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Comment by eric_b | Hacker News Reader

The problem is that there is not a single reason that healthcare is so expensive. Even if you list the top 15 reasons, you still have to apply the "5 whys" to each of them to find root causes and possible solutions.

- Doctor's are paid too much... why? - Well they need to be paid a lot because medical school debt is 250k or more... why? - Medical schools/the AMA are artificially limiting the number of students and residents for their own ends (keeping wages and scarcity high) so they need to charge a lot... why? - I honestly don't know.

But the current political climate in the US is incapable of dealing with any kind of multifaceted problem.

One thing that will not make healthcare less expensive is "Medicare For All". It will just shift the bill to different people. Now, you can argue it's the morally correct course of action, or those people who will be forced to foot the bill (upper middle class taxpayers) are more capable of doing so, but you cannot credibly claim with a straight face that it will make anything cheaper. In fact, the opposite will occur.

(I don't want to hear one thing about negotiating power. That is a debunked line of reasoning. Medicare/Medicaid cover more people than many single payer systems in other countries, and their costs are still outrageous)

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> One thing that will not make healthcare less expensive is "Medicare For All". It will just shift the bill to different people. Now, you can argue it's the morally correct course of action, or those people who will be forced to foot the bill (upper middle class taxpayers) are more capable of doing so, but you cannot credibly claim with a straight face that it will make anything cheaper. In fact, the opposite will occur.

Having every person under the same plan that has the negotiating power of 327.2 million people will definitely drive costs down. Don't want to pay what the government says it is going to pay? Good luck finding customers then, because the government is bargaining on behalf of all of the customers in the US.

People who say this stuff are the same people who proclaim there is no solution to a problem that the only occurs in the US. Literally, every Industrial Nation has addressed this problem for much lower costs with better out comes.

> Having every person under the same plan that has the negotiating power of 327.2 million people will definitely drive costs down.

Why do you think this would be true? Why do you think the bargaining power would work the way you think it would?

If you were correct, then cop cars must be fairly cheap compared to normal cars. Is this the case?

What about other goods? Laptops? Cruise missiles? etc.

Actually is it true for any good which the US Gov is the sole buyer? Can you think of even a single good where your supposition is true?

Perhaps this is a good reason:

>Literally, every Industrial Nation has addressed this problem for much lower costs with better out comes.

Really? So there are zero people from other industrial nations that come into the US for health care?

Zero people from other nations come to the US to save money on health care. The ones that do come are looking for specialists for some exotic condition, not because they love the level of care or the price tags.

And do you think those specialists would exist here if we had medicare for all? no, evidence: all those other countries that have that and no such specialists.

Yes they would. The Americans also go to other countries to seek treatment in special cases.

Also, if our healthcare works well to treat rich foreigners in special cases, but sucks otherwise — I say, we should scrap it.

But sure, we can cherrypick metrics all day long.

This is a great point more people should make. There’s nothing “America first” about preserving the inefficiencies of a system just so that very wealthy people from everywhere can get care and leave (and ultimately specialists would anyway still exist, even if their treatments aren’t covered by Medicare)

Actually, that's completely what "America first" means by those who say it, at the least the ones who are in on the deal.

if everyone had that specific knowledge, there would be no specialists. no, different countries develop different specialties. famously, Kobe Bryant went to Germany (a country with national healthcare) to get a knee procedure from a specialist.

It's not a one way street, though. Americans go to other countries like Canada or Cuba for health care, including, famously, GOP Congressman Paul Ryan.

But why those nations have lower costs isn't so simple. If you remove all profit and admin overhead from the US system, its still something like $5000/person more expensive than other countries (I think that that was vs Canada).

A large component of healthcare cost in the US is simply healthcare use. We are deeply, deeply unhealthy with 75% overweight rates and absurd levels of pre/diabetes, which are the largest comorbidities of all, and comorbidities of each other. Costs will never be comparable until overweight/obesity rates and usage are comparable too. They are not.

High prices in the US are very unfortunately largely explained by usage, and no amount of profit-reducing or cost cutting will work unless you are cutting usage itself:

https://randomcriticalanalysis.com/2016/09/25/high-us-health...

It's not just about cutting usage, it's about cutting the right kinds of usage as well.

Lots of Americans, anecdotally, skip out on regular checkups or checking on minor ailments because of anxiety about paying copays. And then eventually something that could've been easily treated when detected initially blows up into an expensive ER visit or requiring specialists.

A good chunk of this could be solved if we stopped using the ER as the catch-all emergency net for literally everything.

In the UK the NHS negotiates prices for drugs. NICE have to approve all drugs and if a drug is too expensive, the manufacturer either has to lower the price so that the benefit outweighs the cost, or they lose a large market.

This is why hand waving away "bargaining power" ignores one of the sources of high costs.

The other is that our doctors are mostly either employed by the NHS, or employed by a private provider who is paid by the NHS ... yes, there are doctors who do private only work, but they are fairly small in number.

Perhaps our student loans system also helps - fees are £9k a year, but you start paying them back at 9% of income over £25k ... so it's essentially a graduate tax and they are fully written off after a set number of years if you don't pay them off.

The difference in drug spending between countries amounts to a small fraction of overall healthcare spending. $1200 a year in the US versus $900 in Switzerland or $800 in Germany, Canada, and Japan.

It's incidental what the numbers are. Given how effed the US system is, I would fully expect that $1200 being spent on the entirely wrong things, like a few super expensive drugs, and a lot of antibiotics which should have been dirt cheap getting a ridiculous markup, or on Oxycontin.

Doctors should earn enough to pay the loan off

What other goods is the US Gov the sole buyer of, for which the sellers can't easily shift to other customers? Cop cars clearly doesn't apply, as carmakers have other customers. Doctors, hospitals, and pharmaceuticals will face true monopsony, which means sell at gov rates or quit entirely. Some suppliers will quit entirely, but most won't.

Cop cars aren't collectively bought. For one its on a state by state basis, and then in some states individual PDs are responsible for their own vehicles, they just get a budget to buy and fix them.

