Comment by mindslight
3 days ago
> 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.
It sounds like you’re talking about what you want, and I’m talking about how I think things are. I don’t see a wealthy country being able to do anything other than some form of universal care with heavy government involvement in the industry to make it happen. There’s nothing preventing it in terms of economics or technology, I just don’t think people will accept it.
Most of these systems do allow that sort of patient agency for those who can afford it, though. Maybe you had a weird specialist who didn’t want to see you earlier, but there are plenty of doctors who will go beyond your insurance coverage in exchange for cash.