[HN Gopher] Mapping the US healthcare system's financial flows
___________________________________________________________________
Mapping the US healthcare system's financial flows
Author : brandonb
Score : 142 points
Date : 2025-12-03 14:42 UTC (8 hours ago)
(HTM) web link (healthisotherpeople.substack.com)
(TXT) w3m dump (healthisotherpeople.substack.com)
| Taikonerd wrote:
| It's a truism that America's system was never designed -- it's a
| patchwork of different pieces that each pay for _some_ people in
| _some_ situations.
|
| But I've been reading about our system, since I fell down a
| rabbit hole a couple years ago. Things are bad, yes, but there
| are actually interesting ideas out there, and real efforts at
| reform that are being tried.
|
| For example, did you know Maryland has a different way of funding
| hospitals than most other states? [0] And that other states are
| interested in copying it?
|
| [0] https://www.vox.com/policy-and-
| politics/2020/1/22/21055118/m...
| bombcar wrote:
| A system built as a mish-mash patchwork is likely to be solved
| by a similar "ground-up" framework.
|
| Each state should be free to experiment (as Maryland has done
| here) and the federal levels should be restricted to providing
| funding and basic guidelines that have to be met.
|
| Part of the problem is that as you begin to delve in and see
| where the outflows are, you start to realize that fixing the
| fundamental problem involves making _the people_ healthier in
| general, which will rumble the very foundations of Wall Street.
| jpalawaga wrote:
| One of the great powers of federalism is not having to
| duplicate efforts for every state. It also reduces cost by
| allowing 'one-size-fits-all' and economies of scale, rather
| than each state having its own bespoke whatever.
|
| Many countries around the world enjoy the benefits of
| coordinated public health departments. Part of the United
| States' poor response to COVID was because there was no
| central public health department that could work closely with
| state agencies to e.g. provide data about what's going on,
| share best clinical practices, etc. Each state is an island.
|
| So no, I don't agree that the only goal of the federal
| government should be piggy bank. States should have a lot of
| latitude with their policies, but generally standardizing
| things across the nation would be a net positive.
| stronglikedan wrote:
| > rather than each state having its own bespoke whatever
|
| that's states' rights and it's enshrined in the
| constitution
|
| > the only goal of the federal government should be piggy
| bank
|
| that is indeed the only goal that the founders had in mind,
| as it should be
| bombcar wrote:
| Many countries around the world are the size of US States.
| The UK and Germany are only twice the size of California,
| for example.
|
| The problem in the US isn't that we can't _do_ things, it
| 's that nobody can _agree_ on what to do. And to solve that
| problem, let states do their own thing as much as we can,
| and it 'll become obvious where the good systems are.
|
| Or in other words, an argument needs to be made why the EU
| "works" with individual "states" doing their own thing, but
| the US cannot "work" unless it's considered as one large
| country.
| rwj wrote:
| This analogy is quite misleading, because, in addition to
| California, there is also Wyoming, with a population of
| less than <600k.
| emchammer wrote:
| Scalia was right in saying that the checks and balances
| slowing things down is a feature, not a bug. The Framers
| were right about protections against faction. I'm not
| sure they understood how badly malicious schemers could
| deliberately manipulate the system. Things just aren't
| getting done, and it is killing people.
| psunavy03 wrote:
| Half of the problem with American politics these days is
| people from blue and red states trying to force the
| entire country to become one giant blue state or one
| giant red state.
|
| It's too big for one-size-fits-all answers. Every state
| should be able to largely do its own thing as long as it
| isn't violating the Bill of Rights.
| matthewdgreen wrote:
| If you look at some of the more controversial bills being
| passed in the states, they're also being more or less
| lifted out of national political action committees and
| think tanks. Extreme in-state gerrymandering (supported
| by national party organizations) has effectively
| nationalized big parts of state politics in those states.
| psunavy03 wrote:
| I've spent the majority of my adult life in Washington
| State and I've witnessed this firsthand. This place used
| to have a unique vibe that was more purplish-blue
| "granola hippies with guns that just want to be left
| alone." Progressivism mixed with an Old West libertarian
| streak. There was a GOP minority, and the red east and
| blue west played off against each other and kept things
| reasonably center-left.
|
| Now it's a one-party state, and the legislature might as
| well be the state Parliament, taking its marching orders
| straight from the DNC. The Governor is just as all-in on
| drinking the blue Kool-aid, and the state Supreme Court
| seems like it only exists to validate what the other two
| branches decide. And looking at places like Texas and
| Florida, seems like the same is happening on the other
| side of the aisle.
|
| What's infuriating is there are conservatives in blue
| states and liberals in red states getting just
| steamrolled to the point of "why should I even vote or
| participate, when I'm just going to get told to sit down
| and shut up?" That's not healthy for democracy. The
| rights of the minority exist for a reason and you can't
| just vote things away because you have 50.01 percent of
| the vote.
| Taikonerd wrote:
| Yeah, it seems very unfair. If Party A has 60% of the
| seats in the state legislature, and Party B has 40%, then
| intuitively it feels like Party A should get 60% of what
| it wants. But as you said, Party A actually gets more
| like 100% of what it wants.
|
| This is a thing where having _more parties_ would really
| help. If there were (say) 4 parties, each with ~25% of
| the seats, then they would have to bargain with each
| other and form coalitions, which I think would be a
| really healthy process for democracy.
| AnthonyMouse wrote:
| > This is a thing where having _more parties_ would
| really help.
|
| Using a "first past the post" voting system structurally
| results in a two party system, because if there are more
| than two viable parties then the two parties most similar
| to each other split the vote and both lose to the third,
| which gives the first two an overwhelming incentive to
| merge with each other.
|
| Score voting or STAR voting fixes this and allows you to
| have multiple parties. (Avoid IRV or similar systems,
| nearly anything is better than FPTP but if you're going
| to do it at all then do it properly.) Any states that
| could enact this via referendum are encouraged to do so.
| goler wrote:
| Sure, but fighting the impulse to solve problems at the
| Federal level that could/should be solved at the State
| level doesn't preclude individual states from building
| multi-state solutions together.
| bombcar wrote:
| More of these exist than people realize - and are a great
| way to "latch on" to the success of another program.
| JumpCrisscross wrote:
| > _analogy is quite misleading, because, in addition to
| California, there is also Wyoming, with a population of
| less than <600k_
|
| Wyoming has the population of Malta [1][2] but the
| GDP/capita of the United States and Norway [3][4]. It
| should be expected we'd have a different optimal solution
| from California.
|
| [1] https://en.wikipedia.org/wiki/Wyoming _588,000 in
| 2024_
|
| [2] https://www.worldometers.info/world-
| population/population-by... _545,000_
|
| [3] https://en.wikipedia.org/wiki/List_of_U.S._states_and
| _territ... _$90,000 in 2024_
|
| [4] https://en.wikipedia.org/wiki/List_of_countries_by_GD
| P_(nomi... _$90,000 and $92,000, respectively_
| JBlue42 wrote:
| It's the general knee-jerk reaction that's brought out
| whenever people try and have modern ideas for the US,
| like modern healthcare or high-speed rail. "B-but, it's
| so big!"
