Despite all the negative press in the US (and to some extent in the UK) the NHS offers, in my opinion, much greater value for money for the most important medicine (that which has a greater impact on life expectancy and quality of life) than the US health care system. The US spends a lot more money than the UK (both on a per capita and a GDP basis) but does worse in some areas. Like any state institution the NHS gets a lot of flack from the press but this is not really representative of the actual quality of the system.

There is a problem with the a ban on preexisting claims disqualification. And the solution is less than ideal, but leaving 1 in 6 Americans with essentially no health care coverage is clearly much worse.

And another point: Patients aren’t necessarily knowledgable or rational in their choice of health care coverage. And furthermore their decisions in the US create a health care system that maximises treatments that rich people desire rather than treatments that benefit the population as a whole.

1) Because of the existing tax distortion, the easiest way to become part of a group insurance plan is to work for an employer that offers the opportunity to do so.

2) If you take away the tax advantage, many people fear that their employer will no longer let them buy into a group plan.

3) The individual health insurance market in the U.S. is completely fucked up. If you can’t buy into a group plan, your chances of getting the insurance you need at a price you can pay is extremely poor. People don’t trust the insurance companies, with good reason, and insurance companies face adverse selection issues.

4) Therefore, people – quite reasonably – fear that losing the tax advantage will result in them losing their insurance.

Personally I can’t see why it is so hard to turn Medicare or even Medicaid into a public option system. I’d be delighted to pay some $100 a month for the right to see a doctor or go to a hospital which otherwise saw only Medicaid patients, precisely because I do believe — as Robin does — that the vast majority of our most expensive treatments are of dubious utility. Let us divide medicine into bare-bones treatments for those of us who are sceptics and expensive, high-premium service for people who like to visit doctors. Right now I’m signed up for the highest-deductible plan I can find, but my gynecologist – whom I need to see simply to get birth control – sent me a certified letter saying she won’t see me any longer because she believes that I must get a mammogram every year while I believe that I do not want my breasts irradiated every year for the rest of my life. (BTW I also agree with Cass Sunstein’s proposal that adult individuals should be able to opt out of the medical mal tort law system.)

But we need a public option to create this kind of bare-bones approach. The only reason I purchase health insurance at all is so that I don’t lose my apartment and all my savings because I get cancer.

Robin believes that in general, health care is less effective than people think – whether you yourself are healthy or sick. Robin wants, in general, to pay for less health care (in both “healthy” and “sick” conditions) than other people would, because of extensive evidence that marginal medicine is ineffective.

Robin wants to be able to make a commitment to get less health care later in exchange for lower premiums now. His ideal system would let him buy “Rational Health Insurance”, which would – among other things – be purely catastrophic, and either have a standard list of excluded procedures and drugs based on Evidence-Based Medicine showing that they are not relatively cost-effective, or let Robin go down a list and check off particular procedures and medications that he doesn’t want to have covered, in exchange for a discount.

Robin, correct me if any of this is mistaken.

Yes, it can be that hard – if you’re crazy, and other people are crazy.

Sorry for all these comments here, I just want to show the sheer ubiquity of “Can people really be that crazy?” and how often the correct answer is just “Yes, they really are that crazy.”