap rankings. Not even in the top 100.
UNH is up there due to sheer size and the fact that they sell high profit margin software and healthcare. Otherwise, you will not get rich starting a managed care organization. Even Warren Buffet, Jeff Bezos, and Jamie Dimon ran away with their tail between their legs:
https://en.wikipedia.org/wiki/Haven_Healthcare
Unless you are saying there is something exception about the US and profit extractions?
I trust the market to provide healthcare about as much as I expect america to suddenly blast off to join the moon. And i trust vc/finance a hell of a lot less than that.
so that Americans could travel overseas and get healthcare expenses reimbursed over there.
watch prices drop...
On prescriptions, reimbursement for drugs bought from cost plus would also help drive down pharma prices
I don't understand why vertical integration is not made illegal. An insurer should not own a PBM or providers. They all should have an adverse relationship so they put cost pressure on each other.
Also, providers should charge the same prices for the same procedures no matter who pays. Ideally everybody should be mandated to follow Medicare prices. If these prices are too low to survive, then there should be a discussion about adjusting the prices.
The whole system is basically a huge bureaucracy that wastes a lot of money but some of the waste is enough profit for a lot of people to fight tooth and nail to keep the status quo.
In some cases, privacy laws require that fax machines be actively monitored so that sensitive personal information is not just left sitting around in the open for hours.
Yes, there could probably be alleviated with sort form of purely digital fax system, but for regular fax machines, this could be why they are only available during staffed hours.
Kaiser would sometimes tell me that we have to try X first before we do Y, but then the X's worked sometimes, so it seemed like they were asking for reasonable things to reduce cost.
"Unlike the traditional healthcare model, which often pits payers against providers in a bid to control costs, the payvider model merges these roles..."
- https://www.neudesic.com/blog/the-rise-of-the-payvider/
Well I decided that would be extremely inconvenient for me if that was the case, so I’m going to call this “bad regulation”, and say it’s against the “Free Market” so if you support it you are a communist.
If later on I decide this is good for me, then I will call it “good regulation” that supports the “Free Market” and you are in the clear.
All sarcasm aside, if you don’t define what your minimum set of regulations are for you to consider it a “Free Market”, then you are consigning yourself to endless bike shedding over what a “Free Market” really is
Of course, what we have today is not Adam Smith's capitalism.
> That's not capitalism. Capitalism requires heavy competition. Think restaurants for example. Extreme competition drives prices down and keeps prices fair for consumers.
No, that absolutely is capitalism. No True Scotsmanning capitalism when we see this as an end result of capitalism doesn't work as an argument.
For example, in the gig economy which is largely unregulated we see incumbents to the market get destroyed by economy of scale. Did you know Austin had its own non-profit ride-sharing app called RideAustin? Did you know that it blew up after Uber and Lyft completely pushed it out of the market?
I could go on with other examples of these issues. Like for example Bartells in Seattle being bought out by Rite Aid only to be decimated by Rite Aids shitty practices, with little to no ability for incumbents to fill the void due to the costs of rent and rising bootstrap costs. Or the way grocery companies merge and combine until we have five different brands all operating under the same owner.
Capitalism is controlled by the winners who have the most capital. Competition only vaguely exists as a way for capital to exert control.
Counter examples of capitalist industries that have lasted centuries without corporate concentration: restaurants, spas, bars, tailors, car washes, barbers, almost anywhere small businesses exist.
Adam Smith's original capitalism required free markets, which fundamentally require high competition, low barriers to entry.
The low barriers to entry component is missing from the examples you described, which is theoretically where government should step in (and lower those barriers for new companies looking to enter the market).
In healthcare, however, government is essentially working with the companies to raise barriers to entry.
You literally cannot get more unregulated than that. What is your vision here?
The nature of the market is that you need a large network of drivers to succeed. That network is a powerful barrier to entry. And it likely requires a lot of funding to achieve.
A government could foster more competition within the industry by funding new start-ups, in an effort to bring the market closer to free market status.
This is what China does with many of their industries, and they do it really well. Despite their "communist party" brand, they are actually doing capitalism much better than the US in many areas.
Mind you, it's not something I particularly disagree with, but the only way this works is by imposing regulations on the dominating market forces to prevent them from buying out the competition or using their network advantage to crush them. And regulation is considered the antithesis to a free market.
And if a monopoly were to form, it would step in.
Usually when he’d ask them about this, the process of filing these claims with the insurance companies was so onerous, they just fell way behind on the process. Typically you could resolve this by bringing in someone with a LOT of experience filing these claims I believe.
This was back in the 90s, so maybe the advent of computers has improved this particular part of the game (I’m not in the industry myself), but at least back then, it was infuriating doctors too.
I am not surprised in the least to hear that, like every other system in this economy, it seems to have gotten massively more complicated for approximately zero real-world improvement
But just as a major PBM reform bill was set to pass last December, Elon Musk fired off a series of tweets opposing it. Within hours, what had been near-unanimous support collapsed. Five days later, Musk tweeted, "What is a pharmacy benefit manager?"—as if he had only just learned about the issue.
This isn’t about whether Musk was right or wrong on PBMs (though evidence suggests reform would lower costs). The bigger issue is how a single billionaire’s influence can derail democratic processes that were functioning as intended. When a reform has broad bipartisan support, expert backing, and clear public benefits, yet can still be nuked by one well-placed tweet, that’s not just a policy failure—it’s a governance problem.
Tech billionaires reshaping policy via social media whims should concern anyone who cares about democratic accountability. If Musk can tank a bill that helps millions save on prescriptions, what else can be undone with a midnight tweetstorm?
That whole situation was so strange to me. I was in my mid-20s at the time, trying to make sense of the "adult world". Then they tell me something is both illegal and legal at the same time, depending on how your label it - like Schrodinger's cat, but dumber.
And that's when I really started to feel dirty about working for the PBM. I knew the company was part of the machine, helping push drugs onto people, purely driven by profit, not actual need. Like, I dealt with drugs dealers a bunch in college (weed, ecstasy), and none of them ever tried to push drugs onto me. They just sold it, and that was it. But I really started to see how this whole machine operated, and I was part of it. :'(
I'm sure we'll find out soon enough.
Such a pity that this is "easily" remedied via campaign finance reform and revoking Citizens United.
Plurality voting applied to the tragedy of the commons, i.e. the nash equilibrium decision matrix, results in the worst possibility if there's no basis for trust. If we could vote on the results of that matrix, by replacing {+1, 0, 0, 0...} voting with {+1, +0.5, -0.5, 0, 0, 0...} voting, things might actually improve with 3-4 viable, local parties, with smart selection of candidates actually representing districts constructively and campaigning accordingly.
But we don't have that. I fear its absence at all scales from local right on up to resolution of international conflict may end up being the Great Filter: The coordination problem of solving the tragedy of the commons in all its forms.
Source? (Not doubting you.)
https://www.managedhealthcareexecutive.com/view/pbm-reform-i...
https://x.com/elonmusk/status/1869311029131596262?lang=en
They certainly could have just done the PBM reforms in a separate bill instead of shoving it into something else…but then they potentially wouldn’t be able to get their own choice cuts of pork passed.
Anyways, seems odd to blame Musk directly for that even if his tweet did kill the bill.
Musk tanked a bill he obviously didn't read with zero plans for its replacement. So instead of a $1.7 trillion bill in December, we get roughly the same bill (that's what a continuing resolution is) plus $100bn in giveaways in March minus the PBM reforms.
Musk killed PBM reform. The fact that he was too high to know what he was doing isn't exactly redemption.