What is the SDN opinion on Single Payer Health Care?

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Step up your arguments

I don’t really have to. I mean it’s true. You can argue all you want about what belongs to the government, but we live in a country where we pay taxes to fund programs. As a society, we’ve decided that people who have should give a little to help the people who don’t.

Do I agree with the abuse of those programs? No. I also don’t disagree with reforming them to help cut down on that abuse.

But ultimately, you choose to live here when you don’t have to. If you want to debate whether we should have that system in place, that’s fine, but it’s really academic at this point.

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Well I mean I love America as far as its people, but I hate the government. I just mean I'd not have much to complain about. I have plenty of complaints right now.

Fair enough. There are definitely many things I would change about the current government if I could.
 
I don’t really have to. I mean it’s true. You can argue all you want about what belongs to the government, but we live in a country where we pay taxes to fund programs. As a society, we’ve decided that people who have should give a little to help the people who don’t.

Do I agree with the abuse of those programs? No. I also don’t disagree with reforming them to help cut down on that abuse.

But ultimately, you choose to live here when you don’t have to. If you want to debate whether we should have that system in place, that’s fine, but it’s really academic at this point.
Of course the discussion is about whether or not that should be in place....and the problem isn’t waste in a redistribution system, the problem is the existence of the redistribution via force
 
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Of course the discussion is about whether or not that should be in place....and the problem isn’t waste in a redistribution system, the problem is the existence of the redistribution via force
Once again I agree. But you have to put your realist shoes on for a minute.

What's your plan to reverse this and go back to a non taxed country?
 
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Of course the discussion is about whether or not that should be in place....and the problem isn’t waste in a redistribution system, the problem is the existence of the redistribution via force

I get that. But I guess my point is, what is the point of debating about whether something that exists and will continue to exist should exist in the first place when a better question would be to discuss how to improve it?

Edit: and saying, “Get rid of it,” is a non-starter.
 
Of course the discussion is about whether or not that should be in place....and the problem isn’t waste in a redistribution system, the problem is the existence of the redistribution via force
I can't speak for everyone's opinion here, but I'd venture the guess that most of us don't find redistribution via government authority (which, of course, relies on tradition and the threat of violence) as outrageous as chronic poverty and the ills that are concomitant with it to an extent. This doesn't mean abolish class society and begin communist utopia, but in the real-world outcomes it causes much less suffering than it elicits, threat of violence or not.

Neither I nor anyone else can tell you that these outcomes justify the ethical cost of enforced redistribution of wealth, that's a completely subjective value judgment, but you can also entertain how for the majority it may be different from yours.

And surely, this isn't the 18th century where you can just leave society when you disagree with it, but that issue affects everyone and not just in terms of redistribution. For good or for bad, we are bound to the laws of nations and the threats of violence that those entail.
 
I get that. But I guess my point is, what is the point of debating about whether something that exists and will continue to exist should exist in the first place when a better question would be to discuss how to improve it?

Edit: and saying, “Get rid of it,” is a non-starter.
ending slavery and women voting were nonstarters at one point too... and even if it was literally impossible to ever change, that wouldn't change that it is wrong and should
 
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ending slavery and women voting were nonstarters at one point too... and even if it was literally impossible to ever change, that wouldn't change that it is wrong and should
If you feel like those are equivalent I don't even know how to explain this to you.

People are dependent on the system. We've fed the wildlife for too long. How would you propose not babying adults when so many can't even figure out drugs, smoking, excessive drinking, excessive eating, etc are not a good idea? Literally 95% of my patients no matter of age have either used IV drugs, smoked at least a pack a day, drink heavily, or are morbidly obese. We're not the same people we were back when self sufficiency was vital.
 
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Taxes are necessary. Sure some of the things that the government uses it for are debatable, but other things the government pays for would simply be privatized if taxes were eliminated. You’ll still have to pay for those services either way.
 
And then it edged up to 11%. I would also argue we should not be content that we've taken a "step in the right direction" if we still leave most of those who were previously uninsured in that state.

Again, those who are still uninsured may not be uninsured because they cannot afford coverage but rather other issues such as those you cited below in the discussion on Medicaid. There are people who still don't understand the ACA, don't understand their eligibility, and don't understand what the subsidies mean for them. That's why the (botched) rollout of the ACA was so important.

Certainly, but that isn't a problem in those neighbors we're speaking of because it's not an opt-in program. Medicaid has structural issues that impede recognition of eligibility and use by those eligible. Single-payer is almost by definition not an opt-in service that people have to deliberate on joining or not.

A single payer system by definition will ensure coverage for all but coverage for all isn't the goal here, is it? If that's the goal, then I agree - go single payer and goal achieved. We can all go home now. No, the goal is equitable access to care for all and single payer doesn't solve that problem. Just because you're covered doesn't mean you have access to care.

It doesn't mean we need to talk about single payer. That countries with the single payer approach accomplish our coverage goals better and pay less merits that we talk about it. Hardly a nuke.

Again, yes, the countries with single payer by definition must have universal coverage. But that's not the goal. Those countries also have access problems that they are grappling with even today.

Certainly, and those outcomes seek to give an objective measurement for "what we're getting." If we could get more satisfactory results AND pay an equal or, even better, lesser amount, that would probably be dandy to those who want those satisfactory results. Conversely, that we're getting outcomes that are less satisfactory than those of other countries which pay less aggravates the issue.

Of course. And you can improve satisfaction/production by making healthcare delivery more efficient. There's no need to jump immediately to single payer.

There are ways to improve healthcare other than single payer, but the virtue of this system is that it solves the allocation issues (I don't think Americans would go out of their way to exclude 10% of their adults from insurance coverage if it came at no additional cost to insure them) while also tackling some of the already discussed healthcare cost inflation issues that stem from the current system. It'd be killing two birds with one stone assuming it could be implemented.

You're assuming not only successful implementation but also that a single payer system would be cost neutral relative to the current system. I have seen no data yet that proves that. If you know of any, please cite them here so I can take a look.
 
I believe competition and privatization rewards innovation and customer satisfaction, and voluntary choice of service is good. I find this more favorable.
Taxes are necessary. Sure some of the things that the government uses it for are debatable, but other things the government pays for would simply be privatized if taxes were eliminated. You’ll still have to pay for those services either way.
 
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Of course the discussion is about whether or not that should be in place....and the problem isn’t waste in a redistribution system, the problem is the existence of the redistribution via force

Any sort of taxation by your definition would be redistribution by force, would it not? Is there anything you could justify being taxed for? National defense? Public education?

I wish we could all live in a tax-free society where the tragedy of the commons does not exist but such is not human nature.
 
The part that says "powers not expressly given to the federal government belong to the states.

I'm not saying it stops it from happening. I'm only speaking on the constitution and its intent. Healthcare wasn't the focus- defending from the British was. Healthcare wasn't even thought of yet. This was before nightingale and the Crimean wars even.

The power of taxation is expressly given to the federal government (Article I, Section 8) and those taxes are to be used for the general welfare. In a single-payer system, all insurance "premiums" would be paid in the form of taxes and therefore would stand constitutional scrutiny. The problem isn't a constitutional one but rather a structural and logistical one.
 
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I believe competition and privatization rewards innovation and customer satisfaction, and voluntary choice of service is good. I find this more favorable.

Not necessarily. The things the government provides aren’t exactly like the latest computers or cars and etc. How much do you think libraries and roads can improve?
 
The power of taxation is expressly given to the federal government (Article I, Section 8) and those taxes are to be used for the general welfare. In a single-payer system, all insurance "premiums" would be paid in the form of taxes and therefore would stand constitutional scrutiny. The problem isn't a constitutional one but rather a structural and logistical one.
I'm not talking about taxation but the use of taxation. "Freedom for a little bit of security" bit.
 
Not necessarily. The things the provides government aren’t exactly like the latest computers or cars and etc. How much do you think libraries and roads can improve?
Well let's focus on this topic- healthcare. Just in the last couple years I've seen a huge shift from hospitals concerned with outcomes to "customer satisfaction". And many of my patients aren't happy unless they're getting 30 of roxi q8h as well as dilaudid 4mg QID. I asked a resident once why we were giving so much pain medicine to this guy "customer satisfaction. We wanna keep him happy."
 
I'm not talking about taxation but the use of taxation. "Freedom for a little bit of security" bit.

I'm sorry, I'm a bit slow witted. Are you questioning the use of taxation itself as a tool? As in, yes, the Congress has the power to tax but it's abusing that power?
 
I'm sorry, I'm a bit slow witted. Are you questioning the use of taxation itself as a tool? As in, yes, the Congress has the power to tax but it's abusing that power?
I'm not questioning taxation period. I get that we need militaries, infrastructure, etc. they lost me at the point where I can be "taxed" based on my choosing not to purchase a product that I may not ever use.

I got insurance with my RN job, and got the flu this last year. I go into the urgent care and I'm told I have a 1500$ deductible. So the cost of the visit was going to be somewhere between 250-350. And I'll never meet my deductible because the last time I've gone to the doctor for a sickness was when I was a child. I take no medications, and the only time I find myself in offices is for physicals. I said nah no thanks and walked out. It ain't gonna kill me.

So I'm paying for something that's of no use to me.
 
I'm not questioning taxation period. I get that we need militaries, infrastructure, etc. they lost me at the point where I can be "taxed" based on my choosing not to purchase a product that I may not ever use.

I see. I also disagree with the federal government compelling the purchase of a private product. I think that it's a slippery slope - if it can tax us for not purchasing insurance, it will also be able to tax us for not performing any mandated behaviors. And that's dangerous because it is the most dangerous form of coercion.

At the same time, I believe that if the government were to institute a tax specifically for managing healthcare as the single payer, I think that is different. It is providing healthcare, a service and public good just like national defense, for public use. That's different from compelling people to buy something. It's the same sort of logic used for raising funds for any public good, whether that's defense or public works. Everybody will use the healthcare system at some point in their lives so that can be used to justify it as a public good. Now, I should clarify that I am by no means a proponent of a single-payer system, as my posts above can attest. But I just think that if the majority of this country wants a single payer system, then the federal government has the constitutional grounds to institute it.
 
