Why the U.S. Spends So Much More Than Other Nations on Health Care | Hacker News Reader

Why the U.S. Spends So Much More Than Other Nations on Health Care

nytimes.com

324 pointsyeukhon556 comments

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I think the US could easily solve this if they wanted to, but from my (Dutch) point of view:

- The US is philosophically much more egotistic than other developed countries

- Politically the US is the most divided western country with its two party system

- Money in politics means it's one of the most corrupt, preventing solutions that could serve its citizens

- Conservative media does a very good job at keeping at least 50% of the country comically uninformed

- The "American Dream" gives people the impression that working hard solves everything and that their country is the best in the world period

- Religion is not focussed on empathy at all anymore, if it ever was

The billionare .0001% will probably do their utmost to keep the status quo, as evidently, they are the ones that are profiting from the current situation and they are the ones calling the shots for the next 3 years.

The US is doing very good in a lot of areas, but I think collective egotism is preventing it from reaching its true potential.

The funny thing is that, per capita, many european countries has more billionaires than the US. That's saying something about "The American Dream" imo.

What I meant is that the billionaires maybe doesn't need to uphold the status quo?

And that taxes aren't as bad as they think.

Taxes would be a whole of a lot better if they didn't let you pick all the products and then during payment add the % of tax on top of it! Just include it in the price!

I disagree. In Russia an average employed person never even has to file income tax declaration, and any local sales taxes are included in the final price. People don't even know how much they're taxed. All they know is that income tax is 13%, they don't realize how many other taxes are added up to both their salary and the products they buy.

As much as the mental overhead of expecting a sales tax on checkout annoys me, I'll suffer through it so that everyone has a constant reminder that the government is taking its cut.

It will show in details regarding the price/payment here (Netherlands) Beats getting unexpected extra costs suddenly added for me personally... and in Amerika when eating out you even have to pay part of the salary for the staff afterwards...

How much of what you pay for gas is taxes deducted at various levels? If it's foreign oil did it pay other governments, like the Panama or Suez Canal?

Knowing what the take is for what you buy in person is such a tiny portion of the bigger picture. And with the county/state/federal variations how closely do you keep track of who is ripping you off and who is using the money well?

Only "better" in the sense that tax withholding is, i.e. it hides just how much of your money the government seizes.

A friend of mine has a print of a painting showing soldiers around a large container holding goods and money that citizens were being forced to pay in tribute. The central figure in the painting is a man--I think his family is with him. I don't remember whether the painter shows him actually putting something in the container or not, but he's looking daggers at those guarding the tribute and enforcing its collection. That look reflects how people should think of paying taxes, and things like VAT and tax withholding that lull the host into not realizing just how much he or she is being taken for need to go away.

Depends if the "tribute" or taxes payed are actually returning to the people in the form of services like roads or schools, fire department all those things. If not, and a rich guy gets most of it just to get more rich then yea, I'd see why people would see this as a scam and criminal behavior.

> Depends if the "tribute" or taxes payed are actually returning to the people in the form of services like roads or schools, fire department all those things.

That's part of it, but you also need to consider whether these are things the taxpayers would have chosen to purchase on their own, at that price. If that were true, however, then there would be no point in making it mandatory; people would purchase these things on their own. Ergo, taxes, if they have any point at all, must only exist to purchase things taxpayers would not choose on their own, at least not at the prices they are forced to pay.

Depriving others of their property is "criminal behavior" even if the thief provides something the thief considers valuable in return. The key point is not whether you received something in exchange, but rather whether you gave your consent.

Or alternatively, "I like to pay taxes. With them I buy civilization" and some would consider pointless wastes of time as a tax too, just one that benefits no-one.

Apparently the anti-tax element of the Republicans are responsible for taxes in the US being much harder to file than in other countries, because they follow your principle that paying taxes should also inconvenience people in an attempt to make them angry about the whole thing.

Presumably they're not supposed to find out who was responsible for making them angry and wasting their time with pointless busywork.

If the government doesn't make sense look to some group with a powerful lobby trying to save jobs or kids:

https://www.propublica.org/article/filing-taxes-could-be-fre...

> "I like to pay taxes. With them I buy civilization"

Taxes are never about what YOU want to pay; no one is stopping you from "buying civilization" with your own money, if that is what you want. Rather, taxes are all about what you can make OTHER people pay for your "civilization".

Except you can't "buy civilization" as an individual. Civilization is a system of participation and, yes, enforcement of rules.

The so-called "civilization" which taxes buy is a system of forced participation and oppression, devoid of civility, destructive to society, and morally indefensible.

All the things that taxes pay for can be purchased by private individuals and organizations working together of their own free will, and not because they are forced to do so. That is true civilization: civilized people cooperating to build a society where civilized, voluntary interaction, not force, is the norm.

Can you name a system, even a theoretical one, which doesn't meet your anti-criteria of being "forced participation and oppression .. morally indefensible". I don't think you can, which renders your criticisms hollow.

Human beings purchasing things from each other with no legal system? With no property rights? Is this system global, and if not then how do you interact with other nations with their own systems. None of this can exist without someone with a big stick to keep people in line.

per capita, many european countries has more billionaires than the US.

I wouldn't say 'many'. The 'top' countries are places like Iceland, Guernsey, Monaco and Cypress which are skewed due to their tiny populations. The only country which can realistically 'compete' in this metric are Norway, Sweden and Switzerland.

That being said, if we're talking "The American Dream" then simply measuring the number of billionaires isn't a useful metric. We should really focus on self made billionaires rather than people who became billionaires due to inheritance. On that metric I believe the US still leads the pack.

> Guernsey, Monaco and Cyprus

Tax havens. The billionaires themselves are usually "citizens of the world" who live in hotels or a series of holiday homes. Countries don't "have" billionaires in any kind of possessive sense any more. Instead they compete in the hope that billionaires will pass through and trickle down some wealth.

Whilst the US has more self-made billionaires than Europe [0] the US has lesser social mobility than Europe (less the UK), rendering the idea of 'the American dream' more a dream than a possibility [1, 2]

Healthcare is a price-inelastic good. Not having some form of pricing controls is a licence to rip the heart out of a population.

[0] https://howmuch.net/articles/billionaires-map

[1] https://www.theatlantic.com/business/archive/2016/07/social-...

[2] https://www.brookings.edu/wp-content/uploads/2016/07/02_econ...

The article concludes the usa has lower social mobility simply because the very rich, are now much richer thus it is harder to move to that income group.

> That being said, if we're talking "The American Dream" then simply measuring the number of billionaires isn't a useful metric. We should really focus on self made billionaires rather than people who became billionaires due to inheritance. On that metric I believe the US still leads the pack.

Ok, but comparing billionaires isn't then even a useful metric. Let's compare the number of self-made people who are financially independent. I.e. people who doesn't need to work if they wish not to.

I have no if there exists such data, but I would be a bit surprised if the US were leading on that. But perhaps the US is, I have no idea.

Not really clanking down on the US at all btw, I just think most european countries has a better view on work-life balance, social systems like healthcare and school etc. What I wish for the EU would be to put more focus on starting new companies the way the US does. The US is clearly the leader when it comes to that IMO.

[Edit: sigh, never mind.]

Having only two options forces the two to be different, more options provides you with a better spectrum of political ideology.

I don't think so, because you might agree more easily with "other people" on several issues and therefore switch more easily to another party.

In a five party system, it is quite common for voters to not feel too much allegiance to any party in particular.

Exactly, here in the Netherlands you still need a majority, this is often formed from 3 or more parties that have to negotiate a lot before coming up with a plan.

That depends on what you determine is important to you. In the Netherlands there is a 'Party for the Animals', which doesn't compromise on anything and is quite literally a protest one-issue party. Obviously they don't get as much done as other more diverse political parties, but people still vote for them because the party at least shows everyone else that there are citizens who care enough about animals to have a protest vote and have the chance to at least sit in congress.

In most multi-party systems, parties are always forced to compromise and cooperate to get anything done, since it's almost impossible to get a single party majority. Dutch governments are almost always formed by 2 to 4 parties (usually a centrist party plus either left- or right-leaning parties) which largely prevents swings to extremes.

Two parties means one or both can go to extremes pretty easily. If both do, people just pick one and the parties use votes to justify their extreme views. If only one is, it usually leaves the second party simply fighting against insanity (I think this is part of what we are seeing now: Bernie might be the start of a more extreme opposite to the other party). The parties also don't really have to have steady standards or party stance on things, at least not in the states. It more depends on the individual.

Multiple parties mean that more views can be heard. You can have a party with extreme views, but people can choose something different. Hopefully, there is a bigger range. The other thing multiple parties seem to encourage is working together and compromise. If you've 5 or 6 parties, it is harder for one party to hold up the government.

It isn't to say that a two-party system can't be what you describe, but it certainly isn't what is happening in the US right now.

The two party system sucks in all moderates, and forces them to support the most radical positions.

No, it means the natural distribution of views gets turned into a bi-modal system of allegiances. Each party defines itself by its opposite. It then becomes much harder to cross the gap because doing so involves changing most of your political views to their polar opposites and losing most of your friends.

Quantifying "social division" is tricky, but I feel that multi-party systems offer much more scope for saying "we agree on A and B but disagree on C". While small differences can also be very divisive because humans are like that (big problem for the Left) it means you get less negative voting.

"Against X" and "For X" are not symmetrical positions, because there are usually lots of different alternatives to X. Only in a 2-party system do they produce the same answer.

The UK is mostly, but not totally, a 2-party system, and it's really noticeable how the regional parliaments do politics in a completely different way, with different party groupings. This is at least partly to do with the voting systems (AMS for Wales and Scotland, STV for the defunct NI assembly).

It also depends on the way the two party system is organized. One point that keeps the American system as polarized as it is is closed primary elections, which guarantee that only the most fervent and 'ideologically pure' candidates are selected. Since only registered party voters can cast ballets, the type of candidates that resonate are elected and continue on to the national election.

In the last elections for example I heard multiple times from friends and family (that identify more with the democrats) that they would have considered voting for someone like Kasich (2016) or Jon Huntsman Jr (2012), but are robbed of that choice because they are blocked from voting in the republican primary.

> - Politically the US is the most divided western country with its two party system

This sounds like you think that political pointscoring drives up health care costs, but the UK & AU both have strong, long histories of two-party politics & have much lower health care costs.

The US system allows one party to freeze out another for periods of time due to control of different chambers. There were government shut downs under Obama.. I think that shows how terrible the US system is at the moment.

Other countries like the UK and AU will typically have the ruling party in control of a majority. The US seems to almost always be running some sort of minority government due to loss of one of either the senate or house.

> Other countries like the UK and AU will typically have the ruling party in control of a majority.

That's not my understanding or experience, and I'm a voter for both. The number of governments where the ruling party controlled both chambers is fairly rare. AU elects the upper chamber on a different schedule to the lower, so often a new government (in the House of Reps) will face an opposition-controlled Senate. I think this is the same as the US system.

The UK has it worse with the House of Lords, which aren't elected and thus won't ever change hands directly from a General Election result.

Also note that the voting tradition in AU is that if Labour gains control of the Federal government, then the Liberal/National Coalition generally gains control of the state legistlatures (and vice versa).

Perhaps you mean that a UK or AU lower chamber facing a hostile upper chamber is still functional and productive compared to the equivalent in the US. I think the threat of blocking supply or a vote of no confidence (or in the AU, a double dissolution) helps these governments be more willing to compromise with their opponents & pass legistlation, in the absence of a majority.

> some sort of minority government

A minority government is a rather specific term, and can be easily misunderstood when used to refer to an opposition-controlled upper house (which doesn't ever really exist in the UK). Could you please be more specific?

There is a long history of government shutdowns in Australia as well - one got so bad the queen dissolved the government.

Government shutdowns are mostly political theater. They have extremely limited impact on the people.

But the US politcal climate is sick right now. Partisanship has become very extreme.

Certainly the regretful state of health care in the USA is the result of myriad factors, very nuanced, and likely impossible to fix.

But ... AU / UK doesn't have quite the 'two party politics' that I think parent was referring to. In your follow-up you even acknowledged that there are two parties in coalition in AU now. Traditionally they've been aligned, but they're separate parties. Parties outside the three most popular have substantial followings, and are definitely not fringe, like they appear to be in the US. Actual independent representatives are also not uncommon.

In the US, each federal election consistently comes down to the choice between two people.

In AU, ostensibly the house of representatives will select the leader from amongst themselves, once they themselves have been voted in. Normally this has a predictable outcome, but I think we're slowly moving away from that -- in the most recent federal election around 25% of voters did not vote for one of the two major groups.

This ratio is growing, and my (perhaps naive) hope is that we're slowly heading towards something closer to actual democracy here in AU. Either way it's kilometres ahead of the US political scene, even if it's currently populated by personalities aspiring to similarly cynical behaviour.

I also note that you say you vote in both countries, but twice misspelled the Australian Labor Party as Labour.

> Traditionally they've been aligned, but they're separate parties.

The state-level parties of the Liberals and Labor are also separate parties to the federal counterparts, but there's no point specifying that, as they too traditionally align with each other to form a unified whole. There's also Country Liberal parties, and so on.

To the vast majority of the electorate, there is no difference between the Liberal party & the coalition. It's not 'tradition', it's a political agreement reached long ago in the best interests of the supporters of those parties to avoid complete dominance of Labor at all state and federal levels. The agreement is re-affirmed at every election.

> * Parties outside the three most popular have substantial followings, and are definitely not fringe, like they appear to be in the US*

The Greens, the Hunting and Shooting party, Family First (fundamentalist Christian), One Nation (racist)? Most voters would consider them fringe; their share of the vote reaffirms that. Only the Democrats had the wide support and prestige to be considered a legitimate choice, and they're defunct. Third-parties & independents don't stop AU from being a two-party system. No one would claim that the Conservative-lead coalitions in the last two General Elections means that the UK is not a two-party system.

> This ratio is growing, and my (perhaps naive) hope is that we're slowly heading towards something closer to actual democracy here in AU.

I would say it is extremely naïve to expect a Westminster-derived government to move to the consensus-style coalition governments of Europe without fundamental change. The majority requirements for legislation means only block-voting is feasible. Simply counting the number of parties and ignoring the mechanisms which allow factions to push legislation in the face of opposition is a poor rule-of-thumb for classifying if a system is two-party or not.

> I also note that you say you vote in both countries, but twice misspelled the Australian Labor Party as Labour.

How on earth does my terrible spelling relate to my point? Or does the political topic of my comment make an ad hominim a valid response? What pomposity!

I refer to my earlier comment -- two party politics as in use / understood in the US is dissimilar to the political landscape in AU, UK, and elsewhere.

GP was also suggesting there were several factors at play in terms of resolving their health care problem, this being only one of them.

Indeed, the divisiveness that manifests from the US system was the key point there.

I may be naive, but my facts stand - 25% of Australians in the last federal election did not vote for either of the two major parties (or party + coalition if you prefer).[1] This number is trending upwards, and current party politics failing here and abroad are unlikely to turn that around any time soon.

Compare the USA, where 92% of voters were evidently happy to pick from one of two people. [2]

[1] http://www.abc.net.au/news/2016-07-03/election-results-histo...

[2] https://en.wikipedia.org/wiki/United_States_presidential_ele...

The US IS the greatest country in the world (* AT salesmanship *). That about sums up the concept of "The American Dream" for me.. their government is extraordinarily good at selling certain worldviews & suppressing others, both to their own citizens and to the world. Turns out that salesmanship, psychological influence & media control is a pretty powerful combination. They even routinely manage to sell invading & plundering other nations as "defense".

Its a brilliant idea to sell to your citizens as a nation or industrial tycoon... that "we are the greatest because of hard work, hard work implies success, and success implies hard work", and then watch your citizens/employees define themselves by work so that the nation/corporation gets wealthier and more powerful. All the while common sense (or statistics) will tell you that money begets money & power begets power, the rich get richer and the poor usually stay poor. Unfortunately the American Dream idea is not always good for the workers themselves but the people selling the idea were not too concerned about that :) They simply sell just enough mental health care to keep you productive but docile on the side!

You are missing a very important point which is that the US is a country of immigration and of different states and the US is a very very very big country.

You can't compare it to Holland or Denmark or even Germany. These solutions won't work here.

America IS the land of opportunity and I would challenge you to find any other country which provides better opportunity and still protect your rights as well.

Edit: The land of opportunity doesn't mean the land of equality and the expression was never intended to be that.

America is not egoistic it's just a very hardcore country because it's built on top of people who with their lives at stake started exploring and setting up local societies.

So the country is build on tough women and men. They aren't more selfish or egoistic than any other person, their reality is just different than a little country like holland or my own (Denmark).

The US is a big country with different states, but so is the EU.

The policies of Holland, Denmark or Germany could definately work in the US, if only the people developed a different stance on criminal behavior, healthcare, guns and taxes,

America is the land of opportunity for some people. There are a lot of other countries with a lot of opportunities and freedom. More than 2 million people are incarcerated in the US right now. Where's the freedom in that?

America is very egoistic and hard country, built on the lives poor people who were left behind by their fellow countrymen.

With their stance on criminal behavior, healthcare, guns and taxes, the people in the US are definately more egoistic than people in more social democracies.

You are confusing things here. Incarceration has nothing to do with what we are talking about. No one ever said the US is perfect. We are talking about whether 1) you can apply scandinavian style healthcare to the us (you can't) and whether the US provides more opportunities than other places (it still does)

It's not equal and it's not trying to be equal either.

EU isn't big geographically compared to the US and it's not as sparsely populated as the US is. That's what I mean with big.

Yes, America is the land of opportunity for some. I don't think we were debating obvious truths here.

The point is that America does, in fact, provide much more opportunities. That doesn't mean everyone is going to make it.

That's never been the point about that expression anyway.

The US isn't more selfish if we actually look at how many volunteer in the US that alone would show that it's not that simple.

> We are talking about whether 1) you can apply scandinavian style healthcare to the us (you can't)

You keep repeating this throughout the thread without giving any actual arguments why. "Because we're not Scandinavia" is not a reason.

You should read a little more careful what I write then. I do explain it.

Do you know why those people are incarcerated? They broke laws, and they were found guilty by a jury of their peers even upon the presumption of innocence. If charged with a given imprisonable offense, under what other country's court system would you prefer to be tried?

   They broke laws, and they were found guilty by a jury of their peers even upon the presumption of innocence.

Do you know why people committed these crimes? I prefer a justice system that takes their background into account and takes steps to improve the lives of these people. A justice system that only punishes without addressing the underlying issues is not a good system.

The fact that you are arguing that the US' system is unrivaled only shows your prejudice and arrogance.

Sentencing takes into account the background. The law itself is blind, under which all are equal. You're saying you'd let off a murderer because he had a rough childhood or what now? I am not saying our system os unrivaled, I am saying I am content, even happy, to be subject to it over any other I know of. It is not incumbent on me to find a preferable one if I like it. It is on you as the critic to do so. I will consider it if you make a good case.

Have you watched the documentary the 13th? It covers severe issues with the incarceration rate in the United States, for example, the high proportion of black people incarcerated for the same crimes white people are completely let go of or otherwise not charges. How the justice system is very selective on what laws to enforce along racial lines. Stop and frisk turned out to mean “stop all the black people exclusively and search them”. How people are pressured to take plea deals even though they may indeed be innocent. How the police have been known to literally plant evidence or incite violence within communities or protests to force arrests.

Okay let's take Norway as an example. It's a smaller country ofcourse, but there's no reason this can't scale.

In Norway, fewer than 4,000 of the country's 5 million people were behind bars as of August 2014.

That makes Norway's incarceration rate just 75 per 100,000 people, compared to 707 people for every 100,000 people in the US.

On top of that, when criminals in Norway leave prison, they stay out. It has one of the lowest recidivism rates in the world at 20%. The US has one of the highest: 76.6% of prisoners are re-arrested within five years.

Norway also has a relatively low level of crime compared to the US, according to the Bureau of Diplomatic Security. The majority of crimes reported to police there are theft-related incidents, and violent crime is mostly confined to areas with drug trafficking and gang problems.

Based on that information, it's safe to assume Norway's criminal justice system is doing something right. Few citizens there go to prison, and those who do usually go only once. So how does Norway accomplish this feat? The country relies on a concept called "restorative justice," which aims to repair the harm caused by crime rather than punish people. This system focuses on rehabilitating prisoners.

That doesn't at all convey to me what I'm trying to find out: would I wish to be tried in the Norwegian system if I were charged with a given crime rather than in the United States? Neither where would I prefer to carry out my sentence, nor where I think the socioeconomic factors that lead to crime are best prevented. Those are all worthwhile questions, to be clear, but not what I was getting at.

By refering to personal preference, you are ignoring my arguments and the issues at hand.

Why?

You do that yourself

"I prefer a justice system that takes their background into account and takes steps to improve the lives of these people."

That was an answer to his question, not my entire rebuttal.

Your preference for a justice system is your rebuttal. You are discussing whether it's ok or not and you have rules for what you think is ok. That is exactly your rebuttal.

I'm ignoring your arguments because we're on a sub-tangent that I started on just one point of your comment - that our prison population is somehow evidence of our lack of freedom, and I would like to limit it to that in order to get some clarity on it. I have nothing to say on the other points. I may even totally agree with you on them. If you don't want to engage this specific point anymore, fine.

Norway isn't a great example because Norway is also far, far more culturally and economically homogeneous than the US, though that is changing.

Bangladesh has an even lower incarceration rate, but its prisons are apparently horrifying places of routine human right abuse. Should that be the guide? Perhaps that can scale - half of the bottom 15 countries in terms of incarceration rate have histories of extreme human rights abuse but according to the crime information, their criminal justice system is doing something right - few citizens go to prison and most only go once.

> found guilty by a jury of their peers

This statement is factually incorrect for the vast majority of those incarcerated in the US

True in theory but there is widespread abuse of plea deals in the US justice system.

> America IS the land of opportunity and I would challenge you to find any other country which provides better opportunity and still protect your rights as well.

That's pretty easy. The measure you are looking for is social mobility. Most of Europe is more socially mobile than the US. In layman terms, it's easier to climb from the poorest quintile to the richest quintile. It's the result of the free education and social safety net that Europe is famous for. If you really want a country, ironically in Denmark social mobility is double the score of the US' [https://www.economist.com/news/united-states/21595437-americ...]

Social mobility is not what "land of opportunity means" it's not meant to be an equal society in the normal sense. It's meant to be a society with opportunities.

With regards to Denmark. When you look a little deeper in the numbers it's not actually true.

https://www.theatlantic.com/business/archive/2016/08/the-ame...

I think you misunderstand what Social Mobility is, Wikipedia says it's:

> the movement of individuals, families, households, or other categories of people within or between social strata in a society. It is a change in social status relative to one's current social location within a given society.

