I don't understand the American (and it is American) obsession with having a free market in healthcare.

Why do Americans not look at public provision, paid for via your tax system? Canada does it, so it demonstrably does work in North America, Europe does it, with varying degrees of efficiency, but it basically works.

No-one in Europe or Canada lives "in fear having an accident or getting sick" because they know healthcare is provided by the state in the same way as education, fire services and police service are all provided as a public service, for the general good of society, via taxation.

Americans are happy to send their children to school, to be able to call the fire department or the police (we'll set aside the clear problems of US policing - you generally still call the police when you see a bank robbery, so there is a degree of confidence in them still).

So why is healthcare the exception? What sort of mentality says I am to blame for getting sick and told if I cannot afford medical treatment, I should not have become ill?

The question here is not what system to create in a vacuum, but the road in the middle. I live surrounded by a whole lot of ultra-expensive, luxurious hospitals, staffed by extremely well paid professionals (and not so well paid residents), which, in many cases, have six figures worth of debt for the privilege. To move to a public system, all of those things would have to change: Those luxurious, privately owned hospitals are never going to give great prices to a single payer system. The doctors are not going to be happy with lower wages. Medical schools would have to change drastically, so they can actually provide a number of doctors that resembles the rest of the western world. This level of disruption is what makes major changes like that in a system that employs so many people unpopular: It's a bit like how the US military can't take big cuts, as they are political suicide.

So overall, the change would be huge, and would be hard to make slowly. Therefore, I'd much rather solve it in the US through markets. Once the system has a whole lot less rent seeking behaviors, and the incentives are better aligned, a public option would actually be easier than from the catastrophe we live on now, where prices are secret, and yet, a hospitalization will often involve 10 to 20% coinsurance.

There are some problems which exist in America which don't exist in other countries.

Take for instance, when the rest of the world talks about how they ban guns and therefore they have no gun crimes, giving that advice to America is like if Chinese people were giving advice to Australia that they banned Kangaroos, and now they don't have a Kangaroo problem, so why can't Australia do the same?

America will not have universal healthcare like all these other countries for many reasons, which are very American in nature:

* Americans won't accept the huge tax rates which will follow it, calculations show that there would be a 20% tax increase across all income groups to fund it.

* Universal Healthcare would be the single biggest issue on which Democrats and Republicans will fight, win/lose elections, on whether to cut its funding, whether to expand it.

* America is ethnographically different than other countries. Currently our biggest 'universal' service is Courts and Police. Add Healthcare to it, and next thing we know there is an added accusation of systematic racism against certain minorities.

I think it's mostly not going to work here because a lot of people will have to take paycuts (not just doctors / nurses but "administrators" "billing co-ordinators" drug companies and drug resellers, etc etc ...) always follow the $$$

Doctors everywhere else are public servants. They do their jobs because the love it, because it's their calling and because they still get paid very, very well. Canada pays their doctors $232,000 to $676,000 gross (speciality averages, low to high).

Then because malpractice insurance is also socialized (Canadian Medical Protective Association), their costs are significantly lower too. OB/GYNs usually pay the most, and in Manhattan their annual malpractice insurance premium is $125,000. $176,000 in Long Island. [1] The highest in Canada is Ontario, at $44,000 CAD ($34,000 USD).

[1] https://www.excellusbcbs.com/wps/wcm/connect/b7cdbf66-dd6b-4...

[2] http://www.amednews.com/article/20100503/profession/30503993...

Procedures under the public system are scheduled by urgency, so for example you might have a 9 month wait for a torn ACL surgery. That's why most will carry private insurance. Private cover starts around $70 a month so it's much more affordable than US insurance and importantly much simpler to navigate.

It is "free" in the propaganda domain. That it is sold to the voters as "free, therefore efficient and better than government controlled"

Frankly, it's one of the larger reasons why I don't want to be in business for myself. As a consumer? At least outside of healthcare, most of the prices are set, more or less, the way commodities are. There are laws saying that when I get to the cash register, I'm entitled to the lowest marked price in the store. Hell, even with things like cars, which are notorious for ripping off consumers, you are paying at most like 20% more than your neighbor. If you are buying, say, bandwidth, or nearly anything else sold to businesses? It is completely normal for the initial quote to be 200%-400% more than what you end up paying after negotiation.