I see. I also disagree with the federal government compelling the purchase of a private product. I think that it's a slippery slope - if it can tax us for not purchasing insurance, it will also be able to tax us for not performing any mandated behaviors. And that's dangerous because it is the most dangerous form of coercion.

At the same time, I believe that if the government were to institute a tax specifically for managing healthcare as the single payer, I think that is different. It is providing healthcare, a service and public good just like national defense, for public use. That's different from compelling people to buy something. It's the same sort of logic used for raising funds for any public good, whether that's defense or public works. Everybody will use the healthcare system at some point in their lives so that can be used to justify it as a public good. Now, I should clarify that I am by no means a proponent of a single-payer system, as my posts above can attest. But I just think that if the majority of this country wants a single payer system, then the federal government has the constitutional grounds to institute it.
I disagree with single payer as well, but if used in the same way as a "minimum income system" as Milton Friedman actually advocated for (betcha many people didn't know that), I would have much less problem than with compulsatory insurance.
 
Again, those who are still uninsured may not be uninsured because they cannot afford coverage but rather other issues such as those you cited below in the discussion on Medicaid. There are people who still don't understand the ACA, don't understand their eligibility, and don't understand what the subsidies mean for them. That's why the (botched) rollout of the ACA was so important.
Sure, some are not covered because they don't understand their coverage. I don't think that's the majority. There's also the issue of those states which did not expand medicaid (and those in which the expansion may be reversed after this provision is phased out.)

A single payer system by definition will ensure coverage for all but coverage for all isn't the goal here, is it? If that's the goal, then I agree - go single payer and goal achieved. We can all go home now. No, the goal is equitable access to care for all and single payer doesn't solve that problem. Just because you're covered doesn't mean you have access to care.
Of course single payer isn't just an insurance scheme, it entails a public infrastructure. And while being covered doesn't necessarily mean having access to care, not being covered does mean not having access to care (bar the emergency room, free clinics, and the mythical out-of-pocket payment that the poor are unlikely to be able to afford.)

Again, yes, the countries with single payer by definition must have universal coverage. But that's not the goal. Those countries also have access problems that they are grappling with even today.
There is no such thing as a problem-free healthcare system I've ever heard of, they too encounter structural shortfalls. But those shortfalls are in great part the product of less funding than our system has and a limited supply of professionals stretched out more evenly along the population, which is more or less entailed by equitable access to care. And their problems are not nearly equal to our own in magnitude. While I know you're not doing this yourself, I think that the people that equate the hassle of using the NHS to the problems in the United States are being at least slightly disingenuous.


Of course. And you can improve satisfaction/production by making healthcare delivery more efficient. There's no need to jump immediately to single payer.
I never suggested that I advocated immediately transitioning to single payer. Transitioning out of our system would be such a complicated endeavor with so many moving parts for actual policymakers to work out I would be too arrogant to claim I know how our elected representatives would make that pan out. But single payer appears significantly more efficient at getting that delivery. Why not, if not jump, crawl to that, given the aforementioned benefits? It seems that everyone in countries of comparable wealth to our own who did is better off.


You're assuming not only successful implementation but also that a single payer system would be cost neutral relative to the current system. I have seen no data yet that proves that. If you know of any, please cite them here so I can take a look.
Any data in this regard is more or less intelligent speculation, somebody cited a number earlier in this thread but I can't vouch for its veracity. How cost-saving the system would be depends a lot on what system we're talking about, because although we simplify them all into one basket for the purpose of discussion, the public health systems of the U.K., Spain, Germany, etc. have distinct models in place despite the similar underlying single-payer idea. What those countries do have in common is that they all pay less than we do, which doesn't automatically mean that if we had an infrastructure more akin to theirs we'd pay as much as they do, but strongly suggests that we'd be approaching their per capita spending in the long run or at least move in that direction (yes, our demographic makeup and health issues entail higher costs, but I'd venture to guess, not 238% of what the Brits spend per head as we currently do.)
 
Sure, some are not covered because they don't understand their coverage. I don't think that's the majority. There's also the issue of those states which did not expand medicaid (and those in which the expansion may be reversed after this provision is phased out.)

Sure, 45% of the uninsured are uninsured because the cost of insurance is still prohibitively high. But again, that by itself doesn't warrant the logical jump to "single payer is thus necessary." There are ways to improve coverage in that population without resorting to single payer, including promoting more market competition by stabilizing the insurance markets (especially in places where insurers are exiting the marketplaces) or tweaking the subsidies given (perhaps by reducing the percentage of income that the ACA set as the maximum for what you pay for coverage).

Of course single payer isn't just an insurance scheme, it entails a public infrastructure. And while being covered doesn't necessarily mean having access to care, not being covered does mean not having access to care (bar the emergency room, free clinics, and the mythical out-of-pocket payment that the poor are unlikely to be able to afford.)

Again, this isn't as binary as you make it seem. Just because the current system isn't ideal for access doesn't mean that single payer is the only other option. The solution should be to find ways to improve access to care under less radical models. Places with single payer systems face a lot of access issues. We can get around that using more efficient private systems. Single payer should be a last resort as opposed to the first-line response.

There is no such thing as a problem-free healthcare system I've ever heard of, they too encounter structural shortfalls. But those shortfalls are in great part the product of less funding than our system has and a limited supply of professionals stretched out more evenly along the population, which is more or less entailed by equitable access to care. And their problems are not nearly equal to our own in magnitude. While I know you're not doing this yourself, I think that the people that equate the hassle of using the NHS to the problems in the United States are being at least slightly disingenuous.

Having less funding than us isn't their main problem. If throwing more money at it could fix the problem, they presumably would have made the sacrifice and done it long ago rather than suffer the way they are now. Throwing money at a single payer system doesn't solve the moral hazard problem which is what leads to long wait lists for care and dwindling medical resources. We don't face those issues at the same scale they do precisely because of our private system.

I never suggested that I advocated immediately transitioning to single payer. Transitioning out of our system would be such a complicated endeavor with so many moving parts for actual policymakers to work out I would be too arrogant to claim I know how our elected representatives would make that pan out. But single payer appears significantly more efficient at getting that delivery. Why not, if not jump, crawl to that, given the aforementioned benefits? It seems that everyone in countries of comparable wealth to our own who did is better off.

If you parse through the data, you'll find that we are better at maintaining some of the more chronic, severe conditions (which in no doubt contributes to our high costs). You would also find that another contributor to high costs is the amount of money we spend on developing new therapies that the rest of the world uses. When a company can segregate markets, the poorer countries benefit while we suffer. Other countries also have different cultures that emphasize a different set of behaviors that also contribute to health. There's a reason why Americans are becoming increasingly obese and it's not the healthcare system's fault. All these things contribute to why we're worse off and saying that switching to single-payer will lead to us becoming more like other countries assumes that we as a population respond in the same way as they do and that's not necessarily true due to different cultural and societal values.

Any data in this regard is more or less intelligent speculation, somebody cited a number earlier in this thread but I can't vouch for its veracity. How cost-saving the system would be depends a lot on what system we're talking about, because although we simplify them all into one basket for the purpose of discussion, the public health systems of the U.K., Spain, Germany, etc. have distinct models in place despite the similar underlying single-payer idea. What those countries do have in common is that they all pay less than we do, which doesn't automatically mean that if we had an infrastructure more akin to theirs we'd pay as much as they do, but strongly suggests that we'd be approaching their per capita spending in the long run or at least move in that direction (yes, our demographic makeup and health issues entail higher costs, but I'd venture to guess, not 238% of what the Brits spend per head as we currently do.)

As above, we do subsidize a lot of the health costs of other countries by paying for a lot of the R&D. This is of course not the lion's share of U.S. healthcare spending but it contributes. Again, cost can only tell part of the story. If you look at cost alone and if I concede that we might edge towards lower per capita healthcare spending if we adopt a single-payer system, you also have to consider whether Americans can live with such a system in which there are no real options for healthcare, there will be long lines to get care even if you would have been able to afford top-notch care under the current system, and very real concerns about the value of a life. I don't want the government deciding at what point it will stop paying for my care. Under a single-payer system, the government would presumably have the power to do so and I wouldn't have any other options to turn to.
 
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Of course the discussion is about whether or not that should be in place....and the problem isn’t waste in a redistribution system, the problem is the existence of the redistribution via force
That’s not a problem, it’s a foundation of a high functioning affluent society. Show me one without it. If you don’t keep enough of the people basically satisfied wrt their basic needs, you’re not going to convince them to adhere to the lolbertarian non aggression principle vis a vis You and Your Stuff.
 
I laugh at the premeds who actually think they will make half a million a year with Bernie Sanders ideals. I almost want the next president to make single payer go so far as to set salaries on all doctors to be the same with the same government mindset of “neurosurgeons became neurosurgeons because it’s their passion, not to make more money than the pediatrician.”

Choose what you love folks cuz you don’t know what non-medical professional in the White House will do to YOUR salary.
 
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Sure, 45% of the uninsured are uninsured because the cost of insurance is still prohibitively high. But again, that by itself doesn't warrant the logical jump to "single payer is thus necessary." There are ways to improve coverage in that population without resorting to single payer, including promoting more market competition by stabilizing the insurance markets (especially in places where insurers are exiting the marketplaces) or tweaking the subsidies given (perhaps by reducing the percentage of income that the ACA set as the maximum for what you pay for coverage).
There are plausible ways to try to address the individual components of our price inflated, not highly accessible system. That the single payer system has prevented these issues in developed countries before does not suggest that it is the only plausible solution, only that it's a tried and useful tool that costs less on average. "Stabilizing markets" and throwing only increases already bloated spending. It is a possible choice, but I'm at no point saying that single-payer is the only choice, only that it's the best choice we've seen.

Again, this isn't as binary as you make it seem. Just because the current system isn't ideal for access doesn't mean that single payer is the only other option. The solution should be to find ways to improve access to care under less radical models. Places with single payer systems face a lot of access issues. We can get around that using more efficient private systems. Single payer should be a last resort as opposed to the first-line response.
I'm not implying that it's a binary choice, again. Just that it's the system that has done the job for many other countries at a smaller tab, which leaves me wondering why it "should be a last resort" or what is so "radical" about it.

