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Comment by frereubu | Hacker News Reader

Are you accounting for things like free healthcare when comparing wages? (I wish I did't have to say this, but it's a genuine question, not snark). I always wonder when people compare other countries to the US.

Edit: I agree that Brexit was the most incredible piece of self-harm that I've seen a country do to itself. I certainly don't have rose-tinted spectacles about the state of the UK.

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I think most Americans over-index on the cost of healthcare and the availability of insurance because it’s constant in our news and our system absolutely sucks. Most people don’t need regular medical care because most people are healthy (until they start getting older). It’s expensive, sure, but most people in the middle-class have employer sponsored healthcare, and retirees have government sponsored healthcare, and many low-income people have government sponsored healthcare. The difference in out-of-pocket costs is easily accounted for within significantly higher salaries.

Of course, the issue is not the actual availability of insurance, it is that there is a patchwork of laws and protections and it’s not universal to be covered at any point in your life. But many states have well above a 90% insurance rate. California, the most populous state, has 93%. Massachusetts is sitting at 98%. Even Texas, the worst state for health insurance, is at 85% of the population covered.

I quit my job as a dev to care for my father who has dementia. Using COBRA and paying for the identical health insurance I had from my employer is $1,000/mo. I have no dependents. California minimum wage annual income is ~$32k. Almost half the income of someone who works a shit job. I'd say that almost 50% of minimum wage just for the privilege of going to a doctor when I have a problem is rightfully a pretty big deal.

This is the issue with American healthcare - it’s super confusing and people don’t even understand that they have better options. And of course, living with a super pricy COBRA plan while being unemployed is not the normal experience for people, and also not the actual “optimal” way to get healthcare in that situation.

COBRA isn’t meant to be a full healthcare insurance, it’s meant to be a “bridge” care for people in between jobs (that’s why it’s tied to your prior employers plans). You also don’t even need to pay the COBRA premiums unless you actually use it, so you can save that $1K/mo while being implicitly insured (helpful in case you only really want to be insured against catastrophic accidents).

If you were not working because you were caring for a dependent (like a sick adult), or if you’re a minimum wage worker, you wouldn’t use an employer sponsored plan through COBRA, you’d use Medi-Cal (California’s expanded Medicaid) or the ACA marketplace, and could be “free” or ultra low (premiums). Medi-Cal is free, and the ACA plan for a 45yo male in SF making Cali minimum wage (34k/yr) would pay $18/mo.

Healthcare is absolutely a “pretty big deal” and absolutely the system is terrible. But if you actually made 34k/yr, it probably makes sense to spend 1hr googling for the actual programs that exist so you’d discover that you can get it for much cheaper.

I take a biologic that costs $5,000 a month without a prescription. $1k a month is honestly easier and I can afford it. I enjoy the luxury of being able to afford to not have to navigate the stupid “oh, so you’re poor” patchwork bullshit that exists. My roommate is not such a person.

No, that's not how it works. Poor people who lose coverage from employer-sponsored health plans don't pay COBRA premiums out of pocket. They spend much less to either buy a subsidized health plan on the state exchange or go on Medicaid. The system is a mess but let's not exaggerate the problems.

I can’t imagine getting Medicaid to cover the biologic that I take that costs $5,000 a month without a prescription to be anything other than a nightmare.

>The difference in out-of-pocket costs is easily accounted for within significantly higher salaries.

Any sources for this?

Salary Info (25k USD salary difference, before tax)

https://en.wikipedia.org/wiki/List_of_countries_by_average_w...

Cost of healthcare:

There are a bunch of numbers that are trivially accessible via Google, including government sources, but I couldn’t find any that match perfectly with the time range of the wage data.

Here is one quote, from a few years earlier…

> Median annual out-of-pocket spending on medical care ranged from $360 (Hawaii) to $1,500 (Nebraska). In four states, households in the top 10 percent of out-of-pocket expenses spent $7,000 or more on these items.

https://www.commonwealthfund.org/publications/issue-briefs/2...

Roughly speaking, when I've looked into this comparison, for near-median earners, they're better off in the UK, because of things like healthcare. But when you look at the higher-earning roles, especially engineering or software, then the different in pay more than makes up for the increased cost of living (i.e. a higher percentage of your pay may go towards cost of living, but the smaller percentage of money left over is still larger in absolute terms). There's other tradeoffs in terms of work culture and so on, though (e.g. you get much more holiday in the UK).

