With healthcare, it's not just about "what's the cheapest option", it's also "who will deliver the best service"... given the relatively limited ability to optimize the first, I generally will focus on the second, and I think that's what most folks do - they go with providers they trust.

It all comes back to my original point: healthcare, particularly non-elective healthcare, is not well-suited to a free market solution.

If you're unable to discern whether your doctor's preferred solution is the best one, then what is the purpose of asking your doctor in the first place? Or how would it be beneficial if the "worst" provider was forced to charge you the same as the best provider?

If I was qualified to discern if my doc's preferred solution was the best one, I'd be a doctor. I ask my doctor because he's been specifically trained to make that determination.

> Or how would it be beneficial if the "worst" provider was forced to charge you the same as the best provider?

You've got that backwards. Right now, we basically allow the worst provider to charge as much as the best one, because we don't really have any way to differentiate the best from the worst. There's no need to force any business to charge more.

TIL there's no testing, rating, or regulating in the medical industry.

>I ask my doctor because he's been specifically trained to make that determination.

I agree, so this concern of yours is alleviated. The market provided you an expensive option which is the one your trusted advisor recommends, and there's a cheaper one which may offer lower quality service. You are now empowered to make your own decision on the matter.

>You've got that backwards. Right now, we basically allow the worst provider to charge as much as the best one, because we don't really have any way to differentiate the best from the worst. There's no need to force any business to charge more.

Moving to single payer does not help you differentiate the best from the worst. All it does is force the good provider and the bad provider to charge the same. The current insurance regime is not better, because your provider can choose the worse provider for you if they're cheaper, leaving you no option at all.

I can't believe we're going with car analogies here. HN is now the Slashdot of yore.

I do hope you realize that people use fundamentally different methods of choosing things in life depending on the importance and consequences of that choice, and hence asking about how one chooses cars doesn't apply to choosing a healthcare provider.

Unless you are, in fact, a robot, in which case I welcome our new, ah nevermind.

There is no magic here just because healthcare is more important than car choice. You're no more or less safe because you're paying out of pocket. It's not as if paying out of pocket means you're going to be getting healthcare from Joe the crackhead in the back alley. It will still be doctors, NPs, etc. all licensed in your state.

You can speak for yourself. I bought my Honda Fit because I saw a video ad on Youtube.

Worked for me, I love the thing. And if I didn't? No biggie, would have sold it off on Craigslist and bought something else.

Would I select a doctor based on an ad? No, no, and no. Which is my point, actually.

No, the idea that people who have no skin in the game--regulators and bureaucrats--can make better decisions than the people directly involved, particularly about matters with as much at stake as health care--is one of those zombie ideas that just don't die. No regulator or bucreaucrat ever suffers any negative consequences because of bad decisions about other people's health care.

As for people being poor at judging for themselves whether procedures are necessary, another comment upthread already addressed that: there are plenty of other areas (auto repair, for example) where most people don't have the technical knowledge to judge for themselves whether procedures are necessary, yet markets seem to function in those areas. Furthermore, under the current system in the US, people have little incentive to become more knowledgeable, because they are not going to be given a choice anyway; they're going to get whatever their health insurance provider says is the standard care. Under a market system, people would have much more of an incentive to actually learn about the various options. And there would also be much more of an incentive for independent third parties to provide information, particularly information that health care providers might not want people to know.

More generally, the reason market advocates, like me, advocate markets is not that they always give optimal outcomes. They don't. But in cases where they don't, non-market alternatives give outcomes that are even worse.

This shouldn't be a surprise. An individual is going to not make very good decisions about how healthcare dollars are allocated over the course of their life. They're going to usually tend to underspend on preventative care (which has the highest ROI) and tend to overspend on end-of-life care (which has a lower ROI). You can see this played out in things like the US's infant mortality rate (3X other developed nations) and life expectancy (31st worldwide, declining).

I think this "conclusion" depends strongly on how you define "worse outcomes".

> An individual is going to not make very good decisions about how healthcare dollars are allocated over the course of their life.

Not if they have no incentive to learn how, no. And our current system gives them no such incentive, since they don't control the dollars to begin with.

