Thank you for a respectful reply. I feel like we're finally talking.

> You've written a lot without addressing the key point. It seems that you are fine with poor people getting much worse care than rich people. At least, you've declined several opportunities to indicate that you're not fine with this, and none of the suggestions that you're making would make things any better for Americans who currently lack insurance. Indeed, you're quite clear about what happens to people who can't pay up: "When that account runs out, you're screwed." Charming.

I said that blunt thing on purpose, partly to draw you out and get you to express yourself, and partly to express my philosophy.

I am not fine with disparity, I just don't believe we can eliminate it through top-down, central planning or through collectivization. That's my bottom line; we probably won't ever bridge this philosophical chasm between us. But I appreciate having the opportunity to explain myself conversationally to you.

Expanding my thoughts a little, in my opinion government is particularly bad at addressing inequity because on the ground there is zero incentive for individuals in government to fully solve problems - that would put government workers out of a job. Yes, some people get aid, there's some salve for the hurt, but on the whole government spending on "programs" tends to be a racket for cronies.

I don't expect you to agree, just explaining my thoughts. If you want to provide contrary notions, and give some depth to your worldview, I'd like to hear it. I would like to know how we solve the problem of poor and rich getting the same quality services without also degrading the services.

Regarding the "screwed" comment - guilty as charged - that was too harsh. Here's the nagging concern that drives my thinking: when there is a natural disaster and community, family, and government structures are stripped away, people are forced to fend for themselves. If they haven't prepared for disaster mentally and with provisions, they can die needlessly.

So, I favor a government whose policies encourage self-sufficiency and resilience that will lead to a robust populace that can be free and happy in their own situation and not make themselves prostrate to others for their survival. Dependency, like debt, is slavery. Freedom is totally worth the trouble we put people through.

In my dictator scenario, I envisioned forced savings for routine medical bills, optional catastrophic health insurance for the unexpected huge claims, and freedom to shop for providers as the route to "well-nigh universal" health care.

You would need to be my advisor though, because there are always destitute people in any society that have no income and have no insurance. We'd would need to provide for them somehow. I'm open to haggling on various points. ;)

> The fact that the cost of cancer treatment may go down in future is totally irrelevant to the question of how we pay for people's cancer treatment today.

Yeah, it's an awful problem! You sound very fed up and in a rush to see action especially on cancer. What would you do as dictator to address this? Make me your trusted advisor!

I observe cancer treatments are at least improving and we're getting better outcomes. We should at least look for ways to lower costs to make treatments available to more patients. It's not a perfect solution, but it's a start.

> The concept of "catastrophic" health insurance transparently makes no sense.

We just see the utility of insurance differently than you do. I see it as a backstop, not a catch-all. I want people to pay out of pocket for the simple stuff so they search for and demand lower cost options. That lets the market deliver the goods.

> Bizarrely, you seem to think that the main problem with the current system is that people have too much coverage.

No, I don't think that. The US definitely has a dysfunctional way of covering the poor however (emergency rooms that take all comers.) I would love to see some fixes there, because the system we have now encourages the poor to suffer with easily treatable conditions and is very inefficient economically. It's easy to make rational arguments about delivering health care services to the indigent. Frankly, I think such arguments are unassailable.

My position is that health care in the US is overregulated and lacking market forces that could control costs. I don't believe a single-payer system in the US would be accompanied by deregulation, and therefore costs would continue to rise.

> The countries that pay less for drugs are the countries with a greater level of centralisation and government control. Drug companies are behemoths, and it takes another behemoth to negotiate a good deal.

I have heard this argument before and never understood why the blame isn't placed 100% on government. What you describe should have happened decades ago.

Medicare and Medicaid covered 37% of health care costs in the US in 2017.[1] That is HUGE buying power, they can set the worldwide prices for drugs. Noone who is in power at the federal level seems at all interested in negotiating.[2]

That's a very interesting article that takes years to get to the money quote:

> No Negotiation, the Price Is Set

> The major reason for the disparity in pricing is that the United States lacks any sort of central or universal healthcare system or agency that regulates across the board cost. In contrast, negotiations of drug prices between governments and pharmaceutical companies are routine in Canada, most European nations, and most countries in the Middle East and Far East. They have centralized authorities to negotiate more favorable prices with manufacturers, and some also have drug formularies and advisory boards that put restrictions on the use of new and expensive medications.

Wow, sounds good, what's the hold up?? From later on:

> However, by law, the federal government cannot negotiate for Medicare drug prices or obtain any sort of volume discounts.

It was Medicare Part D where the feds jumped deep into the prescription business and this mischief got started. High drug prices in the US is baked into the plan. And there's no incentive to fix the problem because everyone is on the take.

This is where you and I are, I hope, arm-in-arm. Medicare should negotiate with these drug companies such that all Americans get drugs at rates offered to comparable countries! Abolish that corrupt law. I'm not even talking about price controls, I just want the same or better deal that every other country negotiates.

But, Democratic and Republicans are attached like barnacles to the special interest money and that bad law is a worth a fortune. This isn't an abstract issue: people are suffering and dying today because of cronyism. Awful realities like this destroy my faith in government, especially federal. If I am wrong on this, I would love to have you explain it to me.

Thank you again for being so peaceable in your reply. I felt very relaxed replying to you this time.

[1] https://www.cms.gov/research-statistics-data-and-systems/sta...

[2] https://www.medscape.com/viewarticle/835182