> Of course if you are in the top 5-10% of earners

Do you go to a special doctors office for the top 5-10%? The one I go to is full of ordinary middle class people. 80% of Americans polled rate their healthcare as excellent or good: https://news.gallup.com/poll/245195/americans-rate-healthcar....

The American healthcare system isn’t hard to fix because it only works for 5-10% of people. It’s hard to fix because it works for 80% of people. Americans don’t irrationally cling to a system that’s bad for 90% of them. (Even among Democrats, a large fraction oppose getting rid of current health insurance: https://slate.com/business/2019/10/medicare-for-all-is-getti...)

Americans stick to the current system, because it works for most people. Most middle class people don’t go bankrupt when they get sick. And the middle class pays the lowest taxes in the developed world, because they don’t pay 20-30% payroll taxes like in European countries to support healthcare for the bottom quarter of earners. That’s the bargain people have voted for. That is obvious, because candidates who campaign for Swedish style healthcare don’t propose Swedish style taxes to go with it. Elizabeth Warren isn’t running on a top tax bracket that kicks in at $75,000 — she’s running on a wealth tax Sweden abandoned and corporate taxes higher than Sweden. Because Americans won’t vote for the bargain between healthcare coverage and middle class taxes that Swedes have adopted.

It’s not the system I’d prefer, I’d rather pay more taxes and make sure the bottom 25% have adequate healthcare. But the notion that everyone is actually irrational and the current system only benefits a small minority is self deception.

I'm not sure I agree with this -- how do you distinguish between "the system works for 80% of the people" and "79% of the people don't have medical emergencies (but the system would fail them if they did)"?

> but the system would fail them if they did

I'm not convinced on this point. Over 90% of Americans have health insurance[1]. Sure, insurance might not cover every dime of every bill, but I can't imagine falling ill is an instant and universal cause for financial ruin like people claim.

Disclaimer: I've been lucky enough to not have to use my health insurance for anything serious. But I have had to use other kinds of insurance (car, home) and by and large it's been fine. We hear horror stories a lot because they're sensational and they sell well, but people continue to buy insurance because it actually does provide value.

[1]https://www.census.gov/library/publications/2019/demo/p60-26...

There's also this[1] study about cancer and debt in the US.

Insurance isn't equal to insurance. The car insurances in the US are the most comfortable in the world. Something happens, you're covered, the insurance pays. Not so in other parts of the world. You drive out of the parking lot scratch another car? It's considered normal in the US. Not so in Germany. You scratch someones car by accident? Anything is possible now.

Why compare apples and bananas? I had a surgery in Taiwan and worked in Healthcare in a couple of countries. I also had health insurance when I was working in the US and got hit by a car while on a bike.

And while the insurance and the other drivers car insurance paid for most, man you sure have to be careful that someone can tell the emergency not to take you to the wrong hospital.

Let's stop pretending there isn't something seriously wrong with the US healthcare system. If all stars align everything is fine, but just an MRI can take anything from 1000 to 2000 or more dollars depending on whether you have insurance or not. You don't have to pay the 2000 dollars if you know better, but it's basically like a bazaar where you have to bargain if your insurance hasn't done so already.

Germany was at that point in the 1920s(or sometime around that) actually. I'm not a fan of Germanies healthcare system, especially since it's such a huge chunk of an already low income, but all the issues you describe about other countries are mostly non issues in Germany.

https://www.amjmed.com/article/S0002-9343(18)30509-6/fulltex...

That study looks at non-care costs, and groups together everyone, not just insured people.

Studies looking at out of pocket costs for insured people show much lower figures: https://healtheconomicsreview.biomedcentral.com/articles/10....

> The financial burden of cancer varies with the types and coverage of health insurance. An analysis of the 2010–2014 MarketScan data showed that an average patient with employer-provided plan had incurred about $7000–$11,000 OOP expenses over 4 years following diagnosis for a series of care that worths $100,000–$280,000.

Another report: https://www.forbes.com/sites/arleneweintraub/2017/08/10/even...

> More than one-third of cancer patients who carry insurance spend more out-of-pocket for their treatments than they anticipated having to pay. Among those who report being blindsided by the costs of their therapies, the median monthly out-of-pocket expenditure is $703.

Among the one third of people who report being surprised by out of pocket costs, the median payment is $703 per month, or about $8,500 annually. That’s a lot, and it can be surprising. But The median individual income for someone 45-55 is $80,000. That’s about 11% of income, or smaller than the difference in the tax wedge between the US and Sweden.

And to put that in context: out of the minority of people who get cancer, and the 1/3 of those people who report being surprised by out of pocket costs, the amount of out of pocket costs is about the same as what everyone with the median prime age US income would pay in extra taxes in Sweden every year even when healthy.

