Hacker News Folks Get Long Overdue Thanks
linuxlock.blogspot.sg
linuxlock.blogspot.sg
From wikipedia:
The United States life expectancy of 78.4 years at birth, up from 75.2 years in 1990, ranks it 50th among 221 nations, and 27th out of the 34 industrialized OECD countries, down from 20th in 1990. Of 17 high-income countries studied by the National Institutes of Health in 2013, the United States had the highest or near-highest prevalence of infant mortality, heart and lung disease, sexually transmitted infections, adolescent pregnancies, injuries, homicides, and disability. Together, such issues place the U.S. at the bottom of the list for life expectancy. On average, a U.S. male can be expected to live almost four fewer years than those in the top-ranked country.
According to the World Health Organization (WHO), the United States spent more on health care per capita ($8,608), and more on health care as percentage of its GDP (17.9%), than any other nation in 2011. The Commonwealth Fund ranked the United States last in the quality of health care among similar countries, and notes U.S. care costs the most.
http://en.wikipedia.org/wiki/Health_care_in_the_United_State...
From wikipedia:
The World Health Organization (WHO) defines a live birth as any born human being who demonstrates independent signs of life, including breathing, voluntary muscle movement, or heartbeat. Many countries, however, including certain European states and Japan, only count as live births cases where an infant breathes at birth, which makes their reported IMR numbers somewhat lower and raises their rates of perinatal mortality.[24] In Germany and Australia, requirements for live birth are even higher.[25][26]
https://en.wikipedia.org/wiki/Infant_mortality
Not to say there aren't problems with the US healthcare system, but we need to stop these comparisons that are just not relevant.
"However, in 2009, the US CDC issued a report that stated that the American rates of infant mortality were affected by the United States' high rates of premature babies compared to European countries. It also outlined the differences in reporting requirements between the United States and Europe, noting that France, the Czech Republic, Ireland, the Netherlands, and Poland do not report all live births of babies under 500 g and/or 22 weeks of gestation.[34][35][dead link][36] The report concluded, however, that the differences in reporting are unlikely to be the primary explanation for the United States’ relatively low international ranking.[36]"
Your argument, will perhaps partially correct, fails to properly explain the disparity in infant mortality (mostly due to unnecessary premature births) between the US and similar industrial countries.
In no way am I trying to blame the victim or excuse a bad system. I'm only pointing out that these comparisons are very hard to do correctly and can be misleading. We have an urge to compare so that we can make better decisions, but it can be tough to do this. From the stats originally posted it could be argued that we need to spend more money on the healthcare system, when in reality we just need to educate people to wait to have kids.
Researchers from the NCHS found that low birthweight
and short gestational age births—a leading cause of
infant death internationally were more common in the
United States than in Europe. Although outcomes for
these births were similar, they found that the U.S.
rate of low birthweight and short gestational age births
was double that of Finland and Sweden.29 After adjusting
for potential recording differences by excluding very
short gestational age births, they found that the U.S.
IMR would be 3.9 if the United States had the same rate
of low birthweight and short gestational age births as
Sweden.
https://www.fas.org/sgp/crs/misc/R41378.pdfWhen you remove car accidents and suicides from the death rates, factors that are largely independent from the health care system, the US actually has the highest life expectancy in the world.
A good source of info on this is the work of Scott Atlas. This econtalk includes a good look at the statistical biases in the micro rankings that get so much undue attention in the media.
http://www.econtalk.org/archives/2012/07/scott_atlas_on.html
Thank you - as a Brit I read this too. I cycled through emotions - fear and sympathy for the diagnosis, hope as some of our best professionals consider new options, and then.
WTF describes it best.
Americas attitude toward health care is odd from our perspective - not mismatched socks odd but like a Collegue suddenly announcing that aliens are real, they look very talk and thin and one is living in his attic
That kind of odd
(I am glad that the OP has recovered, heartened by every success medicine has against this disease. Just ... It's odd how nearly this was a different story)
May you have a long and happy life.
http://www.telegraph.co.uk/news/uknews/1560849/UK-cancer-sur...
EDIT: specifically, "survival rate" is just "how many people lived for 5 years after diagnosis". Thus, you detect a lot of slow growing prostate cancer and your survival rates go up, even though nothing has been done to reduce the incidence of cancer, or stop any more people from dying of cancer.
