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Comment by jostmey | Hacker News Reader

I agree with the three issues they identify driving up costs. But I fear “Medicare for All” won't fix all the issues, which go much deeper. For example, the US has extremely high standards restricting who can practice medicine compared to the rest of world, limiting the supply of doctors and artificially driving up their demand. There is a need for standards, but perhaps the AMA has too much political influence. Likewise, manufacturers of medical supplies operate as monopolies because the moat to reach approval is really high. I fear the US medical system is becoming so insane the only fix will be to replace it entirely (It's not just about tearing down, but replacing institutions)

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> For example, the US has extremely high standards restricting who can practice medicine compared to the rest of world

Rest of the world, yes. Rest of the developed world, not at all. The major difference is that becoming a doc in the US is much more expensive than pretty much anywhere else. You could also argue it's proportionally harder because of the more numerous competitors. But on an absolute level of knowledge and capability no, it's not harder than say, in western european countries.

I believe it takes longer in the US, when all is said and done.

It’s hard to casually verify this because each country uses different terms and has a different track but I think, when you include the various phases of training, starting from the bachelors degree, the US one is more total years.

Edit:

So for example the UK and France don’t appear to require any sort of bachelor’s degree as a prerequisite for medical. Which saves you 4 years on average. So their tracks may be longer but you can start sooner.

Citation definitely needed here

And just to be sure, I would like you to start from the beginning of the person's medical training and not include the gatekeeping bit of having to get a bachelors in a random subject unrelated to medicine.

I note this Wikipedia article that suggests 4 years messed school plus 1 year internship could get me a license in the US. That sounds like Western Europe to me. Or India...

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

> I would like you to start from the beginning of the person's medical training and not include the gatekeeping bit of having to get a bachelors in a random subject unrelated to medicine.

Why? An apples-to-apples comparison would be to see how long it takes to become a general physician after completing secondary school. In the UK or India it's something like 5.5-6 years.[1]

In the US it's 3-4 years of "pre-med", then 4 years of med school. That's from the article you referred.

1. https://en.wikipedia.org/wiki/Medical_school_in_the_United_K...

> Why? An apples-to-apples comparison would be to see how long it takes to become a general physician after completing secondary school.

Because if the requirement in the US is indeed "bachelor's degree required, any will do", then it exists solely for gate-keeping and says nothing about the standards of education.

Edit: looking at wiki, the requirements are actually a bit more reasonable, but it does seem strange that they are not just rolled into the first year (or two) of medical degree. Why force people to finish undergrad studies if only a few courses are relevant?

Of the people who attempt the pre-med track not all will make it. Forcing students to get an actual Bachelor's degree gives students some fallback.

I think really it's just the system was built this way and nobody's going to change it now.

> Forcing students to get an actual Bachelor's degree gives students some fallback.

That may be one reason, but seems to me that it doesn't really raise the standard of education. So it doesn't really help with proving that "US > the world" in this aspect.

I imagine you could still fall-back from medical college to undergrad & get credit for the completed coursework that is relevant towards the Bachelor's degree you fall-back to. This way, you don't incur unnecessary costs on folks who succeed.

> I think really it's just the system was built this way and nobody's going to change it now.

Channeling my inner cynic: nothing's going to change given that the decision-makers benefit financially from the system being set up like this.

They can switch to a Bachelors when they transfer off the med track.

Some universities in the US offer a 7 year undergrad and medical degree. Those usually have an extremely high GPA requirement but it's possible to do just that.

They typically have acceptance rates in the low single digits too.

Interesting, thanks! That's more in line with what I'd expect coming from Poland - medical degree is 6yrs (& is equivalent to Master's, I don't believe you get a Bachelor's degree during those), specialization then takes additional 5-6 years. For context, "normal" degrees are 3y (BSc) + 2y (MSc), which is also 1 year shorter than comparable education in the US. OTOH, I believe there's no such thing as "associate degree", and colleges are more focused from the get-go - you pick your major when applying for college (& the admission criteria are different based on that).

Not at all, because the question at hand was 'how long does it take to train to be an doctor in the US'. I don't understand why one would include time spent training to be something else? It is like saying 'it took me 30 years to learn to code, 3 months on Udemy and 29 years learning to solve problems as a carpenter'.

Premed is gatekeeping, and not all countries enforce that form of gatekeeping.

