Asset stripping is evil. I think we should have more regulations against asset stripping. How would those regulations be written, though?
In my opinion, as a lay person who reads the news, asset stripping seems to be a way of "hacking the system" - doing a series of things, individually permissible by the rules, to achieve personal gain at the cost of social harm. I think, we should forbid dumping negative externalities on people. But which step is the actual wrong?
I think by asset stripping the parent is including other plays. Private equity buys a company, sells the real-estate to their friends and leases it back to the company on a long term lease. Then after other shenanigans they IPO and dump the company back on the public. It's better than in the old days because they don't fire everyone and sell the assets. They may even make some positive changes, but the company now has to pay rent.
>I think by asset stripping the parent is including other plays. Private equity buys a company, sells the real-estate to their friends and leases it back to the company on a long term lease. Then after other shenanigans they IPO and dump the company back on the public.
Your wording strongly implies you think there's something shady going on, but what's the actual issue here? It's a private company, after all. Minus the concern of minority shareholders getting screwed over by the transaction, there isn't anything obviously intrinsically wrong with restructuring the ownership structure of a company you own. If a given company is only limping along because it owns real estate and pays $0 in rent, arguably the right thing to do is let the company fold - creative destruction and all that.
That might be fine if there were extremely strong regulations about the staffing/stocking/capabilities that must be provided as long as they continue to operate. For example the landlord should be getting notice that the hospital will not be paying the full amount of its rent before there is any reduction in hospital capabilities or effectiveness. And if the landlord wants to evict, that should probably require something like six months to a year's notice to allow notice to the public and orderly shutdown or moving.
But it probably just makes more sense to prevent the development of such wildly opposed incentives that necessitate that kind of highly detailed mediation. For example hospitals are public-facing institutions, they shouldn't be primarily operating out of rented buildings like some vape shop.
I didn't listen to the audio, just the teaser for it in this article, but my guess is they're not digging too much into the issue of hospital mismanagement and misallocation; in Chicago, we've got a lot of hospitals that are more or less slowly shutting down, not because anybody is doing anything shady, but simply because they aren't good and they're in areas with strong competition.
>> Your wording strongly implies you think there's something shady going on, but what's the actual issue here?
There is a distinction between shady and illegal. What they do is legal. Doing it behind closed doors while the company is privately owned and then having an IPO is shady.
The same argument can be used to justify any keeping any sort of zombie business around. The local sawmill has been loss making for years, but shuttering it would mean losing the main source of jobs for the area. That's arguably worse than losing access to healthcare, because most people can survive without access to healthcare, but most can't survive a month without a paycheck. So why not keep it around? Maybe the local/state/federal government should chip in as well to keep it running?
Of course, there's probably a reason why the business in question is faltering. Either it's being mismanaged, or the market conditions can't support the business any more. Letting it limp along might be the politically expedient thing, but it doesn't fix the underlying issue. Moreover, in the case of a market issue being the cause, not fixing it means there won't be competitors to take its place, which is basically a way to guarantee a "too big to fail" situation. To be clear, I'm not suggesting the area go without a hospital because the market conditions aren't right, it's that the government should fix the problem with rural hospitals (or whatever) rather than letting a bunch of zombie hospitals limp around.
Healthcare is not, and will never be, a free market. Applying free market dynamics to it just does not work. It's bad reasoning.
People are quick to jump to free market reasoning because it's quick, easy, and requires little to no thought or nuance. But step number 1 is you have to prove said market is a free market. And, if it's not, you then have to prove forcing it to be a free market is not only possible, but beneficial for society as a whole.
Nobody does that though, because it's hard. So they just hope if they skip the most fundamental part of free market reasoning that nobody would notice. No, we notice.
> People are quick to jump to free market reasoning because it's quick, easy, and requires little to no thought or nuance
... to defend something that is broken, because it assuages their belief in the just world fallacy. I would say that we could actually use more freer market dynamics for many aspects of healthcare. But they need to be appropriately applied to areas where there are specific problems that can actually be fixed with things like more transparency, patient choice, etc - AND NOT in ways that merely justify the existence of problems or even exacerbate them!
