Health care is turning into a consumer product
economist.com
economist.com
Another point is that US healthcare is considered the most expensive and worst-performing in terms of outcomes compared to the other developed countries.
So you basically get the worst performing being also the most expensive. Which doesn't really fit the view that less government involvement results in a more efficient system. Well, I guess it is more efficient if the expected outcome is a larger profit for different private companies and middlemen and not the well-being of the rest of the population.
My hope is that this new-found energy in healthcare products doesn't follow the traditional VC-backed approach of building a product, taking over markets through aggressive marketing and shady closed-door dealings and operating at a loss only to then monetize the shit out of everything.
Theranos really embodied some of these fears, and I'm not sure we'll live in a better world if our health will be in the hands of people that have a financial incentive to tell us we're more sick/healthy than we really are.
Not that your thesis isn't correct but be careful there. You're combining the cost of care for the people who get care with an average outcome that includes people who don't get care. The quality of care for Americans who can afford care is excellent.
Well that's the point, I think everybody should be taken into account in order to paint a comprehensive picture of the quality of the system at country level. The resulting stats reflect the health of a society as a whole not just of the part that can afford it. Not having universal healthcare is still part of the system, even if we don't like it.
I get it that health outcomes of those left out are probably very different. But leaving those numbers out of the comparison doesn't really work with these type of statistics.
At that point how could you compare it to the other countries that take everyone into consideration? The stats are GDP/capita percentages, should I remove the ones who can't afford healthcare from the GDP stats as well to not skew the ratio? I don't really like where I might end up taking this route.
I don't have any experience with US healthcare and I'm sure the quality of the services is really high, but the fact that you need to afford basic healthcare and it's not guaranteed by the government for everyone makes me see it as closer to just another "consumer product" compared to other systems.
There is a sad trend where the small doctors -- who can't survive without group power -- join conglomerates, the conglomerates buy hospitals, and finally the conglomerates close the less performant facilities. You get large states with vast underserved geographies.
The OP headline is we are careening towards a luxury retail arrangement like Trader Joes: they will only have "outlets" in the richest areas. There's no regulation around closing hospitals so this is coming fast. Two in my county closed this year and I am far from rural.
You can't just say you can't close this hospital, you have to find a way to pay the bills on it.
As a Canadian who knows many Americans, works for a US company and has extended US family, this is not quite true.
Most Americans "who can afford care", maximum 70%, have access to medical care that is on par with Canadian health care, but is fraught with peril; "booby traps" such as out of network costs, high co-pay fees that can bankrupt, surprise billing (though 2022 is starting to deal with that). Care may be excellent, but losing your house if you get cancer seems unnecessary.
A few percent of Americans (the rich and the very well insured; FANNG/MAMAA, investment bank employees, etc.) have access to the possibly best health care in the world.
20% of Americans are uninsured or under-insured and have access to the worst healthcare in the G20.
I think it's strange to want to only include the first two categories in the outcome calculation. Strange may not be the right word here ...
The US healthcare is an example of the government being massively over-involved and creating massive inefficiencies.
The NHS (despite fairly extreme under-funding) has better health outcomes for patients than in the US.
“Better outcomes” needs more detail:
Medical bankruptcies per year: ~200k in US, ~0 in UK. Caveat: bankruptcies often don’t have one clear root cause, the other ~600k bankruptcies per year in the US may or may not have an aspect of healthcare costs.
Cost of triple bypass heart surgery: US: $110,000, UK: £8,500 (paid by the taxpayer, not by the patient at the point of care - free for them). (P.s. private healthcare is available in the UK too - the procedure costs around £20,000 privately, payable by the patient or their insurance)
Life expectancy… you get the idea.
The American system’s problem is exclusion, not quality of care. If you get care in America, your outcomes are among the best in the world.
"American healthcare is the best in the world like sportscars- Ferrari, Lamborghini, BMW, Bugatti, etc. are the best cars in the world. Surely they both are the bests in the world- but only for the small percentage of people that can actually afford them."
This is sad.
(Many, including me, wouldn't buy a sportscar even if they could afford one, and sportscars aren't the "best" in their opinion. But this comparison drives the point home.)
Regardless of that, high quality care isn't much good if you can't access it.
The incentives for insurance are to ensure that I don't quit, not that it is good healthcare or a good deal.
> I don't get to choose my insurance, the government has ensured that instead my company does for me.
I didn't look into details of the insurance market plans, but there were 40 different plans available there for me to choose from (as opposed to the 2 my companies gives me). I suspect that something similar to my work plan is more expensive than the one I listed above. I also suspect that if I was to look at all 40 plans I would choose something that wasn't not similar to the choices I have now. However with the amount of money I'd lose it isn't worth my time to examine my options.
years later that transitioned to comprehensive benefits packages
How does the government ensure that?
It really isn't underfunded. It's grossly inefficient, which is what happens to most if not all publicly funded bodies. It is actually ok to criticise the NHS organization.
They're a monopsony, so actually get absolutely gouged by the pharmaceutical companies. They (currently?) refused to recycle crutches, plastic casts and so on. They'll use their own (hospital pharmacy) drugs if you get admitted, and then discharge you with them, even if you have your own dosette box and refuse to take theirs back. My father was discharged with something in the region of £3-5000 pounds of drugs that we threw away on several occasions.
As a percentage of GDP, it's roughly the same as most other western countries.
Of most interest though is figure 3 in [2] - 80% of UK (NHS) funding came from public money, i.e. tax, and 20% from private money (e.g. insurance). For the US, it's 50% public money (tax), and 50% private money. I'm not sure how much more money the UK general public really thinks the UK government can come up with to keep giving the NHS "more!" money. There's a limit to how much people can be taxed. And compound interest (increase the NHS by 10% per annum!!) means we'd spend all our GDP on the NHS at some point rather quickly.
[1] https://www.statista.com/statistics/317708/healthcare-expend...
[2] https://www.ons.gov.uk/peoplepopulationandcommunity/healthan...
You've got that exactly back to front. NHS's immense buying power lets them negotiate lower prices for drugs, exactly as medicare used to (before pharma lobbying stripped them of that power).
Pretty much any trade deal negotiations with the US involve the UK being asked to dial down NHS buying power on behalf of pharmas by making hospitals responsible for purchasing.
>As a percentage of GDP, it's roughly the same as most other western countries.
50% of the US - not because the UK is especially efficient but because the US healthcare is essentially legalized extortion.
>I'm not sure how much more money the UK general public really thinks the UK government can come up with to keep giving the NHS "more!" money. There's a limit to how much people can be taxed.
The UK public adores the NHS and is one of the few things polls say that people would be happy to fund with tax raises. It's very very popular. In no small part because we can see how much of a racket the US is.
The ruling party does not like it, however, which is why it has been slowly degrading service over time as preparation for full privatization in 10-15 years. Part of this has been done by handing over chunks of the NHS to be run privately and incompetently by friends and donors of the party. The problems caused by this backdoor privatization will later be "fixed" with privatization. Whatever the problem, privatization will forever be the answer.
The tories argued for an American style healthcare system in 1948 and while they give tacit acknowledgement of the popularity of the NHS their views havent changed (Christopher Chope is a good bellwether of their more unsightly "hidden" views), they still want a US style system.
In principle, you're correct. In practice the fact that they're the only buyer, means in many cases that they pay at whatever a drugs company sells at since there's no "but company X is only paying Y, why are you charging us Z" as a comparison, particularly in the case of non-generics.
> The UK public adores the NHS and is one of the few things polls say that people would be happy to fund with tax raises.
And that was exactly my point. The UK public might "adore" the NHS, but they have a pretty poor understanding of how it is funded. If the government kept funding the NHS by an extra X percent every year, we run out of public funds.
> The ruling party does not like it, however, which is why it has been slowly degrading service over time as preparation for full privatization in 10-15 years.
The ruling party, being the Tories, that have been "in charge" of the NHS for the majority of its 70 or so years? And who on earth would buy a loss making healthcare system that's funded to the tune of a billion or so a week? Apple?
Lets say the uk gov allocated 10x to the nhs in the next budget - to be clear, this would put just nhs spending at more than total govt income for the year. If this were a company we’re talking about, they’d be insolvent.
But we’re talking about a govt with a sovereign currency. So what would happen in this scenario? It doesn’t go bankrupt…
How is money created? What is fractional reserve lending? How is money destroyed? Can a country issue a fiat currency without an associated public debt? Or to put that last bit another way - could you settle your tax bill in GBP if there was £0 public debt?
That leaves tax or private money to fund the NHS, and we can't tax people much more. So in your comment "how is the money created?" Answer, tax, and there's a maximum limit to how much we can fund the NHS.
Yeah it does. The UK govt has had 6 different sets of rules in only the past 10 years.
The current rules followed by Rishi Sunak are actively opposed to what you say - he’s been celebrating beating borrowing forecasts of the OBR by £26bn, and he makes a big song and dance any time he can stating excessive public borrowing is immoral. He found the magic money tree instead…
The scope of quantitative easing has increased massively since it was introduced. On top of this, the bank of england does not publish a report on which govt bonds have matured - but we know some have already without having been sold.
So, the govt borrowed from the govt (bank of england bought out uk govt bonds held by non govt entities) then held them to maturity (so the govt paid the govt back), while remitting the coupon payments back to the govt. All while we can’t see inside the machine - none of this is available via public reporting.
