Hacker News Reader

Comment by thraxil | Hacker News Reader

I worked with Molly for years at the Web Standards Project. We all owe her more than most people realize when it comes to being able to use and build on the modern web. There aren't many single individuals out there who had a larger impact than her. She was also just a lovely and inspiring human and those of us who were fortunate enough to spend time with her are better for it.

As sad as this is, it also isn't much of a surprise if you've been paying any attention. She's been very sick for a long time and publicly struggling with enormous medical expenses (there have been various crowdfunding efforts over the years and she had to sell her `molly.com` domain to pay for treatment).

View on HN

> She's been very sick for a long time and publicly struggling with enormous medical expenses (there have been various crowdfunding efforts over the years and she had to sell her `molly.com` domain to pay for treatment).

My wife and I were both born in the U.S. and have lived here most of our lives; we love this place. The above is why we have zero intention to retire here.

Norway?

Where retire?

You can find many places with good QOL that are cheaper, like Spain. That said, Norway's pension fund is very attractive...

Taxes in Spain are quite high, even by comparison with other EU states. And it is not easy to get residency for long periods of time unless you have significant financial resources.

She died at 60, so no eligibility for Medicare or Social Security. That's a nightmare scenario in the good old US of A. RIP

I understand you, but health care is expensive everywhere. The difference between the US and many other countries is in the distribution of this cost.

So, for example, if a young person from the US or elsewhere comes to Germany to study they will get health care basically for free.

I think (and I might be wrong) if you move to Germany as retiree the public health care system would not be open to you. You could choose a private insurance but, very much like in the US, the premiums depend on age and existing preconditions. I cannot tell if this would be cheaper than in the US, but I doubt that it could be much cheaper. Also, I think it would be similar in most other EU countries.

Of course you could move to a country with significantly lower living standards to save on medical cost, but then you would increase your likelihood of medical issues and not really gain any real advantage.

I'm not German myself, but I'm pretty sure the public health care system is open to all legal residents, no matter what age they move there. But like most countries, there are significant hurdles to immigration, and they would be even higher for somebody in retirement age.

I am indeed German and to the best of my knowledge our health care system is not open to all legal residents. I worded it carefully above, because it is complicated and there might be loopholes, but in general a person older than 55 that has never been in the German health system will not get in.

What if they are EU citizens?

Doesn't matter. Even if you are a German citizen and by 55 you've never been in the health system you're out of luck.

In the above described scenario (US-based retiree moving to Germany), its likely the social security totalization treaty applies, giving them access to the health system: https://www.ssa.gov/international/Agreement_Pamphlets/german...

This is about social security and has nothing to with health care.

In fact it says:

"Although the agreement between the United States and Germany allows the Social Security Administration to count your German credits to help you qualify for U.S. retirement, disability or survivor benefits, the agreement doesn’t cover Medicare benefits. As a result, we cannot count your credits in Germany to establish entitlement to free Medicare hospital insurance."

There might be other loopholes though.

It appears that if an immigrant was previously in a public health care system in their country of origin, they would qualify:

https://www.tk.de/firmenkunden/versicherung/tk-service-ausla...

https://www.krankenkassen.de/incoming/leben/nicht-erwerbstae...

That would cover most EU countries, though probably not the US (assuming that "private, but mandatory" does not qualify as "public").

So correct me if I'm wrong, but:

* Germany has an Obamacare-like system: Insurance is private, but mandatory.

* You can choose and change your insurance provider freely, and they cannot reject you

So if that is true, health insurance companies have the risk of older residents joining, whether or not the previously resided in Germany, and it's not like they benefited from their contributions before.

So how exactly would this exclusion work? Is insurance not mandatory for immigrants after a certain age? Do insurance companies have a right to reject them?

I was not able to find a direct discussion of the question, but this page discussing the health problems of older immigrants (including "access to the health care system") does not mention the possibility that they would be excluded from the health care system altogether: https://heimatkunde.boell.de/de/2013/11/18/ältere-migrantinn...

I think it’s public, not private.

Ah, I was mistaken. I was correct in that insurance is mandatory, but most people get the insurance from a state-run insurance company:

https://www.informedhealth.org/the-german-health-care-system...

https://www.ssa.gov/policy/docs/progdesc/ssptw/2018-2019/eur...

[Corrected to admit my error]

First of all, it is not mandatory for everyone. Anyone with an income above an entry level IT job is exempt, but there are other exceptions as well.

