Average physician salary in the US: $352,000[2]
That’s a big chunk of the difference. Simply changing who pays for your healthcare won’t close that gap.
[1] https://www.erieri.com/salary/job/physician/france#
[2] https://weatherbyhealthcare.com/blog/annual-physician-salary...
What is most baffling to me, as someone who isn't from America, is how expensive even the most basic tests are.
A CT or MRI (which are admittedly expensive machines) scan shouldn't cost >$1000, and it probably doesn't anywhere else in the planet.
[1]: https://www.npr.org/sections/money/2019/03/12/702500408/are-...
> Baker estimates that the salaries of the roughly one million doctors in the U.S. account for about eight percent of total healthcare spending.
> What is most baffling to me, as someone who isn't from America, is how expensive even the most basic tests are.
If you understand the former, then why is the latter baffling?
The cost of any tests includes labour...
I feel like this is the crux of the US's issue. We have medical care deserts and for many people the hospital is the only way to get something taken care of. This is where the US is different from many other wealthy nations. We really don't get economies of scale at all. We have cities, but a lot of our major cities juet have nothing like the population of other nation's major cities.
If I may ask a personal question, why?
https://en.wikipedia.org/wiki/List_of_countries_and_dependen...
I don’t think this is it. European cities aren’t that big compared to American ones. So Spokane is larger than Geneva. The problem is there isn’t much in terms of healthcare between Spokane, Boise, and Minneapolis.
In Geneva's case, it is composed of several different named cities/towns/etc and those taken together are bigger than Spokane plus the municipalities that comprise its urban area.
And Spokane is a small case. There is nothing comparable to the Seattle metro in Switzerland. The closest you get is Paris in France or Milan in Italy.
I have no connection to the company other than as a satisfied customer.
This is exactly the attitude as to how American costs are out of control. If American healthcare budget was halved (which is still much more per person than other nations), then physician salaries would be 16% of the total. If American healthcare budget was a quarter of its current total (in line with many other nations spending), then physician pay would be 1/3 (32%) of the entire spend!
Clearly, if American healthcare is going to see a 1/2 or even 3/4 cost cut as the proponents of universal/single payer healthcare predict, then physician pay must take a similarly massive cut.
Just as you can find reasons why physicians cannot take a pay cut, so too can every slice of the pie claim that their slice is valid and uncuttable.
Why does just about every doctor in every universal system make dramatically less than their American counterpart? Is their expertise worth less?
A lot of areas already have trouble attracting doctors at all because they can’t compete with the money offered by bigger richer cities. If you want cheaper doctors, something else will have to give, or supply will just plummet.
Most of those doctors European doctors probably got their degree with almost no tuition paid. If I wanted to become a doctor I could start now, and finish in 5 years with zero debt. It wouldn't be an "investment" in any more than my own time and effort.
But I think this shows that the healthcare is just one part of a large interconnected system of things. It's not easy to change into a french or UK or scandinavian healthcare model with great savings if doctors expect to make $300k/year because they made an investment. So single payer universal healthcare might need more doctors and nurses trained with tax money? But when I go to a university to get my tax-funded MD, that university is most likely a public institution too. You wouldn't have a university taking a huge cut of that money.
On the other hand: a US resident dr makes what, $60k? That's comparable to European doctors. I wouldn't make $100k for quite a few years. The first "residency" period here would proabably be more like $50k or even less. But with zero debt that doesn't sound horrible.
I think it's basically a fantasy to imagine that the US could have affordable healthcare if only the system was reformed. Rationing of various kinds is the norm in single-payer systems, because everyone wants the insanely expensive new drug when it's their health and someone else is paying; I don't think that America can do much to control their healthcare spending if they aren't willing to engage in a serious conversation about what they don't want to pay for. Even Medicare covers tons of stuff that I wouldn't get from my universal single-payer system.
France is one of the less efficient in europe due to having a dual system, the universal part is very efficient (5% of budget spend on operational costs), the other part, operated by competing organisms, loses up to 20% of their budget on marketing, plus the general operating cost of having a multi tier for insurance coverage.
US healthcare spending 2023 [1]: $4.7 trillion, 16.6% of GDP, $12555 per capita
France healthcare spending 2023 [2]: €0,34 trillion, 12% of GDP, $6630 per capita
How many physicians can you hire or pay better with an additional $4.x TRILLION?
[1] https://www.oecd.org/unitedstates/health-at-a-glance-United-...
[2] https://fr.statista.com/outlook/co/health-indicators/health-...