When you look at US cancer mortality rates they look pretty good, until you restrict the numbers to the under-65s, when suddenly the numbers look pretty average. This might be because poor americans don't get access to treatment until they're 65 and qualify for some aid.
That being said it would be nice if the disparity in survival percentages on this side of the pond looked more like the stats from your side:
http://www.cancerresearchuk.org/cancer-info/cancerstats/surv...
Similarly, the US screened women for breast cancer and cervical cancer earlier and more frequently than the UK, which again does more harm than good but improves the 5-year survival stats.
The US Preventative Screening Task Force has since recommended that screening should basically fall in line with what the UK's doing, but that happened well after that article was published.
Smaller networks (small population of a country, or by state) could be a factor here.
Could you find the original study?
http://politix.topix.com/homepage/7019-us-is-27th-in-the-wor...
and the paper from which the figure is taken
http://jama.jamanetwork.com/article.aspx?articleID=1710486
Those data show that the USA ranks far below the UK on Years of Life Lost due to several cancers. I don't see how that's consistent with your claim. [Edit: actually, YLL is an incidence statistic, whereas parent's claim is that survival statistics are higher in the US, which the sources I've found agree with.]
The Telegraph is a right-leaning paper and is well known to be anti-NHS. Please; being economically laissez-faire as people are on HN are is not incompatible with supporting state provision of healthcare, along with the other things a state provides. It's sad to see libertarians / laissez-faire economics people bashing the NHS by quoting stories cherry-picked by right wing media sources. It's just not something we need disagree about.
What was broken in this case was described by his statement: "I had no medical insurance and the few benefits I had with the VA would take months of paperwork to get me in." You can blame that on Ted Kennedy, btw. He is the one that made health insurance an institution in the U.S. The best chance we have at good healthcare here has nothing to do with government or health insurance, it was to do with doctors that are willing to say F.U. to the system and provide healthcare directly to paitents without middlemen. So, that's the other side of the politics. Now back to what we really should be talking about...
I think it is wonderful that his cancer was treated and that people here helped. Cancer really fucking sucks. I hate Cancer with a deep passion that some of you out there understand. Others of you like to think of how great your resume looks and how you are going to land a fat house on the beach. I used to also.
I've had three MRIs. All were scheduled the same day they were prescribed. I've routinely scheduled appointments with renown specialists and waited less than 2 days to get in. My double hernia surgery was performed by the same guy who treats the Chicago Bears. My old chiropractor/kinesiologist used to be Andre Agassi's.
To clarify: "not poor" != "rich". At the time of these expenses, I was making a good salary, but nothing unattainable by HN definitions.
However, if you're on Medicaid... you. are. fucked.
I had a kidney stone a few weeks ago. All told, the bills for dealing with that hit $34,000.
For a kidney stone.
That's not about being poor or not, that's highway robbery.
Double hernia surgery was a couple grand out of pocket.
Not all insurance is the same.$34k is robbery.
34 k would pay for the original poster's trip to my country (Uruguay), the best treatment available, and he'd have money left over - heck, 34 k would probably pay the doctor's wages on that hospital for a year.
There are very dodgy and shady costs with US healthcare.
I have the very best healthcare available in my country (Hospital Británico). It costs U$ 150 per month. A kidney stone would probably run me in the hundreds of dollars. 3k would probably bankrupt me.
http://www.hospitalbritanico.org.uy
Some differences are that doctors in the U.S. are paid an order of magnitude more, and I've heard hospitals have legions of well-paid administrators doing paperwork for insurance companies, which will have legions of people doing paperwork on their side, and government doing its bit, and lawyers doing their thing. All that money is obviously not going directly into healthcare, it's basically bureaucracy friction. I suspect "real" healthcare costs, even factoring expensive U.S. doctors, would be shockingly cheap.
Tell me something: Suppose you go in to get your left kidney removed, but the doc removes the right one by accident. What are your options? Law suit? What would you expect to get in settlement?
Surgeons and anesthetists are on a class of their own, they make upwards of 60k per hospital.
yes. health reform (and lots of others) is/are needed.
That's hard to tell, you can also say that because those patient were treated earlier they have a longer life expectancy. But I am agreed, those stats have to be looked very carefully.
http://en.wikipedia.org/wiki/Lead_time_bias
Gil Welch at Dartmouth is one of the experts in unnecessary medical screening and lead time bias. He's written numerous academic and media articles, especially regarding lung, breast, and prostate cancer screening. Also an amazing public speaker:
The other thing is that to say that the US ranks 50th in life expectancy is useless without showing numbers. From what I've seen, the #1 country and the #50 country difference by less than 3 years. So is the number 50 ranked country really that much worse than the #1 country.
