It's interesting to see that "Health care consumes 18% of GDP in America" compared to ~10% in most developed countries. In my (non-american) opinion part of that difference comes from the fact that healthcare is already a consumer product in the US. Maybe not entirely, but much more than in Europe, where universal healthcare sponsored by the state is the norm.
Another point is that US healthcare is considered the most expensive and worst-performing in terms of outcomes compared to the other developed countries.
So you basically get the worst performing being also the most expensive. Which doesn't really fit the view that less government involvement results in a more efficient system.
Well, I guess it is more efficient if the expected outcome is a larger profit for different private companies and middlemen and not the well-being of the rest of the population.
My hope is that this new-found energy in healthcare products doesn't follow the traditional VC-backed approach of building a product, taking over markets through aggressive marketing and shady closed-door dealings and operating at a loss only to then monetize the shit out of everything.
Theranos really embodied some of these fears, and I'm not sure we'll live in a better world if our health will be in the hands of people that have a financial incentive to tell us we're more sick/healthy than we really are.
The problem is that "market" is a really bad fit for meeting healthcare needs, and doubly so when it's intermediated by insurers. People get the amount of healthcare they can afford from their discretionary budget and work their insurers for - not the amount they need. So they may get "more" (or at least more expensive) care than they need, or less.
Note that many of the European systems are semi-private, so you retain choice of providers. It doesn't need to be a full state-run system, which is vulnerable to undercapacity (which the UK is currently suffering from).
There's also an informational problem; in a fully free speech environment it's much easier to sell people unreliable cures, Theranos passim.
I agree. The "everything is a market" ideology had a good run of almost half a century, but it should be heavily criticized in hindsight.
Institutions like healthcare, education, public transport, prisons(!) and so on are more efficient, less corrupt and of higher quality when they are in large parts collectively and democratically organized and funded. The "in large parts" is important here: A community should agree on what that means and let the market play out on the edges, or the bureaucratic costs become too heavy _and_ unfair. Decentralization is key here.
One thing to note about US healthcare is that it seems almost deliberately engineered to not be a market.
I've never received significant health care in another country, so I can't say how the US system differs from others with any expertise. But I can say how US health care differs from just about anything else I spend money on:
1. I don't really get to shop for health insurance providers. My employer picks one, maybe two plans, and I can take it or leave it. If I leave it, I am leaving at least $10,000/year on the table, so I generally take it.
2. Even when I am on the market, the phenomenon in #1 does weird things. Once upon a time, when I was choosing my own health insurance, I started a new job with health insurance benefits that I did choose to take. But my start date was toward the beginning of the month, my old insurance wouldn't let me do a partial month, and the new employer wouldn't let me delay opting for coverage. So I was essentially forced to own two health insurance plans simultaneously for a period of time.
3. Nobody knows what care will cost ahead of time, which makes it impossible for me to make any informed economic decisions. I need to see a physical therapist. I called a few places to shop for prices. They all know what the rate for uninsured people is, but the only way we can find out what it will cost with my insurance is if I receive care, they submit a claim, and then we all find out together what the price was, after the fact.
4. #3 creates a situation where they can hide all sorts of excessive charges. When my first child was born, I got lessons on how to give him a bath and change his diaper. Both of which I already knew; I was really just going along with the lessons to be polite. I certainly wouldn't have said yes if the hospital had been transparent and up-front about the price tag on this lesson: about $2,000.
5. And sure, insurance covered most of it... but that didn't make it free; it just means the price was amortized over a large number of health insurance premiums. Unfortunately, I think that this setup makes it all too easy for us to think of these things as free, which, in turn, reduces public scrutiny over where the money comes from or where it goes.
And it just keeps going like that. Compare with signing up for cell phone service. It's a famously sleazy business, but, even with all the hidden fees they like to tack on, at least they're up-front about the basic price of service. With US health care, every fee is a hidden fee. That makes it impossible for consumers to make free, informed decisions, which is the most fundamental precondition that must be satisfied in order for a capitalist market to form.
All good points. In my mind, a market lets me make informed choices and choose from multiple options for something that meets my needs. As you noted, the only real choice is whatever your employer offers, or something more fantastically expensive. In terms of care, there are lots of choices but not enough information to actually choose. It's more of a choose your own adventure where you have to guess and hope you got it right.
For #4 on your list, I remember the insane bills we got when our first child was born. It was also insane the sheer number of bills that we got.
First we received a bill for the stay in the hospital. And then we received a bill for the doctor performing the delivery. Okay, fine, it makes some amount of sense, that doctor supports multiple hospitals and isn't technically part of the hospital and staff at that maternity ward that is there 100% of the time.
And then the separate bill for lab work, and another for the pediatrician, and another for our baby's stay in the hospital (this one really got me, why?! we were all in the same room), and then another for the lactation consultant, and, and, and...
I don't remember each one specifically at this point, but I believe it was 7 separate bills.
I'm still getting bills from various groups almost a year after having a child. Being so far out from the event always makes me cautious about immediately paying them; I'm rather worried about getting a fraudulent bill that looks real, as many of these bills come from central billing offices several states over. It then takes me time to truly connect the dots from the service and looking at insurance history to ensure this bill is legitimate and that I technically do owe that.
Another sleazy behavior I've noticed is that when I receive care, and state that I'm uninsured, the provide chargers me a different rate then had I handed over my insurance card.
The way this plays out is that if I hand over my insurance card, the provider will attempt to extract as much money as possible and bill an outrageous amount. The insurance provider has maximum limits it's willing to cover for each billing code and so only covers some lesser amount. You pay the difference.
The other side of the "market" is also not very "free". Health care facilities are heavily regulated - and I don't just mean for safety. Try opening an MRI facility or other capital-intensive facility... You'll be required to obtain a certificate of need from a state board. That board will be heavily lobbied by existing supplies to minimize competition from upstart facilities. IIRC, around 2/3 of states have these laws in place.
I would say price discovery is one of the main problems just as you've identified. The other is inelasticity of demand. To put it in a crass way, what's the market value of the morbidity and mortality of your child? I suspect the answer is often all you have and more and I think plenty of actors in the system are happy to take advantage of that.
Many (most? I always take employer-sponsored, not an expert on all plans) health insurance plans in the US have a concept of out-of-pocket max. This is a yearly amount that is essentially your maximum yearly liability. That amount can vary from plan to plan and year to year. Usually a lower out of pocket max means higher premiums, similar to the idea of having a lower car insurance deductible usually means higher premiums.
It looks like all plans sold through the healthcare.gov marketplace is required to have out of pocket maximums.
Trick question...
- Some policies have a cap on benefits. So, your max out-of-pocket might be $10,000/person, but there's also a max benefit of $2,000,000 (made up numbers). This type of plan language was mostly banned with the ACA (Obamacare), but there are some grandfathered plans.
- Balance billing - there is no guarantee that the insurance provider will actually pay what the hospital bills. Insurance companies usually have negotiated rates with some providers. So, if you end up at an ER that's out of network (no negotiated rates), your insurance might pay what they think is reasonable and the hospital bills you the excess. Several California-based hospitals are notorious for this. It also happens with helicopter ambulance transport - frequently, they'll bill $50,000 for a ride, insurance covers $25,000, and the patient is stuck with a $25,000 balance (again, made up numbers).
Though the practice is now largely prohibited, there are instances where insurers will have caps on how much they will pay out, either over a lifetime or within a year.
So it is not an absolutely hard limit in all cases, no.
There are probably ways that we could combine aspects of greater and lesser privatization to achieve the best of both worlds. I have some thoughts that I've been mulling around for a while:
1. Expand the government to achieve universal healthcare coverage.
-- a. ACA public option.
-- b. A conservative UBI, with the twist that uninsured individuals would be automatically enrolled in the public option and have their premiums taken out of their UBI. (Tangentially, for similar reasons, also pay out a portion of each UBI disbursement in the form of food stamps rather than cash.)
2. Shrink the government and quasi-public entities (insurance providers) to unshackle the invisible hand.
-- a. New regulation to ban copays and set a mandatory floor on deductibles (say, $10k). While major emergencies still need to be covered, and while there still needs to be an entity in between the patient and provider eating the risk of non-payment, it's also desirable from an efficiency perspective for patients to be kept aware of the costs of their care — and therefore incentivized to select more cost-efficient options. The market would then naturally find a more reasonable equilibrium without the need for price fixing, in theory.
-- b. Set up a system of tax deductions and credits for out-of-pocket medical costs. (Preferably such that the poorest would have their costs fully covered in most or all cases, depending on what's fiscally realistic.) This must strike a balance between non-disruption of market forces and ensuring that the poorest in society aren't shy about seeking the care they need. My thinking is that the annual nature of tax filings would be enough to address the former, as patients would still be be out of pocket for up to a year waiting on their refunds, representing an opportunity cost that would be difficult to ignore. To address the latter point, set up a standardized/regulated process for the insurer to send the patient something resembling a credit card bill, which they could pay either up front or up to a year later with accumulated interest.
Parts 1 and 2 are essentially unrelated, and could hypothetically be implemented independently of each other. However, #1 on its own doesn't attempt to address the efficiency issue (thus saddling the government with even greater new expenditures), and #2 on its own doesn't address what happens or who gets left holding the bag when an uninsured patient can't pay their bill (which wouldn't be an issue with truly universal coverage).
I also have a lot to say about what the state should and shouldn't be doing to maximize the general health/nutrition/fitness of the population, but we can leave that for another post :).
> New regulation to ban copays and set a mandatory floor on deductibles (say, $10k)
I like everything here except this. Won't a significant amount of healthcare (grouped by specialization, hospital, etc) still be funded by insurance and be outside the reach of market forces?
I am also curious whether there are barriers to producers of medicine, healthcare supply, etc from disrupting existing overpriced producers.
Possibly; I'm not at all an expert on the subject. My goal more directly with that was to ensure that insurance premiums would ultimately be used only to pay for emergency care rather than routine/preventive or elective care. Someone with deeper subject matter knowledge might be able to tweak or flesh it out to better achieve the intended purpose.
Re: prisons - This isn't necessarily the case. Florida's private prisons have air conditioning and the public ones don't in part because of democratic control and the private ones have fewer deaths from heat stroke as a result.
>>> Institutions like healthcare, education, public transport, prisons(!) and so on are more efficient, less corrupt and of higher quality when they are in large parts collectively and democratically organized and funded.
>> Re: prisons - This isn't necessarily the case. Florida's private prisons have air conditioning and the public ones don't in part because of democratic control and the private ones have fewer deaths from heat stroke as a result.
> Extremely suspicious comment. Please elaborate on “democratic control.”
Yeah. Also the GP weirdly collapses "more efficient, less corrupt and of higher quality" into "has air conditioning: Y/N." You have to evaluate those things holistically, and it's quite possible that he holistically-better solution is actually worse in some specific areas.
Also I don't have any specific knowledge about Florida prisons, but private prisons are a new(ish) phenomena [1], and "hav[ing] air conditioning" might simply be an unintended consequence of that, because building standards have changed.
[1] You know what I mean, don't nitpick with some ancient example.
> But I imagine the majority of externalities could be accounted for if we tried.
The irony is if you actually came close to achieving that (e.g. accounting for all externalities in the market price), you'd have something like central planning. That's why externalities are usually managed through other mechanisms.
Also, externalities are only one kind of market failure.
Employer-based healthcare was won by an alliance of corporate and healthcare industry lobbies against a state healthcare plan in the 1950s when the so-called “free market” healthcare system was failing the public. Prices were increasing and the New Deal corporate powers pacified the public with social security and employer-based healthcare.
In the US healthcare was intentionally tied to employment as a means of controlling wage inflation during the 1950s by Eisenhower. He had pushed for the "middle way" of private nonprofit health insurance that could be purchased individually or by employers. As inflation began to spike, the administration added new tax benefits to encourage employers to compete on providing benefits rather than higher base salaries.
Roosevelt also tried to institute a national scheme in the 30s but labor unions were split on notional vs. employer provided and it became a wedge issue that scuttled the plan. Truman's push for that same national health insurance plan was shot down in ~1949, partially killed by AMA lobbying.
It's not Eisenhower's administration that's to blame, it's FDR's. Employer based healthcare is a result of the stabilization act of 1942. Health benefits were offered as incentives to workers because employers could not raise wages.
> Employer based healthcare is a result of the stabilization act of 1942. Health benefits were offered as incentives to workers because employers could not raise wages.
Employers can raise wages, and have been able to for some time, so that's not why we still have it.
We still have it because of tax and other incentives, and because government keeps making policy decisions to protect, and even extend it (e.g., the ACA employer mandate), not because of the employers need to offer health benefits to compete because they can't offer more wages because of WWII-era wage controls.
Employers love employer-based healthcare because it gives them insane amounts of control over their employees’ livelihoods. And as a result, wage competition is far less influential.
