[HN Gopher] Why conventional wisdom on health care is wrong (a p...
___________________________________________________________________
Why conventional wisdom on health care is wrong (a primer) (2020)
Author : jeffreyrogers
Score : 136 points
Date : 2024-10-17 15:57 UTC (2 days ago)
(HTM) web link (randomcriticalanalysis.com)
(TXT) w3m dump (randomcriticalanalysis.com)
| psd1 wrote:
| Well, that was interesting.
|
| What I'm unclear on is whether "health spending", in this
| analysis, is defined as money paid to care providers such as
| hospitals and dentists, or money paid by citizens for healthcare.
| Because you've got insurers and PBMs taking profit.
|
| The ratio of those two numbers is the efficiency of the American
| insurance model. How does it compare to the administration of a
| single-payer system such as the NHS?
|
| Until I see some data indicating otherwise, I'm going to look at
| my PS200pcm national insurance and my PS9.90 prescriptions and my
| free ambulances, and Americans' $500pcm insurance and their
| unlimited prescription costs and their four-figure bills even
| when insured, and I'm going to continue to believe that Americans
| are punching themselves in the face.
| xvedejas wrote:
| Well, there's also the rate of new drug and procedure
| discovery. I've heard it quipped that Americans are subsidizing
| the discovery of new medical techniques for the rest of the
| world. Whether that's worth a higher cost is arguable but I
| think the effect is there.
| bozhark wrote:
| Exactly this, example: biologics.
|
| I am currently prescribed a medication that is over $30,000
| per injection every 12 weeks.
|
| Because we have absolutely atrocious health organization.
| Pharmaceutical companies can set their prices regardless of
| anything but their profit.
| nradov wrote:
| How should pharmaceutical prices be set?
| BobaFloutist wrote:
| In general, anything that's mandatory for life/basic
| quality of life but still needs to be produced by
| industry should should be regulated to artificially
| reduce prices in order to compensate for inelastic demand
| and prevent price gouging. This regulation should include
| supply-side subsidies _and_ dynamic, carefully considered
| price controls.
|
| This should apply to food, water, housing, health care,
| transportation, internet; all those good things that you
| can't do without and are extremely vulnerable to market
| manipulation.
| claytongulick wrote:
| It's worth researching the inevitable consequences of
| price controls, it's a predictable outcome that's been
| tested many times.
|
| Price controls are Hobson's choice: Would you prefer
| expensive bread, or _no bread_?
| ElevenLathe wrote:
| That's right, which is why basic healthcare (including
| production of normal, well-characterized, non-
| experimental drugs) should be taken out of the price
| system altogether and run directly by the government.
| AnthonyMouse wrote:
| Normal off-patent drugs are already pretty cheap. You can
| get a bottle of ibuprofen for like $5. Drugs still under
| patent are, of course, expensive on purpose.
| BobaFloutist wrote:
| By price controls I literally just mean "anti-gouging
| regulation", not "you can't charge more than exactly $5
| for x"
| AnthonyMouse wrote:
| Describe the operation of "anti-gouging regulation" that
| isn't just a price ceiling or a cap on how much the price
| can increase in response to a sudden supply constraint
| that would otherwise result in a shortage.
| AlexandrB wrote:
| Using the free market to respond to a shortage requires
| competition. Patents can make this impossible. When you
| have a fixed supply of something and no other entity can
| produce it having an uncapped price doesn't really help
| the market respond. Consider the example of a Taylor
| Swift concert. Are scalpers creating more supply by
| raising the prices of tickets or is it pure rent seeking?
|
| And, to many, the difference between "expensive bread"
| and "no bread" in the case of drugs is entirely academic.
| Ray20 wrote:
| Define gouging.
| michaelje wrote:
| Every other country appears to have the "bread" at a
| reasonable price. Ironically, it's the US which has the
| same bread for 100x the cost.
| dgfitz wrote:
| Did you know Russian citizens spend half their take home
| pay on food? Wanna keep running with that point of yours?
| sqeaky wrote:
| I thought we were talking about developed nations
| participating in the global economy.
| michaelmrose wrote:
| There are other markets than Russia and the US what about
| all of Europe.
| Ray20 wrote:
| First, define the "basic quality of life" and what are
| you going to do when demand will exceed supply. Because
| we might as well just start the money printing machine
| and expect everyone to become a billionere.
| jltsiren wrote:
| One model is that a government pays a license fee that
| allows them to produce the drug in unlimited quantities
| for their country. (In practice, they could buy the drug
| from the manufacturer at the marginal cost, or they could
| use another pharmaceutical company as a subcontractor.)
| Sometimes there is a deal, and the country may get orders
| of magnitude higher health benefits for a marginally
| higher price. And sometimes the company refuses, because
| the deal would interfere with their business model in
| other countries.
| AnthonyMouse wrote:
| > One model is that a government pays a license fee that
| allows them to produce the drug in unlimited quantities
| for their country.
|
| How does this determine how much the license fee should
| be?
| jltsiren wrote:
| The same way as in any other business contract. How much
| the government is willing to pay, how much they expect to
| benefit, what other uses they have for the money, and so
| on. In practice, the company will likely get a bit more
| profit from the license fee than it would get from
| selling the drug normally.
| vundercind wrote:
| When this gets brought up as a _positive_ to our high
| healthcare spending (which you 're not exactly doing, more
| just making note of the existence of the argument) it's such
| a head-scratcher for me.
|
| 1) OK... maybe we should stop, then? Like, that seems like a
| terrible deal? How is that a justification at all? It seems
| like just a description of something very stupid we're doing.
|
| 2) This _would_ be a good deal if we were getting _other
| countries_ to also pay high prices and bringing that money
| "home", but basically the exact opposite is happening. WTF.
|
| 3) More often than not, the side of the issue that raises
| this as a _good_ thing is also the side full of folks who
| think we should e.g. reduce spending on foreign aid, so it 's
| _especially_ weird that they 're bringing it up.
|
| Plus, I'm very skeptical that the idea that drug development
| would dramatically slow down if the US stopped over-spending
| to the tune of 2x-100x on lots of drugs is even true. But
| setting that aside, it's still just a bizarre line of
| argument, to me.
| AStonesThrow wrote:
| You see, development of new drugs, devices, and treatments
| is definitely something that we must continue at breakneck
| pace, by any means necessary, because people keep
| discovering how awful and harmful the existing ones are, so
| we need to make consistent progress beyond the _status
| quo_.
|
| If you move faster than the science and the lawsuits, then
| you can keep selling deadly crap to a naive and trusting
| populace.
|
| https://en.wikipedia.org/wiki/Reye_syndrome
|
| https://en.wikipedia.org/wiki/Thalidomide
|
| https://en.wikipedia.org/wiki/Tardive_dyskinesia
|
| https://en.m.wikipedia.org/wiki/Fenfluramine/phentermine
| AnthonyMouse wrote:
| > OK... maybe we should stop, then? Like, that seems like a
| terrible deal? How is that a justification at all? It seems
| like just a description of something very stupid we're
| doing.
|
| The US pays for drug development and then the rest of the
| world caps prices and gets the drugs cheaper. If the US
| stops then the money for drug development goes down, which
| is not great. What you really want is to get the other
| countries to pay their share, but how do you propose to do
| that?
| kelseyfrog wrote:
| The reality is we have no evidence that other countries
| other countries wouldn't start developing drugs. Our fear
| that no one else would do is not grounded in the rational
| and we shouldn't let irrational fears decide what we do.
| This isn't something we can logic out ahead of time, we
| simply need to commit to not doing it.
| airstrike wrote:
| Other countries already develop drugs. They just charge
| more in the US market.
| XorNot wrote:
| People always forget it's "what the market will bear".
|
| Price caps set a very explicit bar and then ask a company
| to think very carefully if they truly think the drug
| can't be sold at that price (and surprise: turns out when
| motivated a ton of them discover that yes, it can be).
| zaphar wrote:
| What the market will bear affects an already existing
| product. R&D is driven by one of two things:
|
| 1. An expectation of profit at the end. 2. A highly
| desired outcome from a motivated pool of Investors.
|
| Price caps can dampen #1. Which can put more of the
| burden on #2 as a source of funding. Whether you think
| that is an improvement or not probably depends on your
| particular ideological position around markets and
| healthcare.
|
| But there is definitely an objective argument to be made
| that this might decrease the speed of improvements in
| healthcare technology.
| pfdietz wrote:
| What the US could do is cap prices in the US at some
| modest multiple of the cheapest price charged in other
| countries. The drug maker would then have a choice: cater
| to either the US market at an elevated price while losing
| the cheaper markets, or abandon the US market to have a
| possibly larger market elsewhere at lower prices.
| nradov wrote:
| That is one option. It would mean that some drugs,
| especially those for rare conditions, are never brought
| to market in the first place because the expected
| worldwide revenue would be too low to justify spending
| $1B+ on a stage-3 clinical trial that might fail. Is that
| a good trade-off? Depends on your perspective I guess.
| pfdietz wrote:
| It might actually increase world revenue, if it causes
| some countries to bite the bullet and accept a higher
| price.
| nradov wrote:
| Well then we have a game theory problem. Every country
| wants to freeload on drug development spending to
| minimize their own expenses. It's unrealistic to expect
| that countries like India or France will voluntarily
| accept higher drug prices just to incentivize new drug
| development. If the USA decides to stop subsidizing the
| rest of the world then the most likely outcome will be a
| permanent reduction in the rate of new drug development.
| Would that be an improvement?
| michaelmrose wrote:
| We have people dying of treatable ailments that have been
| understood for decades which cost less than the labour
| used to deny them treatment and lobby against their
| interests.
|
| A slower pace for rare ailments seems like an obviously
| acceptable trade off.
| throwaway14356 wrote:
| you make a committee of old doctors and have them set the
| prices.
| vundercind wrote:
| Let the market figure it out--it'll adjust, companies
| will raise prices in other markets and simply not serve
| the ones that won't let them charge enough to make it
| worth it--and then _explicitly_ , collectively subsidize
| it if that produces a shortfall? Pinning the bill for a
| _subsidy_ on the sick people--but _only in our country_
| --we're claiming to be trying to help, while also
| claiming our entire country is and must remain, uniquely,
| a martyr to the cause is a deeply weird way to go about
| providing a subsidy.
| ForOldHack wrote:
| The market has figured it out. The market has figured
| out, that tech bros will charge you as much as possible
| for that last dyeing grasp, seeking as much profit, while
| just glossing over mistakes and oversites that unalive
| you and your loved ones. The very best of luck with that.
| Hope you have an immediate and effective alternative.
| vundercind wrote:
| I meant use monopsony government buying power and/or
| price controls like 100% of the rest of the developed
| world, and let the market figure it out. Though I
| definitely didn't make that clear, my bad.
|
| Then subsidize, on purpose and directly, not by some
| lopsided roundabout more-expensive-than-it-needs-to-be
| scheme, if problems arise.
| michaelmrose wrote:
| Please define "their fair share". How much of the money
| for US advertising shall they bear whilst we are at it.
| ToValueFunfetti wrote:
| If advertising wasn't net positive for drug companies,
| they wouldn't do it, ie. paying for advertising means
| paying less. But if you disagree with that reasoning,
| advertising accounts for ~3% of US drug spending, so
| taking it or leaving it isn't going to make a big
| difference in prices.
| rsynnott wrote:
| It is notable that the industry spends more on marketing
| than R&D. Virtually all of this spend is in the US; very
| few countries allow the marketing of prescription drugs
| to consumers.
|
| Quite a bit of the high pricing for Americans is also by
| companies who _don't even do_ R&D to any significant
| extent; companies who only make generic price them
| dramatically higher in the US than elsewhere.
| Workers_Own_Co wrote:
| > > other countries to pay their share, but how do you
| propose to do that?
|
| They cannot pay with money, but honestly speaking they
| could "pay" with risk taking, I mean trying drugs that
| the FDA is too risk averse to approve . For example the
| risk profile of basically every day activity is much much
| higher in India or Nigeria compared to the U.S. and so
| the same should be for drugs, medicine is an extremely
| risk averse field as it is, but with the FDA being the
| world authority over medicine safety basically the risk
| profile of the US is being transferred over to the rest
| of the world which is nuts. Consider for example the risk
| profile of daily driving in the U.S. vs India or Thailand
| where everybody goes around in scooters without helmets,
| it works for them, their economy would collapse if they
| tried to have the safety of the U.S. drivers going around
| with 20ft long 7500lbs cars.
|
| The unfortunate thing is that the whole world relies not
| only on the U.S. for drug research but also drug
| approval. If the FDA says no to something then not even
| Lesotho would try it , even though maybe from a risk
| reward standpoint it would make so much sense for Lesotho
| to try it .
| kiba wrote:
| Not all subsidy is a bad thing. The money is used to fund
| real expertise and industrial capacity.
| BurningFrog wrote:
| Yeah, it's unfortunate for the US, but since no one else is
| stepping up to pay for the medical research that benefits all
| of humanity, we have to do it.