May be we should have more supply, less regulation & more open information on pricing. (in the US you can't get a quote on your medical bill beforehand in many places)
Currently the hospitals are working in an environment where the market forces can't work properly. That's why the prices of the medical services are so expensive. No competition, limited supply, over regulation, incentives between the hospitals and the insurers are bad.
The argument of "it's too important to be for profit" is wrong, because food is "for profit" and it's not perfect, but the market forces the big retailers to work with 2-4% margin. Hospitals aren't like that. For profit hospitals work with 14% average operating profit margin (3-5 times higher) because of the regulated industry.
This is a classical microeconomics problem of supply and demand. Markets are good at that to drive the price down. For people who can't afford it the government may redistribute the taxes from the healthy people to pay for treatment. The cheaper is the treatment, the better it will be for all.
Let's say you're lying on the sidewalk and having a heart attack. What do you want to do? Get to the nearest hospital so you have a chance at surviving? Alternatively, conduct a market survey to determine which option offers the best prices for cardiac care.
Market forces don't work for medical for many reasons. It begins with paying the shareholders dividends. That money should go to medical care. Same with C-suite compensation. Every time I hear of a medical system executive getting tens of millions of dollars in compensation, I think, "How many people could get medical care for that money?" $1 million in compensation is roughly equivalent to the annual healthcare premium for 65 people.
Then you have specialized clinics, such as MRIs or ENTs, which also have to generate their profits and pay their shareholders and CEOs. I'm reminded of the time I had to see a gastroenterologist, and the place I was recommended was an extremely well-furnished, high-priced luxury office, with a 15-foot-wide, 8-foot-tall aquarium filled with cichlids. Why were they pissing money away on fancy furnishings and an expensive-to-buy and maintain aquarium instead of using the money to take care of patients?
We have sufficient experience with financial engineering in other industries to know that applying financial rules to the medical environment is likely to result in worse patient outcomes and a higher concentration of wealth for a few.
>This is a classical microeconomics problem of supply and demand. Markets are good at that to drive the price down. For people who can't afford it the government may redistribute the taxes from the healthy people to pay for treatment.
While it is something of a trope, I'm not sure I want to be (or would be able to do so) doing price comparisons between hospitals (or ambulances for that matter) as my internal organs ooze onto the pavement after being struck by a semi truck and dragged 40 meters.
That's the primary issue with using price signals in a healthcare setting. Especially in a system where the recipient of services doesn't actually pay the total costs out-of-pocket for those services.
Which creates perverse incentives for both the payer and the provider.
And since that's not likely to change anytime soon, a single-payer system makes a lot of sense.
Non-emergency treatment/care not related to any emergency care would definitely benefit from increased supply and more information.
What, specific regulations would you like to see removed from hospital settings? I want to emphasize that this is not a rhetorical question.
The supply of doctors and nurses (invite from abroad), certification of medical equipment & FDA drug approval (if it's certified in a normal country do a very lightweight approval process). If the patients want it, allow for more risk on his side.
For drug prices, the current system is also very, very broken. Remove the PBMs from the drug supply and at least there allow for market forces to work.
It's a classical problem of resource allocation that can't be avoided with just good intentions. Medical tourism in countries like Israel & Thailand shows that this can be allocated through market forces.
>The supply of doctors and nurses (invite from abroad), certification of medical equipment & FDA drug approval (if it's certified in a normal country do a very lightweight approval process). If the patients want it, allow for more risk on his side.
>For drug prices, the current system is also very, very broken. Remove the PBMs from the drug supply and at least there allow for market forces to work.
Sadly, the current government seems set on thwarting those suggestions.
>It's a classical problem of resource allocation that can't be avoided with just good intentions. Medical tourism in countries like Israel & Thailand shows that this can be allocated through market forces.
Where are you seeing anyone even paying lip service to some nebulous idea of
"good intentions?"
