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Comment by oceanplexian | Hacker News Reader

In the USA since 1960, healthcare has gone from 5% of GDP to nearly 20% of GDP, something I would consider a crisis. If you think of the enormous amount of money that’s being spent, and then ask if we’re really living better or longer lives, I would disagree.

Some might argue that the average lifespan has gone up a 8-10 years, but take out infant mortality, account for improvements in vehicular safety, the fact that most people no longer smoke cigarettes, and improvements in workplace, food and drug safety, and what are you actually left with?

I would say most dollars in healthcare are selfishly spent squeezing a year or two of extra time in the twilight of most peoples’ lives, while destroying our society in the process.

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> Some might argue that the average lifespan has gone up a 8-10 years

I don't think anyone would argue that's what we're getting for the quadrupling in cost, because nobody else spends half as much as we do and they all live longer than we do. Cubans, Panamanians, Albanians, and the Lebanese have longer life expectancies.

Many of these countries are such that I'd not be very-very certain about their statistics reports.

Cuba's health statistics are backed by the WHO. They were the first, for instance, to prevent mother-infant AIDS transmission.

In the UK healthcare costs about half as much (and you the consumer don't pay any of that out-of-pocket), and the average life expectancy is about three years longer here.

When doing these kind of comparisons, I feel we should separate out deaths from "excess" (drugs / alcohol / cigarettes) - or at least control for differing levels of use in the various countries. I suspect differing incidence of young people dying of drug overdoses makes a big difference to average lifespan, but it seems to me that's more reflective of a society's regulatory and legal environment than a reflection of healthcare

In 1960 if you had a heart attack and collapsed in a mall things weren't going to go well. Today you'll get CPR from a bystander, an AED shock from an EMT, stenting in an interventional radiology lab, and statins to reduce cardiac risk. All of this adds cost but can add a few decades of life.

There are several layers to this story

If you collapsed in a mall in the 1960 your chance of having died on the spot from a preventable cause were much higher (like smoking, or a non-diagnosed heart problem)

Today, that chance is also smaller. Defibrillators help but not in all cases.

> an AED shock from an EMT,

Not if you're having a heart attack. That's a mechanical problem - your heart is gunked up with fatty crud and cannot pump blood. The symptoms are chest pain, sudden weakness, and shortness of breath. *Usually* you don't just drop to the floor clutching your chest.

You're thinking of a cardiac arrest, which is an electrical problem - your heart is not getting the right pulses to generate the right muscle contractions to pump. An AED will absolutely help here and you should not wait to start using it. Just grab the AED that's right there and open the lid, switch it on, and wait for it to start telling you what to do.

It's very unlikely it could ever shock a patient who wasn't actually having a cardiac arrest because they detect the heart's electrical signals and look for a "shockable rhythm". If the rhythm looks normal, or looks like one that won't be improved by a quick zap, it won't do it. Even so, never stick the pads on someone who isn't actually in cardiac arrest because if it gets it wrong it probably *would* drop them into cardiac arrest.

Pretty much every public space has a defib now. Often they're in a box with a locked door which you can get the code for from the emergency services operator. You're going to need to ring for an ambulance anyway so this doesn't waste time.

The main thing though is just start CPR and get someone to call an ambulance. You might just save someone's life with that, maybe even today.

Heart attack (myocardial infarction) leads to cardiac arrest all the time. That's how people die from heart attacks.

If someone has a myocardial infarction and then goes into cardiac arrest with a shockable rhythm, shocking is absolutely the appropriate thing to do. (But it is only a temporizing measure - if the person does not get treatment for the underlying myocardial infarction, they will simply go into cardiac arrest again.)

"Even so, never stick the pads on someone who isn't actually in cardiac arrest because if it gets it wrong it probably would drop them into cardiac arrest."

MD here, I strongly disagree - the AED is designed for use by minimally trained people. And the chances of a shock being wrongly administered is many times lower than the chance of saving a life if they are in a shockable rhythm.

