I don’t think it’s smart to proactively back track without being very careful. One thing that’s needed is for corporate death to be allowed to occur. Right now the downsides of risky behavior is bailed out for large enough risk. Then the companies that fail aren’t robust and the ones that don’t are but bailouts let non robust companies keep going. Otherwise “robustness” is a property without a measure which means that you’ll get robustness theater where actions are being taken in the name of being robust but it’s not actually making a difference at best and could be making things worse.
As for society itself being robust, it’s a much harder property. Being robust is nice but no one actually wants to live in a metered society where there’s insufficient resources - they’d generally rather kill for resources greedily and let others fail without helping them. That’s why socialized healthcare struggles - while it guarantees a minimum of care for everybody, the care provided has longer wait times and most people are not willing to wait their turn.
In a free market economy we shouldn't demand robustness, we should create a system that promotes and rewards robustness. A strict commitment against bail-outs would certainly be part of that. Companies (and private people) can decide to lower their risk exposure (at the cost of efficiency/profit) or take out insurance against risks. And if they go the insurance route they have to assess how likely their insurance is to go insolvent at the next insurance event. That's how you reward those that are actually resilient.
Healthcare is more complicated. It can never work as an efficient free market since nobody goes comparison shopping for the hospital with the best value-for-money when they have a car crash. That's why socialized healthcare achieves much better results per dollar spent. But it's often hamstrung by attempts at efficiency.
I think a better societal example is disaster relief: helping people back up after they have been hit by a hurricane is the humane thing to do, but how much is that encouraging people to settle in high risk areas with insufficient precautions?
>private people) can decide to lower their risk exposure
I think the complexities of modern societies make it too difficult to measure this risk adequately. We just don’t have the bandwidth to think about the second-and-third order effects for every social/financial interaction we encounter. And people are generally very poor at estimating high-consequence/low-probability events. This means people will often take very outsized risks without realizing it; when bad things happen it creates an unstable society. I don’t think we’ve evolved to personally manage all the c risks in a large complex society and farming those risks out to institutions seems to be the current way most societies have decided to mitigate those risks.
It also doesn't strike me as very fair. If you smoke, should you not receive cancer care because you took unnecessary risk?
I can see how you could arrive at similar conclusions from a risk management perspective, but it's not a morally just system. Within the system risk taking must be accepted.
Depending on your definition of “fair” this presupposes people are good at estimating risk. The above premise was is based on the fact that they are not. I think there’s a lot of behavioral research that backs that up.
>...farming those risks out to institutions seems to be the current way most societies have decided to mitigate those risks
Unfortunately, those institutions --be they governments, insurance companies, UL Labs, banks, venture capitalists, etc.--also need to be vetted.
Even when staffed with impeccably well credentialed and otherwise highly capable people, their conclusions may be drawn using a different risk framework than your own.
The risk that they mitigate may even be the risk that you won't vote for them, give them money, etc.
There is also the risk of having too little risk, a catastrophe no worse than too much risk. The balloon may not pop, but it may never be filled.
I don’t think anyone reasonable is advocating believing institutions on blind faith (possibly with the exception of religious institutions). They need to be transparent and also strive to reflect the values (risk and otherwise) of their constituents.
Patients have time to shop for most healthcare services. Only a small fraction of healthcare spending is for emergencies. The highest cost stuff is mostly elective procedures. If you need a colonoscopy or hip replacement then you have time to shop around.
Socialized healthcare has its advantages and is probably more cost effective on average. But we also see affluent Canadians coming to the USA as medical tourists and paying cash for MRI scans in order to avoid the queues back home.
> Patients have time to shop for most healthcare services.
Patients have the time but rarely have the actual ability to shop around outside asking "is this provider in my coverage plan?" They demand me to sign a document stating I'm willing and able to pay while often never being able to actually tell me what the procedure will actually cost. Often, they won't even know that same day the procedure is done, it'll be weeks before I'm actually invoiced. And don't even get me started when you've chosen the surgeon in your plan, the facility in your plan but it turns out the anesthesiologist they scheduled wasn't in your plan. Oops. That's an expensive mistake you made, should have shopped around!
My knee kept locking up and I'd experience tremendous pain. Only once every few weeks though, so I had time to "shop around". I called up several places and tried to get an estimate of what it would cost ahead of actually seeing the doctor. Nobody would actually offer that, they could only make an appointment to see the doctor. No idea what the doctor would actually want to do during that appointment, so who knows what things will cost. Will they want x-rays? Will they want an MRI? Can they do the MRI there? Won't know until you commit to paying!
And out of the few dozen choices of kinesiologists around me which were covered by my insurance few had any appointments available within the next several weeks. Many weren't seeing new patients. So really it was deal with my knee randomly causing me immense pain for several more months or take whoever had the first appointment. And this is in one of the top five largest metro areas in the country, not some small town in the middle of nowhere.