|
| The recent "negotiated prices" for Medicare drugs could be
| the beginning of the end for this system though.
| saulrh wrote:
| Wouldn't it be _even better_ to explicitly funnel our money
| to R &D, rather than hoping that it gets there eventually
| after insurers and paperwork maximizers and intentionally-
| inefficient providers all take their cuts?
| basementcat wrote:
| Which researchers do you funnel money to?
|
| The majority of basic research is done in academic research
| laboratories which are predominantly funded by government
| research grants. If one of these studies pans out and
| something can be patented, a business or investor group may
| license the patent and fund an applied R&D program with the
| goal of getting through FDA trials. This effort is either
| funded by investor capital or internal company funds
| (likely from revenues from the sales of FDA approved
| medications or other products). Presumably if a business or
| investor group has a track record of bringing treatments to
| market (e.g. having a revenue stream from a previously
| economically successful product) they are entitled with the
| option to invest more funds, etc.
| doctorpangloss wrote:
| High interest rates have stopped way more drug development
| than lower or higher drug prices ever have.
|
| Between 2019 and 2022 there were like 88 biotech IPO lockup
| expirations and only 3 were trading higher than post lockup
| for any period of time.
|
| Macro determines the rate of risk taking. Not "details." You
| simply 100% cannot have drug discovery without risk, and risk
| wants returns.
|
| Should we have low rates and high inflation for the sake of
| more "discovery of medical techniques?" Inflation and high
| costs: dude, they are exactly the same thing!
| KingOfCoders wrote:
| "I've heard it quipped that Americans are subsidizing the
| discovery of new medical techniques for the rest of the
| world."
|
| The way Trump touted an invention from the German company
| BioNTech as "Invented in America".
| inglor_cz wrote:
| To be fair, very critical elements of mRNA technology
| _were_ developed in the U.S. Nothing is purely German or
| American nowadays.
| KingOfCoders wrote:
| To be fair, writing a paper is not developing a
| technology. And someone from the town I live discovered
| oxygen. No oxygen, no mRNA.
|
| "Nothing is purely German or American nowadays."
|
| I know that, not everyone seems to though:
|
| "I've heard it quipped that Americans are subsidizing the
| discovery of new medical techniques for the rest of the
| world."
|
| And not even nowadays. Like with the Wright Brothers, who
| used data from Otto Lilienthal.
|
| But the Wikipedia article could not stop trying to
| minimize his impact,
|
| "Lilienthal's research was well known to the Wright
| brothers, and they credited him as a major inspiration
| for their decision to pursue manned flight."
|
| where someone felt the need to add
|
| "They abandoned his aeronautical data after two seasons
| of gliding and began using their own wind tunnel data."
|
| and make it all about the Wright Brothers. In an article
| about "Otto Lilienthal" not the Wright Brothers.
| inglor_cz wrote:
| Going far enough, we should credit some anonymous Homo
| erectus for discovering fire... Not that I am completely
| joking, the tree of human knowledge is fascinating by its
| depth and goes deep into the pre-literate age.
|
| That said, I wouldn't dismiss Kariko's and Weissman's
| discovery of replacement of uridine with pseudouridine as
| merely "writing a paper". It was a pretty crucial
| technological stepping stone that made mRNA treatment
| orders of magnitude less dangerous to humans. Same with
| their discovery of the way how to deliver mRNA into cells
| (using lipid nanoparticles).
| nradov wrote:
| Profit margins for insurers are pretty low on a percentage
| basis. The Affordable Care Act (Obamacare) imposed a minimum
| medical loss ratio on commercial payers. You can read the
| financial statements for those that are publicly traded. Some
| of the largest insurers such as Blue Cross Blue Shield
| Association members are non-profit.
|
| The NHS isn't really a "single-payer system" in any meaningful
| sense. In the UK, most healthcare providers are employed
| directly by the government and their wages are fixed below the
| market rate to control costs. There are internal financial
| transfers but there aren't really arms-length negotiations and
| payments between separate payer and provider organizations.
|
| If the USA was to adopt a single-payer system like the various
| "Medicare for All" proposals that politicians have floated that
| wouldn't do much to reduce costs. Any meaningful cost reduction
| for the system as a whole would require driving down provider
| wages, rationing care, and ending the way that we subsidize
| drug development costs for the rest of the world. Those
| measures might be good things to do on balance, but they aren't
| politically popular.
| bozhark wrote:
| For profit non profits exist. There is no "metric" for how
| much a 501(c)(3) must ratio in order to be considered tax
| exempt.
|
| They must follow their own discipline set in their founding
| documents.
|
| Calling blue cross blue shield nonprofit is disingenuous as
| they made $749,000,000 in 2022.
|
| Per their 990's: https://www.causeiq.com/organizations/view_9
| 90/135656874/101...
| wahern wrote:
| $749 million is revenue. Revenue less expenses (i.e.
| profit) was $57 million, which admittedly is a decent 7.5%.
| But as a nonprofit there are no shareholders or partners to
| siphon off that profit. The common argument is that
| management siphons off that money through salaries, and I
| can't say they don't, but if you look at their assets &
| liabilities it seems like some significant amount of their
| profit is going into savings.
|
| Anyhow, the Blue Cross/Blue Shield system has a very
| complex structure so if you're looking to find where the
| real money is being siphoned off it's unlikely to be at the
| top. BC/BS affiliates are independent, that's why the org
| at the top for a system insuring over a hundred million
| people pulls in less than a billion dollars in revenue.
| abound wrote:
| "Nonprofit", at least in the US, is usually shorthand for
| having received a 501c3 (or similar) designation from the
| IRS. It has little bearing on your ability to make money as
| an organization (with caveats like the public support
| calculations)
|
| Source: Ran a nonprofit for a few years that made money
| doing software consulting
| _DeadFred_ wrote:
| This is so misleading. What you are saying it technically
| true, but also why our system is broken.
|
| If I can only make 10% profit (or whatever the law is), what
| is my incentive to keep healthcare costs down? The ONLY way I
| can grow my income if it healthcare costs go up. 10% profit
| on a $100 medication is way less than 10% profit on a
| $1,000,000 medication. The road to hell is paved with good
| intentions.
|
| Another disingenuous argument on non-profits. Is all of Blue
| Cross Blue Shield non-profit or only the certain parts you
| want us to look at? A 'Pay no attention to the man behind the
| curtain' argument.
|
| Final disingenuous argument is you just asserting 'meaningful
| cost reduction'. There is no way ambulance rides went from
| $200 to $10,000 because of EMT pay.
| FireBeyond wrote:
| > There is no way ambulance rides went from $200 to $10,000
| because of EMT pay.
|
| Absolutely not. EMT pay can be as low as $12 an hour.
| wahern wrote:
| > If I can only make 10% profit (or whatever the law is),
| what is my incentive to keep healthcare costs down? The
| ONLY way I can grow my income if it healthcare costs go up.
|
| You're missing the step where you also have to increase
| premiums, i.e. price. And what normally keeps any seller
| from increasing their prices whenever they want is
| competition--some other insurer will get your business.
|
| That begs the question of how competitive the insurance
| market is. Let's assume it's woefully uncompetitive. But in
| that case I don't see how the ACA 80/20 rule on
| administrative overhead changes incentives and the
| evolution of price inflation one way or another. At best it
| temporarily disrupted existing inflationary schemes, at
| worst it does nothing.
| nradov wrote:
| I'm not asking you to look at anything. Many US healthcare
| payers are private non-profit corporations. That includes
| some (but not all) Blue Cross Blue Shield Association
| licensees. The BCBSA isn't a payer itself and merely
| provides some shared services to their independent
| licensees. Outside of the Blues system there are other
| large non-profit payers such as Kaiser Permanente, HCSC,
| Geisinger, EmblemHealth, etc. This isn't secret
| information, you can just go look it up instead of arguing.
|
| Commercial health plans have conflicting financial
| incentives. Most of them no longer provide much insurance
| (in terms of bearing financial risk) but rather primarily
| act as administrators for self-insured employers. So while
| payers can potentially boost short-term profits by paying
| out higher claims, employers comparison shop between
| competing health plans every year. Your HR department would
| happily switch from Aetna to Cigna (or whatever) next year
| if their analytics forecast shows that would save a few
| dollars on expected claims.
|
| Ambulance fees are a mess but those represent a tiny
| fraction of overall US healthcare spending. Some reform
| there would be a good idea but that wouldn't do much to
| reduce costs.
|
| Significant systemic cost reductions will require some mix
| of lower provider wages, care rationing, and reduced
| spending on new drug and device development. Countries with
| more socialized healthcare systems are more financially
| efficient in some ways but they also just do less stuff:
| less drug development, longer queues for advanced
| treatments, underpaid doctors (relative to market wages),
| care restrictions based on QALYs (or similar metrics).
| Complaints about payer profits, while perhaps somewhat
| legitimate in certain cases, are largely a distraction from
| more fundamental problems. That's just basic math dictated
| by the cashflows. There are no simple solutions and we're
| eventually going to have to make hard choices. No one wants
| to face this reality.
| _DeadFred_ wrote:
| Edited out frustration.
|
| I wrote hospital medical software for 20 years passing on
| way better pay because I wanted to make a difference. And
| I gave up because the system WANTS to be how it is today.
| Everyone in medical is CHOOSING to make it this way, then
| claiming 'ah it's too big, it's too complicated, we can't
| change it'. Americans being to scared to call an
| ambulance means emergency care has completely failed
| them, not a small little thing to be brushed off.
| Americans are making hard choices about medical care
| every day already.
| nradov wrote:
| We're all frustrated. No one is happy with their
| available choices. Join the club.
|
| The system can't want anything. It isn't even really a
| "system" in any meaningful way, in the sense of being a
| unified entity working towards a common goal. US
| healthcare is just a bunch of disconnected people and
| organizations pursuing their own interests, often in
| conflict with each other. Any major improvements will
| require changes at the federal policy level to better
| align incentives with desired outcomes. This is hard
| because we collectively can't even agree on the desired
| outcomes or how to measure them. I mean at a high level
| most people think that everyone should have convenient,
| affordable access to high-quality care but once you get
| into specifics everything gets complicated and making
| trade-offs which disadvantage some voters is unpopular.
| Like should we spend $100K to give a terminal cancer
| patient another month of life? Should surgeons make $700K
| per year?
|
| It's easy to complain and cast blame. And we should
| certainly cut out waste and abuse where we find it. But
| that won't significantly move the needle on overall
| system costs. The problems are much more fundamental.
| eszed wrote:
| > It isn't even really a "system" in any meaningful way,
| in the sense of being a unified entity working towards a
| common goal.
|
| Well said. That this could be equally applied to the US
| as a whole likely explains subsidiary disfunctions.
| selimthegrim wrote:
| Good Lord I wonder what the unexpurgated version was like
| whoitwas wrote:
| This is nonsense. Health care costs about twice as much in US
| as everywhere else and only the rich can afford it. Health
| insurance companies fight against doctors and patients to
| subvert health and profit as much as possible.
| nradov wrote:
| 92% of Americans have health plan coverage, so we're not
| talking only about the rich here. There are certainly
| problems that we should fix but spreading misinformation
| about basic facts doesn't help anything.
|
| https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly_E
| s...
|
| It's easy for populists to demonize health insurance
| companies. But even if we somehow magically cut all payer
| profits to zero that would only marginally reduce total
| system costs. Much of what they do in fighting against
| doctors by negotiating lower reimbursement rates and
| denying claims that don't meet coverage rules actually
| helps to control costs for their main customers, the large
| self-insured employers that purchase health plans for their
| employees. At the national policy level, one change that
| would probably help would be breaking the linkage between
| employment and health plan coverage in order to better
| align incentives.
|
| Other countries that spend less on healthcare also have
| lower provider wages, longer queues for advanced
| treatments, rationed care based on QALYs (or similar
| metrics), and less innovation in drugs and medical devices.
| Maybe that would be better overall but let's not pretend
| that there aren't severe trade-offs. You can't have your
| cake and eat it too.
| whoitwas wrote:
| So what if they have health plan coverage if they can't
| afford to use it? Insurance is wildly out of control and
| needs to be reformed out of it's current form of
| existence. Health insurance companies act in bad faith
| against patients and doctors and many people with
| insurance go bankrupt anyway. What percentage of
| bankruptcies are from medical bills? It's impossible to
| objectively defend unless the goal is to make money at
| the cost of human health.
| nradov wrote:
| The vast majority of consumers with health plan coverage
| do use it. At a minimum they can access preventive care
| benefits at zero out-of-pocket cost.
|
| https://www.healthcare.gov/coverage/preventive-care-
| benefits...
|
| About 4% of bankruptcies are from medical bills.
|
| https://doi.org/10.1056/NEJMp1716604
| XorNot wrote:
| That study (full text[1]) is extremely selective: namely,
| the only factor they looked at was hospitalizations
| causing bankruptcies, and ignored emergency care
| expenses, chronic conditions and other long term
| treatment. In fact from their introduction you can very
| much see the problem: the fraction of
| people filing for bankruptcy who happen to have
| substantial medical expenses.
