HN Books @HNBooksMonth

The reason people are talking past each other is because they’re basing their opinions on personal experience and anecdotes. If you look at the data we pay more for worse outcomes.

https://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

http://www.washingtonpost.com/wp-dyn/content/article/2009/08...

https://www.amazon.com/Healing-America-Global-Better-Cheaper...

And Canada isn’t the only alternative to the U.S. when it comes to health systems.

⬐ splintercell

We pay a lot more for worse outcome in education too, don't we (and from what I heard, in infrastructure also), so by what reason can we believe that Healthcare would be totally different?

Similarly, a Frontline episode:

https://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

An excellent book on the subject ("The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care"):

https://www.amazon.com/Healing-America-Global-Better-Cheaper...

And a comparison by The Commonwealth Fund:

http://international.commonwealthfund.org/

And just a reminder how long the U.S. has been having this argument:

https://en.wikipedia.org/wiki/Clinton_health_care_plan_of_19...

And a quote from that page:

The long-term political effects of a successful... health care bill will be even worse—much worse.... It will revive the reputation of... Democrats as the generous protector of middle-class interests. And it will at the same time strike a punishing blow against Republican claims to defend the middle class by restraining government.

— William Kristol, "Defeating President Clinton's Healthcare Proposal", December 1993

The book The Healing of America by T.R. Reid, 2010 was a phenomenal look at this subject and the conclusion was this: we are the only developed nation whose government allows for-profit health insurance companies to exist with ZERO regulation to cap healthcare prices. Because of this, we spend 20% of every dollar on "administrative" costs compared to 3%-7% in the European and Asian countries. The goal for American healthcare companies is increasing shareholder value, not reducing costs. IMO healthcare is an obvious example of where a "free market" approach has failed and government oversight is critical.

https://www.amazon.com/Healing-America-Global-Better-Cheaper...

⬐ cteague

American healthcare is nowhere close to a "free market".

Have you noticed how there are next to no startups disrupting the health industry? Why can't you sign up for insurance like you can sign up for a stock account on RobinHood?

There's no free market. Government licensing and regulations have created huge barriers to entry. I thought this would be more understood by those technically/entrepreneurially minded.

When things are too expensive, you need to raise the supply to get the price down. Not create price controls and socialize markets.

Read this article because it explains the problem better than I can.

https://hbr.org/2004/06/redefining-competition-in-health-car...

⬐ nabla9

Free market and well functioning market are not synonyms.

Healthcare economy is naturally inefficient if free. Information asymmetries and other market failures emerge without good regulation and mechanism design.

⬐ cteague

Every market has information asymmetry. Software is probably the biggest one today. Yet software keeps getting better and better...

I agree there are needs for regulations--more like proper norms though and a good tort system.

⬐ hannasanarion

No it doesn't. You can negotiate the price of software before you buy it, and you can shop around and choose between alternatives, or choose not to buy at all.

If you need a piece of rebar removed from your chest, then you need a piece of rebar removed from your chest. The price doesn't matter, the choice of provider doesn't matter. The "consumer" is completely at the whim of whatever provider happens to be closest. That's not how free markets are supposed to work.

⬐ cteague

You're engaging in 'all-or-nothing' thinking. The vast majority of medical expenses are not like that. And that's the whole point of insurance--to be covered in case something happens so you don't have to negotiate on the spot.

That's like saying we should socialize food distribution because people can't negotiate when they're starving.

⬐ hannasanarion

Sure, I chose an extreme example, but it's just a fact that healthcare is way less elastic than food.

If the price of beef is too high, I can buy pork instead.

If the price of a hip replacement is too high, what are you supposed to do? Get an appendectomy instead?

⬐ cteague

Demand is inelastic? Meh, my brother is living in Brazil and has been using a ton of private healthcare services because it's cheaper. Again, you're engaging in all or nothing thinking. As the price of LASIK goes down, more and more people use it. Americans go to the doctor less because it's more expensive. Healthcare demand is the furthest thing from an 'inelastic'.

Healthcare is bigger than just things that you absolutely need. Obviously, there are those things, but that's what INSURANCE is for. Then, when you are healthy, you can shop around and when insurance is too expensive and has too many items you don't need, you can instead get a barebones plan which would cover the things that you seem to be worried most about.

If a person failed to get insurance, well... that's not good. We shouldn't encourage that as a society. If someone runs out of resources and has to demand it from others, they are a burden and that is bad. If too many people do that, society collapses.

Obviously, there are going to be those people and I'm not saying we shouldn't care for them, but the more we have a socialized system--one that has a shared resource pool everyone takes from--the less efficient it will be because the incentives applying to individual encourage them to use as many resources as possible because they aren't the ones who bear the cost.

⬐ dsfyu404ed

There's plenty of industries where the customer often needs something done quickly or in an emergency and they still don't get screwed like they do in medical. Plumbers, septic pumping, auto repair, all have a substantial portion of their customers needing "emergency" services that they could charge whatever they want for. They don't though because there's price transparency and if you get screwed you'll never call them again and tell all your friends they ripped you off.

With medical there's no way to know when you got ripped off because prices vary wildly for the same services and there's no price transparency.

If I broke my leg doing something stupid you can bet your ass I'd call around and get quotes if I could. It only takes ~10min, far less than the EMT response time where I live. The problem is I can't even get quotes.

Sometimes you have no options and you get screwed but the vast majority of medical care is not people who will bleed out if they don't go to the nearest hospital ASAP. If normal services didn't cost an arm and a leg and you could reasonably shop around then healthcare and therefore health insurance wouldn't cost nearly as much because the lions share of services would be priced competitively.

Furthermore, price transparency is not incompatible with any other approach to healthcare since that information necessarily needs to exist.

⬐ dragonwriter

> If I broke my leg doing something stupid you can bet your ass I'd call around and get quotes if I could.

Quotes for...what? Even with price transparency on actual services, “I broke my leg” doesn't tell you with much specificity what services you need. And that's not even to discuss, “I'm having chest pain and dizziness”.

⬐ dsfyu404ed

>Quotes for...what? Even with price transparency on actual services, “I broke my leg” doesn't tell you with much specificity what services you need. And that's not even to discuss, “I'm having chest pain and dizziness”.

Sounds a lot like "my car is making a funny noise" or "my septic is backed up". Diagnosis should be cheap/free depending on how involved it is and then you get a quote for how much it will cost to fix and the quote usually includes some language like "and if X happens we'll stop work and call you/charge X to fix it as well".

Figuring out what work needs to be done based on vague descriptions by people who don't know the subject matter is what professionals do. I don't see why doctors should be held to a lower standard.

⬐ kingaillas

And that's why seeing a doctor often involves a battery of seemingly unrelated tests - diagnosis can be difficult and involved.

The fact is "my car is making a funny noise" or "my septic is backed up" are not life threatening situations; they are inconveniences with ready substitutes available. Health care is not a free market like car mechanics and plumbing are.

⬐ bko

I would also add that the parent post is internally inconsistent.

>> The goal for American healthcare companies is increasing shareholder value, not reducing costs

Reducing costs increases shareholder value. The shareholders don't benefit from these inflated administrative costs. This is money that could be converted to profit and distributed to shareholders.

This suggests something else is going on

⬐ matthewdgreen

We know that there is an efficient model for delivering healthcare, which is a government provided/heavily-regulated healthcare market. We know this because dozens of industrialized nations successfully operate in this model, with dramatically lower costs than we have here in the US. An existence proof is usually the simplest kind of proof.

Some people talk about a hypothetical second workable model, which involves a massively de-regulated free market system. It's important to note that nobody has successfully deployed this model in an industrialized nation, and it's not clear if it can even be implemented in practice -- for political as well as practical reasons (unregulated medical providers tend to kill people, so voters enact regulations, and then you're on your way out of the sweet spot.)

Whatever your preferences, the important thing to keep in mind is that while both of these two points may exist, the points between them are highly suboptimal. Removing 10% or even 50% of the regulations on our current healthcare system is unlikely to produce a substantially more efficient system. It produces a new system with most of the weaknesses and entry-barriers of our current approach, but replete with massive new profit-taking opportunities and substantially worse protection for patients.

This is why two decades of political infighting in the US have failed to fix healthcare. There is literally zero chance that the working, de-regulated system is going to come into existence. There is some probability that we can get closer to regulated single-payer, since we already have Medicare and it's much more efficient than private insurance, even though politicians have restricted its bargaining power. There is an overwhelming probability that in the process of trying to deregulate the current system, you end up making everything substantially worse.

⬐ corebit

Just go google "medical coding" and you'll see how your entire uninformed opinion falls apart.

⬐ bko

The US already spends a large percentage of GDP on public health care (medicare and medicaid). It's just that it spends much more in private on top of that.

I quickly found some numbers from 2008. All numbers are a percentage of GDP:

US: 7.4% public, 8.5% private

Switzerland: 6.3% public, 4.4% private

Sweden: 7.7% public, 1.7% private

France: 8.7% public, 2.5% private

graphic:

https://kaiserfamilyfoundation.files.wordpress.com/2011/04/h...

kff study:

https://www.kff.org/health-costs/issue-brief/snapshots-healt...

⬐ refurb

Why would you cap healthcare prices for insurers, they don’t set prices. You mean providers?

Half of US healthcare spending is public payers - Medicare and Medicaid. They do set prices for providers and still spend far more than other countries.

And if you’ve been involved in US healthcare you’d realize it’s drowning in regulations already. It’s not a free market by a stretch.

⬐ will_brown

It’s more complicated, the insurers essentially tell providers how to practice (ie prescribe this generic not the name brand, don’t prescribe 30 day Rx prescribe 90 day and don’t see/treat them in the meantime, etc...) and if the providers don’t listen the provider gets dropped from the network and either the patients are forced to new providers who the insurers control behind the scenes, or more and more the patients are forced to providers the insurers actually own.

⬐ refurb

Insurers control care to reduce costs. The upward pressure on prices is from providers.

In terms of these insurers who control providers, can you give an example?

⬐ will_brown

Insurers are really controlling care to improve their “star rating”. Insurers are given a star rating by many things outside their control and in the domain of providers and pharmacists. That’s why they are dropping docs and pharmacies from their networks and otherwise buying them to consolidate the market and their control.

Next time you go to your primary doctor ask them how many faxes they get from the pharmacist instructing doctors to change prescriptions. Then ask the pharmacists where they get those instructions from to fax to the docs....the insurers.

I’ll admit the star ratings are related to costs, but short term costs. All this watered down care and cookie cutter treatment will lead to higher costs long term (ie hospitializations, waiting until health problems escalate instead of preventative care or proper management).

It’s also why the big groups have reinvented HMO, now called ACO, bc even they don’t want outcomes based payment, so with ACO they can get paid $x/patient per year and make the care fit. HMO failed from a cost and care perspective, again not in the short term but in the long term, and it’s literally being rebranded as ACO by the insurer/provider groups.

⬐ refurb

Star ratings are for Medicare plans only, not commercial. They are related to the quality of the insurers for the customers, not prices.