Shopping for which hospital to do the delivery of my children, the estimates for our costs after insurance had a massive amount of uncertainty to the point of being useless. Could be $4k, could be $20k, who knows. Imagine going to a burger joint and the menu says a burger could be anywhere from $1 to $50, we'll invoice you in a month. Go down the street, menu says it could be $3 to $48, we'll invoice you in a few weeks. What an ability to shop around! Free market at work!
> avoid the queues back home.
I already mentioned, most kinesiologists around me were fully booked for months. Very few had anything within several weeks. That's queueing.
I tried to book an appointment with a new dermatologist a few months ago. Once again, in this very large metro area. For dermatologists in my area covered by my insurance, the earliest appointment was six months out. It took several months to get a family member's hip replacement scheduled. We have queues in this country as well.
Getting medical imaging is generally pretty quick and easy though, and places like MRI imaging centers just want to keep moving people through so if they have an empty spot in an afternoon having someone in the machine constantly is important. It's also generally the easiest thing to automate in healthcare; mostly just a matter of getting enough machines and lightly trained techs to rotate people through. Radiologists are often off-site contractors getting paid for every scan they review.
It's unreasonable for you to expect a cost estimate on knee pain. You can ask the provider organization how much they charge for a regular office visit, and then check your coinsurance or copay amount. During the initial office visit the doctor is likely to recommend follow-up tests, imaging scans, medications, and/or physical therapy; you can then ask for price estimates on those additional services.
The No Surprises Act does give patients some protection against high charges for out-of-network services.
> It's unreasonable for you to expect a cost estimate on knee pain
Ok, but then it goes back to this idea of queueing and the "free market". Ok, so it'll take me a few weeks to go to the first doctor just to get his paid estimate. If I don't like whatever estimate he gives (which once again he probably won't directly) what am I to do? Start calling around, make another appointment with someone else several weeks later and pay yet another appointment fee? Hope his prices are better? Rinse and repeat to get a few quotes?
And so continuing the burger example, you call ahead to book a time well in advance and pay $2 just to be able to look at the menu. What a free market.
One of my kids had to get tubes in his ears. I didn't actually get a good faith estimate of cost until that morning in the hospital despite calling several times. I had to schedule, wait weeks, show up early in the morning, and refuse to sign for the financial liability until I got an actual estimate. Free markets at work here guys, totally not a broken system, easily just shop around. And yeah, sure, I could have gone to see a different audiologist and then gone through scheduling it all again and waiting another few months and a couple hundred dollars. After all its just my kid's speech development, no big deal delaying that another month or two (or three).
At least it's good to see this No Surprises Bill solved at least that one example of the healthcare industry screwing people over. Thanks for sharing that.
That solution is never going to work when black swan events occur on the order of every 5-10 years and executive vision is focused on the next quarter with little concern paid to anything outside the next 2-3 years. Nobody is going to want to give up short term performance to mitigate risks that probably won't manifest until after they've left for a better job.
That solution is how it already works for the vast majority of companies in the US.
“Too big to fail” is a meme that only applied to a tiny handful of companies during the financial crisis. Take a look at SVB for how fast a stalwart huge bank can implode with zero fucks given by the government.
By "zero fucks given by the government" do you mean the government got involved, effectively bought the bank, and took responsibility for 100% of deposits (most of which were the balances of startups, ie venture capital investments)?
Nope, shareholders got wiped out and the bank was done as a bank.
What you’re thinking of is FDIC which is completely the opposite of a bailout for the bank. It’s a bailout for depositors (a huge portion of which were normal people). Arguments for the FDIC protecting people from keeping money in bad banks is a different argument, but it most certainly isn’t a bailout.
If you think going bankrupt and the FDIC seizing your company and wiping out shareholders is a bailout, you don’t know what a bailout is at all. That’s standard bankruptcy with an extra heavy boot on the throat from the government because they are ruthless about maintaining consumer confidence in the banking system.
I didn't say bailout. You said the government gave zero fucks but I think it actually went way above and beyond the normal FDIC insurance to make sure ALL depositors were made whole not just up to the normal 250k.
5-10 years is a perfectly normal investment horizon, and in the end investors are the ones electing the CEO and setting goals and rewards for the executive. If betting on the long term is a winning strategy companies absolutely have the means to do that. But right now it usually isn't.
Yeah, that's the real problem. Too much efficiency in the short term.
My idea on working around this: for any business with actively traded stock there is a salary cap, say $1m/yr *per year*. You want to pay that guy $10m/yr? No, you pay him $1m and he gets 9 sets of shares that are worth $1m now, but they will be delivered one a year. Next year, same thing, you give him $1m, one set of shares from the previous year is delivered to him, he's got 9 new sets coming. So long as you have such shares forthcoming you are not permitted to engage in any trade where you would gain from the stock going down. If you do so inadvertently (say, investing in a fund that shorts the stock) any income from that is taxed at 100%.