Now, how much does this have to do with it being a business, and thus having the expectation that you have professionals on hand to do the money-dance, and how much of this is that there's a lot less regulation in the business sphere than in the consumer space? I don't know. I don't think it has as much to do with the cost of the goods involved as you think; I think the biggest contract I signed was around a third of a million bucks for a five year lease; Well under twice what someone doing what I do, only as a worker would pay for rent in my area. Most of my contracts were in 'mid-priced car' range, and still there was a tremendous difference between initial quote, and what I was actually expected to pay.

But what this article indirectly points out, is the sheer, utter incompetency of US health care providers.

The whole justification for a private system is supposed to be greater efficiency. In many markets, for whatever reason, this seems to work. Goods became cheaper and better due to competition, the invisible hand, etc. etc.

"My cousin was triaged immediately. Within two minutes a nurse checked her ankle, gave her codeine, and then sent her off to an urgent care clinic. She wasn’t even registered in the ER."

"The urgent care clinic had a few people ahead of us. It took about 10 minutes to check in and then no more than 15 minutes to be seen. A lovely nurse named Leslie triaged my cousin and agreed an x-ray was in order and made the arrangements. My cousin did not need to see a doctor or a nurse practitioner to get an x-ray. I’m not sure I’ve ever seen that happen in the U.S."

"The nursing triage was wonderful and actually doing nursing (I hate seeing nurses relegated to charting)."

In our wonderful US free market system, we have very highly trained professionals spending staggering amounts of their time on bureaucratic paper work and busy work, while the NHS just skips straight to treating patients efficiently and professionally.

With a system this bad, people at every level of the health care industry should be getting fired every day for their gross incompetency. From the insurance companies to the health care executives to the health care professionals, they simply suck at their jobs and need to be held accountable.

If a public system can deliver the benefits in reality that a private system is supposed to deliver in theory, let's go with the public system.

Which is very near the top of my list with annoyances with the Republican party, by the way. They are so obsessed with the theory and ideal of private market capitalism, they don't care to observe whether their theory matches up with reality.

I've had a few internet discussions with this particular doctor before and what I've learned is that she's used to things in California because what she describes above is definitely something that I've seen and experienced in the US. Kid fell off bike. We went to ER. Doc & tech met us in triage. Went right back to x-ray. We were in and out of the ER with imaging taken care of in less than 90 minutes.

Also, being punted to urgent care isn't always a good thing. This is how Kaiser missed a damaged disc in my lower spine. They had a habit of turfing me to urgent care and brushing it off as sciatica. It was when I moved to Texas that a Baylor ER did an MRI, revealing the true source of the problem, and was shocked that in all the years before, nobody had ever done that.

Health care systems aren't identical in every state, as I've found out the hard way.

"The nursing triage was wonderful and actually doing nursing" This might be another reason things are so expensive. Not every single aspect of emergency department care needs a full blown RN to take care of it. But when attempts by other levels of provider (LVN, LPN, EMT-Paramedic) are made, nursing unions come in like a hawk and lobby to crush whatever efforts are being made. It's frustrating to see happen.

It cuts both ways. I do not begrudge nurses their income, they sure as hell earn it for the most part. Put an investment banker in a nurse's job at County and see how long they last, then tell me it costs too much.

Texas recently made some legislative changes that will allow facilities to utilize paramedic level providers to their full scope in an emergency room setting, though. that's a huge plus.

It's been a pretty good system.

NHS clinicians have brutal amounts of paperwork. That tends to be done out of sight of patients, but it's there.

Some things are helping: digital dictation; "mobile working" (community staff being able to do electronic paperwork on laptops in the car between appointments).

I think part of it is the culture of believing you can be anything you want to be. It's the same reason the poor often vote against their interests in the US - they believe that soon they'll be rich and want low taxes and few regulations. That they are the exception.

Or then again, maybe they just have a different opinion than you on what is important to them?

There is a minority of people who are actually completely out of touch with reality, so-called demagogues and populists, and to a less extent all politians: they are completely deluded in thinking that by repeating a point a thousand times they can mislead those perfectly informed masses.

As the saying goes: "Fool me once, shame on you. Fool me twice, shame on me." A large part of the American populace has been getting fooled repeatedly for decades.

