You can get the free market back in health care once you can convince society in general that it's acceptable to let poor people die of treatable diseases. Until then, it's simply a question of how it'll be heavily regulated, not if.
This is a red herring. It is not surprising that the cost of care can vary wildly when the customer cannot possibly know the cost of care before purchasing it. Even a person with no immediate need for care cannot obtain the best price since no hospital will provide him or her with a price up front.
"Posting prices publicly" is not the same thing as "completely deregulating the industry" or "repealing EMTALA."
The customer generally cannot even know the cost of care after purchasing it. Not only is the issue muddled by insurance companies' negotiated rates, but the line item prices on doctors and insurance statements are almost complete nonsense. Really they just say what broad category the care fell under for record and insurance purposes, and there is no way to tell if you have, for instance, been double billed for a procedure. The only times I've been able to clearly tell what I paid for was when going to a specialist for a very specific procedure.
It is not surprising that the cost of care can vary wildly when the customer cannot possibly know the cost of care before purchasing it.
Even the healthcare professionals can't estimate the price of care before providing it, because it depends on the outcome of things like surgery and reaction to treatments which cannot be predicted. So there's no way to tell the patient beforehand that their care will cost x amount. In addition to this the customer often doesn't know what they want and has no basis for making an informed choice before seeing a doctor. This is fundamentally different than (for example) selling products in a supermarket where costs are known up front, shops can vary prices and quality, and people can shop around. So the benefits of patient choice of hospital and treatment etc are questionable.
Other countries spend far less using a single-payer system with comparable or better outcomes than the US according to the statistics on life expectancy and expenditure per capita on healthcare, so IMHO the US should have more and better regulation of the healthcare market, not less. Cutting out the insurance companies completely would be a good start, as at present they run a racket extracting billions from the US tax payer for questionable results.
> So there's no way to tell the patient beforehand that their care will cost x amount.
I call B.S. -- unless you're calling B.S. on the data.
There's something called "estimation" which comes in very handy when you don't know something with certainty.
If you have absolutely no idea, then you just guess the average cost for each patient with a similar background, with a disclaimer that it may not be accurate.
Problem solved, unless you don't want to do it because then it'll prevent you from ramping up the prices unnecessarily later.
Problem definitely not solved. There's too much uncertainty, and comparisons are too hard.
This happens all the time in software. Non-techies put a project out for bid. They will get estimates from a variety of consulting companies. The estimates could easily vary by an order of magnitude. Do they go with the lowest, because they are the most efficient operation? Or is the low price a sign that they're the dumbest, and are underestimating? Do they go with the highest, because in a market economy price is correlated with value? Or are those guys just the gougers?
And medicine is worse, because things are so contingent. Complications get complicated indeed. And the person trying to make the decision is pretty likely to be sick. I tell you true: deciding what to do about cancer is hard enough without trying to organize and judge a multi-round competitive bidding process.
Neither did waving away problems as if they didn't exist. If you can solve this, solve it. But arguments of the form "in theory there's a solution, so problem solved" aren't a step forward; they're a way to prevent others from trying.
Well, I was assuming that you were participating in the conversation, rather than just seizing upon a sentence and nitpicking.
The conversation was about the role of the free market in health care.
User curt said that the only way to solve health care pricing was through the free market via individual choices. Mikeash said that would only work if we were happy to let people die of treatable diseases. Anonymoushn said that was a distraction, that the market would be fine if people could know prices up front. Grey-area said that predicting costs was basically impossible, so the market-based solution was unworkable.
You jumped in to say that prices were predictable through this new thing we hadn't heard of called "estimation", saying that this solved the problem. The problem, presumably, being how price opacity and unpredictability make a hash of individual-choice market mechanisms.
So I have no idea what you were trying to do, but as far as I can tell, it was either a) pushing people back toward an unworkable market-based solution for health care, thus preventing them from moving toward a solution that doesn't fit with the fundamentalist liberarian ethos so popular on HN, or b) you're doing this: http://xkcd.com/793/.
Given that you ignored the meat of my point twice in a row with nitpicky comments, as well as doing the same to the previous poster, I'm figuring b.
I was actually responding just to the issue of predicting costs, not to the upthread issue of whether or not a free market is a good idea.
Predicting costs is a benefit regardless of whether or not we have a free market -- I was saying that nothing is completely unpredictable; estimating based on the average value of a treatment gets you much further than knowing nothing at all.
Claiming costs are inherently unpredictable is equivalent to calling B.S. on this report -- that the values in the report are meaningless. Clearly, they're quite meaningfull.
I never claimed estimation = "problem solved", I just said that it's a step forward that needs to happen. But you came along and just dismissed the idea because it wasn't a solution.