Here are some other excerpts from the article:
- The United States is among the few industrialized nations in the world that does not guarantee access to health care for its population.
- lack of health insurance causes roughly 48,000 unnecessary deaths every year in the United States
- In 2007, 62.1% of filers for bankruptcies claimed high medical expenses.
- A 2013 study found that about 25% of all senior citizens declare bankruptcy due to medical expenses, and 43% are forced to mortgage or sell their primary residence.
These quotes are just from the first paragraph of the article... There are many more if you read it through.
For an outside observer it's blatantly obvious that you have a broken system, and it's inexlicable why you keep defending it.
However, using flimsy statistical arguememts to make the arguememt isn't helping anyone.
Btw, the 62% of bankruptcies stat is also misleading. Whether the person had $10 or $100k medical debt is included. It's not surprising that if someone went bankrupt due to a failed business they wouldn't pay their medical bills either. Thus for many of those 62%, medical expenses had nothing to do with their bankruptcies.
Is it mandatory insurance? Insurance doesn't make everything affordable, but it probably wild have been helpful. Though maybe the co-pay would have been $50k.
Universal tax-payer funded insurance? The term "tax payer" is interesting because politicians and pundits forget that we're all tax payers in one form or another. Granted some pay more, some are net consumers of govt services. But tax payers mean us, and those with more earned income more than those with less. I think the main difference between taxes and donation is choice.
Single-payer or government provided healthcare? Pretty sure that no one would identify the government as the picture perfect example of efficiency. Plus, putting elected officials or their appointees in charge of handing out goods and services doesnt seem to be sustainable. Not that putting profit seeking entities in charge has yielded the ideal result.
Making drug providers, healthcare providers and everyone else in that supply chain non-profit? Profit has enormous motivational powers. Not always for good. But it is pretty amazing what can be accomplished by organizations setup to create wealth.
Big Data? Sorry, I couldn't resist. Well, lets use that as a proxy for innovation. It would seem that greater opportunity for innovation would help. Lower barriers to trying new drugs, procedures, diet, treatments would allow for potentially lower cost solutions to be created.
Separating health care from your job? Of your insurer only needs you to be healthy until you find a new job, there's not much in incentive for long-term healthcare and preventative screenings to identify tumors and other problems before they become an expensive problem. Though that would seem to be an arguement in favor of a single payer system.
Sorry, I don't have an answer. Hopefully, great stories like the OP continue. But if we don't make it scale then we haven't really done all we possibly can do.
I could have told them that.
I designed and implemented portable electronic medical records for 5 regional exchanges. Hospitals, clinics, pharmacies, ambulances, permanent stays (nursing homes), insurers, labs, etc.
Coordination was tough, because everyone thinks they own the data (and loathe to share) and are often competitors.
It's all about the incentives. The only fix I can think of is single payer, which will compel everyone to play nicely together.
That said...
Simply having the state by state insurance comparison portals seems to be very effective for price competition, better than I could have predicted. So on balance, it looks like the impact of Obamacare / ACA will be really good, if not perfect.
As of February, it was about $130 billion off over 10 years (i.e. $1.3 trillion vs. $1.17 trillion). That is not 'severalfold'.
http://www.californiahealthline.org/articles/2013/2/6/cbo-up...
And insurance premiums on ACA exchanges are coming in 20% lower than expected:
http://aspe.hhs.gov/health/reports/2013/MarketCompetitionPre...
I do agree Republicans believe this thing is going to fail and are trying hard to encourage that.
I can't easily find a citation for it right now though. But http://www.cbsnews.com/8301-250_162-57589988/smooth-on-time-... confirms that at this point the rollout is facing potential trouble and needs billions more.
I have heard some republican state governors are pushing exchange setup to the Feds as part of their "gum it up" strategy, which may be pushing setup costs up. That said, as strange as it is to say, 5 billion is a relatively small number for the US government or the US economy.
They're still attacking Roe vs. Wade, after all.
It would be political poison, especially given the rollout will have had a few years to cement by March 2017 (the earliest anything could be taken to floor). Hard to tell what public opinion will be like in 3.5 years, but I'd wager it will be net-positive on ACA.