The fear of losing healthcare coverage a severe fear that people in other countries don’t have to worry about.
I think a lot of employers find it to be a giant headache. It’s expensive and tricky to administer and has nothing to do with your core competency as a business.
I did not state that this is why we currently have employer based health insurance, just why it came into existence. Many consider this to be the "original sin" of US healthcare policy.
You’re right. It was earlier than I thought. I updated my comment per your reply.
Heaven forbid “wage inflation!”
Was the AFL pushing for employer-based and the CIO pushing for national? I don’t even know where to find history like this. It’s virtually impossible for an average person to learn about the history of the American labor movement.
I realized after double checking that it was actually a 1942 Roosevelt bill, and they were trying to figure out how to keep a lid on rising prices during the war. It's also not uniformly good if prices also rise quickly. Inflationary spirals are real, and very bad for regular people.
> Was the AFL pushing for employer-based and the CIO pushing for national?
I'd have to double check.
> It’s virtually impossible for an average person to learn about the history of the American labor movement.
A bunch of this stuff is available in more popular history and online now. "The Devil Is Here in These Hills" is supposed to be good, but I haven't read it.
> I suspect the argument is "Healthcare has never been allowed to be a market" Given how many legal restrictions are placed on it, I tend to agree.
Emergency services aren't a good fit for markets. For markets to work, people really need the luxury to shop around with some leisure.
Wasn't there some Roman oligarch that ran a private fire department, and basically just used it to extort property owners when they had a fire? Truly market based emergency medical care without legal restrictions would likely frequently resemble that with some frequency.
> The first ever Roman fire brigade was created by Marcus Licinius Crassus. He took advantage of the fact that Rome had no fire department, by creating his own brigade—500 men strong—which rushed to burning buildings at the first cry of alarm. Upon arriving at the scene, however, the firefighters did nothing while Crassus offered to buy the burning building from the distressed property owner, at a miserable price. If the owner agreed to sell the property, his men would put out the fire, if the owner refused, then they would simply let the structure burn to the ground.
I will also comment that when we talk about "healthcare being a market", we need to separate out providers of healthcare, with insurers of healthcare. Insurers of healthcare are much closer to a market (in that I can generally find out what the cost of the insurance is, and what it covers), but providers aren't (in that prices lists are hidden, it's not clear what is covered vs what isn't, etc). We talk about the cost of the insurance, but that's artificially high because of the practices of the providers (themselves incentivized to behave that way because of the insurers).
And that's the open market; it gets even more cloudy when we talk about employers being involved, so we have an agency problem as well.
It's a system unlike any other, and I don't think general theories really apply very well as such.
Here's a theory: Insurance companies argue and refuse to pay out to hospitals because it's an adversarial relationship.
Hospitals increase rates to cover the overhead of dealing with hostile insurance companies. Insurance companies raise rates to match increased hospital billing. Ironically both industries are incentivized to raise rates on customers while trying to gouge each other.
US healthcare is a four-party arrangement since employers are also intermediaries. Employers select the plan (or plan options) and they pay the bulk of the premiums. Their check is always bigger than yours even if you pay more for your policy than they do. As such, most of the sales effort by health insurance companies is directed at the employer and they exercise a lot of judgment. In contrast, I have never once spoken to a representative of the health insurance company during open enrollment, it is always HR.
This whole situation would be solved by a simple change to the tax code. Managed healthcare (health insurance) can no longer be purchased via employers with pre tax income.
Everyone gets funneled to healthcare.gov where they can choose.
The whole buying things (life insurance, gym membership, retirement savings) with pre tax income if it is bought through an employer system needs to go in the trash.
In my book, it’s a big red flag when a market is intermediated by anyone. The whole point of markets is to crowd source decision making, so if you remove the crowd, then what is it that you actually have left?
> a full state-run system, which is vulnerable to undercapacity (which the UK is currently suffering from)
That's more because we've had decades of deliberate underfunding due to the "austerity"/"capitalism++" lunatics in charge than a natural consequence of a state-run system though.
Greed unfortunately seems to be an endemic issue. It creates these fanatics that want to leech on every part of the system imaginable, even if it means people die
But how is that not "expected"? Feels like the argument that "communism is good, it just wasn't implemented well anywhere so far". Well, sorry, but by this point I chose to believe that a full state-run system is vulnerable to under-funding in the long term.
NHS was a great initiative and idea!! I'm not advocating against public healthcare, at all. I'm saying is that it's not surprising it became underfunded - there needs to be constant effort to prevent (or compensate) that tendency, because it _is_ the natural tendency of such systems.
It's clear that a strong public system is needed, to keep the private ones in check. But e.g. Italy shows that they can co-exist well, and maybe that's a better solution?
No doubt. I know nothing of the Italian system; I’m in Germany now, which seems to be not just what all the left wingers I know in the U.K. are afraid the Tories want to do to the NHS, and what all the right wingers in the USA have been complaining about when they say Obamacare is too socialist, and what the one British anarcho-capitalist I knew didn’t like about UK National insurance: there are a bunch of private healthcare providers, insurance of some sort is mandatory, the providers don’t have clear differences beyond branding, it’s not called “a tax” despite being on end of year tax forms, and rich people are allowed to do some sort of shenanigans that makes it cheaper.
But… it works.
The NHS is cheaper, but — and here I wander dangerously into opinion — I suspect that’s short-term benefits with long-term problems which will bite the U.K. in the backside rather than better overall cost-benefit decisions.
So we should just expect people to be greedy and try to ruin systems for their own benefit. That raises the question of how to make these systems more robust to defend against that sort of attack.
Exactly. Expecting people to be generous and collaborative and selfless and whatnot is just asking for trouble.
Note that I'm not saying that people are not/ cannot be generous, selfless etc. I'm saying that relying on them being so is a crappy strategy. You need a system that continues to work in the presence of greedy people.
That is the pro of a market system. A market with a malbehaving dominant party is liable to be upset by a new contender who will undercut them, thus depriving the misbehaving party of income.
In the real world what will happen is the malbehaving dominant party will capture the market by any means available to them. In thoroughly corrupt countries they will bribe legislators, in less corrupt countries they donate to the legislators' election campaigns.
This is true, but I haven't seen any coordinated efforts at market based healthcare reform. Some of the needed reforms are patently obvious (eg make arbitrary post-facto charges illegal, like every other industry), and yet there are no popular campaigns advocating for them. There are a few comments in this thread chiming in with lists of reforms, and I could write one of my own, but politically it's crickets (likely because the Parties are partially employed by the healthcare industry).
Instead I'm forced to reluctantly support single payer healthcare, despite it being a huge corporate giveaway. It's really saying something when "have the government take it over" is the clearest path to restoring a more functional market.
Out of network charges are only one possible surprise, and it's yet to be seen how the cartels wriggle out of the new regulation.
As far as I am aware, you're still unable to get straightforward answers for questions like "how much will this procedure cost?". Furthermore, this "transparent pricing" revolves around publishing a fake list of inflated prices that nobody actually pays and so is effectively useless.
Meanwhile in every other industry you either get a flat fee ($30 for an oil change), or at the very least an estimate and a contract that fixes the rate (the shop rate is $80/hour, we think this will take 2 hours). Materials are often overcharged (eg $140 for a part that is easily available for $100, because it's delivered from a special supplier) but still within a workable bound, unlike say fraudulent aspirin.
This is a straightforward reform - the reason healthcare doesn't operate like this is they bought laws creating the ability to charge you without needing to establish a contract.
That's assuming that the methods used to undercut are beneficial when in reality they're just optimizing for profits over health outcomes. People don't have enough of a choice for it to matter, most people can't just find new providers. Same with ISPs
Yet we have cities with multiple ISPs which have incredibly cheap internet at blazing speeds. In my city we have 1Gbps fiber for $70/mo and the price goes down quickly as you reduce the speed. That's better than some areas of SF I think, and we only have 2 major ISPs here.
Amazing what a little competition can do. The city was smart enough when the competitor moved in to install the capacity for more ISPs to utilize the existing conduits in the future.
In Romania competition + initial lack of regulation and lucky timing led to incredible speed + cost (my ISP just launched 10Gbps fiberlink for 10EUR/mo; 2.5Gbps is 9EUR/mo, 1Gbps is 8EUR/mo, 500Mbps is 6EUR/mo and the slowest option). That said, I think we just got incredibly lucky and I wouldn't advocate "lack of regulation" in general.
We can ask why those areas with no competition are so, and it is due to overwhelming anti-market bias that makes it hard for other ISPs to compete or even outlaws it directly. Meanwhile cities that have setup one touch laws or fixed right-of-way have seen robust competition emerge.
One area where markets do poorly are where the cost of service exceeds profit, like rural areas. This is an area where government intervention in the form of subsidies can help, but these can also cement single ISP marketplaces if not managed well.
Sounds to me like ISPs should be regulated or managed the same way as telephone and electricity providers
Along with healthcare
People don't seem to have issues getting electricity service or telephone service in those regions. In this case, the special treatment of those services means that people don't get left out
Rich people aren't the only ones who deserve healthcare or good internet
I would rephrase that argument as, "communism is good, it has just been ruthlessly sabotaged by capitalist interests every time an ideologically communist regime forms".
In the case of the NHS, my understanding is that neoliberal politicians have been pushing to privatize it, and have underfunded it to make it look like it's not working in order to make privatization more appealing. The same is true for many programs in the US too.
Nah, Stalin and the communist leadership were perfectly capable saboteurs, didn't need help from capitalist interests. In a system where "the state" has the capability to enforce "public good" policies above anything else, it's only natural that the following will happen:
- individual freedom will be suppressed (because "public good"; can't have greedy people doing greedy things, them weeds need to be killed early).
- since individual freedom is suppressed the regime is naturally going to be autocratic, which means that "the state" is actually a handful of people... who now get to freely decide how they define "public good".
The fundamental error of communism is that in any implementation, it doesn't really have mechanisms to "punish" greedy leadership, only greedy individual citizens. Which is an idea as good as it sounds.
The Bolshevik revolution was carried out under the assumption that world revolution would follow, particularly in Germany. This assumption did not hold, and Russia did not have the needed technological developments to sustain themselves.
Cuba is the best example of a successful communist-ish state. Most if its struggles are due to sanctions imposed by the US and enforced via its allies across the world.
"if the entire world is a sh*thole, nobody will be able to tell it's due to communism"?
I fail to see what "needed technological developments" would West Germany give them.
> Cuba is the best example of a successful communist-ish state
Successful as in "not completely failed, unlike all the others". Look, I sympathize with their struggles being so close to the US & all, but the fact that this is the best-case for you have should give you a bit of pause, because Cuba is by no means close to being a paradise.
To put things in context, both the largest & most populated countries in the world used to be communist. They both had to abandon it & switched to a form of crony capitalism, which, as bad as it is, seems to actually work better for them than the alternative.
Actually, forget I said anything about communism. My intent was to address the original topic, but I just couldn't resist inserting my take on communism to the original analogy used.
Because government actors have agency, parent is implying that they made the choice to underfund the NHS. Such a choice was not inevitable. Contrary to “true communism has never been tried” the NHS was successful, and would be if the dominant austerity ideology had not taken hold.
Market is a fine fit for every healthcare need that doesn't start with a trip to the ER which is the overwhelming majority of healthcare dispensed in the US.
Using insurance, government or some other centralizing layer (e.g. the church) for routine activity would raise massive "you're pissing money away" red flags in literally any other context. We shoehorn so much economic activity (healthcare) though a middle man (insurers) and then act surprised that they take a fat cut. The solution isn't to government-ize the middle man. That will almost certainly just be a wash. It's to get rid of the middle man where possible.
There's no reason someone shouldn't be able to get a physical or a colonoscopy the same way cosmetic surgery and dental care are done. These are cookie cutter outpatient services. The deviation from instance to instance is small and predictable so insurance should not be needed on the consumer side.
Edit: Anyone wanna do me the courtesy of explaining why I'm so wrong?
> Edit: Anyone wanna do me the courtesy of explaining why I'm so wrong?
just a guess, but it might be because of...
Market is a fine fit for every healthcare need that doesn't start with a trip to the ER which is the overwhelming majority of healthcare dispensed in the US.
... one of the reasons most visits in the us is the er is precisely because preventative care is so expensive/hard-to-get in the u.s and people put off visiting the doctor regularly since its so expensive... the market isn't very amenable to these extra costs in the short run, whereas a state-run system might not have the same short-term cost concerns and encourage/subsidize regular visitation/preventative-care...
Preventative care in the US isn't expensive or hard to get for most patients. Under the Affordable Care Act (Obamacare) there are a wide range of preventive services that must be covered at no cost to the patient. While some coverage gaps remain, those plans cover the majority of US residents.
What about treatment for severe conditions such as cancer or chronic conditions such as life-long disabilities where the expense is significant to the point that it may well be crippling for an individual but is rare enough that it's only a moderate cost spread across a society?