⬐ will_brown

Yes but the Medicare plans are private insurance, the same insurers for the “commercial market” as you call it. You can’t separate the insurers dropping providers from networks and buying practices/hospitals from Medicare plans to non Medicare plans.

In other words if you aren’t a Medicare patient and are insured by UnitedHealth for example, you will be subject to the same networks of doctors/hospitals as their Medicare plans, so private is driven my the Medicare plans, because Medicare rules are driving the consolidation of the market.

And yes everyone will tell you star ratings are about “outcomes” not price, but if you knew/know anything about the star rating metrics it’s obvious “outcomes” is marketing/PR for cost cutting. Otherwise I’d ask to point out any metrics that increase star ratings that don’t lower costs, whereas it’s easy to point out the metrics that result in better “patient outcomes”/higher star ratings but lower quality of care.

⬐ mikeg8

Kaiser

⬐ refurb

Yes, and Kaiser has some of the lowest cost healthcare out of all insurers.

⬐ monocasa

The upward pressure on prices is also from the insurers. Insurers have an "80/20 rule" from Obamacare that only 20% of their revenue can be spent on non-medical expenses (ie. profit, insurance administrative overhead, etc.). They pretty quickly hit the caps, and now only by increasing medical expenditures (the other 80%) can the pie slice that contains their profit grow year after year.

⬐ tptacek

Ok, but Americans overconsume health care and are prescribed more procedures than other countries --- that's a dominant factor in our health care costs, unlike prescription drugs and admin costs. How do insurers, which have a direct financial incentive not to fund care, own that problem?

⬐ monocasa

As I said below:

The upward pressure on prices is also from the insurers. Insurers have an "80/20 rule" from Obamacare that only 20% of their revenue can be spent on non-medical expenses (ie. profit, insurance administrative overhead, etc.). They pretty quickly hit the caps, and now only by increasing medical expenditures (the other 80%) can the pie slice that contains their profit grow year after year.

⬐ selestify

Wow, sounds like one heck of an unintended consequence for that well-meaning 80/20 rule.

⬐ lotsofpulp

Only because of a non functioning market due to federal and state laws.

If there was one health insurance marketplace and set of rules, and everyone, young, old, poor, rich, healthy, infirm, we’re forced to buy from it, then it would actually be possible for insurance companies to compete.

Right now, it’s basically a game of hot potato to try and not get stuck with the million dollar hemophiliacs in each state. A lot of the healthy are separated out into employer based insurance plans, and there’s not sufficient possibility of business to have more than one or two insurance offerings on healthcare.gov.

⬐ None

None

⬐ dmitriy_ko

This issue existed before Obamacare 80/20 rule. In a free market the way for a profitable insurer to grow is by growing marketshare -- whether 80/20 rule exists or not. And the way to grow marketshare is to offer cheaper insurance. To offer cheaper insurance insurers have to push service prices down. Somehow this is not happening.

⬐ tptacek

Hey, wait a minute, that's true. The McKinsey study predates the ACA and establishes the overconsumption narrative. The 80/20 ACA thing can't be the problem.

⬐ monocasa

I'm not staying it's the problem; for something as systemically wrong as the US healthcare system there isn't just one thing wrong.

I'm merely debunking your assertion that insurance companies don't have a financial incentive to keep costs high.

⬐ tptacek

What's the financial incentive they had to keep costs high in 2010? You're making an extraordinary claim: health insurance companies are deliberately making themselves liable for provider costs in order to somehow benefit on the backend. You should have some kind of evidence?

What's the trend line since 2010? Since the 80/20 rule went into effect, has the rate of provider costs increased or decreased or stayed the same? If it hasn't increased, does your hypothesis actually explain any empirical observations?

If not, are you concerned this might be a just-so story?

⬐ mikeg8

I did mean providers, I worded that poorly. US government does not set max prices for procedures, checkups, test, drugs etc as other counties have wisely chosen to do.

The reason we spend so much on Medicare and Medicare is because people are less hesitant to use the service. On a per capita basis, the public payers have reduced overhead and costs compared to the private markets. If you have sources proving me wrong, I’d be happy to look at them.

And while the US market my be drowong in various regulations, it is severely lacking in price control regulation - the whole reasons for this discussion.

⬐ refurb

The cost of procedures for Medicare and Medicaid is still much higher than for other countries.

Yes, they reduce costs by saying “this is what we’ll pay”, but it’s still much more costly than other countries’ systems.

⬐ mikeg8

And I agree with those two sentences - never was arguing that we pay less (compared to other models) in our public markets. But you are not strengthening a counter-point to the conclusion I presented from the book regarding zero price control in conjunction with for-profit insurances which jacks up overall costs through coverage disputes, excess admin work etc, lack of price transparency pre-treatment etc. What is your personal hypothesis for why US healthcare is such a poor value for the price?

⬐ refurb

If you look at the vision correction and plastic surgery markets, you'll see they function quite well! Providers compete on a combination of quality and cost. So I don't think there is anything intrinsic to the free market that suggestion it's to blame for ever increasing prices.

My personal hypothesis is that Americans get a lot more healthcare than most countries provide, combined with higher prices. Not all of it is all that beneficial.

If you want to read something really eye-opening, check out this McKinsey report, bottom of page 14[1] It basically compares US healthcare spending across categories, adjusting for GDP (expecting the US' higher GDP means we spend more).

For inpatient care (hospital care), the US actually spends inline with what other countries spend. For long term and home care, the US spends less than other countries. Same thing with durable medical equipment.

Almost all the "excess spend" is in the outpatient setting. American's get a shit ton of procedures done that other countries just wouldn't do. Have a hernia? Providers in the US fix that, where other countries might say "we'll do something if it becomes a problem" (for example).

[1]https://www.mckinsey.com/~/media/McKinsey/Industries/Healthc...

⬐ matthewdgreen

Medicare is dramatically more efficient than private insurance, both in terms of actual health costs paid out and administrative overhead.

⬐ module0000

You cap healthcare prices for insurers because they are heavily influencing the provider prices.

Both institutions work in tandem[0] with one another to establish pricing guidelines. That's why your hospital-purchased ibuprofen is $10 per pill instead of $6 per bottle. The insurer and hospital "work out" a price that let's them achieve the profit needed to pay their administrative costs, plus margin.

In the USA(this is all from a US citizen's perspective), there are regulations that limit what percentage(15% in my state) of an insurer's income can be profit vs administrative cost. This means that a higher hospital price results in a higher profit for the insurance provider. This provides both parties an opportunity to set prices for an optimal profit. With government-mandated health insurance participation, the pool of people paying into this system has increased.

It is what is. Tell your elected official if you think it would help.

0: Anthem, Blue Cross, and UHC executives sit on the Baptist Health(hospital chain) board of directors, and vice versa.

⬐ castlecrasher2

>You cap healthcare prices for insurers because they are heavily influencing the provider prices.

Insurers already have an incentive to limit prices, though, which is essentially what their contracts with providers are. As in, they list how much they'll shell out for CPT codes.

⬐ Dylan16807

They have an incentive to get discounts, which is not the same as limiting prices.

⬐ JarlUlvi

It is actually the other way around - Govt regulated costs (medicare and medicaid) highly influence insurer compensation to private practices and hospitals.

Medical Providers (doctors/hospitals) negotiate based on multiple of Medicare as payment.

⬐ refurb

Health insurers and providers negotiate payments for healthcare. They sit on the opposite side of the table - insurers want the lowest price and providers want the highest price.

The only benefit an insurer would have from a higher price is if they have a monopoly position - no other insurer. Otherwise the other insurers will pay less, charge a lower premium and grab all the customers.

⬐ ddingus

That is what networks are for.

When choice is harder, they can play the price game better.

⬐ braythwayt

"Never confuse an unregulated market with a free market."

---

(Yes, yes, I understand that to an economist, a "free market" is free of regulation, a product of laissez-faire economics. But to the lay person, a "free market" is one where prices are set by perfect competition, which requires a balance of power, the prevention of monopolization, and information symmetry.)

⬐ minikites

Both are about as real in practice as the Easter Bunny, so it's a distinction without a difference.

⬐ james_s_tayler

Yeah lay peoples definition is the markets which they are used to living with which don't match the technical terms exactly but come close enough for them.

I just use the term "free enough market" to describe it.

⬐ PakG1

Really? I thought it was the other way around.

⬐ wjnc

We run a health insurance company at my firm for some € 100 in cost per insured per year (the Netherlands). We do full bargaining with suppliers on our risk, give yearly premiums up front and have to accept everyone for a pretty much standardized premium. Dare say we even try to innovate in combination with other private insurances we offer like disability as well. Of course required for this to work is quite massive government intervention. They lay the backbone for proper risk equalisation and we try to work with that. 20% of total health spending would be about a 14-fold increase. (It gets a little murky since parts of health are outside of our market and the responsibility of local municipalities.)

⬐ nickchuck

From what I understand, the healthcare market isn't free at all. LOTS of regulation is what has caused this mess I believe.

⬐ laurentoget

It is much less free in France or Germany, and they spend considerably less for much better outcomes. You would never get an MRI for a sprained ankle in France, but on the other hand people do not die because they cannot afford insulin.

⬐ RHSeeger

Ugh. I hate this story. In every popular story I've seen of "this person died because they couldn't afford insulin", it's really been a case of "this person died because they couldn't afford the most expensive insulin, and they weren't willing to switch to the DRASTICALLY cheaper insulins available".

- The story I'm looking at now had someone complaining he couldn't afford his Lantus.

- Lantus is pretty much the most expensive 24 hour insulin available. Last I checked it was something like $275 per bottle.

- Walmart has cheaper insulins R, N(PH) for somewhere in the range of $20-25. They're older insulins and don't work as well, but they are an option for any diabetic that can't afford the newer insulins. (Note, I can't find it on Walmart's web site but, as I understand it, you can't but it online, so that may be why)

For context:

- My insurance doesn't cover Lantus either. I take a generic (to be fair, I don't believe that generic was available at the time of the story) version of it.

- I used to take R and N insulin

⬐ fzeroracer

The american healthcare market is possibly the most 'free' one in the world. Yet we're still failing with regards to countries that have far more regulations and restrictions.

It's time to stop perpetuating this myth. Especially in a thread directly about how the US overpays for everything compared to literally every other developed country on the planet.

⬐ JarlUlvi

healthcare costs in the US were at one time far lower.

Before the rise of medicare and medicaid and EMTALA (hospitals must treat anyone regardless of their ability to pay)

⬐ zanny

Its impossible to do an apples to apples comparison but I would imagine by most standards EU health markets are less regulated than American ones, just because the organizational structure is so much simpler and oversight is so much less distributed. Instead of needing policy on every kind of machine you can use in what configuration or parameter codified in law or by an agency by formal declaration the NHS just buys the stuff they want doctors to have.

⬐ tptacek

If health insurance companies are the problem, why are administrative expenses --- which we overspend on, to be sure --- not the dominant factor in our health care expenses? They aren't; they're not even in the top 3.