|
| Like...that is a weird factor to just try and wash away
| with sample selection.
|
| The only factor they considered was the proportion of
| people who filed for bankruptcy by years before/after
| hospitalization, which they found was about 4% of total
| bankruptcies - _for non-elderly adults_.
| we estimate that hospitalizations cause only 4% of
| personal bankruptcies among nonelderly U.S. adults, which
| is an order of magnitude smaller than the previous
| estimates described above.
|
| Now let's put that in perspective: one of the most common
| routine surgeries for a healthy person would be having
| your appendix out. That's a hospitalization, you stay
| overnight. It's also fairly cheap and immensely routine.
|
| It is also notable that the study was focused on patients
| at a single Californian hospital - we
| therefore selected a sample of people who were admitted
| to the hospital in California Our study was
| based on a random stratified sample of adults 25 to 64
| years of age who, between 2003 and 2007, were admitted to
| the hospital (for a non-pregnancy-related stay) for the
| first time in at least 3 years
|
| In short, the way this study is being thrown around to
| assert how medical bankruptcy works is invalid. And I'm
| calling completely bullshit on this methodology. Even
| their conclusions more or less paint the picture:
| We have found that hospitalizations cause: *increased
| out-of-pocket spending on medical care*, *increased
| medical debt*, and decreased employment and income
|
| * asterisk emphasis mine.
|
| [1] https://pmc.ncbi.nlm.nih.gov/articles/PMC5865642/
| whoitwas wrote:
| You work for an insurer? I'm sorry for you. Save your
| soul and quit!
| tightbookkeeper wrote:
| Work for an internet ad company instead!
| whoitwas wrote:
| I suggest you try purchasing insurance through a state
| market place for you and your family for next year and
| then report back on your experience if you're still alive
| in 2026.
| XorNot wrote:
| > longer queues for advanced treatments
|
| Americans always toss this out like it means something.
| If you're not in queue because you can't afford it, then
| you are in the queue it's just infinitely long but you're
| not counted.
|
| Your entire culture here is so broken you are
| fundamentally incapable of even beginning to understand
| how other countries discuss these metrics: when they
| discuss wait times it's for _everyone who needs it_ - no
| one is unable to afford it or being denied it by their
| health insurance. "The queue" is triaged against
| available resources - i.e. patients needing urgent care
| will get it earlier then those who are stable.
|
| Could it be shorter? Of course it could, but it also
| _includes_ everyone who needs it. And if you don 't like
| the queue the _gasp_ you can still pay to be treated
| privately and receive prompter service under most
| systems.
|
| Your system is so broken you literally can't comprehend
| the wording of complaints about other systems because you
| contextualize it through your own. Built into the entire
| model is that "the queue is long _and also we already
| kicked a bunch of people out of it_ , which is not what
| anyone is talking about in regards to the NHS, or
| Australian Medicare or any other system.
| nradov wrote:
| I am quite familiar with the systems in other countries.
| Every country rations care. Some do it by condition
| severity, others by ability to pay. The vast majority of
| US consumers have health plan coverage and the co-
| insurance or co-payment amounts are fairly low. I won't
| attempt to defend the vagaries of the US healthcare
| system but let's not pretend that everyone who needs
| treatment in other developed countries actually gets it
| in a timely matter. Why are 5-year cancer survival rates
| higher in the USA than the UK?
|
| It's pretty common to see affluent Canadians come to the
| US as medical tourists and pay out of pocket for
| procedures like MRI scans or joint replacement surgery.
| This is a real thing that happens all the time. Depending
| on your perspective that might be acceptable in the name
| of fairness and cost control but there are always trade-
| offs.
| Yeul wrote:
| Ah yes the kind of health plan coverage that still
| requires you to pay thousands of dollars out of pocket...
| vundercind wrote:
| We spend even more money on healthcare administration than
| what's directly spent on it. HR departments screwing around
| with insurance. Various government benefits & other agencies
| having to mess with private health insurance issues. Attorneys
| general offices and state rep offices spending time to get
| insurers' and hospital billing departments' heads out of their
| asses (they do a _lot_ of this).
|
| There are also untold hours lost in unpaid labor on the part of
| "clients" messing with insurance and hospital billing
| departments. It's not uncommon for someone who is, or is
| connected to a person who is, seriously sick for even a few
| days to spend a work-week or more of time that year messing
| with the billing from the incident. This can include uneventful
| pregnancies and births.
| eszed wrote:
| The amount of wasteful overhead in the American "healthcare"
| system never fails to shock me. The last two companies I've
| worked for (one a self-insured non-profit, the current a
| "conventionally"-insured for-profit) have both,
| coincidentally, had ~500 employees, and each dedicated about
| one-and-a-half full-time positions to administering their
| healthcare plans. Now scale that up across every company in
| the country: it's... Insane.
|
| Forget any of the squishy humanitarian impulses behind
| "socializing" medicine; eliminating all that un-productive
| labor would be of immense economic benefit.
|
| (Health-plan administrative cost is a moat which advantages
| large businesses to the detriment of small. That goes some
| way to explaining why an economic-efficiency / dynamism
| argument has never gained traction in American political
| discourse.)
| vundercind wrote:
| Right, it's _so bad_ that if we Did A Socialism and somehow
| had the worst cost outcome for such a move on the planet
| such that our direct healthcare spending remained
| identical(ly crazy-high)... it'd still be a win because of
| the huge drag on the rest of the economy and our QOL the
| current system imposes in indirect costs.
| actionfromafar wrote:
| But that would be morally wrong and lead to communism and
| satan worshipping.
| rsynnott wrote:
| One thing I've noticed from American colleagues talking about
| healthcare stuff (insurance and copays and vouchers and HSAs
| and so on and so forth) is that it's just mind-numbingly
| complex. It just seems like an incredible mess. Like, the
| amount of mental energy that goes into it just from the users
| has to be a significant cost to society.
| frsoafdslfdlsa wrote:
| Have you tried phoning a GP or for an ambulance recently?
| psd1 wrote:
| No, let me instead tell you about my healthcare experience in
| America.
|
| I wanted to get travel vaccinations in New Orleans. In my
| ignorance, I just looked up a clinic and went. Apparently I
| don't understand the coding for black clinic.
|
| It was a shack with 30 poor rural black women sitting
| motionless on mismatched folding chairs. We sat and sweated
| for an hour; no practitioner or even receptionist appeared.
|
| I don't think there was a phone at that shack. There weren't
| many cars about, so those women probably walked a decent
| distance to sit and wait.
|
| One of them had an enormous tumour on her face.
|
| It could be that we just killed the vibe. But these women
| were motionless. Like waiting was all they did. I believe
| they waited in that shack for days in a row.
|
| We went to that clinic from a bar where we'd been drinking
| seven-dollar beers while a waspy college band played poor-
| hillbilly music to oyster-guzzling yuppies in raybans.
|
| I've generally found Americans to be smart, humble, funny,
| kind and warm. But when I encounter an American being
| arrogant or self-centred, I think about that New Orleans
| shack.
| frsoafdslfdlsa wrote:
| I could trade stories about experiences with UK and US
| healthcare (I've lived in both countries), but the facts
| speak for themselves. The UK and US are near opposite ends
| of the scale of healthcare expenditure per capita in the
| developed world, yet the average life expectancy is about
| the same.
|
| I am not defending either system - I would strongly prefer
| something like the rest of continental Europe, which is a
| pragmatic mix of private and public healthcare. However,
| the idea that fully-public healthcare (a unique experiment
| in the world) is a sustainable model is a joke. It's hard
| to defend, when our current standard healthcare at the
| point of service could charitably be called "usually better
| than the 3rd world".
| sarah_eu wrote:
| Americans look at their 9k a month salary and don't care about
| loosing an extra 300 USD on health insurance. I've experienced
| the British and Swiss systems - Swiss is like the American -
| pay roughly 600 CHF a month - and it's way better than the NHS.
| You can see a specialist the next day, get a scan the next day
| etc.
| psd1 wrote:
| Is medical bankruptcy common in Switzerland?
|
| 600chf sounds like passable value for money, as long as you
| get excellent care and as long as that's all you pay.
|
| But my concern is always what happens to the poor. Yeah,
| yeah, the Swiss are rich - but not literally every Swiss, I
| presume.
| TMWNN wrote:
| >Is medical bankruptcy common in Switzerland?
|
| Only 4% of US bankruptcies are because of medical bills
| <https://www.washingtonpost.com/blogs/post-
| partisan/wp/2018/0...>. A tipoff that _[insert large
| percentage here]_ of bankruptcies aren 't actually because
| of medical costs is that only 6% of bankruptcies by those
| without health insurance are because of that cause. The
| biggest cause of bankruptcies is lack of income, which
| health insurance doesn't affect in any country.
| psd1 wrote:
| I was asking about Switzerland, since you brought it up.
| It's a fascinating place, I'm keen to hear your
| observations.
|
| Don't conflate bankruptcies. _Purely financial_
| bankruptcy is recoverable, given good health and time.
| (Not to trivialise it.) But, for a peasant with terminal
| cancer: _medical_ bankruptcy generally means a miserable
| and undignified death. There's worse pain than pain, you
| know?
|
| So, while I have to respect the dispassionate argument
| that "not _that_ many people die in a ditch", I reply
| that my PS200 buys me not just passable healthcare but
| also some pride in my nation finding some fucking
| compassion.
|
| That moral point is also an economic point, but I'm not
| ready to articulate it concisely. Let me say simply that
| a nation needs to find character on the way up and then
| again on the way back down, and America is currently
| fumbling for the second step. A nation is founded on its
| citizens. The cost of a zeitgeist of rage and distrust
| is, eventually, everything. What price empire?
| TMWNN wrote:
| > I was asking about Switzerland, since you brought it up
|
| sarah_eu brought up Switzerland, in comparison to the UK
| NHS. I don't know what percentage of Swiss bankruptcies
| are because of medical bills, but can cite the statistic
| for the US (which of course is the main topic here).
| Also, as I alluded to, "[ _insert large percentage here_
| ] of bankruptcies in the US are because of medical bills"
| is a common incorrect trope in/about the US, which I
| wanted to fend off before it came up yet again.
|
| >But, for a peasant with terminal cancer: _medical_
| bankruptcy generally means a miserable and undignified
| death.
|
| Obamacare mandated that the 15%[1] of Americans pre-
| Obamacare that did not have health insurance get it or
| pay a penalty. The figure is 8% now.
|
| And before you say "Well, that's not 100%", while the
| penalty for Obamacare noncompliance is not high enough,
| 92% of Americans having health insurance is not very far
| from the 95-97% elsewhere, and some large share of the 8%
| is from illegal aliens who are ineligible or avoid
| signing up for government health insurance. In every
| country there are people who fall between the cracks,
| whether a German who neglects to sign up for a new
| sickness fund after changing jobs, or a Canadian who
| neglects to sign up for a new provincial health care card
| after moving. The only way to get actual 100% coverage is
| to use the UK NHS model of having no membership card at
| all.
|
| [1] Yes, 85% of Americans before Obamacare had health
| insurance. How many of you non-Americans (heck, many
| Americans) thought that "0% of Americans have healthcare"
| before or after Obamacare? It's OK; you're not alone in
| believing everything you read on Reddit.
| davidgay wrote:
| > Only 4% of US bankruptcies are because of medical bills
|
| I'm going to hazard a semi-informed guess (I grew up in
| Switzerland, live in the US), that 0% of Swiss
| bankruptcies are because of medicals bills.
|
| And https://www.amjmed.com/article/S0002-93430900525-7/fu
| lltext disagrees with you, claiming 62% of US
| bankruptcies are due to medical bills... (other links
| report somewhat lower figures, e.g.,
| https://www.self.inc/info/medical-debt-bankruptcies-
| statisti..., but definitely nothing as low as 4%).
| arpinum wrote:
| Neither of your links are primary source data and give an
| incorrect interpretation. If you follow the links to the
| primary data you will find the phrasing changes from
| "medical problems contributed to..." in the source to
| "health care expenses were the most common cause of
| bankruptcy" in your citation.
|
| The numbers you cite are the percent of bankruptcies that
| include medical debt. The data doesn't say the medical
| debt caused the bankruptcy, or that this debt type was
| the largest percentage of debt. People declaring
| bankruptcy typically have many types of debt as they
| generally fall behind on all their bills.
| TMWNN wrote:
| The _Washington Post_ piece I linked to (Permanent URL:
| <http://web.archive.org/web/20180326154159/https://www.wa
| shin...> discusses the Himmelstein article the letter you
| cited cites. As arpinum said, Himmelstein et al. conflate
| any debt that includes medical bills at time of
| bankruptcy with "medical bills caused bankruptcy".
| pierrebeaucamp wrote:
| > But my concern is always what happens to the poor.
|
| There are subsidies available to low-income households. I'm
| unsure about the specifics as subsidies differ from one
| canton to another and usually depend on your income and
| family status.
