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Comment by ecshafer | Hacker News Reader

One of my main arguments for a universal health care scheme in the united states is how horrendously expensive, for employers, health care is. Lets totally ignore efficacy, moral arguments, expense for the patient, etc. If you are a company in the US a large percentage of the effective compensation of employees is healthcare. A moderately good PPO is like ~$10k+ a year per employee. You can pay workers in some other countries less than just the cost of paying for health insurance for a US employee.

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As someone paying for a family on a marketplace bronze plan, that’s a bargain! I think our premiums will exceed $20K this year.

With all of the medical group consolidation, all of the wait time woes our Canadian friends always complained about are the reality here now as well. So I’m paying more than anywhere else on the world and have to wait 6 months for a PCP appointment. We have the worst of both worlds.

I'm curious to compare this to other countries that have state owned/mandated insurance and are so far still mostly covering everything and which are always touted as "superior" to the US, who "have the most expensive health care system". Can't use Canada as OHIP et. al. don't cover much and the same employer tied insurance scheme as in the US exists and is necessary.

An example of a country with "good healthcare" and such a system would be Germany. Extra insurance does exist there as well nowadays from what I understand but health insurance isn't tied entirely to employment and the extras are things like a 20 EUR per month to cover the co-pay on large and expensive procedures. While private insurance exists there too, I want to compare to the often touted "free healthcare" i.e. public system. There are still different providers even under the one public system.

So from a quick search, Germany has insurance rates from ~14-16% of gross salary, half of which the employee pays from their gross salary. But most insurances have an extra percentage they charge on top. I found one as an example that charges 17.29% total, which if you're self-employed, you have to cover yourself (to be comparable to your marketplace bronze plan being entirely self-paid).

Now the question becomes: Are you paying more or less as a percentage of your salary and by how much?

(and side question for your parent I guess: how does that compare to the $10k the employer pays, which would be 8.645% in this example)

It is actually more complicated than this implies. For example hospitals are often held afloat by Medicare/Medicaid spending (25%/19%). Private health insurance is about 37%, so larger than either, but smaller than both. But then you have to remember that some of the private health insurance is being subsidized by taxpayer dollars (e.g.: the ACA subsidies), and that private health insurance is largely coming from tax exempt dollars (a form of subsidies). So where the costs are actually being paid is more difficult.

https://www.kff.org/health-costs/key-facts-about-hospitals/?...

I am not sure where your question about a percentage of your salary is valid on the face of it. Do you count the employer portion of your medical coverage as part of your salary? Do you count the tax exemption? How do you figure the taxes taken out to support Medicare/Medicaid/Veterans Health (all of which are required to support the system as it exists)? And how do you figure that for single payer systems?

So a much more direct way of comparing is to look at total costs per person, and then figure out how outcomes compare. When you do that the U.S. comes to about double the cost, and generally worse outcomes. Conservative politicians will scream about how long it takes to get procedures, but the research shows that elective procedures take about the same time (and no-one waits for emergency procedures in comparable systems).

https://www.pgpf.org/article/how-does-the-us-healthcare-syst...

That's a fair point overall but not why I asked.

I asked from an employee and cost perspective. So whether or not to count the employer portion depends on whether we're comparing one or the other. If you buy on the marketplace in the US, compare with the full cost in the example I gave for Germany. If you get insurance through your work the US/CA, compare with the employee only portion (as the employer pays part of the insurance there as well).

Theoretically it's even more complicated as at least in Germany private insurance also exists and is cheaper if you're a healthy single youth and more expensive if you're an older family ;)

But again, like you say, it is totally valid to also compare outcomes / wait times per dollar spent of course.

Canadian (OHIP recipient) here. As a long time employer, and former employee, I can tell you that no one takes a job here for the heath care. Some things like dental and vision are not covered (unless you are under 18, over 65, or low income), but everything else is. Over the course of a decade my father in law had 3 heart attacks, a stroke, and ultimately lost a year long battle with lung cancer. The total health care bill to him (or his employer) was $0.

Now the downside … because health care is free, everyone uses it and the wait times are longer. My grandfather recently required an MRI (non life threatening). The wait time in Ontario was 3 months. He drove to the USA, paid out of pocket, and had it done within in week …

> Now the downside … because health care is free, everyone uses it and the wait times are longer. My grandfather recently required an MRI (non life threatening). The wait time in Ontario was 3 months. He drove to the USA, paid out of pocket, and had it done within in week …

Imo, singapore solves this well, by ensuring that some cost is borne by the patient at point of use, but it's never anything excessive. No one goes bankrupt from emergency hospital visits.