If Medicare managed all of US health care and nothing else changed (that is, if we relied on Medicare for funding and kept the rest of the system we had intact), we'd reduce prices by something in the low teens percentage points. Families upset about the cost to insure their families on the ACA markets would not be mollified by that level of price relief.

⬐ Shivetya

please don't foist the entirety of this issue on insurance companies, the states and federal government dictate the paper work to be done and the coverage provided. it is damn easy to mandate paying for procedures when you don't have to pay for them.

California and Vermont found this out when both determined single payer options; read : the state; were not affordable without seriously curtailing care options. As in, when you tell people no it becomes affordable, when you bend over for every little thing it suddenly becomes what we have today.

⬐ joelx

Americans spend more on healthcare but get less for one simple reason. We artificially restrict the number of new doctors each year through licensing and other government regulations, which reduces the supply of medical professionals. When you restrict the supply of anything and demand is inelastic, prices go up.

⬐ mikeg8

This is a totally inaccurate answer. The intricasies of healcare inflation are way more complex than simple supply and demand economics and I’d suggest you read the book I mentioned in the my original comment to be more educated on this subject

⬐ closeparen

There are mutual (policyholder-owned) life insurance companies; why not mutual health insurance companies?

Healthcare is extremely regulated, but poorly. In addition to the much-talked-about “more vs. less” dimension of regulation there is the much more important “better vs. worse.”

⬐ skookumchuck

> allows for-profit health insurance companies to exist with ZERO regulation to cap healthcare prices.

There's zero regulation on the software industry, and prices have trended to zero. I suspect the problem with the health care industry is much deeper than not enough regulation.

⬐ hannasanarion

How often do you get rushed to your local software company in need of an immediate node.js webapp or you'll die within the hour?

⬐ CryptoPunk

The vast majority of healthcare costs are not related to emergency care. For that portion, there is indeed an argument for government-provisioned services being more efficient.

⬐ None

None

⬐ gerdesj

we are the only developed nation whose government allows for-profit health insurance companies to exist with ZERO regulation to cap healthcare prices.

So what are you going to do about it?

⬐ DennisP

I read that book too, and agree it's phenomenal. It's not just about capping insurance profits. The countries doing the best also have price controls on the healthcare providers. Doctors make a lot less money. On the other hand they generally don't have to pay for medical school.

France, Germany, and Japan all have similar systems, according to the book. They have private nonprofit insurance, some kind of mandate to purchase it, a government price list on services, guaranteed coverage of anything on the list, and digital medical records.

A lot of German primary care doctors don't even hire office staff. They prescribe whatever they want, swipe your medical card, and they're guaranteed to be paid in a week, no questions asked.

Japan has a clever way to handle the mandate. If you don't pay your premiums, nothing happens, but if you need healthcare you're not covered until you pay your back premiums.

I wish all the Americans who think the rest of the developed world runs on single payer would read this book. None of the three countries I just mentioned use single payer. The book also covers Canada and the UK, both of which are single payer (and single provider in the UK), and while their results are pretty good, they're not as good as the other three.

⬐ euske

One of the main reasons why I gave up career in the States and came back to my home country (Japan) was healthcare. I had a day surgery in the US and the whole experience (i.e. bills) just scared heck out of me. I am very happy with the system here. Everything is extremely efficient compared to the US. A little while ago, I had this mysterious headache and went to an orthopedist, dentist, psychiatrist, neurosurgeon then took an MRI. All within one week. My Canadian friend told me that it would be a half-year ordeal in Canada. By the way, I'm not rich.

⬐ joering2

Just got hemoroids frozen and cut with laser. Cost here in USA under premium insurance was $12,000. Went to Germany got it done on the same equipment in luxury stay for 14 days at $870. Plus $800 plane tickets. Meanwhile a friend of mine had a heart attack. As a Bank of America emplyee he had somewhat goog insurance that paid some. He was left with $180,000 bill.

⬐ arcticfox

> As a Bank of America emplyee he had somewhat goog insurance that paid some. He was left with $180,000 bill.

Forgive my ignorance but how is that possible? The highest out of pocket maximums for Marketplace plans is $15700 for an entire family.

⬐ EvanAnderson

He may have been traveling when he had his heart attack: https://www.wsj.com/articles/john-stockmans-medical-bills-to...

He may have been attended-to by out-of-network practitioner: https://www.nbcwashington.com/news/local/Out-of-Network-ER-S...

⬐ lostlogin

What’s with the ‘out-of-network’ thing that gets pulled out regularly? Is healthcare really that much more expensive to an insurer if it’s done at one site or another? Sure, they’d prefer it was done in-house so that the ticket can be clipped multiple times, but it’s clearly just made up numbers that are produced currently.

⬐ patient_zero

It doesn't make sense, but you have to (as a patient) make sure that the provider you're getting healthcare from is covered by the insurance company's (changeable) list. Its indefensible but it's reality.

I cannot wait for reform and I hope it hits before I get old and need it often.

As an aside, even the billing system is fucked up. When I get a receipt for covered care, it often looks a lot like a bill. This has to be by design. Its bad enough that I just ignore both "receipts" and bills and wait for the collectors to call me. That's how I know which is which.

⬐ roganartu

It's not that it's more expensive at one place or another for the most part. When you go in-network you are seeing providers that your insurance has a contract with. This contract includes agreed amounts for procedures. Providers will often grossly overbill (mostly because it's easier to let the billing backend resolve these limits than bill accurately in the first place) and your insurance will respond with the amount covered. The remaining amount of the bill is written off because it was in-network so the provider is not allowed (by the contract with your insurance) to bill the balance not covered to the patient.

Out-of-network does not have this protection. Your insurance will possibly cover some of the bill, normally up to some percentage of what they consider a normal amount for the procedure in the area, and then you will be billed for the entire balance. Say your provider bills $100k and your insurance says they think that procedure normally only costs $50k and you have 80% out of network coverage. You would be billed for 20% of the $50k covered as coinsurance, plus the remaining $50k that would've been written off if you were in-network.

This is generally how people get surprise bills.

For a real world example: last year my insurance got billed ~$3k for a routine blood test for my wife as part of an annual checkup. It was in-network and the insurance paid $27 and the provider wrote off the rest.

⬐ lostlogin

I understand this, but don’t understand why millions of people are ok with the system. It has a lot more in common with a protection racket than with patient care in my view.

⬐ komali2

Propaganda and lobbying by the insurance companies ensure that the will of the people doesn't turn against them.

⬐ None

None

⬐ None

None

⬐ sbov

Not true, because people actually hate insurance companies. The best propaganda is by the hospitals because no one ever seems to complain much about them.

There's been a lot of revealing reporting over the past decade but people don't seem to care: the price of a procedure in two different hospitals in the same city can vary by 10x because they literally pull prices they charge from their asses. They tend to justify this by saying "no one ever pays that price".

But when I got a bill for my wife's surgery that included 15k for 1 hour in a recovery room, another 25k for 1 hour in a surgery room, and 9k for an overnight stay (on top of the 20k from the surgeon, 3k from the anesthesiologist, and 3-5k from random doctors we saw for a few seconds) those words sure as shit were not reassuring.

All my past attempts to get an idea of what something might cost me, even when I knew insurance wouldn't cover it, have failed. It takes days worth of time on the phone only to get the wrong answer. One even told me that I only get the cash price if I don't have insurance even if my insurance won't cover it - and I must have insurance because its illegal to not have insurance so I can't get the cash price. What the fuck man?

Hospitals can fuck off. I have no idea why they don't get more blame in this mess.

⬐ marcus_holmes

I think it's something in the American mindset. It's been said before, but Americans think of themselves as "temporarily embarrassed millionaires" when voting (hence why they consistently vote in the interests of the rich - everyone thinks they'll benefit from those tax cuts when they win the lottery/sell their startup/etc).

Same situation here; "health care costs are for those sick losers. I'm not going to get sick, so it doesn't matter to me how much it costs, and I don't want to pay more tax to reduce healthcare costs for those losers".

I exaggerate, but it does seem like there's something like this going on...

⬐ TheOtherHobbes

It is partly a cultural thing - a kind of cult of narcissism.

But those attitudes are carefully cultivated by the media. They don't just happen.

Congress and the Senate are full of corrupt leeches, and both parties are equally guilty.

Votes make no difference. Corporate money buys political careers, and it pays for both sides.

There are a few exceptions, cultivated to maintain the appearance of representative democracy, but they're rarely - if ever - allowed anywhere near policy.

⬐ DaiPlusPlus

> Congress and the Senate are full of corrupt leeches, and both parties are equally guilty.

No, the Democrats and Republicans are not the same.

⬐ EvanAnderson

Both parties are equally guilty of being more worried about holding on to the reigns of power than serving the public.

⬐ macintux

No, I reject that equivalency.

One party is suppressing the vote and constantly sabotaging the workings of the government to retain power.

⬐ None

None

⬐ EvanAnderson

Those aren't the equivalencies I'm asserting. My position is that members of both parties expend far too much energy working on re-election fundraising versus working for the people. That's the equivalency I'm asserting.

⬐ komali2

Both parties, then, are elected (generally. Republicans tend to depend on the electoral college to win).

Both parties eat food.

Both parties drink water.

What's the point of this equivalency? I identify a moved goalpost. Your initial post was "both parties are equal." We are far from there, down here.

⬐ patient_zero

I agree with you in part, but in my opinion propaganda and lobbying are the problem because this is the source of the disconnect. When people got increased protections from the ACA, nobody complained. The insurance and hospitals deliberately shitcanned the healthcare marketplace and MOST pepole don't put much thought into why the mandated insurance became unconscionably expensinve, they just thought "Obamacare is worhtless" because that's what they were told.

I don't think it's specifically an American thing to avoid much thought about becoming really ill. It's an uncomfortable subject.

⬐ EvanAnderson

I don't think millions of people are okay with it. I think the vast majority are unaware, those who are aware have no agency, and very powerful interests seek to maintain the status quo.

⬐ marcus_holmes

yeah. Can you refuse treatment from an OON provider in a hospital? Because that would be my first question if approached by a doctor who could potentially bill me $100K

⬐ brazzy

> Can you refuse treatment from an OON provider in a hospital?

In most cases you will not know that it's an OON provider. You may be under sedation at the time.

The practice is outlawed in many states, as far as I know.

⬐ isostatic

When I go to hospital, on the assumption I'm conscious, the last thing on my mind is deciding which doctor I want

⬐ cm2187

For ER agreed. For anything else that is serious / non trivial, you also want to consider the repuation of the department. Some doctors are world specialist of something, or treat dozens of a particular condition every year. Others rarely do or are simply not good. I don't think there is any way for a layman to know. You kind of need to ask relatives in the profession, who can themselves ask around. I have a few doctors as relatives and they systematically check the reputation.

⬐ howard941

We're not okay with it. And it is a racket. It's not fixed because the racketeers run the place.

