> Unless there is some really amazing alternative, money is one of the best proxies available for for contribution to society

This is an absolutely ridiculous assertion. Many people inherit, luck out, or get wealthy by other means. Personal wealth is a terrible way to determine "societal value". It is deeply disturbing to me that there are people with these types of views. I hate to assume but my impression is that you have not had to personally experience much hardship, would you say that is accurate?

> It is deeply disturbing to me that there are people with these types of views.

Just friendly advice: you're never going to have a meaningful discussion or a productive debate if that's how you treat a differing opinion.

Sometimes a differing opinion is disturbing enough that it should be called out as such.

> This is an absolutely ridiculous assertion.

What do you think is a better proxy?

For one, minimizing disability-adjusted life years lost. Of course it's not perfect and making this the the only criterium would be morally wrong, but it's definitely more fair than going by bank accounts.

Quote (https://en.wikipedia.org/wiki/Disability-adjusted_life_year):

>The methodology is not an economic measure. It measures how much healthy life is lost. It does not assign a monetary value to any person or condition, and it does not measure how much productive work or money is lost as a result of death and disease. However, HALYs, including DALYs and QALYs, are especially useful in guiding the allocation of health resources as they provide a common numerator, allowing for the expression of utility in terms of dollar/DALY, or dollar/QALY.

This is already widely in use btw, it's not exactly a new idea.

I see a decent argument that, but that is basically inverting someone's access to healthcare with the amount of time they've put into their community. It is much easier for old people to look back on a lifetime of doing good than young people, but prioritising healthcare to young people minimises DALY lost.

It also penalises people who are sick with serious diseases, as giving them more healthcare would have less impact than helping someone healthy.

I think it is easy to justify mathematically but in practice would be quite cruel. Plus it creates incentives for shenanigans as people desperately bribe doctors to lie about their potential futures.

I don't think lying has much of an effect, the main thing that counts for "potential future" is being alive / able to "live".

IIRC the metric is routinely used when evaluating new treatments, measuring their associated cost in $/DALY helps comparing and price negotiations.

If things are really tight (think war, poverty, pandemic, etc) I think at least it can be fair and effective. One can't live forever, and IMHO prioritizing younger people for medical care is widely accepted. Of course there needs to be a few humans in the loop as it's just a statistic and there are no guarantees.

And obviously a cold soulless robot AI optimizing for it would be insane, but that goes for most metrics.

You seem to be assuming that "contribution to society" should be the only factor when portioning out health care, and that there should be only one "best" proxy to measure such a factor. Why?

I'm assuming that while people don't like rationing things based on wealth, their objection is to the rationing more than the wealth.

There are alternatives to rationing things by wealth. All the ones I can think of are arbitrary, unfair, or unworkable (raising interesting and difficult questions too, eg, a fun example would be should highly contentious politicians be first in line for the best healthcare due to their mass popularity or last in line due to mass condemnation?).

I think that people are happy to call me ridiculous but not actually able to say how we should be deciding who gets time from a doctor. I'm very doubtful of the alternatives, I suspect that many of them involve magical thinking that wealthy people are somehow hiding hundreds of doctors in their cellars that will suddenly appear and literally cure everyone's ills if only the government mandates it.

There are a lot of problems with US healthcare. It costs too much, and there are too many restrictions that stop one person trying to help another. But the fundamental "pay money, get service" aspect isn't something that is as easy to improve on as people try to believe. It is reasonable for wealthy people to get a much better standard.

There is no need for magical thinking, but you do need to take a step back and look at the bigger picture.

Many countries view it as a much simpler problem of optimizing their society as a whole:

1. There are N doctors & medical supplies.

2. There are M people that have an illness.

3. How can we as a society make sure that these M people don't die?

Then, you (as a society) make up a set of rules and incentives and economic structures so that longterm you are able provide treatment to M people and define what "adequate" means based on your resources. If someone wants more than "adequate" treatment, you add some way to pay for things. Ideally in wealthy countries these are never actual medical necessities.

Once you're there, you just solved 80% of the problem and nobody dies just because they weren't rich.

Of course life is messy, so you need to have some resources to spare for edge cases and exceptions to the rules out of compassion, where there are e.g. experimental treatments, etc. It is true that there will be limits as to what you can provide, as treatments will cost money and disability-adjusted life years gained will go towards zero the older you are.

But that is also the case when you have a "pay money, get service" system, even if you are extremely rich you will not be able to extend your life forever.

The rationing happens either way, and in most countries you would need to be extremely rich to be able to come out on top. Actually you would need to already be born rich in order to be able to pay for anything that comes up in your childhood. That is extremely cruel, but unfortunately a reality in some places in the world.

You're avoiding the question of "how do we choose who doesn't get access to a scarce resource" there though.

It is all very well to say "we'll prioritise illnesses that kill people", but pretty much every death can be traced back to an illness. Even the ageing process could reasonably be defined as an illness, it probably will be one day if the world hasn't gotten there already. That leaves the unlimited nature of healthcare as an open problem. We all die, and arguably anything other than an accident death is people dying sick.

> Then, you (as a society) ... define what "adequate" means based on your resources.

Your country, and the US if if isn't your country, has already done that. The political process asked that question with Obamacare, for example. That is pretty recent accounting of what resources are available and what the people thought they could do with them.

And you've not grappled with the key question - we aren't going to use wealth to decide who gets healthcare. Ok, take that as a premise, we aren't using wealth to decide allocation questions. So someone comes up and says they need more healthcare. We don't have the resources to deal with them. What is the criteria where they get told no vs someone else loses treatment? You're not allowed to say "well, we're assuming there is enough for both" because there are finite resources and infinite demands. We aren't dealing with food here where everyone can reasonably be fed. Everyone suffers from diseases and could use healthcare.

All good questions, but irrelevant to the point you are refuting.

With a public health system, medical care is tied to the country's wealth - not to any individual.

In my country, a government body negotiates with the drug companies on behalf of the entire country.

That does indeed mean that some drugs are not funded - e.g new cancer drugs can take some time, or maybe never be publicly provided.

But what will (should) never happen under the public system is that a poor person is denied equivalent medical treatment to a wealthy person.

For people who want access to a higher level of care - there's private health insurance. Many have it, and use it, but anyone without it is provided the same base level of care, including free hospital treatment, available to everyone else.

> With a public health system, medical care is tied to the country's wealth

This is misleading. In a country with less wealth wages are usually lower, including those of health care provider and so on, making medical care cheaper.

Case in point: Cuba is pretty poor and have excellent medical care.

Look at the percentage of GDP that the US spends on healthcare.

Wealth is a terrible proxy for contribution to society.