[HN Gopher] High cost of cancer care in the U.S. doesn't reduce ...
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High cost of cancer care in the U.S. doesn't reduce mortality rates
Author : gumby
Score : 73 points
Date : 2022-05-29 17:14 UTC (5 hours ago)
(HTM) web link (news.yale.edu)
(TXT) w3m dump (news.yale.edu)
| freediver wrote:
| The relatively poor average quality of healthcare was made
| apparent in covid pandemic where US had among the highest
| mortality rates and deaths per capita in the developed world [1]
|
| And I do not need data to tell me this, just overal experience
| comparing it to my previous experience getting healthcare in
| Europe leaves a lot to be desired.
|
| Getting medical care in US is hard with a lot of
| bureaucratic/insurance overhead and when you finally get to the
| doctor they are more prone to follow strict procedures/checklists
| to reduce liability instead of being genuinly curious about your
| condition.
|
| And all this while most have to pay astronomical price for
| healthcare out of their pocket. Not sure that the case for
| privatised healthcare can hold up with these results.
|
| [1] https://coronavirus.jhu.edu/data/mortality
| jjeaff wrote:
| While your premise may not be wrong, I'm not so sure that COVID
| statistics can tell us much between countries. There are a
| great deal of countries that are either wholly inadequate, or
| purposefully misleading when it comes to their true COVID
| numbers.
|
| For example, India has an official COVID death count of around
| 500k. The WHO has made their own estimates and believe their
| death count to be closer to 5 million, ten times the official
| number.
| kwhitefoot wrote:
| The thing to look at is the excess death rate.
| blipvert wrote:
| Is the best response that you have is to say "We probably
| better than an underdeveloped country like India"?
|
| Talk about damned by faint praise ...
| mlindner wrote:
| > The relatively poor average quality of healthcare was made
| apparent in covid pandemic where US had among the highest
| mortality rates and deaths per capita in the developed world
|
| This has nothing to do with healthcare quality.
| david_l_lin wrote:
| > Findings of this study suggest that the US expenditure on
| cancer care may not be commensurate with improved cancer
| outcomes.
|
| Well yeah, the cost of healthcare in the US is astronomical.
| https://www.healthsystemtracker.org/chart-collection/health-...
|
| This would be the same across diseases, not just cancer.
| pessimizer wrote:
| Since we spend twice as much as anyone else on healthcare but
| rank somewhere around 50th in lifespan, it would be weird if we
| were getting better outcomes in any area due to greater
| spending.
| kurupt213 wrote:
| The average lifespan numbers are rigged. Most countries don't
| count an infant delivered alive but terminal in their infant
| mortality numbers. Like when a placenta ruptures and you have
| an emergency birth before 28 or 30 weeks. Those don't count
| in most if not all of Europe.
|
| In the US, every live birth counts, even if it only lasts
| minutes
|
| I don't know if that completely makes up the difference, but
| the real disparity is nowhere near the numbers that get
| thrown around. It's apples vs oranges.
|
| Covid positives were a similar situation.
|
| Most countries would not report a positive Covid patient
| unless the test was positive and the patient was symptomatic.
| LodeOfCode wrote:
| >I don't know if that completely makes up the difference,
| but the real disparity is nowhere near the numbers that get
| thrown around. It's apples vs oranges.
|
| The CDC[2020] reports an infant mortality rate of <0.6%.
| Excluding _all_ of it would only increase life expectancy
| from 78.8 to 79.2
|
| [2020]https://www.cdc.gov/nchs/products/databriefs/db395.ht
| m
| dpierce9 wrote:
| Data collection differences are well-known to the people
| who produce cross-country numbers. Further, your specific
| observation about when births are counted in the US is flat
| wrong. We have 54 ways of doing things. Furthermore, not
| everything is a conspiracy. Reasonable people do things
| differently. To suggest these numbers are rigged is glib.
| SoftTalker wrote:
| > "The pattern of spending more and getting less is well-
| documented in the U.S. healthcare system; now we see it in cancer
| care, too," said co-author Elizabeth Bradley
|
| It's a cynical viewpoint, but I can forgive those who think that
| modern health care is mostly a way to extract as much wealth as
| possible from sick people before they die.
| MauroIksem wrote:
| Cancer Care costs are insane..my mom is being treated for breast
| cancer..each chemo infusion cost $65k to her insurance company.