These are the cases where insurance is a perfect fit. The issue with letting it be market-based insurance is that (as you say) it allows insurance providers to take a fat cut. The obvious solution is to regulate insurance costs. At which point you might as well state fund it. Which leads us to the system we have in most of Europe.
As these system seem to work quite well, why do you think a market-based approach would be better?
I misunderstood your comment on first read, and looking at other replies others did as well.
> Market is a fine fit for every healthcare need that doesn't start with a trip to the ER which is the overwhelming majority of healthcare dispensed in the US.
I think most people are interpreting this as “market is a fine fit for every healthcare need [except for those that start in the ER] which is the overwhelming majority...”
I.e. that you’re advocating the market for the majority of healthcare rather than the majority.
I think your actual recommendation is the opposite. Maybe this would be clearer if you just laid it out like, “Most healthcare is non emergency, cost is a primary concern which insurance makes worse, markets are good at solving cost issues.”
Responding to your actual argument, however, I see many people claim that insurance companies are taking a “fat cut”, but I see very little evidence of higher than expected ROI/ROE in Aetna / United / etc. (ref: United’s net margin is ~5%, ~15B in net income on 300B of revenue). ROE is ~20% which doesn’t seem ridiculous for an insurance business.
The bigger problem seems to be personnel spending in healthcare (admin, support staff, billing), and generally a systemic culture that’s not even knowledgeable about what prices they charge, let alone price conscious in the services they deliver.
> ~20% which doesn’t seem ridiculous for an insurance business.
I think the issue with healthcare insurance companies in the US is that they collude with the hospitals to artificially inflate the cost of things so that their 20% is 20% of 10x the actual value of the treatment.
But as you observe yourself, that's not the majority of healthcare, which is emergencies and unforseeable needs. Hence there has to be an insurer of some kind.
> There's no reason someone shouldn't be able to get a physical or a colonoscopy the same way cosmetic surgery and dental care are done. These are cookie cutter outpatient services. The deviation from instance to instance is small and predictable so insurance should not be needed on the consumer side.
Sure, whatever, the small part of the healthcare market that actually functions like a market - consumer choice, legible prices - can be left to get on with it. Let's not let that get in the way of a functioning provision of necessary care to the majority of people.
The healthcare industry already pisses away huge amounts of money. Its evident in all those stories we hear about people getting a huge $5000+ medical bill, then calling the hospital and suddenly its $100 or less. That $4900 is literally all wasted
> the fact that healthcare is already a consumer product in the US
I would strongly disagree with this. Healthcare in the US is currently a cartel system, not a consumer product/market system. If healthcare were a consumer product then:
1. It wouldn't be tied to or dependent on my employment.
2. Prices for medical treatment wouldn't be hidden/obfuscated by medical providers.
3. Insurance providers wouldn't be restricted by arbitrary/geographical boundaries.
I think the debate over weather healthcare is a human right is an interesting one, and I personally haven't come to any conclusion on that yet.
If you think healthcare is a basic human right then a single-payer system is probably the most reasonable solution, although I don't think single payer isn't without it's share of problems.
If you think healthcare is not a basic human right then I think a real free-market solution is the most reasonable solution, again I don't think this is without problems either.
I don't believe there is a "perfect" solution. But I think either a true free-market system, or a single-payer system would both undoubtedly be 100x better than the current system in the US. I would be in favor of moving to either of these solutions as my political stance isn't D or R but "lets make improvements" regardless if those improvements are seen as left or right.
The Japanese system is not a single payer healthcare system and in terms of outcomes vs. cost is one of the best in the world, so I am not so sure that single-payer is the most reasonable solution. Particularly in the US where voters are averse to giving up their private insurance.
Japanese system does have a public option and much tighter price controls, which we are missing here.
I totally agree that culture is a big factor. I just think the conversation in the US around healthcare is kind of limited to pro or anti “Medicare for all” when there are actually many ways of doing things which do not require a single payer. Japan is just one example, Germany is another.
Obviously we shouldn’t just exactly copy the system of other countries, but it’s equally shortsighted to not learn take away anything from other existing systems. The possibility for universal coverage and higher cost efficiency without the need for single payer I think is a valid thing to take away from those examples.
I only put this out there because I feel it needs to be, but we can't just put all of health-care into a single basket. Emergency medicine should be separated out of these discussions as there is no "Free Market" option, just as there is no real free market option for police or fire services.
For optional surgery or cosmetic treatment, sure. You can argue a free market option, but that's why I always think there should be separate baskets, for lack of a better term.
Which I think and correct me if I am wrong, is currently the norm for most developed countries?
It is sort of strange it needs to be explicitly written out, at the same time for those of us not from US we just took it for granted and never think much about the system.
Preaching to the choir, but you might be surprised at how many of us in the US don't think these things through. Now, I do think a lot of this has to do with political marketing, so to speak. Let's not kid our selves, the health care industry makes fairly large corporate donations to both political parties and there is no real discussion to get rid of privatized, emergency medicine. Even our "radicals" like Bernie Sanders, who aren't even that far left, are loathe to bring that up in the US as the indoctrination has been dug so deep =[
It's not (just) about whether healthcare is a human right. E.g., interstate transportation on surface roads isn't a human right, but markets lost out to collective action. Why? Because building a well-functioning market for 8 lane interstates across an entire mostly-rural country was impossible in the 20th century (and probably still is).
So, the other important question to ask is the following: how feasible is it to create a well-functioning market for this product?
So far, we don't have an existence proof that such a well-functioning market is possible to construct in the healthcare space.
> E.g., interstate transportation on surface roads isn't a human right, but markets lost out to collective action. Why?
Because if there is a public option funded by taxation (whether you use it or not) and a comparable or even marginally superior private option which you have to pay use fees for (on top of the taxes), the public option will win every time. Simply put, do you want to pay once or twice for the same service? It's not like one car taking the toll road instead of the public road reduces that driver's tax burden by any noticeable degree. In antitrust terms, the government is using its monopoly in one area, "protection" (mostly from itself, as with any protection racket), as leverage to create a monopoly in another area, transportation. The surprising part is that there are some areas where the public roads are just so bad that you can actually run a profitable toll road alongside them. Level the playing field by requiring the government to fund the construction and maintenance of its interstate highways exclusively through use fees and I expect you'll see a very different result.
It's the same with any other bundled service. Having decided to subscribe to a certain service package one tends to stick with the included services, even if on an individual basis there are better services available at lower cost elsewhere. It only becomes viable to switch to the better service provider if you can replace all the bundled services. Except in this case that isn't even an option since there is no opting out of (paying for) the tax-funded package.
To add to the other comment about public-private competition (another example is schools - parents in private schools pay for both), the mostly-private industry managed to build inter-city railroads and local streetcars just fine. It is not obvious that it wouldn't eventually build highways if there was vision and/or existing demand.
Who knows, it might have even achieved a reasonable balance between the two, instead of forcing a car-centric environment everywhere like the public option? ;)
One point that gets skipped over a lot - the US is also one of the most unhealthy countries in the advanced world.
This is a big /part/ of the "worst outcomes" in the "highest cost, worst outcomes".
It is possible that you can spend a ton of money on healthcare - yet smoke and drink, drive everywhere and not exercise at all, and eat trash - that the healthcare spending is doomed to fail.
Europeans walk & bike more and don't eat as much garbage. Most Asians exercise much more, eat healthier, AND smoke and drink less.
Maybe the healthcare part is secondary to just generally taking care of your health?
It is well understood how terrible obesity is for you. Why should we expect the US to have better healthcare outcomes than Vietnam when Vietnam is 2.1% obese and the US is 42% obese. You can take all the heart medicine in the world. It would be better to simply not be obese in the first place!
This never seems to be a talking point. Have the statisticians controlled for all this when they come to these conclusions??
Though I suppose China and India, which combined probably comprise the biggest block of population, are a slightly better shade of red than the US and Europe.
That's a good point, life style does play a major part.
But I think this point also opens another subject, preventive healthcare. Many modern healthcare systems are starting to focus on prevention for 2 main reasons: increase quality of life and reduce long-term healthcare costs.
For example, in Finland public tobacco smoking is(was?) considered a public health issue. The government got actively involved to reduce consumption and this resulted in better overall outcomes in their healthcare systems for diseases caused or exacerbated by smoking.
IMO, obesity is a problem affecting the healthcare systems of many developed countries (Vietnam is not yet considered a developed country) arguably not at the same levels as in the US. But this again is part of how government chooses to get involved in fixing the healthcare system by enforcing policies or passing laws that help with prevention.
The "metabo law" in Japan appears to have been somewhat successful in preventing obesity. But it probably wouldn't be politically acceptable in the USA.
My father is getting old and our healthcare system has done a great job at keeping him alive while he can still eat shit loads of pizza, drink beer and be a 80lbs overweight.
All this medication and treatment he takes is not just to keep him alive but to keep him alive without having to change a single bad habit.
This is a good point, and it's important to also remember that these ideas aren't independent. How people interact with the healthcare system over their lifetimes has an impact on how they think about their health, and the health impacting decisions in their lives.
Not basically the same people. Canadian and US culture aren't the same. And the racial makeup is quite different.
57% of the USA is white, compared to 73% of Canada. Nearly 20% of the USA is hispanic, compared to 1% of Canada. There are many more Asians in Canada and much less people of African origin.
I don't reasonably consider that we can attribute black people and hispanic people simply existing to an additional 8% of GDP in healthcare consumption. That seems like a huge claim with no evidence provided.
I'd like to first see evidence that people of different race has a causality effect on healthcare consumption.
I'm not blaming races, I'm just saying the people are different. Even white Americans and Canadians are not the same.
Per the CDC:
Among men, the prevalence of obesity was over 8 percentage points lower in Canada than in the United States (24.3% compared with 32.6%) and among women, more than 12 percentage points lower (23.9% compared with 36.2%)
In the United States, the majority of the nonwhite population is black or Hispanic for whom the prevalence of obesity is higher than it is for the white population (3). Among nonwhite Canadians, the largest group is comprised of East/Southeast Asian persons for whom the prevalence of obesity is lower than it is for the white population
Canadians don't eat the same diet. The obesity rate is 36% in the USA but only 29% in Canada. I suspect that the difference in life expectancy is influenced more by obesity than by the healthcare system.
And yes we absolutely should control for climate, or at least for incidence of extreme heat waves. It's well known that heat waves kill a lot of frail elderly people.
There is so much wrong with the US healthcare system, from physical therapy centers, ambulance companies and prosthetists, to hospitals and surgery centers, to doctors, to insurance companies, to drug companies, to laws, patents, and the US government. Maybe you don't know the system well?
I am so sick of null hypothesis studies and random statistic slinging. It means nothing. Average obesity rates do not tell the whole story (even so an 8% increase is HUGE). You have to look at variance. If the U.S. has a much wider variance then there would be a greater amount of people with extreme obesity which would definitely affect health care outcomes.
> US is also a super bad infant mortality rate compared to other countries:
Access to healthcare is quite low in the US compared to most of the 50 countries ahead of us. We also have higher levels of poverty, ESPECIALLY for a lot of parents/children.
GDP is irrelevant. The paper says:
> In 2013, the US infant mortality rate (IMR) ranked 51st internationally, comparable to Croatia, despite an almost three-fold di erence in GDP per capita
If you have high GDP per capita, and more poor people per capita, and health care is not free - you're going to have more people not accessing health care and suffering the consequences.
In this world - I would expect infant mortality to be much higher even when the healthcare systems are equal.
which too seems like it's probably a complicated issue, from one of your papers.
> Consistent with past evidence that has focused on comparing the US with Scandinavian countries, we find that birth weight can explain around 75% of the US IMR disadvantage relative to Finland or Belgium. However, birth weight can only explain 30% of the US IMR disadvantage relative to Austria or the UK
> This never seems to be a talking point. Have the statisticians controlled for all this when they come to these conclusions??
I never see this as a talking point of folks who are in favor of universal / state-funded healthcare, but it is often a talking point for those who are opposed. They point to the links between state-funded healthcare and the soda tax in the UK as an example of how allowing the government to control your healthcare results in more aggressive and manipulative social policy to control health outcomes societally. Many people opposed to state-funded healthcare feel rather strongly that you should be able to do pretty much whatever you like with your body as long as you're paying for it yourself. I consider this take to be missing quite a lot, but it does seem to be a common one. I am personally in favor of universal single-payer healthcare systems, so I've had this conversation a lot due to my surroundings and have heard just such this argument many times.
> Another point is that US healthcare is considered the most expensive and worst-performing in terms of outcomes compared to the other developed countries.
In what way is it the worst-performing? I mean, what are the outcomes that are measured to determine its performance?