Can you share your research?

In the US, the average out-of-pocket healthcare spending was $1,424.6 per capita in 2022

Most people have insurance. They might have some high out of pocket maximum like $10k. So worse case scenario you're out an additional $10k.

But you pay a lot less in taxes

In US, a single filer, the 12% bracket covers income from $11,926 to $48,475. In UK it's 20%

So at 40k you're paying an additional 3k in taxes, not to mention VAT and others (although I am ignoring other US taxes like state, local and payroll). More than covers your out of pocket healthcare costs.

And pretty much any job in the US is significantly higher paying, for instance a typical accountant in US makes 80k while in the uk that 37k pounds. Pretty much every office job is like this. And note the US 80k figures includes benefits like ... you guessed it, healthcare!

Even if make the generous assumptions that taxes are the same, UK has same healthcare quality and everyone is hitting out of pocket max every year, it's still not close. The whole "but we don't have to pay for healthcare" strikes me as just a cope.

https://www.statista.com/statistics/484578/us-per-capita-out...

https://www.allbusinessschools.com/accounting/salary/

https://uk.indeed.com/career/accountant/salaries

I think if the health insurance situation was as rosy in the U.S as you make out there would not have been as much support for the killer of the United Healthcare CEO. The figure for the average out of pocket expenses hides a lot of pain.

People have lots of anger about healthcare for many many reasons. I can't tell you how many people I've met who are angry about "Obamacare" but don't realize how it helped them compared to the prior situation. There's also lots of anger at the prices for healthcare that we sometimes see, and that anger gets directed at insurance too, even if it's a hospital or other provider setting the prices. And then there's the anxiety of "will this be covered."

Even without out of pocket costs there's lots of reasons to be angry at insurers.

Whether you agree with the Affordable Healthcare Act or not, I feel like nobody remembers “lifetime maximums.” I have some relatively minor (but massively impactful) pre-existing conditions, and I would have exceeded my lifetime maximum by age 30 due to testing, procedures, hospital stays, etc. I have family members that would have exceeded theirs before age 1.

How does the concept of health insurance, risk pooling, etc., make sense if there are no lifetime maximums…?

Eventually 100% of the population will need healthcare of some type.

And without maximums to plan and set prices against, wouldn’t it just be a wealth transfer scheme from the relatively young and healthy to the particularly old and sick…? (With those in the middle roughly neutral)

At least I can’t see any credible way to insure against something 100% of all possible customers will need.

Health insurance is already a huge transfer to older generations (not that that's a bad thing). Medicare pays for older folks but it doesn't pay anywhere near the cost of the services that older folks receive. Prices are higher for everyone else to fill the gap at health care providers.

Health insurance is in many ways not even insurance, it's in many ways a price negotiation mechanism.

Anyway the whole system is overly complex, based off a tax credit from the 1950s, but the transition to a new scheme is nearly impossible while one political party is dead set against any improvement, especially if it might be perceived as a positive for the other political party, and also they have become so hyper partisan that they are not allowed to work with the other party in a bipartisan manner.

Huh I didn’t know that. I thought those on Medicare only got the bare minimum service that stayed within cost.

In that case, the upstream sources of why Americans accept this huge charade is going to keep on messing with even the best laid plans.

It isn’t a simple money in, money out system. You’re taking higher value money in one year, and paying out some money that’s worth less later (inflation)… while at the same time, you’re investing the pool of money you collected, and earning returns on that before you pay out claims - claims that you’ve already negotiated down in price. But by the time the healthier customers need to start making large claims, they’ve already both subsidized the claims of other customers, and made the insurance company more money than they’ll draw in claims.

It's a simple money in, money out system. Health insurance isn't like homeowner's insurance where the insurer accumulates and invests a pool of money in anticipation of occasional rare events like natural disasters that cause a spike in claims. Medical expenses across a large patient population are very predictable and there is no significant carry over of premiums from year to year. In fact, under the Affordable Care Act (Obamacare), it is actually illegal for most health insurers to do that. Any excess premiums collected must be returned to customers at the end of the year.