It’s not quite “printing money” but it definitely qualifies as a magic money tree.
It’s how govt’s corona responses are paid for today and it’s the reason NHS funding is constrained not by tax receipts but by policy, political decision.
It sounds like you are disputing empirical evidence as well as standard economic theory regarding monopsonies.
>The UK public might "adore" the NHS, but they have a pretty poor understanding of how it is funded.
Not really. It's mostly funded with taxation.
They are not so aware of the corruption going on underneath with taxpayer money.
>If the government kept funding the NHS by an extra X percent
"X" percent? Is this a serious point? That "X" is demanded by the public and X is also too costly? Where "X" is undefined?
What is even the point of that sentence?
>The ruling party, being the Tories, that have been "in charge" of the NHS for the majority of its 70 or so years?
A) If it is a majority of years it's a fairly slim majority and B) they werent there when it was set up.
>And who on earth would buy a loss making healthcare system
Somebody who knew that they could start charging either customers or government through the nose and make it fantastically profitable.
Richard Branson is one example (Virgin Healthcare sucked £2 billion out of NHS coffers, yay for crony capitalism).
When there are multiple sellers of generic drugs, you're correct. When there is one seller of a non-generic, life saving drug with no alternative, the NHS is going to pay whatever the one seller, which by definition is a monopoly, is going to charge. [1]
> What is even the point of that sentence?
That we cannot keep increasing NHS funding exponentially. Some people seem to find that fact hard to grasp - there's an upper limit. Another commenter talks about the UK raising debt to fund the NHS. Thank goodness there's a set of rules for government borrowing in the capital markets.
> A) If it is a majority of years it's a fairly slim majority and B) they werent there when it was set up.
Both parties campaigned for the NHS in the 1940s. Labour won. Blair, in power for over a decade promised to "fix the NHS" whatever that meant, but he didn't do it. Thatcher/Cameron/Johnson, all in charge for 2 decades or so, still haven't "sold it off".
> Somebody who knew that they could start charging either customers or government through the nose and make it fantastically profitable.
Except it will never happen. The government would not introduce a commensurate tax cut since they're no longer funding the NHS, so your cost of living would go up, and even in the UK, I think people would get rather upset.
> Branson is one example (Virgin Healthcare sucked £2 billion out of NHS coffers, yay for crony capitalism).
Did he really? Evidence? 2 billion of private money paid by companies into Virgin Healthcare, sure. But did he take £2bn from the NHS?
> They are not so aware of the corruption going on underneath with taxpayer money.
What corruption? Surely the police should be involved if there's true corruption?
I won't defend the NHS. I'll defend the staff that treated my father, but the organization itself needs fixing.
This is incorrect. If the price is too high they refuse, depriving the company of all income. This has been done for certain cancer drugs.
Even if they dont refuse their pricing power lets them beat down prices.
>That we cannot keep increasing NHS funding exponentially
It's barely even increasing in line with inflation.
>Some people seem to find that fact hard
They really dont.
>Both parties campaigned for the NHS in the 1940s.
This is provably false. The tories wanted an insurance based system rather than the system we have modeled on the soviet union.
I think Im gonna leave this discussion here. We clearly dont live in the same plane of reality.
I think it’s more nuanced than that. There’s inefficiencies for sure but we need perspective to assess them against.
E.g. A triple heart bypass, the most common major heart surgery in the world, costs:
Approx 110k USD in the US system
Approx 50k EUR (56k USD) in Germany
And just under 9k GBP (12k USD) in the UK
>> I'm not sure how much more money the UK general public really thinks the UK government can come up with to keep giving the NHS "more!" money
Can you clarify what you mean by “come up with” in the context of the GBP which is a fiat currency?
Relevant: Private Eye on "24 Hours to Save the NHS": (<https://twitter.com/KulganofCrydee/status/833654730849136641>)
Not bankruptcy statics, or costs
What is the 5 year survival rate for someone who cannot afford cancer care?
The question of affordability is different from the question of quality care, we can solve the affordability problem with out having to lower the over all standard of care which is what you are advocating for, the bringing down of the overall quality of care in an attempt to increase accessibility of care. Ironically putting that faith in the US Federal Government will only result in 1 of those happening.
What exactly is disingenuous about wanting more people to live longer with higher “quality of life” for less overall spend on healthcare? You can’t achieve this without resolving the affordability issues.
>> which is what you are advocating for, the bringing down of the overall quality of care
With all due respect, you’ve made that up to fit with your world view. It’s certainly not something i’ve advocated for.
Those triple heart bypass operations i started the thread with - the 10x more expensive US procedure results in 3 year shorter life expectency post operation.
It costs more, and it’s not as good a result?
(I am being slightly disingenuous at this point - the reason the US outcomes are poorer despite being 10x more expensive for the same operation are due to differences in the health of the average patient - in the UK because healthcare is free at the point of access, there tend to be earlier interventions, in the US there is a marked difference in severity of presentation - ostensibly people wait longer until they’re really unwell before accessing healthcare)
The figures i can find ignore people who can’t afford to become cancer patients in the US - there’s an unknown, but suspected large, number of people cut out of the figures in the US making that stat unfairly stacked vs UK (where everyone regardless of affordability gets access). The people who can’t afford in the US are typicslly the ones more pre-disposed to adverse outcomes in that statistic.
American healthcare has the least involved government of any first world country.
Only an overly credulous interpretation of Koch-style market-knows-best propaganda would make you think that the "level" of government involvement was the root cause of its problems.
> Only an overly credulous interpretation of Koch-style market-knows-best propaganda would make you think that the "level" of government involvement was the root cause of its problems.
Not an appropriate tone for HN discussion.
The point I was trying to make is that government involvement is needed to make sure that the right incentives are in place at all times for all involved actors (public or private). And if the system becomes dysfunctional or is abused it's the government's job to fix it.
Most of the countries that have universal healthcare in Europe have their own take on how it should be done: - France has state funded insurance and (mostly) state funded services - Switzerland private insurance and private/public services
Two totally different takes with arguably very similar (good) results.
The goal of government involvement should be to make sure everyone has access to basic healthcare and avoid double standards and abuse.
Note that many of the European systems are semi-private, so you retain choice of providers. It doesn't need to be a full state-run system, which is vulnerable to undercapacity (which the UK is currently suffering from).
There's also an informational problem; in a fully free speech environment it's much easier to sell people unreliable cures, Theranos passim.
Using insurance, government or some other centralizing layer (e.g. the church) for routine activity would raise massive "you're pissing money away" red flags in literally any other context. We shoehorn so much economic activity (healthcare) though a middle man (insurers) and then act surprised that they take a fat cut. The solution isn't to government-ize the middle man. That will almost certainly just be a wash. It's to get rid of the middle man where possible.
There's no reason someone shouldn't be able to get a physical or a colonoscopy the same way cosmetic surgery and dental care are done. These are cookie cutter outpatient services. The deviation from instance to instance is small and predictable so insurance should not be needed on the consumer side.
Edit: Anyone wanna do me the courtesy of explaining why I'm so wrong?
> Edit: Anyone wanna do me the courtesy of explaining why I'm so wrong?
Market is a fine fit for every healthcare need that doesn't start with a trip to the ER which is the overwhelming majority of healthcare dispensed in the US.
https://www.healthcare.gov/coverage/preventive-care-benefits...
These are the cases where insurance is a perfect fit. The issue with letting it be market-based insurance is that (as you say) it allows insurance providers to take a fat cut. The obvious solution is to regulate insurance costs. At which point you might as well state fund it. Which leads us to the system we have in most of Europe.
As these system seem to work quite well, why do you think a market-based approach would be better?
But as you observe yourself, that's not the majority of healthcare, which is emergencies and unforseeable needs. Hence there has to be an insurer of some kind.
> There's no reason someone shouldn't be able to get a physical or a colonoscopy the same way cosmetic surgery and dental care are done. These are cookie cutter outpatient services. The deviation from instance to instance is small and predictable so insurance should not be needed on the consumer side.
Sure, whatever, the small part of the healthcare market that actually functions like a market - consumer choice, legible prices - can be left to get on with it. Let's not let that get in the way of a functioning provision of necessary care to the majority of people.
> Market is a fine fit for every healthcare need that doesn't start with a trip to the ER which is the overwhelming majority of healthcare dispensed in the US.
I think most people are interpreting this as “market is a fine fit for every healthcare need [except for those that start in the ER] which is the overwhelming majority...”
I.e. that you’re advocating the market for the majority of healthcare rather than the majority.
I think your actual recommendation is the opposite. Maybe this would be clearer if you just laid it out like, “Most healthcare is non emergency, cost is a primary concern which insurance makes worse, markets are good at solving cost issues.”
Responding to your actual argument, however, I see many people claim that insurance companies are taking a “fat cut”, but I see very little evidence of higher than expected ROI/ROE in Aetna / United / etc. (ref: United’s net margin is ~5%, ~15B in net income on 300B of revenue). ROE is ~20% which doesn’t seem ridiculous for an insurance business.
The bigger problem seems to be personnel spending in healthcare (admin, support staff, billing), and generally a systemic culture that’s not even knowledgeable about what prices they charge, let alone price conscious in the services they deliver.
I think the issue with healthcare insurance companies in the US is that they collude with the hospitals to artificially inflate the cost of things so that their 20% is 20% of 10x the actual value of the treatment.
