American economic dominance

[Northwestcoug]

I'm still not sure how I feel about universal health coverage. The UK system should give anyone pause. Still, I have heard other European countries do a better job. I'm just not connected to people to get that firsthand feedback like I am to people in the UK.

On the other hand, I have seen how my own kids have struggled with paying for insurance. Here in the US, health care is still rationed, but there seems to be a divide between those who can afford it and those who can't. Even if they have health insurance, it might only serve as a catastrophic cap of sorts. As a soldier, I am probably the most privileged. I haven't paid a dime for health care for many years.

I wonder if looking at it in supply/demand terms is helpful. Is healthcare zero sum? How much more can we increase resources?

The relative pros and cons of universal and less than that health care are not fixed in time. I respect the argument that despite its major structural flaws, the US system works better for its population than other forms of health care. But that isn't set in stone. Your and my kids' generation are having a difficult time paying for health care, but it is only going to get worse. The US eclipses other developed countries in health care spending per capita, and it's not even close. And the trend is increasing. Irrespective of the undeniable benefits to society this level of health care spending brings, there simply isn't the tax base to continue at this pace, or the political will to force private insurance to provide affordable coverage. There will be a reckoning, probably sooner than later, when the country will have to decide how to reign in health care spending it can't afford. Some might call it rationing.

Other OECD countries are just biding time though. They are doing better holding the line on per capita spending, but there will be constant pressure to fund increasingly expensive health care innovations. And their citizens will not be too happy when there isn't enough money to provide ever higher standards of care to them.

[Northwestcoug]

I also remember individuals between the ages of 18-26 were very much against the mandatory requirement to pay for insurance. I remember this being a big sticking point of it being a mandate and not free or available to anyone who wants it and those who opt out didn’t have to pay.

one item that I think that has been great was the ability to keep our children on our health insurance plans longer that before and the inability for insurance plans unable to deny treatments for specific health conditions.

The outlawing of preexisting conditions is an undeniable good that came with the ACA. I can't believe it took that long. I was a freshman in the dorms when I had an asthma exacerbation. I had some insurance that the university required I pay for (? Deseret), so I didn't think much of going to the ER and getting nebulizer treatment. I'm sure I had a copay but I went on my way, happy I wasn't on the hook for more. A couple of weeks later I got a call from the insurance company stating that since I had a history of asthma the insurance wouldn't cover that ER visit. But they were oh so helpful allowing me to pay it back in installments.

[Bo Diddley]

The relative pros and cons of universal and less than that health care are not fixed in time. I respect the argument that despite its major structural flaws, the US system works better for its population than other forms of health care. But that isn't set in stone. Your and my kids' generation are having a difficult time paying for health care, but it is only going to get worse. The US eclipses other developed countries in health care spending per capita, and it's not even close. And the trend is increasing. Irrespective of the undeniable benefits to society this level of health care spending brings, there simply isn't the tax base to continue at this pace, or the political will to force private insurance to provide affordable coverage. There will be a reckoning, probably sooner than later, when the country will have to decide how to reign in health care spending it can't afford. Some might call it rationing.

Other OECD countries are just biding time though. They are doing better holding the line on per capita spending, but there will be constant pressure to fund increasingly expensive health care innovations. And their citizens will not be too happy when there isn't enough money to provide ever higher standards of care to them.

Every way I think of this, there are no easy answers--no slam dunk course of action. But I do think everyone should have access to basic health care, even if that means I have to wait longer for my own.

I agree there will be some sort of breaking point where enough is enough and something drastic has to change.

Or maybe AI and robotics finally come of age and we can scale up health care access that way. Is that science fiction?

[USUC]

Single payer systems seem to be the most fraught and inefficient. I believe there are other systems in Europe that aren't the crap show that the UK and Canada are.

You guys may be right that public outcry will push the country towards a worse healthcare system. But I'm not sure a pure single payer will ever fly. But I'm certain that the quality and ultimately access to care will suffer as a result. Truly free market elements infused into our system is greatly needed. Especially for more routine and established services.

[Jeff Lebowski]

Single payer systems seem to be the most fraught and inefficient. I believe there are other systems in Europe that aren't the crap show that the UK and Canada are.

You guys may be right that public outcry will push the country towards a worse healthcare system. But I'm not sure a pure single payer will ever fly. But I'm certain that the quality and ultimately access to care will suffer as a result. Truly free market elements infused into our system is greatly needed. Especially for more routine and established services.

But at least when someone is about to die from lack of access (or long wait times) to rationed healthcare under a single payer system, that person can get some comfort from knowing that wealthier people are suffering and dying from the same lack of access.

[Bo Diddley]

But at least when someone is about to die from lack of access (or long wait times) to rationed healthcare under a single payer system, that person can get some comfort from knowing that wealthier people are suffering and dying from the same lack of access.