I'm sorry if I came off an deceptive or disengenious. I don't mean to compare apples and oranges, I'm just making the best comparison I can.

This is where my question stems from I suppose. How well insured is the average American? How often do people get stuck at out-of-network care and how much does that cost?

The study you linked is very interesting. My main takeaway is that the average loss after 2 years is 92k, which is significant.

It doesn't seem like they control for employment status? Cancer and cancer treatment can often mean people are unable to work. So, medical bills or not, I could see keeping up with your mortgage and expenses getting near that figure.

A minor piece of anacdata, I had an MRI. Paid for it out of pocket because I can. Private company provided it. $200. Done. Don’t have cancer and I do have a DVD of my brain that I will never watch because I’m squeamish. The private market can bring down prices if given a chance. Yes we need to fix things, but look at the US track record on the VA.

I assume this was a researched and planned procedure on your part?

I am a much bigger believer in "the market" than most people. But the problem with the medical industry is that many / most things happen under serious time pressure.

The seriousness and imediatness of medical procedures means that competition and choice often do not get to play a role in your decision making. For many people in many circumstances, the MRI machine nearest them has a complete monopoly.

How do we bring the miraculous efficiency of the market to an industry where people often cannot make consenting and informed decisions? Its a very hard problem to solve.

That is true. However urgent care is a small fraction of the US procedures. Cancer treatments, heart operations, etc are most often planned care. They also care touted as likely to bankrupt you. Can we try to optimize the majority of our system first before we rebuild it because of painful corner cases?

That's a fair point, chronic / planned care is definitely a significant portion of the market.

That is a flat lie, Eg. Omnium insurance in Belgium pays everything.

There is also full car insurance in Germany: https://www.howtogermany.com/pages/vehicle-insurance.html

I fell ill and I happened to luck out with exceptional insurance. I'm the 99.9 percent tier of best insurance available. If I had anything like like a typical individual I would be in financial ruin ending in bankruptcy if I don't die first. I'm 37, sometimes devastating illness comes out of nowhere. I'm lucky I was covered. Most people in that situation would be fucked.

Living in Belgium, the healthcare works for every Belgian if it's realistically possible, not the "80%" like in America ( source?).

When I see the costs of an operation in America, they just do unnecessary operations, because they can earn extra money. When your argument is "most people won't go broke", that is a really fucked up statement.

Medicare ( that the current administration is trying to slash) is a partial fix for a very expensive and failed system.

In the US it isn't the poor that suffer but the lower-middle class, who are neither poor enough to get excellent health care for free nor wealthy enough to have high-quality private insurance.

The policy problem is that to adequately cover the lower-middle class you would need to substantially raise taxes on the upper-middle class, which pay anomalously low tax rates in the developed world. And the upper-middle class in the US quite enjoys their low tax rates. (While often focused on, the upper class often pays aggregate tax rates in places like California and New York that are more in line with Europe.)

So _why_ if it works for 80% of polled people does it keep being touted as it resulting in bankruptcy consistently?

The same reason that guns result in 1% of deaths but you hear about them constantly. It makes for a good news program.

You're _honestly_ saying that fears over school shootings in the US are overblown because it makes for good news?

School shootings average 4 deaths per year. They are very tragic and very sad, but you should fear them about as much as you fear cows. In fact, cows kill a lot more people than school shootings do.

All this fearmongering over such a rare occurrence is actively causing harm: https://www.washingtonpost.com/opinions/2019/10/11/lockdown-...

Deaths of children. At school.

For literally nothing.

They are _avoidable_, that's why they are not overstated.

Every death is a tragedy. Many are avoidable. If we want to actually reduce tragedy and suffering, your time and energy is best spent on big problems.

A school age child is nearly 200x more likely to die by suicide than from a school shooting. That's a tragedy. And that's _avoidable_. Which do you hear about more?

The attention and resources of society are limited. We would be better off allocating resources to bigger problems, but we don't. That's a tragedy.

Um, why not both.

The rest of the world doesn't have the school shooter problem.

It's fixable, and the fix is bleedingly obvious. There's no excuse.

How are they avoidable?

The only presidential candidate to speak truth about this... Andrew Yang.

He said the drills are misguided though right?

Not that the US obsession with guns and lax gun control that enables school shootings is defensible.

Americans have guns because we believe that individual citizens may, god forbid, need to kill people. Many Europeans, by contrast, believe that they are past that, at a point in history where only the State needs the power to kill.