| Taikonerd wrote:
| > _there was no central public health department_
|
| If only we had some sort of federal Center in charge of
| Disease Control... ;-)
|
| But I agree with you that the CDC was weirdly passive
| during COVID. You'd think it would have been their moment
| to shine.
| ambicapter wrote:
| From what I remember, there was a LOT of resistance to
| whatever the CDC said during Covid. Kind of a defining
| characteristic of that time period.
| giantg2 wrote:
| "Many countries around the world enjoy the benefits of
| coordinated public health departments."
|
| Many countries around the world are the size of a single
| state and lack the geographic diversity of the US.
| triceratops wrote:
| You said
|
| > generally standardizing things across the nation would be
| a net positive.
|
| The person you replied to said
|
| > federal... should be restricted to providing...basic
| guidelines that have to be met
|
| You may be closer in opinion than you realize.
|
| Btw what the person you responded to described is how the
| Canadian healthcare system - which many liberal-type
| Americans on Reddit appear to admire - works. The federal
| government sets standards and provides some funding. The
| provinces implement it their own way.
| bombcar wrote:
| Exactly - the key is to have _very high-level and
| outcome-driven guidelines_ and not trying to micromanage
| everything; that allows various methods to be tried, and
| the best ones will start to be emulated.
|
| (Another underlying reality is that the vast majority of
| people will say education and healthcare are "very
| important" but very few people will _move_ to improve
| either of those - beyond going out of state for college.)
| triceratops wrote:
| > very few people will move to improve [education]
|
| This is empirically false. People move to better school
| districts or enroll their children in private schools all
| the time. It doesn't require moving to a different state.
| potato3732842 wrote:
| >One of the great powers of federalism is not having to
| duplicate efforts for every state. It also reduces cost by
| allowing 'one-size-fits-all' and economies of scale, rather
| than each state having its own bespoke whatever.
|
| One of the great failings caused by federalism and those
| who simp for it is that when a bad solution is arrived upon
| or a solution becomes outdated immeasurable suffering is
| caused and prolonged by not letting those states who want
| to try and improve do so.
|
| There were a dozen states who were on the precipice of
| having this solved before the feds stuck their dick in it.
| Remember Romneycare?
| bryanlarsen wrote:
| There's a massively underused middle ground -- instead of 1
| or 50 different systems we could have a small N. One
| example would be emissions standards, where N is basically
| 2 -- the federal standard and the California standard, with
| some states choosing to use the California standard instead
| of the federal standard. This happens because that's their
| only 2 choices because of weird historical events, but
| imagine it happening by deliberate choice where the other
| states co-operate more with California in setting the more
| restrictive standard. States should be co-operating more
| often.
| Taikonerd wrote:
| I really like this idea. And it lets ideas grow more
| organically: instead of a promising pilot program in
| (say) Maryland which then tries to go national, there can
| be a club which grows gradually. Another state joins the
| club in 2026, then another two in 2027, then...
| nneonneo wrote:
| Canada's public healthcare system was started in
| Saskatchewan, one of the provinces, and rapidly copied to
| other provinces (and later to a federal level):
| https://www.cma.ca/healthcare-for-real/who-started-
| canadas-u...
|
| If one state can manage to make it actually work, it might be
| enough.
| doctorpangloss wrote:
| There are already numerous and simple policy levers that
| actually affect costs and cannot be gamed. Such as the age you
| become eligible for Medicare. You don't have to reach for
| anything innovative like global hospital budgets. I'm skeptical
| of your category of reforms - you really mean, "benign-looking
| administrative decisions," because if you're not making any
| hard choices, you're not making reforms. I would hardly call it
| "real efforts."
| almosthere wrote:
| So it's a jobs program
| silisili wrote:
| Not all of it, but definitely the insurance part of it IMO.
|
| It's hard to get an actual number, but many say nearly 1
| million people work in health insurance in the US. And I'm not
| sure that even counts the people whose job it is to interface
| with them. That's a ton of jobs(and salaries) that likely
| wouldn't even exist in a sane system.
| IAmBroom wrote:
| > It's hard to get an actual number
|
| It's tracked by the Dept of Labor.
| silisili wrote:
| It is, but under "life, medical, and health" insurance, and
| only based on the employer not function. Any contractor
| like say, maintenance, janitorial, cafeteria, etc for the
| building would not be counted. People who work at hospitals
| doing nothing but insurance related work would also not be
| counted. That makes it hard to say definitively how many
| jobs would actually be affected, in my opinion.
| MarkusWandel wrote:
| All the categories on the right side look perfectly reasonable.
| However what fraction of those big categories on the right,
| Hospitals and Physicians... that make up over half of the total,
| is siphoned off to pay for administratium or "shareholder value"
| and what fraction actually pays for medical care delivered?
| programmertote wrote:
| I'd really love to see the breakdown between how much we spend
| on physicians/doctors vs. caretakers (nurses, therapists, etc.)
| vs. how much on hospital admin and other stuff.
|
| At least in UK's chart, "GP & Primary Care", "Private GP
| Services" and "Administration" are separated. Same in Germany
| too.
| Retric wrote:
| If by shareholder value you include insurance companies etc not
| just the institutions themselves, it's well over half.
|
| Doctor time talking to an insurance company either directly or
| through paperwork is not actually providing any care during
| that time. Where things go vicious is because doctors are now
| so inefficient the time they are actually useful becomes
| increasingly valuable driving ever more paperwork to justify
| that time.
| nradov wrote:
| Physicians spend very little time directly dealing with
| insurance companies. They (or their employers) hire back
| office administrative staff for that. This is somewhat
| wasteful and inefficient but it doesn't directly impact the
| time that clinicians have available for patient care. Usually
| the physicians only have to get directly involved in rare
| peer-to-peer consults with health plans for complex cases
| that fall outside of normal clinical practice guidelines.
| Retric wrote:
| It's the indirect time that's most at issue here, a friend
| of mine is happy to take a significant pay cut and work at
| the VA to avoid the hassle. It's a government institution
| and he still feels way more productive and less stressed.
|
| In private practice a physician now needs to handle extra
| employee(s), there's often a range of software system
| issues etc. Even in a hospital setting where other people
| are handling most of this stuff that's a long way from zero
| friction.
|
| The insidious issue is even a 1% drop on doctor efficiency
| gets magnified by everyone taking a cut of the transaction.
| IAmBroom wrote:
| Yes, the diagrams are deeply flawed, in that they seem to
| suggest 100% of the money input to the system goes to
| hospitals, hospices, healthworkers, and so on.
|
| I don't see a single outcome pointed at insurance companies...
| somehow.
| yannyu wrote:
| The article takes this on a couple times:
|
| > The outcome is $4.9T - which would make it the 3rd largest
| economy in the world, a high 8% admin costs - compared to the
| UK's 2% admin, with medical bankruptcy still possible. We've
| never agreed on what we value. So we built a system that
| embodies our disagreement: employer-based coverage (market
| choice) plus Medicare (social insurance) plus Medicaid
| (safety net) plus exchanges (regulated markets).