That means they usually end up in an imbalanced power relationship of small 20-30 person local PD force approaching Ford / GM asking for their police cruisers.

Some states, of course, do collectively bargain their service vehicles like that, the USPS is probably the most prominent example of collective bargaining on a national scale - the post office bought 140,000 of them over 7 years for below consumer grade vehicle pricing. Even nowadays when they are reevaluating replacing their fleets it only averages out to about 41k per truck for a new model and that includes having to refit garages and post offices to accommodate them.

I'm also pretty sure there are licensing deals between US auto makers and various state bureaucracies to price control service vehicle costs, but its still never like a private automaker is getting an order for 80k cop cars from one entity.

Wait, how much are you paying for cruise missiles? I always feel like my cruise missile guy is ripping me off.

This is how the NHS functions and it has far better rates.

Sure, the government can say they'll only pay half as much as they do now, so providers will only provide half the care. Have you ever actually done any government procurement? Saying the government can just wave a magic wand and lower prices because "they said so" will only hurt the quality of care patients receive in the US.

The quality of care is already so low that you're better off financially and health wise just flying to Europe, or fleeing to Canada.

Thailand. Some of the best medical care of any developing nation, at around 10% of the price for most procedures. A night in a very clean, modern Thai hospital can be less than $100/night.

The 'quality of care' you receive in the US is entirely dependent on your wealth and it's only the upper class that actually benefit from it.

You know what quality care I got as a poor person? Nothing, because my family couldn't afford it. I was given the privilege of going through highschool and college with teeth quite literally broken down to the gumlines and abscessed because it was either that or not being able to have a future.

I'm tired of hearing nonsense about quality of care because for a lot of people the quality is set to null.

Every time I read arguments online of people defending the American system, I almost always get hints that they are wealthy people, usually because they admit they can actually afford the care instead of essentially going broke over it. Healthcare debt is the leading cause of personal bankruptcy in the US, so it is statistically true that it is too much for the people below the median. Even for people in the middle class.

Did something happen to your teeth that basic maintenance like brushing and flossing wouldn't have prevented?

What you're describing doesn't sound very normal, even if you never went to the dentist in your life.

Genetics and diet seem to be large factors in dental health.

Poor people tend to not be able to afford healthy foods and will often eat foods high in sugars, which are terrible for your teeth. Perhaps their parents couldn't afford toothpaste regularly, or floss at all, or could only replace their toothbrushes once a year or two. Perhaps the parents work all the time, and don't have as much time or energy to instill strong daily tooth hygiene habits in their kids or police their brushing.

As an anecdotal data point, a friend of mine always goes for regular dental checkups, and brushes and flosses daily, but still has tartar buildup and gum issues. He had to get a deep-clean, and was in pain and bleeding for several days afterward. I (foolishly) avoided going to a dentist for many, many years, and in that time did a mediocre (at best) job of daily maintenance. When I finally started seeing a dentist again, I got away with two minor fillings (my first ones, and they didn't even numb me at all for the drilling) and a deep cleaning, where I had no bleeding issues and the pain was gone within a few hours (aside from tenderness around the anesthetic injection sites). My gums aren't in great shape, but are better off than my friend's. Unknown as to why the outcomes are so different. I can't imagine what my friend's teeth would be like if he didn't go to the dentist and didn't have good hygiene habits.

There are 60 million people on Medicare. If you can’t negotiate with twice the population of Canada I don’t think the problem is not enough beneficiaries.

https://duckduckgo.com/?q=medicare+negotiate+prices&t=fpas&i...

You know Medicare sets separate prices from normal insurance, right? See [1]. For most procedures, there's the "we make up a number to charge to insurance companies" price and then there's the negotiated Medicare price with associated billing codes.

[1] https://www.healthcaredive.com/news/cbo-reports-show-private...

> Having every person under the same plan that has the negotiating power of 327.2 million people will definitely drive costs down. Don't want to pay what the government says it is going to pay? Good luck finding customers then, because the government is bargaining on behalf of all of the customers in the US.

So my mom and her boyfriend are both under Medicare now, as was her late 2nd husband. My mom and I had both generally been Medicare For All supporters (with some reservations in my case), but I got an earful recently about how people who support Medicare For All don't know what they're in for...

The problem is with Medicare's system of billing codes. Sure, if a hospital doesn't like the reimbursement rate, they can't go find other customers. But they can - and will - find other procedures. Not making enough money from that doctor's visit? Well, we better do some tests, then, just to be sure there's no lurking problem. Oh, there was a spot on that X-ray - more tests. We didn't find anything serious, but there was a benign growth that you probably should get taken care of. Don't worry, it's a quick procedure, it could potentially be done as an outpatient but you might want to make it an overnight hospital stay just to be sure. Shit, you contracted an infection in the hospital? Gotta extend that stay until you're better.

Basically, if they can't raise prices, they will find ways to do more procedures. My mom's description of what modern American health care is like as a senior citizen is truly terrifying - basically they manufacture illnesses so that they can cure them and bill for it.

I came to the conclusion (reinforced by every corporate scandal you read about on HN, and my time in the financial and tech industries) that the problem isn't health care per se, but something is deeply broken in American culture. People don't give a shit about their fellow Americans as people, only as dollars, and as a result no matter what system you institute it will end up being gamed in harmful ways. The U.S. is falling from a high-trust to a low-trust society, and there are few if any ways to bring it back.

This sounds like an ignorant view of getting proper healthcare.

There are more things to check because older people have more medical problems, therefore more tests, more treatments, etc.

We would have to see what would happen if you gave a 25 year old medicare in this country, I doubt it would be the same experience that an elderly person would have.

There is a very strong correlation between which additional tests are requested and what the hospital can charge under Medicare reimbursement codes. (My mother's boyfriend is a former doctor, and intimately familiar with the health-care system from the other side of the table.) Both of them are also in fairly good health (my mom has no pre-existing conditions, her boyfriend has some issues with his back but nothing unexpected for an 80-year-old), and were definitely not treated like this while on private health insurance.