Yes, healthcare is a lot cheaper in Europe (even if your employer wouldn't pay their part) compared to the US, but the quality of the service is rather poor with very long waiting lists, stubborn doctors who don't want to perform certain tests (as simple as a Vitamin D or a testosterone test) so they don't have to justify it to the insurance.
> but the quality of the service is rather poor with very long waiting lists, stubborn doctors who don't want to perform certain tests (as simple as a Vitamin D or a testosterone test) so they don't have to justify it to the insurance.
That's exactly like US healthcare if you aren't either a wealthy private-pay client or someone with top-flight private insurance; we just pay twice as large a share of GDP and even a higher multiple per capita to have the same normal experience and many more people uninsured than any other developed economy (and we've only recently through the ACA, gotten it so the that your top-flight insurance plan wouldn't look to retroactively cancel your insurance when you got an expensive-to-treat condition, leaving you uninsured and uninsurable.)
Affordable Care Act (ACA) outlawed denying insurance to anyone, regardless of how much their future healthcare expenses will be.
It is one of the reasons that everyone complained about ACA increasing health insurance costs - it had to because more people were getting more healthcare.
ACA also outlaws pricing insurance on anything other than age, smoking status, and location. Even the pricing due to age is capped so that the premium for the oldest (riskiest) age is only allowed to be 3x the young age premium.
ACA also implemented out of pocket maximum for in network care, so that there is a maximum cost per calendar year you would be responsible for. Recent law that went into effect Jan 1, 2022, extends this out of pocket maximum to all healthcare providers in the US if it is an emergency.
Finally, ACA also instructed an appeal process if you think the insurance company is denying payment for treatment justified with evidence:
Unless there are some clear symptoms of deficiency, vitamin D or testosterone tests aren't usually justified from an evidence based medicine perspective. Insurance companies usually won't cover such tests unless the patient meets their medical necessity criteria. However in many countries you can order such lab tests yourself and pay for them out of pocket.
As a separate issue, there is now significant clinical evidence that hypovitaminosis D is a major risk factor for COVID-19. So I hope that medical guidelines will be updated to make those tests a routine part of preventive care screening, in the same way that we test for lipids and blood glucose levels.
>the quality of the service is rather poor with very long waiting lists
I can get in to see an Urgent Care doctor in any major US city within 30 minutes of walking in the door. If it's not urgent, who cares what the wait is?
> So you basically get the worst performing being also the most expensive. Which doesn't really fit the view that less government involvement results in a more efficient system. Well, I guess it is more efficient if the expected outcome is a larger profit for different private companies and middlemen and not the well-being of the rest of the population.
Healthcare and Big Pharma have captured regulators at various federal health institutions. The mission is maximizing profit outcomes not health outcomes.
US Healthcare is not the 'worst performing', that's a perennial clickbait theme.
Health issues are bad in the US, and people use that as 'evidence' for quality of the Healthcare system, but that's not fair.
People shooting each other, not eating well or exercising, isn't so much a function of the US Healthcare system.
The US system is probably the most economically inefficient, but that's also expected at the highest end of quality.
The US has most of the best quality systems in the world, it's just expensive and messed up financially, but the quality itself is something to behold.
While I share your reservations about 'privately backed things' - for example, advertising arcane drugs in the US is ridiculous, this whole 'Ask Your Doctor' is an excuse for pushy patients to 'prescribe themselves' over the will of tired Doctors caving in ...
... that said, Theranos is the opposite example. If it had worked, it would have been because of VC backing and it would have been very beneficial to people. And there are many things like that.
Like anything, it's complicated, and we need nuanced thinking about it.
We probably should welcome a lot more VC spend, think of ways to empower doctors with the deluge of information, to empower individuals but at the same time get them to understand that they are not medical professionals and shouldn't be self-diagnosing, etc..
There are huge variations in performance depending on what metric you look at. The US is at or near the top in 5-year survival rates for most types of cancer.
It's not all bad to spend more - consider the extra hospital capacity that so far has helped absorb COVID shock impacts better than neighboring Canada. Hopefully we don't hit the limit of that, even, though. https://www.bloomberg.com/news/articles/2022-01-06/hospital-...
US health outcomes also aren't so bad for those who have affordable access to the system, as I understand it.
But the spending is something to keep in mind when anti-healthcare-for-all advocates say things like "do you want to have to wait months for procedures like in Canada" - if the US continues to spend more money per person, there's no reason it can't continue to have more capacity.
Surely you aren't suggesting that having more hospital beds per capita in the US is causing more deaths? Capacity is hardly the only factor in how Covid is hitting the population (and having more hospital capacity reducing pressure to lock things down will itself affect the rate of spread).
For instance, per https://ourworldindata.org/grapher/total-covid-cases-deaths-... Canada has seen 66K cases per million and 807 deaths per 1M cumulatively. The US is at 180K and 2515. Slightly different numbers than yours, but close enough. Deaths/cases to date is very similar, 1.4% in US and 1.2% in Canada. So the difference in total deaths is largely policy and behavioral, the aggregate policy across the US has largely been one of "at this point we can't eradicate it so we need to live with it as best we can" where even the liberal US states remain quite open compared to initially in 2020 in the face of recent surges. Whether or not that's the right policy is separate from whether or not that policy would've even been realistic without as much health care capacity.
no im suggesting that 'yolo lol we have more beds' is meaningless if u end up with worse outcomes. and let me be clear that 66k per 1M cases and 807 deaths per 1M is better than 180K per 1M And 2515 per 1M.
You won't really know which is better until 2025, 2030, sometime like that for total deaths due to COVID numbers. Canada is hardly out of the woods. Push the date to 2040, 2050 if you look at things like what were the long-term impacts on different policies on people who didn't die of COVID.
You still aren't engaging with the point under discussion, though, which has become publicized due to COVID but exists independently of it. Spending more on healthcare contributes to having an overall better health care system, but the US suffers due to large problems of access and distribution. Regardless of payment structure, I would argue in favor of continuing to spend more on health care than other nations; we have the money, it's a good use of it.
> Well, I guess it is more efficient if the expected outcome is a larger profit for different private companies and middlemen and not the well-being of the rest of the population.
My favorite example of this is when I had to get an MRI. The lab imaging said it would be $800 if they billed it through insurance, or it would be $600 to just pay for it directly out of pocket. So the cost of having to deal with my insurance (which always advertises the "discounts" they negotiate and the "lowest cost") was actually more than what the insurance would actually cover.
This is always extra annoying because it might be a false savings to pay cash there. Let's say your MRI says you need a $5500 procedure, and your plan's deductible is $3000, 90% coverage after, and out of pocket max is $6000, and there's nothing else you've spent on the plan this year.
Pay $800 for MRI with insurance, you'll then pay $2200 for the procedure to hit the deductible + 10% of the remaining $3300, so $2530 total for the procedure. $3330 total for the year between the two things.
Pay $600 cash for MRI, you'll then pay $3000 for the procedure to hit the deductible, and 10% of the remaining $2000, so $3200 total for the procedure. Now you've paid $3800 total, so you've spent $470 more despite the MRI being "cheaper"!
If you have other expenses so your out of pocket max comes into play, that difference approaches the full $600.
Yes, unfortunately so. You have to play the stupid game of "expected medical expenses".
For example, am I going to do something major like have a baby this year. Then yes it probably makes more sense to get me to my deductible and pay the extra money to go with insurance. Or if you (or someone on your plan) has an ongoing medical issue where you know you will meet your deductible. Or on the flip side, I met my deductible one year and was going to physical therapy. Since I met my deductible the physical therapy visits were cheap, but going in to the next calendar year now my deductible reset. Could I have used more PT? Maybe, but the visits were about to be 5x more expensive.
But "expected medical expenses" is just the dumbest thing.
Usually no, most people just use doctor-suggested or in-insurance-network providers and billing because it's easier than calling multiple places and hyper-optimizing on the math.
But we have to pay the bills after the insurance company does the calculation, which often results in annoying surprises.
The better your insurance, the less nasty surprises, which largely in the US means "the better you're paid, the less you have to pay out of pocket for health expenses" which is a nasty thing because then the people most likely to be hit with a big bill are those who can least afford it.
No. I know that my total expense in a given year will never exceed $X (Premium + out-of-pocket max). Worrying about every single transaction is not worth it.
Yes, so. The typical American response to that is: "the government controls everything. Let the free market do its job!"
And then wonder why they get shit care for a huge price BUT swith nice marketing and a smiling "health dealer" getting you a 0% lease... oh sorry, we got you confused with a Chevvy!
And also, "we have the best care in the world because our docs are better selected". This one never fails to make me laugh, as a swiss MD
Yes, that's the response, but healthcare in America is far from a free market. It's more a circle of sloppy middlemen, in much the same way that I hear privatized passenger rail in the UK described.
in 2019 I would have agreed with you.
In iceland you will not be charged for cancer treatment, but the medical costs of getting a long term illness in Iceland are not trivial.
Add that to loss of income and the situation for many chronically ill is actually so terrible that laughing at the US is not something Iceland can afford.
And covid has painfully displayed exactly how poorly managed the hospitals are and how starved the health care system really is.
The equivalent of a bus accident will put the healthcare system on its knees or 80 people needing intensive care.
of course Iceland has more hospital beds than 80, but it cannot handle a disease that may put 80 people in ICU ( not counting ventialtion here at all, just intensive care ).
I think many in Iceland, myself included, are a bit in shock of exactly how poorly managed and starved the health care system is.
Up until 2019 I laughed at the dumb americans and their awful health care, man did I get my sit-upon whopped in the past 2 years.
Icelands is so bad that we are regularily filling hospital break rooms and garages with patients.
THat is on a normal non-influenze season. Let alone sars-cov-2 introduction.
I suspect Canada is having a similar realization as we are. Free care in all its honour.
Starved free care, heh...... Shame on us. Really. Shame on us.
Another point is that US healthcare is considered the most expensive and worst-performing in terms of outcomes compared to the other developed countries.
Not that your thesis isn't correct but be careful there. You're combining the cost of care for the people who get care with an average outcome that includes people who don't get care. The quality of care for Americans who can afford care is excellent.
> The quality of care for Americans who can afford care is excellent.
As a Canadian who knows many Americans, works for a US company and has extended US family, this is not quite true.
Most Americans "who can afford care", maximum 70%, have access to medical care that is on par with Canadian health care, but is fraught with peril; "booby traps" such as out of network costs, high co-pay fees that can bankrupt, surprise billing (though 2022 is starting to deal with that). Care may be excellent, but losing your house if you get cancer seems unnecessary.
A few percent of Americans (the rich and the very well insured; FANNG/MAMAA, investment bank employees, etc.) have access to the possibly best health care in the world.
20% of Americans are uninsured or under-insured and have access to the worst healthcare in the G20.
I think it's strange to want to only include the first two categories in the outcome calculation. Strange may not be the right word here ...
Also, this idea that Elon Musk is going to wait in line to get a checkup is ridiculous. Those who can afford it will always be able to buy premium care. But we have millions of people who are waiting to be financially ruined by an act of God.
> You're combining the cost of care for the people who get care with an average outcome that includes people who don't get care.
Well that's the point, I think everybody should be taken into account in order to paint a comprehensive picture of the quality of the system at country level. The resulting stats reflect the health of a society as a whole not just of the part that can afford it. Not having universal healthcare is still part of the system, even if we don't like it.
I get it that health outcomes of those left out are probably very different. But leaving those numbers out of the comparison doesn't really work with these type of statistics.
At that point how could you compare it to the other countries that take everyone into consideration? The stats are GDP/capita percentages, should I remove the ones who can't afford healthcare from the GDP stats as well to not skew the ratio? I don't really like where I might end up taking this route.
I don't have any experience with US healthcare and I'm sure the quality of the services is really high, but the fact that you need to afford basic healthcare and it's not guaranteed by the government for everyone makes me see it as closer to just another "consumer product" compared to other systems.
When it comes to healthcare in the US, a lot of people who can afford it don't care about people who can't afford it. Hence the common belief by the middle class that the US has the best healthcare in the world. (That's before you add in a large dose of American exceptionalism.)
Yes, but anyone in US that has healthcare in US and reads the paragraph above will come to a conclusion along the lines of 'Wait, my experience wasn't bad; what am I missing?'. As a result, you may end up making an opposite of the point you are trying to make.
There is a sad trend where the small doctors -- who can't survive without group power -- join conglomerates, the conglomerates buy hospitals, and finally the conglomerates close the less performant facilities. You get large states with vast underserved geographies.
The OP headline is we are careening towards a luxury retail arrangement like Trader Joes: they will only have "outlets" in the richest areas. There's no regulation around closing hospitals so this is coming fast. Two in my county closed this year and I am far from rural.
I’m interested in this worst performing stat. By what measure? Because I’ve always read that when controlling for the relative poor health of the us population regarding diseases related to poor eating and exercise habits, the US was a top performer for heart and cancer treatments.