Which would be exactly what people would call opportunities. Social mobility is not at all aimed at fixed equality. It's about being provided equal opportunities, for example by having good, free, public education.

In the US, if your parents can't pay for your university degree, you need to either get lucky and get some kind of scholarship or go a couple 100k into debt. This leads to low social mobility, since the rich have a better chance at getting a degree than the poor do.

No, I understand very well what it means. The land of opportunity isn't the same as social mobility and isn't meant to be the same either.

You don't come to the US because of social mobility, you come here to improve your current situation and relatively, the US provides in spades compared to going to many European countries where you are stuck in some social welfare system and will never actually be able to move out of it.

The European welfare system is great for equality but it doesn't do much for the opportunity.

The ability to break out of your social heritage isn't better in Denmark in any meaningful way. It's a common misconception but was debunked by ex. the Rockwool Foundation who found that Despite free education people were still ending up doing the same as their parents no matter the US or Denmark.

  The European welfare system is great for equality but it doesn't do much for opportunity.

I'm not sure what your argument is here. Are you saying there's more "opportunity" in the US because their healthcare sucks? What are you trying to say?

I was responding to your claim:

"The "American Dream" gives people the impression that working hard solves everything and that their country is the best in the world period"

Which is both wrong and missing what the American Dream is all about. It's very far from any European idea of equality, I say that as an European myself and grew up in one of the most equal countries (Denmark).

But once you get to live in the US you quickly realize why Scandinavia style healthcare can never work in the US. It's simply not structured both geographically, culturally, immigration wise and politically to ever work.

As a country with opportunities, nothing really beat the US when all things are considered. That doesn't mean everyone is making it that's not the goal either.

I think you're saying that you have more opportunity in the US because the risks are higher? Your argument reads like an incomplete thought. I fail to see how immigration and geography are related. Culture is related, but that could easily change if people weren't told what to think by conservative pastors and media.

I happen to think that opportunities are bigger in the US because of less regulation, a bigger market with no language barriers and more venture capital and that the US could do even better if people didn't have to worry about hospital bills. There's a lot more potential.

There is more opportunity because of a lot of different things one of them being culture, another access to capital, access to global markets, another being big English speaking country, another being a much bigger reliance on civil society to take care of many of the things that governments take care of in Europe and of course the military.

The US is actually not doing well on a lot of individual parameters but if you look at everything as a whole it just ends up being a country with more opportunity than any other country and I would challenge you to find any country that's better than the US in those terms.

When it comes to healthcare geography and immigration is related because of the way a single payer social healthcare system works.

The US have to deal with immigration both legal and illegal. You can't just give 11mio illegal immigrants access to to healthcare just as people who immigrate much later haven't been paying to the system their whole lives.

Furthermore because of the distance if you want to provide equal treatment it's going to be very expensive or you have to spend a lot of money on transportation.

These are just some of the issues which normally gets completetly ignored but are actually crucial to understanding why the US can't be the same as European countries.

You're mixing multiple discussions into one:

- Does welfare help opportunity?

- Is social mobility the same as opportunity?

The bottom one is the one we're discussing and the answer is yes, because that's what it is. Social mobility also isn't equality, because in a truly equal state, social mobility would be virtually non-existent, since everybody would be equal.

Also, like you previously mentioned yourself, there is no 'European welfare system'. There are lots of different countries with lots of different systems and they all work out differently. The common denominator is that most of them work out better than the US does.

I would recommend reading the wikipedia page on social mobility for some more info. It also explains why equality is in fact important for opportunity, unlike what you wrote:

https://en.wikipedia.org/wiki/Social_mobility

No I am responding the OP who mixed in a lot of different discussions into his analysis of why the US spend much more than other nations.

We are talking about a very specific idea of opportunity (the american dream) which was what I responded to.

When it comes to social mobility again Denmark isn't doing much better than the US. I would recommend you read the Rockwool Foundation report on this matter. I am well aware of social mobility and wha tit means.

https://www.ncbi.nlm.nih.gov/pubmed/28649168

> In the US, if your parents can't pay for your university degree, you need to either get lucky and get some kind of scholarship or go a couple 100k into debt

The average student loan debt is something like $40K, not $200K, and there are quite a few scholarships. I got one for going into STEM--it paid something like $2K/year and I got my degree with only $7K of debt, but I set up my schedule so I could work while I wasn't in class and I didn't lead the lavish lifestyle that my peers did. Of course, the US education system is still unnecessarily expensive--but this falls out from the government's attempt to make it affordable--the government subsidized education by giving students loans and universities responded by competing on things students care most about: manicured campuses and lavish amenities. There are other things as well--additional administrators ("diversity officers" and "bias response teams"), but it mostly falls out from student loan money. Even still, there are lots of great schools that still compete on education and great services to help you find them, so doing better than the average $40K in debt is definitely feasible if not easy even without a scholarship.

> The average student loan debt is something like $40K, not $200K

You are correct, I picked the most extreme cases to make a point. Here in the Netherlands €40k is about the maximum you'd get and that is after taking your time and having a lavish lifestyle. The schools themselves are only €2k a year, currently.

You definitely don't have to go into debt like that. I know plenty of people that worked and went to community college for two years, transferred to the state school for the final two years, and graduated with little to no debt. People miss out on the 'college experience' aka drinking and partying, but they graduate with no debt. Also, there is no such thing as free services provided by the government. They are paid for by taxes.

> Social mobility is not what "land of opportunity means" it's not meant to be an equal society in the normal sense. It's meant to be a society with opportunities.

Social equality and social mobility are almost opposite ideas. Mobility measures how likely (easy) it is to climb up the ladder, if you're good and/or lucky. Equality measures how steep/long is the ladder - in a totally equal society, there wouldn't be a ladder at all, so there would be zero social mobility.

Yes and the Denmark isn't doing any better than the US when it comes to that.

Again I refer to the OP who started talking about a selfish US .

You fail to distinguish equality of opportunity from equality of outcome.

I interpreted "equality" from the OP as equality of outcome, it looked pretty clear in that context.

Social mobility measured by movement across quintiles is bullshit.

The top quintile in the US is much higher than the EU. As a result someone in the EU moving from 10,000 EUR to 80,000 EUR might be going from the bottom to the top quintile.

Someone moving from $10,000 to $125,000 in the US might be going from the bottom to the 3rd quintile. Less income mobility, but higher overall incomes.

I'd prefer the US scenario.

You need to get out of your SV bubble if you think that $125k is 3rd quintile for the US.

https://en.m.wikipedia.org/wiki/Income_in_the_United_States

It was an example, I made that number up. That why I said "might".

I disagree. Money stops buying you happiness below $80k/year, or at least gives a very poor ROI. Knowing this, why would any sensible person choose a system which gives a much smaller chance of reaching this level?

It's a very American way of thinking, in which we fixate on being incredibly wealthy, instead of just moderately wealthy. Why else do Powerball sales skyrocket when the jackpot is hundreds of millions, instead of just millions? Statistically, your chances of winning were much better when it were in the mere millions, and now you have a much smaller chance, though to be very elite instead of just elite.

> Money stops buying you happiness below $80k/year

I assume you mean above and that's a very strong claim that I've found personally to be quite false.

Yes, sorry, above. And I should've linked a source: https://lifehacker.com/the-perfect-salary-for-happiness-by-s...

Obviously this is referring to people in general and not you personally.

> The study, which analyzed Gallup surveys of 450,000 Americans in 2008 and 2009, suggested that there were two forms of happiness: day-to-day contentment (emotional well-being) and overall “life assessment,” which means broader satisfaction with one’s place in the world. While a higher income didn’t have much impact on day-to-day contentment, it did boost people’s “life assessment.”

Couple huge notes here:

1. Overall life assessments improves; that is a part of happiness.

2. These numbers are 2009.. during the recession. They are way higher now almost certainly.

3. Needs to be COLA adjusted (linked article does that)

4. Is this pre-tax or post-tax?

5. I can't find the study itself, but I can't see how household composition wouldn't affect this number.

$130k single person in SF Bay Area might have well peaked on day-to-day happiness - you are generally making enough to not stress about breaking a budget.

At $130k living in the SF Bay Area with 2 young children, you are still going to need to budget, leading to heavy marital arguments about money that hurt day-to-day happiness. I would venture that $350k (pre-tax) is about the level where such a couple would peak by eliminating budget pressure.

> still protect your rights as well

There are few western countries that are as bad at protecting rights as the US. See:

- Guantanamo Bay, where people are held indefinitely without trial

- Abuse of civil forfeiture

- Mass surveilance

- Cops not being sentenced after needless shootings

- Gerrymandering messing with the will of the people

- Private companies often being more important than the public interest

I could keep going, because there's plenty where that came from. It all depends on which rights you mean though, because the right to bear arms has indeed been well protected in the US (which isn't really considered a right anywhere else in the western world though).

The US has also failed to ratify the UN convention on Rights of the Child.

That's because the UN is nothing more than a feel-good body that gives strongly wording condemnations while people die.

The UN isn't exactly something to hold as a beacon for anything besides spending a lot of money on practically nothing.

In which case, where is the harm?

"Children have the rights to:

- Protection (e.g., from abuse, exploitation and harmful substances) - Provision (e.g., for education, health care and an adequate standard of living) - Participation (e.g., listening to children’s views and respecting their evolving capacities) - Specific protections and provisions for vulnerable populations such as Aboriginal children and children with disabilities"

The UN is so much more and if you spent any time with them like I have you realize how absurdly wasteful it is as a system.

Those are all true, they just have nothing to do with what we are talking about.

You go to England and tell me they don't have mass surveillance, the EU has plenty of regulations that benefit companies not consumers,

The US is far from perfect but again I would challenge you to find a country with better opportunity as an immigrant.

I was talking about protected rights in the context of material rights and the opportunities this land provides.

The reason why Scandinavian style healthcare (unfortunately) won't work here is that it's not like Scandinavia and it can never be like Scandinavia.

Even Obamacare which I as a person with two melanomas under my belt is very happy with isn't really working.

Only technology will help in the long run. The US healthcare system can't be solved realistically through political means.

> a country with better opportunity as an immigrant

It's virtually impossible to immigrate to the US without any financial backing, like a stack of cash or an employer wanting to hire you. So yes, the odds of an immigrant succeeding in the US are pretty good, I wouldn't call this an opportunity for people who aren't already well off though.

No it's not. The US system is actually much more liberal than the EU. It also provides opportunities for the 11mil illegal immigrants. How many syrian immigrants are part of the job market in EU?

50% of the non-western refugees in The Netherlands are working at least part-time. With most companies scrambling to find personnel even in low-paying jobs, I think we'll conclude in a few years that those refugees were a net-benefit to society.

If your report where anything like the Danish one it concluded that they were a net negative to society.

And you still haven't shown a country that provides as much opportunity as the US when it comes to "The American Dream"

You and I clearly have different definitions of opportunity or what it means to the average individual.

That's what I have been trying to explain to you now for several posts. The US general idea of opportunity and the American Dream isn't what you think it is.

So glad you finally got that part.

It's a fundamental difference in how these things are percieved.

> The US system is actually much more liberal than the EU

How so? Here are the options to immigrate to the US for an IT professional:

- be hired by some rich company, try H1B, most likely fail in the lottery and wait for another year;

- be hired by some rich megacorp with presence in multiple countries, move to one of the countries, wait for a year, get L1 and move to the US. Too bad if you have a partner, he/she won't be able to work for a few years

In both cases your position is really precarious until you get your green card, so oftentimes you can't really afford to change employers. How on Earth is it "liberal"?

You are missing a lot of different ways that you can get into the US and still be part of society in ways that simply aren't possible in Europe.

But don't take my word for it.

https://www.nytimes.com/2015/12/09/business/international/fo...

I would really appreciate if you would mention visa types instead of an article about integration.

Also please elaborate on the "ways than aren't possible in Europe" if you don't mind.

> You are missing a very important point which is that the US is a country of immigration and of different states the US is a very very very big country.

And yet not even the biggest country in North America, an entire continent of immigration; the only difference between the people in what is now the USA and what is now Canada was the degree of loyalism to the British.

> America IS the land of opportunity and I would challenge you to find any other country which provides better opportunity and still protect your rights as well.

For that not to be just an empty slogan you'd have to explain what you mean by "opportunity" and "rights", to which races and genders those opportunities and rights have historically applied to in actuality, and how you think every other country suppresses or represses those rights or opportunities.

> So the country is build on tough women and men.

The USA was "built" (leaving aside how) by, among others, Danes, Dutch and Germans. I don't understand how they suddenly became tougher, just by stepping on a boat.

Edit: and there goes the autodownvote bot, within not even enough time to read this post.

> I don't understand how they suddenly became tougher, just by stepping on a boat.

I don't understand the OP's point, but "selection bias" is why many immigrant populations out-perform their counterparts back home. The folks who are willing to strike out are necessarily more intrepid.

But not north of the 49th parallel?

I didn't make that claim.

Willing and able

Besides there living like 10x the amount of people than in the US and besides Canada actually has a very strict immigration politics compared to the US then sure.

I was responding to the "American Dream" by the OP. You find any other country where immigrants are running many of the countries most successful companies and where you have so much opportunity to establish a company in a great market. I am not talking about how fast you can set up an LLC or a C-Corp I am talking about how big your opportunity to create something in the US is no matter who you are and where you are from compared to other places.

The US is far ahead.

The tough people were the ones who endured what it meant to live in the US in the beginning. There weren't tough when they went on a boat but they soon became just as their children and their children.

> I am talking about how big your opportunity to create something in the US is no matter who you are and where you are from compared to other places.

What does this even mean?

Please give a specific, concrete explanation of how and why it's easier for someone to "create something" (create what?) in the USA than in the EU or Canada.

> Canada actually has a very strict immigration politics compared to the US then sure.

And yet apparently accepts around three times as many new immigrants per year than the USA, as a percentage of population.

> The tough people were the ones who endured what it meant to live in the US in the beginning. There weren't tough when they went on a boat but they soon became just as their children and their children.

So is the USA the land of opportunity or the land of greater hardship and toughness?

People don't typically leave the country they know and love for another land, unless enduring hardship already. OTOH, while they may believe (at least in part due to propaganda[1]) another land will provide greater opportunity, that doesn't mean it does.

[1] The UK government notoriously considered an ad campaign a few years back about how bad life was in the UK, to deter immigration.

It means that if you come to the US from more or less any country you can get started working and building up a good business and end up on the top in fact you are expected to. There is no social welfare system for you. You go to Europe and you point to how many places that happens.

In the US almost half of all Fortune 500 companies are founded by foreigners. Let me know where that happens in Europe.

And yet apparently accepts around three times as many new immigrants per year than the USA, as a percentage of population.

But a fraction of what the US have of illegal immigrants (approx 100K vs. 11mio). Furthermore the IRS and Immigration actually doesn't communicate about illegal immigrants because of the US Privacy Act which means you can actually pay taxes even though you are here illegally.

The US is many times more flexible for anyone who wants to stay here.

But don't take my word for it.

https://www.nytimes.com/2015/12/09/business/international/fo...

Even the fact that Dreamers are even discussed shows how different the US is form Europe.

So is the USA the land of opportunity or the land of greater hardship and toughness?

What part is it you don't understand?

The US is the land of opportunity, the US sentiment isn't like the european where equality is a goal in itself because of the US history and how it was founded.

With regards to your [1] Denmark did that, it helped but what does that have to do with anything?

11mio illegal immigrants in the US plus all the legal immigration and add to that the last 200 years and it's pretty obvious that the US is based on very very different principles than EU.

>I don't understand how they suddenly became tougher, just by stepping on a boat.

Stepping on that boat was risk taking. I think they'd teach their children those same values.

But I think the bigger difference in US v. European culture is that inside America there was no landed gentry. The Northeast had some "society," but for long streches of American history anyone could go buy land for cheap and farm.

Without an intrenched gentry and an intrenched lower class, American class has always been more mobile. There were certainly rich and poor, but poor enterprising people could get land much cheaper by moving west.

Industrialization changed that, but by that time American culture was already distinct. Plus, America was richer than than Europe during the 20th century. Our middle class had it pretty good.

Canada is more like American culture than British.

Counterpoint from a fellow european. I found americans to not be more selfish, but more appreciative of self-reliance. In europe in most countries the philosophy is that of the nanny state, taking care of its citizens no matter what got them into a care-needing situation. In much of the US there’s much more a perception of responsibility for your own success, with negative individual outcomes being considered a necessary evil linked to personal freedom.

Looking at the stats clearly the US needs a little more nanny state to generate better outcomes for the bottom half of the country. But equally europe needs more appreciation of self-reliance and entrepreneurship to enable a richer startup culture and let the EU become an economic leader instead of follower.

> But equally europe needs more appreciation of self-reliance and entrepreneurship to enable a richer startup culture and let the EU become an economic leader instead of follower.

Does it? Is the purpose of a nation state to compete with others based on economic metrics? Yes, I know that most countries are doing that, but in a thread where we compare individualism/selfishness with nanny/"charity" state, shouldn't this competition be questioned?

Yes it should be questioned. Would I enjoy being filthy rich, while my neighbour is struggling with his hospital bills? Hell no. For me government is about taking care of the sick, poor and vulnerable as much as taking care of wannabe millionairs.

>Would I enjoy being filthy rich, while my neighbour is struggling with his hospital bills? Hell no.

Nobody would stop you from helping with your neighbour's hospital bill if you were filthy rich.

Sure, I could add if/thens to my apps for each specific undesirable scenario, but I would much rather prefer to solve the underlying bugs.

I prefer a consistent reliable efficient health care system and social security system to philantropy, charity and donations as well.

The USA is still the violent prudish religious DIY Wild West compared to most areas in Europe (East-Europe excluded that is more like the USA).

> a consistent reliable efficient health care system

what makes you think that this is reasonable for government to provide? How do you know that the era 1950-20xx is not an anomaly? If you look at the broad scope of history, governments are not very good at doing the things that you suggest they should be doing.

If you look at the broad scope of history, cannibalism is a good thing.

I suggest you revise your argument to one that's more plausible and convincing.

There's a mechanistic reason why it's a bad choice. Government is by necessity a hierarchical system, by its very nature its process of allocating resources requires a concentration of wealth and power. From first principles, there's no way around it. Any system that enforces 'good feels' top-down is unstable and has a half-life; systems of social support will eventually be redirected to benefit the wealthy. For example, if we go to single payer healthcare, it eventually will become a vector for lining the pockets of phamaceutical companies.

'Good feels' there you have it. You think empathic people are just virtue signalling, totally ignoring the benefits of a more social democracy. You believe in a system that's totally unfair to a lot of people, ignoring that I am from a country that proves that there's absolutely another way.

you're not an ethnic minority, are you? You have no clue what it means for society to be unfair, and it has nothing to do with money.

Doing what is right isn't the same as "good feels" -- does conceding your own personal self interests on behalf of a group feel good? Trying to empty the ocean with a bucket is "good feels". You present a theoretical reason against a system that works already in other jurisdictions -- this is not some far off space age shit with flying saucers, it can be done and if done and it functions well enough will improve the lives of A LOT of people.

> what makes you think that this is reasonable for government to provide?

[disclosure: am Canadian]

Pragmatically, the fact that it works well and has reasonably good outcomes in every first world country other than the United States.

You need to do more research. There are several first world countries where medical insurance is private.

I'll let you google and find out which ones.

They seem to work just fine.

Every OECD country except the United States and, at one point, Mexico—though they may now, too—has universal healthcare largely driven by government mandates, though the systems may be either direct government programs, mandated private insurance, or a combination.

https://en.wikipedia.org/wiki/List_of_countries_with_univers... looks like a pretty reasonable list. The US definitely stands out on the No lists.

Uh... that's universal health insurance. It has nothing to do with whether or not the system is private.

Either way... I personally don't care much whether it's run by the government or not, but rather that the government does what's necessary to have free/super low cost health care for everyone (On the order of $20 for a doctor's visit). Maybe the government runs it itself; maybe it provides the funding for private organizations to provide the health care.

Know what's awesome? Knowing that I can break my arm and have it taken care of with virtually no out-of-pocket cost.

Tax-wise, I'm totally speculating here because I don't know the ins-and-outs of the American tax system, but here we go.

https://simpletax.ca/calculator https://www.irscalculators.com/tax-brackets-calculator.php

I'm going off of $85,000USD/$106571CAD (equivalent today according to Google), and using California.

California: total tax paid $25,252.56USD, you keep $59,747USD

Saskatchewan: total tax paid $30,465CAD ($24,308.33USD), you keep $76,106CAD ($60,702.91USD)

So on the same amount of income, we pay about the same as California residents, but all of our health care costs come out of the taxes we've paid. Seems like a pretty good deal, not having to pay any health insurance premiums on top of that.

Doing a conversion of USD to equivalent CAD is not reasonable. Salaries are generally higher, dollar for dollar in the USD.

You're also ignoring the multiple tax breaks available in the US that aren't an option in Canada: mortgage interest deduction, uncapped 401K contribution, etc.

We can keep going here...

https://en.wikipedia.org/wiki/List_of_California_locations_b... http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/f...

Median family income in California: $70,187 USD Median family income in Saskatchewan: $86,970 CAD ($69,516.86 USD)

The currency conversion seems pretty reasonable. And yes, I'm ignoring the various tax breaks available on both sides, as well as a number of other perks (e.g. 55% paid maternity/paternity leave for 35 weeks). We're in the same ballpark here though.

Is medical care something people need? That's how you tell if the government needs to provide it or subsidize it -- the market like US politics has schizophrenia which doesn't lead to a terribly efficient mechanism for allocating certain resources - it's great at giving people what they want. The right will come around eventually and maybe it will a little harder since there is a larger population to draw from to form a critical mass of stupidity. You just need to wait for the entrenched living carcasses that have been in the game since the 70's & 80's to die out gradually before anything will really change -- I will bet anything this is why kings and emperors were convinced to drink mercury.

>Is medical care something people need?

No, nor is it a right. It's a luxury.

What makes law enforcement a need, or a right, something that you're willing to stand up for, in your previous comments, but not health care?

It's not a need or a right, it protects your rights. A right is something your have by nature, not something that can be provided to you by others.

Life is not a need or a natural right. Nature can continue to grind on regardless of what you think. It seems you think that having other people enforce a system that offers you guarantees is something you are automatically entitled to having -- how much security you get is dependent upon the resources of the larger group, just like all other rights.

Saying people don't need healthcare is like saying people don't need food. Whether a country's government should let people starve or die of cardiac arrest on the streets is another question, but I would say from a moral standpoint that it shouldn't.

If you look at the broad scope of history, health care is useless or worse. 1950 onwards is a major anomaly in nearly every area. We’re in that anomaly, so looking to earlier eras for lessons in things they didn’t have and wouldn’t have imagined is pointless.

I see nothing that could end the general health care system. Unlike political opinions, science and technology progress (only).