It has not been established that they are voting against their own self-interests. You are just assuming you know what their interests are better than they do.

Wow, into being condescending much? How about this... maybe, just maybe those people know what "their interests" are better than you or I. Have you considered that?

Many are hunters, or serve(d) or have family in the armed forces, or just grew up around guns. They remember, before the big-box stores came along, when the town hardware and general stores sold shotguns, rifles, and ammo. They see the liberals in SF Chicago and NYC wanting to stop their multi-generationally deep and rich tradition in hunting and defending and baring arms. If there is one rail that should never be touched, one single-issue that will move that type of voter, it is preserving the 2nd amendment. I mean, sure, you don't have to worship it and Hillary won't have to sit there holding an AKM-74 with 100-round drum mag to pander for votes, but just don't go after it with such vigor and I can bet dollars to donuts that you can win over at least 40% of the voters 1 hour outside the Triangle.

They vote republican not for their non-existent tax breaks or wait in bated breath for their drip of the trickle-down. They're savvy enough that that junk has been tried all over the country and has mostly failed (in the case of Kansas, utterly and miserably with negative job growth). They just don't want you to mess with their traditions.

I mean, these folks don't even care to fight over marriage equality, either. You don't see much gay-bashing in these areas. They simply don't care. Ditto abortion. Sure, there are ardent bible-thumpers, but on the whole, they are nuanced enough to know that we don't want a nation filled with unwanted children.

So, really, don't mess with THEIR rights (guns), and they won't vote against their own interests. I can't get why a lot of democrats (both politicians and voters) can't see that. I _know_ that democrats and liberals are about as far from single-issue voters as you can get, so they'll be kinda-sorta bummed that guns aren't the big focus for legislation, but it would certainly NOT be the end of the world.

Someone's said that it's because one day they think they'll be rich, and suggested that this was foolish. An alternative explanation is that they're voting for it because they've considered the question very carefully and are voting for what they think is morally the right thing, even though it'll harm them. In which case it's far from foolish.

I think the offence was taken in assuming the foolish explanation instead considering the one where people were making a sacrifice to do what they think is the right thing.

We don't know unless we ask them, of course.

This whole mindset of "you're too stupid to know what's good for you, so just let us smart people be in control and make things OK" is something that is very condescending and is repugnant to many (most?) Americans. Which is one good reason it's hard for politicians pushing such policies to gain ground. It might be better to actually, you know, talk to those people and try to understand what their principles, goals, and motivations are, instead of assuming that they're stupid.

I have considered that notion for a long time, but ultimately dismissed it as pure nonsense. The fact of the matter is that people can be tricked and be taken advantage of. It is not condescending to point that out when it happens.

If someone gets conned into transferring all the money in their bank account to a stranger in Nigeria on the belief that it will "free up" millions that will be theirs, you cannot possibly make the argument that pointing out they got conned is condescending, that maybe that person knew what was actually in their best interest. They thought they knew, but they were, frankly, wrong.

The exact same thing happens with many poor people in our society: they get conned into voting for politicians who will absolutely screw them over. Furthermore, it doesn't happen once or twice. It happens repeatedly. And again, pointing this out is not condescending. It's just the truth.

Alright, glad we have you here to save all the stupid poor people from themselves. After all, if someone is poor, they must be stupid. Or lazy. Or both. FSM knows, they need some philosopher-kings to come along and show them the light.

I think part of it is the culture of believing you can be anything you want to be. It's the same reason the poor often vote against their interests in the US - they believe that soon they'll be rich and want low taxes and few regulations. That they are the exception.

Implied in every single sentence of this paragraph is and underlying sentiment of: "this is a false belief and they are stupid for holding it."

And ALL of that aside, nobody has really responded to my question of "why assume these people are wrong?" Except that camel guy who basically said "no, they're stupid so there is no reason to consider that."

So we're back where we started. I say that poor people who vote for lower taxes and the like, may actually be making a perfectly rational decision. It may not be a optimal decision if you only take financial outcomes into consideration but it may still be rational... because the people making the decision may not be basing it on financial considerations to exclusion.

Without going into the politics, size and population/density are two major differences:

- Canada has about 10% of the population of the US with much of it clustered around a handful of major cities so the vast majority of citizens can be covered by having good systems in a handful of places.