|
| > Decision #1: Workers pay at least twice
|
| Here's the first thing that jumps out: if you work a job in
| America (and you presumably do, to afford the internet where
| you're reading this), you're already paying for healthcare in
| multiple places on this chart: Taxes:
| federal, state, and local taxes finance Medicare, Medicaid,
| and various public health programs in so many places. Our
| attempt at embedding it in single payer.
| Payroll: if you're employed, your employer pays taxes on
| Medicare (even though you presumably can't use it until you
| retire at 65). This is a cost that doesn't go to your salary.
| Insurance premiums: get deducted from your paycheck to fund
| the employer group plans ($688B from employees alone).
|
| > Could America make this choice? Technically, yes.
| Politically, we'd need to agree that healthcare is a right we
| owe each other, funded collectively through taxes. That would
| mean massive tax increases, eliminating private insurance as
| the primary system, and trusting a single federal agency.
|
| The operational resistance alone would be too much: I've
| watched hospital execs squeeze out thinning margins and payer
| executives navigate quarterly earnings calls. We're talking
| about unwinding a $1T+ private insurance industry,
| reconfiguring every hospital's revenue model, and convincing
| Americans to trust the federal government with something they
| currently (sort of) get through their jobs. That ship didn't
| just sail - it sank decades ago.
| bombcar wrote:
| We've unwound industries before - if we have the political
| will we can do amazing things.
|
| But the people _in_ and _using_ those industries have no
| desire to change so anything that does happen is likely to
| occur slowly from expansion - e.g, bringing Medicare to
| earlier and more people, and expand children coverage, etc.
| yannyu wrote:
| I think there's some significant evidence that "users" of
| the private healthcare industry are actually quite
| unhappy about it. Due to some structural quirks of the
| US, it seems like it's less about how many people are
| happy or unhappy and more about how many dollars are
| spent in favor or opposition of a change.
| hibikir wrote:
| Those are probably the easiest levels for simplification,
| but I'd expect significant pushback anyway. Something
| like start medicare at 55 would be a huge difference to
| most providers, just due to changes in reimbursement.
| bombcar wrote:
| There's always pushback - the key is to identify who will
| push back, what their motivations are, and if you can do
| something to "disarm" them.
| velcrovan wrote:
| Amazing, every single dollar goes to care! Not a single dollar to
| overhead! Where are these insurance companies' profit margins
| coming from? How do they even pay their executives' salaries? Boy
| have I been mistaken about how inefficient the American system is
| asmodeuslucifer wrote:
| Beat me to it. This chart is only 1/2 complete. It doesn't show
| where the money goes after hospital care, for instance.
| harvey9 wrote:
| Do you mean the breakdown of staff wages, equipment and so
| on?
| gwbas1c wrote:
| > How do they even pay their executives' salaries?
|
| I suspect less goes to executives than you think. Most of it is
| going to pay employees in the insurance industry.
|
| The irony is that they are being paid to say "no." Perhaps if
| they instead went to work as service providers, we could get
| more services for what we spend.
| dangus wrote:
| Healthcare executive pay is pretty darn high, more money than
| any family needs to live comfortably.
|
| Keep in mind this is just for Blue Shield California. There
| are executives of other health insurance systems in other
| states and regions who are making similar compensation.
|
| However, I'll go ahead and say right now that I support the
| idea of these executives being paid these salaries, but on
| one condition: that we first achieve the goal of 100% of
| Americans having affordable access to healthcare. Once that
| goal is achieved, then we can start paying executives big
| bonuses and incentives. Deal? (Yeah, right...)
|
| https://www.blueshieldca.com/content/dam/bsca/en/member/docs.
| ..
|
| Below is a summary of the compensation paid in 2024 to Blue
| Shield of California's President and Chief Executive Officer
| (CEO), Chief Financial Officer (CFO), and top three highest
| paid executives (other than the CEO and CFO) who were
| employed by Blue Shield of California at year-end.
|
| Paul Markovich
|
| President and Chief Executive Officer
|
| $11,191,674
|
| Sandra Clarke
|
| EVP, Chief Operating Officer
|
| $5,765,368
|
| Peter Long
|
| EVP, Strategy and Health Solutions
|
| $4,360,245
|
| Lisa Davis
|
| EVP, Chief Information Officer
|
| $2,873,613
|
| Michael Stuart
|
| EVP, Chief Financial Officer
|
| $2,406,837
|
| Some other CEOs:
|
| Cerner (EMR provider to the VA), $35 million pay package:
| https://kffhealthnews.org/morning-breakout/cerner-to-pay-
| new...
|
| Pfizer, $24.6M pay package:
| https://www.fiercepharma.com/pharma/rebound-year-pfizer-
| ceo-...
|
| Epic Systems is a private company, so there's no executive
| pay information, but the founder Judy Falkner's estimated net
| worth is $7.8 billion. Perhaps Epic could reduce the price of
| its _very expensive_ software for providers to help ease
| healthcare costs and maybe Judy could give up some of those
| billions and not notice any difference in her quality of
| life?
| wmfiv wrote:
| BCBS CA revenue is approximately $25B. The total of above
| is $25.6M. That's 0.1%.
|
| You may view those salaries as appropriate for leading
| companies of this size or immoral and outrageous. But
| either way executive comp is not the big problem with US
| healthcare costs.
| dangus wrote:
| $14,570 per person is our healthcare cost per capita.
|
| For one thing, cutting out even that tiny 0.1%, that's a
| savings of $15 a year if I wasn't paying my insurance
| company's CEO. I would absolutely love to keep that $15.
| The idea that more than one dollar every single month
| from every single person is going to the CEOs of all our
| healthcare services is actually INSANE when you think
| about it.
|
| 0.1% is actually a LOW amount for some entities in the
| system. For example, the Cleveland Clinic spends 0.4% of
| revenue on executive compensation: https://projects.propu
| blica.org/nonprofits/organizations/340...
|
| That really means that out of my $14,570 yearly
| healthcare cost I could be paying something like $5/month
| just on executive salary. Who knows, maybe it's even
| more!
|
| This is, again, insane. Why do Cleveland Clinic
| executives need to be paid $30 million/year?
|
| This isn't administrative cost, like all the hard-working
| people who do the clerical work that keeps these systems
| operating. This is _just_ the salaries of an extremely
| small group of people, less than 10 people per company.
|
| All of these entities are allowed to make excess profit
| and/or have loose definitions of non-profit status, and
| pay CEOs dozens to hundreds of times the salary of their
| lowest paid employees. There isn't really a limit to the
| amount they can compensate top executives.
| systemtest wrote:
| > Why do Cleveland Clinic executives need to be paid $30
| million/year?
|
| So they can hire bodyguards?
| SpicyLemonZest wrote:
| Blue Shield of California has 4.5 million plan members, so
| all of these executive salaries combined add up to 49 cents
| per member per month. It's not a significant factor in
| premium costs.