> 'how long does it take to train to be an doctor in the US'. I don't understand why one would include time spent training to be something else?

Because you can't train to be a doctor in the US without that gatekeeping? I thought the point GP was making was it takes in the longer because of this pointless gatekeeping.

I'll bring an example for the sake of comparison. In Italy the path to becoming a physician involves a six year degree focused entirely on medicine (so not a bachelor), followed by a specialized degree of variable length (4-6 years depending on the chosen specialty) during which you practice in a hospital and study for exams at the same time, mostly the former. Entrance exams are required at both levels and acceptance rates are very low. Also, many students end up needing 1-2 extra years to complete it all.

Well, I can answer that very clearly from personal experience: you are wrong. Medical education is much shorter in the US compared to most western countries. You have to understand that in medicine, school years are not all there is to it. The real issue is when do you get to truly practice without supervision, and that's much earlier in the US. Basically, a short residency and 1-2 years of fellowship and... done! In Europe, you're still a junior at 35.

> The real issue is when do you get to truly practice without supervision, and that's much earlier in the US.

Is it? If a doctor in the UK can graduate from medical school and practice as a GP 6 years out of secondary school, but for a US doctor it takes 8-9 years, it's not really "earlier". What you're talking about is status within the profession.

For GPs, it may be true. I admit I was speaking from the POV of a specialist.

It really is harder in the US. The standards are much higher in the US than anywhere else. The US only accepts doctors who went to Canadian or American medical schools. And then on top of that, it is much harder to get into a medical school here in NA than practically anywhere else, except maybe India. I know that in the UK you can go directly from high school, meanwhile in the US & Canada you need a 515 MCAT, 3.7 GPA, and lab time to even get in to a mid-range school.

The US only accepts doctors who went to Canadian or American medical schools.

That's absolutely not true. Foreign medical graduates do have to take the US board exams, complete a US-based residency, and possibly take additional courses to fill educational gaps, but they absolutely can practice in the US with a foreign medical degree.

Here's an article that describes the pathway by which foreign doctors can get a medical license in the US: https://www.voanews.com/student-union/how-indian-doctors-get...

In brief, they have to sit the MLE (medical licensing exams), but the real hurdle is getting into a US-based residency program beforehand. In practice, this means only the best candidates tend to make it.

-> complete a US-based residency

This is the kicker. There are incredibly difficult to get, they are incredibly stressful, and it's another 3-5 years of your life.

If you allowed any non-us developers to practice in the US but you made them work a 5 year 80hr/week internship for 1/6th of what professional developers made first, that basically bans non-us developers from writing code in the U.S.

Absolutely. And that's due to AMA lobbying in the 90s. It doesn't have anything much to do with stringency of US medical licensing or ensuring quality and everything to do with existing MDs protecting their lucrative practices.

Practicing medicine must be lucrative because it costs an individual student around $240,000 in tuition for the M.D. itself, excluding cost of living.

Doctors are made out to be predatory vultures, but unless they come from money they must undergo massive debt burdens that they are not able to even begin paying down the principal on until they're well-into their thirties. Imagine the feeling of taking out half-a-million dollars in student loans to cover both undergrad, and graduate-level training. After that look forward to your 80-hours a week of residency making below hourly minimum wage. [1]

Make medical school free, and you'll have people lining up the door to practice for low-cost. Make it half-a-million pay-to-play, and you'll have people desperately clawing their way out of debt so that some day they can have a family and own a home after a decade of hellish training.

Cut the docs some slack. They're taking on unimaginable debt burdens for a job that often isn't in the same universe of cushiness as something at FAANG (inspecting that anal fissure in the ED at 3am with perks including, well, hospital food), but involves an tremendous service to society.

[1] https://www.mdlinx.com/physiciansense/is-it-better-to-be-a-d...

You are either deliberately misleading people or are ignorant of the UK education system.

Highschool in the uk ends at 16, you graduate with GCSEs. After this there are 2 extra years of education (compulsory in England), you start university at 18 (at the youngest).

Medical schools are competitive and require strong a-level results, typically 3 As (the second highest grade, after A*) [0]. It's a 4 year degree, you then go onto train for another 5 years as a junior doctor.

There is a _lot_ of training for UK doctors.

[0] https://www.manchester.ac.uk/study/undergraduate/courses/202...

[1] https://www.healthcareers.nhs.uk/explore-roles/doctors/train...