- Compared to Europe, the difference is even more striking. Just considering Texas: it is roughly the size of France but with half the population despite having 3 of the top 10 biggest US cities. And that's still not even 10% of the US population.

Whatever approach is tried in the US needs to take these differences into account.

Texas might be "roughly the size of France" but a huge chunk of that is uninhabited desert.

Yes, in France you might be 1h/2h by car from a hospital depending on what you need

You have a tiered system: 1st level is "everyday stuff", 2nd level is regional centers (so you get routine surgeries and more complex stuff), and at the 3rd level you got your excellence centers for specialized stuff (think transplants, major surgeries, etc)

In the US case yes, you might want to have a 3rd level center per state (might not be exaustive)

I guess I could see having one tertiary center to serve say VT and NH but if memory serves even they have one apiece.

A majority of Medicare coverage is provided through private companies (100% for the drug benefit). Last I saw 80%+ of Medicaid patients are covered by a private plan.

What are the benfits? The private companies take on the risk. If the lump sum the gov't gives them isn't enough to cover costs, tough, the company takes a loss. Gov't loves it as it makes budgeting easy.

The other benefit is choice. A patient can select from a multitude of plans that benefit them the most. Want a top doctor? Pick a plan where his/her hospital is in network. Have a chronic disease where you take a lot of meds chronically? Pick a plan with better drug benefits.

Medicare Part D - the drug benefit created in 2005 that is entirely private - came in dramatically under cost forecasts.

Yeah, Original Medicare is pretty awful - I wouldn't recommend it to anyone who's able to get a Medicare Advantage plan. It's not just the cost-of-care and the overall expense to the patient (even though Medicare Advantage tends to win out on both of those aspects as well). It's that Original Medicare is a horribly frustrating experience for the patient as well.

Of course, most people (especially most people under the age of 65) don't understand the difference, and when they think about Medicare, they think of a publicly-run program, even though around 40% of the Medicare population is on a Medicare Advantage plan.

Because raising taxes is bad, obviously one day you'll be big and don't want to pay health care for all the people down there. And of course it's a slippery slope. Today it's health care, tomorrow it's minimum wage and the day after you find yourself in a Gulag /s

Just look at how hard republican states tried to push against Medicaid.

This article presents a good argument for why Single Payer won't work well in the US: https://www.bloomberg.com/view/articles/2014-04-30/single-pa...

> Americans are happy to send their children to school

Americans are, on average not happy to send their children to public schools

One of the reasons why Americans are so vehemently against Universal Healthcare because once you go there, you don't easily get to come back.

Once govt starts to provide a certain service, it kills the private sector market for that. Then no matter how terrible govt service is, there isn't much which can be done about it.

When you have a distressingly high chance of getting a terrible system, you wind up somewhat skeptical of people who want to tear down what's already in place and do public provisioning. Good and pure intentions are not an adequate substitute for competence.

The fear is that a system that works for some will be replaced by system that everyone can access but works for nobody.

Note the Bernie phenomenon in the current election. He pulled the entire Democratic party to the left, including public provision of health care. Also note, if current polls are a good indicator, Trump and the Republicans could be headed towards an historic drubbing on election day.

And Bernie drew overwhelming support from young people.

So I think that politically, the US may very well be moving towards supporting public health care.

Socialism really doesn't work here as well when 'other' people are getting more benefits than you. I'm sure part of it xenophobic, but part of it is actually legitimate.

For example, a bad accident left my credit ruined in my early 20s due to medical bills. I do remember, several times, waiting in agonizing pain in an emergency room full of people who could not even speak English. Essentially, the reason my bills were so high was because the hospital was allowed to recoup the nonpayers' bills by upping mine.

It would cost the average taxpaying couple tens of thousands of dollars to have a child in the US. So we have declining birthrates amongst educated people. In contrast, undocumented (illegal, whatever) purposefully come to the US to have an anchor baby. Those playing by the rules pick up the tab. This can rub even the most socially progressives the wrong way. Same with public education, unemployment benefits, and social security.

I think that you are going to see many social services cut, and move towards the US style, in places like Canada, Western Europe, and Australia as more and more immigration creates a less homogeneous population. The fact that many immigrants purposefully head to the nations like Sweden and Germany with the most generous social systems shows that the end results will not be good for the native population.

