The Amish health care system
slatestarcodex.com
slatestarcodex.com
> I asked my literal grandmother, a 95 year old former nurse, how health care worked in her day. She said it just wasn’t a problem. Hospitals were supported by wealthy philanthropists and religious organizations. Poor people got treated for free. Middle class people paid as much as they could afford, which was often the whole bill, because bills were cheap. Rich people paid extra for fancy hospital suites and helped subsidize everyone else.
In other words... allow rampant inequality in the healthcare system. The rich would pay for their designer surgeries, and let that subsidize the rest.
I am not suggesting this explains all of it. Our health care system is definitely overpriced and overloaded with badly designed bureaucracy, but it definitely explains some of it.
* Poor people either get hit with huge bills because they're uninsured, or, if they know how to navigate the system, sometimes get these bills written off through "financial aid."
* Middle class people frequently have insurance, but get hammered by deductibles and out of pocket maximums, rarely qualifying for "financial aid." This can be ruinous.
* The rich still get what they want.
If the rich are "subsidizing" things anymore, it's not to a great enough extent to benefit the poor and middle class. The system has been broken over the past 40 years by medical and insurance costs that have risen much faster than the rate of wage growth for the average worker.
Switching from fee-for-service to prevention (capitation) would give us another 25% savings.
But I'm newly interested in notions related to cost disease. Am keen to hear anything anyone has to say about mitigation.
[0] https://time.com/5759972/health-care-administrative-costs/
2. Nobody has a right to earn a living by causing suffering to others.
2. Is a good slogan, but understand that most of those people don’t think they’re doing a bad thing. Spending too much time demonizing the line level workers at insurance companies is probably counterproductive.
But the principal still stands, no matter how much I may sympathize with someone they don’t get any right to make income from causing other people suffering.
Repeating myself:
Another low hanging fruit is transition from free-for-service to rewarding wellness (capitation). Some are already doing this.
I'd like to understand if, how, why cost disease is a factor. https://en.wikipedia.org/wiki/Baumol's_cost_disease I have zero understanding, intuition about this. Feels like black magic. But some of the experts I've read say it's important.
There's no shortage of management efficiency and quality of care innovations to explore. In the spirit of Atul Gawanda's book Better, like specialized clinics for cystic fibrosis, diabetes, and whatnot. And whatever we're calling people traveling for procedures. Like USA people going to Thailand and Mexico clinics.
USA's R&D and regulatory overhead (FDA) carries the world. That first adopter expense might be easier to accept if the accounting was transparent.
Any way.
I designed, implemented, supported 5 regional healthcare exchanges. Even in our little corner of the problem space, there was so much room for improvement. Alas, most of it was prevented, because our participants were competitors, so the incentives were all wrong. A single payer system (or rough equivalent) completely moot most of those roadblocks.
All 3 are connected and make healthcare absurdly expansive.
One such common thread is the financialization of consumer debt.
I recently learned (from Michael Lewis' Against The Rules podcast) that removing ban on usury debt (high interest rates) opened the flood gates. Sorry, I forget which episode.
They can be absurdly expansive because there is an expectation that students will indebt themselves with this one kind of debt you can't default on. So doctors have to earn more to be able to pay it back.
Then you have lawsuits where cost of lawsuit is paid by both sides, no matter who is at fault. So if it takes 2 years and costs 100 000 USD to determine you weren't at fault - you are still going to default (except yo ucan't default on your student's debt). So doctors are expected to be insured against lawsuits. Which is expansive. So they have to earn more.
Then there is a system where one drug company has 100 insurance provider customers who have to buy that drug. Who has more power in that relationship :) ? So you pay absurdly high prices.
re lawsuits, I advocate a specialized healthcare court for adjudicating those cases.
Our current system of legal precedent does not recognize progress of science. So we end up with nonsense like unnecessary c-sections for decades because a jury of laypersons determined vaginal births increases cerebral palsy.
https://web.archive.org/web/20090424115607/http://www.nytime...
We already have separate specialized courts. Bankruptcy, youth, etc. My local judges have innovated by creating separate courts for vets, addicts, and so forth. Much more fair, efficient, and effective.
re education. Yup, totally on board. We (society) need more healthcare workers, of all flavors.
re big pharma. I don't know enough to comment.
If someone ruled once that Indians aren't people and can be expelled from their property is that still a law? It can't be, right?
Or how about when you legalize something?
Precedent isn’t really about outcomes, it’s about lines of reasoning. If the law says that something has to be purple, the courts may need to decide what standard to use for purpleness. If another case then comes along that requires something to be green, the courts will try to make their greenness test work the same as the earlier purpleness test as much as possible. That way, everyone can get an understanding about how the courts reason about color. If the legislature disagrees with the court, they can amend the law to specify more precisely which color they wanted.
There’s a little bit of extra subtlety in that the US court system is hierarchical, and precedent is only controlling if it came from a court in your part of the tree. Different circuits may apply different reasoning for the same issue, and that’s probably the most common kind of case for the Supreme Court to take: two competing standards are in use, and they need to decide which one the whole country should use.
Thanks for tip re Canada's admin overhead. Will research.
The government tried to centralise and digitise the whole thing but because it was mismanaged, most of the project was abandoned and cost billions to the taxpayer https://en.wikipedia.org/wiki/NHS_Connecting_for_Health
Now we are in a bit of a catch 22 where the costs keep increasing, and the government is always under pressure to spend more but there doesn't seem to be a solution to slowing down the increasing costs.
How large are these OOP maximums and deductibles on average? I’ve always kept an emergency fund that’s well in excess of my OOP max. Is this unusual? Also, I’m off the impression that you can get onto payment plans if you can’t pay your bills right away? These aren’t rhetorical questions (although that won’t stop people from downvoting as though they are, I’m sure), I’m genuinely curious.
29% of households have < $1000 in savings, and the median is $11,700[1].
$1000 disappears almost immediately given deductibles, and $11,700 isn’t that far off either. People just don’t have the chance to “get ahead” when making <$15/hour.
[1]: https://www.google.com/amp/s/www.cnbc.com/amp/2018/09/27/her...
Unfortunately, it is unusual among Americans to have an emergency fund this large.
Yes. I have a friend in tech (contractor, bay area) who doesn't have insurance. his plan is to just show at the ER without an ID if he needs anything and give a fake name.
^ why we can't have nice things..
I’m not sure how that’s different from today, other than the exorbitant costs that exist today.
If you want something better (and there are tiers), you pay more. You can buy insurance policies that pay for the more comfortable stay.
We have universal health care, but anyone is of course free to forego that and pay (or use their private insurance) for a private room rather than a ward, or just go to a private hospital instead.
I don't understand the debate about this in the US. It's as if the rich assume that things will change for the worse for them if universal health care is enacted.
An MRI cost me about 0€.
A 4000€ test which tests for nearly any rheutmatic diseases markers and the visit to the hospital for that test cost me 0€, both things got done within two weeks.
Even if you are poor and want to go to a private doctor it will cost you not nearly as much as in the usa. For me it was about 100€, for one visit and that was on the higher end.
Socialized healthcare is always cheaper.
My mom is a doctor, she worked ICU, ER, etc, board certified in 10 states and holds a medical license in 3 countries(yes, she did residency three times, it's a long fascinating story for another time). Eventually she decided to open a private practice for family medicine bec it was less stress, but she's got tons of experience, and is highly regarded, and she charged less than $40 a visit for the uninsured. She would spend ages talking patients out of procedures that were harmful or simply unnecessary. You got high end care from her each time.
The gist of this is: you have no idea what you're talking about and individual anecdotes don't prove one system is better then another.
I'll just add as food for thought: nothing is free, avg effective tax rate in EU is 50%
Avg ETR in the US is less than 30%.
If there is demand for private healthcare affordable to the middle class, the demand will be met with supply.
And if that fails, they should be taught about democracy.
That if it turns out that socialised healthcare doesn't work for most Americans most of the time, then the country can revert to the system it currently has.