Having less funding than us isn't their main problem. If throwing more money at it could fix the problem, they presumably would have made the sacrifice and done it long ago rather than suffer the way they are now. Throwing money at a single payer system doesn't solve the moral hazard problem which is what leads to long wait lists for care and dwindling medical resources. We don't face those issues at the same scale they do precisely because of our private system.
Funding is a problem, and it is a talking point on virtually every electoral season in the U.K. and Spain at the very least. The reason that they don't throw more money at it is that "the way they are now" doesn't entail the suffering it entails in America. Medical resources in these countries aren't "dwindling," they are simply equitably spread. We don't face those issues because we exclude a large chunk of our population. It should be mentioned that their clinical outcomes are still comparable to ours and that their disease burden is lower than our own (even though they spend half or less than what we do in those resources.)

...Also, the anecdotal "I waited so and so much to see my doctor" is more common in the United States than in those neighbors.
Am4y4qI.png


If you parse through the data, you'll find that we are better at maintaining some of the more chronic, severe conditions (which in no doubt contributes to our high costs).
We have slightly better outcomes for people who receive that maintenance. If we excluded 10% of the United Kingdom's population from any care, the remaining 90% would also have a higher budget to maintain their chronic diseases.

This doesn't of course mean that the United States is the best in every outcome. We do many right things in disease management, and as such have better cancer 5 year survivals and stroke management than most of them. We still see a comparable if not slightly higher mortality from clinically treatable diseases in the United States, and higher DALYs than most of them (the latter, naturally, also the result of other health issues)
UkZ4dkm.png
(source for this and the previous graph)
You would also find that another contributor to high costs is the amount of money we spend on developing new therapies that the rest of the world uses. When a company can segregate markets, the poorer countries benefit while we suffer.
Though surely we spend more than other countries on pharmaceutical research (graph below) and probably on clinical research as well, this HARDLY explains the gap in costs.
medperhead_large.gif

Other countries also have different cultures that emphasize a different set of behaviors that also contribute to health. There's a reason why Americans are becoming increasingly obese and it's not the healthcare system's fault. All these things contribute to why we're worse off and saying that switching to single-payer will lead to us becoming more like other countries assumes that we as a population respond in the same way as they do and that's not necessarily true due to different cultural and societal values.
This is very vague on your part. Though as of last year we had 36% adult obesity prevalence in adults compared to 24% in the United Kingdom (source) our bill is over twice as big. As for the "cultural" aspect, I ask that you clarify your point since I cannot conceive of the American cultural values (as opposed to varied Spanish, British, Italian, German, etc.) that would make us decline healthcare when offered at no additional cost or would make us hostile to the idea of universal coverage. I don't ask this to be disingenuous, I can grasp how the United States is different from European neighbors, simply not how this would make single payer not significantly more effective than the current system.

As above, we do subsidize a lot of the health costs of other countries by paying for a lot of the R&D. This is of course not the lion's share of U.S. healthcare spending but it contributes.
Per the previously embedded graph, less than 5% of the gap.

Again, cost can only tell part of the story. If you look at cost alone and if I concede that we might edge towards lower per capita healthcare spending if we adopt a single-payer system, you also have to consider whether Americans can live with such a system in which there are no real options for healthcare,
As has been amply mentioned in this thread, there ARE real options for healthcare in most of these systems. Public healthcare infrastructure does not private hospitals exclude.

there will be long lines to get care even if you would have been able to afford top-notch care under the current system, and very real concerns about the value of a life.
Refer to my first graph in this post about those lines. And please, again, be a bit more specific with what the value of life issue is. These countries don't fail to value life, and they certainly do a better job at preserving this life in the entirety of their constituents as opposed to those able to foot the bills.
I don't want the government deciding at what point it will stop paying for my care. Under a single-payer system, the government would presumably have the power to do so and I wouldn't have any other options to turn to.
As already mentioned, you do have options other than public hospitals, and the governments of those countries aren't simply terminating patients when it becomes inconvenient to hold them. This sounds too much like Sarah Palin's famous "death panels" and is also a very sensationalistic concern raised by American conservatives against single-payer, given the higher mortality that the alternative entails for less visible and accounted-for citizens.
 
Any sort of taxation by your definition would be redistribution by force, would it not? Is there anything you could justify being taxed for? National defense? Public education?

I wish we could all live in a tax-free society where the tragedy of the commons does not exist but such is not human nature.
National defense is a legitimate federal function and we got by for quite some time without a federal income tax

We do not need a federal dept of education
 
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If you feel like those are equivalent I don't even know how to explain this to you.

People are dependent on the system. We've fed the wildlife for too long. How would you propose not babying adults when so many can't even figure out drugs, smoking, excessive drinking, excessive eating, etc are not a good idea? Literally 95% of my patients no matter of age have either used IV drugs, smoked at least a pack a day, drink heavily, or are morbidly obese. We're not the same people we were back when self sufficiency was vital.
Darwinism man, it shouldn’t obligate anyone else just because I make bad decisions with my life
 
Darwinism man, it shouldn’t obligate anyone else just because I make bad decisions with my life
True but do you really think the MILLIONS of people who rely on the system will just change?
 
National defense is a legitimate federal function and we got by for quite some time without a federal income tax

We do not need a federal dept of education

I see. We can go on and on about what we do or do not need. I don't think we need a federal Dept of Education either. But do you believe that the federal government had the constitutional power to expand to its current state or do you think the mere existence of some federal programs/departments is unconstitutional? Because if you do, then that's a whole other discussion and I understand why we would differ on so much.
 
There are plausible ways to try to address the individual components of our price inflated, not highly accessible system. That the single payer system has prevented these issues in developed countries before does not suggest that it is the only plausible solution, only that it's a tried and useful tool that costs less on average. "Stabilizing markets" and throwing only increases already bloated spending. It is a possible choice, but I'm at no point saying that single-payer is the only choice, only that it's the best choice we've seen.

I'm not implying that it's a binary choice, again. Just that it's the system that has done the job for many other countries at a smaller tab, which leaves me wondering why it "should be a last resort" or what is so "radical" about it.

You mean it is the best choice we haven't seen. Just because other countries use it at lower cost doesn't mean that it can be implemented in the U.S. with similar per capita costs. That's assuming too much on your part. Do you have any data on per capita Medicare or VA costs relative to private payer? From all the data I've seen, Medicare costs are very similar to private payer costs even though Medicare is more like a single-payer system for the elderly. The VA is probably one of the largest examples of what government-run healthcare might look like in the U.S. and while they seem to have good health outcomes, there are access issues as well as bureaucratic ones that need to be dealt with.

Funding is a problem, and it is a talking point on virtually every electoral season in the U.K. and Spain at the very least. The reason that they don't throw more money at it is that "the way they are now" doesn't entail the suffering it entails in America. Medical resources in these countries aren't "dwindling," they are simply equitably spread. We don't face those issues because we exclude a large chunk of our population. It should be mentioned that their clinical outcomes are still comparable to ours and that their disease burden is lower than our own (even though they spend half or less than what we do in those resources.)

America spends a lot of money advanced medical and surgical techniques and treatments that other countries don't have or use other alternatives for. Further, I agree that we have a lot of low-value care. If I want an MRI of my knee to make sure that nothing's wrong even if my doctor doesn't think there's anything wrong, then I should be able to get it on the 1% chance that something might actually be wrong. If a single payer system is to reduce cost, then that system will necessarily deny that test. We can argue all day about whether I should be given that option and whether personal choice should be taken into account and that gets into the core of the issue. Americans like choice and many people think that healthcare choices should be made just like any other consumer choice - by the consumer and not by some paternalistic third party.

We have slightly better outcomes for people who receive that maintenance. If we excluded 10% of the United Kingdom's population from any care, the remaining 90% would also have a higher budget to maintain their chronic diseases.

We have better outcomes overall in those chronic conditions, not just for people who receive treatment. The Kaiser data doesn't include only those patients who receive treatment. Most of these studies also have lead time bias issues where we do a great job of early detection and screening.

Though surely we spend more than other countries on pharmaceutical research (graph below) and probably on clinical research as well, this HARDLY explains the gap in costs.

You can't look at the spending on R&D alone. You also have to consider that once those drugs are developed, the markets can be split so that what the UK government pays for a certain drug won't equal what we pay for it. In many cases, what other countries pay for the same drug here is much less, with a notable example being Sovaldi. So not only do we spend more in pharmaceutical research, we also spend more on clinical treatments that result from that research (which would be wrapped into the hospital charges that make up the vast majority of US health spending).

This is very vague on your part. Though as of last year we had 36% adult obesity prevalence in adults compared to 24% in the United Kingdom (source) our bill is over twice as big. As for the "cultural" aspect, I ask that you clarify your point since I cannot conceive of the American cultural values (as opposed to varied Spanish, British, Italian, German, etc.) that would make us decline healthcare when offered at no additional cost or would make us hostile to the idea of universal coverage. I don't ask this to be disingenuous, I can grasp how the United States is different from European neighbors, simply not how this would make single payer not significantly more effective than the current system.

The American cultural value of personal freedom of choice and self determination. Most of the European countries are perfectly content in trading a little liberty for security, so to speak. We as a country simply are not. If I have a disease that is treatable but costs a lot, I want to be able to get that treatment if I can afford it (or if I can afford the premium for private insurance that pays for it). I don't want the government saying that they won't pay for it because it's too expensive. See what happened in the UK with palbociclib.

As has been amply mentioned in this thread, there ARE real options for healthcare in most of these systems. Public healthcare infrastructure does not private hospitals exclude.

The name "single-payer" is self-explanatory, really. If we've been talking about a two-tiered system this entire time, then some of my objections would disappear. You should be more careful about throwing the word "single-payer" around if there isn't going to be a single payer.

Refer to my first graph in this post about those lines. And please, again, be a bit more specific with what the value of life issue is. These countries don't fail to value life, and they certainly do a better job at preserving this life in the entirety of their constituents as opposed to those able to foot the bills.