What do you think would be different between 25-year-olds and elderly people? The incentives are the same in both cases, produced by the billing code.

And yet for all that, Medicare is vastly cheaper per capita than private healthcare. You get more service for less money? Sign me up.

25 year olds have fewer health problems that need treatment than 80 year olds.

My point is that people are being treated for health problems that are not problems because the provider can then bill Medicare for it. That's not going to go away because there are fewer health problems; the whole issue is that it doesn't matter if there are health problems, the provider will find or create some that they can bill for.

Oh, okay. I can't speak to that specifically, that seems like an unethical healthcare provider if they're genuinely performing unnecessary procedures. They should probably be reported to the state medical board.

I think there is also a matter of what you view as 'necessary medical care'. Preventative medicine is vastly cheaper (and more effective) than reactive procedures to fix things that have become serious issues.

(It makes practical sense, right? You properly maintain your roof so it doesn't leak, that's cheaper than fixing the damage caused by the leaking roof).

This is particularly true with older people who have higher incidence of cancer, heart disease and major organ problems.

So yeah, they may send you for a battery of tests that they can charge the state for, but it might be preventing a much more expensive (and traumatic/painful) surgery down the line.

But people seem to focus on the collective bargaining and price aspect of everyone having proper healthcare, which is weird because it shouldn't be about that, it should be about increasing the efficiency of the overall system and quality of life of the people involved.

>But they can - and will - find other procedures. Not making enough money from that doctor's visit? Well, we better do some tests, then, just to be sure there's no lurking problem. Oh, there was a spot on that X-ray - more tests. We didn't find anything serious, but there was a benign growth that you probably should get taken care of. Don't worry, it's a quick procedure, it could potentially be done as an outpatient but you might want to make it an overnight hospital stay just to be sure. Shit, you contracted an infection in the hospital? Gotta extend that stay until you're better.

Right. This is exactly what we want (save the MRSA). The problem with the American healthcare system isn't just that it's expensive; it's expensive and still has worse outcomes than in other industrialized countries. Part of the reason for that is that patients cut off their care for financial reasons, and not because they've reached a satisfactory conclusion about their state of health.

The way you describe the mindset isn't a function of Medicare per se, but of the fact that there's still a profit motive involved, even when receiving Medicare funding, in a system that is largely privately-funded. Maybe releasing that source of pressure and competition and scarcity will change the way people on both sides of the doctor-patient relationship approach their care.

You're not wrong they are deeper problems, but you say these things as if M4A would cause them when they are happening now. I was recently asked by a dentist if I wanted a special kind of cleaning. She then nervously admitted that it wasn't necessary, but she "wanted to make sure." M4A won't fix all the problems, but it would definitely make things better, and hopefully, lead to people demanding more.

So your conclusion is that we shouldn’t fix the part that we can fix because people will still be assholes?

Peter Attia discussed this issue pretty extensively Mart Makary on his podcast. It seems like most of the medical community agrees this would drive down costs in the near-term. The issue is what happens to care, choice, and price long-term in a single-payer system.

I think is we force the disclosure of what every company or individual pays for specific treatment or medication, this transparency alone should be a big step in the right direction to normalize costs.

That explains our highly competitive, low profit margin defense industry.

This episode of planet money talks about this https://www.npr.org/2019/09/04/757645741/what-medicare-for-a...

Because of redundancies in the US system, there are like 5:1 administrators for each doctor. That’s a huge source of the costs.

Medicare for all will likely cut a lot of those jobs to gain the savings. This show talks about if that’s good or bad for society.

It amuses me when people think that letting the government run something will make it more efficient. I do not disagree there is tremendous waste in the current system. I strongly believe that expanding the government's role will only make it worse.

If only we had examples where the government running something like healthcare resulted in a better outcome for citizens.

Perhaps a country in Europe, as developed as the US is. I mean, a country that we literally border with would be too much to ask for.

Perhaps some of us would be less amused by the concept of government-run healthcare.

Too bad we don't have the example of literally all of Europe, Australia, and Canada to kill that amusement vibe.

To play devil’s advocate, those nations are also good at providing other services that the US provides poorly.

In my opinion, the best yardstick for a health care system is how long you have to wait to be treated for cancer. By that yardstick, countries like Canada and England stack up quite poorly when compared to the USA. Canadians don't come to the US to save money on health care. They come to the US because they have an expensive potentially fatal medical condition, and they might not survive a six month waiting period for treatment.

The wait time for cancer treatment for the poor in Australia is the same as the rich, whereas the wait time in the US for the poor is "have you made funeral arrangements?"

Having had a family member just go through the Australian health system for breast cancer, her treatment was on a time-scale of a few weeks, but she had the time and was being checked often. In the US, we'd be making funeral plans and bucket lists because they'd not be able to afford treatment.

>In my opinion, the best yardstick for a health care system is how long you have to wait to be treated for cancer.

To quote a famous movie: well, you know, that's just like uh, your opinion.

Why would the wait time (and not treatment outcome, or rate of occurrence) for one group of diseases be a good metric for evaluating the overall performance of a healthcare system?

In my opinion, it's a horrible metric. To give a car analogy, the 0 to 60 time in snow while towing is surely a metric, but there are other things to consider as well when you are buying a vehicle.

>[Canadians] come to the US because they have an expensive potentially fatal medical condition, and they might not survive a six month waiting period for treatment.

A lot to unpack here! But, first, the TL;DR is no[1].

More specifically:

1)Cite sources on people and England and Canada having six-month waiting period on cancer treatments in cases where urgent intervention is deemed necessary ("might not survive").

2)Look at the number of those cases.

3)Compare and contrast with similar cases in the US when people don't get treated because they don't have the money.

4)Look at the numbers again.

5)Look at how many Canadians do come to the US (in absolute numbers, as a percent of the Canadian population, and as a percent of patients seeking the particular treatment).

6)Stop perpetuating misleading opinions.

I won't cite the numbers - that's your homework when making bold claims. I found the numbers hard to find, which means to me that your claims are likely not substantiated.

I'll be glad to be proven wrong here.