> Another point is that US healthcare is considered the most expensive and worst-performing in terms of outcomes compared to the other developed countries.
>>e most expensive and worst-performing in terms of outcomes compared to the other developed countries.
That is only true if you cherry pick statics that over sample for life style choices, and under sample of actual health care.
If you look at statics that are directly attributable to the care provided, not the life style choices of the patients then the US Healthcare system is far better than any other nation
I'm curious how you can suggest the US government spends the most money in the world, by far, on healthcare and the simultaneously suggest there's less government involvement.
The government is involved in every step of American healthcare. As you can imagine of a system that gets all of its funding thru companies completely overseen by regulatory bodies or thru social programs.
I didn't really suggest that the US Government spends money on healthcare, I was merely quoting the article: "Health care consumes 18% of GDP in America"
Please note that the wording implies that 18% of GDP is spent on health care overall not that the US Government is spending all that money out of its pocket directly on yearly budgets. The way I understand it is that it includes both money spent by public and private actors for all health related service.
I see this type of stat a warning that something might be dysfunctional within the system, and it's the government's job to get to the bottom of it.
There is some crazy amnesia here about the US healthcare system. Some 40% of the US are already covered through Medicaid/Medicare - "socialism" is long here!
Much like US Defense spending subsidizes the rest of the globe, US for-profit healthcare spending spurs massive investment in pharma and biotech research that benefits the rest of the world. Are there inefficiencies and waste? Yes. But outcomes overall are much better for it.
The us healthcare system is not capitalistic. If I get my flu shot I have no idea how much it cost my insurance company. CVS, Walgreens, Safeway all the same to me for a flu shot.
If instead we use health insurance like home insurance for unforseen major issues, and had price transparency. Then prices would go down as people would shop around.
What you're describing is the lack of a normal market, and even that only applies if you have insurance. For the millions of people without insurance, they do indeed shop around.
It is very much a capitalist system, since the ownership (& control) of the system is not in the hands of the workers - in insurance companies, hospitals, pharma, etc - but in the hands of wealthy shareholders.
To be fair, I suspect your definition of capitalism is very different from mine...
> So you basically get the worst performing being also the most expensive. Which doesn't really fit the view that less government involvement results in a more efficient system.
The US healthcare is an example of the government being massively over-involved and creating massive inefficiencies.
Counter point: the NHS in the UK has more government involvement than the US healthcare system.
The NHS (despite fairly extreme under-funding) has better health outcomes for patients than in the US.
“Better outcomes” needs more detail:
Medical bankruptcies per year: ~200k in US, ~0 in UK. Caveat: bankruptcies often don’t have one clear root cause, the other ~600k bankruptcies per year in the US may or may not have an aspect of healthcare costs.
Cost of triple bypass heart surgery: US: $110,000, UK: £8,500 (paid by the taxpayer, not by the patient at the point of care - free for them). (P.s. private healthcare is available in the UK too - the procedure costs around £20,000 privately, payable by the patient or their insurance)
Someone told me this a few years back and it stuck with me.
"American healthcare is the best in the world like sportscars- Ferrari, Lamborghini, BMW, Bugatti, etc. are the best cars in the world. Surely they both are the bests in the world- but only for the small percentage of people that can actually afford them."
This is sad.
(Many, including me, wouldn't buy a sportscar even if they could afford one, and sportscars aren't the "best" in their opinion. But this comparison drives the point home.)
I think you're mostly right. Although there are exceptions. Consider to opioid crisis. That's a case where profit motive directly leads to poorer quality care.
Regardless of that, high quality care isn't much good if you can't access it.
The US government is involved in ways that make it inefficient. For example, I don't get to choose my insurance, the government has ensured that instead my company does for me. While I can in theory get insurance elsewhere I lose a large subsidy in doing so, no insurance I can buy can possibly be a better deal for me, even the company insurance is bad.
The incentives for insurance are to ensure that I don't quit, not that it is good healthcare or a good deal.
I don't know what my company pays for my insurance, but if I opt out of that insurance that money is lost. I know I pay $100/month (not the real number but close), and plans on the government health market start at $800/month (after the tax credit), plus by using the company plan they kick in another $100/month in a HSA match, and HSA money is a tax advantaged investment (AFAIK you can only get in an HSA from your employer). So by using my companies insurance it is like getting an additional $800/month in income (some of which is invested!).
I didn't look into details of the insurance market plans, but there were 40 different plans available there for me to choose from (as opposed to the 2 my companies gives me). I suspect that something similar to my work plan is more expensive than the one I listed above. I also suspect that if I was to look at all 40 plans I would choose something that wasn't not similar to the choices I have now. However with the amount of money I'd lose it isn't worth my time to examine my options.
WWII Wage Freezes is where it started, the government regulated that employers could not raise wages so employers started offering services to attract talent, in those days it was having a doctor on site at the factory, or office that employees and there families could see for free.
years later that transitioned to comprehensive benefits packages
> The NHS (despite fairly extreme under-funding) has better health outcomes for patients than in the US.
It really isn't underfunded. It's grossly inefficient, which is what happens to most if not all publicly funded bodies. It is actually ok to criticise the NHS organization.
They're a monopsony, so actually get absolutely gouged by the pharmaceutical companies. They (currently?) refused to recycle crutches, plastic casts and so on. They'll use their own (hospital pharmacy) drugs if you get admitted, and then discharge you with them, even if you have your own dosette box and refuse to take theirs back. My father was discharged with something in the region of £3-5000 pounds of drugs that we threw away on several occasions.
As a percentage of GDP, it's roughly the same as most other western countries.
Of most interest though is figure 3 in [2] - 80% of UK (NHS) funding came from public money, i.e. tax, and 20% from private money (e.g. insurance). For the US, it's 50% public money (tax), and 50% private money. I'm not sure how much more money the UK general public really thinks the UK government can come up with to keep giving the NHS "more!" money. There's a limit to how much people can be taxed. And compound interest (increase the NHS by 10% per annum!!) means we'd spend all our GDP on the NHS at some point rather quickly.
>They're a monopsony, so actually get absolutely gouged by the pharmaceutical companies.
You've got that exactly back to front. NHS's immense buying power lets them negotiate lower prices for drugs, exactly as medicare used to (before pharma lobbying stripped them of that power).
Pretty much any trade deal negotiations with the US involve the UK being asked to dial down NHS buying power on behalf of pharmas by making hospitals responsible for purchasing.
>As a percentage of GDP, it's roughly the same as most other western countries.
50% of the US - not because the UK is especially efficient but because the US healthcare is essentially legalized extortion.
>I'm not sure how much more money the UK general public really thinks the UK government can come up with to keep giving the NHS "more!" money. There's a limit to how much people can be taxed.
The UK public adores the NHS and is one of the few things polls say that people would be happy to fund with tax raises. It's very very popular. In no small part because we can see how much of a racket the US is.
The ruling party does not like it, however, which is why it has been slowly degrading service over time as preparation for full privatization in 10-15 years. Part of this has been done by handing over chunks of the NHS to be run privately and incompetently by friends and donors of the party. The problems caused by this backdoor privatization will later be "fixed" with privatization. Whatever the problem, privatization will forever be the answer.
The tories argued for an American style healthcare system in 1948 and while they give tacit acknowledgement of the popularity of the NHS their views havent changed (Christopher Chope is a good bellwether of their more unsightly "hidden" views), they still want a US style system.
> You've got that exactly back to front. NHS's immense buying power lets them negotiate lower prices for drugs, exactly as medicare used to (before pharma lobbying stripped them of that power).
In principle, you're correct. In practice the fact that they're the only buyer, means in many cases that they pay at whatever a drugs company sells at since there's no "but company X is only paying Y, why are you charging us Z" as a comparison, particularly in the case of non-generics.
> The UK public adores the NHS and is one of the few things polls say that people would be happy to fund with tax raises.
And that was exactly my point. The UK public might "adore" the NHS, but they have a pretty poor understanding of how it is funded. If the government kept funding the NHS by an extra X percent every year, we run out of public funds.
> The ruling party does not like it, however, which is why it has been slowly degrading service over time as preparation for full privatization in 10-15 years.
The ruling party, being the Tories, that have been "in charge" of the NHS for the majority of its 70 or so years? And who on earth would buy a loss making healthcare system that's funded to the tune of a billion or so a week? Apple?
>> If the government kept funding the NHS by an extra X percent every year, we run out of public funds
Lets say the uk gov allocated 10x to the nhs in the next budget - to be clear, this would put just nhs spending at more than total govt income for the year. If this were a company we’re talking about, they’d be insolvent.
But we’re talking about a govt with a sovereign currency. So what would happen in this scenario? It doesn’t go bankrupt…
How is money created? What is fractional reserve lending? How is money destroyed? Can a country issue a fiat currency without an associated public debt? Or to put that last bit another way - could you settle your tax bill in GBP if there was £0 public debt?
The govt has rules for borrowing from the capital market, and that's (mostly?) for national infrastructure projects. It will never (hopefully) borrow from the capital markets to fund the NHS, and then continually pay it off.
That leaves tax or private money to fund the NHS, and we can't tax people much more. So in your comment "how is the money created?" Answer, tax, and there's a maximum limit to how much we can fund the NHS.
>> The govt has rules for borrowing from the capital market
Yeah it does. The UK govt has had 6 different sets of rules in only the past 10 years.
The current rules followed by Rishi Sunak are actively opposed to what you say - he’s been celebrating beating borrowing forecasts of the OBR by £26bn, and he makes a big song and dance any time he can stating excessive public borrowing is immoral. He found the magic money tree instead…
The scope of quantitative easing has increased massively since it was introduced. On top of this, the bank of england does not publish a report on which govt bonds have matured - but we know some have already without having been sold.
So, the govt borrowed from the govt (bank of england bought out uk govt bonds held by non govt entities) then held them to maturity (so the govt paid the govt back), while remitting the coupon payments back to the govt. All while we can’t see inside the machine - none of this is available via public reporting.
It’s not quite “printing money” but it definitely qualifies as a magic money tree.
It’s how govt’s corona responses are paid for today and it’s the reason NHS funding is constrained not by tax receipts but by policy, political decision.
> It sounds like you are disputing empirical evidence as well as standard economic theory regarding monopsonies.
When there are multiple sellers of generic drugs, you're correct. When there is one seller of a non-generic, life saving drug with no alternative, the NHS is going to pay whatever the one seller, which by definition is a monopoly, is going to charge. [1]
> What is even the point of that sentence?
That we cannot keep increasing NHS funding exponentially. Some people seem to find that fact hard to grasp - there's an upper limit. Another commenter talks about the UK raising debt to fund the NHS. Thank goodness there's a set of rules for government borrowing in the capital markets.
> A) If it is a majority of years it's a fairly slim majority and B) they werent there when it was set up.
Both parties campaigned for the NHS in the 1940s. Labour won. Blair, in power for over a decade promised to "fix the NHS" whatever that meant, but he didn't do it. Thatcher/Cameron/Johnson, all in charge for 2 decades or so, still haven't "sold it off".
> Somebody who knew that they could start charging either customers or government through the nose and make it fantastically profitable.
Except it will never happen. The government would not introduce a commensurate tax cut since they're no longer funding the NHS, so your cost of living would go up, and even in the UK, I think people would get rather upset.
> Branson is one example (Virgin Healthcare sucked £2 billion out of NHS coffers, yay for crony capitalism).
Did he really? Evidence? 2 billion of private money paid by companies into Virgin Healthcare, sure. But did he take £2bn from the NHS?
> They are not so aware of the corruption going on underneath with taxpayer money.
What corruption? Surely the police should be involved if there's true corruption?
I won't defend the NHS. I'll defend the staff that treated my father, but the organization itself needs fixing.
>When there are multiple sellers of generic drugs, you're correct. When there is one seller of a non-generic, life saving drug with no alternative, the NHS is going to pay whatever the one seller, which by definition is a monopoly, is going to charge.
This is incorrect. If the price is too high they refuse, depriving the company of all income. This has been done for certain cancer drugs.
Even if they dont refuse their pricing power lets them beat down prices.
>That we cannot keep increasing NHS funding exponentially
It's barely even increasing in line with inflation.
>Some people seem to find that fact hard
They really dont.
>Both parties campaigned for the NHS in the 1940s.
This is provably false. The tories wanted an insurance based system rather than the system we have modeled on the soviet union.
I think Im gonna leave this discussion here. We clearly dont live in the same plane of reality.
>I'm not sure how much more money the UK general public really thinks the UK government can come up with to keep giving the NHS "more!" money. There's a limit to how much people can be taxed.
To add a little nuance, look at the survival for various cancers in the NHS vs the US. Cancer care for example is measurably better in the US in terms of overall survival, early detection, and access to drugs. You "get what you pay for" when it comes to highly specialized care.
