Could a working health care system be built by industry under the threat of the current industry's destruction?

Making any phone or tablet able to read the vital signs is the sort of innovation that could bring down healthcare costs

Several former Democratic contenders have promoted single payer health care under the name "Medicare for All." While I'm not old enough for Medicare, I have lived for several decades under the Canadian system and several decades under the U.S. system. In addition, I spend 2-3 months/year in Europe and have had to make access as a tourist to the systems in the UK, Germany and France. The attraction of the single payer systems, with their much lower costs per citizen and equal or superior health outcome scores, are hard to resist. At the same time, many voters are concerned at having a government agency run their health care, or elimination of the free market system which works so well in so many areas. The current US system is deeply broken, and does not much resemble a free market system, if it ever did. So the political push for a single payer system has become stronger.

It's not going to happen soon. Biden has won the nomination (though only Sanders seems not to know it), and even if he somehow won, most analysts expect it's pretty unlikely the Democrats would win control of the Senate in 2020. If they do win control of the White House, the historical pattern has always been to lose seats for the President's party in the midterms, though 2022 looks particularly risky for the Republicans otherwise. (So much so that if Trump wins 2020, the Senate will almost certainly go to the Democrats in 2022, strongly impeding his actions.) A GOP Senate is not going to pass single payer health care, so most of the debate within the Democratic party is moot, at least for now. While it's possible 2020 would flip the Senate, it would be unwise to bet on it.

Even so, if it became a real possibility, here's an option to try to consider both sides. Before nationalizing the health care industry, give them a chance to avoid that by beating the other single payer systems around the world. They will be very, very motivated, knowing that if they fail, they are gone.

If you're going to nationalize an industry, and have decided that's moral, then it's also moral to threaten that nationalization in order to get better results from the existing system.

To do this, you define some metrics from countries like Canada, the UK and others. Metrics on cost per person, as a percentage of GDP, for example. This would be all costs -- insurance premiums, personal expenses and co-pays etc. for in-network care plus everything the government spends (for example on Medicare, Medicaid, VA) together. The new system must cost within a reasonable range of that. It can cost a bit more if it offers more, based on the metrics below.

That means the system has the power to put government spending in its budget. The system can, for example, say that people that choose can have a private plan, and everybody else goes on a single payer plan, so long as the total cost of both is within range and the performance metrics are met.

Performance metrics

For all this money, the new plan must deliver

  • Health outcomes the same as the target wealthy countries with single payer systems. Death rates of major types and many other things -- these already get measured and compared. Superior outcomes can justify higher cost thresholds.
  • No person pays an amount greater than 15% of their income or 20% of their liquid net worth (whichever is larger) for medical costs, including any increase in their taxes due to the program, or net any reduction. In particular, no previously solvent person enters bankruptcy through medical costs.
  • No person lacks basic coverage, and all can afford more comprehensive coverage as per rule 2. No child lacks comprehensive coverage.
  • Wait times must be superior to those in Canada/Europe. While those times are not that bad, people are afraid of this and will want to be assured this will be the case.
  • Co-pays, drug costs and other expenses are allowed as long as they don't go over the financial limits above.

This is a very tall order, and to do it would take some time. As such, the industry would be permitted to follow a set of levels to show it is on track for delivering the above by 2030. If, by 2025, it's not halfway there, a single payer system could then be installed.

Once set in motion, cancellation of this plan would require a 2/3rds majority in congress and signature of the President, so that partisan changes do not reverse the course. The health industry would agree to those terms (or face nationalization.)

More Kaisers?

Some may point out that companies like Kaiser Permanente already have taken a stab at this, and while they are cheaper than the regular system, they are not as cheap as other systems. They still have to compete in the US system, and they must pay US drug and medical equipment prices, and compete in the market for all other medical resources. So would any company trying to match this test, though, so it might be reasonable that the test allow for that factor when evaluating cost.

Could anybody do this? What would stand in their way? The convoluted structure of the US system has failed, but under the right incentive structure, free markets should be able to produce the very best results, which is key to the overall system of the United States.

But if they can't, there is a limit as to how many should die or become bankrupt or spend much larger fractions of their household income on health care than anybody else in the rich world. It's time to start putting the innovation ability of entrepreneurs to work.