In other words, the system complains that people don't do something that the system prevents them from doing.

> In other words, the system complains that people don't do something that the system prevents them from doing.

Uh, this has nothing to do with the system, and mostly everything to do with behavioral economics and risk pooling. People are poor at investing in preventative care, because the benefit is extremely hard to perceive at the individual level. And they over-invest in end of life care, because, well, they don't want to die. That's not the result of "the system", that's human nature. Attempting to build a healthcare system on how we "should" act instead of how we actually do isn't a plan.

This also ends up being a pretty unfair way to apportion care because a rich man couldn't care less about a $100 fee and a poor man can find it prohibitive.

One example would be how the US has one of the worst infant mortality rates in the developed world.

If you stratify by income then the lower end of the income scale have it far worse than equivalent cohorts in many other developed countries.

I mean sure if you are upper middle class and work for a large national or international company then healthcare is probably up there with world class but that's not a lot of people percentage wise.

Because if you wait until you need it, it's going to be a pretty bad time to negotiate.

Further, "skin in the game" is mostly a euphemism for increasing out-of-pocket prices for care to encourage patients to be "discriminating consumers," a concept I've already detailed my objection to.

> Further, "skin in the game" is mostly a euphemism for increasing out-of-pocket prices for care to encourage patients to be "discriminating consumers," a concept I've already detailed my objection to.

First "euphemism" implies some ulterior motive. I don't think people are trying to make people poorer. Hanlon's Razor would have us presume everyone at least thinks they have a mostly good idea.

Next, if people were somehow using their own money, they'd also have the option of choosing something 10 or 20 percent more affordable, keeping the difference for other valuable things, like paying off a house, paying for grandkids' college, buying those plane tickets to see their cousins, etc. The reason there is no downward pressure to save on individual things (even predictable, non-emergency things like deviated septums) is because there's no best viable alternative. We don't keep the three grand we save by saying, "Hmmm... maybe I'll just lose 15 pounds instead." That's how things are supposed to work.

But don't take my word for it; here's the Rand Corporation offering a studiously even-handed assessment and giving a definition of the term matching the one I suggested: https://www.rand.org/pubs/research_briefs/RB9672/index1.html

> These plans are intended to give consumers more "skin in the game" — that is, to make them responsible for a greater share of spending. Proponents of this approach contend that consumers in such plans will have more incentive to make prudent, cost-conscious decisions about using health care, which, in turn, should drive down overall health care costs. Critics, however, have voiced concerns that consumers lack information needed to reduce spending without reducing quality of care.

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> We don't keep the three grand we save by saying, "Hmmm... maybe I'll just lose 15 pounds instead." That's how things are supposed to work.

Well, first of all, that's false, in the sense that, increasingly, deductibles are substantial (a few thousand, at least), co-pays are higher, and co-insurance (where it's difficult to even predict what you'll owe) is becoming more common. Almost nobody has a plan where they don't have to pay something for medical care.

But besides that, maybe in your scenario someone decides to lose weight. But let's think of another scenario. I start to experience some pain but I haven't really got the money for the doctor's visit. I decide I can tough it out. I keep doing this until the pain is truly unbearable and then I go to the doctor and find out I'm terminally ill and I waited too long to be treated. Or I forego preventative care and miss an opportunity to catch and treat cancer early. There aren't outlandish scenarios; they're the result of a system where patients have to shoulder more of the cost of care out-of-pocket, especially when combined with a state of affairs where a great many Americans do not have the savings to pay an unexpected expense of a few hundred dollars out-of-pocket.

No. They are just cherry picked. There are very few scenarios now where the consumer benefits from saying "no" or "less" to their doctors. Single payer doesn't solve that. They just have an unelected government official saying no. And the patient doesn't benefit in that case. I haven't heard any reply about the moral hazards of turning healthcare decisions into lobbying efforts. Do we not think the well-connected and otherwise favored will still benefit over people in poverty? I'm skeptical.

Who wants doctors out of the loop? I want them more in the loop.