Cost effectiveness threshold. If there is a single-payer, that single-payer then has all the power to set the cost effective threshold for any treatment and therefore also to deny access to that treatment if it is deemed not cost effective. If it costs $1 million per QALY, you can bet they're probably not gonna cover it. That's where having private payers can give patients more choices. They could always go to another country for treatment but I would rather have a private system where that isn't necessary.
 
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Darwinism man, it shouldn’t obligate anyone else just because I make bad decisions with my life

This is your opinion on how taxes work, but many including me do not share it. I am more than willing to pay into a system from which others derive benefit so that I may withdraw from it when I need it. This is how our system works in terms of police/firefighting services (your semantics aside), road maintenance, and public schools, and there is no reason to say that the same logic cannot be extended to healthcare, especially if it provides potential solutions to our out-of-control health spending that those like you arguing against single-payer have provided no alternatives for.

It is also a gross oversimplification and frankly insulting to assert that all those utilizing healthcare services do so because of poor life decisions. What about genetic conditions one is born with? Getting hit by a drunk driver? Accidents that occur while engaging in sport? These are not things that should have to be explained to you at this point in your life, but you have certainly not gotten where you are alone - sometimes people just need a helping hand. Show some compassion, for god's sake. (Edited for grammar - I'm hopeless)
 
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Haven't read this entire thread, forgive me. But, my .02.....

I think an argument for moving healthcare more into the government's domain really revolves around what is overall best for the country and its government. We can argue and debate wait times, physician pay, and all those details. Sure. But, isn't it in the best interest of the government, to have a healthy citizenry? Shouldn't the federal government strive to ensure its population is fit, healthy, and in a state of overall well-being?

An easy example of this is in the realm of infectious disease. Look at HCV. Sovaldi is currently marketed in the US for curing Hep C infection. Gilead owns the IP rights and it currently costs about $84,000 for the 12 week treatment. That's before any rebates and coupons, etc. etc. Now, ironically, when you watch a Sovaldi commercial, it doesn't mention any Hep C rates from around the world. It's not advertising for that. Instead, it only mentions the Hep C rates in the US. Where patients may actually be able to afford it.

Now, back to my original point. Since HCV is an infectious agent. Wouldn't it be in our best interest to do everything we can to limit transmission, infection rates, etc.? On top of that, isn't it in our best interest, if we have a drug that can cure the viral infection, to use this as much as possible? I think the answer is yes but we currently can't. Because a private company bought the IP rights and has the price on lock down. This company is publicly shared on the stock exchange and its shareholders are making money. While many individuals with HCV can't afford the cure.

If there was a way that the government could negoitate drug prices like they do via medicare, the price could go down and be more affordable. That would mean less transmission, more cures, and a overall healthier population. Instead, with this simple example of HCV, the potential profit is in the hands of a private corporation. And the government can't do much about it.

I personally think capitalism is great and the free market is awesome. But it has its limits. Healthcare is one of them.
 
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You mean it is the best choice we haven't seen. Just because other countries use it at lower cost doesn't mean that it can be implemented in the U.S. with similar per capita costs. That's assuming too much on your part. Do you have any data on per capita Medicare or VA costs relative to private payer? From all the data I've seen, Medicare costs are very similar to private payer costs even though Medicare is more like a single-payer system for the elderly. The VA is probably one of the largest examples of what government-run healthcare might look like in the U.S. and while they seem to have good health outcomes, there are access issues as well as bureaucratic ones that need to be dealt with.
VA is a minority competitor in a largely private market, meaning it has to compensate pharmaceuticals, distributors, and employees at similar levels as everyone else or face the prospect of being cut off from other products. Hardly the same as National Health Service. It's not too much on my part to guess that an insurance covering everybody has stronger leverage to keep costs reasonable as it does elsewhere.

America spends a lot of money advanced medical and surgical techniques and treatments that other countries don't have or use other alternatives for. Further, I agree that we have a lot of low-value care. If I want an MRI of my knee to make sure that nothing's wrong even if my doctor doesn't think there's anything wrong, then I should be able to get it on the 1% chance that something might actually be wrong. If a single payer system is to reduce cost, then that system will necessarily deny that test. We can argue all day about whether I should be given that option and whether personal choice should be taken into account and that gets into the core of the issue. Americans like choice and many people think that healthcare choices should be made just like any other consumer choice - by the consumer and not by some paternalistic third party.
And again, those alternatives do exist in private hospitals in countries with single-payer. We've mentioned multiple times this here, countries with single payer do have private alternatives just as you may take your children to private school in the United States. And, Americans who receive no coverage may or may not like choice, but financial necessity precludes their choice in the first place.


We have better outcomes overall in those chronic conditions, not just for people who receive treatment. The Kaiser data doesn't include only those patients who receive treatment. Most of these studies also have lead time bias issues where we do a great job of early detection and screening.
My mistake. That Kaiser source also cites https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2014.0174 which, accounting for that lead-time bias, shows we don't outperform Western Europe in all these metrics despite spending much, much more than they do, concluding with "Our results suggest that cancer care in the United States may provide less value than corresponding cancer care in Western Europe for many leading cancers."

You can't look at the spending on R&D alone. You also have to consider that once those drugs are developed, the markets can be split so that what the UK government pays for a certain drug won't equal what we pay for it. In many cases, what other countries pay for the same drug here is much less, with a notable example being Sovaldi. So not only do we spend more in pharmaceutical research, we also spend more on clinical treatments that result from that research (which would be wrapped into the hospital charges that make up the vast majority of US health spending).
Indeed, those countries spend less on medications and procedures which cost similar amounts of money to produce and perform as in the United States. This is another area where a national public insurance, with the higher bargaining capacity that it entails, helps reduce costs for those using the public system. The providers of those price-inflated goods and services are less likely to be willing to be left out of a system which most people use than they are of being willing to be left our from insurance competitor X or Y, who also has the interest of providing comparable goods and services from its competition and is therefore more willing to budge to those inflated costs at the expense of those paying premiums. This is one of the structural causes of bloated costs I argued single payer would help remediate earlier.


The American cultural value of personal freedom of choice and self determination. Most of the European countries are perfectly content in trading a little liberty for security, so to speak. We as a country simply are not. If I have a disease that is treatable but costs a lot, I want to be able to get that treatment if I can afford it (or if I can afford the premium for private insurance that pays for it). I don't want the government saying that they won't pay for it because it's too expensive. See what happened in the UK with palbociclib.
This seems like a broad generalization of what "self-determination" means to people, and one that neglects that private insurance providers also decline medications on the basis of cost. You are, again, not precluded by national health insurance from buying costly medications on your own, either structurally or by law. Also one that neglects, as I have repeated before, that a significant number of Americans lacks any such agency in reality. Even if Americans are so set on their individual agency, it seems anything but rational for the majority of those unable to pay healthcare costs out of pocket in the first place to support a system with all the right incentives to keep costs high for everyone and exclude them or their options on that basis.
(Also, palbociclib was approved after the NICE negotiated a lower price with manufacturers—which benefits all. Not quite a story of the shortcomings of national insurance)

The name "single-payer" is self-explanatory, really. If we've been talking about a two-tiered system this entire time, then some of my objections would disappear. You should be more careful about throwing the word "single-payer" around if there isn't going to be a single payer.
There is a single-payer system in countries like the U.K. in that there is a single public authority paying for healthcare. That physicians and hospitals may, independently of the single-payer system, open up shop and that patients and private insurance providers may use these systems does not take away from the "single-payer"ness of the public system.


Cost effectiveness threshold. If there is a single-payer, that single-payer then has all the power to set the cost effective threshold for any treatment and therefore also to deny access to that treatment if it is deemed not cost effective. If it costs $1 million per QALY, you can bet they're probably not gonna cover it. That's where having private payers can give patients more choices. They could always go to another country for treatment but I would rather have a private system where that isn't necessary.
Refer to my previous paragraph in regard to the argument that consumers lack choices because in a single-payer system.
The cost effectiveness threshold reflects an attempt to quantify spending in a reality where healthcare resources are limited and need to be allocated rationally. They're not just a consideration for private insurance in the United States, which, as mentioned, declines medications on the basis of their cost-ineffectiveness as well. They're a consideration for the under-insured who pay copious co-pays (no alliteration intended) for expensive treatments, not to mention the uninsured who want to avoid financial ruin. It seems that the choice we're making here is reserved for a very small number of people—who again would not be precluded of choice because of a public insurance system—at the expense of a system that is more expensive for everyone and excludes more people. So again, given "single-payer" doesn't entail making private hospital industries illegal virtually anywhere (and as a consequence you can find an ample range of private hospitals in all the countries I've mentioned so far,) and that the wealthy for whom costly treatment that strains resources is not a financial concern are unlikely to be deterred from paying an extra million dollars per QALY, or a really expensive private insurance because of what in the United Kingdom amounts to less than $4,000 a year per head in public spending, whose rights to individual agency are we protecting, and at how much of an expense in terms not only money, but also human cost?
 
And again, those alternatives do exist in private hospitals in countries with single-payer. We've mentioned multiple times this here, countries with single payer do have private alternatives just as you may take your children to private school in the United States. And, Americans who receive no coverage may or may not like choice, but financial necessity precludes their choice in the first place.

here is a single-payer system in countries like the U.K. in that there is a single public authority paying for healthcare. That physicians and hospitals may, independently of the single-payer system, open up shop and that patients and private insurance providers may use these systems does not take away from the "single-payer"ness of the public system.

By definition you are describing a two tier system which is not single payer. That’s one issue I see with your argument with Aldol in that you will present a discussion point for a true single payer system and then respond to his discussion points describing dynamics that exist in a two tiered system.
 
