I basically treat NP/PAs and doctors as a pulse with a DEA license attached. Once you realize you basically need to figure it out for yourself, for much of anything but surgery and meds, you'll realize you are better off with them vs having police put you in a tiny cage for ordering drugs without a prescription (in my state I can self order imagery and labs, so don't need docs for that). I consider their opinion totally disposable but they offer some stuff the government will imprison me for if I don't get the magic signature for.

Just treat them as totally incompetent and nudge them where they need to go. No need to assume or rely on competence that may not exist.

A minute of research has led me to conclude the discussed limit which comes from the 1997 Balanced Budget Act[1] was, like most of these sorts of efforts, passed by a Republican controlled Congress with weak opposition from Democrats. Republicans in the House voted 219 for and 7 against with Democrats 51 for and 154 against[2]. There was even less resistance in the Senate with 52 Republicans for with 3 against and 21 Democrats for and 24 against[3]. OP's "suspicion" was not "unfounded" and there was in fact "one party... driving this policy more than the other." If your complaint is simply that OP speculated on this without evidence, you're just as guilty of flagging their comment based on your own speculation without any evidence.

[1] - https://www.cms.gov/priorities/innovation/files/migrated-med...

[2] - https://clerk.house.gov/Votes/1997241

[3] - https://www.govtrack.us/congress/votes/105-1997/s130

I’ll take it. I’ll take the flag. My comment was cynical and unfounded in the kind of discourse that we should see on HN. I will not edit it either. For posterity, I was thinking of the recent cutbacks to prevent “waste, fraud and abuse”, which, coming from a senator, should have been grounded in an even higher standard, rather than walking away from requests for clarification.

There are a lot of hospitals where there is an endless supply people showing up to the ER with non-emergent stuff because it is the only place required to take them, and their number is only limited by wait time due to triage; they'll just leave if it takes too long as their life isn't threatened and they have something else to do.

You could hire a whole army of doctors and they'd still be there, word gets around. If the doctors are cheap enough to cover whatever you can get from debt collection agencies to sell off the debt they'll never pay, then you could hire a lot.

Most markets fail here. I can't even make good decisions about which electronics or appliances to buy, which restaurants to visit, which mechanic to use, and it's not for lack of research or unwillingness to pay. Advertising allows brands to build undeserved market reputation, and brands regularly sabotage their own legitimately established brand reputation for financialization.

For the overwhelming majority of things people to go to the hospital for, where you go doesn't really matter, because the treatment and diagnosis is extremely routine. This includes very serious things like cancer. My mother, through a variety of fortuitous events, was able to have her breast cancer treated at one of the top ranked cancer specializing hospitals in the US. She had acquaintances that had theirs treated at the local university/training hospital. They ended up receiving literally the exact same treatments.

Same for my own stuff. The first time one of my children got sick it was terrifying, so I naturally took him to the most premium pediatric healthcare institution. And what did they do? Basic tests to rule out anything particularly nasty, and fever management. The exact same thing the cheapest hospital does, except I got the privilege of paying 10x more for it and feeling like a complete sucker. From that point on - 'oh he's sick? shall we go to the university hospital, or the religious nonprofit?'

That's a cart-before-the-horse analysis.

Labelling markets "rational" is pure rhetoric. There's nothing even remotely rational about a market system, because the moral basis of calling markets "rational" is... greed.

Just greed. Nothing else.

All of the failed outcomes, deaths, pollution, lost opportunities, distortions of democracy, and other damages are a direct consequence of this moral system which claims that greed is rational - when in fact unfettered greed is clearly and objectively sociopathic, with predictable sociopathic outcomes.

Huh, I really like this approach. My economics knowledge isn't great, but I do know that healthcare is quite inelastic because people are willing to pay high prices to be healthy. A mixed model would siphon off the most desperate to a good option, and inject local competition.

I advocated against universal healthcare for a long time, since I was worried that it would cause stagnation in health innovation, but now I see a need for universal healthcare for the 80-90% most common procedures (and leave private clinics to innovate). The only downside I can think of is less dependence on insurance, which has the potential to drive up premiums. But, if that means taking care of the poor for the most common ailments, then it's a worthwhile tradeoff.

What I mean is that the dynamics of healthcare are not conducive for a competitive market.