We bitch and complain about the NHS in the UK but bloody hell I can't think of other systems that are better. I worry about losing my job and looking after gf/son in the aftermath like when I was made redundant from CSCO last year. But i've never had to pile on top of those worries having to worry about an illness taking my redundancy money and savings.

(I'm a Brit btw)

Hospitals are required to take care of you, even if you have no insurance in the US. If you get a bill you cannot afford, you can negotiate a much lower rate with the hospital (I have done this and my family members have also done this).

I run my own business and so I need to pay for myself and my spouses healthcare. Obamacare actually made things worse for me. It doubled my costs (which was promised not to happen) and I was forced out of an otherwise great plan.

Getting sick is not even an issue. Medication is fairly inexpensive and if I have major surgery, I will only be out a couple thousand (the cost of a laptop).

I have many relatives in Canada and the only reason the system works there is because it borders the US. They get all of their regular care paid for by their taxes and the middle class drive over the border and get major surgery done.

The waiting lines are pretty long for most major surgeries and many older people die before they actually get it. The government there continues to promote getting checkups for specific diseases and disorders later and later in life because they don't have the facilities to get it done in a timely fashion for everyone.

NHS isn't the panacea everyone makes it out to be. There are no free lunches and when it comes down to it, a finite resource like healthcare has to have a filter/limiter. Since the majority of government run services are not that efficient and will not be able to keep up with demand or technology, it's much better to have a free-market/private care solution.

I agree with the sentiment of your post. We need to get rid of the bloated government-supported insurance companies and let the free market decide the price of everything..and offer a form of insurance to the poorest.

I'll tell that to my buddy who is a general contractor. He put off major ankle trauma surgery for 6 weeks until his insurance kicked in. The alternative was $40,000 out-of-pocket.

Sounds like you really don't like the single-payer system. Let me recommend Paul Starr's "Social Transformation of American Medicine". I'm pretty sure he hates the system more than you do, but his book walks through the history of how we got here while other countries got to other outcomes. It becomes undeniably obvious that opinions like yours were manufactured by agents of the political parties and the medical industry without your realization.

As a skeptical small business owner, I really encourage you to get some more facts, do a lot of homework. Go read that book. Because this system will bankrupt you. It has bankrupted major American corporations. You alone, as busy as you are, cannot win against millions of smart people who have a century of law and public signalling to have crafted the information environment that created the system of thought in your brain right now.

Trouble is, that only applies to emergencies. If you just want to see the doctor about the funny lump you have to pay first.

"We need to get rid of the bloated government-supported insurance companies and let the free market decide the price of everything."

So when I break a leg I should pay the ambulance to drive around different hospitals collecting quotes for the treatment? This doesn't work for a number of reasons:

1: Most obviously, urgent treatment is urgent. Collecting quotes will take time.

2: Hospitals won't give a quotation for medical treatment. They prefer a cost+ situation, partly because they then make money no matter the outcome, and partly because the costs are so variable that you can't estimate the cost. Just how much is that funny lump going to cost? After a few $K of tests you might be able to put a lower bound on it, but not an upper bound.

3: Medical costs for something serious are bankruptingly large for most people. One serious illness and you have to remortgage your house. Insurance is the only option, but then people at serious risk of illness or injury are more likely to take out insurance, and people who are already ill can't get it or change it. Imagine if you have epilepsy: every few months you wake up in ER and they hand you a $5,000 bill. No insurer will touch you.

Have you actually ever had a major medical problem? Medication can run in the thousands (or be $5, it varies) and even minor surgery is several thousand dollars out of pocket minimum and certainly more expensive than any laptop. It's also a struggle to afford even the premiums for some people

I don't know how accurate this is but I recall hearing that something like 40% of personal bankruptcies in the US are due ot medical debt.

I'm speaking from experience. If I wasn't high income I dont know how I'd be able to afford my bout of illness.

Okay, now what if you don't have a couple thousand lying around? There are many people who can't afford a laptop.

>I have many relatives in Canada and the only reason the system works there is because it borders the US. They get all of their regular care paid for by their taxes and the middle class drive over the border and get major surgery done.

Yeah, this is the shitty part of single-payer, public healthcare. That's why many countries in Europe have a hybrid private/public system. Canada, as you mentioned, effectively has one too.