While I agree that market forces can be useful in certain situations (cf. Germany, Japan, and others), but basic health care, emergency services, life-saving care and a raft of other services aren't improved with to a race to the bottom.
Socialized hospitals have waiting lists while for profit hospitals have health insurance companies denying coverage. The problem is the demand outstrips the supply and you end up with some form of rationing of care, this is not a problem with profit motive.
Just because a hospital is non profit doesn't mean it's "socialized." A lot of places have county or state hospitals, but most non profit hospitals were originally started by a religious or community organization, or a group of doctors.
Medicine has a lot of things that make it naturally not work like a normal good or service market. To deal with some of these issues, it's a heavily regulated field, but many of these regulations also make it ripe for exploitation by for-profit entities.
So increase taxes and increase supply until it meets demand. You can still do this while prohibiting private ownership of medical systems and their underlying real estate.
Easy to say, very difficult to do. Public funding and the single-payer portion of the US health care system is responsible for the scarcity of doctors --- Medicare controls residency slots, and deliberately restricts them to prevent an oversupply of doctors. Medical systems around the world in every configuration have these problems in one form or another.
Certainly, I expect more of the UHC CEO’s outcome until the system moves towards success versus failure as long as the US for profit machine continues to squeeze the population for healthcare while public funding declines in the near term.
“We’ve tried nothing and we’re all out of options.” seems to be the equilibrium we keep arriving at, despite it being unsustainable.
I'm not taking a moral perspective on it, I am saying cause->effect. If people run out of options in a failing, suboptimal system (which I'm unsure you can say the US healthcare system is anything but, based on the evidence), they will resort to the options that remain for recourse.
The framing smuggles in a moral perspective. You have the cause wrong; the shooting wasn't a policy intervention, except as to how America handles mental health and gun ownership.
It was a policy intervention in the sense that Americans have no choice in policy.
Your healthcare is entirely decided by people who are not your doctors. Every medicine you take, how long you go to the doctor, what surgeries you can get - your insurer unilaterally decides this. Not your doctor.
There's no voting system or merit system. You can't just simply find a better doctor - because your doctor is an empty vessel, they make no decisions. You have, legitimately, zero recourse.
Shooting someone is then very rational. We have made that one of the only choices, period. The insurance companies have all but guaranteed this outcome.
... thus giving the whole system the constraints of public funding and single-payer, so that scarcity isn't something to be feared - we're already suffering it. But furthermore, that scarcity is then leveraged by less regulated market actors to constrain competition and jack up prices, giving us the worst of both worlds.
A fully public single payer system would mean bureaucrats would produce a report concluding that more doctors are needed to keep costs from spiraling, and the number of residency slots would be increased. A more freer market would mean hospitals/doctors were paying for all of their own residency slots and they'd up the number through price signals. Instead, we have neither feedback mechanism.
We already have exactly that system: Medicare (and its bureaucrats) determine how many doctors we need, by setting the number of residency slots. The system that makes this calculation is public, single-payer, and state-driven, and it produces the outcome you experience in American health care.
Yes, I agreed with your point and then kept going.
If you're referring to my second paragraph - the difference is that the medicare part of the system does not have to fully contend with the resulting cost from doctor shortages as it sets its own prices below market rate.
The larger overall point is that system is only responsible for half of what we experience with American health care - the shortage part. But then we don't even get the benefits of the price controls until we reach Medicare age.
Medicare should fund drastically more residency slots. But that aside, I think Medicare is a pretty slick compromise between what's challenging about state-funded health care and private market health care: at the lifetime inflection point where people's medical costs drastically increase, publicly-funded single-payer kicks in; before that, people with (actuarially) far lower costs get the benefits of private market care. A thriving private market is created that provides benefits even to the publicly-funded care.
Obviously, the system has an enormous problem: it costs too much, because medical providers operate cartels that jack prices up.
> medical providers operate cartels that jack prices up.
These two statements are in direct conflict. If it were a thriving private-sector market, then providers wouldn't be able to form cartels that jack prices up.