European politicians prognose bad times because of the demography (too many old persons, too few young persons).

IMO politicians and many experts are very bad at predicting the future. Like many other people, they feel smart when they prognose problems and anounce austerity.

IMO technology and automation could and probably will solve any poverty problem soon enough for most Europeans. Even today, most poverty in the world is a political problem and not a natural or technical necessity.

You can't solve the underlying bugs because it's impossible for you to force your neighbor to make good choices and to live a net productive life. The only question that needs answering is how much of your productive output should be diverted to someone else, someone whose life choices you get no influence on, but somehow they are allowed to have influence on yours.

This is the standard myth of personal irresponsibility which excuses "punishment" for failure.

The reality is that the opposite is not just possible, but encouraged - right-wing governments in the US consistently use economic policy to prevent social mobility, economic freedom, and the kind of collective social investment that generates long-term social, political, and economic benefits.

It's all about concentrating economic power among an increasingly narrow sub-group, and economically disenfranchising the rest of the population.

https://www.oecd.org/eco/Decoupling-of-wages-from-productivi...

Well, I am forced to pay for my jobless neighbor. I also pay for the road between me and him. I also pay for the guy on the corner with mental health problems and for the cops that are patrolling the streets at night. I am more than happy to pay for everyone, because it's this system that enables to me to focus on my job.

And I voted for a system like this. Just like my parents, my neighbor, the guy on the corner and my jobless neighbor.

It's not holding anyone back in any way.

You're not paying for everyone - a significant chunk of the transfers you're endorsing are paid by deficit spending, so you're still signing up other people who don't get to vote to pay for what you want.

Of course there are probably government spending you disapprove of (long-term prison sentences for drugs, war on drugs, "bridge to nowhere", and military/foreign wars are likely candidates)

Everyone disapproves of some government spending, but it involves compromise between differing perspectives on what government should be doing.

But couldn't his money go farther if we had a more efficient health care system? Do you realize that they passed a law specifically making it illegal for the government to negotiate the price for medicine.

If you lack compassion, like him probably, it's very easy to ignore how the system that's benefitting you is screwing over an awful lot of people.

Maybe his neighbor would? If the culture of self reliance is so important, shouldn't people who take handouts from others be shamed and vilified? Sure seems like that's the Republican party line.

Whereas if healthcare was properly regulated, his neighbor could pay for it himself and actually be independent in his community.

I'd rather be independent among my peers and neighbors even if I have to rely on a supra entity to regulate my food quality and organize my warfighting than the other way around. We're all dependent at some level even if just to the past, no matter what "Atlas Shrugged" says.

That's quite possibly the most inefficient way to handle such a thing. As a reminder: there's a very good chance that, with healthcare, inefficiency => people die.

Beyond that, it's an insulting way to avoid having a real discussion on this issue. If the charity of the rich were enough to solve this social problem, we wouldn't be talking about it. Why are you participating in these discussions if the only solution you have to offer has been tried and failed for most of human history?

> Why are you participating in these discussions if the only solution you have to offer has been tried and failed for most of human history?

So you agree we should stop massive government programs that have always resulted in centralization, bankruptcy, and systemic poverty? Venezuela, Cuba, USSR, Greece, Spain, Italy, China, ... How much more failure do you need to realize Government isnt the answer?

Let me know when Canada fails. Or Germany. Or Sweden. Or Norway. Or... Or... Or...

https://mises.org/blog/if-sweden-and-germany-became-us-state...

they would be amongst the poorest states by median household income, purchasing power parity, cost of living, and gdp per capita

So your argument is that these statistics "prove" that Sweden and Germany's people are worse off than the citizens of most US states?

First, it would seem that all those people are too ignorant to understand how much better their lives would be if they were, for example, living in Michigan. If only we could teach them how unhappy they are!

Second, the claim that the people are "poorer" is not a cogent claim that their countries are failures. Your argument reminds me of something I tell my children:

"Human beings are the most successful form of life on Earth, by all the metrics that humans choose to measure success."

That sounds like the most efficient way to handle such a thing. Please explain...

>Why are you participating in these discussions if the only solution you have to offer has been tried and failed for most of human history?

I'm sorry, I was unaware of the existing solution that has succeeded at solving all social problems in the countries in which it's implemented.

You're the one saying we should effectively stick with the current mechanism, despite its flaws. The onus isn't on me to provide an alternative, it's on you to defend a problematic solution.

>You're the one saying we should effectively stick with the current mechanism, despite its flaws. The onus isn't on me to provide an alternative, it's on you to defend a problematic solution.

If the alternative is not flawless, then one needs to show that the disadvantages of the alternative vs the current situation are outweighed by its advantages over the current system.

> For me government is about taking care of the sick, poor and vulnerable as much as taking care of wannabe millionairs.

For me, I'd say that society is about taking care of everyone -- government should merely (!) play the role of the administrator in that process.

I always feel that way too many people I speak to think that 'the government' is some kind of independent force, rather than a reflection of what society wants. (Sure, in many cases, it really is a reflection of what a tiny handful of people orchestrate -- but since we're talking idealism here...)

For me, I don't think the driving forces of capatilism are always compatible with 'caring for people' and that there are tasks that are better left to governmental organizations.

Yes, agreed entirely -- I didn't mean that more things should be privatised (I actually think many things should either remain, or be re-, nationalised). I meant that government should be acting in a way that reflects the will of an informed, thoughtful, responsible, empathetic society ... rather than 'inflicting' responsibility upon its citizens.

Exactly. The government should represent the will of the people. Too often I see people argue from the point that government is intrinsically some alien entity they have no control over, but when that's the case, that just means your government is wrong. Government should represent the people, and any government that doesn't, needs to be fixed. (The US government certainly needs to be fixed.)

that's really dangerous, because the will of the people can get really hairy.

Besides, if the will of the people is to take care of everyone through social services, then why do you need a government to do it? It should just happen naturally. What you are saying, is that a few select people that are chosen by a popularity contest should be given the authority to make people do things against their will.

Government is always the will of some people.

The question is - cui bono?

Your alternative presumably is the current system, where a few self-selected people, kept in power exclusively by wealth, caste, and social connections - often in defiance of real wisdom or foresight - force everyone else to act in ways that benefit that self-sustaining governing class at the expense of everyone else.

No, how about many people act together voluntarily in a distributed system of social support that is resilient to attack by small numbers of powerful people?

Because people need to pool into something to be able to afford big projects for the benefit of all. Government is the effect of this, you collect taxes so you can afford to build a shiny new hospital to attend to a region.

If you want to pool resources collectively in a smaller scale you are just replicating this structure with different powerful people, or different structure of power, but a society will always need it, doesn't matter if resources are money, materials or labour.

> that's really dangerous, because the will of the people can get really hairy.

Yes, but that's a direct consequence of having an ill-informed, poorly educated , credulous, angry, compliant majority. Societies where the elite are looking to retain their power base will typically channel fewer resources to public education, and more to the institutions that reinforce their own position.

Difficult to undo once it's been started, and (IMO) it's been happening for a very long time in AU, UK, US -- and presumably almost everywhere else that self-identifies as a capitalist democracy.

So, yes, the will of the people can get hairy, but of the two options -- force the agenda of the elite upon everyone else, or work towards a better society -- the preferable option very much depends which of those groups you're in right now.

Also noting that if you're in the uninformed group, you may not recognise that, or think anything needs changing.

>For me government is about taking care of the sick, poor and vulnerable as much as taking care of wannabe millionairs.

You're free to donate as much of your income to people in need as you want, but you need to stop thinking you should be able to make other people do the same thing. You may not like it but we have a right to our labor and freedom to spend it how we please.

Sweden and Norway, both flagship nanny states are extremely entrepreneurial and not just by volume but success. This goes against the logic you can't have social support and people reaching for entrepreneurial success.

I think, though know this is anecdotal, US startup success is based largely on its market size of both consumers and venture capital.

That's true, a lot of European startups focus on making it in their local market and from there branch out to other countries, whereas startups in the US are from their inception focussing on their large, single market with no language barriers.

I think that's slowly changing. Dutch startups are told to think big nowadays and access to venture capital is also improving.

Is that really true of Silicon Valley startups? It seems that they start focusing on international sales shortly after their inception, mostly from VC pressure. Most SV startups that get big are international by default (can you think of one that wasn’t?).

Uber then named UberCab was limited to just San Francisco at the start, they then did other US cities before going international over a year later. https://en.wikipedia.org/wiki/Timeline_of_Uber

Even international by default aka pure internet companies like Facebook start as English only and tend to stay that way for a long time.

Facebook was far from international by default. They scaled very slowly, individual college by college (you needed an email address on a whitelisted .edu domain).

You could still use it in a foreign country when you went home for the summer or on a vacation etc. Edu only was all about fake exclusivity and building a network effect not inherent necessity.

Uber on the other hand is only useful inside specific cities.

No, it was about managing the growth curve. Nobody can turn on a website for the world all at once. It would be better for network building if they could.

It's more than just growth curve as they could have simply limited signups to handle growth issues.

Remember they where .edu only for 2 years even thought they had significant funding. Their core problem was if nobody in Australia signs up then it's boring for the first users in Australia. However, by starting with an EDU focus they could leverage word of mouth to grow a network by location.

The path was starting a Harvard, then other ivy's, then other US collages, then US high-schools. That's clearly designed to leverage exclusivity.

Sure, then how does that compare to non-SV startups in Europe?

How long was Facebook English only after they got VC?

What are you talking about? That's the complete opposite of what happens.

Nordic startups that focus too much on their local market die. The whole point of startups is to SCALE. This cannot be when the country you live in has less population than greater LA.

What actually happens is that the startups here are "Global-first". They immedietly start talking about branching overseas and meeting with investors that can help them do so.

It's actually the SV startups that can huddle in their bubble for years of time, before doing an easy US wide launch, that already is a huge market.

Please. For innovation, Denmark and Finland plays in a different league than Norway. /the swede

Sweden is, not Norwawy.

Yes, I think you are right. There are a lot of factors involved. Hard to say that US success is due to specific things. California is a US state that has higher social support and higher taxes but does well economically. It is too simplistic to say the philosophy of the country is a certain way therefore success.

California has aspects of it that do well economically, overall its situation is quite dismal. It boasts the COLA adjusted highest poverty rate in the country. Worse than Mississippi, West Virginia or Alabama.

[1]http://www.politifact.com/california/statements/2017/jan/20/...

From my experience as someone having moved to California from Canada, it seems there is quite a large homeless population which actively chooses to be in California as opposed to other places owing to its extremely mild climate.

Since I moved to San Jose, it's only rained a handful of times, and this place's harsh colds of winter have reached such dreadful temperatures as I'd witness on a mild fall day in my former country of residence.

That certainly can't help those numbers, even if I do think the absurd costs of living are quite bad, depressing the QOL for everyone outside of the engineer class here.

The median home price to median income ratio in San Francisco is 10.8x.

In San Jose it is 7.8x.

Nationally, it is 3.8x (5.8x in NYC metro).

http://www.burbed.com/wp-content/uploads/2017/09/SFvNational...

Homeless populations are small silver of people measured in thousands, compared the to millions in poverty in california.

And of those homeless, a fraction of them create the 'bad experience' chronic homeless with drug or mental problems that make most people dislike the homeless.

California is doing well economically? No it's not.

How on earth is Norway entrepreneurial by volume OR success?

It's not. They have a lot of oil which allows them to give back to their citizens.

and shit on the environment. this comment thread is full of the exact condescension that conservatives and libertarians are sick of. People who uphold the Constitution and the vision of the Founders are comically uninformed? Stanford's Hoover Institute is comically uninformed? What a joke.

Given every libertarian/conservative economic theory that's been advanced since Reagan entered office has been tried and without exception resulted in increased income inequality and bricking the economy, comically uninformed seems pretty accurate. Given conservatives collective track record of having legislation thrown out in court on constitutional grounds claims of upholding it are likewise clearly unfounded.

Totally and utterly false and uninfotmed nonsense. Quite accurate if leftist policies - the failures of which can be measured and hundreds of millions of dead bodies and collapsed economies.

Is Peter Thiel comically uninformed?

Fascinating. So we should ignore Kansas' state economy going belly up due to grotesque mismanagement by "conservatives" attempting to implement libertarian-inspired economic policies? What about the sharp (and enduring) spikes in income inequality and the market crashes provoked by the Reagan and Bush Jr. regimes? We pretending basic economic indicators are hard to track or something?

Incidentally, you probably don't want to drag body counts into a conversation that's teetering on the brink of a larger critique of capitalism. Unless, that is, you'd like to review deaths world-wide from preventable illness due to lack of access to healthcare? In the US alone it's estimated to be 45,000 deaths annually. Meanwhile Texas (in all it's staunch conservative glory) has 3rd world infant mortality rates.

Regarding collapsed leftist economies, what percentage of these are attributable to inherent failures of socialist policy vs simple economic sabotage and regime tampering by the US and it's allies? Would you like to review what the CIA has been up to since the 1950's?

Or would you rather simply review the number of times conservative legislators have run afoul of the constitution just in the last 5 years? We can start with the electoral maps of North Carolina getting chucked over illegal racist gerrymandering, and a thick stack of executive orders that have died in a judge's trash can this year.

As if upholding "the Constitution and the vision of the Founders" magically makes people informed about everything else?

51% of Republicans STILL believe Barack Obama was born in Kenya. http://www.newsweek.com/trump-birther-obama-poll-republicans...

There are definitely principled conservatives that are highly informed.

But the strategy the Republican party and media uses to win elections, includes a lot of disinformation and caters to the uninformed.

50% of Democrats believed George W Bush was complicit in 9/11 [1].

People like to believe their own tribe is the exalted one, but exploiting the uninformed isn't a partisan strategy.

[1] https://www.politico.com/blogs/ben-smith/2011/04/more-than-h...

and that's a false equivalence. It is provably true that Obama wasn't born in Kenya. However, it is plausible that some in government (not just W) wanted that war. The survey you refer to does not compare to the simple yes/no of the Birther idiocy

I presume you're considering this per capita, and not a raw comparison of volume compare to the US? Norway has a population of around 5 million.

Whether comparing very large and very small populations is reasonable is a separate question mind you, but that aside, the comment stands.

Having lots of natural resources entrepreneutrial.

If not for NATO Sweden and Norway might well be part of Russia.

Nations are not isolated systems. Comparing national policies as though they didn’t interact gives wrong answers.

I find that hard to believe, given that Finland, sitting between Russia and Sweden and Norway, is not a part of Russia.

Finland was invaded by the USSR multiple times and never got the eastern city of Vyborg (as well as a large chunk of national territory) back from Russia, even after the USSR collapsed.

That territory is the price for being in bed with the Germans -- it's like people conveniently seem to forget why it is so; my mother likes to talk about history when she has had too much wine, it's surprising there is anything left between Stalingrad and Berlin -- I still get mistaken for being Jewish which is ironic considering Jews didn't exist in the region I'm from after around 1944 - also about 25% to 30% of the civilian population. Given how much a pain in the ass the Winter War was (my grandfather volunteered for the Red Army in the 1930s) somebody likely decided it simply wasn't worth it at some point to have the Scandinavian countries be part of the USSR -- has it really worked out that bad in the end? Best of both worlds between capitalism/socialism and widely regarded as a region people want to live in.

Can someone please explain why this well written post was downvoted?

Except Finland was never invaded by the USSR at any time after WW2, so NATO can't be implicated in any way for those.

FYI, Finland's relationship with Russia inspired an entire word to describe a country that is not formally occupied, but behaves as if it were:

https://en.wikipedia.org/wiki/Finlandization

Entrepreneurship and cultural appreciation self reliance/independence don't necessarily go together. I think it was a mistake of the GP comment to make that link.

So how much time do these same churches spend supporting policies and politicians that are actively trying to harm people?

> ... europe needs more appreciation of self-reliance and entrepreneurship to enable a richer startup culture ...

A good social support system is not detrimental at all to a rich startup culture. It is financed by taxes, and as startup you only need to pay taxes on profit, so you don't bear any additional costs.

This is a bit simplistic.

If you are in a high-tax state, your employees will pay a lot in taxes, and the cost is passed on to you, their employer. You will need to pay them enough to pay 40% in taxes and have some money left for living expenses.

Which may make your startup (or any business, really) uncompetitive, or even infeasible compared to low-tax countries/states.

There needs to be a cautious balance between providing social support (which I am all for) and overtaxing. For me, the most important part is the amount of tax money that actually goes to benefit the people who need it, rather than the bureaucracy.

In the US, the value we get for our taxes is VERY low.

> Which may make your startup (or any business, really) uncompetitive, or even infeasible compared to low-tax countries/states.

Well, you could have a "unicorn or bust" strategy, chasing primarily high margin b2b and b2c products so big salaries aren't a dealbreaker.

Of course, I just described the current SV startup scene, including why things like Juicero get funded while affordable real estate development is a comparatively unattractive investment.

That's the price you pay for having a big country, there are quite a few benefits you enjoy from this -- carve it up into more easily manageable jurisdictions or deal with it. A bigger fraction of your tax dollars being absorbed by the bureaucracy in the US compared to let's say Canada or Estonia isn't something that can be changed -- your Congress doesn't seem to have an appetite for trimming waste or implementing responsible oversight. How is the Great Wall of Trump doing btw? ;)

More relevant is that a vastly larger fraction of your tax dollars go to things related to the military-industrial complex, aka "defense".

Naw. Take a look at the percentage of GDP the US spent on the military -- 3.3% according to wikipedia, higher than average overall but less than average if you look at other countries that are actively using their militaries -- not necessarily correct unless the mechanics of the tax system are known but it is a vastly closer approximation than what your comment implied.

The flip side is of course:

If you are in a low-tax state, your employees (or you) will pay a lot for things like health care and retirement, and the cost is passed on to you, their employer. You will need to pay them enough to pay those costs and have some money left for living expenses.

Humans, in general, are not good at delayed gratification or long term planning. They don't plan for health care expenses or save enough for retirement. As a result, your employees will for the most part, happily defer those costs which means those costs don't go into the calculus for how much your employees need to get paid to do the work you need of them.

If done well, it will actually help startup culture. How many Americans want to start their own business but can’t afford to lose the health insurance they get with their corporate job?

Looking at the stats the Netherlands had a small budget SURPLUS last year and national debt is only 60% of GDP.

There are economic advantages to a high tax welfare state as well.

Did you just cherry pick one country and make a claim that high tax welfare states have an economic advantage?

Statiticians the world over are rolling over in their graves.

One year in one country no less...

I think it’s more accurate to say we Americans expect/demand self-reliance than it is to say we are more appreciative of it. It doesn’t quite make sense to say we appreciate it—that’d imply we do not expect it, but notice and value it when it is present. Quite the contrary—our culture leaves very little room for appreciating, valuing, revering, looking up to, or attributing positive social accolades to anything but self-reliance.

The general rule in America is that the individual gets all the credit for the great things they do, and doesn’t have to share it with any social inputs/factors—and the individual gets all the blame when society deems them worthless, and society doesn’t have to share any of that blame.

You expect/demand self-reliance? Well, my father finished his studies and had a stable job as an engineer. Suddenly he got ill: Multiple sclerosis (MS). In the early stages he got called a fraud by his parents, people called him lazy. They didn't even know he had MS in the first place. He had tremors in his hands. He could barely walk. He could see less than 10%. He couldn't read anymore, except with special glasses. He couldn't drive anymore. (How this all affected me as a child is another discussion.) His disease slowly progressed. He eventually ended up in a wheel chair, ended up with dialysis, and the plaque in his brains made him look like Alzheimer's. According to the "American Way" [1] he should end up on the street, at the mercy of some philanthropist he'd have to know or magically meet, and if he failed to achieve that, well I guess he didn't pray hard enough? The "European Way" [1] shows mercy. I'm grateful my father lived in Europe when this all happened. The only sad part about the story, is that my father was so pro-capitalist that he voted on political figures who destroyed some bricks of the very system which supported him!

> our culture leaves very little room for appreciating, valuing, revering, looking up to, or attributing positive social accolades to anything but self-reliance.

Our societies are made up by individuals, but we are all in this together. All of us are human beings who are trying their best to succeed in life.

I believe that someone like my father made no known mistake in his life to blame him for his disease (the cause of MS is still unknown), and I have zero understanding for someone who beliefs that he, in his situation, should've ended up on the street, forcing him to be self-reliant. Like, how? He'd have died rather quickly as a blind, homeless man who cannot walk. And his example is just one of the many. I have one word for a society in the 20th/21st century who pushes people towards that path: compassion-less. And I judge a society by the way it treats its weakest links. Because that is a sign of wealth. Not United_States_Dollar-wealth, but maturity of society akin to how a parent nurtures their child. (Its not the same in this context because the child has a chance to succeed in life, but its close, and in case of temporary illnesses its accurate.)

[1] America is bigger than USA, and Europe isn't one nation either. These are caricatures of Europe and America. We're overgeneralizing, in so many ways.

I think we are very much on the same side. I'm not suggesting what the US does is right--I'm criticizing my culture. What I wrote is, to me, inexcusable and deplorable, even as a caricature--albeit one I do not believe is overly broad or unfairly overgeneralized. We need to do much better.

When I say we expect/demand self-reliance, I mean that is the dominant cultural & historical narrative & social expectation here in the US. I do not mean I personally expect or demand that of others as a general rule--but I am expected to. A fair amount of the political division in this country often revolves around where individuals fall on the spectrum of expecting/demanding self-reliance of their fellow citizens. America doesn't care about its poor, homeless, disadvantaged, disabled, and otherwise weaker citizens. In fact, I don't think Americans typically look at such people as citizens at all--or at least not as equals. They are, instead, burdens.

> to enable a richer startup culture

Why is a richer startup culture considered something positive?

It's HN, it's like a mandatory one liner to toss out -- the equivalent to "that's what she said" on here. A healthy diet of HN reinforces the reality from a couple of years ago when things actually seem to look more and more barren with actual opportunities scarcer than ever. But the answer is the idea that these words represent in the heads of the people who spout them doesn't actually reflect what it means in practice.

As an American, getting very sick or hurt shouldn't cause you to lose your entire livelihood. There's no choice there (except in some circumstances). Yet we also perceive "bad luck" as a choice or a matter of circumstances that were the natural outcome of choices either you made or your parents or their parents made.

Unless, of course, you're the one who's afflicted, then all of a sudden, it's a great tragedy and it wasn't your fault. In other words, we're full of shit.

>getting very sick or hurt shouldn't cause you to lose your entire livelihood.

We've had great mechanism to address this, namely insurance and savings. The underlying principle here is planning ahead, and sacrificing some of today's sweet instant gratification in exchange for protection tomorrow should you need it. This is a concept that people have seemed to lose sight of, so we're now seeing people want protection today even though they made no sacrifice yesterday. Those people with zero foresight have now ruined it for the people that did plan ahead.

