Life expectancy rise in rich countries slows down: took 30 years to prove

> the free market-based US healthcare system

market, maybe, "free" market? I doubt it.

It's not a very free market when there is such a large power differential between the buyer and the seller. You can't exactly shop around for the ambulance or the hospital when you need it, nor can you realistically circumvent the artificially constrained supply [1] of doctors to get cheaper healthcare (unless you live next to the border).

When the alternative is a one-sided market like this, government becomes rather more appealing.

1. https://en.wikipedia.org/wiki/American_Medical_Association#R...

> You can't exactly shop around

The vast bulk of health care is by appointment, not a dash in the ambulance.

Even so, when was the last time someone needed cancer treatment but said "ooh, that's pricey, nah, I'd rather buy a new car instead".

This is my main argument against private healthcare: there's no real choice involved. Without even getting into what a free market is and perfect information etc, the main advantage of a capitalist society is you get to choose what you like. Nobody chooses healthcare (at least, not the super expensive part).

You’re still significantly limited by your insurance carrier’s network and also the consolidation of the healthcare industry. I used to live in a city of 1 million that had essentially two hospital networks that bought everything. You could not find a specialist not associated with those two companies. Pre-natal, allergy, cardiac, two choices. When my seventy year old doctor who ran a practice out of his house retired he sold the practice to one of the two.

It’s not shopping for a tv. You can’t choose not to buy. It’s often time sensitive even if by appointment. Pricing is incredibly complex as are the details of the product. Your average person does not have the information necessary to navigate the market.

To me that is the funny thing today if you look at markets Chinese markets under it's communist system are actually freer than US. China is not interested any 1 company getting a monopoly and becoming more powerful than the government so they promote finance multiple companies resulting in a truer capitalist market than the US.

It's so ironic. Market competition is definitely intense over there.

Even for non-emergency, the short amount of time before a health issue turn serious means that it's already hard for you to take second opinion.

There's also a lot of regulation and lots of subsidies (the US has similar per capita public spending to Canada - old people on Medicare are not cheap). If something is so heavily regulated and subsidised that the private sector is only there to outsmart the government to line their pockets, it's inferior to even a public system.

Even more fun is when your doctor refers you to a specialist that's in-network, but your insurance comes up with a bunch of reasons to deny it.

How did we collectively decide that it's okay for insurance companies to overrule medical professionals?

"free" is newspeak for "rules only apply to the poor, ie.e the lower 99.9%"

Not really. Chinese SOEs comprise around 60% of market capitalization and around 23% of GDP, far higher than USA or other developed economies.

While they do have a competitive market, the government very much does pick and choose winners and loosers here like Huawei, resulting in consolidation into a few large conglomerates like every other country. Their (software) tech scene certainly dosen't like more particularly "capitalist" than Big Tech, nor is the Fed pumping subsidies to Tesla like BYD, if anything they're sidelining Elon Musk.

>>the free market-based US healthcare system

>market, maybe, "free" market? I doubt it.

The consumer of healthcare is doubly removed from the price of healthcare. This is the opposite of a free market.

The patient did not pay the doctor, the insurance company does. In most cases the patient does not pay for insurance their employer does.

So the normal pricing forces of a free market are removed.

Then we need to talk about certificate of need laws which restrict the supply...

The free market aspect is the insurance marketplace.

If you’re poor, you’re fucked. If you’re old you’re ok. If you work for the government or certain companies, you have access to world class care. Everyone else is on a spectrum from high quality PPO to the shittiest Cigna plan.

There is no free market when pain and distress is involved, that is for sure.

When I am psychotic I cannot exactly choose which psychiatric hospital I want to check into and ponder about the price to put it off for another day.

And this is what the free market did to psychiatric hospitals: https://www.wral.com/holly-hill-hospital/21507953/

There is nothing free about the health insurance market. It is regulated to hell to the point where a common complaint of actuaries I know is that they are not allowed to price your health risk.