The idea is to make your top people care about the long term prospects of the company, not merely the prospects of their area for whatever time they're in charge of it.
Businesses won't plan for black swan events when the people operating them have other sufficient wealth that the death of the company doesn't pose a serious problem for them. When CEOs make enough in a year to retire, there's no need to to worry about a potential catastrophic failure next year.
I don't see why people can't comparisons shop for hospitals before they get in a car crash. Unless I am literally unconscious I would go to the hospital in my area that I trust the most, and I have plans for which urgent care, clinics and hospitals I would take someone else to if they needed a driver.
In fact I think a pretty small fraction of patients arrive at the ER unconscious.
How would develop the "trust" and why would it be correct? How would you diagnose yourself or others before selecting a hospital if those have different trust for different things? How do you balance urgency vs different trust levels if the hospitals are not all the same distance?
It also ignores that huge swaths of the country have no choice at all and the only hospital within a hundred miles is only viable due to huge Federal subsidies. We’ve been helping a close family member navigate that scenario and sure, he could vote with his dollars but it would involve a three hour drive to a neighboring state for an 80-yr old. I’d rather just enforce minimum quality standards on everyone like most other civilized countries rather then relying on “the free market” which so far in my experience has just led to PE goliaths swallowing entire health systems to focus on bill collection and union busting.
CMS does enforce minimum clinical quality standards on hospitals (at least those that accept Medicare). The problems in areas without meaningful competition tend to be more around shortages of qualified practitioners, high prices, and abusive billing policies.
edit: didn't realize I was feeding a troll. Feel free to ignore.
I expect the objections are in how quality is measured and enforced.
It reminds me of education system in the US - most people (project 2025 aside) think it's good to have a public education system; having a pipeline of skilled workers makes it easier to build an economy filled with a diverse set of businesses.
However, the attacks start to fly when there is disagreement about who should be allowed to teach, how they should be measured, and how they should be paid.
Just to be clear: You're asserting that the average citizen
* has the same capacity to research an unknown number of medical procedures and the doctors performing them as they do researching onion prices or CPU specs
* faces a similar scale of consequences when failing to properly analyze medical procedures as they do when they fail to properly price-compare onions or PC services
* has the same freedom of choice to "purchase their preference" in an emergency, life-threatening situation as they have when shopping for PCs or groceries
Dietary and metabolic problems are an epidemic that outweights malpractice in terms of quality and quantity of life by more than two orders of magnitude - so yes, I am saying people face "shopping problems" of life or death magnitude every day.
I've never needed a medical diagnosis to decide between calling my GP and going to an urgent care. It's just a bit surreal to hear everyone else say my ordinary survival skills are impossible and more than could be asked of anybody!
You said you have a hospital selected you trust (by whatever your metric is). Hospitals tend not be all equal for all things, so trust should probably be differential - how do you assess yourself as a patient then to decide on where to go? And if you do not differentiate the trust any further than to a single hospital regardless of what the issue is: why is that sufficient?
I think it is fine to have some preferences for a hospital, but not sure how much benefit that confers outside of some narrow situations.
Sinply replace hospital with any other service, take your own answers and then translate it back. In economic terms I researched medical facilities until the expected marginal benefit of the information fell below the marginal cost. There are a lot of reasons to reform the US healthcare system but you can't argue that consumer choice is too complex to be realized.
The usual cycle for business in a free market is it appears young and fresh, lacking any parasites. It grows rapidly, displacing existing mature businesses. Then, it accumulates bureaucracy and parasites, becoming less and less efficient, strangled by bloat and inability to adapt, and slides into bankruptcy, replaced by the next generation of new businesses. The remains of the business are then reallocated to the next generation of businesses.
(This is quite unlike the common view that businesses inevitably grow to take over the world.)
I.e. business is much like a living organism.
Problems set in when the government bails out failing businesses.
Even worse are government "businesses". They are not allowed to fail, and the inefficiencies, parasites, corruption, grow and grow. When can you remember a government agency being abolished? Eventually, the government will collapse.
Not just government agencies. Everybody wants their finger in the pie to justify their job. And every politician wants to do things their voters like.
I'm thinking of a reasonably recent article I saw that was talking about helping people navigate the 30+ assistance programs they might be eligible for. There's your problem right there--there should not be 30+ programs doing approximately the same thing! That's an awful lot of duplication of effort.
Or look at what happens with business licenses. Two things I see:
1) They want their $ from entities that shouldn't really be "businesses" in the first place. Around here an awful lot of licensed professionals have to have a "business" license--never mind that the nature of their work means they're inside some other entity that actually is reasonable to license. And that means a sales tax registration which has an annual minimum that such people almost certainly will never reach. (Sales tax includes use tax--but it's their office that actually engages in such transactions.)