Yeah, as someone who works in healthcare IT, what we call "insurance" in the US for healthcare in no way resembles a proper insurance model. It's heavily slanted in favor of the insurer, who have zero hesitation kicking people out of the pool, despite having accounted for their costs in their actuarial tables. Despite the fact that the risk of having condition X in the population doesn't change, you're subject to limitations and/or outright rejection should you choose to use that free market you seem so fond of. You can equally be kicked out of that pool despite having made that sacrifice you describe.

For example, health insurers have been found to have done such things as kick cancer patients off insurance as a pre-existing condition, based on previous general practitioner visits. "Oh, we, and you, didn't know it was cancer at the time, you were just sick. But since you were sick shortly after getting insurance, you most likely already had cancer. Therefore it was a pre-existing condition, you didn't disclose it, whether or not you knew about it, and we are terminating your coverage back to the first physician visit about your illness".

Or "We are refusing to cover the costs of the ambulance/air ambulance ride that ferried you to the trauma center after your MVA, because that ride wasn't pre-approved by a call to the insurer".

Both of the above examples happened. I'm not sure what should have happened in either case, but I'm pretty sure in the latter it wasn't, "Hello, Blue Cross? This is John, I'm a paramedic working on one of your patients who was hit by a truck. We would like to fly him to the hospital due to his extensive multisystem trauma but we need your approval. His name? Hang on, let me find his wallet. No, that's Smythe, S-M-Y-T-H-E, sorry, it's a bit loud with the jaws of life in the background... Yes, I can hold for a nurse consult..."

Health insurance in the US is amortization of costs, and has little to do with risk pooling and actuarials.

Counter-counterpoint from an American. It actually is selfishness. Most people and fight and vote in their own self-interest, and only take note of the welfare of others when it affects them directly. Sad, but true..

>>> But equally europe needs more appreciation of self-reliance and entrepreneurship to enable a richer startup culture and let the EU become an economic leader instead of follower

Isn't the EU the biggest economy in the world? For now at least, Brexit and all that...

Depends on how you measure economy size, but by most metrics the EU is a close-ish second.

> europe needs more appreciation of self-reliance and entrepreneurship to enable a richer startup culture

A part of this is cultural (appreciation of self-reliance) but the other half of it (the state-/support-structure-influenced side, let's say) is surely the precise opposite of your suggestion? Countless studies have shown that support structures encourage risk-taking behaviour and entrepeneurship. Even in the US, entrepeneurship will be much more common amongst those with well-educated, supportive family backgrounds - the rags-to-riches stories are certainly highlighted as inspirational examples of the American dream but are minority cases in reality.

Also speaking as an European immigrant who's been living in the US for nearly two decades.

Both of you are right. Americans are not more selfish than other nations, individually. Culturally they do tend to hoist self-reliance up on a high pedestal. In theory these traits should be unrelated, more or less.

However, it is a very unfortunate "feature" of the American political system that there are many, many demagogues who take things that are inherently good, virtues one could say, such as self-reliance, and weaponize them to serve the interests of some extremely selfish rich power brokers. Not every time, but in many cases when you hear the word "freedom" in the American political discourse, you might be close to an example of this pernicious distortion of basic notions.

TLDR: Americans, stop obsessing over by now empty slogans such as "freedom", start thinking more about building a society that works well for all its participants.

USA with a safety net like that of EU would be unstoppable. It's already sort of there business-side, now it needs the social side to work, so any individual who falls on hard times can get back on their feet fast. The EU is too risk averse.

Your comment about religion is incorrect. Americans are very generous: https://givingusa.org/giving-usa-2017-total-charitable-donat.... Conservative Evangelical Churches spend an enormous amount of time and money helping people. For example: The Southern Baptist Convention runs the third largest disaster relief organization in the country behind the Salvation Army (also religious...) and the Red Cross.

I could give lots of other examples. I'm not sure where this perception about religion is coming from. Maybe in Europe the church is largely dead, but that's not true in the US.

> I'm not sure where this perception about religion is coming from.

Mostly the high-profile anti-abortion campaigning (which by extension poisons all women's healthcare and sex education discussions), and homophobia. And the segregation. https://www.nytimes.com/2017/07/17/opinion/why-im-leaving-th...

> Maybe in Europe the church is largely dead

"Europe" is a huge place that's a lot more diverse than the US. Christianity is still official state religion in various places; Germany still has tithing baked into the tax system!

http://www.telegraph.co.uk/news/worldnews/europe/germany/113...

Ireland is in the middle of the long process of evicting its theocracy.

Also, the Salvation Army is an evangelical church, and it is one of the most significant charities in the US.

The Salvation Army has a history of homophobic and anti-lgbtq policies and practices.

My point was that SA itself is an evangelical charity. But you're right that SA (like many religions) considers homosexuality to be sinful to the extent that they'll employ LGBT people in all positions except clergy, and they've served LGBT people in need long before it was fashionable.

Most Christian denominations teach, to one degree or another, "love the sinner but hate the sin." So while they may think of homosexuality as a sin, they don't hate people who are homosexual. All people are sinners, after all.

I agree. AFAIK this holds for SA as well.

> "love the sinner but hate the sin."

The homosexuals still receive a disporpotionate amount of hate relative to "other sins", often by people pretending they are not hating as they parrot this phrase.

Probably, but correlation isn't causation and no group deserves to be judged by its worst constituents.

> correlation isn't causation

That misleadingly implies the reasonable plausibility of a coincidence, for example that it is random chance that gay marriage is a nation-wide political topic but the legal status of eating shellfish isn't.

No it doesn't.

Even if so, if a group shouldn't be judged by its worst constituents, then should it also not be judged by the silent majority who do nothing?

I'm suspicious of SA's support of LGBTQ people actually, given they are in a case in which NYC is pursuing them for anti-trans practices.[1]

1. PDF: http://www1.nyc.gov/assets/cchr/downloads/pdf/press-releases...

NYC government has a particular moral ideology and they don't like that SA performs such an important function (caring for the poor that NYC neglects) in their city without buckling to their moral agenda. They would spend the lives of tens of thousands of impoverished citizens if they could force SA into a more palatable theology.

NYC went after them several years ago for exercising their right to refuse to employ openly gay clergy. They wanted to close down SA in NYC despite that SA provided a huge portion of shelters and other homelessness relief (something like 60% by some measure IIRC). And they wanted to pin the blame on SA ("We can't believe you'd force us to shut you down and let all our poor people starve!") when it was clearly their prerogative. They only changed their minds when it became apparent that they would lose the PR battle.

Around that time, someone started a "Let's hate on SA for being homophobic" thread on Reddit, but so many formerly poor people from all over the country (including many LGBT) came forward with their stories of how the SA saved their family from poverty; none of the first hand accounts corroborated the "SA is homophobic" narrative.

If you truly care about social justice, you support SA because they are clearly doing more good than any similar organization in the US; everything else is just social justice fashion.

You can be both. Not sure how many families you need to save to even out the homophobia.

My perception about religion is coming from the fact that evangelicals supported Trump and recently Roy Moore. Without that support, the ACA wouldn't be dismantled and a lot of minorities would be better off. It's like evangelicals in America invented their own form of Christianity that is far different than what Jesus preached.

The original post was about empathy not "being generous". I was raised in a very religious family and in my experience most religious people are not empathic at all. Yes, there are exceptions, especially amongst the more mystical types, but most religious people are "generous" because they are trying to score points for the afterlife. It's fascinating to see how people act in church (where they feel God is watching) versus how they treat eachother the rest of the week.

Exactly. Generously donating to a charity (or worst case: an anti-abortion fund) has nothing to do with empathy. Even in church I have heard people say the most insensitive things about less fortunate people (sure, she was raped by this violent rapist, but she wants an abortion, tssk!). The most empathic, loving and caring people I know aren't in church.

Could I not restate your comment as "Ignore the measurable stats, my anecdotal experience suggests a lack of empathy?"

In my experience, those who are most empathetic are generous in spirit, which would include not necessarily revealing to you that they are very religious, as well as in generosity toward those in need.

The comparison is valid only if monetary generosity is linked with empathy. It seems as unproven a statement as saying monetary giving frees people from the dirtier emotional work of empathizing.

Societally, not sure it matters much. OTOH, I think it's probably more fair to compare church giving relative to the tax breaks they receive, rather than simply say they give a lot. They do, but it's amplified by a tax deduction, which isn't available to emotionally supporting/empathetic people.

There is, of course, no reason someone couldn't be in both camps, but this comment is long and rambling already.

This is interesting. How would you quantify empathy?

It’s pretty hard to compare. Perhaps donations isn’t the right measure. What is more accurate?

I'm not sure I have a solution for quantifying. Even defining "empathetic acts" is something I struggle with. To me, the crux is whether someone puts themselves in the shoes of a less fortunate person. You can do this without helping, just like you can help without doing this.

Anecdotally, the homeless people I've spent time talking to seem to appreciate the conversation (or maybe being treated as a human being?) as much or more than the dollar or two I frequently give.

Utilitarianism might suggest donations as a decent proxy. Can't say I disagree, although I'd like to know how generous churches can be if they didn't receive a tax break.

Ooh, not so much. There are arguments about that postulate the conservatives give more to charity than liberals.

That's only true when you count religious giving.

Now then, yes, there are many, many valid religious charities (and by this I mean organizations, as well as that component of church giving that factors into benevolence).

But by studies performed by religious organizations themselves (who if anything are likely to skew the numbers more positively), across the board, "Local and national benevolence receives 1 percent of the typical church budget", and an additional 5% goes to "church run programs" (be it after school care, social or group activities).

If a secular charity - and lets go back to Charity Navigator here - Top Ten Inefficient Fundraisers (http://www.charitynavigator.org/index.cfm?bay=topten.detail&...) we see some of the worst charities spending 15% of their donations on "program expenses" (i.e. doing what they are being given money to do).

I'm not familiar with the monitoring of 501(c)3 groups, but I suspect if charities were to regularly spend only one per cent of their givings on what they got to enjoy tax exemption to do, they'd likely have such a status revoked.

And, if you factor in this average percentage (even the six per cent combined, which is generous, as as much fun as social and youth activities are, they're not necessarily serving a critical need), and start to question 'how much money is being spent on 'spreading the word', patting themselves on the back, competitions in Texas to see who can built the world's biggest cross just down the road from where the world's previously biggest cross was built at costs of millions, there comes more and more skepticism of just how highly you can value "giving to your church" on the scale of charitable contributions.

What's the Dutch perspective on American media?

We don't watch much American (news) media, but our own journalists say they try to not directly quote the hyperpartisan, hyperbolic, fear-instilling American media but go to the source whenever possible.

>> What's the Dutch perspective on American media?

My perspective on American media is that even though everyone has access to (mostly) unbiased, factual sources, quality investigative journalism, uncensored internet etc, for some reason a very large cross-section of the population willingly chooses to believe the partisan crap and plain and simple bullshit peddled by outlets like Fox News and (to a somewhat lesser degree) MSNBC. I regularly visit the US, and frankly I'm appalled by the downright evil crap that seems to be on 90% of the time on televisions everywhere in public. I would be thoroughly embarrassed if the situation at home would be even remotely comparable. And now you have a POTUS that actively promotes to make the situation even worse by labeling anything he dislikes as 'fake news', while at the same time spreading easily falsifiable information as truth.

I really have no idea how the US got to this place. The problem is not that the US does not have free press, but there seems to be a level of partisanship that feeds this vicious cycle of misinformation, always putting the blame at the other side, and a total disregard for simple facts that things could be so much better for everyone if the two sides would actually try to work together and find compromises for once.

The health care system is just an example of this. Even though there are countless examples of developed countries that have a much better system with significantly lower costs because of things like single-payer insurance, maximum tariffs, etc, somehow the american people don't want it 'because socialism' or whatever nonsensical argument based on the in-grained illusion of the 'American Dream' of a merit-based society where everyone decides their own fortune. Meanwhile social mobility in the US is among the lowest of all developed nations. The level of cognitive dissonance really is mind-blowing.

I think what people in Europe don't appreciate about American healthcare is that the quality of care is a bi-modal (or maybe even more than 2 modes) distribution where a very large fraction of the population does in fact have the best access and quality of care in the world. On the other hand, there is a significant fraction of the population that has a lower overall access and quality of care. It is not irrational for the 40% to 70% (the fractions are debatable) of the population to not want to reduce their quality of care to average European care, which is in fact a lower standard for them.

Right...

According to the WHO [1] the US health care system scores first on exactly one metric, which is cost...

It boggles the mind that someone could rationalize a healthcare system that leaves millions of people uninsured, bankrupts and destroys people unfortunate enough to attract even minor health problems, and results in higher costs than anywhere in the world as ‘better’ than ‘average European care’, because it is ‘bimodal’. What does that even mean, practically speaking? What does the US health care system offer the more fortunate citizens that you won’t have in, say, Japan, or Sweden, Malaysia, the Netherlands?

Question: do you think people live longer in the US, compared to other countries? Die less of common illnesses? Can get treatments for covering the 99% most common health care needs that are available exclusively in the US? I don’t think so...

[1] https://en.m.wikipedia.org/wiki/World_Health_Organization_ra...

I think you completely missed what I said...you are again pointing at numbers that compare averages and I am saying that the averages are irrelevant. If half the people do great and half do terrible, the avergage will look merely ok but the people doing great aren't irrational to want to continue to do great. How is that in any way in conflict with WHO metrics?

I understand what you were saying, but my point is that it doesn't make a lot of sense.

What I'm saying is that you can have a system that is great for probably close to 95% of all health care needs, at lower cost and for all of your population. This is what the WHO data shows. For the remaining health care needs there may be differences between countries, but I don't see any evidence the US is leading in all forms of advanced treatments (obviously they are in some, but not all). For example, survival rates for the most common forms of cancer are not all that different between US and Europe or Asia, and not highest in the US for all of them [1].

What I don't understand is what you mean by 'half the people do great' in the US system, and in which way it is 'better' than other countries? Do you assume they fix a broken leg better in the US than in say Canada? That better medicines for common illness are only available in the US? Is the hospital staff more friendly, or do the ambulances drive faster because you paid more for your insurance? I'm not trolling, I'm sincerely curious what you mean.

Whether it is rational to prefer a system where you pay (a lot) more for probably all the health care you will ever need in your whole life, under the premise that there is a very small chance you would attract a condition that requires treatment that may not be 'best in the world' in your country and health care system, that's a different question. It does not seem rational to me, for lack of evidence the quality of care would go down if the system were built on solidarity instead of egoism. Anyway, I don't think it actually matters when comparing health care systems. In the end only survival rates and available treatments are relevant, and I don't see any signs the rest of the developed world is severely trailing the US in that regard.

By the way, I cannot speak for other countries, but e.g. in the Dutch health care system you are also insured for treatments that are only available overseas. For example rare forms of cancer or genetic diseases. So even under the assumption such treatments are always exclusively available in the US, this does not mean you are left hung to dry if you are unfortunate enough to suffer from them.

[1] https://www.cdc.gov/cancer/dcpc/research/articles/concord-2....

Because it's not true. I think there's very cogent arguments to be made to say that, should you have certain severe conditions (cardiovascular, cancer), some of the best treatments in the world are indeed to be found in the US.

I think it's equally plausible to say that over the last 30 years, family/general/primary care practice has deteriorated, significantly, where priorities have shifted to billing from patient care, witness less times spent on visits, more of a rush to prescribe at times often unneeded medications, a swarm of at times invasive imaging to prevent not just deterioration, but litigation. I think it's hard to argue that the above is automatically a "higher standard of care" than received by the "average European".

We love Netflix and HBO.

I mean we KNOW that the US is a sinking ship and that in order for our continued economic success a pivot to China/Asia is necessary. But American TV shows are just too good.

You're aware that China's economy is propped up in large part by their government and is enabling speculative investments far and away above what happened between 2000 and 2007, right? Not exactly where I'd want to tie my economic hopes.

As an american I tend to agree with your viewpoint except for one- We are still the best in the world :)

Can you expand on that?

Show me all the indices where the US is #1 and I'll take your argument in consideration.

At what?

As measured .. how? I understand liking your country. I'm an American, too. I like my country, a lot. But, I think that the phrase "we are the best in the world" gets thrown around a lot as a meaningless platitude. It gets used more as a "my team is the Yankees"-style of statement. e.g. expressing your preference/allegiance, rather than meaning what it actually says, which is that the US is the 'best' in the world.

To be the 'best' at something, you need to define how you're measuring that. Healthiest? Happiest? Longest life span? Because when you look at actual metrics for these types of things, across multiple countries, the US does not rate at the top.

Have you seen this clip of Jeff Daniels in "The Newsroom"? https://www.youtube.com/watch?v=wTjMqda19wk ("America is not the greatest country in the world anymore")

Your comment has almost nothing to do with the actual point raised in the article and is just a general tirade critical of the US. How does your comment relate to the the main cause of issues in American healthcare: raw cost of care?

Why should it take 10s of thousands of dollars to get 20 mins of general anesthesia (like it costed me, billed to my insurance)? And what does that cost have to do with "empathy" or "ego" of Americans?

Because you're told that the flawed way OP set out is the better way despite the lack of results.

Could you explain your comment please? It's not clear (at least I don't get it), what do you mean by flawed way and better way.

Take the first point, "The US is philosophically much more egotistic than other developed countries". If all Americans accepted that they as a whole would pay less if they pre-paid in taxes rather than post-treatment bills then the country would be better off. What's stopping them accept this is the overlap of media, politicians, rich people (and maybe more, not my area of expertise) telling you that isn't true. The better way is to ignore them, to let money speak not money holders.

That can be expanded on with another point, the American dream. If the millionaires tell an American dreamer that something isn't a good idea the dreamer will consider it a roadblock to their own riches.

> If all Americans accepted that they as a whole would pay less if they pre-paid in taxes rather than post-treatment bills then the country would be better off.

> What's stopping them accept this is the overlap of media, politicians, rich people (and maybe more, not my area of expertise) telling you that isn't true. The better way is to ignore them, to let money speak not money holders.

Or perhaps this is just not true. See adventured's comment.

And also, why should all Americans prepay in taxes to subsidize 10s of thousands of dollars for one 20 min anesthesia session? Why should they continue encourage these insane health care costs by pre paying for them? How is the country better off this way?

It's not just one 20 minute session. It's the lifetime of care of an average person, or the average cost per person of care for the nation.

Evidently, the US could change the system to work better, but there's a general unwillingness to change it because it would mean they would have to compromise on taxation and captilist ideals, something they're unable to do, because there are cultural premises in their way.

The reason the US healthcare system remains as it is, is because it's actually working extremely well for the top 1/3, which also happens to be most of the voters.

If you make $50,000 per year in the US, which is the median full-time wage, your healthcare is almost entirely paid for by your job. The top 1/3 earns far more than that, they have extremely good coverage and extremely fast access to healthcare - along with easy access to the world's best medical technology and drugs - that is superior to comparable systems in Canada and the UK. The top 1/3 in the US do not suffer from rationed care, as other systems do. That top 1/3 has access to elite doctors, and elite hospitals. That top 1/3 is the wealthiest large group of people on earth, in basically every regard.

That top 1/3 has absolutely no interest in changing the status quo until it no longer works for them.

The elderly in the US also do not want the system changed. In France, Canada, the UK, and many other similar nations old people have highly rationed care access. Whereas in the US, old people drain an immense share of healthcare resources, far out of proportion to comparable nations. Old people in the US are a large voting block, and a rather powerful influence group (AARP etc) in terms of lobbying to keep what they have.

The bottom 1/5 gets free healthcare, and it's OK. In the US, it's primarily the next 20% above the bottom 20%, that suffers when it comes to the existing system (they make enough money from time to time to fall on and off free healthcare, they're trapped in healthcare hell frequently, and they make up a large percentage of the people that declare medical bankruptcies every year).

I think this is the most rational analysis on this thread.

And Congress gets their own healthcare plan. They don't have to use the system they create for the rest of us.

This is really accurate. As someone who used to live in Canada, the top 1/3 of Americans with good insurance would scream bloody murder if they had live with the Canadian system.

>>> If you make $50,000 per year in the US, which is the median full-time wage

That's household wage, not full time wage.

I'm confused about the top 1/3 references. You're not comparing like with like at all.

Are you under the impression private insurance is inaccessible to the top 1/3 of Canada?

I bought biking shorts yesterday it was an American medium/European large. Americans eat way too much easy carbs and "unhappy" meat. Sure there are other reasons but this is the reason they spend so much. Ppl would be willing to pay healthcare for others who fall on bad times, but most sick ppl are ppl who made bad lifestyle choices and everyone knows this.

Very true. While chasing American Dream people of America have become very much business minded and profit-centric. American egoism basically means looking for "Whats in it for me?" everywhere.

I agree with a lot of your points, but "Religion is not focused on empathy at all anymore, if it ever was" is a bit of a blanket statement and is mostly untrue. It is certainly true for certain fundamentalist groups. Those are the loudest groups but are a minority among religions here in the states.

I was raised Protestant and am now Catholic. The mainline Protestant churches, the majority of the Catholic church, and every Jewish and Muslim organization I've encountered-- all very much focus on social justice. The USCCB (Catholic bishops) were big proponents of Obama Care before they realized it would contain some clauses that ran afoul of magisterial Catholic teaching. In general, I'd say that religion here has a heavy focus on empathy.

[EDIT: spelling]

I'm too young to remember, but I feel that religion or religious people in America used to be deeply empathetic. Every single person I've known from the Greatest Generation seem to have strong senses of empathy and generally live mindfully.

Nowadays it seems that a lot of that has died out in most places though...except for like, Utah...

You’ve confused the problem with solution.

The problem is government (as I will attempt to explain), so the solution can not be more government.

Healthcare started to go very wrong in this country when the government stepped in [1].

Because of tax laws, it became more economical for employers to provide healthcare insurance. This has all sorts of consequences.

1) I don’t pay the premiums, so it doesn’t matter how often I go to the doctor. It is essentially free to me.

2) I’m not price sensitive about the service the insurance pays for and I’m not price sensitive for the premiums paid by my employer.

3) Having customers who are not price sensitive reduces incentives to lower prices.

Then there are the government regulations that limit the supply of healthcare services[2].

Then there’s out out of control sue-happy society who are encouraged to sue everyone if they don’t like their outcome[3]. We need tort reform.

The problem with Europe is that you guys don’t seem to understand the difference in scale, culture, and demographics between our situations.

You guys have small nations with homogeneous cultures. So, you’ll have to excuse us for not taking your advice.

The closest you’ve come to rivaling the US government is the EU and look how well that’s going. It’s a hard problem and we’re actually doing pretty good.

1- http://www.americanthinker.com/articles/2009/09/understandin...

2- https://scholarlycommons.law.case.edu/cgi/viewcontent.cgi?ar...