From the link numbered [1] above, medical school in the UK is normally five years long. Followed by 2 years of Foundation training, and 5-8 years of specialist training, or 3 years if you go into general practice.

Note that the US education system is more expensive though, so becoming a doctor costs more.

> You are either deliberately misleading people or are ignorant of the UK education system.

I don't think either is necessarily the case - he isn't saying it's easy to become a doctor in the UK, he's saying it's easier than in the US, and that's sort of true, if not by all that much.

In the US you also start university at 18 - med school is a 4 year degree you must have completed your undergraduate degree to begin, then you go on to train for 3-7 years as a resident, depending on specialization. Then maybe more for a fellowship.

That said, I've got both doctors trained in the UK and in the US in my immediate family, I don't really see much of a distinction in difficulty of training to be honest but I'm not a doctor myself so what do I know.

22.5% of students get 3 As or better so that doesn't sound very impressive to me. US med schools are much more competitive than that.

There is a weird discontinuity in the data for 2020 which your quote - it was 12.3% the previous year according to https://lginform.local.gov.uk/reports/lgastandard?mod-metric...

This is also a proportion of students who take A levels which is already filtering down to about 38% of the population in that age group (766k 18 year olds in U.K. so about 643k in England of which about 250k take at least one A level.)

So in a normal year that 12.3% of A level students getting 3 A’s is only 4.8% of the age cohort.

Edit: I should add that medicine is about the hardest subject to get into in U.K. (other than vet med which has so few places) and one of the only ones where they expect you to demonstrate suitability beyond academic performance, e.g. work experience in a caring setting. (Source: shared a house with a med student in undergrad.)

Only accepting doctors who went to medical school in the u.s or Canada is not the same as having higher standards (necessarily).

> The US only accepts doctors who went to Canadian or American medical schools.

This is factually incorrect. There are tons of doctors that graduated from European, Indian and Chinese medical schools. To practice medicine in the USA they need to pass the ECFMG tests (US graduates take similar USMLE tests) and then complete medical residency. The last part is the hardest, for the medical residency admission offices are routinely discriminating against the foreign medical graduates.

Why shouldn't domestic medical students have priority over foreign medical graduates?

Why should they? If I take the same tests as US medical students and pass, am I not at least as good as they are?

Global market?

It's much easier for an us citizen anyway as it is easier for an employee.

I'm european, never set foot in a us or canadian medical school but worked in Boston. So no, it's not as set in stone as you think it is.

In Germany the grades you need to study medicine is really high. You need the best grade of 1.0. you can wait if you just have something like 1.3

Do you have sources which shows your argument?

Isn't the problem that US requires having bachelor's degree before you even can start studying medicine, which effectively makes people start 4 years later?

The question is not "when do you leave school?" it's actually "when are you employable as an independent practitioner?". In my personal experience, it's _much_ easier to get an attending/private practice position in the US at a younger age. Just because the country is huge and lots of places lack docs, probably. Of course, that's my experience and I could be wrong.

Just because there is a Dr shortage in the US due to having a limited number of medical schools, there are still thousands of students who get their degree and can't find a residency:

>.... The matching challenge comes as the U.S. faces a physician shortage. The nation could be short as many as 139,000 physicians by 2033, according to the Times, which cites Association of American Medical Colleges data. Despite this shortage, thousands of medical school graduates are consistently rejected from residency experience, rendering their MD or DO "virtually useless," according to the report.

https://www.beckershospitalreview.com/hospital-physician-rel...

That must be understood in the context of the number of applicants to U.S. residency programs from Caribbean medical schools (which are well-known to be a little predatory).

From that article you cited: International medical graduates in particular have low match rates for residency programs. American medical students have a 94 percent match rate, according to the Times, which cites information from the National Resident Matching Program. However, Americans who study at international medical schools have a match rate of 61 percent."

Kids from the U.S. get sold on a Caribbean M.D. school, and spend thousands and thousands of dollars only to find out that things get really complicated when it comes time to do clerkship rotations or apply to residency.

An M.D. or a D.O. from a school on U.S. soil is definitely not useless, and your chances at matching a residency are extremely high, as cited above.

The bottleneck is not the number of people with an MD. The bottleneck is the number of residency programs. These are funded by Medicare and I believe they are not profitable for hospitals.

There's some good reason to think that residencies are profitable: in 2019, 550 of them were auctioned off for $55 million in a controversial bankruptcy case.

https://www.inquirer.com/business/hahnemann-university-hospi...