And my reply, which you thought was ignoring your comment, was that a step forward doesn't have to be a solution -- you can't just dismiss it because it doesn't stamp "Problem solved" on the bottom of the page.
Unless you or others are claiming that being given an estimate of costs HURTS anyone, I don't see how you can argue it's a bad idea. "Problem not solved" never solved any problem.
Responding to some random sentence in the middle of a discussion as if you actually have something relevant to say is annoying, and a big waste of other people's time. If you want to go off on a tangent, say so. Then nobody has to try to figure out what you're on about.
Predicting costs is not an inherent benefit. That only is useful if somebody will change a decision based on the prediction. Otherwise, it's wasted effort. My mom was on Medicare throughout her cancer treatment, and I promise you: not knowing the costs was perfectly fine.
In fact, not knowing was better. The cognitive load of a major illness is huge. Not knowing is also better for most medical personnel. Their goal should be to maximize patient outcomes. Asking them to juggle some sort of cost-benefit tradeoff in the middle of treatment adds an insane and impossible burden.
Also, you quite literally did say "problem solved" after proposing SWAG estimation as a solution to a problem. Maybe you wanted me to have some other understanding, but I have no idea what it would be. And, since you admit you are off on some sort of tangent, I don't really care.
Tell me my surgery will cost $100,000 at hospital X and $200,000 at hospital Y (both of which are close to me and staffed with competent employees). It won't influence my decision as long as my insurance company doesn't care. I'll pick based on the doctor and the insurance company can negotiate either bill (down to a very similar level, I presume).
If I don't have insurance, I may be swayed by the $100,000 price, but either way they'll have to sue me to get all of the money that they ask for.
Not all emergency room decision-making happen with blood pumping out of your pulmonary artery. There are parents who take their babies to ERs, and through repeat business decide to like one better (maybe because it's cheaper, maybe because it's a bit more expensive, but never have any waiting time) than the other. There are consumer reporters who will look into why one hospital is cheaper than the other. Smart phone "Yelp for hospitals".
EDIT: Forgot the conclusion: This will drive down prices in the general case, which will also result in lower prices for the emergency case, even if in an emergency you don't have the luxury of calmly evaluating all the options.
> Also, how shall people make an initial determination on care when no diagnostics have yet to be performed?
The same way you decide which restaurant to go to before you know exactly which dish to have: Ranking by a general cost/quality scale.
I wouldn't bank on free markets fixing emergency room problems. While anecdotally some parents may choose to take their children to one hospital or another, I doubt this is a statistical norm. I imagine most people choose the nearest emergency room for most emergencies, and hold off for an appointment with a doctor otherwise. Sometimes, it's just a baby with colic. But sometimes (increasingly in a country with a serious obesity problem) it's a heart attack, and no one is going to drive their dad 45 minutes to the cheap hospital when the one that will save his life is 10 minutes away. Because of this I don't think hospitals have any incentive to drive down ER costs.
But maybe I'm projecting, since my experience with ERs tends to be "Oh shit... get me to a hospital now Google Maps" rather than "I should Yelp some reviews of hospitals, because I have time."
Of course it's hard to predict what will happen. But right now, nobody has an incentive to even check, so obviously it doesn't happen.
Some people will live 10 minutes from one ER and 45 from the next. But some will live 25 from one and 30 from another. Or have three within 15 minutes (ie. short enough that they're equidistant for "the baby has colic"). Some will have more time than money and drive 45 minutes if it means saving $20.
But there's another factor in free markets you're not accounting for: new entrants. If an ER charges high rates because they're the only player in the area, someone could set up a competing ER and charge less.
I love how easy everyone always makes this sound. Yeah, just setup a hospital near the other hospital and make your prices lower. I'm sure they wouldn't respond by lowering costs until I'm driven out of the market and then immediately raise them again.
And amazingly we still have businesses that compete and don't price all their competitors out of business. So I don't think this is an obvious conclusion.
Or it could actually have nothing to do with regulations. Something called imperfect competition: very few people want and sell the exact same thing. That makes it very difficult to sell superior products at lower cost.
As far as I can tell it is very difficult to prosecute for predatory pricing in the US. This doesn't particularly matter, since it is an awful idea and almost no businesses would do it anyway.
Doctors have no idea how much a procedure or test cost (and they don't care or want that burden)--that stuff is generally insulated by insurance. In my experience, they are vaguely aware of the price of different prescriptions (after insurance) because that directly affects the patient. The economic forces are all out of whack. I'm not blaming doctors--the information should be more easily available to them to provide to the patient.