I think it's really hard to definitively diagnose cardiac arrest in the first few seconds to minutes, even for some medical personnel - even if you have no cardiac output, a person often still has some residual apparent breathing ("agonal breathing") which often leads people to delay CPR, and delay applying the AED/monitor+defibrillator.

Perhaps we can agree there is no point placing it on patients who can talk to you? :) But if as an untrained person you applied it to every person who lost consciousness in front of you, you would do a lot more good than harm, with almost zero absolute risk of harm.

> Perhaps we can agree there is no point placing it on patients who can talk to you?

Yes, that's kind of what I was getting at.

Or to put it another way "don't fuck about with the AED because it's not a toy and its safety systems are not infallible". If you stick it on someone unresponsive - and you've got enough reason to suspect they're in a shockable state - it probably won't make them any worse.

Like my old trauma instructor used to say, "You can't make dead any deader!"

>All of this adds cost but can add a few decades of life.

The cruel irony, though, is that you now have several decades in which to potentially come down with cancer, Alzheimer's, or other illnesses associated with old age that are even more costly to treat.

> I would say most dollars in healthcare are selfishly spent squeezing a year or two of extra time in the twilight of most peoples’ lives, while destroying our society in the process.

The vast majority of spend is on chronic disease patients in the 50–85 age range.

The insurance middle man takes a huge slice too without offering much in return.

But I do agree with you. What’s the solution though? How do you decide when to let people die?

I think this is a bit of a fallacy (the decision to let people die). Do we know that all this money and processes (as described in the article) has led to better outcomes? Has the impact of the current methodology been objectively evaluated after excluding all other variables?

Brutal take. Squeezing hundreds of thousands of dollars out of patients/insurance for maybe a few extra months is immoral imo

And months that often aren't a great quality of life and are questionably in the patients' interest.

It made a huge impression on me as a kid when my greataunt, a physician, decided that she didn't want to be treated for her leukemia diagnosis. She died within a month (I assume it was late-stage).

(IIRC, better end-of-life counseling is what the Obamacare "death panels" kerfuffle was in reference to)

It is an American problem, we must do something. Which leads to antibiotics being over prescribed because parents don’t want to leave the doctors office without something to do afterwards. Life is worth living well, but it’s also worth accepting the end, something to which many people are openly hostile.

Which leads to antibiotics being over prescribed because parents don’t want to leave the doctors office without something to do afterwards.

You're not wrong, but sometimes this is purely preemptive and might still be a sound decision. For example, influenza almost never directly kills anyone--the monster flu in 1918 is an exception--whereas secondary bacterial infections (leading to pneumonia) can and do. Antibiotics are often prescribed as an extra precaution; given the atrocious financial resources of most Americans, most doctors know that they only get one shot with most patients, because they can't afford the copays or get the time off work, and that if they under-prescribe and are read to have missed something, they'll face malpractice suits from the desperate. So, they err on the side of immediate caution, since antibiotic resistance is one of those diffuse long-term problems.

Life is worth living well, but it’s also worth accepting the end, something to which many people are openly hostile.

Part of the problem is that capitalism creates a collapse of trust from which there is no recovery. Is the hospital denying or rationing care based on sound medical reasoning (i.e., that the requested procedures won't work, and will divert resources away from people who need them) or because they don't think the patient will be able to pay? Is the doctor performing a surgery because it will improve the patient's quality of life, or because he needs to generate fees? I'm sure most doctors are ethical and try to make the best decisions for the patients--I imagine, at least 90 percent of them do--but, as soon as the profit motive gets involved, distrust becomes endemic and personally mandatory.

Medicine is, to put it bluntly and factually, too important to trust to the profit motive and capitalism.

Are you sure it was "capitalism" that led to the "collapse of trust"? Did Soviet citizens trust the local healthcare system when the quality of care you received depended on your party rank?