It seems odd to me that so many Americans seem pessimistic about their own government. I could understand if the attitude was, "We could make universal, socialized healthcare work. We could make it cheaper than Canada's. We could make it better than Sweden's. We just don't want to for ideological reasons."
But how can it be that the attitude is, "It would never work here?" You're the greatest empire in the history of civilization. What is this word "can't" and why is it in your vocabulary?
Since the US doesn't annex territories for itself and keep them as colonies as part of some Commonwealth Realm.
Although the US could have if it tried, with the slightest flex of a myoblast, in the last great war. It still can.
Pretty sure that's what he/she meant.
Nope. Neve happens. (Cough >Hawai'i<, cough)
(And yes Scotland has an upcoming referendum in 2014 on the issue of independence from the UK.[1] This is widely believed to be a losing proposition.)
Commonwealth Realm Antigua and Barbuda, Australia, Bahamas, Barbados, Belize, Canada, Grenada, Jamaica, New Zealand, Papua New Guinea, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Solomon Islands, Tuvalu
Crown dependencies: Guernsey, Jersey, Isle of Man
British Overseas Territories: Akrotiri and Dhekelia, Anguilla, Bermuda, British Antarctic Territory, British Indian Ocean Territory, British Virgin Islands, Cayman Islands, Falkland Islands, Gibraltar, Montserrat, Pitcairn Islands, Saint Helena, Ascension and Tristan da Cunha, South Georgia and the South Sandwich Islands, Turks and Caicos Islands
[1]http://en.wikipedia.org/wiki/Scottish_independence_referendu...
Perhaps what the Scottish people don't like the idea of is the SNP becoming the governing party of Scotland. However, and this is frequently ignored by the unionist press in Scotland, the SNP would not necessarily be the ruling party. There would be a new general election to vote for a new Scottish government in an independent Scotland and that could be Labour, SNP, Tory, Democrat, Greens or whatever.
There is a huge amount of disinformation banded about by Cameron, Osborne and other unionist politicians about Scotland's capabilities.
You see it in million places: The limited number of medical schools, The lack of nurse practitioners doing the simple routine jobs in most specialties(dental, family, colonoscopy, anesthsia. Many others could exist), The lack of automation and expert systems[4] and automated patient interview[3] tools, the fact that family practitioners could replace a lot of the specialists work at lower costs[1], Many medical jobs could be done with a lot less training[2], the lack of use of proven processes like checklists[5], etc.
All those changes could save a lot of money, and raise quality. We know what to do, But how do we implement it ?
[1]http://www.rwjf.org/en/grants/grantees/project-echo.html
[2]Because there's a brain drain in africa to the west, some countries have started a 3 year surgeon degree program. Doctors who finished this degree seem to have equivalent results to fully trained doctors in simple/medium complexity surgeries.
[3]Research showed doctors only ask about half of the questions needed in a typical visit. Automated interview systems could at least gather more complete data.
[4]There's research review showing that correct implementation of decision support/expert systems could improve results.
[5]Peter provonost showed that checklists could reduce infection rates in one procedure from 8/12 percent to zero.This was around 10 years ago. I think gawande showed similar results in other stuff. checklists are still not commonly used.
When I have challenged doctors about this, they tend to say "Ah, but you're focused on data, we focus on diagnosing the patient", which is basically gibberish.
That web app can name any person you think of by asking 20 or so questions. Just imagine what you could do if you made that but for diseases.
The problem is the morass of laws we've accumulated around healthcare over the years for various reasons that now interact in complex ways that nobody foresaw. Like the law designed to make Medicare or Medicaid (I forget which) drugs cheaper that ended up making it illegal to give free birth control to college students.
We also have the laws from when people believed that competition increased costs and so tried to ban competition between hospitals. Or the committee that sets doctor's reimbursement rates for Medicare procedures based on the *$%@# labor theory of value. And the laws designed to prevent people from overcharging Medicare that means that everybody has to worry about those rates across the industry. Or the way that the makeup of that committee means that primary care physicians gets shafted.
And the fact that we allow so few schools to teach medicine means that they can charge an arm and a leg, which means that those poor shafted PCPs need the kickbacks they get for assigning specialist care in order to pay off their student loans and malpractice insurance.
And I could go on.
And now we have this system that's incomprehensibly complex. So Congress has no way of figuring how to fix it on their own. There are people who've spent years figuring out how all of this works, but that's their job and if the system was actually fixed their job would be gone and that understanding they spent years acquiring would be useless.