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By definition you are describing a two tier system which is not single payer. That’s one issue I see with your argument with Aldol in that you will present a discussion point for a true single payer system and then respond to his discussion points describing dynamics that exist in a two tiered system.
Except, countries generally defined as single-payer do have private hospital systems and private insurers. This doesn't mean you can "opt-out," nor does it mean that single-payer is exclusive. It does mean that you cannot "opt out" of being covered by the "single-payer" system, which is different from being precluded from adding private insurance coverage, what is referred to as "two-tiered," as in this convenient Wikipedia article on single-payer care:
Single-payer contrasts with other funding mechanisms like 'multi-payer' (multiple public and/or private sources), 'two-tiered' (defined either as a public source with the option to use qualifying private coverage as a substitute, or as a public source for catastrophic care backed by private insurance for common medical care), and 'insurance mandate' (citizens are required to buy private insurance which meets a national standard and which is generally subsidized).
This isn't to say that I find such "two-tiered" system unreasonable, perhaps I should have been more general in my use indeed.
 
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By definition you are describing a two tier system which is not single payer. That’s one issue I see with your argument with Aldol in that you will present a discussion point for a true single payer system and then respond to his discussion points describing dynamics that exist in a two tiered system.

We have been talking about what Bernie Sanders calls "Medicare-for-all," which the OP referred to as single-payer but as I understand it would still allow for a private insurance market.
 
True but do you really think the MILLIONS of people who rely on the system will just change?
People are responsible for themselves. They can make good choices or bad and all the repurcussions of those choices are theirs...it’s not actually anyone else’s problem if they don’t change
I see. We can go on and on about what we do or do not need. I don't think we need a federal Dept of Education either. But do you believe that the federal government had the constitutional power to expand to its current state or do you think the mere existence of some federal programs/departments is unconstitutional? Because if you do, then that's a whole other discussion and I understand why we would differ on so much.
of course not
 
This is your opinion on how taxes work, but many including me do not share it. I am more than willing to pay into a system from which others derive benefit so that I may withdraw from it when I need it. This is how our system works in terms of police/firefighting services (your semantics aside), road maintenance, and public schools, and there is no reason to say that the same logic cannot be extended to healthcare, especially if it provides potential solutions to our out-of-control health spending that those like you arguing against single-payer have provided no alternatives for.

It is also a gross oversimplification and frankly insulting to assert that all those utilizing healthcare services do so because of poor life decisions. What about genetic conditions one is born with? Getting hit by a drunk driver? Accidents that occur while engaging in sport? These are not things that should have to be explained to you at this point in your life, but you have certainly not gotten where you are alone - sometimes people just need a helping hand. Show some compassion, for god's sake. (Edited for grammar - I'm hopeless)
There is no compassion in taking other people’s stuff, don’t pat yourself on the back for supporting that

I’m all for personal voluntary charity and do quite a bit of it. I vehemently oppose the notion that anyone has a right to claim my stuff against my will

And the best solution to out of control spending is to force people to actually pay for their own care, that would force price shopping and negotiation to a degree we have forgotten recently
 
Societies where there are wealthy people and also people literally getting thrown out of the hospital to die in the street are not stable, safe or pleasant to live in. Yes it is your problem if you’d like to live in peace with your stuff unmolested.

Have you ever asked yourself why every even moderately prosperous nation has some degree of redistribution in place? Do you suppose it’s all dewy eyed charity? Think again.
 
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VA is a minority competitor in a largely private market, meaning it has to compensate pharmaceuticals, distributors, and employees at similar levels as everyone else or face the prospect of being cut off from other products. Hardly the same as National Health Service. It's not too much on my part to guess that an insurance covering everybody has stronger leverage to keep costs reasonable as it does elsewhere.

An insurance covering everybody as a single payer system has a monopsony but that also means that it has the power to decide what to pay for and what not to pay for. That's is inherent in a single-payer system that does not have a strong private sector to compete with.

And again, those alternatives do exist in private hospitals in countries with single-payer. We've mentioned multiple times this here, countries with single payer do have private alternatives just as you may take your children to private school in the United States. And, Americans who receive no coverage may or may not like choice, but financial necessity precludes their choice in the first place.

Do those countries have private insurers? Private hospitals =/= private insurers. If there is a strong private insurance market (which would make the whole system no longer single-payer), then I would have no objections. The problem is that there is no strong private insurance market in a single-payer market (which is precisely what makes it a single payer market). If I could choose between a public option (which I may be mandated to contribute some small amount into in the form of taxes) and private options that may have more generous coverage, then I would have no problem with that system. I have a problem with single-payer systems - not with systems with a public coverage option, even if everyone has to pay into that public option.

My mistake. That Kaiser source also cites https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2014.0174 which, accounting for that lead-time bias, shows we don't outperform Western Europe in all these metrics despite spending much, much more than they do, concluding with "Our results suggest that cancer care in the United States may provide less value than corresponding cancer care in Western Europe for many leading cancers."

Let me read that more in depth and get back to you.

Indeed, those countries spend less on medications and procedures which cost similar amounts of money to produce and perform as in the United States. This is another area where a national public insurance, with the higher bargaining capacity that it entails, helps reduce costs for those using the public system. The providers of those price-inflated goods and services are less likely to be willing to be left out of a system which most people use than they are of being willing to be left our from insurance competitor X or Y, who also has the interest of providing comparable goods and services from its competition and is therefore more willing to budge to those inflated costs at the expense of those paying premiums. This is one of the structural causes of bloated costs I argued single payer would help remediate earlier.

The costs of R&D remain and somebody has to eat the cost somewhere in order to drive innovation. If a company knows that it can develop a drug and have market exclusivity for 20 years where it can charge a premium to recuperate R&D costs and make a profit, then it will fund that kind of research. If you have a monopsony where the pharma company must take the lower costs that the single payer deigns it appropriate to give, you remove that incentive for research into innovative new treatments. If we all suddenly start paying less for drugs, somebody somewhere must eat that cost - otherwise that's just stifling innovation.

This seems like a broad generalization of what "self-determination" means to people, and one that neglects that private insurance providers also decline medications on the basis of cost. You are, again, not precluded by national health insurance from buying costly medications on your own, either structurally or by law. Also one that neglects, as I have repeated before, that a significant number of Americans lacks any such agency in reality. Even if Americans are so set on their individual agency, it seems anything but rational for the majority of those unable to pay healthcare costs out of pocket in the first place to support a system with all the right incentives to keep costs high for everyone and exclude them or their options on that basis.
(Also, palbociclib was approved after the NICE negotiated a lower price with manufacturers—which benefits all. Not quite a story of the shortcomings of national insurance)

Private insurers deny coverage on the basis of cost but their thresholds vary and you can usually find some private insurer who will cover something that you might want if you were to come down with a condition in the future. That's the beauty of having competition. In a single-payer system, you don't have any options. The decision by the single payer to cover or not cover is final. You would have to eat the costs all by yourself and that is not effective risk-pooling. I want a situation where I can be insured against whatever condition I want - if the public option doesn't cover it, there should be private options that make up the difference. I shouldn't be forced to eat the cost.

It is a shortcoming if a lower price had not been negotiated, as in the case of a company refusing to budge. It can always market its drug in another market that is willing to pay the higher cost. The U.S. market is large, but companies now have access to global markets. What happens in a single-payer system when the drug company refuses to accept the lower price for the drug? Make anybody who wants it pay out-of-pocket entirely?

There is a single-payer system in countries like the U.K. in that there is a single public authority paying for healthcare. That physicians and hospitals may, independently of the single-payer system, open up shop and that patients and private insurance providers may use these systems does not take away from the "single-payer"ness of the public system.

You're talking now about a system with a public option but still with private insurers. In the case of the UK, the market share is dominated by the public option so it resembles but is not a single payer system. That's when you run into the problems I outlined earlier, where you don't have strong competition because there's not a strong private market. There simply aren't that many competitors. If you're advocating for a strong public option but an equally or slightly less strong private market (with any one private insurer holding only a small portion of the remaining market share thereby giving the public option the plurality of the market share), then we can find some agreement.

The cost effectiveness threshold reflects an attempt to quantify spending in a reality where healthcare resources are limited and need to be allocated rationally. They're not just a consideration for private insurance in the United States, which, as mentioned, declines medications on the basis of their cost-ineffectiveness as well. They're a consideration for the under-insured who pay copious co-pays (no alliteration intended) for expensive treatments, not to mention the uninsured who want to avoid financial ruin. It seems that the choice we're making here is reserved for a very small number of people—who again would not be precluded of choice because of a public insurance system—at the expense of a system that is more expensive for everyone and excludes more people. So again, given "single-payer" doesn't entail making private hospital industries illegal virtually anywhere (and as a consequence you can find an ample range of private hospitals in all the countries I've mentioned so far,) and that the wealthy for whom costly treatment that strains resources is not a financial concern are unlikely to be deterred from paying an extra million dollars per QALY, or a really expensive private insurance because of what in the United Kingdom amounts to less than $4,000 a year per head in public spending, whose rights to individual agency are we protecting, and at how much of an expense in terms not only money, but also human cost?

The cost effectiveness threshold is an arbitrary threshold that sets an arbitrary limit on the value of a QALY. As I've said again and again, although any individual insurer might deny coverage based on a specific cost-effectiveness threshold, if there is strong private competition, I will be able to find a private insurer with the generous coverage that I desire - I would just have to pay a higher cost for it. And if that's okay with me, I should be able to do so and purchase that coverage. That's the difference between having a strong private insurance market and having just private hospitals. It should be obvious that in any democratic society, if I have the money to buy any treatment outright, I should be able to do so even in a single-payer system. Nobody is arguing against that straw man. But the question is, what if I don't have the cashflow to shell out $300,000 a year in a treatment but I am willing to pay $30,000 a year in an insurance policy that would cover that condition should I come down with it? In a true single-payer system, I don't have that option because there are no private insurers. But in a system with a public option and some strong private competition, I would be able to find just such a policy and purchase it. Now you might decide that the arbitrary coverage limits set by the public option are okay for you and decide to stick with that. That's fine with me. As long as I have the choice to purchase the kind of coverage that I want.
 
An insurance covering everybody as a single payer system has a monopsony but that also means that it has the power to decide what to pay for and what not to pay for. That's is inherent in a single-payer system that does not have a strong private sector to compete with.
Given that that system is accountable to our representative bodies, this doesn't translate into some Draconian scenario where people don't receive care because they have no options. The competition is with the elected officials of other parties, and a look at election season in the United Kingdom will show how real it is.