That line forgets the size of the populations. US population is 333 million; France is 65 million.
How many more physicians can you hire with an additional $6000 per capita? That is a relevant question.
Holy cow, really? Is this a case of over-diagnosing things, or are virtually half of Americans legitimately struggling with multiple health issues?
There isnt much incentive in the US to prevent disease, doctors make their money from visits fees, procedures, etc. Not saying they purposefully make people sick, but I think there is some Darwinism in a system like this -- a hospital system that keeps people healthy would wither and go bankrupt because hospital systems dont get paid to keep people healhty, they make most of their money when people get very ill.
what usually causes this also causes a bunch of other chronic issues. So, yeah.
Life expectancy rates in the US were going down before COVID. Chronic illness.
The numbers aren’t looking good. Unless you’re trying to make money on healthcare. Healthcare income goes up when health goes down. Capitalism.
Far more than a super majority of those with high cholesterol are due to lifestyle. At my least yearly doctors appointment I asked about the genetic case. My doctor, in his mid-40s, said he had only had a few patients with that in his career. I've listened to lipid PhDs lecture and they talk about it being rare but present.
We cannot change the genetic case. But everyone else can be affected.
I was talking with someone recently who changed her diet. In a matter of weeks her LDL cholesterol dropped 50 points.
Can you provide any basic literature on how large of an effect can be achieved through lifestyle alone? It sounds like my vaguely recalled ~15% is way, way off.
(I do wonder how statins are so easily justified if lifestyle is so effective, but pharma profits/lobbying may explain that.)
Instead we as a country are glamorizing obesity, which has become a bizarre and deadly trend in the USA, we should attack it like we did smoking.
Even my local doctors office is advertising how you can be 'healthy at any weight' - talk about gaslighting, no you cannot.
Without a doubt the 'healthy at any weight' campaign is directly or indirectly funded by food companies and drug companies - neither of them which want thin and health populice.
The body positivity movement, plus sedentary lifestyles, plus the increasing cost of healthful foods, the time it takes out of your day to exercise, almost mandatory amounts of sitting in a car daily… there’s a lot of factors in modern American life that are just bad for our health. It’s not just the money spent on healthcare.
in many cases, when looking at total life spending, things that kill you earlier actually can reduce total life spending (smokers are a great example) because it means you don't incur the three knee replacements and bouncing in and out of hospital for the last 2 years of your life and spend the last 2 weeks dying in an ICU. Having a heart attack and dying on the surgical table is pretty cheap in terms of total healthcare spending.
Obesity is still cost-positive, but it's a lot less than you think from numbers like "X% of total medical funds spent on obesity" - you are going to substitute around 50-75% of that cost in cancer treatment and knee replacements instead (see table 2).
https://dom-pubs.onlinelibrary.wiley.com/doi/full/10.1111/do...
anyway, one of the problems is that obese people are massively stigmatized and shamed. they are already treated worse (and receive worse medical care, etc) than others, for every moment of their lives, they have constantly-reinforced negative body image, which is psychologically unhealthy to impose on people. And the point of "healthy at any size" (when not taken to an absurd extreme) is to get people to at least feel like they aren't so far gone that it's pointless to make better choices, because starting to make better choices are the foundation of starting to climb out.
This is usually met (even here, in past discussions) by some variety of "good, they should feel bad", and "well, I was fat and it helped me!", but that's basically a riff on "my parents spanked me and I turned out fine". Not only is that probably not a medically-supportable opinion (stress and fear are themselves powerfully negative causative factors that place actual physical damage on the body over time), but not everyone's brains work the same in the first place. What inspires you to improve might just reinforce someone else's depressive spiral, a lot of obese people have very negative body image ("good", says the peanut gallery).
Black Mirror wasn't wrong, people love having an underclass to look down on, and obese people are a very visible and very socially-acceptable underclass to punch down on. A "steelmanned" view of HAES, when not taken to ridiculous extremes (and I'm not saying nobody does!) is that it's simply asking that we not go full Black Mirror on shaming fat people, but frankly I think a lot of people don't even agree on that much, or that it would be a good thing. "It's for their own good" etc.
The whole reaction to the idea of HAES, itself, is a microcosm of the social problems around obesity and self-image - how dare you feel good about yourself? Why aren't you going through every day in a haze of shame like you deserve to? It's for your own good!
While obesity is a huge issue and a huge cost factor, there are more obese countries with nevertheless a tiny sliver of the US medical budget - even after adjusting for life expectancy.
