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Comment by UnpossibleJim | Hacker News Reader

It's a matter of priorities. If we decide these things are important as a nation they don't have to be scarce. We make the best war machines on the planet and spend a lot of money on them. That is more of a priority than the good health of our nation.

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We spend 5-8x more on healthcare than defense. You have to ration somehow. If everyone use as much of the healthcare system as we wanted it would consume our society.

In the US, we ration by price… “the doctors expensive and I don’t feel too bad so I’m not going to go”. In Europe, they ration via lines… you’ll get your free healthcare eventually.

Either way there are problems, but seems like other countries might be onto something

We pay a lot for healthcare, but that money is not spent on healthcare.

It is an important distinction. For example, about 33% of healthcare dollars go to paying “claims proceesing” people at your insurance company and your doctors office to haggle with each other and produce duplicate paperwork.

If the low end of your estimate (5x) is the correct multiplier, the money that goes to claims processing would be enough to pay for universal healthcare in pretty much any other first world country.

Other things, like absurdly high drug prices, also are not healthcare spending. 90+% of drug discovery research money is spent at universities, and not by pharmaceutical companies. Also, those companies pay more for prescription drug advertising than for drug research.

"90+% of drug discovery research money is spent at universities"

Afaik this is simply not true, and even if it was, this would be misleading if you consider that most costs are made during clinical trials, which test the effectiveness of the drug.

> It is an important distinction. For example, about 33% of healthcare dollars go to paying “claims proceesing” people at your insurance company and your doctors office to haggle with each other and produce duplicate paperwork.

This is not true, but there is a big non patient healthcare services culprit in US healthcare costs, and that is legal liability. In the US, every entity in the healthcare chain is doing so much extra to prevent themselves from being liable, and charging extra in case they are found liable, that it inflates all costs dramatically.

Without tort reform, I doubt we see much improvement.

Tort reform is a red herring here in that most insurance companies do things that they deserve to be sued over as a matter of routine, and they like to talk about ways to statutorily limit your right to sue them like having a system of complaints with a commissioner who has no time to process complaints. I think healthcare costs are a result of lots of different insane things that snowball rather than something simple like too many lawsuits.

What’s the easiest, ocams razor solution here? Tort sounds easy

Here in TX they put caps on awards for medical malpractice. As far as I can tell it hasn't helped costs all that much. Also if my Dr. leaves me paralyzed I can only get 500k damages. Malpractice law is a problem, but I don't think it's the one to focus on.

Good point to be able to compare different states.

Your numbers are way off. The Affordable Care Act capped the insurance company's share at 20% (minimum 80% medical loss ratio). In practice most commercial payers are taking less than that. Certainly nowhere near 33%.

I'm not sure what point you're trying to make about drug discovery research. The major expense in bringing a new drug to market is not in the basic research but in the phase-3 clinical trials. Those often cost pharmaceutical companies upwards of $1B now.

How much do pharmaceutical companies make off of that $1b investment though? The scale of the investment only matters if they don't have the capital to cover.

Pharmaceutical company profit margins are generally in the 15% - 20% range.

https://www.gao.gov/products/gao-18-40

By comparison, several major tech companies have significantly higher profit margins.

That's more an argument against major tech companies than for pharmaceutical companies.

Citation for the 33%?

It’s a common argument that somehow people who live in countries with good health coverage have to wait a very long time for health services. Things that are not urgent, this can be true. And you can certainly hear anecdotes here and there about more serious problems. But most of the time for the vast majority of people in the vast majority of situations, healthcare is delivered when it’s needed, on time, without dangerous delay. This talking point that somehow elevates the American approach because it is faster is misguided.

A war machine can be built once and maintained for a long time. Medical care is a personal and time consuming process with multiple parties and tests that need to be coordinated across. All of this is expensive because for every person being given that time of day, there's someone else that needs it. There aren't enough hours in the day and smart people in the country to scale up healthcare.

Contrary to what we would like to believe, there is a scarcity of intelligent people willing to devote their entire lives to the study of medicine across specialties.

If you cannot afford it, the US healthcare is terrible. If you have the means to afford it, the US healthcare system is one of if not the best in the world.

> If you have the means to afford it, the US healthcare system is one of if not the best in the world.

That's unfortunately not even the case. Americans spend more money on healthcare AND have worse outcomes.

https://jamanetwork.com/journals/jama/article-abstract/27843...

https://www.healthsystemtracker.org/chart-collection/quality...

https://www.pgpf.org/blog/2022/07/how-does-the-us-healthcare...

