Hacker News Reader

Comment by arcticbull | Hacker News Reader

Strange, this neglects that portion of health care spend that is accounted for by profits, by marketing expenses and administrative/billing bloat that ensues.

It also neglects that for its massively higher spend 10% of Americans aren't covered and therefore don't receive preventative care yielding massively higher final costs, and it doesn't take into account the WHO ranks the US system as 31st in the world dramatically under all the socialized players.

[Edit] as I suspected [1] indicates a full 20% of spend is wasted mostly on profits and administrative costs. That should be taken off the top.

IMO this is a case of "figures don't lie, liars figure" but without the malicious intent.

[1] https://www.cms.gov/CCIIO/Resources/Files/Downloads/mlr-repo...

View on HN

What amazes me is how few people value the value of profits in our system. The US is responsible for ~40% of the world's output in terms of medical research, which is 10x the country with the second largest amount of output, England.

Profits provides the impetus for many of the medical advances invented here in the US, and many of these advances find their way to other countries. Because of profits, the US is essentially the medical R&D powerhouse for the world and every human in the world benefits. We help make more care options available to more people are lower prices sooner.

In a way, the US is providing socialized medical care over time beyond its borders and for more people instead of having it just be socialized in the present.

Until I hear solutions that acknowledge this very important detail, I'm going to remain skeptical of all comparisons with countries with socialized medicine and attempts to take the US in that direction. I learned long ago to be skeptical of anyone criticizing any system where they can't point out the value of that system versus the others they prefer.

Making the US healthcare system function like the socialized medical systems seen in Europe risks destroying the profit motive and therefore jeopardizes improvements in medical care quality, speed, options, etc. for everyone everywhere.

I far prefer a system where some lose out in the present in favor of a system where far fewer people lose out in the future. This is essentially the trolley problem. We can provide care for X people in the US who don't have care in the present or we can provide care for several times X people in the US and elsewhere in the world in the future.

[1] https://www.forbes.com/sites/matthewherper/2011/03/23/the-mo...

Points like this sound a lot better when its not you that are lacking access to medical care.

(Presently) Consequent is not the same thing as nessisary.

As someone with an autoimmune illness that is currently incurable, yes, I do lack access to medical care so to speak. No amount of money in the world can buy me a cure right now.

The specialist I currently see is considered the best doctor in the world for my illness because he's the foremost researcher in the world studying it. He's French. He's in the US because the system here provides him with the resources to study it and come up with better treatments.

I'm very sorry to hear that, and I wish you the best.

Think how you'd feel if you were underinsured or uninsured? There'd be no hope at all. In any socialized system I'd be surprised if you didn't have access to the best doctors in the system anyways, as would anyone else in the country regardless of their employment status or net worth.

For every one person like you who is able to take advantage and be covered, how many more are left hopeless and isolated because they are deemed unsuitable for coverage due to their net worth -- effectively the luck of the draw? What of them? I have no interest in taking away your access. I want to make sure everyone else can get it too without fear of financial ruin.

FWIW, at least in Canada, if the government is unable to get you taken care of at home they'll pay for your coverage abroad which I would can only hope would happen to you if somehow your doctor moved back to France if the system were socialized.

The point more broadly is that of Tommy Douglas [1] the guy who brought the Canadian system to being: "I felt that no boy should have to depend either for his leg or his life upon the ability of his parents to raise enough money to bring a first-class surgeon to his bedside."

[1] https://en.wikipedia.org/wiki/Tommy_Douglas

No hope at all? If I were underinsured or uninsured, I would still have the option of working to get the insurance I need. If I couldn't afford it, I could still ask others to fund me if they were feeling charitable. Overall, there would still be options. Lack of wealth is not an insurmountable barrier.

Insofar as the best doctors are concerned, they are pretty much all here in the US. Everyone who matters specializing in my illness is in the US. When I lived abroad, I saw a doctor specializing in my illness and the level of knowledge they had relative to the specialists I've seen in the US was laughable. The only medical care I've had abroad (I've lived on three different continents in my life) that was comparable cost as much as healthcare in the US.