That's more because we've had decades of deliberate underfunding due to the "austerity"/"capitalism++" lunatics in charge than a natural consequence of a state-run system though.
Note that I'm not saying that people are not/ cannot be generous, selfless etc. I'm saying that relying on them being so is a crappy strategy. You need a system that continues to work in the presence of greedy people.
Amazing what a little competition can do. The city was smart enough when the competitor moved in to install the capacity for more ISPs to utilize the existing conduits in the future.
One area where markets do poorly are where the cost of service exceeds profit, like rural areas. This is an area where government intervention in the form of subsidies can help, but these can also cement single ISP marketplaces if not managed well.
Along with healthcare
People don't seem to have issues getting electricity service or telephone service in those regions. In this case, the special treatment of those services means that people don't get left out
Rich people aren't the only ones who deserve healthcare or good internet
In the real world what will happen is the malbehaving dominant party will capture the market by any means available to them. In thoroughly corrupt countries they will bribe legislators, in less corrupt countries they donate to the legislators' election campaigns.
Instead I'm forced to reluctantly support single payer healthcare, despite it being a huge corporate giveaway. It's really saying something when "have the government take it over" is the clearest path to restoring a more functional market.
Hospitals now are required to make pricing transparent and surprise bills (out of network charges) are now prohibited, both are recent reforms.
As far as I am aware, you're still unable to get straightforward answers for questions like "how much will this procedure cost?". Furthermore, this "transparent pricing" revolves around publishing a fake list of inflated prices that nobody actually pays and so is effectively useless.
Meanwhile in every other industry you either get a flat fee ($30 for an oil change), or at the very least an estimate and a contract that fixes the rate (the shop rate is $80/hour, we think this will take 2 hours). Materials are often overcharged (eg $140 for a part that is easily available for $100, because it's delivered from a special supplier) but still within a workable bound, unlike say fraudulent aspirin.
This is a straightforward reform - the reason healthcare doesn't operate like this is they bought laws creating the ability to charge you without needing to establish a contract.
But in the medium term, the NHS was doing pretty well until Austerity became the dominant U.K. policy:
https://fullfact.org/election-2019/ask-fullfact-nhs-waiting-...
https://ifs.org.uk/publications/15557
(That said, I don’t have longer graphs to hand, and I am slightly concerned by the convenient start date on the graph in the second link).
But… it works.
The NHS is cheaper, but — and here I wander dangerously into opinion — I suspect that’s short-term benefits with long-term problems which will bite the U.K. in the backside rather than better overall cost-benefit decisions.
In the case of the NHS, my understanding is that neoliberal politicians have been pushing to privatize it, and have underfunded it to make it look like it's not working in order to make privatization more appealing. The same is true for many programs in the US too.
- individual freedom will be suppressed (because "public good"; can't have greedy people doing greedy things, them weeds need to be killed early).
- since individual freedom is suppressed the regime is naturally going to be autocratic, which means that "the state" is actually a handful of people... who now get to freely decide how they define "public good".
The fundamental error of communism is that in any implementation, it doesn't really have mechanisms to "punish" greedy leadership, only greedy individual citizens. Which is an idea as good as it sounds.
Cuba is the best example of a successful communist-ish state. Most if its struggles are due to sanctions imposed by the US and enforced via its allies across the world.
"if the entire world is a sh*thole, nobody will be able to tell it's due to communism"?
I fail to see what "needed technological developments" would West Germany give them.
> Cuba is the best example of a successful communist-ish state
Successful as in "not completely failed, unlike all the others". Look, I sympathize with their struggles being so close to the US & all, but the fact that this is the best-case for you have should give you a bit of pause, because Cuba is by no means close to being a paradise.
To put things in context, both the largest & most populated countries in the world used to be communist. They both had to abandon it & switched to a form of crony capitalism, which, as bad as it is, seems to actually work better for them than the alternative.
Institutions like healthcare, education, public transport, prisons(!) and so on are more efficient, less corrupt and of higher quality when they are in large parts collectively and democratically organized and funded. The "in large parts" is important here: A community should agree on what that means and let the market play out on the edges, or the bureaucratic costs become too heavy _and_ unfair. Decentralization is key here.
But that never actually happened. Externalities were never part of the market.
Emergency services aren't a good fit for markets. For markets to work, people really need the luxury to shop around with some leisure.
Wasn't there some Roman oligarch that ran a private fire department, and basically just used it to extort property owners when they had a fire? Truly market based emergency medical care without legal restrictions would likely frequently resemble that with some frequency.
Edit: Yep: https://en.wikipedia.org/wiki/History_of_firefighting#Rome
> The first ever Roman fire brigade was created by Marcus Licinius Crassus. He took advantage of the fact that Rome had no fire department, by creating his own brigade—500 men strong—which rushed to burning buildings at the first cry of alarm. Upon arriving at the scene, however, the firefighters did nothing while Crassus offered to buy the burning building from the distressed property owner, at a miserable price. If the owner agreed to sell the property, his men would put out the fire, if the owner refused, then they would simply let the structure burn to the ground.
And that's the open market; it gets even more cloudy when we talk about employers being involved, so we have an agency problem as well.
It's a system unlike any other, and I don't think general theories really apply very well as such.
Hospitals increase rates to cover the overhead of dealing with hostile insurance companies. Insurance companies raise rates to match increased hospital billing. Ironically both industries are incentivized to raise rates on customers while trying to gouge each other.
Is it any wonder healthcare is a scam?
> But that never actually happened. Externalities were never part of the market.
But isn't the essence of an externality that it's a social cost not factored into the market price?
It may be that some of these cannot in principle be accounted for, and even more which cannot in practice be accounted for.
But I imagine the majority of externalities could be accounted for if we tried.
The irony is if you actually came close to achieving that (e.g. accounting for all externalities in the market price), you'd have something like central planning. That's why externalities are usually managed through other mechanisms.
Also, externalities are only one kind of market failure.
Edit: updated 1960s to 1950s per info in replies
Roosevelt also tried to institute a national scheme in the 30s but labor unions were split on notional vs. employer provided and it became a wedge issue that scuttled the plan. Truman's push for that same national health insurance plan was shot down in ~1949, partially killed by AMA lobbying.
Heaven forbid “wage inflation!”
Was the AFL pushing for employer-based and the CIO pushing for national? I don’t even know where to find history like this. It’s virtually impossible for an average person to learn about the history of the American labor movement.
I realized after double checking that it was actually a 1942 Roosevelt bill, and they were trying to figure out how to keep a lid on rising prices during the war. It's also not uniformly good if prices also rise quickly. Inflationary spirals are real, and very bad for regular people.
> Was the AFL pushing for employer-based and the CIO pushing for national?
I'd have to double check.
> It’s virtually impossible for an average person to learn about the history of the American labor movement.
A bunch of this stuff is available in more popular history and online now. "The Devil Is Here in These Hills" is supposed to be good, but I haven't read it.
Employers can raise wages, and have been able to for some time, so that's not why we still have it.
We still have it because of tax and other incentives, and because government keeps making policy decisions to protect, and even extend it (e.g., the ACA employer mandate), not because of the employers need to offer health benefits to compete because they can't offer more wages because of WWII-era wage controls.
The fear of losing healthcare coverage a severe fear that people in other countries don’t have to worry about.
I've never received significant health care in another country, so I can't say how the US system differs from others with any expertise. But I can say how US health care differs from just about anything else I spend money on:
1. I don't really get to shop for health insurance providers. My employer picks one, maybe two plans, and I can take it or leave it. If I leave it, I am leaving at least $10,000/year on the table, so I generally take it.
2. Even when I am on the market, the phenomenon in #1 does weird things. Once upon a time, when I was choosing my own health insurance, I started a new job with health insurance benefits that I did choose to take. But my start date was toward the beginning of the month, my old insurance wouldn't let me do a partial month, and the new employer wouldn't let me delay opting for coverage. So I was essentially forced to own two health insurance plans simultaneously for a period of time.
3. Nobody knows what care will cost ahead of time, which makes it impossible for me to make any informed economic decisions. I need to see a physical therapist. I called a few places to shop for prices. They all know what the rate for uninsured people is, but the only way we can find out what it will cost with my insurance is if I receive care, they submit a claim, and then we all find out together what the price was, after the fact.
4. #3 creates a situation where they can hide all sorts of excessive charges. When my first child was born, I got lessons on how to give him a bath and change his diaper. Both of which I already knew; I was really just going along with the lessons to be polite. I certainly wouldn't have said yes if the hospital had been transparent and up-front about the price tag on this lesson: about $2,000.
5. And sure, insurance covered most of it... but that didn't make it free; it just means the price was amortized over a large number of health insurance premiums. Unfortunately, I think that this setup makes it all too easy for us to think of these things as free, which, in turn, reduces public scrutiny over where the money comes from or where it goes.
And it just keeps going like that. Compare with signing up for cell phone service. It's a famously sleazy business, but, even with all the hidden fees they like to tack on, at least they're up-front about the basic price of service. With US health care, every fee is a hidden fee. That makes it impossible for consumers to make free, informed decisions, which is the most fundamental precondition that must be satisfied in order for a capitalist market to form.