Well, it depends on the implementation, but Bernie Sanders has been on record numerous times as stating that his Medicare-for-All proposal would absolutely ban private insurance. Elizabeth Warren is another Democratic front-runner who indicated that she's on board with that, though her proposals didn't necessarily reflect it.
For what it's worth, the M4A _plan_ from Bernie's camp that I've seen didn't actually specify that it would eliminate private insurance, but he's also been keen on reminding us that he wrote it, and knows best what's in it.
So while it seems unlikely to me that political reality in America would prohibit banning private insurance, there are definitely those who espouse banning it for the greater good, so perhaps that fear isn't wholly unwarranted.
That said, answering your question, they would presumably not ban it because a) the aforementioned arguments upthread make it pretty silly to do, and because b) it seems impossible to me that banning a wholly legal service just because it competes with the government would ever be deemed as constitutional.
Well, not ever -- but not today, and not with the direction that the Supreme Court has been taking for decades now in regards to government power. Licensure seems possible, but I think even prohibitive licensure intended to dissuade private entities from competing with the government would be tossed out, and we already have such programs for insurance providers anyway.
For any of the services covered by Medicare. Quoting the Kaiser Family Foundation, "private insurance would be prohibited from duplicating the coverage under Medicare."
[0] The full quote here is "If you support Medicare for All, you have to be willing to end the greed of the health insurance and pharmaceutical industries. That means boldly transforming our dysfunctional system by ending the use of private health insurance, except to cover non-essential care like cosmetic surgeries."
[1] - https://www.bloomberg.com/news/articles/2019-07-05/harris-ke...
That's correct. Supplemental insurance can still cover copays and other out of pocket expenses. It can also cover procedures not covered by Medicare.
Now, tell me, how is that "banning private insurance" if insurance companies can still sell those policies?
Q: "Does private insurance go away under Medicare for All?"
A: "Yes, it does, because you're not going to a have a need for private insurance"
A tweet[1] from Bernie Sanders: You're damn right we're going to get rid of greedy health insurance companies.
CNBC describes Bernie Sanders plan as "Bernie Sanders is pushing a “Medicare for All” bill, which would create a government-run program and end private insurance."[2]
The Hill's headline covering Bernie's policy is "You're Damn Right Health Insurance Companies Should Be Eliminated"[3] and references a quote in an interview from MSNBC in which Bernie says universal health care can't be achieved "unless you get rid of the insurance companies."
So feel free to quibble over the nuances of what "eliminate," "end," and "abolish" mean as much as you like, but if you're a person who is concerned that your private insurance is going to be eliminated, and you're listening to Bernie Sanders talk about it, it seems like his statements would reinforce that fear.
[1] https://twitter.com/berniesanders/status/1111363118867927040...
[2] https://www.cnbc.com/2019/07/18/these-2020-democrats-want-me...
[3] https://thehill.com/policy/healthcare/436033-sanders-youre-d...
> In other words, while Sanders' plan doesn’t ban supplementary coverage from private insurers, it does offer such generous coverage by the government that there's not much room left for private coverage to fill any gaps. This is the logic upon which both conservative critics — and supposedly nonpartisan mainstream reporters and pundits — hang the logic that Sanders' plan would "ban" private coverage. It's a dramatic "gotcha" question.... [0]
You're essentially reinforcing a right wing talking point that completely mischaracterizes what Bernie's M4A plan actually does.
---
[0]: https://theweek.com/articles/850638/no-really-wants-ban-all-...
"I could whack pharmaceutical companies, and I don’t need Medicare for All to do it, but I do need Medicare prices for all to deal with what the real profits are — whether you call them profits or not — which is hospitals."
https://www.politifact.com/factchecks/2020/jan/15/bernie-san...
You're reaching. Why are you trying to push a right wing spin on M4A, when studies show that it would reduce costs and increase access to care?
But to the point of why people might be wondering about changes to their healthcare policies, well, perhaps it's because they've been listening to the politicians. If folks would like to obliquely sidestep what I feel was a rather small, simple point and have an argument about efficiency gains in healthcare, you're free to, but I'm not trying to participate in that argument.
Edit: Actually, consider this my last post on the topic at hand, as I'd rather not engage in any argument where reputably sourced facts and direct quotes are regarded as "right wing spin."
I did not do that
> Yours are exactly the words I would expect to hear from scaremongers
I quote the author and it's scaremongering? Yeah, count me out of this conversation altogether. You've uncharitably interpreted what I'm saying, and are doubling down on the sort of rhetoric I explicitly stated having no interest in.
And, as for the conversation, you were supposed to be out already. It would be better if you stayed out rather than amplifying false statements. If you want to critique M4A, then quote the actual policies put out, not the rhetoric.
b) I've made no critiques of M4A.
c) You're wrong to the point of malice, perhaps deliberately.
I think it's fair (if a bit naive) to take politicians at their word on occasion. Moreover, I think it's more than a bit disingenuous to assert that plans that are disallowed by law from competing with Medicare services still being allowed to exist for only elective operations as "not banning them." If I disallowed Netflix from streaming any videos longer than a minute in length, I guess technically I have not banned Netflix, but in practice, I have totally banned Netflix, and that's exactly the scale of disallowance we're discussing here.
Do you understand the difference between primary and secondary / supplemental insurance coverage?
Again, I'm not making the claim that it's what's in the policy, but it's what Bernie has said, and others have echoed. Reasonable people can disagree on what policies are practicable or likely, but if you're a person who believes their health insurance might change based on those statements, then it seems like a warranted fear.
Price controls on healthcare (socialization) has positive and negative impacts. The positive impact is universality. Everyone gets approximately the same basic level of care. In some countries you might be able to pay for a nicer room, or quicker service, but generally speaking it's all the same. The downside is that price controls stifle innovation. That's just basic mainstream economics and is the case in every industry, not just healthcare. The trick about stifling innovation is you don't feel it immediately. On day 1 of the price controls, the rich are about the same but the poor are better off. On year 50 of the price controls, everyone is worse off because of all of the innovation that never came to fruition.
I never hear advocates of universal healthcare have an adult conversation that they are trading long term benefits for short term gains. I think that's a reasonable position to hold, but if we just pretend that it's all benefits and no cost we're not having an adult discussion. It's not as if one side is right and one side is wrong. Once we accurately discuss the economics, it's easier to understand that this is a very difficult moral decision and not the trivial one that is sometimes portrayed in the political sphere.
My speculation is that the rich people you refer to are more likely to be trained in economics (formally or otherwise) and are more likely to have a long term mindset regarding cost benefit tradeoffs.
2.) With this theory, if it is true, you are basically volunteering American patients to pay for innovation worldwide. That is quite a bad deal for quite a lot of American people.
3.)
> My speculation is that the rich people you refer to are more likely to be trained in economics (formally or otherwise) and are more likely to have a long term mindset regarding cost benefit tradeoffs.
They have also different interests. Good cost benefit tradeoffs for one group is often very bad deal for another group.
2) America doesn't have to let this happen. We could charge other countries for our innovations or otherwise demand reciprocation.
3) For people rich enough to have serious political power, the short term price difference is negligible or perhaps even cheaper under price controls.
Fostering innovation is of course important. Which is why you can deduct a lot of your R&D expenses from your taxes. Again, each country has its own tax code, so generalization might not be possible, but in a lot of cases, the hard work of finding new drugs is funded by the citizens, through tax breaks or research grants. The public sector, via universities and public labs, is a major player (although not the only one, of course) in the medical field.
Let's not forget that forcing people to stay with their employer to maintain insurance coverage is also a way to stifle innovation. How many of those workers could have and would have started a business, if not for the fear to loose everything in case of medical issues ? Surely the republicains would love to remove those kind of barriers to worker movement and innovation, wouldn't they ?
The universal healthcare system obviously isn't free. Altough some studies, and real life examples elsewhere in the world, showed it wouldn't be the money pit some imagine, it certainly doesn't run on love and compassion and fresh water only. The taxes in my country can show you that. But the social benefits and the peace of mind I enjoy are, in my very own and somewhat biased opinion, worth the cost.