| dangus wrote:
| I think that's highly significant. Keep in mind that
| that's only one provider in the system. You've also got
| to pay the executive salaries of your hospital system,
| your pharmacy chain, your drug company, medical equipment
| company, etc.
|
| If we figure that every company involved in your
| $15k/year healthcare cost is paying 0.1-0.5% of their
| revenue to executive compensation (Cleveland Clinic as a
| random example pays 0.4% of revenue to the executives,
| $30 million) then we are talking about a small streaming
| video subscription worth of cost just which is allocated
| not on paying a productive group of administrators to
| keep the lights on, but instead paying excess incentives
| to an extremely small group of people.
|
| In reality, if CEO compensation was capped to something
| reasonable like $500,000/year or 10x the pay of the
| lowest paid employee, there would still be CEOs and the
| quality of CEOs would not decline because it would still
| be the highest paid job on the market. Everyone involved
| in our economy would be just that much richer if the
| wealth wasn't getting unnecessarily concentrated.
| SpicyLemonZest wrote:
| $500,000 is a lot of money, I don't want to minimize
| that, but it would not be the highest paid job on the
| market. There's a number of roles in medicine, law,
| finance, and nowadays software that pay more for fewer
| managerial duties. There really isn't much room to argue
| for cutting executive pay without arguing that it's
| unimportant to get the best people in executive roles.
|
| And that's an argument you can certainly have, but it
| seems strange to make it a precondition to fixing the
| healthcare system, when cutting executive pay would
| resolve only a small fraction of the problem.
| _DeadFred_ wrote:
| Sweet. Let's charge 49 cents per million dollars of
| unrealized capital gains per month, it's not significant
| and less of a burden than 49 cents per month for
| healthcare.
| SpicyLemonZest wrote:
| I don't understand what connection you're trying to draw
| here. Why would we set the rate for a new tax based on
| the per-subscriber compensation of Blue Shield
| California's executives?
| adolph wrote:
| > Let's charge 49 cents per million dollars of unrealized
| capital gains per month
|
| Uh, Blue Shield of California is a nonprofit mutual
| benefit corporation. There are no "unrealized capital
| gains."
| quantumwoke wrote:
| I think this summary is reductive, because it ignores the
| surprisingly dense layers of middle management in hospitals
| and clinics that are paid more than the medical
| professionals (and even that ignores external middle
| managers like PBMs etc).
| amanaplanacanal wrote:
| One thing to note: blue shield of California is a non-
| profit. So no money is going to shareholders.
| philipallstar wrote:
| There's no point using this issue to gossip about these
| people's salaries. Their salaries don't scale, and so don't
| matter. Scaling costs matter.
| IncreasePosts wrote:
| That's pretty pathetic pay when we have run of the mill
| employees(ie non-founders) like Sundar and Satya becoming
| billionaires from their pay packages.
| HDThoreaun wrote:
| Absolutely not. Over use of service is already one of the
| bigger problems in US healthcare. We need more death panels,
| not less.
| ch4s3 wrote:
| I'm loathe to agree here, but you are highlighting a point
| that people miss about other OECD countries. Many very
| expensive treatments available in the US are covered by
| insurance (to a point) but are simply unavailable in the
| UK, Japan, or France. In the US a tremendous amount of
| money is spent to extend lives by a few scant months at a
| very low quality of life.
| HDThoreaun wrote:
| End of life is the biggest problem with over use but it's
| not limited to that. In the US literally everyone who
| shows up at the emergency room talking about chest pain
| gets an expensive ct scan even if theres effectively no
| chance of it catching anything. Procedures that have been
| shown in studies to not work are still prescribed,
| because why not/lobbying groups of the doctors that
| perform them whine loudly enough. At no point is anyone
| in the system trying to save money, so costs just grow
| and grow and grow.
|
| I think about the fact that everyone in the hospital gets
| a private room a lot. Having a private room does not
| increase health outcomes at all, but it costs an absolute
| ton of money. It does increase satisfaction so it should
| be available, but hospital users should be able to choose
| shared rooms and get a portion of the savings they create
| but this just isnt possible in the US because of the
| incentives we've created.
| redmattred wrote:
| > Where are these insurance companies' profit margins coming
| from?
|
| Vertical integration.
|
| UnitedHealthcare's (Larger insurance company in the US) profits
| are effectively limited by the Medical Loss Ratio rules from
| the Affordable Care Act.
|
| But they are owned by UnitedHealth Group, which also owns
| OptumHealth (the largest network of physicians in the US),
| OptumRx (pharmacies), and OptumInsight (technology consulting,
| which goes into the COGS for UnitedHealthcare). This is where
| they make their profits.
|
| UHG controls which physicians + pharmacies are in their network
| and what their negotiated rates for many services are (the
| exception being medicare + medicaid).
|
| Here's a write up on their strategy:
| https://www.unionhealthcareinsight.com/post/unitedhealth-gro...
|
| And an infographic that breaks it down:
| https://static.wixstatic.com/media/be1b8b_b0d4ebb04ce04b44a3...
| riku_iki wrote:
| > Amazing, every single dollar goes to care! Not a single
| dollar to overhead! Where are these insurance companies' profit
| margins coming from?
|
| they kinda have it on chart but without overhead numbers:
| insurance collects 1T of payments, than for business segments,
| they pay around 60% of that as medical expenses, and for
| individual plans it is more like 40% of medical expenses,
| meaning for individual plans insurance corps have 60% profit
| margin.
| IAmBroom wrote:
| "A Fairytale Map of Every Dollar of America's $5T Healthcare
| System" is the complete, accurate title.
|
| Is this funded by an insurance company?
| Thrymr wrote:
| The author calls himself a "Real Estate Novelist and recovering
| healthcare consultant" (https://substack.com/@andrewtsang).
| IAmBroom wrote:
| Ah, so it's fiction?
| SoftTalker wrote:
| Did he ever have time for a wife?
| nycticorax wrote:
| It would help if you would say what exactly you think is wrong
| with it.
| bombcar wrote:
| Here's an idea. If other countries can provide healthcare for
| much less per patient, _why can 't they sell that to Americans_?
|
| In other words, allow US citizens to "opt out" of the US
| healthcare system and participate in the German one? You'd have
| to make some allowances for replacing taxes with costs, billing,
| and allow "German" healthcare to operate in the US ...
| watwut wrote:
| Healthcare insurance works when everyone including currently
| healthy people participate. What would happen is only Americans
| needing an expensive healthcare signing in.
| piva00 wrote:
| The systems are so different there's no product to sell, it's a
| whole system of healthcare that permeates through society...
| You can't sell a national-level system of healthcare as a
| product, it's done through policy.
| systemtest wrote:
| I don't think US doctors will want to work for German pay.
| bombcar wrote:
| That's why you let German doctors work for German++ pay ;).