First we received a bill for the stay in the hospital. And then we received a bill for the doctor performing the delivery. Okay, fine, it makes some amount of sense, that doctor supports multiple hospitals and isn't technically part of the hospital and staff at that maternity ward that is there 100% of the time.
And then the separate bill for lab work, and another for the pediatrician, and another for our baby's stay in the hospital (this one really got me, why?! we were all in the same room), and then another for the lactation consultant, and, and, and...
I don't remember each one specifically at this point, but I believe it was 7 separate bills.
Edit: typos
There are probably ways that we could combine aspects of greater and lesser privatization to achieve the best of both worlds. I have some thoughts that I've been mulling around for a while:
1. Expand the government to achieve universal healthcare coverage.
-- a. ACA public option.
-- b. A conservative UBI, with the twist that uninsured individuals would be automatically enrolled in the public option and have their premiums taken out of their UBI. (Tangentially, for similar reasons, also pay out a portion of each UBI disbursement in the form of food stamps rather than cash.)
2. Shrink the government and quasi-public entities (insurance providers) to unshackle the invisible hand.
-- a. New regulation to ban copays and set a mandatory floor on deductibles (say, $10k). While major emergencies still need to be covered, and while there still needs to be an entity in between the patient and provider eating the risk of non-payment, it's also desirable from an efficiency perspective for patients to be kept aware of the costs of their care — and therefore incentivized to select more cost-efficient options. The market would then naturally find a more reasonable equilibrium without the need for price fixing, in theory.
-- b. Set up a system of tax deductions and credits for out-of-pocket medical costs. (Preferably such that the poorest would have their costs fully covered in most or all cases, depending on what's fiscally realistic.) This must strike a balance between non-disruption of market forces and ensuring that the poorest in society aren't shy about seeking the care they need. My thinking is that the annual nature of tax filings would be enough to address the former, as patients would still be be out of pocket for up to a year waiting on their refunds, representing an opportunity cost that would be difficult to ignore. To address the latter point, set up a standardized/regulated process for the insurer to send the patient something resembling a credit card bill, which they could pay either up front or up to a year later with accumulated interest.
Parts 1 and 2 are essentially unrelated, and could hypothetically be implemented independently of each other. However, #1 on its own doesn't attempt to address the efficiency issue (thus saddling the government with even greater new expenditures), and #2 on its own doesn't address what happens or who gets left holding the bag when an uninsured patient can't pay their bill (which wouldn't be an issue with truly universal coverage).
I also have a lot to say about what the state should and shouldn't be doing to maximize the general health/nutrition/fitness of the population, but we can leave that for another post :).
I like everything here except this. Won't a significant amount of healthcare (grouped by specialization, hospital, etc) still be funded by insurance and be outside the reach of market forces?
I am also curious whether there are barriers to producers of medicine, healthcare supply, etc from disrupting existing overpriced producers.
If I understand your last point, I really like this approach in the context of my proposal: https://www.rubio.senate.gov/public/index.cfm/2021/3/rubio-s...
Apologies for asking, but when faced with a medical situation do you have any idea when you have insurance what your maximum liability could be?
NB I'm not from the US so I very little understanding of how the system works.
It looks like all plans sold through the healthcare.gov marketplace is required to have out of pocket maximums.
https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...
Is that a hard limit and you'll never have to pay more than that?
So it is not an absolutely hard limit in all cases, no.
Edit: originally wrote year twice.
- Balance billing - there is no guarantee that the insurance provider will actually pay what the hospital bills. Insurance companies usually have negotiated rates with some providers. So, if you end up at an ER that's out of network (no negotiated rates), your insurance might pay what they think is reasonable and the hospital bills you the excess. Several California-based hospitals are notorious for this. It also happens with helicopter ambulance transport - frequently, they'll bill $50,000 for a ride, insurance covers $25,000, and the patient is stuck with a $25,000 balance (again, made up numbers).
https://www.usnews.com/news/best-states/articles/2021-07-09/...
The way this plays out is that if I hand over my insurance card, the provider will attempt to extract as much money as possible and bill an outrageous amount. The insurance provider has maximum limits it's willing to cover for each billing code and so only covers some lesser amount. You pay the difference.
This is such scumbag behavior.
Everyone gets funneled to healthcare.gov where they can choose.
The whole buying things (life insurance, gym membership, retirement savings) with pre tax income if it is bought through an employer system needs to go in the trash.
The government may not pay for the actual service but there is huge government involvement and mountains of regulations to climb.
The government is involved in every step of American healthcare. As you can imagine of a system that gets all of its funding thru companies completely overseen by regulatory bodies or thru social programs.
Please note that the wording implies that 18% of GDP is spent on health care overall not that the US Government is spending all that money out of its pocket directly on yearly budgets. The way I understand it is that it includes both money spent by public and private actors for all health related service.
I see this type of stat a warning that something might be dysfunctional within the system, and it's the government's job to get to the bottom of it.
I have family in Canada with family members the same age on both sides.
Canada is great if you are a healthy broke college student.
No one in their right mind would ever pick Canadian health care over the US though if you are 60+.
There is no way you would rather have cancer in a country with free health care.
Unless you can't afford for-profit healthcare. Then any sane person would 100% prefer one of the fifty or so developed nations with free healthcare.
This is a big /part/ of the "worst outcomes" in the "highest cost, worst outcomes".
It is possible that you can spend a ton of money on healthcare - yet smoke and drink, drive everywhere and not exercise at all, and eat trash - that the healthcare spending is doomed to fail.
Europeans walk & bike more and don't eat as much garbage. Most Asians exercise much more, eat healthier, AND smoke and drink less.
Maybe the healthcare part is secondary to just generally taking care of your health?
It is well understood how terrible obesity is for you. Why should we expect the US to have better healthcare outcomes than Vietnam when Vietnam is 2.1% obese and the US is 42% obese. You can take all the heart medicine in the world. It would be better to simply not be obese in the first place!
This never seems to be a talking point. Have the statisticians controlled for all this when they come to these conclusions??
Tobacco consumption in Asia is incredibly high: https://en.wikipedia.org/wiki/Tobacco_consumption_by_country
https://worldpopulationreview.com/country-rankings/alcohol-c...
Though I suppose China and India, which combined probably comprise the biggest block of population, are a slightly better shade of red than the US and Europe.
Maybe you want to control for the cold weather too?
57% of the USA is white, compared to 73% of Canada. Nearly 20% of the USA is hispanic, compared to 1% of Canada. There are many more Asians in Canada and much less people of African origin.
I'd like to first see evidence that people of different race has a causality effect on healthcare consumption.
Per the CDC:
Among men, the prevalence of obesity was over 8 percentage points lower in Canada than in the United States (24.3% compared with 32.6%) and among women, more than 12 percentage points lower (23.9% compared with 36.2%)
In the United States, the majority of the nonwhite population is black or Hispanic for whom the prevalence of obesity is higher than it is for the white population (3). Among nonwhite Canadians, the largest group is comprised of East/Southeast Asian persons for whom the prevalence of obesity is lower than it is for the white population
And yes we absolutely should control for climate, or at least for incidence of extreme heat waves. It's well known that heat waves kill a lot of frail elderly people.
US is also a super bad infant mortality rate compared to other countries:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4856058/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5844390/
> Consistent with past evidence that has focused on comparing the US with Scandinavian countries, we find that birth weight can explain around 75% of the US IMR disadvantage relative to Finland or Belgium. However, birth weight can only explain 30% of the US IMR disadvantage relative to Austria or the UK
Access to healthcare is quite low in the US compared to most of the 50 countries ahead of us. We also have higher levels of poverty, ESPECIALLY for a lot of parents/children.
GDP is irrelevant. The paper says:
> In 2013, the US infant mortality rate (IMR) ranked 51st internationally, comparable to Croatia, despite an almost three-fold di erence in GDP per capita
If you have high GDP per capita, and more poor people per capita, and health care is not free - you're going to have more people not accessing health care and suffering the consequences.
In this world - I would expect infant mortality to be much higher even when the healthcare systems are equal.
I never see this as a talking point of folks who are in favor of universal / state-funded healthcare, but it is often a talking point for those who are opposed. They point to the links between state-funded healthcare and the soda tax in the UK as an example of how allowing the government to control your healthcare results in more aggressive and manipulative social policy to control health outcomes societally. Many people opposed to state-funded healthcare feel rather strongly that you should be able to do pretty much whatever you like with your body as long as you're paying for it yourself. I consider this take to be missing quite a lot, but it does seem to be a common one. I am personally in favor of universal single-payer healthcare systems, so I've had this conversation a lot due to my surroundings and have heard just such this argument many times.
But I think this point also opens another subject, preventive healthcare. Many modern healthcare systems are starting to focus on prevention for 2 main reasons: increase quality of life and reduce long-term healthcare costs.
For example, in Finland public tobacco smoking is(was?) considered a public health issue. The government got actively involved to reduce consumption and this resulted in better overall outcomes in their healthcare systems for diseases caused or exacerbated by smoking.
IMO, obesity is a problem affecting the healthcare systems of many developed countries (Vietnam is not yet considered a developed country) arguably not at the same levels as in the US. But this again is part of how government chooses to get involved in fixing the healthcare system by enforcing policies or passing laws that help with prevention.
https://www.theatlantic.com/health/archive/2012/09/big-gover...
My father is getting old and our healthcare system has done a great job at keeping him alive while he can still eat shit loads of pizza, drink beer and be a 80lbs overweight.