[1]https://www.washingtonpost.com/news/fact-checker/wp/2016/10/...

Rather than pull up the specific data regarding US/UK/Canada, I'll just reply with a link to a general overview of how free (but rationed) government provided health care compares to what exists in the USA:

https://www.forbes.com/sites/johngoodman/2019/03/05/what-soc...

I'd expect more from someone with "numbers" in the username.

Your source is wonderful. Here's my favorite part:

> In Canada, when patients see a doctor the visit is free. In the U.S., the visit is almost free

If someone can tell me how to move to that US, I'll be packing my bag right away!

>In my opinion, the best yardstick for a health care system is how long you have to wait to be treated for cancer. By that yardstick, countries like Canada and England stack up quite poorly when compared to the USA

I don't know who told you that about Canadian healthcare, but it's simply not true.

When my mom was diagnosed, she underwent surgery within days, and was getting chemo/radiation as soon as was medically safe.

The wait time thing is a total canard. Countries like Canada do have long wait times for things that do not require immediate attention. As an example, often you make your appointment for a physical a year in advance. And then, people who like to twist the facts into a false narrative point to the "year long wait time" to get a physical. Nonsense.

You realize there multiple working examples of a national healthcare plan right? Including one very obvious example to our northern border. You're arguing like this is some huge open ended problem like climate change.

Almost every developed country has a national system that provides excellent care for far more reasonable costs. Except the US, of course.

I'm starting to realize why America will never get its shit together. Too many people without facts in the debate, believing they are correct, without any evidence at all.

Switzerland doesn't have nationalized healthcare and Singapore has a hybrid model. In a ranking of top 5 healthcare systems, on average you will find some that are nationalized and some that are not.

One thing that is unequivocally a mistake in healthcare in the US is making it a "free market" and then having employers pick the insurance for their employees.

If you do not want to hear one thing about negotiating power then you are missing the main reason why medical costs are skyrocketing.

Medicare/medicaid does not negotiate drug costs down because it is prohibited by law from doing so. This is because of a law signed by the Bush administration (https://en.m.wikipedia.org/wiki/Medicare_Prescription_Drug,_...).

In a sense, wasn't the choice to not negotiate drug costs itself the result of a negotiation? I believe the way it works is that health insurers and providers threaten to fund fear-mongering attack ads against politicians who support laws that don't like. The politicians cave and carve out rules for the industry.

So it's not that the Medicare drug care costs aren't negotiated, its that the chance for lower costs was traded away by Congresspeople of the past (many of whom aren't in office anymore) in exchange for campaign funds. Not literally a campaign fund check, of course, but countering an attack ad costs campaign money that they could be spending otherwise.

> (I don't want to hear one thing about negotiating power. That is a debunked line of reasoning. Medicare/Medicaid cover more people than many single payer systems in other countries, and their costs are still outrageous)

It is illegal for Medicare to negotiate drug prices. That needs to be fixed.

I was going to comment the same thing. Pointing to Medicare/Medicaid as examples for why drug negotiation doesn't work is an impressively incorrect line of thought.

Medicaid mandates drug prices at a fixed percentage of what private buyers pay.

So just raise prices.

Private buyers won't just automatically pay more, so they can't "just raise prices".

Of course prices will still be raised, but the point is that Medicaid drug spending is rather directly linked to negotiated prices for drugs, not just based on whatever the manufacturer asks.

The private companies that administer much of Medicare drug coverage in fact do negotiate prices. CMS can't step into those negotiations.

And Medicare costs are lower than private healthcare. OP just seems to be arguing that it's not low enough?

> Medicare/Medicaid cover more people than many single payer systems in other countries, and their costs are still outrageous

I appreciate your reasonable breakdown, but I don't understand this one. I've seen many reports talking about how the costs of basic supplies and procedures are dramatically higher in the US (and vary wildly within the US). Things like X-Rays, MRIs, etc, being off by an order of magnitude or more (though I'm sure if the median price differences are less dramatic than the extreme examples, the results I vaguely recall said there was still a noteworthy difference)

How does this not indicate some fundamental difference between the US and other "developed" nations outside of the factors you list above? (Honest question)

I think we agree. I'm just saying it's not a single fundamental difference between the US system and other systems, it's myriad differences that combine to make things way more expensive in the US.

But you eliminate negotiation as one of those factors using other countries as a reasoning. I've never heard that this is debunked (though I don't expect that it is the sole factor). Do you have sources?

Or did I misunderstand and you are just saying that negotiation (or lack thereof) alone isn't responsible for all the cost headaches?

MRI is like 5x cheaper here (I paid less than 300$ for both knees) without any insurance just doing it privately. The reason I think is that it's easier to open a medical business here, people can't sue for damages (or they can but will never be awarded anything substantial), there is less regulation you need to comply with and the doctors and technicians make less money. All this makes it possible to provide medical services at reasonable price.

We have public single payer healthcare. The quality is low and lines are long (it's several months at least if you would like to get free MRI using that option and then like a year or more to get actual arthroscopy). Still I think shitty but somehow working public option keeps private providers in check because they can't charge arbitrary amount as there is always shitty option to fall back on.

To give you an idea about prices here if you go private: typical doctor visit: 40$, dentist (one tooth filling): 60$, arthroscopy: 1000$, full blood panel with about everything under the sun included (hormones, vitamins, minerals, insulin response etc.): 200$. The quality of service is low but higher than in major metro areas in US (according to my sister who lives in NYC). This is Poland so low wages are surely one component that makes cheap services possible but I think not the only nor the most important one.

> The quality of service is low but higher than in major metro areas in US

This is always my question when I hear about service being "great" or "terrible" - relative to what? I honestly have no idea if my healthcare is "good" or "bad", because I've only experienced one system. I have plenty of complaints, but there are also lots of things that don't go wrong that could.

People complain about lines in other countries, but me/my family has had waits of 2-6 months getting appts for new ob/gyn, dermatologists, rheumatologists, sleep specialists, etc. Mental health experiences have been worse until we stopped trying to do it through insurance at all and just ate the costs. Involved treatments (e.g. at a hospital, even outpatient) involve multiple, pricey bills.