> Can't use Canada as OHIP et. al. don't cover much and the same employer tied insurance scheme as in the US exists and is necessary

False. From what I know, only prescription drugs, dental, and vision are not covered. And since Americans frequently drive to Canada to buy prescription drugs, we can assume that's not as big a burden as in the US. But hospital stays, surgeries, lab testing, imaging, doctor visits, vaccines are all fully covered.

Fair enough, I guess I got carried away given the private insurance has to cover drugs, which would otherwise be covered by the provincial insurance (like OHIP), if you have it.

Private insurance also can cover a higher percentage, i.e. provincial plans do not always cover 100% of everything. Also, Health Care Spending accounts are in many cases part of private insurances and can be used to cover things that provincial plans do not cover at all (unapproved drugs et. al.)

And just for context … if medication is not covered and has to be paid out of pocket, the cost is generally under $100. Canadians don’t have $1000 medical costs

> provincial plans do not always cover 100% of everything

Like what?

Since we were using OHIP as an example: https://www.ontario.ca/page/get-coverage-prescription-drugs#... and following.

The first info about what's not covered for example is concerning diabetes. There's a limit to the number of test strips for example. I'm no diabetic, so I don't know if these numbers are "enough" or not but there is an actual limit. It also then states:

    Syringes, lancets, glucometers and other diabetic supplies are not covered by the ODB program.

If you're a senior with "too much income" you also have co-pays/deductibles, meaning the coverage is less than 100% of the cost of the drug:

    A single person aged 65 years or older with a yearly income above $25,000 after deductions pays:

    the first $100 of total prescription costs each program year (August 1 to July 31 the following year)
        this is called the deductible and is paid down when you fill your prescriptions
    after paying the deductible, up to $6.11 for each prescription, filled or refilled
        this amount is called the co-payment

This: https://www.vivahealthpharmacy.com/private-insurance-vs-ohip... too.

I'll stop here but I'm sure this is both similar in other provinces and/or other limits may apply in specific cases.

Just to be clear: I'm not saying the OHIP / other Canadian insurance programs aren't great overall in comparison to the US. But neither they nor I suppose Germany's "full coverage" actually are in all real world cases.

This is all prescription drugs.

Correct. Which doesn't invalidate either your or my previous points.

I'm pretty sure the original 10+k/yr/employee for good ppo coverage is a radical underestimate, for what it's worth, though I guess "way more than ten" is technically part of the "ten+" range, haha.

The last time I had reason to look at full market-rate price for a family of four for a good PPO (Seattle market, circa five years ago, large tech company), it was around 3300 USD per month, or over $39k/yr. That was for cobra coverage, so a combination of what I would have normally paid and what the employer would've (about one third us and two thirds them when I was employed by that corp). I can only imagine it's gotten more expensive since then; we left the country three years ago.

Just as an FYI, that is a massive outlier based on available data.

My employees are about $500 per month in a major metropolitan area, and a family of 4 can run up to $2000 a month for the most expensive plans (I cover individuals and their spouses in full for standard plans, and could cover one dependent for basic plans).

I looked at marketplace plans in WA because I was curious, and it looks like it's about the same as where I am but nowhere near what you were quoted 5 years ago.

I got the $10k a year employee from chatgpt with "Assume I have a company with 100 employees in New York, how much on average does it cost to provide health insurance" and it gave me poor, moderate and good ppo plan prices. I figure this seemed reasonable for ballpark figures from employer friends, so the numbers may be very well off.

The key part of your statement is that you're paying for a family.

Individuals do not cost $10k per year under any normal circumstances, and if you're paying almost $2k a month for a family bronze plan, you either have a lot of kids, you have some unusual needs, or you are getting ripped off. Even more so if you're waiting for a PCP appointment, because that is unusual as well.

So the ~$10k a year is just what the employer is paying in my example, taking some numbers from chatgpt for a medium sized company in new york. Not even counting the employee side of the premiums, which can be crazy high as well.

> One of my main arguments for a universal health care scheme in the united states is how horrendously expensive

The costs need to be fixed, first. Moving to the government/taxes paying for it doesn't fix that.

> Moving to the government/taxes paying for it doesn't fix that.

It kinda does, bigger players have more bargaining power. There is no bigger player than the government in a universal healthcare system.

Furthermore, a significant cost in healthcare is all of the bureaucracy around billing. Much of that goes away with single payer.

It would be very tough to reduce pay for doctors and other staff. The United States medical industry is one of the highest paying in the world.