Who knows who is right. But it’s ridiculously arrogant to say that the American position is not defensible. It was literally just a couple of generations ago when the US was air dropping rifles into France to support the Resistance. Even if we have now entered an age where ordinary people don’t need guns—that new age is younger than computers, supersonic flight, or television. Its far too soon to conclude that’s this is how the world will always be from here forward.

I think you're missing that Europeans also recognise that giving every dumbass, desperate person or dormant psychopath a gun, is far more likely to get people killed NOW, than the chances that when the 'end-times' you imply come, all these same people are going to someone effectively unite and overthrow the regime.

It's a crackpot idea to think that 'arming citizens' helps the whole. And the fact you think it's 'arrogant' to spell out a basic truth that the rest of the world understands is dumbfounding.

Yes, that the drills are misguided. And he is fine with the obsession with guns, suggested using palm/grip recognition to tie guns to owners with free updates paid for by govt. Reasonable.

More reasonable than the anti gun control people, but it's still an insane solution to the problem, in the grand scheme of things.

Because?

Because in the grand-scheme of things, the countries that have banned guns don't have the problems you have.

Crazy, I know.

Yes.

Do you mean that 1 in 100 gets shot dead during their lifetime? In the US

It’s a misleading statistic that gets used because it helps push the narrative that things are broken: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5865642.

> However, the magnitude of the bankruptcy effect is much smaller than previously thought: we estimate that hospitalizations cause only 4% of personal bankruptcies among nonelderly U.S. adults, which is an order of magnitude smaller than the previous estimates described above.

I'm not so sure that rate of medical bankruptcies is the metric I'd use to measure the healthcare system! But point taken.

The other 20% is a lot of people.

Yup, the US is the 3rd most populated country on the planet.

Take a look at bankruptcy due to health issues in Canada. It’s lower than the US, but still a problem. They have a single payer system, but what people tend to forget is if you’re really sick, you often can’t work, so even if health costs are minimal, you can still go bankrupt.

What I think would be helpful in the US is universal catastrophic insurance. Worst case scenario, you’re covered. If you want everyday health insurance, let people buy it or get covered if low income.

Many universal system use this type of coverage.

If you're already in a lot of debt, getting a medical bill is just going to add to that debt. As a result, anyone who sees a doctor and declares bankruptcy can say that healthcare is at least partially to blame.

I get the logic, but I'm more looking for statistics.

I can't tell whether there are "too many" medical bankruptcies, but I know that pundits are exaggerating the degree of severity. This link has some statistics, so you can take what you want from it.

https://www.politifact.com/factchecks/2019/jan/31/jose-oliva...

Money for employer provided health insurance doesn't come from nowhere either. Bumping payroll taxes up to 20-30% would actually be cheaper than the $30,000 per year my employer pays for my health insurance.

I think a better metric would be to find out what percentage of people who NEED their healthcare for major medical issues rate their healthcare insurance as good or excellent.

https://www.commonwealthfund.org/press-release/2018/new-surv...

>> Most middle class people don’t go bankrupt when they get sick.

The median American household currently holds just $11,700 in savings. most people in usa would be ruined financially by a serious sickness where each day at the hospital alone could be up to $5000.

Literally why insurance exists

No one ever actually pays that. With insurance a deductible is around $4,000. Or they have medicaid. Or they negotiate with the hospital. Or they just don't pay.

Those news stories about people being ruined, are in the news exactly BECAUSE they are unusual.

I'm personally I the camp of, why the hell can I not know how much stuff costs up front, why can I not tell them no I dont an unnecessary x-ray, and why am I not told cost owed by me until after the procedure only to find out it's just an absurd amount of money

Private insurance blows cause we're all basically required to have it but it's worse than a tax because we barely ever know how much we owe.

There's plenty cash-only doctors and clinics out there. There's also companies that handle healthcare for their employees via personal accounts (they put more cash in your account each year, and you spend or don't as you see fit). People on such plans do a lot more shopping around.

And as the other poster said, you always have the right to refuse treatment, up to your death if you like (unless it is some kind of involuntary commitment where you are put there because you are supposedly dangerous). Many terminally ill people choose to go this way.

Oh sounds like everything is fine then!

Seriouy doesn‘t your hair stand up in horror when you re-read this?!

„You can always choose to die when you can‘t afford treatment“. WTF?!

>why the hell can I not know how much stuff costs up front

Prices should be publicized, I agree, but you can ask to get something pre-authorized. It just takes longer.

>why can I not tell them no I dont an unnecessary x-ray

You can ask your doctor why you need an x-ray, why they deem it necessary, and refuse if you like

>and why am I not told cost owed by me until after the procedure only to find out it's just an absurd amount of money

Again, you can ask for pre-auth.