How about we go with single payer under the same terms and then move to a free market system when that fails?

(That's a rhetorical question, of course. We should move to a free market system immediately. No sense wasting 5 years proving that Americans are unhealthy for reasons that go far beyond our health care system.)

The best result is a system where people are free. That includes the freedom to choose an unhealthy lifestyle. It includes the freedom to spend every penny of their hard earned fortunes on expensive treatments that will do little to prolong their lives, as well as the freedom to refuse treatment and thereby shorten their lives. The metrics you propose stand firmly in the way of these and many other freedoms.

Freedom is the only metric that matters when it comes to making laws.

Right now we have a not-free-market system which has failed, in that it is far worse in terms of quality of outcomes and customer experience per dollar. So everybody is talking about replacing it with one of those nationalized systems that have done so much better there. A full free market system is not on the table. I wrote this post to suggest that there might be a window, before switching to the nationalized system, of letting the entrepreneurs have a real go at it because people get pretty incentivized with a gun to their heads, and something can happen before the trigger is pulled.

You're not letting entrepreneurs have a real go at it by giving them a set of metrics that are impossible to achieve (at least without draconian measures; we could, I suppose, threaten obese Americans with jail for messing up our statistics).

You don't think an entrepreneurial system could outcompete the nationalized systems? You could control for different inherent health factors, ie. measure health outcomes for generally healthy people, people with different risk factors etc. Why couldn't it win in almost every category, if not every one?

I'm not sure what is meant by "an entrepreneurial system," but I think if you measure success based on collectivist metrics you're bound to wind up with a collectivist system.

Your metrics dictate how much people should spend on health care, when people should not file for bankruptcy, what kind of "coverage" (I guess by which you mean insurance?) people should have, how long people should wait, etc. How would you "control for" people's individual preferences, both in the future and in the past, without abandoning those centrally planned metrics altogether?

The goal of an entirely free market is not attainable. One needs an option that tries to get the best of that. It will include some collectivist statistics. Though you could include customer satisfaction levels of course (Kaiser has the highest) but again, in aggregate.

The main first point is that there should be something out there which is better than a government run plan and better than the broken system today, and that if we can figure out how to set the goalposts, business can probably figure out how to find it, particularly if the alternative, for them, is to have their business nationalized.

So yes, it's hard to set the goalposts and impossible to do it perfectly. You don't even get enough time to experiment to do it really well.

It's hard to figure out how to get actual free market health care. Almost everybody is quite irrational in how they buy it. It's quite different from most markets, all of which have their quirks but nothing like this. And of course, in the USA, only a small minority buy their health insurance privately (I am one) or their health care privately (I do some of it this way.) The vast bulk get it through some group buyer, mostly employers or the government.

I think an entirely free market is attainable. Furthermore, I think a mostly free market, such as the market we have for most other goods and services, is quite readily attainable. One of the things we need to achieve it is to stop letting collectivists frame the problem in terms of collectivist metrics. So that's what I'm going to continue to do.

The proper goalposts are freedom. Are we letting people who want to buy a good or service buy that good or service? The current system fails miserably on that metric, and it got much worse during the Obama administration (and not much better under the Trump administration). Fixing this is very easy. It's easy to figure out how to get actual free market health care. Remove federal regulations and add a federal law that preempts all state regulations. Now you have a mostly free market for health care.

People being irrational is not unique to health care. And I'm not sure they're all that irrational. When someone else is paying for your health care, it's natural to not care about costs. When others are forced by government to pay for your health care, it's not clear to me what the rational choice even is. What specifically do you think people are irrational about in terms of health care? Why don't you fear that government leaders (who are, after all, people) will be just as irrational? At least with a free market, you bear the consequences for your own irrationality, not the consequences of the irrationality of your political leaders.

I think that's how we should treat adults. Give them choices, with the understanding that they bear the consequences for those choices. That's how I want to be treated - as an adult, not as a child.

Just removing all regulations is not politically remotely likely. Do you assert otherwise?