I'd say Medicare is a good chunk of what's giving us the worst of both worlds. It's full of mandates that warp the entire system, but then fails to take responsibility for the warped system. Like sure we both agree that Medicare should fund drastically more residency slots. But my point is that the problem is Medicare doesn't actually have to pay the full cost of the high prices it has created with things like the residency slot shortage.
> where people's medical costs drastically increase, publicly-funded single-payer kicks in; before that, people with (actuarially) far lower costs
This analysis is entirely backwards on so many fronts. I'm not even really a proponent of single payer, but your point pushes me in that direction. Higher variance but lower average costs earlier in life are exactly where it would be most effective to spend public funds - keeping more people from financial ruin per dollar spent, more productive and enjoyable years of life, younger people are more likely to proactively obtain/consent to medical care, better outcomes from interventions being done earlier.
Imagine the opposite of what you're championing - use public funds to try to keep everyone alive until they've had 65 years of life, after which point part of your retirement savings would be a plan that determines how many resources might be spent on giving you a few extra years of not-so-great life. That seems both more efficient and more fair to me.
No, there's simply more than one axis on which to evaluate a health care system; one is expense, another is accessibility/availability, another is outcomes, and there are others.
I don't understand your strident "entirely backwards" argument, since I'm literally stating the premise of Medicare; I didn't make any of that up.
Sorry, I agree that is the analysis of the current system. I don't think we're disagreeing on facts here. What I was characterizing as backwards was that being considered a good public policy goal, as elaborated on in the rest of the paragraph.
And sure, there are many metrics by which to evaluate a health care system. It feels like the US system is somewhere from poor to mediocre on most of them, and only excels in outcomes for the extremely rich (enough money to stomach paying for your own concierge doctor to diligently follow your case and make up for the system's failings). Which is why your succinct description of the government-induced supply shortage resonated with me, and why I keep coming back to the general condemnation of "the worst of both worlds". But it seems like you aren't spending enough effort reading my comments to get my substantive points.
> Socialized hospitals have waiting lists while for profit hospitals have health insurance companies denying coverage
For-profit hospitals have waiting lists too. I had to wait 6 weeks to see one doc, who referred me to another doc. I waited 3 weeks to see that, then was referred to yet another. Another 5 weeks to see the third, and another 5 weeks to see a fourth. Each time I have to take time and money out of my schedule to do this important runaround.
I’m lucky to schedule an appointment of any kind less than 8 weeks out, unless there’s a cancellation. Recently, it took me like six weeks to get an MRI to diagnose a broken pelvis.
I live in a rural area and there’s a hospital system here that owns basically all the providers - everything is all remarkably expensive and booked out way into the future. There’s a smaller independent provider that I recently looked into but they’re scheduling new patients out by more than a year!
There are apparently more MRI machines in Pittsburgh than there are in all of Canada. Access to imaging is very definitely not a comparative weakness of the American system; most analysts would say part of our problem is we do way too much imaging.
Agreed. MRI machines are not the bottleneck - we have 3 in my area, serving maybe 100k people. Assuming most people are like me and spend about an hour in an MRI machine every 40 years, we should be at something like 25% utilization, which seems comfortable.
I’m in my early 40s and have had 1. Everyone I know well has had 1 or (more typically) none, including my parents and in-laws, so I figured ~2 lifetime MRIs would be in the right ballpark
Well apparently there are ~40m MRIs per year in the US, implying around 9-10 lifetime MRIs, which seems... pretty high? It's also wild that, at 85-90m CTs per year, apparently the average person is getting more than 20 lifetime CT scans.
And the distribution is likely heavily skewed in one direction. For example, Medicare recommends and covers annual chest CT for smokers and ex-smokers.
Oh for sure it’s skewed, and it doesn’t surprise me that there are people that will get 20+ CTs. Wild that that’s the average though - the skew must be massive.
from a system cost perspective, absolutely. For specific beneficiaries, not so much, especially after they have aged out of paying into the system. This is a textbook challenge with the US healthcare economy.
Not just from a cost perspective: overuse of imaging, particularly in orthopedic medicine, is apparently a major driver of iatrogenesis in American medicine. It actively does harm.