All this medication and treatment he takes is not just to keep him alive but to keep him alive without having to change a single bad habit.
That is only true if you cherry pick statics that over sample for life style choices, and under sample of actual health care.
If you look at statics that are directly attributable to the care provided, not the life style choices of the patients then the US Healthcare system is far better than any other nation
And then wonder why they get shit care for a huge price BUT swith nice marketing and a smiling "health dealer" getting you a 0% lease... oh sorry, we got you confused with a Chevvy!
And also, "we have the best care in the world because our docs are better selected". This one never fails to make me laugh, as a swiss MD
In what way is it the worst-performing? I mean, what are the outcomes that are measured to determine its performance?
Yes, healthcare is a lot cheaper in Europe (even if your employer wouldn't pay their part) compared to the US, but the quality of the service is rather poor with very long waiting lists, stubborn doctors who don't want to perform certain tests (as simple as a Vitamin D or a testosterone test) so they don't have to justify it to the insurance.
That's exactly like US healthcare if you aren't either a wealthy private-pay client or someone with top-flight private insurance; we just pay twice as large a share of GDP and even a higher multiple per capita to have the same normal experience and many more people uninsured than any other developed economy (and we've only recently through the ACA, gotten it so the that your top-flight insurance plan wouldn't look to retroactively cancel your insurance when you got an expensive-to-treat condition, leaving you uninsured and uninsurable.)
This one is pretty messed up indeed. What's the purpose of being insured to begin with if it will fuck you over when you need the insurance?
Affordable Care Act (ACA) outlawed denying insurance to anyone, regardless of how much their future healthcare expenses will be.
It is one of the reasons that everyone complained about ACA increasing health insurance costs - it had to because more people were getting more healthcare.
ACA also outlaws pricing insurance on anything other than age, smoking status, and location. Even the pricing due to age is capped so that the premium for the oldest (riskiest) age is only allowed to be 3x the young age premium.
ACA also implemented out of pocket maximum for in network care, so that there is a maximum cost per calendar year you would be responsible for. Recent law that went into effect Jan 1, 2022, extends this out of pocket maximum to all healthcare providers in the US if it is an emergency.
Finally, ACA also instructed an appeal process if you think the insurance company is denying payment for treatment justified with evidence:
https://www.healthcare.gov/appeal-insurance-company-decision...
My local very not fancy clinic schedules within 48 hours (within 8 hours if you pay the $10 convenience fee) and has always done a very good job.
Do you have any citation that US healthcare typically has very long waits?
Here's a recent report that measures: - Access to Care - Care Process - Administrative Efficiency - Equity - Healthcare Outcomes.
US comes last in all but Care Process among developed countries. https://www.commonwealthfund.org/publications/fund-reports/2...
As a separate issue, there is now significant clinical evidence that hypovitaminosis D is a major risk factor for COVID-19. So I hope that medical guidelines will be updated to make those tests a routine part of preventive care screening, in the same way that we test for lipids and blood glucose levels.
I can get in to see an Urgent Care doctor in any major US city within 30 minutes of walking in the door. If it's not urgent, who cares what the wait is?
Health issues are bad in the US, and people use that as 'evidence' for quality of the Healthcare system, but that's not fair.
People shooting each other, not eating well or exercising, isn't so much a function of the US Healthcare system.
The US system is probably the most economically inefficient, but that's also expected at the highest end of quality.
The US has most of the best quality systems in the world, it's just expensive and messed up financially, but the quality itself is something to behold.
While I share your reservations about 'privately backed things' - for example, advertising arcane drugs in the US is ridiculous, this whole 'Ask Your Doctor' is an excuse for pushy patients to 'prescribe themselves' over the will of tired Doctors caving in ...
... that said, Theranos is the opposite example. If it had worked, it would have been because of VC backing and it would have been very beneficial to people. And there are many things like that.
Like anything, it's complicated, and we need nuanced thinking about it.
We probably should welcome a lot more VC spend, think of ways to empower doctors with the deluge of information, to empower individuals but at the same time get them to understand that they are not medical professionals and shouldn't be self-diagnosing, etc..
of course Iceland has more hospital beds than 80, but it cannot handle a disease that may put 80 people in ICU ( not counting ventialtion here at all, just intensive care ).
I think many in Iceland, myself included, are a bit in shock of exactly how poorly managed and starved the health care system is.
Up until 2019 I laughed at the dumb americans and their awful health care, man did I get my sit-upon whopped in the past 2 years.
Icelands is so bad that we are regularily filling hospital break rooms and garages with patients. THat is on a normal non-influenze season. Let alone sars-cov-2 introduction.
I suspect Canada is having a similar realization as we are. Free care in all its honour. Starved free care, heh...... Shame on us. Really. Shame on us.
My favorite example of this is when I had to get an MRI. The lab imaging said it would be $800 if they billed it through insurance, or it would be $600 to just pay for it directly out of pocket. So the cost of having to deal with my insurance (which always advertises the "discounts" they negotiate and the "lowest cost") was actually more than what the insurance would actually cover.
Pay $800 for MRI with insurance, you'll then pay $2200 for the procedure to hit the deductible + 10% of the remaining $3300, so $2530 total for the procedure. $3330 total for the year between the two things.
Pay $600 cash for MRI, you'll then pay $3000 for the procedure to hit the deductible, and 10% of the remaining $2000, so $3200 total for the procedure. Now you've paid $3800 total, so you've spent $470 more despite the MRI being "cheaper"!
If you have other expenses so your out of pocket max comes into play, that difference approaches the full $600.
But we have to pay the bills after the insurance company does the calculation, which often results in annoying surprises.
The better your insurance, the less nasty surprises, which largely in the US means "the better you're paid, the less you have to pay out of pocket for health expenses" which is a nasty thing because then the people most likely to be hit with a big bill are those who can least afford it.
For example, am I going to do something major like have a baby this year. Then yes it probably makes more sense to get me to my deductible and pay the extra money to go with insurance. Or if you (or someone on your plan) has an ongoing medical issue where you know you will meet your deductible. Or on the flip side, I met my deductible one year and was going to physical therapy. Since I met my deductible the physical therapy visits were cheap, but going in to the next calendar year now my deductible reset. Could I have used more PT? Maybe, but the visits were about to be 5x more expensive.
But "expected medical expenses" is just the dumbest thing.
> So you basically get the worst performing being also the most expensive. Which doesn't really fit the view that less government involvement results in a more efficient system. Well, I guess it is more efficient if the expected outcome is a larger profit for different private companies and middlemen and not the well-being of the rest of the population.
Healthcare and Big Pharma have captured regulators at various federal health institutions. The mission is maximizing profit outcomes not health outcomes.
Considered by whom?
US health outcomes also aren't so bad for those who have affordable access to the system, as I understand it.
But the spending is something to keep in mind when anti-healthcare-for-all advocates say things like "do you want to have to wait months for procedures like in Canada" - if the US continues to spend more money per person, there's no reason it can't continue to have more capacity.
For instance, per https://ourworldindata.org/grapher/total-covid-cases-deaths-... Canada has seen 66K cases per million and 807 deaths per 1M cumulatively. The US is at 180K and 2515. Slightly different numbers than yours, but close enough. Deaths/cases to date is very similar, 1.4% in US and 1.2% in Canada. So the difference in total deaths is largely policy and behavioral, the aggregate policy across the US has largely been one of "at this point we can't eradicate it so we need to live with it as best we can" where even the liberal US states remain quite open compared to initially in 2020 in the face of recent surges. Whether or not that's the right policy is separate from whether or not that policy would've even been realistic without as much health care capacity.
You still aren't engaging with the point under discussion, though, which has become publicized due to COVID but exists independently of it. Spending more on healthcare contributes to having an overall better health care system, but the US suffers due to large problems of access and distribution. Regardless of payment structure, I would argue in favor of continuing to spend more on health care than other nations; we have the money, it's a good use of it.
If instead we use health insurance like home insurance for unforseen major issues, and had price transparency. Then prices would go down as people would shop around.
To be fair, I suspect your definition of capitalism is very different from mine...
Even getting a price quote is often impossible.
Government should enforce the same pricing to all parties or allow everyone to get the same prices Medicare negotiated.
I would strongly disagree with this. Healthcare in the US is currently a cartel system, not a consumer product/market system. If healthcare were a consumer product then:
1. It wouldn't be tied to or dependent on my employment.
2. Prices for medical treatment wouldn't be hidden/obfuscated by medical providers.
3. Insurance providers wouldn't be restricted by arbitrary/geographical boundaries.
If you think healthcare is a basic human right then a single-payer system is probably the most reasonable solution, although I don't think single payer isn't without it's share of problems.
If you think healthcare is not a basic human right then I think a real free-market solution is the most reasonable solution, again I don't think this is without problems either.
I don't believe there is a "perfect" solution. But I think either a true free-market system, or a single-payer system would both undoubtedly be 100x better than the current system in the US. I would be in favor of moving to either of these solutions as my political stance isn't D or R but "lets make improvements" regardless if those improvements are seen as left or right.
For optional surgery or cosmetic treatment, sure. You can argue a free market option, but that's why I always think there should be separate baskets, for lack of a better term.
It is sort of strange it needs to be explicitly written out, at the same time for those of us not from US we just took it for granted and never think much about the system.