I'm not in the medical industry (but my g/f was seeking out her own insurance recently), but I would guess that the ER would work similar to a car mechanic. Where the paperwork you're already signing upfront includes a flat price you're paying for diagnostics. Then after the diagnostics (or possibly at the same time you signed the diagnostic paperwork), you agree to a price range for treatment/tests. It would itemize the fixed costs and estimate the variables. If things go outside of that range, there's an amendment. You walk home with the bill.
In actuality, it would be: "Each blood test paid by insurance company $A costs $X, Each blood test paid by insurance company $B costs $Y." Etc.
I really think a big part of the problem in healthcare pricing is insurance company policies regarding networks and guaranteed volume. Your auto insurance doesn't demand you use a certain body shop, why should your health insurance?
Here's a practical example that recently came up for me. My wife is a nurse at a few clinics. At one clinic, she's got health insurance and that clinic provides IUDs via their hospital, which she wanted to get. At this clinic, the price billed to her insurance would be $4700.
At another clinic she works at, she could get the same IUD brand and procedure for $600.
When she asked her insurance about it, they said they would pay 100% of $4700 in-network but 60% of $600 out-of-network. Obviously, being selfish, she decided to let the company eat the $4100 they would otherwise save so that she would pay $0 instead of $240.
Because that $4700 isn't the cost the insurance company is paying. The real reason you can't go without insurance in the US is they're negotiating steep discounts - where I live it's supposed to average 80%.
It may well be they paid less than $600 for a procedure that lists at $4100.
And of course the government numbers don't take this into account, so what they've published is pretty much worthless.
I doubt it. That $4700 is what was listed in the insurance packet, then again in the bill along with a few other minor expenses incurred during the procedure, and finally paid for by insurance in a later notice to us. The 100% is because of ACA requirements.
I don't disagree with you that insurance companies negotiate different discounts, though, which is what I was trying to get at in my post regarding pricing.
>That way patients can ask the doctors if the tests are actually needed.
How does this work? If a doctor prescribes a blood test, he's already said it's needed. Put yourself in a doctor's shoes for a minute. You told the patient he needs a blood test. Then he asks you whether it's actually needed.
How can you possibly say "Nah, just kidding. We don't need that one"?
>Doctors order tests to help them choose the right treatments.
No they don't, except in very rare cases. Doctors order tests to make a diagnosis. The treatment follows from that.
>If they have absolutely no idea what the possibilities are then they wouldn't be ordering tests anyway.
I'm not sure a doctor would have "no idea what the possibilities are" unless you don't have any symptoms. If you don't have any symptoms, why are you at the doctor's office?
> > Doctors order tests to help them choose the right treatments.
> No they don't, except in very rare cases. Doctors order tests to make a diagnosis. The treatment follows from that.
What I said didn't contract what you said. If test => diagnosis => treatment then test => treatment.
Overtesting is more or less a thing in the U.S. Many tests are not harmless, so even a person who carries an infinite amount of money around would do well to question the necessity of tests.
I don't believe that. Over the years I've had to fight to get tests that turned out to be important, and I'm suspicious of government studies showing "overtesting" right when the government is in the process of taking over health care.
You can certainly eliminate a lot of testing without affecting mortality rates significantly. But that's because in absolute terms a lot of extra people have to die before mortality rates are affected significantly.
Well, let's look at the alternatives. If we don't want people to have to pay for the services they use, we can let people enslave doctors. Or, we can steal from every citizen in the whole country and use the resulting money to pay the doctor. This second option would be called "single payer," and it is my preferred policy, but it does not seem to be obviously morally different from enslaving doctors or obviously morally preferable to requiring people to pay for the services they use.
Or, and I'm going out on a limb here, and we could have a thing called a "democracy", where we jointly decide to pay for health care for everybody. And then we could come up with some sort of system for sharing out the costs of the joint project in a more-or-less equitable fashion.
Right, this is what I proposed. We should democratically agree to use the threat of violence to steal money from everyone to pay for medical services for everyone.
More like: we agree together to set up a society, then people in it have to follow the rules. If you don't like that, there are rules that let you change the rules.
Actually, if somebody else is paying for me, that's inequitable. I like to pay my way.
That something is subjective doesn't mean that it's unknowable. Justice is subjective, but that doesn't mean we should abolish the courts and the police. Those institutions will never be perfect, but we can nonetheless always work toward perfection.
First off the courts and police have nothing to do with health care. Secondly, the courts don't dispense "justice", and judges will tell you that first thing as you arrive for jury duty. They dispense the law.
So? We have sewage systems, but their purpose is health. Imperfect systems are how we work toward ideals.
We evaluate the legal system in large part by whether the outcomes are just. For example, the revision of the three strikes law in California is happening because a number of people have received obviously unjust sentences. And we got the law in the first place because many people thought that letting serial offenders free to harm people again was unjust.