>> look at the survival for various cancers in the NHS vs the US
The figures i can find ignore people who can’t afford to become cancer patients in the US - there’s an unknown, but suspected large, number of people cut out of the figures in the US making that stat unfairly stacked vs UK (where everyone regardless of affordability gets access). The people who can’t afford in the US are typicslly the ones more pre-disposed to adverse outcomes in that statistic.
"better outcomes" when talking about health should be things like 5 year cancer Survival rates, Wait time for Surgery, Wait time for Heart Stints, 5 year heart Attack Survival rates, Wait time for Specialist Care, etc
I am not assuming anything at all, people that attempt to inject affordability into the care debate are doing so for disingenuous reasons.
The question of affordability is different from the question of quality care, we can solve the affordability problem with out having to lower the over all standard of care which is what you are advocating for, the bringing down of the overall quality of care in an attempt to increase accessibility of care. Ironically putting that faith in the US Federal Government will only result in 1 of those happening.
>> people that attempt to inject affordability into the care debate are doing so for disingenuous reasons
What exactly is disingenuous about wanting more people to live longer with higher “quality of life” for less overall spend on healthcare? You can’t achieve this without resolving the affordability issues.
>> which is what you are advocating for, the bringing down of the overall quality of care
With all due respect, you’ve made that up to fit with your world view. It’s certainly not something i’ve advocated for.
Those triple heart bypass operations i started the thread with - the 10x more expensive US procedure results in 3 year shorter life expectency post operation.
It costs more, and it’s not as good a result?
(I am being slightly disingenuous at this point - the reason the US outcomes are poorer despite being 10x more expensive for the same operation are due to differences in the health of the average patient - in the UK because healthcare is free at the point of access, there tend to be earlier interventions, in the US there is a marked difference in severity of presentation - ostensibly people wait longer until they’re really unwell before accessing healthcare)
As opposed to what, the Singaporean system where you get sent to jail for charging above government mandated price caps?
American healthcare has the least involved government of any first world country.
Only an overly credulous interpretation of Koch-style market-knows-best propaganda would make you think that the "level" of government involvement was the root cause of its problems.
Less involved, more corrupt. It's over-involved because it's corrupt. Giving the government more power will only increase corruption.
> Only an overly credulous interpretation of Koch-style market-knows-best propaganda would make you think that the "level" of government involvement was the root cause of its problems.
I guess my initial phrase is a bit superficial, from my European-centric point of view the US government seems less interested/involved in the health of their healthcare system compared to what I'm seeing in europe.
The point I was trying to make is that government involvement is needed to make sure that the right incentives are in place at all times for all involved actors (public or private). And if the system becomes dysfunctional or is abused it's the government's job to fix it.
Most of the countries that have universal healthcare in Europe have their own take on how it should be done:
- France has state funded insurance and (mostly) state funded services
- Switzerland private insurance and private/public services
Two totally different takes with arguably very similar (good) results.
The goal of government involvement should be to make sure everyone has access to basic healthcare and avoid double standards and abuse.
The greatest healthcare improvements in the US could be brought about by:
- Dismantling the insurance/big hospital complex that milks the US population for the enrichment of c-suite executives.
- Removing the capacity for lobbying by insurance companies, large hospital groups, device and pharma companies (so they're less able to price gouge consumers).
- Price transparency on all links of the chain of healthcare delivery.
- Changing the incentives for physicians and other providers towards expensive, often harmful and unnecessary interventions.
- Facilitating improved therapeutic relationships between providers and patients (More time spent, more communication, more incentives for harm reduction).
- Social changes including less stigma for things like drug use, greater emphasis on community cohesion and care.
- Demilitarization (Not only are absurd amounts of money spent on the military that could be redirected to better community health services; but innumerable veterans (not to mention foreign and local civilians) are injured psychologically and physically annually in the absurd pursuit of 'global security'.
- Better end of life care. I think something around 40% of healthcare expenditure is on patients in the last 2 years of life. Patients and families would benefit from earlier access to hospice care and less aggressive therapies that only prolong suffering.
- A greater emphasis on preventative health and lifestyle choices (better diet, exercise and sleep regimes - ideally within the context of a long term health care provider relationship).
Its very typical of modernism (especially in the US) to think that the way to address everything is a nice app with a better UI. This also facilitates the corporate narrative of marketing the shiny new thing to throw money at (make money for the company) to solve everything whilst digging the hole even deeper (and letting society absorb the collateral damage).
EDIT* Thanks for the feedback, I have added some of the points made by others to the list above.
This probably also is the hardest part. And the most alien to the whole American model of which lobbying is an integral part. IMHO you can only counter lobbying by allocating more to fact checking so it would be harder for them lobby things which are objectively wrong.
We had such a congressional fact check organization. It was called the OTA (Office of Technology Assessment). Sadly it stood in the way of institutionalized lobbying (The K Street Project), so the Republicans eliminated it shortly after they came to power in congress in 1994.
It was on borrowed time anyway. The OTA was a threat to the fiefdom of literally every other agency. Their job was to butt in and ruin everyone's gravy trains of "not quite graft".
Imagine the OTA weighing in on the recent net neutrality shitshow. Wouldn't have made the FCC look to smart would it have? That same threat existed for every agency and congress and the executive. Literally everyone wanted them gone.
Why would fact checking have an influence on lobbying? Everyone knows what is going on. It isn't like the politicians, lobbyists, technical experts or public are in the dark about what is happening.
If anything, a fact checking organisation has incentives to align with or even become a lobby group. We've seen what happens to "fact checking" in the political sphere.
> Why would fact checking have an influence on lobbying?
Some would say, if a senator doesn't believe in climate change that's a question of fact, and if they merely received better advice they'd change their opinion.
A cynical person, on the other hand, would say they know full well that climate change is real but they've accepted money to pretend they believe otherwise. In that case, no amount of independent advice will change their minds, as it is not a question of facts but of money.
Not everyone. I will grant you that congress holds a low rating for Americans suggesting some level of understanding that they are being taken for a ride, but I genuinely think that if people in general population understood what is going on, there would be a lot more people taking action ( even if it is just taking it to FB and organizing a local page ). Sadly, I agree on the sentiment on 'fact checking'.
There's a really, really, really fine line to walk between preventing the AMA from lobbying congress to screw us and preventing actual grass roots people from paying someone to argue on their behalf.
Strongly disagree, that fine line will always be stretched beyond your definitions.
Besides, without lobbying groups working against you, the feedback loop of voting them out actually starts working. (no it's not a complete solution so please don't argue against that straw man, it's just the most important first step to unblock others)
> - Better end of life care. I think something around 40% of healthcare expenditure is on patients in the last 2 years of life. Patients and families would benefit from earlier access to hospice care and less aggressive therapies that only prolong suffering.
I feel like the choice has to be removed from families as our current system has proven that life will be extended regardless of quality simply due to the fact nobody wants to make a difficult choice. As the only quantitative item on the list and a very substantial one this should be ranked much higher in terms of priority (not sure if list was unordered or not).
Yes check the app while your limp unconscious body is shoved into the back of an ambulance. Type in appendectomy near me while you're writhing in pain in the passenger seat and decided, the hospital the next town over is a better deal
You use an absurd scenario, not sure why, but we both know there are tons of times you go to a medical provider where if you could pay less for a slightly longer car ride, you'd do it. But that information isn't even available now. The only fucking industry that is allowed to sell you stuff without telling you how much it will cost.
Who cares how much it costs if your health insurance cover it?
The reality is that healthcare is so expensive that it can bankrupt anyone who isn't a millionaire- which is why it needs to be mandatory and comprehensive.
Right now millions of Americans are basically committing fraud: they go to a doctor who has taken an oath to help you. The bill is not getting paid so the government has to step in anyway.
May as well make it official.
>Who cares how much it costs if your health insurance cover it?
At least under the current model, many people don't hit their deductible or max out of pocket. I know some older retired couples who are buying insurance on the market with 10k+ deductibles because they're generally in really good health, and the cost of insurance isn't absolutely insane with that level of deductible.
They would absolutely drive an hour rather than 5 minutes for non-emergency situations!
Exactly but why not blame the people who can't afford health insurance of committing fraud instead! After all if you're dying and have other choice than die or commit fraud, you're definitely a dirty fraudster!
So you're not qualified enough to fix what you don't know is wrong (is this pain in your leg a simple thing, is it an actual fracture you're just surviving on on pure adrenalin, is it microfractures that might take more to heal), but you think for some reason you (or an app) would be qualified enough to tell you how much you'd pay for "leg pain" ?
In my view, the fact that we don't know, is a major part of the problem. Our system is such an entangled web of business entities, that we probably have no idea where the money is coming from and going to. Everybody says that somebody else is gouging us, which means that they're all probably gouging us.
And they are all invested in each others bags. For instance I've read that doctors are major investors in health providers, are often the owners of the expensive equipment, and also heavily invested in the malpractice insurance industry.
Half of billing is multiple businesses billing one another.
It seems quite possible that what makes government health care more efficient is simply knowing where the money is going, if it's all coming out of one checkbook.
Predominantly (there's also general overall bureaucratic bloat with absurd numbers of administrators at all levels) .
It's certainly not the majority of healthcare workers.
Physicians are often scapegoated as responsible for healthcare costs when in reality physicians in Canada, New Zealand and Australia earn similar salaries without the massive cost blowout.
There can be instances where physicians are paid the same or more outside the US (I've heard family practice can pay better in Canada), but overall US physicians earn much more.
I guess it depends on your comparison - that article didn't include Australia, NZ or Canada.
Also if you factor in earnings and expenses over a lifetime (including cost of studying and the fact that many of the countries mentioned have free healthcare and education and far lower insurance requirements) it evens out substantially.
More importantly, even the highest physician salaries are orders of magnitude less than insurance company CEO salaries.
Disclosure: I'm a physician, currently practicing in the US, previously in New Zealand and the UK.
I’ve got several friends who specifically moved to the US from Canada because the pay was so much better. No doubt it varies by circumstance, but docs ive known in the US pay off their $500k in student debt pretty quickly if they specialize.
And sure insurance CEOs are paid more, but there are also a several magnitude more doctors than insurance CEOs. You could pay all the CEOs $1 and the cost of healthcare isn’t going to budget much.
doctors in Australia, NZ and the uk generally have only 30-50k in loans. And earn a living wage during their residency (in Australia can reach 6 figures within 1-2 years as opposed to flat 45k for 6 years in the US)
> First, according to multiple sources, doctors’ salaries account for only about 8% of U.S. healthcare costs. Even a 40% cut in these salaries, which the Kaiser Family Foundation concluded would result from reimbursing providers at current Medicare rates, would reduce healthcare spending by only about 3%.
I'm not trying to convince anyone. That was just a passing observation on my part because, as an MD, I have a very good idea of why healthcare is expensive. But I lost any hope of making anyone who's not working the clinics understand this
Indeed, I think the deal should be: You go to medical school for free, then you work for the government for a nice professional salary. Malpractice insurance can be a government function.
An interesting side effect might be to change the demographics of who can become a doctor, maybe attracting more people from middle class or blue collar backgrounds.
As opposed to working for the insurance industry? My knee jerk response is that incentivizing the best and brightest has gotten us to where we're at now. I've read that doctors are deluged in paperwork and bureaucracy, and incentivized to choose treatment options based on insurance coverage. I've had more than one doctor say to me: "The insurance says I can do X but not Y," and "your treatment ends when your coverage runs out." Of the several doctors among my friends, those who are not also professors or entrepreneurs have opted for part-time status, or have retired early.
Incentivizing the best and brightest in the software industry has gotten us to where we have to give new computer science graduates a coding exam, to find out if they can program.
It's worth noting the debt burden that different medical education systems place on physicians. Debt load and lost income are huge in the US medical education systems.
Many people that browse this forum will likely have lifetime income similar to that of a physician.
It's much higher than other countries. There's also a 7 to 10 year period of medical school and residency where you're making no wage or a poor wage. People tend to get fixated on the attending-level annual salary while ignoring that piece. That's 7 to 10 years where you're not really building any savings, retirement, or wealth.
My wife (a doctor) and I (a non-SV software engineering who's career has taken a backseat to hers) ran the math. On an hourly basis, she will likely never come out ahead of me. She just has too many unpaid and low-paid hours in med school and residency to overcome. In aggregate, she will likely out-earn me - but that break-even point will be in our 50's with her having worked many more hours than me. That's 30 years into our careers.
I'm curious, you seam to have a particular animosity towards physicians. (Or at least animosity towards the idea that physicians should be well reimbursed.)
Is there a particular reason for this?
In a world where people are making billions for photo-sharing apps and financial rent seeking, is it really that egregious for people that treat disease to do well financially?
