Please think this through.

I have already said the variables, or points of influence, are significantly greater and deeper than just one item.

Government has its paws in dentistry and eye care just as much as it does everywhere else in the medical field. Let's take three of those layers.

First: By guaranteeing exorbitant student loans it causes people to graduate with $300K+ in hard costs for their degrees. Medical education is not a free market in that sense. Universities can charge whatever they want because they have guarantees from the federal government. It's easy for an 18 year old to enter into a $300K+ commitment without having a clue what that means in the long term.

Second: Government has known that our tort laws are in real need of modification. The cost of malpractice insurance varies from specialty to specialty, yet it can be in the tens of thousands of dollars per year. It is important to note that, when you walk into a hospital, the entire medical staff has to be on malpractice insurance and the hospital itself has a set of umbrella policies.

Third: If you are going to face attorneys, you need attorneys of your own. Hospitals have expensive law firms, attorneys on staff or more.

Fourth. Medical device and drug regulatory costs are insane. I tried to develop a simple hearing assist device years ago. The FDA costs to get this super-simple device (that would have potentially helped tons of people) was easily in the tens of millions of dollars. Massive. It also required years of pounding your head into the FDA wall to push it through. This is one of the reasons for which we have lots of bright engineers working on how to get people to click on ads rather than on developing medical solutions.

Fifth: The tort reform issue extends into the medical device and pharmaceutical industries. Let's say I did make that simple hearing assist device. Well, I would have had to have a sizable amount of cash devoted to both liability insurance and simply paying attorneys a ton of cash to defend from lawsuits. This is a sad reality of any industry in the US and it is particularly worse in the medical domain. Our companies get sued all the time, and it cost a ton of money to defend yourself and your company. This is why most of them try to settle and avoid courts. It's expensive, yet cheaper. In fact, this could be a sixth point, how the government has fucked-up courts, but I'll leave that one out.

There's more, a lot more. I haven't just had a casual look at this. I've been running businesses my entire life. I am very much used to deep analysis of the cost structure of things before reaching conclusions. Most people don't do this. They look at something like "raise minimum wage" and think of it as a single variable problem rather than the complex multivariate system of equations it represents.

The medical industry is governed by financial equations as well. And just like in any other industry, the cost of goods sold (COGS) drives the cost of products and services end-users pay. Just like nobody is going to sell you a laptop or an iPhone at a loss, nobody is going to perform surgery or see a patient at a loss. Each layer in the chain has costs, families, loans, responsibilities to look after.

At the most basic level the problem is simple: If you increase COGS, prices go up.

And then there's the need for profit. Yes, I did say "need". I know some think profit is evil. Well, get over it. It is a necessity.

Have you ever had to keep people employed, leases and rents paid, mortgages paid, student loans paid, for, say, six months or a year because of some event that led to an economic downturn?

Most people only think of this pandemic as such an event. Not so. This kind of thing happens every so often in business due to a range of reasons. I had to take a second mortgage on my home and fill-up a bunch of credit cards to keep people at my company employed back in 2008~2010. We had a bunch of money (from profits) saved-up, yes. It wasn't enough. We were coming out of a couple of years of capital intensive R&D and were not ready for what happened with the economy. Profit --business and personal-- leads to savings which leads to stability.

In a nutshell, a person graduating with hundreds of thousands of dollars in student loans, needing tens of thousands of dollars per year in malpractice insurance, with hundreds of thousands of dollars (or more) in additional debt (home, cars), etc., will demand a high salary. Not because they are greedy, because they could not live without it. When your base burn is $15K to $20K per month, you can't work for minimum wage.

This leads to healthcare costs being high. You have millions of medical professionals and millions of medical clinics of all kinds who's financial equations are driven by exorbitant costs that are a direct result of government action or inaction for decades.

These are not new problems. They've been talking about them every election for as long as I can remember. It's just talk. Nobody does a thing about it. Just like gun control. Talk, talk, talk. People vote for you and then you do nothing about it. I don't understand why millions of people don't rise up and protest the abject incompetence and dishonesty of our elected officials. They have been talking about fixing this and fixing that for over fifty years and do nothing. Our political system is badly broken. And we pay for it in more ways than one.

You might disagree with me because, perhaps, you like government to run everything. Yes, government is necessary, and yet it has to be controlled and in moderation. Reality doesn't change because you don't like what you just read. And our reality is that our healthcare system has the government's fingerprint all the way to the starting point, when a well-intentioned 18 year old decides they want to become a medical professional. We have friends who have literally sent their children to other countries to study medicine (they can because they have dual citizenship) because they can graduate with a good medical degree at a small fraction of the cost of what the equivalent education would be here in the US. That, to me, says it all.