There may be a few countries that are exceptions in terms of the socialized medical care available, but I would be surprised if any were as genetically heterogenous as the US or had a population even 1/5 of the US.

One of the main problems in the US is that there isn't a clear way to compare health insurance policies. You can't exactly go out and say, I want health insurance that covers the 90% of the most likely issues I'd most likely be afflicted with for one price or choose one that covers 99.99% of the things for another price. That lack of comparability and enforcement of payout is what lacks. If these features existed in the market, it would be possible to find insurance at $50 a month all the way to $500 a month. Transparency and comparability would make the market function much better. Something that covers 90% of the things that could go wrong is already way way way better than whatever the richest could afford 50 years ago.

Your point about Canada is only worthwhile if another country exists where you want to be treated. If the US socialized medical care and ended up with a system comparable to Canada, all of a sudden that option wouldn't be all that useful because you've lost the best market in the world for providing care that Canada can't.

The US subsidizes everyone research on behalf of all people in other countries. Maybe the rest of the world can find it in their heart to help those in the US that lack healthcare instead of lecturing us on how our system is broken when it already does so much for medical progress for the entirety of humanity.

Something like 95% of all drugs developed are developed in the US. I went to a university where many of my colleagues went on to join companies that were creating the most advanced medical textiles available, such as artificial aortas and whatnot.

>> No hope at all? If I were underinsured or uninsured, I would still have the option of working to get the insurance I need. If I couldn't afford it, I could still ask others to fund me if they were feeling charitable. Overall, there would still be options. Lack of wealth is not an insurmountable barrier.

What if you had a disease that left you unable to do that? Physically, mentally? You can't work, you don't know people, now what? Why should society deem that life not worthy of saving because of an illness and a bank account balance? It's not civilized. Why should these people depend on the charity of a few individuals and not distribute that burden across society as a minimum guarantee?

>> One of the main problems in the US is that there isn't a clear way to compare health insurance policies.

IMO it doesn't make sense to. You can't know what kind of disease you'll get or when. How can you choose to exclude cover for a broken leg? Are you planning on walking extra carefully, or buying special boots? And why settle for a 90% plan to prop up the health insurance industry when you can give everyone the 100% deal?

>> Your point about Canada is only worthwhile if another country exists where you want to be treated.

The way I see it, it goes one of two ways. (1) everyone has socialized medicine, the doctors are equally distributed but you can still find them [no passionate doctor worth their salt will just pack their bags up rather than treat everyone] or (2) one or more countries exist where they congregate due to lack of socialized medicine, and you're free to travel there if you find the home country offerings unsuitable.

Also, many of the best hospitals anywhere in the world are in Germany, Hong Kong, Singapore, etc.

>> The US subsidizes everyone research on behalf of all people in other countries.

The US government subsidizes the research heavily (as do foreign countries) it's not re-invested proceeds. [1]

[1] http://undsci.berkeley.edu/article/who_pays

This is absolute demonstrable horseshit (he says without providing any references).

The cost of a gallbladder surgery does not go around and get funnelled back into research and innovation; it is padding the pockets of coders (an almost unheard of profession in much of the rest of the world), administrators and doctors who are busy paying off student debts the size of most doctors in the western world's mortgages.

Drug costs are completely out of control and the bankrupting effect this has on the most vulnerable members of a community is completely outrageous and out of touch with what a reasonable society should be expected to do. The high price of monoclonal antibodies and other treatments is no excuse for the blatant market failure that occurs here.

To further expand on this: Healthcare is a price inelastic good. The current situation in the US is one of abject market failure as what should be considered an essential service is made available to only those able to pay for it (or willing to bankrupt their families). The worst instances of this are in cases of cancer, where life-extending therapies (maybe only a few months, maybe many years, and a tiny pay-off of a long future) are only available for tens to hundreds of thousands of dollars. So vulnerable families pay it - middle class families that thought they were doing everything right, sell or re-mortgage the family house in the hope of keeping their loved one around forever. Then they die. Then the hardship begins. This is, in my considered opinion, criminal.