From a Wikipedia article on the Soviet healthcare system[1]

"Many medical treatments and diagnoses were unsophisticated and substandard (with doctors often making diagnoses by interviewing patients without conducting any medical tests), the standard of care provided by healthcare providers was poor, and there was a high risk of infection from surgery. The Soviet healthcare system was plagued by shortages of medical equipment, drugs, and diagnostic chemicals, and lacked many medications and medical technologies available in the Western world. Its facilities had low technical standards, and medical personnel underwent mediocre training. Soviet hospitals also offered poor hotel amenities such as food and linen. Special hospitals and clinics existed for the nomenklatura which offered a higher standard of care, but one still often below Western standards"

I think the problem more generally is that of adverse incentives, whether in "capitalist" or "socialist" systems. I worked in the UK National Health Service which is "free at the point of use" which often results in rationing via waiting list. In my experience, many patients believe that their GP is inappropriately limiting their treatment to save money, particularly with respect to limiting testing, which is unsurprising because "gatekeeping" is often an explicit responsibility for general practitioners in the NHS [2][3]

[1] https://en.m.wikipedia.org/wiki/Healthcare_in_Russia#Early_S...

[2] https://www.theguardian.com/society/2001/sep/15/NHS

[3] https://bjgp.org/content/69/681/e224

Everything you're saying about the Soviet health system is true of capitalism's health system now. The difference is that, in the US, we go into debt for our mediocre care.

The main reason for the discrepancy in care quality during the midcentury is... drumroll please... that the Soviet Union was poor, due to initial conditions. It encompassed countries that had long been impoverished. The US had a middle class to build on; the USSR did not. It built a middle class where none had ever existed. Not to mention, the US was in the historically rare situation of winning a war (since, in economic and humanitarian terms, wars are negative-sum and most often only have losers). The USSR, on the other hand, consisted of nations that had taken a beating in World War II.

If you compare Kyrgyzstan to Alabama, the Soviet Union looks bad, but that's not really a fair comparison. Capitalism, as a sea empire, could dominate people from afar and keep them in nominally separate nations while exacting tribute; the Soviet system, as a land empire, could not. It had to integrate them. That's a harder problem. If you make a fairer comparison--say, if you compare Kyrgyzstan to Honduras or Haiti, the picture lines up a lot better. I imagine the quality of healthcare in the poorest countries under capitalism's thumb is even worse than it was in the poorest SSRs as of 1989.

This isn't to say the USSR was great. It was an authoritarian regime, and it launched some really ugly wars (such as the one in Afghanistan). It remained poor (relative to the West) throughout its lifespan because, ultimately, there is no magical economic system that guarantees 12% annual GDP growth--doesn't exist, never has. Socialism solves one set of problems--and a big set of very ugly problems--that capitalism lets fester, but does it automatically bring about utopia? No, not even close. On the other hand, socialism iterates toward a better standard of living for the common people; capitalism, unless heavily checked (as it was in the Cold War) iterates toward a worsening standard of living. So, on that dimension alone, capitalism loses. Everything said above about shortages and nosocomial infections and substandard care applies to capitalism's medical system today.

Just happened to read a report on this exact topic last week: https://ourworldindata.org/us-life-expectancy-low

A lot as gotten considerably worse since the 60s. Pointing out why gets you flagged though.

Medicare is what pays for that btw. Dialysis is covered, as is any life saving treatment (like heart attack).

What ends up happening is hospitals then charge others to cover their costs (hence high rates). Granted hospitals do take a bigger cut imo than they deserve, as do pharma, doctors, etc.

Let’s not forget the number of doctors is intentionally restricted. They also seem to have a political bias imo (how much volunteer work and what kind you’ve done).

Then you have regulations around drugs (FDA), hospitals / practice insurance, etc

Combined, the entire industry is over regulated and captured effectively by cartels (what is Johnson and Johnson but a legal cartel). You can’t even sue for vaccine (any vaccine) injury. Think about that for a moment and explain it.