We're talking about changing the velocity of innovation. Let's do a thought experiment about what innovations might be missing today if we implemented price controls everywhere in the globe 50 years ago. We might be missing the HPV vaccine leading to many cases of cancer for women. We might not have CRISPR. We might not have HIV treatments. High prices, profits, however you wish to put it, incentivized people to create these thing and go through the extremely difficult process of bringing them to market.
Now that's just a thought experiment about the past. It's impossible to know exactly what would have happened then, just like it's impossible to imagine the things that won't get invented 50 years from now. But we do know, according to basic mainstream economics, that price controls change the velocity of innovation. Since the velocity decreases, the farther you go into the future the more harm you cause through the lack of innovation.
I'm glad you brought up the fact that healthcare is tied to your employer. If you look up the history of this situation, you can see that it's the result of price controls enacted by the government on wages. Dumb things happen when we implement price controls.
HPV vaccines were first developed by the University of Queensland in Australia [1] and further improved by the the University of Queensland, Georgetown University Medical Center, University of Rochester, and the U.S. National Cancer Institute [1].
CRISPR was discovered by several researchers from the University of California, Berkeley, the Broad Institute of Harvard and MIT [2].
The public helped in the discovery of those treatments (through tax payer subsidies), and as such, in my view, are entitled to some kind of retribution. Having a form of universal healthcare, where the public can put pressure on companies to decrease the price of different treatment, is exactly that.
Regarding the velocity of innovation, I don't think it is hurt by a universal healthcare system. Everyone has access to those treatments, and so the profit on each instance of the treatment can be lowered while keeping the same total profit for the company manufacturing the pills.
What is the point to discover insuline if the price asked for a shot makes it impossible for some people to buy it ?
Even if some treatments, like drugs, can be made generic, and through that, have their price descrease in the futur, what about medical procedure ? Hip replacement won't suddenly or magically become cheaper in 5 years. Look at the price of stitches in the USA (For patients without health insurance, stitches typically cost $200-$3,000 or more, depending on the provider, the injury and the complexity of the repair [3]).
I do not propose to slash the profit of pharma companies. Like you said, academic studies consistently show that a reduction in current drug revenues leads to a fall in future research and the number of new drug discoveries [4]. Forbidding them one way or another to make a profit would be a net negative on the long term. But were our differences arise are in the implementtion of this principle. You propose, and correct me if I misunderstood, to let them set the price, and those how can will buy it. I propose to contain the cost so that all who need can afford it. The net result could be the same.
Price controls, like other types of controls, are a necessary evil in lots of case. It would be cheaper to allow companies to pollute everything and everyone, but we decided that society as a whole is better off with environmental controls. It would be cheaper to not test all those drugs and just let the market sort out which pills are working and which ones are dangerous, but we decided against it.
[1] https://en.wikipedia.org/wiki/HPV_vaccine#History [2] https://time.com/time-person-of-the-year-2016-crispr-runner-... [3] https://health.costhelper.com/stitches.html [4] https://itif.org/publications/2019/09/09/link-between-drug-p...
There's no such thing as a new drug that reaches the market without massive investment from private companies to do things like pay for FDA certifications, drug trials, etc. These are different categories of activities besides research. I don't think we're in conflict here.
>What is the point to discover insuline if the price asked for a shot makes it impossible for some people to buy it ?
What is the point to avoid discovering ways to create insulin altogether just because some people might not be able to afford it while the patent is active? What are the regulatory hurdles preventing generics?
>Hip replacement won't suddenly or magically become cheaper in 5 years.
Regulatory capture by medical unions is a separate topic.
>I propose to contain the cost so that all who need can afford it. The net result could be the same.
The net result is NOT the same if the new treatment is never created in the first place. That's the whole point.
>Price controls, like other types of controls, are a necessary evil in lots of case.
Again, this whole thread is about making sure we acknowledge the "evil" part, which is long term increase in death and suffering but short term reduction in death and suffering. After that, you can decide on your own whether or not things are "necessary."
The most innovation I am seeing coming up from the US health system these days is in finding ways to extract more wealth.
Innovative things like "let's make a cartel, increase the price of insulin by 1000%, and use some of that money to buy politicians so they don't stand in our way".
What you are talking about is that rich people don't need insurance at all. They just pay out of pocket.
If you want private health insurance for say $50 a month[1], then insurance gives access to procedures more quickly and the rooms are much nicer than the public health care system. It may give access to rare but expensive procedures.
If you don’t want insurance, then the default is the public healthcare system, which is paid for by taxes. You will usually be in a ward with other patients. You pay small amounts on use (to prevent abuse, and even those amounts are reduced to nearly free if you are poor). The level of care is reasonable, but can be slow for non-urgent elective surgery, and extremely expensive procedures are not available. The public healthcare system handles ongoing chronic conditions much better than a private system could.
[1] You can see a quote from https://www.southerncross.co.nz/ if you give your age, gender and tick whether you smoke. Note that Southern Cross is a nonprofit co-op, most premiums get returned to members (on average, less an approx 10% administrative overhead).
He couldn't afford to go to hospital, so never did. I was visiting from Australia at the time and was utterly horrified, having no idea the US worked like that. Now years later his shoulder is still screwed.
Of course people in the US avoid going if at all possible, it's horrendously expensive, and medical bills are the number one cause for bankruptcy in the US [1]
In a stack of OECD countries (all the other ones?) nobody has ever gone bankrupt from medical bills, because that's impossible.
[1] https://www.thebalance.com/medical-bankruptcy-statistics-415...
Or use physical therapy, it's cheap.
Now imagine that was scaled up to a whole country. That's New Zealand. Check out the Accident Compensation Corporation. All medical costs related to accidents are automatically covered!
But who pays the costs! Everyone, via levies. How much? $2000 on a $150K IT income.
But how do you control costs? Who is entitled? Who is at fault? Surprise! It's a no-fault accident insurance system that covers all accidents.
In exchange for that, we gave up our right to sue in accidents for medical damages. Why pay a lawyer when they're not required?
There are people that cannot afford insulin. THAT is a problem. But the fact that he took a risk, for fun, and suffered the consequences, rather than having everyone paying for it? That sounds a bit reasonable...
Note: important that the risk is voluntary, optional and recreational rather than professional. Why would the collective bear the costs, in those circumstances? Why is that fair?
If monthly, the answer is still no, but only because testing for covid is a significant public good.
Otherwise, yes, sure?
It is an unpredictable, low probability event, with not so big an impact (the payment, I mean, not covid)
Severe health problems don’t bankrupt NZers, and you are not locked into a job just to (a) keep your insurance, or (b) keep your insurance benefits.
How many recently unemployed in the US have lost cover for their pre-existing conditions?
I expect you can find the benefits list document for Southern Cross, if you wished to check out the details of cover for cancer or pre-existing conditions.
Germany allows people to opt out entirely, although there are a bunch of conditions and limitations. Most people don't, so the public system can still pay for itself.
If you're avoiding paying into a system because you don't want to claim from it then letting you hop back on whenever you need it would destroy the system very quickly.
So if you were self-insured and broke a leg, then decided to switch back to insurance, you'd still be on the hook for the costs of the ongoing physiotherapy until it is healed back up. The insurance doesn't have to actually pay anything that happened before a switch (switching from public to public insurance or private to private doesn't have this limit, private to public and the other way round but you don't pay, your old insurance pays).
The only universal way to switch is to marry someone in public insurance.
Pensions are in a way similar. When steelworkers retiring at 65 could expect on average a few golden years, then deciding how to pay for that wasn't such a huge deal. When they can expect a third of their lifetime to be in retirement, then it's very different.
The chart on [0] is incredible. I also shows how much that percentage has grown over the last 45 years.
[0] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea... [1] Source data OECD: https://stats.oecd.org/Index.aspx?DataSetCode=SHA
Whether it will come down, I guess that's partly a forecasting guess. Will the healthcare sector be a smaller part of the economy in 10, 20 years? Employ fewer people? I would be extremely surprised if this happened in any advanced country.