| Her surgery to remove her left breast cost $165k. 5k going to the
| surgeon fee while the rest was a facility fee. It's been less
| than a year now and the insurance has paid out almost a million
| dollars.
| grecy wrote:
| My Mum was diagnosed with stage 4 lung cancer - had 2.5 years
| of radiation, chemo and monthly doctor visits. Saw many
| specialists, etc. etc.
|
| Never saw a single bill, and in fact was paid actual money for
| the inconvenience of having to drive 3.5 hours to a bigger
| facility that had equipment the local small-town hospital did
| not. Also got a free apartment to stay in for those out of town
| appointments, meal allowance, etc.
|
| Mum had never paid a cent in insurance premiums in her life,
| etc.
| xqcgrek2 wrote:
| Not mentioned: the US research complex and healthcare spending
| subsidizing development of state-of-the-art therapies for other
| countries.
|
| They don't bear the cost so expecting the US to do better at same
| or lower cost is structually impossible.
| biorach wrote:
| You'd really need to show some numbers to back this up.
|
| Is the cost of funding the "research complex" included in the
| expenditure on health care?
|
| At least some of this cost is born by the Federal government,
| foundations etc, is this counted as general health care
| expenditure (I doubt it)
|
| Some of the research is funded by companies - since they sell
| globally this funding cannot be counted as purely of US origin.
|
| Other countries also have significant health research - e.g.
| UK, France, Germany - your point would also apply to them.
|
| Overall your point is dubious, and vague - you'd need to
| present some solid numbers to back it up.
| mjewkes wrote:
| Hey biorach - I would suggest:
| https://www.rand.org/pubs/research_briefs/RB9412.html and The
| Great American Drug Deal, by Peter Kolchinsky.
|
| Specific claims:
|
| - The US pays more for new drugs than the rest of the world
|
| - The US contribution is disproportionate, and is major
| driver of the drug development industry.
|
| -If the US paid less for new drugs, the entire industry would
| slow, and we would have fewer more effective treatments.
|
| ...
|
| Routine medical procedures being crazy expensive is unrelated
| and pathological.
| raverbashing wrote:
| You're assuming that most of the "extra" money goes back in
| research and not to shareholders and management bonuses
|
| Given how pharma companies operate, I kinda doubt it.
| mjewkes wrote:
| No assumptions. The rand article addresses that directly.
| cjbenedikt wrote:
| Do you have any data to backup your claim? For example Cuban
| healthcare/treatment/outcome is excellent based on its own
| research. Roche(Swiss) nor Merck ( German, not related to US
| Merck) don't benefit much (if at all) from US subsidies.
| lr4444lr wrote:
| Cuba's data is pretty suspect. Too lazy to find it at the
| moment, but I recall reading that their cancer rates or
| deaths were some absurd fraction of what would be expected
| given smoking rates even compared with better developed
| countries. They also had some eye raising way of counting
| perinatal infant death that makes their infant mortality
| rates look a lot lower.
| mjewkes wrote:
| >Do you have any data to backup your claim?
|
| I would suggest The Great American Drug Deal, by Peter
| Kolchinsky.
|
| Also - https://www.rand.org/pubs/research_briefs/RB9412.html
|
| >For example Cuban healthcare/treatment/outcome is excellent
| based on its own research
|
| Cuba does not contribute substantially to global
| pharmaceutical research.
|
| >Roche(Swiss) nor Merck ( German, not related to US Merck)
| don't benefit much (if at all) from US subsidies.
|
| Roche makes 55% of its revenue from US drug sales
| (https://assets.cwp.roche.com/f/126832/x/db9d31e8a7/fb20e.pdf
| p22)
|
| EMD Serono (formerly Merck KgAA) is similar.
|
| These revenues are the topline driver of the drug development
| industry.
| ch4s3 wrote:
| Cuba has developed a few drugs and exports doctors as chattel
| for foreign income but their actual healthcare is abysmal.
| They larger operate without antibiotics, pain killers, and at
| times clean water. They can't provide 24h power to hospitals
| so most modern tech is pointless there. The notion that
| anything else is true is just Cuban propaganda. There are
| tons of accounts from NGOs and doctors who have defected.
| byecancer21 wrote:
| This mirrors my personal experience. To make a treatment
| decision, against the advice of my local doctors, that was key
| to survival I relied on US research.