Even if there were majority support for that, I suspect people would still call for regulations and subsidies to solve the problem of getting universal insurance -- which you value for yourself because it reduces the spread of infectious disease, in the same way you don't want it optional to get sewer or garbage pick up service. And as we know, the incidence of medical-induced bankruptcy is very high in spite of the availability of insurance (or sometimes because many of the common forms of insurance don't prevent it.)

The core irrationality, though, revolves around a deliberate wish to not make financial decisions about health care. Ask people if their health is important and they will say it's #1. Ask if they want to spend $500 on a test which will only find something useful 2% of the time and they will be quite averse to it. They don't want to be having to look at the financial aspects of each medical decision, and that prevents having an efficient market for those individual procedures, you can at best have an efficient market for insurances. But that got scuttled when everybody moved to insurance through employer. Large group insurance became the only way to get affordable care for pre-existing conditions.

Even in the more competitive market for individual plans, I have never seen anything so expensive that is so hard to shop for. Vastly complex, without the usual private sources of information (consumer reports style) on the plans and providers.

It's hard to figure out good solutions under those constraints.

None of what we’re discussing here is “politically remotely likely” in the near future. Do you assert otherwise?

I’m not sure why people (other than lobbyists for medical providers) want to prevent medical-induced bankruptcy. If someone can’t afford to pay their medical bills, why shouldn’t they be able to claim bankruptcy? Why is it better for the taxpayers to pay the hospitals than for the bills to be cancelled?

Why is it irrational to wish to not make financial decisions about health care? What is irrational is forcing taxpayers to pay to fulfill that wish. What is irrational is voting for politicians who you know or should know are going to expand the size of government. If you don’t want to spend $500 on a test that will only find something useful 2% of the time, then don’t do it. If you also don’t want to be bothered with having to make that sort of decision with each medical decision, then sign up with insurance that doesn’t cover $500 tests that only will find something useful 2% of the time. Except you can’t, because the government doesn’t let you. A huge part of the problem is that the government forces everyone to value their health the same way, and in the USA that value tends to be way higher than you’d find under a free market system. The solution to that Is to let people choose how much coverage they want. If you want insurance that’ll pay to keep you alive for an extra few months after you’ve been diagnosed with a terminal illness, you’ll pay more. If you don’t, you’ll pay less. It’s not irrational to not want to have to make that decision. But it is irrational to not allow others to make that decision.

“Everybody” (it’s far from everybody) moved to insurance through employers because governments charged higher taxes for not doing so, and then outright forced large employers to do so. They also sent the cost of individual health insurance through the roof by eliminating the ability to buy insurance that only covers what you want it to cover. The solution, again, is deregulation. Stop forcing employers to pay for their employees health insurance. Give individuals who buy health insurance on their own (or who have no health insurance at all) the same tax benefits as employer-provided coverage. Let people choose what coverage they want. Let people choose if they want coverage for preexisting conditions. First and foremost, repeal Obamacare.

Individual plans are hard to shop for because of government regulations. The solution again is deregulation. But beyond deregulation, the federal government needs to step in and preempt state regulations. Then we can have true nation-wide markets. (That said, I have an individual plan, and it wasn’t hard to shop for. But I don’t live in California. I wouldn’t be surprised if their regulations are the worst in the country.)

You say it’s hard to figure out good solutions under “those constraints.” It seems to me that the constraints are the ones you are imposing, and on that I agree.

Re: They also sent the cost of individual health insurance through the roof by eliminating the ability to buy insurance that only covers what you want it to cover.

Who wants to buy insurance that *doesn't* cover the illness that they will have next month? This sounds like something that only the wealthy could afford.

The reason you might want to buy insurance that doesn't cover the illness that you will have next month is that it'll be less expensive. I'm not sure what you mean that only the wealthy could afford it, as it'll be less expensive.

"A quarter of the total Medicare budget is spent on the last year of recipients’ lives, with 40% of that money going to their final 30 days." Wouldn't it be great if the senior citizens who choose to forego these treatments weren't forced to pay the billions of dollars spent on those who insist on it? How much better would the USA's collectivist metrics be if people could fill out an advance health care directive and start getting a check in the mail every month after they sign it?

But moreover, people should have the ability to buy insurance that doesn't cover the illness that they won't have next month.