Pre-authorization sounds good, but unfortunately a lot of the time it isn't possible. For example, when I was in the ER they gave me a few choices on how they could do stiches on a big cut... But there is definitely no way I could compare the costs! I just ended up paying a $500 bill a few months later.

Lack of pricing information is ridiculous in the US.

You can’t base a system on the “free market” then prevent consumers from having pricing information.

It certainly wouldn’t fix everything in the US, but it would be a huge help.

To be honest, I’m not sure why hospitals in the US haven’t taken the lead on this. If I had a choice between two hospital of similar quality, but one provided price transparency and maybe even a price guarantee (your procedure will cost $X, guaranteed), I would certainly go to that hospital.

Yes, emergency situations are different. Not much of a chance to wait and shop around.

This doesn't seem to be something that's common knowledge. Can you point to information on how to use private health insurance like this?

You just ask the front desk to pre-authorize the prescribed treatment. They work with the insurance carrier and let you know what your cost will be.

Price transparency is a tremendously difficult problem because healthcare is a multi-layered bureaucracy.

Even then though, making prices transparent wouldn’t address the primary scenario that results in personal bankruptcy, which is emergency care. You can’t exactly shop around for the cheapest ER facility if you’re bleeding from a gunshot wound.

Information asymmetries are a huge problem in "market solutions" and there's a huge one here: doctors have 8+ years of medical training and most patients....don't. It's going to be very hard for many people to second-guess a doctor's recommendation or estimate the expected value of decisions.

In a non-emergency situation, you can certainly try to read up on your own, but the medical literature is not always easy to interpret. A friend of mine asked for advice after he was diagnosed with Parkinson's Disease. Despite having a PhD in neuroscience and working as a researcher in a PD Center of Excellence, I had a really hard time making a recommendation. (Neuro conditions are particularly hard, but this is also possibly the best-case match with my experience).

I had a good friend who worked in a leadership role at a major health system in CA.

He readily admitted that the hospital has a very poor grasp on their own costs. At a high-level, they just charge as much as they can - sometimes they lose money, sometimes they make a 90% profit. They pool it all together (usually by line of business) and hope it all works out as a profit.

That’s why specialized, stand alone clinics (e.g. MRI clinic) have some of the best prices. They know exactly what things cost and can make sure prices reflect it.

What types of injuries/illnesses are the leading cause of personal bankruptcy?

It's so ridiculous. I had Kaiser for a period, because I was under the impression the bundle of insurer and healthcare provider would avoid these issues. It worked that way for a bit, but then I got some X-Rays. Paid up front, and then a few months later got an additional bill.

> I was under the impression the bundle of insurer and healthcare provider would avoid these issues.

It gets worse, bundling those two is the epitome of conflict of interests when you find yourself the victim of the hospital's negligence and expect your insurer to act in your best interest.

Nope!

Interesting. Kaiser paid for a 4 hour ambulance ride for me from one hospital to another for immediate surgery. I think I remember paying like $100.

Problem is that sometimes you have to wait even for actually critical things - friend's mom waited almost 2 months for her cancer operation. In US if you've got money you're more or less covered, while in Europe the difference is that in some (admittedly rare) situations even if you earn well you're screwed just like everyone else.

You can get private insurance in Europe if you want.

At least in the UK, private hospitals tend to focus on basic care or routine surgeries. Once you have a more complicated or urgent case you'll end up in a publicly funded (NHS) hospital anyway. Which means that in the end, anyone independent of income has access to the best doctors, criticality of their illness decides who gets to see them, not money.

Yeah, I pay less than 1k/yr for fancy private health insurance in Europe.

What do you mean by fancy?

Medevac, top tier hospitals around the world (except US, lol) in network.

Trauma Team too?

Covered, but availability unsurprisingly depends on if the care provider decides to activate it.

Hmm, I mean the Cyberpunk one. Your insurance must really be good.

Haha, I wondered about that. Providers like Cigna and Bupa are the big ones in this space. Intl insurance is sooo much cheaper than US ones.

You can, but you need to think about it ahead. And no one expects the Spanish inquisition...

In Europe, urgent surgery can be performed same day. The reason many people have to wait is because it's not time critical so others will get surgery first. Having a system where anyone (with the right amount of money) could get complicated surgery without wait times sounds incredibly inefficient as you need much more capacity than necessary.

Europe is a whole damn continent, so no, it's not true. It's not true even for the entire EU. I happen to live in Croatia which is in EU, and I know first hand that in Romania and Bulgaria health system situation is even worse, as I spent some time there. You get urgent operations like if you're in car accident and you're brought into the ER, of course they'll not let you bleed out. But if you need, say, heart aortic valves replaced (happened to my mom), or anything else a bit more advanced, you end up on the waiting list, and unless you pull connections and give bribe that means months of waiting.