"Equitable" is another one of those ideals, and that it is just as subjective as justice or health. But we can work toward it.
Which is the greater moral disservice - a set price, to be paid for by a non-profit, heavily regulated healthcare org -- or letting people die because they can't afford to go to a hospital that isn't overrun by MRSA?
It's not clear to me what you are proposing. Particularly, the source of funding in your proposal seems to be something like "A miracle occurs, and then the healthcare org is sufficiently funded to pay for people's health care."
One could just as easily ask "Which is the greater moral disservice - a global food distribution network that ensures every person will have safe sustenance, or letting people starve because of regional droughts, tyrannical governments, and currency speculators?" but the question does not apparently lead to any actionable policy decisions.
Because those industries work better when they do*
Just like health care works better when it is provided by a single payer.
* In the case of shelter, temporary shelter for those who need it is also provided free of charge, but that is not the normal situation for most people.
He said reintroduce market forces, not remove all regulations.
I'm a pretty big fan of the swiss model, I think it contains the best of both worlds:
You're forced to buy a certified policy with a certain (broad) coverage. If the cost of such a policy exceeds 8% of your annual income, government makes up the rest.
Both insurers and providers are regulated heavily for quality control, but compete freely for their business.
The result is a generally consumer driver system, as opposed to an insurer driven (US) or state-bureaucracy driven (most of Europe) model.
Didn't the US basically go with the Swiss model with the ACA?
We've still got all of our previous healthcare systems (Medicare, Medicaid), but the ACA added mandatory insurance with specified minimum coverage, and helps pay for the insurance of the poorest people.
EDIT: And, since it apparently wasn't clear from context, by "best of both worlds", I mean that it manages to get a competitive, consumer oriented system without sacrificing universal coverage and regulation of quality.
> Life expectancy correlates nicely with wellness.
It may correlate reasonably well, but there are plenty of ways life expectancy can be the same for systems with very different level of "wellness". For a long time, Sweden had special wards for people in persistent vegetative states because there was no provision for ending care, for example, resulting in people being kept alive for years long than they otherwise would. I believe they loosened the requirements for ending care quite a while ago. But there are plenty of other ways that life expectancy can correlate badly with "wellness", e.g. poor treatment of patents with long term conditions such as dementia where patients can often easily survive for a decade or more but where quality of life can be massively different depending on treatment.
In the free market you could argue that 'customer satisfaction' is the only measure of effectiveness you need to consider. Equating customer satisfaction with best solution fails in everything from automobile ratings to elections.
This is laughably wrong. The biggest influence on life expectancy isn't the medical system at all - it's the lifestyle habits of the populace. Genetics play a big role as well.
The UK healthcare system is 96% or so publicly funded. Yet I choose my private GP. If they don't treat me well, I go somewhere else. So while they can't compete for me by price, they need to be efficient enough to be able to afford to provide care their patients are happy with, or they loose their patients, and with it their funding.
They also need to keep their cost under control, as their cost determines their profitability: The rate they get paid to take NHS patients is set across the board.
And if/when the NHS sees the cost of providing certain care drops across the board, they can and do push the price they are willing to pay for it down.
The UK incidentally has a healthcare system that is substantially cheaper than the US, yet ranked substantially higher by the WHO.
I spent 5 weeks in hospital last year for Pulmonary Edema (fluid on the lungs) related to diabetic-induced heart problems. Two ops and 5 stents later I can't fault the UK NHS model. It's not perfect, but it does a great job without bankrupting the patient.
Think of car insurance, which is mandatory (agree some people still ignore it) yet is super competitive. And they don't compete on price. They just differentiate in the market around price and services.
To get more customers from 'the other guy?' If they all cost the same, then no one will switch, but if Insurance Company A is cheaper, then maybe someone will switch from Insurance Company B.
[ I'm assuming that you mean 'insurance providers' and not 'medical care providers.' ]
Odd how three people all responded to me with the interpretation that I was being a moron rather than the interpretation that I was asking a tough question.
> If everyone has insurance, what makes providers compete on price?
Strictly speaking, they don't.
But they have a strong incentive to limit costs because of insurance company reimbursement policies and the conditions for getting "in network" for HMO-style plans.
I don't understand, they compete like any other business? The same for less money or a better product for the same (or more) money (a poor product for even less money, of course, is not an option).
Providers, dammit, not insurers. Makes sense now. Sorry.
Good question, I don't actually know. Surely the insurers will make them compete, but that should also happen in the US, and obviously not fixing the problem.
The United States is the most charitable country in the world. On top of that I never said to deny coverage to those that can't afford it. There are other ways. How about the giving them an annual voucher for $X, whatever they don't spend gets rolled over into the next year. Just like a HSA.