You’re complaining about our government’s systemic dysfunction, which is not something I’ll argue with. I think we are circling the drain and already totally fucked, honestly. So when I talk about making some aspect of our society work better (e.g. healthcare) I’m presupposing that we’ve managed to sort out a government that’s halfway interested in making things work.

Put another way: it’s a false dilemma to say we can either accept the non-attempts of our non-functional government to fix issue X, or throw Americans to the capitalist wolves and trust them to build us a libertarian utopia where the free market solves all ills. The latter is extremely naive.

Despite what you seem to assume about me, I do believe in capitalism up to a point, actually. I think it’s the best way to bubble up drive and vision to a place where the individuals so endowed can move us forward as a civilization. But, when we’re talking about administration of a broad application of settled technology (in the broadest sense), the advantages of capitalism tend to be subsumed by blind profit motive; this gets us monopolies, it gets us rent-seeking and racketeering, it gets us abuse of consumer “rights” and outright human rights in many cases. I really don’t buy that all of this is the government’s fault; corporations with unchecked power have done some pretty horrible things.

Your claim that profit is necessary isn’t true, either, except in the broadest reference frame. One example: public transit is a huge economic enabler for dense cities where driving isn’t practical. It’s fine for it to lose money considered on its own, because it drives overall growth.

Now, do we need to do a better job at the interface between public and social services (e.g. the people who run the trains) and private enterprise (e.g. the people who manufacture the trains)? Yes, we do. The same would go for an expanded socialized medicine program, or just an attempt to stop the bleeding with our current system. But this brings us back to the same place: everything is broken, and the outlook is bleak. And the proposed solution of a “well regulated” (imagine I’m waving my hands around) free market does not convince me, simply because profit motive does not necessarily align with human happiness and well-being. History is full of examples of just how incompatible those two things are, and the present has some good ones too.

> One example: public transit is a huge economic enabler for dense cities where driving isn’t practical. It’s fine for it to lose money considered on its own, because it drives overall growth.

As I said before, and I'll add a little bit: Please, grab a spreadsheet, start to develop the financial equation for anything you care to look into and think it through.

Public transportation probably has a much larger profit motive than any private enterprise. You have to look at the financial equation that drives the thing. They don't call it "profit", and yet it is exactly the same thing.

What form that it take?

Go research benefit and pensions. People in these government organizations get life-long pensions that they did not pay for. They also get life-long health coverage...they did not pay for. These pensions are unsustainable without the "profit" in the form of ever-increasing taxation, bonds and other methods.

It's money in excess of the cost of goods sold. Same thing. Different name.

I think you misunderstood my perspective on this. I am not proposing some crazy scenario where capitalism runs rampant doing as everyone might wish and make an even bigger mess out of healthcare. Not at all.

My point of view is very simple:

Government is bad at executing on just about everything.

Their role should be to engage in creating the legal and regulatory framework within which entrepreneurs have to function in order to deliver goods and services.

They should not be in the business of implementing any of it. They fuck it up more often than not. Look at the mess the Trump administration made out of the vaccine deployment as a recent and painful example. This isn't a Republican or Democrat thing, they all suck at getting things done correctly, effectively and efficiently.

They should have grand debates (in public) exploring how to engineer a legal and regulatory framework for healthcare that allows our entrepreneurs to deliver excellent products to everyone. No monopolies. No exclusions. Etc.

Of course, they also need to make sure their rule-making deals with all relevant elements of the financial equation.

Simple example: You cannot, positively cannot, lower the cost of healthcare in the US if a medical education costs hundreds of thousands of dollars, malpractice insurance tens of thousands, and a hospital has more lawyers than doctors. It's crazy. So, again, for example, get out of the student loan business and education costs will come down.

There's a lot of "structural" work that needs to be done before any insurance entity, public or private, can reduce costs. I've been saying this all along. This isn't magic. It's math. There's a financial equation for everything and you can't force lower end-user costs if the cost of goods sold is high.

It's the no-free-lunch principle. Probably the fundamental law of the universe, right up there with gravitation.

> Go research benefit and pensions. People in these government organizations get life-long pensions that they did not pay for. They also get life-long health coverage...they did not pay for. These pensions are unsustainable without the "profit" in the form of ever-increasing taxation, bonds and other methods.

Yes. Public money subsidizes public transit, and that money comes from taxes etcetera. I'm not sure how any of this is supposed to contradict what I said, which explicitly acknowledged that public transit examined in a context-free vacuum is often a money loser—do you think I imagined that the funding for it pops out of thin air? The point is that mass transit is necessary for cities to function beyond a certain density, so the economic dividends of a growing city must in part be credited to it.