Do those countries have private insurers? Private hospitals =/= private insurers. If there is a strong private insurance market (which would make the whole system no longer single-payer), then I would have no objections. The problem is that there is no strong private insurance market in a single-payer market (which is precisely what makes it a single payer market). If I could choose between a public option (which I may be mandated to contribute some small amount into in the form of taxes) and private options that may have more generous coverage, then I would have no problem with that system. I have a problem with single-payer systems - not with systems with a public coverage option, even if everyone has to pay into that public option.
Private hospitals, though they can be used by a public insurance, often do entail a private one in countries that have a public infrastructure. But yes, those countries have private alternatives, that, as discussed with AnatomyGrey, don't allow citizens to "opt out" of the single-payer system but allow additions to it. This is virtually every aforementioned country, I cannot think of a country where private insurance is illegal or nonexistent to use the term "single-payer" in this sense in. Sorry if my vocabulary wasn't clear.
As for strength, I don't know what you'd qualify as "strong," but there are multiple private insurance options.

The costs of R&D remain and somebody has to eat the cost somewhere in order to drive innovation. If a company knows that it can develop a drug and have market exclusivity for 20 years where it can charge a premium to recuperate R&D costs and make a profit, then it will fund that kind of research. If you have a monopsony where the pharma company must take the lower costs that the single payer deigns it appropriate to give, you remove that incentive for research into innovative new treatments. If we all suddenly start paying less for drugs, somebody somewhere must eat that cost - otherwise that's just stifling innovation.
The R&D investment gap, per the graph I posted earlier, is less than 10% of the gap between the U.S. and the United Kingdom (which is pretty low on the scale even compared to its peers.) A significant percentage, of that R&D necessary for innovation goes through our NIH, which receives somewhere north of $30 billion/year assuming they haven't recently cut their funding as well. The health technology sector, which as defined by the graph below includes pharma and (I believe) all those administrative middle-men who distribute that technology to hospitals for fat profits, is not very lacking in its profit margins, only comparable perhaps to banks. Increased bargaining leverage and a public health infrastructure could help curb the business of those middlemen and companies raising everyone's costs and making the bulk of the excess profits of our system. Hardly to stifle innovation in an industry for which billions upon billions of dollars just go to shareholders and administrators.
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Private insurers deny coverage on the basis of cost but their thresholds vary and you can usually find some private insurer who will cover something that you might want if you were to come down with a condition in the future. That's the beauty of having competition. In a single-payer system, you don't have any options. The decision by the single payer to cover or not cover is final. You would have to eat the costs all by yourself and that is not effective risk-pooling. I want a situation where I can be insured against whatever condition I want - if the public option doesn't cover it, there should be private options that make up the difference. I shouldn't be forced to eat the cost.
The existence of aforementioned private alternatives aside, how many people do you think have this alternative in the present state of affairs? This is with the benefit of no "pre-existing condition" based exclusion, legislated into being because the competitors had no interest in covering patients who are a burden to the pool (and the profits) that allows you to change your coverage plan. We're trading the theoretical agency of someone who can just pay a higher premium for no coverage at all (and who would still be treated for his condition, as women with breast cancer were not denied coverage when palbociclib wasn't in the NHS) for over 30 million Americans.

It is a shortcoming if a lower price had not been negotiated, as in the case of a company refusing to budge. It can always market its drug in another market that is willing to pay the higher cost. The U.S. market is large, but companies now have access to global markets. What happens in a single-payer system when the drug company refuses to accept the lower price for the drug? Make anybody who wants it pay out-of-pocket entirely?
There are indeed global markets, as there were when palbociclib was negotiated down. The deterrent of the overwhelming majority of the population of a country like the United Kingdom (of 65 million people) was evidently a sufficiently strong deterrent to get Pfizer, perhaps the world's biggest and most global pharmaceutical company, to enter negotiations and lower its price to a more reasonable amount. I wouldn't imagine a smaller effect with the bargaining power of a country of over 300 million people. If the drug company is, in theory, yet undeterred, you take it out of the public insurance. Doesn't entail its exclusion from private insurers, though those can also refuse to distribute the drug on their own by virtue of being privately owned for the interest of profit or at the very least, solvency.


You're talking now about a system with a public option but still with private insurers. In the case of the UK, the market share is dominated by the public option so it resembles but is not a single payer system. That's when you run into the problems I outlined earlier, where you don't have strong competition because there's not a strong private market. There simply aren't that many competitors. If you're advocating for a strong public option but an equally or slightly less strong private market (with any one private insurer holding only a small portion of the remaining market share thereby giving the public option the plurality of the market share), then we can find some agreement.
Though I already addressed the first part of this paragraph, please tell me what a "not strong private market is." Does covering a smaller share of the population make them less willing to risk pool those willing to pay higher premiums, as you suggested? Most people don't go into those expensive risk pools because either they cannot afford them (as is the case with so many Americans) or because they'd just rather use their money in a public alternative that is rather competent despite anecdotal complains.


The cost effectiveness threshold is an arbitrary threshold that sets an arbitrary limit on the value of a QALY. As I've said again and again, although any individual insurer might deny coverage based on a specific cost-effectiveness threshold, if there is strong private competition, I will be able to find a private insurer with the generous coverage that I desire - I would just have to pay a higher cost for it. And if that's okay with me, I should be able to do so and purchase that coverage. That's the difference between having a strong private insurance market and having just private hospitals. It should be obvious that in any democratic society, if I have the money to buy any treatment outright, I should be able to do so even in a single-payer system. Nobody is arguing against that straw man. But the question is, what if I don't have the cashflow to shell out $300,000 a year in a treatment but I am willing to pay $30,000 a year in an insurance policy that would cover that condition should I come down with it? In a true single-payer system, I don't have that option because there are no private insurers. But in a system with a public option and some strong private competition, I would be able to find just such a policy and purchase it. Now you might decide that the arbitrary coverage limits set by the public option are okay for you and decide to stick with that. That's fine with me. As long as I have the choice to purchase the kind of coverage that I want.

I'll respond to this better once you have clarified what you mean by strong competition. But let's assume that there is a weak competition in, say, the United Kingdom, because the majority of individuals who would be making up those competitor risk pools just opt to stick with the public system. By opting for a private system instead, are we not coercing those people who would be in your theoretical risk pool to pay more for their coverage, aside from refusing coverage to those for whom competitors are not affordable enough (see graph below)? Private insurances in aforementioned countries are optional, which means they rely on the opting in of individuals for their competitiveness. Which returns us to the earlier question, too, of who these individuals are (and how many there are) for whom under $5,000 per head in public spending (less than we foot on public health spending right now from our own taxes!) is a deterrent in getting a $30,000 insurance coverage they would choose to go into anyways. If we can curb the costs they incur via the government (i.e. reduce that public health spending on the tax dollar) with a public majority system, are we not essentially leaving those $30,000-premium-insurances at the mercy of individual choice? And then, can we say that we have reduced the agency of those who would go into this $30,000 insurance coverage when so many of them decide it's not necessary for their individual "self-determination" that those are not viable?
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Edited grammar and added some semantic clarity
 
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Given that that system is accountable to our representative bodies, this doesn't translate into some Draconian scenario where people don't receive care because they have no options. The competition is with the elected officials of other parties, and a look at election season in the United Kingdom will show how real it is.

Do we really want to get into a discussion about whether the majority of our current representative bodies is actually accountable to reason? Everywhere I look, it's becoming more draconian. Thank goodness they were one vote away from sending us back into the stone age where high-risk pools would have become even more real. These are the people you trust to determine what to pay for and what not to pay for? You're digging your own grave.

As for strength, I don't know what you'd qualify as "strong," but there are multiple private insurance options.

Options =/= strong competition. I think we all understand that. If the private "option" is junk or very limited in terms of options, then that's not true competition. A strong private sector exists if, say, I want coverage for drug A just in case I ever came down with disease A but since it's $1 million a year, the public option won't cover it. If I can find a private insurer that will offer me such a plan at actuarially-fair price (with a reasonable load), then that's a strong private sector. If there's not a strong private sector, then I won't be able to get that option. Perhaps there's enough crowd out of the private sector by the public option that there aren't enough people to do adequate risk pooling.

But for the sake of discussion, let's put an arbitrary number on it. Let's say for discussion's sake that the private market has no less than a 33% share of the insurance market (that is, everybody contributes to the public option but those who want to can find and buy extra coverage for what they want - this represents 33% of the total pool).

The R&D investment gap, per the graph I posted earlier, is less than 10% of the gap between the U.S. and the United Kingdom (which is pretty low on the scale even compared to its peers.) A significant percentage, of that R&D necessary for innovation goes through our NIH, which receives somewhere north of $30 billion/year assuming they haven't recently cut their funding as well. The health technology sector, which as defined by the graph below includes pharma and (I believe) all those administrative middle-men who distribute that technology to hospitals for fat profits, is not very lacking in its profit margins, only comparable perhaps to banks. Increased bargaining leverage and a public health infrastructure could help curb the business of those middlemen and companies raising everyone's costs and making the bulk of the excess profits of our system. Hardly to stifle innovation in an industry for which billions upon billions of dollars just go to shareholders and administrators.

I agree that marketing and administration costs can be cut. But you're assuming that if revenue declines for a pharma company, they cut marketing and administration first before digging into R&D. That's usually not the case. R&D goes first - that's why so many big companies now have M&A departments instead of R&D. It's easier for them to shift risk onto smaller companies - and those companies don't have the marketing budget to cut.

Slightly off topic, but sorry to break it to you - the NIH doesn't need $30 billion/year to carry out its mission. It funds a lot of junk research that isn't ever actually used to improve human health and there are many many better things to do with that money (subsidizing insurance for the poor, for example). They need to either get their funding cut or somehow become much more efficient with how they make funding allocations.

The existence of aforementioned private alternatives aside, how many people do you think have this alternative in the present state of affairs? This is with the benefit of no "pre-existing condition" based exclusion, legislated into being because the competitors had no interest in covering patients who are a burden to the pool (and the profits) that allows you to change your coverage plan. We're trading the theoretical agency of someone who can just pay a higher premium for no coverage at all (and who would still be treated for his condition, as women with breast cancer were not denied coverage when palbociclib wasn't in the NHS) for over 30 million Americans.