Fixing the medical industry can only be done by deregulating it. I don’t think it would even be that hard; but people would lose their minds. I’ve spent a lot of time in one of the largest medical billing companies in the US. My family worked in this space for decades. The issue is really just fear.

Regulatory / legislative changes:

1. Remove any protections pharma has against lawsuits

2. Remove bloated credentialing for doctors, instead have an apprenticeship program (at least for military and gov doctors)

3. phase out Medicare, no one under 60 will ever receive it again.

4. Completely defund the FDA

5. Remove much of the requirements around drugs. Enable easy purchasing of medication. Could just be consultation with pharmacist. Or maybe nurse. Or no one.

Do that and overnight the cost of medicine would drop massively. The medical costs in the US would be less than Mexico.

It's not fear, it's money. All of those unnecessary things are huge profit centers for certain people. Health care is middle-manned to death, and not just insurance. There are loads of other middle men at every step.

I mean fear of deregulation. The truth is that we push politicians to do what we want.

As it stands, people are afraid to completely deregulate healthcare.

Funny enough, even though imo it is the only way. I do think money would stop it from becoming a movement. When’s the last time you saw a leader stand up and say “let’s dissolve XXX three letter agency!”? You don’t see it. Wonder why?

Last one I recall was Trump. Media did a number on him, so much so we can’t even discuss him without worrying about being attacked. Isn’t that something?

Negotiate to pay for medical services with cash - the price difference is astonishing.

The overhead of the insurance companies is insane!

Overhead itself might not be the problem. But it is process it leads to. One way I could see is to mandate one single list price. No discounts. If hospital wants to do charity they can setup fund that pays the bill or part of it back to itself.

Why this obsession with deregulation, it seems to be inconsistent with empirical evidence?

Basically every first world country other than the US has better and cheaper healthcare, but they don't have any less regulation.

> As it stands, people are afraid to completely deregulate healthcare.

The countries that America is compared to and found wanting aren't running completely deregulated healthcare. What makes them different?

It varies. But often it is less regulated or more efficient. There will be 10 suppliers of a generic medication rather than 2 or 3. 8 years for college and med school won't literally include 2 to 3 years of vacation. And so on.

A much simpler first step that I think would be really helpful is:

1) Prevent any group discounts or employer discounts for health insurance

2) Possibly, to go even farther, ban health insurance as employee compensation

Benefits:

1) People see the actual cost of their health insurance

2) People can choose insurance on a competitive market instead of picking between 3 packages their employer subsidizes, so insurance companies actually have to be competitive

3) People aren't forced to pick a difference insurance company every time their employer renegotiates with a different provider, which can also change their healthcare network

4) Lower barrier to leave or change jobs since you can keep paying the same known amount for health insurance and receive the same service

5) Lower barrier to self-employment since you are no longer at a disadvantage for health care costs

For 2) it is much simpler to say something like "employer pays half of the monthly rate up to $X", while you freely pick which insurance. That is how it works in Germany by the way.

Concerning the competition I would caution that from my experience some American insurances lack standards. For example insane copay, cancer not covered or other crazy exceptions. So to have actual competition you should also require by law that all essentials have to be covered with a limited copay and not discriminate. The insurances can still compete on non-essentials (e.g. fitness, cheaper checkups). Otherwise you run into the issue that poor people are forced to buy scam insurance.

Agreed. We actually have some of those standards for insurance packages in the “Obamacare” market.

But many people don’t participate in that market because they get a much better deal with their employer’s negotiated and subsidized option.

Step 1 should be “every health plan is a high deductible health plan.”

Step 2 should be “Absolute price transparency.”