You could probably make a reasonable argument that if workers kept more of the wealth they create then public transit could more easily operate in the black. Instead, the people least likely to use it keep most of the money the people most likely to use it might have spent on it. Holding our current (extreme) wealth inequality equal, the solution to this is to disproportionately tax the wealthy to fund it. They may make a fuss, but they (or at least we) should remember that they made their money on the back of a functioning society.

Most of the very large cities in the Western world do appear to have relied to some degree on public transit to attain that status, so if you want to argue that it was actually an economic drag they'd have been better off without, the onus is on you to put together the spreadsheet (or whatever) proving that.

(We also have a problem of it being extremely expensive to build public transit in our cities, much moreso than in e.g. European countries with heavily socialist policies. To me, that suggests that there's a lot more going on here than big government bad, big corporation good.)

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> Government is bad at executing on just about everything.

> Their role should be to engage in creating the legal and regulatory framework within which entrepreneurs have to function in order to deliver goods and services.

There's a problem here, which is that the latter is something they will have to execute on, and I bet neither of us believes our current government is up to it. So that begs the question: if we did have a government actually capable of executing well on hard problems, why should they not directly solve the public problems that private enterprise is not well suited for, i.e. the ones that do not produce tangible local profits in the short to medium term?

Our government put men on the fucking moon, and IG Farben made Zyklon B for the Nazi gas chambers and bought slaves from the SS to use in lethal medical experiments. The right answer isn't easy; it may not exist at all, in the sense of having a destination and a workable route thereto through the intermediate configuration space. It's certainly not going to be as simple as people on Twitter want to imagine it is. Unfortunately, your vision of government stepping back to let private enterprise (with a gentle guiding hand) create a utopia where all people are provided for in their every need seems just as hopelessly idealistic as anything else.

> There's a problem here, which is that the latter is something they will have to execute on

That could be slicing it too thin. Either we trust them to work on legislation and regulatory matters or we don't. In which case we have an even larger problem. When I say "execute" I mean the act of creating, administering and running organizations. Yes, there are examples of what I will call corner cases where they do OK.

> Our government put men on the fucking moon

I'm going to pull the "that was a different era" card on that one (and a bunch of others).

One thing that seems to be painfully clear of our era is that we can't seem to get anything of note or scale done. Here in California they sold everyone on high speed rail. Ten billion dollars they said. LA to San Francisco or some such thing. Well, we are up to, I think, $100 billion and, as far as I know, we haven't even built ten miles. Even worse, what we built doesn't even qualify for "high speed" by any stretch of the imagination (and you can't even ride it because it isn't finished). If I remember correctly, the project started in 2008. Twelve years later and we spent ten times what it was supposed to cost and have absolutely nothing to show for it. At this rate we are going to end up spending a trillion dollars on this disaster.

That's what I mean by "government is bad at executing on just about everything". There are so many examples of this its a tragedy.

Here's another one that drives me insane. The postal treaty of 1879. This is the treaty that makes it so parcels from China travel across the US for free. Yes, taxpayers subsidize transit of Chinese shipments through the US. The intent, back then, was good: Help developing nations gain access to markets and grow. China is the second economy in the world. This treaty is beyond ridiculous. I, as a US-based manufacturer, cannot compete with Chinese counterparts along a number of vectors. And yet, if my cost structure was exactly the same and my COGS was exactly the same as theirs, I could not ship across the US for free...and they can.

How incompetent do politicians have to be not to understand something like this and rescind it 25 to 30 years ago, if not earlier? The only politician in memory who even spoke about this and wanted to rescind it was Trump. And, of course, because our politicians are far more interested in party warfare than actually delivering results for the nation, nobody supported him. And here we are, subsidizing China's businesses.

This is a failure of execution in the sense that, when a problem is identified you move to resolve it. Ignoring something like this handicaps every single US business and it is objectively wrong.

> The right answer isn't easy; it may not exist at all

I could not agree more. While I believe my analysis of the various scenarios we discussed has merit, I have completely failed at even imagining what a real executable solution could look like. The reason, I think, is that the system has so many moving parts, so many variables, and such history, that it is now nearly impossible to alter the course we are on. Well, until we crash into a bank and they have to dig us out of the mud. Sorry, didn't mean to be defeatist...I just haven't come across anyone who can conclusively demonstrate that we have path out of this mess.

> Unfortunately, your vision of government stepping back to let private enterprise (with a gentle guiding hand) create a utopia where all people are provided for in their every need seems just as hopelessly idealistic as anything else.

Likely so.