So when you say "quality is low", what does that MEAN?

I am assessing it in two ways. One is comparing it to other services: do they have modern equipment? Is bureaucracy a burden? Do people working in those services generally act like decent human beings? Are doctors/technicians competent? Is it easy to imagine a service at higher quality and how much would it cost? Using those criteria I think medical services in my country are low quality, especially the public option.

Another way is comparing to other countries. I have family living in US (both immigrants from different countries, now US citizens, having children there) and very close friends living in Switzerland. Both lived in Poland for many years and often visit so we are all in good position to make comparisons. Both US and Poland suck in comparison to Switzerland in all imaginable respects. They comparison between US and Poland comes out about equal at least according to us.

Healthcare is driven by profits in the US and in the absence of any safeguards companies will charge as much as they can get away with.

He's comparing the higher per-person costs of elderly care to lower per-person costs of whole-population care.

> Doctor's are paid too much... why?

You can also branch off here: because malpractice insurance is insanely expensive. Why? Because people sue over absolutely everything. Why? Because lawyers in this country are vultures.

If anything is overly expensive, you can usually track it back to insurance costs somewhere, which can typically be tracked back to the fact that we live in a litigious society.

they sue and get awarded insane damages, which is probably something that could be regulated more strictly, but then what do i know.

You think the government should cap the price of suffering? What do you think should happen with malpractice or medical errors?

For example, take this recent news story and pretend this was in the USA, where a woman goes in for a routine procedure and ends up with an abortion.

https://nypost.com/2019/09/24/doctor-performed-abortion-on-w...

How would you like to strictly regulate damages for that? What do you think is reasonable for that situation? How about if someone is rendered disabled or impaired? Marred? Dead?

People like to point to malpractice and lawyers and blame it all on that. Every actual study I've read totals the cost of tort liability (insurance, law suits, damages, etc.) at about 5% of total health care spending. Significant to be sure, but not the bogey man people like to make it out to be.

It sounds like an industry argument that would be introduced by insurers to benefit insurers, since it would obviously benefit them.

I see no benefit to the patient to limiting medical error liability, but I'd be interested to hear the arguments in favor.

This is compounded by our high medical costs. People who sue often have chronic medical conditions as a result of the malpractice, and the settlement is basically paying them for their extortionately expensive medical care.

At the same time doctors are given immense authority and depending on circumstance very limited oversight in their administration of care. People will go to three different practices and get radically different diagnosis and prescriptions. There are substantive and documented biases amongst medical practitioners as well, including how women are substantially less likely to be treated for a heart attack because many doctors don't believe their reported symptoms.

Medicine is also a precipitously massive field of study and in the same way a programmer isn't expected to know every language and technology - hell, most are not expected to understand even the full breadth of the standard library or code base they are presently working in - few doctors are actually as informed as they like to act. A lot of it is cultural, doctors are supposed to be authoritative, but the US has a very problematic medical culture of assumed authority that has people putting blind faith in doctors who "trust their instincts" and end up being completely wrong and hurting people for it.

Remember that medical malpractice lawsuits are still overseen by a judge. If there is a settlement, there often was a mistake made. The solution to malpractice costs is not have doctors make mistakes but to reduce how often mistakes happen.

A lot of those remedies require a reform of culture though, and that is one of the hardest challenges to approach. And don't think I'm just "blaming" practicing doctors here, its structural to the industry and is why MDs are being put on 18 hour highly stressful shifts where its unbelievable they make as few mistakes as they do in such unreasonable working environments.

Malpractice insurance is < 3% of total healthcare cost in the US. Considering malpractice occurs and has an actual cost, not even all of that is wasted.

> I don't want to hear one thing about negotiating power. That is a debunked line of reasoning. Medicare/Medicaid cover more people than many single payer systems in other countries

That's... not true at all. In European countries, single payer covers almost everyone, and the government has negotiating power to drive down prices. This is proven workable and effective in many places, including Canada. Literally every other industrialized nation has solved this problem.

If you don't agree with universal healthcare, fine, whatever, but don't go throwing around clearly obvious falsehoods.

This is like one of those "we can't solve it" arguments like gun violence where literally every developed country except for the US has solved it.

> But the current political climate in the US is incapable of dealing with any kind of multifaceted problem.

I fear this may be true of all political issues now.

Sound bites and catch phrases that way oversimplify complex issues to the point of absurdity seem to sway a lot of voters.

> One thing that will not make healthcare less expensive is "Medicare For All".

A large part of what makes American per-capita healthcare costs so outrageous is how much is treatment rather than prevention. Because going to a doctor is so expensive people just don't go, and then mundane problems that could have been fixed with at worst a routine surgery end up in an emergency room on life support expending a hundred thousand dollars of resources a day to correct.

Thats in addition to substantive productivity losses incurred by people being sick all the time without the financial resources to actually fix their ailments.

Even when you have health insurance the absurd deductibles mean you can't see a doctor anyway without being out the equivalent of half the months food or your entire utility bill.

It is absolutely imperative that any nations people have affordable access to medical professionals before they are suffering ill from all the things they noticed were off but didn't want to become indebted over.

> Medicare/Medicaid cover more people than many single payer systems in other countries, and their costs are still outrageous

This is not a fair comparison. Medicare/Medicaid predominantly covers the elderly. You can't compare their price spend to a mix including many more healthy people covered in single payer systems in other countries.

There is a WHY (or at least a general why): Obfuscation.

- lack of clarity on competitive pricing

- obfuscation by adding multiple layers in buying process (broker - insurance - claims adjuster - hospital)

- obfuscation through too-many-options syndrome (Obamacare versus Medicare versus state-driven healthcare versus emergency-only healthcare)

- lack of clarity when being billed (getting several bills from several different departments)

There's also the problem of insurance companies being a for-profit enterprise that answers more to stockholders than to patients.

This is the result of "free market" idealists at work. Health is something that everyone needs, so businesses want a piece of the big pie by trying to wedge themselves somewhere in there. Only massive government overhaul can fix this.