People with serious diseases will outspend their voucher, and then many of them will die unnecessarily.
Give me a proposal that stops poor people from dying of treatable diseases (or at least gives the appearance of legitimately attempting to, as is the current state of things) while preserving market forces, and I'll change my mind. I've yet to see one, though. Not being allowed to refuse treatment screws up too much.
> Give me a proposal that stops poor people from dying of treatable diseases (or at least gives the appearance of legitimately attempting to, as is the current state of things) while preserving market forces, and I'll change my mind.
No such proposal exists. Any proposal that does requires a third party to intervene as either an angel to donate whatever resources are needed or as an agent enforcing policy that one group of people must provide services to another group of people regardless of means.
Both of the aforementioned scenarios do not exist within the realm of market forces because market forces cannot make guarantees.
People will always die because they don't have the resources to fix what ails them. We can only hope to lower the amount of resources to get treatment, and "market forces" are absolutely a legitimate solution to that.
But if you're stuck on "stop people from dying from preventable diseases" or "appearing to do so", then you've implicitly ruled out market forces completely.
"But if you're stuck on "stop people from dying from preventable diseases" or "appearing to do so", then you've implicitly ruled out market forces completely."
We are in agreement. My point is that society is stuck on this (note that I have made no value judgment in these comments myself) and until and unless that changes, market forces are implicitly ruled out.
Actually, the Israeli system does sort-of stop people from dying yet still lets market forces do some magic. It is single payer (gov) through taxes, every person chooses their HMO. The HMOs get paid per member (so they compete for the members) and they are also allowed to offer extra services to their members (which they also compete on). And finally - and I think this is also crucial - the government has a special fund for expensive life saving treatments that the HMOs tap into when needed - so they do not have an incentive to avoid those treatments.
People with sufficiently serious diseases will die, period, even if they're the wealthiest people on Earth. I don't see how the inevitability of death caused by disease is a useful argument. If there was some disease that one person had, and that could be cured only by pooling the entire wealth of the Earth, should we forcefully take that wealth to cure that one person?
Death isn't preventable, you can only delay it. Should the people pay for someone's heart surgery if their kidneys are on track to fail in a few months anyway?
Life expectancy estimates are often all over the board and wrong. Imagine it's a close relative who is having the heart surgery. Would you actively try to persuade them to not do the surgery to possibly extend their life because their kidneys might fail later, so they might as well die now because they're not worth the money that would go into the surgery?
It's easy to say a Big Mac isn't worth the cost on the menu, it's harder to say that your mom's life isn't worth the cost.
Keep in mind we're talking purely about economics here, as that is what your post is about. We're not talking about quality of life.
Economically speaking, I think it's fine for a person to spend huge amounts of their own money that way if they want. Also, it's fine if they ask around for friends, family, or even total strangers to finance their health. But forcing people to pay (via taxes) for an operation seems outrageous to me.
Not really the point I was making. People will go to great lengths and effectively destroy their own life in the pursuit of saving a loved one. This makes it hard to take seriously the concept that a a free market full of economically rational consumers would exist when it comes to costly medical decisions.
It's easy to say "if you didn't want to be poor, you shouldn't have bought that plasma tv or new smartphone", versus "if you didn't want to be poor you should have let your wife die instead of taking a second mortgage out on your house".
Most people do not have a maximum price on something they consider priceless.
You benefit immensely from society. To expect you to pay some portion of your income to help that society function is not unreasonable, and extensive healthcare is consistently one of the things people in most developed societies see as one of the top priorities for society to spend that money on.
I'd fully support your right to opt out of taxes if you also opt out of each and every benefit society otherwise provides you.
If the government starts paying (at least some) of people's medical bills, there will be a committee somewhere that determines who is deserving of care and who is not.
If the government doesn't, peoples finances decide who is deserving of care and who is not, which more often than not means an insurance company decides.
Personally I'm far more comfortable with a board under democratic control setting rules based on clinical considerations for whether or not someone is suitable for care, than having someone with a profit motive to avoid paying for my care making that decision.
You're more optimistic than I am if you think that a government committee will be democratic, or that such a committee (democratic or not) would base its decisions on clinical considerations, or that people would not be outraged at rational clinical decisions.
In general, I think this kind of decision is highly personal and dependent on circumstance, and cannot possibly be regulated at the federal level.
I am optimistic of that because I've lived all my 38 years in countries where all of those are the case for the most part, and where violations leads to lawsuits and heads rolling, resulting in health systems ranked substantially higher than the US, while costing less money per capita (UK and Norway).