We need to make patients cost-sensitive. It’s utterly ridiculous that there’s a pill to treat low testosterone that’s $1,000 a month when a weekly injection costs $20 a month. Sure, taking a pill is easier and less painful. 99.9% of people would still choose the needle if they actually had to pay for it - and that would mean the manufacturer of the pills would have to lower the cost.

The same thing goes for many other medications and treatments. Why bother trying to price out that MRI if you’re hitting your deductible either way? Not like they’d tell you the cost up front anyways.

Switching everyone to a high-deductible would be disastrous for people with expensive chronic conditions like diabetes. It would force people to forgo treatment or select suboptimal treatment even in the absence of chronic conditions, leading to complications that require further treatment down the line. Not a fan of this idea.

Ideally for the truly low income there would be subsidies, but it’d have to be limited enough for them to still have skin in the game.

The end point is that what are now expensive, chronic conditions would become much less expensive. There would be some pain in the interim.

Frankly I’d be all for tying our drug prices to the prices in other countries. If I were king for a day I’d do both that and what I detailed above.

> 2) People can choose insurance on a competitive market instead of picking between 3 packages their employer subsidizes, so insurance companies actually have to be competitive

You're only solving half the problem. The other half of the problem is that you'll still have no idea as to what you'll be getting for the money you pay your insurer.

I don't really care about whether the copay for a doctor's visit is $10 or $20, what I care about is whether or not I'll get a surprise bill for $15,000 for a medical procedure. And I can't predict which insurer it's more likely to happen with.

When you're buying a pig in a poke, knowing how much you'll pay for it isn't of much use.

Sure, but you also can’t guarantee that without insurance either.

Are you going to ask the ambulance to take you to a different hospital when the first one gives you their rate schedule for heart attack interventions?

That's the other, other half of the problem.

I haven't used it and don't know how good it actually is, but I have browsed for insurance on the Healthcare Marketplace (aka Obamacare) and they set out some pretty strict levels of coverage, services, deductibles, etc. in a standardized way.

But most people don't participate in that market because it would be silly to when your employer gives you a group buy rate plus an extra employer-paid subsidy to incentivize you to be part of the group buy.

You’re still just adding more regulation. More complexity and spaghetti laws aren’t going to solve things. Pre 1970s healthcare costs were in-line with the rest of the world. Revert the push to corporatize and socialize and we’d have cheaper care.

The fact employers pay for healthcare isn’t an issue. Who cares? It’s just part of compensation. I can take my money and do the same thing. No one will btw, they’d just buy cheaper insurance and have a higher out of pocket expense.

End-of-the-day Medicare and regulatory capture is the issue. I can’t go to my local store and get antibiotics, even if I have a test showing strep. Instead, I have to go to a doctors office. A doctor who is intentionally being made scarce (ie driving up demand). Then I get my antibiotics, but they request a follow up.

No amount of insurance wizardry will fix that scenario. You have to deregulate to fix it.

i do think, Insurance companies will insist you follow their rules to cut their costs. Making healthcare worse for you. Even if you were to deregulate, insurance will still be able to apply pressure. IMO ban insurance outright for medical related items. You have a right to medical privacy and the idea insurance is required is BS.

> I can take my money and do the same thing.

It will cost more than the package negotiated by your employer since you are out of the group-rate.

Which means it isn’t actually a free market choice with competition.

Applying free market choice to the healthcare itself sounds great but it’s difficult to make such choices when unconscious in the back of an ambulance, or after a drug company or doctor causes you permanent injury or death.

> Completely defund the FDA

Deconstructing a necessary regulatory agency isn't the solution.

Best case, you end up creating a worse version of the same thing.

Er, "best case" you end up creating a better version of the thing. We are on HN where you always see "Rewrite from scratch in rust, go,..." or "Version 3.0 drops backward compatibility and greatly improves ....".

After multiple decades large agencies probably need big reforms. If you can implement these within the agency, great. If not, splitting off some of the work to a new agency with these changes is a practical option.

FDA 2.0 the complete rewrite is a good idea.