I don't think the term "elective medicine" means anything useful in this conversation. But, yes: I'm referring to unnecessary surgeries consequent to MRI; a big problem, especially for stuff like knees and spines.
eh, If I have elected to undergo a procedure, I would want the best and most imaging possible.
I dont see data as the problem, but the decision making around it. Preventing the generation of data may be a solution, but I dont care for it as a strategy.
"Elective" medicine is simply medicine that can be scheduled in advance. The opposite of "elective" is "emergency". Plenty of elective procedures are not in any meaningful sense optional.
I feel we are quibbling about terminology instead of the central point. Feel free to substitute discretionary procedures if that is clearer, although nearly all medicine is discretionary (elective or emergency).
Is it Boston? It's one of those cities. I went and Googled for it because I remembered hearing about it on Derek Thompson's "Plain English" podcast last year with Jonathan Gruber (the MIT health economist, not the Apple guy). I don't know if it's Pittsburgh or not, but it's not a made-up stat.
The point Gruber was making in the podcast wasn't that Canada didn't have enough machines. It's the opposite: the point was that --- Massachusetts, I think now? --- has way too many, and conditions that would never get imaged in Canada get imaged as a matter of routine in MA, which then leads to unnecessary further treatments.
If you Google it, AI / Gemini says it's true, and it's Pittsburgh. If you go into the references, Canada has roughly 432 MRI machines and at last count Pittsburgh has roughly 142. But, you know, AI is going to take all our jobs. Or at least the ones where we email each other poorly researched urban myths.
Again: I'm comfortable with the claim that the Pittsburgh thing is AI slop, but the underlying claim I'm making is not based on AI (though I apparently have the city wrong).
> Recently, it took me like six weeks to get an MRI to diagnose a broken pelvis.
Bruh, where I am in European socialized medicine land, six weeks wait for an MRI is rookie numbers. How about 6-12 months. Sure, you might die until you get your turn, but at least it's "free"*.
EDIT: Spot checking in a Canadian town with similar demographics as my own shows wait times roughly comparable to mine, and nothing anywhere near 6-12 months - worst case is about 14 weeks.
Right. I still don’t think your original contention that for-profit systems are, in general, orders of magnitude better than socialized ones is accurate, but I do concede that your particular situation seems pretty bad.
EDIT: Just checked NHS too, most recent month had ~3% of MRIs waitlisted more than 13 weeks, so pretty similar in that European country as well.
I mean if we’re doing analogies here, I’d say it’s more like you said “the sky’s always blue in the US”, and I said “actually it’s kind of cloudy here right now, and in fact it’s often as cloudy as other places.” To which you just keep responding that I’m wrong because there’s a tornado outside your house.
The US medical system is objectively bad, period. It's not even an argument so please stop trying.
Not only do we pay significantly more, but we have significantly worse health care outcomes. The hallucination and delusion that Americans get "good healthcare" because they pay so much is just not true. We, objectively, get worse healthcare.
The experience of "socialized hospitals" since the 1980s is also biased by the neoliberal push to cut everything to the bone and then justify privatization. The NHS and provincial healthcare in Canada are two examples where they've gotten less functional over the last 50 years on purpose because the government wants to push for a two-tier system with inferior care for poor people.
Please explain what exactly that would change about this situation.
The entire point is most of the surplus from the hospital is being extracted as real estate rent. The hospital itself doesn't need to post a profit in order for the overall scheme to be profitable for the perpetrators.
Furthermore as far as getting into this situation, administrators of a non-profit are just as capable of asset stripping to post good numbers in short term, and self-dealing to enrich themselves long term.
Healthcare is a concept that few people wish to compromise on.
It's also an area that most people lack the background to make educated decisions for.
For a grocery store, you're talking about 'a commodity' with many suppliers all supplying an equivalent product. So changing grocery stores isn't a big deal.