So residences are basically taxi medallions. Interesting.

They are taxi medallions to newly graduated MDs but not to the hospital. Without a residency slot MDs often times are relegated to a lifetime of med school debt servicing.

It is not that the residencies themselves are profitable. It is that medical schools need to be able to provide residency slots to their students to have an effective program. Definitely an issue for newly formed for-profit medical schools.

I don't know how residencies could not be profitable for hospitals. Hospitals receive something like $120k/yr per resident, then work residents 80+ hours/week at $50k/yr pay, amounting to right around minimum wage (for my city). Residents do a tremendous amount of work in supporting the hospital, so much so that a single resident getting deathly ill and needing to stay home (e.g a surgery resident getting covid, which I witnessed) is enough to send a massive shock through a hospital and force other residents into 100+ hr/week schedules. I know this because my wife is a surgery resident and I'm describing a situation from this year.

Edit: But there are still way too few residency spots. I think it has to do with the difficulty and administrative work around starting a new program or with getting federal funding for more spots.

The residency slots are so limited right now because the AMA lobbied hard against expanding them in the 1990s (fearing a "glut" of doctors).

Edit: Every time this comes up I go down a rabbit hole of looking for an article from the mid-to-late 90s where a medical lobbyist spoke about how doctors would be forced to leave the profession and do "mundane" jobs like driving cabs if the residency slots weren't capped. It did not paint the lobby in a good light, and I've love to see it trotted out today. I never have been able to find the article online. If somebody with better search-engine-fu than me can find it I'd be greatful.

The AMA is actively lobbying for more residency slots.

https://www.ama-assn.org/press-center/press-releases/ama-fun...

They are now. They weren't back in the 90s.

Is it this one?

https://www.baltimoresun.com/news/bs-xpm-1997-03-01-19970600...

Or maybe this one?

https://www.nytimes.com/1986/06/14/us/ama-board-studies-ways...

I don't know how residencies could not be profitable for hospitals.

If it helps, think about it this way,

how does the malpractice work?

There are a lot of indirect costs around residents. For example, staffing mandates. Think what implications there are to regulations that say, for instance, no more than 4 patients for each RN on duty. That said, there are a lot of indirect funding sources too. The problem is, of course, sometimes the funding doesn't equal the costs depending on where you are.

And now we come to the rub. Which of the MDs are willing to do their residences in places where everything matches up nicely to support a lot of residents? Keeping in mind that those places may not be Sarasota, or Tampa, or Charlotte, but rather places in Alaska, a small desert city in New Mexico, or some small place on the tundra of North Dakota.

If you're asking, does the US government give enough funding? You can get an answer that's "Yes" if you consider nothing else.

Does that funding cover every regulatory cost of having a provider on staff? Not likely, depending on the rules in the state you're in.

Does that funding get to where MDs want to practice? Rarely at all does that happen.

I don't think it's about the profit it's the fact that anything involving Medicare is a big political fight

A helpful link on this subject. Apparently, medical schools in the US are now allowing more graduates. Not sure about profitability of residency programs, but certainly not all hospitals are teaching hospitals and the latter are federally subsidized.

https://www.aamc.org/news-insights/us-medical-school-enrollm...

This is correct and needs to be upvoted more. The number of residency slots is artificially capped and already fails to serve the number of medical school graduates in the country. The Balanced Budget Act of 1997 is the basic vehicle for this cap. In Dec 2020 the first expansion in decades was passed, adding a whopping 1000 residency spots.

Look up Graduate Medical Education program for more info. For more key words, see this document from the U of California system that has an agenda (increase capacity) but also effectively lists salient points: https://www.ucop.edu/federal-governmental-relations/_files/f...

Agreed.

Entrenched institutions are the general problem with America. It's the police unions protecting bad policing, the restricting of doctor supply via the residency bottleneck, and local governments preventing new building for burgeoning populations.

They're all the same problem really. Beneficial to the incumbent group at the expense of those they service. It's kind of amazing.

Institutional trust is certainly a huge problem right now.

> the restricting of doctor supply via the residency bottleneck

Assuming that you're referring to the AMA here, their role is pretty unclear to me. They appear to have played a lobbying role to get Congress to freeze residency funding in 1997 to avoid having lots of doctors [1], but for several years now, the AMA has at least publicly claimed that they've been lobbying congress to increase funding for residency slots [2]. Maybe they're lying? But I for one don't actually know who is keeping residency funding low.