| BlueTemplar wrote:
| Yes, exactly, while the average USian might still keep up
| with the rising costs of healthcare,
|
| (and in fact being the cause of rising costs because that
| is where they are going to spend their disposable income),
|
| the median USian will _not_.
|
| Partially this also comes from statistical effects that
| aren't scale-invariant :
|
| Countries with more people are more rich (including per
| capita).
|
| Countries that are richer are more inequal.
|
| Countries with more people are more inequal.
| Loudergood wrote:
| 9k a month is not typical for sure.
| DaveExeter wrote:
| $300x12 = $3,600/year for US health insurance?
|
| I think it costs more than that!
| xmddmx wrote:
| Exactly. I think they are confusing the employee portion
| with the overall cost? As an example, I currently pay about
| $200/ month but my employer is paying $1800, so total cost
| is $24000/year.
| deathanatos wrote:
| TBF, the $300 is a "more" number in their post, the
| difference I think from the further upthreads comparison of
| $200/mo cost of non-US, vs. $500/mo cost for US. So,
|
| > _don 't care about loosing (sic) an extra 300 USD on
| health insurance_
|
| It's the difference we allegedly don't care about. But
| they're claiming the cost is $500/mo, not $300/mo.
|
| Still, I think they're wrong: $300/mo or $3,600/y would be
| a decent sum to a lot of people that they would like to
| have, to spend on things like housing or basic items.
|
| Also, my searching says $500/mo is a bit below the average
| single-person coverage premium. And if you have a family,
| my Google searches suggest you'd _love_ to see $500 /mo for
| healthcare, as you're paying >>$500/mo.
|
| Even if we (I think generously) use $500/mo, I think we can
| only generously call that a premium-only number. But if
| you're comparing my private insurance premiums to a nation
| with universal/government insurance, I think you have to
| add in both the higher costs I pay out of pocket for things
| insurance won't cover, and the taxes I pay for government
| healthcare programs.
| Yeul wrote:
| I very much doubt that every American makes 9k per month.
|
| Ofcourse what it really comes down to if poor people deserve
| healthcare or if we should just pretend that they don't exist
| (the state of healthcare in Europe before WW2).
| deathanatos wrote:
| > _I very much doubt that every American makes 9k per
| month._
|
| We know they don't[1]:
|
| > _For the year 2022, the U.S. Census Bureau estimates that
| the median annual earnings for all workers (people aged 15
| and over with earnings) was $47,960; and more specifically
| estimates that median annual earnings for those who worked
| full-time, year round, was $60,070._
|
| The upthread's figure is $/mo; the higher (full-time)
| figure there is $5005/mo.
|
| $9k/mo is within top 20%'tile. Every trying to read the
| statement as "most Americans" doesn't work.
|
| [1]: https://en.wikipedia.org/wiki/Personal_income_in_the_U
| nited_...
| nonameiguess wrote:
| It is surprisingly hard to track down what is meant exactly. It
| is not either of the options you listed here, but closer to the
| first. Chasing a very long chain of citations to other
| citations, it appears this paper contains the original
| explanation of where the data come from: https://sci-
| hub.st/10.1007/s11205-015-1196-y.
|
| They survey all of the possible healthcare goods and services
| available across OECD nations, make their best attempt to
| select a representative basket that is both available across
| all nations and reasonably similar, then estimate what they
| call a "quasi-price" per unit of good and/or service, to
| account for the fact that the actual charged price is often
| artificially suppressed or set to zero by government fiat. This
| seems to be done by scouring management accounting databases to
| figure out what the payers and providers consider to be
| reasonable reimbursement rates for accounting purposes, whether
| or not that is what they actually receive.
|
| I get what they're trying to do, but this probably explains
| some of the counterintuive results, because mostly people are
| probably thinking more along the lines of "add up all premiums
| paid to insurers, out of pocket expenses paid directly by
| consumers to providers, and all government outlays classified
| as healthcare" and that's how much your country spends on
| healthcare.
|
| That's a reasonable comparison to make, but as the blog and the
| OECD report both point out, it does nothing to account for
| differences in quantity and quality of healthcare goods being
| paid for. The problem is this discourse then inevitably leads
| to "well the US gets worse outcomes," but to what extent is
| that fair? The only reason I can walk today is because of US
| healthcare. If you incur a musculoskeletal injury that requires
| intervention in various different countries, how likely are you
| to fully recover? If you get cancer, how likely are you to go
| into remission? I don't necessarily know exactly what _should_
| be measured, but I know that when the discussion goes straight
| to lifespan, that is heavily confounded. Americans drive more,
| own more guns, are fatter. There has been tremendous industrial
| pollution in various places, though I don 't know how that
| compares to the rest of the OECD. I wouldn't be surprised if we
| have more backyard pools. There are many, many reasons we might
| live shorter lives that have nothing at all to do with the
| quality of the healthcare we receive.
| AnthonyMouse wrote:
| > What I'm unclear on is whether "health spending", in this
| analysis, is defined as money paid to care providers such as
| hospitals and dentists, or money paid by citizens for
| healthcare. Because you've got insurers and PBMs taking profit.
|
| > The ratio of those two numbers is the efficiency of the
| American insurance model.
|
| The ratio of those two numbers is quite divorced from the
| efficiency of an insurance model.
|
| On the one side, this would count wasteful spending on
| unnecessary tests or overpriced services as an efficiency
| _improvement_ because proportionally more money is going to
| providers. On the other side, if insurers better at preventing
| fraud have lower premiums and therefore get more customers and
| make more money, that would count as "inefficiency" and the
| fraud _prevented_ would _also_ count as inefficiency (because
| that money went to "providers"), even if the net result is
| less fraud and lower premiums.
|
| That isn't to say that the US system is efficient. It's clearly
| quite broken. But its brokenness is because the government has
| been thoroughly captured by the industry -- which is the
| providers as much as the insurers -- and they oppose any
| measures that would improve actual efficiency because the
| inefficiency is their profit. Which is why the US system costs
| more than the systems in other countries regardless of whether
| the other countries use public or private systems.
|
| An efficient regulatory system for a private insurance market
| would be something like, a schedule of service codes where each
| provider is required to publish a fee schedule representing the
| uniform fee paid by all institutional insurers, eliminating the
| overhead of "negotiating prices" (a major source of
| inefficiency) in favor of price transparency and allowing
| patients and insurers to choose a provider on the basis of
| price and distance, while still subjecting providers to
| competitive pressure because people would naturally favor
| providers with lower fees. But the existing US system doesn't
| do that at all.
| nradov wrote:
| I generally agree with your points, but the US healthcare
| system does now have pretty much the level of price
| transparency that you want. Commercial health plans have been
| required to publish their negotiated network provider fee
| schedules since 2022. You can just download the files and
| take a look. Of course as an individual health plan member
| that won't tell you your out-of-pocket cost for a particular
| service, but it is useful to self-insured employers
| comparison shopping between health plans.
|
| https://www.cms.gov/healthplan-price-transparency/plans-
| and-...
|
| Longer term though we should move away from the fee-for-
| service model based on providers submitting claims for
| service codes. A value-based care model where provider
| organizations bear at least some financial risk and are
| accountable for patient outcomes will probably work better
| for everyone.
| AnthonyMouse wrote:
| > the US healthcare system does now have pretty much the
| level of price transparency that you want.
|
| They made a little progress toward it but the providers are
| fighting it every way they can. Apparently one of the
| methods is to use many different codes for the same thing
| so they can't easily be compared. You need to get to the
| point where it's like a price comparison service; your
| doctor tells you to get a scan and you get a list of every
| service in the country that offers it, sortable by both
| price to you and distance from your house. They should also
| eliminate the premise of "in-network" and just have all
| providers publish their prices and insurers publish the
| amount they cover in your region.
|
| > A value-based care model where provider organizations
| bear at least some financial risk and are accountable for
| patient outcomes will probably work better for everyone.
|
| It would probably be better to combine them, i.e. you get
| primary care your way but when primary care wants you to
| get a scan or take a medication you have competing
| providers. Lumping the entire network into one entity is
| likely to lead to market consolidation and then
| inefficiency.
| nradov wrote:
| The price transparency requirement I linked above applies
| to health plans, not providers. (There's a separate price
| transparency requirement for hospitals but it's less
| useful to consumers with health plan coverage.)
|
| I'm not sure what you mean about different codes for the
| same thing. The health plan MRFs all use the same
| CPT/HCPCS codes. Each code has a unique meaning.
|
| Health plan member portals also have online shopping
| tools where you can do price comparisons for every
| network provider within a certain distance. So what
| you're asking for pretty much already exists, although
| many consumers aren't aware of this.
|
| https://www.cms.gov/healthplan-price-
| transparency/consumers
| lukeschlather wrote:
| > Of course as an individual health plan member that won't
| tell you your out-of-pocket cost for a particular service
|
| If I can't get this, there's no price transparency. Of
| course it's even worse than this in practice, since not
| only can no one tell me my out-of-pocket cost for a service
| I'm about to purchase, they can't tell me what the
| negotiated rate is going to be, and it could be over a year
| before anyone can tell me either the negotiated rate or my
| share of the negotiated rate. (Odds are it will take at
| least a month and these figures will be renegotiated
| multiple times before I get a bill.)
| nradov wrote:
| If you're a health plan member then you can access
| consumer price transparency data through their mandatory
| comparison shopping tool.
|
| https://www.cms.gov/healthplan-price-
| transparency/consumers
|
| Reimbursement rates are negotiated between payers and
| network providers at most once per year. Rates don't
| change monthly.
| chiefalchemist wrote:
| > and are accountable for patient outcomes will probably
| work better for everyone.
|
| What's to stop providers cherry-picking who they treat?
| Who's going to treat the patients who are high risk? That
| will ruin the outcomes metric?
| nradov wrote:
| Accountable care organization (ACO) contracts between
| payers and providers usually don't allow cherry picking.
| They have to take all comers. There are typically higher
| capitation rates for older, sicker patients. It does take
| some actuarial sophistication to price those risks
| correctly but with large numbers of patients things tend
| to average out.
| chiefalchemist wrote:
| Who and how is that going to be monitored and enforced?
| What's the punishment? Cost-of-doing-business fines that
| the market only ends up paying anyway?
|
| I'm not disagreeing w/ the theory of your proposal. I
| haven't - yet? - seen how it can actually work.
| nradov wrote:
| For Medicare ACOs you can read about monitoring and
| enforcement here.
|
| https://www.cms.gov/priorities/innovation/innovation-
| models/...
|
| For ACO agreements between provider organizations and
| commercial payers, the parties can negotiate any contract
| terms they like. The agreements are usually confidential
| but payers aren't naive about this stuff and are fully
| aware of how to protect their financial interests against
| cherry picking by providers.
| TMWNN wrote:
| Studies have found that Kaiser Permanente (an integrated health
| insurance/care provider--basically a non-governmental
| equivalent of the NHS in comprehensiveness--that is available
| in many US states) is more efficient and effective than the NHS
| for about the same cost.
|
| Examples:
|
| * <https://www.bmj.com/content/324/7330/135>
|
| * <https://www.bmj.com/content/327/7426/1257>
| twoodfin wrote:
| Kaiser's effectively an HMO, right? Consumers (i.e. employees
| evaluating their corporate benefits) _hated_ HMO's at their
| peak in the '90's so much that the initials became
| politically toxic.
|
| Cheaper plans with more restrictions could exist more
| broadly. Consumers don't want them, politicians make hay on
| the consumer unhappiness and ban the things that allow the
| plans to be cheap in the first place.
| TMWNN wrote:
| Kaiser is like the NHS in that it does everything in-house.
| Kaiser members go to Kaiser doctors, stay at Kaiser
| hospitals, and get prescriptions fulfilled from Kaiser
| pharmacies.
|
| I agree on "HMO" being tainted. Kaiser has a good
| reputation in its territories, as does Intermountain, the
| other big western US integrated system.
| zaptheimpaler wrote:
| Anecdotally anyone can talk to a few doctors and find out just
| how much time they spend on updating charts/documenting
| information that's not directly relevant to the care, its just
| to protect against liability or work with insurance. Or how
| many hours they spend on phone calls fighting with insurance
| companies. The people who actually understand medicine wasting
| hours with some clueless rep with 0 understanding and a
| flowchart who's only job is to deny claims. Dr. Glaucomflecken
| on youtube has many videos about that too.
|
| So on the ground level, it's already clear some of our highest
| paid most valuable people spend 20-30% of their time on a
| flavor of administrative junk which isn't necessary in a
| single-payer system. I'm skeptical of claims that this waste
| doesn't translate into the higher level metrics.
| xapata wrote:
| It'd still occur in a single-payer system. The problem is
| fees for services instead of fees for results.