> Chinese markets under it's communist system are actually freer than US

Right up until the moment that the CCP decides to purge your entire sector, sure. I don't know if it counts as "free" if the government stands ready to nuke the sandbox they so generously let you play in.

https://www.reuters.com/technology/beijings-regulatory-crack...

AFAIK the overruling is done by a "medical professional" as well, albeit one that's on the insurance company's payroll.

^ When the grossly overweight 60yo smoker pays the same amount as a health-conscious 30yo, we have a problem.

The American health care system is also highly regulated. There’s nothing free about it in any sense if the word.

Maybe but I'm more concerned about a) easily demonstrable and measurable risks not being addressed and b) separating people from the consequences of their own choices.

Ignoring risk and consequences doesn't make them go away.

What about the 60 year old with autoimmune issues? That have expensive drugs but it wasn’t “their actions” that led to this?

The entire system only works if healthy 30 year olds are putting in somewhat similarly (it will be cheaper regardless). Insurance is based on the idea of spreading risk. Without it insurance cannot function.

Even the insurance side isn't really a free market. I've only ever gotten like two choices of insurance provider at any job I've had. More than two plans, but very limited provider choices. You can't get a job offer and then during onboarding say, "sorry, this insurer is unreliable, can we use this other provider instead?"

A large portion of healthcare could be free market. Insurance should be for unlikely events not every single thing deemed "medical". My home and auto insurance don't cover regular costs for maintenance. Why must health insurance cover a checkup with the doctor?

> the patient does not pay for insurance their employer does

Not really true, as the employer could otherwise pay that money to the employee who would then shop for his own insurance. So the employee pays, but doesn't have a choice.

The US healthcare system is deeply flawed but only a small fraction of spending goes to emergency care involving ambulance transportation. The vast majority of healthcare spending is for elective services and patients do have time to shop around. Self-insured employers have been cutting costs by pushing employees to high-deductible health plans with HSAs, which gives plan members a financial incentive to find cheaper options. Of course there are still challenges around getting meaningful price estimates from providers despite recent federal regulations on this topic.

> This is my main argument against private healthcare: there's no real choice involved.

Is your argument that there is choice involved in public healthcare? Or simply that it's not even a question?

other than normal doctor’s office visits, i have no idea what i’m going to pay when i get a small procedure done.

a basic heart ultrasound cost me over $1k while my vasectomy cost me a $60 copay. i was expecting those prices to be flipped.

and don’t get me started on labs. i’ve gotten bills for basic screens years later for thousands of dollars.

you can’t shop around if you don’t know what you’ll pay until months after it happens. if you call the insurance company beforehand you wait on a static filled line with a call center in india, and even with the CPT code they can’t give you a straight answer.

It's usually not the same amount. The Affordable Care Act (Obamacare) explicitly allows health plans to set premiums based on age and smoking status. However, this might not capture the full risk differential for some members.

https://www.cms.gov/marketplace/private-health-insurance/mar...

There's a deeper philosophical question here about how we should spread risks and costs across society. Like should some plan members pay more because they have a history of cancer, or because they engage in risky activities like flying light airplanes?

But what's the point of a health care system where only those that don't need it can afford it?

Legally speaking the insurance company isn't overruling medical professionals. They're simply refusing to pay. Patients still have the option of paying for treatments out of pocket. (I do understand that for poor patients this is a distinction without a difference, I'm just clarifying the legal issue.)

Some states have recently passed laws which limit the authority of health plans to conduct medical reviews or deny payment for services that providers deem medically necessary. This will reduce hassles and expenses for some patients, but it will also accelerate the inflation of insurance premiums paid by everyone else.

On the subject of (b), shouldn't tobacco companies be paying the risk premium for their customers? Why does the buck stop at the individual consumers and not those making money from their misery?

To put it into more technical, economic terms: why should the individual tobacco consumer bear the full cost of their externalities while the tobacco company does not?