I don't want to paint with too broad a brush, but in Poland, physicians are genuinely a separate, well-organized labor class. As such, and I have not followed it as closely for a while, during last 'reform' what I heard was lip-service about patient care followed by implementation so bad that people actually opt for a private insurance ( if they can afford it ). If they are scapegoated, it is because they are part of the equation. Luckily for them ( and pharma for that matter ), they are the only part that is actually necessary.
The app thing is very true and so ridiculous, I at one point contracted for a health insurance company (with a team of 10 people) for over a year working on an app that never saw the light of day.
It was essentially a calorie and exercise tracker that also displayed your health insurance info, absolutely nothing special compared to fitness apps already out there, but millions of dollars down the drain.
Not everyone agrees on what “better” means though. When you start putting dollars and days into formulae around dying, many people lose their damn minds…
The simplest changes we could make would be to ban the addition of sugar to certain mainstream food categories (drinks, bread, sauces), and also to require nutritional information to be listed as per 100g, not per serving size.
Follow that by banning burning of coal and oil, we also remove a significant amount of noise and air pollution.
Next we can ban any hormone-disrupting chemicals (including as plastic additives) from being used in anything that will ever touch human food or drink, or ground water.
Finally we can legaize euthanasia for anyone aged 70 or older and with a terminal health condition.
With these changes you have a human population much healthier and less reliant on expensive healthcare.
You missed maybe the most important thing: Allow cities for humans to be built. The American suburbia model is unhealthy on so many different levels. This only became apparent to me on my trips back stateside after living in Europe for a while.
So, folks under 70 get out of suffering, but someone dying in their 30's can't get euthanasia? This seems cruel, especially so given the number of folks that suffer and die before they reach 70.
And it shouldn't be for financial reasons. I fully support someone's right to death, but I do not support creating systems that might encourage it. I also don't realistically care if the health condition is terminal: I care more that folks are suffering and want death to escape it.
On the euthanasia point I would agree that this should be a legal option (but on a humanitarian rather than a financial basis).
We definitely need do do a better job with end of life care/terminal diseases - in practice this would look like earlier/more hospice/compassionate care, less needless end of life treatments and interventions).
There is a difference between being hungry and needing something sweet to satisfy a craving even though you're full. The later is called hedonic hunger and is (IIUC) very similar to addiction neurologically.
seems symptomatic that you would rather give away some really basic freedoms and be treated like cattle just to avoid making the healthcare system public
It is 100% obvious that amounts spent on the military in the U.S. today are insufficient and will have to go much, MUCH higher than they are today. Probably 5x higher - to the Cold War 10-12% levels - because of standoff with China and Russia at same time.
It will still not be enough to win over China, but at least enough to keep the free world in existence. Otherwise democracy will be just simply gone from the world altogether in one generation.
Continuing to head in the direction of militarism, will continue the disaster of a world that we live in, and almost certainly guarantee the end of mankind.
>>Here's some food for thought: The number of physicians in the United States grew 150 percent between 1975 and 2010, roughly in keeping with population growth, while the number of healthcare administrators increased 3,200 percent for the same time period.
*
>>Supporters say the growing number of administrators is needed to keep pace with the drastic changes in healthcare delivery during that timeframe, particularly change driven by technology and by ever-more-complex regulations. (To cite just a few industry-disrupting regulations, consider the Prospective Payment System of 1983 [1]; the Health Insurance Portability & Accountability Act of 1996 [2]; and the Health Information Technology for Economic and Clinical Act of 2009. [3])
In contrast, areas of medicine which are subject to much fewer subsidies and regulations, as a consequence of being electives, have seen prices actually decline in inflation adjusted terms. [4]
Regulations and subsidies do not seem to make other countries' systems inefficient. They make it so that folks are safe and that they can actually get health care.
I really want regulation in health care. I do not want medication to be a free-for-all like supplements are in the US. I'm not a doctor, after all, and they are slow to take supplements off the market even if they are harming or killing folks (take a look at diet pills to see this effect). I do not want average folks to be able to get antibiotics willy-nilly because I want to be able to take them when I'm old. And so on.
The big difference up to now has been that US hospitals have been run by a huge layer cake of administrators for a long time, while in other western countries healthcare workers have had much more direct control over how things are run.
This is changing fast though, and Europe is migrating to the US model at a rapid pace, with growing administrative layer and loss of control over prices. Interestingly, european politicians are also telling everyone that the problem is that docs earn too much and people tend to believe them.
I have so many issues with this: Europe is a big place and the countries do not exactly work in unison on these things. I only have experience in Norway - and that's only for the last 8 or 9 years. The prices have always been pretty standard - the doctors office doesn't set the rates, at least not in the public system (there is a private system, but the majority of doctors are in the public system). There hasn't been huge layers of administration, at least not in the way of the US - and this is, in part, because the insurances in the US create the layers of administrators. (Doctors offices do not need nearly as much staff for paperwork duties). For the end user, they've actually removed a layer - there were two types of deductibles that were merged into one (and is less than half the cost of the two combined)
And honestly, I find it very difficult to think that this is the administrative cake you were thinking. I also find it really difficult to think that Norway, Poland, Greece, Italy, Germany, and Britain are all taking the same steps and adding complexity.
Nope, that's just experience from daily life. I'm a doc in a public hospital in Switzerland, and also worked in the US.
Europe is still a bit behind in terms of admin, but getting there. And yes, american influence is felt all over Europe, with varying degrees of implementation among countries, as you noted.
I can understand that outsiders don't believe what we have to say when political propanganda is so strong. But for us insiders, it's really crystal clear what is happening. It used to be that problems arising in clinical management was solved by asking frontline workers what they needed. Healthcare workers had a lot of control over their working environment. Nowadays, admins are taking all decisions from above. European hospitals are now in competition with the private sector due to changes in the billing and insurance system coming from the US. As a result, european hospitals are now managed much more like your usual run-of-the-mill company than they used to. This is a terrible result for anyone but upper management.
>>Regulations and subsidies do not seem to make other countries' systems inefficient.
Other countries' healthcare systems are growing increasingly more inefficient as well, with the proportion of GDP expended on healthcare rapidly rising, with many seeing it double over the last 40 years. [1]
And they face critical shortages, like this case of a woman in Canada who had to wait two years to get a test that diagnosed her with cancer, because of a shortage of state-licensed doctors:
>>I really want regulation in health care. I do not want medication to be a free-for-all like supplements are in the US.
I think the best of both worlds would be most regulations being opt-in, while disclosure regulations are mandatory.
More specifically, I think healthcare would benefit from legalizing the provision of medical service by un-certified individuals, as well as providing more than one tier of certification, where people who can't afford fully certified practitioners, but would like the assurance of some certification, have that option.
Instead of making it illegal for individuals who don't possess full certification to practice medicine, the law could instead require medical practitioners to disclose their level of certification, and any warnings the state provides in relation to that.
So for example, an uncertified doctor/nurse may be required to disclose not only that they are uncertified, but also the warning that the state strongly advises against using uncertified medical practitioners.
Why providing these options is critically important is that sometimes the prescribed institutions fail, and an escape hatch is a life saver, as in the case of a woman in Canada mentioned above.
>>I do not want average folks to be able to get antibiotics willy-nilly because I want to be able to take them when I'm old.
If the negative externalities of irresponsible antibiotic use is your concern, maybe you could advocate specifically regulations on antibiotic use.
When you advocate wholesale centralized gatekeeping of all manner of healthcare interaction, you deny people a way to escape failures of over-regulation, like regulations that prevent people from accessing life-saving medical products/services in a timely manner [2][3] or deny people access to a vaccine due to a risk from side effects that is orders of magnitude lower than the risk the vaccine mitigates. [4]
> Other countries healthcare systems are growing increasingly more inefficient as well, with the proportion of GDP expended on healthcare rapidly rising, with many seeing it double over the last 40 years.
There are two (mostly) unrelated issues: the efficiency of the healthcare system and increasing availability of effective but expensive treatments.
I believe we have already reached the point where even 100% of GDP is insufficient for healthcare. There is always something more you can do, something better you can try. No matter how much money you choose to spend, somebody must eventually make the decision to withhold better care because the economy is not big enough.
There is in fact a correlation between per capita GDP, and the proportion of GDP expended on healthcare, so you may be correct. It's worth noting that the US has much higher per capita GDP than most OECD countries.
In any case, the price inflation seen in highly regulated vs lightly unregulated markets is, to me, telling:
This seems more like a symptom of the wildly broken American health-care system than anything else.
In countries with a more functioning healthcare system, disruption of the status quo (especially by VC-funded private companies seeking a large payday) is neither necessary or desirable, slow iterative improvements are the name of the game.
Furthermore, the US spends far more per capita than every other country on healthcare, and receives worse healthcare outcomes as a result [1], [2]. If you think that the solution is throwing more VC money at the problem, well, I have a bridge to sell you.
Sadly for Americans, the obvious solution that most (~70%) Americans apparently want (Medicare for all) seems very unlikely to happen anytime soon.
To add to this, the absurdity of the 'healthcare' system in the US is made even more apparent as a non-US citizen buying health insurance for (long-term) international travel.
Firstly (loosely regulated) insurance is an absolutely stupid way to provide healthcare. Pre-existing conditions? Maybe you just don't deserve to live, either way we're witholding life-saving care from you because our tables say so. Need to claim near the start of your cover? You must be lying about pre-existing conditions. Need to fix something that wasn't acute enough to seek care about previously? Nope, no cover for you. And on and on and on. Anyone who thinks an insurance market is a solution for healthcare is just an idiot, there's no way around that. (I realise some universal systems run on a private insurance basis but they're a lot more regulated)
But then, even in that entirely messed up system, designed to cut you off from urgently needed medical care, all policies are divided into 'regions'. There's not much cost difference between regions until you get to any region "including the US". It's even named, the only country in the world they do that for. That's how badly those guys have messed up their healthcare system. And if you select that? It's at least double the cost, for no extra cover in terms of policy limits.
That for me clarified that, no, I wasn't missing anything. Anyone who supports the current US system is so far removed from the commonly inhabited reality that none of their opinions are worth listening to.
Yep. This is like writing an article about the increasing prevalence of gas generators and storage batteries, and saying that "electricity generation is turning into a consumer product". Really the centralized providers are failing with no hope in sight, so people are opting for distributed means to take care of their needs. If you tell someone they can pay a well-defined price for a device that might help them, or they can spend hours on the phone to make an appointment three months out that will result in indeterminate bills and likely further cycles through the bureaucracy, obviously they'll prefer the straightforward option!
I don't know how any American can accept the pile of trash that the US healthcare is. The only good thing is that in some cases you will get state of the art care, this is "rare" and may not result in better outcomes.
1. The cost is insane. It doesn't matter how much money you have, if you stay long term in a hospital your bill will be insane and more than an average cost of a house.
2. Single ER visit? 10 different bills over the next few months. Apparently, there is a new law trying to tackle this but hospital can opt-out by having you sign paperwork.
3. If you have an illness and need to see many doctors and have many tests in a short period of time get ready for your insurance to fight you and deny claims. You will be calling them all the time.
4. There are now 3rd party businesses set up to "VERIFY" no other party is responsible for the care you received(meaning you did not have an accident). If you fail to respond to their letters, your claim will be denied.
5. MRI, X-rays, dental work, physician visits are SO MUCH more than other developed nations. It is a joke. I'm talking without insurance here, just going to a private clinic and paying out of pocket as these also exist in Poland even though it has socialized healthcare.
6. The insurance prices are out of control, and the insurance company don't give a shit. In fact, they welcome the high prices. Obamacare capped insurance companies profit margins at a percentage of money spent, this is the result. The more they pay out, the more they make. The cost falls on the policy holders.
7. Covid is really showing cracks in for-profit healthcare. I have friends who work in the field and are complaining about people coming in with positive covid tests because they are asymptomatic. If they don't want to come in they risk getting fired, and in some areas large hospital networks own many smaller clinics and being fired may result in not being able to find a job without relocating.
The problem from my point of view is conflating ongoing healthcare with catastrophic coverage. Outpatient care should absolutely be a free market (prescriptions, lab tests, specialist visits etc.). Catastrophic incidents/diagnoses should be a simple lump sum payout (Cancer, Hear Attack, Stroke, etc.).
Alternative options I've seen being offered for ongoing healthcare is Direct Primary Care where essentially you pay a membership fee to have unlimited access to a primary care physician.
I think the root of the problem is subsidization and the patch work of legislation that gets piled on year after year to "fix" the issue. The entire price function is completely out of wack and as long as the patient is stuck between the provider, insurance carrier, and government debating who has to pay, they will lose.
Your average American doesn’t have the pull to effect change. The majority of Americans support government taking a greater role in healthcare (per Pew Research), but Congressional reps won’t vote for it, so you have to wait for people to age out for change. In the interim, everyone overpays and suffers.