⬐ tialaramex

It's not that millions of people are "OK" with it, but that in practice democratic elections aren't actually about policy. Suppose Alice's policy is to do X, and Bob's policy is to do Y, we might suppose voters who overwhelmingly want X will go vote for Alice, but nope, the Bob voters will still vote Bob and then be annoyed that Y happened, independent of continuing to support Bob. That doesn't make sense, but it's what happens.

This would be a grave defect if the purpose of democracy was to achieve good government, but in fact we haven't the faintest idea how to get good government, democracy is a fix for bloodshed during the inevitable power transitions. So, a bunch of idiots with no clue are still in charge, but now a _different_ bunch of idiots can take over without having to murder a bunch of people to do it.

⬐ istruble

Number two for sure. You are almost guaranteed to be seen by an out-of-network provider. It does not matter if you go to an in-network hospital/ER, the providers go out of their way to work a couple hundred miles from home just to bring in the big OON prices. Out of three visits to in-network ERs (in two different states) in the last seven years, how many do you think resulted in crazy charges from OON providers? If you said anything other than all of them you must not be from the states. It is basically impossible not to get fleeced by "health care" in the US.

⬐ kasey_junk

I’ve been to the ER twice in the last 2 years. Once at the hospital blocks from my house & once while traveling for work 800 miles away. In neither case did I get charged out of network charges.

In fact in the 25 years I’ve paid for mine or my families health care I’ve never seen what you describe over lots of ER visits.

There are lots of things wrong with the US health system, providers systematically trying to get out of network fees isn’t one of them.

⬐ dd36

Your experience is the only experience. Good point.

⬐ vonmoltke

Not what kasey_junk said at all. It was responding to someone who said:

> It is basically impossible not to get fleeced by "health care" in the US.

The experience is evidence against this very strong statement. You have uncharitably decided it was making an equally strong statement in the opposite direction.

⬐ JAlexoid

There are interesting cases, where doctors prescribe stuff they get no valuable information from.

I had this in US. Shoulder pain, that was diagnosed via an XRay... But the doctor decided he wanted an MRI. That's no unusual, but unnecessary in my case. Got charged extra $500 for the pleasure. Thankfully I was on an HDHP, so the HSA savings got hit.

⬐ lostlogin

That’s not an unreasonable charge for an MRI and I’d argue that you got off quite lightly. You can’t diagnose many of the potential problems shoulders have from an x-ray but a good clinical examination will catch many of them, with an MRI for confirmation. Labral tears would be an example of this.

⬐ JAlexoid

No it's not an unreasonable charge. The amount I had to go through and the necessity of it was the question.

I got charged with two things - XRay and MRI. One was enough, apparently... And I wasn't in any critical condition to an XRay immediately.

⬐ yholio

It's 2-3x more than you would pay in a regular civilized country... it speaks volumes about the US system that you think it's not an unreasonable fee.

⬐ lostlogin

I’m not sure you are correct in that - MRI scanners are expensive to run as they are rarely as low priced as you are suggesting. See link below which is a little old but gives a spread of prices. Note that the prices cited i this thread is less than half the US average.

Another factor that is relatively rarely discussed is the quality. You can do a fast scan or a good scan. That’s inherent in how MRI works. A good gynaecological, cardiac or liver scan takes about 45mins, and there isn’t much you can do to improve on that as you are limited by metabolic activity (eg liver or heart contast wash-in and wash-out). If corners are cut here diagnosic quality will be reduced.

I regularly see scans that are of such poor quality that they are initially mistaken for the survey scans/scouts that we use to localise the patient in the bore. They are generally from places that you would intuitively avoid for healthcare, but not always.

https://www.statista.com/statistics/312020/price-of-mri-diag...

⬐ patient_zero

For a second I read your comment as liberal tears, and had to do a double-take. :)

Speaking to the 500$ charge, are you saying that is a typical cost around the world for a MRI? Is there something about the machine's cost that justifies this or are you just saying that a 500$ charge is typical in the american system?

⬐ Fiahil

And here I thought my last 120 EUR MRI was very expensive... (in France, of course)

⬐ lostlogin

That’s impressive. The purchase price and running cost are high. Then there are expensive labour costs (doctor, probably 2x techs and admin/reception staff. Often a nurse is around for more complex procedure too). Peripheral equipment isn’t cheap, with defib, contract injectors, RIS/PACS, reporting stations etc. Scans are slow relative to CT and x-ray so I have no idea how they make that work. Did you pay the whole bill? I am an MR tech.

⬐ asdff

That negative MRI result can be just as informative as a positive one. Maybe your XRay gave the doc only 80% confidence in the diagnosis, and the MRI was to rule out a larger issue. Like an engineer, doctors work deductively to rule out potential diagnoses, so all that is left is the correct one. Inductive logic brings in subconscious bias and assumptions.

⬐ JAlexoid

Nope. He ordered MRI immediately with the XRay... and he didn't even look at it, as I was informed by the assistant.

I checked if he needed to do that with my other doctor - he said that only one was needed, not the other.

⬐ vasili111

>I had this in US. Shoulder pain, that was diagnosed via an XRay... But the doctor decided he wanted an MRI.

Xray is mainly for bone problems. MRI shows well soft tissue. In medicine, if something you suspect even it has a low probability and the diagnostics are not invasive, it is better to check than to miss and regret later. Why are you so sure that MRI was not necessary in your case?

⬐ JAlexoid

I saw my other doctor, slightly more decorated orthopaedic surgeon, that literally told me that I was blasted with XRay for no reason or my MRI wasn't necessary.

I have an irritating bone spur in the shoulder, that's the only problem.

The doctor ordered both Xray and MRI at the same time, while there was literally no need for one of them.

⬐ notabee

You are reasoning backwards. Had the cause been something besides a bone spur, such as a tumor or vascular problem, the X-ray might have missed it. Some things like soft tissue calcification don't show up as well on MRI as on a plain X-ray film which is a really low radiation dose these days anyways. Go read up on the terms sensitivity and specificity.

⬐ None

None

⬐ gumby

In a hospital you'll likely be seen by a variety of providers some, or even many of whom are not in your network. You insurer will pay some amount out and then the provider will bill you for the rest...which can be huge. This bill is unrelated to your insurance and is unrelated to any out of pocket maximum. That maximum only relates to copays etc as part of your insurance.

⬐ narrator

When I had a kidney stone, I made sure to get to Kaiser. Not the closest hospital, but at least everyone's going to be in network.

That's the biggest benefit of Kaiser IMHO, no wacky out of network stuff at their hospitals.

⬐ VBprogrammer

In the UK which hospital you would go to is nearly 100% based on ease of getting there and the facilities they have on hand.

The idea of driving past a hospital to get to another which is more friendly to my insurance plan completely blows my mind.

⬐ dogma1138

Only if you use the NHS, private insurance would require you to pay extra if you don’t live there especially for inner London Hospitals.

⬐ VBprogrammer

Have you lived in the UK? I personally haven't encountered anyone who has had that issue. Most people primarily use the NHS and private health insurance is provided only occasionally as an employee benefit (often by American companies). That's nice for perhaps getting faster treatment for minor issues and maybe getting a nicer room but generally not required.

I'm sure that the 1% have other arrangements but that's another thing altogether.

⬐ dogma1138

If you get private insurance you pay extra to cover inner London hospitals unless you live there.

I haven’t used the NHS for the 6 years that I’ve lived here tried it once when I was looking for some physiotherapy for my knee got told by the GP that it will take 3 months called AXA which was then my provider and got an approval for 3 sessions which was then extended to 12 the same week.

I don’t even book GP appointments via the normal NHS route any more all of the GPs are technically private anyhow they just accept NHS patients and getting a booking via private health care is just that much more convenient since they see you within 24 hours and evening appointments are much more available.

⬐ VBprogrammer

> If you get private insurance you pay extra to cover inner London hospitals unless you live there.

That's kind of the opposite of what I was saying anyway. It's fair enough if you are making a decision to go to a more expensive hospital for your own reasons.

Yeah, private healthcare in the UK is convenient but far from essential. Physiotherapy was actually exactly what came to mind, I believe it's one of those parts which are always chronically under-resourced.

⬐ dogma1138

It’s also the fact that you can’t register with more than one GP so if you don’t live within say 30min of your work going to doctor appointments is a day off essentially not to mention that if you don’t pretend to be dying when you call them they’ll tell you to get some rest and call again in 3 days.

If you go to A&E sure NHS is good enough, but for preventative care and general appointments however it’s pretty poor same goes for any kind of specialist care unless you are getting it at the hospital.

Don’t get me wrong universal healthcare is important single payer universal isn’t, and the NHS’s trust structure is really poor so if you live in an area where the trust is literarily bankrupt the level of care you get is piss poor at best.

I think the biggest mistake the Brits did is to prevent the NHS from providing premium services at a cost like better rooms or cosmetic surgery.

The best healthcare systems in the world are those in which the healthcare providers are non-profit, are required to maintain a specific subset of services defined by the government, aren’t allowed to deny service but are allowed to make money on the side with things that aren’t covered by the government.

That extra money is key because as non-profits the only thing they can do with it is to reinvest it in either their staff or their services there are no shareholders to give dividends too.

This is something the NHS lacks I would much rather pay the NHS the same money I pay to Bupa and get the same service as I can get now knowing that some of that money is going to go into improving the NHS as a whole.

⬐ NeedMoreTea

The NHS's trust structure is more about forcing a market into somewhere it has no place than about healthcare outcomes.

When we once elected to go private to queue jump we got to see an NHS consultant privately, in an NHS hospital, and all follow on treatment was on the NHS. So it was a simple case of a few hundred pounds for private scan and consultation.

Most hospitals and maternity units have private rooms as an option. As far as I know they're not restricted or limited in any way, unless it's changed since our experiences. We've not needed a hospital for a while.

⬐ dogma1138

Yes but those funds aren’t going to the trust as in the actual public pool.

Most hospitals have private wings, but the NHS doesn’t see any profit from that.

⬐ NeedMoreTea

Hmm, I didn't realise this.

If I see an NHS consultant privately they get a little extra personal income. So if I took a private room where does the profit go in the current system? Treasury?

⬐ lostlogin

How is that possible? Is the rest of the bill paid by the state?

⬐ pjc50

No, it's just cheaper labour, has far fewer billing overheads, less profit, and is an actual market price rather than the oligopoly fiction the US calls prices in healthcare.

⬐ dzhiurgis

Should have treated yourself with business class seats...

⬐ 01100011

How was the recovery?

⬐ masonic

  Went to Germany got it done on the same equipment in luxury stay for 14 days at $870

A "luxury stay" in a plain hotel with no medical services should cost a lot more than $60 a day.

⬐ fiblye

It's crazy how even with insurance, things are far more expensive in the US. I can get xrays, blood tests, and medicine all together for less than $50 in my current country. In America, even with good insurance, I'd be looking at a couple hundred in fees. A simple piss test and antibiotics there for a kidney infection set me back $300. Here, I'd maybe pay $20 for the same treatment.

