Hacker News Reader

Comment by codelord | Hacker News Reader

I think Sweden is very romanticized in American media and amongst the elites. Having lived there for 6 years before moving to US, I think it's an ok country but nowhere near the paradise that is promised by the American media. They say the best thing in Sweden is its health care. In the entire time I was there I attempted to see a specialist for a condition that I had maybe two or three times, I ended up giving up every single time after I was told the wait time is between 3-4 months. I keep my American employer sponsored private insurance and employer determined time off policy, thank you very much.

View on HN

Of course if you are in the top 5-10% of earners (which I suppose many/most on this forum are), a privately funded system will almost always be better simply because you can afford to pay for the best.

For myself I’d much, much rather live in a society where a cancer diagnosis doesn’t financially ruin you and your family for you life, and where everyone no matter their income receives quality care when it’s needed. Even if that means that I have to wait weeks/months to get something non-critical seen.

> Of course if you are in the top 5-10% of earners

Do you go to a special doctors office for the top 5-10%? The one I go to is full of ordinary middle class people. 80% of Americans polled rate their healthcare as excellent or good: https://news.gallup.com/poll/245195/americans-rate-healthcar....

The American healthcare system isn’t hard to fix because it only works for 5-10% of people. It’s hard to fix because it works for 80% of people. Americans don’t irrationally cling to a system that’s bad for 90% of them. (Even among Democrats, a large fraction oppose getting rid of current health insurance: https://slate.com/business/2019/10/medicare-for-all-is-getti...)

Americans stick to the current system, because it works for most people. Most middle class people don’t go bankrupt when they get sick. And the middle class pays the lowest taxes in the developed world, because they don’t pay 20-30% payroll taxes like in European countries to support healthcare for the bottom quarter of earners. That’s the bargain people have voted for. That is obvious, because candidates who campaign for Swedish style healthcare don’t propose Swedish style taxes to go with it. Elizabeth Warren isn’t running on a top tax bracket that kicks in at $75,000 — she’s running on a wealth tax Sweden abandoned and corporate taxes higher than Sweden. Because Americans won’t vote for the bargain between healthcare coverage and middle class taxes that Swedes have adopted.

It’s not the system I’d prefer, I’d rather pay more taxes and make sure the bottom 25% have adequate healthcare. But the notion that everyone is actually irrational and the current system only benefits a small minority is self deception.

I'm not sure I agree with this -- how do you distinguish between "the system works for 80% of the people" and "79% of the people don't have medical emergencies (but the system would fail them if they did)"?

> but the system would fail them if they did

I'm not convinced on this point. Over 90% of Americans have health insurance[1]. Sure, insurance might not cover every dime of every bill, but I can't imagine falling ill is an instant and universal cause for financial ruin like people claim.

Disclaimer: I've been lucky enough to not have to use my health insurance for anything serious. But I have had to use other kinds of insurance (car, home) and by and large it's been fine. We hear horror stories a lot because they're sensational and they sell well, but people continue to buy insurance because it actually does provide value.

[1]https://www.census.gov/library/publications/2019/demo/p60-26...

There's also this[1] study about cancer and debt in the US.

Insurance isn't equal to insurance. The car insurances in the US are the most comfortable in the world. Something happens, you're covered, the insurance pays. Not so in other parts of the world. You drive out of the parking lot scratch another car? It's considered normal in the US. Not so in Germany. You scratch someones car by accident? Anything is possible now.

Why compare apples and bananas? I had a surgery in Taiwan and worked in Healthcare in a couple of countries. I also had health insurance when I was working in the US and got hit by a car while on a bike.

And while the insurance and the other drivers car insurance paid for most, man you sure have to be careful that someone can tell the emergency not to take you to the wrong hospital.

Let's stop pretending there isn't something seriously wrong with the US healthcare system. If all stars align everything is fine, but just an MRI can take anything from 1000 to 2000 or more dollars depending on whether you have insurance or not. You don't have to pay the 2000 dollars if you know better, but it's basically like a bazaar where you have to bargain if your insurance hasn't done so already.

Germany was at that point in the 1920s(or sometime around that) actually. I'm not a fan of Germanies healthcare system, especially since it's such a huge chunk of an already low income, but all the issues you describe about other countries are mostly non issues in Germany.

https://www.amjmed.com/article/S0002-9343(18)30509-6/fulltex...

That study looks at non-care costs, and groups together everyone, not just insured people.

Studies looking at out of pocket costs for insured people show much lower figures: https://healtheconomicsreview.biomedcentral.com/articles/10....

> The financial burden of cancer varies with the types and coverage of health insurance. An analysis of the 2010–2014 MarketScan data showed that an average patient with employer-provided plan had incurred about $7000–$11,000 OOP expenses over 4 years following diagnosis for a series of care that worths $100,000–$280,000.

Another report: https://www.forbes.com/sites/arleneweintraub/2017/08/10/even...

> More than one-third of cancer patients who carry insurance spend more out-of-pocket for their treatments than they anticipated having to pay. Among those who report being blindsided by the costs of their therapies, the median monthly out-of-pocket expenditure is $703.

Among the one third of people who report being surprised by out of pocket costs, the median payment is $703 per month, or about $8,500 annually. That’s a lot, and it can be surprising. But The median individual income for someone 45-55 is $80,000. That’s about 11% of income, or smaller than the difference in the tax wedge between the US and Sweden.

And to put that in context: out of the minority of people who get cancer, and the 1/3 of those people who report being surprised by out of pocket costs, the amount of out of pocket costs is about the same as what everyone with the median prime age US income would pay in extra taxes in Sweden every year even when healthy.

I'm sorry if I came off an deceptive or disengenious. I don't mean to compare apples and oranges, I'm just making the best comparison I can.

This is where my question stems from I suppose. How well insured is the average American? How often do people get stuck at out-of-network care and how much does that cost?

The study you linked is very interesting. My main takeaway is that the average loss after 2 years is 92k, which is significant.

It doesn't seem like they control for employment status? Cancer and cancer treatment can often mean people are unable to work. So, medical bills or not, I could see keeping up with your mortgage and expenses getting near that figure.