| conception wrote:
| Resident salary: approx. EUR 60,000 - 75,000 Specialist
| salary: approx. 75,000 EUR - 98,000 Senior physician salary:
| approx. EUR 90,000 - EUR 150,000 Chief physician salary:
| approx. EUR 150,000 - EUR 370,000
|
| Seems fine? Especially if you subtract a substantial amount
| of benefits fringe.
| sxg wrote:
| Are you comparing residents to specialists? They're not at
| all comparable. Residents in the US are typically within
| 3-7 years of graduating med school and are not able to
| practice independently. Specialists have typically finished
| 6-9 years of training after graduating medical school and
| are independent practitioners.
|
| Source: am a US physician.
| selectodude wrote:
| Sure it's fine. It's also a significant pay cut for almost
| every American doctor.
|
| Normal specialists in the US out-earn chief physicians in
| Germany by hundreds of thousands of dollars. All the fringe
| benefits in the world aren't gonna buy you a new boat.
| rr808 wrote:
| US doctors earn that every 12 weeks.
| 91bananas wrote:
| Time for a change.
| IAmBroom wrote:
| "Seems fine?" isn't a very solid argument.
| HDThoreaun wrote:
| doctors in the US would strike if you tried to force these
| wages on them
| hibikir wrote:
| Basically every bit of the current system, from how much people
| are paid to how a hospital looks like, is a side effect of the
| way we pay for healthcare, and the way we decide which provider
| to select. So we cannot just wave a magic wand and get the
| German system, as a whole lot of capital decisions are now just
| straight out wrong.
|
| We see similar things in education. People wonder how many
| European systems are cheaper than US universities: Well, it's
| very easy to see once you attend a university in Spain and then
| one in the US. The shape of the university, from facilities to
| salaries to class sizes, make them look like completely
| different organisms, even though 18 year olds come in from one
| side and come out with degrees in the other. And note that this
| is also connected to healthcare: How many doctors do we train,
| or bring in from other countries? How many years do they spend
| training, and how much debt do they incur getting training? How
| much are they going to ask in pay just to handle that debt?
|
| Changing the US system is a very good idea, but the changes
| would be very traumatic to most people working for the system,
| or invested in the system. All of them would lobby against
| changes that make their lives worse, and therefore makes
| legislature that makes the change happen very difficult to
| pass.
| jimt1234 wrote:
| The healthcare system in the US is, indeed, the best...if you're
| rich. If you're _not_ rich, you 're gonna spend a lot of time on
| the phone, arguing with bureaucrats and getting treated like
| shit.
|
| A friend of mine is rich. We both have a health insurance plan
| from UnitedHealthcare. His experience is radically different from
| mine. He can make a phone call, and actually talk to his doctor
| within a few minutes. He can see his doctor the same day he asks
| to. He talks to one person who manages all the BS for him.
| systemtest wrote:
| > If you're not rich, you're gonna spend a lot of time on the
| phone, arguing with bureaucrats and getting treated like shit
|
| Sounds a lot like the Spanish healthcare system.
| IAmBroom wrote:
| > The healthcare system in the US is, indeed, the best...if
| you're rich.
|
| Actually, the data doesn't even support that notion for the
| rich. But then, they can opt to fly to a specialist...
| dbg31415 wrote:
| Where are salaries? Where are administration overhead? Where are
| insurance company profits and dividends coming from?
|
| This whole thing loses all credibility by not listing those
| things.
| jimt1234 wrote:
| If we're gonna stick with private insurance in the US, we should
| detach it from employment. The current system has created a
| society of indentured servants, not for money, but for "health
| insurance". The current system is expensive for employers that
| are often mandated to provide health insurance plans. And it
| forces people to work for something they have little or no
| control over.
|
| When you work for money, you can do whatever you want with the
| money once you've earned it. But being compensated with "health
| insurance", you've got almost no control over it; you get what
| the company gives you - and btw, you can't purchase the same
| thing on your own, with your own money (way too expensive for
| most middle-class folks).
|
| Detach health insurance from employment. Open "health insurance
| plans" to the free market, just like auto insurance. Free
| employers from all the administrative overhead of managing health
| insurance for employees (the stock market will love it!) And let
| health insurance companies work for their actual customers
| (health care patients!)
|
| Or, just open Medicare to all.
| srameshc wrote:
| One of the best explanations I have ever read about American
| Healthcare. Even after such good infographic it is still hard to
| comprehend such complexity.
|
| > The $441B in prescription drugs - the story of incentivizing
| American innovation over price controls.
|
| This itself speaks for how messedup the entire design is.
| lvl155 wrote:
| It actually doesn't incentivize innovation. That's the biggest
| scam in healthcare. If it actually led to innovations and
| notable uptick in quality, other countries would have done the
| same. The whole argument is so flawed it makes my brain hurt.
| srameshc wrote:
| I think the author seems to be using sarcasm when he said
| innovation.
| nradov wrote:
| How is the argument flawed? On average the USA has more
| innovation than any other major country in pharmaceuticals in
| terms of new drugs per capita per year.
| daft_pink wrote:
| I wish they had this per capita in each country, so we could
| compare them.
| jmpman wrote:
| I'm concerned with anyone proposing "Medicare for all" in
| America, because they all state - for doctors who want to stay
| out of the system, they can be paid directly... that immediately
| causes a slightly different 2 tier system. Right now our 2 tier
| system is the 90% with health insurance and the 10% without
| health insurance. In the new Medicare for all, it will be the
| 99.9% on government insurance, and the 0.1% - the ultra wealthy -
| who dominate tax policy and are heavily financially incentivized
| to reduce their tax contributions to the public system. They will
| influence politicians to spend less on healthcare, with no impact
| to their health outcomes. The only system which will work in the
| US is one in which the ultra wealthy have an incentive to provide
| funding to the public system, and that seems like you'd need to
| force them to be on the public system too.
| PieTime wrote:
| This is precisely what allows for the NHS to be cannibalized.
| They underfunded one of the best systems of healthcare and
| replaced it with private care for ultra wealthy while reducing
| quality of care for vast majority of people.
| harvey9 wrote:
| Private care has been available in Britain throughout the
| history of the NHS and is available to people far below the
| 'ultra wealthy' strata. Don't ruin a valid point with
| hyperbole.
| cj wrote:
| > The only system which will work in the US is one in which the
| ultra wealthy have an incentive to provide funding to the
| public system, and that seems like you'd need to force them to
| be on the public system too.
|
| In my state, I pay $15k/year in school taxes, yet I have no
| children. I pay $1000/year in property taxes to support my
| city's library, yet I don't have a library card. People are
| taxed for lots of things they don't actually benefit from. I
| don't think we would need to force rich people to use the
| plans. If they want to buy medical services from private
| doctors, sure we can let them.
|
| The issue then becomes more about allocation of resources (how
| many doctors are available to be seen on the public system vs.
| only available to self-pay customers) rather than the issue
| being about how to collect taxes.
| teachrdan wrote:
| This may be small potatoes, but I've heard it said that
| people like you benefit "by not living in a state full of
| dumbasses." There's definitely an indirect benefit from these
| payments.