Compare grocery shopping:

You have frequent/repeated interactions; if you always get ripped of by one shop, you can go to another. Before you go grocery shopping, you will have a decent mental model for: prices levels at each shop, quality of produce and accessibility/distance. You also have the full choice in where to go, basically every time.

Hospital interactions (especially ER) is the polar opposite:

You will have few interactions with it over your lifetime (hopefully), costs are basically impossible to know beforehand (and difficult to compare, too), quality of treatment is extremely difficult to judge as patient (because every case is somewhat unique, and outcomes can easily come down to luck/individual doctor). Especially in the ER case, you often don't even have a real choice of hospital and even in cases where you could (and had all the info) there might be throughput limitations on "desirable" hospitals that prevent you from switching (=> having to wait for 5 months).

Another factor I think is that hospitals gain less from being "good": As a "good" grocer, you get to steal market share from your competition at low cost and risk to yourself; for the hospital, scaling up is more difficult and risky, thus "good" competitors are also less threatening comparatively (thus less of a motivation to improve things).

> I could tell you some stories about folks who wound up worse off because the care was still rationed, just by the state instead of an insurance company.

I wish this would stop being used like it's a credible argument. The truth is that we can find these cases in any healthcare system. The only valid evidence when weighing system versus system is aggregate numbers.

For the record: With "classical free market selfregulation" I mean something that is quite far from any civilized system. Standards of care, education of caregivers and even pricing levels to some degree are all regulated in your example (which I think is a good idea).

I would literally expect overpriced snake-oil from actual free market healthcare, and there is significant empirical evidence that this would happen from my point of view.

When the government accepts AMA lobbying and sets a regulatory cap on the number of new residencies, it is regulating, and is fully culpable for doing so. Your logic basically defines the government away, treating it instead as the product of the influences acting on it.

I think you misread the original post. It is about overregulation fostering the spread of PE operated hospitals. Not about overregulation causing PE operated hospitals to have worse outcomes.

Rural/urban split. Many cities instead contend with local politicians who want to put a feather in their cap by giving concessions to developers to build new, expensive facilities (instead of, say, driving that money into actual healthcare or the rehab of existing facilities). What will happen is that the taxpayers will give millions to have a greenfield facility built, and around that time, the older local facility (likely to be servicing poorer residents or those without transportation access) will get shut down. Expanding building doesn't fix this dynamic, it makes it worse.

Slightly more than half have CoN laws and other states have a number of restrictions of facility construction that complicate building smaller clinics.

So, unless every state has a regulation, that regulation doesn't exist and has no effect?

Any other goal lines you want to redraw? Let's get that out of the way now instead of going back and forth.

(To answer: in my personal experience Illinois also has such a regulation.)

Hospitals typically lose money on emergency visits and make it back on scheduled inpatient care and outpatient services. This would accelerate a poor performing hospital's demise, because ambulances will go to the closest one but patients who have options will look elsewhere.

If you now have two ERs within driving range, you have the choice to go to the cheaper one if you are conscious and in a stable enough condition to reflect. This is the sort of thing people already think about in the US.

> Customers always end up paying for inefficient supply chains.

Obviously not. There is nothing that compels a customer to do business with an inferior competitor, if there is an alternative. The end result of having a sufficiently inefficient supply chain can be that the company involved goes out of business, as it cannot operate at a profit.

They can't just raise the prices because people will bring their business to the competition. I've personally done this for CT scans. In my local market we literally got a scan for 2k where the hospital we'd usually go to wanted 10k.

The same works for non-emergency surgery as well. Take a look at https://surgerycenterok.com/ it's such a breath of fresh air to see the full price for each procedure right there. People travel there from all over the country to get needed procedures. So competition clearly works but the system doesn't really enable it. For example insurers don't want to work with the linked center because they won't give them rebates but charge everyone the same price. More details: https://www.econtalk.org/keith-smith-on-free-market-health-c...

If we look at "food" more generically, rather than bananas specifically, we are literally in that situation where every person has to have X amount per day or they will die. And competition still works great.

There are two things that set healthcare apart here. One is that sometimes people need unusual treatments to stay alive that are extremely expensive, and our desire not to let people die is at odds with the normal market mechanism where products that cost too much just don't get purchased. The other is that sometimes people have emergencies so urgent they can't really choose their provider.