Japanese system does have a public option and much tighter price controls, which we are missing here.
Obviously we shouldn’t just exactly copy the system of other countries, but it’s equally shortsighted to not learn take away anything from other existing systems. The possibility for universal coverage and higher cost efficiency without the need for single payer I think is a valid thing to take away from those examples.
So, the other important question to ask is the following: how feasible is it to create a well-functioning market for this product?
So far, we don't have an existence proof that such a well-functioning market is possible to construct in the healthcare space.
Because if there is a public option funded by taxation (whether you use it or not) and a comparable or even marginally superior private option which you have to pay use fees for (on top of the taxes), the public option will win every time. Simply put, do you want to pay once or twice for the same service? It's not like one car taking the toll road instead of the public road reduces that driver's tax burden by any noticeable degree. In antitrust terms, the government is using its monopoly in one area, "protection" (mostly from itself, as with any protection racket), as leverage to create a monopoly in another area, transportation. The surprising part is that there are some areas where the public roads are just so bad that you can actually run a profitable toll road alongside them. Level the playing field by requiring the government to fund the construction and maintenance of its interstate highways exclusively through use fees and I expect you'll see a very different result.
It's the same with any other bundled service. Having decided to subscribe to a certain service package one tends to stick with the included services, even if on an individual basis there are better services available at lower cost elsewhere. It only becomes viable to switch to the better service provider if you can replace all the bundled services. Except in this case that isn't even an option since there is no opting out of (paying for) the tax-funded package.
Who knows, it might have even achieved a reasonable balance between the two, instead of forcing a car-centric environment everywhere like the public option? ;)
- Dismantling the insurance/big hospital complex that milks the US population for the enrichment of c-suite executives.
- Removing the capacity for lobbying by insurance companies, large hospital groups, device and pharma companies (so they're less able to price gouge consumers).
- Price transparency on all links of the chain of healthcare delivery.
- Changing the incentives for physicians and other providers towards expensive, often harmful and unnecessary interventions.
- Facilitating improved therapeutic relationships between providers and patients (More time spent, more communication, more incentives for harm reduction).
- Social changes including less stigma for things like drug use, greater emphasis on community cohesion and care.
- Demilitarization (Not only are absurd amounts of money spent on the military that could be redirected to better community health services; but innumerable veterans (not to mention foreign and local civilians) are injured psychologically and physically annually in the absurd pursuit of 'global security'.
- Better end of life care. I think something around 40% of healthcare expenditure is on patients in the last 2 years of life. Patients and families would benefit from earlier access to hospice care and less aggressive therapies that only prolong suffering.
- A greater emphasis on preventative health and lifestyle choices (better diet, exercise and sleep regimes - ideally within the context of a long term health care provider relationship).
Its very typical of modernism (especially in the US) to think that the way to address everything is a nice app with a better UI. This also facilitates the corporate narrative of marketing the shiny new thing to throw money at (make money for the company) to solve everything whilst digging the hole even deeper (and letting society absorb the collateral damage).
EDIT* Thanks for the feedback, I have added some of the points made by others to the list above.
Follow that by banning burning of coal and oil, we also remove a significant amount of noise and air pollution.
Next we can ban any hormone-disrupting chemicals (including as plastic additives) from being used in anything that will ever touch human food or drink, or ground water.
Finally we can legaize euthanasia for anyone aged 70 or older and with a terminal health condition.
With these changes you have a human population much healthier and less reliant on expensive healthcare.
We definitely need do do a better job with end of life care/terminal diseases - in practice this would look like earlier/more hospice/compassionate care, less needless end of life treatments and interventions).
Most things have added sugar in them.
Things you wouldn't think have sugar, and are not sweet, have sugar!
Sauces, pickles, plain yogurt, it's ridiculous
And it shouldn't be for financial reasons. I fully support someone's right to death, but I do not support creating systems that might encourage it. I also don't realistically care if the health condition is terminal: I care more that folks are suffering and want death to escape it.
https://www.youtube.com/channel/UC0intLFzLaudFG-xAvUEO-A
Clearly, they mainly focus on cycling being the solution, but still, the overall analysis seems quite good.
This should be step one, always.
While those perverse incentives exist everything else is an uphill battle.
Imagine the OTA weighing in on the recent net neutrality shitshow. Wouldn't have made the FCC look to smart would it have? That same threat existed for every agency and congress and the executive. Literally everyone wanted them gone.
If anything, a fact checking organisation has incentives to align with or even become a lobby group. We've seen what happens to "fact checking" in the political sphere.
Some would say, if a senator doesn't believe in climate change that's a question of fact, and if they merely received better advice they'd change their opinion.
A cynical person, on the other hand, would say they know full well that climate change is real but they've accepted money to pretend they believe otherwise. In that case, no amount of independent advice will change their minds, as it is not a question of facts but of money.
No, no it shouldn't
There's a really, really, really fine line to walk between preventing the AMA from lobbying congress to screw us and preventing actual grass roots people from paying someone to argue on their behalf.
Besides, without lobbying groups working against you, the feedback loop of voting them out actually starts working. (no it's not a complete solution so please don't argue against that straw man, it's just the most important first step to unblock others)
Edit: clarity
It's certainly not the majority of healthcare workers.
Physicians are often scapegoated as responsible for healthcare costs when in reality physicians in Canada, New Zealand and Australia earn similar salaries without the massive cost blowout.
https://www.physiciansweekly.com/how-do-us-physician-salarie...
Also if you factor in earnings and expenses over a lifetime (including cost of studying and the fact that many of the countries mentioned have free healthcare and education and far lower insurance requirements) it evens out substantially.
More importantly, even the highest physician salaries are orders of magnitude less than insurance company CEO salaries.
Disclosure: I'm a physician, currently practicing in the US, previously in New Zealand and the UK.
And sure insurance CEOs are paid more, but there are also a several magnitude more doctors than insurance CEOs. You could pay all the CEOs $1 and the cost of healthcare isn’t going to budget much.
https://www.latimes.com/opinion/story/2021-09-14/dont-blame-...
https://www.beckershospitalreview.com/payer-issues/what-5-he...
And its not just the CEOs - its all the parasites in the c-suite.
And these people contribute less than nothing to the health of patients, quite the opposite.
Seems likely enough that adding another 100 CEOs wouldn't make the total much more.
An interesting side effect might be to change the demographics of who can become a doctor, maybe attracting more people from middle class or blue collar backgrounds.
Doctors already come from a variety of different backgrounds.
Incentivizing the best and brightest in the software industry has gotten us to where we have to give new computer science graduates a coding exam, to find out if they can program.
Many people that browse this forum will likely have lifetime income similar to that of a physician.
And sure, comparing it to Silicon Valley looks bad, but so does every other job. “Amazing how bad other jobs look when you compare them to the top 1%”
Is there a particular reason for this?
In a world where people are making billions for photo-sharing apps and financial rent seeking, is it really that egregious for people that treat disease to do well financially?
It's much higher than other countries. There's also a 7 to 10 year period of medical school and residency where you're making no wage or a poor wage. People tend to get fixated on the attending-level annual salary while ignoring that piece. That's 7 to 10 years where you're not really building any savings, retirement, or wealth.
My wife (a doctor) and I (a non-SV software engineering who's career has taken a backseat to hers) ran the math. On an hourly basis, she will likely never come out ahead of me. She just has too many unpaid and low-paid hours in med school and residency to overcome. In aggregate, she will likely out-earn me - but that break-even point will be in our 50's with her having worked many more hours than me. That's 30 years into our careers.
And they are all invested in each others bags. For instance I've read that doctors are major investors in health providers, are often the owners of the expensive equipment, and also heavily invested in the malpractice insurance industry.
Half of billing is multiple businesses billing one another.
It seems quite possible that what makes government health care more efficient is simply knowing where the money is going, if it's all coming out of one checkbook.
I'd be happy if the app could show medical expenses before the treatment.
Right now millions of Americans are basically committing fraud: they go to a doctor who has taken an oath to help you. The bill is not getting paid so the government has to step in anyway. May as well make it official.
At least under the current model, many people don't hit their deductible or max out of pocket. I know some older retired couples who are buying insurance on the market with 10k+ deductibles because they're generally in really good health, and the cost of insurance isn't absolutely insane with that level of deductible.
They would absolutely drive an hour rather than 5 minutes for non-emergency situations!
https://www.athenahealth.com/knowledge-hub/practice-manageme...
>>Here's some food for thought: The number of physicians in the United States grew 150 percent between 1975 and 2010, roughly in keeping with population growth, while the number of healthcare administrators increased 3,200 percent for the same time period.
*
>>Supporters say the growing number of administrators is needed to keep pace with the drastic changes in healthcare delivery during that timeframe, particularly change driven by technology and by ever-more-complex regulations. (To cite just a few industry-disrupting regulations, consider the Prospective Payment System of 1983 [1]; the Health Insurance Portability & Accountability Act of 1996 [2]; and the Health Information Technology for Economic and Clinical Act of 2009. [3])
In contrast, areas of medicine which are subject to much fewer subsidies and regulations, as a consequence of being electives, have seen prices actually decline in inflation adjusted terms. [4]
[1] https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Paymen...
[2] https://www.hhs.gov/hipaa/for-professionals/privacy/laws-reg...