A minor piece of anacdata, I had an MRI. Paid for it out of pocket because I can. Private company provided it. $200. Done. Don’t have cancer and I do have a DVD of my brain that I will never watch because I’m squeamish. The private market can bring down prices if given a chance. Yes we need to fix things, but look at the US track record on the VA.

I assume this was a researched and planned procedure on your part?

I am a much bigger believer in "the market" than most people. But the problem with the medical industry is that many / most things happen under serious time pressure.

The seriousness and imediatness of medical procedures means that competition and choice often do not get to play a role in your decision making. For many people in many circumstances, the MRI machine nearest them has a complete monopoly.

How do we bring the miraculous efficiency of the market to an industry where people often cannot make consenting and informed decisions? Its a very hard problem to solve.

That is true. However urgent care is a small fraction of the US procedures. Cancer treatments, heart operations, etc are most often planned care. They also care touted as likely to bankrupt you. Can we try to optimize the majority of our system first before we rebuild it because of painful corner cases?

That's a fair point, chronic / planned care is definitely a significant portion of the market.

That is a flat lie, Eg. Omnium insurance in Belgium pays everything.

There is also full car insurance in Germany: https://www.howtogermany.com/pages/vehicle-insurance.html

I fell ill and I happened to luck out with exceptional insurance. I'm the 99.9 percent tier of best insurance available. If I had anything like like a typical individual I would be in financial ruin ending in bankruptcy if I don't die first. I'm 37, sometimes devastating illness comes out of nowhere. I'm lucky I was covered. Most people in that situation would be fucked.

Living in Belgium, the healthcare works for every Belgian if it's realistically possible, not the "80%" like in America ( source?).

When I see the costs of an operation in America, they just do unnecessary operations, because they can earn extra money. When your argument is "most people won't go broke", that is a really fucked up statement.

Medicare ( that the current administration is trying to slash) is a partial fix for a very expensive and failed system.

In the US it isn't the poor that suffer but the lower-middle class, who are neither poor enough to get excellent health care for free nor wealthy enough to have high-quality private insurance.

The policy problem is that to adequately cover the lower-middle class you would need to substantially raise taxes on the upper-middle class, which pay anomalously low tax rates in the developed world. And the upper-middle class in the US quite enjoys their low tax rates. (While often focused on, the upper class often pays aggregate tax rates in places like California and New York that are more in line with Europe.)

So _why_ if it works for 80% of polled people does it keep being touted as it resulting in bankruptcy consistently?

The same reason that guns result in 1% of deaths but you hear about them constantly. It makes for a good news program.

You're _honestly_ saying that fears over school shootings in the US are overblown because it makes for good news?

School shootings average 4 deaths per year. They are very tragic and very sad, but you should fear them about as much as you fear cows. In fact, cows kill a lot more people than school shootings do.

All this fearmongering over such a rare occurrence is actively causing harm: https://www.washingtonpost.com/opinions/2019/10/11/lockdown-...

Deaths of children. At school.

For literally nothing.

They are _avoidable_, that's why they are not overstated.

Every death is a tragedy. Many are avoidable. If we want to actually reduce tragedy and suffering, your time and energy is best spent on big problems.

A school age child is nearly 200x more likely to die by suicide than from a school shooting. That's a tragedy. And that's _avoidable_. Which do you hear about more?

The attention and resources of society are limited. We would be better off allocating resources to bigger problems, but we don't. That's a tragedy.

Um, why not both.

The rest of the world doesn't have the school shooter problem.

It's fixable, and the fix is bleedingly obvious. There's no excuse.

How are they avoidable?

The only presidential candidate to speak truth about this... Andrew Yang.

He said the drills are misguided though right?

Not that the US obsession with guns and lax gun control that enables school shootings is defensible.

Americans have guns because we believe that individual citizens may, god forbid, need to kill people. Many Europeans, by contrast, believe that they are past that, at a point in history where only the State needs the power to kill.

Who knows who is right. But it’s ridiculously arrogant to say that the American position is not defensible. It was literally just a couple of generations ago when the US was air dropping rifles into France to support the Resistance. Even if we have now entered an age where ordinary people don’t need guns—that new age is younger than computers, supersonic flight, or television. Its far too soon to conclude that’s this is how the world will always be from here forward.

I think you're missing that Europeans also recognise that giving every dumbass, desperate person or dormant psychopath a gun, is far more likely to get people killed NOW, than the chances that when the 'end-times' you imply come, all these same people are going to someone effectively unite and overthrow the regime.

It's a crackpot idea to think that 'arming citizens' helps the whole. And the fact you think it's 'arrogant' to spell out a basic truth that the rest of the world understands is dumbfounding.

Yes, that the drills are misguided. And he is fine with the obsession with guns, suggested using palm/grip recognition to tie guns to owners with free updates paid for by govt. Reasonable.

More reasonable than the anti gun control people, but it's still an insane solution to the problem, in the grand scheme of things.

Because?

Because in the grand-scheme of things, the countries that have banned guns don't have the problems you have.

Crazy, I know.

Yes.

Do you mean that 1 in 100 gets shot dead during their lifetime? In the US

It’s a misleading statistic that gets used because it helps push the narrative that things are broken: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5865642.

> However, the magnitude of the bankruptcy effect is much smaller than previously thought: we estimate that hospitalizations cause only 4% of personal bankruptcies among nonelderly U.S. adults, which is an order of magnitude smaller than the previous estimates described above.

I'm not so sure that rate of medical bankruptcies is the metric I'd use to measure the healthcare system! But point taken.

The other 20% is a lot of people.

Yup, the US is the 3rd most populated country on the planet.

Take a look at bankruptcy due to health issues in Canada. It’s lower than the US, but still a problem. They have a single payer system, but what people tend to forget is if you’re really sick, you often can’t work, so even if health costs are minimal, you can still go bankrupt.

What I think would be helpful in the US is universal catastrophic insurance. Worst case scenario, you’re covered. If you want everyday health insurance, let people buy it or get covered if low income.

Many universal system use this type of coverage.

If you're already in a lot of debt, getting a medical bill is just going to add to that debt. As a result, anyone who sees a doctor and declares bankruptcy can say that healthcare is at least partially to blame.

I get the logic, but I'm more looking for statistics.