American insurance is merely rent seeking. It soaks up money like a goddamn sponge and offers absolutely nothing in return. It's literally worse than nothing since it's driving prices up. There are companies out there with--no joke--hundreds of thousands of employees, just growing bigger by the day, and offering negative value to Americans. UnitedHealth has 270000 employees. That's as big as Apple and Microsoft combined, but they've got nothing to show for it except colossally fat and minimally taxed earnings.

⬐ stuxnet79

In Canada, if it was serious, half a year is actually even quicker than I'd expect. I'd really love to try out the Japanese healthcare system. As it stands, I'm convinced that healthcare is an impossible problem to solve.

⬐ Cthulhu_

It's not though, it's solved in a lot of countries. Even - or particularly - those that are economically worse off than the US, such as Cuba.

⬐ dalore

UK is fine too. Even minor surgery I was scheduled in for 2 days after seeing a doctor.

We are having some trouble due to austerity cuts and freezes by the current conservative government. But in the whole it works.

⬐ david927

I'm convinced that healthcare is an impossible problem to solve.

You need to travel more. The German system, for example, is very old, very simple and works very well.

⬐ egeozcan

I like the healthcare situation in Germany but normally you would have to wait months for a surgery, if it's not very critical. An appointment with a specialist can also mean waiting weeks or months.

⬐ david927

I don't know where this idea comes from. I'm American but my experience with healthcare in European countries where I've lived (England, France, Czech Republic and Switzerland) is unparalleled. I had my gall bladder removed (non-critical) in France; the wait was two weeks and everything about the experience was impeccable.

⬐ GFischer

Weeks is not bad... Months is. And as you said, it's for non-critical stuff.

A mixed system - government-managed for important things, with extra healthcare you can pay on top, like the one we have here in Uruguay, seems to work best.

As far as I can tell, we have the best healthcare for anything but special/rare cases which would be best served by a top specialist from the US or Germany. For the remaining 99% of cases it beats any system I know of.

⬐ thousandautumns

That's not that uncommon in the US either though. My mother had an issue that required seeing a dermatologist, and just getting in to see a dermatologist was initially going to take about 6 months. After calling for a month, she was eventually able to get her wait down to 2.

⬐ DennisP

That fits with what the book described. The author had a bum shoulder and saw a doctor for it, in each of the countries he covered. In Japan he got an appointment immediately and the doctor offered surgery the next day.

Financially they're the most efficient of all the countries in the book.

⬐ None

None

⬐ laurencerowe

Germany and the UK have very similar health outcomes [1] but the UK spends significantly less - 9.7% vs 11% GDP [2]. The UK probably should spend some more on healthcare but it's an open question whether that would be more effective at improving health outcomes vs spending the money on reducing poverty.

[1] https://www.commonwealthfund.org/chart/2017/mortality-amenab... (2014 figures)

[2] https://data.oecd.org/healthres/health-spending.htm (2014 figures)

⬐ growlist

> The UK probably should spend some more on healthcare but it's an open question whether that would be more effective at improving health outcomes vs spending the money on reducing poverty.

There are other policy interventions that could also make a big difference to health e.g. making our urban environment friendlier for exercise by reducing traffic, reducing emissions, introducing dedicated separate cycle lanes, stricter punishment for speeding, and making our mental environment less hostile by e.g. stricter controls on advertising, control of body fetishism e.g. Love Island etc. in the media, limiting development/improving access to nature, etc.

⬐ jellicle

Sufficiently advanced regulation is indistinguishable from single-payer - insurance is completely reliable, covers everything, and is completely fungible. Who cares what name is on the card? The easiest way to accomplish that is just to have a single government insurer. But you can finagle your way in the back door by regulating the shit out of insurance companies too.

One-third of the US population is on a US single-payer system right now.

⬐ ascar

Germany has a split system between mandatory government healthcare and voluntary private healthcare, once you pass a certain income threshold (about 80% above average income) or are self-employed.

There are differences. The voluntary insurance usually pays 2x to 3x of the mandatory one and covers more treatments that are seen as optional by the government insurance. E.g. physiotherapy is covered by government insurance only for clear indications while private insurances might cover it as a precautionary measure in many more cases. Also private patients can usually skip some waiting time (e.g. days instead of a few weeks).

But (nearly) everyone is covered, government or private, and can go to the doctor without worrying about money.

Even the government insurance isn't a single entity, but you can choose between multiple providers. All charge the same 14.6% of pre-tax income (capped at ~55k income) plus an additional 0.7% to 1.x% depending on the provider. They also compete on additional services. E.g. my provider adds a free professional tooth-cleaning per year and free travel-vaccination among other things.

⬐ None

None

⬐ null000

> Also private patients can usually skip some waiting time (e.g. days instead of a few weeks).

See, now, that just really doesn't sound like a good idea to my ears. Why should someone be forced to sit through weeks of suffering while a handful of others don't, for the sole reason that they have more money to throw at the problem? I can understand buying better or more thorough treatment, or buying treatment from more expensive providers I guess, but line jumping via money just seems immoral when it comes to health care.

⬐ foepys

It is already illegal, yet practiced widely because the burden of proof is on the patient that cannot look into the doctor's records because of privacy.

⬐ ascar

Why do you think line-jumping is more immoral than getting worse treatment? In one case you just have to wait in non life-threatening and non-urgent cases (you only have to wait if you actually can wait). In the other case you are actually in a worse physical or mental position.

⬐ asdff

This is like if the whole town is on fire, but you have enough money to pay the fireman to save your house first. Priority access to universal needs shouldn't be given based on personal wealth. I wonder if the people who wrote this line jumping into law qualified for the public or private insurance.

⬐ nradov

There actually are private firefighting companies which homeowners or insurers can pay to save their houses first.

https://www.businessinsider.com/california-wildfires-private...

⬐ RHSeeger

> universal needs

Not everyone agrees Person A's needs should be paid for by other people. The system described (that pays for everyone, but treats people that can afford it better) may be a reasonable compromise to those people.

⬐ asdff

Yet everyone uses the roads, schools, and safety paid for by everyone to ultimately get to their advantaged economic position. Healthcare is a public effort just like any of the above, and no one should suffer unequally due to class favoritism being built into public efforts. We shouldn't compromise with people who lack the humanity to see this.

⬐ RHSeeger

To be clear, I'm in favor of everyone having healthcare. To some extent, I'm playing the devil's advocate here. Also to some extent, I think getting from where the US is to everyone having healthcare is a very difficult trip to make. That being said...

- There is no way to support roads without everyone supporting them for everyone. It's not possible to pay for "just the roads I use". - Educating the next generation helps everyone. - Keeping someone else healthy does not help me in any real way (I disagree with this, but it is a viewpoint that can be had).

⬐ asdff

It does help you in a real way just as existentially as educating the next generation helps everyone. A healthy population is an economically productive population, and ensuring people get preventative care on time prevents strain on emergency services and saves the whole system money. In fact, this is how private insurance works too, your regular bill pays for other customers services, yet private insurance is somehow not viewed with the same contempt by conservatives.

⬐ isostatic

That sounds like the UK system, where everyone gets NHS, but those that want to spend £1k a year extra or whatever get private healthcare (BUPA etc)

⬐ ascar

No, it's not. This analogy would only apply for shorter wait times in emergency cases. And that's not true and I explicitly said that. Everyone gets the same wait time in emergencies and urgent cases. But a significant amount of cases can actually wait.

It's more like your car broke down and you have to wait longer than the guys who pay extra to get a same-day repair. But if you are a taxi driver and depend on it, they repair it anyway on the first day.

The private insured patients also sponsor better treatment for the government insured patients.

It's a good compromise (and I'm saying that as someone who is government insured) and there is law in place like a maximum of 3 weeks wait time for a specialist appointment.

⬐ DennisP

If you define single payer that broadly, ok. I'll just mention that Japan gives you your choice of about 2,000 insurance providers, which advertise extensively.

⬐ kaibee

> I'll just mention that Japan gives you your choice of about 2,000 insurance providers, which advertise extensively.

How does all of this additional overhead provide more value to the consumer at the end? How are they actually differentiated?

⬐ DennisP

I'm not sure (possibly because I read the book years ago). The other two countries handle it differently.

Japan's healthcare cost is the lowest of the three though, at 5% GDP, despite an aging population of heavy smokers. So there doesn't seem to be that much overhead.

⬐ philwelch

Despite Japan's aging, heavy-smoking population, Japanese people tend to be very healthy for reasons that aren't necessarily related to their healthcare system.

⬐ nradov

Due to Japan's "metabo law", adults are required to get their waistlines measured every year and those who exceed the recommended limit have to get treatment.

https://mic.com/articles/84521/japan-has-cut-obesity-to-3-5-...

I don't necessarily agree with that policy, however it does appear to be effective in cutting healthcare causes. In the US a large fraction of our healthcare expenses are due to chronic conditions related to obesity.

⬐ kenhwang

And Americans tend to be overweight and unhealthy. Access to healthcare doesn't automatically shift culture to live a healthier lifestyle (and I suspect it might even do the opposite).

⬐ whitepoplar

It would be great if gym memberships could be made free for everyone. I bet it would even be cheaper in the long run to buy an Equinox membership for every American than it would be to do nothing.

⬐ ethbro

American health care plans are starting to offer financial incentives for maintaining fitness.

Which seems a bit like a tragedy of the commons situation.

In that insurance company X is paying me for later life benefits that may be reaped by insurance company Y that I have 40 years from now.

We need to hurry up and get to baseline genetic risks, then directly rebate insured out of a central pot if they exceed their expected fitness metrics.

⬐ distant_hat

Free gym memberships are unlikely to result in higher use. I've had multiple workplaces where gym is free and I've rarely used it, thankfully, I am blessed with a skinny physique and parents who inculcated good food habits. In fact, places which charged for gyms explicitly saw slightly higher usage since some folks logic went, since I am paying for it, I might as well get my money's worth.

⬐ thinkcontext

The paper considers that hypothesis and rejects it, honing in on prices not utilization as the problem. Indeed its title is "It’s Still The Prices, Stupid: Why The US Spends So Much On Health Care, And A Tribute To Uwe Reinhardt"

https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05144

⬐ cmrdporcupine

One of the problems with the Canadian system is frankly its proximity to the U.S. A large portion of our homegrown medical talent goes immediately south of the border for higher salaries (see your point about price controls on healthcare providers above).

⬐ AngeloAnolin

Going south of the border is not necessarily an easy option for any medical professional in Canada. Even though the standards in terms of education are the same, there are licensing and professional standards that needs to be hurdled by the individual.

The problem in Canada seems to stem from an inefficient manner with which health care is being administered. In hindsight, Canada's health care is following the US model, which have for a lot of reasons, failed spectacularly to provide what it was mandated to do - provide health care accessible for all.

⬐ vasili111

If you need talents to stay in your country then you need to pay them more.

⬐ samatman

I think that misses the point.

Germany pays doctors less, and can, because the switching cost is far higher. Canadians get to keep their first language (most of them do at least), stay on the same continent, which reduces travel to see old friends and extended family, and otherwise have fewer culture shocks to adjust to.