|
| To compare costs: For an extremely rare cancer, total cost of
| treatment was 100k EUR in Germany, whereas US patients report
| case costs of >2m USD.
|
| Part of these savings stem from the public healthcare system
| not providing adequate treatment, while strictly necessary for
| a reasonable chance of survival in this case. What happens in
| Germany then is the amazing doctors do stuff anyway (if you can
| convince them), bill whatever they can, and write off the
| remainder. Profits from privately insured patients make up for
| this shortfall here.
|
| Public healthcare being adequate is somewhat of a myth, for
| Germany at least.
| awinter-py wrote:
| on the research side, this would tend to _reduce_ prices,
| right? clinical trials usually aren 't charging (per [1]).
|
| this 2017 article[2] claims that the US pharma $ premium is
| more than R&D spending for 13 of 15 top pharma cos. (Note: this
| isn't even talking about profit, it's talking about the _excess
| profit_ from higher US prices). Maybe you can make an argument
| that R &D is lockstep to margins, and would shrink if margins
| went down?
|
| 1. https://www.hhs.gov/ohrp/sachrp-
| committee/recommendations/no...
|
| 2.
| https://www.healthaffairs.org/do/10.1377/forefront.20170307....
| nextos wrote:
| As a researcher in the field and someone who has seen a few
| friends go due to cancer, the current standard of care is very
| frustrating.
|
| I believe cancer is orders of magnitude easier to treat when it
| is still asymptomatic but detectable using metrics such as
| circulating tumor DNA (ctDNA). However, it is taking ages to
| deploy this technology because healthcare struggles with any
| data-oriented solution.
| vimy wrote:
| Is this something private labs offer?
| nextos wrote:
| Yes, and it's not very expensive. Many EU & US labs would do
| a test for you for ~$300--$500.
|
| I guess it'd be really cheap if it was deployed nationwide.
| Furthermore, predictions would be a lot more sensitive /
| specific as they would be tuned with millions of datapoints.
|
| It's the same for other technologies such as TCR-seq. They
| could theoretically bring immense prevention benefits, but
| it's really hard to bootstrap them without collaboration from
| big healthcare systems as you need thousands of datapoints to
| get it going. Very frustrating.
| david_l_lin wrote:
| Healthcare is notoriously slow with adoption of new technology.
| IMO this is because healthcare is fee-for-service, which is
| basically incompatible with prevention. A movement to value-
| based care would vastly improve adoption of preventive and
| personalized healthcare.
| lordgrenville wrote:
| The HMO model was basically designed to bring in an element
| of value-based reimbursement. For example, the CMS capitation
| payments to Medicare Advantage plans are weighted by (inter
| alia) health outcomes.
| wtch98 wrote:
| OK that explains a few countries which have a fee-for-service
| model, what about those countries incentivized to prevent
| problems? Do they take new technology on faster?
| adammunich wrote:
| how can people take action themselves here
| nextos wrote:
| I guess creating startups that offer polished ctDNA solutions
| or pressing local governments to make healthcare more
| streamlined, perhaps even with healthcare IT startups too.
|
| The problem is that most healthcare systems are too
| fragmented and not geared towards prevention. Hence, one
| faces a huge uphill battle.
| TrackerFF wrote:
| A bit unrelated - but I always thought the American concept of
| "annual checkups" sounded a bit weird. Here where I come from,
| Norway, that is not a thing - unless you have / or have had some
| serious illness in the past. Obviously cancer patients, or those
| in remission, get checked up every x months.
|
| But for regular people, it's pretty much not a thing. It also
| made me wonder: How much more would it cost our health-care
| system, if everyone took advantage of things like annual
| checkups, or going through those extensive screens/tests that a
| lot of American patients go through. I guess the fear of
| malpractice lawsuits, higher insurance rates, or whatever make
| the medical centers in US a bit more incentivized to catch
| anything at all.
|
| But AFAIK, we don't have any higher mortality rate here than
| those living in the US. Earlier this year I went to the doctor,
| because I was feeling a bit lethargic - turned out I had severe
| vitamin D deficiency. But other than that, it must be 7-8 years
| since I talked with a doctor.
|
| (But credit where credit is due - the US seems like an excellent
| option IF you really need to get treated for certain cancers.