Something I'll note, Jay Gould, one of the wealthiest men of his time died of tuberculosis - something we now think of as a poor persons disease.
She also stole kids and let babies die from lack of care...
If insurance was gone tomorrow and there was a cap on how much a single payer system would pay I am pretty sure million dollar surgeries would go down significantly in price.
I mean surgeons are paid well but a million dollars for a few hours of their labor?
Constraints on how many people are permitted to become doctor's also reinforce this issue.
It's funny how today's most complex problems are so simply avoided by simple people.
Source?
By what definition? According to mainstream health organizations and even still government guidelines, they eat very poorly. Their diet is very high in saturated fat, which although healthy in reality, is not healthy according to the government. They also eat plenty of sugar, the other common scapegoat for dietary problems.
>don't drink or smoke,
They drink and smoke at lower rates, but they absolutely do drink and smoke.
Part of it is patent law, part of it is dysfunctional American healthcare system that drives prices up, but big part of that is that medicine just got much better and much more inherently expansive.
Like just chopping off a leg instead of spending a 12 hour operation and months of physiotherapy to save it.
Letting people die from chronic conditions instead of managing them.
Letting old people die, because the cost of medical treatment was too high.
Not performing operations for heart disease, so people got one heart attack and then died a year later.
Which we could totally go back to, it really is a lot cheaper.
Insurance companies are awful, but seriously, we can train field medics to do stitches and set bones, why should it cost $3000 to have an MD do it? Listening the hand wringing about it is infuriating when you realize that the reason you have to wait for simple procedures that barbers used to do is because there is a med school bottleneck.
It's another problem or set of problems that occurs in the USA.
I mean do doctors really need to spend 4 years getting a bachelor's degree in "pre-med"? If you know you're going to be a doctor why not just start off with biology, anatomy, physiology, chemistry in year one and go on to cutting up bodies in year 2? It seems utterly ridiculous to spend 4 years majoring in humanities, or calculus[1] only to seek entrance to med school.
The UK doesn't feel the need to do this.[2]
1. https://prepexpert.com/pre-med-class-recommendations/
2. https://en.wikipedia.org/wiki/Medical_school_in_the_United_K...
Granted, you could theoretically shorten the program by removing all the humanities courses; but shouldn't doctors-to-be take ethics courses?
You're right, I hold my hands up. I don't have any medical training.
> Where I went to Uni, you didn't take biochem until you were a senior. The reason for this is because before you take biochem you need General Chemistry 1 & 2, Organic Chemistry 1 & 2, and some smattering of Biology. You have to take these courses sequentially, they build on each other.
You obviously know what you're talking about and I won't debate you on how this works. But again, does a prospective doctor need to spend 4 years on this? How does every country other than the US and Canada manage to train their doctors without making them get a Bachelor's along the way in something non-medical? Why can't doctors study 5 or 6 years and graduate with a medical degree, ready to become a general practitioner? That's how they do it in the UK. Are you saying their docs didn't pass biochem or don't know what a nucleophile is?
> shouldn't doctors-to-be take ethics courses?
Pretty sure med students have time to take ethics courses if they do a 5/6 year medical degree.
Do doc's need to spend 4 years doing an undergrad before med school? Maybe. There are a lot of things that you need to learn before you can learn what you need to be a doctor. Do you need to know physics? Eh, only kind of.
I'm not terribly familiar with the system in the UK, but at least where I went to school, most of the folks who were planning on going to med school studied either Chem, Biochem or straight Biology. In fact, it was something of an issue because the Chemistry courses tended to be weed out courses, i.e. you had to pass Organic chem 1 & 2 with a (3.0+)/4.0, or you didn't have a ghost of a chance of getting in to med school. I, personally, didn't know anyone who was planning on going to med school who was studying anything outside the STEM umbrella.
>Pretty sure med students have time to take ethics courses if they do a 5/6 year medical degree. Reasonably. I was really only picking on this point because of, what I had thought was, a dismissal to the usage of the humanities as a doc.
Things you need to learn, not an inclusive list, before med school: Chemistry, drug interactions, A&P, Ethics, Statistics, Maths, and Biology.
That's (6, 2, 1, 2, 3, 4) 18 courses minimum. Remembering that they have to be done sequentially rather than concurrently and you're looking at, bare minimum, 2 years rather than 2 semesters.
This is as it should be. To bring it back to your CS example, if you are making a web app and you fail to secure your attack surface, the worst that happens is that folks get their info stolen. If you fail to do your drug interaction math correctly, people die.
Finance capitalists keep the vicious cycle going. Doctors' unions scratch and claw for high comp because without it their new entrants are screwed.
The free market in shampoo is okay, sort of. For a lot of other stuff "free market" + fiat looks like a mess.
Why haven't dental costs fallen through the floor if it's a free market?
Of course since the latter are elective, customers have the luxury of shopping around and taking their time.
I've had to deal with the true cost of dental work and I can guarantee you anyone that's needed to deal with significant dental issues has had the same experience. So why hasn't the free market dropped down prices? Why are we still paying more for basic dental work compared to other countries?
In light of this, Abraham Flexner was commissioned by the Carnegie Foundation to produce a report on the state of medical education and to make recommendations.
The Flexner Report was published in book form in 1910 and set forth a programme of reform for medical education and the broader healthcare system in America. The structure envisioned by Flexner largely remains with us to this day.
The crux of the problem is that in response to a very chaotic system, order was imposed in the form of strict licensing and educational requirements which made sense given the problems of the time but have contributed to new problems in our time. Outdated regulations, standard practices and conventions have artificially restricted supply of qualified medical personnel in America and it's time we address these structural issues.
Targeted reform of the system is the best solution for American healthcare.
The issue seems more complex than something simple like number of physicians. A high ratio is unnecessary for cheaper, quality healthcare (e.g. Canada, Japan), and whatever dynamics control the ratio in the U.S. (schooling, licensing) probably also exist in other countries with similar legal systems, but with different outcomes.
Data: https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?location...
EDIT: Looking at the ratio of GP to specialists for Canada (~1:1) and California (~1:2), it's more likely that the problem (such as it relates to numbers of physicians) is that we have too many specialists in the U.S. See https://www.cma.ca/sites/default/files/pdf/Physician%20Data/... and https://www.chcf.org/wp-content/uploads/2018/06/CAPhysicianS... And that probably has to do with 1) how we consume healthcare in this country and 2) the career expectations of medical students. And arguably this is a typical pattern of American culture more generally and in all our industries. Everybody wants to push the envelope and everybody expects the products and services they consume to be bleeding edge, both as a cultural expectation and in pursuit of higher profits--as consumers we tend to assume more costly services are more advanced.
It costs <$300 of an MD's time to set a bone, even if you get MD service. GP doctors aren't very expensive. The costs are elsewhere.
Before you call someone ignorant and say that the bureaucracy disagrees and so what possible standing could I have, consider a little bit of charitable reasoning would add some much needed credibility to the objection.
That you've done consulting to the healthcare sector doesn't mean much of anything to me, one way or another. Heck, the IT consultant for our CTO in my health chain can say the same, and all he does is EMR rollouts. He has about 0% understanding of healthcare policy, or how the system actually works. He understands EMR implementations. The financial analyst consulting to our COO has been in the hc sector for about a year and his knowledge of actual hc policy outstrips the EMR guy by at least an order of magnitude.
As a physician and healthcare policy expert, I don't much need any credibility, outside of that provided by the contents of my posts. I'm happy to let them speak for themselves, rather than appeal to authority - the latter of which is essentially non-existent in this pseudonymous context.
As the job of physician is being reduced to that of a health care service project manager who assembles and directs specialists using technology tools, it's becoming vulnerable to the same technology changes that sidelined project managers.
Skill is pareto distributed, and there is a long tail of medical services that could be done by apprenticed tradespeople, and the only thing preventing that is medical associations - and as you say, holding litigation risk.