I also feel that a big part of the problem is that I have no way to know how much any medical procedure will cost. If you ask your doctor, they will simply ask what insurance you have or quote your co-pay. I would bet in fact that they are not allowed to tell you because of their contract with the insurance companies.

Just like a mechanic, a doctor can't always know exactly how much a medical procedure will cost (there might be complications, for instance), but I'm sure they (or someone at the place they work for) could give you an estimate if you insisted.

One reason I'm sure of this is that I have, in the past, had a high deductible health insurance plan, so I used to ask prices and shop around. Unfortunately, the Democrats have done their best to make high deductible health insurance plans not cost effective. Obamacare largely killed the HDHP, by subsidizing other plans. So I no longer have an HDHP, I no longer care about price, I no longer shop around (based on price), and therefore everyone's costs go up.

I'll take that bet.

Up until now, the installation of a single payer system has not been likely, but now there is a growing movement for it. But it's more likely that a compromise approach would be possible, and becomes likely if you have a groundswell of public support for M4A, pushing the GOP to find a more bipartisan compromise. My proposal is along those lines.

What I mean by irrational is that with most products, you want an active marketplace, with an efficient market with lots of information, and the ability to easily choose the best provider and for competition to make providers fight for your business.

Health care, like, say, fire department service, is something you often buy in an emergency, without time for research or comparison shopping.

But, as I said, quite often you find yourself with a doctor suggesting a drug or a diagnostic which might be quite expensive. I find that if you have a very high deductible health plan, you are going to look at that as a financial decision, "is it worth $2,000 for this test?" A competitive market would need people doing that. But I don't want to do that. I would rather pay a bit more each month so that if that happens to me, the only question is whether it makes medical sense -- with some copays to put a small, but not giant amount of financial question in the decision. Just the right amount, so to speak.

I don't understand your point about signing up for insurance that doesn't cover that test. That's exactly what people don't want, to be forced to now decide if it comes out of pocket.

Even HSAs, which are generally a good idea, face this problem. At least you have committed the money to the HSA but you still have resources to consume.

We want expensive health care that frees us from those decisions, I think. But of course, with something to balance it so it doesn't just spend like water. Today that balance is putting the decision in the hands of doctors, and to some extent insurance admins. That has its own problems too.

Yes, I know what forces pushed employers into the game. Today your insurance is deductible, though, but not your private expenditures below 7% of income.

I will say on a personal note that if Obamacare were repealed, I would then be locked into my current insurance for life, because I do have preexisting conditions. If I lost that insurance, I would either have to get an employer plan, or leave the USA.

Single-payer would be better than the convoluted system we have now. Compromise approaches are often the worst possible solution.

Health care, and fire department services for that matter, could easily be something you subscribe for in advance. There's nothing inherent about it that prohibits research or comparison shopping. What hinders research or comparison shopping is government.

Yes, government involvement in health care enables us to avoid personally making hard decisions like whether or not it's worth $2,000 for a test that has a 1 in 10,000 chance of saving our life. Instead we can complain that our health insurance company is evil for denying the test. Or we can complain that our health care system costs way more than other health care systems that have better results. Or both, like most of the liberals are doing today.

If you want to pay more each month to not have to take personal responsibility for these hard decisions, I have no problem with that. What I have a problem with is when you don't allow me to refuse to pay more each month and accept the fact that the value of my life is somewhat less than infinite. (That said, if you did give people that choice, I think you'd find that you'd have to pay a lot more to be able to hold your head in the sand like that.)

My point about signing up for insurance that doesn't cover the test is that, if I don't think the test is worth $500, then I don't want to be forced to sign up for insurance that covers the $500 test. Again, I'm willing to accept that the value of my life is less than infinite. The value of my health is less than infinite. If the test is only $500, and I'm in good health already, a $500 test is probably going to be worth it if it provides virtually any benefit. Maybe I might want to forego a $500 test if it provides close to zero benefit. And there's a strong likelihood I will want to forego a $500 test if I'm already terminally ill and have little quality of life.

You want expensive health care that frees you up from those decisions, maybe. I don't. I'm fine with you getting what you want and me getting what I want. I'm not fine with you forcing everyone to get what you want. And I'm especially not fine with you then complaining that health care is too expensive, and blaming it on the free market.