This is where we can start to get into a philosophical discussion, the start of which is a simple question that is likely almost impossible to answer completely:

Are human beings free; or are we meant to be controlled by a ruling class?

These are two extremes. At the "I am free, man" end of things you have a complete mess. All you have to do is look at what happens at a Walmart when people get desperate. And, of course, at the "submit to our rule" extreme you have pain and misery...because men are evil to each other and we do evil things to each other...that's why my grandparents had to face a genocide and the death of so many members of their family...just because they existed.

I don't believe we do well in a 100% free state. What I mean by that is that humanity has shown this framework doesn't deliver a better life for the community, much less a large nation. In fact, this has never reached the scale of an entire nation for a reason; it doesn't work.

We do have examples of the opposite extreme, and as I said, it ends badly. I think reading The Gulag Archipelago should be required reading (perhaps in abridged form) in order for our young adults to understand what some of these systems can turn into.

I can't tell you what the right balance between those extremes might be. The US seems to oscillate around a centroid that has, so far, delivered decent standards of living and a sense of future that does not exist in other parts of the world. And yet I shudder to think about what could happen here if and when unemployment doubles or triples due to the almost impossible-to-stop domination of business markets by China.

What then? How will we behave? How are our politics going to change?

I have my predictions --based on having lived in multiple cultures, including under military rule. I'll spare readers the gory details at this point. It's too depressing to write about.

Here's a painful and personal example of the dysfunction one can experience in our broken medical system.

My mother is dealing with stage four pancreatic cancer. She has done OK but, of course, there is no stage five for a reason.

She is currently in the hospital (I was with her yesterday; I typed my prior comment from the hospital) with some complications. Doing OK, we think.

Here's the bullshit: Her oncologist can't go see her at the hospital because he is not in the system. The best they can do is consult with him over the phone for his opinion and then make their own decisions. Yes, she is on the ACA.

The sheer lunacy of this scenario is hard to describe with words. Screaming is more in line with a proper description.

I am not going to blame government for this. I have no clue how this situation is so other than to understand that it is about money, about who gets paid for what. And yet, our government makes the laws and rules that govern such industries. They have fucked up healthcare beyond what any objective observer would, I suspect, think is a good system that serves patients as first class citizens in a healthcare system.

Even in third world countries your doctor can come see you at any hospital. Here, in the US. Not so.

If you were wondering why I am so down on what our politicians have done (or not done) over decades, it comes from far more than an academic thought exercise.

Really sorry to hear about your mom. I wish her the best.

I'd been meaning to write a more substantial reply to your last comment, but I've been underwater at work and haven't had the time; maybe this weekend. But I do think we have a lot of common ground, and you certainly won't hear me defending our current healthcare system or many of our current politicians.

No problem. Part of life. She is doing fine and out of the hospital for now. Thanks.

One of the issues I have with trying to have longer discussions on HN is that there are a lot of non-participants who have nothing better to do than to downvote rather than participate. I don't care about the little karma counter, could not care less. What I do care about is being able to have reasonably intelligent discussions where people might not necessarily agree without using karma violence to silence one or more participants by eventually having posts flagged, etc.

HN, for the most part, is a decent community and they have done a great job of maintaining order. As someone who has been participating on discussion communities since the days of USNET I am equipped to fully appreciate the effort that has gone into HN.

That said --and I know this is hard-- I wish they could figure out a way to eliminate what I perceive as sophomoric punitive down-voting that is generally devoid of any substance and has, from my perspective, no value at all.

The only way we learn anything is to engage in substantive conversations where we openly explore ideas we might necessarily agree with. Canceling those we might not align with serves nobody, does not lead to anyone learning and all sides of an argument lose.

Yes, I know this is a hard problem.

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My general view of what government can accomplish and how tends to be very negative because I have seen them muck-up just about everything they touch. People will demand more from a fast food restaurant than the politicians they elected. It's crazy.

For example: Why is it that politicians suffer absolutely no consequences for lying to us? None. In fact, as a matter of law, if you or I lie to the federal government we go to jail. They can lie to us on a daily basis without consequences. How is that possible. You lie to a police officer and, same thing, the consequences to you are severe. The opposite is not true.

This asymmetry is very, very wrong. And yet, as I mentioned, we demand more of a fast food eatery than the politicians we elect. How does that happen? Lack of education? Lack of information? Indifference?

Same with the freedom of the press. Do we really think the bill of rights created this protection to include lies, fabrication and manipulation? I know this isn't an easy problem to solve. Sure. Well, how many centuries do we need to sort it out?

Oh, wait, these are things that require politicians to do their jobs. Never mind.

Yeah, the idea of having these people have full control of healthcare terrifies me.