| It's not like we have "death panels" or awful long wait time
| here, but I know patients that have gone to the US to get
| treatment - on their own bill - for cancers that were deemed too
| advanced for treatment, here in Norway.)
| pessimizer wrote:
| > I know patients that have gone to the US to get treatment -
| on their own bill - for cancers that were deemed too advanced
| for treatment, here in Norway.
|
| The US is outstanding at taking money from sick people, just
| not any better at getting them well.
| [deleted]
| raverbashing wrote:
| Well, overdiagnosis/overtreatment _is_ an issue
|
| Both approaches have pros and cons, because while an early
| diagnostic of some diseases can make a huge difference, there
| are also false-positives and needless invasive procedures
|
| (And I guess the people that are the most oblivious about their
| health are the ones that are more prone to have lifestyle
| related conditions - some people have never measured their
| blood pressure or blood glucose)
| paulcole wrote:
| Part of the reason why it's a thing in the US is that a huge
| number of people _do_ have /have had a serious illness in the
| past: heart disease, diabetes, obesity, etc. Part of the reason
| they have those illnesses is because they neglected their
| health due to the cost of prevention.
| chmod600 wrote:
| What's the cost of preventing those diseases? Aren't those
| mostly diet/lifestyle?
| paulcole wrote:
| Diet and lifestyle aren't free.
| trgn wrote:
| Is this really the case though?
|
| The annual check up is something that's been advocated a long
| time, 50s at least, and predates the obesity epidemic.
|
| The annual checkup is a symptom of a therapeutic view of
| health care, a view which cannot be divorced from modernism.
| The body is a machine which must be oiled and greased,
| frequently submitted to tests and expert investigation, so it
| can be tuned perfectly, just like a car, like a machine.
|
| This really was _the_ obsession in post war America: that all
| human activity (really, all of it), needed to be mediated by
| technology. This included personal transportation, education,
| cooking, ... and also maintaining our health.
|
| And that is where we are now; a chronically medicated
| population and a bureaucracy optimized to propagate this
| state of affairs. The annual checkup fits perfectly in this
| mindset.
| dghlsakjg wrote:
| Just FYI, annual checkups are recommended, but certainly
| something that a lot of young people skip. A quick google shows
| that only around 60% of Americans see a doctor yearly.
|
| The checkup also isn't a battery of tests unless you are at an
| age or condition for that. For a healthy 20 something that goes
| it's basically the doctor checking your blood pressure and
| asking if anything has changed.
| kurthr wrote:
| Yeah, that annual check-up is a 15min consult with maybe a
| blood test or a mail in colon cancer test even if you're 55+.
| Many people will completely ignore extreme signals of
| unhealthiness (pain, shortness of breath, trouble sleeping),
| because it's "normal" while another group simply can't
| believe they don't have some treatable disease to explain all
| their aliments.
|
| This research was about just cancer detection/treatment, but
| it's worrying that once they only mention correcting for
| smoking rates (umm duh, that's the least you need to do)...
| but then they don't mention weight... so weird?
| bnjms wrote:
| > It's not like we have "death panels" or awful long wait time
| here, but I know patients that have gone to the US to get
| treatment - on their own bill - for cancers that were deemed
| too advanced for treatment, here in Norway.)
|
| This sounds like the right way to go, but I want you to
| understand this is exactly what people mean when they say
| "death panels".
| tetraca wrote:
| The argument never made sense to me because that's surely not
| much different from how a private insurance company in the US
| already operates - you can bet they have a team of actuaries
| who has calculated the exact point it's probably not worth
| their money to try to save a patient.
| decebalus1 wrote:
| Not to defend anything about the American model (I personally
| hate it and think it's broken) but the annual checkup is a very
| cheap way of dealing with a possibly expensive condition.
|
| The checkup is non-intrusive and for presumably healthy people
| consists of a physical, basic blood tests (glucose and some
| metabolic indicators + infection markers) and a blood pressure
| check. As an example, it's way cheaper to find out you have
| pre-diabetes this way, than to go to the doctor with symptoms
| when you have full on diabetes. This is mainly the reason why
| insurances pay for these in full, as they're part of
| 'preventive care'.
|
| > How much more would it cost our health-care system, if
| everyone took advantage of
|
| Annual checkups are definitely not the reason healthcare costs
| are sky-high in the US.