| looping__lui wrote:
| So the wealthy can finally cheat death efficiently once and
| for all ;-)
|
| On a more serious note: that might be hard in medicine per
| se to pay for "results". And I found some of the insights
| from "Outlive" quite interesting: how we focus in cure but
| not prevention; and how in the bigger scheme of things
| Antibiotics was almost the only "real big invention" in
| western medicine for a very long time (e.g., in terms of
| actual medical impact)
| contrast wrote:
| Any evidence for that claim? The issue is not whether there
| is administrative overhead, but the amount of it. It's not
| obvious to me that completely different funding models
| would incur the exact same amount of overhead on the
| practitioners.
| cmrdporcupine wrote:
| It does happen in a fashion in the Canadian system where
| family doctors at least operate as private businesses
| that bill the gov't, and because of that have to spend
| quite a bit of time on paperwork which then requires a
| whole edifice which there has been a lot of complaint
| about recently.
|
| A search will find you plenty of articles about this.
|
| That and the nature of the relationship introduces
| conflict. Plus the bulk of provincial governments
| administrating the thing are ideologically biased against
| it because they are conservative or neo-liberal in bent,
| and have been chronically underfunding it for years....
| xapata wrote:
| If I only earn when I treat, then I have an incentive to
| over-diagnose. Insurance thus forces me to document my
| diagnoses, and I spend much of my time on documentation
| and appealing denials.
| btilly wrote:
| How would you measure results? Go to a doctor, get a
| prognosis, get a treatment then a new prognosis? The
| incentive to inflate results is obvious.
|
| How else would you measure it? Survival rates? Doctors now
| have a strong incentive to avoid taking on sick patients.
| miki123211 wrote:
| > So on the ground level, it's already clear some of our
| highest paid most valuable people spend 20-30% of their time
| on a flavor of administrative junk
|
| This is most definitely not just a US problem. I work
| adjacent to this industry in Poland, where we basically have
| a single-payer system[1], and I'd say 20-30% is definitely in
| the ballpark.
|
| Especially in larger institutions (think hospital, not a
| single doctor's office), records must be kept and handovers
| between different doctors must occur. This means that you
| have to do all this work anyway, regardless of how much of it
| is actually transmitted to the insurance provider, and in our
| case, it's definitely far, far too little.
|
| [1] we do have private healthcare, but that's typically small
| / less-complicated procedures and usually covered out-of-
| pocket by those who can afford it, so there are no insurance
| considerations there.
| inglor_cz wrote:
| "This is most definitely not just a US problem. I work
| adjacent to this industry in Poland, where we basically
| have a single-payer system[1], and I'd say 20-30% is
| definitely in the ballpark."
|
| I wonder if _this_ could be the killer app for AI. Teach it
| how to do this sort of bureaucracy instead of humans, and
| let doctors treat actual people instead.
| btilly wrote:
| _I 'm skeptical of claims that this waste doesn't translate
| into the higher level metrics._
|
| The claim is that the size of the pot of money to be split is
| determined by the willingness of consumers to pay. Which is
| determined by their wealth. Therefore the inclusion of a lot
| of administration changes the split of where that money goes.
| More administration = less money for nurses and doctors. Less
| administration = more money for nurses and doctors.
|
| This fits observed behavior in other places. Your potential
| client has a problem and a potential budget for the solution.
| Clients are remarkably indifferent to how that budget is
| split up, as long as a solution to the problem is worth
| spending the budget. Here is the example that originally
| brought this point home to me. When Oracle moved from Solaris
| to Linux around the year 2000, it was able to charge more
| money for the database. Why? Because companies were willing
| to spend money on Oracle that previously went to the hardware
| and operating system. This incentive to open source the
| complement of whatever product you're providing is one of the
| reasons why so much money has been invested into creating
| open source.
| seadan83 wrote:
| Interesting point, though would you agree that an
| individuals budget for healthcare is unique? The budget for
| healthy vs not, tends to be 'all of it.' Hence, excessive
| healthcare costs.
| btilly wrote:
| Exactly. And the relationship seems to be that if your
| income goes up 1%, your available wealth at a point in
| crisis goes up 2.8%.
|
| However your willingness to spend at the moment of crisis
| is dictated by your problem and available wealth. And now
| how that money is going to be split among different
| parties.
| rsynnott wrote:
| > Anecdotally anyone can talk to a few doctors and find out
| just how much time they spend on updating charts/documenting
| information that's not directly relevant to the care, its
| just to protect against liability or work with insurance.
|
| It's not just for that. Documentation and checklists exist in
| public health systems, too, and IIRC there's some fairly hard
| evidence that they do reduce errors. Doctors hate them, tho.
|
| I was in hospital a few years back for a fairly inoffensive
| surgical procedure (public hospital, though in Ireland's
| rather weird hybrid system, because I had private insurance
| my insurance was paying), and I'd say I was asked at least
| ten times if I was allergic to anything, and had the barcode
| on my wristband read more times than I can count. This was
| extremely irritating... but apparently it does _work_; some
| patients don't always give the same answer to that question
| every time.
| ForOldHack wrote:
| "our highest paid most valuable people spend 20-30% of their
| time on a flavor of administrative junk..."
|
| By choice. Medical coders are a dime a dozen. Front
| office/back office/in office. You hire and train other people
| or you whine and complain, and be unproductive. Hopefully you
| will get one of the smart ones who understand this.
| akira2501 wrote:
| > I'm unclear on is whether "health spending",
|
| They list their source as 2017 OECD data. OECD seems to define
| this as:
|
| "Health spending is the final consumption of health care goods
| and services including personal health care and collective
| services."
|
| Their charts are also drawn in a standard and more
| understandable way.[0]
|
| > Americans are punching themselves in the face.
|
| Hurtful, but okay, I do hope you realize it's the rampant
| monopolization of health care that is the problem in this
| country. Yours solved it by simply creating a single publicly
| held monopoly.
|
| It's not as if either system is perfect and doesn't create it's
| own share and particular style of inhumane healthcare outcomes.
| Prescription label prices are noticeably different but are they
| meaningfully different where outcomes are concerned?
|
| [0]: https://www.oecd.org/en/data/indicators/health-
| spending.html
| WalterBright wrote:
| Health care prices in the US were reasonable until the
| government got involved in it in the 1960s.
|
| Prices rose with inflation until 1968, when they started
| angling up steeply. 1968 was soon after the advent of Medicaid
| and Medicare.
|
| The 1962 FDA amendments also resulted in a steep rise in drug
| costs, and a sharp reduction in new drugs being developed.
| keldaris wrote:
| If that's true, how are they so much more reasonable in most
| developed countries with far greater government involvement
| still? Is the US government just uniquely bad at healthcare
| somehow? Why?
| WalterBright wrote:
| It is true. Look at graphs of it.
|
| > Why?
|
| I don't know how other countries manage their health care
| systems, though I know that the British one is facing
| bankruptcy, and while health care was free in the Soviet
| Union patients had to pay for anesthetic for root canals,
| and bribery was the norm.
|
| Here's a link to what's wrong with the American system:
|
| https://www.theatlantic.com/magazine/archive/2009/09/how-
| ame...
| tonyedgecombe wrote:
| >British one is facing bankruptcy
|
| No it isn't.
| tightbookkeeper wrote:
| By reasonable do you mean 30-50% of your income for your
| entire life? Regardless of whether you use the services?
| Galaxeblaffer wrote:
| No country in the world has you paying 30-50% og your
| income to health care, it's more like 15-18%
| Angostura wrote:
| Where on earth are you getting that figure from?
| tightbookkeeper wrote:
| The uk tax receipts in 2024 was 342.2 billion.
|
| The nhs budget was 181 billion. Half of all government
| money appears to be going to healthcare.
| immibis wrote:
| What percentage of people's money is government money?
| rsynnott wrote:
| ... Where on earth are you getting that? As a high earner
| in a European country, about 8-9% of my income goes on
| the health service (though that includes some non-
| healthcare stuff). And I'm an extreme outlier;
| multinational salary and equity, single, no kids. For a
| single childless person on the average wage it's about
| 2.5%.
| tightbookkeeper wrote:
| What's your effective tax rate?
| mindslight wrote:
| Didn't the de jure government get involved in WWII with
| prices caps on wages yet exempting benefits, and this set the
| stage for the anticompetitive bundling of healthcare with
| employment? And wasn't the standard of care back then
| predominantly flavoring plus opium, which has a quite low
| cost basis?
| WalterBright wrote:
| Yes, employers during WW2 started offering health care as a
| fringe benefit because the US had wage caps. Even earlier,
| the government required licensing of doctors, the original
| purpose of which was to drive out Jewish and Black doctors.
|
| https://www.amazon.com/Competition-Monopoly-Medical-Care-
| Fre...
|
| But the big government push into health care happened in
| the 60's.
|
| Another big driver of American health care costs is the
| FDA:
|
| https://www.amazon.com/Regulation-Pharmaceutical-
| Innovation-...
| Amezarak wrote:
| The US government(s) spend about as much money per capita on
| health care as the average European country. Obviously US
| health care costs are out of control for other reasons than the
| existence of private insurance.
|
| To be clear because that's easy to misunderstand: despite the
| fact Americans do _not_ have universal public health care, the
| government _already spends_ as much as many European countries
| that _do_ , _per capita_. Part of this, of course, is because
| US public health care spending is concentrated on the old
| (Medicare) and disabled /poor (Medicaid). But it's still a
| shocking testament to US health care costs.
| naming_the_user wrote:
| NI does not pay for the NHS, it comes from general taxation,
| you're comparing the wrong figures.
| tonyedgecombe wrote:
| NI is part of general taxation in all but name. Nominally
| there is an NI fund but any money deposited there is
| immediately lent back to the government to be spent on
| whatever they want.
| psd1 wrote:
| Oops. I've spoken enough already in the thread, but I do want
| to thank you for the correction.
|
| In my defense, I'm attempting to perform data operations on a
| kilo of fatty grey meat from a savanna hominid. I've been
| meaning to upgrade but have you seen gpu prices lately.
| o11c wrote:
| Certainly a significant number of its points were defined to
| explicitly exclude insurance overhead, which I have often seen
| cited as "very high in the US".
|
| It's also completely ignoring the possibility of Hollywood-
| style accounting.
|
| One thing I'm curious about is any correlations to number of
| grandchildren.
| refurb wrote:
| > Until I see some data indicating otherwise, I'm going to look
| at my PS200pcm national insurance and my PS9.90 prescriptions
| and my free ambulances, and Americans' $500pcm insurance and
| their unlimited prescription costs and their four-figure bills
| even when insured, and I'm going to continue to believe that
| Americans are punching themselves in the face.
|
| This is a odd position to take. You're going to firmly hold
| onto a view despite admitting it's not that informed?
|
| Not to mention you're not even comparing the right costs. What
| the patient pays is not the total cost.
| simonh wrote:
| You forgot to mention the taxes they pay to support CHIP,
| Medicaid and Medicare. Which are not far off what many
| Europeans pay for universal health care, before most Americans
| even start to look at private health insurance so they actually
| get health care for themselves.
| tightbookkeeper wrote:
| > Which are not far off what many Europeans pay for universal
| health care,
|
| Effective tax rates of 40-70% do not exist in the Us. It's
| still a ridiculous amount of the economy to tax and spend.
|
| But what I think is more annoying is that the US has health
| systems for special interest groups:
|
| - seniors - veterans - native Americans - women and children
| - government employees (especially teachers) - immigrants
| seeking asylum
|
| This must be getting close to half the population. Either get
| rid of them, or pay for everyone.
| 9dev wrote:
| > Effective tax rates of 40-70% do not exist in the Us.
| It's still a ridiculous amount of the economy to tax and
| spend.
|
| That isn't true. In Germany, where we have fairly high
| taxes, I get to keep about 60% of my gross income, and I'm
| in the maximum taxation group. This 40% includes universal
| health care, pensions, tax, and mandatory insurance for job
| loss.
| inglor_cz wrote:
| Don't forget the effects of VAT and various consumption
| taxes. If you buy stuff with your net income, ~ a sixth
| of the money spent will be indirect taxes again.
| bdauvergne wrote:
| Those tax rates have nothing to do with healthcare, to take
| France as an example most of it is for other things, like
| pay-as-you-go pension plan or free education. Budget of
| french "assurance maladie" is 25% of the PIB or 450 billion
| euros for 68 million people, most of it paid by salary
| taxes. All things being equal, for the USA the same system
| would cost 2322 billion dollars.
|
| https://www.securite-sociale.fr/la-secu-cest-
| quoi/chiffres-c...
| eszed wrote:
| The way that I've seen GP's point expressed that makes
| sense to me is that the per-person cost to provide health-
| care for those special interests you mention is roughly
| equivalent to the per-person tax burden in most other
| developed countries _to care for everyone_. That gives me a
| useful handle on how _gob-smackingly_ wasteful the US
| system (writ large) actually is.
| rsynnott wrote:
| Very high tax rates in Europe are generally less about
| healthcare than about pensions, really, in most cases. Most
| European countries are a bit further down the demographic
| crisis road than the US is (and they mostly have higher
| life expectancies, too), so the cost of pensions has really
| become quite a big deal. Most European countries also have
| either very cheap or free university tuition; if you don't
| qualify for a grant it's 2k here, say. (This is an
| increase, due to the GFC; when I was in university it was
| 50 euro a year...)