By the way, actual cost transparency has winners and losers too. The winner is generally private insurers, who can use it to negotiate reimbursement further downward. The losers are everyone else. It's pretty much never the patient, regardless of what advocates of "patient consumerism" cry. When you're a grain of sand between two massive gears, you don't ever win the game of policy arbitrage.
If all you need is stitches, you can go to your PCP ($20-$60), surgeon's private office ($50-$100) or Urgent Care ($50-$200). Instead you go to the highest overhead center, occupy the attention of at least 2 nurses, a mid-level, and a doc, and... yes, pay for all of the above. In a space whose allocated overhead includes the weighted average of "stitches that shouldn't have come in" to "diabetic ketoacidosis with multiple organ failure."
Part of our systemic problems is, due to how we're structured, it's borderline impossible for an ER to say (a polite version of) "You're fucking kidding me. We have an urgent care center across the street - go there." [1]
We have many, many, many systemic problems. People using the ED as a primary care office and complaining about the disparity in prices is the least egregious of them.
[1] In part because hospitals used to try to bounce indigent patients. So now they can't do anything that smacks of bouncing anyone. So even if you try to divert patients from the ED to an in-house Urgent-ish Care, they still have to go through the ED pathway to determine that they're stable (meaning a doc has to evaluate them), before they can be shunted over. And now you're in a hospital, so the overhead of the Urgent-ish Care is already way higher than just having gone to UC to begin with. The hospital has no incentive to establish a spot for providing the same level of care, at high overhead, for lower reimbursement.
The concept of 'efficiency of scale' does not translate to service industries. The only efficiency that happens is efficiency of funneling more money to higher salaries of higher executives. Hospitals are driven by profit and their incentives do not align with the precepts that led to their formation.
1. We are fractured. There is no "healthcare system." That's a singular noun. We have a marketplace: that means things like three top-tier specialty centers in walking distance of each other in some areas, and nothing at all in others. About 90% of our problems derive from this. As do a number of our strengths (if you're in Boston, you should never have to wait more than two weeks for a colonoscopy. Ever.)
1a. The healthcare "system" is not equivalent to hospitals. Hospitals are a single strain of profit-seeking enterprise (non-profit hospitals are the same shit.) People keep confusing the two, resulting in advocacy for policies that just concentrate power harder into the hands of a few, massive, corporations.
2. We are bipolar. A huge, huge proportion of our healthcare dollars flows from medicare. A large portion of our people are uninsured or underinsured. The result is that healthcare operations are built (generally) around Medicare's billing practices and needs - that's what you optimize on to stay afloat. This means when someone uninsured comes in, though, they're thrown into an operational flow for which they're barely an after-thought. Prices set as a negotiation point with private insurers are brought to bear against uninsured people - and they get nailed with ridiculous, unpredictable prices that have nothing to do with... almost anything. These people either need to be brought under the umbrella of contracted rates (Medicare For All), or I don't know what. You're not going to convince an organization with operating margins <2% to launch a massive operational restructuring to accommodate people that generate <<1% of its profits. And don't think there isn't legislative collusion in this - in places like CA, hospitals are obligated to go to collections for all patients. They used to say, fuck it, that guy was poor as fuck, write it off as uncollectible and deduct it as charity care. The state didn't want to lose the tax dollars the hospital didn't bother collecting, so now hospitals are required to send those indigent patients to collections, or else the hospital has to eat the entirety of the cost - not even a tax deduction to soften the hit. That adds up to a lot of dollars.
3. Unfunded Mandates. Every policy change pushed through our healthcare system is perceived as targeting "those wealthy doctors" (doctor != hospital != healthcare system). Most docs I know drive a Nissan Altima or a Camry - they're middle-class cogs buried under debt. But the stereotype makes a good excuse for pushing policy changes and then not allocating money to accomplishing them. Which means every policy change fractures the system further apart socioeconomically - you have wealthy-client practices that can afford to stop taking insurance, opt-out of Medicare, and thus avoid all these unfunded mandates... and then you have everyone else. Which puts basically everyone but hospitals out of business, because only hospitals have the capital and the scale to be able to meet the new requirements. You think FB likes privacy regs because it builds a moat? Hospitals don't just get moats, they basically get to buy up every small practice in the area at cost. Your local PCP is small and nimble enough to say "oh, you're uninsured? Fuck it, $40." It's the hospital that says, "Oh, we'll send you a bill later," and then ho boy, get ready. This also includes getting docs who are super-bought into the status quo: "We profited off charging you hundreds of thousands in tuition. We sold the idea that you'd be set afterwards, and could just be a good doctor. Turns out that while paying off your loans, you're just middle-middle-class, after having been impoverished into your 30s. And now, for the good of society, we'd like to cut your income by another 20%, while asking you to continue working like a madman. No, we will not offer you one penny of federal loan forgiveness, even though it is the federal government that is gutting your income. In fact, we won't even let you declare bankruptcy - that's cause for revoking your license." Yeah, docs are going to buck really hard against most changes in hc reimbursement. Even so, look at organizations like Doctors For America - a shit ton of docs still agitate for reform, for the good of their nation, if not the good of their own pocket. A related point is the "shortage" of docs: training positions in hospitals are funded by the federal government. Funding which barely crawls. "We have a doctor shortage!" "Will you open new training positions?" "No." "Then..." "No worries, we'll have nurses take some night classes, skip the entirety of actual residency training, and then we can call them doctors, too! We'll just confuse people by telling them they're going to see 'providers', and that way we can avoid paying doctors for doctoring."
There's a lot of other headline bullet points, but most issues in American healthcare boil down to an interaction of the above three.
edit: I should add, big picture, that healthcare isn't magically divorced from the rest of our social ills. As wealth inequality grows, bear in mind two things: (1) wealth correlates to health, and disease burden to correlates to poverty, (2) people can still vote themselves healthcare allocation (i.e., medicaid). The result is that increasingly more disease is concentrated among the increasingly impoverished, which means they're legislatively allocating themselves healthcare ... without the resources to pay for it. Whether or not you like or dislike any of the above, a lot of our issues with hc reimbursement are linked - directly or indirectly - to questions of wealth inequality. Adjusted for inflation, most docs have seen their real income stagnating, hard, for decades - and that's specifically as a result of trying to cheapen them, because they're increasingly paid for with redistributed tax dollars rather than anyone actually buying healthcare.
I mean I get it, wounds can turn (really) bad, but other people than MDs (like nurses, or pharmacists were even discussed for this in France) should be able to do them, and give a follow up appointment to some MD / nurse a few days later to check if recovery is going well. Only time tells how the healing goes anyways.
edit: that said though, your opening question is kind of odd - doesn't pretty much everyone view the medical field as a racket?
Just as with politics, it's mostly well-intentioned, "good people in a bad system"; nonetheless, each individual is perversely-incentivized to normalize the moral hazard.
Yet, these are highly paid jobs because It’s not about being able to do it, it’s about understanding what they are doing. This way, they don’t just know how to do it but why to do it and what are the implications of doings it and how to debug it when the outcome is not the expected one.
Any junior can probably do %99 of what their seniors can do, yet when you look for a highly paid senior you don’t take a cheap junior as an option.
US health system might be a racket but not the health profession. No where else visiting a hospital is a financial decision(yet the med staff is still well paid), you only worry about the medical issue and it’s impact on your life and the lives of your loved ones, except maybe when you need some very novel treatment for your rare condition.
I have to add that this way of thinking, in general, is a very blue collar mental model on how world works. Nurses claim that they can do what doctors do, mechanics claim that they can do what engineers do all the time.
If someone wants to hire someone who can kinda program a little, because they charge less, and are likely able to accomplish the task the person has in mind, then they should be free to do that.
(Of course, if the task is one where failure causes a big problem, then one should get someone more qualified.)
Low affordance causes spilled blood, blood causes regulations.
The vast majority of developers cannot kill you if they screw up. In the cases where that isn't true, e.g. software for medical equipment, I'd expect to find some significantly higher hurdles to get past before you can release that software.