I can't tell whether there are "too many" medical bankruptcies, but I know that pundits are exaggerating the degree of severity. This link has some statistics, so you can take what you want from it.

https://www.politifact.com/factchecks/2019/jan/31/jose-oliva...

Money for employer provided health insurance doesn't come from nowhere either. Bumping payroll taxes up to 20-30% would actually be cheaper than the $30,000 per year my employer pays for my health insurance.

I think a better metric would be to find out what percentage of people who NEED their healthcare for major medical issues rate their healthcare insurance as good or excellent.

https://www.commonwealthfund.org/press-release/2018/new-surv...

>> Most middle class people don’t go bankrupt when they get sick.

The median American household currently holds just $11,700 in savings. most people in usa would be ruined financially by a serious sickness where each day at the hospital alone could be up to $5000.

Literally why insurance exists

No one ever actually pays that. With insurance a deductible is around $4,000. Or they have medicaid. Or they negotiate with the hospital. Or they just don't pay.

Those news stories about people being ruined, are in the news exactly BECAUSE they are unusual.

I'm personally I the camp of, why the hell can I not know how much stuff costs up front, why can I not tell them no I dont an unnecessary x-ray, and why am I not told cost owed by me until after the procedure only to find out it's just an absurd amount of money

Private insurance blows cause we're all basically required to have it but it's worse than a tax because we barely ever know how much we owe.

There's plenty cash-only doctors and clinics out there. There's also companies that handle healthcare for their employees via personal accounts (they put more cash in your account each year, and you spend or don't as you see fit). People on such plans do a lot more shopping around.

And as the other poster said, you always have the right to refuse treatment, up to your death if you like (unless it is some kind of involuntary commitment where you are put there because you are supposedly dangerous). Many terminally ill people choose to go this way.

Oh sounds like everything is fine then!

Seriouy doesn‘t your hair stand up in horror when you re-read this?!

„You can always choose to die when you can‘t afford treatment“. WTF?!

>why the hell can I not know how much stuff costs up front

Prices should be publicized, I agree, but you can ask to get something pre-authorized. It just takes longer.

>why can I not tell them no I dont an unnecessary x-ray

You can ask your doctor why you need an x-ray, why they deem it necessary, and refuse if you like

>and why am I not told cost owed by me until after the procedure only to find out it's just an absurd amount of money

Again, you can ask for pre-auth.

Pre-authorization sounds good, but unfortunately a lot of the time it isn't possible. For example, when I was in the ER they gave me a few choices on how they could do stiches on a big cut... But there is definitely no way I could compare the costs! I just ended up paying a $500 bill a few months later.

Lack of pricing information is ridiculous in the US.

You can’t base a system on the “free market” then prevent consumers from having pricing information.

It certainly wouldn’t fix everything in the US, but it would be a huge help.

To be honest, I’m not sure why hospitals in the US haven’t taken the lead on this. If I had a choice between two hospital of similar quality, but one provided price transparency and maybe even a price guarantee (your procedure will cost $X, guaranteed), I would certainly go to that hospital.

Yes, emergency situations are different. Not much of a chance to wait and shop around.

This doesn't seem to be something that's common knowledge. Can you point to information on how to use private health insurance like this?

You just ask the front desk to pre-authorize the prescribed treatment. They work with the insurance carrier and let you know what your cost will be.

Price transparency is a tremendously difficult problem because healthcare is a multi-layered bureaucracy.

Even then though, making prices transparent wouldn’t address the primary scenario that results in personal bankruptcy, which is emergency care. You can’t exactly shop around for the cheapest ER facility if you’re bleeding from a gunshot wound.

Information asymmetries are a huge problem in "market solutions" and there's a huge one here: doctors have 8+ years of medical training and most patients....don't. It's going to be very hard for many people to second-guess a doctor's recommendation or estimate the expected value of decisions.

In a non-emergency situation, you can certainly try to read up on your own, but the medical literature is not always easy to interpret. A friend of mine asked for advice after he was diagnosed with Parkinson's Disease. Despite having a PhD in neuroscience and working as a researcher in a PD Center of Excellence, I had a really hard time making a recommendation. (Neuro conditions are particularly hard, but this is also possibly the best-case match with my experience).

I had a good friend who worked in a leadership role at a major health system in CA.

He readily admitted that the hospital has a very poor grasp on their own costs. At a high-level, they just charge as much as they can - sometimes they lose money, sometimes they make a 90% profit. They pool it all together (usually by line of business) and hope it all works out as a profit.

That’s why specialized, stand alone clinics (e.g. MRI clinic) have some of the best prices. They know exactly what things cost and can make sure prices reflect it.

What types of injuries/illnesses are the leading cause of personal bankruptcy?

It's so ridiculous. I had Kaiser for a period, because I was under the impression the bundle of insurer and healthcare provider would avoid these issues. It worked that way for a bit, but then I got some X-Rays. Paid up front, and then a few months later got an additional bill.

> I was under the impression the bundle of insurer and healthcare provider would avoid these issues.

It gets worse, bundling those two is the epitome of conflict of interests when you find yourself the victim of the hospital's negligence and expect your insurer to act in your best interest.

Nope!

Interesting. Kaiser paid for a 4 hour ambulance ride for me from one hospital to another for immediate surgery. I think I remember paying like $100.

Problem is that sometimes you have to wait even for actually critical things - friend's mom waited almost 2 months for her cancer operation. In US if you've got money you're more or less covered, while in Europe the difference is that in some (admittedly rare) situations even if you earn well you're screwed just like everyone else.

You can get private insurance in Europe if you want.

At least in the UK, private hospitals tend to focus on basic care or routine surgeries. Once you have a more complicated or urgent case you'll end up in a publicly funded (NHS) hospital anyway. Which means that in the end, anyone independent of income has access to the best doctors, criticality of their illness decides who gets to see them, not money.

Yeah, I pay less than 1k/yr for fancy private health insurance in Europe.

What do you mean by fancy?

Medevac, top tier hospitals around the world (except US, lol) in network.

Trauma Team too?

Covered, but availability unsurprisingly depends on if the care provider decides to activate it.

Hmm, I mean the Cyberpunk one. Your insurance must really be good.

