From the comments, more on health care

Again this comment is from Sure:

The US does not have a healthcare system. It has several. Medicare is single payer option with overwhelmingly private provision and some alternative administrative choices with a thick skim of secondary overlays of private health insurance. The Indian Health Service is full Beveridge. Kaiser is a single private system with nearly full vertical integration. Tricare is a social insurance model with limited private provision. Employer based healthcare is privately funded (with a generous tax break on said provision), privately administered (subject to millions of pages of regulation), and privately provisioned (with minor exceptions for state funded hospitals and the like). Then we have health sharing which are explicitly not health insurance, but involve “voluntary” assumption of costs by members, often linked by religious belief.

Then you have the growing cash healthcare option where providers take all comers, but only those who can put cash on the barrel because the paperwork is too expensive. And of all the ways healthcare is administered in this country, this and the VA are the only ones that do not run the full gamut of provision (at least not yet).

I have worked for most of these. All of them are larger systems than multiple small European countries. All of them are wildly more expensive than similar mechanisms of provision overseas. All of them suffer from intrusive, expensive meddling by politicians and bureaucrats that result in active degrading of patient care in my experience.

There is no good way to pay for healthcare in the US. Chances are, if you name an option somebody has at least failed to get the necessary buy-in at the state level. If you have some essential feature list, there is almost certainly an option that has already tried it.

Changing who signs the checks seems to make very minimal difference. We chase after crumbs by focusing on if the overall model should be more Kaiser or more IHS or more Medicaid.

The far bigger impact are the patients. We need 500 dollar chairs in the waiting room, to ensure that those with BMIs >50 will not have them collapse underneath their weight. We had to order a larger CT scanner a few years back when it was deemed unacceptable to send patients to the zoo for imaging. Opioid use means that I have to detail a lot of warm bodies to manage patients in withdrawal. I need an order of magnitude more warm bodies for suicide watch that my predecessors required back in the day according to the records (and for “low risk” suicide watches I can use telesitters to monitor multiple patients). I need huge numbers of social work hours because once patients hit the ED I need to deal with the complete lack of social service contact they had while homeless. The psychiatric population is an ever revolving door where I can make them basically normal (albeit low functioning) again with the aid of emergency required antipsychotic medications but will see them relapse once they hit the streets and discontinue care (and will have their best shot at long term recovery only once they victimize enough “good” people to get jailed). And, of course, I need an order of magnitude more expensive home health because everyone is single and estranged from the rest of humanity (most unmarried 30+ patients report having no one who can learn how to change dressings for example).

And, in spite of all this, survival rates for health matched controls are great. You get diagnosed with lung cancer? You survive longer and better in the states than your doppleganger in Britain or France. You need a liver transplant from Hep C? Get it here if you want lower rejection odds.

American healthcare starts with sicker patients and no amount of crafty planning about signing checks or shuffling patients is going to change that.


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