3- https://www.forbes.com/sites/rickungar/2010/09/07/the-true-c...

Do you go to the doctor when you don't need to? Going to the doctor is essentially free to me as well and I haven't gone in years.

Elasticity of demand goes both ways.

States like mine (Texas) have instituted tort reform. What happened? Insurance prices stayed the same and the insurance companies pocketed the difference. Also, hospitals had far less incentive to self-police their employees so we ended up with a lot of bad doctors and surgeons blithely continuing their malpractice.

As for scale: cost-sharing scales phenomenally well. Larger scale is an argument for national healthcare in the US.

I've never understood the perceived mechanism between the 'culture and demographics' argument.

To explain “need to go to the doctor”...

To be clear, I’m talking about the cost/benefit. If the cost is $0, then that equation is out of balance. There are literally people going to the ER for a stomach ache. I’m only going off of personal experience here.

You made a few interesting assertions about TX without references. Could you please site statistics for the increase of malpractice since tort reform went in place?

Looking for myself, I only found articles refuting your assertion about insurance premiums [1].

1- https://www.insurancejournal.com/news/southcentral/2013/09/0...

https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1635882

"...find no evidence of reduced spending in Texas post-reform, and some evidence that physician spending rose in Texas relative to control states. In sum, we find no evidence that Texas’s tort reforms bent the cost curve downward."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5701901/

"...our conclusion is that reforming the malpractice environment has largely insignificant economic implications for health insurance markets."

So, I mispoke. Claims went down 75%. Malpractice premiums went down 50%. Yet, overall, medical costs to insurance companies and consumers rose at the same rate as everyone else.

http://www.wfaa.com/news/prescription-for-disaster-is-the-sy...

https://www.theguardian.com/world/2014/may/02/texas-legal-do...

And, finally, here are the numbers of cases referred to the Texas Medical Board for investigation.

http://www.tmb.state.tx.us/dl/63D5291E-982C-D14C-B266-8983C5...

  medical costs to insurance companies and consumers rose

that directly contradicts what you wrote in the parent comment.

You have expertly found a flaw in my offhand comment.

But the point, that much lauded tort reform doesn't do much, if anything, to help consumers (and, in fact, could hurt them) in the healthcare space, stands.

If you step back from pedantry and consider ideas rather than pick apart the flaws in the imperfect words used to express ideas, you might find that the world becomes a more interesting place.

  Insurance prices stayed the same

... which is a big improvement over double-digit-percentage annual increases in the rest of the country.

I'll just pick on the low hanging fruit here:

>> Conservative media does a very good job at keeping at least 50% of the country comically uninformed...

goes both ways depending on your "camp". it's funny though how this contradicts your point about US being "divided" since clearly this statement is as partisan as it gets.

>> The "American Dream" gives people the impression that working hard solves everything and that their country is the best in the world period

what's wrong with that exactly?

>>working hard solves everything and that their country is the best in the world period

>what's wrong with that exactly?

I think I can answer this.

The Puritan work ethic is great. Working hard actually does solve many, many problems.

So, why is there an issue? When it is assumed that working hard fixes all problems, then it is also assumed that if there are problems then the reason must be that someone didn't work hard enough to solve that problem. This causes people to dismiss problems as if they know the root cause when they really don't. This is a huge problem.

As for the 'best in the world, period' issue? Well, when you're convinced you are already the best, why work to improve? If there are problems showing, then it must be a fundamental characteristic of life or the situation we find ourselves in (the 'we have a very heterogeneous society so other nation's solutions couldn't possibly work here' argument comes to mind), not that we could possibly need to improve. We're already the best!

Resting on one's laurals. Never a good thing.

I've always thought the biggest "root cause" issue of what we see is that our political system doesn't handle trial and error well at all...anymore.

In the last 100 years the US has moved much more towards consolidated federal policy. Federal level policy comes with a lot of issues.

First, combining politics with trial and error doesn't work in a 2 party system. 1 party will point out its flaws, while the other party will pretend they don't exist or be defensive about those flaws. The country will be left with people who feel the pain of that problem and those who do not. The ones who feel the pain will vote to end the pain, regardless of anything else. The ones who don't feel the pain won't see the big deal and will focus on other issues...and those other issues will be seen as issues that the other party was voting "against".

The other issue is that with federal policy, the entire country suffers from the consequences of issues. Once the legislation is in place, it's nearly impossible to change or remove so if you think there MIGHT be an issue you're better off voting staunchly against it.

State level policy doesn't suffer from this issue. With 50 states and a national idea that all policy should be state level, we'd have 50 experiments. If one state tried something and it worked, other states would research what they did and follow suit. If it didn't work, they'd stay away. Or try something new. County/City level is even better.

That's why when people were selling the ACA as "what Romney did in his state" were missing the point. The point was that was state level...so other states could follow if they wanted. It didn't mean that should be the policy at a federal level. The entire point was that it was a state level policy.

At the federal level and in the election, Hillary wouldn't even acknowledge there were problems with the ACA and IMO that is what cost her the election, because new premium letters started coming out just before election and there was a lot of pain to go around.

>The point was that was state level...so other states could follow if they wanted.

When it comes to cost-sharing schemes the bigger the pool the better -- costs are more predictable the more people are in the pool.

I agree with the general idea that laboratory democracy is a good idea but health care costs, 'insurance' etc. are well understood and best handled at the largest level possible.

Hillary acknowledged problems with the ACA but believed that it needed to be patched, not re-written from scratch.

I agree. A few patches that would have a big impact:

A national public option to force competition (along with cross-state selling of insurance -- but not one without the other or at least that cross-state selling of insurance must be done across all states if offered that way) would go a long way to pushing competition and reducing perverse incentives that the ACA created with the 'profits based on percentage spent on care' scheme.

Redefining full-time employees as full-time equivalents for defining thresholds within the law. This was a flat-out mistake that pushed some employers to do some very silly things.

Create incentives for patients to shop around for the best cost of care.

Require some level of transparency in pricing even if it is only common treatments and tests.

The mandate would have to stay. The choice is, have a mandate and force people to buy insurance they need or don't have a mandate and force people who buy insurance to pay for the health risk of those who mistakenly believe they shouldn't have to pay for their own.

I tend to agree with you on all of those point, for a cost sharing scheme.

When a lot of people don't want the policy at all it becomes a cost forcing scheme though...and that's the crux of the problem.

If this was California legislation and it had problems, local politicians in California would be campaigning to make the changes right now. The question of how long we're going to be stuck with the current issues is where the federal flaw lies. It removes the ability of people to adapt and react to problems. The larger pool is a negative when the pool size expands the scope of issues.

Unless we are going to, as a society, agree that people who don't pay don't get treated for disease, then it is a cost-forcing scheme whichever path is chosen.

Before the ACA those that paid for insurance were forced to shoulder the cost of those that didn't. Now, those who think they don't want to pay for health insurance are forced to pay one way or another (though I think the penalty is too small).

I find it hard to feel bad for people that don't want to pay for their own health risk or who think they don't have any.

> Now, those who think they don't want to pay for health insurance are forced to pay one way or another

Not anymore. The new tax law removed the individual mandate.

True. I forgot about that.

Trump seems to think it will lead to the ACA falling apart. He might be right but only as part of the entire current insurance system falling apart around it. I really don't know what the intention was, there. As simple as fulfilling a campaign promise no matter the cost?

The issue is that based on the reasoning that people who were paying for insurance before were already bearing the costs. If that’s the case then it doesn’t make much sense for those same people to see dramatic cost increases.

Unless there are other variables at play that contribute to the cost increases of premiums, which, of course, there are.

I lean heavily towards the libertarian side of things, but it didn't take that long for me to come to the conclusion that unless "we" (as a society) were going to let people die in the streets from curable diseases, we are all going to pay for everyone's health insurance, in some way/shape/form anyway.

I still believe a more open market would be a "better" solution, with a tight safety net to maintain standards across economic levels, but as that is unlikely, fixing the glaring issues with the ACA seems like a good starting point.

I agree.

There is no reason we can't pursue both simultaneously. Nothing in the ACA prevents posting of price lists or incentivizing patients with cash payouts for finding cheaper than average care.

That is what has driven me crazy about politics -- it is more about making noise about the other side than actually doing something that might push things forward. Republicans could have pushed open market reforms the moment ACA was passed. If they did it on a state by state level they could even point to data of success vs pure ACA states to bolster their agenda.

Indeed. The cancer at the heart of the american dream can be summarised by the cry of the rugged individualist: "Why should I pay for your health care?"

Wrong. Many Americans, including myself, think of personal responsibility first. Actions may have consequences, period.

I exercise regularly, eat healthy, keep the amount of sugar/glucose I consume to a minimum, keep alcohol and drug use in check and I don't smoke. Those are MY life choices. Nobody forced me to do any of the above. I choose to live this way because I want to remain healthy and hopefully life a long, healthy life.

So why do I ask the question of "Why should I pay for your health care"?

If an individual smokes regularly, eats McDonalds weekly or more, does not exercise or even attempt too, does not get adequate sleep, is morbidly obese for a large portion of their life (due to their decisions above), and regularly partakes in a large amount of alcohol and drug use, it is almost CERTAIN that their cost of health care, especially later in life, will be magnitudes higher. Those are decisions THEY made. Not me, not the government, themselves.

So no, I will not pay for your healthcare when you make the decision to live a life like that. Take responsibility on yourself. Want to ignore your body? Fine, but don't make me pay for it.

Unfortunately, a larger percent of our population is obese, which is one of the largest causes of other complications that end up costing our healthcare system a considerable amount. If we could focus that money into solving health issues that are not the cause of an individuals' actions, we would have cancer solved by now. But no, we spend it on the guy who is 55 and weighs 450 lbs because he ate fast food every fucking day for the last 25 years. No. Just No.

Sorry this is just such a bad, bad, bad example. It completely ignores so many facts:

1) Your example ignores accidents that happen: people get sick even when they've got healthy lifestyles, people are hurt in accidents, etc. Sometimes you have a baby prematurely born that has to stay in the NICU for months, already running up a $1 mil bill before they've even come home. Childhood cancers.

2) A lot of what gets people unhealthy is also things that they aren't aware of. We've only in the past 5-10 years had more awareness of just how much sugar is in EVERYTHING. Same goes for chemicals, pesticides. These are all choices that consumers haven't actively made, but were made for them by money'd interests.

3) Would you say the same about your parents? About your loved ones? About your children that ate too much candy, or drove too fast in their teenage years? Probably not.

My opinion is that American society (of which I'm a part of) has gone too far in the direction of individuality and "I've got mine, screw you" – and we're all suffering for it. We no longer think as a collective, but instead just look at everything through the lens of ourselves. Healthy people included. You just don't know it yet.

My argument is made against things you CAN control and DO know about. Sorry, I should have included that disclaimer.

So taking that into account now, is it still a bad example? Should I pay for somebody's lung cancer treatment after they have smoked a pack or more a day for the last 30 years? We have been well aware of the risks with smoking and we can almost for certain say the lung cancer has a high correlation to the 30 year smoking history. So yes, that person knowingly made that decision, why do I have to pay for it?

I'm sorry, but there has to be consequences for peoples decisions. We can't all grow up eating fast food, smoking, drinking, watching Netflix and getting fat knowing that our long term healthcare costs per individual that chooses that lifestyle will be astronomical. Society can't afford that.

Also, we are learning more and more about just how much being obese affects the rest of your health. Along with more correlations in the causes of cancer. Yes, there are many things we do not know, and I do not fault anyone for that. But a large percent of health issues and the costs associated with those in America are VERY well known and VERY much preventable. Period.

I would never want the government to step in and say, no you can't eat that twinkie because your BMI is over a certain level. I will always advocate for an individuals right to make a decision for themselves. However, if they know the risks and consequences associated with those decisions and still choose to make them, why in hell would that burden fall on the rest of the society?

I think you need to go read, or re-read, Adam Smith's book, The Wealth of Nations, or the principles of enlighten self interest. You have the wrong mindset that taking personal responsibility for your own actions is a "I've got mine - screw you" thing. Suffering? The freedom for individuals to make their own decisions and why we are a prosperous nation in the first place. It's why people came here. What do you propose as far as going in the right direction of individuality? Limiting consequences of known actions? Forced government redistribution? Maybe I just live in a very nice state (Texas), but down here, we do take care of our neighbor. We do help one another when in need. I would even say we do so more today than ever before. However when you knowingly do something on your own accord that is risky, you will pay for the consequences, not your neighbor. Maybe we should just take the approach of, hey, I know you smoked for 30 years knowing it will kill you eventually and will cost a ton in medical bills... and we told you that every single time you took a cigarette out of the pack, but we'll cover that cost for you! Hey, we know you were fully aware that when you robbed that store that the risks of getting caught were high and the consequence is going to jail, but you know what? We'll pay that for you too and you're free to go. You can't remove consequence from the decision making process, it's human nature.

I assure you, if you measured the amount of hours people in America spend talking about healthcare, health insurance, and employer insurance policies in the workplace, you'd really see how anxious we are as a society because we simply have no great guarantee of something as basic as healthcare. It's like walking on thin ice.

As a society, we decided we are (generally) ok to pay for a road even if someone speeds or drives drunk on it, or we are fine to pay for good public education even if many kids drop out of school, because on the whole, these things are a net benefit to society when more of the population can take advantage of it.

Why isn't healthcare one of those things? I used to date a woman who grew up in Canada, and she talked about how strong dental care was there, where all the kids were taught the right habits for dental care automatically. IT didn't matter what money you had, you all had access to not only good dental care, but also information about what makes your teeth go bad, etc.

Similarly, in the US maybe we would actually have less obesity with a combination of preventative care and more education about some of these things. I'm not saying we'd eradicate it of course. But we'd most definitely have less.

I can't imagine someone would be even more irresponsible with their health if medical care was free. Only because the opposite isn't true (people aren't less reckless just because medical care is so expensive)

Don't you have health insurance? How is that different?

As a European immigrant to the US, it pains me to see such misconceptions so widely held. Some of this is complete nonsense, but some stems from a mix of unsophisticated thinking and a profound lack of understanding of the country.

> The US is philosophically much more egotistic than other developed countries

A weakness and a strength, see below.

> Politically the US is the most divided western country with its two party system

Political gridlock and fighting is largely irrelevant because the commercial sphere is the real motive force of the country. This point seems especially difficult to comprehend for Europeans accustomed to pervasive state participation in daily life. The vibrancy and diversity of the capitalist economy here is unparalleled.

> Money in politics means it's one of the most corrupt

The corruption flows from America's egotism; money is a red-herring. Political fund-raising is about relative success, not absolute (you just need to outspend your opponent), so the vast amounts in play are simply a function of a zero-sum arms race: American society deploying its ever-growing wealth to buy a fixed quantity of political influence. $1M creates no more obligation than $1000 if the latter is sufficient to win.

> Conservative media does a very good job at keeping at least 50% of the country comically uninformed

This is just silly. Fox News is 95% of "conservative media," and viewership on any given night is 2.6 million people, ~0.8% of the population. Multiply by whatever fudge factor you want to get to total viewership. You've got a ways to go to get to half the country.

> The billionare .0001% will probably do their utmost to keep the status quo

Paranoid, conspiracy-minded nonsense.

> The "American Dream" gives people the impression that working hard solves everything and that their country is the best in the world period.

This is very true, conditional on you being capable. The USA has an immensely deep bench of talent and does an excellent job assimilating talent from around the world. All of these talented people are immensely incentivized to deliver, and they deliver in spades! Their contributions pull the rest of the world up with them, despite all the inequality belly-aching from collectivist types. If you are a person of intelligence and ambition, there is no better place than the US to maximize your gifts.

> The US is doing very good in a lot of areas

You're damn right it is! Most curiously to me, many Europeans bemoan the state of our lower and middle classes, despite those same people doing _better_ than their European counterparts on almost every material measure at almost every decile! [try to play with e.g. EDHI by DECILE at http://www.lisdatacenter.org/data-access/

> but I think collective egotism is preventing it from reaching its true potential.

Perhaps. It certainly makes it more difficult to solve certain collective action problems, but it also encourages citizens to tackle problems others find trivial. I doubt, for example, that Twitter could have been built outside the US: the a priori use is to selfishly broadcast thoughts about me, me, me; the vast social utility is an emergent property.

I am probably what you would consider an extreme conservative, but I wanted to thank you for sharing your perspective. What do you mean by:

> The US is philosophically much more egotistical than other developed countries.

It isn't a criticism that I had heard before.

> Conservative media does a very good job at keeping at least 50% of the country comically uninformed

A bit of an oversimplification. More like it keeps about 25-30% convinced they'll someday be a CEO of a corporation, so to vote in the interest of businesses. There's another 5-10% that have zero issues taking advantage of that naiveté for their own end goals.

But, on the other side, you have a highly apathetic and disillusioned crowd who hardly show up to vote. And, who can blame them? The system seems built against their own interests. But it's a self-destructive thought process.

"The US spends more on healthcare because the prices are higher!"

Um, okay. Duh. A better question to ask would be: Why are prices not falling? In the "normal" economy, people can't offer any arbitrarily high price they want: They have to compete with others to offer their good or service at a low price. The more you raise your price, the more you invite competition and give them room to run a profitable business.

Anyone who has gone to a doctors office or hospital lately knows why there is so much overspending in health care: The health care system is the most fucked up, overcomplicated, ridiculous system you could possibly imagine. You start out by filling out a big paper form with all your info on it... They use that to bill your insurance, which then says okay, we're going to pay you half of what you asked for. What ridiculously perverse incentives. Now the provider will naturally ask for twice as much, knowing they won't get everything they bill for.

Health Care will be fixed not by laws or insurance companies, but by technical innovation and good old fashioned economics. You know, those old ideas Adam Smith had. If there was serious technical and economic / business model innovation in the industry (an Apple of health care) prices would go down, outcomes would improve, etc.

Because there is no competition on the supply side. Do you shop around when you're gravely sick? Can you even get transparent prices out of hospitals?

Exactly. There is no competition on the supply side. Suppliers are often granted legal monopolies as a matter of fact!

The incindental economist blog covers this issue well. Basically you have providers and payers both striving to be monopolies. Payers are a two sided monopoly so they can pass on costs. Patients are a captive audience.

> "The US spends more on healthcare because the prices are higher!"

> Um, okay. Duh. A better question to ask would be: Why are prices not falling?

It's an excellent observation, and it begs your excellent question.

Unfortunately, we can't get to an excellent answer. The US is ideologically incapable of acknowledging that "market failure" exists.

Health care is the absolute prime example of a Veblen good as people are willing to pay for perceived quality. After all would you prefer the heart surgeon who charges $5000 or the one who can charge $25000

Seems like a bad example. All board certified cardiothoracic surgeons have to report their mortality rates from procedures (there are problems with that, but one could easily look this up). Not to mention most work for a hospital and therefore have a fixed salary. On top of this, most healthcare consumers in America are directed by their insurance provider as to who they can even go to for these sort of procedures.

I'm in the UK not the US. The example is actually a friend who has watched his private practice (1 day a week) expand as he tried to reduce demand by increasing his rates.

Oh, I see. I figured you were talking about the US due to the article. Your friend works one day a week?? That's awesome.

4 days NHS (the day job), 1 day private practice. That's typical for Consultants in the UK...

After I posted the comment I figured that was the case.

> Not to mention most work for a hospital and therefore have a fixed salary.

Unless you have knowledge to the contrary, I'd dispute this. Most physicians, and specialists in hospitals in at least the Pacific North West are NOT hospital employees.

This is how you can get into ridiculous situations where your hospital is "in network", but your provider is not (because of course, you get a choice on the physician you are assigned at a hospital, especially in ED...).

Mortality rate is a poor metric.

First, it "penalizes" doctors/hospitals that take on the most severe cases. There is no objective metric for "we saved X people who would have died at an average facility." Do you want a metric that would encourage a doctor/hospital to deny an aggressive procedure for fear of taking a hit in its mortality metrics?

Secondly, it ignores ongoing quality of life. A cardiac surgery can have a later death that does not count in its mortality rate, even if it was due to a complication caused by, or significantly contributed to, by inferior medicine.

Oh, I'm in agreement, and should have made my point about this more clear. The reason I brought it up at all is that there are other external factors that influence a patients decision, or lack thereof, in choosing a CT surgeon for their non urgent (or emergency I guess, but there's even less choice there) procedure.

You'd probably find most people would go with the $5,000 guy.

We're not talking Drunk Eddie suddenly being allowed to practice as a surgeon, the $5k guy will still have standards and steady hands.

The risk differential is probably not worth a cheap car.

Especially if you can only borrow 5k

A concrete example: Private health insurance in the UK is cheap, because it excludes a lot of the basics - you use the NHS for that, and only call your private insurer if you e.g. need a specialist or if you can't get an appointment with your GP.

Yet only 10% opt for it, because the NHS is generally good enough. And of those 10% a lot only have it because it's offered as a mostly free perk by their employer.

But I do think that there is a segment - part of those 10% who opt for private insurance - that will always pay extra to get "the best" whether or not there is a major difference.

This. I moved to Switzerland a while ago and noticed that they are suffering from the same issue: Switzerland is one of the richest countries in Europe and just like the US, they are also faced with health care costs that are completely getting out of hand.

Another example is day care for children, which is also disproportionally expensive here. Both are cases when people just don't want to cut on money, they want to have the best option for their health or their children, the costs are only a secondary consideration. Which means that the health care market has not much of a competition on prices and as a result everything that is health related is expensive. Even basic things like nutrition supplements are around 5 times more expensive than in other European countries.

> Health care is the absolute prime example of a Veblen good

"Veblen Good: A good for which demand increases as the price increases, because of its exclusive nature and appeal as a status symbol."

I'm not following. Heart surgery demand is based on having a heart problem. Taking a step back, health care encompasses more than just picking a heart surgeon. Most practitioners won't tell you the dollar price of a service beforehand even if you ask. Standard behavior is to go see whoever is covered by your insurance.

> Standard behavior is to go see whoever is covered by your insurance.

Standard behavior is to see the best provider covered by your insurance.

It's a small textual difference, but a massive actual difference (and what makes it a Veblen good).

Well, unfortunately both surgeons charge the same, which is the maximum what your insurance pays. Capitalism doesn't work here.

Are we having a market failure, or a failure to have a market?

I'm content with either framing. Both can be fixed through deliberate construction of a market using regulation.

But in the US, we don't acknowledge that we are already regulating, and we are wholly ideologically committed to the notion that "regulation" is bad.

Things like Lasik, Invisialign, and plastic surgery prove the market can work in healthcare. They are relatively affordable and good service is easy to find.

I will admit that these may work because they fall into the area of human vanity, and our current image obsessed society may be driving that behavior.

But then, doesn't that hint the total healthcare market could work with similar market adhering dynamics as in Lasik (its easy to get a quote and find a competent doctor) and a long run advertising campaign, a la brushing teeth back in the day, to get people to have regular checkups rather than ER visits.