Haha, I wondered about that. Providers like Cigna and Bupa are the big ones in this space. Intl insurance is sooo much cheaper than US ones.

You can, but you need to think about it ahead. And no one expects the Spanish inquisition...

In Europe, urgent surgery can be performed same day. The reason many people have to wait is because it's not time critical so others will get surgery first. Having a system where anyone (with the right amount of money) could get complicated surgery without wait times sounds incredibly inefficient as you need much more capacity than necessary.

Europe is a whole damn continent, so no, it's not true. It's not true even for the entire EU. I happen to live in Croatia which is in EU, and I know first hand that in Romania and Bulgaria health system situation is even worse, as I spent some time there. You get urgent operations like if you're in car accident and you're brought into the ER, of course they'll not let you bleed out. But if you need, say, heart aortic valves replaced (happened to my mom), or anything else a bit more advanced, you end up on the waiting list, and unless you pull connections and give bribe that means months of waiting.

I just spent two hours today to wait at an “urgent care” facility in southbay (my regular doctor of 20 years! wouldn’t give me an apt after several days of trying). I think I owe north of $400+ for this one time visit because I am in the early phase of a high-deductible plan. But I haven’t got my bill yet. After the two hour wait, I didn’t even get to see a doctor, but a Physician Assistant. So much for my private plan..

I think this is the biggest issue with private healthcare. You pay a lot of money for it, yet you can still end up with subpar care and extra charges for out of network professionals

This was one interesting thing about my visit to China. Pay $25, see a doctor right away. In fact you can pick how good of a doctor you want to see (prices on the wall at the hospital I was at). This wasn't a small place - it's probably comparable to Kaiser in Redwood City.

In contrast when I was in a much much smaller "community" hospital in China I just walked in, talked to the lady at the desk, and she gave me a prescription. No temperature taking or anything...

Well two hours < three months. I’ve had to wait longer for urgent care. If I can get it same day I’m happy.

> where a cancer diagnosis doesn’t financially ruin you and your family for you life,

If a cancer related, life-saving surgery takes 4-5 months to happen before you can have it, I'm not sure it really matters if it ends up being free or not.

Life threatening stuff is obviously not going to be a 4 month wait. The OP obviously didn’t have this sort of issue.

No. Look at NHS stats in England

https://www.theguardian.com/society/2019/jan/10/nhs-england-...

> Over 18,000 suspected cancer patients a month in England are now not getting to see a specialist or starting their treatment within prescribed timescales, NHS England’s latest performance data has revealed.

And others get treatment same day. It all depends on criticality. One of the reasons for long wait times is that there are always urgent cases being pushed to the top of the list. I agree that it sucks having to wait for an important surgery. But they don't make you wait if it's life threatening.

> But they don't make you wait if it's life threatening.

That's literally what is written in the article. People who wait several months to get a necessary CT or imagery before they can decide to do anything about it. Some cancers can progress very fast in the space of a couple of months, it's basically the difference between life and death in some cases.

> where a cancer diagnosis doesn’t financially ruin you

What OP is suggesting is that it doesn’t financially ruin you in Sweden, you just die waiting to see a doctor.

Yeah this does not happen. Of course you go to the front of the line if you have anything near life-threatening.

The problem (which I think is what OP were talking about) is anything that’s not critical but still need to be looked at by a specialist. In that case long waiting times are not uncommon. Yes it’s a big problem but it’s not a problem that will kill you.

I don't think the wait for cancer patients is 4 months. Even in Portugal you'll get treated and we're much poorer with a much more deficient health system.

This leads me to wonder...

Do cancer survival rates differ in countries with government health care vs. private?

Looks like the US has some of the highest rates across the board: http://worldpopulationreview.com/countries/cancer-survival-r...

I am not sure if 5-year survival rates are the best metric for this. Survival rate may be because of better outcomes or earlier detection. Is there any statistics that normalize for this?

Yes.[0] But I'm unsure whether this is due to private vs public healthcare. My guess is that it has more to do with how developed the medical industry is in the country. Size of the country probably matters as well.

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

5 year survival rates may be heavily influenced by detection rates. If country A detects my lung cancer at 55 and country B at 59 and either way I die at 60 - I’m no better off in A. Maybe worse.

Life threatening stuff is obviously not going to be a 4 month wait. The OP obviously didn’t have this sort of issue.

If people were dying left and right from waiting for cancer treatment. There would be a ton of news about that. No less in American media showing how bad European health care is.

Statistics on mortality don't show that happening.

Does that actually happen?

I mean, growing up on welfare/social security our family didn't have trouble seeing any kind of doctor.

The chances of getting cancer are so low you’d think some smart insurance company would want to sell you a catastrophic cancer policy with a low monthly premium. Then it wouldn’t have to mean financial ruin, the same way I have homeowners insurance (without which a fire would spell financial ruin for most).

Why isn’t this a thing? Can someone in the industry chime in?

Huh? I thought cancer was one of the big killers after heart disease.

While you are relatively young maybe the probability is low. That’s also when you are working so private health insurance and income protection insurance would have you covered I imagine.

Ok went to cancer.gov and Approximately 39.3 percent of men and women will be diagnosed with cancer of any site at some point during their lifetime, based on 2014-2016 data.

So, I can’t see why any insurance company could offer reasonable rates given those odds.

Same in Austria. The healthcare system is free and very good if you have something life threatening but if not, you're looking at 2 month waiting time to see a specialist and there's no way I can be living and working with a health discomfort for that long so I pay up and see a private doctor.

The current situation benefits the lower class with voting rights who have access to good healthcare without paying much taxes and the upper class can afford private anyway but if you're hard working middle class you're kinda screwed since you have to go private and pay if you want quality treatment and diagnosis in a timely manner but you're also forced to pay and subsidize the public system, which you don't use anyway, with your very high taxes.

I feel Europe is slowly migrating to a two tier healthcare system, a private and quality but expensive one for the ones who can afford it and a public underfunded one for everyone else.

> The healthcare system is free and very good if you have something life threatening but if not, you're looking at 2 month waiting time to see a specialist and there's no way I can be living and working with a health discomfort for that long so I pay up and see a private doctor.

The private doctor is still cheaper than copays/deductibles in the US. So that seems like a weird argument to make.