So if one grocery store charges a fortune, you just go to a different one. For healthcare, how often do you visit a hospital and when you do, how much do you care about price since you cannot tell the difference in quality beforehand
Price shopping for hospitals is very much a thing. Read up on surgical centers! Meanwhile: food is a much more fundamental human need than medical care is.
Under certain circumstances you can price shop for hospitals. For certain types of procedures, especially self pay ones like elective or cosmetic ones, the market works fairly decently.
There are other circumstances, that I recently dealt with in our family, where someone shows up to the ER with an emergent issue, and then, say, based on what's found in the ER, winds up in the ICU for a significant period of time. It's extremely difficult to price shop this, because you don't know what you're going to be buying until after you've already chosen the hospital.
This is also why provider networks were invented, so that these prices are negotiated in advance.
The word "elective" is doing a lot of lifting in that sentence. Elective procedures aren't like cosmetic procedures; they're not "procedures you can maybe do or maybe not do". "Elective" in medicine is a term of art for "you can schedule it in advance". A total hip replacement is elective; so is a lung resection, so are many coronary bypasses.
It's ironic that you managed to pick a surgery that the US is actually capable of delivering at lower cost than Europe (generally, our procedure costs are integer multiples higher than Europe, because of the doctor cartel). Most Americans getting a knee replacement will "pay" more than Europeans pay (nominally, through their employer-provided health insurance), but price-shopping Americans can significantly outdo Europe by getting that procedure done at a surgical center.
Sure that wasn't the point.
Your point was that healthcare (for profit hospitals) and grocery stores are equivalent.
You've so far argued that they're not. Unless you also go price shopping for your groceries every time.
I don't know of anyone forgoing medical care they needed because of cost. People go deep in debt to pay for it. Most people go to a hospital because they want to get better not because they're looking for a bargain.
And finally, the people that get their healthcare through work probably don't have time/will to get quotes because it's not like that's straightforward
I can't tell how facetious this is, but food is a human right. The government running grocery stores in food deserts or to avoid predatory behaviour from chains exploiting poor people is totally reasonable. This is something cities in the US do.
The thing is, asset stripping is how failing companies finance continuing operations.
If you outlaw sale and lease back, businesses and hospitals will fail sooner, but with their real estate intact. At least until they figure out that they could move into a rental and sell their existing facility, but moving facilities is very expensive for hospitals, so they'll probably not be able to afford that.
For hospitals, especially rural hospitals, I think trying to run them for economic gain just doesn't work. They're expensive, they have obligations to provide expensive care without promise of payment in many cases. Municipal hospitals seem to make a lot of sense to me, although the same communities that are having trouble with hospitals failing would likely have trouble paying for a municipal hospital as well.
> For hospitals, especially rural hospitals, I think trying to run them for economic gain just doesn't work.
In current day America it doesn't seem like anything useful is compatible with making money. From the outside, it looks like you've entirely divorced money from common good.
It is possible to make hospitals profitable, but it requires you to take control over what sorts of things you wish to make a profit.
You can just look to any well-run hospital chain to see organizations doing extremely valuable work lucratively. But many of the largest hospital chains are non-profit; in Chicago, Rush, Northwestern, UChicago, and Edwards-Elmhurst --- all of the largest chains --- are non-profit. Non-profit and rapidly expanding.
I'm not sure if I believe that story, though. Look at Sears, for example. Yes, they mostly missed the wave on e-commerce, and were on a decline ever since then. But are you really claiming Eddie Lamport didn't do anything wrong that worsened the already bad trajectory?
My claim is not that the trajectory didn't change, but that the destination didn't change.
Sears was clearly failing. Asset stripping turned a slowly failing company into a company operating normally for a period of time until it became a failed company all at once. The alternative to asset stripping would be Sears either selling off stores in chunks until it figured out how to operate profitably or became small enough to acquire; or Sears closing stores and renting them to others. Both of those strategies are hard to execute on, especially with Sears shaped stores, nobody is looking to expand into that at the scale that Sears needed to shrink.
But, for a single location hospital, you can't continue operation and let someone else use the building. If someone wants to take over operating as a hospital, that's fine... but if the hospital is consistently losing money, who wants to take over operating it? So, sell and lease back lets you keep running for a while longer.