|
| That said, for _most_ countries, 40-70% effective tax is
| very high, and not encountered by the average person. To
| pay 40% effective in Ireland, say, you'd have to be earning
| at least 150k, and that's assuming you're single, have no
| kids, don't pay rent or mortgage, and have no private
| pension (401k equivalent) contributions. Realistically,
| almost no-one hits those sorts of rates; for realistic
| setups you're looking at closer to 200k for a single
| childless person.
|
| It is impossible, here, outside of ultra-contrived
| circumstances, to pay over a 52% effective tax rate.
| luckylion wrote:
| > It is impossible, here, outside of ultra-contrived
| circumstances, to pay over a 52% effective tax rate.
|
| It depends on what you include though. You could look at
| someone earning 100k, having it taxed, paying all the
| things that are not taxes but obligatory just the same
| (social security, depending on the country), and then
| spending the rest on rent, travel, food & entertainment
| (and paying sales tax and various other specific taxes).
| How much of their total income has gone to the state?
|
| If you want to extend that comparison, look at someone
| running a company. The value they create with their
| company will be taxed as well, then they receive
| dividends from their company which also will be taxed at
| different rates.
|
| Of course, you'd need to either compare to individual US
| states, or make some choices about how to average their
| very different tax levels.
| rsynnott wrote:
| At least here, social security (PRSI) is a tax. Rent
| isn't subject to VAT, nor is a lot of food. Someone
| running a company wouldn't normally pay themselves with
| dividends, becuase it's not tax efficient; they'd take a
| salary from it instead (that's a cost, and thus is not
| subject to corporation tax).
|
| Someone earning 100k (assuming single, no kids, no
| private pension) pays about 33% effective tax (including
| social security) and some VAT on spending. 50-70%, again,
| is just kinda nonsense.
| AtlasBarfed wrote:
| We have immigration (illegal or otherwise) to stave off
| demographic cliffs. As much as the right hates illegal
| immigration, it is mostly Christians and they integrate
| well.
|
| The EU either has to integrate muslims, which is a
| rougher ride, or Russians/Ukrainians, of which there is a
| more limited number to import.
|
| The country with the worst demographics, South Korea,
| still IMO has an out: it can topple North Korea and
| import a huge number of people from there.
|
| China is in deep, deep trouble. They have restated
| demographics downward, and probably it is still worse
| than that. Combined with increasing levels of
| totalitarianism, allegedly a huge financial house of
| cards in real estate and regional governments, and a
| likely invasion of Taiwan that results in blockade and
| sanctions...
|
| Russia was having huge problems before the war. Now they
| are throwing away a badly needed generation, and causing
| 2-5x that amount to flee the country.
|
| Democracies have the potential to pivot from demographic
| disaster, but totalitarian regimes don't care about them,
| because demographic cliffs mean there is just an older
| more compliant population to suppress. Of course it means
| long term their country will fade to irrelevance and
| perhaps starvation/economic collapse, but totalitarian
| regimes exist primarily to ensure the survival of the
| regime, not the population.
| galdosdi wrote:
| > We have immigration (illegal or otherwise) to stave off
| demographic cliffs. As much as the right hates illegal
| immigration, it is mostly Christians and they integrate
| well.
|
| Indeed, but, even Mexico and much of Latin America now
| has below replacement fertility too. So now what?
| djtango wrote:
| This may be tangential but the NHS is not without some
| sickening expenses. The costs are just opaque and hidden but
| ultimately taxpayers are paying for PS300 for a stainless steel
| bucket for patients to pee in thanks to bureaucracy and
| government contracrs. (that figure is pre 20s inflation)
|
| So every month the government siphons off 40-45% of your income
| and donates a lot of it to Big Healthcare. So a case of being
| damned if you do and damned if you don't...
| snarf21 wrote:
| We should also not forget the $1B in drug advertising spend
| that must be recouped. People from other countries are
| frequently dumb-founded when they see US tv with prescription
| ads. Also look at all the companies buying up old drugs and
| immediately raising the price 10X or more.
| oceanplexian wrote:
| Doesn't advertising drive prices down? For example there is
| currently a booming industry for GLP-1s and the prices are
| dropping as the drug is becoming more available. Consumers
| know they have lots of choices and therefore price discovery
| is occurring.
| ericjmorey wrote:
| If you used those two profit numbers you would be missing all
| of the expenses that medical insurance companies have, none of
| which do anything for providing healthcare. Furthermore, you
| would be missing all of the expenses which exist to accommodate
| the systems insurance companies invented to account for things
| that only they care about. Insurance is the least efficient
| method of providing healthcare and we've committed hard to it
| for the benefit of few.
| FredPret wrote:
| The most efficient system would be direct payments only.
|
| The downside is only the very roch can afford expensive
| medical emergencies.
|
| But with insurance individuals get to pull the value of
| future premium payments forward to pay for large expenses in
| the present. There's also a degree of socialization.
|
| The downside is there will always be an overhead.
|
| Government health care is insurance writ large and has the
| same tradeoffs, just on a larger scale.
| miki123211 wrote:
| > Government health care is insurance writ large
|
| I would argue that it has even more tradeoffs; unlike
| private insurance, it's usually both mandatory and a
| monopoly, and that can go very wrong very quickly.
|
| The US system is extremely overregulated and preventing
| true competition, even though US insurance is private, so
| there aren't really any good data points to compare,
| though.
| actionfromafar wrote:
| Public systems can work very well and I can't name one
| system which went downhill very quickly.
| fao_ wrote:
| Exactly, the NHS is only going downhill because the
| dominant ideology among MPs has been that the NHS is the
| first place to get gutted for cheap savings. A lot of
| very efficient systems were removed and farmed out for
| "cheaper" private systems, that end up being rather
| costly in the long term with respect to increased error,
| price rising, and all the myriad ways incompetence and
| explicit money-grabbing messes with healthcare. They
| gutted the administration systems and now doctors have to
| work overtime on the weekends just to get their notes in
| the system, and now because doctors are overworked,
| they're putting more work into the hands of the
| incredibly underqualified PAs. And on top of all of this,
| repeated mismanagement of the money that is distributed
| to the NHS -- including, of all things, incredibly inept
| bartering, putting hospitals on a "target system" where
| underfunded hospitals are given less money for not
| hitting targets, etc. It's a complete joke, but every
| step was damned near deliberate for the case of farming
| public money into the pockets of the friends of MPs.
| detourdog wrote:
| The problem with the system in the USA is that paperwork
| can make all the different in costs. The burden is on the
| individual to comprehend all the implications of their
| choices. These choices are beyond do I want my ailments
| addressed.
| fao_ wrote:
| Often, people in situations where they require healthcare
| are least able to assess the implications of their
| choices, as well. It is very literally praying on the
| sick.
| Spooky23 wrote:
| You could provide every American with extremely robust
| healthcare for a trillion dollars a year. Probably less
| as you allocated resources based on need.
|
| We choose to spend that on the military. Basically you
| can choose guns or butter, we choose guns and empire.
| Whether that is a "correct" decision is an exercise for
| the reader.
| FredPret wrote:
| The US spends more on healthcare than arms.
|
| You could argue for lower defense spending, but there's a
| hard lower limit (which is unknown) and if you cross that
| threshold, the world changes for the worse very quickly.
|
| The rules-based order is underpinned by tanks and planes
| and nukes. Diplomacy is a layer of abstraction over
| violence and potential violence.
| CrazyStat wrote:
| Medicare costs $800 billion/year and only covers 20% of
| the population. They are on average the most expensive
| 20%, but I doubt you're going to cover all the rest for
| another $200 billion.
|
| Medicaid is another almost $1 trillion/year.
| uoaei wrote:
| I've resorted to calling this kind of breathless
| fearmongering out for what it is. There are too many
| people suffering too greatly in the existing system to be
| civil at the expense of maintaining the fictions of
| libertarian idealogues.
|
| Hyperfixation on an idealistic interpretation of real-
| world dynamics will always be thought-terminating. In the
| dichotomy of map vs territory, _the map is definitionally
| a cliche_. We can be better than that.
| actionfromafar wrote:
| With many insurance companies there are lot of coordination
| costs.
| thayne wrote:
| Government "insurance" has several advantages:
|
| - it has a much larger pool of insured, which reduces
| overall risk, and thus can have lower premiums/taxes
|
| - there is no need for profits, which again lowers costs
|
| - providers only have to deal with a single "insurer",
| which significantly reduces complexity of getting paid.
| Patients no longer have to waste time filling out paperwork
| about their insurance provider, and dealing with
| misunderstandings and miscommunication about whether they
| are insured, who they are insured by, etc.
|
| - You no longer have to worry about if your preferred
| provider is "in network". Which also removes needless
| beurocracy.
|
| - There is more of an incentive to care about longterm
| health, because the government will pay for all healthcare
| over the life of the patient. This used to be the case for
| private insurance, back when people stayed with the same
| employer, and same insurance company for most of their
| life. But now, insurance companies just want to minimize
| costs while you are with them, which probably won't be that
| long.
|
| - Employers no longer have to waste time and resources
| providing health insurance for employees, and employees no
| longer need to spend time, energy, and anxiety on "open
| enrollment" every year.
| g-b-r wrote:
| Furthermore, you can have rich people and big companies
| pay for a good portion of it, through taxes
| detourdog wrote:
| It does feel that way. The worst part is that enough of our
| elected officials insist we enjoy the abuse.
| throwme0827349 wrote:
| This is fine as a high level economic discussion, but I think it
| misses the point of the complaints from actually US consumers:
| when I consume healthcare as an individual I am paying with a
| blank check, and I am therefore likely to be tricked into
| consuming more health care than I would otherwise choose to
| afford, perhaps to a ruinous degree.
|
| I think ordinary consumers care much less about whether their
| country spends a nominal share of GDP on the heath sector, than
| about whether they will be unexpectedly bankrupt by consuming
| health services, and this is why people are actually mad.
| kcsavvy wrote:
| I started and sold a company in the industry, and agree that
| macro level analysis misses this. In the us healthcare as a
| "product" has an AWFUL customer experience. On so many levels.
| And the worse it gets the more people want to "burn it all
| down", despite the fact that it might not be as dire as we
| think when we do the high level analysis. Whether or not that's
| a good thing is up for debate.
| darth_avocado wrote:
| > The claim that US health care prices are inexplicably high
| was never well-evidenced
|
| I can provide anecdotal evidence that prices inexplicably high.
| A primary care physician will charge anywhere between $200-$500
| for a visit. If you have good insurance, you don't pay out of
| pocket. In the same city, I once had to go to a PCP who would
| only work without insurance. I had to wait a lot because of how
| many people were lined up in front of the office, but I paid
| $50 for the visit. I'm already paying 4-10x in a comprable
| market for the same services.
|
| When I was abroad, I had to visit a doctor's office for food
| poisoning. I paid 200 in the local currency. I could have gone
| to a hospital and they would charged me 500 in the local
| currency. But what's important to know is that the median
| monthly wages in the country were 25000 in the local currency.
| So all in all, you'd pay a smaller portion of your wages for a
| simple checkup.
|
| And that tbh is why people are actually mad.
| _DeadFred_ wrote:
| I recently had skin cancer surgery. I was offered a 20%
| discount to self pay. Because of my deductible I would have
| paid more if I used insurance than if I just paid. We are now
| to the point where it's not cost effective to use our private
| insurance for cancer surgery. How anyone is defending this
| system is crazy to me.
| BirAdam wrote:
| My wife had a kidney transplant. Two of her medicines cost
| hundreds each per month with insurance, but without
| insurance are under one hundred each for three months.
| 3D30497420 wrote:
| Agreed. I have trouble squaring an argument like that with my
| own personal experience. (I also did not read the article,
| but I get the gist from the comments, for whatever that's
| worth.)
|
| To take two ER-related examples:
|
| * In the USA, I had some brief, sharp chest pain and my
| general practitioners office refused to set an appointment
| without be going to the ER. I was quite certain it was not a
| heart attack, but I complied. I was briefly triaged and not
| admitted. I believe the bill (with very good insurance) was
| more than 2000 USD.
|
| * In Germany, my wife had an eye injury that required a trip
| to the ER. She was triaged, saw several doctors, including a
| specialist. She fortunately did not need treatment, but was
| required to check with another specialist within a few days
| to check how things were healing. There was no cost for this
| beyond our public insurance.
|
| I can cite dozens of other examples where medicines were
| free/cheap, tests or specialists were covered by default,
| elective procedures were dramatically cheaper, etc. And this
| doesn't even include several fights with US insurance
| companies over tests that were recommended by a doctor.
|
| Is the system here perfect? Certainly not, FAR from it. But
| it is a big reason why I'm not interested in moving back to
| the US.