⬐ ObnoxiousProxy

Yes you are correct, but that is why Canadian healthcare is less efficient on a cost per dollar basis than it could be (Im Canadian). Canadian doctors dont get paid as much as their US counterparts but are generally higher paid than their European counterparts partly due to this reason already. Yet Canadian healthcare is not as efficient as say UK for example.

⬐ cmrdporcupine

I think doctors are paid pretty well, frankly. I also think we need more of a role for nurses and midwives, and less of a focus on centralized hospital based medical care.

But as others have pointed out: we're culturally and linguistically contiguous with the U.S. and have fairly free movement of skilled professionals. It's hard to compete with an economy with a population that is ten times ours.

It's the same in our/my industry. Being right next to the U.S. means the bulk of the quality engineers here go straight south to the valley after getting their very good subsidized university education. This is a problem.

⬐ djrobstep

No, the US needs to stop over-paying their doctors.

And doctors need to stop being corrupt by reducing supply of doctors through restrictive medical school entry.

⬐ rscho

Then, you should be targeting lobbyists and politicians. Front line workers (including doctors) are a very poor target for pressure if you want to achieve the same level of care for a cheaper price (including cheaper docs). The only result of your conspirationistic views will be worse care for a higher price.

But, I suppose no one will be able to sway you from your current opinion...

⬐ cmrdporcupine

Nobody is 'targeting' the doctors or front-line-workers themselves really. It's the medical professional associations and the power they wield over admissions and thus restricted supply that are a bit of a concern.

There's an odd balancing act in Canada. On one hand it was doctors that fought (tooth and nail) against the introduction of "single-player" (we just call it Medicare) back in Saskatchewan in the 60s, including going on an (unsuccessful) strike. And they are continually in a battle with the provincial governments about rates, because in Canada (unlike the NHS in the UK) doctors are independent businesses and not on salary (unless they're in the hospital system I believe?)

On the other hand, doctors in Canada have become huge advocates of our Medicare system and a big political opponent of privatization and tiered medicine generally. Not completely, but on the whole and through their professional organizations. 50ish years of working with the medicare system and seeing its outcomes, and seeing the failure to our south I think has made our doctors advocates of our system.

Canada's system is by no means perfect. It's probably not a good model for the U.S. as it is. But it's much better than what the U.S. has.

In general wait times here are a product of restricted resources, not institutional inefficiences per se. MRI machines are expensive, and doctors ration their use based on evidence-based criterion. E.g. no MRIs and back surgeries for non-specific low back pain, etc. because medical science doesn't really support it.

It's also worth pointing out that it was a huge battle to get it here. A big struggle that was successful at the time because at that point Canada's left wing was much stronger, and we had no strongly entrenched insurance mafia like in the U.S. Also Canada, as a British ex-colony, had the U.K's NHS as a model, and politics here was still _very_ strongly influenced by U.K. politics, where the Labour party was very strong.

I'm not sure what the path to U.S. single payer would be, but it would be very difficult one.

⬐ collyw

Is it bad that medical school entry is restrictive? Isn't the idea that you only want smart people to do it.

⬐ nradov

Restrictive medical school admissions aren't the problem. The real bottleneck is in the number of residency slots available for medical school graduates. Every year people graduate with an MD degree but are unable to actually practice medicine because they can't get matched to a residency slot.

Most residency programs are federally funded, although some are also funded directly by teaching hospitals. If you want a larger supply of doctors then lobby the federal government for more residency program funding. And knock off the uniformed conspiracy theories.

https://news.aamc.org/for-the-media/article/gme-funding-doct...

⬐ None

None

⬐ JauntyHatAngle

The argument being made is that USA is allowing companies and medical practitioners to price gouge, therefore allowing for wages for medical practitioners higher than can be offered locally.

I don't think inflating your own wages to match a system that appears systemically ineffective is the right response, especially when your own system is more effective overall than the one you are losing talent to.

In the USA, medical practioners get paid more and the country might gain talent as a result, but the people pay more for it and it results in it being less accessible and less effective overall.

⬐ joe_the_user

"In the World Health Organization's rankings of healthcare system performance among 191 member nations published in 2000, Canada ranked 30th and the U.S. 37th, while the overall health of Canadians was ranked 35th and Americans 72nd" [1]

So despite this problem, the Canadian health care system still manages to be superior to the US system. Perhaps in the field of health care, "top talent" is not as pressing a question as is often implied.

[1] https://en.wikipedia.org/wiki/Comparison_of_the_healthcare_s...

⬐ mac01021

Doesn't overall health depend on lifestyle much more than on healthcare?

⬐ cmrdporcupine

I don't think you'll find much demographic differences between the U.S. and Canada, apart from a much higher poverty and incarceration rate in the U.S.

Arguably our stronger safety net and better education system, while not technically part of the healthcare system, is also part of producing better health outcomes.

⬐ icelancer

> A lot of German primary care doctors don't even hire office staff. They prescribe whatever they want, swipe your medical card, and they're guaranteed to be paid in a week, no questions asked.

Any sort of change towards this in the United States (and I agree, it's a good one) will be spun as losing jobs and crushing the economy, which is a very hard argument to defeat.

⬐ ThePhysicist

I haven’t come across a single doctor in Germany who didn’t have at least one office assistant to handle incoming patients, schedule appointments and do the bookkeeping. Most doctors seem to have more though these days as the administrative burden has increased. There’s also a trend for doctors to share office space and have a joint office and reception (also to reduce cost).

⬐ DennisP

That makes sense. But many U.S. medical offices have people devoted entirely to billing insurance companies and fighting with them over what will be covered.

⬐ snarf21

Exactly, plus all the people at the insurance company that are paid to try to find ways to NOT cover it or to pay at a lower billing code.

⬐ luckydata

Ok but why focusing on the insurance systems that are still sub-par compared to Italy, UK and Spain where the single payer system yields even better results for less money?

⬐ DennisP

The book did cover the UK and Canada, and found they did not get better results for less money. The author didn't visit Italy or Spain.

For quality results, the book used rankings by international organizations, based on statistics like "cure rate after diagnosis of major disease." For cost, it used percentage of GDP and cost per capita. Germany, France, and Japan were tops in quality, and Japan was also the cheapest at 5% GDP. Germany spent 13% GDP but with expansive coverage.

Incidentally, the UK is not single payer like we're talking about in the U.S. It's also single provider. All doctors in the system are employees of the NHS, much like the VA in the U.S.

⬐ _benedict

I'm not sure what statistic you are referring to, but for cancer at least the definition of 'cure' is typically a number of years of life after detection (e.g. 5). In jurisdictions with less aggressive testing, this can give a worse measurement of cancer survival rates than the reality, since earlier detection by definition gives a higher chance of surviving to a time X years after detection.

https://www.bmj.com/bmj/section-pdf/187734?path=/bmj/346/789...

⬐ foldr

GPs are not really employed directly by the NHS.

⬐ DanBC

> It's also single provider.

For England that's completely incorrect.

Services are commissioned mostly by local clinical commissioning groups (There are about 195 of these across England), but sometimes centrally by NHS England, but they are provided by a range of different organisations. Some of these are NHS organisations, but they don't have to be. It's possible that NHSEngland and CCGS commission NHS services from non-NHS providers.

Doctors (and all other healthcare staff, and all manager, and all admin staff) are employed by NHS Trusts, or by other provider organisations.

Some examples of non-NHS providers who are commissioned to provide NHS services might be-

Livewell South West, a large community interest company that provides a range of in-patient and outpatient treatment. https://www.livewellsouthwest.co.uk/

Priory Group, a large private provider that also provides some in-patient NHS treatment, especially around in-patient eating disorder treatment or inpatient learning disability "care". https://www.priorygroup.com/

(Note that LiveWellSW are pretty good, and Priory Group are piss-poor and often abusive.)

Even NHS Trusts aren't single provider. They are their own organisation, with their own executive boards and accounts, working independantly from other NHS Trusts. If they're a foundation trust they have a bit more freedom with their budgets and staffing.

Here's a nice description of what the NHS is and how it works: https://www.kingsfund.org.uk/audio-video/how-does-nhs-in-eng...

⬐ tdhoot

>> Japan has a clever way to handle the mandate. If you don't pay your premiums, nothing happens, but if you need healthcare you're not covered until you pay your back premiums.

Wouldn't it always be a good idea to not pay premiums until you have a major expense then?

⬐ joshcain

I'd guess there's some kind of interest/penalty you have to pay along with the back premiums.

⬐ bitcoinmoney

Then they’ll add up the premiums?

⬐ tdhoot

Unless there is interest or a penalty then you can take all the premiums you've saved + interest and just pay them.

⬐ DennisP

You could, but you'd have to keep the money in savings anyway, and there'd be some hassle at a time when you might not want to deal with hassle. In practice, it turns out most people just pay their premiums, at least in Japan.

But if it turns out to be a problem, you could always charge interest.

⬐ tdhoot

I wonder what they do if someone can't pay.

The system doesn't seem too different from the US to be honest, in that people with poor financial planning skills may decide to skip on insurance premiums and end up not having enough money saved to pay for medical expenses/back premiums when they occur.

⬐ ethbro

Be that as it may, it sounds like the Japanese system is much more effective at keeping prices low.

⬐ null000

I think a baseline requirement for these types of systems is that people don't go out of their way to be assholes for negligable gains.

My understanding of Japanese culture is that, by and large, people don't do that. Americans, meanwhile, have a pretty heaping helping of petty asshats. For exhibit A, go look up some of the asinine BS tax protesters try to get out of pretty basic civil responsibilities.

⬐ philwelch

> Japan has a clever way to handle the mandate. If you don't pay your premiums, nothing happens, but if you need healthcare you're not covered until you pay your back premiums.

So what happens when you go to the ER? Obviously if it's a true emergency they'll save your life and try to bill you later, but then what?

Would it ever make sense to deliberately stop paying your premiums? If you can pay "out-of-pocket" for medical expenses, you might be better off saving your premium money until you need medical care that's actually more expensive than the back premiums. That creates an adverse selection problem (assuming that enough of your prospective customers are devious enough to try this). Even if you can't pay out-of-pocket, you could just stop going to the doctor until something serious happened.

⬐ JAlexoid

I presume for people that have jobs, the premiums are withheld. So only the minority never pays up.

That's hardly unusual. I come from a similar system.

⬐ DennisP

Maybe there's a little interest on back premiums. Whatever the details, it's working out very well for Japan. They get great results at very low cost.

⬐ adventured

It's about to stop working out very well for Japan. The costs in their system are exploding higher rapidly and putting everything at risk. Their system won't remain intact for much longer at the rate healthcare costs are outpacing economic growth.

Here's the relevant chart: https://i.imgur.com/s97bp9R.jpg

"Health-Care Paradox Threatens to Add to Japan’s Debt Problems"

"Japanese seniors, who enjoy the world’s longest life expectancy, pay as little as 110 yen ($1) out of pocket for specialist appointments. While these visits may help prevent expensive-to-treat diseases, they’re becoming unaffordable in a country where almost 1 in 7 people is 75 years or older, and annual health-care expenditure grew at a pace 40 times faster than the economy from 2000 to 2016."

https://www.bloomberg.com/news/articles/2018-12-13/health-ca...