I doubt you would have to get an employer plan or leave the USA. Based on what you've said in the past I'm sure you have quite a lot of assets and quite a bit of annual income, so I bet you would be able to pay for your own health care without forcing others to pay for it. But maybe you'd choose to get an employer plan, or leave the USA, in order to continue to leach off of others.

(Even before Obamacare, we still had Medicaid. If your medical expenses are so expensive that you'd be left with less than $2,349/month in income and $2,000 in non-exempt assets after paying for them, you could set up a medicaid income trust, keep $2,349/month in income, and leach off the California taxpayers for the rest. I doubt your medical expenses are that expensive, though. Even if you've got AIDS and diabetes, you're only talking about $40K/year in medical expenses, and I bet you make at least $100K/year in income.)

But we're not likely to get that level of choice. My main question in this thread is, what other paths are politically possible other than continued tweaking of the current system, or single payer, or possibly current system plus government option, though in the past that sort of hybrid has run into trouble.

In the short run, the answer is none. In the longer term, people might learn the evils of utilitarianism and collectivism and move to a much more free market system. Alternatively, eventually the US system is bound to collapse and maybe a more free market system will arise from the ashes. In either case, I think rejecting the very metrics that collectivists use to measure success will be key. This hybrid stuff being touted as capitalism is just giving capitalism a bad name.

But then are you saying that if, with nationalization imminent, that it would be best just to give into it, or is it better to look for superior alternatives that are at least partly market driven?

Though I should point out that I think that if you are a Libertarian, it is inconsistent not to be in favour of taxpayer funded free health care for infectious diseases. Which would be an interesting partial step.

On your first question, I'd say two things. First of all, I think single-payer would be drastically better than the partly-market driven system we currently have (and probably any partly-market driven system that strives for universal coverage). Secondly, I'm not sure what's meant by "just give into it." I won't directly support it, but there's nothing I really can do about it. I might even indirectly support it when voting for the lesser of two evil candidates.

If someone presented a realistic superior alternative that had a reasonable chance of becoming law, I'd support that, at least as an interim solution. But nothing you've suggested here comes remotely close to that, in my opinion. And I don't see how you can get there without abandoning universal coverage as a goal. If you want universal coverage, then single-payer is the way to go. Even if you want universal basic coverage (with optional coverage beyond that), single-payer for that basic coverage (and free-market for coverage beyond that) is the way to go. If you want universal coverage for treatment of infectious diseases, single payer for treatment of infectious diseases is the way to go.

My argument is that universal coverage is not a proper goal. Like anything else, those who are willing to pay more, should get more, and better, coverage.

I'm not sure what you're saying in the second paragraph. I'm pretty sure Libertarians don't support taxes, at least not in the long term. Are you suggesting that they should?

Maybe you're saying that a Libertarian who had control not over how much in taxes are generated but only on where those tax dollars are spent might support "free" health care for infectious diseases as one of the less-bad places to spend? Even then I think unless you're talking about a once-in-a-lifetime black swan event like the Coronavirus, I think most Libertarians would probably prefer that the government stays out of these sorts of things other than in providing police and/or military. I don't see any reason we need government involvement in providing health care for people with a common cold/flu/STD/etc.

Normal libertarian doctrine accepts the use of taxes to defend against foreign invaders, because you can't easily do that for some and not do it for everyone, and it's essential for the preservation of life.

But who says those foreign invaders have to be people? It is necessary to stamp out infectious diseases in others to prevent me from getting them (or having me stuck in my house for a month.) As such, I think repelling disease is a similar national interest to having a military. Not that I think it should be run military style, so it's not identical, but it is ideologically quite similar.

If there were simple and easy cures for all these diseases so they represented only a minor cost, with no risk to me, you could argue that it could be a private matter.

I think you're severely misstating "libertarian doctrine." But I'm not an expert on libertarian doctrine so much as an expert on what I personally believe (and I'm not sure the term "libertarian" is even well-enough defined), so I'll focus on that.