They conduct appraisals of technology and medicine, and the NHS is required by law to provide treatments that NICE recommends.
The NHS trusts may elect to provide funding for additional treatments, though.
A number of their working groups etc. are open to healthcare professionals, and some are open to patient representatives, carers and lay people. Consultations are open to anyone. On top of that they are accountable to their sponsoring department.
Overall, this system works. You hear people complain about wait times for non-essential treatments, but everyone gets treated.
> You're more optimistic than I am if you think that a government committee will be democratic, or that such a committee (democratic or not) would base its decisions on clinical considerations, or that people would not be outraged at rational clinical decisions.
As opposed to the democratic decision that's already being made in board rooms?
Oh, so as long as people are "killed" democratically it's cool.
Nobody's killing anybody. People die. It happens. Maybe someday I will have a heart attack. On that day, I'm not going to rob somebody at gunpoint and demand they give me $33k. Equivalently, I'm not going to have the government threaten fellow citizens with jail time and garnished wages if they don't pay their taxes to pay for my treatment. And I'd appreciate it if they'd extend me the same respect.
You know what? You're right. Fuck it. People die. Let's not even bother. Let's cut out the police department, the military...even if you did have the money, why bother? You're just going to die.
Why bother eating right or exercising? Fuck, why not just off ourselves and save all the hassle.
There's absolutely no difference amongst the different kinds of things people can die from, especially ones that are easy to fix and ones that we can't do anything about.
There's absolutely no difference amongst the different kinds of things people can die from, especially ones that are easy to fix and ones that we can't do anything about.
Hey, we actually came back to the point, kinda! There's a lot of things you can die from that fall in between "easy to fix" and "can't do anything about it". Where you draw the "fuck it, people die" line is hugely variable between different people, and it's not something you'll find a shred of consensus on across the 300,000,000 people in the USA. It's better for people to negotiate coverage with individual hospitals (and voluntary charities) than to have standards of care dictated by a central authority.
apparently it's provably not since countries with a strong centrally controlled health care system seem to be providing superior health care vs systems that let people do what you propose
- Total giving to charitable organizations was $298.42 billion in 2011 (about 2% of GDP). This is an increase of 4% from 2010.
- Giving by individuals (which includes bequests and family foundations) is critically important as it represents nearly 9 out of every 10 dollars donated.
- 32% of all donations, or $95.88 billion, went to religious organizations (down 1.7%). Much of these contributions can be attributed to people giving to their local place of worship. The next largest sector was education with $38.87 billion (up 4%).
- Donations were up to health charities (2.7%), to public benefit charities (4%), to arts, culture, humanities charities (4.1%), to International charities (7.6%), to human services charities (2.5%), to environmental and animal charities (4.6%).
So if the $298.42 billion donated world wide, almost half ($135 billion) went to fairly self-serving purposes (e.g. me donating to my alma mater to improve the stature of the school).
First, those numbers were US exclusively as that was the situation you referred to.
Second, while many of the donations were to religious organizations, many food banks, shelters, etc are run by the same institutions. Assuming those categories are mutually exclusive is risky at best.
I don't think data really helps you get to an answer. I can only go by my experience living in America.
My observations are that Americans definitely look out for themselves. People tend to give (as you stated) in ways that directly or indirectly benefit themselves.
These are broad generalizations but having lived here for 30 years I'd not consider our society to be generous by any stretch of the imagination.
All I can say is, I am glad I don't live where you do or hang around the people you do. Having lived here all my life I cannot count the number of people who bend over backwards to help others. I watch people with half my income give money to church, charity, and the like.
Now, in the techy world I work in, I can find a wealth of self centered pretentious types who are more concerned about how their seen that what they see.
I was thinking he had pretty bad selection bias. If I applied the same to my day yesterday, you'd assume every software developer was a sharp female game hacker with a little too much caffeine in her system. ;)
Charity is an excuse to keep the poor around in order to look good pretending to help them. As a stopgap in the immediate future? They're good things. As a long term strategy? It's intentionally ineffectual.
No charity has, or ever will, end major problems like hunger or poverty.
Also, on a dollar per dollar basis, the government is vastly more efficient than nearly any charity. The Social Security Administration's overhead was 0.8-1.4% (depending on how you count) last year. Find me a private charity that efficient.
Make a Wish Foundation crows about spending 76% of funds on programs. If the SSA were as efficient as Make a Wish Foundation, it would have an overhead of an additional $185 billion a year (i.e. approximately equal to all federal payroll expenditures).
The bulk of charitable spending is on programs and fundraising, usually in that order. The SSA doesn't have to worry about fundraising, hence the disparity in admin expenses.
overhead is not the best measure of charity, QALYs saved is. If one charity has 50% overhead but saves 10 times the QALYs as one with 0% overhead you want the one with the overhead.