⬐ Robin_Message

> pay as little as 110 yen ($1) out of pocket for specialist appointments

In the UK we pay nothing. I think this article is biased by American thinking.

⬐ SmellyGeekBoy

Not strictly true - we do pay a nominal fee for prescription drugs and NHS dentists (although some classes of people, eg students and retired people, are exempt).

⬐ arethuza

No prescription fees here in Scotland!

⬐ kitd

Additionally, a lot of long-term care in the UK is provided by charities (Cancer Research, Macmillan, Heart Foundation, etc) which can be expensive but IIRC doesn't appear in the NHS budget.

⬐ Robin_Message

True enough. I was thinking of specialist Doctors appointments, which are covered. It seems crazy, in a kind of roll your own adventure way, to pay for diagnosis, per specialist.

I sort of imagine conversations going like:

Doctor A: You might have this other nasty thing, but I'd have to send you to doctor B to check. Doctor B will cost you a hundred bugs. Patient: I don't have a spare $100 Doctor A: we'll just hope it isn't that then. Me: WTF?

⬐ max76

Japan has a very unique healthcare crises based on it's aging population. The median age in Japan is over 9 years older than the United States and the population is continuing to get older. This crises would be very hard to deal with in any health care system, and it compounded by other pressures of taking care of an older population. Pensions programs are being stressed as the relative number of young workers are decreasing. Additionally the older population is likely to prefer economic policy that reduces inflation (to make pensions stretch further), making the working generations fight harder in international trade.

Japan's healthcare system doing so well given current stresses is a testimony to it's strength.

⬐ icebraining

It's not "very unique". Germany has a similar median age (47.3 vs 47.1) and low inflation rate, and much of Europe is not that far on both.

⬐ luckydata

Seems completely unnecessary though, just wrap that in the taxes and be done with it.

⬐ SilasX

There’s nothing innovative about cutting off someone’s health care until they can pay, and it probably wouldn’t last long as a policy here.

⬐ simonh

>A lot of German primary care doctors don't even hire office staff. They prescribe whatever they want, swipe your medical card, and they're guaranteed to be paid in a week, no questions asked.

It seems to work that way in France too, my mother lives over there half the time. She gets medical appointments and treatment almost immediately for almost anything where in the UK she'd be in multi-month long queues. I'd take the NHS over the US system any day, but there definitely seem to be useful lessons to learn from Europe as well.

I'ma huge Maggie fan, she was our best post-war PM by far, and a good candidate for best PM ever, but her market based reforms of the NHS were utter failures.

⬐ mikeg8

Thanks for your great comment and I agree especially with your last paragraph. While reading the book, I was so frustrated with how poorly my county has handled such an important issue, probably the most important.

⬐ jdhn

>If you don't pay your premiums, nothing happens, but if you need healthcare you're not covered until you pay your back premiums.

So what happens if you don’t pay your premium but then have to use the ER? Do they refuse to take you, or are you stuck with a bill? Does that bill go away if you pay your back premiums or not!

⬐ mrep

Don't quote me, but I've read many places in the US that ER's are required to take you if you are in a life threatening situation and if you cannot pay, the hospital just ends up owning the costs and then passes those costs to everyone else through insurance fees.

⬐ adventured

Legally the ER can't turn you away if you can't pay, in the US.

What they can do - specifically relevant if you're a US citizen - is send you a bill and then after you don't pay it send it off to collection agencies, which then harms your credit rating for the next five or seven years (I believe various states have different laws on when these have to drop off your credit rating, it's usually either seven years or slightly less). This has improved a bit lately, with new credit scoring updates that considerably reduce the hit from medical bill collections on your credit. However it's obviously still a ridiculous situation.

Most non-private hospitals in the US have low income programs you can sign up for (eg if you go into the ER due to an emergency and run up a big bill), that eliminate most or all of your bills if you fall under a certain income level. That's subsidized by government funding programs. Typically though if you're at that low of an income level, you should just sign up for Medicaid anyway. Those programs are usually most valuable when someone in the eg 22-50% income bracket (the most vulnerable in the US insurance system, where you're above Medicaid and below typical good paying career or job status) is caught inbetween insurance / jobs for a number of months and gets hammered by an ER visit.

⬐ tathougies

Is that in Japan (where the question was asked) or the United states?

⬐ mrep

Sorry, US. I updated my comment and I'm from the US but I have yet to use my personal medical care outside of my parents when I was a kid

⬐ mac01021

I've witnessed this first hand. For a nonemergency even. A friend with bad English went to the ER to have a rash looked at (not understanding what the more appropriate action would have been).

The ER don't doctor spent about 2 minutes with her and wrote a prescription for some topical thing.

Later the hospital sent her a bill for about $1500. I went with her to the hospital's billing Dept, helped her fill out a form that basically said "I have no insurance and no money".

The hospital ate the bill.

⬐ rndgermandude

>A lot of German primary care doctors don't even hire office staff.

I have never been to a German doctor who didn't have some staff. It's true however that they usually do not have admin-only staff.

They have, depending on the size (and specialty) of their operation, 1-3 "Medizinischer Fachangestellte" (MFA, qualified medial employees) per doctor and maybe 1-2 "Auszubildende" (people still in training). This a qualified job which requires formal training and a diploma. Usually it's one person in charge of the appointment book and reception/waiting room and additional people helping the physicians.

They are helping during examinations, calling up people from the waiting rooms, keeping appointment books, keeping the patient files and printing out the prescriptions etc (to be signed by the doctor), and to some degree interact with the health insurers. But they also do some hands-on jobs, like they are usually allowed to apply some medications, and operate medical equipment on their own (e.g. last time I visited my dentist, the x-ray machine was operated by an MFA; she had to have a special qualification for that). They are also in charge of writing the invoices for procedures not covered by health insurance providers (e.g. additional checkups).

My GP is a single lady shop, and she hired 3 MFAs. My dentist shop has 3 dentists working there and one "technician" and has an MFA support staff of maybe 15.

So there is still a lot of admin work, after all.

>They prescribe whatever they want

Not exactly. German doctors prescribe an "active agent" (even tho a lot of times they will put a brand name). German public insurers will only pay for a max price for a given agent. So if "generics" are available, the pharmacies will likely fill prescriptions with those.

>swipe your medical card

Eh, you give your card to the doctor's MFAs and they will put it in their card reader, etc. It's not like there is a checkout line where you swipe stuff yourself.

>they're guaranteed to be paid in a week

Usually one month to four months.

It goes like this: Every physician has to be a member in the "Kassenärtzliche Vereinigung" (KV, physicians association, and KZV for dentists) of their federal state. Otherwise, you cannot be reimbursed by the public insurers. There is about 160k physicians and 60k dentists organized in the KVs and KZVs.

The physicians then report all the items (procedures, prescriptions, consolations, etc) they want to charge to the KV, which collects the information, tallies up everything and calculates the earnings based on a complicated "points" system, charges the insurers and distributes the money back to their members.

The physicians are paid once a month (usually the 15th of each month for most KVs) a progress payment, based on the estimated earnings for a quarter, estimated based on previous quarters in particular. The actual final tally is done only once a quarter where any money not yet paid through the progress payments is paid out. In the worst case, this could be a negative number, meaning a physician has to pay back some of their previously collected progress payments. That's why (AFAIK) KVs will usually underestimate the progress payments to avoid exactly this later.

>no questions asked.

The KVs will totally ask questions if your doctor starts billing a lot "funny" items (e.g. if a single doctor would charge a lot of flu vaccinations during the summer months, the KV will ask about it). And last I heard, there are spot checks/(not-so) random audits too. The KVs by law are required to make sure everything is OK, so they also dabble in fraud detection and quality control.

⬐ freddie_mercury

tl;dr: All of my comment is basically agreeing with rndgermandude that the OP's description of German medical care is not accurate.

I co-founded a company that sells practice management software to primary care doctors in Germany. We work closely with the Hausärzteverband -- something like a union for primary care physicians -- and I speak with doctors in Germany, board members of the HAVG, and so on basically every day.

Germany has three different medical/insurance systems -- KV, HzV, and private insurance -- I worked with HzV so am most familiar with that but everyone has at least a passing understanding of KV as well since it was the only one until recent decades. HzV is more popular in certain geographies -- for instance if you work for Volkswagen you'll be in the HzV system and not the KV system under a BWQ contract.

I've never met a doctor in Germany that doesn't have staff. A quick check of the analytics of all the practices using our software doesn't show a single one.

As rndgermandude says, every single one has at least an MFA (and nowadays probably a Vera as well, since they can earn extra money that way). Our analytics shows 2-3 MFAs per doctor is the average but there are always edge cases.

>They prescribe whatever they want

This is not really true. Every insurance contract will have different rules about what can be prescribed. They can't FORCE a doctor to follow those rules but they doctor is monetarily incentivized to do so. For instance, getting a bonus every quarter so long as 80% of their prescriptions follow insurance company rules. The checks are done at run-time, every doctor knows instantly if a prescription is against insurance rules, and practice management software is REQUIRED to suggest alternatives that meet insurance requirements.

>they're guaranteed to be paid in a week

Doctors are basically NEVER paid in a week. They submit their billing at the end of the quarter (here I'm speaking primarily of HzV contracts; I'm not sure how the third option -- private insurance -- works) and then get paid a while after that.

>no questions asked.

No, this is not remotely true.

⬐ rscho

Absolutely true. As a doc, the US problem boils down to a cultural issue that can be summarized as:

"there is no reason my money should pay for the care of others, but if I personally need care, then it should be of the absolute best quality and should be provided until my last breath no matter what"

The people maintain the system themselves by insisting on that, and that is the root of every other problem. Before alleviating restrictions for med school, US people should think about pulling the plug on the legions of evidently terminal patients receiving maximal care that just prolongs their intense suffering every day around the country.

Why do you think your doc does every exam under the sun as soon as you step foot in the office?

1 - if solo, more money; if networked, makes you look better for the "employer" (insurance company/hospital/HMO, etc.)

2 - if you have too many exams, you will complain on the internet. If you have too few exams and something goes wrong, you will drag the doc into court.

Weigh the incentives and I think even the most conservative person should see a problem.

⬐ arethuza

"there is no reason my money should pay for the care of others"

Isn't the cultural issue largely a idealogical issue - things like the UK NHS are avowedly socialist? In the words of Aneurin Bevan, founder of the NHS:

" A free health service is pure Socialism and as such it is opposed to the hedonism of capitalist society."

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

Personally, at least when it comes to healthcare, I'm a socialist:

"The collective principle asserts that ... no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means."

⬐ tim333

Kind of. As a Brit I don't think the UK is especially socialist. Also we don't generally think of the NHS as socialist more than Americans would talk about having a socialist army or police force. The fact that the above are funded by the government from tax in my view doesn't really make them socialist. It's more just a common sense way of funding some stuff.