Well, at least the rich and poor can finally agree on something. "The wait times are terrible!" Perhaps bringing the rich and poor together in this way of shared dying is truly the first step in healing the divide.

[Green Monstah]

I don’t know what the right answer is. Or that there is one. I do know that I’m paying 10% of my salary (which is not particularly small) for a high deductible plan that I’ll almost never get coverage through—but it does give me access to an HSA, so all is not lost!

[Goatnapper'96]

I've thought about this for a bit, and I really believe the health care debate is more of a philosophical rather than a practical one for most people. The fundamental issue is whether or not a country believes health care is a human right or not. For those governments that believe it is, some form of universal heath care is mandatory. Funding questions flow from that premise, including rationing however you want to define it. For those who see it as more of a privilege to live with the availability of 'top-notch' health care, governments can and will decrease funding for health care social nets. There is an implicit compromise that as long as excellent health care is available to most people, there will be those who get left behind.

Spoiler alert: realities in both types of government fall short of their ideals. In this day and age an American on disability who is developing pneumonia will choose not to go to the hospital because they can't afford it (real current story from an acquaintance!). Whole swaths of specialty care can opt out of seeing medicare or medicaid patients. And there is no denying that the quality of health care many people get is dependent on their income or lack thereof. And I don't think it's debatable that most Americans are OK with those realities. Whether it triggers some brain stem reflex of individual freedom or a the pros outweigh the cons for many, a complete transition to socialized medicine is a non-starter. If health care expenses continue to get more prohibitive, that may change.

That doesn't let countries with some form of socialized medicine off the hook. Someone on my curling team had heart bypass surgery a year ago, yet there aren't enough specialists here for him to get routine follow-up. And it took him a long time just to get a primary care provider after moving here. If health care is a right, there will be a constant fight about adequate funding, which in the future will only get worse as it gets more expensive. As I've said before living in a rural area on an island presents a government constant headaches to fund health care, but once the decision is made that it is a basic human right, you're kind of stuck with that. But since universal health care plays so much into the Canadian ideal many here accept real deficiencies. If adequate health care coverage becomes a problem for more here, that may change.

This is a very good post- probably your best ever! Most political issues are similar in that they include various tradeoffs wrt security vs freedom etc.

I tend to think some level of a socialized medicare for all would be good in the US. Perhaps Wuap might take up my facebook bandwidth complaining that poor people don't get as good looking teeth as rich people and how if we only made perfect teeth part of the medicare for all then all poor people would feel better about themselves. Their driving records would improve as they would stop getting into accidents having long face looking at themselves in the their rearview mirrors as they drive. They would find better paying jobs with their prettier smiles and suddenly there would be no need for welfare in any form by just fixing all the poor folks teeth! Berkley professors would get gazillions in government grants, thus keeping their R1 status and their sports teams in a better conference than BYU's, to generate studies and "data" about the good that experts know would follow if we just made poor kids mouths as ascetically attractive as rich kids mouths.

[Northwestcoug]

This is a very good post- probably your best ever! Most political issues are similar in that they include various tradeoffs wrt security vs freedom etc.

Thanks!

I tend to think some level of a socialized medicare for all would be good in the US. Perhaps Wuap might take up my facebook bandwidth complaining that poor people don't get as good looking teeth as rich people and how if we only made perfect teeth part of the medicare for all then all poor people would feel better about themselves. Their driving records would improve as they would stop getting into accidents having long face looking at themselves in the their rearview mirrors as they drive. They would find better paying jobs with their prettier smiles and suddenly there would be no need for welfare in any form by just fixing all the poor folks teeth! Berkley professors would get gazillions in government grants, thus keeping their R1 status and their sports teams in a better conference than BYU's, to generate studies and "data" about the good that experts know would follow if we just made poor kids mouths as ascetically attractive as rich kids mouths.

I...think?

[dabrockster]

Curious. Does Canada or Europe have Physician owned hospitals? The ACA and Hospital lobbyists efeecriceky stop this alternative option to healthcare that could’ve been ideal and affordable.

Let me tell you about the finest sentence ever written in American healthcare.

Not by a physicians.

Not by a nurse.

By a lobbyist.

The ban on physician-owned hospitals, he said, “wouldn’t be there if it wasn’t for the Federation.”

Read it again.

Again. This time slower….

He is not apologizing.

He is not spinning.

He is taking credit.

Standing at a microphone, in a suit I probably paid for, announcing that he personally removed my competition from the board.

I have that sentence framed.

I look at it when I am sad.

---

Understand What Almost Happened To Me


Picture the nightmare.

