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PaperclipPerfector  2d ago (text post)   7949 thread views

Culture War Roundup for the week of July 7, 2025

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Posted this in the comments last week, but was curious to get some more thoughts on a potential path forward on the healthcare front that isn't just single-payer across the board:

I do occasionally wonder if you could get to a decent place via:

  1. Get rid of Medicaid. It maybe made sense at one point, but it's current incarnation is, as far as I can tell, such a disgusting mess for all involved parties that it's better to just kill it with fire.
  2. People who would be on Medicaid can now get insurance via the ACA exchanges - they'll get a 94% CSR plan for 2% of their income. There's some annoyance around how they will enter their income, but much less paperwork than it takes to interface with Medicaid. There would need to be a small legislative tweak to allow this to happen (let <138% FPL income people get subsidies), but in practice they should trade a bunch of annoying documentation and everything is free for a functional network (ie a blues plan) and everything is very cheap + 2% of their income.
  3. Expand Medicare to more disease categories other than just end stage renal disease (in addition to the elderly). In practice I think you want to try to capture an additional several million of the sickest people. Hemophiliacs, organ transplant, some cancers, some rare genetic disease perhaps, that sort of thing. This will dramatically lower premiums in the ACA. However power-law distributed you think healthcare costs are, the reality is they are likely more power law distributed than you think.

That's going to create some winners and losers, hospitals will be upset that more high cost people are on Medicare, but shifting people from Medicaid to commercial reimbursement rates should help out with that. The amount of bureaucratic nonsense saved by getting rid of Medicaid should be huge.

All a bit of pie in the sky dreaming anyways...

that isn't just single-payer across the board

Why avoid this when every single proposed solution seems like replacing the current inefficient massive headache with yet another inefficient massive headache?

Single payer also has tons of issues, but when your healthcare system also involves a massive extra layer of insurance bureaucracy (and knock-on bureaucracy requirements for hospitals, etc. to interact with the insurance bureaucracy) and value capture (every dollar of insurance profit is a dollar not spent on making humans healthier) it seems like you're doomed to fail.

I'm open to examples of healthcare systems that do a great job of juggling this (Germany and Switzerland?) but it seems to me that you fundamentally must make trade-offs in a healthcare system. It is also too important and chaotic to leave to market mechanisms, for reasons like: no one who needs an ER is going to shop around for the best/cheapest/highest utility to them ER, people who can't pay for healthcare get treated anyway and then hospitals can't collect and have to charge everyone else more, etc.

To my amateur observations, it seems like you can:

You can have a collective/single payer healthcare system that tries to take care of everyone, and is constrained by resource availability/requires you to pay taxes that mean people you don't like get healthcare.

or

You can have a privatized healthcare system that siphons a ton of value/resources into insurance profits/bureaucracy and thus deprives the actual humans who need medical care of the medical care they need. It also functionally requires you to pay taxes that mean people you don't like get healthcare in the form of insurance premiums and meme-tier prices because hospitals have to eat the cost of people with no money still getting healthcare (yet another way that healthcare breaks market mechanisms, because hospitals don't like when people die, they treat people first and ask for payment after).

I would be a lot more sympathetic to the USA's current healthcare system if it managed to be either cheaper than it's peers, or more effective, but it is somehow both more expensive and worse.

(yet another way that healthcare breaks market mechanisms, because hospitals don't like when people die, they treat people first and ask for payment after).

It's not that hospitals "don't like it", it's that they are legally forbidden from doing so. If it was legal to turn people out to die, you would absolutely have some cheaper hospitals that made sure you could pay out of pocket or had insurance before they treated you, and if you didn't they would just escort you off the property.

It sure seems like all the liberal examples of 'women dying because of abortion bans!!!' were, well, obviously not that, but the thing they actually were seems to be mostly EMTALA violations. Hospitals obviously violate EMTALA if they think they can get away with it.

IIRC there was a pilot program in parts of Texas to guarantee EMTALA care gets paid for, but it was canceled because illegals were benefiting from it.

Yeah exactly. Healthcare systems fundamentally cannot play nice with market mechanics because people get unhappy when the market mechanics cause people to die.

So privatized healthcare seems to end up being an awful chimera hybrid of the worst of both worlds.

But you can say that about anything? "People don't like it when the market causes people to starve/end up homeless, so we need socialized grocery stores/housing". We don't; we just need to make it cheap enough that the possibility of starving/ending up homeless/dying for lack of healthcare becomes remote for any reasonably functional person. We are pretty much there with food; for housing and healthcare, we literally just need to stop stopping people from building housing/providing healthcare.

I'm with you on that.

I think the floor (no pun intended) cost for housing is much lower than healthcare, I am somewhat doubtful that healthcare can ever be a non-risk pooled consumer good but I'd love to be wrong.

Down with doctor training cartels, I mean the AMA*

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