Secondly it is not open to anyone. If you opted out of it at a young age you usually cannot come back (it's a bit more complicated). If you were not in the system for a couple of years and are over 55 you are out. So the US retiree will not get in, but the migrant with a low-incone that worked a couple of years in Germany has mandatory health care forever.

Thirdly, it is not a single state-run insurance company. There are many companies that provide mandatory health care and you can choose freely but you have to choose one if health insurance is mandatory for you. The companies differ in premiums and benefits but usually not by much. They also cannot refuse you if (and usually only if) health care is mandatory for you. The biggest ones are AOK, Barmer and maybe Tk. Bigger companies like BMW run their own ones for their employees.

Of course there are many companies that provide private health care. You can have private insurance in addition or, if you are exempt from mandatory health care, instead of the mandatory providers.

Everything is more complicated, but that is the rough idea.

The insurance companies are private but of course mostly financed by public money.

I think health insurance for civil servants (who are in a completely separate system) is state-run, but regular health insurance is private.

> health care is expensive everywhere

That's simply not true: per capita spending on healthcare (regardless of how that spending happens) is dramatically higher in the U.S. than anywhere else on the planet. For example, Germany spends 60% Per Capita compared to the U.S. https://www.pgpf.org/chart-archive/0006_health-care-oecd Spain spends just over 30% compared to the U.S.

And I've paid for/received healthcare in Portugal, Thailand, Nepal, and England. It's more cost effective (I started to say cheaper and better, but "better" is a loaded word) pretty much everywhere else.

Out of interest: Did you receive public healthcare or did you take out a private insurance in those countries you mentioned? I'm especially curious if you were able to receive NHS health care as (I assume) a foreigner?

When you say cheaper do you mean (private) health insurance or directly paying for medical services, or both?

Portugal: paid out of pocket, no insurance. A trip to the ER to refill a prescription (it's what our landlord told us to do) took about twenty minutes and cost under $30. Filling that prescription cost less than the copay in the U.S.

Thailand: paid out of pocket, no insurance. A trip to the ER for digestive issues took under an hour and the visit plus antibiotics cost under $200. This was at Bumrungrad, one of the best hospitals in Thailand.

I'll double-check, but I'm pretty confident my wife's care in the UK was under the NHS. Nepal was also her, I think it was out of pocket, but I'll check.

Thanks, that's insightful. I take your point from above.

I checked with my wife:

Nepal: she had some form of insurance. She doesn't know how much it cost, but presumably not much (she was volunteering for a non-profit) and her out-of-pocket costs were zero for a multi-day stay at a hospital.

UK: she doesn't remember having insurance, but thinks she must have (she was a student at the time). She used the NHS, again with no out-of-pocket expenses.

Thanks!

That's absolutely false. For example, I buy a brand medication in Europe without insurance for price many times lower than the generic drug in the State's copay! There numerous examples, but most recent example is my wife's Levothyroxine. I buy a German-made medication for $1 in Bulgaria. In the States, a generic version made by noname Indian company has a $10 copay. Same with the Metformin I buy. The original brand medication (Glucophage) I get at around $2/month supply. And this is just meds.

The most advanced MRI in Bulgaria costs without insurance cost a fraction of the copay in the States.

Same for labs. I recently got a comprehensive labs including advanced lipid profile (with lipoprotein(A) and ApoB, cholesterol fractions, etc.) for less than $20 out of pocket with no insurance. Same with my wife's thyroid test - full picture, not just TSH for less than $15. All self-ordered by the way! No need for intermediary companies to authorize it - you just go directly to a lab, which keeps the costs low as there's fierce competition for your business unlike in America where Labcorp and Quest keep the prices ultrahigh!

An quantified American (by Abbott) COVID-19 IgM + IgG antibody test in Bulgaria was less than $20 - here a yes/no test starts at $75.

Again, I'm talking about paying pure cost plus hefty private companies' margins here - no subsidy, no insurance, all up-to-date technology and materials.

The margins in America are unimaginable for any humane organization anywhere in the world. Healthcare should never be a business!

That's from your privileged position but for the majority of Bulgarians an MRI is equally expensive than an MRI for the average American - simply unaffordable.

For most people health care is expensive no matter where they are.