I do support the use of government to defend against foreign (human) invaders. I absolutely do not support it "because you can't easily do that for some and not do it for everyone, and it's essential for the preservation of life." That is utilitarian reasoning. Utilitarian reasoning like this would indeed lead to the conclusion that "repelling disease is a similar national interest to having a military." It would also lead to the conclusion that any government service related to the preservation of life is a similar national interest to having a military. Why stop at nationalizing health care? We'd also have to nationalize food, and housing, and clothing, and education, and toilet paper, and hand sanitizer, and pretty much everything.

I support the use of government to defend against foreign human invaders because defense against foreign human invaders involves the use of force by humans against humans. Citizens place the right to use force in self-defense against others (other than immediate self-defense) in the hands of the government in order to keep the use of retaliatory force under control (i.e. to prevent "war of all against all"). Government needs to maintain a military because individuals aren't allowed to. Individuals are not allowed to engage in military (or police, or court) actions against other individuals without the permission of government. By "not allowed" I mean that government prohibits them from doing this. Government, by definition, has a monopoly on the use of force ( Individuals do have a natural right in certain circumstances to attempt to overthrow their government. (This, by the way, is the difference between my philosophy, which some might refer to as libertarian, from the philosophy of anarchism. Unfortunately, many anarchists also refer to themselves as libertarians, which is part of why I generally avoid the term.) The military, and the police, and the courts, must be run by government, because individuals aren't allowed to do it. Because diseases don't have rights, there's normally no need to involve government when fighting diseases.

I hope you'll take the time to carefully read that last paragraph rather than argue against it. Again, I don't care if you want to say that this is not "libertarian." I did not ever refer to myself as a libertarian. You are the one who introduced that term. I generally avoid that term because people with a very wide range of philosophies use it so it tends to be a term that confuses things more than it helps.

It is necessary to stamp out infectious diseases in others to prevent me from getting them (or having me stuck in my house for a month.)

And I don't deny that government has a role to play in this. Government does have a role in using force to protect people from each other. For almost all infectious diseases, civil remedies for damages are sufficient. For a once-in-a-lifetime black swan event like Coronavirus, I think government can go further, and order quarantines and travel bans and similar measures to protect people from each other. Furthermore, I recognize that the society we currently live in has become reliant on government services in a whole host of areas where government shouldn't have become involved, so I wouldn't suggest abruptly changing everything, especially not during a crisis.

In the long run, I don't see a role for government in paying for treatment, even during a crisis. This is something that could easily be handled by non-profit organizations, funded by people who are acting in their own self-interest. The argument that "you can't easily do that for some and not do it for everyone, and it's essential for the preservation of life" is an excellent pitch for soliciting voluntary contributions to your non-profit organization. We only need government to be involved when the actions of that organization constitute the use of force.

Also in the long run, I think the need for quarantines and travel bans will largely go away. You say you have to stamp out infectious diseases to prevent you from getting them or having you stuck in your house for a month. I think it's quite illuminating that you feel that your house is a place that will protect you from infectious diseases. I think this is because one's home is essentially the only place where the rights of private property are substantially respected. Your home is the only place where you have the fairly absolute right to exclude others. In a free society, stores and restaurants and sidewalks and airports and most or all other places would also be true private property, and you wouldn't need government to ban people from them, because the individual owners would have the power to enact their own bans.

But that's in the long run. Unlike many people who call themselves "Libertarians," I believe in gradual change to a free society.

Without yet having read links, but two key issues. Libertarians (and almost everybody else) give the government a monopoly of offensive use of force, not defensive. And many want a military only for defense. However, there is the problem of defense requiring offense.

Secondly, the issue isn't simply protecting people from dying. It's that to defend myself from disease, I have to defend you from disease. Disease doesn't just fire a gun at me, it bounces off you first and hits me.

Count me among those who want a military only for defense. Read the links (or better yet, read the references from the links) to understand what I mean by a "monopoly on force." Governments typically do allow citizens to use defensive physical force in order to meet an imminent threat. That doesn't negate the fact that governments, by definition, hold a monopoly on the legitimate use of force in a particular jurisdiction. ("Monopoly on force" is short-hand, which is why I provided a link.)

And governments typically do not allow citizens to use defense physical force in order to defend against a non-imminent threat.

Secondly, the issue isn't simply protecting people from dying. It's that to defend myself from disease, I have to defend you from disease.