[3] https://www.hhs.gov/hipaa/for-professionals/special-topics/h...
[4] http://healthblog.ncpathinktank.org/why-cant-the-market-for-...
I really want regulation in health care. I do not want medication to be a free-for-all like supplements are in the US. I'm not a doctor, after all, and they are slow to take supplements off the market even if they are harming or killing folks (take a look at diet pills to see this effect). I do not want average folks to be able to get antibiotics willy-nilly because I want to be able to take them when I'm old. And so on.
This is changing fast though, and Europe is migrating to the US model at a rapid pace, with growing administrative layer and loss of control over prices. Interestingly, european politicians are also telling everyone that the problem is that docs earn too much and people tend to believe them.
And honestly, I find it very difficult to think that this is the administrative cake you were thinking. I also find it really difficult to think that Norway, Poland, Greece, Italy, Germany, and Britain are all taking the same steps and adding complexity.
Where do you get information? Do you have links?
Europe is still a bit behind in terms of admin, but getting there. And yes, american influence is felt all over Europe, with varying degrees of implementation among countries, as you noted.
I can understand that outsiders don't believe what we have to say when political propanganda is so strong. But for us insiders, it's really crystal clear what is happening. It used to be that problems arising in clinical management was solved by asking frontline workers what they needed. Healthcare workers had a lot of control over their working environment. Nowadays, admins are taking all decisions from above. European hospitals are now in competition with the private sector due to changes in the billing and insurance system coming from the US. As a result, european hospitals are now managed much more like your usual run-of-the-mill company than they used to. This is a terrible result for anyone but upper management.
Other countries' healthcare systems are growing increasingly more inefficient as well, with the proportion of GDP expended on healthcare rapidly rising, with many seeing it double over the last 40 years. [1]
And they face critical shortages, like this case of a woman in Canada who had to wait two years to get a test that diagnosed her with cancer, because of a shortage of state-licensed doctors:
https://www.cbc.ca/news/health/doctor-shortage-cancer-video-...
>>I really want regulation in health care. I do not want medication to be a free-for-all like supplements are in the US.
I think the best of both worlds would be most regulations being opt-in, while disclosure regulations are mandatory.
More specifically, I think healthcare would benefit from legalizing the provision of medical service by un-certified individuals, as well as providing more than one tier of certification, where people who can't afford fully certified practitioners, but would like the assurance of some certification, have that option.
Instead of making it illegal for individuals who don't possess full certification to practice medicine, the law could instead require medical practitioners to disclose their level of certification, and any warnings the state provides in relation to that.
So for example, an uncertified doctor/nurse may be required to disclose not only that they are uncertified, but also the warning that the state strongly advises against using uncertified medical practitioners.
Why providing these options is critically important is that sometimes the prescribed institutions fail, and an escape hatch is a life saver, as in the case of a woman in Canada mentioned above.
>>I do not want average folks to be able to get antibiotics willy-nilly because I want to be able to take them when I'm old.
If the negative externalities of irresponsible antibiotic use is your concern, maybe you could advocate specifically regulations on antibiotic use.
When you advocate wholesale centralized gatekeeping of all manner of healthcare interaction, you deny people a way to escape failures of over-regulation, like regulations that prevent people from accessing life-saving medical products/services in a timely manner [2][3] or deny people access to a vaccine due to a risk from side effects that is orders of magnitude lower than the risk the vaccine mitigates. [4]
[1] https://www.researchgate.net/figure/Healthcare-spending-as-a...
[2] https://www.propublica.org/article/this-scientist-created-a-...
[3] https://www.nytimes.com/2020/03/10/us/coronavirus-testing-de...
[4] https://www.nytimes.com/2021/04/13/us/politics/johnson-johns...
There are two (mostly) unrelated issues: the efficiency of the healthcare system and increasing availability of effective but expensive treatments.
I believe we have already reached the point where even 100% of GDP is insufficient for healthcare. There is always something more you can do, something better you can try. No matter how much money you choose to spend, somebody must eventually make the decision to withhold better care because the economy is not big enough.
In any case, the price inflation seen in highly regulated vs lightly unregulated markets is, to me, telling:
https://www.aei.org/carpe-diem/chart-of-the-day-or-century-3...
It will still not be enough to win over China, but at least enough to keep the free world in existence. Otherwise democracy will be just simply gone from the world altogether in one generation.
https://worldbeyondwar.org/ - is an organization dedicated to the abolition of war. I encourage you and anyone reading this to take a look.
Also take a look at possible alternatives. (A global security system that doesn't require violence) - there's an ebook discussing this system in full.
https://worldbeyondwar.org/alternative/
Continuing to head in the direction of militarism, will continue the disaster of a world that we live in, and almost certainly guarantee the end of mankind.
Stick to watching fox news.
It was essentially a calorie and exercise tracker that also displayed your health insurance info, absolutely nothing special compared to fitness apps already out there, but millions of dollars down the drain.
I feel like the choice has to be removed from families as our current system has proven that life will be extended regardless of quality simply due to the fact nobody wants to make a difficult choice. As the only quantitative item on the list and a very substantial one this should be ranked much higher in terms of priority (not sure if list was unordered or not).
In countries with a more functioning healthcare system, disruption of the status quo (especially by VC-funded private companies seeking a large payday) is neither necessary or desirable, slow iterative improvements are the name of the game.
Furthermore, the US spends far more per capita than every other country on healthcare, and receives worse healthcare outcomes as a result [1], [2]. If you think that the solution is throwing more VC money at the problem, well, I have a bridge to sell you.
Sadly for Americans, the obvious solution that most (~70%) Americans apparently want (Medicare for all) seems very unlikely to happen anytime soon.
[1] https://ourworldindata.org/grapher/life-expectancy-vs-health...
[2] https://www.nytimes.com/2021/04/08/learning/whats-going-on-i...
Firstly (loosely regulated) insurance is an absolutely stupid way to provide healthcare. Pre-existing conditions? Maybe you just don't deserve to live, either way we're witholding life-saving care from you because our tables say so. Need to claim near the start of your cover? You must be lying about pre-existing conditions. Need to fix something that wasn't acute enough to seek care about previously? Nope, no cover for you. And on and on and on. Anyone who thinks an insurance market is a solution for healthcare is just an idiot, there's no way around that. (I realise some universal systems run on a private insurance basis but they're a lot more regulated)
But then, even in that entirely messed up system, designed to cut you off from urgently needed medical care, all policies are divided into 'regions'. There's not much cost difference between regions until you get to any region "including the US". It's even named, the only country in the world they do that for. That's how badly those guys have messed up their healthcare system. And if you select that? It's at least double the cost, for no extra cover in terms of policy limits.
That for me clarified that, no, I wasn't missing anything. Anyone who supports the current US system is so far removed from the commonly inhabited reality that none of their opinions are worth listening to.
1. The cost is insane. It doesn't matter how much money you have, if you stay long term in a hospital your bill will be insane and more than an average cost of a house.
2. Single ER visit? 10 different bills over the next few months. Apparently, there is a new law trying to tackle this but hospital can opt-out by having you sign paperwork.
3. If you have an illness and need to see many doctors and have many tests in a short period of time get ready for your insurance to fight you and deny claims. You will be calling them all the time.
4. There are now 3rd party businesses set up to "VERIFY" no other party is responsible for the care you received(meaning you did not have an accident). If you fail to respond to their letters, your claim will be denied.
5. MRI, X-rays, dental work, physician visits are SO MUCH more than other developed nations. It is a joke. I'm talking without insurance here, just going to a private clinic and paying out of pocket as these also exist in Poland even though it has socialized healthcare.
6. The insurance prices are out of control, and the insurance company don't give a shit. In fact, they welcome the high prices. Obamacare capped insurance companies profit margins at a percentage of money spent, this is the result. The more they pay out, the more they make. The cost falls on the policy holders.
7. Covid is really showing cracks in for-profit healthcare. I have friends who work in the field and are complaining about people coming in with positive covid tests because they are asymptomatic. If they don't want to come in they risk getting fired, and in some areas large hospital networks own many smaller clinics and being fired may result in not being able to find a job without relocating.
There are significant problems but whose Vaccine did you take for Covid-19? Pfizer (Us), Moderna (US), Johnson and Johnson (US)...
I think it would not be relevant to the vaccines as we would still spend money on R&D under the pandemic threat.
Yes, I would think a massive fundamental change in the healthcare system would have an effect on Pharma. But who knows what that would look like
> I think it would not be relevant to the vaccines as we would still spend money on R&D under the pandemic threat.
They would spend money, but it's not hard to envision a world where we didn't have multiple fully tested, safe & effective vaccines in less than a year.
A better hybrid public/private system would be for the government to put out bounties for companies to run large studies on research that looks promising, to determine effectiveness and optimize formulations. In return for paying for the research, government would get the patents. Paying for drug development with a patent reward only encourages deceit and high prices.
Dean Baker has explored this extensively, and is posting steadily about it recently:
The basic idea of government-funded research should not be hard to grasp since the government already funds a large share of biomedical research. The National Institutes of Health gets over $40 billion a year in federal funding, with the Biomedical Advanced Research and Development Agency (BARDA) and other government agencies getting several billion more. This puts the government’s total spending in the $45 to $50 billion range, compared to a bit over $90 billion from the industry. So the idea that the government would fund research really should not be that strange.