| kwhitefoot wrote:
| > the annual checkup is a very cheap way of dealing with a
| possibly expensive condition.
|
| Is it? Or is it something that just seems obvious?
| alexanderdmitri wrote:
| Both if the checkups help catch issues early or avoid them
| [0][1].
|
| [0] https://www.cdc.gov/pcd/issues/2019/18_0625.htm
|
| [1] https://www.bbc.com/news/health-35073966
| lr4444lr wrote:
| Wait a sec: mammograms, postate exams, colonoscopies? You don't
| have these regular screenings when you hit a certain age?
| AFAIK, the data is very good on the early detection power of
| these exams.
| pessimizer wrote:
| > mammograms, prostate exams
|
| For these two, the data is very good that we're doing them
| too early.
| deskamess wrote:
| What is the right time? Here in Ontario, Canada a letter
| gets sent at around 50 (I think) asking you to do a FIT
| test. Call your Dr, get the kit, do the self-test and mail
| it in.
| sneak wrote:
| It's also a Japanese concept. Regular low-cost health
| screenings can catch big problems early.
|
| You don't get annual bloodwork performed? Does your cat/dog?
| kwhitefoot wrote:
| Also from Norway: no I don't, nor anyone else I know,
| certainly not any pets.
|
| Women get regular mammograms after a certain age; prostate
| examinations are offered if you are concerned and if anything
| is found then more frequent checks will be offered but
| nothing like annual checks for people not known to have a
| problem.
| sneak wrote:
| I wonder if us/jp are the outliers here, or if Norway is.
| lordnacho wrote:
| We shouldn't expect outcomes to be much different, because when
| someone gets cancer in the rich world, they get treated with
| whatever medical science thinks is best. Contrast that with an
| ordinary purchase like a washing machine.
|
| What's left when you're definitely going to buy the Cadillac is
| that the price depends on how much money you have, and Americans
| tend to be wealthy.
|
| It also depends on factors relating to restriction of
| competition. If there's only so many doctors, which is the case
| because they restrict how many can be trained, doctors can
| extract more. Add to that the fear of litigation (friend dated a
| girl whose father made a living suing US doctors) and they end up
| spending money on tests that they wouldn't in the rest of the
| west. Possibly collective purchasing in national systems means
| something too, not sure.
| awinter-py wrote:
| this 2020 paper is probably a better source
|
| Association Between Spending and Outcomes for Patients With
| Cancer https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6994252/
|
| ^ looks into more granular data, surveys sources that show +/0/-
| correlation between spending + outcomes, compares end-of-life vs
| non-end-of-life, cites a few studies about specific cancer types,
| wasteful spending. Does a better job of investigating
| international change in spending vs outcomes over time.
|
| the OP globocan paper is using a country average; averages don't
| tell you that much, esp in the US.
|
| cancer data is _very granular_ these days (NY mandates per-case
| reporting, for example
| https://www.health.ny.gov/statistics/cancer/registry/about.h...).
| would be interesting to have a live model somewhere of outcomes
| by cancer, stage, comorbidity + hospital
| mlindner wrote:
| This discounts the fact that the vast amount of money spent on
| Medical practices is in the US which causes the advances here.
| Once the advances happen though they're global, so the US does
| not get the benefits from that money.
|
| This "tragedy of the commons" with regards to medical science
| causes everyone to misattribute things. Europe for example can
| pay little money for their medical practices because of the US
| bankrolling the research and drug development that allows them to
| do so.
|
| One route to fixing things in the US, if we really wish to do so,
| is to create by law a "most favored" status for the US such that
| if a US drug company sells outside the country, they must sell
| the drug in the US for the same price as the lowest price they
| sell it to any other country. This would largely fix our
| expensive healthcare, but would also harm the world heavily in
| advancement.
| mjewkes wrote:
| I work in the drug development industry, its a shame this has
| been downvoted, it's largely true - at least for new drug
| innovation. The fact that routine procedures are expensive in
| the US is unrelated.
|
| The US is ~35% of the global pharmaceutical industry, which is
| the topline driver of new drug development.
|
| When the US pays top dollar for new drugs, it does effectively
| subsidize European access to the new research.
|
| >Do you have any data to backup your claim?
|
| I would suggest
| https://www.rand.org/pubs/research_briefs/RB9412.html
|
| or the Great American Drug Deal, by Peter Kolchinsky.