You would expect market cap of the largest players to decline if the market becomes more competitive... which was China's primary goal with their recent crackdown.

They proactively forced interconnectivity and limited the ability for companies to make "walled-garden peudo-monopolies", as we have in the US with Apple and Google.

If the same happens here (through act of congress, or legal outcomes), you can expect their market caps to decline as well. A decline in market cap doesn't speak at all to whether it's beneficial to the industry or consumers

> They proactively forced interconnectivity and limited the ability for companies to make "walled-garden peudo-monopolies", as we have in the US with Apple and Google.

WeChat is the inspiration for the idea of the "everything app" that so many US companies want to create but have always failed to. Has it somehow been newly limited in its ability to control an absurd percentage of all Chinese internet-connected activity?

> ^ When the grossly overweight 60yo smoker pays the same amount as a health-conscious 30yo, we have a problem.

It depends on what your goals are. The reasoning behind why the ACA ("Obamacare") is the way it is:

> Suppose you want to make health coverage available to everyone, including people with pre-existing conditions. Most of the health economists I know would love to see single-payer — Medicare for all. Realistically, however, that’s too heavy a lift for the time being.

> For one thing, the insurance industry would not take kindly to being eliminated, and has a lot of clout. Also, a switch to single-payer would require a large tax increase. Most people would gain more from the elimination of insurance premiums than they would lose from the tax hike, but that would be a hard case to make in an election campaign.

> Beyond that, most Americans under 65 are covered by their employers, and are reasonably happy with that coverage. They would understandably be nervous about any proposal to replace that coverage with something else, no matter how truthfully you assured them that the replacement would be better.

> So the Affordable Care Act went for incrementalism — the so-called three-legged stool.

> It starts by requiring that insurers offer the same plans, at the same prices, to everyone, regardless of medical history. This deals with the problem of pre-existing conditions. On its own, however, this would lead to a “death spiral”: healthy people would wait until they got sick to sign up, so those who did sign up would be relatively unhealthy, driving up premiums, which would in turn drive out more healthy people, and so on.

> So insurance regulation has to be accompanied by the individual mandate, a requirement that people sign up for insurance, even if they’re currently healthy. And the insurance must meet minimum standards: Buying a cheap policy that barely covers anything is functionally the same as not buying insurance at all.

> But what if people can’t afford insurance? The third leg of the stool is subsidies that limit the cost for those with lower incomes. For those with the lowest incomes, the subsidy is 100 percent, and takes the form of an expansion of Medicaid.

* https://archive.is/HzS1G / https://www.nytimes.com/2017/07/10/opinion/obamacare-repeal....

* https://thehealthcareblog.com/blog/2023/02/15/all-three-legs...

The goal of the ACA in the US was getting closer to universal coverage, and that means 'subsidizing' bad behaviour to a certain extant.

Certainly smokers and such should practice more (so-called) 'personal responsibility', but there are a lot of situation where the pre-existing condition is not smoking or other lifestyle choice, but something genetic / congenital. So unless we want to get into (social) Darwinism and leave those folks on the sidelines, the lifestyle folks can end up coming along for the ride when society decides to protect other non-lifestyle pre-existing people.

This was and is part of their goal, yes.

https://asia.nikkei.com/Business/Technology/Beijing-asks-Ten...

"Beijing asks Tencent to lower WeChat's mobile payment market share"

https://www.forbes.com/sites/zennonkapron/2022/11/09/chinas-...

https://www.business-standard.com/world-news/china-may-impos...

"China is planning to introduce a new mobile payment regulation aimed at reducing the market share of Tencent Holdings' WeChat app, similar to efforts made by the National Payments Corporation of India to curb Google Pay and Phone's growing dominance in the market"

China's methods are more authoritarian than are viable in the west. But the general premise of a competitive market being better for society than dominance by a small number of firms is supported well by history

> China is not interested any 1 company getting a monopoly and becoming more powerful than the government

Those are 2 different things.