>The private doctor is still cheaper than copays/deductibles in the US.

Skilled workers in the US also earn way more than their European counterparts.

Emphasis on skilled. Most Americans make less, adjusted for inflation, than they did 40 years ago, they work longer hours, report more stress and are more productive (not necessarily by choice). The average American worker got shafted. Oh, and the American healthcare system costs people twice as much than average developed countries but with worse outcomes. Single-payer would save people money because of the collective negotiating leverage to push back against $100 insulin, $350 Epipens and $20 acetaminophen.

Furthermore, the US labor force participation rate never gets measured honestly or discussed because it's crazy.. there are untold millions and millions of men and women who have given up looking work. (Idle, disenfranchised people who don't have a future or families is a recipe for revolution, drug abuse and mass shootings.) Also, with automation, outsourcing and increased net population, there aren't as many good jobs as there were 40 years ago and there too many people for regular, less-skilled jobs.

Most Americans make less, adjusted for inflation, than they did 40 years ago

Only if you look at salary. If you look at total compensation, it’s grown quite a lot in the US, across income levels, adjusting for inflation.

What other components are there than salary, for the average non-tech worker?

Health insurance, life insurance, 401k match or other retirement benefits, etc.

The median income in the US has in fact been on the rise for a long time: https://en.wikipedia.org/wiki/Household_income_in_the_United...

And unskilled workers earn less. So what?

Not necessarily. One datapoint: Amazon pays fulfilment workers $15/hour in the US, but €11/hour (~$12) in Germany

I imagine if you took a look at total compensation (vacation, PTO, insurance, maternity leave), stronger labor laws and other societal benefits such as cheaper college, those workers earning €11/hr would probably be able to save a lot more of it compared to their counterpart in the US.

And bonus if they get sick, they don't have to worry as much about losing their job and spiraling down into crippling debt.

How far does $15/hour go in some parts of the US vs €11/hour in some parts of Germany?

Even accounting for differences in income the cost for private doctor visits don’t make the US system cheaper.

Especially because the private doctors need to provide pricing before you go there, there is an actual market with reasonable prices.

Since someone will know before they go to a doctor what it will cost them it makes a huge difference to the US.

> And unskilled workers earn less.

Is this actually true?

Well, that's highly dependendent on what country in Europe you compare it to, as it can go both ways...

They also have a lot more student loans. Doctors graduate with $300k+ in student debt.

> I feel Europe is slowly migrating to a two tier healthcare system, a private and quality but expensive one for the ones who can afford it and a public underfunded one for everyone else.

Not sure if I'd agree. There are certainly fancy hospitals that look like 5* hotels but they're for routine surgery only. Top specialists are still at big hospitals because that's where the most complicated cases are treated and where the infrastructure is. You might be able to skip waiting time with private insurance but you won't see a better doctor or get better quality medical treatment. In the end, having a nicer meal and single room in your hospital don't matter that much medically.

> eel Europe is slowly migrating to a two tier healthcare system, a private and quality but expensi

can you give example of private healthcare costs?

In the UK, a 15m follow-up telephone appointment with a private consultant is ~£100-£150. An in person 30m appointment varies between £100-£300 depending on specialism and location. If they decide to prescribe something there is no extra charge. They will write to your GP with the outcome, for which there is also no extra charge.

As regards blood tests and the like, the cost depends on the type of test, but could be anywhere from £25-£300.

I do agree with the GP about a 2-tier system evolving in the EU, at least from my perspective in the UK and what I hear from colleagues around the EU; if you have something easily diagnosed and treated, the state health service is literally a life saver, even if you have to wait several months to be seen. But don't expect your doctors to be experts - your endocrinologist will likely no nothing other than diabetes etc.

Shoulder MR scan in Austria: €235 including 10% VAT

You can usually get 80% back from public healthcare insurance. You can do it all via public healthcare, but wait time is usually several weeks.

Shoulder MR scan in Romania: €115.

https://medimar.ro/tarife-rmn/

No way you're getting 80% back. More like 25%.

I'm on good private insurance in the USA right now and on a 3 month waiting list after calling 35 specialists and taking the only one who was even accepting patients with an under 6 month wait. I'm on Aetna, a huge health insurance company here and when I call a specialist my first question is "Do you accept Aetna?" because I only have a 30% chance that they do.

The only way to speed up the process would have been to pay cash to a specialist who doesn't accept any insurance, which would be a $350 consultation then $250-350/hr each visit after the fact.

Swede here: Yeah, Sweden tends to be romanticized by the american "progressives". As a swedish "rightist", you end up being in an annoying position. There's a lot of stupid stuff that happens here, for sure.

That said, it seems like the really expensive/complicated healthcare needs gets taken care of in a competent way, "for free" (paid for via the taxes).

My then 73 yo mom had a tumor that was growing behind her left eye-ball being removed, two years ago. Zero complaints about that hole produdure, and the 10+ post-prodedure checks.

I spent a few hours googling the doctor that was going to perform this particular surgery on my mom - I was left with the impression that he was on the international fore-front on this particular procudure. He was doing a bunch of international speaking on the the topic. I saw videos of him lecturing hundreds of surgeons on particulars of this kind of procudure. Quite re-insuring.

(And yeah, my mom ended up being okay after the surgery.)

The worst insurance you can get + max out of pocket is 12,000usd per year.

10 or 20 procedures, still 12k.

For the 10%ers/6 figure earners, this is 10% of the before tax income.

For the 90% making 15-19$/hr, I can't even imagine managing this.

And that's assuming you can keep working. Getting fired or laid off because you can't work means you're no longer getting paid AND you now have to pay for the healthcare you can no longer afford. It's stupid.

It took my spouse 3 months to get an appointment with a specialist in the US. She definitely didn't shop around but it was a miserable wait time considering we lived close to some of the best healthcare facilities in the world and had one of the best health insurance one could buy.

I’m really glad that I live in Asia. Here in Singapore I can ring up a specialist and go in the same day...

I don’t understand why in Asia I have cheaper and better health care than if I lived in Europe or America.

Some of the things I’ve heard just about Hospitals scares me to not get sick when I’m in europe...