| ninalanyon wrote:
| Is a primary care physician what we would call a family
| doctor or general practitioner (GP) in the UK? In Norway an
| employed adult will pay about 240 NOK (about 22 USD) to visit
| their family doctor (allmennlege). I'm not sure what the
| rules are for the unemployed but I'm sure they pay less,
| children (under 18s), full time students, and pregnant women
| pay nothing. Median income is about 55 kNOK/month.
|
| I don't normally have to wait unless I turn up at the surgery
| without an appointment. If the previous appointments run over
| I sometimes have to wait but rarely ore than half an hour.
| darth_avocado wrote:
| Yes a PCP is what family doctors or GPS are elsewhere.
| HDThoreaun wrote:
| The outsize portion of gdp that healthcare takes up is why it
| is likely to bankrupt you in this country, although it isnt the
| reason for the lack of transparency.
| pessimist wrote:
| This analysis in the end doesn't show what it claims to show and
| actually proves the reverse - US Health care spending _is_ much
| larger than other countries, it eats up _significant_ fraction of
| productivity gains in other sectors (rises faster than income as
| shown by the 1.8 slope in the very first graph), and _does not_
| lead to better health outcomes. It actually proves we would be
| better off if we spent less and focused on lifestyle.
| YetAnotherNick wrote:
| What was it claiming exactly that it proved to be reverse?
|
| > we would be better off if we spent less and focused on
| lifestyle.
|
| I didn't see any claim opposite of this.
| betaby wrote:
| > US Health care spending is much larger than other countries
|
| The thing is that in USA (and Canada) radiologist compensation
| went from 300k/yer to 500k/year over the last 10 yeas. It's the
| same radiologist. While spending is growing quantity of doctor
| per population is diminishing.
|
| In USA/Canada there is cartel enforced cap on how many new
| doctors can be minted per year, and this cap is not even
| scaling up with the population growth.
| nradov wrote:
| The immediate limit is a government (Medicare) funding cap on
| the number of residency (graduate medical education) program
| slots. At one time the American Medical Association lobbied
| to put that cap in place but they reversed course years ago.
| Congress still hasn't acted, and so every year there are some
| students who graduate from medical school but are unable to
| practice.
|
| https://savegme.org/
| smnrchrds wrote:
| What I could never understand is why government funding is
| needed for residency spots in the first place. From the
| outside, it seems like residents are cheap labour for
| hospitals. Even without getting any money from the
| government, the value of residents' labour should exceed
| their relatively small salary--so hospitals should be
| incentivized to hire many more residents. What are the
| economics (or regulations) of residency that make this not
| work?
| nradov wrote:
| It's tough to get an accurate sense of the economics of
| teaching hospitals. Much of the analysis comes down to
| highly subjective management accounting decisions about
| how to allocate fixed costs to various cost centers.
| Residents (especially the junior ones) require a lot of
| supervision by attending physicians, and much of that
| work isn't directly billable. The fact that those
| hospitals aren't rushing to voluntarily take on more
| residents indicates that the programs are net losers
| without government subsidies.
| programmertote wrote:
| Wife is a doctor at a Miami suburb hospital (it's
| relatively well known), so I can tell you with confidence
| that the hospitals CAN absolutely pay $64K/year salary of
| residents on their own. It's just that they are cheap and
| do the bare minimum.
|
| But yeah, AMA should stop requiring 8 years of education
| + 3 years of residency to become a garden-variety doctor.
| I can look up UpToDate, which most doctors and residents
| do, to diagnose and treat myself for most common
| illnesses IF I can purchase medication from pharmacy on
| my own.
| mullingitover wrote:
| > In USA/Canada there is cartel enforced cap on how many new
| doctors can be minted per year, and this cap is not even
| scaling up with the population growth.
|
| This. The primary purpose of the AMA is to _prevent_ doctors
| from existing and providing care, all in order to drive up
| their wealth and status.
|
| Korea has a similar problem right now, their doctors just
| flexed their power to gain the upper hand economically[1].
|
| [1] https://www.npr.org/2024/09/15/nx-s1-5113082/as-medical-
| stri...
| matheusmoreira wrote:
| You should be _very_ careful with this narrative. It
| invariably concludes that the market should be flooded with
| doctors. They are minted by medical schools, so naturally
| the mechanism to flooding the market involves opening more
| of them and dumbing down the graduation requirements.
|
| I live in a country where that exact process is happening
| right now in real time. It's not pretty. The level of
| charlatanism and straight up incompetence in this country
| is off the charts. There are people graduating medical
| school right now who don't know how to diagnose a heart
| attack, let alone treat it. And these are the people
| manning the emergency services. Because wages were driven
| down, no doctor worth his salt is gonna accept that job.
| Why work in some shithole hospital when you can be a
| dermatologist? Emergency services turned into "reassigned
| to Antartica" tier jobs only failed doctors put up with. I
| don't even want to think about the number of people who are
| dying as a result of this.
| mullingitover wrote:
| > They are minted by medical schools, so naturally the
| mechanism to flooding the market involves opening more of
| them and dumbing down the graduation requirements.
|
| Nope, in the US we have an extra filter that takes
| perfectly good med school grads and _throws away a large
| fraction_ for no good reason other than their bad luck in
| not getting into a residency program. These are people
| who passed four years of quite rigorous medical school at
| great expense, and we effectively ruin their lives (and
| create artificial health care shortages) by denying them
| careers arbitrarily. In the US it doesn 't matter if
| you're in the top 1% of the graduating class in the best
| medical school in the country: if you don't get into a
| residency program (required before you can be an MD) your
| medical career is over before it begins.
|
| Even if we did nothing but guarantee a 1-1 relationship
| between graduates of our medical schools and residency
| program seats we would have more doctors and would not be
| watering down our talent pool of doctors one iota.
| rangestransform wrote:
| On the other hand, the medical school admissions process
| in Canada has become such a pissing contest between
| people who are extraordinarily high achieving. I don't
| think the difference between someone who got a 99th
| percentile MCAT and a 95th percentile MCAT will ever make
| a difference in patient outcomes.
| naveen99 wrote:
| 10 years ago radiology residency spots were going unfilled in
| the usa. Now there aren't enough radiologists. but if chatgpt
| can do radiology in 10 years, once again residency spots will
| go unfilled or worse.
| _heimdall wrote:
| > It actually proves we would be better off if we spent less
| and focused on lifestyle.
|
| Speaking purely anecdotally, I can 100% get behind this. I live
| in a more rural area, work outside regularly, and a large
| majority of what I eat is either grown locally (without
| pesticides/herbicides) or I grow it myself. I haven't been to a
| doctor in 7 or 8 years and am in better shape, and feel better,
| than I ever have.
|
| Its amazing the difference fresh air, fresh food, and time
| working in the sun and dirt can make.
| AlexandrB wrote:
| How old are you?
|
| I work from home, sit on my ass all day, love to eat
| processed foods and _also_ haven 't been to the doctor in 7+
| years but feel great. But I'm (just) under 40.
|
| A lot of stuff doesn't catch up to you until you're older.
| _heimdall wrote:
| I'm also almost 40.
|
| It absolutely could make no difference in the long run,
| though I do know quite a few people in our age group
| (including siblings) already dealing with an assortment of
| health issues, regular doc visits, medications, etc.
| Zelphyr wrote:
| I'm 51 and I'm healthier than I was 20 years ago because I
| improved my nutrition and started moving my body on a
| regular basis. I go to the doctor about once a year for a
| physical and I actually had a provider tell me recently
| that she rarely sees someone my age as healthy as I am.
| watwut wrote:
| I mean, not being sick enough to need a doctor for 7 or 8
| years is super common for people in cities too. And rural
| living people do get diseases and injuries requiring doctors
| too.
| _heimdall wrote:
| Well that is partly why I made clear that I was just
| sharing my anecdotal experience, everyone is different and
| there is no one miracle cure.
|
| Though I would find it hard to believe that fresh air,
| fresh food, and a bit of time working outside each day
| would make anyone's health worse.
|
| Injuries and trauma care in general are absolutely a
| different story. While I am less certain about the net
| positive of many modern treatments that only treat symptoms
| and ignore root causes, modern trauma care seems to have a
| massive pile of evidence showing how beneficial it is.
| neves wrote:
| A quick reading of the summary shows a lot of debunking and just
| one item that explains the bad health of North Americans:
|
| Diminishing returns to spending and worse lifestyle factors
| explain America's mediocre health outcomes
|
| https://randomcriticalanalysis.com/why-conventional-wisdom-o...
| firejake308 wrote:
| As an armchair economist, this is my personal favorite theory.
| With one of the most obese populations in the world, I think
| it's obvious that we'll also be the most sick and we'll have to
| spend a lot to try to dig ourselves out.
| pessimizer wrote:
| How does people being fat make asthma inhalers from the 50s
| cost $70 when they're $5-$10 everywhere else in the world?
| nradov wrote:
| Which specific asthma inhalers are you referring to?
| Generic albuterol inhalers are available for $27 cash
| price, or less if you have health plan coverage.
|
| https://costplusdrugs.com/medications/albuterol-90mcg-
| inhale...
|
| Obesity obviously doesn't cause high drug costs but it is a
| risk factor for asthma. Non-obese people are less likely to
| have to spend anything on inhalers.
|
| https://www.cdc.gov/asthma/asthma_stats/asthma_obesity.htm
| cmiles74 wrote:
| The argument here is that the US will have worse health
| outcomes than another country because the people are less
| healthy. Cost of care doesn't factor into this argument.
| nickpsecurity wrote:
| I skimmed what I can while on break. What I didn't see is
| something I've heard from doctors but can't verify. It's that
| insurance companies require them to do extra procedures or have
| extra employees they don't think they need. Some who didn't take
| insurance say it keeps their cost down.
|
| One told me the insurance companies incentivize him to treat
| patients like an assembly line where cash only lets him spend one
| on one time with customers. He also might treat people for
| several things on the same bill which he claimed he'd have to
| itemize and charge separately for with insurance.
|
| So, do people here have specific examples (esp links) to support
| or refute those anecdotes? If they were true, it would mean
| insurance rules were driving much of the cost. Looking at their
| causes, my first guess would be how they respond to losses from
| both real malpractice and greed-driven lawsuits. I can't imagine
| that costs aren't impacted by this with all the lawyer ads I see
| for suing insurance companies. ;)
| cmiles74 wrote:
| Health insurance in the US is a large, complicated mess. OTOH,
| hospitals and healthcare providers are also a large,
| complicated mess. In my opinion they are somewhat codependent
| and, in many cases, fighting for the same dollars. That is, I
| suspect any dollars you save on insurance will be eaten up by
| increasing money spent on providers and vice versa.
|
| I think the author made the right choice to leave these lumped
| together. It would be interesting to see how these costs
| confound over time but would make this article even longer.
| aDyslecticCrow wrote:
| GDP per capita and other "per capita" metrics are also unreliable
| metrics for household income, as they suffer from the same issue
| as averages. This is a common trap that is done in population
| statistics, as mean and averages are always easier to calculate
| and reduce the complexity of the calculations.
|
| Large wealth inequality makes GDP per capita and average
| household spending not representative of a real-world median
| household. If healthcare costs have outpaced median income but
| kept up with mean income, that is a MASSIVE societal issue.
|
| Most of the plots and arguments in the article overlook this, so
| I don't trust the arguments much.
|
| However, it is still interesting how strong the correlations are.
| It gives some interesting insights into what goes into the cost
| of running hospitals, I suppose.
| not2b wrote:
| I notice that the terms "debt" and "bankruptcy" (and their
| variants) appear nowhere in the article.
| cryptonector wrote:
| So what? TFA is about national aggregates, not individuals.
| cryptonector wrote:
| > Health spending is determined by income
|
| Whoa. That's eye-opening. If country X spends less than country
| Y, rather than surmise that country X is more efficient with
| their healthcare spending we might want to look at whether
| country X has less per-capita income than country Y.
|
| This makes sense, though it's very surprising. I've seen so much
| commentary here about how much better the Europeans are at
| dealing with healthcare than us Americans...
| mullingitover wrote:
| You can look at the health outcomes to gauge the efficiency.
| Does the population in country X live longer? Are infant
| mortality rates higher? Preventable deaths?
|
| We know the US healthcare system is a ripoff _exactly because_
| while the spending as a percentage of GDP in the US is
| dramatically higher, the measurable outcomes are embarrassingly
| bad across the board.
| getnormality wrote:
| Why would we assume that the health of a country is mainly
| determined by its healthcare system?
|
| I think the big drivers of worse American health outcomes are
| things like obesity, car-based lifestyles, and long working
| hours, all of which have nothing to do with our healthcare
| system.
|
| The healthiest countries succeed by rarely needing their
| healthcare system because people behave in healthy ways.
| Needing the system a lot means you've already failed.
| mullingitover wrote:
| I don't think lifestyle explains our problem with infant
| mortality rates. That's something where you, first thing in
| life, depend on the health care system before you even have
| a lifestyle.
|
| In addition, yes, I think we _can_ blame obesity on (the
| lack of) healthcare. If people routinely met with a
| physician and got advice, they might be able to turn things
| around before merely being overweight becomes obesity.