The dictionary has socialism as "means of production, distribution, and exchange should be owned or regulated by the community as a whole" and I've never thought of health care as a "means of production". Now if the government tries to own all the factories that's socialism.

⬐ arethuza

Note that Bevan isn't saying that UK society is socialist (although he was probably in favour of it) - rather than the spirit of the NHS is socialist. Note that I would agree that it seems "common sense" for us in the UK and I'm definitely not keen on basing arguments on ideologies but it clearly doesn't seem "common sense" for people in the US.

⬐ DennisP

And yet, in the U.S. we have a system like the NHS for veterans, plus a system like Canada's for everybody over 65.

⬐ arethuza

Yes, I believe the US government spends more per capita on government provided healthcare than the UK does - even though the end results are only available to a subset of the population.

Doesn't that annoy people?

⬐ entity345

Healthcare is broadly a service and thus what hospitals, GP surgeries, etc. produce in the economy.

The NHS is a socialised system based on socialist ideas and indeed can be seen as a socialist construct within a capitalist overall economy. Nothing inherently wrong with that, that's just objectively the way it is. Bevan just said it the way it is.

Now, the military and police are regalian functions of the state. The government and regalian functions cannot really be labelled 'socialist', that would make much sense.

⬐ fsloth

"regalian functions of the state"

Sorry to nitpick, but does "regalian" mean something else than emblems or insignia of royalty?

A credible sovereign state generally needs some force projection capability within it's political domain, hereditary monarchy or not.

Hence military is definetly in a different category than healthcare.

⬐ entity345

The etymology of the term indeed comes from the prerogatives of the sovereign.

"Regalian functions of the state" is a common term that means the basic powers of the state (monarchy or not) that used to be the prerogative of the sovereign. I.e. law & order, military, and taxation. You could also call these "inherent powers of the state".

⬐ arethuza

"Hence military is definetly in a different category than healthcare."

Why is that - one is defending the citizens of the state against external threats and the other is defending the citizens against medical threats?

⬐ entity345

The military is a regalian function (and arguably its first function is to defend the state, not the citizens...), while healthcare is not usually considered a regalian function.

The line must be drawn somewhere.

You can imagine healthcare being provided fully by the private sector without state intervention (how that works for the poor is another issue) but the military has to be controlled by the state even if in fine the state hires mercenaries.

⬐ dragonwriter

> "Regalian functions of the state" is a common term

It's really not; I mean, I've got a poli sci degree so I've seen it, but it's not really a common term.

> that means the basic powers of the state (monarchy or not) that used to be the prerogative of the sovereign. I.e. law & order, military, and taxation.

The pre-modern-limited-governnent prerogatives of sovereigns were much broader than law enforcement, defense, and taxation. And, in fact, the principle thing denoted by regalian power is the fundamentally ownership of all land which is superior to all private title, which is the root of all the other (essentially unlimited) powers associated with sovereignty, in a “my house, my rules” kind of way.

The term “regalian functions”, though, is most often used to refer to the three functions Adam Smith identified as essential to the sovereign in The Wealth of Nations, which are still much broader than what you suggest:

“The first duty of the sovereign, that of protecting the society from the violence and invasion of other independent societies, can be performed only by means of a military force.” [0]

“The second duty of the sovereign, that of protecting, as far as possible, every member of the society from the injustice or oppression of every other member of it, or the duty of establishing an exact administration of justice, requires two very different degrees of expense in the different periods of society.” [1]

“The third and last duty of the sovereign or commonwealth, is that of erecting and maintaining those public institutions and those public works, which though they may be in the highest degree advantageous to a great society, are, however, of such a nature, that the profit could never repay the expense to any individual, or small number of individuals; and which it, therefore, cannot be expected that any individual, or small number of individuals, should erect or maintain.” [2]

> Hence military is definetly in a different category than healthcare.

This is true, not in the sense of not being subsumed within “regalian functions”, but in the sense that the military is the first regalian function identified by Smith while healthcare delivery systems that broadly and effectively serve the whole population are in the third.

[0] book V, chap. 1, part 1

[1] Ibid, part 2

[2] Ibid, part 3

⬐ entity345

> while healthcare delivery systems that broadly and effectively serve the whole population are in the third.

That's your interpretation but that's really a political view, and indeed the definition of that third duty is highly subjective. As I wrote in another comment, the line must be drawn somewhere.

Note that my point wasn't to discuss regalian functions in general but to counter the argument that calling the British NHS 'socialist' was like calling the police or the army 'socialist'.

(Btw, I heard the term "regalian functions" in secondary school/high school...)

⬐ dragonwriter

> That's your interpretation but that's really a political view

Smith's concept of regalian functions is just as much a “political view”.

> and indeed the definition of that third duty is highly subjective.

So are the definition of what particular actions of sovereign are within the boundary of the what is essential within the other two (and all three expressly vary by context, including available physical and social technologies, as perusal of the relevant parts of the Wealth of Nations makes clear.)

> Note that my point wasn't to discuss regalian functions in general but to counter the argument that calling the British NHS 'socialist' was like calling the police or the army 'socialist'.

Which the reference to regalian functions fails to do: all fall within the broad ambit of what could be considered those functions, and whether the dpecifics of either do is debatable, and, in any case, whether or not a function is within the scope of regalian functions is irrelevant to whether or not it is socialist.

⬐ entity345

It is very relevant otherwise one might indeed draw a parallel with the police and the military, as already said.

As also said, health are is a productive service that has the potential of being 'socialist'.

I'm not here to argue for the sake of it and I don't see any actual argument on the original points in your replies...

⬐ cm2187

Paying for the care of others is also the insurance model, which is not socialism. I think where you lose support from part of the population is when the system is being abused. I understand France for instance has an abnormally high number of depressions, as it is a common way for a lazy employee to take some time off at the expense of the system. In the US I understand there is an abnormally high number of people on disability benefits.

The hostility I think comes not from the fact that it is mandatory, but from the fact that if it is managed by the state, it will be badly managed, abused by a minority, and you end up over-paying while getting a bad service yourself the day you need it.

⬐ telchar

Fact, you say? I think you're right about the psychology here but if you're going to assert that state management is factually bad please provide some support to that.

⬐ dalore

> but from the fact that if it is managed by the state, it will be badly managed, abused by a minority, and you end up over-paying while getting a bad service yourself the day you need it

Fact you say? Sounds like an opinion to me.

⬐ dalore

I think have a socialist healthcare improves the capitalist opportunities for people in those countries. Having your job tied to your health insurance means people are less likely to change jobs, thereby not giving their true optimal output to a capitalist society.

A worker who is free to offer his labour to whomever he wants knowing that his healthcare is not tied into their employment has more options and choice to them then someone who can't change jobs.

A point on your last point, people would argue that even in the US you can still access the emergency room when you have no money so no one is turned away due to lack of means.

⬐ rscho

Indeed, I think so too. Ironically, people essentially tend to ask for freedom of choice above all in the US healthcare system (I want complete price info, yada yada...) when the US system is evidently already the one offering the highest level of patient autonomy, probably worldwide (regarding the ethics principles of beneficence, nonmaleficience, Justice and autonomy). But guess what? That has a price, who would have thought?!

Another point is that IMO, you can't go extreme on one principle without impacting the others. Nonmaleficience is clearly a problem in the US.

⬐ arethuza

Indeed, its why I dislike ideological based arguments - once people commit to an ideology they will stick with it way past the point where it is clearly not effective (and this goes for right wing and left wing ideologies).

⬐ DennisP

People want complete price information because we don't have price controls, like they have in Germany, France, and Japan. Having a "free market" in healthcare without showing prices in advance of providing services is sort of obviously the worst way to get a reasonably priced healthcare system.

That's somewhat mitigated by negotiations between insurers and providers, but not entirely given out-of-network charges.

⬐ rscho

Agreed, however there is a solid base of evidence (as solid as medical evidence can be, which is not saying much) that health can't humanely be handled as a commodity.

Plus, providing complete price info itself is not free. Talk about administrative inflation!

⬐ DennisP

So then, go with price controls. We have multiple examples of that working just fine. The answer cannot be that we make people responsible for payment before telling them what the price will be, and it's unsurprising that by doing that, we have the most expensive healthcare system in the world.

⬐ edoloughlin

You: "if I personally need care, then it should be of the absolute best quality and should be provided until my last breath no matter what"

Your healthcare industry: "if you personally need care, then it should be of the absolute best quality and should be provided until your last cent no matter what"

⬐ jbob2000

In America, cent and breath are the same. Your statements read the exact same.

I really recommend this book: https://www.amazon.com/Healing-America-Global-Better-Cheaper...

It goes into comparing health systems around the world and understanding the history of why they went into effect.

There is a cheeky answer to your question: we have _all_ the main systems that are used in Europe and other places in the world.

There are 4 main systems 1. Beveridge (public health care providers and insurance rolled into one, like the NHS in UK): The VA and healthcare systems used for native americans use this system

2. National health insurance (private healthcare providers and public insurance funded by the government, like Canada's system): Medicare was copied from the Canadian system (even the name!).

3. Bismarck Model: (private healthcare providers and mostly private insurance, along with an individual mandate and heavy regulation of insurance companies: this is used in Germany and Japan). Obamacare was an incomplete attempt to move more towards this model.

4 Out of pocket model: (fully private: a non-system used by most poor countries in the world). This is what the uninsured fall back on.

A less cheeky answer involves looking at the common factor in the rise of systems 1, 2 and 3 in countries around the world. The fundamental political driving force behind this was a moral and ethical decision that healthcare is a human right that the government should provide. When Clinton attempted healthcare reform in 1994 he couched the politics of it in economic terms saying that we need to reduce costs, and it failed. Obamacare only began to make some headway once the politics and debate around it started focusing more on the basic moral and ethical question of whether our society should provide universal access to healthcare.

So it's this weird situation where maybe some people want it for economic reasons (our system is by far the worst in terms of costs per outcome), but politically the best thing is to make this a fundamental moral question of healthcare as a human right. Most constitutions written in the second half of the century include some kind of reference to healthcare as a human right.

⬐ mynameishere

You keep saying "human right" and I don't think you realize this undermines the persuasiveness of whatever else you might be saying.

It may well be for the overall good to expand Medicare to everyone. But it isn't some sort of "human right" in the same way free speech is. It never will be, as that implies we have the "human right" to demand services from others. We don't--that's nonsense to anyone who actually considers it for five seconds.

⬐ c0nducktr

Ugh its the "human rights" gatekeepers again.

⬐ dontreact

Yeah I think for someone more libertarian like you appear to be the argument is more about how bad our system is in terms of costs and outcomes and how good everyone else’s is. We should look at those other systems and see why they work well. The common factor seems to be a commitment to providing universal coverage.

My point is that an argument in economic terms historically has been ineffective for actually getting reform to happen, whereas an argument based on healthcare as a right is effective (I get why it’s not effective for someone like you)