The typical insurance company returns are pretty small (~5%) so that alone doesn't seem to explain why prices are so high.

But that's the return (net margin, not gross cost that the insurance company is adding to the whole system). You have to look at gross, which is way higher (~5x).

>This is the result of "free market" idealists at work.

Huh? I can't think of anything less free market then the American medical system!

Ok, maybe defense contracting is less free market. But at least that is paid for out of federal tax money.

The AMA is a cartel, and we (in the US) are all suffering for it.

> One thing that will not make healthcare less expensive is "Medicare For All". It will just shift the bill to different people.

One of the myriad reasons healthcare in the US expensive is the middlemen who stand to profit from taking as big a cut of your premiums as possible, while paying for as little care as possible. Without this fundamental force driving healthcare prices it doesn't seem clear to me at all that prices would stay the same. Your dismissal of single-payer plans like M4A glosses over the largest proposed change to the structure of medical billing.

>One thing that will not make healthcare less expensive is "Medicare For All". It will just shift the bill to different people. Now, you can argue it's the morally correct course of action, or those people who will be forced to foot the bill (upper middle class taxpayers) are more capable of doing so, but you cannot credibly claim with a straight face that it will make anything cheaper. In fact, the opposite will occur.

Isn't the NHS or Canada's system better? How are they different from 'Medicare for all' ?

Define "better".

Substantially cheaper, with similar patient outcomes.

> so they need to charge a lot... why? - I honestly don't know.

Does anybody else know the answer to this?

> Doctor's are paid too much... why?

Are US doctors paid too much when compared to say... Japanese doctors? European doctors?

In many cases US doctors make 2x (or more if you're a specialist) than their European counterparts. The outcomes are not materially better in most cases.

(Also, I'm just picking on one small reason for healthcare costs, the point is that is just one of many)

> In many cases US doctors make 2x (or more if you're a specialist) than their European counterparts.

That sounds outrageous but isn't the same for software engineers as well?

Senior level software engineers in (not San Francisco/New York/Los Angeles) can easily make $80k - $160k.

The salaries given relate back to expenses paid. Doctors in Europe broadly don't pay anything for medical school and thus don't have a mcmansion of debt to recoup after graduating.

Developers throughout Europe find their salaries regularly pegged to cost of living wherever they are. In the US salaries are distorted for 2 reasons - most major global tech companies are here and thus there is higher demand for developers here than elsewhere - and two that those tech companes congregate in the most expensive cost of living places on Earth due to NIMBYism and Americas broken city planning culture.

In general almost everyone in the US is paid, comparatively, more than their European counterparts because their raw income has to afford to cover potential medical expenses that nobody else abroad has to contend with. Americans also get much reduced food, utilities, and housing benefits compared to the broader first world.

> Developers throughout Europe find their salaries regularly pegged to cost of living wherever they are.

Even if that is the case, if you compare salaries for mid-level developers in cities like Miami and Amsterdam, I think the pre- and post- tax situations are pretty drastically different.

> > so they need to charge a lot... why? - I honestly don't know.

> Does anybody else know the answer to this?

They don't _need_ to. But they do charge a lot because they can -- they know that doctors can afford to pay it using future earnings. And now we're back up the stack in terms of explaining high costs.

Part of it is the Baumol effect as explained by Tabarrok et al [1]. But I believe most of it is due to the nature of the healthcare industry when there are no govt-imposed limits on prices: there is no incentive for hospitals and doctors to lower their prices, since they are not in competition with each other for patients. The insurance industry is just passing the cost to the employers. I could even argue that this explains some of the wage stagnation -- costs went into health insurance premiums.

[1] https://marginalrevolution.com/marginalrevolution/2019/06/sp...

Software Engineers in the US often make 2x as much as our European counterparts, yet we don't have any artificial limits on the number of people able to study Software Engineering. I'm not disagreeing with you the point on the AMA, but even if they removed their limits -- would many more people want to enter the field? It seems extremely intensive, not only during your education and residency, but on the job too. 12+ hours days, multiple days per week? No thanks.

Speaking for Canada rather than Europe but I imagine the argument is mostly the same. The supply and demand ratios are different. Canada has very few pure software firms like Google or Amazon compared to the US, so there is significantly less competition for the engineers that work there. This drives prices down - or rather, prevents prices from being driven up.

>In 2011, 43,919 students applied to medical schools. However, only 20,176 of those applicants were accepted into at least one medical school. In other words, 54% of applicants got rejected to every medical school they applied to.

Even if we remove the bottom 10% or even 20% of un-accepted individuals (who we might assume, unfairly or not, are not cut out to be doctors) an absolutely significant number of people would enter the field.

I wonder what’s the graduation rate for medical school? You’d think it should be difficult enough to flunk out 2/3 of the students (like engineering), but I’m guessing that is not the case.

It's practically 100%. Once you're in, they'll do everything in their power to graduate you (legitly). Every incentive they have points at a perfect graduation rate.

EDIT: In the US, anyway. Things are different in, say, Caribbean medical schools.

I read someone mention that French medical schools are easier to get into but the graduation rate is much more like engineering schools. About 1/2 to 2/3 of students drop out or fail. Said the result was French doctors were functionally better in general than US ones and happier.

Since I don't have any experience with French medical schools I don't know if that is true or still true.

I do have experience with US doctors and about half of them are just phoning it in every day.

I also used to assume it was a field full of highly intelligent people, but when I told this to my cousin who is a doctor he laughed and said something to the effect of "The medical profession selects for mediocrity", and went on to point out that being a doctor is a fairly rote profession; most of their work does not involve creative problem solving or critical thinking. It is a very challenging profession in terms of having to learn an enormous body of material, work grueling hours in dangerous and unpleasant environments, and deal with customers who are definitionally unhappy to be your customer. But it's a set of challenges that a fairly wide portion of the population can rise to.

Software engineers are in such high demand in the US that we can't train supply fast enough. In addition, most tech companies tend to be clustered in areas with the highest cost of living in the country. Those two things combined are what serves to push salaries up.