I just spent two hours today to wait at an “urgent care” facility in southbay (my regular doctor of 20 years! wouldn’t give me an apt after several days of trying). I think I owe north of $400+ for this one time visit because I am in the early phase of a high-deductible plan. But I haven’t got my bill yet. After the two hour wait, I didn’t even get to see a doctor, but a Physician Assistant. So much for my private plan..

I think this is the biggest issue with private healthcare. You pay a lot of money for it, yet you can still end up with subpar care and extra charges for out of network professionals

This was one interesting thing about my visit to China. Pay $25, see a doctor right away. In fact you can pick how good of a doctor you want to see (prices on the wall at the hospital I was at). This wasn't a small place - it's probably comparable to Kaiser in Redwood City.

In contrast when I was in a much much smaller "community" hospital in China I just walked in, talked to the lady at the desk, and she gave me a prescription. No temperature taking or anything...

Well two hours < three months. I’ve had to wait longer for urgent care. If I can get it same day I’m happy.

> where a cancer diagnosis doesn’t financially ruin you and your family for you life,

If a cancer related, life-saving surgery takes 4-5 months to happen before you can have it, I'm not sure it really matters if it ends up being free or not.

Life threatening stuff is obviously not going to be a 4 month wait. The OP obviously didn’t have this sort of issue.

No. Look at NHS stats in England

https://www.theguardian.com/society/2019/jan/10/nhs-england-...

> Over 18,000 suspected cancer patients a month in England are now not getting to see a specialist or starting their treatment within prescribed timescales, NHS England’s latest performance data has revealed.

And others get treatment same day. It all depends on criticality. One of the reasons for long wait times is that there are always urgent cases being pushed to the top of the list. I agree that it sucks having to wait for an important surgery. But they don't make you wait if it's life threatening.

> But they don't make you wait if it's life threatening.

That's literally what is written in the article. People who wait several months to get a necessary CT or imagery before they can decide to do anything about it. Some cancers can progress very fast in the space of a couple of months, it's basically the difference between life and death in some cases.

> where a cancer diagnosis doesn’t financially ruin you

What OP is suggesting is that it doesn’t financially ruin you in Sweden, you just die waiting to see a doctor.

Yeah this does not happen. Of course you go to the front of the line if you have anything near life-threatening.

The problem (which I think is what OP were talking about) is anything that’s not critical but still need to be looked at by a specialist. In that case long waiting times are not uncommon. Yes it’s a big problem but it’s not a problem that will kill you.

I don't think the wait for cancer patients is 4 months. Even in Portugal you'll get treated and we're much poorer with a much more deficient health system.

This leads me to wonder...

Do cancer survival rates differ in countries with government health care vs. private?

Looks like the US has some of the highest rates across the board: http://worldpopulationreview.com/countries/cancer-survival-r...

I am not sure if 5-year survival rates are the best metric for this. Survival rate may be because of better outcomes or earlier detection. Is there any statistics that normalize for this?

Yes.[0] But I'm unsure whether this is due to private vs public healthcare. My guess is that it has more to do with how developed the medical industry is in the country. Size of the country probably matters as well.

[0] https://www.cdc.gov/cancer/dcpc/research/articles/concord-2....

5 year survival rates may be heavily influenced by detection rates. If country A detects my lung cancer at 55 and country B at 59 and either way I die at 60 - I’m no better off in A. Maybe worse.

Life threatening stuff is obviously not going to be a 4 month wait. The OP obviously didn’t have this sort of issue.

If people were dying left and right from waiting for cancer treatment. There would be a ton of news about that. No less in American media showing how bad European health care is.

Statistics on mortality don't show that happening.

Does that actually happen?

I mean, growing up on welfare/social security our family didn't have trouble seeing any kind of doctor.

The chances of getting cancer are so low you’d think some smart insurance company would want to sell you a catastrophic cancer policy with a low monthly premium. Then it wouldn’t have to mean financial ruin, the same way I have homeowners insurance (without which a fire would spell financial ruin for most).

Why isn’t this a thing? Can someone in the industry chime in?

Huh? I thought cancer was one of the big killers after heart disease.

While you are relatively young maybe the probability is low. That’s also when you are working so private health insurance and income protection insurance would have you covered I imagine.

Ok went to cancer.gov and Approximately 39.3 percent of men and women will be diagnosed with cancer of any site at some point during their lifetime, based on 2014-2016 data.

So, I can’t see why any insurance company could offer reasonable rates given those odds.