I'm not sure that's true. But I'm even less sure why that would be a bad thing. Is the problem one of consent? Does the person who is a danger to you not consent to you making them not be a danger? If so, then that might be a place for government to get involved. If not, it sounds like a good place for the free market to get involved.

Actually, I don't think the government keeps a strict monopoly on defence. If there is a state of war with an enemy, and that enemy is attacking the homeland, I suspect any resident of the homeland is probably allowed to attack them, unless there is a cease fire.

The police, on the other hand, have a true monopoly on the use of force. The army, of course, is not to be deployed in the homeland unless there is an invasion, and then their job is to stop the invaders.

However, I refer not to that, but to the idea that it is OK to tax people to pay for it. One could have an army that only gets funding from those who donate. It's not found to work well. Likewise, the fight against microbes could be done that way, but it works better if all who benefit -- which is all who are not immune -- pay for it.

The police are part of the government, so I'm not sure what your point is.

I believe that it's not "OK" to tax people to pay for anything. At most I'd support taxation in a transitional phase from current society to a free society. Maybe not even that, depending on whether or not the government could bridge the gap from current society to a free society by selling all of its non-essential assets.

But moreover, fighting microbes is not the job of the government. The government's job is limited to those things that non-government entities are not allowed to do. Imposing quarantines is a job for government. Arresting criminals is a job for government. Adjudicating disputes about damages is a job for government. Assassinating the leader of a terrorist organization is a job for government. Running a clinic that gives people penicillin is not a job for government.

I understand that you think taxation is justified on utilitarian principles. But surely you can understand that not everyone agrees with that.

Finally, I don't even think you're right that "the fight against microbes works better if all who benefit pay for it." It's odd that you'd claim that, though, as in the current system, and even moreso in a single payer system, there are many many people who are not immune but pay nothing. If you really wanted to join with those supporting socialized medicine you'd be saying something like, "the fight against microbes works better if rich people pay for it and poor people don't."

But I think the whole notion that society is somehow less optimal if anyone ever gets anything for free, is an enormous error. Sometimes, actually extremely frequently, it's in my self-interest to do something that benefits others, without asking for those who benefit from my action to directly pay for it. Non-profit organizations thrive on this notion, but for-profit organizations sometimes give things away for free too. And if we weren't so heavily taxed by government, I think you'd see it a lot more.

Life is not a zero-sum game.

I hardly said life is zero sum. Anyway, the particular point is for those of the fairly common libertarian school who make an exception to the normal opposition to taxation for the military, police and courts. That's not everybody. There are systems where courts and police are private, and even some where military is private, but my impression is the general majority accept a tax funded military for a variety of reasons, and I am considering the question of whether the fight against infectious disease has parallels. Of course, if you don't support tax funded military, then that would be beside the point for you.

It seems you have created a strawman. Good job knocking it down.

The answer is massive automation.


How would the private sector offer improved metrics (essentially better service for lower cost, unless I'm missing something?) without deregulation of costs?

For example, with health insurance company profit margins of e.g. 5%, there isn't much *there* to squeeze by threats of nationalization.

There are plenty of people who would *like* to offer lower cost medical care... if it wasn't illegal to do so.

And if lower cost medical care was legal, the government could simply *buy* a base level of health care for everyone (similar to how for example Costa Rica provides a base level of universal health care, with better outcomes compared to the USA, for 1/10 the cost)... and much like how the government now purchases roads (pays for road paving) for everyone to drive on.

But squeezing the industry between mandated metrics on the one hand and mandated high costs on the other...? *I'm* not a health policy expert, so I don't really know, yet I'm dubious :-)

I would hope that many regulations would relax, but that is hard. A large portion of the cost is administration. Not just the cost of plan administration but the large cost of patient and doctor time dealing with the bureaucracy. That's part of how Kaiser managed to make a plan which has good outcomes and low costs without breaking any regulations.

There are some changes that are obvious, in fact Trump even announced one this afternoon -- they are going to waive the regulations that block telemedicine from getting wide use. We certainly can't easily get rid of all the bad regulations but the hope is there would be chances for something radical.

But I am interested in other approaches. Right now the two choice seem to be "continue with existing system, tweaking it slowly in a world of regulatory capture" or "nationalize." There are probably better options.

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