Pfizer was BioNTech, developed in Germany. They might have also had Astrazeneca (UK) or any number of vaccines developed in tandem globally. Also, worth pointing out that healthcare is a separate and distinct industry from pharma. Co-dependent but dealt with under very different rules globally.
Yeah we live in a globalized world, corporations are global entities and companies from other countries made meaningful contribution. They still were predominately developed, tested, manufactured and distributed by US companies... thats why BioNTech had less than a billion of revenue last year to Pfizer's 7.5B Operating Income. You wouldn't have it at this scale without the so-called 'trash' US healthcare system.
> Do you think universal healthcare would affect pharmaceuticals?
Yes, I would think a massive fundamental change in the healthcare system would have an effect on Pharma. But who knows what that would look like
> I think it would not be relevant to the vaccines as we would still spend money on R&D under the pandemic threat.
They would spend money, but it's not hard to envision a world where we didn't have multiple fully tested, safe & effective vaccines in less than a year.
Rather it would be more relevant in the case of vaccines, becaase the reason we didn't have them was not because we didn't have the science, but because drug companies didn't see them as profitable.
A better hybrid public/private system would be for the government to put out bounties for companies to run large studies on research that looks promising, to determine effectiveness and optimize formulations. In return for paying for the research, government would get the patents. Paying for drug development with a patent reward only encourages deceit and high prices.
Dean Baker has explored this extensively, and is posting steadily about it recently:
The basic idea of government-funded research should not be hard to grasp since the government already funds a large share of biomedical research. The National Institutes of Health gets over $40 billion a year in federal funding, with the Biomedical Advanced Research and Development Agency (BARDA) and other government agencies getting several billion more. This puts the government’s total spending in the $45 to $50 billion range, compared to a bit over $90 billion from the industry. So the idea that the government would fund research really should not be that strange.
Most of the public funding does go to more basic research, but there are plenty of instances where the government has actually funded the development of new drugs and also done clinical testing. But under the current system, most of the later stage funding does come from the industry and is funded through patent monopoly pricing. Relying on open-source government-funded research for later-stage development and testing would be a major change.
To my view, the best way for the government to support the development of new drugs is through long-term contracts (10-12 years), which would be awarded through competitive bids for research in specific areas, like cancer or heart disease. The plan would be that the contracts would be relatively large, with the idea that the winners would be comparable to prime contractors for the military.
The current healthcare system in the US is just as bad for service providers as it is for service recipients, maybe even worse.
My girlfriend has worked with children with special needs for around 20 years, mostly children with autism. A few years ago, the field began migrating from almost entirely state-funded to funding from private insurance (California, not sure about other states). The problems with private insurance funding began almost immediately and couldn't be clearer. Under the state-funded program that existed for decades, her company met monthly with the state funding agency, discussed individual cases, and got funded. Easy, efficient. With private insurance, well, the best way to describe it is that her small company had to hire a full-time person just to manage the billing/funding with the insurance companies. And this is not a do-nothing position. This position is responsible for much of the company's revenue, which is inherently important. Also, understanding all the different processes/procedures/BS of each insurance company is highly skilled. That might sound ridiculous, but it's totally true. I hear the stories about fighting with insurance companies, trying to get paid for services rendered months prior. Quick example: one private insurance company (a big one, you've heard of them) only accepts payment requests via fax. Yes, fax. But it gets better. The fax line is only "active" during regular business hours, and the line is almost always busy, because as you might expect, other companies are trying to get paid, too.
At least in my mind, "consumer product" quite clearly implies that the price is advertised, or at least easily found. And it does not change during the transaction.
Which is definitely not the case in American health care - unless you have "For the Top 1%" health insurance, or are buying at the bottom end (a bottle of aspirin, maybe an eye exam or dental cleaning).
I really believe in this general category. Giving people healthcare that isn't a shitty experience will change the world.
I'm not confident a typical telehealth-style consultation with one of these direct-to-consumer companies is that great, but by the same token, I am confident the medical care I get in a traditional setting is mediocre. For example, the time an MD tried to convince me I couldn't be feeling pain... after I told him I was specifically there for pain.
The US has a strange relationship with healthcare. and by that I don't mean professionals in white coats, I mean people taking care of their health in general, of which visits to white coated professionals is only a small part.
People seem to have this attitude they can spend money (or have someone else spend money) instead of taking care of themselves. Take a pill instead. Some think every little thing is an emergency or are otherwise unreasonably terrified (Recent Covid scare comes to mind. A very real and serious disease but some people inaccurately assess their risk and become neurotic). Unfortunately it doesn't work like buying a new car.
Many years back I dated a girl who was a physical therapist. She loved going to the doctor and hospital. When she felt slightly sad she would get "sick" and go get some attention which she paid through the nose for. I'm exactly the opposite and likely to Steve Jobs myself to death in the end.
I've read (don't know how true it is) that Americans take something like 60% of the worlds prescription drugs.
The whole thing is completely unbalanced and I don't believe other areas of the world are like this. Because of this I don't see an easy solution for the US. The government taking over health care is likely to result in deep dissatisfaction but the current system is super wasteful and frankly just bonkers.
The thing people don't want to understand for some reason is reality. Sometimes we feel bad. Sometimes we get sick. Eventually we will die. Sometimes medical professionals can help. Very often they cannot but that won't prevent them from billing you large sums of money. Also it's not rare for professionals to worsen the situation. Incentives are not always aligned and the body is a very complex system. Throw the US mid level manager hospital pharma insurance scam complex in the mix and incentives misalign even further.
The best dentist I've ever been to was in Mexico. Light years ahead of what I'd experienced in the US without the ceremony. The best doctor I've ever been to is an old time country veterinarian in his 60's. But that was for my dogs. Real practical sense a and humility with an eye to results and the understanding of uncertainty involved. I've always thought that's who I would like to treat me in the event of serious illness and practically speaking there little no reason he couldn't in most cases because I'm not very different then my dogs physically. In neither case was the hospital-pharma-insurance scam complex involved. That groups has made things immensely worse and killed large numbers of people.
Don't get me started on psych drug overuse in the US.
Healthcare in the Netherlands or Switzerland is not free and neither of them have the social disruption and problems you find in the US.
There is no point in making broad generalizations, it is a complex issue were you have a multi-decade and multi-billion dollar business tightly coupled with the healthcare of millions of people.
The cost of healthcare in the Netherlands is however extremely affordable, which I think is the most important difference between Europe and the US.
In NL, you pay ~€110/month annually, with a max out-of-pocket cost of €385 per year. So, maximum €1600 cost annually.
People with a low income, students, etc, get approximately the same amount of money as a cash benefit to cover these costs.
I'm not saying this is good, it isn't, healthcare costs should be covered by general taxation like in the UK. But it's not very expensive.
(It also seems pretty stupid in the Netherlands, because you have to pay an insurer for your health insurance, but they all charge pretty much the same, since it's highly regulated, and then out of pocket costs are capped. Seems much simpler to eliminate the insurance companies and let the state administer costs and pocket the profit that the insurance companies are extracting)
>In NL, you pay ~€110/month annually, with a max out-of-pocket cost of €385 per year. So, maximum €1600 cost annually.
My provider, CZ, charges ~€150/month with max-out-of-pocket ~€385. If you get the full ~€850 out of pocket then your monthly payment drops to ~€110/month.
I would guess that you are also including "anvullende verzekeringen", additional cover for e.g. dental/glasses/physiotherapy etc in your premium, because if you check a price-comparison site [1], then the majority of insurance policies are in the €110 - €120 range.
The extra insurance (dental/glasses etc) is also a bit of a scam, because the amount covered is often less than or just equal to the premiums that you pay in a given year, and you'd need to also be buying a new pair of glasses every year, always visiting the dentist, and so on. It's probably more economical to simply pay these costs out of pocket.
There is a similar system in Germany. As someone who is from the UK and now living in Germany, I would say the health system is 5x better in Germany, so the highly regulated but private insurance and healthcare system seems to do a lot for improving things.
Worth noting that Germany also spends more on healthcare than the UK does: $6,646 per capita vs $4,653 per capita in 2019 [0]. That's quite a significant difference.
As someone also from the UK and now living in NL, I would say that the health system is definitely better in NL, seems like higher quality of care and somewhat smaller waiting times, but definitely not 5x better, maybe 1.3x.
When I was living in NL with no income, after subsidy the cost was around 10 euros.
The arrangement was indeed strange though with the government paying me to pay the insurance company and then for the employed there was then a further health care tax amount.
> the government paying me to pay the insurance company
it gives you the direct control over which insurer to buy, thus encouraging market competition.
If the gov't controlled which insurer got paid instead, there'd be a lot more lobbying and "corruption" and backroom deals which would not benefit the citizenry.
> Everyone else must pay an annual deductible equivalent to an average of 2,040 NOK (222 USD). After paying this, one receives an exemption card which entitles them to free healthcare for the rest of the year.
It isn't free, it's paid by people's taxes AKA redistribution of wealth, a % of the salary and mandatory health insurances. Private hospitals also do exist. Nothing is for free.
In Norway a lot of it is paid for by oil. Once the world transitions to clean energy Norwegians will be in for a wake up call. In their defense they are trying to diversify but it's not an easy task
What I want is going to the doctor to be more personal, more like it was in the 90s.
Right now I go to the doctor, and they stare at the computer and take notes for 20 minutes before they can even actually look at me or look at at why I came in.
Just dot the room with mics and record our conversations or something if you need it logged.
In America this has always been the case. Anything that's not 100% your literally going to drop dead without it, isn't covered by insurance.
Therapy is essentially a luxury good, around here none take insurance so if you don't have 1200 to 1600$ a month sucks to be you. It's comical, say your spending is out if control, unless your excess spending exceeds 1200$ a month your better off with a "Stupid" line item in your budget.
As long as your spending less than 1200$ in the stupid category, your coming out ahead.
In this space we've seen tons of quasi legal startups trying to capitalize. Who cares if these therapists are licensed to operate in the same state as their clients, we got money to make and vC funding to raise.
Healthcare is consumer product. That is not the issue. The issues are:
- information asymmetry & credence good
- negative selection
- lack of standards
- lack of oversight
Which is an anti-pattern. Healthcare is not a product with supply and demand dynamics of, say, cars. Capitalism does not help with its delivery. Biotech, equipment manufacturing, yes, but not delivery.
"I am just not going to get sick" is not a strategy. No one can control the inherent risk of life. Slipped, swiped by a car, and since we are talking about the United States, let's just go there - caught in a crossfire.
According to you. I happen to live in a single payer, free healthcare system (Spain), and the claims about “how nice it is” are pure BS.
All of my family has medical insurance, even when we could ill afford to pay extra.
- I almost lost my brother on the public health system (they sent him home with some antibiotics, instead we took him to a private hospital were he got surgery that same day, he had internal necrotic tissue).
- My mother needed a mammogram, the doctor suspected cancer. the appointment they gave her was in two years. We went private again, she ended her radio + chemo before the diagnostic appointment of the public sector.
In the meantime, my effective tax rate is over 70%.
I’ve had to visit a hospital in the US (San Francisco) for a recurring issue. It was way better than anything in my area.
With the amount of lobbying, financial contributions to campaign funds, oligopoly, the market isn't free.
This is also one of the market where you have to pay. You can choose to not go to vacations or not to buy an apartment (even if you live horribly); you cannot just not have an appendix operation or not fix your ankle if it is broken.
But wouldn’t a single “good” provider quickly undermind the business of the existing ones? Or is the entire thing rigged in favour of the current healthcare providers?
That was kinda my point. I can see why you’d do health like the US does, but I fail to understand why it doesn’t work in the US. In theory it could be much cheaper, but is the US seriously so corrupt that it underminds the free market that is values so highly.
It’s pretty simple why it doesn’t work. For most people somebody else (usually the employer) chooses a health plan for them. The employer chooses the health plan that’s convenient for them, not for the employee. The patient has no visibility into the contracts between providers and insurance. The patient has (almost) no insight into actual pricing. So basically we are pretending that this is a market but the patient has no say in any of the choices made for them.
It’s a market for employers, insurances and hospitals. All of them have vastly different interests from the patient and are passing on their costs to the patient . The patient is left with having to pay for somebody else’s decisions.
Another point is that US healthcare is considered the most expensive and worst-performing in terms of outcomes compared to the other developed countries.
So you basically get the worst performing being also the most expensive. Which doesn't really fit the view that less government involvement results in a more efficient system. Well, I guess it is more efficient if the expected outcome is a larger profit for different private companies and middlemen and not the well-being of the rest of the population.
My hope is that this new-found energy in healthcare products doesn't follow the traditional VC-backed approach of building a product, taking over markets through aggressive marketing and shady closed-door dealings and operating at a loss only to then monetize the shit out of everything.
Theranos really embodied some of these fears, and I'm not sure we'll live in a better world if our health will be in the hands of people that have a financial incentive to tell us we're more sick/healthy than we really are.