> You dramatically underestimate how many people have decent employer paid healthcare.

> $1,100 per year out of pocket in USA, versus $690 for Germany

I don't think these numbers are being interpreted properly or they are they just hand-waiving away your employer contribution (which ultimately is part of your employee compensation). I've been self employed in both countries so I can tell you first hand the actual price of health care in both.

In Germany your public health insurance premiums scale with your income. It maxes out at around 700 EUR per month for family coverage. You pay extra for prescriptions (not that much though) but there is basically no such thing as a co-pay or a deductible. My daughter had part of her kidney removed, was on chemotherapy, had club feet treatment, tons and tons and tons of treatment, AND physical therapy. Zero extra charges. We even got a free 4 week vacation in the Black Forest "for families with children who have a severe disease". So, total out of pocket cost for me was 700 EUR per month.

Now back in the US my own company's health care plan, which isn't awesome but it's also not terrible, costs my company $1300 a month for my family. And on top of that we have a $1500 per person deductible with a $7000 out of pocket maximum. Physical therapy here also costs $40 per session.

So, the math is pretty simple. By far Germany is way way way way more affordable. And this isn't even counting how much time and energy you spend in the US dealing with your fucking insurance and billing.

Yeah, I also don't know how you'd square the "Healthcare Costs as Percent of GDP" chart with the argument that Americans pay only a couple hundred dollars more than Europeans. We pay drastically more than Europeans.

I didn't say we pay only a little more than Europeans. I said that, accounting for employer-paid healthcare, we pay only a little more on average out of pocket. That means that the average voter whose employer already provides health insurance is facing significant uncertainty if private health insurance was replaced with public health insurance. Their taxes would go up a lot, and their out-of-pocket expenses would not go down that much.

But you get that even if our employers are paying, we're paying, right? It's not free money, it's just a hidden toll our our salary.

Also, I'm assuming "out of pocket" is exclusive of premiums and deductible payments.

>The average out of pocket healthcare expenses in the US are less than a couple of hundred dollars a month higher than in most European countries

Probably, but nobody in Europe is afraid to call an ambulance because they'll go bankrupt. First time I read on Reddit about people in US with "Don't call ambulance" bracelet, it really blew my mind a little bit.

“The UK NHS for example, is extremely aggressive in “saying no to treatment””

This hasn’t been my experience and I don’t know anyone the NHS has turned down for treatment.

I know of things like hip replacements where they said the patient should be older so they don’t have to do it again at a riskier age.

I know sometimes they don’t always approve every treatment but generally they don’t aggressively say no, not at all.

There was political pressure on the NHS a few years back to say "yes" more often. This led to the introduction of the Cancer Drugs Fund to increase access to unproven cancer treatments. The disaster was as big as everyone predicted: a billion spent with nearly no clinical benefit. They should have listened to the bureaucrats at NICE.

Aggarval et al. have the data: https://www.ncbi.nlm.nih.gov/pubmed/28453615

Unproven? There were plenty of proven cancer drugs the NHS said “no” to, not because there was no data, but because they said the cost wasn’t worth it. You’ll live another 6 months? No we won’t pay $50K for that.

That actually makes a lot of sense, in that if there is a limited amount of funding then that 50K should go to a treatment that will give someone another 10 years. Under the US system, private insurance is just as quick (if not quicker) to deny that treatment.

Of course, under either system, if you come up with the 50K, then the treatment is all yours.

I’ve lived through a cancer and dragging it out for another 6 months doesn’t help anyone.

As someone who has worked in the US system, private insurers often pay for treatment quite quickly after approval. Unless the evidence is quite shaky, it’s usually paid for.

Now whether that’s a good thing is a separate question.

> Under the US system, private insurance is just as quick (if not quicker) to deny that treatment.

It’s hard to find data on this, but I haven’t seen any basis for concluding that private insurers are “just as quick” to deny treatment. In the past, private insurers tended to have lifetime limits. They’d let you blow through the lifetime limit, and then deny care. In the NHS, the cost benefit of care was more carefully scrutinized from the outset. There is a lot of coverage of the NHS denying hip replacements and cataracts surgery, which is almost universally covered in the US: http://www.telegraph.co.uk/science/2016/04/27/hip-replacemen.... The US also does quite a bit better in cancer survival rates, suggesting that insurers aren’t just denying treatment to cancer patients: https://qz.com/397419/the-british-seem-less-likely-to-get-ca....

The ACA eliminated lifetime limits, but also limited insurer profits to 20% of expenditures. So now, insurers really have no reason to deny care.

Cancer survival rate is tricky but probably explained by better screening in the US: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4706735/

The hip replacement issue is known as the "little old lady problem" in NHS circles. Hip replacement is not urgent, you'd like to concentrate the limited funds where lives are at risk. Unfortunately, little old ladies are fodder to enemies of public healthcare and always rolled out in this context.

Cancer survival rate uses "5 year survival rate".

Take every man over the age of 50 and then give them prostate screening, and then don't do anything else at all. Don't test any of the prostate cancer that you find.

Your 5 year cancer survival rates go up, because most prostate cancer is slow growing.

But this situation isn't what happens. The US screens a bunch of men, and then treats the cancer they find. Does this reduce all cause mortality?

No.

https://www.harding-center.mpg.de/en/fact-boxes/early-detect...

This is what people in the American system pay for: testing and treatment that causes harm and which doesn't prevent death.

It's my understanding is the U.S. is especially aggressive with screenings, which might have some impact on % of cancer deaths, but has an even larger impact on cancer survival rates.

Ex. If a cancer will kill you in 5 years and there is no treatment. Catching it year 2 vs 3 will prolong your lifespan 50%.

A complete misrepresentation of what happened.

People didn't live longer, many of them died sooner, and most of them had pretty severe side effects.

https://www.bmj.com/content/357/bmj.j2097

> The Cancer Drugs Fund (CDF) has not “delivered meaningful value” to patients with cancer and may have exposed them to “toxic side effects of drugs,” an analysis has found.1

> The CDF was established in 2010 in England to provide “patients with faster access to the most promising new cancer treatments” and to ensure “value for money for taxpayers.” It funded drugs that were not available through the NHS because the drugs had not been appraised, were in the process of being appraised, or had been appraised but not recommended by the National Institute for Health and Care Excellence (NICE). The fund was overhauled last year.

Erm, the apples to apples comparison here is “private” plus “out of pocket” which ends up as $5000 per year in the US and $800 in Germany. Private seems to refer to the premiums, and out of pocket the expenses. Premiums are crazy high.

And Poland is even cheaper, but you might have to wait for a bed unless it's urgent. Private don't do everything because some of it is not profitable. Public takes the slack, but even paying out of pocket likely won't bankrupt you unless you're very poor.

On the other hand, nurses especially are too few and underpaid. Not enough doctors too. They still do a great job and are achieving some raises via protests. Polish healthcare is not rich. German is. Buildings and some facilities here need some refurbishing, which is happening slowly over time.

Why shouldn’t we consider “employer paid” healthcare the same way we consider a tax?

The last time I checked, the total cost of family health care at my last job (including what the employer paid) was $12,000 a year. Even at $100,000 a year - $40K more than the median income - that’s still around 10% of total compensation.

Average out of pocket expense is not what this story about. How about you look at the tail, say 80th percentile. These are the people that are getting screwed.

> The UK NHS for example, is extremely aggressive in “saying no to treatment.

No it isn't.