Which isn't to say that this is entirely hopeless. There have been some efforts at the hospital level like Kaiser Permanente's to ameliorate the perverse incentives in the system and capture some of the value unlocked by that. And there are some laws that could be changes or repealed (like the one against hospital competition) without really breaking anything. So I think that gradual reform might be possible, but it's going to be a long road that doesn't particularly involve the issues that people tend to talk about around healthcare.
To an extent I wonder how much of that is due to lack of recent experience with starting from scratch. The United States hasn't had a revolution, a war on its territory, or a regime collapse in a long time.
Maybe it would be "lower quality", but least it would offer choice for many , and be a great research lab for low cost healthcare.
Local solutions don't really work for medical care, in terms of the legalities and economic structure, you have to require everyone to participate.
In this case, size and diversity work against us, it's just a lot easier in a small homogenous Scandinavian country.
Anyway, we have Obamacare gradually being implemented, where all employers above a certain size are supposed to offer insurance, and everyone else is supposed to buy it (the 'mandate' which the Supreme Court says is really just a tax).
So, maybe a minimum level of health care will start to be universal. But in order to get it through they made sure everyone was well greased. If the doctors, the hospitals, the insurance companies, or the pharmaceutical companies had to tighten belts a notch that would have been enough to sink it. So, it's going to stay very expensive.
I really think that people don't appreciate this fully for a lot of problems that the US has which have been 'solved' in other countries -- usually smaller European ones. Mail delivery, rail transportation, healthcare, etc. The US has a very unique blend of very urban and very rural areas that makes it hard to scale lots of services easily to everybody.
From what I understand, drugs are much cheaper in Canada. Almost all medical procedures are cheaper here. I met a couple from Texas who flew up here for something, and they said it was cheaper for them buy plane tickets, stay here in a hotel for two weeks, and all other travel expenses, and get the procedure done here than to do it at home (uninsured). They still saved thousands of dollars after all that. That's craziness.
Maybe there's no perfect system. But the United States spends the most on health care per citizen, and has the lowest percent of government support. [1] You should at least consider what others are successfully doing to get the costs down and increase the quality of care for the uninsured and poor.
[1] http://en.wikipedia.org/wiki/Health_care_compared#Internatio...
Knowing this, if one really wanted to implement single payer care in America, it would be more likely to succeed if the program was marketed as something like "Super Patriot America Care, just like our boys get in the US Military!" rather than calling it single payer care, which is some Euro/Canada not-invented-here thing that can't possibly ever work, because of America.
It's not just that many Americans have been persuaded that a single-payer system works for the old and disabled, but for some reason isn't right for everyone else. Rather, many Americans have been brainwashed into simultaneously supporting Medicare and opposing a generalized single-payer system, with equal fervor, without noticing the contradiction.
(Yes, really. I saw a photo a year or two ago of a protester at a rally carrying a sign that said "NO SOCIALIZED MEDICINE / DON'T TOUCH OUR MEDICARE", or similar language.)
Which is not to say there is a perfect solution. But just about any of the alternatives would be better than the US system.
The fact of the matter is that we've somehow managed to end up with a set-up that has just the bad parts from both models. All the runaway costs of regulatory capture, and all of the gross inefficiency of entrenched bureaucracy.
One note on efficiency - something like 30% (yes yes, citation needed) of American health dollars go towards insurance administration. A family member of mine works in Canadian health care and had a recent arrival (a physician, IIRC) from the States ask where the "billing floor" was because an out-of-country patient needed some sort of paperwork done. Well, Canadian hospitals don't have floors dedicated to processing payment. There was a small office.
On a second note, having your healthcare connected to your employment situation seems like insanity - I can't fathom anything that would argue in favour of that, unless you're an employer looking for additional leverage over your serfs.
It really is, although I don't think people realize it until you say it out loud. Precisely when you can least afford paying for a medical emergency -- when you're unemployed and thus have no income -- is precisely when it's most expensive. How broken is that? It would be insane in any other industry to charge your customer significantly more for the exact same service, simply because they're using a different payment method. Not to mention the horrible situation that arises if you acquire a medical condition so debilitating -- which usually also means it's expensive -- that it prevents you from working.
I lived in the US for two years, and I never understood the aversion to government healthcare. The Canadian system is far from perfect, and I know there are failures. But it's still a lot better than soliciting for online charity on a case by case basis.
