It's easy to give businesses a pass on internal inefficiency because you don't typically need to do business with any particular company in order to live your life and businesses don't tax you in order to pay for that inefficiency like governments do. If a business is inefficient and has projects that go over budget, that's not my problem in the same way it is if the city government where I live does.

It's more about making a fair assessment of whether servicing a market via private or public enterprises is more or less efficient. What you mention is a comparison between different markets, not a fair comparison of the same market run either publicly or privately. Health care insurance companies definitely "tax" you for their inefficiencies (through higher costs) and they are definitely something you "need to do business with".

The classic "government can't do anything right"-trope is quite strong and influences voting and policy making. My hypothesis is that the reality is closer to "cooperating with many many people in big organisations is very very hard to do efficiently".

Health insurance is so regulated and so intertwined with public policy aims, that ostensibly private health care companies are themselves essentially an arm of the government. Indeed, the fact that I "have to do business with" them is itself a consequence of particularly-complicated government regulation. The American health insurance system is one of the most unpleasant (sets of) bureaucracies I personally have to deal with, especially because I have changed jobs a lot recently which entails losing and then regaining employer-benefit insurance (which itself really annoys me - I wish I could just pay for ordinary health care in a way completely unrelated to my job and that my job had nothing to do with). I don't have a grand theory of how best to reform the entire American health insurance system, but I'm in favor of doing so; and I suspect that a better system would look a lot more like removing the insurance component of it in more contexts, and having more medical procedures paid for out of pocket at point of use by ordinary people - which is something I try to do right now anyway when I can.

> I have changed jobs a lot recently which entails losing and then regaining employer-benefit insurance

COBRA is always an option when you leave a job and don't have another one lined up that will give you another insurance plan without a gap.

Yes, it's annoying to have to make the switch in general to a new employer's plan, since your existing slate of doctors might not be covered by your new plan, deductibles reset, and you have to navigate a new-to-you bureaucracy.

> I wish I could just pay for ordinary health care in a way completely unrelated to my job and that my job had nothing to do with

You can, you just aren't going to like the price tag. ACA marketplace plans are open to everyone, even if your employer offers health insurance. You can always decline the latter and sign up for your own plan. Depending on where you live, you might be able to get a barebones plan for as low as $350/mo, but in some markets your cheapest option could be hundreds of dollars more. And that's going to be a HMO-type plan with a high deductible, so you'll be paying out of pocket to the tune of thousands of dollars for anything other than preventative care, and your choice of providers will be limited. If you want something similar to what an established tech company offers (for example), you'll be paying north of $1k/mo in most situations.

(Source: our COBRA just ran out a couple months ago, we don't have jobs that offer health insurance, and I went down this rabbit hole and spent hours researching options.)

> I don't have a grand theory of how best to reform the entire American health insurance system, but I'm in favor of doing so

I'm with you there. What we have sucks. We (or our employers, which we end up paying for indirectly) pay much more for care than people in other developed nations with socialized medicine, and our outcomes are not meaningfully better, or at least not anywhere near better enough to justify the added cost.

> more medical procedures paid for out of pocket at point of use by ordinary people - which is something I try to do right now anyway when I can

That's good that you're able to, but in the absence of an insurance system, and no state-supported subsidy, healthcare would be something only a relatively privileged few would be able to afford in the US.

While our private insurance system does cause inefficiencies that raise the price of care, eliminating it won't solve enough of the cost problem to matter.

I don't think there are better options than some sort of single-payer, government-subsidized healthcare system. Those systems do of course have their flaws (some of them quite significant), but they tend to provide care to everyone more or less equally, with generally good outcomes, and completely avoid the problem of people facing a choice between foregoing needed care and bankruptcy.

> Indeed, the fact that I "have to do business with" them is itself a consequence of particularly-complicated government regulation.

No, it isn't. Life without health insurance (in some form) is awful.

> I suspect that a better system would look a lot more like removing the insurance component of it in more contexts, and having more medical procedures paid for out of pocket at point of use by ordinary people - which is something I try to do right now anyway when I can.

Getting cancer is like winning the shit lottery and you're effectively saying that people should just "save for if that happens or die of they don't". The fucked up health insurance system in the US makes medical bankruptcies a thing. Your idea here turbocharges that.

More importantly, you ignored the main point in my reply. Please respond to this:

"It's more about making a fair assessment of whether servicing a market via private or public enterprises is more or less efficient. What you mention is a comparison between different markets, not a fair comparison of the same market run either publicly or privately.