I am talking about absolute costs not affordability. MRI costs might be mostly salaries, but it's not the same for drugs, labs, etc. Given the much bigger purchasing power in the US, prices should be lower, not higher. Why the economics of consumer electronics don't apply to health care? TVs and laptops are much more expensive in Bulgaria, but drugs are way, way cheaper and not subsidized - and these are commodities. Levothyroxine is a commodity available around the globe. Why it's so expensive in the States?! Why are American pharmacies buying generics from India, which so often have recalls due to contamination, and don't buy European drugs (such as from BERLIN-CHEMIE [0])? Because they want much bigger margins - I have no other explanation.

[0]: https://www.berlin-chemie.de/en-us/about-us/our-history

I take your point and learned something, thank you.

> No need for intermediary companies to authorize it - you just go directly to a lab, which keeps the costs low as there's fierce competition for your business unlike in America

> Healthcare should never be a business!

... seems to me like Healthcare should actually be a normal business. Instead of whatever it is in the US - which as you explain, really makes no sense.

Yeah, because it's already a business but non-competitive like in the States. Pharmacies can still sell me medications without an Rx - it's not allowed, but they still do it, because why do I need to schedule a doctor's visit get a medication thats for life (like my wife's Levothyroxine).

The cash price will often be lower than the copay (which isn't a good thing, but it signals that the issue is benefit design rather than cost of provision).

For example, Walmart sells a month supply of levothyroxine for $4 if you don't get your PBM involved.

Yeah, but Walmart generics are made in India by companies known for recalls due to carcinogen contamination. Not that recalls in Europe don't happen, but I'd rather purchase from a pharmaceutical company in business from the 19th century. If US regulators believe that India has more stringent pharmaceutical standards than Germany, then something is fishy! And there's so much corruption in generics [0]!

[0]: https://www.washingtonpost.com/business/2023/04/04/big-pharm...

Extortionist medical insurers coupled with regulatory capture.

I quite like this graph (https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...) on the expense of health care.

One of those things is not like the others.

"Dr. Glaucomflecken" [1] is doing a satirical daily video on the US a healthcare system this month, and the short videos cut right to the heart of the insane practices that reduce patient welfare, from insurance policies to hospital administrators.

[1] https://www.youtube.com/@DGlaucomflecken

F'ing incredible that the USA doesn't have universal healthcare yet. We lose so much efficiency, productivity, and creativity because of it. One of the primary reasons our average living standards keep going down.

Got to fight tooth and nail to protect tax cuts for bajillionaires, yo. Who knows, any one of us might be one someday.

I always scoff at all of the endless "How will we pay for it???" crap. We'll pay for it by cutting out massive inefficiencies like the insurance system (which is basically a giant RICO scam), which would introduce an incredible burst of innovation and efficiency, as Americans got unshackled from jobs they were only in for insurance benefits & were able to take more creative risks and move into jobs more suited for them. Also, the way we do healthcare straight up costs twice as much while also producing less care.

yeah, I find it odd, just add up the revenue of the health insurance industry, that's how much you americans are paying, then see how much profit and overheads they have, that's how much health care money is directly not going to actual health outcomes, and then work out if you can do a better system. Should be a case that overall, everyone pays less and you get better outcomes. But, I can't see it ever happening for you guys. Americans are weird, they seem ok when americans let americans die and suffer, but if anyone else trys it, they spend whatever they have to show the world not to mess with America.

Literally. What is called "profit" in a private industry is what would be called "waste" in a public service. It's literally money that runs through the system and accumulates rather than being used. Ironically when politicians want to run a public service more "like a business", they will try to squeeze the budget to cut costs to in turn justify further cuts until the service fails to do what it was originally meant to do and has to be replaced by a for-profit industry that generates an even larger overhead at even more cost to society once you factor in the fees, subsidies and other factors.

We were just one Senate vote away (Joe Lieberman) from getting a public option during the Obama administration. The law essentially needed a 60% supermajority to pass and it had 59% support of our legislature. Quite tragic - the next generation may get to try again.

Yup. The guy from Connecticut had to side with the insurance lobby. He had been on the ticket with Gore in 2000, so this was a total betrayal by a democrat. He didn’t even run for reelection after that vote, so he just burned everyone for no reason other than he wanted to keep the system we have today that hurts people and helps insurance companies. This guy is trash.

https://www.theguardian.com/world/2009/dec/16/joe-lieberman-...

You can try right now.

It will not stand a chance without a filibuster-proof majority. Time is better spent pursuing policy changes that actually stand a realistic chance of passing.