Elective procedures (that may have cheaper substitutes) are not all that likely to inform how other services will be priced. To capture a wide market, Lasik can only be so much more expensive than glasses or contacts.

Also, for medical care it turns out that healthy people don't benefit much from regular checkups. That way of stating it is a little tautological, but people lacking conditions that need management get little benefit from scheduled checkups.

I would argue that it is not difficult to construct a functioning market for elective procedures. For elective procedures not covered by insurance, the consumer has time and motivation to educate themselves about alternatives. For elective procedures covered by "insurance", the insurer has the option not to provide such coverage. Competitive pressures can work as they do in the rest of the economy.

The harder question is how to construct a market for non-elective procedures, such as emergency care. Consumer choice doesn't work under those circumstances. We have a market failure. How do we solve it?

Possibly. I thought the top answer in the Uber-as-ambulance discussion offered a lot of insight as to how the current system is a market failure:

https://news.ycombinator.com/item?id=16007246

>> I don't have the time or expertise to do the months of legalese and calculus it would take me to understand my insurance policy, so I have no idea how much an ambulance ride would have cost me. $0? $400? $15000? None of those numbers would surprise me. As best I can tell, insurance companies throw a dart to decide whether you're covered or not, and then the healthcare provider makes up some insane number if you aren't.

>> The Uber got me to the hospital faster than an ambulance would have, for less than $10, and I knew it would cost less than $10.

It would be interesting to have a conversation about how you deliberately construct a sane ambulance market (liability, dispatch, predictable pricing, proper competition) to handle a wider range of emergencies.

But in the US, I don't expect such a reasonable conversation. I expect to be bludgeoned to death with the word "deregulation", as if the only control we have is a a single dial to turn "regulation" up or down.

You never get to zero "regulation". "Deregulation" is always selective and another form of market interference -- and like any market constraint, selective deregulation will always favor certain players.

So, can we have a conversation about constructing a market? It's the US. I'm not getting my hopes up.

Even if there were an ambulance market, it's not like I'm going to spend time researching pricing when I need an ambulance. That'd be like if 911 and police services were market-based instead of public utilities. I know police do charge for special events and misuse, but I just mean the average citizen emergency.

The simple answer is not to construct a market, but just have the government set a reasonable price.

Another option would require localities to use a bidding system for ambulance providers rather than doing it themselves or contracting a gold plated service.

Maybe mandate the ambulance charge the same rate to insurers as they do non-insured people. A huge part of the "list price" for these services are just an attempt to set the negociation with insurers high.

Also, comparing Uber to an ambulance is silly. They aren't comparible services. Ambulences aren't a hospital taxi. They provide some level of first aid and stabilization.

If you don't think you are going to get or potentially die, you should be taking an uber/taxi/friend ride to the ER.

> The simple answer is not to construct a market, but just have the government set a reasonable price.

My point is that all markets are artificially constructed. Having the government set prices is simply constructing a market using a different set of rules.

Your proposal sounds like applying the "all-payer" system to ambulance service.

https://en.wikipedia.org/wiki/All-payer_rate_setting

There probably isn't a more appropriate use case for all-payer than ambulance service!

> Also, comparing Uber to an ambulance is silly. They aren't comparible services.

Au contraire -- it's a brilliant, revealing comparison. It illustrates exactly what is missing from ambulance service today: price transparency.

It's the most frustrating thing in today's climate.

Everyone agrees there are good and bad regulations, but everything gets framed such that any regulation is bad, and any deregulation is good!

There's no real conversation about which regulations are which! It's just naive free market vs full socialism debates in every public sphere.

>Things like Lasik, Invisialign, and plastic surgery prove the market can work in healthcare.

It's no coincidence that all three of those are optional services that (most) people do not need to not die. The free market has worked relatively well for services like that, and most healthcare does not fall under that category.

Most healthcare actually does fall into that category, and the unwillingness to acknowledge that is a big root factor in what's keeping costs high.

What's your mechanism here? Anything that's covered by "insurance" is disconnected from consumer choice and thus normal competitive pressures don't work to constrain prices?

Would you outlaw insurance, then? I guess that could be a good approach if all of us were rich enough to self-insure!

> Anything that's covered by "insurance" is disconnected from consumer choice and thus normal competitive pressures don't work to constrain prices?

Not "anything." Obviously there are other types of insurance whose rates aren't skyrocketing higher than inflation, like car, auto, or life insurance.

> Would you outlaw insurance, then? I guess that could be a good approach if all of us were rich enough to self-insure!

I would make employer-provided coverage no longer tax deductible, and possibly even reverse that initially so that consumer-purchased coverage is tax deductible. This would cause a shift over the next few years away from employer-provided coverage.

This would be a net zero change in spending on day one, but now consumers will care about what they're paying for insurance and can switch on their own. This isn't a problem that will fix itself overnight, but when consumers actually see $1k+/mo leaving their checking accounts every month, they will actually shop around and make choices based on pricing. They don't do that now because they don't see the cost or pay for it directly.

With consumers making choices based on pricing, insurance providers will care much more about prices and push back, just like they do in other markets.

It won't solve everything, but it's a start.

> I would make employer-provided coverage no longer tax deductible, and possibly even reverse that initially so that consumer-purchased coverage is tax deductible. This would cause a shift over the next few years away from employer-provided coverage.

This is something that I have argued for as well; the disconnect right now between what insurance costs, what it pays, and what the customer pays is too confusing and provides a very strange incentive structure. I would even go further and argue that all medical expenses should be tax deductible, with insurance premiums just being a special case of the general deduction. Get rid of all this FSA and HSA nonsense.

That said, I think part of the problem is that medical insurance is increasingly being used for routine medical care. Auto insurance, for example, does not cover preventative maintenance or oil changes, so consumers need to price those themselves. Similarly for other major kinds of insurance, like life or homeowners.

Vision insurance plans are increasingly common now, like VSP, and as a result, I've anecdotally noticed strange distortions of the market for eye checkups; we're still at the point where you can get a quote for one, but increasingly it's buried behind talk of co-pays and co-insurance that serves to hide the fact that the costs are going up for no reason, and the quality of service is being put at the exact minimum level that the insurance generally will cover.

I'd much prefer a high deductible plan (in fact I'm on one now) but I'm hampered by the fact that it is almost impossible to actually manage -- the billing comes from three different places and I can never figure out whether I've already paid a bill because they keep billing for different amounts for the same visit. And sometimes they bill my insurer, and other times they bill me directly, or sometimes they just go ahead and do both, and also send me threatening letters about paying bills that I've already paid.

I would love to see increased competition in this space, but until we get rid of employer plans, I don't see that happening.

This concept is addressed in the book “Catastrophic Care: How American Health Care Killed My Father--and How We Can Fix It.”

Highly recommend it. It’s got some great ideas. And I've mostly just copy/pasted this from another comment I made recently. I really hope some of the ideas in that book start making inroads via legislation.

You do realize that the US has this problem alone.

It doesn't require innovation or technology.

Just proper policy on pricing, like every other western nation has. The market will fix the efficiency, but not as long as the medical field itself can set the prices, since life and death choices are the ultimate i-will-rob-a-bank-for-this price elasticity.

'Nobody else is this incompetent.'

Here in the UK we have 'free' healthcare and the system is equally incompetent.

You aren't spending nearly as much as Americans and for that money you treat everyone.

Are large organisation inefficient? Yes. Is it frustration when you look at it? Yes. Does this mean the US situation where they are spending 3 to 5 times as much to provide the same level of care to only a part of the population, is objectively worse than the UK situation? Yes.

(I removed the quoted line, because the tone of voice is suboptimal - but it doesn't change the argument)

I agree the sum total cost may be significantly different but I was simply acknowledging that inefficient health care administration wasn't purely an American phenomenon.

It is not unique to healthcare either. It is simple a common aspect of large organisations that have too many stake holders that need to coordinate to get things done.

It is an interesting organisational problem.

But inefficient does not mean expensive. Generally you see a lot of inefficiency, much like with code, when it is not the hot path. If you would fix all the obvious inefficiencies it will not drastically reduce cost (actually: it would mean the hospitals have more money, so anybody selling anything to them would up their prices)

Inefficiency only makes a difference when the price is based on cost not on negotiation position (i.e. value based). So in a red ocean as they say, there is a strong economic incentive to fix all in efficiencies and squeeze the last dollar out of it. This is referred to a race to the bottom.

But health care is the opposite of a red ocean. And no price is too high if it means survival, so the consumer (i.e. the patient) needs a much better negotiation position. For example: having all patients collectively negotiating the price. If only over time the invisible hand of the market would have created structures for this purpose again and again everywhere in the world. Oh wait! It did. It's called government.

The "UK" NHS is failing because government has made the choice to defund it and to privatise it.

It's a purely political choice from a health minister who believes in homeopathy and who has previously written about the need to sell off the NHS.

The NHS has been failing for at least the last 25 years.

We've had labour, lib-dem/con and conservative Governments and countless health ministers in all this time.

I fail to see the political connection?

That's an awfully long time to be in a state of "failing"? Can we quantify what we mean by "failing" here?

'Can we quantify what we mean by "failing" here?'

'In decline' maybe? The NHS has been in some crisis or another for all of these years.

No, it hasn't.

Standards have got considerably worse in many measures recently.

When people talk about the winter crisis it's differently to previous winter crises -- A&Es turning away ambos because the corridors are full isn't something that used to happen.

In the past Ambos have been turned away, but that's because the beds were full. Those A&Es still had emergency capacity (in the corridors).

'A&Es turning away ambos because the corridors are full isn't something that used to happen.'

'In the past Ambos have been turned away, but that's because the beds were full...'

And before this, what? Ambos queuing up, patients treated in ambos, patients waiting a long time for ambos, etc, etc.

You have to go a long way back to find a time when everything was working as it should be.

Before this an A&E would tell an Ambo that the beds are full, and to go to a different hospital.

This leaves some spare in the system for when things are very busy - you put people in corridors.

But now all the corridors are full. We've had A&Es declare major incidents.

We've even seen, and I don't think we've seen it before, triage on resus. That alone is a big flag that things are fucked.

> And before this, what? Ambos queuing up, patients treated in ambos, patients waiting a long time for ambos, etc, et

Right, you think we'll go from fully working NHS to fully broken NHS in the blink of an eye. These things you mention were fixed once, and they've been getting steadily worse (as the Conservatives de-funded social care, and privatised drug & alcohol services, and cut MH services, and defunded the rest of the NHS) - the crisis started a few years ago, and is building year on year.

'These things you mention were fixed once, and they've been getting steadily worse...'

OK, it was the Conservatives what done it. I get it.

Yes, clearly and unambiguously the Conservatives have destroyed the NHS.

I said this in my first post.

Here, for example, is a chart of A&E 4 hour breeches: https://twitter.com/FactCheck/status/948953869509423108

They haven't destroyed the NHS since the NHS still exists.

However, this aside, do you have any ideas regarding turning around this perceived calamity?

Personally, I think the solution is politically unpalatable but I am not so narrow minded as to think there may be a solution that doesn't simply resort to giving doctors and nurses a bonanza pay rise.

> The NHS has been failing for at least the last 25 years.

You sound like the Daily Mail.

If it's been "failing" for a quarter of a century why is it always ranked as one of the best health services in the world?

Yes it has it's problems but it far from failing.

https://www.kingsfund.org.uk/projects/health-and-social-care...

http://www.commonwealthfund.org/~/media/files/publications/f... [PDF warning]

http://www.independent.co.uk/news/uk/uks-healthcare-ranked-t...

http://www.bmj.com/bmj/section-pdf/187348?path=/bmj/343/7826... [PDF warning]

Could the rating organizations be biased to weigh disseminated coverage and care more than individual quality of care? Just a question, since I seem to get that impression these types of quality of life surveys.

As a USer with good insurance, it's a hard pill to swallow to trade next day doctor appointments, same day urgent care (not ER) with very short waits, and quick schedules for surgical procedures for the broader coverage other countries offer with more rationed care.

Purely anecdotal but I've never had a problem getting a GP (Doctor) appointment for the next day (and get same day if they're not busy). Not sure what would be urgent enough to warrant same day but not ER?

That said I am fairly healthy and can probably count the number of doctor visits in the last 10 years on one hand so I may have just been lucky in my limited experiences.

As far as I know it's not. Here are two pieces of anecdotal evidence:

- cycle responders in London [1]. I can't see how private companies can get enough "client density" to afford the fleet in a congested city centre to reduce response time. Moreover, centralized dispatch is inherently more efficient.

- centralized and somewhat open control of life-saving procedures' efficiency [2][3]. In this particular case it's children heart surgery. NHS not only applied country-wide risk-adjusted statistical model, they also did a project to communicate it to patients. I'm not sure if it's possible in the US healthcare system.

From the POV of a recent immigrant it looks like most dissatisfaction with NHS stems from their approach to mundane and/or chronic problems, that's where you see GP resistance and long waiting times. They seem very good at not letting people die. Arguably it's a reasonable tradeoff given their constrained resources.

[1]: http://www.londonambulance.nhs.uk/calling_999/who_will_treat...

[2]: https://www.youtube.com/watch?v=-NebRpbMTK8

[3]: http://childrensheartsurgery.info/

IMO technology can improve much.

But the decision to use the technology or not is a political one.

> Why are prices not falling?

In many European countries, prices are negotiated by the publicly-funded health service or a government-appointed body.

Every country will attempt to negotiate the cheapest price they can get. Even so, drug prices across Europe vary widely by country. And there are powerful European pharmaceutical companies[1] who naturally resist price discounts or cheaper alternatives (UK example: https://www.theguardian.com/society/2017/nov/01/drug-giants-...).

[1] Large European pharmaceutical companies: GlaxoSmithKline (British), AstroZeneca (Anglo-Swedish), Novartis (Swiss), Roche (Swiss), Bayer (German), Sanofi (French)

Perhaps this is working better at the moment than the American system in some regards (such as price), but I'm wary of any third party (especially the government) setting prices. Should the government tell Apple what they can charge for a phone, or what you can charge for your web service? A good system should set the price automatically. For those rolling their eyes, yes, clearly this market system for health care has not been invented yet. But that doesn't mean it's not possible.

European governments can not and do not dictate the prices of products of companies like Apple or BMW.

IMO there is a clear difference between health and survival and a new phone or a new car.

That's precisely where everyone is mistaking. Healthcare has turned into profit making business. Doctors, healthcare organisations, Multi speciality hospitals are more concerned with profits, top line, bottom line, share-holder values, etc. In India, there are still some old, reputed, brilliant Ayurveda/ Allopathy/ homeopathy doctors who are treating patients for nominal charges over decades of their practice just because of one principle - Treating patient means service to God.

[1] https://www.thebetterindia.com/107629/balwantghatpande-oldes...

> Every country will attempt to negotiate the cheapest price they can get. Even so, drug prices across Europe vary widely by country. And there are powerful European pharmaceutical companies[1] who naturally resist price discounts or cheaper alternatives

The only reason those countries are able to "negotiate" low prices is that the US is a much larger market and doesn't fix prices, so they can simply mark up prices in the US to make up the difference.

Every single one of those European pharmaceutical companies you mentioned? They make the bulk of their revenue in the US market, even though Europe is more than twice the size of the US. That's why half the R&D done in the entire world is done in the US, and a large portion of the R&D done elsewhere is still funded by revenue generated from the US market.

> You start out by filling out a big paper form with all your info on it...

This drives me insane. Why do we still not have a working system of digital medical records? They ought to just be able to punch in my name and social security number and be able to pull up all my history, without me having to try to remember when I've been operated on and scribble it on a paper form.

> "Health Care will be fixed not by laws or insurance companies, but by technical innovation and good old fashioned economics. "

I doubt market forces can drive the healthcare prices to normal values. The success of a free market hinges on supply-demand balance and consumer choice. In healthcare, both factors are skewed against the consumer. If I am consumer of a non-essential product and if I find a supplier unsatisfactory, I either have the choice of going with a better competitor or even forego consuming the product altogether. When it comes to healthcare, I don't have much option. Even the competitive forces are weakened due to high barrier for entry and lack of bargaining power from the consumer. If you are sick and even if all the existing healthcare providers are expensive, you don't have the luxury to sit out. When consumers are locked in like this, there is no motivation for healthcare providers to drop their rates.

Are you familiar with the path that an American needs to take in order to become a cardiologist capable of financially supporting a family in a city where their children can realize their potential? The system that creates an American cardiologist is designed such that the cardiologist and it's respective delivery system will charge as much as economically possible for services. There aren't many cardiologists in the country and that is by design. A hospital can't even establish itself without the explicit consent of other hospitals already operating in a region -- healthcare entrepreneurs require a "certificate of need" issued before they are permitted to open a new hospital -- and dare not compete. The American Medical Association, medical schools, lenders, cardiologist fellowship programs, and others play a role in manufacturing a cardiologist. Everyone is participating in the system as a profit seeking, economic growth oriented player. Long ago, their objectives shifted to maximizing shareholder value and honoring fiduciary responsibilities.

No one has managed to control the cost of care in a system like this.

I was hopeful to see something about the difference in how countries control the supply of doctors, but looks like we'll need to wait longer till someone thinks to look into it. These well-trodden 'insights' must be too tempting.

CONs aren't required in all states (and none at the federal level since the 1980s).

http://www.ncsl.org/research/health/con-certificate-of-need-...

States that don't have them don't have dramatically lower prices.

this is good to know (OC)

Every state except LA had a CON law.. You can't restrain supply for a couple of decades, then repeal the law, and immediately say: see, there's no difference.

We're already seeing a difference in prices after a few years[0].. and it takes years and hundreds of millions of dollars (up to $1B+) for a hospital to go from a proposal to operating:

CON laws raise overall healthcare spending by 3.1 percent—5.0 percent for physician care. As for type of provider, while CON has little effect on Medicaid spend- ing, it increases overall Medicare spending by 6.9 percent.

States that repealed CON laws have seen overall healthcare spending reduced by 0.8 percent per year, leveling out to a 4 percent drop after year five. The greatest decline in spending is with physicians at 1.4 percent per year, compared to a drop of 0.3 percent per year in hospital expenditures.

And by constraining supply of beds, hospitals redirected investment into equipment, increasing per-unit costs of providing care [1,2]. Arguably CON laws have contributed to unnecessary tests (since hospitals need to use the equipment they buy to pay for it), and use of more expensive equipment than necessary.

Of course this isn't the sole problem with our health system... there are many that contribute to the problem. But CON laws are negative, and are one of the issues we need to deal with if we want to reduce health costs.

0. https://www.mercatus.org/publication/health-spending-reined-...

1. https://jhu.pure.elsevier.com/en/publications/impact-of-stat...

2. https://www.mercatus.org/publication/do-certificate-need-law...

It's hard to contain costs when there is no transparency regarding them.

Just try to figure out the price of a medical procedure. The prices of procedures vary depending on who you are.

Having the need to get a particular type of MRI every few years, I call around looking for 1) the equipment the facility has to do the MRI, and 2) the cost. It's hard enough to get #1 (there's a large disparity in quality of MRI based on equipment). #2 is practically impossible to get, and has no correlation to the equipment quality.

If providers were required to be fully transparent on pricing, and provide the same price to all, then you might see cost containment.

As someone who worked for CareFirst, I had a privilege to accidentally overhear the panel of doctors who work for C.F. deciding if C.F. will cover procedure for the patient....fuck those guys. Next to the building, there was a helicopter landing platform for CEO. US insurance system anti-humane.

When Obamacare was being drafted, house Republicans were busy condemning the 'death panels' of single-payer systems.

How much of that egregiousness has been fixed by ACA’s cap on insurance company’s profits, in your opinion?

Wouldn't a profit cap encourage profligate spending on things like corporate helicopters?

Only if that's deductible.

I assume you mean in a sarcastic way. If not:

Of course it is. That’s what our man in congress is for.

No. The ACA's profit cap (the "80/20 rule") requires that at least 80% of premiums taken in must be spent on actual medical care costs.

The ACA requires the somewhat perversely called Medical Loss Ratio (MLR) to be at least 80% (and 85% for large group plans). The MLR is the percentage of revenues from insurance premiums that are being used on actual healthcare benefits (and thus can't go towards profits, hence the name). Corporate helicopters don't increase the MLR and reduce profits.

This is a perverse incentive. If I'm running an insurance company and my goal is to maximize absolute profit, how do I do that when my profit margin is capped by law in this manner?

Well, I certainly don't have an incentive to reduce healthcare costs; quite the opposite. 20% of a larger cost leaves me with more profit, and most of my customers won't drop my service. It's required by law and subsidized in a lot of cases.

This is why there are marketplaces where you have to compete against other insurers. And companies in particular will evaluate their group plans critically.

Funny. The biggest input for the law was from large companies like the insurance companies, large hospital systems, and other cronies. And it shows.

How does it show?

The cap on profits encourages higher spending on medical procedures, since the more you spend the more you can make, so it works to keep prices high.

Living in the US and having to pay the high deductibles for health care, here is my idea: - price transparency - The problem is not easily being able to shop around for procedures and doctors. It is extremely difficult to know how much things will cost. If the prices have to be published in some way so the cost is known up front, the price will go down. Many people's insurance doesn't start paying until after the deductible. Most people just pay the price whatever it is because it is impossible to know how much something will cost until after. Of course, this means that hospitals can charge whatever they want with no recourse. When insurance companies pay, they fight back and get lower prices, but people can't do that. Voting with their feet will increase competition and drive down costs.

Price transparency doesn't help when you don't realistically have a choice. If I'm going to ER or taking an ambulance I can't check prices to decide what hospital to go to. If I'm in hospital and need surgery I can hardly decide to change hospital because their surgery is cheaper. When my I discover on my bill that my doc consulted with an expensive expert, it's too late for me to ask her to use a cheaper one.

Hospital's aren't like grocery stores.

When it comes to emergency, you probably right we can't shop around. But when it comes to taking medication, there should be a price. In HK, we can find out the price of a treatment or a surgery from the hospital's website. Maybe not the full exact amount, but close enough for someone to know what to expect. There shouldn't be a "we will take care of the rest of your treatment and send the bill to you" as in your own story.

Even with regard to emergencies, there is no reason you can't shop around in advance so that you already know which hospital you want when the emergency occurs, given that there is more than one in your area.

I understand your point. but let me refer you to a previous discussion: https://news.ycombinator.com/item?id=16007125

In short, if you call 911, the operator will call for an ambulance. You can't choose. If you have a minor stroke, you can certainly choose to have a friend to drive you there, or you can call a specific ambulance (I have never done that before and I am not even sure if that's even possible). But risk is on you.