75% of Americans with employer-provided health coverage are satisfied with their current plans

For Americans overall, 71% rate the quality of healthcare they personally receive as excellent or good. Similarly, 72% give excellent or good marks to the quality of care they receive personally.

Regarding health insurance coverage, 65% of Americans rate their own coverage as excellent or good. Another poll found 63% rated their own health care coverage as excellent or good.

You have to get offline

https://www.ahip.org/news/articles/new-poll-strong-majority-...

https://news.gallup.com/poll/654044/view-healthcare-quality-...

https://news.gallup.com/poll/468176/americans-sour-healthcar...

You have to get offline

Perhaps. But if I weren’t online I wouldn’t know how widespread the support of Luigi is.

Only 75% of people on employer healthcare plans are satisfied? A great many people aren’t on employer plans.

From the third link you provided:

For the first time in Gallup’s two-decade trend, less than half of Americans are complimentary about the quality of U.S. healthcare, with 48% rating it “excellent” or “good.” The slight majority now rate healthcare quality as subpar, including 31% saying it is “only fair” and 21% -- a new high -- calling it “poor.”

> The poll by CloudResearch found that 27% of U.S. adults expressed “moderate” or “a lot” of sympathy for Mangione.

> A smaller but significant share of adults, 12%, said they were supportive of the decision to murder Brian Thompson, 50, who was shot in New York on Dec. 4.

12% is basically zero in this country. To give you a frame of reference, 14% of people think Obama is antichrist

https://www.msn.com/en-us/news/us/1-in-4-americans-sympathiz...

https://www.yahoo.com/news/12-million-americans-believe-liza...

The former DHS head seems to think it’s a lot of people. Don’t know any other murderers who have 27% of the population having sympathy for them.

12% is not basically zero.

https://www.thewrap.com/luigi-mangione-discourse-alarms-home...

Is the support that widespread, or is it a bubble created by social media?

I think there's great dissatisfaction with healthcare in general, but social media is not a good way of judging social attitudes across the US. It's great for finding a small niche, however.

He’s got a lot more support than any other murderer I know about.

Not to mention, they are satisfied compared to what? The situation they'd be in if they were unemployed and had to pay for the entire overpriced thing themselves?

The thing about insurance is that the reason you purchase it is for managing tail events. And the only way to know if you are satisfied with your insurance company is to experience a tail event and see how your insurance company behaves. If you develop an expensive to manage chronic illness, is your insurance company prompt in paying claims? Does it try to deny all of them and require you to hire an attorney to get them to pay anything at all? Does it turn out that much of the treatments you need for recovery were never covered by insurance at all? And even if it is paying - how many hours a week do they expect you to spend submitting and resubmitting claims and calling various doctors to collect more information and submit more and more paperwork?

I've lived in the UK, the USA, and Australia. I've had excellent employer funded/subsidised health insurance in the latter two. The moment my wife & learned we were having our first child it focussed our priorities in an incredibly clear and sudden way, and healthcare was a huge component of that. It was immediately clear we did not want to have a raise a family with the US healthcare system given the other alternatives we had available to us. We saw out the pregnancy in the USA and moved home to Australia shortly after. Our second child was born in Australia. The out of pocket cost difference between the two countries was negligible. My wife would subjectively say the quality of care we got in the USA was slightly higher, though there was nothing wrong with the care we got in Australia either so it's almost splitting hairs just to declare a winner. The most obvious difference is how little planning or effort needs to be made around healthcare decisions in Australia. No worrying about if we're in network or not. No worrying about if the pathology lab that's doing the testing is in network. Is some out of network surgeon going to be attending/observing on the day? What are the financial impacts if there are complications? Do we need to pre-agree a plan of what's acceptable financially? Is the bill we receive at the end accurate? Are there risks of signification on-going medication or other costs for medications if there's a complication in surgery?

Just a whole swathe of anxiety and stress that doesn't exist anymore. I'm not sure I can put a price on how valuable that is for our family. I clearly priced it higher than the higher income and lower tax I'd be paying if I'd stayed in the Bay Area though.

> So at 40k you're paying an additional 3k in taxes

Your calculations don't take into account personal allowance, which is £12750($15680) in the UK.

At $40k the difference is much closer to $1.5k.