Bottom line: I firmly believe there is no excuse for the wastage and high costs that the American system provides. Healthcare should be about innovation; and yes we need to fund it. But in the US as in other countries, significant funding is provided by governments for basic research which goes on to be capitalised by private companies, when this information should be free. Bottom line- this article, and indeed your comment, is a post hoc rationalisation of high healthcare charges, with little recognition of the true drivers, and it does not need to be this way

> The US is responsible for ~40% of the world's output in terms of medical research, which is 10x the country with the second largest amount of output, England.

These seem to be academic publications and according to this Quora post [1], it's primarily driven by American universities and research institutes. It is not entirely clear to me how profits within the US would be a major factor here: I would have thought that NIH spending is more important in this context. While it's sort of true that NIH spending is more relevant for the R in medical R&D and industry spending for the D in R&D, the Forbes article seems to be only about peer-reviewed published research.

[1] https://www.quora.com/What-countries-have-lead-the-world-in-...

What percent of new medicines and treatments developed are developed in the UK? How does that compare to the US?

I don't know, and the UK may not even take a dominant role here (as the commercial research infrastructure is very likely to be different). We'd also have to account for the fact that a lot of drug development goes into drugs that do not provide any novel treatments, but merely exist because somebody wants a share out of a big market (e.g., Viagra alternatives) or to find a replacement drug that can be patented to sell in lieu of a drug where patent protection is running out (which doesn't work too well in countries with reference pricing, but reference pricing is still uncommon in the US, and the US practice of prescription drug advertising doesn't help, either).

In any event, if you want to make such a claim, it's up to you to support it. I was merely pointing out that your argument is fairly incomplete as it stands. It doesn't even address the question whether it may be due to economic clustering effects or a superior bioscience infrastructure in America; after all, if selling drugs in the US were so profitable and that was the cause of research, that would also spark research in other countries.

How much medical R&D spending is based on government grants, government-funded university research, and tax incentives, versus reinvesting those profits?

How many of those contributors to medical R&D have actually brought new drugs and new treatments all the way to market?

The D in R&D dwarfs the R.

Oh give over, without the R there is no D.

First, not everything needs a direct and unrestricted profit motive, and I draw the line on that where people don't have a choice whether to engage in a service or not and whether providing that service provides in general a good above and beyond the person in question.

Fire: it's to everyones' benefit if a persons' house catches fire to prevent burning down the neighborhood.

Education: all society benefits from more educated youth.

Prison: all society benefits from remediation of people with criminal tendencies (not punishment, btw, but preventing it from happening again)

Police: everyone benefits from lower crime rates.

Health: everyone benefits when people who are sick are treated to prevent infecting those around them, and people tend not to have a choice in whether they get sick, it's something that happens to them beyond their control.

It's strange to me that people tend to draw the line just before they get to health. They see the benefits to society of everything else on the list being socialized (most do, anyways) but they don't map it to health.

There's no risk of demolishing a profit motive. Canadian doctors get paid upwards of $300,000 per year. Nobody there is suffering. Patents ensure that even when realistically negotiated, drug companies can secure a healthy profit for novel drugs. Drug reasearch often funded by public money.

It's also strange to me that your argument for not covering many Americans is that doing so hurts people beyond the border. You should look out for the broader good but why not look out for yourself and your neighbors first? As much as I'm a globalist I don't think it's worth sacrificing American lives to the nebulous goal of trickle-down healthcare to people outside America. Can you cite some evidence of the effectiveness? I'm not an American, by the way, and I'm all in favor of exporting surplus healthcare, and I feel like you should make sure you've got your house in order first.

What percent of new medicines and treatments developed are developed in Canada? How does that compare to the US?