| biorach wrote:
| > they must sell the drug in the US for the same price as the
| lowest price they sell it to any other country. This would
| largely fix our expensive healthcare, but would also harm the
| world heavily in advancement
|
| Drug prices are far from the leading cause of the high cost of
| US healthcare.
|
| The whole system is deeply dysfunctional with massive perverse
| incentives.
| biorach wrote:
| I don't believe that there is any research backing this.
|
| Do you have any articles, papers etc from reputable sources to
| back this up? Or is this just personal speculation?
| mjewkes wrote:
| The claim is largely true for drug development, but not for
| routine procedures. Those are expensive for unrelated, and
| largely pathological, reasons.
|
| I would suggest:
| https://www.rand.org/pubs/research_briefs/RB9412.html or The
| Great American Drug Deal, by Peter Kolchinsky.
| mrtksn wrote:
| Do you have the numbers to back these claims? Is the
| extravagant money spend on healthcare in US actually drives
| everything ahead? Do countries like UK, Germany, Switzerland
| and Japan lag behind due to the smaller amounts spent?
| mlindner wrote:
| No they don't lag behind, because as I mentioned, once
| they're developed the drugs are available globally, and often
| reverse engineered and re-sold by less scrupulous countries
| that don't care about intellectual property.
|
| As to your first question, I don't have an answer for you off
| hand.
| mrtksn wrote:
| Okay, what are the sources of this claim? I'm kind of
| surprised that Germans and the British steal American
| technology developed though bankruptcy inducing
| childbirths.
|
| edit: Hmm, if that's true then US must be actually behind
| because every now and then the UK or some Europeans might
| invent something but the Americans won't have it because
| they respect intellectual property. Which means Americans
| will have only American stuff but the Brits and the EU will
| have Europeans stuff too.
| mjewkes wrote:
| The claim is largely true for drug development, but not
| for routine procedures. Those are expensive for
| unrelated, and largely pathological, reasons.
| mrtksn wrote:
| Okay, can you provide some literature on that claim? Do
| you, by any chance refer to the European governments
| buying directly from the pharma companies, thus getting
| solid discount? Or is it the case that European companies
| simply copy the drugs and move on? If that's the case, is
| the US healthcare expensive because pharma companies need
| to make money from the US sales only?
| mjewkes wrote:
| https://www.rand.org/pubs/research_briefs/RB9412.html and
| The Great American Drug Deal, by Peter Kolchinsky.
| Specific claims:
|
| - The US pays more for new drugs than the rest of the
| world
|
| - The US contribution is disproportionate, and is major
| driver of the drug development industry.
|
| -If the US paid less for new drugs, the entire industry
| would slow, and we would have fewer more effective
| treatments.
| auganov wrote:
| Healthcare spending is almost as unequal as wealth, with a tiny
| minority consuming most of the resources [0]. Don't have data for
| this, but I see no reason not to assume a similar distribution
| applies to groups like cancer sufferers. That is - those most
| likely to die account for most of the cancer spending, while
| those with good outcomes account for relatively little. If you
| set a per person spending cap, you could expect a great reduction
| in per capita spending without much impact on aggregate outcomes
| (perhaps even an improvement). Which is exactly what public
| healthcare systems effectively do by strict rationing and
| discouraging private spending.
|
| [0] https://www.healthsystemtracker.org/chart-
| collection/health-...
| lr4444lr wrote:
| [deleted]
| rr808 wrote:
| I kinda feel that with American's terrible diet and lack of
| exercise, matching other countries' mortality shows actually a
| pretty good medical system.
| jphoward wrote:
| But this is adjusting for the baseline illness, remember. This
| isn't just age-standardised mortality rates. It's disease-
| standardised mortality. Hopefully they've adjusted for
| confounders...
| asdff wrote:
| Yeah, because people would rather go bankrupt than die. Doesn't
| make it a good system.
| salt-thrower wrote:
| Very true. The headline is misleading though. The actual
| article is framed as the inverse: "does spending more on cancer
| care give the US better outcomes?" and the answer is no. We're
| on par with other wealthy countries that spend half as much per
| person on cancer care.
|
| So yeah, the exorbitant costs of US healthcare do not correlate
| with better health outcomes. Just worse financial outcomes.
| [deleted]
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