We don't generally require developers to have certain qualifications, but their output can be measured in other standardised ways nonetheless.
What are these standardised ways to measure developer output? I've never seen any, beyond "burndown charts" and "LOC", which I don't believe pass the sniff test.
It is if you are developing software in some high risk settings!
Let me suggest you fire-up a spreadsheet and start to calculate the cost structures surrounding healthcare in the US. I don't think you have enough information yet to fully understand the subject enough to answer the question you posed.
I'll suggest you model something like a team conducting surgery at a mid size hospital.
You have to model the cost structure each person in that room is subjected to. Three simple items are the cost of their education, malpractice insurance and taxes.
The next step is to estimate the number of people who support that team within that hospital. From administration to nurses and janitors.
Add to that external services such as labs.
Now calculate the equipment costs. You could dig deeper and understand the regulatory costs, taxation and liability equipment manufacturers are subjected to. Interesting point to note: The Trump administration had to guarantee protection from liability before anyone was willing to make even something as simple as an N95 mask for use in hospitals.
Now calculate the cost structure for the hospital. Again, regulatory, liability/malpractice, taxation, etc. If the ambulance service is independent, add them to the exercise.
If you run through the above exercise you will actually be surprised that it only costs $3,000 for an MD to perform a procedure.
Notice insurance isn't anywhere in these calculation. Health insurance is an easy to point to evil, yet it is perhaps the most insignificant portion of the cost matrix that drives the cost of healthcare in the US. In fact, health insurance is NOT a driver, it's a symptom. You cannot fix our medical system by manipulating insurance. If the costs are high, care will be expensive. If the costs are lower, care will become more affordable. And this will drive insurance costs down as a result. Insurance isn't the cause, it's the effect. Remember that next time you hear a politician claim that they can improve things by screwing with insurance. They are lying to you. Don't allow that to happen. Be informed.
If the equipment is the same, the admin overhead is the same and the education is the same, then that leaves only one real difference between us and other countries. And that's our Byzantine insurance system.
But the most striking difference is that everything is for profit. Health care.
Exact same costs? Surely you are joking.
Costs, regulatory overhead, education and taxes are different everywhere.
My wife pays tens of thousands of dollars per year in malpractice insurance...and she isn't even at the top of the scale in terms of these costs. The cost of education? An MD can graduate with anywhere from $300K and more in debt.
And lawsuits? Show me a place on earth where attorneys will go after anyone, medical industry or not, as quickly, easily and violently as they do in the US?
Show me a place on earth where the government guarantees student loans to the extent that university costs are bloated to the point of creating financial slavery for graduates.
Show me a place on earth where doctors have to order a pile of unnecessary tests in order to protect themselves from being sued.
Show me a place on earth where developing the simplest medical device costs tens of millions of dollars in regulatory fees alone (if you are lucky).
Show me a place on earth where bringing a drug to market comes with potentially billions of dollars in regulatory costs.
Show me a place on earth where a manufacturer of N95 masks and gowns is not allowed to supply them to hospitals during an emergency due to regulatory burdens, the fear of lawsuits and has to demand immunity from the president of the country before they are able to do so.
I tried to develop a relatively simple hearing device to help people who suffer from SSD (Single Side Deafness). We have someone in the family with this condition. I designed and built a device for her. She loved it. I then looked into going to market with it. The costs would run into the tens of millions of dollars (or more). There was no way to take that leap. And that doesn't include protecting from or fighting the inevitable lawsuits.
No, nothing is "the exact same". And that's my point. Unless you pull-up a spreadsheet and analyze the cost structure you will never understand why healthcare costs what it does in the US. It has nothing to do with insurance, or profit, or greed or any of the nonsense ideas being floated around --particularly by politicians who just want to manipulate the audience for votes.
This is a simple equation: If you want to lower consumer costs you have to lower the cost structure driving the process and resources necessary to deliver the goods and services they receive.
I would urge you not to form opinions as you have until and unless you have taken the time to truly understand the details of the matter, which is to say: Analyze the cost structure tree down to a good level of granularity and then see what you would change in order to reduce consumer costs. Insurance will not be on that list.
[1]https://www.npr.org/sections/money/2019/03/12/702500408/are-...
This gets so rarely uttered if ever I'm having a hard time believing it hasn't been down voted by hyper-credentialists on HN.
I fully believe the number of doctors allowed to start practicing medicine is heavily controlled using arbitrary rationales and spurious education / training thresholds.
There's no need for so much garbage bureaucracy in medical pedagogy especially when so many doctors are paid insanely lofty salaries.
The whole enterprise of medicine and the way its practiced in the U.S. ( including HIPAA ), needs some heavy de-bloating.
"Of course" says everyone because it seems like an easy answer.
"Then you're sprained ancle will need a team of 20 super MDs, an MRI, CAT scan, sterile isolation ward and a helicopter to get you there. That will be 100 million dollars please!" says the greedy fuck maximising profit, and he's giving you what you said you wanted...
This is basically the US system in a nutshell. Other nations have an approach with more focus on affordability, but the US system (from hospitals, to doctors themselves, to insurers, to drug makers, to the courts) is entirely focused on maximum quality. That's what makes it unaffordable. That's also why you don't have teired treatment like you say: an MD is 0.5% better than a trained nurse at setting a bone. They cost 100 times more. But you decide purely based on the 0.5%
You do, however, need to be an MD to recognize some of the other 20% as not being part of the 80%.
You might well think this has broken down in America. There's both a lack of formal restraint in the form of laws holding down the price, like in the Swiss private health system, as well as a lack of informal rules like he's mentioned, preventing people who've hit their deductible from going nuts with their treatment. And the culture of suing doctors has led to even more issues.
The trustful society thing is interesting. A friend of mine lost a grand-uncle in Denmark a couple of years back. Now this guy had grown up before the welfare state, and took pride in not taking handouts that he didn't need. He lived on a family farm on an idyllic island called Bornholm. When he died, the authorities called and asked what to do with nearly 2M DKK of pension money he hadn't collected.
At the other end, you get people growing up having never seen what preceded the welfare state. You often get debates about whether the kids are spending their student allowances wisely, because obviously you see them around town and they are having a good time. This is a cash grant from the government that you don't even need to use for tuition. Are they being profligate with the state's money? It's a debate that keeps going.
Yes, it is, but it doesn't scale. It only works for communities that are small enough that everyone can keep track of the trust relationships and how well everyone is honoring them. The problem we moderns have is that many of us either don't want to live in such a community (even Scott notices this when he says there is something to be said for not having your neighbors judging your lifestyle all the time) or don't have access to one. So we have a different set of priorities, and we therefore have to make different choices and tradeoffs.
I do think there are some interesting insights in the article though.
Edit: another observation is that the author is probably not putting enough emphasis on the additional cost of end-of-life care (though he does mention it), especially if he's correct that the Amish tend not to spend as much on prolonging the life of older people.
This does a number of things:
1) It puts patient skin-in-the-game in that they have the direct incentive to shop around and/or negotiate lower bills since they have to front the cost.
2) it removes the costly middle-men referenced in this article and all the administrative cost that goes with that.
3) It puts much more of the administrative burden on the patient because they have to negotiate and pay, keep track of things, then get reimbursed.
These three things result in reduced monetary costs, but add other costs like the patient's time and stress level.
Healthshares previously could only exist if they had been grandfathered in via a special provision in the ACA. Since then enough of the ACA has been eaten away that new healthshares are taking advantage of the resulting loopholes.
The hospital will work with you and put you on a payment plan if you don’t just disappear. If you stop communicating they’ll sell your debt to a debt collector which is a bad deal for both you and the hospital. They’d rather have you paying $20/month for ever then sell your debt.
More importantly to me though was this less-talked-about perk of having a doctor who -- once he knows he's not just going to receive a negotiated rate from an insurer -- will actually take a little bit longer with you and hear out your complaints. Knowing that if you take longer, he can bill you more is actually a net good, IMO.