|
| We're effectively in a shortage situation, and by design.
| If you don't get preventative care, that's considered a
| good thing by the healthcare system because they would
| honestly collapse if everyone got the recommended doctor
| visits. So we have people not getting preventative
| treatment and dying of preventable causes at depressingly
| high rates. This is generally considered fine, because the
| health care system is bursting at the seams with more money
| than it can count, so it's considered successful.
| getnormality wrote:
| I'm not sure the infant mortality has much of an impact
| on longevity, and while there may be things the US could
| do about obesity within the healthcare system, I doubt
| that the reason for the US-world gap is that the rest of
| the world does these things and the US doesn't.
|
| You can name things that are bad about US healthcare and
| could be improved but that's a different topic than why
| Americans are in relatively poor health compared to other
| developed countries.
| mullingitover wrote:
| > I'm not sure the infant mortality has much of an impact
| on longevity
|
| Infant mortality is a measurable performance indicator
| for the healthcare system regardless of overall
| population's longevity.
| getnormality wrote:
| There's still the same problem of disentangling the
| population health from the efficacy of the system. Maybe
| mothers are less healthy in the US and that affects
| infant mortality.
|
| Not an expert by any means, just confused by the
| complexity of it all.
| chiefalchemist wrote:
| > If people routinely met with a physician and got
| advice, they might be able to turn things around before
| merely being overweight becomes obesity.
|
| Anecdotally, two stories:
|
| - A while back, I had dinner with two friends who do
| pharma research. At the time they were working on
| treatment for T2 diabetes. Naive me asked, "Why not just
| focus on prevention?" They said it's doesn't happen. Too
| few people are willing to change.
|
| - More recently I had a conversation with a doctor at a
| social event. A similar topic came up, again I suggest
| prevention. And again I was told the same, it just
| doesn't happen.
| ninalanyon wrote:
| I'm sure these anecdotes are true. But is it true because
| this behaviour is immutable or is it because there has
| been no serious attempt to change it? For instance why
| not teach how to be healthy in primary school and in
| society generally? The US and other countries have a high
| incidence of Type 2 diabetes largely because of over
| consumption of sugar. This is a social issue. I saw this
| very clearly when I took my family to the US for three
| months many years ago and we visited one om my colleagues
| for Thanksgiving. Our host's wife was astonished when my
| children asked for a drink of water, she asked them
| several times if they would not prefer a sweet fizzy
| drink. But my children were thirsty and knew that water
| was the best remedy.
| chiefalchemist wrote:
| I'm not so sure that's the healthcare system. The USA doesn't
| do well in preventing that which is preventable.
|
| The System is only as healthy as the population it serves. In
| the USA demand is high, price naturally follows. Reduce
| demand, prices will fall.
|
| This link just happened to be what I found. I'm certain I've
| seen others.
|
| https://www.thelancet.com/journals/lanpub/article/PIIS2468-2.
| ..
| refurb wrote:
| > You can look at the health outcomes to gauge the
| efficiency. Does the population in country X live longer? Are
| infant mortality rates higher? Preventable deaths?
|
| Those aren't great metrics as they are highly confounded by
| other factors that have nothing to do with a healthcare
| system.
| avidiax wrote:
| I don't find this to be surprising.
|
| Healthcare services have inelastic demand. If you have a broken
| leg, and the average income is $X or $2X, clearly the hospital
| can charge twice as much in the second case and still mend
| legs.
|
| What is surprising is the third section:
|
| > The rising health share explained by rising quantities per
| capita (not prices!)
|
| I don't think the author really makes the point, however.
|
| They don't seem to claim that higher income people are getting
| more doctor's visits or more procedures done or taking more
| medicine (though this may all be true).
|
| Rather, they claim that the we are putting more resources into
| healthcare, a somewhat orthogonal claim.
| gcanyon wrote:
| N=1, or, Story Time!
|
| In 2017 my wife and I were living in Portugal for several months.
| When we needed to refill her prescriptions, our short-term rental
| host said, "Go to the ER."
|
| Backstory: we're well familiar with ERs in the U.S. Due to
| various conditions, we've been to at least a dozen ERs a total of
| perhaps twenty times. For anyone who doesn't know, unless you are
| actively dying, visiting the ER in the U.S. is sloooow. The
| average time to see a doctor, in our experience, is about an
| hour.
|
| So we replied: "the ER? seriously?"
|
| He assured us it would be fine, so we walked ten minutes to the
| ER and signed in. We had barely turned in the history paperwork
| when they called us to go back. No preliminary check-in with the
| nurse -- straight to the doctor.
|
| She said, "Why did you come to the ER? We could have been busy
| and you would have had to wait."
|
| We explained how our host had assured us this was the best way to
| go, and that the ER would take care of us.
|
| The doctor nodded and said, "Sure, I'll sign for the
| prescriptions, but just remember it might take more time the next
| time."
|
| We went back to the front desk. Remember, we had no travel
| insurance, this was full freight. "That will be twenty-eight
| euro." We happily paid, and walked out the door, prescriptions in
| hand, less than 30 minutes after we walked in.
|
| Bonus: the cost to buy the prescriptions, again with no
| insurance, was _less_ than the co-pay in the U.S. with employer-
| healthcare.
|
| N=2: When my daughter was visiting me in Bangkok, she got a bit
| of a gastro issue. Same as in Portugal, we had no insurance for
| her. I took her to Bumrungrad, one of the best hospitals in
| Thailand. We were in and out in under an hour, including picking
| up the prescription, and the total cost was under $100.
|
| I'm not trying to rebut the article, just throwing out some
| details.
| qup wrote:
| > visiting the ER in the U.S. is sloooow. The average time to
| see a doctor, in our experience, is about an hour.
|
| This is such a bizarre couple of statements for me. First, I
| would consider an hour very, very fast. If I show up for an
| appointment on time, I still don't see the doctor for about an
| hour.
|
| And for a non-emergency emergency room visit (even a fairly
| serious one like a broken bone, abscessed tooth, etc) I've had
| family give up after 8-12 hours of waiting in the lobby without
| being admitted to see a doctor, often in relatively empty
| lobbies. (The hospital is hoping for this, I'm sure)
| obastani wrote:
| If I'm understanding correctly, by "income", this article means
| "actual individual consumption", which is the amount of money
| spent by a household. Thus, the article is saying that for
| countries where households spend more, they spend more on
| healthcare. Given that healthcare is a huge fraction of household
| expenditures (almost 20%), this seems tautological. Am I
| misunderstanding something?
| gcanyon wrote:
| Summarized into 11 bullet points by Claude:
|
| Here's a summary of the key points from the document in 11 bullet
| points:
|
| * Health spending is primarily determined by income levels, with
| higher-income countries spending more on healthcare.
|
| * The rising health share of GDP is driven by increasing
| quantities of healthcare consumed, not primarily by price
| inflation.
|
| * Technological advancements and intensity of care are major
| drivers of increased health spending.
|
| * The U.S. health system is not uniquely inefficient; its high
| spending is consistent with its high income levels.
|
| * Commonly cited utilization indicators do not show that the U.S.
| uses less healthcare than expected given its spending.
|
| * Physician incomes and hospital profits do not explain the high
| U.S. health spending.
|
| * The U.S. healthcare workforce has grown significantly,
| reflecting increased intensity of care rather than just higher
| wages.
|
| * America's mediocre health outcomes are explained by diminishing
| returns to healthcare spending and lifestyle factors like
| obesity.
|
| * Rising healthcare spending does not mean reduced consumption in
| other areas due to productivity gains in other sectors.
|
| * Price comparisons between countries are often methodologically
| flawed and do not accurately reflect true healthcare costs.
|
| * The income elasticity of health spending is high, meaning
| people spend proportionally more on healthcare as they get
| richer.
| Angostura wrote:
| If anyone, like me was looking for the UK and the NHS on those
| graphs - it's labelled GBR (I guess), assuming that's not
| Gibralter
| bluedino wrote:
| Nothing makes sense.
|
| One prescription I get is $1.30, another is $85.
|
| My son goes to a specialist and all $395 is paid by insurance,
| while my wife goes to a different one and we pay $86 out of
| pocket after a $14 "insurance discount", insurance pays nothing.
|
| They're both in-network. I save my old antibiotics and such
| because it takes so long to get into urgent care, and it's
| expensive, and I can't go to my regular doctor for a sinus
| infection because it takes two weeks to get in.
|
| Thankfully I pay $0 out of my check for Blue Cross since my
| employer pays for it. I just have co-pays, deductibles, etc
| zahlman wrote:
| >I save my old antibiotics and such because it takes so long to
| get into urgent care, and it's expensive, and I can't go to my
| regular doctor for a sinus infection because it takes two weeks
| to get in.
|
| I cringed so much reading this.
|
| * When you're prescribed an antibiotic, you're expected to
| finish the course of medication. Not doing so leads to
| resistant strains.
|
| * Medication has an expiration date for a reason. You generally
| shouldn't expect to be able to save it from one illness to the
| next, nor to know that the one from before is applicable to the
| current condition.
|
| * The large majority of disease is caused by viruses, and
| antibiotics won't help. Your "sinus infection" might not be a
| local infection at all but just some respiratory illness
| resulting in sinus congestion. Never mind whether it's viral or
| bacterial.
| NHQ wrote:
| Healthcare became like public education in the USA, a political
| ideology that subverts the body politic to support jobs for
| people who do not have real skills but whose great granddad had
| 33 degrees in secrecy. In other words it is entirely a support
| system for the least of the privileged, while also paying huge
| sums to the owners and "providers" of those systems (textbooks,
| syringes, insurance, etc).
|
| If U.S. Americans did not have an irrational verve for education
| as the supposed panacea of democracy, there would be no public
| education system. If they did not believe the intense
| pseudoscience of the medical industry, they would not care about
| health insurance.
|
| But as they are under the sway of such false conscience, the
| system of gradual decline called inflation pays for unqualified
| people to keep a livelihood at the expense of a misled and
| deluded public. That expense is not only the costs of running
| these systems but their detriments to the health and education
| they pretend to treat.
|
| The increased spending on healthcare is no different than
| spending more on education or the "homeless problem", it is
| simply a politics of shifting more funds into systems that are
| legally obligated to pay high sums for a lot of nothing. It only
| appears different than education because we pretend its not
| completely wrapped up in public spending and politics like
| education is. Obama made sure that healthcare would hold such a
| place as education in the system with the reforms to healthcare,
| and the people applauded this.
|
| High incomes paying more for healthcare is simply those who can
| afford it using the system that ultimately pays for the health
| and education of the rich at the expense of the health and
| education of the poor. After all we know that nobody who is rich
| is paying any of their healthcare bills, they have excellent
| health insurance for that.
| efitz wrote:
| The big problem with modern health "insurance" (as opposed to
| catastrophic major medical insurance, which is true insurance),
| is that it prevents the formation of of health care businesses
| that cater to different socioeconomic strata. I most other
| businesses, there are usually product offerings at different
| price points, eg Ford Fiesta vs Ford Raptor R, bespoke
| steakhouses vs Denny's, Wal-Mart vs Nordstrom, etc.
|
| There are some hard to discover offerings in healthcare but
| overall very little differentiation.
|
| Why don't we have multiple chains of monthly subscription
| diabetes centers, for instance? If it weren't for insurance and
| over-regulation of every aspect of healthcare, we would see
| market flourishing in the US as there is an over abundance of
| chronic illness.
|
| I sympathize with the PoV that we want someone else to pay
| because it's expensive, but another way to solve that would be to
| remove all the regulatory capture and industry collusion and
| predatory middlemen (PBMs I'm talking to you) and let new
| delivery mechanisms evolve. Let supply adapt to demand.
| phil21 wrote:
| The biggest problem with modern health "insurance" is that it's
| not insurance - it's a health care plan that presents a giant
| principal agent problem throughout the entire medical system
| starting with the patient and cascading from there.
|
| I'm old enough to remember a time you could break an arm, show
| up to your primary doctor's office that day without a pre-
| scheduled appointment, and walk out with a cast on plus pain
| meds all for less than a week's take-home pay for a blue collar
| employee. This was largely due in part for the reason you were
| the one paying the bill and there was almost no overhead. Plus
| the doctors who charged absurd fees simply lost patients to the
| competition down the street.
|
| Principal agent problems are rife in modern society, starting
| with medical care. They basically remove almost all pricing
| competition from the equation.
| hammock wrote:
| What laws in the last 20 or so years have made this situation
| better or worse?
| Peteragain wrote:
| Nope. The price of something is somewhere between the cost of
| production and what the market will bear (with exceptions not
| relevant here). The well-to-do in the USA will bear high prices,
| and The State doesn't care about the rest. This is a bit of agi-
| prop for the health insurance industry. The graphs go up on the
| right: good; and down: bad. Arrrrr!!! There MIGHT be content, but
| that is not the message. And btw the "(a primer)" in the tag line
| is (according to this linguist) setting you up to think you're
| stupid if you don't get it.
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