| cj wrote:
| Exactly, same with health insurance! I'm less likely to get
| sick if everyone around me has access to doctors when they
| get sick.
|
| (I personally don't mind subsidizing my library + local
| school district... good schools and libraries are good for
| the community)
| smileysteve wrote:
| Not only are you less likely to get sick,
|
| You're less likely to see sick people.
|
| Healthy people are more productive (you'll have better
| businesses)
|
| Healthy people are nicer (especially if we consider
| mental health, and then violence)
|
| Healthy people use the ER less.
| nradov wrote:
| Be careful what you wish for. Having health insurance
| doesn't equate to having access to care. Especially in
| the mental health space, fewer and fewer providers will
| even accept new patients on government-sponsored health
| plans due to low rates.
|
| https://www.wsj.com/health/healthcare/medicaid-insurers-
| doct...
| folkhack wrote:
| > (I personally don't mind subsidizing my library + local
| school district... good schools and libraries are good
| for the community)
|
| Just sharing random coffee break thoughts... it always
| blows my mind is how many people _don't_ think like this.
| When base conditions improve for society, the conditions
| improve for _everyone_ regardless if they directly
| benefit you.
|
| I'm also in the boat where I don't have kids, but I'd
| also like to live in a place that has educated people -
| so schools make perfect sense to me. Heck, even if I
| didn't benefit from it, providing children education is
| just the gosh-darn right thing to do.
| themanmaran wrote:
| > how many people _don't_ think like this
|
| It's just lack of trust. It's not that people want a
| worse community, it's that they have a hard time
| believing that taking extra money from their paycheck
| will create a better community.
|
| Part of it is real; seeing massive amounts of state/local
| government waste and corruption makes it feel safer to
| keep your extra dollars instead of giving them away.
|
| Part of it is difficulty evaluating timelines; more tax
| dollars for a better elementary school to be built in 3
| years and to yield higher educated people 18 years from
| now it a lot to bet on.
| mef wrote:
| IMO it's because there's both benefit and
| waste/corruption in these kinds of social benefit
| structures. some people choose to only see one or the
| other:
|
| "these benefit everyone including those who don't use
| them directly! how could you be against it?"
|
| "this money that I'm having to pay is either overpaid to
| corrupt vendors, or just straight wasted, why would we
| ever want to increase how much we're paying into this
| system?"
|
| in reality you can't have one without the other. it's up
| to each person to decide whether they can take the bad
| with the good
| Projectiboga wrote:
| Yes, universal health will start saving money even during
| the first transition year. We spend almost 1/3 or more of
| those total health dollars on billing administration.
| That amount surpasses the uninsured number. And the
| reality is if we can get medical care during the daytime,
| eventually emergency rooms might get less hectic. My hope
| is that more days than not ER personell have to pass the
| time like at a Firehouse.
| charcircuit wrote:
| That would require that the more tax money the school
| system gets the smarter the students will be. Every time I
| see a bill for increasing school taxes their justification
| is not for improving education quality, but for some other
| pet project they want to do.
| 0ckpuppet wrote:
| you can either build good schools or good jails, so
| contributing to your schools is contributing to your town
| infrastructure.
| cwmoore wrote:
| There are no good jails.
| sharts wrote:
| School is jail
| cwmoore wrote:
| So is some healthcare.
| apercu wrote:
| Every western country that has a single payer system as far as
| I know allows for private clinics, doctors and labs.
|
| I spent 18 years in Canada. The healthcare I got was as good as
| anything I received in America (in both cases it depends on
| where you live, unfortunately) and looking ahead to 2026 was
| cheaper (comparing my tax burden in Ontario to the terrible
| insurance I can afford for 2026 in America).
| nradov wrote:
| Healthcare quality and access varies widely between Canadian
| provinces. It's common for affluent Canadians to come to the
| USA as medical tourists and pay out of pocket for elective
| procedures like MRI scans or joint replacement surgeries due
| to excessive waiting times at home. There are advantages to
| the Canadian system but some clear downsides as well.
| jjtheblunt wrote:
| > is the 90% with health insurance and the 10% without health
| insurance
|
| it's even more complicated, because you can have insurance
| fully accepted at one clinic and "not contracted" with a
| different clinic. it's a total mess.
| rr808 wrote:
| That's the same as most countries then.
| matthewdgreen wrote:
| You're never going to make a system that prevents the ultra-
| wealthy from augmenting it with private services. You might,
| however, reduce the power of the ultra-wealthy.
| sharts wrote:
| All of that applies to military spending, highways, schools,
| etc.
|
| Does that mean we can't have these things unless the wealthy
| want them?
| notepad0x90 wrote:
| Insurance == Social Disease
|
| There is a healthy concept of insurance where people pay to hedge
| against potential risk, and that's all fine and good. But one of
| the most insidious social diseases is mandatory insurance, or
| industries expecting individuals to insure themselves in any
| capacity whatsoever.
|
| It is never ok for a business (or government) to offer a service
| that comes with risks, but then ask their customers/subjects to
| insure themselves for the risk to the business/government.
|
| If I am charging people $100 for a service, then I ask them to
| insure themselves and everyone reliably insures themselves (the
| majority at least), they can still afford to pay my me $100, so
| why don't i just raise the cost to $100+$10000 where $10000 is
| the maximum the insurance will pay? You see the problem right,
| all the insurance achieved is the increase in prices, people
| still pay the same, you just now have a middle-man economy
| sucking up all the wealth/value people are generating.
|
| If we could all agree on one thing, I wish it would be this. No
| more mandatory insurance in any context. Not fire, not flood, not
| health, not cars. Optional is fine, people who can afford it can
| hedge against the risk. But a bank shouldn't require fire
| insurance on mortgaged homes.
|
| Businesses must eat the cost of doing business, in the end the
| price increase they impose will be less than the price increase
| of insurance mandates. That, or greed should be a felony (not
| happening).
|
| For health insurance, it should be a simple subsidy for those who
| can't pay out of pocket. Some industries must be regulated, even
| in a capitalist free-market country. Health care, prisons, law
| enforcement, defense contractors, banks to name a few. Regulated
| as in centrally price-controlled.
|
| For uninsured people that get sick, house burns down, car
| accident,etc... the government (for health care) or businesses
| convert the cost to debt. Same as when someone takes out a
| mortgage and refuses to pay at some point, or refuses to pay
| their car notes.
|
| It's like we have had this 50+ year running experiment, it's
| failing really badly and everyone is coming up with ideas that
| don't involve scraping the experiment, just modifying it and
| waiting a bit longer to see if it works out.
| coredog64 wrote:
| > For health insurance, it should be a simple subsidy for those
| who can't pay out of pocket. Some industries must be regulated,
| even in a capitalist free-market country. Health care, prisons,
| law enforcement, defense contractors, banks to name a few.
| Regulated as in centrally price-controlled.
|
| Maybe not now, but 10-ish years ago that was the French system.