[1] https://qz.com/1676207/the-us-is-on-the-verge-of-a-devastati...

[2] https://www.ama-assn.org/press-center/press-releases/ama-bui...

AMA is a bad actor. They refuse to allow junior doctors (doctors who are MD school graduates but who have not completed residency) to practice medicine in ANY capacity.

Common sense says that junior doctors should have the same practice rights as physician assistants - but the AMA refuses to let that happen. They are a medical cartel.

A few states have allowed junior doctors to start practicing medicine in a limited capacity, because every other doctor so damn expensive. But the AMA does not support those states' decision.

The AMA also argues against prescription rights for other health professionals like pharmacists (who often have much more in-depth education on drugs)

What do you have to do before you prescribe a drug? Make a diagnosis, which is what is taught in medical school and not in pharmacy school. Pharmacists are frequently embedded in care teams in hospitals and primary care clinics where they make medication recommendations and know how to get drugs approved by insurance companies (sad that this has to happen...).

It's totally possible to have one party diagnose and another prescribe.

you are correct, doctors should stay in their lane and diagnose and leave treatments to others

Does the AMA want that or is that the purview of state medical boards? AMA doesn't set practice laws. The people who lobby against new grad MDs having the same practice rights as NPs/PAs are NPs and PAs (more NPs). NPs lobby against assistant-physician laws because why would you want someone who has had 500 hours of clinical shadowing while completing their part-time online, direct-entry, 100% acceptance, diploma-mill school (NP) vs. a new-grad physician who's had 2 years of physiology, anatomy, and pharmacology and 2 years with 5000 clinical hours where there's actually an expectation that you contribute treatment plans and care to the team. The fact that the AMA has been asleep at the wheel and unable to stop NPs from getting independent practice in 20+ states show that they don't have any real influence on who practices where.

Is there any reason the slots can't be privately funded?

Like, could minting more doctors drive down costs for hospitals (that need doctors for services)?

I just realized Physician Assistants (PAs) and Nurse Practitioners (NPs) have been forgotten in this equation.

126,000 practicing PAs [0]

325,000 licensed NPs [1]

985,000 practicing physicians (MDs and DOs) [2]

I know that nurse practitioners are not under the same artificial residency constraints of MDs/DOs. I'm not sure about physician assistants.

For someone not in the U.S., NPs and PAs often do the same role as general practitioners/family doctors e.g. see patients, prescribe medicine, etc. They can also specialize.

[0] https://www.thepalife.com/physician-assistant-stats/

[1] https://www.aanp.org/about/all-about-nps/np-fact-sheet

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

PA/NA education is a complete joke compared to what your average MD gets.

They are not qualified to practice as general doctors at all.

However, they are really cheap, which is why corporations are pushing them so hard. Substandard care in the name of profits.

Wow I was about to gush about how much I LOVE my NP compared to my old crappy, braindead MDs. I could share stories of how bad MDs are...and the horrors of insurance.

She is sharp as a whip. Smarter and more motivated than ANY MD I've EVER had. Anything she doesn't know about, she researches (on her own time/dime). She prescribes everything - dirt cheap. Lets me text/call/email ANY time. Refers me to a specialist for anything beyond her expertise (just like any MD would!) DIRT CHEAP (eg: MRI for $300, scheduled within a day or two down the street). A single, cheap, monthly fee ($65/mo!) lets me see her any time day and night, ask anything, discuss as long as I like...and I do all these things! No MD going through standard insurance would allow anything even remotely similar.

...I could go on...

imo the NP model is FAR superior than the traditional insurance+MD crap model we have right now. It's one of those things "they" don't want people learning about since it'll crush the traditional way of doing things once people realize how amazing that model is.

Yes I have basic insurance since it's required. And, just in case - she obviously doesn't have an emergency room.

Your access to care is the result of the direct primary care model not your NP necessarily. Your NP might be good, but I'm willing to bet on average the people who have a minimum of 15,000 hours of clinical training (MDs/DOs) before independent practice are more competent than the ones who only are required to get 500.

More motivated? Why wasn't she more motivated to go to school for four years, get in-depth training in residency, and become an expert in her field rather than taking the easy "route" to practice "medicine"? I guarantee the IM docs and surgeons slugging it for 80+hour work weeks in residency to become experts are more dedicated and motivated to care for patients than the NPs who train part-time and online.