You can easily flip that around too. The healthcare system would become less efficient because time spend gets valued instead of results.
There are some hospitals that proudly make a point of not accepting insurance. They avoid the administrative overhead of negotiating insurance contracts and pricing procedures, and accordingly have a smaller salary footprint.
As a byproduct of not working with insurance, they're allowed to advertise standard prices per procedure, because there actually is a standard price instead of 3-5 different "negotiated" prices. This price transparency is a competitive advantage, and it means they can attract price-sensitive patients for elective procedures.
The competitive advantage of price transparency is just enough to make them competitive with insurance-taking clinics.
The difference is that, in these setups, your clinic lives and dies by its reputation. Being in a big insurance carrier's network will effectively guarantee you a baseline patient volume. Going it "on your own" means you get no such guarantees. It's a riskier proposition.
I work in health insurance tech, but if you're curious to hear it from the horse's mouth, Keith Smith is the head person of an insurance-refusing operation in Oklahoma: https://www.econtalk.org/keith-smith-on-free-market-health-c...
Given this opener, it seems bizarre that the article doesn't use the word "diet" even once. The comment there by "Scoop" seems right on.
Google tells me the USA is estimated to have around 300,000 obesity-related deaths per year. Apparently [0] obesity is around 10% as common in Amish communities as in the USA as a whole.
Aside: this is compared to around 35,000 gun-related deaths, around 40,000 traffic-related deaths, and around 50,000 opioid-overdose deaths. Presumably the Amish are spared these too.
[0] https://time.com/5159857/amish-people-stay-healthy-in-old-ag...
I'm seeing a single relevant sentence:
> As far as I can tell, most of the secret is spending your whole life outside doing strenuous agricultural labor, plus being at a tech level two centuries too early for fast food.
If that's what counts for improving health, why doesn't the article discuss that, rather than discussing only healthcare? (That's not to downplay the important issues the article raises, of course.)
I think my point stands here. There's an unfortunate trend to treat the healthcare system as the answer to health problems, and to dismiss the enormously important lifestyle questions. Compare the opening paragraph of the article with what the article goes on to discuss:
> Amish people spend only a fifth as much as you do on health care, and their health is fine. What can we learn from them?
An article that explores what we can learn from the Amish regarding health, should spend more than a sentence on diet.
Of course you point does stand, and diet and obesity are important topics to discuss, and perhaps scot should have gone into (a lot) more detail. But that is not to say that every article should focus on those, it seems to me that having articles focussing on these issued as well is not a problem.
Like you said, more than a sentence should be spent on diet.
Perhaps you and I wouldn't be having this discussion if at the top Scot had given a disclaimer that he's only focussing on this one side of the situation and neglecting the other side for the purposes of discussion.
That's not really what they believe. Here's a better description[1]:
> Amish commonly believe that commercial insurance plans undermine the religious duty of community accountability
They don't pay social security tax (really, an insurance premium_ for the same reason, and were exempted from it on religious grounds.
As an atheist I find the Amish's religious view quite attractive. Ignoring god, it becomes plain humanitarianism and about helping each other.
Aside: I suppose one could well argue that non-commercial insurance plans would be just a formalisation of community accountability. Edit: and that's pretty much exactly what's described in the article, only without calling it insurance.
> For people who rarely leave their hometown and avoid modern technology, a train trip to Mexico must be a scary experience.
You mean when they're not traveling all over the states to do business with the English, or carting themselves around in wagons with electric lights, or fueling their diesel generators to power batteries to run power tools and heavy machinery they use to create products for English customers? .... I'm pretty sure boarding transport technology that's been around since well before the 16th century to talk to "outsiders" is nowhere near scary to them (especially after Rumspringa, for example).
It's easy to get into a romantic, over-simplified idea of a general people based on some preconceived notions about them, and those can often cloud further ideas and lead to things like cherry-picking data to support a theory that "sounds right".
What pushed life expectancy down was infant mortality, and communicable disease. Amish would have likely lived for longer than average simply because they didn’t live in cities.
There’s also the obvious problem of the methods of old statistics, did it include infant mortality and childbirth deaths?
They could even do double-blind studies on things that are not ingestable, like sunlight, doing enough exercise, getting enough rest, etc., etc.
But will they, ever?
No they will not.
That's because they will not make any money if these studies are successful.
Quite the opposite.
If there is any successful study in one or more of these areas, it could very well have negative and damaging economic impact to the medical community.
I like Doctors, and believe that most of them are good, honest, decent, hard-working (especially now, during CoronaVirus!) people.
They are not the enemy, quite the opposite!
But we really need to think about double-blind studies on non-patentable things that could potentially cure people, or at least alleviate their condition in some small way.
That, and the FDA needs to allow those things as treatments that Doctors may legally prescribe, if the double-blind studies prove successful...
Is there any great mystery as to the health benefits of each of those items you mentioned that has gone unanswered?
Undoubtedly resources are commonly committed where there is opportunity for a return on that investment, but there are decades of research (and plenty of anecdotes too!) on each of the items you mentioned. I just don’t think they are packaged in a way you like.
I think of myself as a skeptic when it comes to healthcare and healthcare professionals - mostly because of the bravado and certainty healthcare professionals exude regarding the actual utility of what they think they know (which is, embarrassingly, not much much more than your average self-aware and discerning Joe or Jane Public). But even as skeptical as I am, I think you characterize healthcare, healthcare professionals, and the business of healthcare too cynically.
Of course if we cared about preventive healthcare in the United States we could also greatly reduce the incidence of chronic disease and free up $$ for actually researching interesting aspects of disease and not just putting out fires.
[0] https://en.m.wikipedia.org/wiki/Nurses%27_Health_Study [1] https://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC2027... [2] https://en.m.wikipedia.org/wiki/Framingham_Heart_Study
But... they do? Pretty much everything you mentioned is well studied, although a lot of times it’s hard to get conclusive evidence when the effect size is small.
Why are only pills, pills with which pharmaceutical companies (and usually doctors, via commission payments) make money, prescribed, and nothing else?
Maybe it's not the Doctors' fault however.
Perhaps the mindset was taught to them via most Medical Colleges and Universities, who accept large amounts of money from big pharma to teach that prevailing, patented-pharmaceutical-drug-centered mindset... and perhaps it was regulated into them by well-meaning, yet exclusionary and limiting government regulations...
I hold Doctors harmless... but they could prescribe less man-made products for profit, and more that are made by nature for free, or pretty close to free...
When you take car insurance, it does not pay for oil changes, tire repair etc, since these are considered regular maintenance. If you don't do this, then your car will fall apart faster and again, you are on your own...
Not a straight analogy, but if we make people pay on their own for regular visits, mandate tha they must visit a doctor (their choice) etc which they pay out of pocket -- then only unexpected events are actually covered by insurance -- and the cost is lower.
The employer spends less, and hopefully, a substantial portion gets back to the employee's paycheck.
They are sort of like paying to fix chips in windshields, if you want an analogy.
(The actual billed cost for those sorts of visits is ~$100, which doesn't add up very fast compared to ER visits or any sort of complex care)
This is just a side comment in the post, but I think it's an important observation. People really, really don't like feeling (or looking) like suckers. When we see other people breaking the rules, we're much more likely to break the rules. Some of this is that we're seeing evidence that breaking the rules won't be punished, sure. But I think the larger effect is that now we feel like suckers for following the rules.
This page: https://amishamerica.com/how-fast-are-the-amish-growing/ says that the doubling time is about 19 years.
How do they find enough suitable land to practice their way of life?
It seems that, at least until very recently, they prefer to be where there are already substantial numbers of Amish people already (quite sensible of course). The biggest increase in absolute numbers 2010-2019 was Pennsylvania which is also the state with the highest Amish population.
It's a stupid answer, but I would guess they buy it, just like anyone else. I've heard about groups of Amish moving to new areas to start communities.
I think Spain has one of the world's best health care systems. https://en.wikipedia.org/wiki/Health_care_in_Spain
I guess US can apply the same principles. Some things might be more important than making money.