Monopoly doesn't mean "more powerful than the government". I'm not sure what that means, since the CCP disappears or coerces anyone who might threaten the supremacy of the CCP (or Pooh Bear) in any way.

Capitalism results in a single winner, for many industries. CCP prefers kingmaking in various industries, because it's easier for the government to control a few players than a multitude. This isn't what "fair market" means, in context. It's modern communism. State owned companies that are directed by government, rather than direct investment or day to day management. China learned from Russia's failures, I would say. I would also concede it's less regulated, under a political lens.

> why should the individual tobacco consumer bear the full cost of their externalities while the tobacco company does not?

Because people are well aware that smoking is dangerous and can freely choose to smoke or not.

> i have no idea what i’m going to pay when i get a small procedure done.

All you gotta do is ask.

There are many options for cancer treatment, with different prices, efficacy, misery, etc.

> Nobody chooses healthcare

Yeah, they do. Root canal vs implant vs dentures, for example. Ozempic vs diet+exercise, for another.

In fact it's almost impossible to get a price estimate up front in many cases. A procedure may involve multiple codes which may or may not be covered by your insurance, and the only way to find out if they are covered is to have the procedure and then check the bill. Frequently you won't even get the codes up front. If you call they can't even say if a particular procedure will be covered or not, the call centers are just not set up to do that. There is incredible complexity as the procedure may or may not be covered depending on patient, provider, plan, how much they've spent this year, region, if the doctor's front office made a clerical error at any point, if the insurance company made a clerical error, if the claim is processed on a Wednesday vs. a Friday, etc... If you have a procedure done twice the coverage may be totally different on the second time, with some parts covered that were previously not covered and vice versa.

Thankfully you can often get denials reversed after the fact by calling and complaining, but that takes an hour and is another roll of the dice. The only people who like the US system are wall street people who own stock in the companies.

> The goal of the ACA in the US was getting closer to universal coverage, and that means 'subsidizing' bad behaviour to a certain extant.

Yes, therefore separating people's lifestyle choices from the plainly obvious risk and consequences involved.

But if you can socialize your losses (banks) or bad decisions (people) and avoid some of the consequences, I get it.

It is incredibly frustrating to have only one option for insurance provider, and then discover that a solid majority of the health care providers in your area don't take that insurance because they have such a bad reputation.

Then you get into the wonderful world of getting receipts for every procedure and manually submitting them, only for them to be rejected so you have to call and tell them to provide the service they promised you. The insurance isn't even cheap! My monthly deduction would be close to the same price as an Obamacare plan, and that doesn't include the employer contribution. Healthcare is such a racket.

That "medical professional" has literally 90 seconds to review your case and say yes/no. They've never met you. They don't know your doctor. All they have are some notes on the case, a billing code, and a quota to reach every day. They get bonuses based on how much money they save the insurance company.

All of that cost savings makes US healthcare cost double what it does anywhere else in the world.

they could but they don't.

and salaries are stagnant. why would they pay extra? at least they're obligated to provide insurance, even if it's terrible and impenetrable

They don't know. Nobody does until the bill is processed. There are a thousand factors that might affect your coverage. This is the nightmare I'm living through right now. Even if you have the code and doctor and patient the help desk at the insurance company can't say for sure if they will cover it or not. That comes down to the discretion of the claims adjuster. You won't know if something is going to cost $100 or $10,000 until after it is done.

The problem with your outlook is you can’t follow through unless you’re a sociopath. Are you willing watch your parent/child/friend/spouse reap the consequences of their “lifestyle choices” and suffer and/or die? I have watched that happen - i guarantee you that you wouldn’t.

Last year, my wife died from a recurrence of metastatic melanoma. By your standard, that suffering was her “fault”, because she failed to use sunscreen as a teenager. If insurance was rated like general liability insurance, she would have been dropped 8 years ago when the original cancerous lesion was removed. Fuck that noise.