If only we could have stopped doctor salary inflation instead, like other developed countries :)

Cheaper salary and they order more unnecessary tests, imaging, and consults, which, what do you know, the hospital system also makes money off of. It's a win-win for the hospital, but patients and the healthcare system lose.

> They are not qualified to practice as general doctors at all.

The way we train MDs is... highly counter-productive to say the least. First a completely unrelated undergrad, which really adds no value (hint: Foreign doctors can do a fellowship and get licensed to practice in the US without having an unrelated undergrad degree pre med-school). Then med school, which is completely detached from any clinical experience. Then residency, where practical knowledge is theoretically built but in practice is more of a legally sanctioned hazing (patient outcome doesn't really matter, what matters the most is impressing whoever is slightly higher on the pecking order in order to get the spot you want).

Multiple years of zero sum games and competition against your peers. Then, once you get your license, you are supposed to make a complete 180 and start becoming a team player.

To be completely honest, if you add up the useful time spent in school, an MD is just about on the same footing as a PA/NA.

> For example, the US has extremely high standards restricting who can practice medicine compared to the rest of world, limiting the supply of doctors...

Really? Can you give some examples? There are a lot of immigrant physicians in the USA.

An anecdotal counter example: my mother is a physician with medical licenses from Australia, UK and the USA (obviously two have lapsed) and though she is quite critical of countries X and Y and positive about country Z she has never expressed any such opinion or said that one might be tougher than another, which is exactly the kind of thing she would point out.

all those immigrant physicians went thru the same programs as the non-immigrants.

In fact, I hear this is continuously a problem for well qualified , practicing, and established physicians to migrate to the US. They are fed up with their own home countries lack of security, opportunities for their children, freedom etc, but they cannot imagine going back to medical school to be accredited to practice in the US.

This does not apply to every country. Notably, 4, all here:

https://www.theabfm.org/become-certified/i-am-certified-coun...

While many foreign physicians will have years of experiences diagnosing, treating patients, and administering medicine, in order to practice as a US doctor, it essentially requires them to start all over again academically, especially when the curriculum differs from overseas qualifications. [1] https://www.fnu.edu/foreign-physicians-work-healthcare-pract...

No, they most certainly did not. I've spent a large chunk of my career in healthcare technology, and one thing I can say for sure is that with very few exceptions, foreign doctors are no where close to the knowledge and capability of those educated in the US.

I'm not going to specify to avoid slamming particular countries, but I would definitely refuse to be treated by doctors from several major countries that crank out tons of doctors, many of whom worm their way into US practice. (This isn't based on race, etc, at all just competency, and I have a much larger exposure to this than most people. These people kill way too many patients with their incompetence, but (especially lately) they cannot be criticized for fear of being branded racist. My body, my choice.)

I disagree.

I've spent my own career in healthtech and at actual clinics.

While I won't dispute the fact that medical care abroad can be hit or miss, we are certainly not strangers to substandard doctors ourselves.

The difference between your experience and reality, is that the bad US doctors get put in corners where you have not been looking.

You should read marty makary's book unaccountable.

So, while your heuristic may be valid for someone living in a large metro area with tons of options, I would make a safe bet that it wouldn't be as useful in rural, underserved areas where the bad doctors end up.

> one thing I can say for sure is that with very few exceptions, foreign doctors

The word ‘foreign’ is doing a lot of work here. It encompasses nearly everywhere, and likely includes the best and worst training systems in the world.

>Likewise, manufacturers of medical supplies operate as monopolies because the moat to reach approval is really high.

I can tell you for a fact this simply isn't true. The reason manufacturers of medical supplies operate as a monopoly is because they have turned to acquiring everyone and anyone in the medical supply/device business and there's been 0 opposition to it.

https://www.beckersspine.com/orthopedic-a-spine-device-a-imp...

https://mergr.com/abbott-laboratories-acquisitions#cma-tab

https://www.greenlight.guru/blog/top-100-medical-device-comp...

You can go through the last link which is a list of device manufacturers and look at their acquisitions. They just eat up every small player that shows even a hint of providing competition. Some of them have been averaging an acquisition a month for years.

You just conflated two partners in the whole mix of what we call "healthcare" in the US.