Politicians claim they're in favor of small business and then refuse to enact the simplest changes (as in, reducing the age of eligibility for Medicare) that would reduce business overhead.

OOH LOOK a shiny new proxy war we can grift off - lets make sure senators with no business there get to go schmooze with the top brass as we siphon through the MIC!

The US is a plastic Imperialist joke of "democracy" -- its Oligarchs all the way down. Always has been.

Bootstraps and all that…

Lots of people don't want universal health care for reasons that are not incredible. I've had employer provided insurance I'm happy with ever since I left my student insurance plan over 25 years ago and have few complaints about it. I'd prefer not to risk transitioning to a universal system that might provide worse care than what I've always had. Kaiser in CA for example is the worst insurance I've had - would not want to return to anything like that where there is a single network of providers. That was my mistake though - I didn't have to choose Kaiser, I had other options.

Universal health care doesn’t preclude the existence of private care. A number of countries have universal public health care, but if you want to pay extra, there is also private insurance and a private network of physicians and hospitals.

A number of countries have universal healthcare largely acheived through private providers and insurers, e.g., through means-tested subsidies and coverage mandates.

In addition to that: Universal health care does not mandate a single provider. Where I live there are many health insurance companies to choose from, some are statuary others are private. All it means is that the statuary ones cannot deny you as long as you fulfill certain requirements ("Universal" health care is never really universal).

So I would have to spend more for the same care I have now? No thanks.

Not necessarily. For some countries mandatory public health contributions plus good private insurance, can still work out to cheaper than good private insurance alone in the US. This is because when private insurance has to compete with a universal public option, prices go down.

"I'd prefer not to risk transitioning to a universal system that might provide worse care than what I've always had."

Your insurance is employer provided? You risk that every day then. Lots of people in the past few years have woken up to find out that their job - and with it their employer provided insurance - has gone bye-bye.

Yeah, we have COBRA to continue it at exorbitant rates for some period of time. But health care should not be tied to employment.

I'd be OK with a universal health care system where employers can offer better but everybody has a baseline health care where nobody - absolutely nobody - has to struggle to get basic healthcare. (And that includes dental and vision, which is absolutely boggling that we've decided "oh, those body parts are not included.")

It's a minuscule risk I'm comfortable with and manage actively. I got into this line of work because there's high demand. I haven't been without a job and make all of my career related decisions to optimize continued employment. I got bored of software 20 years ago and really am only in it for the insurance and pay. I've been laid off and gotten another job the same day.

> I got bored of software 20 years ago and really am only in it for the insurance and pay.

And you don't see how this is a horrible state of affairs? What of those who are forced to the same, but in careers that are actively harmful to their person?

I’d transition to worse and more expensive healthcare if that’s what it takes to get to healthcare for everyone.

The transition will be painful for many who have good employer provided healthcare, but at least then we’ll have a somewhat unified voice demanding better care at better costs.

Every politician would be beholden to every voter on healthcare issues during every election.

So millions of Americans don't have access to healthcare and die early because they can't afford it, but you don't want things to change because you're comfortable? Got it.

I advocate for myself, others should do the same. Medicaid is there for retirees and disabled folks and the rest of us should be working. I don't know what these millions you mention are doing where they can't afford healthcare, but there are plenty of job and education opportunities out there that will provide insurance if you're willing to study and work, which I think is fair.

What if someone trying to pay for their kid's chemo hit you over the head with a hammer to take your wallet and left you unable to continue your current line of work?

I never quite understood this fear that you're going to lose some benefit of the insurance you have now. It's not like all the hospitals and doctors suddenly go away so if you have a preferred doctor or facility you'll most likely be able to keep going to them and you'll have more choices as every place will be "in-network". Contrary to your experience, I've had good results with Kaiser and one thing I like about it is not having to call around to various "in-network" providers to find out if they are taking new patients and if they can see me.

Ah the age old “F- you, I’ve got mine”.

Twice in my career had the insurance plan swept out from under me. Both times my decent, but not great PPO was replaced with HSA only options. Forcing me to change jobs.

Personality, I’d rather not have my insurance options tied to the whims of a CFO and whatever kickbacks they’re getting.

An easier first step would be to force all healthcare and hospitals to be non-profit, and never enter the stock market. Shareholders want profit, and an easy way to profit on healthcare is to deny benefits.

Reply on news.ycombinator.com