I'm impressed and humbled that it worked in this case. Just a little disturbed that it was necessary at all.
Maybe if the system was flexible, nimble and could make judgement calls on the side of compassion, it might work, but this is difficult in both public or private sector institutions.
Then he went on some rant about how all the Canadians have to come down here for health care, and that was why you never hear of Canadians having surgery up there. I mentioned I had a Canadian friend who had a 3 part bowel surgery done recently, with very reasonable waiting times, and that of my several dozen Canadian friends, all but one was satisfied with their system, and he was just like, well, that's anecdotal, the statistics don't bear that out. That's not true at all, but he wouldn't hear of it.
Even before my health problems started, I was pro-single payer. But people like my classmate are everywhere, and seem to think that health care SHOULD be expensive and hard to get. It's inordinately cruel.
I've lived here all my life, but I'm actually moving out of state next month partially because my state's refusing to accept federal funds to cover my demographic next year, and I can't live without the medication I'm on. (Plus going to college out of state is cheaper than going to college in state (!). And they wonder why they have such a brain drain problem...)
Doctors deserve a paycheck to feed their families and pay off medical school debt just like everyone else.
Are you aware of the health insurance debate/disaster in the US? How long can doctors operate at a loss?
I must say that you are very fortunate if you do not know someone who has died of cancer and was unable to see/pay every specialist they could fit in to their final months days. People die of cancer all the time wishing they had the money to see the ______ oncology specialist.
The way it works is that they bill ridiculously large amounts, which nobody without insurance can pay. They know this. The insurance companies negotiate it, other people pay what they can, and it all more or less works out in the end. I'd much, much prefer to see a single payer system.
Seeing every specialist is different than being in treatment with a doctor and having them cut you off because you can't pay. It's very rare I hear of a doctor going "well it's a shame you can't afford to pay for this surgery" - nearly always they do it, bill it, and accept the losses. Hospitals recover less than 20% from people without insurance.
We have a very long way to go.
David Goldhill is the author of Catastrophic Care: How American Health Care Killed My Father--and How We Can Fix It
He advocates restricting the insurance system gradually and phasing out eventually, to increase accountability and vastly improve delivery standards.
His father was afflicted by a series of hospital infections that compounded his condition and eventually killed him.
When admitted in hospitals, he was thrice subjected to medical procedures that were meant for other people.
This Atlantic article is eminently readable.
How American Health Care Killed My Father
http://www.theatlantic.com/magazine/print/2009/09/how-americ...
http://www.youtube.com/watch?v=Y_7qCpiS_ZQ
Well bully for them. If they want people to stop "politicizing" issues that are entirely the result of the political game they play, then maybe they should stop being so selfish when a story like this comes up and some poor American has to pass around a hat so he can continue to live.
The minor inconvenience of ruining some feel-good story for you is nothing compared to the blind eye you choose to turn in regards to everyone out there who has the exact same problems but doesn't have HN to turn to to fund their treatment. One is barely an issue, the other is a travesty that you can help to change.
Expect this to come up every time until it's no longer needed.
If only all of humanity did this to each other.
P.S.: I am from Pakistan.
So, it's not just as easy as "let's pack up and move to the EU so we can get free healthcare tomorrow." Otherwise, you can imagine that every time a non-insured American got sick, they could compare the cost of getting new insurance to the cost of a plane ticket, and the plane ticket would win, I'm sure. =)
Packing up and moving is simply not an option for those who cannot afford to pay for healthcare in the US in the first place, and oftentimes logistics like family, employment, and language would prevent that anyway.
I'm living in Budapest partly for low tuition - my wife is Hungarian, which makes it less random than it seems.
Also, very few people in America can understand that life outside the United States could possibly be fulfilling. Or that tuition in much of Europe is free - I tell friends and family and they just boggle. There is such a strong feeling in the States that we have everything better than anybody else in the world.
When we were talking about moving to Budapest last year, I was asked by the plumber, "But is there enough food there?" He honestly believed, apparently, that everyone else in the world is starving except for the well-known massive foreign aid we provide. (That's tongue-in-cheek; most foreign aid is money specifically earmarked for the purchase of American industrial output, so it's really a handout to American industry, not to foreigners - and it's a tiny fraction of our annual budget to start with, but many people in America think that's where a substantial portion of their taxes goes.)