This is true, but frontline healthcare staff wages are only one part of the problem. For specifics you can see details here (e.g.: US average front-line healthcare worker salary: €74.450, Germany: €40.522):

https://www.qunomedical.com/en/research/healthcare-salary-in...

But even absent any movement there you have a lot of savings to be had away from that: 1. The U.S. medical administration costs have ballooned, in large part because of the highly adversarial billing system between insurers and practitioners. Medicare/Medicaid is much less (but not completely) unpredictable. Doctors complain bitterly about the prices at times, but the system is much more efficient. 2. U.S. insurance companies are woefully inefficient. To the point that companies complained bitterly when the ACA required them to pay out 80% of premiums as medical payments. Before that there were companies making more than 20% profits. The most efficient insurance companies today use about 12% of their revenues for non-medical care. In comparison Medicaid uses about 3.9%.

There are lots of other parts you could address as well: 1. Fraud drawn to the huge payouts for medical bills. If people's accidents were just covered as a normal part of life those payouts, and most of that fraud just goes away. 2. Malpractice insurance. This is like the first, but would mostly be solved by a combination of single payer and a working medical review system (seriously, what we have now is the definition of regulatory capture).

Wages for doctors and staff are not the cause of high medical bills.

The US spends something like $4.9 trillion dollars on medical care, and employs around 1 million physicians, 4.5 million nurses, or 9.8 million health care workers in total [1].

If this was paid out in wages the average health care worker would be make almost $500k/year. Compare that to the wage of the average doctor at $335k/year [2] or average nurse at under $100k/year. There is a lot of money in medical care that is not going to wages.

[1]https://www.census.gov/library/stories/2021/04/who-are-our-h...

[2]https://www1.salary.com/Doctor-Salary.html

>The United States medical industry is one of the highest paying in the world.

Which the industry views as a historical accident, and now that they basically own all the hospitals and other companies, you can expect them to fix it.

I would expect neutering Doctor labor power will happen soon. This admin will get a small donation or two, and the republicans will insist that letting doctors have high wages is the sole cause of our expensive healthcare. They've never really cared about the truth, seeing as they have often claimed "Medical tort" is the cause of healthcare costs, even though places like Texas, which have limits of Medical tort payout don't have cheaper healthcare.

Medical tort is a large part of our bloated healthcare costs. The problem with these discussions is that our healthcare system is horrible and has many things going wrong, so both sides can simultaneously be right.

Doctor and nurses are not bureaucrats. Single payer would significantly reduce the bureaucracy in healthcare, and simplify everything for citizens and businesses.

The main cost driver in medical care is provider (nurse, doctor, etc.) wages, not bureaucracy or drug prices (though they're frequently cited). I have tired of posting sources for the statistics, but they are very easy to find.

From what I've heard from doctors online, a large chunk of their time is basically spent just coaxing insurance. They waste time figuring out what they can and cannot bill, tailoring that to every patient, and constantly keeping records of everything. I think, for many doctors especially in small practices, treatment is a minority of their time.

Obviously, paying someone 300K a year to sit on a 1 hour peer to peer explaining why they think they should do a surgery is just bad business. But, we do it, and I think a lot.

Exactly. You can believe the "main cost driver in medical care is provider (nurse, doctor, etc.) wages" all the live long day, until you realize they too spend a lot of their time dealing with bureaucracy. The true cost of bureaucracy cannot be accounted for by simply tallying the number of bureaucrats and their salaries.

So, let's look at UnitedHealth Group; do they deliver health care?

If there were single payer, what would their role be in the healthcare delivery process?

Apparently they made 2.3 billion in profits on 113 billion in revenue in Q3 of 2025. How much of that friction would evaporate if they weren't in the healthcare delivery infrastructure.

Someone once said "the best part is no part" ?

Compare UPS or FedEx to USPS; the first two companies are profit-seeking, yet very competitive with the 'public-oriented' (and legally privileged) USPS. Having the government in control does not necessarily lead to better value.

They are very competitive in the places where most people live, but the USPS delivers to many more places that the others do not, and still maintains cost competitiveness.

This turns out to be a decent analogy to healthcare: insurance companies do not provide the coverage, universality and simplicity that a single payer system would; instead, you'll get something like insurance coverage networks providing spotty and inconsistent care.

Either approach has upsides and downsides, but single payer, universal coverage for basic and emergency healthcare seems like a no-brainer.

I've lived in cities where the city ran the utilities; they were generally way cheaper than the utilities from PG&E.

The USPS is obligated to deliver letters at the same cost to everyone in the country, and they do a pretty okay job at it -- I've certainly had horrid events from UPS and FedEx, and those guys get to just pass the crap delivery tasks off to USPS if they don't like it.