When my wife was in hospital for the birth of our daughter I slept over night in the room with my wife. While in France my wife’s friend wasn’t allowed to have her husband stay. The whole experience we had vs them was polar opposite.

Have you noticed that in Singapore all the nurses are Filipino though? I don't think they earn much and I reckon that has to help with getting costs down...

I also disagree that healthcare is uniformly cheap here. GP visits are not particularly cheap. You get to spend very little time with the GP and typically are sold a bunch of drugs you don't need (in Europe there's separation of clinics and pharmacies, which introduces some checks & balances).

To give another example, in Europe I used to go for a glaucoma test every year (due to family history) and pay about 20-30 euros. However, in Singapore, doctors look at you funny when you request to be tested for this as preventative health care is not really thing here. I did get tested twice for Glaucoma in Singapore (at the National Eye Center) and ended up with a bill of 250 SGD (~ 175 EUR) each time. The second time around, the doctor afterwards admitted that the bulk of the tests I had been given hadn't really been warranted. (Oh, and I couldn't exactly go in the same day by the way. There was a waiting list, though I don't recall how many days/weeks I had to book in advance.)

Finally, getting cancer has been known to bankrupt people in Singapore.

> Have you noticed that in Singapore all the nurses are Filipino though?

Nope? I’ve been in hospital 4 times in the past 8 years. And a 5th time if I include when my daughter was born.

The Nurses in the wards were not filipino. But one of the Nurses in A&E were.

> I also disagree that healthcare is uniformly cheap here. GP visits are not particularly cheap. You get to spend very little time with the GP and typically are sold a bunch of drugs you don't need

I can’t compare to Europe. But I can say that seeing a GP and getting drugs is FAR cheaper in Singapore than Australia... by ALOT. The entire cost of a consultation + drugs is cheaper than the consultation fee in Australia.

Not only that having to then go to a pharmacy to pick up drugs is the worst.

Doctors here also don’t just give drugs you don’t need. They do give drugs more often and that’s due to the mentality of Asia where If they see a doctor they often want drugs to fix a non existent problem. But I’ve had Doctors in Singapore ask more questions than in Australia and give me only what I need or want to give me nothing.

> To give another example, in Europe I used to go for a glaucoma test every year (due to family history) and pay about 20-30 euros.

Specialists aren’t cheap compared to Europe or somewhere like Taiwan, but compared to America it’s peanuts.

> getting cancer has been known to bankrupt people in Singapore.

I don’t believe this for a second, because for Citizens, healthcare is subsidised. And company with more than 50 employees has to have health care insurance. Basically it would only bankrupt you if you were a foreigner at a small company and didn’t buy insurance for yourself. Which again is still cheaper than NZ/Aus.

>She definitely didn't shop around

Why not? So she wanted to go to a specific doctor, and that doctor had a waiting list. How does any other system solve for that? A single doctor can only see so many patients.

It's the same thing they say about France (having a great healthcare system). But doctors [1] are going on strikes because of lack of amenities. Makes you wonder...

A private system where you chose your provider will always be better, imo, because the providers will have to compete. I think the US could do much better if they improve the pricing visibility and get the free market to make the prices go down. (I'm not very well versed in this topic, I'm just reading the news)

1 - https://www.cnews.fr/france/2019-12-14/pourquoi-les-medecins...

I can't see any way health care can become a truly free market, the patient doesn't have enough information or knowledge. They could rely on their doctor but you can see from the painkiller overprescription that doctors are open to manipulation. Also if I'm writhing around on the floor in agony because my Appendix is about to burst I'm not going to be phoning around for the cheapest quote.

> the patient doesn't have enough information or knowledge

You don't need one, all you need is brand and reputation. Customer doesn't know much about products in most markets: electronics, cars, software. It's never a problem when you have lasting brands/companies servicing many people with various level of knowledge.

It's not working that well in software, one company has 90% of the desktop market. Phone operating systems are divided between two companies. The car industry is being dragged screaming and kicking into EV's. And these are industries where it's reasonably easy to pick and choose compared to trying to switch hospitals or doctors part way through your treatment.

> It's not working that well in software, one company has 90% of the desktop market.

Because the company uses quite a lot of administrative pressure (patent trolling, vendor's bullying etc etc), hence the market is not competitive.

You are talking about competitive markets here, not information asymmetry. I see no evidence that monopolies are the outcome of asymmetry of knowledge, but rather that they are the outcomes of significant administrative measures like license-bullying or patent-trolling.

The only markets that have the problem of information asymmetry are lemon markets.

> And these are industries where it's reasonably easy to pick and choose compared to trying to switch hospitals or doctors part way through your treatment.

It's way easier to change a doctor than to change a car. There are only few conditions which restrain one from bargaining: heart attacks and other severe conditions, and these should be treated differently.

But in case of the vast majority of diseases from common cold to Epstein-Barr changing the doctor and bargaining is even simpler than in most other markets.

But again, bargaining power has nothing to do with information asymmetry as well.

Because the company uses quite a lot of administrative pressure (patent trolling, vendor's bullying etc etc), hence the market is not competitive.

and you think that won't happen with health care?

> and you think that won't happen with health care?

It could happen, but it's totally unrelated to the original thesis regarding information asymmetry.

It is related, it is part of the obfuscation that corporations engage in to gain an advantage.

There are some things that work really well in a free market but health care will never be of those.

We should absolutely have full transparency into services, providers, and cost, regardless of what other public policy is adopted.

One can make the argument that some big share of the affordability issue has been generated by the government in its policies of preventing cost transparency for medical services and drugs.

I'm not saying cost transparency will solve every problem, but this is a government caused problem. I have heard no good reasons for the monopoly pricing granted the medical industry.

Also bear in mind the whole system of government subsidized employer group health insurance was invented by the government to satisfy the labor unions, way back when private sector labor unions had influence.

Now only government employee labor unions have influence, and boy what influence they have. Just remember, public employees are in entirely different social benefit and retirement systems than us mortals.

This is my major problem with the US system. Also lots of doctors or dentists will require you to have unnecessary procedures which pile on to the costs. And they will refuse to provide you service unless you get them oftentimes too.

It's almost just as bad as the collegiate system here as well. Except the college system you can somewhat anticipate costs. Insurance is a total gamble.

I'm confused as to why you're being downvoted.