The government probably has a worse QALY because it runs Medicare, but that's not the government's fault -- anyone who runs the medical care program for old people is going to have horrible numbers there.
(You are more likely to die if you are on Medicare than if you are uninsured. This isn't because Medicare is killing you, it's because old people are on Medicare.)
In addition, we'd have to examine marginal-QALY versus average-QALY. Depending on the question one or the other could be more important.
Americans freak out whenever anyone tries to do QALY measurements, so we don't know just how good (or bad) our various programs are, public or private.
What a ridiculous statement. Most of the charities' overhead is money spent on fundraising. The SSA doesn't have to fund raise since it's illegal to not pay into it.
>Not sure what charity really has to do with it. Americans aren't going to willingly give money to "help the poor" to the extent that medicare does.
"Medicaid" is the program you're looking for, not Medicare. Anyway, Americans did willing give money to "help the poor" get medical treatment. There were various organizations that operated charity hospitals (Shriners and the Catholic Church come to mind) where you paid what you could pay, and Americans donated generously to keep those hospitals running. It was normal for doctors to put in some amount of unpaid time in charity clinics because that was considered the right thing to do.
But the government crowded all that out, and since it's been a few generations people don't remember.
>I would imagine that the US is also among the greediest countries in the world.
Most of that "charity" is for religious brainwashing. Sending kids on thousand dollar flights to work on a cinder block indoctrination center and also get a beach vacation out of it.
Don't remember where I read it, but someone had a good line about youth pastors essentially playing the role of cruise ship activities coordinators.
Hospitals generally won't deny life-saving treatment. But they would deny anything less. Even, paradoxically, providing cheaper preventive care to avoid expensive emergencies later.
>Hospitals generally won't deny life-saving treatment. But they would deny anything less.
That's right, they will let you get sick enough to need intervention, and if you can't pay, they'll try in the meantime to find a gov't program to foot the bill.
Isn't that just rationing in a different form? If someone has $X to spend on treatment, and the best treatment costs 10*$X, then they will not be able to receive that treatment.
Do we expect that our medical professionals and facilities have the capability of providing the best treatment to everyone all the time? If they do not, how should we decide how to allocate the medical care?
I agree, that's exactly the question. Well, unless we get to a situation where literally every person can receive the best treatment for every ailment, at high-quality facilities with no waiting. If we're not in that situation, then some people can't receive the best treatment for their condition, and the question is who and when.
poor people might find better services locally if the Federal government allowed insurance across state lines. This would increase competition and bring costs down. With lower costs more money would be freed up to service those who cannot pay.
I have not heard of my local hospitals refusing care. If anything the ER seems to be majority sniffles or need a ride people.
Sure, but the system is still bent by the attempt not to let this happen, and serious market forces won't be allowed to do their thing as long as people continue to insist that this attempt be made.
"Letting" someone not get treated because they can't afford it is no different in terms of my obligation than "letting" someone not have a new car, a new TV, an education, clothing, food, or anything else they need to live.
None of us are born in hock to the needs of others. If we were, that would be moral slavery.
All of us are born incredibly dependent on others. After a long period of investment, we can function on our own. (Well, if by "on our own" you mean "without being directly dependent, but requiring a rich and complicated society where other people take care of most things for us".) Most of us choose to pay that forward by contributing to the maintenance of society and the species.
If you don't want to, godspeed. There is no law preventing you from being a selfish ingrate. You are allowed to opt out at any time and move to a country that is less interested in, say establishing justice, promoting the general welfare, or securing the blessings of liberty for the citizenry current and future.
For example, I hear that the tax rates in Somalia are very reasonable. Do start a blog! And maybe we can start a pool on how long you'll last in a place where helping others to survive is seen as optional as having a new TV.
All of us are born incredibly dependent on others.
"Others" as you use it is far too imprecise. A person is born dependent on his parents, who have an obligation to raise him once they've chosen to carry a child to term. That obligation does not extend to people that didn't make the choice to bring the child into the world.
Also, you're attacking a straw man. I'm not an anarchist.
Sustaining a rich and complicated society requires that people act as traders. That entails producing things that are valuable to others, in exchange for things that are valuable to you, quid pro quo. And that requires a government, whose sole duty is to retaliate against people that try to bypass that process by force or fraud. A market cannot exist without an objective arbiter that keeps the peace (which can only be accomplished by having a monopoly on force - private armies, courts, police forces would lead to war) and enforces laws.
Yes, that's the fundamentalist libertarian perspective. Like most fundamentalisms, it is hermetically sealed: you can never convince a Freudian it isn't all about sex, or a bible thumper that it isn't all about God's word.