Most of the public funding does go to more basic research, but there are plenty of instances where the government has actually funded the development of new drugs and also done clinical testing. But under the current system, most of the later stage funding does come from the industry and is funded through patent monopoly pricing. Relying on open-source government-funded research for later-stage development and testing would be a major change.
To my view, the best way for the government to support the development of new drugs is through long-term contracts (10-12 years), which would be awarded through competitive bids for research in specific areas, like cancer or heart disease. The plan would be that the contracts would be relatively large, with the idea that the winners would be comparable to prime contractors for the military.
https://www.cepr.net/more-on-open-source-versus-patent-monop...
-----
Getting Ready for the Next Pandemic: Can We Get Patent Monopolies on the Table?: https://cepr.net/getting-ready-for-the-next-pandemic-can-we-...
Financing Drug Research: What are the Issues?: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1134983
Johnson and Johnson was developed by Janssen which is based in the Netherlands and Belgium [1].
And as others have pointed out, Pfizer was developed by BioNTech in Germany [2].
[1] https://en.wikipedia.org/wiki/Janssen_COVID-19_vaccine
[2] https://en.wikipedia.org/wiki/Pfizer%E2%80%93BioNTech_COVID-...
https://www.nhsinform.scot/covid-19-vaccine/the-vaccines/cor...
Alternative options I've seen being offered for ongoing healthcare is Direct Primary Care where essentially you pay a membership fee to have unlimited access to a primary care physician.
I think the root of the problem is subsidization and the patch work of legislation that gets piled on year after year to "fix" the issue. The entire price function is completely out of wack and as long as the patient is stuck between the provider, insurance carrier, and government debating who has to pay, they will lose.
My girlfriend has worked with children with special needs for around 20 years, mostly children with autism. A few years ago, the field began migrating from almost entirely state-funded to funding from private insurance (California, not sure about other states). The problems with private insurance funding began almost immediately and couldn't be clearer. Under the state-funded program that existed for decades, her company met monthly with the state funding agency, discussed individual cases, and got funded. Easy, efficient. With private insurance, well, the best way to describe it is that her small company had to hire a full-time person just to manage the billing/funding with the insurance companies. And this is not a do-nothing position. This position is responsible for much of the company's revenue, which is inherently important. Also, understanding all the different processes/procedures/BS of each insurance company is highly skilled. That might sound ridiculous, but it's totally true. I hear the stories about fighting with insurance companies, trying to get paid for services rendered months prior. Quick example: one private insurance company (a big one, you've heard of them) only accepts payment requests via fax. Yes, fax. But it gets better. The fax line is only "active" during regular business hours, and the line is almost always busy, because as you might expect, other companies are trying to get paid, too.
</venting>
Which is definitely not the case in American health care - unless you have "For the Top 1%" health insurance, or are buying at the bottom end (a bottle of aspirin, maybe an eye exam or dental cleaning).
I'm not confident a typical telehealth-style consultation with one of these direct-to-consumer companies is that great, but by the same token, I am confident the medical care I get in a traditional setting is mediocre. For example, the time an MD tried to convince me I couldn't be feeling pain... after I told him I was specifically there for pain.
People seem to have this attitude they can spend money (or have someone else spend money) instead of taking care of themselves. Take a pill instead. Some think every little thing is an emergency or are otherwise unreasonably terrified (Recent Covid scare comes to mind. A very real and serious disease but some people inaccurately assess their risk and become neurotic). Unfortunately it doesn't work like buying a new car.
Many years back I dated a girl who was a physical therapist. She loved going to the doctor and hospital. When she felt slightly sad she would get "sick" and go get some attention which she paid through the nose for. I'm exactly the opposite and likely to Steve Jobs myself to death in the end.
I've read (don't know how true it is) that Americans take something like 60% of the worlds prescription drugs.
The whole thing is completely unbalanced and I don't believe other areas of the world are like this. Because of this I don't see an easy solution for the US. The government taking over health care is likely to result in deep dissatisfaction but the current system is super wasteful and frankly just bonkers.
The thing people don't want to understand for some reason is reality. Sometimes we feel bad. Sometimes we get sick. Eventually we will die. Sometimes medical professionals can help. Very often they cannot but that won't prevent them from billing you large sums of money. Also it's not rare for professionals to worsen the situation. Incentives are not always aligned and the body is a very complex system. Throw the US mid level manager hospital pharma insurance scam complex in the mix and incentives misalign even further.
The best dentist I've ever been to was in Mexico. Light years ahead of what I'd experienced in the US without the ceremony. The best doctor I've ever been to is an old time country veterinarian in his 60's. But that was for my dogs. Real practical sense a and humility with an eye to results and the understanding of uncertainty involved. I've always thought that's who I would like to treat me in the event of serious illness and practically speaking there little no reason he couldn't in most cases because I'm not very different then my dogs physically. In neither case was the hospital-pharma-insurance scam complex involved. That groups has made things immensely worse and killed large numbers of people.
Don't get me started on psych drug overuse in the US.
There is no point in making broad generalizations, it is a complex issue were you have a multi-decade and multi-billion dollar business tightly coupled with the healthcare of millions of people.
In NL, you pay ~€110/month annually, with a max out-of-pocket cost of €385 per year. So, maximum €1600 cost annually.
People with a low income, students, etc, get approximately the same amount of money as a cash benefit to cover these costs.
I'm not saying this is good, it isn't, healthcare costs should be covered by general taxation like in the UK. But it's not very expensive.
(It also seems pretty stupid in the Netherlands, because you have to pay an insurer for your health insurance, but they all charge pretty much the same, since it's highly regulated, and then out of pocket costs are capped. Seems much simpler to eliminate the insurance companies and let the state administer costs and pocket the profit that the insurance companies are extracting)
[0]: https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
My provider, CZ, charges ~€150/month with max-out-of-pocket ~€385. If you get the full ~€850 out of pocket then your monthly payment drops to ~€110/month.
The extra insurance (dental/glasses etc) is also a bit of a scam, because the amount covered is often less than or just equal to the premiums that you pay in a given year, and you'd need to also be buying a new pair of glasses every year, always visiting the dentist, and so on. It's probably more economical to simply pay these costs out of pocket.
The arrangement was indeed strange though with the government paying me to pay the insurance company and then for the employed there was then a further health care tax amount.
it gives you the direct control over which insurer to buy, thus encouraging market competition.
If the gov't controlled which insurer got paid instead, there'd be a lot more lobbying and "corruption" and backroom deals which would not benefit the citizenry.
> Everyone else must pay an annual deductible equivalent to an average of 2,040 NOK (222 USD). After paying this, one receives an exemption card which entitles them to free healthcare for the rest of the year.
> Why is Norway’s Healthcare So Expensive?
(hah!)
It isn't free, it's paid by people's taxes AKA redistribution of wealth, a % of the salary and mandatory health insurances. Private hospitals also do exist. Nothing is for free.
Right now I go to the doctor, and they stare at the computer and take notes for 20 minutes before they can even actually look at me or look at at why I came in.
Just dot the room with mics and record our conversations or something if you need it logged.
In America this has always been the case. Anything that's not 100% your literally going to drop dead without it, isn't covered by insurance.
Therapy is essentially a luxury good, around here none take insurance so if you don't have 1200 to 1600$ a month sucks to be you. It's comical, say your spending is out if control, unless your excess spending exceeds 1200$ a month your better off with a "Stupid" line item in your budget.
As long as your spending less than 1200$ in the stupid category, your coming out ahead.
In this space we've seen tons of quasi legal startups trying to capitalize. Who cares if these therapists are licensed to operate in the same state as their clients, we got money to make and vC funding to raise.
I am looking forward to blood glucose monitoring via the Watch.
The forces that are driving this have little or nothing to do with healthcare outcomes.
* tight connection to insurance
* typical consumer-producer relation relation broken into consumer(patient)-prescriber(doctor)-producer-payer(insurance or government)
* large externalities
These factors led to health care being provided by the public sector in most of the countries.
"I am just not going to get sick" is not a strategy. No one can control the inherent risk of life. Slipped, swiped by a car, and since we are talking about the United States, let's just go there - caught in a crossfire.
According to you. I happen to live in a single payer, free healthcare system (Spain), and the claims about “how nice it is” are pure BS.
All of my family has medical insurance, even when we could ill afford to pay extra.
- I almost lost my brother on the public health system (they sent him home with some antibiotics, instead we took him to a private hospital were he got surgery that same day, he had internal necrotic tissue).
- My mother needed a mammogram, the doctor suspected cancer. the appointment they gave her was in two years. We went private again, she ended her radio + chemo before the diagnostic appointment of the public sector.
In the meantime, my effective tax rate is over 70%.
I’ve had to visit a hospital in the US (San Francisco) for a recurring issue. It was way better than anything in my area.
As broken as the US healthcare system appears from the outside, the free market SHOULD have pushed prices down, not up.
This isn't.
With the amount of lobbying, financial contributions to campaign funds, oligopoly, the market isn't free.
This is also one of the market where you have to pay. You can choose to not go to vacations or not to buy an apartment (even if you live horribly); you cannot just not have an appendix operation or not fix your ankle if it is broken.
Seriously, I don’t know.
It’s a market for employers, insurances and hospitals. All of them have vastly different interests from the patient and are passing on their costs to the patient . The patient is left with having to pay for somebody else’s decisions.