But I completely agree with you on the free market. My personal issue with going to the doctor is I have no idea what my bill will be at the end of the day.

Perhaps he's being downvoted (not by me!) because the claim is self-contradictory. Either a market based system "always will be better", or it could be "better if they improve the pricing visibility", which is it? Unless he's saying the US system is already superior to all others, but could be made better still. That seems like an ambitious claim.

A non-transparent system is not one I'll define as a free market based system.

That's a "no true Scotsman" problem, though. If the US doesn't (or didn't pre-ACA) have a market-based healthcare system, then who does? And if no one does, how do we know it's better?

No, it's not a "no true scotsman" problem. The US is fundamentally not a market based system. Painting it as such is just wrong.

> In the entire time I was there I attempted to see a specialist for a condition that I had maybe two or three times, I ended up giving up every single time after I was told the wait time is between 3-4 months. I keep my American employer sponsored private insurance and employer determined time off policy, thank you very much.

I've waited 6 months to see a specialist here in the US. The fact is that countries with universal healthcare have shorter wait times than the US does[1], and they manage to cover all of their citizens.

[1] https://www.healthsystemtracker.org/chart-collection/quality...

Usually long wait times in the US are provider specific. I’ve also experienced long wait times, but it’s because I wanted to go to the top academic system in my city.

If I was willing to go to any specialist, I could have seen one pretty quickly.

In this case, this was across the board for the types of specialists I wanted to see. I had called dozens of practices, and spent hours with insurances representatives trying to find a provider who wasn't booked for the next 5 months. For mental health specialists, I had to wait on two different waiting lists for both someone who could prescribe medication and for someone who provides therapy. Specialists who could do both had even longer waiting lists.

It isn't just the mental health field. I have a colleague with a daughter who needed an addiction specialist, and that was another 6 month waiting list. People die waiting on those lists.

There are private health insurances here too. If the public system would be so bad as you describe it everyone would use the private ones but very few do.

Wait what? I live here too, and many employers do pay for private insurance because it saves heaps of time for the employees. Why do you think the private options sprung up in the first place?

The public system has serious flaws. I was told by the public system to take antibiotics for 6 months straight while waiting for a tonsil removal operation. Got my operation a few days later through my private insurance.

From my experience in the UK, people typically don't get private insurance because they _believe_ in the public system, not because they have a generally positive experience with the public system. They don't really realize that the service could or should be much different, so they just put up with it because they believe in the system being the way it is. They believe in chipping in, paying their fair share, and everyone being in the pot. It's a mind set, not an optimal set of circumstances. I admire the mindset in many ways, but it doesn't make for quick or efficient service. It all kind of depends on what you optimize for, and what you are willing to put up with based on your worldview of what is most important.

It's not super-common, but some employers do offer private health insurance. The numbers I saw suggested about 10% were covered by such insurance which isn't a huge number but isn't nothing either.

I would guess less than half of those people ever use the coverage, and those that do still use the public option for more than half their medical needs. It's often bundled with employment packages with the idea that it provides some kind of insurance when a key member of staff need treatment and can be prioritised to jump some queues, but in everyday situations like when their kid falls off a bike and spits out some teeth, they're going to use the same service as everyone else, because it's simply quicker and more effective to do so.

Private insurance is very much a supplement, not a totally parallel system in the UK:

https://www.moneyadviceservice.org.uk/en/articles/do-you-nee...

It might change depending on exactly how you define efficiency but the UK system scores highest in some global comparisons in terms of bang for buck.

From the way you phrase it I assume you actually mean inefficient service, like you'd get at a high end restaurant or hotel, where they have lots of people hanging around doing nothing a lot of the time so no one ever feels they're being treated less than a VIP in busy periods.

Private Health insurance without group plans does not really work well so the fact people don't choose it doesn't mean much to me.

Essentially, since sick people are more likely to choose such plans the costs are going to be very high. Either that or the restrictions on the plans need to be high to prevent it. Both make such plans unattractive independent of how bad or good the public plans are.

>If the public system would be so bad as you describe it everyone would use the private ones but very few do.

that's simply dishonest. there are tons of other variables to consider when pondering private insurance adoption rates.

> If the public system would be so bad as you describe it everyone would use the private ones but very few do.

Maybe they can't afford private insurance?

> If the public system would be so bad as you describe it everyone would use the private ones but very few do.

Ah, that's simply wrong, because you pay for public healthcare anyways (through taxes), hence private one is to be paid twice.

I doubt the system is `that bad`, but even in Russia, where private healthcare is super cheap (and very good) and public healthcare is a total disaster, a few people use the private one (until they are wealthy) due to exact same reason: they've already paid for the public one and feel like paying twice is not an option.

Regarding healthcare, my employer gives me private insurance but I tend to use both systems.

Generally I get same-day care. I call up DKV, report my symptoms, they find a specialist in my area, and I pay nothing. (I mention the symptoms bit to contrast with the system where you have to see a general practitioner who then refers you to a specialist - that does not happen here AFAIK). I've used this for allergies, asthma, ear problems. I also had a knee injury where I got an x-ray (same day I think?) followed by weekly sessions of physio.

My partner recently gave birth in the public system. I think the delivery was free, but the 4-night stay cost us around 4000 SEK (400 USD) total.

I also had a remote doctor's appointment using the KRY app. I don't actually know how that was billed - public I'd guess.

Paying 4000kr for staying four nights sounds really weird since Swedish law say that the fee for staying at the hospital can’t be above 100kr/day. I also recently stayed about four nights after my partner gave birth and we payed a couple 100SEK.

You got me curious so I checked my records. Looks like I remembered incorrectly and paid 2300 SEK.

From https://bbstockholm.se/content/practical-information:

> Each new 24 hour period cost 100 SEK from the time you arrive at the clinic. Your partner/labour support person is charged 600 SEK/24 hours from the time the baby is born. Food, towels, sheets, sanitary products and diapers are all included free of charge during your stay.

Makes more sense. I guess you are free to charge the partner whatever you like. I live in a more left leaning part of sweden so here the partner is also charged 100 sek.