2) Businesses that perform their work on-site have to have business licenses for every license area of the metropolitan area they work in. Hey, guys, get together and define the superset of the rules of your area and allow someone to get a license that covers the whole area based on that superset.
The Republicans are "right" in that we have far too many regulations. But they are very wrong in wanting to take an axe to them--most of the rules are individually sensible (and when they produce nonsense it's often situations where it's not worthwhile to special case), there is a horrible problem of duplication of effort and fingers in the pie. It's not chopping that's needed, it's organization.
> Even worse are government "businesses". They are not allowed to fail, and the inefficiencies, parasites, corruption, grow and grow. When can you remember a government agency being abolished?
In Commonwealth countries and the UK itself there are plenty of businesses called “crown corporations” which are owned by the government. Change in attitudes towards more liberalism led governments to deregulation and selling off bits and pieces or the entire corporation. Here are some Canadian examples:
America is a relatively young country and has very peculiar philosophies sometimes not found in the rest of the world. Be very careful extrapolating an American perspective abroad or as capturing some elemental truth of the universe.
The problem with this is principal-agent problems. The owners of the business don't want it to fail. The people working there want to make money. They generally live their life and enjoy what money they make before the chickens come home to roost. It can be hard for the owners to realize the business is fragile before that fragility becomes apparent. In the mean time the people running the business made a bunch of money, potentially jumped to other jobs or retired or died.
And the owners could have sold when the business was propped up by unknown fragility.
Human lives are too short for these kinds of feedback loops to be all that effective.
One of the primary reasons people bail out companies are the knock-on effects. People losing jobs, etc. If society itself is robust enough to cover for people in those situations, we could let companies fail far more.
There's a sentiment on here often that, even if a company has been essentially blown up by technology or market change, they should have transformed themselves to adapt. But that implies they probably needed to rototill their workforce in any case. At some point, you're probably better off just declaring bankruptcy and starting fresh or letting someone else do so.
True, but for some companies there are also national security concerns. If we lose the domestic supply chain for certain items then that limits our freedom of action and leaves us vulnerable to supply disruptions.
If you depend on a single company to supply certain items, you have a big problem already. Pouring money in that company will mostly help the executive bonuses, not the national security.
I would love to see a good proof that it works, all the discussions, rumors and anecdotal evidence suggest the contrary. I am open to learn the truth, with hard numbers.
Very long waiting times are the first thing that comes to mind regarding such failures, with UK and Canada at the top spot. It is not uncommon to die waiting for a consultation to be diagnosed in 1-2 years.
What do you wanna good proof of?
Life expectancy? What population health metrics do you want?
Almost all EU countries with socialized healthcare beat US and even UK. Canada is more near EU level.
Do you also want US anedoctal evidence?
What’s the consultation time for diagnose in the US for people without insurance/ insurance doesn’t cover/insurance says it doesn’t cover/no money??
Never?
How does that affect the average/mean?
Life Expectancy:
Italy 83.7;
Spain 83.7;
France 83.3;
Sweden 83.3;
Canada 82.6;
Portugal 82.4;
Germany 81.4;
United Kingdom 81.3;
United States 79.3;
Poland 78.6;
Sometimes insufficient capacity and long wait times can be the result of a government's agenda.
Here in BC, we have (mandatory) auto insurance provided by a crown corporation with a monopoly. The neo-liberal government before the current more socialist leadership hated it and wanted desperately to privatize car insurance. The problem is that ICBC is dearly loved by most residents here. There is a playbook for this problem.
They appointed a fairly incompetent civil servant to run things, and also started raiding the fund, to the tune of billions of dollars.
After about a decade of this, the company was a mess and nearly broke. They were forced to raise rates. The premier characterized the situation as a "dumpster fire" and editorials started popping up arguing for privatization.
That government was defeated, and the new leadership sorted it all out. Within a couple of years, drivers in BC were getting cheques in the mail because ICBC was making too much profit.
There are powerful interests very interested in getting a piece of healthcare in Canada, and some of the shenanigans you see here smell a lot like a set-up to make things become broken enough that the voters will demand privatization.
Just for one example, in the last few years staffing agencies have been hiring away nurses by offering higher wages and then contracting them back to the health authorities at ~$130/hr. This has cost billions to taxpayers and lead to great resentment within the regular staff.
As for society itself being robust, it’s a much harder property. Being robust is nice but no one actually wants to live in a metered society where there’s insufficient resources - they’d generally rather kill for resources greedily and let others fail without helping them. That’s why socialized healthcare struggles - while it guarantees a minimum of care for everybody, the care provided has longer wait times and most people are not willing to wait their turn.