| Very poor people get outpatient care that is free at the point
| of service. Everyone else gets highly regulated private
| insurance with a strong market component. Emergent/inpatient
| care is provided by hospitals that aren't part of the insurance
| system.
|
| There are definitely some trade-offs there, but I wouldn't be
| opposed to such a system in the US.
| notepad0x90 wrote:
| States should do their own trade-off calculation maybe, but
| at the federal level the policy makes sense.
| cookingmyserver wrote:
| > so why don't i just raise the cost to $100+$10000 where
| $10000 is the maximum the insurance will pay?
|
| Theoretically because you are not the sole provider offering
| that service and the patient could go elsewhere, or in this
| case, the insurance company would require the patient to go
| elsewhere. Obviously, this sucks absolute donkey balls and
| health care will always involve a healthy dose of "I can't just
| shop around for where to get help for a heart attack".
|
| In my naive opinion banning discriminatory pricing (no special
| negotiated insurance pricing), the sale of medical debt, and
| counting bill forgiveness as tax deductible charity would be a
| good start. With the absolute technical and capital-intensive
| marvel that is modern health care I just don't see anyone being
| able to reasonably get away with no insurance. Maybe there is a
| mandated co-insurance for all plans that could be covered by
| HSA accounts that everyone would get access to. That way there
| is a cost that is transparent to the patient that scales. At
| that point though I would just go to single payer.
|
| (Rant incoming) Another thing that might need to happen is
| billing caps based off of certain outcomes. Especially in the
| emergency medicine realm. If you go to the emergency room and
| rack up a huge bill for something simple there should be a cap
| on the amount the hospital can actually recover. All I see is
| (rightfully) constant bitching and moaning from ER staff that
| people should be going to primary care or urgent care for
| issues which are less resource intensive and cheaper. The issue
| is the ER could provide those same services for just as cheap.
| Build out those same capabilities in or near the ER. The triage
| nurse can then send those low priority patients to the facility
| right down the hall. The issue is hospital admins have no
| incentive to do that, because as you said, why bill $200 when
| you can bill a minimum of $2,000 when you have your patient
| captive.
|
| I also think it is silly we ask people to self-triage. It
| externalizes a lot of the costs to other parts of society. I
| can attest to this from the constant Volunteer Fire Department
| air-raid sirens I hear followed by a "EMS to Well Now Urgent
| Care for Patient in Distress". I'm sure the volleys love having
| their evening interrupted when it could have been a simple walk
| down an aisle.
| notepad0x90 wrote:
| so long as insurances are the "single payer" the problem will
| never go away. The single payer should either be individuals
| or the government (by mandate).
| LorenPechtel wrote:
| Absolutely agree on the negotiated price bit. That is the
| root of an awful lot of evil.
|
| I have no problem with the sale of medical debt--what's
| needed is sanity in the debt collection business. Combined
| with making one-party record the law of the land--you're
| automatically free to record telephone calls without notice.
|
| Bill forgiveness as charity? No, that's counting twice. They
| didn't collect the debt in the first place, there is no
| profit to be taxed and thus you are deducting $0.
|
| ER: Two problems here.
|
| ERs are mandated to stabilize a patient, urgent cares are
| not. Thus you see people in ERs with situations that could be
| handled in an urgent care because the urgent care rejects
| them for unpaid bills. And the ER can't provide those
| services just as cheap--a big part of what you're paying for
| in the ER is potential even if it's not actually used. The
| freestanding radiologist books their machines as solid as can
| be done without too much friction. The ER needs the same
| machines but needs them available NOW. I've been in an urgent
| care over a kidney stone--they had a CAT manned and ready to
| go at 3am (the only urgent care in town even open at those
| hours even before you consider the machines--every ER needs
| those machines 24/7.) CATs don't cost much to run, the main
| cost is the machine and personnel time (operator and
| radiologist) and that's incurred whether it's doing anything
| useful or not. (And then the urgent care punted anyway. Yeah,
| you're right, stone, we can't deal with it, go over to the
| ER.)
|
| I will also say that transport isn't always as simple as you
| make it out to be. Consider that stone I just mentioned--the
| ER was half a mile away, trivial under normal conditions.
| Even under those conditions I could have *slowly* walked it--
| except there was a major street in the way and I most
| definitely did not want to cross that. Is a taxi going to
| take the call? No. Call a friend/rideshare/ambulance.
| cookingmyserver wrote:
| RE medical debt sale - if you have the ability to just sell
| debt easily instead of having to go through the process of
| trying to collect it you are not incentivized to charge
| reasonable prices as you can overcharge and then be
| perfectly fine collecting much less (but still above your
| costs) via selling it to a third party. Any debt that is
| incurred forcibly or as a matter of health of the debtor
| should not be able to be moved around. The hospital should
| have some skin in the game.
|
| Bill forgiveness doesn't necessarily target the for-profit
| hospitals. Not talking about debt discharge. It actually
| probably isn't even the right term. Essentially what
| shouldn't be allowed is non-profit hospitals counting
| discounts for low-income individuals as charity performed
| by hospital. The value of the charity shouldn't be sticker
| price but actual cost of services. Maybe that is already
| the case, but what I hear from randoms suggest that is why
| some hospitals are happy to "work" with you on your bill. I
| shouldn't have included "tax-deductible" in there, this is
| more about maintaining non-profit status.
|
| RE ER. I don't see how keeping the ER and Urgent Care
| separate matters. In a combined system you would still have
| two sets of doctors, two sets of CAT scan machines and
| operators and radiologists, okay maybe not separate but the
| capacity for both (an appropriately reserved). In the
| current system you actually have more overhead from having
| a whole separate billing system, HR, building, landscaping,
| etc. Yes, the ER still needs to stabilize a patient whether
| they can pay or not but that becomes *cheaper* when you
| have a whole other pipeline to send them to. You aren't
| engaging a highly paid ER doctor and set of ER nurses to
| prescribe antibiotics to the homeless person that just came
| in. You can have the RN, or an internal medicine doctor do
| it instead in the area down the hall. If at any point that
| homeless person starts to code or the RN/Internal Med doc
| identifies something concerning, they can get them over to
| the ER. But again, if you are the hospital why would you do
| this? You can take in that homeless patient and charge them
| big money for some antibiotics and hopefully get reimbursed
| by the government. It's not like the hospital would even
| lose money on it, you would still charge for the urgent
| care services, just at the reduced reasonable price it
| takes to provide them plus a little more. Heck, I'm sure
| that an urgent care wing incorporated into an ER would beat
| any standalone urgent care in the business sense, you've
| generally got a whole waiting room full of prospective
| customers.. but alas.. you would cannibalize your ER
| "sales".
|
| And if that cannibalization of ER sales would leave the ER
| unprofitable, then raise your prices! I don't think any
| reasonable person would be mad if you charged what it
| actually costs to provide lifesaving care. Insurance
| companies would be okay with paying real costs for the
| fewer cases of legitimate emergencies if they know that the
| much more common cases of people going to the ER for more
| minor things would be much cheaper. I would posit that with
| urgent care support you would need less ER capacity as you
| wouldn't have it filled up with non-emergent cases.