Hej! I’ve been in Sweden now nine years. It’s true that it takes time to get to certain specialists, but only if you are in a non-threatening situation. The system works with a triage concept, and the moment your condition is deemed serious you are in the front of any cue, meaning you get care immediately. I know some people with skin cancer that got amazing care , fast, at no cost. I have a coworker that had an extremely premature born : 24 weeks. the level of care he described, the team around his son and 10 different surgeries had cost him nothing. Luckily they are home now , with oxygen equipment provided to theM and nurses visiting every other day to monitor him.

This in the US would probably have meant a bankruptcy for someone in his income bracket.

The system is not perfect but after living in the US for 13 years I can tell you you never worry about health care here.

Edit: Nobody mentions you can also pay extra and visit a specialist right away! The wait is if you want the visit for the government price: 12 dollars for initial visit, 30 dollars for a specialist.

Yeah, my cousin is a doctor in Sweden and according to him Sweden has the most failed/Americanised system of the Nordics.

Wait times for specialists are a thing in the US too, even with good employer-sponsored insurance. Specialists are a limited resource - usually artificially - in virtually every country.

> I attempted to see a specialist for a condition that I had maybe two or three times, I ended up giving up every single time after I was told the wait time is between 3-4 months. I keep my American employer sponsored private insurance and employer determined time off policy.

I am in the US and go to good dentists and doctors, who are out of my insurance network incidentally, and they and the specialists they refer me to can easily have three month waiting times.

Also Sweden has been following the US lead of cuts and privatization since the 1990s, often led by the Social Democrats. It's a great strategy for the idle class - push through public health spending cuts due to costs, then bemoan the inevitable wait times as reason to privatize.

The system is gating the specialists way too much. But the actual care once you are there is usually very good.

Private insurance often just gets you past those gates.

Aussie in Sweden here. I had to wait 4 weeks to see a GP and then 4 more weeks for them to refer me each time they said "wait 4 weeks and come back if it's still an issue"

Public healthcare works way better in Australia, I went home and saw a doctor there, got to see a doctor straight away, got scans & referral etc within a week.

Other expats have told me I should go to Germany or the UK if I urgently need health care

If you want to see a doctor here in Sweden, you do what the Swedes do: call at 8am to the Vårdcentral. Then say whatever you have is urgent (akut). You get a time the same day, 90% of the time. Otherwise, most vårdcentral have "akuttider" (emergency times) when you can just drop in.

I went to the vårdcentral drop in that morning, saw a nurse who said "come back in 4 weeks if you still have an issue" they decided me suddenly having ringing in my ears that has not stopped was not an urgent issue or a problem

There's also a few 'apps' - "kry", which are cheap and give you an immediate time. The docs on those apps can give you a referral.

That's bad luck. I agree it's a crap system, designed to keep costs down. If you live in Stockholm, you can pay 500kr and go to cityakuten.

Isnt US employer determined holidays 2 weeks per year? No thanks. Time off work is important.

There's around two weeks total of holidays (spread over the entire year). There's also a vacation benefit, which typically starts at two weeks and increases the longer you stay. Big companies give more and a senior person at a large company may get 4 or 5 weeks a year. There may also be separate sick days.

It varies by employer. I get 24 days that I pick plus 9 or 10 that the company picks each year. Plus an additional 4-week block (that I pick, but has to be contiguous) every five years.

Thanks to those that replied, I learned something today.

The people that replied are likely software engineers and likely high earners in a very employee favored market.

It's true that it varies by employer.

Here are average numbers from the Bureau of Labor Statistics: https://www.bls.gov/news.release/ebs.t05.htm

The average is just one week a year (two weeks a year past 15 years of work), well below world average.

Like most everything in the US, vacation time varies by employer. Last year I took 6 weeks not counting holidays and wfh 2-3 days a week.

Counterpoint, in an affluent area of the US, I was told 6 weeks for a gastro appointment when I reported vomiting of blood - top-notch private "insurance".

I’ve had to wait to see endocrinologists about 6 months at multiple practices while having very good insurance in the US. It’s mostly a location and a supply and demand issue with most specialist medical professions, not an insurance issue (which it’s often conflated as in the media).

Your argument for why Sweden is no paradise makes sense, but your argument for American system being better just because of your personal experience alone is not sound.

> 3-4 months

Welcome to the magical universal healthcare.

You realize that American healthcare has wait times as well, right? My family has had to wait months to see specialists as well. I'm honestly just tired of people acting like American healthcare somehow doesn't have wait times.

And not to mention if you're saddled with a particularly bad employer, they won't give you the time off to see the doctor in the first place.

Is this an HMO? I signed up for one once and the delays were pretty stupid (even to get a referral to a specialist you needed to come back to see a different doctor first). I've never signed up for the HMO plan again since. With a PPO you can always pick another specialist that is available.

Meanwhile there are companies in Canada that help Canadians get their MRI's in the US because it's so slow there. And clinics near the border advertise in Canada.

In large metro areas, even a PPO doesn’t help much. Specialists are in short supply in the US and elsewhere for various reasons.

Usually people are saying the US has too many specialists, except for certain lower-paying specialties like obgyn.

I've never had a problem with delays in large metro areas in california. I do recall hearing Boston was the worst big city to find a new doctor, supposedly due to Massachusetts' push have universal coverage.

My mom lives in the DFW area and makes $50k. Within the past 5 weeks she's gone for a routine mammogram screening, seen a specialist about a grown that thankfully was benign, and been seen by a surgeon who removed the growth to be on the safe side because my mom is considered high risk.

Indeed. I just found out that in 2019 alone, over 230 bombings took place in Sweden, more than any other Western country.

I really don't understand why this myth persists. Ideological blinders or obstinate ignorance.

Organized crime in Sweden likes grenades and some similar explosives, largely because they - by accident - was legal to import a couple years back.

Grenades became much easier to get ahold of than handguns, which have had some weird effects, as they seem to have come to be used as intimidation between rivals.

The use has been dropping the last few years, and should hopefully be back to the pre "legalization" levels soon.

It's all certainly quite unfortunate, but the number of casualties are perplexingly low. It really seems that whomever it is that does these bomb/grenade attacks go out of their way to avoid people getting killed. Not that I understand why exactly, except that it seems to be about intimidation in the majority of cases.

Reply on news.ycombinator.com