If there were more doctors, they wouldn't have to work 12+ hour days. They are overworked and have to pack patients in because of the limited supply of doctors.

What I've noticed is that everybody in the system cries poor and believes that someone else is gouging us. But the system is so labyrinthine that nobody can figure out where the money is actually going. And every group (e.g., doctors) has an investment stake in the other groups (e.g., medical and malpractice insurance companies), or is a partner in an LLC that makes money by buying a machine and billing for its use. Etc.

The likely answer is: They are all gouging us.

One potential benefit of a single payer system is simply being able to untangle that mess and put every player on a reasonable footing. For instance, make medical school free, but then doctors get to work for the government for a decent professional salary. It might even change the mix of people who are willing to become doctors -- more middle class. The primary expenditures of the medical system should be materials (capital and consumable like drugs) and salaries.

”The likely answer is: They are all gouging us.”

Exactly. It’s pointless to spend time on trying to find a single culprit. Corruption is spread throughout the whole system.

And what's more - look at the UK where we spend half as much per capita on healthcare and achieve broadly similar results. Yes, if you get a sporting injury you're going to be waiting 6-8 weeks for physio, but if you have a heart attack, cancer, are in a serious accident there is no wait.

Oh the thought of going to the doctor without that time of uncertainty about the bill that'll be coming. $200? $500? No, no bill is coming.

The official NHS target for cancer treatment is that patients should get it within a month of the decision that it's necessary. The NHS has been missing that deadline quite a lot: https://www.theguardian.com/society/2019/jan/10/nhs-england-...

When you don’t pay for a service, you are not the customer but the vector to get to the real customer.

Think: Television, radio, Google, Facebook, healthcare.

There are gigantic pools of funds out there in quasi-private insurance, Medicare, and Medicaid. Costs explode. Similarly, gigantic pools of funds are available thanks to subsidized student loans that cannot be bankrupted. College costs explode. Being uninsured is terrifying because the individual healthcare buyer is competing with deep-pocketed insurers and government programs who are much less price-sensitive.

Healthcare is expensive because the patient is not the customer. Insurance is going crazy because insurance is legally compelled to pay for oil changes and basic maintenance, so insurers must accept more exposure.

You're forgetting that medicare for all also comes with a lot of promises about free education. The artificial barriers for education will be slowly removed and the supply will quickly match up the demand.

The solution isn't going to fix everything immediately, but it IS required for a full solution.

Nothing about removing tuition costs to universities changes the AMA artificially restricting the number of medical doctorates issued every year.

Except now starting a training program does guarantee you'll have students that don't need a ton of money to pay off their loans. It becomes less risky.

Part of the problem is that Medicare/Medicaid pays market prices. Its a pricetaker not a pricesetter, because of poor regulation, in spite of its larger position. If you pay market prices, expect inflation every year on top.

No they do not.

>Medical schools/the AMA are artificially limiting the number of students and residents for their own ends (keeping wages and scarcity high) so they need to charge a lot... why? - I honestly don't know.

The AARP advocates for social security... why? - I honestly don't know.

Imagine if you put the teamsters in charge of infrastructure spending, every road in the country would be under construction perpetually. It would be illegal to shovel your own driveway without paying someone in the union to sit in front of your house and supervise.

>- Doctor's are paid too much... why?

Haven't doctor's historically had high salaries? Becoming a doctor requires years of training which leads to a low supply of doctors for a field that has always had high demand. Likewise, Doctors seem to be overworked so I'm not sure I can say they are being overpaid.

I don't think all the money that is being spent on healthcare is actually being funneled into doctors pockets.

You did say there are a top 15 reasons, but I think doctor salaries are a bad example.

No, the low supply of doctors is caused by the AMA, which keeps the number of accredited medical schools low. In the 90s, they were instrumental in getting Congress to pass laws that cap the number of residencies permitted per year. Medicare pays much of residents' salaries, and the law stipulates a maximum number it will pay for, a number that was fixed in 1997, and only changed once, in 1999 (and then only for teaching hospitals in rural areas).

The US population has grown by around 25% since then, but we're still getting the same number of new practicing doctors per year that we got over 20 years ago. Doctors are overworked because we have a shortage, not for any reason inherent to their profession.

> One thing that will not make healthcare less expensive is "Medicare For All". It will just shift the bill to different people.

This is what happens with corporate healthcare plans already, those costs get past onto the consumer (middle to upper middle class) and they pay a hidden healthcare tax on every purchase.

Heathcare costs are part of employee compensation. The tax is on employees.

Any evidence of this? Some quick googling and I couldn't find anything about about employees with healthcare plans being paid less than employees without them.

If I understand the history of it properly, healthcare was always meant to be an extra incentive from a period where they weren't allowed to pay more. It's never been a tax on employees.

Ask yourself this question: why does anyone get paid more then minimum wage?

I don't think negotiating power is debunked.

No reason? Hey, let's assume you're running a business. Only it's a special business. The customers really need your service. And they don't pay for your service. Someone else pays the bill for them. And they are extremely interested in acquiring the absolute top quality possible when using the service. So when you charge $50, but the guy across town charges $500, the customer will fight tooth and nail to get in and use your competitor instead. Call it 'reverse capitalism.'

That's insurance-supported medical care in the US. No one wants to go to the cut-rate bargain-basement doctor. And the majority of patients aren't paying their own medical bills. The insurance company is footing that bill. So when their kid gets sick, they're price-shopping in reverse. They only want the premium level, and offering a good deal actively stops people from using the service.

And that doesn't even get into the price-fixing that insurance companies engage in, entirely legally, because insurance is determined to be "not commerce" and therefore exempt from all antitrust laws. There is definitely a reason why Americas sub-standard care is so expensive - insurance.

"Medical schools/the AMA are artificially limiting the number of students and residents for their own ends (keeping wages and scarcity high) so they need to charge a lot."

That is the peril of this type of analysis. Clinician cost is only 20% of total healthcare spend. Your premise is flawed so your conclusion is invalid.

His premise is not flawed; yours is.

Looking only at clinican costs is akin to saying that a sandwich should only cost $1.50 because that's the cost of the ingredients.