However, the point of a single-payer system is to ensure that everyone can afford the most crucial, urgent treatment. We're talking about being in an ambulance and being driven down to the ER.

If you live in Canada and suddenly require urgent treatment, you can go to the hospital nearest you, because there's no such thing as "out-of-network" or "in-network". You can get treated by any doctor. And you'll get the same consistent billing everywhere you go, precisely because it's a single payer system.

AFAICT it's pretty rare, and usually done to receive a 'experimental' treatment not approved in Canada.

> The waiting lines are pretty long for most major surgeries and many older people die before they actually get it

Source?

AFAICT the wait times are bad for things like hip replacements and cataract surgery. Not so for things like cancer.

I suspect that not everyone would think this is a small amount of money. From this article:

http://www.theatlantic.com/magazine/archive/2016/05/my-secre...

"Nearly half of Americans would have trouble finding $400 to pay for an emergency."

News flash, folks: physicians in the UK and Canada still make a bit above a living wage. It's the insurers that suddenly have to compete, like when a school district finally gets its shit together and parents start wondering why they're paying $40k a year for equal or worse outcomes.

Granted plenty of Canadian plastic surgeons split to practice in the US, but that's a different (and competitive) market.

This is where the plan that Trump has makes sense. It takes away a lot of the decisions from the insurance companies and puts it back with the healthcare providers. In addition to letting the existing insurance companies compete across state lines.

Hmm, I live in fear of getting sick in Cameroon or Honduras. Maybe we're afraid of different things.

I have had to stop considering the USA a country in the same way I view most other places. I have a suspicion that China may be the same kind of entity but I am not knowledgeable enough to say for sure.

As a first time visitor to this country many years ago I went an clinic because I had severe strep throat. Waited 1 hour, then some intern saw me for 5 minutes. Gave me a codeine pill and later sent me a bill for $400. That was 1990's $400 dolars, and I had a stipend of only $200 month as a student.

That right there is fucked up. Actually, I would rather they just turned me a way -- "Sorry bud, this will be more than you can afford".

I know what people will say "Oh you don't have to pay, declare bankruptcy or call and haggle with the hospital". But you know where you haggle with the hospital -- in a 3rd world country when you are bribing the doctors to not kill you. You haggle there as well, and you also have to haggle here to get he "special, I can't pay" rate.

http://www.creditcards.ca/credit-card-news/top-ten-reasons-w...

1. Overextension of credit (22 per cent of all Canadian bankruptcies).

2. Seasonal employment (15 per cent).

3. Job loss (12.8 per cent).

4. Medical problems (11.3 per cent).

...

However, in Canada, a debilitating injury might necessitate bankruptcy because of bills that you can't pay thanks to a medical condition which precludes your usefully working.

In America, a debilitating injury might necessitate bankruptcy because of bills that you can't pay thanks to a medical condition which precludes your usefully working AND an usurious hospital bill.

A. It's not most. Not even close.

B. If you take the countries that do have socialized medicine, and add the criterion that the funding is not in constant jeopardy, there are very, very few countries that "manage it".

Most developed countries. In fact, I'd go as far as to call it a qualifier to be a developed country.

Everyone lives in fear of getting in an accident. Therefore, I assumed that what codegeek meant was that Americans live in fear of getting in an accident because they won't get treatment. But that is obviously not the case, so I'm not sure what codegeek's point was.

The only reason those ERs are open in the first place is that you can't be accredited as a general hospital without one (which has specific tax benefits). Anyone who uses this example is either woefully ignorant or a troll.

Not really, at #31 in the WHO rankings [1], it's not even close to the best. At #1 in per capita expenditures, it's also wildly inefficient.

For half the per-capita expenditure Canada covers all its citizens. The US spends $8713 per person, per year on healthcare, where Canada spends $4429. [2] The result is a very comparable quality healthcare system (#30 vs. #31 in [1]) that covers everyone.

The truth is allowing for profit in a social security program is by definition allowing for inefficiency. Socialized systems do not need to spend money on advertising, on individual billing/accounting systems, or on profits. Nor should they, IMO. Social programs are for everyone. There's plenty of other businesses out there people can profit from. Caring for people when they need it most shouldn't be one of them.

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

[2] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...

When it's provided. If you have employer health insurance, you're usually fine. Otherwise ...