Asset stripping is fine. If a chain restaurant doesn’t work without its land use being subsidised by incumbency, the land probably has a better use. (Nobody is asset stripping beloved single-location family-owned restaurants).
The problem is hospitals run for profit don’t make sense. The profit motive is the problem. Not how it is pursued.
Who cares how they would be written? They would never get passed. It's called capitalism for a reason - capital calls the shots. Why does nobody understand this?
So you mean that there is just one rule, capital calls the shots. Then why do we even have laws and regulation?
I think that every market needs regulation to work well. Different rules for different markets, but they need regulation to keep participants on relatively equal footing, for example to avoid cartels.
This is the thing I think alot of people dont understand.
Capitalism is not about people and their interests, its about capital, its perfectly willing to sacrifice social good, people's lives, etc. all in pursuit of Capital and its interests.
Until people start to wisen up to this, we will continue to hear stories of organizations doing clearly evil things to serve their bottom line.
The opioid crisis being caused by pharmaceudical companies in America being a clear example of this.
Agree. If this was the movie studios, or the record industry, then this kind of creative destruction would be ok, but we are talking about regulatory arbitrage and financialization leading to a market failure, and in this case it is our health system. Traveling 50-75 miles to the nearest ER will most often just lead to death. This is perhaps the most basic service a modern economy can provide ... third world countries will have better options than many US citizens.
I'm just saying: that isn't the system driving into the ground. Even after this administration royally screws up the ACA, we'll still be in a better position than we were prior to the passage of the ACA.
The US spends far more per-capita on healthcare than other OECD nations [1] and has objectively less coverage and worse outcomes [2].
Buying up property then leasing it back is straight from the private equity playbook. It almost always ends badly. And it's driving up the cost of everything. Hospitals, vets, housing, etc.
At some point you have to realize that the only innovation under capitalism is building enclosures and rent-seeking.
Whereas in China, a command economy, they've built 20,000km+ of high speed rail in <20 years and just unveiled a 600kmh maglev train (note: that's faster than commercial aircraft) that will go from beijing to Shangai, over 1000km, in 2.5 hours.
The US government, regardless of party, operates to transfer wealth from the young and poor to the old and wealthy, and the "old" part is on shaky ground. And it can't go on like this.
I think by 2100 we'll see a collapse of this system, the kind that ends in land reform, guillotines, nationalization and sovereign debt default.
>Whereas in China, a command economy, they've built 20,000km+ of high speed rail in <20 years and just unveiled a 600kmh maglev train (note: that's faster than commercial aircraft) that will go from beijing to Shangai, over 1000km, in 2.5 hours.
It's less because China is a command economy (ie. the government determines the allocation of capital), and more to do with the fact that it's an authoritarian state where the local population and interest groups basically has zero ability to object/block construction projects.
There are plenty of examples of invidiuals who do object. However, unlike in other countries, developers and the government are free to bully them and ruin their lives for daring not to sell their homes. Plenty of examples of houses in the middle of highways (one famously literally in the middle of the road), packed between huge flats, in the middle of active construction sites, placed on top of huge hills or pits when land height is altered, and other places where you'd never want to live.
That said, the Chinese state is also doing this by spending a lot of money on infrastructure. This isn't unlike what the west did when everybody got electricity, phone lines, clean water, sewers, heating, and things like bridges and infrastructure. Of course the government helped rollout of rail infrastructure in populated areas by creating the necessary laws and ordinances (less populated land was still cheap enough that companies could just buy land). That approach worked fine, until populations grew so there was less cheap land and property became a method of investment that drove up prices to a ridiculous degree.
My country's rail network has been reduced to the essentials, after several mergers and services that became unprofitable were shut down (despite them working fine as independent companies). Building new rail now takes decades of negotiations instead of a few years of laying tracks, if funding can even be secured, as politicians seem to hate the idea of investing in public transport when we could add Just One More Land. The entire system has been clogged.