Some issues could be resolved completely if attended to early, but instead the patients suffer until they have no choice.
If it were free/cheap to visit a doctor then more people would go, which would cut down on long-term suffering.
and doctors don't even try to solve that problem anymore - they just push pills to counter the bad diet and bad lifestyle.
You can point to activity levels, but weight is about food consumption, not activity levels, and (eg) Aussies are a pretty car-reliant culture too. Pretty much any way you can argue that the US is "unique" - it's not, we are a culture exporter and some other place has inevitably picked up some of our habits.
Americans aren't even uniquely fat anymore. There are other populations (like aussies) that are getting close to our obesity levels and they still don't 5x their healthcare spending. And the idea that obesity makes up even a simple majority of total healthcare costs (as it would need to be for this to be the factor that 2-5x's healthcare spending) is generally ridiculous.
(also, paradoxically, a lot of things that we think of as unhealthy actually reduce total life healthcare spending, because US care is heavily weighted towards end-of-life care. It's cheaper to die of lung cancer at 40 than to have three knee replacements and spend a month in the ICU at 80, and US health care is heavily weighted towards the latter because of medicare, everyone else struggles to get affordable access to the system.)
Like it would be interesting to see an attribution of what specifically americans are eating so differently vs everyone else, and the caloric/macronutrient balance and total inflow/outflow, and total life expectancy (and total spending) changes. I suspect it's just a "how much of it" more than anything, but the "gosh americans just eat like shit, that's why!" really doesn't justify 5x per-capita expenditures on the face of it, in the way people try to use it. The rest of the world drives cars and eats like shit, and eats too much too, in varying proportions.
But to go back to spending - it's really hard to argue that it's any one thing. It's everything. Everyone at every layer is bleeding everyone else. Americans are a bit unhealthier, but we also have for-profit hospitals (even non-profits make a "profit", it just goes into real estate investments), for-profit insurance, doctors who make $400k because they need to pay off $300k of loans from for-profit education, drug and device manufacturers who have no cost containment before approvals, a political system that tolerates evergreening and similar practices, an "access problem" for delivering basic care before it escalates into expensive problems (even "preventative care" often still ends up costing), etc etc.
That is really the problem and why the system cannot be reformed. Medical care is at the nexus of every single "unsolvable problem" of the US political system, from patents to education to farm-lobby and environmental regulation, and it involves a million taking hands that after a true reform will no longer be able to take. There is a lot of people who have become reliant on the revenue streams from this rent-seeking/unproductive activity, and they will lobby heavily to make sure they can keep taking.
1. Where “western diets” go in the world we see healthcare costs go up.
2. The US fits the bill for about 90% of the global R&D costs on healthcare. Many universal healthcare systems only fund existing methods.
3. The US is more unhealthy than most other places. This can be observed with higher percentage of the population having chronic illnesses.
People wake up, go to an incredibly stressful workplace and use up all possible productive hours of the day, come home extremely tired, pop on the incredibly stressful news cycle and get permanently angry as they eat their TV dinners, then fall asleep in their chair as the news continues to unsettle and disturb them even in their most peaceful moments. I've seen this over and over again, it's how a lot of people live here.
There's a million places a resolution to this type of issue could start, but damn it's gotta start somewhere!
Most doctors are never taught to deal with lifestyle. It’s sick care with things like medications and surgery. Doctors office visit won’t address this for most.
I agree - it won't come from doctors - there is no financial incentive to keep people healthy.
and even more so, patients don't even want to hear it, they want the magic pill instead.
What if people just never had most of those issues that require treatment?
In a healthy individual, cholesterol intake is not related to blood cholesterol levels (beyond some reasonable threshold, like not eating a tub of lard in one sitting).
So, just keep in mind with these types of news, it might be more economical system overall when you look just the numbers, but it's not like everything is working great in EU either...
Are you in a city, perhaps? That is not universally true across the US, in my experience.
> That’s a big chunk of the difference.
The math disagrees with you.
Are you confused as to the meaning of 'big chunk'?
It by no means implies a majority or even close to a majority.
If you are confused about my previous comment, I added the 40% to 50% example to demonstrate the likely overall contribution of salaries to costs.
This appears to be a random pseudonym account so it's unproductive to phrase it in this way, because it requires a lot more credibility to back it up.
A simple counterexample: I clearly think 10% is fine, and I've met at least a few dozen people who share a similar view. Which suggests it's a common enough sentiment among HN readers.
I've met at least a few dozen people who share a similar view. Which suggests it's a common enough sentiment among HN readers.