Don't compare your "single-payer" system to the current state of affairs. As I said, if your sole goal is to get universal coverage, then by definition, there's no better way to do it than through a single-payer system - and a real one at that. Compare your single payer system with no or few private alternatives to one in which a strong private market (defined as above) exists in conjunction with a public system. Everybody would be covered but those who wish to purchase more expensive coverage have the option to do so. Everybody gets the same basal level of care. Better than no care at all, which is what they would have now. Now argue why a single-payer system or one in which the private sector occupies a much smaller share than 33% of the market is better.

There are indeed global markets, as there were when palbociclib was negotiated down. The deterrent of the overwhelming majority of the population of a country like the United Kingdom (of 65 million people) was evidently a sufficiently strong deterrent to get Pfizer, perhaps the world's biggest and most global pharmaceutical company, to enter negotiations and lower its price to a more reasonable amount. I wouldn't imagine a smaller effect with the bargaining power of a country of over 300 million people. If the drug company is, in theory, yet undeterred, you take it out of the public insurance. Doesn't entail its exclusion from private insurers, though those can also refuse to distribute the drug on their own by virtue of being privately owned for the interest of profit or at the very least, solvency.

The problem isn't that a huge market can't force the seller to reconsider. That point was well established when the idea of a monopsony was invented. The problem is that the forced lowering of that price causes what economists like to call a deadweight loss and seller must eat that. As I have argued above, the first things to go aren't marketing and advertising but R&D. R&D will become less lucrative for big and small companies alike - and you're going to have less innovation. If the cuts could somehow affect only marketing and advertising, you might be able to get away with it but this market doesn't respond in that way. Even if your drug works super well, nobody is going to know about it if you're not talking about it at the latest meeting of specialists in your field or giving samples to providers to let them try it out.

Though I already addressed the first part of this paragraph, please tell me what a "not strong private market is." Does covering a smaller share of the population make them less willing to risk pool those willing to pay higher premiums, as you suggested? Most people don't go into those expensive risk pools because either they cannot afford them (as is the case with so many Americans) or because they'd just rather use their money in a public alternative that is rather competent despite anecdotal complains.

Having a tiny market share means that risk pooling is not as effective (law of large numbers and regression to the mean and all) and so insurers must take on more uncertainty, which is then reflected in premiums. It's not a matter of an expensive risk pool - expensive risk pools are expensive now not because people want more things to be covered but rather because they come in with a pre-existing expensive condition. If I wanted coverage for a $1 million/year treatment and my chance of actually getting said disease was 1%, then the actuarially fair premium would be $10,000 per year. But if I have that condition and then want coverage for it, then the actuarially fair premium would be $1 million/year - it's just pre-paid healthcare at that point. That's the key difference. Expensive pools now are expensive due to the latter and so-called "high-risk pools" which are really "lots of sick people" pools rather than the former. The point is, if I want more expensive coverage for a condition I don't have yet but might come down with in the future, I should be able to purchase it at a reasonable (actuarially-fair plus some load) price if the public option doesn't cover it.

I'll respond to this better once you have clarified what you mean by strong competition. But let's assume that there is a weak competition in, say, the United Kingdom, because the majority of individuals who would be making up those competitor risk pools just opt to stick with the public system. By opting for a private system instead, are we not coercing those people who would be in your theoretical risk pool to pay more for their coverage, aside from refusing coverage to those for whom competitors are not affordable enough (see graph below)? Private insurances in aforementioned countries are optional, which means they rely on the opting in of individuals for their competitiveness. Which returns us to the earlier question, too, of who these individuals are (and how many there are) for whom under $5,000 per head in public spending (less than we foot on public health spending right now from our own taxes!) is a deterrent in getting a $30,000 insurance coverage they would choose to go into anyways. If we can curb the costs they incur via the government (i.e. reduce that public health spending on the tax dollar) with a public majority system, are we not essentially leaving those $30,000-premium-insurances at the mercy of individual choice? And then, can we say that we have reduced the agency of those who would go into this $30,000 insurance coverage when so many of them decide it's not necessary for their individual "self-determination" that those are not viable?

You lost me at coercion. Nobody "opts" into a private system. By definition, the private system is one that naturally occurs in a society where free markets rule. Even if being in a private system is a force of coercion, I'm not suggesting that we as a society need to stick with the private-only sector. I'm saying, as I have been since the beginning, that I am firmly against any single-payer system. Again, a single-payer system is a system where, surprisingly, there is only a single payer. I'm also against any system that has such weak private competition as to make it effectively a single-payer system. If the government has decided that it will pay $50,000 per QALY and no more and I believe that my life is worth $100,000 per QALY, why shouldn't I be able to take out a policy for the remainder?
 
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Do we really want to get into a discussion about whether the majority of our current representative bodies is actually accountable to reason? Everywhere I look, it's becoming more draconian. Thank goodness they were one vote away from sending us back into the stone age where high-risk pools would have become even more real. These are the people you trust to determine what to pay for and what not to pay for? You're digging your own grave.
I'm digging no such grave, we can argue this through heuristics of how bad government is or point to the fact that removing ACA altogether was as politically impossible as it is politically impossible for parties in the U.K., Spain, etc. to do these theoretical draconian policies.


Options =/= strong competition. I think we all understand that. If the private "option" is junk or very limited in terms of options, then that's not true competition. A strong private sector exists if, say, I want coverage for drug A just in case I ever came down with disease A but since it's $1 million a year, the public option won't cover it. If I can find a private insurer that will offer me such a plan at actuarially-fair price (with a reasonable load), then that's a strong private sector. If there's not a strong private sector, then I won't be able to get that option. Perhaps there's enough crowd out of the private sector by the public option that there aren't enough people to do adequate risk pooling.

But for the sake of discussion, let's put an arbitrary number on it. Let's say for discussion's sake that the private market has no less than a 33% share of the insurance market (that is, everybody contributes to the public option but those who want to can find and buy extra coverage for what they want - this represents 33% of the total pool).
As I explained earlier, reducing the share of the public sector reduces its bargaining power. As for the choice point, I will address it at the end with your last paragraph for the purpose of brevity.

I agree that marketing and administration costs can be cut. But you're assuming that if revenue declines for a pharma company, they cut marketing and administration first before digging into R&D. That's usually not the case. R&D goes first - that's why so many big companies now have M&A departments instead of R&D. It's easier for them to shift risk onto smaller companies - and those companies don't have the marketing budget to cut.
Refer to my earlier graph on research. Much smaller countries than our own with public insurance schemes and much reasonable prices contribute their proportional share of R&D. Though this is more solid evidence than any deduction on the behavior of pharma you or I can come up with, I would guess that it is because the incentive for R&D (larger dividends in the future) doesn't disappear when you stop making absurd profit margins for your products. And because R&D is still necessary to have exclusive rights to sell your pharmaceutical products, given that patents eventually do expire.

Slightly off topic, but sorry to break it to you - the NIH doesn't need $30 billion/year to carry out its mission. It funds a lot of junk research that isn't ever actually used to improve human health and there are many many better things to do with that money (subsidizing insurance for the poor, for example). They need to either get their funding cut or somehow become much more efficient with how they make funding allocations.
Though I would welcome it, I have no data to speak of NIH's research funding breakthrough/junk ratio relative to private. My point was that a significant portion of the R&D funding goes through the taxpayer indeed.

Now argue why a single-payer system or one in which the private sector occupies a much smaller share than 33% of the market is better.
See point #2 for why I don't think having a smaller share of the market allocated to public sector is "better." I also never argued about additional private options being bad, it looks like you're trying to pin me to that position for ease of arguing. Save your energy.



The problem isn't that a huge market can't force the seller to reconsider. That point was well established when the idea of a monopsony was invented. The problem is that the forced lowering of that price causes what economists like to call a deadweight loss and seller must eat that. As I have argued above, the first things to go aren't marketing and advertising but R&D. R&D will become less lucrative for big and small companies alike - and you're going to have less innovation.
See my point above, with the linked graph. Trying to shorten these responses.


If the cuts could somehow affect only marketing and advertising, you might be able to get away with it but this market doesn't respond in that way. Even if your drug works super well, nobody is going to know about it if you're not talking about it at the latest meeting of specialists in your field or giving samples to providers to let them try it out.
Except, again, this is not the case at all in countries with overwhelmingly public insurance health schemes. They're paying a fraction of what we do for the same medications, and don't for that reason have their doctors advertised less towards. Their incentive to keep making returns doesn't go away because their profit margins are suddenly proportional with those of almost every other industry


Having a tiny market share means that risk pooling is not as effective (law of large numbers and regression to the mean and all) and so insurers must take on more uncertainty, which is then reflected in premiums. It's not a matter of an expensive risk pool - expensive risk pools are expensive now not because people want more things to be covered but rather because they come in with a pre-existing expensive condition. If I wanted coverage for a $1 million/year treatment and my chance of actually getting said disease was 1%, then the actuarially fair premium would be $10,000 per year. But if I have that condition and then want coverage for it, then the actuarially fair premium would be $1 million/year - it's just pre-paid healthcare at that point. That's the key difference. Expensive pools now are expensive due to the latter and so-called "high-risk pools" which are really "lots of sick people" pools rather than the former. The point is, if I want more expensive coverage for a condition I don't have yet but might come down with in the future, I should be able to purchase it at a reasonable (actuarially-fair plus some load) price if the public option doesn't cover it.
I understand what risk pools are, but thank you. It seems like the collective "let's give everyone favorable risk pools" in this instance is overshadowing the "let's give everyone the ability to choose their care." But this relates to my last point too, so let me respond after this last quote.

You lost me at coercion. Nobody "opts" into a private system. By definition, the private system is one that naturally occurs in a society where free markets rule. Even if being in a private system is a force of coercion, I'm not suggesting that we as a society need to stick with the private-only sector. I'm saying, as I have been since the beginning, that I am firmly against any single-payer system. Again, a single-payer system is a system where, surprisingly, there is only a single payer. I'm also against any system that has such weak private competition as to make it effectively a single-payer system. If the government has decided that it will pay $50,000 per QALY and no more and I believe that my life is worth $100,000 per QALY, why shouldn't I be able to take out a policy for the remainder?