The authoritarian system is one way to work around the problems of modern high-density society, but it's not necessarily the only way. The trouble lies in convincing enough people to accept the downsides, and to stop the greedy fraudsters from bleeding any development plan dry in any way they can.
Why do we spend so much and still have such a busted system? Is it that the money goes towards price gouged services, or Americans have bad preventative health practices? Other things? Likely a combination of a lot?
We spend so much because mostly we're spending other people's money, and no party is really in a position where cost control is possible and beneficial.
The patient might prefer to pay less out of pocket, but they often aren't presented with cost information until a month after the service. Often nobody can tell you how much something costs before hand. Anyway, there is incentive to get more covered care, because insurance is paying for most of it.
Insurance companies are generally limited on administrative costs and profit to a % of medical costs. More costs allowd them to pay higher executive salaries and profits. Insurance companies do have a cost control function, but the incentive isn't there to do it well.
Individual practitioners and medicial facilities and facility groups have incentive to bill more things.
People paying for the insurance, which is often employers, do have cost control incentives, but things are pretty murky at that level.
Somewhere in all of those costs, we're paying for an army of billing specialists and an army of claims handlers.
Throwing out insurance and moving to billing at time of service would be terrible for access but it would make cost control a lot more possible. Single payer systems can make cost control possible too, if the single payer system is able to do analysis and effectively set policies to avoid things that are not cost effective, and curtail billing abuses... Of course, nobody likes it when cost control says the thing they want to do isn't cost effective and they can't do it.
Yes, from what I have read it is that Americans pay for more for doctors, drugs, and services. And when attempts are made to begin to curtail these costs, the lobbyists swoop in and buy off our politicians.
We have a shitty universal healthcare system where the destitute get unlimited healthcare but only at emergency rooms, which is both extremely expensive and not that effective at making them healthy compared to e.g. regular primary care visits with free insulin and antipsychotics. The unpaid emergency rooms bills bring the hospital down and they have to take it out on the middle 50%
No money and diabetes? You can’t walk in to a Walgreens and get free no questions asked insulin, but you can absolutely pass out in a walgreens and get a ride to the hospital, diagnostics, and insulin (a $7000 value) and when a habit of this doesn’t keep your diabetes in check, they’ll do the amputation for you too ($50,000 a foot!)
Americans also consume a lot more healthcare than others. Yes, if you are poor and uninsured in US it sucks. But americans go way more to the doctor and wait less in time than in Europe.
Weirdly, my sister in the US with good insurance waits more then I do in my post Soviet country. Although I have insurance and money to skip the lines.
Still, I was surprised to hear how much she waits.
Okay, but you understand this isn't actually beneficial, right? Because American spend more, but Sweden has significantly better healthcare outcomes. So the American system is just worse, period.
Also: on the topic of same-day visits because I think there's some confusion here. American can, maybe, get same-day visits if and only if they have a PCP, which is increasingly rare.
Your PCP cannot do jack fucking shit. At best, they can swab your throat. Every type of condition management outside of Strep MUST go to a specialist. Your tummy been hurting a lot? That's a job for a gastroenterologist, not your PCP.
For specialists, it's not uncommon to wait many months or even a year. Especially because most insurance plans require a referral - so you have to see two doctors.
As one counterexample, there is a statistically significant spike in cancer diagnoses in the US at age 65 [1]. Why? Because people are on Medicare then so they finally go see a doctor.
Another: the US is the worst for wait times [2].
The US has almost the lowest rate of annual doctor visits of any country, in large part due to lack of access and cost [3].
What I just find incredibly hard to believe is that we are accepting comments about inequality and profiteering "in cooperation" with Al-Jazeera. Seriously? From the Qatari government?
Does it really need to be stated that this is propaganda? Really? Are we to believe that these people are worried about the rights of poor patients in the US?
In my opinion, as a lay person who reads the news, asset stripping seems to be a way of "hacking the system" - doing a series of things, individually permissible by the rules, to achieve personal gain at the cost of social harm. I think, we should forbid dumping negative externalities on people. But which step is the actual wrong?