Things used to get overhauled more regularly. The last however was probably 20 years ago with the creation of the Department of Homeland Security. Since then, crickets.

You cannot simply reenact the same policies in a different organization and not get the same problems. Politically, you have to start over on many established political policies. While there would be an opportunity to split the org chart, then introduce new shortcuts and workarounds to the previous implementation, you just restart the same divisive issues with new contexts.

This approach makes no sense to start on. You want an overhaul of FDA policies, then advocate for that unless you have some plan other than throw everything away and let someone else deal with the practicalities.

Phase out medicare? How will poor people afford any kind of care? No matter how efficiently you do things, it's still going to be somewhat expensive to provide modern standards of care. And the poorest people get a lot of injuries, germs, and pollutants.

I think it's not that everyone is chasing their extra 1.5 years at the end. People always did that as much as they could.

A massive portion of healthcare spending (50%) goes to a tiny percentage of the population (<2%). We've grown that population and increased our spending on them in various ways. Back in the day, many issues would not have arisen because the way people lived prevented them, or they would have not been acknowledged as matters for healthcare at all.

- Many kinds of drug addiction basically didn't exist, due to lower availability and a very different social environment. - Diseases of affluence like obesity and its endless related problems. - People would deal with their mental health issues on their own, or with their family. - Many things back then didn't have treatments, which now do have treatments - often expensive ones.

Life was both harsher on individuals and less corrupted by illnesses that come from technology, affluence, and worldly connections. People's every mental and physical issue wasn't held up as a thing for sociotechnological treatment, and they were left on their own, but this also made people have more inner strength and not fall into a pit of helpless victim mentality.

We've gained a tremendous wealth surplus since then, and it seems to be a law of societies that industrial surplus mostly gets consumed by concurrent bio-social deterioration. We coddle and support people who would have been told to deal with their own issues, or just laughed out of the doctor's office back then. For better or worse.

Society is also lower in trust and less homogenous. Because of concerns about discrimination, decisions that would have been made cheaply and informally on the spot now have to be formalized and done through rubrics which give suboptimal answers because they lack human judgment and also consume more resources. Society is way more litigious and doctors have to spend a lot more time and effort covering their asses from lawsuits and accusations of all kinds.

It's a complex issue with a lot of causes.

I suspect Scott Alexander has some good writings on this.

If by "back in the day" you mean the half-century following WWII, the USA had it uncommonly good: dirt-cheap post-secondary education, increasing upward mobility for everyone, low cost of living relative to income, and pensions. That's 3 of the 5 Social Determinants of Health, arguably better on average throughout the 1950s-1990s than post-2008.

To the extent there is a wealth surplus now, it hasn't reached most people. Some of our current situation (including what you call diseases of affluence) feels linked to increasingly insecure prospects of housing, income, and retirement for the people who our increasingly labor-automated economy is leaving behind.

This is all nonsense. Other affluent countries spend much much less, live much much longer, and don't practice eugenics.

“Much much longer”

Imo all western countries are within the margin of error. The real truth is that the US subsidizes the medical fields of Europe.

The US provides protection; which means the EU doesn’t have to pay for military and they dedicated funds to healthcare. Further, all the drug revenue for R&D recovery comes from the US market.

With the countries of Europe gearing up for war. I’m curious if they’ll keep paying for the medical treatments of everyone.

That makes no sense. The point is that those countries spend way less money for better outcomes and your "rebutal" is that they have more money to spend? And pharmaceutical companies just charge less in these countries because of the kindness on their hearts? Eventhough they supposedly could charge much more than the US because Europeans have money left over?

They charge less because those countries would simply go “no, we’re not going to offer that drug for that price” if the manufacturers ask for too much.

If insurers did that here people would be upset, and with their revenue tied to how much they pay out they don’t have much of a reason to.

All that leads to them making up the difference in the US market.

If you look at the US state by state you would see similar outcomes.

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