Doctor wages tie into personal health insurance, medical malpractice insurance costs, hospital system insurance costs, and more.

Even if you were correct on the cost bit (you aren't), you're completely ignoring that artificially constraining the SUPPLY of doctors causes massive cumulative ripple effects adding up to significant costs across the system.

The AMA is absolutely a cartel restricting supply and artificially keeping wages high. Have you taken a look at any other health care system in the world?

You just proved my point, you know that right? It's the healthcare delivery and the markups along the way. If you paid doctors $0 tomorrow, healthcare costs would go down by 20%, at best, and probably less. Your analogy is perfect, actually. The problem in sandwich cost is rent, utilities, administrative expenses, marketing, an acceptable return on investment to the owners, etc, etc. The actual good being sold, a sandwich, probably costs 10% of what you pay retail.

Your repeated use of the phrase "cartel" is not impressive or convincing to me. In every other field: civil engineers, lawyers, real estate agents, accountants, teachers, police, and countless others have licensure, education, and training requirements.

And thanks for you concern, but I am familiar with many other global heath systems.

I notice you ignore LNPs and PAs in your analysis.

On the contrary, you proved mine. I worked in medical devices and hospitals for a significant portion of my career, and I really don't care that you aren't impressed by the term "cartel", that's your prerogative to turn a blind eye to the facts. It's a combination of inflated salaries plus numerical shortage of doctors (the two are related) causing the root issues here. You claim to be familiar with other health systems; care to explain why in every other developed nation where doctors are not so overpaid, health care costs are reasonable?

NPs and PAs are not allowed to perform a significant number of medical procedures; I see you ignore that, conveniently, and bringing it up isn't much other than a red herring.

The "cartel" term has been used both colloquially and in academic literature for quite some time:

https://www.jstor.org/stable/2352286?seq=1#page_scan_tab_con...

Here are some other reading links.

http://www.jparksmd.com/blog/a-massively-overpaid-cartel

https://wallstreetpit.com/5769-medical-cartel-md-salaries-hi...

https://www.forbes.com/sites/timworstall/2017/06/04/milton-f...

https://fee.org/articles/the-medical-cartel-is-keeping-healt...

For the record I want to say that the second link you pasted - http://www.jparksmd.com/blog/a-massively-overpaid-cartel -actually argues against even more effectively than I was able to.

I'm very glad you pointed that out; I mean, jparks makes the same claim you make - that salaries aren't the problem - and doesn't address the artificial restriction of doctors at all. In other words, he fails to refute the "AMA isn't a cartel" claim. If you prevent the AMA from artificially restricting doctor supply, the overall cost of health care drops significantly, and the health of the population increases considerably.

As a consequence of the overwhelmingly positive benefit of lifting the artificial supply of MD (or DO), doctor salaries will naturally drop, as necessitated by economics.

I think you're focusing a bit too hard on this. If we broke the AMA cartel, prices would not magically fall to be in line with other developed nations. The AMA cartel is certainly a factor, and not small one, but it's not the only factor.

We also need to fix the high administrator-to-doctor ratio that adds costs.

Insurance companies provide little value and just extract money from people. They need to go away.

Many low-income people skip out on preventative visits because they can't afford them. This leads to high-cost illnesses later down the road that could have been prevented or mitigated with proper care.

So yes, doctor salaries are inflated, there is a shortage of doctors, and the AMA is a cartel that limits supply. But there's more to it than that.

With more doctors (and consequently lower salaries) the cost of preventative care drops, no? And perhaps just as importantly, the EASE and time-delay of getting an appointment drops.

Blue collar workers tend to wait, as you said, until an illness becomes critical - because they have to work 9-5, the same hours doctors work. With an additional 25 or 50% of MD workforce, we can easily begin offering preventative care services outside of 8-5, allowing low-income people to get the preventative care they deserve without affecting their livelihood.

We should strive for primary care visits to be available 7am-7pm (at least), 7 days a week, in every hospital/clinic in the nation. And specialist visits should be bookable in ~2-3 weeks max, not the 6+ week timeline many individuals requiring a specialist face.

I agree with all your points, and definitely the administration costs I hope will drop as we get better ML/AI technology. I don't personally see a realistic way to get rid of the insurance companies, but they can be quite harmful. Finally I also would like to double down that the "cartel" aspect is the single largest contributing factor.

> The problem is that there is not a single reason that healthcare is so expensive.

I'm recently fond of saying that the ultimate root cause of all suffering is greed.

If you follow the money, I'm sure that is exactly what you'll find.

> Well they need to be paid a lot because medical school debt is 250k or more... why?

You are doing something called confusing cause and effect.

Medical school costs a lot because doctors earn a lot of money.

> Medical schools/the AMA are artificially limiting the number of students and residents for their own ends (keeping wages and scarcity high) so they need to charge a lot...

That sounds like a strange conspiracy, do you have evidence to support that?

Keep in mind 20+ years ago that insurance was much cheaper, deductibles were almost nonexistent, and care networks were giant. Talk to your US parents or grandparents about their costs of health care, you'll still be stunned at how much cheaper it was. Medical schools and the AMA still existed then too BTW.

Look up what "match day" and the NRMP is.

The AMA quite literally fits the definition of a cartel. It's quite absurd to use the term "conspiracy".

Academic papers going back to (at least) 1977 have suggested this: https://www.jstor.org/stable/2352286?seq=1#page_scan_tab_con...

Here are some other reading links.

http://www.jparksmd.com/blog/a-massively-overpaid-cartel (this doctor attempts to refute that the AMA isn't a cartel by making the point that doctors are "overpaid" in the US as compared to Europe by the same factor as for many other professions. He however intentionally avoids the point of the restricted supply, which is the root cause of the issue, the artificially high salaries are simply a symptom of the disease)

https://wallstreetpit.com/5769-medical-cartel-md-salaries-hi...

https://www.washingtonexaminer.com/thanks-to-doctors-there-a...

https://fee.org/articles/the-medical-cartel-is-keeping-healt...

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