Like who?
It appears to reinforce my point, in that it never defines 'large chunk' to have any specific range of values. Certainly not anywhere near a majority.
> Like who?
Some of the human individuals I've met and talked with throughout life.
This seems like ignoring the question, so the opinion is noted, but it doesn't sound convincing.
I still stand by my belief.
Is there some rationale behind the seemingly incredible agitation, and bizarre attempts at deflecting direct questions?
Otherwise this just seems like a self-parody.
If you'd please review https://news.ycombinator.com/newsguidelines.html and stick to the rules when posting here, we'd appreciate it.
I have many friends who are doctors. There is the salary they make, and then there are all the extras. Some have used their salary to buy the equipment in their office, and charge thru for equipment usage (added money on top of salary.)
Some have used their salary to buy the building used for their medical practice, and charge thru the facility fee (added money on top of salary.)
I agree both are "investments" but it is a non-traditional investment where you have a huge edge and a ready customer.
Politicians pushing single payer or similar such state owned entity are just looking for power and influence.
Also I don't think you can come up an example where transitioning from private to state operated enterprise has improved the quality of service. Tragedy of the commons/OPM etc.
We also need to consider hospital, ER and ambulance costs.
In this case, having a single universal plan can greatly reduce those costs.
https://www.pgpf.org/blog/2022/11/how-much-does-the-united-s...).
You also factor in a percentage of their salary incase you need to exit them (maybe doesn’t apply to doctors). I’d assume the states is still ahead but not as drastic as the shared numbers
I mean, it absolutely will.
Well, look at all the other countries where universal healthcare has been implemented.
> The government essential funds colleges educations (through loan guarantees and grants etc) for tens of millions of students - has that driven down the cost of college?
Look at all the countries with free university. Yes, the cost is lower.
> or did it have the opposite affect?
Fixed fees and a single payer obviously would have that effect, like everywhere else it's been tried.
Oversimplification. Most countries that have universal healthcare do many other things in addition that you aren't accounting for. The US healthcare system is not the same as Europe's but its not single payer.
>Look at all the countries with free university. Yes, the cost is lower.
See the above.
>Fixed fees and a single payer obviously would have that effect, like everywhere else it's been tried.
So now you're starting to get the idea. It's not just single payer. Never was.
Edit: I do love the deliberately obtuse comments from Americans on political topics like education, healthcare, gun control, etc. It's hard to believe intelligent people honest hold these absurd views.
I'm not saying single payer wont work. I'm saying single payer on its own isn't a solution because so much more is broken that isn't broken elsewhere.
If students were given grants, and universities were given grants, and that was all the money on the table, what pressure would there be to increase the cost of tuition?
None - and we know this because the more the system was privatised and deregulated, the more fees started shooting up.
Forced debt is slavery. Whether it's medical debt, educational debt, or rentier landlordism, it's the deliberate creation of unnecessary scarcity to reduce the personal agency of most of the population.
Physicians per 1000 people:
Germany: 4.25
France: 3.27
USA: 2.61
One of the major reasons the U.S. has low physicians numbers is because med school is just so expensive. You either have to pay a ridiculous amount of money upfront, but more importantly, need to figure out how to pay for your existence for nearly your entire 20s where you’re studying and not earning, or you need to take massive student loans.
That’s just too much of a ln upfront burden or risk for large chunks of the population to take.
Doesn't the US also require that people study medicine as a second degree? That can't help with the costs...
e.g. Here in the UK you can go straight from high school to study medicine at university.
How can they be more restrictive when they are licensing way more doctors? USA is at the bottom of the developed world in number of physicians per capita but also pay the most. The only plausible way that can be true is if USA is the most restrictive in the developed world, like requiring way more years of schooling than necessary or limiting residency spots or limiting how many schools are allowed to educate doctors or making it hard for immigrants to become doctors etc.
Japan has less doctors, but they are also among the healthiest in the world so maybe they don't require as many for that reason. But USA is at the other end of the healthiness spectrum so you can't use that explanation there.
The cost of employee is around an additional 22% of Salary in France but around an additional 140% in the US [1] (401k, SSA, Health Insurance, etc), which brings the total spend much higher in the US.
[0] - https://www.internago.com/how-much-does-it-cost-to-employ-pe...
[1] - https://www.sba.gov/blog/how-much-does-employee-cost-you
Those 22% you mention is extra cost for employees, on top of the gross salary (in Croatia that's called gross1, while the actual total amount for employees is called gross2)