A surgeon builds a hospital. He owns it. He runs it. He replaces your knee for a fraction of what I collect, and he does it better, because he is standing in the building with his name on it and he cannot hide behind a system.

His patients love him.

His outcomes embarrass me.

His prices are printed on a wall.

Now picture him doing that across the street from me.

I would have to get good.

I have thirty vice presidents. I have a brand consultant.

I have a mission statement carved into travertine in a lobby that cost nine million dollars.

I cannot get good.

There is no room in the budget.

---

So We Did The Sensible Thing


We banned him.

March 23, 2010. Section 6001 of the Affordable Care Act. One paragraph.

No new physician-owned hospital may enter Medicare under the exception. The existing ones were frozen at their statutory baseline. Every bed. Every operating room. Every procedure room. Counted once, and never again.

Congress did leave them a door.

They may apply to the Secretary for permission to grow. They may qualify as an applicable hospital, or a high Medicaid facility, and if they do, they may be allowed to expand.

On the main campus only. To no more than double what they had.

And when they apply, the request is published, and their community is invited to comment on whether they deserve it.

I am their community.

Congress wrote that part in. No administrative review. No judicial review. None.

They did not lose an argument.

They did not lose a market.

Congress simply stopped allowing them in the building.

That is not competition.

That is taxidermy.

---

The Beautiful Part


Appreciate the craftsmanship.

Congress did not ban bad hospitals. They banned ownership.

Understand the difference, because it is everything.

We did not ban bad doctors.

We still have those. Every one of them.

They are in my building right now.

They are in the VA.

They are in every nonprofit system in America, and they are staying, because a bad doctor is the safest asset I own.

He cannot leave. Nobody is recruiting him. He will not open a surgery center, because he cannot fill one. He does not ask what a case costs. He does not print his prices on a wall. He shows up, he bills under my tax ID, and he goes home.

I do not have to compete with him.

I have to schedule him.

The one who scares me is the good one.

The good one has patients who would follow him anywhere. The good one has outcomes he is proud of and a waitlist he did not buy. The good one can walk out of my building on a Friday, and by Monday he is across the street, doing my knee for a third of my price, with his name on the door and his numbers on the wall.

So we did not write a law about quality.

We wrote a law about ownership.

Because quality was never the problem. Quality was the threat.

---

How We Said It Out Loud


So we called it a loophole. We said self-referral. We said cherry-picking.

We said “patient safety” into a microphone. Congress converted it into market share.

Nobody had to prove a patient was harmed. We only had to sound concerned.

And the man who ran the for-profit lobby went out afterward and told everyone it was his.

I have never respected anyone more.

---

What He Actually Did For Me


Do the arithmetic with me.

He spends a few million a year. Pocket change, in this business.

In return: an entire class of competitor is legally frozen. Not slowed. Not regulated. Frozen. For fifteen years and running.

I have not had to lower a price. I have not had to improve an outcome. I have not had to explain a bill.

And I did not lift a finger. I did not spend a dollar of my own. I am nonprofit. I have a mission.

I let the for-profits do the punching. Then I go to the gala.

---

The Man Retired. The Paragraph Did Not.


He stepped down at the end of last year. Long career. Well earned.

I sent flowers.

But here is the thing about a man like that. He is replaceable.

The paragraph is not.

He goes home, and Section 6001 stays exactly where it is, doing its work, quietly, forever, without a salary or a pension or a single day off. The greatest employee I ever had, and he does not know my name.

Somewhere in this country there is a surgeon with a plan, a lease, and a spreadsheet, and he is about to find out he needs permission.

He will call a lawyer. The lawyer will read the paragraph. There will be a long pause on the phone.

I love that pause. It is the sound of me winning without waking up.

---

So Thank You, Federation


To the men who took a fight I would lose on quality and turned it into a fight I win on paper: thank you.

To the man who bragged about it on the record, in public, with his name attached: thank you, sincerely.

Physicians are so busy being right.

We were busy being there.

-Rojas out.

https://read.rojasreport.com/p/i-love-the-federation

[wuapinmon]

Perhaps Wuap might take up my facebook bandwidth complaining that poor people don't get as good looking teeth as rich people

You mock me, but you also can't refute me.

[tooblue]

The Best Countries for Quality of Life in 2026, Ranked

https://www.mentalfloss.com/geography/countries-best-quality-of-life-2026-ranked

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[Pelado]

Still based on *subjective* perceptions as expressed in surveys and not on any objective data.

[Jeff Lebowski]

China over the US? Lol.

[BlueK]

It says it's based on perceptions from people across 33 countries. So what this is really showing is how badly MAGA has damaged our standing and reputation around the world. That's still not a good thing even if it's not accurate in reality in terms of standard of living. An anecdotal example of this is how surprised the international visitors for the World Cup were to find out it's nice here.