Lots of old people in the USofA seem to like their government run medical insurance, same with people in the VA system.

The Doge crew spent months looking for fraud waste and abuse and I don't see any big law enforcement results from all the fraud they found, and I don't see anyone crowing over all the waste they curtailed.

It's possible that the world's more complex than you imagine, and that sometimes people just do their jobs (IE the bureaucrats) and hard problems get solved.

Now, tell me again, what part of the health care system is UnitedHealth? What critical problem do they solve?

$2.3 billion is nothing in a $5 trillion system. Doctors make around $500 billion in the US. Their wages are much more significant than insurance profits.

$2.3bn is profit after subtracting costs. Doctors charging time to deal with bureaucracy needed by insurance adds to the costs that are already factored into the revenue. Single payer wouldn't just eliminate the profit, but also those costs.

Buddy.

That's 2.3 billion in ONE QUARTER of 2025, on a revenue of 115 billion. In a quarter. There are four quarters in a year.

$5 trillion is how much is spent in all of healthcare in the USA for the whole year.

UnitedHealth's revenue was $500 billion (and net profits is 10 billion) for the year. For one insurance company. There are 6 that each have more than $80 billion per year in revenue. This isn't to mention the billing departments for each hospital, the claims processing providers smaller doctors need to enlist, the endless hours interacting with insurance companies, etc.

And tell me, please, what specific healthcare outcomes are driven by insurance companies?

Insurance companies are instrumental in ensuring that useless procedures arent performed. Over use of service is one of the biggest reasons for inflated costs in our healthcare system. Now to be clear I would prefer a medicare for all system implementing that, but under m4a doctor salaries are still a major issue that need to be addressed.

Basically all healthcare spending in the US goes through insurance companies, Im not sure why you have a problem with that. Under m4a medicare would spend trillions a year, would you be complaining about that too? Large profits would be a problem, but that doesnt exist. Our healthcare system is rotten top to bottom, insurance is part of that but imo it gets way too much blame for existing in the system the government has created.

Insurance companies basically mirror the reimbursement policies put in place by medicare. I'm sure most providers would gladly take lower reimbursement from a single provider over the chaos and pain driven by insurance companies right now.

Basically every provider does not take medicaid so I suspect you are wrong about that. Again Im not happy with the insurance situation, I just think its barely top 10 in terms of problems with our healthcare system. The bureaucracy is required because of our horrible fee for service payout system. Without getting rid of that m4a would still requires an army of billers because republicans would constantly be screaming about the government being scammed(and they wouldnt really be wrong, healthcare providers do tons of wasteful procedures and the bureaucracy is the only thing slowing that down(recent example I came across, currently we wake up obgyn's to perform emergency medically required abortion services at the hospital even though abortions can be done with a pill and the nocturnist can safely oversee the whole thing, no need to wake anyone up. This is only done so providers can charge us more money. This shit is happening constantly over and over again every time providers can find ways to nickel and dime us and patients have no choice)). We dont actually need single payer to get rid of fee for service so really I think private insurance is an orthogonal problem to the billing army.

Out of curiosity...

I said "medicare sets fee schedules" and you respondeed "nobody takes medicaid"

Presumably you know the difference between them?

Asking as not an American - $10k per year, how much % of a yearly salary is it?

In Europe (here: Germany example), which is frequently seen here as the ideal example of healthcare spending:

Employees and employers typically split around 14.6% of gross salary for public health insurance. [1]

[1] https://feather-insurance.com/blog/germany-healthcare-statis...

The problem is that in the US it's a fixed amount vs in Germany a proportion of your income. This works OK for higher incomes but for lower incomes it's a big problem. And as always, the people in the middle get screwed. Not enough money to afford the premiums easily but too much money to get subsidies.

SO this is just what the employer pays. The employee then pays premiums monthly as well for access. Employers pay somewhere between $5k and $25k (or more) per employee a year for health care depending on quality and portion of premiums they pay for the employee. Usually its split, so someone makes $80k a year, they pay $10k a year in premiums, employer pays $10k a year in premiums.

> Asking as not an American - $10k per year, how much % of a yearly salary is it?

Depends on if you make 35k or 200k/year

The irony of the situation when you realize that you can probably get healthcare yourself in India (not sure about other countries) but for even a very good healthcare program to be around 25$ per month

And that 10k$/year can be considered middle class / heck I can even argue just slightly above middle class in India

And you can actually enjoy food and a lot of things really cheap as well

Usually the only problem becomes if something is inherently expensive (think college or land) which is where PPP does hurt but in everyday life, I think India's decent to live in.