Based on conversations in other threads, it has been posited that it isn't the profit motive pushing that but rather the US governments' heavy investment in drug research [1], [2].

Canada doesn't have a big drug sector to the best of my knowledge though playing along, plenty of countries with socialized medicine do:

Denmark has Novo Nordisk.

Germany has Boeringer Ingelheim and Bayer.

Switzerland has Roche.

Astra/Zeneca is Swedish/British.

GlaxoSmithKlein is British.

Sanofi is French.

Novartis is Swiss.

Actually, of the top 10 by revenue, only two (Johnson and Johnson, and Pfizer, #1 and #3 respectively) are American. All the rest are European. Assuming based on the references that development has more to do with funding, I'm willing to bet the EU spends an awful lot.

[1] http://abcnews.go.com/WNT/YourMoney/story?id=129651

[2] http://undsci.berkeley.edu/article/who_pays

The Atlantic ran an analysis of where the costs go:

https://www.theatlantic.com/magazine/archive/2009/09/how-ame...

Essentially, it's a mess of perverse incentives that are unintended side effects of heavy regulation.

If you are going to nitpick over what should and shouldn't be there, don't forget the implicit subsidy of socialized health plans borne by US ratepayers. Price controls on prescription drugs, for example impact pricing in the US.

Also don't forget about how the US's socialized system - Medicare makes the whole system really bizarre by setting defacto price controls and encouraging over capacity of hospital beds and under capacity of primary care.

What do you mean "neglects"? Did the author somehow remove that from his numbers?

The WHO ranks the US low because 62.5% of their score is a measure of inequality. Only 37.5% of their score is related to actual health care measures (health outcomes and patient satisfaction). The US scores #1 on patient satisfaction.

http://www.who.int/whr/2000/en/whr00_en.pdf

Neglects as in they don't consider that spend to be "waste" in the computation of whether Americans are paying more than a comparable country. IMO that should be subtracted off the top as none of that exists in a socialized system. They appear to be attributing those costs to the "higher standard of living".

Note: World Health Organization report is from 2000

Do you have something more current?

what you really mean to ask is "Do you have something more current that supports my biases about healthcare"

We have something more relevant, which is that the US spends far more on healthcare than anywhere else, but is in the 10 OECD countries with the lowest life expectancy.

http://visual.ons.gov.uk/how-does-uk-healthcare-spending-com...

> While the USA outspent the UK on healthcare (£6,311 and £2,777 per person2 respectively) in 2014, average life expectancy at birth in the USA was 78.8, compared with 81.4 in the UK.

> Despite spending, by far, the largest amount on healthcare, the USA was among the 10 OECD countries with the lowest life expectancy.

We are all aware that the US spends a lot on healthcare. The article we are discussing provides a good explanation of why.

The fact that health care and health outcomes are minimally correlated is well known; see RAND, Oregon, and lots of non-RCT studies that generally fail to find much correlation (e.g. this one, which made the rounds recently https://jamanetwork.com/journals/jama/article-abstract/25135... ). I'm not sure what the relevance of that is to this article, however.

AFAICT, the article explains it only in the statistical sense of the word, not the plain-English sense, so I think you're missing the point of the comment.

The plain english explanation is that Americans consume a lot of everything relative to GDP/capita, and health care is not an exception to this.

I assume patient satisfaction only takes into account people who managed to become patients, and doesn't include people in the U.S. who needed treatment but couldn't get it.

Why assume when you can read the report?

Because the report is 215 pages, searching for "satisfaction" doesn't produce anything useful, and most other surveys I've seen use the metrics in that way.

Patient satisfaction is positively correlated with mortality. It does not necessarily indicate superior care. https://www.ucdmc.ucdavis.edu/publish/news/newsroom/6223

Then apparently a full 75% (rather than the merely 62.5% I thought) of the WHO's scores are nonsense, and not indicative of health care quality.

Reply on news.ycombinator.com