I always find that a little depressing with libertarianism, as there's enough useful material there that I hate to see fanatics turning people off to it. There's a giant difference between "an important function of government is" and "government's sole duty is". The latter is appealing to people looking for simple answers to complicated problems, but is actively off-putting to everybody else.
I understand you don't think you're an anarchist, and, for a different reason, I'd even agree. I think the step-over-the-dying school of libertarianism would turn out, in practice, to be indistinguishable from the sort of chaos that people who don't know any actual anarchists think when they say "anarchy". (The interesting sorts of anarchism, like what the anarcho-syndicalists were pursuing, depend upon a human moral sense. Which, bringing this back, include compassion for the ill.)
The reason things will fall apart lies in another gap in your thinking. Parents are the most obvious thing a child depends upon. But try telling a teacher or a grandparent or a cop or a social worker or a neighbor or an aunt that they don't matter, that they don't have an impact on the kids they deal with. It takes, as they say, a village. Or, if you'd like a richer society, a lot more than that. You'll of course wave that away as inconsistent with your chosen theoretical framework. But that you can't perceive the value in something doesn't prove that it's valueless. It only shows you haven't bothered to really understand it.
Why is "If you don't like it, get out" perceived as a reasonable response to only a very narrow set of ideas? It seems very strange to me. Nobody says "If you don't like your neighbor owning guns, move to Canada," "If you don't like the small size of your future social security payouts, naturalize in some country with larger entitlements," or "If you want to sell cars directly to consumers rather than to dealerships, just do it in Europe," because of course it would be completely unreasonable to say these things. Instead, for most ideas, people will bother to agree or disagree, knowing that both society and the law tend to change over time based on the views of people.
I think if somebody is saying, "I fundamentally disagree with the foundation of our society", then "try someplace else" is a reasonable answer.
In this case, though, I'm not expecting anybody to move to Somalia. I'm pointing out that places with no effective social contract or taxation system are hellholes. It's not a literal recommendation; it's a reductio ad absurdum to show that the poster's views aren't thought through.
You're making the mistake of defining "life" as only the things you need to for physiological/material functioning. But there's more to life than metabolism!
A human life also includes art, music, fine cuisine, fresh cut flowers, travel, and an almost endless number of other things, depending on whose particular life you're talking about.
Think of someone that loves movies. He definitely needs a new TV to live, and he's got a right to it as long as he's earned it.
This seems like a further attempt to muddy the waters. There is a vast difference between "let's make sure people don't die from easily treatable disease" and "let's give everybody free TVs". I understand why, rhetorically, it's convenient for you to pretend they're the same, but the approach mainly persuades me that you're not serious.
This does nothing to answer me. I was making an ethical point, not a political one (although it does have political ramifications).
I don't advocate that people not pay taxes. That's just a good way to get fined and/or go to jail. But I do advocate that people fight to abolish taxation, and especially the ethical ideas that support it.
Oh, I get it, you're one of those guys that thinks all roads should be toll roads and you should only be protected by the police and the military if you can personally pay for that protection and all schools should be private -- wanna learn? gotta pay.
Yuck. Never mind I'd rather not debate this with you.
I'm not an anarchist. We need a government! Without creating the conditions necessary for a market, that market cannot exist. What are those conditions? The only fundamental one is to retaliate against anyone that initiates physical force against another. (Examples of this include murder, theft, fraud, assault, etc.)
I suspect you need a lot more than that. You need a police force to enforce it, for example, courts to try and prisons to put away offenders. Then you need communications so people know what the penalties are, and somewhere they are compiled, and a system for changing them and keeping them current.
And then you'll need a financial system to pay for it, which means you will need some sort of currency combined with laws to regulate counterfeiting and some sort of contract law to let people make deals. Oh, and it might be an idea to have a boundary so people know where the law is valid, as well as a language in which the law is written, which means it's a good idea to educate people in that language.
Then what happens if someone doesn't initiate force against another, but just abandons them - eg a mother abandoning her child. Has she committed a crime? What about international fraud? Better have inter-country arrangements in place. But then you might need diplomats, and maybe an armed force just in case.
I could go on. My dream if ever a libertarian paradise comes to fruition is to buy up a one mile strip of land fully enclosing a village and refuse everyone the right to cross it - food delivery, immigrants, emigrants - everyone, trapping the people inside and letting them starve. After all, I can do whatever I like with my property, and the only law we need to implement is property rights, correct?
I hope you're not trying to imply that it is unacceptable to let poor people die of treatable diseases. Spending 1 million in other people's money to save one life when that money could also save 1 thousand lives elsewhere (givewell cost per life calculations) is morally inexcusable.