I can't go to Mount Sinai West Hospital (midtown in NYC) if I am in Brooklyn at this moment. You understand emergency means racing with time. I can be transferred to Mount Sinai West later after I am discharged though. Also, I believe there is protocol for how far an ambulance is allowed to serve on active duty, unless another area is requesting additional availability, but don't quote me on this.

If only we can teleport...

> In short, if you call 911, the operator will call for an ambulance. You can't choose.

That is merely a procedural issue. There is certainly no reason why the 911 operator can't honor your request for an ambulance from a specific hospital, provided that it's within their range. In the absence of a specific request, the operator has a duty to look out for your interests, which should include not sending you to a hospital known for over-charging when there are other reasonable options available. (This is the same logic that says they shouldn't just send you to the hospital that pays them the most kickbacks.) Their default balance between cost and care might reasonably differ from yours, but if you have expressed a preference then they have a responsibility to honor it.

Of course, not every emergency is quite as time-sensitive as a stroke or heart attack, and depending on your location, and the locations of the hospitals, the difference in travel time may not be significant. Even if price is not the determining factor in the majority of cases, competition over the patients for whom where it is a factor can help keep costs in check for everyone.

In true emergencies, your coverage works everywhere, although your insurer can request that you move to a facility in their network once you are stable.

The point of emergency care is to get you the quickest competent care. This almost always means the closest facility unless there is a specialization issue (e.g. a severe truama case may be evacuated to a Level 1 rated trauma care facility, even if that means an air ambulance).

I have a friend who worked with the billing system at a major hospital in Florida. Beyond the obvious practice of providers billing for much more than the actual cost of service, to maximize insurance reimbursement after rounds of "negotiations" after each client, there is something more insidious going on as an industry.

My friend (anecdote, sure, but something like this will never be written in policy, so I can't cite) said "we were told NOT to send anything to collections unless the amount was "very high." He was then told that the hospital was made whole with every insurance reimbursement, and that any amount "owed" from clients aren't actually a big deal- if they pay it, great, if not, it's alright. Furthermore, the impetus for not sending to collections was because there is a certain threshold where if the populous found out about their many shady billing practices, they would be exposed, and would rather not deal with that.

I'd like to say that I am surprised nothing has been done about this, but I'm honestly not surprised because the incentives and economics are there in your face.

I am sorry, but I read it three times and I am still unsure how the practice helps the providers? I was looking for "stealing more from clients", but I can't deduce any from this anecdote.

Much of the cause of the high cost of care in the US is not social, or political, or demographic, but economic:

The single biggest line item in the US healthcare budget is hospital care

The price of hospital care (as measured by cost of inpatient bed day, [1]) in the US is on the order of twice as high as that of France, Germany and the U.K.

The time period where the cost of US healthcare in OP article separated from other countries coincides with the increase in hospital consolidation in the US

Hospital consolidation is demonstrated to lead to increase in price without commensurate increase in care [2]

There are other factors as well, but this is probably the single biggest cause of high US healthcare cost, and it's almost never discussed

Good article with historical context here: https://www.nationalaffairs.com/publications/detail/the-peri...

1: http://www.who.int/choice/country/country_specific/en/

2: https://www.rwjf.org/en/library/research/2012/06/the-impact-...

> The price of hospital care (as measured by cost of inpatient bed day, [1]) in the US is on the order of twice as high as that of France, Germany and the U.K.

And why do you think that is? Everything is political, including economics.

the articles i linked suggest it is in part because of hospital / health system consolidation leading to higher negotiating power. i think that is an economic factor, although i think i can see where you are coming from

i assume youre suggesting that having a single payer would balance out the negotiating dynamic? that could certainly be the case. to be pedantic, if the US does get a single payer system, one could argue that the political act of creating a single payer system is driven by economic factors (local provider monopolies increase cost of care, payers adopt high deductible plans in response, people suffer financially as a result, therefore vote with their wallets)

i dont think politics supersedes economics or vice versa, theyre very intertwined

Some guy was telling me how IBM Watson was going to make healthcare more efficient by helping doctors make smart choices. I replied that that wasn't going to help profits, so it probably wouldn't be adopted. Hospitals and insurers really should be merged so the incentives are all properly aligned. Kaiser Permanente works this way and, IMHO, it's actually not that bad.

I always wonder why kp hasn't expanded more.

They've been doing a huge amount of infill in Northern California, replacing whole facilities with brand-new complexes in existing core patient areas. (One example is their Santa Clara facility, which replaced a predecessor less than a mile away with one maybe 5 times its size.)

It must be an insane amount of capital expenditure.

just passed by the SC facility (the one on Homestead?) and it did indeed look massive.

Great to hear that they are expanding in their core practice and geographies. Hope they continue to do well.

That new residential neighborhood on Kiely Boulevard across the street from Central Park is where the prior Kaiser medical center was, going back to at least the 1960s.

You way underestimate IBM sales staff.

The real problem is that Watson doesn't work, and health care providers spent millions on it which could have gone to real, actual research.

https://www.forbes.com/sites/matthewherper/2017/02/19/md-and...

https://www.forbes.com/sites/jasonbloomberg/2017/07/02/is-ib...

https://www.healthnewsreview.org/2017/02/md-anderson-cancer-...

Kaiser's HMO is much worse than a PPO. It's not that great of care.

Now compared to Medicare sure it's great.

>Kaiser's HMO is much worse than a PPO. It's not that great of care.

care to elaborate why?

With a PPO I can go to whatever specialist I want. With Kaiser you are stuck with the specialists Kaiser directly employes.

So if the Kaiser clinic by you is good then sure Kaiser is great. However if you ever want a second opinion or want to use a non Kaiser doctor your out of luck.

A PPO plan offers you freedom to choose what doctors you see. It will also enable you to go straight to a specialist without your general practitioners consent.

Obviously Kaiser is cheaper than the PPO plans.

Lack of price transparency feels like a big part of the problem here. It's nearly impossible for a consumer to shop around based on price, allowing prices to go up freely.

I'm actually surprised healthcare providers can legally be as opaque as they are: how is it okay to charge arbitrary amounts after the fact and require the consumer to pay? Even car mechanics make upfront estimates and get them signed by the consumer, because otherwise the consumer might refuse to pay. Why doesn't the same happen in healthcare for at least non-emergency procedures?

I see a retina specialist twice a year. I recently changed to a high deductible plan with an HSA. I called to see what the cost of my appointment would be. They could not or would not tell me. Incall three separate times, talking to different people and different departments. I went in and continued asking the front desk. "It depends on the services you end up getting." Ok, sure, but for a standard appointment, what then? "I can't say." Listen lady, I'm looking for a ball park. $50? $100? $1000? $5000? "Oh, I can't imagine it will be that much." Which one? "We will have to just bill you after." So absolutely frustrating. It ended up being like $150. Without price transparency like a public menu, we won't get better.

Had the same experience with my son's ear infection on a holiday weekend. Received a bill for $900. I refused to pay it, I wrote them and said I had asked to receive an itemized list of charges for a typical ear infection and had been refused and that if these prices were known at the time of the service I wouldn't've undertaken the service.

So of course they came down to $450 without even batting an eye. Complete madness. I've still never paid it, with no apparent consequences.

Bingo. Healthcare is the only place where courts will tolerate a contract where a patient "consents" in advance, to paying any amount without bound.

Doctors, surgeons, nurses, lab techs, hospital bureaucracy and staff, etc....

All of these people need to get paid, and in the US they get paid very well.

High health care costs are not a mystery or a conspiracy. There are just many people in the industry that make a lot of money, and they charge high fees to maintain their incomes.

That's such a simple thing and yet no one seems to acknowledge it. Look at Obamacare, it's going to lower health care costs. How? Savings! What does that mean? Everyone you don't like won't make as much money. All the people you like will keep getting paid. I understand we all hate health insurance and pharmaceutical CEO's but taking them out back and shooting them will save less then is commonly understood. The same goes for money wasted on advertising.

Saving money on health care is (to repeat an oft told joke) like going to heaven. Everyone (Republicans and Democrats both) wants to do it but no one wants to die.

There's too much money in the system, both private and public, thus supply-and-demand equilibrium results in high costs. And the supply is carefully limited by healthcare providers. (The middleman takes the profit, so why would the number of actual doctors increase?)

The hospital bureaucracy is out of control in the US. See http://www.commonwealthfund.org/publications/in-the-literatu...

As for the cause, start with https://www.nytimes.com/2014/05/18/sunday-review/doctors-sal...

They probably need that income to pay their debts. Becoming a doctor is not cheap.

There is no competition. The day there is competition is the day you walk in to your doctor's office and the prices are posted above the reception desk like a restaurant menu. $50 general visit, $75 for a broken arm, $100 treat common infection, etc. You don't see prices because you don't pay. Insurance pays. If you are ever without insurance and have to pay, they always have different, lower rates. Doctor's scamming insurance companies, insurance companies scamming the government, the government scamming all its citizens.

This is the root cause, the fact people don't pay for their own healthcare and there's no competition. Then we layer on this huge complicated system to try to contain costs other ways.

Now can we have a "Why the U.S. Spends More than the Next Eight countries combined, and 63.7% More than The Entire Rest of The World on Defense"?

https://en.wikipedia.org/wiki/List_of_countries_by_military_...

---

Oh wait, we spend even more now:

http://clerk.house.gov/evs/2017/roll378.xml

The US gets that much more military for its money. Look at the diagram on the bottom of https://www.globalsecurity.org/military/world/carriers.htm . Or remember that the US Air Force is the world's biggest air force, the US Navy is the world's second-biggest air force, and the US Marines are the world's third-biggest air force.

There's space for people to disagree on whether what we get out of the military is worth what we spend on it, but there's no mystery about where the money's going.

I grew up on a US Army base.

Believe me: There is plenty of mystery, and plenty more obvious waste. The most obvious is called "use or lose".

Why in the hell do we need it?

China has a billion more people, borders Russia, North Korea, Afghanistan, and Pakistan, yet spends less than a quarter as much as the US on defense, even by the most liberal estimates.

I can see arguing the merit of spending more than every country on Earth. I would still disagree, but it would definitely be a discussion.

However, the US contributes more than a third (closer to 1/2 now) of defense spending for the entire goddamn world.

It disgusts me that my country takes so much money from its citizens, and throws it at all into a machine of death, whilst simultaneously blaming its egregious debt on Social Security.

> China has a billion more people, borders Russia, North Korea, Afghanistan, and Pakistan, yet spends less than a quarter as much as the US on defense, even by the most liberal estimates.

Sure. But it has no (conventional) power projection capacity, whereas the US has been engaged in two simultaneous occupations of outright hostile foreign countries literally on the other side of the world for a decade, at the same time as deploying troops to defend dozens of friendly nations all around the world, enforcing freedom of the seas again all around the world... . The front line of a US-China conflict would likely be Taiwan, that's what spending 4x as much is buying us. Again, we can argue over whether that's something we should be spending money on, but on the whole (of course there is some level of waste, as there is in all large organizations) we're getting what we're paying for.

> the US has been engaged in two simultaneous occupations of outright hostile foreign countries literally on the other side of the world for a decade

And spying on the entire world, including its own citizens, etc.

Even if you believe the US should play world police, and demand a group of people with a totally different culture and history pay by it's rules, there are plenty of significant areas where we are clearly wasting significant amounts of tax dollars, all under the umbrella of "defense". Instead, Congress overwhelmingly decided, after Trump asked for a $20 billion increase, to have a $100 billion increase.

> We're getting what we're paying for

I don't buy that. We are paying an unfathomable about * 5.

There is extremely significant and obvious waste. Even what is not "waste" does not clearly help taxpayers in any way. Very significant portions are clearly to the detriment of taxpayers.

Empires are expensive.

I can recommend "The Shadow World: Inside the Global Arms Trade" by Andrew Feinstein. The book argues that most arms deals are done to line the pockets of a few key players (and in the case of the US, pork-barrel politics) - it even goes so far as suggesting that political decisions to go to war can often be blamed on a desire to generate demand for new weapons systems that means more $$$$ and ££ in the right places. I found it quite depressing....

Eisenhower warned of this in 1961, and claims (sometimes correct) that war profiteers were responsible for causing wars can be found throughout history.

The US isn’t even in the top 10 for military spending as a percentage of GDP.

When you have a small GDP, exist in the middle east, and your capitol city is an old word for peace, you end up spending a significant amount on defense.

The thing I keep wanting to bring up:

>Higher prices aren’t all bad for consumers. They probably lead to some increased innovation, which confers benefits to patients globally. Though it’s reasonable to push back on high health care prices, there may be a limit to how far we should.

Fundamentally speaking, much like education, while I agree that healthcare is unaffordable to many, I point out that this is different from being too expensive. I think the idea that we are spending too much of our wealth on education and healthcare is... wrong.

I mean, sure, there are limits on what we want to spend, as a society, on healthcare, and yes, I personally think that a lot of the public money being spent on healthcare (and I think a lot of public money should be spent on healthcare) should be spent on research that benefits all, but overall? as a society? I don't think spending 17% of our GDP on healthcare is a problem (assuming we're receiving good benefits from that, which I think we are)

And yeah, maybe there needs to be 'community college' equivalent of healthcare; a system where anyone can show up and get care that is good but not the best for next to nothing. And yes, we do need more and better-funded research for the public good. I certainly don't have a problem with private industry researching new drugs for us, but we have to understand that their incentives are... different, and that there's a place for public-funded work for the public-interest.

> I think the idea that we are spending too much of our wealth on education and healthcare is... wrong.[...]I don't think spending 17% of our GDP on healthcare is a problem (assuming we're receiving good benefits from that, which I think we are)

You're missing a dimension to both of these numbers: Outcome. The U.S. spends more on healthcare than any other country — but not with better health outcomes [0].

"The US stands out as an outlier: it spends far more on health than any other country, yet the life expectancy of the American population is not longer, but actually shorter than in other countries that spend far less." [1]

[0]http://beta.latimes.com/nation/la-na-healthcare-comparison-2...

[1]https://ourworldindata.org/the-link-between-life-expectancy-...

One explanation of the difference in outcomes, especially your "Number of deaths per 100,000 from preventable diseases or complications had adequate healthcare been available, in 2013" statistic has mostly to do with accessibility. Lack of access. That, and a cultural avoidance of seeking help, but I bet it's mostly the lack of access.

If you have bad insurance? there's huge variance in what a procedure will cost, and in my experience, hospitals aren't setup to deal with the "how much is this going to cost me?" question.

The ACA may have helped with this. With my yearly out of pocket limits, I have some peace of mind that it won't, at least, go over that.

Personally, I think we can continue to compare this to the education system, we need something like 'community colleges' - Sure, you need paperwork and to go through a bunch of hoops if you want to go to Stanford- and you get a better product than at the community college, if you can make it, but anyone can walk into the community college and get half a pretty decent education that is almost completely paid for by the government. I think we need something similar in medicine... a place anyone can walk in where they know they can get care that meets minimal government standards that is next to free.

But... my point is just that making the whole system cheaper is not the best way to solve that. We don't want to replace Stanford with the University of Phoenix.

To continue my analogy, the private sector does beautifully at the high end, in both schooling and medicine. To bring back the University of Phoenix example, at the low end? I would much rather have the low end government product than the low end private sector product.

It's precisely about lack of access, hence the conclusion of the quote: ".. had adequate healthcare been available." There is a cultural avoidance of seeking help because the help will bankrupt you. Because it's too expensive.

Making it cheaper = better access = better health outcomes. How do we know? Every other industrialized nation does it better than we do for cheaper.

>Making it cheaper = better access = better health outcomes. How do we know? Every other industrialized nation does it better than we do for cheaper.

My understanding was that the nations that have better outcomes for the poor tax people and use that money to pay for government supervised medical care, and that it's the government paying for and supervising the care that leads to better access.

Private sector solutions, as I said before, seem to work extraordinarily well for the rich, both in medicine and education. If Stanford will let me in, sign me up. But, when I am shopping on the low end? I want some government intervention. Cheap private sector medicine, I suspect, would look a lot like cheap private sector education... ITT tech, Corinthian Colleges, or at best, the university of phoenix.

It spends so much more on healthcare because of its obsession with possessive individualism and the ridiculous notion that a government of the people is out to get them.

It'll change one the USA resembles India and China leads the world.

"It'll change one" -> "it'll change once"

It took me 15+ seconds to make this correction and parse the last sentence, here's it so that you don't have to spend them.

You have huge variation in the life expectancy between rich and poor individuals in the US. Here you have a lot of poor people with no healthcare and then you have more affluent people who may be spending hundreds of thousands of dollars a year on healthcare. If I have a few million dollars saved and I can spend a couple hundred thousand to live a few more years there’s a good chance that I’ll take that option. This system is not intended to provide the greatest benefit to the most people but rather to provide the greatest benefit to those people who can afford it. Coming from Canada and seeing the quality/detail of care you get with private insurance here is astounding. There is certainly a lot of fat in the US system but it’s also incredibly comprehensive if you’re fortunate enough to have good insurance.

It's simple economics: third party payment. Patients want as much care as possible, doctors are incentivised to provide it and insurance companies pay for it. Until that changes healthcare costs will not decrease

That can't be the reason, as most other industrialized nations have that too, yet pay less.

Single payer systems are popular and work well, but you are right that it is not the only solution. Countries like Germany use heavy regulation to manage the healthcare system. However, I don't think Americans would accept this level of "government interference".

They already have that level of government interference, just not in the right way.

That is the bizarre part of the US system - it might very well work better than today if it was actually a free market, but they've managed to get the worst of both: A highly regulated market where the regulations doesn't ensure proper service.

I used to think that. My only argument of skepticism is sort of weird. Animal health care costs. Apparently the cost of vets is going up just as fast as that of humans. And in that case it's mainly first party payment. It could be that the two have no connection but for me, it raises doubts.

Honestly my current theory about health care costs is that they're high - and are inflating - because people like health care. There's a basket of potential goods and people really like that particular item. To get it they spend what they have and then pressure politicians to get them ways to spend money they don't have. They complain more and so the politicians find ways to hide the costs from them.

I agree with you, as people get richer they spend more on health, for themselves and their pets.

But just because vet costs are increasing at a similar rate (or more) than human costs doesn't mean the third party vs first party thing isn't the issue. Absolute overall human health care costs are still way higher then vet costs for similar services(1), despite the rates of increase the past few years.

Also, anecdotally, some vets are going the other way. There's a vet near my house, for example, that just started weekend + holiday hours with rates the same as to their normal ones. We hadn't even gone their before, but when my dog woke up last Easter with some eye problem, we called around, found them, and got some ointment that helped. The other two options would have been: wait a day, or go into an emergency clinic that's k's of dollars. If we had pet insurance I'm sure we just would have gone in without thinking.

1: http://parkhillvet.com/2012/09/comparing-costs-of-human-vs-p...

Could this problem be attacked by a goodwill billionaire with a long-term plan? Open several private medical schools that will offer "free" med education in exchange for multi-year contracts. Open many small copycat clinics. Manufacture your own generics if possible, import whatever is cheapest, focus on things you can do cheap, be transparent about pricing, build awareness and brand.

McDonaldize/Amazonize American healthcare.

Something I've always heard but not mentioned in this article is that America is a very litigious culture, everyone sues everyone for nearly any reason, which is uncommon in most parts of the world, and doctors must have lots of malpractice insurance to guard against this; and when doctors pay a lot for insurance, they must increase their prices to help cover that, and the wheel spins that way.

A lot of these comments due a great job of hitting the nail on the head on most issues, but I have not seen someone talk about the fact that the United States believes in treating versus _prevention and or curing_.

>he sacrifices his health in order to make money. Then he sacrifices money to recuperate his health. And then he is so anxious about the future that he does not enjoy the present; the result being that he does not live in the present or the future; he lives as if he is never going to die, and then dies having never really lived.

-Dalai Lama

Part of the reason it is more expensive in the US is because medical school is very costly in the US. This increases the financial risk of those aquiring a medical degree. Higher risks usually demands higher profits in the market.

Hence free university education could be a factor in reducing US health care costs.

Fundamentally you see how the free market approach to everything drives up costs everywhere.

Or more specifically drives up costs in industries/services which don’t naturally have functioning markets.

Free market approaches to health care found in Europe or Asia that works tend to be strongly regulated. E.g. max prices for procedures

Part, but definitely not the main reason. If the doctors worked for free, US would still be more expensive than Germany or Japan.

Agreed. There are around 80,000 medical students in any given year in the US. Assume that all of them pay $50,000 per year in tuition. That's maybe $4b per year. The costs of health insurance, diagnostic testing, pharmaceuticals, etc more than eclipse that number.

And the bigger problem is that there is profiteering at every step of the way... Medical Insurance, devices, private testing labs, hospitals, doctors, pharma...it all adds up. As someone else said, it's a free market without a real market for competition... I don't remember where I heard it, so citation needed, but the number that sticks on my head is that we spend 25% on administration alone. Lots of billing companies exist just to handle the complicated mess we have created... More profits in the system.

Bertolini the CEO of Aetna walked away with a $500 million parting gift. Courtesy of your healthcare premiums. There's the fox guarding the henhouse off to a new henhouse. STOP THIS OBSCENITY of administrators paying themselves so much to work in a risk free environment. When they run red ink, the government bails them out. Taxpayers again - shafted from both ends. We should find this guy and put him in a stock, the kind the puritans used, not the Wall Street kind,

The math in the article is not quite right. Growth from 1.2 trillion to 2.1 trillion in 17 years (1996-2013) only amounts to 3.3% annual growth, which is not that far away from the 2.4% of the overall economic growth.

The U.S. does spend more per capita than any other country, with Switzerland, Luxembourg and Norway being the runners up.

https://www.npr.org/sections/goatsandsoda/2017/04/20/5247741...

I think that statistics gives a hint: the richer the country, the more it can afford to spend. Also the mostly private health care sector in the U.S. doesn't have similar incentives to cap their spending at a certain point as their publicly funded counterparts in Europe. There must be a lot of cases where a rich person buys expensive treatments for a terminal illness that would be deemed hopeless and left untreated elsewhere, and that has to show in the statistics somehow. I don't consider this a big flaw in the U.S. system.

There must be a lot of cases where a rich person buys expensive treatments for a terminal illness that would be deemed hopeless and left untreated elsewhere, and that has to show in the statistics somehow. I don't consider this a big flaw in the U.S. system.

Probably not a lot, since most people aren't rich. But more to the point: That stuff happens other places as well. I'm in Norway, and there is a private healthcare system. Most of the time, I hear it being used for shortened waiting times or more luxury in the hospital, but I'm pretty sure rich folks can go to other lengths - on their own dime. This doesn't affect the state much because it isn't their freaking money.

Also the mostly private health care sector in the U.S. doesn't have similar incentives to cap their spending at a certain point as their publicly funded counterparts in Europe.