But the vast majority of healthcare doesn't fall into those categories, and normal market mechanisms work fine for those. Competition would lower prices for most healthcare just like it does for food and everything else.

>Unlike grocery stores, hospital ERs don't get frequent repeat customer interaction...

Oh yes they do. I can think of any number of patients I'm familiar with who end up in the ER multiple times a week. Practically daily for some people. And a few who are known for getting discharged from one hospital and immediately heading to another nearby one.

How could you even compare prices?

If you go in because of a killer stomach ache you could end up needing a CT and emergency surgery. Or you could end up getting some pepto-bismol.

And if you are taken there by an ambulance (which you also have no ability to compare any price to). You'll be sent to the hospital the paramedics decides to drop you off at.

There is an inherent complete lack of information when going in for a medical situation that can't be fixed by the free market. You need (or believe you need) treatment now. There's no way for you to know what that treatment will be.

Even going in for an annual physical can be the exact same. Some dicey numbers on your blood work and you might be looking at some huge unplanned bills that are completely unavoidable.

That's what reviews and word of mouth are for. Don't you do research before picking a hospital and doctor?

We do need price transparency though.

An ER is only a small part of what a typical hospital provides. And life-threatening, must-get-treatment-immediately-or-die emergencies are only a small part of what a typical ER provides.

Yes, there are some kinds of care that aren't very amenable to competitive market forces, but the vast majority is.

A town with ten people won't have five grocery stores in the first place. Nobody's going to spend a bunch of money to open a store in a place where there isn't a customer base to support it.

You just contrived your sob story to falsely fit a narrative I didn't portray. Cancer isn't considered an STD and it's not the flu, and your wife was victimized by the very people I'm describing that wasted ER resources.

You're confusing the symptom and the reason.

The symptom is that emergent cases are getting worse care.

The reason is that non-emergent cases go to the ER even when it is known apriori the case is non-emergent.

The solution is to disincentive non-emergent cases from going to the ER when it is known apriori they are non-emergent.

How you actually accomplish that could be violence (use IRS men with guns to fund PCPs by taking away money from someone else they could have used on necessities as we currently do in social security), it could be charity (monetary or labor donations for medical services), or it could be finding ways to make people pay for abusing the ER system, or it could be deregulating health care so it's cheaper. There are lots of ways to implement the solution but your comment presents a false premise it's the only choice.

Unfortunately my attitude is the only one that will actually help you fix things because I'm bringing you a sober view of what the situation is. And people much "better suited for it" who worked in inner city ER generally had even less rosy thoughts than I did, if you want to defer to "experts" it's hilarious you would think this is unusual takeaway and that my opinion wasn't formed in large part by the experts thinking the very same thing (which of course they are never going to tell to the patients, you're probably not going to hear it unless you actually work in an ER and are close and comfortable enough with doctors for them to risk themselves to tell you what they really think as it's totally unacceptable to say it publicly).

> Who is gonna decide how the R&D money gets spent?

Same way the NHS previously funded medical research. Grants and grant review. You can expand that department and effort.

> What's their skin in the game and their feedback mechanism?

Believe it or not, some people just want to research and look into cures for diseases. Shocking I know. Feedback can be reviews of their work and blackballing bad actors that consistently kick out bad research.

> Why will they do a better job picking what to research than current pharmaceutical companies?

Because they already are. Pharmaceuticals aren't doing the majority of research, they are taking NHS funded research and running it through FDA approval.

Ozempic, for example, didn't come from pharmaceutical research, it came from grant research into lizard spit.

> Who is gonna decide how the R&D money gets spent? What's their skin in the game and their feedback mechanism? Why will they do a better job picking what to research than current pharmaceutical companies?

Pharma companies are pretty terrible (e.g. pricing a cure for a kind of hepatitis just under a liver transplant, not because it costs that much, but because they can make the most money that way even though access is severely restricted). Getting rid of that market-driven terribleness may be a enough gain to justify the reform.

Personally, I'm so sick of the business-all-the-things approach and its well-known failure modes that I think society needs to put some effort into making other models work. Either straight up nationalization (with perhaps internal competition between research centers), or stricter oversight (e.g. putting government officials, patients, etc. on pharma company boards with enough power that the shareholders have to take a back seat).