Your reasoning appears to go "public system is something" ergo "no public system is default."

The "defaultness" here is not relevant, we're discussing two different sets of policies because both can be instituted (i.e. we can have a private system without so many of the burdens of our own and we can have a single-payer or two-tiered system, call it what you may.) Because of that, we have to ask what in a system that is public but which offers private options (like those in aforementioned countries) makes the competition weak. These are countries in which, again, the public burden of healthcare is lower, meaning that they should if anything have more of the income designated for health spending to set aside for private insurance. Yet, as you probably are aware, 33% of the health insurance market share in the United Kingdom doesn't belong to private insurers.
If a theoretical Brit has the real option to enter into a private insurance that covers medications that the NHS won't, but, most likely does not, what is keeping him or her out of that risk pool? It doesn't appear to be the exorbitant cost of the private option. Now, this person in the majority has the option to continue using the NHS or live in a private system that may cost him more (and the citizens of the UK overwhelmingly don't want to get rid of their NHS)—if we were to institute such a private system, would his transition into his less desired choice be coercing?
And if such a system has the merit on its own of more favorable risk pools for those seeking alternative treatment options, are those individuals which in countries with public health insurance (who we can assume would also exist in a homologous system in the United States, else 33% private market would never become an issue) not also having their agency and, in your words, "self-determination" curbed for the sake of, instead of their country, the other members of their alternative higher-cost-drug-paying risk pool? It seems like your reasoning of prioritizing this self agency is selective to you and those who would, private or public insurance aside, choose to enter into that pool regardless of system. If those were or are numerous enough in America to cushion expensive risk pools, then we're discussing a non-issue because nobody wants to make private insurance illegal and those risk pools would populate themselves. If they are not and we need a limited public system so that people are sufficiently incentivized to go into the private alternative, are we not taking those people's right to a favorable choice away as well? And in the process hurting the public risk pool (see my point after your second quote) for the sake of the alternative?

This is a very wordy way to stress my earlier point that, in a system with a public default option, the private alternatives exist and occupy a market share consistent with public options. If they aren't more competitive, it is not because of the law but because their target public prefers the public alternative, which is as much a reflection on agency and self-determination as the choice of someone who doesn't like the public alternative.

Edit: typed first point, meant to say second
 
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You guys are giving some really good insight into this issue. Being able to have intellectual discussions like these are part of why I want to go into medicine. That being said, you have also made me remember how grateful I am to never have to take the CARS section again.
 
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When everyone is guaranteed healthcare, eventually the entity that is paying for the healthcare can dictate life choices.

The question is: are you okay with the government regulating aspects of citizens lives more closely regarding things like: smoking, alcohol, fattening food, sugar, exercise etc?
 
I'm digging no such grave, we can argue this through heuristics of how bad government is or point to the fact that removing ACA altogether was as politically impossible as it is politically impossible for parties in the U.K., Spain, etc. to do these theoretical draconian policies.

Repealing the federal income tax is politically impossible. Undoing social security benefits is politically impossible. Skinny repeal of ACA was one vote shy of being extremely possible. To the point of reality, really. Your bar for "impossible" must be pretty low.

As I explained earlier, reducing the share of the public sector reduces its bargaining power. As for the choice point, I will address it at the end with your last paragraph for the purpose of brevity.

So your argument is 100% public option or bust? Reducing the share of the private sector reduces its bargaining power in a graded fashion just like any other market. Just because you take 33% of the market power away and split it up among a lot of smaller companies doesn't mean that that 67% market power under a single public option goes poof. As I say below, as long as you're arguing for a public option that competes with private options in the market and let the pieces fall where they may, I would accept any allocation that results from that - whether it's 99% public or 50%. The question is, would you?

Refer to my earlier graph on research. Much smaller countries than our own with public insurance schemes and much reasonable prices contribute their proportional share of R&D. Though this is more solid evidence than any deduction on the behavior of pharma you or I can come up with, I would guess that it is because the incentive for R&D (larger dividends in the future) doesn't disappear when you stop making absurd profit margins for your products. And because R&D is still necessary to have exclusive rights to sell your pharmaceutical products, given that patents eventually do expire.

It's not a deduction, it's from experience working in and with pharma. Throughout my PhD in chemistry, I worked with pharma companies and saw a lot of what goes on behind the scenes in their marketing and R&D schemes. A big pharma company isn't going to cut marketing just because you stop paying them as much for their drugs. They're going to cut R&D and shift risk to smaller companies by buying up drugs that the smaller companies develop first. Small companies may not have the marketing divisions or market power to bring their drug all the way to market and so they sell out to the bigger companies. This is happening today at a faster and faster rate. It's how the world works. So no, R&D isn't necessary to have exclusive rights to some product. Not if they can acquire it from a smaller company, which is what they're doing now to a large extent.

Though I would welcome it, I have no data to speak of NIH's research funding breakthrough/junk ratio relative to private. My point was that a significant portion of the R&D funding goes through the taxpayer indeed.

Most of the costly parts of R&D are born out by pharma companies, not by NIH-funded research. Even if I grant you that 60% of NIH funding goes on to produce a useful therapeutic for human use, that's far outshadowed by the billions that pharma companies sink into developing even just one drug (Innovation in the pharmaceutical industry: New estimates of R&D costs - ScienceDirect). That amount of NIH funding is equivalent to developing 7 or 8 drugs a year (and that data is old, not taking into account the even higher costs needed to develop biologics and precision medicine nowadays). And that's a generous estimate for the NIH since a lot of NIH funding ends up in projects that further human knowledge but do not end up being used to benefit humans clinically.

See point #2 for why I don't think having a smaller share of the market allocated to public sector is "better." I also never argued about additional private options being bad, it looks like you're trying to pin me to that position for ease of arguing. Save your energy.

Save us both the time by being clear with what you're supporting. First you argue for "single-payer" systems and now you believe that some private competition is okay? How much? You think that 33% market share is too high. Give me a number at which that share would be acceptable to you.

Except, again, this is not the case at all in countries with overwhelmingly public insurance health schemes. They're paying a fraction of what we do for the same medications, and don't for that reason have their doctors advertised less towards. Their incentive to keep making returns doesn't go away because their profit margins are suddenly proportional with those of almost every other industry

And why can those countries pay less? Because we're the cash cow here for pharma. We effectively subsidize the rest of the world's drugs. Take that away and who eats the cost? You seem to be under the impression that you can just take some money away and no one will have to bear the cost. Who bears the cost? The pharma companies. What do they do to bear the costs? Invest less. It's not rocket science here. Just basic accounting. Other countries can pay less now because we pay more. And when that goes, not only is pharma revenue and investment going to drop, they're also going to have to charge other countries higher prices. I wonder what will happen to the costs in other countries then.

Your reasoning appears to go "public system is something" ergo "no public system is default."

The "defaultness" here is not relevant, we're discussing two different sets of policies because both can be instituted (i.e. we can have a private system without so many of the burdens of our own and we can have a single-payer or two-tiered system, call it what you may.) Because of that, we have to ask what in a system that is public but which offers private options (like those in aforementioned countries) makes the competition weak. These are countries in which, again, the public burden of healthcare is lower, meaning that they should if anything have more of the income designated for health spending to set aside for private insurance. Yet, as you probably are aware, 33% of the health insurance market share in the United Kingdom doesn't belong to private insurers.
If a theoretical Brit has the real option to enter into a private insurance that covers medications that the NHS won't, but, most likely does not, what is keeping him or her out of that risk pool? It doesn't appear to be the exorbitant cost of the private option. Now, this person in the majority has the option to continue using the NHS or live in a private system that may cost him more (and the citizens of the UK overwhelmingly don't want to get rid of their NHS)—if we were to institute such a private system, would his transition into his less desired choice be coercing?
And if such a system has the merit on its own of more favorable risk pools for those seeking alternative treatment options, are those individuals which in countries with public health insurance (who we can assume would also exist in a homologous system in the United States, else 33% private market would never become an issue) not also having their agency and, in your words, "self-determination" curbed for the sake of, instead of their country, the other members of their alternative higher-cost-drug-paying risk pool? It seems like your reasoning of prioritizing this self agency is selective to you and those who would, private or public insurance aside, choose to enter into that pool regardless of system. If those were or are numerous enough in America to cushion expensive risk pools, then we're discussing a non-issue because nobody wants to make private insurance illegal and those risk pools would populate themselves. If they are not and we need a limited public system so that people are sufficiently incentivized to go into the private alternative, are we not taking those people's right to a favorable choice away as well? And in the process hurting the public risk pool (see my point after your second quote) for the sake of the alternative?

This is a very wordy way to stress my earlier point that, in a system with a public default option, the private alternatives exist and occupy a market share consistent with public options. If they aren't more competitive, it is not because of the law but because their target public prefers the public alternative, which is as much a reflection on agency and self-determination as the choice of someone who doesn't like the public alternative.

I understand your point. But realize that you are not arguing for a single payer system or even very much of a two-tiered system. What you're arguing for is a public option with a set benefit schedule that competes with private options equally in the market. And let the pieces fall where they may. If 99% of people elect to take up the public option and only that, then that means that 99% of people believe that the public option is sufficient to meet their goals. If this is the case, then I have no quarrel with that. As long as the private option exists and people have the right to freely choose to purchase private coverage (even if everyone contributes to the public option). My only concern in that case would be what premiums the public option would set - I would agree only if they were actuarially fair or very close to it.
 
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Taxes are necessary. Sure some of the things that the government uses it for are debatable, but other things the government pays for would simply be privatized if taxes were eliminated. You’ll still have to pay for those services either way.

If you did use per mile use fees for roads, people who drive less would pay less.

Similarly, forced national health insurance is forced subsidy of obesity, smoking, risky sex, and those with a lot of leisure preference.

If you could deliver a plan that is much more efficient, then, not very objectionable. But requiring subsidy of voluntary risks in an extremely inefficient system?
 
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