Payers = Medicare for All, UNH, Aetna, etc.

Providers = Hospitals, doctors, medical supplies, etc.

It's entirely possible to have one payer and then having a governing body regulate a free market[0] comprised of providers in the market.

[0] - I'm using the word free market not in its purest form (which rarely exists) but rather in a more colloquially way.

> limiting the supply of doctors

Possibly, but the cost of doctors (+nurses, technicians, etc) is in the noise, just a distraction. The vast majority of the cost of medical care in the US goes to the middlemen who contribute no value at all, just extract profit.

A 15 minute session with a general practicioner here (CA) costs around $300. That doctor isn't making $1200/hr ($2.5M/yr).

That doctor is likely only making a bit over 200K: https://www.salary.com/research/salary/benchmark/family-phys...

The other $2M+ are going hangers-on who're not contributing to health care, just inserting themselves into the chain to get rich. Take a look at the billions in revenue collectively by all insurance companies. That's all a tax on health care that provides no value.

Huh? You'd need to look at billions in profit, not revenue, since insurance does pay out for the cost of care. When you look at that, the margin is actually lower than most industries. It is true that there are a lot of middlemen with hands in the pot but it's not quite that simple.

The biggest driver of healthcare is that Americans just consume a lot of it. We get surgeries, we opt for long, expensive treatments at the end of our lives, we use extremely sophisticated and expensive medical equipment a lot, we pay people to take care of our old people exorbitant sums of money.

Like, in other countries, when your lungs and kidneys start going, you don't go to the hospital for a multiple surgery. When you fall and you can't move around and wipe your own ass, you don't get moved into a facility where people are paid to take care of you, you move in with your family. And, if you don't have those options, you die.

I'm with you that the system is fucked but the underlying reason doesn't _really_ have anything to do with greed in medicine and everything to do with the way that we treat medicine culturally: the duty that children (don't, in this country) have to care for their elders, the attitude we have about prolonging death. That every part of the medical system says: we will never, ever make the decision to let someone pass away, even when "fixing" their problem (of death!) with all the technology and labor we've got turns out to be ludicrously expensive.

> profit, not revenue

No, because profit is substracting all the operating costs of the insurance company, including salaries of hundreds of thousands of paper pushers and multi-million dollar bonuses to their executives. All of this is just overhead that provides no health-care value and can be eliminated.

It's not that the standards are high, it's that they are protectionist. I think one of the biggest hurdles is the US residency requirements.

Everything you say is true, though.

The United State's healthcare don't even appear in any "Top-10 global healthcare" rankings available anywhere, and are consistently overshadowed by many European countries, Singapore, Australia, Japan etc. I don't think you can use "extremely high standards restricting who can practice medicine" as reasoning when it doesn't appear to impact the quality of care at all.

They state early in the article that this research details how to tackle those three issues without resorting to Medicare for All.

If we do medicare for all or some other kind of universal healthcare in the US we're also going to need to train doctors way more cheaply than we do now. At the least we're going to need to offer free or heavily subsidized education to incentivize more people to go into medicine without graduating with debt higher than many mortgages.

The supply of doctors in a lot of primary care roles is supplemented by Nurse Practitioners and Physicians Assistants who have less restricted licensing bodies. Like NPs and PAs aren't required to go thru residency and can switch specialties more easily than a doctor.

The bottleneck is the cost of medical school. That cost is linked to the colleges raising prices because they can.

Medicare for All will surely help this, but free college will help as well.

The U.S. is like a dysfunctional family where the parents will not pay for the kids college even though they have the money.

The cost of medical school is not a bottleneck. Lower prices would be nice, but even with current high prices all accredited medical schools have essentially full enrollment.

The real bottleneck is in lack of federal funding for residency programs. Every year students graduate from medical school with an MD but are unable to practice medicine because they don't get matched to a residency slot.

Demand is also "artificially" driven up by the American diet and lifestyle.

If the preventables (e.g., Type 2 Diabetes) were prevented, otherwise mitigated (less sugar!) then the resources / system could focus on real disease.

The issue with the USA is it wants its cake, it wants to eat it, and expects to pay less for consistently making unhealthy choices.

Sure but most other countries are on track to have the same diet and lifestyle health problems as the USA. They're running a few years behind us but they'll catch up eventually.

Germany doesn't.

I can think of plenty other European countries.

Germany has a high rate of obesity just like most comparable countries.

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