Comment by wat10000
3 days ago
The problem is that it is different. What other industry sells a product that you might need in order to survive or to not be disabled which requires the dedicated efforts of multiple professionals with a decade of post-secondary education? What other industry sells a product that you might suddenly need at a moment’s notice that is the only way you’ll survive the day, that requires sophisticated equipment, dedicated facilities, and a team of the aforementioned highly educated professionals?
Most industries are either optional things you want to have but can live without, or necessities you need on an ongoing basis that need more than a few minutes of individual attention.
There’s a lot more to medicine than emergencies and lifesaving treatments. But I think those are the original sin from which the rest flows.
The basic question is this: should people be left to die if they have a sudden life-threatening event (heart attack, hit by a bus, shot) and they can’t demonstrate an ability to pay for treatment? (Note, not the same as not being able to pay for treatment. This would potentially apply to a rich person who got mugged and left for dead, for example.)
Few will answer “yes.” And everything else flows from the “no.” The US’s universal health care system is built around it. We pretend we don’t have universal health care, but we do. It’s just tremendously shoddy and weird. The one place with universal care is the hospital emergency room. Those have been required to treat everyone regardless of ability to pay since 1986. Once you start doing that, the rest flows from there. People start saying, what if it’s not critical to survival but they’ll be crippled without it? What if it’s life critical but there’s time to verify payment?
Can we do better without removing that? No doubt. But we’ll have a hard time getting to a proper competitive market.
Other industries with these characteristics (police, firefighting, rescue, ambulance if you count that separately from medicine) are usually handled by the government or at least contracted by them.
> Few will answer “yes.” And everything else flows from the "no."
Everything else has flowed from the "no", but I do not think it needs to have. Imagine the government being a definitive payer of last resort, instead of this unfunded mandate where hospitals have to provide emergency service for free but then receive a bunch of regulatory capture to make up for it.
That still leaves an avenue for hospitals to defraud the government about how much providing that care cost, and emergency care has that dynamic intrinsically regardless of who is paying. But that's still leaps ahead of basing the entire industry on a foundation of billing fraud shakedowns. And it would be a lot harder for emergency departments to claim exaggerated fraudulent costs when the rest of the hospital is charging much less.
The vast majority of care is not life saving emergency treatment, and this is where the brokenness of the current system gets really galling. For example I just had a specialist declare that the proper course of treatment is to follow up in 12 months. I nudged them that 12 months seemed like an awful long time, but they held fast. I would happily pay for another check in 6 months if the system would let me. But instead, the concept of patient agency has been completely scrapped in favor of top down "necessary" and "not necessary".
I think there are two paths. Having the government be a payer of last resort for emergency services starts you down the road of paying for more and more things. You’ll start asking questions like, why are we paying massive amounts to stabilize a poor, terminal cancer patient who collapsed when we could have paid 10x less on screening and early treatment? Why aren’t we paying for procedures that allow people to work and bring in more taxes than the procedure costs? Why are we ok with paying to save someone’s life when they’re hours away from death but not when it’s weeks away?
Eventually you’ll get something like the systems you see in most wealthy countries.
Or you can go the way we did, which is enact universal care in the dumbest way and pretend we didn’t.
I don't agree with this dichotomy. It asserts a monolithic top-down perspective, making it completely inapplicable to the dynamic I described in my last paragraph. It's "universal care" only in the sense that its universe has been defined to exclude most patient agency. Divergence from other possible patient-desired choices then tends to get rationalized away.
For example, perhaps having a follow up after 6 months only increases the expected value of the outcome by 0.1% and then multiplied/integrated by expected lifetime earnings it's not worth the economic cost of the system paying for that earlier follow up. But being my life, I should be able to spend my resources (including my time, which this current top-down model certainly doesn't account for) to achieve an outcome with much more utility to me personally than simply how much income (/taxes) I'm expected to produce.
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