Doctor-patient relationships don't work that way. If they did, we wouldn't have people getting illicit prescriptions from doctors. Doctors, surprise, do listen to their patients wishes and accommodate them when they're OK with what the patient wants.

Doctors should be advising us, "Here are your options (with prices). What do you want to do?" One option on the table for "laceration on your back" should be "have an uglier scar and give a big check to your son as a wedding present". Right now, with good insurance, there's no incentive not to treat you like an underwear model that needs scar-free skin and do experimental scar-lightening UV treatments.

If a procedure (or doing nothing) is foolish, of course good doctors won't put that on the table. But single payer doesn't have doctors and patients making these decisions. They would instead look at a pre-determined schedule of options as handed down from the Bureau Of Wellness. Maybe, because of lobbying and political infighting, "uglier scar" is the only option. "Check for my engaged son" certainly isn't on the schedule.

A guy with a minor cut on his back is bombarded with a 24/7 targeted ad campaign for ScarAway!TM, that convinces him this experimental...er..."cutting-edge!" UV treatment is the only thing standing between him and a constant stream of fawning, eager females twenty years his junior. He then obtains this treatment from his "true believer" local doctor at the low, low price of a $2,000 "co-pay" for himself and $20,000 from his insurer. After three months of ScarAway!TM his back is of course completely disfigured and looks far worse, at which point his own wife refuses to sleep with him, necessitating years of therapy. A decade passes and he is diagnosed with melanoma from the UV he was exposed to and dies one year and one million USD in healthcare costs later. The most memorable moment of his son's wedding is a tearful toast to his deceased father, whilst each of the doctors involved in his "treatment" as well as the ScarAway!TM salesman cut checks to their engaged children.

>There are very few scenarios now where the consumer benefits from saying "no" or "less" to their doctors.

is totally off base. The primary benefit to saying "no" is avoiding damage to your health from dangerous and unnecessary treatments that American doctors have a financial incentive to sell. People in the U.S. have their life expectancy reduced every day because we, almost uniquely among developed countries, have removed nearly all limits on the cultural acceptability of medical professionals and the medical industry as a whole treating patients as sales marks rather than patients. If you would like to experience this firsthand, respond to any AdWords or TV advertisement for a medical treatment. The sleaze is limitless.

>They tend to gloss over who actually decides when a procedure isn't worth it.

Salaried civil servants with advanced degrees who have an interest in cutting through BS to protect the health of the country. If you want to reduce people like Frances Kelsey to "unelected government officials" be my guest, but you're only showing how naive you are.

Could it be that the model is wrong?

The example of an automobile doesn't seem apt. Are you going to trade in Grandma for a new one when the treatments prescribed get too expensive and they can't figure out what's wrong with her?

Ask any doctor, and there's a reason they personally do not want to go anywhere near a hospital at the end of life. It's usually the children/grandchildren who live far away and never visit who insist that every last thing be done prolonging their grandparents' suffering in my opinion. The ones who live nearby and spend plenty of time are usually okay with letting them go.

Another problem is that procedures and appointments that could be considered routine maintenance in other areas are paid for by insurance. You don't use car insurance to pay for oil changes or new tires. Services such as annual physicals/check ups, vaccinations, etc should be cheap enough to pay for out of pocket.

That would leave insurance to pay for the more expensive forms of care, just like one would use car insurance to pay for damage as a result of a collision.

The flip side of that is that they aren't contributing much to insurance premiums. At a policy level it may be worth a slight increase in cost if building it into insurance significantly increases the number of people that actually get the shot.

Can we be certain of that? That is, even if the vaccination costs $30 to $40, will the insurance be billed for that amount, or do they get billed something like $300 instead?

I haven't tried to pay for a influenza vaccination out of pocket recently, so I don't know what most places would charge.

[0] https://www.bradsdeals.com/blog/where-to-get-a-cheap-flu-sho...

Even so, that's more money that the insurance company is paying out that could just as well be paid for directly everyone who gets the vaccine. If routine care was affordable without having to involve insurance, then insurance premiums wouldn't be as high and the out-of-pocket costs for medical care wouldn't be as high either.