[...]

The classic "government can't do anything right"-trope is quite strong and influences voting and policy making. My hypothesis is that the reality is closer to "cooperating with many many people in big organisations is very very hard to do efficiently"."

> If a business is inefficient and has projects that go over budget, that's not my problem in the same way it is if the city government where I live does.

Right, but if someone’s point is that bloated government should be replaced by lean, efficient companies, then it does matter whether they are actually lean and efficient.

Often "minimizing costs" for a for-profit organization means providing worse services to their customers, though.

> would you characterize Amazon as bloated, corrupt, and inefficient, despite being an effective monopoly?

It's funny you should bring this up in the context of healthcare. Amazon acquired One Medical a few years ago. Within no more a year, One Medical got so much worse. Harder to book appointments, wait times increasing, and care team not responding to in-app messages as quickly. (And sometimes being significantly less helpful than they used to be; e.g. "you don't need a recommendation or a referral for a general surgeon since you're on a PPO; just look through UCSF Health's directory and pick one". And this, after I specifically asked for a recommendation, twice. Not to mention most of UCSF's departments will turn you away without a referral, regardless of what kind of insurance you have.)

So I don't know if Amazon is bloated, corrupt, or inefficient, but Amazon acquiring what used to be a genuinely useful medical group made it much, much worse, and I assume that was all in the name of "minimizing costs".

Amazon also owns whole foods and it seems to be doing just fine. Maybe not the exact same as when it launched, but in many places it is one of the best places around to buy groceries.

One Medical, I had before/after Amazon and was never that impressed. They had nice offices and a good booking system, but the GPs were a couple notches above webmd IMO.

> That, along with competition (if applicable, see below), drives them towards minimizing costs, increasing efficiency, and innovating.

Highly debatable. Not making a profit on paper (or moving it to low tax-environments) is a great way to dodge paying taxes. Innovation is a side effect of competition, not of profit-seeking. Plenty of examples of oligopolies and monopolies where innovation ground to a halt in favor of siloization, buying up competitors, dark patterns, regulatory capture, etc.

The right way too look at this is that the organisation of private industry creates a selection pressure on "making money" (not profit!), with the minimum being "able to cover costs" and thus stimulates evolution of strategies to do so. Like in biological evolution, there are many, many pathological situations that can occur.

> Government has the major focus of taking money, and largely spending it arbitrarily.

This is false. The US is a bad example because it has an incredibly corrupt political system, especially since Citizens United. In general in most modern developed democracies spending by the government is supported democratically to a very large extent. That is not to say that 80% of citizens support each bit of spending, but for 95% of the things where money is spent by the government, a majority agrees that money needs to be spent there. The word "arbitrarily" is definitely not warranted.

> would you characterize Amazon as bloated, corrupt, and inefficient, despite being an effective monopoly?

Don't know, yes, and don't know.

For corruption, I think it is necessary to determine how it would even look like for Amazon. Corruption in government is often "favoring entities friendly to the people making the decisions over objectively better options". I'd argue that that is wholly accepted in private enterprises and even encouraged. A "quid pro quo" in private enterprise is just "a business deal" or "customer relations". "Nepotism" is just "helping your friends out". Etc. I would assume that things like that are very, very common within Amazon.

With regard to bloated/inefficient: This is incredibly hard to make definitive statements on without having worked there and having a lot of intimate knowledge, so I'll refrain from doing so. I think it is, but I don't know.

Also, whether an organization (private or public) is bloated and inefficient is often only a reference to what you think the goal of the organization is.

If the goal of the USPS was to turn a profit, then serving rural addresses is inefficient and the jobs and infrastructure to do so is bloat. Luckily that’s not the goal of the USPS.

I hesitate to mention Mamdani in this forum but it seems like he has done a lot to make NYC’s government “more efficient” in many ways. But also many people disagree on who that government should primarily serve.

I feel that a lot of government spending on roads is inefficient and would be better spent on transit systems. Many people disagree with my values tho.

Stop voting for politicians who keep starting pointless unwinnable wars and you can cut the military budget in half. Boom, 10% of the expenses gone, and $500B less of a budget deficit. Tax some billionaires and it'll be net-positive in no time.

No kidding. Eliminating the federal deficit isn't particularly difficult in mathematical terms; the political will just isn't there, and both Democrats and Republicans can blame the other party when they're in power for out of control spending.

(At least the Democrats seem to be more open to actually taxing to make up for shortfalls, unlike Republicans.)