A big part of why we spend more is cultural and environmental. The government incentives encourage unhealthy food to be everywhere and subsidizes things like adding corn syrup products to everything. Policy also encourages driving instead of walking. And we've made it culturally acceptable to be fat. There are big movements trying to convince people their weight is not a problem, not something they have control over, and you can be "healthy at any size". Many doctors have stopped warning patients about their obesity because of social pressure not to fat shame! I started with a doctor like that when facing blood pressure and related issues and have since ditched them. Caring more about sensitivity, being accused of fat shaming, and expediency than my health is malpractice in my book.

All of those sources are discussing average outcomes across the entire population.

None discuss outcomes among only those who "have the means to afford it" so none of them refute GP's claim.

Correct, where do the princes and sheiks of the Middle East head when they need the best medical care money can buy?

I’m not at all convinced they look carefully at health outcome and cost efficiency metrics before deciding where to point their private jets. Instead, I’ll bet (in part) they use high cost as a surrogate for quality. And the immediate availability of any test or consultation they desire.

> If you have the means to afford it, the US healthcare system is one of if not the best in the world.

This is untrue according to all metrics I have seen (such as life expectancy). Do you have any evidence to back this statement up?

It depends on which metric you look at. The USA is at or near the top in 5-year survival rates for most types of cancer. We also have unrivalled trauma care. In other metrics we're well many behind other developed countries.

Many of our worse outcomes though have nothing to do with the healthcare system. The decrease in life expectancy is being driven by factors like obesity, substance abuse, sedentary lifestyles, vehicle crashes, suicide, and violence.

survival rates are a pretty bad metric because you can easily change them by changing the amount of screening without making people live longer or healthier. when you compare cancer mortality rates, the US is not doing well.

Nope. Certain types of cancer screening are helpful in making people live longer and healthier. It is much easier to treat cancer when it is caught early.

Absolutely, but 5 survival rates are still a really bad metric because they make things look better even for uncurable cancer (or cancer that was curable but treatment was given up on because of price). Also, if a 90 year old gets a slow growing cancer that doesn't require treatment (cause they'll be dead before it's a problem), screening for it will increase survival rates even though you didn't actually treat anything.

The drivers of poor US life expectancy is mostly guns and cars. Cars are the #1 killer of Americans between 5 and 45 (approximately). That doesn’t have much to do with the medical system.

Leading causes of death in the US: https://www.healthline.com/health/leading-causes-of-death

10 of the leading 12 causes of death are diseases, with the first non-disease cause coming in at #4.

You missed the point. Cancer and heart disease primary kill people when they're already old. Treatment of those diseases, while important and necessary, doesn't impact average life expectancy much either way. Whereas fentanyl overdoses are now the leading cause of death for adults 18 - 45. That has a huge impact on average life expectancy because those people would have otherwise lived many more years.

https://www.gbhoh.com/fentanyl-becomes-leading-cause-of-deat...

OK, here are the leading causes of dying at various age groups: https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_dea... and unintentional injuries comprising: https://www.cdc.gov/injury/wisqars/leadingcauses.html

I still fail to see cars and guns being the leading cause of death.

Do you see something I don't?

Your information is outdated. The rate of accidental death among younger adults due to opioid poisonings has increased significantly in just the last few years.

https://peterattiamd.com/anthonyhipolito/

https://www.statesman.com/story/news/politics/politifact/202...

> death among younger adults due to opioid poisonings

The point under debate is guns and car accidents being asserted as the leading cause of death. I continue to assert it is not true.

My primary assertion was that life expectancy does not inform you about the quality of the US medical system. I focused on guns and cars, but adding opioids (and even lifestyle issues like obesity) doesn’t change my argument or the conclusion.

Someone dying a few years earlier than otherwise has a smaller impact on _life expectancy_ than someone dying young. Furthermore, the #1 cause is correlated with lifestyle factors which medical treatment has little control over.

You can see the breakdown of life expectancy reducing factors here, none of which are attributable to "limited specialized treatment": https://ourworldindata.org/us-life-expectancy-low

> A war machine can be built once and maintained for a long time.

This might be true in theory but is somewhat irrelevant here given the gargantuan levels of waste in US military spending.

There is also gargantuan waste in healthcare costs, but those are spread out via insurance, not taxes.

The presence of gargantuan waste in both sectors and the different avenues of spending both make any after-the-fact, simplified explanation of why one costs more than the other kind of moot.

The presence of gargantuan waste should also be addressed before implying that the costs of healthcare are all presumed necessary.

> Contrary to what we would like to believe, there is a scarcity of intelligent people willing to devote their entire lives to the study of medicine across specialties

Why? Are money and social status insufficient motivators? Or is there another reason?

There is no country on the planet that doesn't have a scarcity of medical resources. In fact there is an entire set of academics devoted to the appropriate utilization of medical resources - healthcare economics.

Cuba?

Artificial crisis no? Doctors keep split low

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