|
| And yeah, it would be ideal to have them in the same
| building close together. Retrofitting would be hard or
| impossible. It would mostly be for new hospitals going
| forward. It all boils down to designing hospitals to be the
| most efficient as possible at providing care to patients,
| not efficiency on generating the most profits.
| lvl155 wrote:
| You can go one step further and make this a time-series. Costs
| skyrocketing. Quality of care actually going down across the
| country but especially in rural settings. Provider satisfaction
| plummeting. No one is happy...except greedy executives and
| shareholders.
| warkdarrior wrote:
| > No one is happy...except greedy executives and shareholders.
|
| It is a fairly effective system to extract money from customers
| (patients) while also ensuring that patients do not use too
| many services (afaik, US population has shorter life spans than
| rest of Western world).
| lenerdenator wrote:
| I'd be more interested in how much of that $5 trillion finds its
| way to shareholders.
|
| Most people generally don't have a problem with the idea of being
| charged a fee for a healthcare service. They have a problem with
| a system that grossly inflates that fee so that people who had
| nothing to do with the service get paid at the expense of people
| who are ill or injured. And of course, with the people in the
| system who are heavily incentivized to make sure that those dead-
| weight actors get as much money as possible.
| gwbas1c wrote:
| > So what does the US value?
|
| Every time we (the US) try to fix / change anything, a bunch of
| wonks with irrational arguments whine and complain until they get
| their way. The initiative fails, and we don't fix / change
| anything.
|
| In short, we value letting irrational sabotage any form policy
| making; _because we don 't exclude people who negotiate in bad
| faith._
| 7952 wrote:
| Or people are acting in good faith (generally) but want to
| avoid being accountable for something deeply serious. You end
| up with a web that neatly prevents anyone really being held
| responsible for anything. In an industry that was supposed to
| be vocational and treat its duty as sacred.
| phkahler wrote:
| One large thing missing. Where is the flow to insurance company
| profit, and provider profit?
| EcommerceFlow wrote:
| The more free market an industry/service, the more efficient the
| outcome.
|
| Why do people readily accept this for everything else, but don't
| see the reality in regards to healthcare?
| postflopclarity wrote:
| the more competitive, orderly, and fair market, the more
| efficient the outcome
|
| that is _not_ synonymous with "absent of regulation."
|
| market failures exist, believe it or not.
| michael_michael wrote:
| Assuming we take the statement "more free market equals more
| efficient outcome" as always and absolutely true, it raises the
| question: Are the healthcare-related needs of a society aligned
| with the most efficient outcome that a free market can deliver?
| I don't think they necessarily are.
| paddleon wrote:
| Could you please define "efficient"?
|
| and also "free market"?
|
| oh, and just for fun, also define "outcome"
| LorenPechtel wrote:
| 1) Some people have more expensive problems than others. The
| average person can't realistically budget for big things.
|
| 2) The "efficient" option is to let the big problems die.
| siliconc0w wrote:
| The problems and solutions are all well documented. Like the
| article mentions, there are many existence proofs of cheaper more
| effective systems. The real problem is the legalized bribery that
| prevents any action and the current media environment that pushes
| people to consume partisan rage slop so we don't hold mediocre
| politicians accountable.
| waffletower wrote:
| Taken together, as Andrew Tsang (too) beautifully depicts, the
| United States Healthcare system is arguably the largest
| bureaucracy on planet Earth. Larger in employees and collective
| spending than any effective bureaucracies in India or China.
| LorenPechtel wrote:
| This chart breaks it down by spending, it does nothing about
| determining the effectiveness of said spending. How much actual
| care per $ spent?
|
| I've been on a mock jury for a personal injury lawsuit--and it
| was obvious to a couple of us that the smoking gun presented by
| the defense clearly showed she was running up the bill on
| something minor. We were pointing out the problem--did that sway
| the majority? No. The general opinion seemed to be she was owed
| something for what had happened--and they had failed on the voir
| dire, they asked about my background, didn't ask anything about
| family. Oops--I knew it would end up all going to the lawyer and
| doctors, nothing to her (the proposed amount was less than the
| bills she had run up.) I played it fair and didn't speak up about
| what would happen.
|
| And all the national systems have a fox guarding the henhouse
| problem. Provide proper treatment for the expensive stuff or
| lower the standards? So long as you make a sufficient portion of
| the electorate think you're doing a good job the reality is the
| standards get lowered. And cook the books in pretending it's
| fair. (Two examples that come to mind: Including "fairness" in
| the measure of health system quality--automatic selection for
| UHC, and comparing infant mortality (they admitted the comparison
| was not valid, did it anyway.) The reality is the biggest "cause"
| of infant mortality in the developed world is how the medical
| world falls on the stillbirth/infant mortality line. Even
| elsewhere--Cuba gets it's good infant mortality numbers by
| setting a minimum birth weight. The ones that were born too early
| and never had a chance get classed as stillbirths.)
| HDThoreaun wrote:
| Over litigation of medical malpractice is a huge problem in
| this country and is a large contributor to why our system is so
| expensive. Medical malpractice juries should not be made up of
| people who have no idea how medicine works.
| purplezooey wrote:
| The author says, _" The operational resistance alone would be too
| much."_ True. But we need to continue reforms that clearly will
| improve the system. That effort seems to be stuck as we instead
| pause to relitigate the advances of the second half of the
| twentieth century. These would go a long way: mandate price
| transparancy, decouple insurance from employment, let Medicare
| negotiate prices broadly, and ban PBMs.
| robocat wrote:
| > Another choice we made without admitting it: we socialize the
| costs of aging, but only after families go broke first.
|
| We effectively do the same in New Zealand even though our
| healthcare system is very similar to the NHS. Once you go into
| state funded nursing, then you can keep NZ$284,636 of assets (if
| unmarried) and NZ$56 per week of any income. Median house price
| is NZ$770,000 so individuals often are forced to sell their home.
|
| So effectively bankrupted although not quite $0.
| kalap_ur wrote:
| I think this analysis has little to say. What would be important
| to know how those $ are being spent, not where they are collected
| from. We do not know how those $ are being spent.
|
| 1. Doctors, Nurses, Administration (management and field
| administration), other. We need to know total employment and
| total salaries (including private practices).
|
| 2. OTC, prescription and hospital administered drugs (separated
| for acute, such as ER, and chronic, such as inpatient and
| elective surgery). We need to know how much is being spent on
| these, which is _potentially_ one of the culprits of large
| discrepancy between US healthcare vs European healthcare. What
| would be great to have these by large cohorts of population (<20;
| 20-65; 66-85; 85<) and maybe the top 5 buckets (i am guessing:
| cardiovascular - chronic; diabetes; accidents; hospice; dialysis)
|
| 3. Facility expenses (rent, maintenance, utilities, other
| contractor)
|
| 4. Other
|
| Without these, very hard to opine reasonably on the state of
| affairs. And to be fair, I suspect there is a reason why proper
| expense breakdowns are not available.
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