Not to the people that run the US it isn't. They are pushing to fix the pandemic problem by just letting a couple of percent of the population die.
But the flip side of that is a bout of cancer, a heart attack, baby needing to spend a month in NICU doesn't bankrupt you.
>But the flip side of that is a bout of cancer, a heart attack, baby needing to spend a month in NICU doesn't bankrupt you.
>Cancer services may be rationed to those most likely to survive, says NHS report
>National Health Service insist limited care for cancer patients is 'unlikely scenario'
https://www.telegraph.co.uk/news/2020/03/22/cancer-services-...
>...the Amish are honorable customers. This separates them from insurance companies, who are constantly trying to scam providers however they can. Much of the increase in health care costs is “administrative expenses”, and much of these administrative expenses is hiring an army of lawyers, clerks, and billing professionals to thwart insurance companies’ attempts to cheat their way out of paying. If you are an honorable Amish person and the hospital knows you will pay your bill on time with zero fuss, they can waive all this.
Imagine how many social problems would disappear if people had more integrity and stronger morals. Literally every aspect of life would improve. But instead, we have to bulletproof everything (largely without success) from people who scheme and scam their way through life. We sink enormous costs into this, and it slows the progress and complicates life for everyone else.
I'm not a religious person, but the thing that the anti-religion movements have failed spectacularly at is providing a universal, teachable framework for basic morality. Religions, for all their faults, and for all of their misguided morality, at least had morality frameworks that were more or less unified and teachable. What do we have now in their place?
Truth is the Amish self select as the young ones can leave if they find the rules too constricting.
Granted, everyone in the world is suddenly moral and of utmost integrity and everyone gets used to this new reality. The economic upside in lying/cheating is now so high that a few minutes later the world is back to exactly what it was, except for the first few persons to decide that lying wasn't such a bad idea, who are now a few billion dollars richer.
> Religions, for all their faults, and for all of their misguided morality, at least had morality frameworks that were more or less unified and teachable
This is your daily reminder that the Catholic Church is the organization with the most identified pedophiles in the world. (I'd have written "convicted", but they work really hard - and are really good - at preventing that outcome).
Although as of today? Yes I totally agree.
By definition, it is not integrity if you give it up immediately to gain an advantage by lying and cheating.
>This is your daily reminder that the Catholic Church is the organization with the most identified pedophiles in the world. (I'd have written "convicted", but they work really hard - and are really good - at preventing that outcome).
This a non-sequitur when you consider that there are over 4000 religions in the world, all with their own morality frameworks.
Within my personal morality framework, it is completely ethical to lean into rage if you can hold your logic, and those few persons have just sacrificed themselves to becoming a lesson.
There's a great saying which is "if you're incapable of violence, you're never peaceful, merely harmless." It's time we start talking about was is and is not okay within the context of intentional harm and suffering. What are the pros and cons of punishment? When should it be applied? How?
I'd say a week of waterboarding could be enough to get someone very adamantly expressing "it wasn't worth it." Those words would never go unsaid by these culprits. "It wasn't worth it" should be the slogan of every evil deed.
Clever retort. But even if proven true somehow is it the religion that made the bad do good or agreed upon ethics with consequences for those who broke them? Must it include belief in some unprovable future consequence?
But there is no universal, teachable framework for basic morality. Even the seemingly most basic rule: don't hurt anyone, has so many exceptions.
There is no 'small' set of rules you can use to describe morality. Reality is messy, human interactions even more so. We need to teach people to be empathic, and to be willing to try and understand the others position and view
As soon as you have a heterogenous group arguments will break out about what's right and wrong, how people should live, who gets what stuff...
For a more detailed breakdown, take a look at _The Four Cardinal Virtues_ by Josef Pieper
Reminds me of playing https://ncase.me/trust/
What bulletproofing? Humanity has operated on an extremely high trust basis since the beginning of civilization - it's the only reason we've been able to grow so fast and reshape the planet. It's why McDonald's employee don't check someone's ID at the pick up window and why social engineering works so well. It's the reason why we even have power grids, indoor plumbing, and modern medicine - all of those systems require extreme levels of trust.
That's not hyperbole: A decent sized power plant joining the grid out of phase can crash the entire system, destroying - aka exploding - other power plants and distribution infrastructure. Our water supply systems and reservoirs are almost completely unprotected and vulnerable to malicious actors. A significant fraction of our health and safety regulations operate on scout's honor and personal liability: the FDA approved the diagnostic tests at the clinical labs I've worked at because they trust some certified lab managers (that we hired) to review our procedures and quality control - for life or death clinical testing - without a regulator ever stepping foot in the lab. Our species has even scraped our noses against nuclear war several times, ending in some low level officer deciding "nah... not today."
As a species we are weak: we can't run fast or climb very well, our stomachs and immune systems aren't worth squat in the wild, and it takes us longer to raise our young than most animals' life expectancies. It is only through intelligence and trust have we been able to overcome those limitations to build the world we have today.
The problem isn't individual morality, it's the systemic incentives built up over millennia of societal debt, tribalism, and a dash of corruption. Trying to moralize at an individual level is a big reason why so many people are anti-religious to begin with.
A lot of 'social technology' exists, in part, to help increase our ability to scale trust up. This includes things such as nations and religions. As people become more irreligious and nationalism declines (including into an us vs them mentality within the nation - simple cheerleading of your country is not what I mean by nationalism), trust declines, and people are more likely to scam, grift, and fleece others. And once it is gone, it is very hard to get back.
Medical pricing should be simple, upfront and direct. It should not require lots of clerks and "billing professionals"
It shouldn't required armies of expensive lawyers to settle disputes. Whether the bill was not paid by the customer, or the doctor failed to deliver what the customer paid for.
As for billing, who would they bill - I've never had a bill from the NHS or even heard of someone getting a bill from the NHS? In some parts of the UK you have to pay a small amount for prescription medicines but that doesn't go to the NHS etc.
It literally is "free at the point of delivery".
Edit: The NHS directly employs about 1.4 million people https://fullfact.org/health/how-many-nhs-employees-are-there... - and that's not including people who work in GP practices or dentists or opticians who do NHS work but aren't employed by the NHS.
That the central problem of human life. "Hell is other people."
Arguably, cities are a bad idea. There's no a priori reason to expect our so-called civilization to work. In evolutionary time-frame it has only just appeared and it shows every evidence of being an ephemeral flash-in-the-pan. I mean, not only are we about to roast ourselves in our own waste heat, but a single virus has deranged our whole global economic structure.
It may well turn out that coming down out of the trees and inventing digital watches was wrong, and the Orangutans and Dolphins have got it right all along.
Government (kings and whatnot) is a kind of machine to manage human wickedness.
> ...a universal, teachable framework for basic morality. ... What do we have now in their place?
The simple answer is e.g. the Universal Declaration of Human Rights:
https://en.wikipedia.org/wiki/Universal_Declaration_of_Human...
My wife came from a splinter of that group.
I skimmed the article. It is missing the most important cultural part -- Amish even when sick will continue to work and eventually simply die. Culturally they do not try to extend life at any cost.
> Amish people are more willing to stop interventions earlier and resist invasive therapies than the general population because, while they long for healing, they also have a profound respect for God’s will. This means taking modest steps toward healing sick bodies, giving preference to natural remedies, setting common-sense limits, and believing that in the end their bodies are in God’s hands.
>The Amish health care system has an easier job than ours does. It has to take care of people who are generally healthy and less interested in extreme end-of-life care.
This is my problem with Evangelical Atheism. The people who go hard against religion (well, two of the large three for political reasons) refuse to accept that there are good things that come with the structure and that some people really take to that.
Because no such framework exists? If we remove totalitarian pressure to enforce one coherent moral framework (either religious or secular) to all, we end up with pluralistic society in which various persons have fundamentally different moral intuitions, and therefore it needs extensive formal system for cooperation and conflict solving.
Given the numerous genocides committed in the name of religion, I would reckon that religion has failed to do so as well.