I think most of what you said is on the mark, but the core problem is still what the providers are charging. I wouldn't worry so much about in/out-of-network or claim denials, and might not even worry about having insurance coverage at all, if: a 90-minute ER visit (even for a false alarm) didn't cost $10k; or if one night in the hospital (just for observation and a couple blood tests) didn't cost $50k; or if anything actually serious didn't cost hundreds of thousands or millions of dollars.

>it doesn't change the fact that "insurers" absolutely add a layer of uncertainty to the process.

Not relative to the case of having no insurance.

You're implicitly blaming insurers for the fact that the US doesn't have universal public healthcare. Don't hate the player, hate the game.

Now, why doesn’t the United States have universal public healthcare? Because every time it’s been proposed since the 19th century there’s been stiff opposition from doctors, hospital owners, and private insurance companies. So while it’s true that they didn’t start the problem, it’s fair to blame all of them for the problems of a system they’ve poured enormous amounts of money into preserving.

The US doesn't have universal public healthcare because it is a country of 350M people and would probably be a disaster. Significantly smaller countries (UK/Canada) have major issues with their systems with a fraction of the population.

That’s just silly. What mechanism do you believe makes healthcare fall apart in a larger country but not, say, the larger EU? Similarly, these alleged major problems don’t seem to show up in stats where residents of those countries live longer and healthier lives at much lower cost, and medical bankruptcy is rare.

The EU is not one country. It is certainly not one healthcare system.

But yes, I 100% agree with you. If the US wants to implement public healthcare, it should follow the EU's lead and implement it at the state level with very limited (if at all) top-down interference from the Federal government. Imo, the only thing that it makes sense to do at a nationwide level is negotiating drug prices.

To answer your (flawed) question though, humans have demonstrated time and time again that they struggle to top-down manage large economical undertakings at scale. It seems that at a small scale, we have the capacity to do all sorts of things with all sorts of means of management. But past a certain point we start to get in our own way with internal strife, graft, poor abstractions and assumptions, etc. Some people think AI will help us figure this out, but I'm skeptical. So far the only consistent tool that helps us work against this is the invisible hand of a free market, which does enough to align incentives that the problems become tractable.

> The EU is not one country. It is certainly not one healthcare system.

That was my point: even if there is some hypothetical property of size where a national healthcare system would fall apart, which we have no reason to believe exists, letting each of the 50 states run their own should be similar to the European model where a larger population is covered by a variety of programs and that provides natural experiments for the efficacy of different approaches.

Is anything actually preventing each of the 50 states from doing this?

> probably be a disaster

disaster is a strong word, but yes, it would definitely have issues. but would it be an improvement over what we currently have, for most people? that is the standard that matters.

no system will be perfect. i'd argue that no healthcare system will even be that good, knowing human nature, especially given the culture in the US which values the individual's right to obtain money over most everything else. but even given these facts, i think it's defeatist to think that this is honestly the best we can do.

I didn't say it was the best that we can do, merely that I don't think humans currently have the capacity to manage a project of that nature and scope effectively.

My alternate proposal would be for states to implement public healthcare on their own, which they can already do.

How does that make any sense? Would having public healthcare per state suddenly work? What prevents scaling the healthcare to more people?

Yes, why don't we already have public healthcare per state?

And why do you think that a nationwide system (which by necessity needs to be vastly more complex) is more achievable?

> Yes, why don't we already have public healthcare per state?

I don’t know, but what does that have to do with my point?

> And why do you think that a nationwide system (which by necessity needs to be vastly more complex) is more achievable?

I never said that nationwide would be more achievable. I think both options would work.

I’m asking why you think public healthcare works for countries with 90 million inhabitants but doesn’t work for 330 million. What’s the thing that prevents scaling?

Humanity is what prevents scaling. We've demonstrated time-and-time again that we struggle to administer something at scale without the benefit of free market dynamics like supply and demand.

So there’s a hard border somewhere between 90 and 330 million people? But per-state would work in your opinion?

Nope, no hard border. Just progressively more difficult (and not linearly). My assumption is that, because any such large-scale human endeavor is a network, the complexity increases by some superlinear rate with size unless a almost superhuman effort is effected to counteract that.

Even in the 50-90M range, healthcare systems start to show serious orchestration/efficiency/coordination issues. Healthcare is just the final boss of this type of thing, because everybody needs it and there actually isn't enough to go around.

Regardless yes, I think the US should definitely have states try to figure this out at a smaller scale before even thinking about trying to achieve it at a national level for 300+ million people. Added benefit that some friendly competition amongst states might actually help move things along.

I would actually say it can only scale linearly or slower than that. Either you gain efficiency due to economies of scale, or worst case, you make 10 smaller systems.

But I still don’t see how the scaling would be worse than linear.

How is managing 300 million people more than 3 times harder than 100 million people? The effort per person shouldn’t increase, and everything common scale lower than linear.