I would have bankrupted the entire family to fight for the 60% survival rate in a few months, and she would have suffered even more without adequate care at the end.

We have Medicare “socialism” because social security was allowing the elderly to support themselves and live longer. Many were neglected and dying in inhumane ways, or saddling families with the burden of being a full time caretaker. It’s gross that we live in a society drowning in riches, but we take a principled stance to avoid taxation for rich people, at an incalculable human cost.

Definitely disagree with at least the ‘can freely choose to not smoke’ Nicotine is highly addictive much more so than many illegal drugs.

and then wait 3 weeks for them to get back to you, as they contact your insurance and work out what they can get away with billing

> They don't know

It works every time I asked.

The provider or the insurance company? The provider can give you the cash price, but that's a made up number with no relation to reality. The Insurance company can give you what the standard discount would be on that procedure, but they can't say if they'll cover it, give only that discount, give nothing, or anything in between.

Don't use quotation marks if you're going to rephrase what I said.

Because they compete with other employers? If an employee costs X, it doesn't matter to the employer if X is all cash to the employee or split with the insurance provider.

The entire reason health insurance got so mixed up with employment was as a workaround to WW-II era wage freezes. Employers couldn't pay more salary, so they offered other benefits including insurance to attract and retain employees. Now we're stuck with that.

Ironically, two of his three factors are still able to be priced in: age and smoking status. Weight, gender, and many other risk factors are not, though.

I think you're a little confused about causality. All healthcare systems, including fully socialized ones, perform similar types of case review to ration care and hold down costs. US healthcare costs might be high now but would be even higher if the payers (including the Medicare / Medicaid government payers) paid every claim that came in without denying those that fail to mean plan coverage rules.

If we want to hold down costs then we'll have to put a greater focus on preventative care, stop expensive treatments for terminal patients, impose price controls on providers, and stop subsidizing drug development for the rest of the world. None of those measures are politically popular.

The point of insurance is to cover unforeseen costs. Not to foist bills you know you're going to have onto other people.

Yes, those bills should be paid out by the state such as happens in developed countries like Brazil.

Choose two from: Good/fast/free.

Those "civilized" countries universally have very long wait lists that make health outcomes worse.

Price controls always result in shortages.

The provider. And yes, I negotiate.

The tobacco company (also composed of people) is well aware of the health consequence of smoking to its customers yet freely chooses to continues to sell tobacco products. Where's the difference?

Actually it's much worse than that. The tobacco company is not just selling tobacco products, it's marketing them and actively encouraging their use!

Yes, exactly. Since demand for healthcare services is essentially unlimited, creating artificial shortages is one way to ration care and hold down public spending. The US government already creates healthcare shortages in other ways, such as constraining the number of residency slots to limit Medicare spending. (I don't support this, but it is somewhat effective from a fiscal policy perspective.)

But the point of healthcare is to help people not die, regardless of if they can pay or not. We have a problem then, because outcomes don't line up.

If anything, healthcare and insurance have almost completely perpendicular incentives. No wonder then we have the world's most inefficient system.

The prices you're getting are fake, whether you know it or not. Because you're not the one paying.

This is why it's sometimes cheaper to have no insurance than insurance.

if you ask the provider you will eventually get burned. they can only give you the cash price as a backstop.

if you ask the insurance company you’ll never get an answer. providers are usually more helpful about what “should be covered”, but that’s not guaranteed.

seems like prior authorization is the only way to really make sure charges are covered but takes forever. but even then, if your insurance covers $x and they bill $y, you might get a balance bill in the mail.

point is, the market is heavily skewed against the consumer.

> shouldn't tobacco companies be paying the risk premium for their customers

How would that even work? Any such tax would be priced in into the price of the product. It doesn’t really matter if the government is collecting it directly or through the tobacco companies.

Or if we wanted tobacco companies to pay for all the damage they did retroactively they would just go bankrupt, since they don’t have even remotely enough cash/assets to cover it.