Also there's the question of costs of living. That same 40k buys you 30% more in the UK if you're including rent.

Total healthcare spending per capita includes insurance premiums too though, which is $8,951 for single coverage and $25,572 for family coverage[0], and needs to be added to that ~$1,400 to get the total cost. Some amount of this may be paid by employers, but is still theoretically money that could go to you otherwise.

[0] https://www.kff.org/report-section/ehbs-2024-section-1-cost-...

It's not free.

My US job comes with NHS level never seeing a bill. This is really easy to do in CA.

Saying “fuck you, I’m rich” is not a good look.

A health plan like that costs your company 25K/yr on the backend. They pay that as part of your compensation, you just don’t see it.

Even the most basic HDHP Bronze Kaiser plan currently costs over 1K/mo, and that increases about 10% per year.

If you’ve ever had a coworker (or yourself) decline COBRA coverage because it was “so expensive”, you need to understand that the price under COBRA was the price the whole time, you just didn’t see it.

> Saying “fuck you, I’m rich” is not a good look.

This is a pitch-perfect example of the Brexit-like self-destructive politics that come with the "win" of appearing strong.

Here is a person who has the typical experience, who could easily be convinced by their positive experience to say "everybody should have this." But instead of going that route you impute negative motivations and put very ugly distasteful words into their mouth. Which, even if they are highly supportive of your position, will likely turn them against you. Instead of using this opportunity to advocate for a really good thing, you use it as an opportunity to hit somebody you view as the enemy with a rhetorical hammer. End result: no more people in favor of better means of distributing health care, and perhaps a net negative.

Especially in the context of how to account for free-at-point-of-care healthcare, which started this. If the employer is paying the prices that are revealed to employees only via COBRA, should that be accounted for in part of the wages or not? The US chooses to put about twice the fraction of GDP into healthcare that the UK does, and that per-capita GDP is also higher, how do we account for that in terms of wages and individuals? The $1T that employers pay for healthcare should be accounted for how, exactly? It's a tough question, and most likely in any comparison of nations there's a couple different ways to see how it impacts the average person. And when the "average" person in the US has such varying experiences, that has to enter into any comparison too.

In California there is great healthcare coverage for those with extremely low to no income, due to subsidy. Those with healthy salaries and savings can weather the times of unemployment and pay the COBRA prices. Those who struggle the most are the ones in between, and improving that involves getting those on the high and low end to advocate for the in-between incomes. It does not involve making enemies of them.

> Here is a person who has the typical experience

This is bullshit: not seeing a bill is atypical in California. Parent is also bullshitting by saying it's easy to get a job with no-bills health insurance in CA, unless they are ignoring 98% of Californians.

Check out how Californians get their healthcare here:

https://www.chcf.org/wp-content/uploads/2024/10/HealthInsure...

Medicare and Medical are not going to see a bill ever (if the people I know on them are anything to go by), and that's almost 40% of the population. A huge majority of people on employer plans are in the same situation, so thats some fraction of the 47%. For example, nearly a quarter of Californians are covered by Kaiser. It's not some super rare privilege reserved for those making >$500k.

Medicare patients get bills. There are deductibles and 20% co-insurance on most services. Inpatient care has a hard limit on number of days.

https://www.medicare.gov/basics/costs/medicare-costs

No the fee for service system results in bills. It's the quarter on Kaiser that don't see bills.

I never see bills from my employer based healthcare, and it's not anything super fancy, and it's not Kaiser, just BC/BS. I had a surgery that billed my insurance in the tens of thousands of dollars and I never saw a bill. My spouse sees bills but it's because she has her physician order tests that are a bit outside well established medicine that would never be covered by NHS in the UK or Health Canada.

My relatives on Medical never see bills.

It's not just Kaiser.

It's Kaiser in northern California. This is an extremely common healthcare option. Yeah, we're rich. That's the whole point: even out of pocket prices for that plan are dwarfed by the gap in salary to the UK professionals.

Most people aren't professionals, though. Nobody's arguing that the US isn't set up for the comfort of people making $500,000+/year.

Kaiser was an option when I was making 130k a year.