Now I want to ask you but even if someone spends around ~$10k+ a year, even then I have heard people describe american healthcare subpar. Like why? Is it just corruption at healthcare level and lobbying efforts?

Is there truly nothing that the average american can't do about to make things better for the healthcare situation. To me its feeling like america's moving even backwards right now from cutting medicaid putting even more strain on the amount and still even on the average person themselves as well.

There is no simple explanation, but an important issue is that there is no price discovery mechanism or system pressure for efficiency. You also may not know that the US healthcare system is also an elaborate jobs program. Walk into any hospital and you will see 5-10 mostly young women doing basically nothing. I don’t know why the powers that be decided that the US should divest itself from any useful work, but here we are. Now we’re a couple generations into this social experiment by “smart” billionaires and their courtiers, and the military industrial complex is begging the Taiwanese to hold our soft hands and teach a blossoming generation hipsters and resentful immigrants how to build the computers we invented. We had a good run, but we’re Rome circa. 400-500 AD. Don’t let the marketing in Venezuela fool you. I’m just hoping the robots give us a few more decades of working plumbing.

It's like every other compliance cost. It hurts the little guys more than the big guys. Too much of the US economy is big players so the status quo persists.

It's a price to, in a way, handcuff workers. Systemically combined with policies that make sure unemployment doesn't get too low, weaken labor power, tie other benefits to employment, etc. Workers know they need your job to have affordable healthcare, so they have no choice but to stick with it even if it is somewhat crappy.

"how horrendously expensive, for employers, health care is."

So why aren't they pushing for abolishing employer-based health insurance? They had no problems getting rid of pensions but for some reason nobody really lobbies for employers to get out of the health care business. The same for 401k. Why do companies have to manage those instead of just contributing some money and let the employees find the right package on the open market?

It's really weird.

Union employees have negotiated healthcare into long-term contracts, making it hard for those employers to switch. (Feel free to read up on so-called "Cadillac plans" during the original ACA negotiations for more details). The size of this market makes employers exiting a non-starter IMO. Any org that wants to exit will see a huge resistance to this change even if they can showcase all the common benefits.

Because if they let employees manage their own retirement accounts some of them would gamble all of it on crypto or options and lose it all. Then, because our society has become fundamentally incapable of saying "You are an adult. You have nobody to blame but yourself, and now you will face the consequences," this will become someone else's problem to pay for it.

>Because if they let employees manage their own retirement accounts some of them would gamble all of it on crypto or options and lose it all.

This part is true.

>Then, because our society has become fundamentally incapable of saying "You are an adult. You have nobody to blame but yourself, and now you will face the consequences," this will become someone else's problem to pay for it.

Except that's an incredibly stupid short-term way of thinking. Because regardless, we end up paying for people's mistakes. As we should, because that's the whole point of society - we need to take care of the failures, the degenerates, the pieces of shit, etc because they play an important role in society - they too are humans and some of them weren't gambling away their savings out of a sense of fun, they did so to be able to continue to live in a day and age where costs continue to skyrocket, job growth is negative, and the economy is being hollowed out. We have many tools and mechanisms to help the winners in society. We need that for the opposite party, too. In winner-take-all capitalistm, the losers will always outnumber the winners. And you need to make life palatable for the losers, in hopes that their luck may one day change. Because if you don't take care of people who continue to lose and have nothing going for them, they will grow in numbers and eventually eat you.

And besides, we've bailed out enough bad actors in important sectors of the economy that main street deserves to be taken care of too.

Someone will always have to pay for it, because we don't generally just let people die. And even if we do, someone still have to scrape their rotting corpses off the street, no?

Radical individuality is an illusion. Yes, it would be nice if everyone could be solely responsible for paying for their healthcare or retirement. But is it possible? If you can't answer if it's possible or not before you do something, you probably shouldn't be doing it.

And yet they never lobby for nationalized health care.

Because "Deal with our illegal, immoral, or stupid work requests or literally lose your healthcare" is such a massive bargaining chip for them.

They would rather spend more money and have more docile and controllable workers, but not spend that money on paying workers more to be docile and controllable.

It's not about the money.

We almost do. Employers must provide insurance. If you’re unemployed you can probably get Medicaid. We have private entities handle the details instead of something that looks like the Post Office. There is nothing anyone in Congress can do which results in all 8 billion people on Earth having instant access to all conceivable treatment in any location the the US. Like socialized medicine, there is no meaningful price discovery mechanism in the US. Unlike socialized medicine, it’s a lot harder for political parties to conduct pogroms by rationing resources and euthanizing demographics that don’t vote the way they like.

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