I think this is correct, but I think the fragmentation is what causes it. The fragmentation means there is no incentive to combine resources to make things cheaper and easier. Where I live in Norway, people can have - free - up to 6 nurse visits a day. Even if you live on an island or are spending your summer in a remote cabin. All because overall, the outcomes are good. People live longer, happier lives the longer they can be at home and it is cheaper than sending the same people to a nursing home.

Actually in Norway there is relatively little you can do in Norway, as private providers are highly restricted in what services they can legally provide in areas that are covered by public healthcare, in part because it's long been seen as immoral to let people buy preference to what is effectively a limited resource as long as the number of doctors available is limited (and the answer is not to drastically increase the pool of doctors either, as the problem there is training - you don't have enough heart transplant cases, say, to train a much larger pool of transplant surgeons). I believe the restrictions are lighter than they were, but it's still far more regulated than most places.

But of course rich people can easily fly to get private treatment abroad.

Healthcare in Norway is close to US costs mostly for other reasons: A much flatter salary curve means the services that are typically cheap elsewhere, like e.g. cleaning staff, is much closer to the cost of higher level staff, driving up overall staff costs significantly; this also drives up costs of goods and services bought externally by the healthcare system. The population density is also extremely low - less than half the US, and the US is extremely low too - and that affects cost to e.g have good hospital coverage and emergency services. Providing service at all in some places is an ongoing challenge, with the Northern regions finding it hard to hire and retain staff despite the tax breaks (for the non-Norwegians: people in the Northernmost regions gets various tax breaks and other benefits such as student debt write-downs to get people to stay/move there)

Thanks for the information. Most of what I know about the private system here (Norway) is from language & civics classes - though I hear rumors of tourism as you've mentioned.

Most people are not rich, but if the richest 1/10 spend ten times the amount of what the rest in average, that alone almost doubles the total average. Averages are funny that way. I don't think this is even far fetched, because if you have the money and you are going to die, why would you not clutch to any straws you are being offered?

Certainly the same takes place in other rich countries as well, but maybe in not quite the same extent. Anyway, it would be very interesting to see how the healthcare spending would look like when grouped in percentiles by the total spending of each patient. I wouldn't be surprised if there was quite a bulge on the far right with the U.S. and not so much elsewhere.

Another reason why I don't consider this a big flaw is that expensive treatments are also often experimental and drive the general medicine forward, which may make them more affordable and more generally accessible in the future.

Not saying the system is perfect. Just that maybe it's not such an outrageous rip-off as the article makes it look like.

Rich people can still buy supplemental insurance in most other places.

E.g. in the UK 10% have private insurance (though very often as a employee benefit that they don't pay much for and so the takeup is artificially inflated that way).

But presumably the fact that they have to convince people it's worth paying extra on top of their taxes provides massive additional competitive pressure and is part of what helps keeping the prices low relative to the service provided.

E.g. I've seen cases where it'd pay for Americans to fly to London and stay in a luxury hotel and get treated at top private clinics in London vs. getting relatively basic private treatment in the US.

Note that private insurance in the UK does not cover chronic conditions - they shunt you off to the NHS for anything that isn't easily curable. That's a large reason why it's cheap.

Everything I've read says that especially post 80's health care inflation in the US is somewhere in the middle of the pack of OECD countries.

That should give everyone on a high horse convinced that they have a solution in their pocket a real cause for concern. It doesn't of course. But it should.

> There are ways to combat high health care prices. One is an all-payer system, like that seen in Maryland. This regulates prices so that all insurers and public programs pay the same amount. A single-payer system could also regulate prices. If attempted nationally, or even in a state, either of these would be met with resistance from all those who directly benefit from high prices, including physicians, hospitals, pharmaceutical companies — and pretty much every other provider of health care in the United States.

And then end up like Venezuela has after implementing price controls? How about you let intelligent macroeconomics majors who have spent years in college studying exactly the ideal solution to this predicament give thoughtful and effective solutions. I understand the writer was likely good intentioned, but:

1) The road to hell is paved with good intentions.

2) For every complex problem there is an answer that is clear, simple, and wrong.

While some liberal arts majors have their own theories and hunches to inject on how our world economy should run, a well-studied economist would give the best answer for providing a solution that establishes the perfect price-point between satisfying as much of the medical demand as possible while having a never-extinguished supply of medical care.

A little history: During the great depression, the US implemented price controls on wages; capping the wages. So companies started adding in health coverage in with the job as a perk instead. The great depression was extended and the health insurance in our country has been forever screwed up by that event.

Btw, I'm not pro government or anti-government, left or right. I'm pro-lets-get-the-facts-straight-before-we-jump-to-conclusions-that-affect-the-whole-country. Admitting that you don't know the answer to something goes a long ways.

Because it's a business designed to make maximum profit?

Because of the fraudulent agents in the insurance, healthcare and government. And the innocent american citizens who nod yes for every crap policy and rule that is thrown at them. Isn't it obvious?

Same medical service costs 10 times less in other countries for same or better quality. Because they have kept the service of a price 1$ as 100$.

We need some disruptor to simply crush the insurance industry.

If you don't take insurance you may become medical bankrupt if somewhere you screw up your health.

They started with 1 $ few decades back and slowly increased and since world has majority of un smart people people collectively couldn't find a just system.

And everyone and every future generation has to pay the price for the mistakes previous generations made.

Its just is hell guys.

Simply because it is acceptable to maximize profit from people fears and misery, coupled with shameless politicians that support/bend to the will of the health care mafia with a regulation environment that diffuse any incentive to lower cost

"Because it's more expensive" seems like a non-answer to me. Why is it more expensive, and who's getting the money, and what rules are allowing this to take place, and who made those rules? That's what we need to know.

the problem is that the people telling you what to do (the healthcare providers / docs) are getting paid to provide services to you. additionally, insurers are not smart enough to communicate the costs and benefits to patients appropriately.

we need a decoupling of the guide (maybe insurers that are actually good) that tells patients what to do next for optimal care and the org that provides the care. that way providers (docs) dont have an incentive to say do more if more isnt helpful

It's a simple reason: Monopsony

Power of collective bargaining drives the price down.

The AMA and other collectivizations of providers drive the price up (cartels). That's why becoming a doctor in the USA is such a long and hard ordeal, relative to other countries. And also why litigation is so high.

Oh and of course... THE PATENT SYSTEM causes the USA to pay for most of the innovation that scientists in the redt of the world are prevented from building upon with open source.

It's fascinating, and kind of horrifying too. I've of course been a patient, and I saw the initial bill for a neck injury that led to no treatment other than Tylenol - $16,000. My HMO paid about half that, I believe. I was not on the hook for the difference. This is negotiated by contract between the HMO and the hospital. The high bill is the beginning of negotiations between two large and powerful organizations.

Here's the thing - lacking access to good health care in the US is even worse than not being able to pay the bill. It means you get stuck with the higher bill, and no pre-negotiated contract or negotiators to knock it down. I've talked to people who work at hospitals, and they say their billing department may knock it down a bit, but it means that the person not represented by an HMO or similar gets hit not with an $8,000 bill but one much closer to $16,000.

I know I'm supposed to hate my HMO and everything, and they can be irritating, but there's no way I'd want to experience the US medical system as an "independent".

As you said, you're already dealing with a Monopsony. It's worse, because you don't know what they're charging, whether it's important, whether it should be done, none of it. And it is run by something closely resembling a cartel, the AMA and hospitals simply do not operate in anything remotely resembling a free market. I guess my HMO is my government backed cartel. I pay through the nose for the insurance (well, my employer "pays" some of it, but it's all through the employer, so what does it matter the portion that is added to and then deducted from my actual paycheck vs the part that never makes it to my paycheck and is paid on my behalf?). But as a result, I have a powerful cartel on my "side".

When I describe the AMA as a cartel, people often think this means I oppose occupational licensing entirely. No, not necessarily. That's an interesting discussion, but there is plenty of room to criticize the AMA (and other professional and trade licensing bodies). while supporting some limited form of occupational licensing (actually, you could support substantial licensing and still be appalled with the AMA and ABA).

I think a lot of it is due to America being so litigious. Doctors and hospitals are afraid of being sued, so they need lots of insurance to protect them, and they order lots of arguably unnecessary tests to cover all their bases. This drives up costs for consumers.

My guess:

People with some money will pay through expensive insurance, and everybody else can't pay at all.

This way, pharma and hospitals have near 0 incentive to focus on people with anything less than mid to high tier insurance plans.

And everything else results from that, like regulatory capture by insurance companies and everybody teaming up with them.

Even without draconian restrictions on generic drugs, labour mobility in medical professions, and needlessly elevated standards of care in hospitals for many conditions, medical treatment in US will still be out of reach of majority, and the market will still be skewed towards high tier insurance plan holders.

A more radical, slash and burn reforms will be required by US to reach countries with private, but affordable to masses healthcare.

I can draw a parallel with restaurant or affordable clothing markets in my home country - Russia.

In the centre of Moscow, you have countless fancy restaurants that are nearly always empty. Those ones have $30 average price for a basic meal.

At around 10 km away from the Kremlin, you begin to see rare soup kitchens serving <$1 meals with 100+ people line ups during lunch hours accommodating everybody with less than $2k USD of monthly income.

See, if a fancy restaurant will serve even two customers per hour, it will get more money than a soup kitchen.

The same situation, if not worse goes for affordable apparel. Most people can't afford anything more than an "Abibas" tracksuit for $2, yet you genuinely can't find anything that cheap in Moscow's urban core. Putin ordered the only public market in Moscow serving the masses to be crushed, and its owner prosecuted in a show trial, just out of resent for its existence showing the extend of poverty in the country.

This and expensive education as well. Nust take a look at Germany or France you will see free gratis high quality college education. Oh well...

Government setting rates for medicare/medicaid reimbursement is what has driven up prices. One of the brilliant aspects of market economics is that, if allowed to operate freely, the market would establish price points for all levels of service. Government involvement is preventing the market from functioning as it should.

..And US is not more healthy than the other advanced nations.

that's what subsidies to a private sector do, duh

This is a classic american problem - keep throwing money at something until it works.

This conundrum plagues their healthcare, their education, their military, their welfare spending and so on. For example, they spend more on their military than the next 15 highest spending countries combined, and don't get proportionally better results. They spend a lot more on education (per student) than most European countries, but suffer from worse education quality than some developing nations. There is a fundamental problem with how this money gets spent, instead of how much of it is available.

It's a pity that they don't try throwing money at poverty. Maybe that problem will actually go away with more money being thrown at it.

https://news.ycombinator.com/item?id=16040903

I think the primary problem with poverty is that the means to get out of poverty like education, healthcare and housing have exploded in cost.

Supply. Demand.

Tuition costs skyrocketed because demand* skyrocketed. (Student debt)

Healthcare costs went haywire because demand* is insanely huge.

* - demand meaning the actual micro-economical concept, that is the curve/graph/function/relation describing the "preferences" of the customers. And since there is a lot of money in the system, the demand is big. A lot of people can and are willing (and of course forced) to spend a lot on health care. (And similarly on education. Since you want the a better future, at all costs, right? Right.)

America is a net importer of capital. Money is cheap. The world pays America to be wasteful and spend. All of these problems will be "solved" when that reverses.

There will be rioting in the streets when that happens.

> America is a net importer of capital.

How is that calculated? Do you happen to have sources/articles on this topic?

I'd think that the larger economy eats the smaller (that is US money goes and makes profit in the smaller ones), but maybe it's a lot more complex than that.

You may be confusing where profits can be made and who makes them vs. where capital is deployed.

http://mjperry.blogspot.com/2010/10/trade-deficit-capital-in...

http://topforeignstocks.com/2009/06/13/the-top-net-capital-i...

It has to do with the balance of payments. US entities do invest and make profits overseas. However, investments into the US (including loans to the US Treasury, for example) happen in larger amounts than investments from the US into other countries. Regardless of where profits are made or who made them, people prefer to put their money in the US.

I do not understand why insurance companies are not able to or do not wish to exert downward pressure on prices?

Because their benefits are mainly indexed on the cost.

Not enough competition. Too high barriers for entry.

(The market is actually not one big, but 50+ smaller ones. Furthermore each of those have very high regulatory limitations for entry.

And since we're talking about a risk-premium business, it has inherent risks - so the easy actuarial areas are already well covered - like life insurance, but the various others are a lot harder to estimate ROI-wise better than the competition.

And since you can make a lot of money elsewhere, there's relatively not much money chasing new health care insurance.)

Plus the market is set up very inefficiently, as the HMOs (health maintenance organizations, the networks, the "insurers") can play the divide and conquer game. Play employees and employers and the government against each other, so there's no real incentive to compete on prices.

Their margins are limited by law and the people paying (employers) are mostly price inelastic.

This puts them in a position where they're incentivized for costs to go up, because 15% of $2000 is more than 15% of $1000. In other industries, you'd see insurance companies push back because ultimately consumers will push back and either drop insurance or switch to another provider.

Switching insurance at an employer, though, is a colossal undertaking that is bound to frustrate employees, so often it isn't done. And until recently, individuals would be fined for not having insurance, so dropping insurance wasn't really an option.

If consumers were the ones paying for it, switching weren't a pain to do, and insurance companies weren't incentivized to maximize costs, that'd go a long way toward fixing this.

They try. They insist on paying doctors as little as possible. They challenge the necessity of procedures. Doctors fight back by choosing to classify procedures in more expensive ways. It's a tug of war. There are whole teams of people at hospitals whose job it is to make as much money as possible by arguing as much as possible with insurance companies over prices and necessary procedures.

The fundamental problem is the antagonistic nature of that system, as disconnected from the need of the patient. Doctors want to do more and charge more. Insurance wants to do less and pay less. Nobody is asking whether a procedure is worth what it costs the patient.

You can't improve system prices with distant and ignorant downward pressure, even if you're a huge buyer. You just don't have the information and intelligence. Medicare tries that, with the result that it sometimes pays for lots of unnecessary procedures and spends too much, and sometimes insists on prices that are too low and has doctors quit taking it. It doesn't have the information to get it right in either direction, and insurance has the same problem.

What is needed is price discrimination at the point of sale. In a very blunt sense, we have this in the patient's decision to go to urgent care rather than the ER. In a broader sense, though, when a doctor says (for example) they'd like to do a test just to be on the safe side, there should be a discussion about how much that test costs and what the consequences might be of not taking it. When someone says (for example) with respect to end of life care, "We can try this very expensive probably-futile procedure", costing the grandkids their inheritance is a not unreasonable piece of that conversation.

My experience is that doctors in insurance-dominated environments typically do not even know what their suggested interventions cost. But I once had a conversation with a doctor in a self-pay environment (urgent care) who said, "We did test A, $5, and it's negative. We have the option to do test B which is more accurate with respect to false negatives but $100, but I'm pretty sure you don't have it based on other signs." Reeeeally useful conversation if you're looking to save money and understand the consequences of a decision. More of that can bring the price of healthcare down by orders of magnitude. The insurance doctor did test B twice a month without even asking me about it, and probably had a team of specialists ready to argue for its necessity with insurance (there was no insurance, I was paying, and I would not have regarded it as worth the cost).

Isn't it rather: keep throwing politics at something until "it works"?

Politics is usually the most expensive way to get anything done.

No, it's actually not enough politics. (Or you can say too much of course, because it's a totally nonsensical analogy.)

The problem is a very inefficient compromise. The US system is a worst of both worlds, because it has both private and public elements and those both work to jack up the prices.

If the public part (medicaid/medicare) negotiated the prices and healthcare providers weren't allowed to go above that, then things were peachy, but that's not the case.

> For example, they spend more on their military than the next 15 highest spending countries combined, and don't get proportionally better results.

Hmm what do you mean by results here? Like winning more wars? You can’t really compare two different wars. I don’t think it’d be crazy to say instead that the US can indeed project as much power as the next 15 spending countries, so results are proportional.

Don't forget that the usa sells arms at a loss to it's Ally's when you consider all the r&d aspects.

I'd also bet that you are underestimating some of the militarys classified weapons. Wouldn't even surprise me if we have nukes in space.

Finally look at it this way. There's 23 aircraft carriers in the world right now. The us has 11 of then. China's aircraft carriers are 2nd hand from Russia.

The us navy might not be 15x the size of the next 15 county's. However on a per equipment basis it's likely got a good advantage and we are likely some multiple bigger.

You don't need nukes in space with the "Rods from God" kinetic bombardment technology. The easiest way of putting WMDs in space even without breaching any international treaties:

https://en.wikipedia.org/wiki/Kinetic_bombardment#Real_life_...

> Wouldn't even surprise me if we have nukes in space.

There's a treaty prohibiting that. Of course, it wouldn't surprise me if the US broke a treaty unilaterally, then was eventually discovered prompting an international arms race to space to the detriment of everyone.

There is also the issue that they look at the top of the line to aknowledge an issue (or not).

Show how their healthcare system is not very good for the bucks for the average person, and you get answered that the very top specialist at the very top hospital for the very top money there gives you the best treatement ever. Thanks but I will still take my average specialist at my local hospital for a low price that's included in my mensual who gives me top of the line.

Show the student debt problem or their school system issues, and you get answers about the top ivy leagues and the likes ...

I'm not sure where this comes from.

I'm not saying they're wrong and I'm right, but that I'm even having issue understanding the other's side point of view; I can't really see the benefit to society of that kind of model. To me this feels like going back to feudalism and nobility without the titles. Because I can't see the discussion from their point of view, I'm not able to argue and discuss propely either.

Try saying that America isn't #1 in public and see what happens. You will be shunned, ignored, or plain out told to leave the country. There is a fundamental ideological issue going on here that needs to be addressed to allow for open communication for the big personal issues that you brought up. It's time we all get a bit uncomfortable and perhaps give up things personally for the benefit of everyone.

It's not that Americans spend the most, either, but also the fact that unlike other governments, the U.S. government has little incentive to fix national healthcare crisis, especially when Big Pharma benefits from those crisis and lobbyists against the fixes.

In countries where the government foots the bill for healthcare, and healthcare is obviously a big portion of their expenses, the government will usually scramble to do everything it can to improve the population's general health. That includes trying to limit pollution, better regulating the "food" that comes on the market, and so on.

> In countries where the government foots the bill for healthcare, and healthcare is obviously a big portion of their expenses, the government will usually scramble to do everything it can to improve the population's general health.

That is actually one of the bigger problems with the single-payer system. Your health is fundamentally related to everything you do, and consequently giving the government an interest in your health opens the doors to monitoring and controlling every aspect of your life in the name of regulating health care costs. In forfeiting the liberty to do things which may negatively impact your health then you become not a free individual, but more akin to the government's pet, your every action subject to their approval.

>Why the U.S. Spends So Much More Than Other Nations on Health Care

The conclusion of the article: Because prices are higher.

Seriously?

tl;dr: US spends so much more than other nations because US hospitals (and by extension, doctors, which NYT is too chicken to say out loud), keep increasing prices for the same care.

There is nothing here about insurance companies. It's lack of competition on the supply side.

No, it is not a supply side problem. Why do you thing that? Compare the US system to other systems' cost of care and providers per capita.

There's no competition at all on the supply side in Canada or Taiwan. Why are their health care costs microscopic compared to the US?

They are more regulated. More use of max prices, more standarization. US hospitals can charge whatever they want and hide it.

Because a large single payer fixes prices for most people.

Most? Could you specify how someone loses out?

Shortages, as with any price ceiling—when someone is willing and able to pay more but there is none available at the fixed price.

> [M]ost of the explanation for American health spending growth [...] is that more is done for patients during hospital stays and doctor visits, they’re charged more per service, or both.

Regarding Single/All Payer:

> If attempted nationally, or even in a state, either of these would be met with resistance from all those who directly benefit from high prices, including physicians, hospitals, pharmaceutical companies — and pretty much every other provider of health care in the United States.

They don’t seem shy about laying the blame where they feel it belongs.

If they aren't shy they would have put that in the first paragraph instead of beating around the bush for the entire article, and also not immediately hedged to say high prices isn't all bad/can't do anything about it because "limits."

I'll be honest, I didn't read most of the rest of the article until I found their conclusion. It's at least falsifiable, even if we have different definitions of shy.

The US jumped the shark in 1971. A comeback is very unlikely.

After WW2, the US established a system that was used extensively for its own economic advantage: Bretton Woods.

Many countries could use dollars as their reserve currency, and those dollars could be redeemed for gold.

The US abused this system by printing more dollars than what it had in gold, giving rise to the concept of "exorbitant privilege" (virtually unlimited money with no chance of accountability).

This started some sort of bank run and since the US did not have enough gold, Nixon suspended the convertibility of dollars into gold. After that, dollars were allowed to float, and if it wasn't for exclusive deals (e.g: oil), it would have a much lower value.

Now spending on healthcare, education, infrastructure, science, space exploration: all gone.

It doesn't spend it on 'other nations'.. it spends the money on US billionaires. 'Other Nations' is just a facade, as it's much easier to loose track of a few billions here and there in a god forsaken country, than it is in the middle of NY. The military industrial complex costs a lost, but a BIG chunk of that money goes to US billionaires. The US population (aka military people) only get their wages paid, everything else is paid directly to Y and Z billionaire's tank/gun/warship/plane/drone/software/encrypted computer/add stuff to this list manufacturer. And these manufacturers buy a lot of politicians' vote to keep the war machine going.

..the same with pharma...

Looks like you had so much to say about billionaires that you didn't have time to read the headline.

It doesn't say anything about spending on other nations. The U.S. spends more on health care of its own citizens than other nations do. The system is clearly not very efficient, at least in terms of what it offers to poorer citizens, although at the top end, results are excellent and the U.S. still is in the front lines in research and technological progress of medicine.

Depends on what you take the word efficient to mean, even at the top end I don't find medical care very efficient. Basic procedures can be very expensive for my insurance company. I'll define efficient here as results to cost. In the US, there are groups at every level between patient, doctor, insurance and big pharma where often their goal is to create inefficiencies because the less efficient the treatment, the more money make. Look at something like insurance billing codes; I have a friend who's entire business is telling Dr's which codes to book procedures under so they make more money from insurance. His company is make 10s of million a year. There is stuff like that at every level.

GP didn't say the top end was efficient, just that their results were excellent.

Yes, that was my point.

And I might add that the inefficiency (in terms of national health outcomes vs. national public and private spending) is partially the reason, or explanation, that U.S. is the forefront of medical technology. The U.S. spends on things that develop technology but do not contribute much to national health.

Things like transplants, or cures for rare diseases, are generally not important for national health outcomes, but U.S. does a lot of work on these. You achieve low child mortality by forcing relatively simple things done for every child and family, even those who are not very receptive to care. U.S. does not do that as much as many other countries with lower spending but better national health outcomes.

yes, my bad. But the comment stands. Just replace war machine with insurance companies. It's way easier to charge $100 for a pill, in bulk, on one invoice, than to do the same to an actual person, end user of that product. Insurance companies and laws that protect them are to blame for sky high prices in the US.

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