$130K a year still puts you at the 87th percentile of income in the US.

https://dqydj.com/income-percentile-calculator/

You said it was "easy" to get a job with Kaiser upthread - what percentage if CA residents are on it?

roughly a quarter of California (9.4 in CA vs 38 for CA total)

> A health plan like that costs your company 25K/yr on the backend. They pay that as part of your compensation, you just don’t see it.

That's very true, but of course the NHS costs some amount of money on the backend, it's just abstracted away in taxes. The real difference is how much care you get for your money, not* which way of not directly paying for health care is better.

* You get more in the UK.

It’s also about predictability: medical bankruptcy is an American phenomenon. The average cost isn’t what worries people, it’s the possibility of having coverage denied, being hit with “out of network” charges like an ambulance taking you to the closest hospital or a specialist showing up at an in-network one, or having your health decline rapidly while you need to get a lawyer to convince your health insurer to pay for treatment your doctor considers necessary. It’s especially about what happens if your health declines to where you cannot work and lose all of the treatment that you’ve setup so far.

That isn't the question in this thread though. The question is if you are on net better in the UK vs the US inclusive of taxes, healthcare expenses and salary differences. You get more for your money in the UK, but if you more than that difference for the same job (net of taxes), you could still come out ahead, as an individual. Society as a whole might be worse on some measures (due to the gaps in coverage for many in the US, or the hassle of the whole thing, the behavioral influences and impact of avoiding preventative care, the risk of falling into a scenario where you aren't covered and the anxiety of that risk). There are many downsides. But if you make enough then at some point that covers those risks. The salary gap has gotten sufficiently high that the break-even appoint seems to be somewhere at middle-level salaries now, not jut the high end.

Not really, the US health system is so broken is just costs more. The system of who pays what is very different, but at the end of the day the cost of healthcare is much higher in US than any other country.

Yup, I feel that until someone has seen and understood the first graphic in this article, they really don't grok the situation:

https://ourworldindata.org/us-life-expectancy-low

I'm curious, did you see that little asterisk at the end of my comment?

$25k doesn't sound like a lot. Doesn't sound like it accounts for the difference in salary.

$25K is a lot.

Respectfully, You're out of touch until you lost your 6 digits job.

I’m not sure what your point is?

25K/yr IS a LOT.

Per the US Census, the median income in the US is a bit over 37,500, so it’s literally an entire paycheck.

Remember - the NHS is available to everyone, not just the rich.

Source: https://datacommons.org/place/country/USA?utm_medium=explore...

You're misunderstanding how the ACA subsidies work.

According to article linked to below there are 48 million uninsured Americans. Fifteen percent of the UK population isn’t without coverage. The subsidies don’t work well.

That's not how it works for millions upon millions of Americans that are not fortunate enough to work at a job that provides tens of thousands of dollars in healthcare insurance as a benefit.

This line of thinking is exactly why the "American Dream" is falling apart; we increasingly place a handicap on some Americans and then wonder why some slice of America is not advancing generationally.

Americans who have jobs with health benefits that include Kaiser in CA is a whole lot of them in CA! It's a massive hospital system that covers 9 million people, a full quarter of the state.

You're tied to your job though. Not so in say, UK, Canada.

I was unfortunate enough to have a job that gave me Kaiser healthcare. My job was not my only source of income. Everything about the experience of Kaiser sucked so much that I often paid out of pocket to go to other orgs.

Example: I transferred my prescriptions to Kaiser, walked in and saw the dozens of people standing in line, and immediately transferred them back to CVS (where Kaiser doesn’t apply). They called me before I got home with my scripts ready for pickup. I walked in and it was one of the rare moments when no one was in line. But even when they’re busy, I’ve not seen more than ~10 people and mostly more like 1-3.

Kaiser sucks. It’s the worst healthcare system I’ve had to deal with in terms of my effort vs my satisfaction. I’m very happy to work a job that lets me choose again so that I can go where I please.

I am happy that the doctor calls me to schedule things instead of the other way around. My prescriptions come by mail order, and the few times I've had to get to the pharmacy it's been a very straightforward process.

That's not how it works for millions upon millions of Americans that are not fortunate enough to work at a job that provides tens of thousands of dollars in healthcare insurance as a benefit.

Wal-Mart provides pretty decent health insurance and they hire anyone. If you don’t have health insurance, it’s a choice.

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